BOARD OF DIRECTORS Wednesday 5 May 2021 at 09:30-11:35 MS Teams/Boardroom, Yeovil District Hospital NHS Foundation Trust AGENDA - PART 1 Action Presenter Time Enclosure

1 Welcome and Apologies for Absence Chairman 09:30 Verbal

2 Register of Declarations of Interest and to Confirm Receive and All Appendix 1 Declarations Relating to Items on the Agenda Note

3 Minutes of the Meetings held on 3 March 2021 and Approve Chairman Appendix 2 to Discuss Matters/Actions Arising

4 Executive Director Report Receive Execs 09:35 Appendix 3

ASSURANCE REPORTS

5 Board Assurance Reports: . IPC Board Assurance Framework Review Shelagh Meldrum 09:50 Appendix 4 . Q4 Board Assurance Framework Review Executives Appendix 5 . Q4 Board Corporate Risk Register Review Executives Appendix 6 . Q4 Learning from Deaths Report Review Merry Kane Appendix 7 . Q4 Freedom to Speak up Guardian Report Review Shelagh Meldrum Appendix 8 . Q4 Guardian of Safeworking Report Review Merry Kane Appendix 9

FINANCE & PERFORMANCE

6 YDH Group Board Overview Quadrant Receive & Shelagh Meldrum 10:25 Appendix 10 (Inc. updates on Finance, Quality, Performance, Workforce Note Matthew Bryant for YDH and Subsidiary Companies) Stacy Barron- Fitzsimons Sarah James

7 Financial System Plan and YDH Position Approve Sarah James 10:40 Appendix 11

8 Going Concern Statement Approve Sarah James 11:00 Appendix 12

ITEMS TO NOTE/FOR INFORMATION/APPROVAL

9 Risk Management Strategy Approve Ben Edgar-Attwell 11:15 Annex A

10 Constitutional Documents Approve Ben Edgar-Attwell 11:20 Annex B

11 Committee Updates and Minutes: . Financial Resilience and Commercial Committee Receive Martyn Scrivens 11:25 Verbal . Governance and Quality Assurance Committee Note Jane Henderson Appendix 13 . Audit Committee Note Paul Mapson Appendix 14

12 Any Other Business and Meeting Close Chairman 11:35 Verbal

13 Date of Next Public Meeting 2 June 2021 via MS Teams in the Boardroom, Level 1, Yeovil Hospital

Board of Directors – Declarations of Interest April 2021 the following table sets out the declaration of interests of the Board of Directors (voting and non-voting).

Name Position Interests Declared Chairman and Non-Executive Directors (Voting) Paul von der Heyde Chairman -Trustee and Adviser Howlands Furniture Group, Office Furniture Manufacturer -Sister-in-law is the sister of Dr Ali Parsa who is the Founder and Chief Executive Officer of Babylon Healthcare Services -Chairman and Director of The Worshipful Company of Furniture Makers’ Charitable Funds incorporating the Furnishing Trades Benevolent Association -Director and Shareholder of Herswell Coaching and Consulting Limited -Chairman of Psoriasis and Psoriatic Arthritis Alliance & PAPAA Enterprises Ltd -Director and Shareholder of Sweetfish Limited -Chairman of Axminster Tool Centre Limited Jane Henderson Non-Executive Director -Private Practice Therapeutic Counsellor -Part-time, self-employed counsellor for Frome Birth Talk Martyn Scrivens Non-Executive Director -Chairman of Simply Serve Limited -Non Executive Director and Chairman for Retail Money Market Limited (trading as RateSetter and a 100% subsidiary of Metro Bank Plc) -Director of Tanyard Consulting Limited -Non Executive Director and Chair of Audit Committee of Hampshire Trust Bank Limited Graham Hughes Non-Executive Director -Volunteer Advisor at Citizens Advice -Parish Councillor of Babcary Parish Council -Chairman and Trustee Director of Avon Mutual Paul Mapson Non-Executive Director -No declarations Executive Directors (Voting) Jonathan Higman Chief Executive -Director, Symphony Healthcare Services Limited -Director, Yeovil Property Operating Company Limited -Director, YEP Project Co. Limited -Management Board Member, Yeovil Strategic Estates Partner Board Shelagh Meldrum Deputy Chief Executive/Chief -Non-Executive Director, Simply Serve Limited Nurse & Director of People -Husband is employed as Contract Manager at Yeovil District Hospital Sarah James Chief Finance Officer -Branch Treasurer for South West Branch of Healthcare Financial Management Association -Trustee of RICE (Research Institute for the Care of Older People) -Director, Symphony Healthcare Services Limited -Non-Executive Director, Simply Serve Limited -Management Board Member, Yeovil Strategic Estates Partner Board -Director, YEP Project Co. Limited -Member of Southwest Pathology Services Board (Joint Venture) Merry Kane Chief Medical Officer -Shareholder/Director of Jobson Medical Services Limited -Husband works for Jobson Medical Services Limited which holds contracts with CARE UK -Husband is a consultant at Musgrove Park Hospital Executive Directors (Non-Voting) Matthew Bryant Chief Operating Officer -Chief Operating Officer (Hospital Services) at Somerset NHS Foundation Trust -Trustee for Hospiscare, Exeter -Visiting Specialist, Plymouth University Peninsula Medical School Stacy Barron- Director of Operations -Husband is employed as Cyber Security Manager at Yeovil Fitzsimons District Hospital NHS Foundation Trust Jeremy Martin Director of Transformation -Trustee, Spark Somerset

Paul Foster Deputy Chief Medical Officer -Wife is a GP Partner for The Grove Medical Centre Non-Executive Directors Observers (Non-Voting) Barbara Clift Non-Executive Director -Non-Executive Director, Somerset NHS Foundation Trust Observer -Trustee of SWEDA -Daughter’s partner is CIO of KPMG Stephen Harrison Non-Executive Director -Non-Executive Director, Somerset NHS Foundation Trust Observer -Chair, YMCA Mendip -Trustee, Lawrence Centre, Wells -Governor, Wookey Primary School

APPENDIX 2

BOARD OF DIRECTORS DRAFT Minutes of the Part 1 Board of Directors Meeting held on Wednesday 3 March 2021 via MS Teams at Yeovil District Hospital

Present: Paul von der Heyde Chairman Jonathan Higman Chief Executive Jane Henderson Non-Executive Director Graham Hughes Non-Executive Director Paul Mapson Non-Executive Director Martyn Scrivens Non-Executive Director Shelagh Meldrum Deputy Chief Executive/Chief Nurse & Director of People Sarah James Chief Finance Officer Merry Kane Chief Medical Officer

In Attendance: Matthew Bryant Chief Operating Officer Jeremy Martin Director of Transformation Stacy Barron-Fitzsimons Director of Operations Ben Edgar-Attwell Company Secretary Paul Foster Deputy Chief Medical Officer Barbara Clift Somerset NHS FT Non-Executive Director Stephen Harrison Somerset NHS FT Non-Executive Director David Recardo Appointed Governor Observer Janette Cronie Public Governor Observer

Presenters: Michelle Goddard General Manager for Patient Flow

Ref: No: Action 1-96/ 1 WELCOME AND APOLOGIES FOR ABSENCE 2021 1.1 Paul von der Heyde welcomed everyone to the meeting, which included David Recardo and Janette Cronie as Governor Observers. There were no apologies for absence.

1-97/ 2 DECLARATIONS OF INTEREST 2021 2.1 The register containing the declarations of interests from members (voting and non-voting) of the Board was noted.

1-98/ 3 MINUTES/ACTIONS OF THE PREVIOUS MEETING 2021 3.1 The minutes of the meeting held on 3 February 2021 were approved as a true and accurate record. With regard to actions and matters arising, it was noted that meetings and work on the development of a system risk framework continued. The review of statutory roles had been delayed although this would take place in the future. Graham Hughes said he had taken on the Guardian of Wellbeing role; reporting would filter through the Workforce Committee.

1-99/ 4 EXECUTIVE DIRECTOR REPORT 2021 4.1 The Board noted the items included within the Executive Director report where the following updates were provided:

4.2 Jonathan Higman provided an updated position of the hospital and system with COVID-19; the position was improved compared to previous weeks with no COVID-19 patients currently within ICU. This represents a significant improvement in the position only a few weeks ago when the Trust was at its maximum state of critical care escalation. There continues to be pressure on the system, with increasing numbers of minor attendances to the Emergency Department. The latest announcements regarding the roadmap for reducing and

removing lockdown measures may result in increased attendances, therefore it is important that people remain vigilant and continue to social distance etc.

4.3 The vaccination programme continues with the second doses having commenced. This has been a fantastic piece of work across the system with over 200,000 people in Somerset having received their first vaccination. A review of the programme from April onwards is required to ensure a more sustainable footing as we go into the latter part of the year.

4.4 A significant amount of capital works has and is taking place across the hospital, such as the creation of additional majors bays in the Emergency Department and improving the layout and capacity of the waiting area to support social distancing. Work in ICU has allowed this to be split into hot/cold areas and an additional bed space has been created. Window replacement has commenced alongside roof replacement projects for the Women’s Hospital and Convamore. The residential accommodation project is due to be completed and handed over at the end of the month. There has been strong uptake for these units, so a priority list has been created to ensure there is capacity for overseas staff who will be due to arrive. An opening ceremony will be planned; David Recardo offered to attend as Mayor of Yeovil.

4.5 The staff survey results will be presented via the Workforce Committee in due course along with the national WRES indicator results. The initial high-level results of the staff survey indicate a strong position with the Trust being one of the best performing across a number of indicators. Proactive media regarding this will take place once the data can be published.

4.6 Shelagh Meldrum reported that the Trust had recently had an Infection Prevention and Control (IPC) focused inspection, which included an unannounced Care Quality Commission (CQC) on-site inspection. This was a standard inspection and was not a result of any concerns in this area. The formal report will be received in due course. The inspection team visited all areas of the hospital and spoke to staff and patients. Positive feedback was received on the day regarding the level of internal challenge for IPC, the links between the IPC team and operational patient flow and finance teams and how the Trust has linked the patient flow teams into IPC management. No immediate concerns were raised.

4.7 Jane Henderson asked if the outputs of the report would link into the Trust’s overall CQC rating or the Well-led aspect. Shelagh Meldrum said it would form part of the Well-led domain although it was not expected the inspection would influence or change the Trust’s overall rating at this stage. Matthew Bryant said that the inspection allowed the Trust to demonstrate the fantastic work completed and this sort of review would inform future inspections. The positive verbal report was useful to validate current practice.

1-100/ 5 BOARD ASSURANCE REPORTS 2021 IPC Board Assurance Framework 5.1 Shelagh Meldrum said that this report would be regularly reviewed, updated and reported to Board. A new version of the framework has since been published although notification of this was not received. The new version would be reviewed for the next report. As outlined in the framework, there are some areas where work continues. Audits will take place to ensure arrangements are in place and working well. In terms of staff IPC training, there needs to be a mechanism for recording the interactions taking place across departments with the IPC team where “on-the-job” training is taking place. Antimicrobial rounds 2 | Page

will also need to move back to being on-site rather than the current virtual round. There are challenges in ventilation of some areas due to the aged estate although mitigating actions are now in place.

5.2 The latest framework specifically mentions requirements for inpatients to wear masks. This is difficult to enforce in some instances when patients leave their bed space. Paul von der Heyde asked if this has been raised by the CQC during their inspection. Shelagh Meldrum said it had not been raised during the feedback session.

5.3 Martyn Scrivens said the outputs from the CQC inspection were fantastic. He noted the references to Somerset system agreements and interpretations of guidance. He asked to what this referred. Shelagh Meldrum said that it related to guidance about not moving patients until two negative swabs had been received. The agreed interpretation is around facilitating patient moves from assessment areas (such as within ED or EAU), otherwise patients could not be moved from ED until two negative swabs had been received, which would not be operational feasible.

5.4 Martyn Scrivens asked if there was any evidence of positive impacts from self- testing and whether there was data around nosocomial infection rates. Shelagh Meldrum said that over 2000 self-testing kits had been issued to staff and an app was in place for the recording of results. Those showing a positive lateral flow test have generally then received a positive PCR test; some individuals have also been asymptomatic so there is a big advantage in completing these.

5.5 In terms of the nosocomial rate, as of today no positive patients in the hospital were the result of nosocomial infection although this has fluctuated throughout the pandemic. The Trust monitors and reports on cases defined as suspected hospital-onset and those as definite hospital-onset (i.e. a positive test 8-14 days and 15+ days) due the incubation period. A retrospective review of cases is underway. Matthew Bryant added that a review across the whole system is likely to take place in the future.

Ockenden Maternity Self-Assessment Report 5.6 Shelagh Meldrum explained that the initial response to the Ockenden Maternity report had been presented at the previous meeting. The self-assessment has since been completed against the expanded view of requirements and this had been reviewed with Jane Henderson and Sallyann Batstone, Head of Midwifery, prior to submission. The next phase is for the regional team to review and moderate the responses. An evidence portal has been created for the submission of audit evidence. The initial feedback is that YDH has harshly rated itself against the guidance, therefore a number of amber areas are expected to move to green. One key gap relates to audit capacity in the organisation due to COVID-19 and staff shielding.

5.7 Guidance is awaited on the review requirements for maternity significant incidents. The Trust will also be reviewing its website content to ensure the information is robust enough for mothers to make informed consent on treatment. The Non-Executive Director role in relation to this also appears to be bigger than anticipated; this is being questioned. Graham Hughes welcomed this bearing in mind the governance remit for Non-Executive Directors.

5.8 The results are expected to be pulled into a national gap analysis for the central teams to review and identify actions and funding where possible. Jonathan Higman said that a system meeting was also taking place the following week to

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review the requirements across the system and look at more strategic questions. This will be a joined up provider review.

5.9 Jane Henderson noted the point about using internal audit. She questioned if the internal audit plan would need to be amended to reflect. It was suggested that the Trust’s own audit functions within the clinical governance team would be used if required for this rather than the services provided by BDO.

Six Month Safer Staffing Report 5.10 Shelagh Meldrum presented the Safer Staffing Report, which covered the six- month period to December 2020. The Trust has continued with some enhanced staffing due to COVID-19 pathways plus the early opening of Jasmine Ward, swabbing clinic and vaccination programme. There has been some additional funding for some of these areas, however it does result in a pull on teams, plus exacerbated by higher than previous sickness absence rates.

5.11 The various pathways due to COVID-19 measures mean that staff cannot easily be moved between departments and wards leading to increased agency usage and an impact on the care hours per patient data indicator.

5.12 In terms of staffing incidents, there has been additional commentary to explain that these may arise where staffing levels may be lower than typical and where additional staff are required. There has been no direct patient harm as a result of these and there are regular safest staffing meetings in place to review and resolve any issues or concerns.

5.13 Martyn Scrivens said that it was a helpful report. He asked if departments and wards establishments that had increased during the pandemic were easily identified, and could effectively shrink back when required. Shelagh Meldrum said that as pathways change back, staffing could be changed; good governance and oversight processes are in place to identify these areas. Martyn Scrivens thanked the teams for this, adding that it was vital that system workforce planning still take place. Shelagh Meldrum agreed that this was vital and that a longer-term masterplan was needed.

1-101/ 6 2021/22 STRATEGIC PRIORITIES 2021 6.1 The Board noted that the Trust had previously rolled over the priorities from 2019/20 for this financial year bearing in mind the pandemic. In recent weeks, a review and identification of the priorities going forward has taken place. These recognise the system wide working and the continued response to COVID-19. A number of the priorities have shared ownership due to their size.

6.2 Paul von der Heyde asked if these would be reflected within Somerset NHS Foundation Trust (SFT). Matthew Bryant confirmed that there was a high degree of similarity and they recognised the slight variations in the services and sectors provided by both Trusts. Thought would need to be had in due course regarding the Board Assurance Frameworks of the two organisations.

1-102/ 7 YDH GROUP BOARD OVERVIEW QUADRANT 2021 7.1 The Board reviewed the YDH group overview quadrant, where the following was discussed in more detail:

Safety / Patient Experience 7.2 Reducing the number of patient falls remains a key area of work; this had been discussed in detail at the Governance and Quality Assurance Committee (GQAC). Closed bays and the other infection control arrangements affect this and this position is observed nationally. The number of pressure ulcers have 4 | Page

reduced with attending patients less likely to arrive in a deconditioned state. There was one case of MRSA bacteraemia although the patient was admitted with this and it was not hospital-acquired. A post infection review is underway.

7.3 There has been a reduced number of complaints. Themes for complaints largely relate to communications or a feeling of being moved or discharged too quickly. These are all reviewed and some complaints are being considered under the vexatious policy. Graham Hughes asked if there was any indication of increased number of legal claims arising. Shelagh Meldrum said there was not at this stage.

Operational Performance 7.4 The Board noted the performance indicators as included on the Board quadrant where performance for the ED waiting times, cancer treatment and diagnostic waiting times was strong against the national targets. In comparison, performance for referral to treatment waiting times is strong, although it is recognised that this has been significantly impacted by the pandemic. The risks relating to long waiting patients is recognised and this is managed and reviewed on a case-by-case basis.

Workforce Performance 7.5 Spend relating to agency staff has increased due to the sickness and absence rate and the need for additional staffing due to COVID-19 pathways etc. Staff absence is being closely monitored to ensure that there is a not a larger issue of departmental resilience. The revised shielding rules have had an impact on staffing numbers across a number of departments and some staff have been distressed about not being able to come to work because of these changes. Staff appraisal rates remains under the target although managers are encouraged to complete these where possible.

Financial Performance 7.6 Sarah James reported that the financial position was continuing in line with the forecasting although the favourable variance is reducing as cost continuing for agency and COVID-19. The Trust is likely to meet the plan under the current regime although confirmation is awaiting on the annual leave provision.

7.7 A good level of cost improvement plans are being delivered despite the pandemic and the rate of these being recurrent is encouraging. The Trust is also on target to achieve its capital plan for the year.

1-103/ 8 RESTORATION OF ELECTIVE SERVICES AND OPERATIONAL RECOVERY 2021 8.1 Stacy Barron-Fitzsimons presented a summary of the plans and the work underway for the restoration of elective services and operational recovery. This included an overview of the current position and the guiding principles, such as safety and sustainability. A programme of weekly meetings are in place with the ability to react to the current position and prevalence. The current number of patients waiting over 52-weeks for elective surgery has significantly increased as a direct consequence of COVID-19 and a roadmap for the restoration of services has been drafted across six weeks. Martyn Scrivens asked if it was possible to see a further breakdown of the priority lists across the various specialties. Stacy Barron-Fitzsimons said that this could be shared after the meeting. SBF

8.2 Diagnostic services continue to deliver over 80% of pre-COVID-19 levels and this will stabilise further going forwards. The backlog will not be cleared immediately due to reduced capacity with the various cleaning and infection control aspects. The rate of cancer referrals is increasing with some cancer sites already back or above previous levels. There continues to be a focus on 5 | Page

cancer patients with services having continued throughout where possible and appropriate. Jonathan Higman said it was important to recognise the phenomenal amount of work completed over recent months during the pandemic to ensure that services have continued where suitable.

8.3 Matthew Bryant agreed and wished to thank the teams. He added that there are regional discussions regarding the restoration of services. It is likely that the position with regard to 52-week waiters will deteriorate further before it improves.

8.4 Graham Hughes said it was important to look at this from a system point of view and asked about the position with restoration of services was at SFT. Stacy Barron-Fitzsimons explained that plans are developed as part of system restoration and recovery plans using capacity from all providers. As part of this, there will be actions taken to ensure equity of access and the best use of resources. Jeremy Martin added that various digital solutions were being reviewed to see if technological developments could further support this work. Matthew Bryant suggested that the plans as reviewed by the Elective Care Delivery Board could be shared with Board members. MB

8.5 Paul von der Heyde asked about feedback and communication with patients. Stacy Barron-Fitzsimons advised that the Trust had written to all patients on waiting lists asking if they wished to wait, if they were happy to come in or if their condition had since changed. A large number have chosen to wait until prevalence levels have reduced. The CQC IPC inspection will help provide assurance of the safe measures in the hospital.

1-104/ 9 NEW CRITERIA TO RESIDE STANDARDS 2021 9.1 Michelle Goddard joined the meeting. She explained that there has been a national change in bed management in response to COVID-19 to ensure that beds are used for the right reason, at the right time. These new standards were designed to replace the delayed transfers of care monitoring and provide a way of reviewing the reasons for a patient being in hospital. The four new Criteria to Reside standards cover: Physiology, Treatment, Recovery and Function. If a patient does not fit into one or more of these criteria, then they would be the focus of the discharge team to understand what action could be taken. A clear process is in place for those who have No Reason to Reside; recent additions to this are those awaiting diagnostic and awaiting a designated setting.

9.2 Michelle Goddard said the patient flow teams support the consultant and ensure that there are safe measures in place in order to facilitate discharges. Part of this is looking at any barriers to discharge and gather data to improve the system to facilitate discharge where this is suitable. There also plans to raise the profile and improving the accuracy of the Criteria to Reside standards and reporting, and following this, the Trust will consider reversing to cover Criteria to Admit.

9.3 Matthew Bryant thanked Michelle for the presentation and an overview of the work underway, which was exciting and meaningful to patient care. Jane Henderson said it appeared to be complex; she asked if it would make a difference in reality. She also asked about mental health patients, as they did not appear to fit in any of the four criteria. Michelle Goddard said that a number of patients would not come under one of the four headings. This would raise the profile of the various barriers, improvements and services required across the wider system to ensure that patients are treated in the most appropriate setting. It does not mean that patients would be discharged if they do not meet one of the four criteria.

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9.4 Barbara Clift said it was an excellent presentation whilst sounding exciting and challenging. She said there would need to be a focus on dependences across the system. She said it was clear that the system was on the right trajectory but raised concerns about this, bearing in mind one of the biggest challenges is community hospital capacity and staffing.

9.5 Stacy Barron-Fitzsimons agreed that the wording and definition of the new criteria was not particularly helpful but it would lead to good challenge around other parts of the system that may need review to support patient care and treatment.

Stephen Harrison asked how well the new criteria are understood across the 9.6 system. Matthew Bryant advised that the new standards were well understood in terms of social care and partnership working continues with them. Primary Care has understandably been under pressure and concentrating on the vaccination programme. The new criteria will need to be used seamlessly across the system.

Jonathan Higman wished to thank Michelle Goddard for her work throughout the 9.7 pandemic and the links formed with the IPC teams. The new criteria will provide useful information and the idea to review criteria to admit is an exciting concept.

1-105/ 10 INTERMEDIATE CARE DEVELOPMENTS 2021 10.1 Matthew Bryant presented an overview of analysis from the Intermediate Care services across Somerset. There has been recognition from Professor John Bolton on the outstanding work in the area within the system. Matthew Bryant gave an example of a patient who had benefited from the Intermediate Care services, leading to the patient returning to the majority of their previous activities of daily living. The services are based upon the Ian Philp principles of care from 2012.

10.2 The latest analysis of the intermediate care services suggests that circa 63% of patients aged 65+ are discharged via Pathway 1 Discharge to Assess (D2A) model and 37% are discharged to a bedded facility. The D2A pathway is taking on average 42% more people home each month than the Home First Pathway. There has been involvement of the voluntary and third sector; this offers a valuable alternative to formal care support. Despite the increase demand, the percentage of people requiring bed-based care has decreased.

10.3 An overview of length of stay and outcomes was provided. Length of stay for bedded units has increased, partly due to COVID-19 but also due to a positive shift in people going directly home. Data suggests that people in interim placements have poorer outcomes than those in other bedded facilities.

10.4 Matthew Bryant explained what was next for Intermediate Care. This includes discharge decision-making, mix of capacity and types of options in Intermediate Care, optimising reablement in pathways, and connection to neighbourhoods and community. The services are making a difference every day on how our hospitals work and are providing benefits for patients.

10.5 Jeremy Martin said it was an excellent presentation and it was good to see the clear benefits and developments in this area. He said that there needed to be an emphasis on the importance of linking with neighbourhoods. Martyn Scrivens agreed that there were clear merits and more time reviewing this might be helpful. He said it was not clear to him who is responsible for what and where the associated funding was provided. The achievements are substantial in an unusual environment. Barbara Clift agreed the outcomes and development was 7 | Page

excellent but agreed with Martyn Scrivens that the challenges in sustainability and funding needed to be recognised; there is likely to be clear cost benefits as well. Additional funding may be required for social care to support and decisions would be needed regarding this. The voluntary care sector funding is also vital. Jonathan Higman picked up these points and said that the entire system should be looking at this within the ICS, with the benefit of centralised funding for the benefit of patients and outcomes.

10.6 Sarah James advised that a business case on Intermediate Care was being drafted and this would consider the funding streams and opportunities. She said that one area under review is to understand the wider impact on acute hospitals, both in terms of resources and capacity, but also patient experience for the acute pathway. This is difficult to measure. Matthew Bryant said that the teams would also be picking up how the services link with community based care and it was important to be proactive rather than reactive, allowing people to retain independent living for longer.

1-106/ 11 COMMITTEE UPDATES AND MINUTES 2021 Financial Resilience and Commercial Committee (FRCC) 11.1 The Board noted that the financial position was covered in the above update.

1-107/ 12 ANY OTHER BUSINESS 2021 12.1 Sarah James said that the guidance for the operational and financial planning for 2021/22 was expected in the coming weeks. The timelines are unlikely to align with the Board meetings, therefore there may be a need to utilise the FRCC meeting on 31 March 2021. She therefore asked for delegated authority to the FRCC should this be required. This was agreed and the need to be flexible on reviewing and approving the plan following the release of guidance was recognised. Paul von der Heyde said it was important to have all voting members in attendance for these meetings.

1-108/ 13 DATE OF NEXT MEETING 2021 13.1 5 May 2021, Boardroom, Level 1, YDH

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APPENDIX 2b BOARD OF DIRECTORS

BOARD OF DIRECTORS – ACTION SHEET 5 March 2021

Minute Action Progress Due By ACTIONS FROM 29 APRIL 2020 1-7/2021 Development of system wide risk register / Work ongoing on this topic Ongoing Ben Edgar-Attwell (7.4) sharing of risk registers between YDH and – includes SFT/CCG/ICS SFT. ACTIONS FROM 25 NOVEMBER 2020 1-79/2021 Address concerns regarding the use of two Complete November Ben Edgar-Attwell (7.5) systems for risk assessments. Response 2020 should be circulated to all Board members. 1-82/2021 Using guidance, review individual recorded List of mandated roles March 2021 Ben Edgar-Attwell (10.2) Board level roles to ensure required. received from CoSec network. Mapping exercise underway and updates will be provided to individuals ACTIONS FROM 3 MARCH 2021 1-103/2021 Breakdown of RTT priority lists across the Circulated with Board April 2021 Stacy Barron- (8.1) various specialties to be shared. Papers Fitzsimons

1-103/2021 Restoration of services plans as reviewed by April 2021 Matthew Bryant (8.4) the Elective Care Delivery Board to be shared with Board.

Appendix: 3 REPORT TO: Board of Directors REPORT BY: Executive Team PRESENTED BY: Executive Team EXEC SPONSOR: Jonathan Higman, Chief Executive REPORT TITLE: Executive Director Report DATE: 5 May 2021

Purpose of Paper (Please select any which are relevant to this paper)

☒ For Assurance ☐ For Approval / Decision ☒ For Information

Reason for Presentation to The Executive Director Report to the Board includes matters of Committee/Board topical importance and key business items. It is also an opportunity for the Executive Team to highlight achievements and to provide updates on the latest developments within the Trust.

The Board are asked to note the key items within this report. A verbal report of other matters of importance may also be provided. Any Key Issues to Note

Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) ☒ Care for our Population ☒ Develop our People

☒ Innovate and Collaborate ☒ Develop a Sustainable System

Implications/Requirements (Please select any which are relevant to this paper) ☒ Financial ☒ Legislation ☒ Workforce ☒ Estates ☒ ICT ☒ Patient Safety / Quality

Reference to CQC domains (Please select any which are relevant to this paper)

☒ Safe ☒ Effective ☒ Caring ☒ Responsive ☒ Well Led

Is this paper clear for release under the Freedom of Information Act 2000? ☒ Yes ☐ No

Day of Reflection

The 23 March 2021 marked one year since the start of the first lockdown, and was recognised as the first national Day of Reflection by people and organisations across the country.

Jonathan Higman recorded his own thoughts on the last 12 months with a special thank you for staff.

Click the following link to watch https://youtu.be/cCdoEX08LkE

Boards approve Strategic Case for merger

As part of the programme of work for the potential merger with Somerset NHS Foundation Trust (SFT), a Strategic Case has been drafted.

This document, which outlines the rationale and benefits of a proposed merger and sets out the process through which we would achieve this, is now complete and was submitted to the boards of both Trusts for consideration in March 2021.

After separate, detailed discussions, both boards have approved the Strategic Case, agreeing that it sets out a compelling case for how care for our population can be improved by bringing our organisations together.

As a reminder, last year YDH signed a memorandum of understanding that committed us to develop this strategic case, considering what form the future relationship between the two Trusts would take. Our aim is to bring the expertise and experience of our organisations together to provide better mental and physical health services for our population, and support the move to a more integrated way of planning and delivering care.

As the next step in the process, the strategic case has now been submitted to our regulator (NHS England/Improvement) which will review the case over the coming weeks. Sign-off by the regulator means we are then able to start the work to develop the more detailed full business case, which would be considered later this year. However, whilst we wait for the regulator’s decision, work between our Trusts will continue, particularly to engage staff in the discussion about the potential future shape of services.

Relevant Committee Oversight: Pt2 Board of Directors, Executive Committee

NHS Staff Survey results – YDH maintains health and wellbeing top-spot for third consecutive year

The results of the latest national NHS staff survey were released in March 2021 and we are delighted to report that Yeovil Hospital has maintained the highest rating in the country for health and wellbeing, for the third consecutive year.

More than 600,000 NHS staff completed the survey, in October and November last year. As well as maintaining its health and wellbeing top-spot, our Trust was ranked top in the country for providing flexible working opportunities and in the top-three for staff engagement. It also ranked highly – significantly better than the national average – in important areas such as equality and diversity, equal opportunities and the support provided by managers. Overall, the Trust was in the top 20% of all trusts in the country for 61 of the 78 questions asked. Our Trust had the highest response rate in the country – again for the third year running – making the results even more significant.

During the past year, more has been demanded of staff than ever before. There is not a single person, regardless of their role, who has not had to adapt and rise to new challenges as part of the hospital’s response to the pandemic. As a trust we have tried hard to ensure that staff feel supported, cared for and listened to and, whilst we will not get this right all the time or for every individual, these results show we have been able to maintain this during an incredibly fast-paced and difficult 12 months.

We all know that providing good care for patients starts with providing good care for staff, so to know that those working within the YDH family have, for the most part, felt supported, engaged, and respected.

Our results also show how important good managers are to staff experience. With the pandemic putting a stop to face to face gatherings, we have relied more on managers to keep staff informed and engaged and to teams to adapt working practices and respond to the needs of individuals to keep people safe and comfortable at work.

One area of continued focus for the Trust, and one of just two areas in which we are below the national average, is in relation to staff experiencing abuse or violence from patients – though fewer of staff said they had experienced such incidents compared to the previous year.

Due to the nature of the care we provide and with many patients living with conditions such as dementia, it is unfortunately inevitable that some staff will experience abuse from those they care for at some point. It is also true that some staff will have been subject to aggression from those who have full capacity and this can never be excused.

Regardless of its nature, any experience of abuse can be distressing and we must continue to provide training and promote the importance of reporting any such incidents, whatever their nature, so we can respond appropriately to safeguard staff and our patients. We are encouraged that levels of reporting such instances are higher in our Trust than the national average.

Colleagues at Simply Serve complete their own survey and we are pleased to report they also saw a very high response rate, plus very positive responses and improvement in many key areas, including satisfaction with leadership, standards of care, and the care-focused priorities of the organisation. Some specific communications has already taken place with the SSL team with more to come in the coming days.

There is always more to be done and we will, as always, be using the results to make YDH an even better place to work or receive care.

You can see more detail about the NHS Staff Survey and our own results at https://www.nhsstaffsurveyresults.com/

Relevant Committee Oversight: Workforce Committee

YDH Vaccination Hub update

On Saturday 24 April 2021, we provided what we expect to be the last of our COVID-19 large-scale vaccination clinics from the YDH hospital hub for the coming months.

We took the opportunity to say a huge ‘thank you’ to all those staff who have worked as part of our vaccination clinic so far, this has included clinical staff, administrative staff, volunteers and other support staff. When our vaccination hub was set up in early December, it was one of the first 50 vaccination clinics in the world. Since then, the many thousands of vaccination we have provided have contributed to an historic international vaccination programme and helped prevent serious illness, hospitalisation and death.

The Somerset Vaccination programme, of which we are part, has produced commemorative badges for all those who have played a part, and these will be shared in the coming days.

We do not expect to be running a vaccination clinic within YDH in the immediate future other than some specific clinics for those with vaccine allergy and our pharmacy team will also continue to support the vaccination programme in Somerset.

Virtual Visiting

A new virtual visiting service for inpatients went live at YDH in April.

The service means every inpatient has the opportunity to enjoy a daily, booked video call with a family member or friend, supported by a volunteer. A dedicated, online booking system (available via the Trust website) has been created to enable family and friends to easily book a ‘visit’ up to 72 hours in advance.

From Monday 19 April, following careful consideration which includes monitoring of the rate of COVID-19 cases within south Somerset community, controlled, booked visiting on site also commenced.

As with virtual visiting, an online booking system has been created to enable visitors to book their own appointment and ensure teams can maintain strict control over footfall and occupancy within wards and the hospital.

The safety of physical visiting will be continually reviewed as part of the Trust’s ongoing infection prevention and control measures.

Keys received for new key worker accommodation complex

(Pictured, L-R. Paul von der Heyde, Chairman; Jonathan Higman, Chief Executive; Shelagh Meldrum, Chief Nurse and Director of People; Paul Foster, Deputy Chief Medical Officer; and Dr Merry Kane, Chief Medical Officer visiting the apartments last week)

At the end of March, after two-years of construction, we were handed the keys for our brand new accommodation complex, designed and purpose-built for our staff. The complex consists of 176 bedrooms across 66 light, modern and spacious apartments. It is located just off Reckleford on Goldcroft, just five minutes’ walk from the hospital

When our tenants are settled in and restrictions eased, we will be holding a small opening ceremony (currently scheduled for June) and look forward to sharing more photographs from this event.

This is a huge achievement for the Trust and we are proud to have this facility to offer existing and future staff.

Relevant Committee Oversight: Board of Directors, Executive Committee, Daily Coordination Huddle

Wellbeing Day for all YDH and SSL staff

This has been an extraordinary year in the history of YDH as we have dealt with the many and varied challenges of the pandemic. In recognition of the incredibly hard work and dedication by all of our staff, we have offered a ‘Wellbeing Day’ as a small token of the Trust’s thanks and appreciation.

This is a one-off additional day away from work, and it is a day for staff to be able to take time away from work to do something that supports their own physical and mental wellbeing. We have agreed this as a common offer for all colleagues working for Yeovil Hospital, Simply Serve, Somerset Foundation Trust, Somerset CCG and Somerset County Council.

COVID-19 Scrapbook - Part 2

It has now been a year since the start of the COVID-19 pandemic, and what an extraordinary time it has been. We have truly seen the best side of every member of staff whose hard work and compassion shines daily.

Every single member of the YDH family has gone above and beyond, providing exceptional support to our patients and colleagues, and in celebration of all your hard work and massive strives we took, we have released the COVID-19 digital scrapbook - Part 2.

You can access the YDH COVID-19 Scrapbook- Part 2 here.

If you missed the first COVID-19 Scrapbook click here.

Sharing some good news from Simply Serve Limited

Catering receive their 5* food hygiene rating SSL in the last month is that our catering team and the Breeze Café have received their 5* food hygiene rating after an unannounced inspection from the council. The unannounced inspection only highlighted four areas for improvement, two of which have already been put in place. This is a wonderful achievement for the catering team, well done to everyone in the team for all of their hard work.

Procurement team accredited with Level 2 NHS Commercial and Procurement standards The latest accolade to share is that the Procurement team have been accredited with their Level 2 NHS Commercial and Procurement standard. The Level 1 standard was achieved in 2017 and we are now one of a few Procurement teams in the South West that has managed to achieve Level 2 status. The NHS Commercial and Procurement standards are set out by the Department of Health to ensure best practice and it is a benchmark of procurement performance. To achieve this standard the team go through a rigorous process of checks in a number of categories. They had to provide lots of evidence including a virtual tour to the assessors remotely and they commented that the team were the best prepared and organised out of all the assessments that they had carried out. Interviews were carried out with Directors and senior managers as customers of the Procurement team. Congratulations to everyone in Procurement and Materials Management.

Appendix: 4 REPORT TO: Board of Directors REPORT BY: Yvonne Thorne, Deputy Director of Infection Prevention & Control PRESENTED BY: Shelagh Meldrum, Chief Nurse & Director of People EXEC SPONSOR: Shelagh Meldrum, Chief Nurse & Director of People REPORT TITLE: IPC Board Assurance Framework DATE: 5 May 2021

Purpose of Paper (Please select any which are relevant to this paper)

☒ For Assurance ☐ For Approval / Decision ☐ For Information

Reason for Presentation to Effective infection prevention and control is fundamental to our Committee/Board efforts. NHS England and Improvement have developed this board assurance framework to support all healthcare providers to effectively self-assess their compliance with Public Health England (PHE) and other COVID-19-related infection prevention and control guidance and to identify risks. The general principles can be applied across all settings; acute and specialist hospitals, community hospitals, mental health and learning disability, and locally adapted.

The framework can be used to assess measures taken, in line with the current guidance, and assure directors of infection prevention and control, medical directors and directors of nursing. It can be used to provide evidence and also as an improvement tool to optimise actions and interventions. The framework can be used to assure trust boards.

The Board are asked to note the updated V1.6 framework for assurance.

February 12th 2021. V1.6

Any Key Issues to Note

Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) ☒ Care for our Population ☐ Develop our People

☐ Innovate and Collaborate ☐ Develop a Sustainable System

Implications/Requirements (Please select any which are relevant to this paper) ☒ Financial ☒ Legislation ☒ Workforce ☒ Estates ☒ ICT ☒ Patient Safety / Quality

Reference to CQC domains (Please select any which are relevant to this paper)

☒ Safe ☒ Effective ☒ Caring ☒ Responsive ☒ Well Led

Is this paper clear for release under the Freedom of Information Act 2000? ☒ Yes ☐ No

INFECTION PREVENTION AND CONTROL BOARD ASSURANCE FRAMEWORK

Version Control:

15th October. Version 1.5 January 2021 Update to reflect new guidance: February 12th, 2021. V1.6

YDH Updates /Author: Deputy DIPC /IPC Team

Name of Responsible Committee/ YDH Board Assurance Individual:

Next Review Due: Next Board and following any significant IPC national guidance changes

Significant documentation since last update:

• COVID-19 Guidance for maintaining services within health care settings (21.1.2021) • PHE C1116 – version 1 Supporting excellence in infection prevention and control behaviours. IPC guidance ‘every action counts. Tools / materials to support IPC.

All changes to V5 template to V6 template in blue Area in Brown has been removed from V6 template New updates in italics

Publications approval reference: 001559

Infection prevention and control board assurance framework

15th October. Version 1.6

Foreword

NHS staff should be proud of the care being provided to patients and the way in which services have been rapidly adapted in response to the COVID-19 pandemic.

Effective infection prevention and control is fundamental to our efforts. We have developed this board assurance framework to support all healthcare providers to effectively self-assess their compliance with PHE and other COVID-19 related infection prevention and control guidance and to identify risks. The general principles can be applied across all settings; acute and specialist hospitals, community hospitals, mental health and learning disability, and locally adapted.

The framework can be used to assure directors of infection prevention and control, medical directors and directors of nursing by assessing the measures taken in line with current guidance. It can be used to provide evidence and as an improvement tool to optimise actions and interventions. The framework can also be used to assure trust boards.

Using this framework is not compulsory, however its use as a source of internal assurance will help support organisations to maintain quality standards.

Ruth May Chief Nursing Officer for England

2 | IPC board assurance framework 1. Introduction

As our understanding of COVID-19 has developed, PHE and related guidance on required infection prevention and control measures has been published, updated and refined to reflect the learning. This continuous process will ensure organisations can respond in an evidence- based way to maintain the safety of patients, services users and staff.

We have developed this framework to help providers assess themselves against the guidance as a source of internal assurance that quality standards are being maintained. It will also help them identify any areas of risk and show the corrective actions taken in response. The tool therefore can also provide assurance to trust boards that organisational compliance has been systematically reviewed.

The framework is intended to be useful for directors of infection prevention and control, medical directors and directors of nursing rather than imposing an additional burden. This is a decision that will be taken locally although organisations must ensure they have alternative appropriate internal assurance mechanisms in place.

2. Legislative framework

The legislative framework is in place to protect service users and staff from avoidable harm in a healthcare setting. We have structured the framework around the existing 10 criteria set out in the Code of Practice on the prevention and control of infection which links directly to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The Health and Safety at Work Act 1974 places wide-ranging duties on employers, who are required to protect the 'health, safety and welfare' at work of all their employees, as well as others on their premises, including temporary staff, casual workers, the self-employed, clients, visitors and the general public. The legislation also imposes a duty on staff to take reasonable care of health and safety at work for themselves and for others, and to co-operate with employers to ensure compliance with health and safety requirements.

Robust risk assessment processes are central to protecting the health, safety and welfare of patients, service users and staff under both pieces of legislation. Where it is not possible to eliminate risk, organisations must assess and mitigate risk and provide safe systems of work. In the context of COVID-19, there is an inherent level of risk for NHS staff who are treating

3 | IPC board assurance framework and caring for patients and service users and for the patients and service users themselves in a healthcare setting. All organisations must therefore ensure that risks are identified, managed and mitigated effectively.

4 | IPC board assurance framework

Infection Prevention and Control board assurance framework

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

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

Systems and process are in place to ensure:

• infection risk is assessed at the COVID-19 Triage pathway in place. CDU Outbreaks in care settings are not always Outbreak communication from ICC shared front door and this is dedicated as ‘hot’ zone RAZ for safe communicated by accompanying staff with CSM to communicate with ED and documented in patient notes assessment of all suspected cases, (12/11/20) patients follow a Hot pathways (12/11/20) irrespective of presentation. TrakCare Care setting information from CCG shared record of risk; ED passport evidence of with CSM / ED reception teams swab test; Evidence of testing on (November 2020) admission – digital dashboard in use.

• There are pathways in place COVID-19 Triage pathway in place. All Constant need for pathway maintenance Daily IPC / patient flow teams review which support minimal or avoid pathways support minimal movements. and review to ensure operational capacity IPC team represented at directors huddle patient bed/ward transfers for of the trust does not cause unnecessary Patients will be moved for clinical need where concerns ref IPC / pathways can be duration of admission unless moves or IPC breached and with IPC guidance. discussed and understood clinically imperative Cohort COVID-19 wards operational to Assess moves and incident report and ensure patient flows maintained for all investigate any concerns patients and under IPC guidance.

• That on occasions when it is Existing Decontamination Team trained in No gaps identified NA necessary to cohort COVID or specific requirements and use of UV non-COVID patients, reliable machine. National guidance followed. application of IPC measures Teams allocated, appropriately trained and are implemented and that any led. Additional personnel employed, vacant areas are cleaned as trained, deployed and led. per guidance Daily IPC meeting discusses any planned patient pathway changes / concerns, included in decision making, housekeeping representation on the call. Environmental audits in place. Housekeeping audits / training schedules in place 5 | IPC board assurance framework • patients with possible or Use of identified ‘hot’ zones to limit patient Outbreak policy following national PHE and CCG ICC invited to all outbreak confirmed COVID-19 are not movement and ensure appropriate guidance in place some conflict in meetings which run 7/7 until outbreak moved unless this is essential environmental controls are in place. information between PHE and CCG ICC closed to their care or reduces the risk Immediate isolation of patients with Clinical needs of patient can dictate Somerset wide agreement on patient of transmission suspected COVID and those exposed if patient moves movements and interpretation of 2 required with restrictions placed on bay or negative swabs guidance ward; deep cleaning of bed space or patient area; risk assessment of other IPC and patient flow team working closely patients; contact tracing if indicated – in together to minimise moves whilst accordance with national guidance maintain safe patient care. Point 4 (17.11.20) patients are not moved Both teams on daily outbreak meeting and until at least 2 negative test results are IPC 7day service obtained Patient moves tracked on CSM / trakcare Point 4(23.12.2020) moving patients and reviewed. increases their risk of transmission of infection

• compliance with the national National guidance adopted. Pre-discharge There is now local policy changes System group looking at this with urgent guidance around discharge or test undertaken 48hrs prior to discharge to meaning that residential and care homes action planned for w/c 16/11/20 transfer of COVID-19 positive another care setting or care provider. are asking for negative tests on +ve Comm hospital side rooms in Somerset patients Rapid Turnaround tests available for same patients prior to discharge leading to designated as COVID positive placements day results where needed. discharge delays as no Somerset Isolation from acute trusts Facility in place. Dorset facility identified and used where appropriate 10.2.2021 comm hospital reset in somerset, no covid positive cases to be transferred out and comm hospital positives could be transferred into YDH. Somerset facility being requested and discussed

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

• monitoring of IPC practices, IPC practices monitored through IPC Constant need for monitoring, spot audits, System group looking at IPC Team ensuring resources are in place team, matrons and other leaders within the 7 days expert support requirements have resilience for county with regional NHSI/E to enable compliance with IPC hospital. Communications reminders sent increased team support. Additional resource practice regularly along with video messaging. PPE allocated to IPC including Deputy Chief resources available in all areas along with Medical Officer and Matron to act as PPE o staff adherence to expert advice and senior leadership at and Social Distancing Guardians, WTE hand hygiene Director level available 7 days per week Deputy DIPC and Administration support. through Gold Command structure. o Staff social distancing Business case for increased IPC cover across the workplace Environment audits across all areas across trust being submitted

6 | IPC board assurance framework o Staff adherence to Office assessments and posters ref wearing fluid resistant occupancy levels reviewed and refreshed. surgical facemasks PPE champions identified and active (FRSM) in: . a) clinical . b) non-clinical settings Additional resource allocated to IPC • PPE compliance monitored through IPC Constant need for monitoring & spot audits Monitoring of compliance with including Deputy Chief Medical Officer and team, matrons and other leaders within the inside and outside of the hospital site wearing appropriate PPE, Matron to act as PPE and Social hospital. Communications reminders sent within clinical settings Distancing Guardians. Enhanced regularly along with video messaging. PPE • communication campaigns delivered. Consider implementing the role resources available in all areas of PPE guardians/safety Daily IPC walkabouts champions to embed best Environmental audits completed CG auditing Managers briefing daily practice. Point 3 (17.11.2020) staff wear right level HR / staffing office involved and informed of PPE when in clinical settings / face of covid areas and staff minimised as masks in non-clinical settings much as possible. Tracking of staff Point 3 (23, 12, 2020) wear correct level contacts completed and actions taken PPE- systems in place to monitor. Movement of staff between covid and non- Business case for increased IPC cover covid areas minimised across trust being submitted

• Implementation of twice weekly Implementation across YDH commenced No gaps identified NA lateral flow antigen testing for 22.11.2020 NHS patient facing staff, which Information systems in place (App) to include organisational systems record test results in place to monitor results and staff test and trace Results communicated via Director Huddles as required Staff track and trace via centralised HR helpline, on site PCR available to staff and booked via HR helpline (7 days)

• Additional targeted testing of all Lateral Flow testing available No gaps identified NA NHS staff, if your trust has a Additional PCR testing undertaken in high nosocomial rate, as nosocomial outbreak situations, IPC team recommended by your local involved in decision making. and regional infection prevention and control / Public 7day bookings available through HR health team. Helpline

7 | IPC board assurance framework • staff testing and self-isolation Staff testing and self-isolation strategies in Asymptomatic regular staff testing has not Lateral Flow regular asymptomatic staff strategies are in place and a place and robust 7 days per week on-site been in place other than in the event of an self-testing for patient-facing staff has process to respond if swabbing drive through and absence help- outbreak been introduced wc 23/11/20 in line with transmission rates of COVID- line available to all staff over 7 days national roll-out and continuing to date. 19 increase IPC team involved when outbreak and all Staffing reviewed and staff movements staff on ward and associated staff restricted as much as possible reviewed and tested as required.

• training in IPC standard Training has been part of the mandatory Due to social distancing requirement On-line video being produced to mitigate infection control and training package in the Trust and has been mandatory training updates in groups and the unavailability of face to face training transmission-based further enhanced through bespoke COVID face to face not appropriate IPC daily rounds, training opportunities on precautions are provided to all transmission mitigation training carried out one to one basis taken staff in departments IPC contactable and respond to requests On induction training available for updates and reviews on wards Daily manager comms / matron meetings / outbreak meetings all provide opportunities for training and support of ward and departmental teams Business case for increased IPC cover across trust being submitted

• IPC measures in relation to Infection control, health, and safety Due to social distancing requirement Mandatory / induction training on-going COVID-19 should be included training for both Induction and Mandatory mandatory training updates in groups and with social distancing in all staff Induction and Training has continuing (with social face to face not appropriate On-line video to mitigate the unavailability mandatory training distancing) and staff are encouraged to of face to face training use the e-learning and Clinicalskills.net to support COVID knowledge. All new IPC daily rounds, training opportunities on starters or returners are being given one to one basis taken training in line with the frameworks and IPC contactable and respond to requests includes PPE/Health and Safety. for updates and reviews on wards Additional training can be accessed by Manager for specific/individual need IPC Daily manager comms / matron meetings / team provide departmental training as outbreak meetings all provide required. opportunities for training and support of ward and departmental teams FFP3 testing – academy training in place Swab Taking – Academy training in place

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

8 | IPC board assurance framework • all staff are regularly reminded New comms implemented through Constant need for monitoring & spot audits Additional resource allocated to IPC of the importance of wearing summer and autumn, manager inside and outside of the hospital site including Deputy Chief Medical Officer and face masks, hand hygiene and accountability outlined and senior PPE Matron to act as PPE and Social Changing rooms reviewed / audited, maintaining physical distance guardians in place including a Matron and Distancing Guardians. Enhanced added to risk register as unable to mitigate both in and out of work the Deputy Chief Medical Officer joining communication campaigns delivered. all risk due to buildings the IPC team. Constant reminders in place Manager updates daily to share with staff and whole hospital signage developed and Poster review and refresh in December in place. 2020 Business case for increased IPC cover across trust being submitted

• all staff (clinical and non- All staff have received instruction on No gaps identified n/a clinical) are trained in putting putting on, removing and disposal of PPE on and removing PPE; know throughout the pandemic with clear what PPE they should wear for instruction and reminders issued each setting and context; and continuously. FIT testing for FFP3 masks have access to the PPE that in place and renewed each time new protects them for the masks types issued. Donning and Doffing appropriate setting and context training and assessment in place. as per national guidance

• There are visual reminders Posters / information available in all non- Pippa Media system agreed / financed and displayed communicating the clinical and clinical areas in place will give further reassurance with importance of wearing face audible message at ward and department Managers Comms daily to further reinforce masks, compliance with hand entrances trust IPC messages ref internal and hygiene and maintaining external behaviours. Automated Comms at all main entrances physical distance both in and out of the workplace Verbal messaging at main entrance

• national IPC guidance is Dissemination of guidance by COVID No gaps identified n/a regularly checked for updates control room 7 days per week; CAS alert and any changes are effectively cascade in place; regular checking by IPC communicated to staff in a Team in place. All relevant SOPs updated timely way as required. NHS.gov site regularly monitored by IPC team

9 | IPC board assurance framework • changes to guidance are Daily huddle in place; Board level update Some guidance is coming with limited Local interpretation agreed and brought to the attention of provided by CEO’ CMO and CNO. Board detail leaving it open to local interpretation implemented – questions raised with boards and any risks and comms sent weekly (enhanced now regional team as required. mitigating actions are prevalence has increased) and bi-weekly highlighted NED webex in place to provide regular updates DIPC / Deputy DIPC on daily Director huddles to hear and share new guidance

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

• risks are reflected in risk Decision log and decision minutes No gaps identified n/a registers and the board maintained by control room and Gold assurance framework where Commander. Risk register review and appropriate reporting undertaken. COVID Risk Register established. PPE risks reviewed at PPE Action Group. BAF and Risk register reflecting updates. Daily IPC Outbreak meeting notes available

• robust IPC risk assessment Existing risk assessments and testing for No gaps identified n/a processes and practices are in MRSA, MSSA, E.coli, and Cdiff remain in place for non COVID-19 place. Surveillance of MRGNOs infections and pathogens continues. Mandatory reporting maintained. PIR process continues as required. Reporting continues via the existing governance processes (Patient Safety Steering Group/Infection Prevention and Control Committee) Normal business discussed and maintained by IPC team

10 | IPC board assurance framework • That Trust Chief Executive, the This is in place with either the CEO, CNO No gaps identified n/a Medical Director or the Chief or CMO signing off on a daily basis, if not Nurse approves and personally available delegated Gold Commander signs off, all daily data (Director or Deputy Director Level) signs submissions via the daily off. nosocomial sitrep. This will IPC leads check daily nosocomial ensure the correct and reporting for accuracy accurate measurement and testing of patient protocols are activated in a timely manner.

• This Board Assurance Board Assurance updated for Trust Board No gaps identified n/a Framework is reviewed, and as guidance and versions change by DIPC evidence of assessments are / Deputy DIPC. made available and discussed Discussed Bi-monthly or as required at at Trust Board Trust board

• ensure Trust Board has Daily huddle in place; Board level update Oversight of action plans not yet tested Verbal communication in place updating oversight of ongoing outbreaks provided by CEO’ CMO and CNO through Board on findings and associated actions. Will and action plans. regularly. Board comms sent weekly establish a more formal process regarding (enhanced now prevalence has increased) updates on actions and bi-weekly NED webex in place to Action plans developed for new guidance provide regular updates. and discussed and actioned as required Shared in huddle where financial / risk to achieve is identified

• there are check and challenge Daily huddle in place; Board level update No gaps identified NA opportunities by the executive provided by CEO’ CMO and CNO /senior leadership teams in regularly. Board comms sent weekly both clinical and non-clinical (enhanced now prevalence has increased) areas and bi-weekly NED webex in place to provide regular updates. Deputy Medical Director part of IPC team and on daily IPC updates

11 | IPC board assurance framework 2. Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

Systems and process are in place to ensure:

• designated teams with Cohort staffing in place when patients As prevalence increases there is a greater Escalation structure in place, COHORT appropriate training are require with full support and guidance of need to cohort patients and staff and for ward in place, awaiting further guidance assigned to care for and treat IPC. Spot training and assessment step-down arrangements which need on step down. Screen now being patients in COVID-19 isolation implemented further clarity. implemented in between beds that are or cohort areas <2m apart – following agreement of national fire officer and risk mitigation. Staff cohorting for smaller teams where possible and guided through HR staffing teams / clinical safety reviewed. Stepdown guidance in place including action card and covid passport. Shared learning and guidance with SFT

• designated cleaning teams with Existing Decontamination Team trained in No gaps identified n/a appropriate training in required specific requirements and use of UV techniques and use of PPE, are machine. All housekeeping and domestic assigned to COVID-19 isolation staff have access to PPE. 24 hour or cohort areas decontamination and PPE supply team in place

• decontamination and terminal Existing Decontamination Team trained in No gaps identified n/a decontamination of isolation specific requirements and use of UV rooms or cohort areas is machine. National guidance followed. carried out in line with PHE and Teams allocated, appropriately trained and other national guidance led. Additional personnel employed, trained, deployed and led.

12 | IPC board assurance framework

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

• increased frequency at least Additional training provided to all team Need to consistently apply enhanced level Cleaning products supplied, guidance twice daily of cleaning in leaders. National guidance followed. UVC of frequent touch points in non-clinical issued regarding phones, keyboards, areas that have higher and manual decontamination techniques areas – all staff responsible desks etc. Hand hygiene requirements environmental contamination employed. One additional UVC machine also Constantly communicated. rates as set out in the PHE and purchased to improve turnaround times. Housekeeping teams / military assisting in other national guidance Nationally approved cleaning products, twice a day cleaning and specific touch materials and techniques used. National point cleaning guidance followed. Risks re-assessed. Enhanced levels of cleaning in all clinical Wipes / gloves and instruction in toilets areas twice a day. Cleaning schedules and high use staff areas and frequencies updated to reflect revised Offices – staff aware of need to clean own risk ratings. Additional personnel work stations / touch points employed, trained, deployed and led. Housekeeping leads on IPC outbreak Comms regularly on social areas actions meetings / standing agenda required.

• cleaning is carried out with Nationally approved cleaning products, No gaps identified n/a neutral detergent, a chlorine- materials and techniques used. Talley based disinfectant, in the form TecCare and TecCare Ultra agreed with of a solution at a minimum IPC Team as suitable and effective strength of 1,000ppm available alternative. Product already in use for chlorine as per national existing decontamination and covered in guidance. If an alternative Trust Outbreak Management and disinfectant is used, the local Decontamination Policies. UV light infection prevention and control source also available and utilised in high team (IPCT) should be density areas such as Ed, EAU, HRU and consulted on this to ensure that ICU. this is effective against Evidence available from IPC team on enveloped viruses consultation, system in place for last 5 years +

• manufacturers’ guidance and Compliant with all cleaning and No gaps identified n/a recommended product ‘contact disinfectant solutions. Decontamination time’ must be followed for all regimes agreed by Authorised Engineer cleaning/disinfectant (Decontamination) solutions/products as per national guidance 13 | IPC board assurance framework

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

• ‘frequently touched’ surfaces Enhanced cleaning implemented in high- Touch point cleaning not recorded in all Spot checks of touch point cleaning in e.g. door/toilet handles, patient risk clinical areas and outbreak areas. areas place with immediate actions call bells, over bed tables and Compliant with national guidance Twice implemented, additional comms sent out bed rails should be daily cleaning with additional touch point and manage accountability reiterated. De-

decontaminated more than cleaning in all clinical areas. cluttering encouraged and assisted. twice daily and when known to Monitored and actions through IPC be contaminated with outbreak meetings. secretions, excretions or body Decluttering undertaken – January 2020 fluids action across trust Touch point – continual rounding by housekeeping teams in place Lift team to follow patient developed

• electronic equipment e.g. Increased comms implemented to ensure Need to audit compliance Cleaning equipment in place in all areas, mobile phones, desk phones, all staff hold accountability for their COVID Secure areas spot checked and tablets, desktops & keyboards immediate environment including personal action taken as required. Further manager should be cleaned a minimum equipment led audit to be implemented of twice daily

• rooms/areas where PPE is PPE removed in the following area: Inside Need to audit compliance Spot audits undertaken, need to move to removed must be isolation rooms – cleaning undertaken in manager audits decontaminated, ideally timed accordance with guidance. Outside to coincide with periods isolation rooms: (FRSM.FFP3 masks only) immediately after PPE removal –twice daily cleaning in COVID areas by groups of staff (at least twice CDU/Resus – decontamination of daily) bed/trolley spaces between patients, twice daily cleaning of communal areas; Use of UV machine.

• linen from possible and National guidance followed. Contaminated No gaps identified n/a confirmed COVID-19 patients is linen separated, bagged and laundered in managed in line with PHE and separate streams. Additional stocks of other national guidance and the linen and laundry items purchased. appropriate precautions are Washable gowns being managed through taken dedicated handling process if required.

14 | IPC board assurance framework • single use items are used National guidance followed. Compliant No gaps identified n/a where possible and according where single use items in use. to single use policy

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

• reusable equipment is National guidance followed. UVC or No gaps identified n/a appropriately decontaminated manual decontamination techniques in line with local and PHE and employed. Clinell wipes; Talley TecCare other national guidance and TecCare Ultra all suitable cleaning and decontamination products to effectively destroy and remove viral contamination.

• ensure cleaning standards and Increased comms implemented to ensure Need to audit compliance Cleaning equipment in place in all areas, frequencies are monitored in all staff hold accountability for their COVID Secure areas spot checked and non- clinical areas with actions immediate environment including personal action taken as required. Further manager in place to resolve issues in equipment led audit implemented maintaining a clean environment

• ensure the dilution of air with Window open in areas where this is Issues with safely opening some windows Review taken place and mitigating action good ventilation e.g. open possible in the tower block and concerns over low implemented windows, in admission and temperatures Safe use of external air air- conditioning waiting areas to assist the units in ECRU – 2 bays prepared for non- dilution of air invasive ventilation patients. Vents purchased and installed in bay windows. Offices – windows opened and staff aware of need for ventilation Replacement window programme agreed

15 | IPC board assurance framework • monitor adherence Nationally approved cleaning products, No gaps identified NA environmental decontamination materials and techniques used. Talley with actions in place to mitigate TecCare and TecCare Ultra agreed with any identified risk IPC Team as suitable and effective alternative. Product already in use for existing decontamination and covered in Trust Outbreak Management and Decontamination Policies. UV light source also available and utilised in high density areas such as ED, EAU, HRU and ICU. Evidence available from IPC team on consultation, system in place for last 5 years + Housekeeping environment audits in place, Housekeeping team represented on IPC daily meetings

• monitor adherence to the Environmental Audits in place Audit of clinical equipment in wards and New audit in place and being undertaken decontamination of shared departments – requires refresh Equipment Library protocols dictate ‘single Book system reviewed and adherence not equipment with actions in place patient use’ and decontaminate and return universal and books removed and audit to mitigate any identified risk to equipment library now in place Housekeeping standards and audit in Equipment Library incident reporting place reviewed by IPC team Housekeeping team training in place TV equipment stock increased to encourage early return to equipment library between patients

• there is evidence organisations National Guidance followed for low risk Process required in stepping down when Non-symptomatic patients identified in low have reviewed the low risk pathways. Talley Tec Care used. Step up outbreak closed. risk pathways, IPC involved in cleaning COVID-19 pathway, before to TekCare ultra in outbreak areas agreed products and regime changes through choosing and decision made to through IPC outbreak meetings Product outbreak group. revert to general purpose already in use for existing decontamination To date on changes to products used, detergents for cleaning, as and covered in Trust Outbreak frequency of cleaning enhanced and opposed to widespread use of Management and Decontamination reviewed through Director Huddle and disinfectants Policies. UV light source also available. daily Outbreak meetings

16 | IPC board assurance framework 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 advice available 24/7 from No on-site Consultant antimicrobial ward Telephone advice provided by Consultant antimicrobial stewardship is on-call microbiology service via telephone rounds in place. Microbiologists. Countywide formulary in maintained service. Audits of antimicrobial use place. Antimicrobial audits in place. maintained. Monitoring of Cdiff and MRGNOs continues. Normal IPC business and cross county / CCG monitoring and meetings in place and continuing On site visits by microbiologists to recommence May 2021

• mandatory reporting Antimicrobial usage reported to Medicines No gaps identified n/a requirements are adhered to Management Committee, Infection and boards continue to Prevention and Control Committee and via maintain oversight CQUIN reporting system. Cross county and CCG monitoring in place and maintained

17 | IPC board assurance framework 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 process are in place to ensure:

• implementation of national National visiting guidance initiated – March No gaps identified n/a guidance on visiting patients in 2020. End of Life visiting SOP approved a care setting and updated in response to compassionate visiting guidance and joint statement from IPS and BACCN. Changed in summer 2020 in line with national guidance and staggered controlled number visiting implemented due to environmental constraints.. Restricted visiting implemented in Nov 2020 – EOL and specialist need carers continue to visit. Birth partners plan continues. Maternity guidance refreshed following national guidance review on testing of partners. IPC linking with maternity teams as required

• areas in which suspected or Restricted Access Guidance signs on No gaps identified n/a confirmed COVID-19 patients main doors of COVID inpatient areas, and are being treated in areas outbreak areas. Clear restricted access clearly marked with appropriate signage in place in ED. Restricted Access signage and have restricted signs to be re-instated in the event of access critical care surge and ICU being cohorted.

• information and guidance on Range of information about symptoms, No gaps identified n/a COVID-19 is available on all testing, risks, visiting, hospital services trust websites with easy read published in Trust website including links versions to www.gov.uk COVID clinical links on Y-Cloud refreshed Public website document links reviewed and refreshed

18 | IPC board assurance framework • infection status is TrakCare alert in use for positive cases, No gaps identified n/a communicated to the receiving COVID status communicated as part of organisation or department handover. Covid status sticker developed when a possible or confirmed as part of EAU QI project COVID-19 patient needs to be COVID patient passport developed and in moved use for all discharged patients COVID positive Patient discharges to on-going care facility – COVID status communicated and action documented before patient leaves YDH

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

• There is clearly displayed and Signage displayed throughout all areas in No gaps identified n/a written information available to the hospital and reminders given in written prompt patients’ visitors and format and verbally. Internal comms sent staff to comply with hands, face on a very regular basis with reminders and space advice. Signage at all YDH entrances and exits, volunteers / military staff at main entrances to support and remind staff, patients and visitors of requirements

19 | IPC board assurance framework 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 process are in place to ensure:

• screening and triaging of all Screening and triage in place including No gaps identified N/A patients as per IPC and NICE pre-admission screening and triaging for Guidance within all health and planned care patients, screening on other care facilities must be admission and screening at day 5, undertaken to enable early Symptomatic in-patients are also screened recognition of COVID-19 cases. along with those pre-discharge to another care setting. Screening SOP revised and 1, 3, 6 and weekly screening of in patients implemented. Outbreak wards IPC guidance used to increase staff and patient screening as required

• front door areas have “Ratting” and Triage system in place. No gaps identified NA appropriate triaging COVID-19 Triage pathway in place. CDU arrangements in place to cohort dedicated as ‘hot’ zone for safe patients with possible or assessment of all suspected cases, confirmed COVID-19 irrespective of presentation. TrakCare symptoms and to segregate record of risk; ED passport evidence of from Non Covid- 19 cases to swab test. Patient FIRST actions minimise the risk of cross- implemented/being implemented infection as per national Actioned - Outbreaks in external care guidance settings communicated by CCG/PHE and external accompanying staff (12/11/20) from ICC shared with CSM to communicate with ED and patients follow a Hot pathways (12/11/20)

• staff are aware of agreed Staff are aware of symptom checker and No gaps identified n/a template for triage questions to advice. ask

20 | IPC board assurance framework • triage undertaken by clinical “Ratting” and Triage system in place with No gaps identified NA staff who are trained and competent staff. COVID-19 Triage competent in the clinical case pathway in place. CDU dedicated as ‘hot’ definition and patient is zone for safe assessment of all suspected allocated appropriate pathway cases, along with red and amber surgical as soon as possible and medical admission pathways.

Required agile management of bed base as patient numbers increase and decrease Operational team approach implemented to ensure agile bed configuration and resource requirements to meet changing COVID needs

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

• face coverings are used by all All patients issued masks on arrival to ED. No gaps identified n/a outpatients and visitors From 15th June, all patients and visitors required to wear a mask and provided with one if required when entering the hospital. Visitors asked to change to fluid resistant hospital mask on arrival to maintain quality of face covering across the organisation and to protect themselves and others Visitors all wearing masks on entry to the trust, security and volunteers at main entrance to always advise wearing of mask

• face masks are available for Masks made available to all inpatients who No gaps identified n/a patients and they are always wish to wear a mask and all patients advised to use them asked to wear a mask when leaving bed space (if tolerated)

21 | IPC board assurance framework • provide clear advice to patients Masks made available to all inpatients who No gaps identified n/a on use of face masks to wish to wear a mask and all patients encourage use of surgical asked to wear a mask when leaving bed facemasks by all inpatients in space (if tolerated) the medium and high-risk Written guidance in place in inpatient pathways if this can be areas tolerated and does not compromise their clinical care Guidance produced, and verbal messaging continues

• monitoring of inpatient SBAR to Directors huddle to agree and Reviewed early February, not assured that Patient mask wearing added to compliance with wearing face communicate need for patients to wear all wards supporting the patients to wear environment snap audit masks particularly when face coverings following updated national face covering in bed and away from their Message reinforced through Deputy moving around the ward (if PHE guidance bed space. Director of Nursing / Matrons and Sisters clinically ok to do so) Further trust wide comms to update staff on the need to encourage patients to wear masks when away from their bed space

• Ideally segregation should be Screens are in place in most reception Staff social areas subject to movement of Continual review / walks of communal with separate spaces, but there areas in the hospital and have recently furniture etc by staff areas and actions taken as required. is potential to use screens, e.g. been implemented in ward bays and in the Managers responsible of the COVID to protect reception staff. canteen. secure status of their areas of Social distancing measure in place responsibility through signage, tape indicating where to stand, furniture placement and removal

• for patients with new-onset Rapid isolation and testing in place. Immediate side room isolation of individual Mitigation in place and continue to isolate symptoms, isolation, testing Contact tracing in place Details shared is not always possible due to bed patient as first priority and instigation of contact with Public Health Teams via lab. availability and requirement to limit tracing is achieved until proven Outbreak detail also provided by Trust. movement. negative Screens implemented on wards, masks used and disposable curtains to provide additional barrier. Bay doors fitted and temporary barriers being implemented if required. Daily outbreak meetings / CCG and PHE attend / invited

22 | IPC board assurance framework • patients that test negative but Rapid isolation and testing in place. Immediate sideroom isolation of individual Mitigation in place and continue to isolate display or go on to develop Contact tracing in place Details shared is not always possible due to bed patient as first priority symptoms of COVID-19 are with Public Health Teams via lab. availability and requirement to limit segregated and promptly re- Outbreak detail also provided by Trust. movement. tested and contacts traced Screens implemented on wards, masks promptly used and disposable curtains to provide additional barrier. Bay doors fitted and temporary barriers being implemented if required. Daily outbreak meetings / CCG and PHE attend / invited – contact tracing discussed

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

• there is evidence of compliance IT system audits available – system shows No gaps identified n/a with routine patient testing staff when patient testing missed or protocols in line with delayed Key Actions: infection Systems in place with patient flow / CSM prevention and control and and ward staff to check system daily for testing document testing requirements Early review of nosocomial cases – first 30 no testing issues raised as contributing to nosocomial case.

• patients that attend for routine Patients are managed depending on No gaps identified n/a appointments who display clinical urgency, if appointment is clinically symptoms of COVID-19 are urgent patient will follow a hot pathway managed appropriately through ED, if patient is not urgent will be advised to immediately return home and isolate along with household and given advice on Tier 2 testing. Areas exposed by patient will be cleaned. IPC informed and any further actions / tracing required will be completed

23 | IPC board assurance framework 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

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

Systems and process are in place to ensure:

• Separation of patient pathways Clear signage in place indicating restricted No gaps identified n/a and staff flow to minimise areas, flow through ED avoids movement contact between pathways. For through hot areas. Additional entrances example, this could include closed to avoid crowding in waiting areas provision of separate and directional signage throughout entrances/exits (if available) or hospital. use of one-way entrance/exit Different Main Entrance and Exit on level 3 systems, clear signage, and achieved to prevent queuing of staff, restricted access to communal patients when apply hand gel / masks areas Signage reviewed and regular observational audits completed

• all staff (clinical and non- Infection control, health, and safety Mandatory training required to switch from IPC team developed video / on-line clinical) have appropriate training for both Induction and Mandatory face to face group training to on-line training with academy team training, in line with latest PHE is continuing (with social distancing) and and other national guidance to staff are encouraged to use the e-learning ensure their personal safety and Clinicalskills.net to support COVID and working environment is knowledge. All new starters or returners safe are being given training in line with the frameworks and includes PPE/Health and Safety. Additional training can be accessed by Manager for specific/individual need IPC running regular mandatory and induction programs- video is kept with academy in case IPC team unavailable The rest of the IPC related training / FFP3 testing, swab taking is being conducted by academy weekdays as required.

24 | IPC board assurance framework • all staff providing patient care Guidance has been placed on our intranet Some changes if FFP3 masks suppliers Early alerts in place through PPE group and working within the clinical pages for staff to view and PHE guidance lead to need to re-train/test and trainers available, environment are trained in the posters have been put up in all patient Academy trainers linking with PPE group selection and use of PPE areas for visual reminder. Donning and to react in timely manner for retraining of appropriate for the clinical Doffing is delivered in line with the PHE staff when mask availability changes. situation and on how to safely guidance for the various levels required Don and Doff it and again posters placed in clinical areas.

• a record of staff training is All training recorded on our ESR system Informal and one to one training is not Formal high risk training such as FFP3 maintained always recorded mask Fit Testing is recorded

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

• appropriate arrangements are Incident reporting process in place and No gaps identified n/a in place that any reuse of PPE standard monitoring systems in use to flag REMOVED FROM 1.6 VERSION in line with the MHRA CAS issues. FTSU also in use Alert is properly monitored and managed

• any incidents relating to the re- Incident reporting process in place and No gaps identified n/a use of PPE are monitored and standard monitoring systems in use to flag REMOVED FROM 1.6 VERSION appropriate action taken issues. FTSU also in use

• adherence to PHE national PPE Safety Champions identified and Audits have been adhoc and need to Spot audits undertaken and action taken guidance on the use of PPE is training given. Online audit tool developed move to a more formal programme of audit as required regularly audited with actions in and results available to IPC Team. place to mitigate any identified risk

• hygiene facilities (IPC measures) and messaging are available for all patients/individuals, staff and visitors to minimise COVID-19 transmission such as:

> hand hygiene facilities including Hand hygiene facilities in place across the Patient and staff toilets reviewed and Available within toilet area and signage instructional posters Trust. wipes/gloves / waste disposal and clear instruction in place in all areas not always instructional posters implemented w/c possible to have this within each individual 23/11/20 toilet

25 | IPC board assurance framework Patient and staff toilets reviewed and wipes/gloves / waste disposal and instruction in place in all areas

> good respiratory hygiene Masks available across the trust No gaps identified n/a measures

> staff maintain physical Constant comms sent out, staff challenge No gaps identified n/a distancing of 2 metres wherever encouraged, spot audits undertaken by possible unless wearing PPE as IPC team, senior staff / PPE champions part of direct care and managers and posters and signage in place Managers daily comms > No gaps identified n/a staff maintain social distancing Chief Nurse comms (2m+) when travelling to work HR helpline guidance shared with staff (including avoiding car sharing) Signage refresh and remind staff to follow public health guidance outside of the workplace

> frequent decontamination of Frequent decontamination in place and Decontamination of non-clinical equipment Environmental audits in place and being equipment and environment in enhanced in high risk areas. Frequent is not always documented. reviewed both clinical and non-clinical comms in place Use of clean tape being reviewed on areas clinical equipment / audits being reviewed for clinical equipment

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

• clear visually displayed advice Clear advice in place, masks worn in all No gaps identified n/a on use of face coverings and areas other than those certified as COVID facemasks by Secure and when people are eating or patients/individuals, visitors and drinking. by staff in non-patient facing Canteen reviewed and social distancing areas measures in place, staff instructed to use new mask on exit of canteen

• staff regularly undertake hand Hand hygiene audits undertaken regularly No gaps identified n/a hygiene and observe standard and enhanced in all clinical and high risk infection control precautions

26 | IPC board assurance framework areas, Standard precautions well embedded. compliance to hand hygiene is based on WHO’s 5 moments of hand hygiene wherein the patient is the focal point • the use of hand air dryers No hand dryers in clinical areas No gaps identified n/a should be avoided in all clinical Review of hand dryer use in public toilet areas. Hands should be dried areas and provision of hand towels as an with soft, absorbent, disposable alternative in place paper towels from a dispenser which is located close to the sink but beyond the risk of splash contamination as per national guidance

• staff understand the Guidance issued; changing facilities No gaps identified n/a requirements for uniform provided; scrub bags available laundering where this is not provided for on site

• all staff understand the Regular communication of signs and Requires constant reminder and Repeated and new comms in place, have symptoms of COVID-19 and symptoms; HR Helpdesk; timely overview monitoring been working with PHE on comms used in take appropriate action (even if of absence and results on daily basis at other industry. Staff well checks experiencing mild symptoms) in Exec huddles. Surveillance undertaken implemented in clinical areas at the start of line with PHE national guidance and all positive cases provided with self- a shift asking about own health and and other if they or a member isolation leaflet. household. of their household display any of the symptoms

• a rapid and continued response Health Protection Board in place to enable No gaps identified n/a through ongoing surveillance of ongoing surveillance along with ICC and rates of infection transmission Gold Command structure across the within the local population and system for hospital/organisation onset CCG/PHE invited to daily outbreak cases (staff and meetings and contribute to system wide patients/individuals) knowledge

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

27 | IPC board assurance framework • Positive cases identified after Governance processes in place and tested No gaps identified n/a admission who fit the criteria for to enable, case reviews, outbreak investigation should trigger a management, serious untoward incident case investigation. Two or reporting, StEIS reporting and Duty of more positive cases linked in Candour following national guidance time and place trigger an published Oct 2020 outbreak investigation and are reported.

• robust policies and procedures Policies and procedures in place and No gaps identified n/a are in place for the tested. Moving to electronic outbreak identification of and reporting November 2020 replacing paper management of outbreaks of IIMARCH form reporting infection

28 | IPC board assurance framework 7. Provide or secure adequate isolation facilities

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

Systems and process are in place to ensure:

• restricted access between Red, amber and green pathways in place Size and layout of hospital does not allow Continue to review pathways and IPC pathways if possible, with restricted access between red and full restriction however mitigating actions guidance included to ensure mitigation (depending on size of the green pathways in place either physically are implemented promptly implemented facility, prevalence/incidence or through SOP. rate low/high) by other Staff and resource pathways in place. patients/individuals, visitors or Visitor control in place. Signage staff designates areas along with other visual prompts. Enhanced screening regime to implemented nationally for staff and patients w/c 23rd Nov Patients 1,3,6 and weekly Staff lateral flow testing twice weekly Close working of IPC team and patient flow teams mitigate risk of cross over and prompt management of patient pathways meeting IPC guidance

• areas/wards are clearly Signage in place, comms reminders sent Size of hospital and changing prevalence Comms and temporary signage used. signposted, using physical and any changes communicated as soon makes it difficult to identify set areas for barriers as appropriate to as possible with temporary signage used restriction. patients/individuals and staff as appropriate. understand the different risk areas

• patients with suspected or Designated areas achieving effective Permanent solutions will give greater Any increase from 4 to 6 beds in bays is confirmed COVID-19 are distancing and design in place for red and assurance and are in progress following undertaken following a risk assessment isolated in appropriate facilities green pathways. Temporary solutions in funding allocation. 6 bedded bays do not with patient type and individual risks or designated areas where place to enable hot and cold pathways in allow consistent 2m distancing. assessed. Screens will mitigate some risk appropriate ED and ICU. Screens between beds in 6 but additional beds will still be designated bedded ward bays are fitted following risk assessed beds (not counted in main prolonged national fire sign-off. bed stock) and require individual risk assessment.

29 | IPC board assurance framework • areas used to cohort patients Areas have been assessed and are seen Ventilation is an issue in some areas of Ventilation review being undertaken with suspected or confirmed to be compliant with any risks mitigated the hospital as windows cannot be imminently with mitigating risk COVID- 19 are compliant with through screen use, distancing or consistently safely opened recommendations being brought to daily the environmental requirements alternative patient pathways huddle. set out in the current PHE Windows fitted with vents in ward bays – More window vents ordered to complete national guidance action across all bays and side rooms Non-invasive ventilation bays x 2 fitted with ventilation systems Staff awareness of need for ventilation enhanced through comms, IPC daily rounds / CSM interactions

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

• patients with resistant/alert Compliant with pathways No gaps identified n/a organisms are managed according to local IPC guidance, including ensuring appropriate patient placement

30 | IPC board assurance framework 8. Secure adequate access to laboratory support as appropriate

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

Systems and process are in place to ensure:

• ensure screens taken on Yes and daily average reporting times are point of care testing availability testing at Rapid testing utilised, Point of Care testing admission given priority and monitored YDH limited due to go live w/c 23rd Nov reported within 24hrs Nudge machine circulation on hold Trial of POC testing in ED commenced January 2021.

• regular monitoring and Yes as above No gaps identified n/a reporting of the testing turnaround times with focus on the time taken from the patient to time result is available

• testing is undertaken by Swabbing technique training in place and No gaps identified n/a competent and trained audit of swabbing technique implemented. individuals Distribution of Nudge machines On hold • Yes though point of care testing is not yet Limited availability of point of care testing patient and staff COVID-19 indefinitely. Problem with machines. available on site available at YDH. testing is undertaken promptly Advised we are unlikely to receive them. and in line with PHE and other Rapid testing utilised, Point of Care testing national guidance trial in ED as trial COVID Point of Care testing update Lateral Flow staff self-testing in place and LumiraDX POCT in use in ED. Lateral in line with national roll-out w/c 23rd Nov Flow test and so PCR always needed to to enable twice weekly testing of patient confirm. facing staff. Strict SOP in place to ensure that patients not placed in incorrect beds on results of this test. Some issues with this test still to be resolved.

A second VitaPCR (Menorini) machine has been installed at YDH ESL.

The daily Fast Track testing capacity at the ESL is now 40 - 50 per day, 08:30 – 17:00. 31 | IPC board assurance framework After 17:00 Fast Track specimens will continue to be sent to the Hub laboratory, Lisieux Way.

This figure assumes a regular flow of Fast Track requests being received by the ESL. • regular monitoring and Yes, regular review undertaken, issues No gaps identified n/a reporting that identified cases noted and rectifying action taken have been tested and reported in house w/c 16/11/20 to enable greater in line with the testing protocols efficiency, more enhanced reporting and (correctly recorded data) immediate wellbeing management

• screening for other potential Yes No gaps identified n/a infections takes place Normal IPC business maintained

• that all emergency patients are All admission that start their journey No gaps identified n/a tested for COVID-19 on through ED are tested for COVID-19 admission

• that those inpatients who go on All inpatients who go on to develop No gaps identified n/a to develop symptoms of symptoms of COVIC-19 after admission COVID-19 after admission are are retested and appropriate IPC guidance retested at the point symptoms and retesting guidance followed. arise

• that those emergency Yes all emergency admissions following No gaps identified n/a admissions who test negative inpatient-testing regime following on admission are retested on admission. day 3 of admission, and IT system / process in place for ward staff between 5-7 days post to track and follow testing regime for all in admission patients

• that sites with high nosocomial IPC guidance followed and yes this No gaps identified n/a rates should consider testing process would be followed if required COVID negative patient daily

• that those being discharged to No patient is discharged to a care home No gaps identified n/a a care home are being tested without a within 48hr swab and this is for COVID-19 48 hours prior to communicated to care facility in advance. discharge (unless they have 32 | IPC board assurance framework tested positive within the Discharging patients have COVID previous 90 days) and result is passport for follow through information to communicated to receiving be communicated to receiving care facility organisation prior to discharge and for patients returning to their home.

• that those being discharged to Dedicated care facility in Dorset. No gaps identified n/a a care facility within their 14 Designated side rooms in community day isolation period should be hospitals in Somerset and processes in discharged to a designated place for discharge care setting where they should complete their remaining Recent changes to Somerset processes isolation and no current discharges of Positive patients to Somerset care facilities

• that all Elective patients are Elective pathway in place and No gaps identified n/a tested 3 days prior to documentation clearly stated this admission and are asked to requirement self-isolate from the day of their test until the day of admission.

33 | IPC board assurance framework 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 process are in place to ensure:

• staff are supported in adhering Yes regular communication, spot checks, No gaps identified n/a to all IPC policies, including advice lines and access to expert help those for other alert organisms available. IPC team available over 7 days

• any changes to the PHE Yes with effective communication in place. Changes to FFP3 masks require frequent Academy have tried to limit changes to national guidance on PPE are PPE action group also in place to review re-training masks and have full training ability in quickly identified and effectively supply and training needs reporting to house which can be stood-up rapidly. communicated to staff daily huddle on a weekly basis Little control regarding distribution from central supply

• all clinical waste and Yes No gaps identified n/a linen/laundry related to Waste management nation guidance confirmed or suspected adhered to and IPC regular COVID-19 cases is handled, communications with waste management stored and managed in team accordance with current national guidance

• PPE stock is appropriately Yes No gaps identified n/a stored and accessible to staff who require it

34 | IPC board assurance framework 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

Systems and process are in place to ensure:

• staff in ‘at-risk’ groups are Full risk assessment programme in place Needs updating regularly as more risk In-house systems easy to change, comms identified using an appropriate which includes an all staff risk assessment areas and vulnerabilities added also alert staff to any changes so that risk risk assessment tool and current completion rate 96%. An enhanced assessments can be re-run as required. managed appropriately manager risk assessment for staff seen to including ensuring their be vulnerable and a home worker risk physical and wellbeing is assessment. supported

• that risk assessment(s) is (are) Full risk assessment programme in place Needs updating regularly as more risk In-house system so easy to change, undertaken and documented which includes an all staff risk assessment areas and vulnerabilities added comms also alert staff to any changes so for any staff members in an at current completion rate 96% (BAME staff that risk assessments can be re-run as risk or shielding groups, 95%). An enhanced manager risk required. including Black, Asian and assessment for staff seen to be vulnerable Minority Ethnic (BAME) and and a home worker risk assessment. pregnant staff

• staff required to wear FFP Full FIT testing programme in place with a Frequent Changes to availability of FFP3 Have tried to limit changes to masks and reusable respirators undergo record of training maintained masks require re-training have full training ability in house which can training that is compliant with be stood-up rapidly 21.1.2021 IPC guidance update on valved PHE national guidance and a respirators reviewed and circulated to record of this training is appropriate managers for action. maintained and held centrally Academy trainers aware

• staff who carry out fit test Yes training carried out by competent No gaps identified n/a training are trained and academy staff competent to do so

• all staff required to wear an Yes training carried out by competent No gaps identified n/a FFP respirator have been fit academy staff and repeated if models tested for the model being used change and this should be repeated each time a different model is used

35 | IPC board assurance framework Key lines of enquiry Evidence Gaps in assurance Mitigating actions

• a record of the fit test and result Records are held and staff are given a New mask types require re-testing Academy staff and process in place for re- is given to and kept by the paper record to take away, managers are testing. Limiting numbers of new masks trainee and centrally within the also informed of outcome of fit tests. supplied organisation

• for those who fail a fit test, Yes repeated tests are undertaken and No gaps identified n/a there is a record given to and hoods supplied/staff member redeployed held by trainee and centrally to a lower risk area if required within the organisation of 21.1.2021 IPC guidance update on valved repeated testing on alternative respirators reviewed and circulated to respirators and hoods appropriate managers for action. Academy trainers aware

• for members of staff who fail to Yes repeated tests are undertaken and No gaps identified n/a be adequately fit tested a hoods supplied/staff member redeployed discussion should be had, to a lower risk area if required regarding re deployment 21.1.2021 IPC guidance update on valved opportunities and options respirators reviewed and circulated to commensurate with the staff appropriate managers for action. members skills and experience and in line with nationally Academy trainers aware agreed algorithm

• a documented record of this Record kept as part of formal risk No gaps identified n/a discussion should be available assessment process and held by HR, for the staff member and held manager and staff member centrally within the organisation, as part of employment record including Occupational health

36 | IPC board assurance framework

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

• following consideration of Yes repeated tests are undertaken and No gaps identified n/a reasonable adjustments e.g. hoods supplied/staff member redeployed respiratory hoods, personal re- to a lower risk area if required. Record usable FFP3, staff who are kept as part of formal risk assessment unable to pass a fit test for an process and held by HR, manager and FFP respirator are redeployed staff member using the nationally agreed algorithm and a record kept in staff members personal record and Occupational health service record

• boards have a system in place Centrally held records kept. Not currently reporting to the board but will Recorded centrally, to be added to board that demonstrates how, be added to quarterly quality pack reporting pack with immediate effect regarding fit testing, the organisation maintains staff safety and provides safe care across all care settings. This system should include a centrally held record of results which is regularly reviewed by the board

• consistency in staff allocation Staffing matron and clinical rota office do As prevalence grows and with the layout Mitigating actions in place but under should be maintained, reducing what they can to maintain cohorts of staff of the hospital and staff resource this constant review, comms in place to ensure movement of staff and the in pathways. Care is taken when moving required constant review to allow both changes rapidly communicated and crossover of care pathways staff to look at pathways and risks. Red COVID and clinical safety agreed with departments between planned/elective care areas have set teams or mitigating actions pathways and in place to allow staff movement. Staff urgent/emergency care movement in outbreak areas is restricted. pathways as per national Daily staffing meetings in place. Deputy guidance Director of Nursing on outbreak meetings and aware of areas of concern Evidence on outbreak management of moving staff with positive patients to cohort ward to lower risk of contacts becoming positive

37 | IPC board assurance framework • all staff should adhere to Guidance and signage in place including Requires constant reminder and Manager and personal accountability re- national guidance on social maintain social distancing when wearing a monitoring particularly in communal areas iterated, senior support given to IPC team, distancing (2 metres) if not mask wherever possible both inside and and outside of the hospital. Exec Team charged with the role of wearing a facemask and in outside of the hospital. hands, face, space guardians. Continuous non-clinical areas comms sent

Key lines of enquiry Evidence Gaps in assurance Mitigating actions

• health and care settings are Yes No gaps identified other than the n/a COVID-19 secure workplaces requirements above as far as practical, that is, that any workplace risk(s) are mitigated maximally for everyone

• staff are aware of the need to Yes all staff aware of need to wear No gaps identified n/a wear facemask when moving facemasks through COVID-19 secure All staff encouraged and supported to areas. challenge thos staff not meeting requirements

• staff absence and well-being Staff absence help-line and wellbeing No gaps identified n/a are monitored and staff who advice in place 7 days a week with access are self- isolating are supported to other support through 2 well-being and able to access testing guides

• staff who test positive have Staff absence help-line and wellbeing No gaps identified n/a adequate information and advice in place 7 days a week with access support to aid their recovery to other support through 2 well-being and return to work guides and isolation support packages. A COVID +ve return to work package is also in place to identify any needs on return.

38 | IPC board assurance framework IPC Board Assurance Action Plan – commenced 24.11.2020

Gap Analysis on current plan – updated 22.11.2020 / 14.12.2020 / 15.2.2021 / 21.2.2021

No. Objective Planned Action Lead/Action Due By Status Comment Holder 1 ensure the dilution of air with YT - information has been sent to huddle Clive Radstock / NHS paper shared with good ventilation e.g. open COVID 19 box for review in huddle 24.11.20 SM CR/SM windows, in admission and CR – window review ongoing, asbestos waiting areas to assist the Remains AMBER until all issues ref opening all windows. dilution of air vents fitted. SM – further information required and options to be explored by CR 13.2.21 CR emailed for Cr – window survey completed, 11/12 dates of completion update provided means to ensure windows in each 15.2.2021 CR update, 30 bay (after risk assessment) to be opened vents expected by and kept open safely. 19.2.2021 MC contacted to have plan for urgent Order placed for bespoke ventilation vents access to bays for fitting for windows and to be fitted to every multi and requesting SR5/6 to be bed bay – all vents ordered have been fitted fitted with vents. – further order x 40 placed for side rooms and more bays (January 2021). All fitted and window CR update to Directors huddle (6.2.2021) 3 replacement plan in place wards windows on order – commencing with 7A. MC/CR Project plan and SBAR to huddle ref patient

pathways / closure of bays required (1 or 2 weeks) 2 a record of the fit test and YT clarify with DM (emailed 24.11.2020) YT/DM Before the Academy took result is given to and kept by Academy holds the record of all fit tests, over the fit testing it was the trainee and centrally within when completed and which masks on our being delivered in local the organisation OSM data base. Staff are allocated a slip of areas with no record kept paper for their own records, as well as their of the masks or dates, managers so they know which masks they although we did begin to have been successfully fitted, as well as get attendance sheets. those that have not and the number of Most of these are now attempts. unavailable masks not in stock and therefore refits completed and recorded through the academy.

1

The organisational records can also been pulled as a list for the staff member at any point.

Session can be increased at any point

3 hand hygiene facilities Instructional posters not available at all YT/IPC Team Continue to review on IPC including instructional points rounds replace as required posters Audit all areas already in place Laminated signage in place

4 contractors advice / induction Confirm actions with CR (email sent YT / CR 24.11.2020) Induction for all on site contractors – which includes IPC advice and instruction – records stored COVID checklist and register in place and being used and information stored Appropriate PPE supplied or is it instructed that contractors supply their own and to what level Mechanism in please to ensure SSL office aware of current restricted areas on a daily basis to instruct contractors as required Every contractor being sent statement ref their responsibilities and COVID responsibilities and record kept of response. Records of travel history and postcode kept by SSL office.

5 rooms/areas where PPE is Confirm actions with BW (email sent YT removed must be 24.11.2020) decontaminated, ideally Confirmed through outbreak meetings cleaning schedules in place timed to coincide with periods immediately after PPE removal by groups of staff (at least twice daily)

6 ensure cleaning standards Confirm actions with BW (email sent YT and frequencies are 24.11.2020) monitored in non- clinical Confirmed cleaning schedules in place

2

areas with actions in place to resolve issues in maintaining a clean environment

7 Shower curtains check with Confirm actions with AP (email sent IRobins Adrian that have been 24.11.2020) curtains in organisation/ fittings purchased ordered – plans in place to fit from 1.12.2020 Doors have been fitted across the trust.

8 patient Screening SOP to be SOP completed and sent to SM 23.11.2020 YT / MR updated and implemented as Discussed in Director Huddle 24.11.2020 a matter of urgency – For manual circulation 24.11.2020 Meets 17.11.2020 key Actions: infection prevention and control and testing guidance

1,3,6 and weekly in place.

9 Patient face mask - Email to MR 24.11.2020 YT / MR Guidance being produced, SBAR to Huddle agreed currently messaging is verbal Guidance in place – patients asked to wear masks when tolerated and when moving from the bed space.

YT (24.11.2020) Version 1. YT (13.12.2020) Version 1.1 YT (13.2.2021) Version 1.2 YT (21.2.2021) Version 1.3 YT (26.4.2021) Version 1.4

3

Appendix: 5 REPORT TO: Board of Directors REPORT BY: Ben Edgar-Attwell, Company Secretary PRESENTED BY: Ben Edgar-Attwell, Company Secretary EXEC SPONSOR: Jonathan Higman, Chief Executive REPORT TITLE: Board Assurance Framework – Quarter 3 2020/21 DATE: 5 May 2021

Purpose of Paper (Please select any which are relevant to this paper)

☒ For Assurance ☐ For Approval / Decision ☐ For Information

Reason for Presentation to The Board Assurance Committees carry out detailed monitoring and Committee/Board review of the principal risks that relate to the organisation’s strategic objectives and priorities. These risks shall be proactively managed and reported on as a minimum requirement quarterly to the Board Assurance Committees and to the Board of Directors through the BAF. The Board Assurance Committees provides assurance to the Board with regard to the continued effectiveness of the Trust’s system of integrated governance, risk management and internal control. Committees continue to review the extent to which they are assured by the evidence presented for each risk.

The BAF includes all principal risks that represent higher levels of opportunity/threat, which may have a major, or long-term impact on benefits realisation or organisation objectives and which may also impact upon the strategic objectives and outcomes positively or negatively. Any Key Issues to Note The BAF was reviewed and updated by the Executive Leads for each Principal Risk to the organisation. Scrutiny of the risks takes place within the following Board Assurance Committees: Financial Resilience and Commercial Committee, Audit Committee, Governance and Quality Assurance Committee and Workforce Committee. The BAF is also reviewed by the Executive Committee.

Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) ☒ Care for our Population ☒ Develop our People

☒ Innovate and Collaborate ☒ Develop a Sustainable System

Implications/Requirements (Please select any which are relevant to this paper) ☒ Financial ☒ Legislation ☒ Workforce ☒ Estates ☒ ICT ☒ Patient Safety / Quality

Reference to CQC domains (Please select any which are relevant to this paper)

☒ Safe ☒ Effective ☒ Caring ☒ Responsive ☒ Well Led

Is this paper clear for release under the Freedom of Information Act 2000? ☒ Yes ☐ No

Introduction

The Department of Health provided guidance on Assurance Frameworks in 2003. The document states that, ‘the Assurance Framework provides organisations with a simple but comprehensive method for the effective and focused management of the principal risks to meeting their objectives’. The Board Assurance Framework (BAF) forms part of the Trust’s risk management strategy and is the framework for identification and management of strategic risks.

In line with the Trust’s Risk Management Strategy and the revised monitoring arrangements therein, the Board will receive the BAF on a quarterly basis (April, July, October and January). The BAF provides evidence to support the Annual Governance Statement.

Board Assurance Framework

The Board Assurance Committees carry out detailed monitoring and review of the principal risks that relate to the organisation’s strategic objectives and priorities. These risks shall be proactively managed and reported on as a minimum requirement quarterly to the Board Assurance Committees and to the Board of Directors through the BAF. The Board Assurance Committees provides assurance to the Board with regard to the continued effectiveness of the Trust’s system of integrated governance, risk management and internal control. Committees continue to review the extent to which they are assured by the evidence presented for each risk.

The BAF includes all principal risks that represent higher levels of opportunity/threat, which may have a major, or long-term impact on benefits realisation or organisation objectives and which may also impact upon the strategic objectives and outcomes positively or negatively.

The identified high-level objectives for Yeovil District Hospital are: . Care for our Population . Develop our People . Innovate and Collaborate . Develop a Sustainable System.

Underneath each high-level objectives are various key priorities to be achieved.

The Board is required to review the risks that Board Assurance Committees have highlighted for Board review where further assurances may be required. This provides a filter mechanism that enables the Board to maintain a strategic focus.

Risk Quantification Matrix

As per the Trust’s Risk Management Strategy, risks are scored using the 5x5 matrix:

Likelihood Consequence Rare - 1 Unlikely - 2 Possible - 3 Likely - 4 Certain - 5 Negligible - 1 1 2 3 4 5 Minor - 2 2 4 6 8 10 Moderate - 3 3 6 9 12 15 Major- 4 4 8 12 16 20 Catastrophic - 5 5 10 15 20 25

Updates and Changes to the Board Assurance Framework

One of the purposes of the BAF is to ensure that all principal risks are mitigated to an appropriate or acceptable level. It is expected that not all risks will be able to have mitigating controls that reduce the risk to the target level. The attached BAF details the total number of risks to the four Trust strategic objectives that are scored as follows (based on current risk score):

Significant Moderate Low High Risk Risk Risk Risk (16-25) Objective (12-15) (8-10) (1-6) Current Risk Score Care for our Population – We will seek and seize opportunities to continually improve the quality, accessibility and safety of our services, and the experience we provide. We will support and 0 2 1 0 encourage our local population to live healthier lives. Develop our People - We will ensure our teams have the skills, capacity and environment to enable them to provide the care that they aspire to. We will 0 2 0 1 make our hospital an employer of choice. Innovate and Collaborate - As part of a sustainable Somerset care system, and working with our partners, we will develop and deliver 0 1 4 0 outstanding services, employing new models of care and innovative technology. Develop a Sustainable System - We will manage our resources responsibly to ensure the sustainability of our services and the local care 0 3 0 1 system, without compromising on safety and quality.

Headline information by Objective (BAF)

The principal risks identified and monitored by the Board of Directors and Board Assurance Committees through the BAF are:

Care for our Population – We will seek and seize opportunities Current Risk Target Risk to continually improve the quality, accessibility and safety of our Rating Rating services, and the experience we provide. We will support and Likelihood x Likelihood x encourage our local population to live healthier lives. Impact Impact SR1: There is a risk that increasing levels of demand and the COVID-19 pandemic would exceed capacity leading to challenges in maintaining the safety of our services, leading to 3x5 2x4 deteriorating operational performance SR2: There is a risk to the Trust of static or decreasing population health if the wider system is adversely affected by the COVID-19 pandemic and is unable to prioritise prevention 3x3 2x3 and healthy living activities SR3: There is a risk that our scale (or other factors, including COVID-19) results in us not being able to continue to achieve nationally mandated quality standards leading to vulnerability in 3x4 1x3 the services we provide

Develop our People - We will ensure our teams have the skills, Current Risk Target Risk capacity and environment to enable them to provide the care Rating Rating that they aspire to. We will make our hospital an employer of Likelihood x Likelihood x choice. Impact Impact SR4: There is a risk that we fail to recruit and retain key staff with the skills required resulting in us being unable to maintain service continuity, increasing costs and negatively impacting on 3x4 2x3 the quality of service we provide SR5: There is a risk that the Trust does not develop a future workforce strategy resulting in a workforce that is not aligned 3x4 2x3 with the Phase 1-4 COVID-19 recovery and ICS development SR6: There is a risk that the Trust does not have an engaged workforce performing at the required level in order achieve its 2x3 2x2 ambition of becoming an employer of choice

Innovate and Collaborate - As part of a sustainable Somerset Current Risk Target Risk care system, and working with our partners, we will develop and Rating Rating deliver outstanding services, employing new models of care and Likelihood x Likelihood x innovative technology. Impact Impact SR7: There is a risk that we do not deliver our digital strategy and sufficiently transform our services leading to poor patient 3x3 2x3 experience and increased benchmarked costs SR8: There is a risk that in a digital age heavy reliance on electronic systems may expose the Trust to risks around business continuity, data protection and internal systems 3x3 1x5 reliance SR9: There is a risk of failure to agree and adopt new models of care and a clear clinical strategy across Somerset leading to 3x4 2x3 increased demand and unsustainable services at YDH SR10: There is a risk of ineffective partnership working (and other factors) slowing the development of an Integrated Care 2x4 2x4 System within Somerset SR11: There is a risk that the volume of change activity leads to an inability to focus and deliver on priorities 3x3 1x5

Develop a Sustainable System - We will manage our Current Risk Target Risk resources responsibly to ensure the sustainability of our Rating Rating services and the local care system, without compromising on Likelihood x Likelihood x safety and quality. Impact Impact SR12: There is a risk that we fail to deliver our control total and associated financial plans by not securing sufficient income for the Trust and not delivering our cost improvement and 3x4 1x5 transformation plans SR13: There is a risk that we take decisions that compromise quality and safety in order to achieve financial balance 2x3 2x3 SR14: There is a risk of not delivering our strategic capital programme and therefore not continuing to develop our 3x4 2x3 equipment and facilities SR15: There is a risk that the group’s subsidiary companies fail to deliver their plans which could undermine the Trust's strategic 3x4 2x3 and financial plans

Corporate Risk Register Overview

The Corporate Risk Register is a supplementary report which aims to provide details of the key risks details on the Trust’s risk register with a scoring of significant or higher (12+) on the risk matrix. Further information on the top operational risks to the organisation are captured and presented within these reports.

The top 3 risks to the organisation during Quarter 3 2020/21 were:

• Risk 63 - Increased use of medical locums / agency locum costs due to levels of vacancies of substantive medical workforce / those appointed delayed in arriving / 14 day quarantine on arrival. This will result in a significant financial impact for the Trust which detrimentally impacts Trust's deficit and cash position

• Risk 542 - Inability to safely manage the increasing numbers of mental health patients in a safe and appropriate area of the ED department. This is due to the environment not being purpose designed for patients who may be suicidal, agitated, violent or distressed. There is the potential significant risk to all patients’ not just mental health patients but also to staff including the security team

• Risk 100 – Risk of breaching National RTT Standards at aggregate and specialty level due to performance deterioration following in a lack of ability to manage long wait patients as a result of operational limitations and patient choice resulting in patients waiting longer than expected resulting in poorer health outcomes

Since 1 October 2020, the changes within the Corporate Risk Register are noted below:

Total Quarter 3 2020/21 Corporate Risk Register Update Number Risk Numbers of Risks 579, 584, 586, 589, 590, Total number of new significant or high risks added 9 600, 607, 608, 613 Total number of risks previously scoring less than 12 which 44, 198, 372, 439, 534, have increased within the Quarter & now form part of the 6 539 Corporate Risk Register Total number of risks previously scoring 12 which have 0 n/a increased within the Quarter 21, 56, 63, 64, 77, 97, Total number of risks that have remained the same within 14 100, 211, 235, 357, 542, the Quarter in terms of risk score 549, 550, 569 Total number of risks which have reduced and no longer 5 24, 91, 236, 497, 551 form part of the Corporate Risk Register Total number of risks which have been archived and no 1 503 longer are on the live risk register

The most notable change within the quarter is the increase in the number of risks recorded under the category of ‘continuity of service’. The number of risks under this category on the corporate risk register have more than doubled during Quarter 3 mainly due to the impact the pandemic is having on services within the organisation.

General Quarterly Risk Register Update

As of 31 December 2020, there were 433 open risks on the Trust’s risk register, which includes risks for the YDH Group subsidiary organisations, compared to 425 open risks at the end of Quarter 2 2020/21.

39 new risks have been added to the risk register within Quarter 3 2020/21, 22 of these were risks not associated with COVID19 and 17 were associated within COVID19. This is compared to 31 new risks added within Quarter 2 2020/21, 20 of those not associated with COVID19 and 11 associated with COVID19.

32 risks have been archived within Quarter 3 2020/21, 25 of these were risks not associated with COVID19 and 7 were associated with COVID19. This is compared to 21 risks archived within Quarter 2 2020/21, 16 of those risks not associated with COVID19 and 5 were associated with COVID19.

COVID19 Quarterly Risk Register Update

As of the 31 December 2020 there were 125 live risks on the Trust’s COVID19 risk register compared to 109 live risks on 30 September 2020, 102 live risks on 1 July 2020 and 81 live risks on 16 April 2020. Of the 125 live risks, 17 of these are significant risks and 2 high risks. This is compared to the report covering the period 1 July – 30 September which highlighted 6 significant risks and 1 high risk; the report covering the period 1 April – 30 June 2020 which highlighted 9 significant risks and 1 high risk and the report covering the period 6 March – 16 April 2020 which highlighted 28 significant risks and 12 high risks on the COVID19 corporate risk register.

COVID19 associated risks represent 28.87% of the Trust’s full risk register reported risks at the end of Quarter 3 2020/21. This is a slight increase when compared to COVID19 associated risks representing 25.65% of the Trust’s full risk register reported risks at the end of Quarter 2 2020/21.

Since 30 September 2020:

• There have been 17 newly identified risks added to the Trust’s risk register associated with COVID19, 6 of which are on the COVID19 corporate risk register • There have been 6 risks which were already on the risk register which have been directly impacted by the pandemic within the quarter and now form part of the COVID risk register. 4 of these risks form part of the COVID corporate risk register. • 1 previously moderate risk increased within the quarter and now is a significant risk • 4 previously low risks increased within the quarter, 3 are now moderate risks and 1 is now a significant risk • 7 risks were reduced within the quarter (1 low risk, 4 moderate risks and 2 significant risks). 2 of the risks which were reduced no longer form part of the COVID19 corporate risk register • 7 risks from the COVID19 risk register were archived within Quarter 3 2020/21, none of these from the COVID19 corporate risk register

A breakdown by risk score is shown below:

Risks already on the risk register Risks which New Risks Total Number of which have been have been Risk Rating ADDED during LIVE COVID19 directly impacted ARCHIVED Scores Quarter 3 Risks on by the pandemic during Quarter 3 2020/21 31 December 2020 during Quarter 3 2020/21 2020/21 High (16+) 0 1 0 2 Significant 6 3 0 17 (12-15) Moderate (8- 10 2 5 68 10) Low (1-6) 1 0 2 38 Total 17 6 7 125 Number of Risks:

Board Assurance Framework 2020/21 Quarter 4 Summary of Principal Risks

Care for our Population Executive owner(s) Principal Risk Monitoring Group(s) Current risk rating Movement Risk target Strength of controls Movement Strength of assurance Movement SR1: There is a risk that increasing levels of demand and the COVID-19 pandemic would exceed capacity Chief Nurse Governance & Quality SR1 leading to challenges in maintaining the safety of 15: Significant Risk 8: Moderate Risk Blue Green Chief Operating Officer Assurance Committee our services, leading to deteriorating operational    performance SR2: There is a risk to the Trust of static or decreasing population health if the wider system is Governance & Quality SR2 Director of Transformation adversely affected by the COVID-19 pandemic and is 9: Moderate Risk 6: Low Risk Amber Amber Assurance Committee unable to prioritise prevention and healthy living    activities SR3: There is a risk that our scale (or other factors, Chief Nurse including COVID-19) results in us not being able to Governance & Quality SR3 Chief Medical Officer continue to achieve nationally mandated quality 12: Significant Risk 3: Low risk Blue Blue Assurance Committee Chief Operating Officer standards leading to vulnerability in the services we    provide

Develop our People Executive owner(s) Principal Risk Monitoring Group(s) Overall risk rating Movement Risk target Strength of controls Movement Strength of assurance Movement SR4: There is a risk that we fail to recruit and retain Chief Nurse key staff with the skills required resulting in us SR4 Chief Medical Officer being unable to maintain service continuity, Workforce Committee 12: Significant Risk 6: Low Risk Amber Amber Director of Human Resources increasing costs and negatively impacting on the    quality of service we provide

New Risk: There is a risk that the Trust does not Chief Nurse develop a future workforce strategy resulting in a SR5 Workforce Committee 9: Moderate Risk 6: Low Risk Amber Amber Director of Human Resources workforce that is not aligned with the Phase 1-4    COVID-19 recovery and ICS development

SR5: There is a risk that the Trust does not have an engaged workforce performing at the required level SR6 Director of Human Resources Workforce Committee 6: Low Risk 4: Low Risk Blue Blue in order achieve its ambition of becoming an    employer of choice

Innovate and Collaborate Executive owner(s) Principal Risk Monitoring Group(s) Overall risk rating Movement Risk target Strength of controls Movement Strength of assurance Movement SR6: There is a risk that we do not deliver our digital strategy and sufficiently transform our services Finance Resilience & SR7 Director of Transformation 9: Moderate Risk 6: Low Risk Blue Blue leading to poor patient experience and increased Commercial Committee    benchmarked costs SR7: There is a risk that in a digital age heavy Managing Director of SSL reliance on electronic systems may expose the Trust SR8 Audit Committee 9: Moderate Risk 5: Low Risk Amber Amber Chief Information Officer to risks around business continuity, data protection    and internal systems reliance SR8: There is a risk of failure to agree and adopt Chief Executive new models of care and a clear clinical strategy Governance & Quality SR9 12: Significant Risk 6: Low Risk Amber Amber Chief Medical Officer across Somerset leading to increased demand and Assurance Committee    unsustainable services at YDH SR9: There is a risk of ineffective partnership working (and other factors) slowing the SR10 Chief Executive Board of Directors 8: Moderate Risk 8: Moderate Risk Amber Amber development of an Integrated Care System within    Somerset SR10: There is a risk that the volume of change Finance Resilience & SR11 Director of Transformation activity leads to an inability to focus and deliver on 9: Moderate Risk 6: Low Risk Blue Blue Commercial Committee priorities   

Develop a Sustainable System Executive owner(s) Principal Risk Monitoring Group(s) Overall risk rating Movement Risk target Strength of controls Movement Strength of assurance Movement SR11: There is a risk that we fail to deliver our control total and associated financial plans by not Chief Executive Financial Resilience & SR12 securing sufficient income for the Trust and not 12: Significant Risk 5: Low Risk Blue Blue Chief Finance Officer Commercial Committee delivering our cost improvement and    transformation plans SR12: There is a risk that we take decisions that Chief Nurse Governance & Quality SR13 compromise quality and safety in order to achieve 6: Low Risk 6: Low Risk Green Green Chief Medical Officer Assurance Committee financial balance    SR13: There is a risk of not delivering our strategic Chief Executive Financial Resilience & SR14 capital programme and therefore not continuing to 12: Significant Risk 6: Low Risk Blue Blue Chief Finance Officer Commercial Committee develop our equipment and facilities   

SR14: There is a risk that the groups’ subsidiary Chief Executive Financial Resilience & SR15 companies fail to deliver their plans which could 12: Significant Risk 6: Low Risk Blue Blue Chief Finance Officer Commercial Committee undermine the Trust's strategic and financial plans   

Key: Likelihood of Occurrence Controls and Assurances

Risk rating 1 2 3 4 5 Red Assurance indicates poor effectiveness of controls/assurances

Rare Unlikely Possible Likely Certain Amber Some assurances in place or controls are still maturing. 1 Negligible 1 2 3 4 5 2 Minor 2 4 6 8 10 Reasonable assurance. Some issues which could increase Blue 3 Moderate 3 6 9 12 15 likelihood of risk materialising.

Impact 4 Major 4 8 12 16 20 Green No gaps in controls or assurances 5 Catastrophic 5 10 15 20 25 Board Assurance Framework 2020-21

Strategic Objective: Care for our Population Monitoring group(s): Governance & Quality Assurance Committee Date last reviewed: 27/04/2021 We will seek and seize opportunities to continually improve the quality, accessibility and safety of our services, and the experience we provide. We will support and encourage our local population to live healthier lives. Executive Owner(s): Director of Operations/Chief Operating Officer

Strategic Priorities: P1: In partnership with Somerset Foundation Trust develop a Clinical Strategy for the County in the first instance P6: Ensure that elective care for patients is recovered in line with clinical need and that delays in treatment are monitored and concentrating on provider trusts and then moving on to the Integrated Care System. acted upon to minimise harm P2: Consistently demonstrate high standards of care P7: Continue to improve end of life care with a particular emphasis on recognition, planning and communication P3: Ensure Cancer Standards are consistently achieved P8: Achieve all new National Safety Standards including the recommendations from the Ockenden Report P4: Implement the new Urgent and Emergency Care Standards P9: Improve mental health care with a particular focus on the care of CAMHS patients and integration of services to ensure P5: Ensure excellence in Infection Prevention and Control parity

What is the risk to delivery? SR1: There is a risk that increasing levels of demand and the COVID-19 pandemic would exceed capacity leading to challenges in maintaining the safety of our services, leading to deteriorating operational performance

What controls are in place to manage the risk to delivering the objective? What assurance do we have that our controls are working? 1) Regular review of patient safety data including incidents, 4) Weekly reviews of longest stay patients to reduce inpatient delays 1) External reports and visits to clinical areas 6) HSMR/SHMI indicators HSMR etc. 5) New models of care roll out for prevention 2) Quality and performance dashboards 7) Safeguard Reports 2) Nursing staffing levels benchmarked and monitored 6 Increase in Intermediate Care and Rapid Response capacity 3) Compliance with NICE guidance 8) Governance and Quality Assurance Committee reports against acuity & bed numbers 7) Escalation space and policies in place and regularly reviewed 4) Performance measures for ED including corridor waits and 4 9) Feedback from CQC (periodic) 3) Reviewing staffing levels in ED to ensure sufficient to cope 8) Additional capacity available to be stood up for weekend operating hours 10) Dashboards tracking key metrics linked to managing demand safely with levels of demand 5) Good Fundamentals of Care/New Harm results and improving flow

Are there any gaps in our controls (and what are we doing about them)? Relate to the actions below Are there any gaps in our assurance (and what are we doing about them)? Relate them to the actions below 1) KPIs monitoring the effectiveness of the Intermediate Care 3) Inability to control patients choosing to come to YDH because of 1) Changes to services provided by Trusts surrounding YDH 2) Deteriorating performance in surrounding trusts and 111 and & Rapid Response service lower waiting times which we aren't aware of leading to unexpected transfer of lack of understanding of mitigating actions 2) Recognition of cost of activity above contracted levels 4) Robust referral pattern report to give early view of demand transfer demand 3) Lack of formal review of data around last winter to inform 5) Inpatient bed closure at Hospice with uncertain consequence on winter plan admissions to and discharges from YDH

Likelihood Consequence Rationale for overall risk rating: 3: Possible 5: Catastrophic Overall risk rating 15: Significant Risk A number of controls and actions are in place to ensure that quality of services and operational performance is maintained, however the potential consequence could be major if these are not Key: Controls and Assurances Overall target risk rating 8: Moderate Risk in place or fail. Assurance indicates poor effectiveness of controls. Immediate action is required for ongoing Low management of the risk Strength of controls Amber

Some assurances in place or controls are still maturing so effectiveness cannot be fully Medium assessed at this moment but should improve. Strength of assurance Green Risk Appetite Low - Risks Rated 1-6 Reasonable assurance provided over the effectiveness of controls. However, there are some High issues identified that if not addressed, could increase the likelihood of the risk materialising.

Strong No gaps in controls or assurances

Change in Risk - Overall risk rating Actions to mitigate risk and to fill the gaps in controls and assurance Jan 2020 Apr 2020 Jul 2020 Oct 2020 Dec 2020 Mar 2021 15 15 15 15 15 15 Action By who? By when? Progress Monitor levels of demand and causes, implement programme of South Somerset Care Board established to oversee Director of 20 1 work to reduce non-elective demand to reduce capacity Ongoing programme. Further roll-out of nursing home programme Transformation pressures. commenced 15 Business Case has been approved and Works completed. Business case around expansion of AEC and ED staffing to Chief Operating 2 October Wider case has progressed to Systemwide funding as part 10 provide resilience being reviewed by execs and FRCC Officer of 21/22 business planning. 5 Intermediate Care funding to support expansion of Intermediate Chief Operating Secure loonger term funding for capacity and further 15 15 12 15 15 15 15 15 3 care, rapid response and escalation beds April 2021 0 Officer system controls on intermediate care.

Board Assurance Framework 2020-21

Strategic Objective: Care for our Population Monitoring group(s): Governance & Quality Assurance Committee Date last reviewed: 26/04/2021 We will seek and seize opportunities to continually improve the quality, accessibility and safety of our services, and the experience we provide. We will support and encourage our local population to live healthier lives. Executive Owner(s): Director of Transformation

Strategic Priorities: P1: In partnership with Somerset Foundation Trust develop a Clinical Strategy for the County in the first instance P6: Ensure that elective care for patients is recovered in line with clinical need and that delays in treatment are monitored and concentrating on provider trusts and then moving on to the Integrated Care System. acted upon to minimise harm P2: Consistently demonstrate high standards of care P7: Continue to improve end of life care with a particular emphasis on recognition, planning and communication P3: Ensure Cancer Standards are consistently achieved P8: Achieve all new National Safety Standards including the recommendations from the Ockenden Report P4: Implement the new Urgent and Emergency Care Standards P9: Improve mental health care with a particular focus on the care of CAMHS patients and integration of services to ensure P5: Ensure excellence in Infection Prevention and Control parity

What is the risk to delivery? SR2: There is a risk to the Trust of static or decreasing population health if the wider system is adversely affected by the COVID-19 pandemic and is unable to prioritise prevention and healthy living activities

What controls are in place to manage the risk to delivering the objective? What assurance do we have that our controls are working? 1) Executive involvement in ICS development across Somerset 4) Collaboration Forum 1) Collaboration Forum focus on population health 4) ICS development plans 2) YDH involvement in Neighbourhood Board. 5) Operational Plan 2021/22 with identified priorities 2) Confirmed system-wide Operational Plans 5) South Somerset Strategic Board monthly meetings 3) Clinical Strategy development for Trust merger 6) South Somerset Strategic Board 3) Collaborative working across Somerset

Are there any gaps in our controls (and what are we doing about them)? Relate to the actions below Are there any gaps in our assurance (and what are we doing about them)? Relate them to the actions below 1) Greater clarity on roles in relation to leading population 3) Ensuring neighbourhoods work fully embeds a focus on healthy 1) Develop integrated person-level data set to support this health living - will become increasingly clear as strategy developed work. 2) Embedding personalised care to improve management of 2) Support PCNs and other partners to share learning and long term conditions in primary care develop approach.

Likelihood Consequence Rationale for overall risk rating: 3: Possible 3: Moderate Overall risk rating 9: Moderate Risk Whilst there are a number of actions taking place to ensure improved overall population health, given financial challenges and factors outside health and care control, there is a risk that this Key: Controls and Assurances Overall target risk rating 6: Low Risk deteriorates. The consequence score reflects the significant but protracted impact this would have on the health system. Assurance indicates poor effectiveness of controls. Immediate action is required for ongoing Low management of the risk Strength of controls Amber

Some assurances in place or controls are still maturing so effectiveness cannot be fully Medium assessed at this moment but should improve. Strength of assurance Amber Risk Appetite Low - Risks Rated 1-6 Reasonable assurance provided over the effectiveness of controls. However, there are some High issues identified that if not addressed, could increase the likelihood of the risk materialising.

Strong No gaps in controls or assurances

Change in Risk - Overall risk rating Actions to mitigate risk and to fill the gaps in controls and assurance Jan 2020 Apr 2020 Jul 2020 Oct 2020 Dec 2020 Apr 2021 9 9 9 9 9 9 Action By who? By when? Progress Ensure YDH plays active part in ICS and drives the inclusion of 10 1 population health interventions here CEO Ongoing ICS status granted. 8 Support PCNs and other partners to develop their approach and Director of 6 2 share learning. Ongoing Work has commenced. Transformation 4 Work with partners to ensure clarity about approach to CEO & Director of 2 3 Population Health in Somerset Ongoing In progress 9 9 9 9 9 9 9 9 Transformation 0

Board Assurance Framework 2020-21

Strategic Objective: Care for our Population Monitoring group(s): Governance & Quality Assurance Committee Date last reviewed: 22/04/2021 We will seek and seize opportunities to continually improve the quality, accessibility and safety of our services, and the experience we provide. We will support and encourage our local population to live healthier lives. Executive Owner(s): Chief Nurse

Strategic Priorities: P1: In partnership with Somerset Foundation Trust develop a Clinical Strategy for the County in the first instance P6: Ensure that elective care for patients is recovered in line with clinical need and that delays in treatment are monitored and concentrating on provider trusts and then moving on to the Integrated Care System. acted upon to minimise harm P2: Consistently demonstrate high standards of care P7: Continue to improve end of life care with a particular emphasis on recognition, planning and communication P3: Ensure Cancer Standards are consistently achieved P8: Achieve all new National Safety Standards including the recommendations from the Ockenden Report P4: Implement the new Urgent and Emergency Care Standards P9: Improve mental health care with a particular focus on the care of CAMHS patients and integration of services to ensure P5: Ensure excellence in Infection Prevention and Control parity

What is the risk to delivery? SR3: There is a risk that our scale (or other factors, including COVID-19) results in us not being able to continue to achieve nationally mandated quality standards leading to vulnerability in the services we provide

What controls are in place to manage the risk to delivering the objective? What assurance do we have that our controls are working? 1) Regular review of patient safety data including incidents, 5) Active monitoring of data and patient pathways 1) Monthly and Quarterly review meetings with CCG, daily 5) National benchmarking HSMR etc including a weekly Exec review 6) New models of care roll out for prevention and vaccination outbreak meetings, weekly calls with CQC – limited actions 2) Identified quality priorities monitored 7) Establishment of the Home First and Rapid Response service outstanding 3) GIRFT and Model Hospital monitored and acted upon 8) Good patient flow procedures and monitoring in place 2) Information on vacancies by area and type 4) County-wide service review and mutual aid for at-risk 9) MAPRAD programme developing sustainable clinical workforce 3) Quality and Performance Reports services 10) MOU for movement of staff in place 4) SBU meetings

Are there any gaps in our controls (and what are we doing about them)? Relate to the actions below Are there any gaps in our assurance (and what are we doing about them)? Relate them to the actions below 1) Full forward view of clinical workforce make-up over next 5 2) Insufficient pipeline of medical trainees to meet need for staff – 1) Workforce long term plan - in progress alongside system 2) Assurance around national ongoing investment in workforce years – being worked on through ICP Clinical Strategy looking at extended nursing roles and other pathways workforce plan pipeline – seeking national assurance

Likelihood Consequence Rationale for overall risk rating: 3: Possible 4: Major Overall risk rating 12: Significant Risk Some specialties struggle to recruit medical staff and so more countywide review required. Increased sickness absence due to COVID-19, the rapid implementation of a 7/7 vaccination Key: Controls and Assurances Overall target risk rating 3: Low risk service and the increase in hospital admissions due to COVID-19 has significantly increased this risk as recognised nationally. It is anticipated that the vaccination hospital hub programme will Assurance indicates poor effectiveness of controls. Immediate action is required for ongoing Low pause in May 2021 management of the risk Strength of controls Blue

Some assurances in place or controls are still maturing so effectiveness cannot be fully Medium assessed at this moment but should improve. Strength of assurance Blue Risk Appetite Low - Risks Rated 1-6 Reasonable assurance provided over the effectiveness of controls. However, there are some High issues identified that if not addressed, could increase the likelihood of the risk materialising.

Strong No gaps in controls or assurances

Change in Risk - Overall risk rating Actions to mitigate risk and to fill the gaps in controls and assurance Jan 2020 Apr 2020 Jul 2020 Oct 2020 Jan 2020 Apr 2021 6 6 6 12 12 12 Action By who? By when? Progress Retention work continues with continued reduced 15 Continue to improve retention and look for long term staffing SM turnover, MAPRAD reporting under review, working with 1 Ongoing solutions including new roles MK LWAB to increase system working and opportunities. MOU 10 in place to enable staff to work across settings Initial phase for review complete, findings presented and Complete clinical workforce review & act upon findings, regularly actions identified and ongoing. Will form part of the work 2 MA Ongoing 5 updating of the system People Board to feed into the Somerset Clinical Strategy 6 6 6 6 6 6 12 12 12 0 Escalation process in place regarding the implementation of Escalation process in place and reviewed daily, safer 3 reduced staffing numbers, quality indicators and control SM COMPLETE staffing policy reviewed and linked to escalation with measures to be implemented in line with national guidance control action implemented. Continued focus on staff resilience and effect on retention and Sickness and absence reviewed in detail daily with areas of 4 SM Ongoing sickness/absence concern further explored.

Board Assurance Framework 2020-21

Strategic Objective: Develop our People Monitoring group(s): Workforce Committee Date last reviewed: 12/04/2021 We will ensure our teams have the skills, capacity and environment to enable them to provide the care that they aspire to. We will make our hospital an employer of choice. Executive Owner(s): Chief Nurse, Director of People & Deputy Chief Executive & Director of Human Resources

Strategic Priorities: P10: Further build on the positive 2020 survey with areas of focus being preventing/managing violence and aggression P13: Develop a future workforce strategy aligned to collaborative working and ICS development and ED&I P14: Increase our focus on staff resilience and wellbeing recognising the staff recovery needed as a result of pandemic P11: Ensure grip and control of staff spend with a focus on temporary staffing P15: Explore ways to provide recognition and reward during the pandemic and subsequent recovery P12: Maintain and improve our culture and values through the pandemic and recovery

What is the risk to delivery? SR4: There is a risk that we fail to recruit and retain key staff with the skills required resulting in us being unable to maintain service continuity, increasing costs and negatively impacting on the quality of service we provide

What controls are in place to manage the risk to delivering the objective? What assurance do we have that our controls are working? 1) Overseas recruitment campaigns 5) Robust recruitment processes 1) Workforce Committee scrutiny of the data 5) Key workforce KPIs 2) Various workstreams in place to improve staff retention 6) Early adoption of new roles 2) Leading recruiter for nurse staff groups and radiology 6) Fully established nursing workforce (zero ward vacancies) 3) Health and Wellbeing Strategy 7) Talent identification and support 3) Staff Survey results improving year on year 7) Medical and nursing staff excluded from Tier 2 restrictions 4) Leadership Development Prog. & Management Training 8) Cross county working to establish a Somerset Nurse Associate 4) Improvements in recent retention rates Programme

Are there any gaps in our controls (and what are we doing about them)? Relate to the actions below Are there any gaps in our assurance (and what are we doing about them)? Relate them to the actions below 1) Acknowledged national and regional shortage of key 5) Work required to equip staff to manage conflicts - need to expand 1) E&D Strategy in place with increasing networks groups of staff training being given 2) Workforce long term plan - in progress 2) Medical recruitment challenges contributing to high 6) Full forward view of clinical workforce make-up over next five years 3) People and Organisational Development Plan with a focus on temporary staff spend 7) Workforce impact of COVID 19 both on substantive, future and ‘just culture’ - complete 3) External issues outside of YDH's control (e.g. COVID) training workforce. 4) Uncertainty regarding GP and Nursing training numbers

Likelihood Consequence Rationale for overall risk rating: 3: Possible 4: Major Overall risk rating 12: Significant Risk Continued challenges in the recruitment of medical consultant and GP staff contributing to high temporary staffing spend. Impact of COVID-19 on recruitment, particularly recruitment from Key: Controls and Assurances Overall target risk rating 6: Low Risk overseas has been mitigated in recent months as air corridors have re-opened – we have also implemented a quarantine flat. Concerns regarding ongoing resilience of the workforce and the

Assurance indicates poor effectiveness of controls. Immediate action is required for ongoing likelihood that in the coming months this may lead to decisions around earlier than planned Low management of the risk Strength of controls Amber retirement. Vaccination has also caused staffing issue due to resource requirement and attractiveness of role going forward. Some assurances in place or controls are still maturing so effectiveness cannot be fully Medium assessed at this moment but should improve. Strength of assurance Amber Risk Appetite Low - Risks Rated 1-6 Reasonable assurance provided over the effectiveness of controls. However, there are some High issues identified that if not addressed, could increase the likelihood of the risk materialising. Strong No gaps in controls or assurances

Change in Risk - Overall risk rating Actions to mitigate risk and to fill the gaps in controls and assurance Jan 2020 Apr 2020 Jul 2020 Oct 2020 Dec 2020 Apr 2021 16 16 16 12 12 12 Action By who? By when? Progress Recruitment plan has been developed to refresh hard to fill campaigns and Nursing plan achieved, HSCW plan implemented and 1 MA Ongoing 20 make positions more attractive. funded. Medical plan implemented and ongoing 2 Complete clinical workforce review & act upon findings, regularly updating. SM Ongoing In progress though delayed due to COVID-19 15 Reduce violence and aggression towards staff through robust training, use Achieved and ongoing – improvement shown in monthly 3 DM Ongoing 10 of prosecution where required and environmental change statistics and 2020 staff survey. MA & MR active members and leading on some 4 Play an active role in People Board looking at system learning and solutions MA Ongoing 5 workstreams 16 16 16 16 16 16 12 12 12 5 Continue to improve retention & look for long term solutions inc. new roles SM / MK Ongoing In progress 0 Continue to review staff health and wellbeing in light of winter and COVID- H&WB programmes in place. One year staff recovery plan 6 MA Q3 19 resilience concerns being developed

Board Assurance Framework 2020-21

Strategic Objective: Develop our People Monitoring group(s): Workforce Committee Date last reviewed: 12/04/2021 We will ensure our teams have the skills, capacity and environment to enable them to provide the care that they aspire to. We will make our hospital an employer of choice. Executive Owner(s): Chief Nurse, Director of People & Deputy Chief Executive & Director of Human Resources

Strategic Priorities: P10: Further build on the positive 2020 survey with areas of focus being preventing/managing violence and aggression P13: Develop a future workforce strategy aligned to collaborative working and ICS development and ED&I P14: Increase our focus on staff resilience and wellbeing recognising the staff recovery needed as a result of pandemic P11: Ensure grip and control of staff spend with a focus on temporary staffing P15: Explore ways to provide recognition and reward during the pandemic and subsequent recovery P12: Maintain and improve our culture and values through the pandemic and recovery

What is the risk to delivery? SR5: There is a risk that the Trust does not develop a future workforce strategy resulting in a workforce that is not aligned with the Phase 1-4 COVID-19 recovery and ICS development

What controls are in place to manage the risk to delivering the objective? What assurance do we have that our controls are working? 1) YDH is an active member of the Local Workforce Action 3) Regular joint board meetings with SFT & YDH 1) ICS people plan developed 4) Joint bid for £700k to support H&WB within ICS Board (LWAB) 4) KLOE for ICS completed 2) YDH is ICS lead for H&WB 5) Staff survey results and retention improvement 2) Weekly HRD network meetings across ICS 3) Constructive working relationships among system HRDs

Are there any gaps in our controls (and what are we doing about them)? Relate to the actions below Are there any gaps in our assurance (and what are we doing about them)? Relate them to the actions below 1) Political issues outside of YDH’s control 3) Impact of COVID 19 both on substantive and future workforce 1) The unknown consequence of COVID 19 on staff resilience 2) External issues outside of YDH's control (e.g. Brexit)

Likelihood Consequence Rationale for overall risk rating: 3: Possible 3: Possible Overall risk rating 9: Moderate Risk 1) Significant progress in working relationships within the ICS 2) Agreed people plan in place Key: Controls and Assurances Overall target risk rating 6: Low Risk 3) Feedback from Simon Fuller (regional HEE who was on the panel assessing with NHSE/I) was very positive Assurance indicates poor effectiveness of controls. Immediate action is required for ongoing Low management of the risk Strength of controls Amber

Some assurances in place or controls are still maturing so effectiveness cannot be fully Medium assessed at this moment but should improve. Strength of assurance Amber Risk Appetite Low - Risks Rated 1-6 Reasonable assurance provided over the effectiveness of controls. However, there are some High issues identified that if not addressed, could increase the likelihood of the risk materialising.

Strong No gaps in controls or assurances

Change in Risk - Overall risk rating Actions to mitigate risk and to fill the gaps in controls and assurance Jan 2020 Apr 2020 Jul 2020 Oct 2020 Dec 2020 Apr 2021 n/a n/a n/a 12 12 9 Action By who? By when? Progress

1 ICS E,D&I plan in place Mark Appleby March 22 On target 15

2 ICS Workforce plan in place Chris Squire March 22 On target 10 Isobel 3 ICS Talent attraction plan in place March 22 On target Clements 5 4 ICS Talent acquisition plan in place Marianne King March 22 On target 12 12 9 0 5 ICS Talent management and wellbeing plan in place Mark Appleby March 22 On target

Board Assurance Framework 2020-21

Strategic Objective: Develop our People Monitoring group(s): Workforce Committee Date last reviewed: 12/04/2021 We will ensure our teams have the skills, capacity and environment to enable them to provide the care that they aspire to. We will make our hospital an employer of choice. Executive Owner(s): Chief Nurse, Director of People & Deputy Chief Executive & Director of Human Resources

Strategic Priorities: P10: Further build on the positive 2020 survey with areas of focus being preventing/managing violence and aggression P13: Develop a future workforce strategy aligned to collaborative working and ICS development and ED&I P14: Increase our focus on staff resilience and wellbeing recognising the staff recovery needed as a result of pandemic P11: Ensure grip and control of staff spend with a focus on temporary staffing P15: Explore ways to provide recognition and reward during the pandemic and subsequent recovery P12: Maintain and improve our culture and values through the pandemic and recovery

What is the risk to delivery? SR6: There is a risk that the Trust does not have an engaged workforce performing at the required level in order achieve its ambition of becoming an employer of choice

What controls are in place to manage the risk to delivering the objective? What assurance do we have that our controls are working? 1) Overseas recruitment campaign 3) Health and Wellbeing Strategy 1) Workforce Committee reports 5) Key workforce KPIs 2) Various workstreams in place to improve staff retention 4) Leadership Development Programmes 2) Leading recruiter for nurse staff groups and radiology 6) Increasing number of new nursing starters rates 5) Robust recruitment processes 3) Encouraging staff survey results 7) Medical and nursing staff excluded from Tier 2 restrictions 4) Reduction in recent retention rates

Are there any gaps in our controls (and what are we doing about them)? Relate to the actions below Are there any gaps in our assurance (and what are we doing about them)? Relate them to the actions below 1) Acknowledged national and regional shortage of key groups of staff 2) External issues outside of YDH's control (e.g. Brexit)

Likelihood Consequence Rationale for overall risk rating: 2: Unlikely 3: Moderate Overall risk rating 6: Low Risk Encouraging results from national Staff Survey 2020 however, some external issues outside of YDH's control (e.g. Brexit and COVID-19). Key: Controls and Assurances Overall target risk rating 4: Low Risk Assurance indicates poor effectiveness of controls. Immediate action is required for ongoing Low management of the risk Strength of controls Blue

Some assurances in place or controls are still maturing so effectiveness cannot be fully Medium assessed at this moment but should improve. Strength of assurance Blue Risk Appetite Low - Risks Rated 1-6 Reasonable assurance provided over the effectiveness of controls. However, there are some High issues identified that if not addressed, could increase the likelihood of the risk materialising.

Strong No gaps in controls or assurances

Change in Risk - Overall risk rating Actions to mitigate risk and to fill the gaps in controls and assurance Jan 2020 Apr 2020 Jul 2020 Oct 2020 Dec 2020 Apr 2021 6 6 6 6 6 6 Action By who? By when? Progress Identification of key areas for improvement from 2020 Staff 10 1 Survey. MA March 21 Achieved and ongoing 8 Provide support to workforce potentially affected by external 6 2 factors such as Brexit. MA Ongoing Achieved and ongoing 4 Provide support to workforce during the COVID-19 pandemic Counselling services available, health and wellbeing 3 MA Ongoing 2 initiatives in place, HR Helpline implemented. 9 9 6 6 6 6 6 6 0 Ensure that restoration and recovery of services along with collaboration/merger plans with SFT are not undertaken at the 4 SM Ongoing Staff engagement and recovery plan in progress expense of staff – there must be a continues and increased focus on staff health, wellbeing and resilience

Board Assurance Framework 2020-21

Strategic Objective: Innovate and Collaborate Monitoring group(s): Financial Resilience & Commercial Committee Date last reviewed: 26/04/2021 As part of a sustainable Somerset care system, and working with our partners, we will develop and deliver outstanding services, employing new models of care and innovative technology. Executive Owner(s): Director of Transformation

Strategic Priorities: P16: Complete the formal business case for collaboration with SFT P20: Support the development of local ‘Neighbourhoods’ P17: Refresh and align our digital transformation strategy with both the system digital and clinical strategy P21: Further develop virtual outpatients, virtual ward and other digital solutions developed during the pandemic P18: Implement EPMA & radiology Order Comms P22: Fully engage and collaborate in the formation of the Somerset ICS ensuring the voice of YDH and SHS is heard P19: Enhance and use our business intelligence capability to inform Trust and system planning

What is the risk to delivery? SR7: There is a risk that we do not deliver our digital strategy and sufficiently transform our services leading to poor patient experience and increased benchmarked costs

What controls are in place to manage the risk to delivering the objective? What assurance do we have that our controls are working? 1) Robust governance structure for Transformation team to 4) Weekly transformation senior team meeting reviewing weekly 1) Oversight through monthly Exec sessions and TrakCare manage delivery of Transformation and Digital Strategies, and priorities and progress against the plan(s) Board. support CIP schemes 5) Digital Strategy approved by board in January 2020 and new Digital 2) Updates to Board through Executive Director reports 2) Monthly formal Transformation Exec sessions to oversee Lead took up post on 6 April 2020. 3) Roll out of the Trust's EPR system improvement programmes and benefits 6) Supplier contract management 4) TrakCare governance structures 3) Operational steering groups, reviewing operational 7) Development of joint Digital Strategy with SFT 5) Merger process governance priorities Vs digital project delivery by specialty/area

Are there any gaps in our controls (and what are we doing about them)? Relate to the actions below Are there any gaps in our assurance (and what are we doing about them)? Relate them to the actions below 1) Benefits management processes are being updated 2) Identification of key influencers and relevant members of staff to through PowerHub deployment. attend continuous improvement and QI training to support transformation as BAU.

Likelihood Consequence Rationale for overall risk rating: 3: Possible 3: Moderate Overall risk rating 9: Moderate Risk Digital projects represent a large portion of the enabling work that can support the overall Trust efficiency, quality and cost improvement projects. There is a very large volume of Key: Controls and Assurances Overall target risk rating 6: Low Risk simultaneous change activity at a time of recovery from the pandemic and proposed merger with SFT. Assurance indicates poor effectiveness of controls. Immediate action is required for ongoing Low management of the risk Strength of controls Blue

Some assurances in place or controls are still maturing so effectiveness cannot be fully Medium assessed at this moment but should improve. Strength of assurance Blue Risk Appetite Low - Risks Rated 1-6 Reasonable assurance provided over the effectiveness of controls. However, there are some High issues identified that if not addressed, could increase the likelihood of the risk materialising.

Strong No gaps in controls or assurances

Change in Risk - Overall risk rating Actions to mitigate risk and to fill the gaps in controls and assurance Jan 2020 Apr 2020 Jul 2020 Oct 2020 Dec 2020 Apr 2021 6 9 9 9 9 9 Action By who? By when? Progress September 1 Develop joint Digital Strategy with SFT as part of merger work CIO Workstream set up 10 2021 Complete benefits management process improvement through 8 PowerHub deployment underway. Completion in May 2 PowerHub Head of Digital May 2021 2021. 6

4 3

2 9 9 6 6 9 9 9 9 9 4 0

Board Assurance Framework 2020-21

Strategic Objective: Innovate and Collaborate Monitoring group(s): Audit Committee Date last reviewed: 16/04/2021 As part of a sustainable Somerset care system, and working with our partners, we will develop and deliver outstanding services, employing new models of care and innovative technology. Executive Owner(s): MD of Simply Serve Limited

Strategic Priorities: P16: Complete the formal business case for collaboration with SFT P20: Support the development of local ‘Neighbourhoods’ P17: Refresh and align our digital transformation strategy with both the system digital and clinical strategy P21: Further develop virtual outpatients, virtual ward and other digital solutions developed during the pandemic P18: Implement EPMA & radiology Order Comms P22: Fully engage and collaborate in the formation of the Somerset ICS ensuring the voice of YDH and SHS is heard P19: Enhance and use our business intelligence capability to inform Trust and system planning

What is the risk to delivery? SR8: There is a risk that in a digital age heavy reliance on electronic systems may expose the Trust to risks around business continuity, data protection and internal systems reliance

What controls are in place to manage the risk to delivering the objective? What assurance do we have that our controls are working? 1) Monthly status update of outstanding business continuity 4) Annual Review of key risk areas, as part of our yearly IG and GDPR 1) Monthly meeting of the IG Steering Group work and projects with Simply Serve. submission progress (formerly the IG toolkit) identifying areas of risk 2) Updates to Board through Executive Director report 2) Ongoing Quarterly review and assessment of Infrastructure around security of patient or staff information and data. 3) Monthly review of progress against the Plan (IT Update Resilience measures in place, aligned with external 5) Interim IT Business Continuity Plan Meeting) penetration testing and security review. 6) Final IT Business Continuity Plan 4) Internal Audit Reports on GDPR and IT Security 3) Reporting to audit committee on technical measures and 7) Information Asset Register application 5) CIS Control Point Audit & Evidence tool near completion to processes that are in place to sustain a secure and resilient IT 8) CIS Control Point Audit & Evidence tool give assurance of review and evidence of all relevant security infrastructure. controls for IT

Are there any gaps in our controls (and what are we doing about them)? Relate to the actions below Are there any gaps in our assurance (and what are we doing about them)? Relate them to the actions below 1) Alignment with operational business continuity plans is to 3) Pending review of all operational areas, and their dependency on 1) IT Monthly Meeting does not have ToR, nor regular be completed digital solutions to feed into the Trust wide business continuity attendance from invited members of the team - RESOLVED 2) Assurance of regular review of relevant IT services and planning and development 2) Internal Audit Reports on GDPR and IT Security controls to ensure business continuity & data security in the event of an incident

Likelihood Consequence Rationale for overall risk rating: 3: Possible 3: Moderate Overall risk rating 9: Moderate Risk On technical review, our resilience against IT outages is high, and the Trust has an IT Business Continuity plan in place. Additional cyber security controls now in place, with ongoing work on Key: Controls and Assurances Overall target risk rating 5: Low Risk the CIS Audit tool to provide assurance of regular check and review of key IT areas and services. Whilst we have assurance that we understand the extent of our dependency on Digital across Assurance indicates poor effectiveness of controls. Immediate action is required for ongoing Low the Trust, we are exposed to coordination delays, or missed elements of our planning that could management of the risk Strength of controls Amber impact the level of care received by a patient during an outage. Some assurances in place or controls are still maturing so effectiveness cannot be fully Medium assessed at this moment but should improve. Strength of assurance Amber Risk Appetite Low - Risks Rated 1-6 Reasonable assurance provided over the effectiveness of controls. However, there are some High issues identified that if not addressed, could increase the likelihood of the risk materialising.

Strong No gaps in controls or assurances

Change in Risk - Overall risk rating Actions to mitigate risk and to fill the gaps in controls and assurance Jan 2020 Apr 2020 Jul 2020 Oct 2020 Dec 2020 Apr 2021 15 10 10 10 9 9 Action By who? By when? Progress Priority is set, and support provided to ensure delivery of an 20 1 IT Business Continuity INTERIM Plan IT Manager Jul 2020 INTERIM plan. Review of recent outage identified key supporting actions. 15 Interim Plan in Place Final Business Continuity Plan for IT, including links and IT Manager/ 10 2 dependencies to other Trust, external suppliers/vendors and full Director of Aug 2020 IT Business Continuity Plan now approved and in place map of operational dependencies on systems (internal/external) Transformation 5 System dependency Map - showing links to other systems and IT Operations A map of our clinical Software solutions and their interfaces 15 15 15 15 10 10 10 9 9 0 3 operational areas/department that have a dependency on digital Manager / EPRR Mar 21 through Integration engine is in place – and maintained through solutions Manager the Solution Development Team. Full list of IT Systems in use throughout the Trust now obtained from all Business Units. Consolidation and formatting work under way. Ongoing, list of systems now 80% complete IT Manager / IT Web application for control point system is 80% complete, COVID 4 Security Control Points Audit and Evidence System Feb 2021 Services Dept priorities have pushed back the completion date to Jul 2021 An Digital Asset Register to formally capture all data processing IT Operations Information Asset Register complete as a record system and live. relationships the Trust has, who the Information Asset Owner is, Manager / Data 5 Further enhancements scheduled for development and due to be the nature of the processing, and confirming it is compliant with Protection live Aug 2021 Data Protection Legislation Officer

Board Assurance Framework 2020-21

Strategic Objective: Innovate and Collaborate Monitoring group(s): Governance and Quality Assurance Committee Date last reviewed: 22/04/2021 As part of a sustainable Somerset care system, and working with our partners, we will develop and deliver outstanding services, employing new models of care and innovative technology. Executive Owner(s): Chief Executive & Chief Medical Officer

Strategic Priorities: P16: Complete the formal business case for collaboration with SFT P20: Support the development of local ‘Neighbourhoods’ P17: Refresh and align our digital transformation strategy with both the system digital and clinical strategy P21: Further develop virtual outpatients, virtual ward and other digital solutions developed during the pandemic P18: Implement EPMA & radiology Order Comms P22: Fully engage and collaborate in the formation of the Somerset ICS ensuring the voice of YDH and SHS is heard P19: Enhance and use our business intelligence capability to inform Trust and system planning

What is the risk to delivery? SR9: There is a risk of failure to agree and adopt new models of care and a clear clinical strategy across Somerset leading to increased demand and unsustainable services at YDH

What controls are in place to manage the risk to delivering the objective? What assurance do we have that our controls are working? 1) YDH and SFT merger process and governance 4) YDH Transformation team and system collaboration hub 1) YDH/SFT Strategic case and Full Business Case 2) Joint Executive Programme Board and Provider 5) Board to Board meetings 2) Feedback to Board on specific service change that has Development Committee 6) YDH 2030 Programme governance taken place 3) FfmF system vision 7) PLICS data 3) Board seminar sessions

Are there any gaps in our controls (and what are we doing about them)? Relate to the actions below Are there any gaps in our assurance (and what are we doing about them)? Relate them to the actions below 1) Integration of all enabling workstreams in support of the 3) Lack of a system wide digital strategy 1) Formal update reporting to the Board on service changes clinical strategy, especially digital and estates complete and benefits 2) Population health data and insight to inform quantification of impact

Likelihood Consequence Rationale for overall risk rating: 3: Possible 4: Major Overall risk rating 12: Significant Risk If new models of care are not rolled out across the organisation and local system, demand and workforce sustainability issues will continue to increase and services provided by YDH will Key: Controls and Assurances Overall target risk rating 6: Low Risk remain financially unsustainable. The system clinical vision developed as part of the Fit for my Future work is clear and there is a high level clinical strategy developing as part of the YDH/SFT Assurance indicates poor effectiveness of controls. Immediate action is required for ongoing Low merger process. management of the risk Strength of controls Amber

Some assurances in place or controls are still maturing so effectiveness cannot be fully Medium assessed at this moment but should improve. Strength of assurance Amber Risk Appetite Low - Risks Rated 1-6 Reasonable assurance provided over the effectiveness of controls. However, there are some High issues identified that if not addressed, could increase the likelihood of the risk materialising. Strong No gaps in controls or assurances

Change in Risk - Overall risk rating Actions to mitigate risk and to fill the gaps in controls and assurance Jan 2020 Apr 2020 Jul 2020 Oct 2020 Dec 2020 Apr 2021 12 12 12 12 12 12 Action By who? By when? Progress Develop a system wide digital strategy as part of the merger Director of 20 1 Oct 2021 work programme Transformation 15 YDH/SFT Continue engagement around the emerging clinical strategy and 2 Programme Oct 2021 development of specific plans 10 Board

3 5

15 15 12 12 12 12 12 12 4 0

Board Assurance Framework 2020-21

Strategic Objective: Innovate and Collaborate Monitoring group(s): Board of Directors Date last reviewed: 22/04/2021 As part of a sustainable Somerset care system, and working with our partners, we will develop and deliver outstanding services, employing new models of care and innovative technology. Executive Owner(s): Chief Executive

Strategic Priorities: P16: Complete the formal business case for collaboration with SFT P20: Support the development of local ‘Neighbourhoods’ P17: Refresh and align our digital transformation strategy with both the system digital and clinical strategy P21: Further develop virtual outpatients, virtual ward and other digital solutions developed during the pandemic P18: Implement EPMA & radiology Order Comms P22: Fully engage and collaborate in the formation of the Somerset ICS ensuring the voice of YDH and SHS is heard P19: Enhance and use our business intelligence capability to inform Trust and system planning

What is the risk to delivery? SR10: There is a risk of ineffective partnership working (and other factors) slowing the development of an Integrated Care System within Somerset

What controls are in place to manage the risk to delivering the objective? What assurance do we have that our controls are working? 1) System Leadership Board and ICS Executive Group 3) Regular reporting to YDH Board of Directors 1) Updates to Board of Directors 3) Reciprocal NED representation on all provider Boards 2) YDH engagement and leadership of 'Fit for my Future' 4) Provider Development Committee (PDC) 2) Somerset system designation as an Integrated Care System 4)Regular Board to Board and Exec to Exec meetings Programme workstreams 5) CEO OD Executive Programme in November 2020 5) YDH/SFT merger case

Are there any gaps in our controls (and what are we doing about them)? Relate to the actions below Are there any gaps in our assurance (and what are we doing about them)? Relate them to the actions below 1) Standardised reporting across the Somerset system 3) Maturity of personal relationships between key leaders 1) Standardised reporting across the Somerset system 2) Maturity ICS Governance structure 4) The development of the ICS is likely to impacted as a result of the 2) ICS Governance structure is in its infancy 3) Not currently a consistent vision agreed by all ICS partners COVID-19 pandemic

Likelihood Consequence Rationale for overall risk rating: 2: Unlikely 4: Major Overall risk rating 8: Moderate Risk The ICS designation process has enabled progress to be made in defining the high level ICS structure but there remains continued uncertainty about the impact of future legislative change; Key: Controls and Assurances Overall target risk rating 8: Moderate Risk Good progress is now being made relating to the YDH/SFT collaboration but there remains a lack of an agreed vision for the wider ICS . Assurance indicates poor effectiveness of controls. Immediate action is required for ongoing Low management of the risk Strength of controls Amber

Some assurances in place or controls are still maturing so effectiveness cannot be fully Medium assessed at this moment but should improve. Strength of assurance Amber Risk Appetite Moderate - Risks Rated 8-10 Reasonable assurance provided over the effectiveness of controls. However, there are some High issues identified that if not addressed, could increase the likelihood of the risk materialising.

Strong No gaps in controls or assurances

Change in Risk - Overall risk rating Actions to mitigate risk and to fill the gaps in controls and assurance Jan 2020 Apr 2020 Jul 2020 Oct 2020 Dec 2020 Apr 2021 12 12 12 12 8 8 Action By who? By when? Progress Complete the Assurance Process for the YDH/SFT strategic case November Strategic Case signed off by the Boards of both YDH and SFT. Work 15 1 and start work on the Full Business Case for submission in CEO 2021 commencing on Full Business Case November 2021 10 31 March 2 Complete the Strategic Case for merger between YDH and SFT CEO Complete; NHSE/I Assurance process underway 2021 Develop clear work programme between YDH and Somerset NHS 5 Joint Executive meeting monthly with work programme focussed FT Exec Team that demonstrates tangible actions in support of 3 CEO Ongoing around delivery of the strategic case; New Joint Chief Operating ICP working 12 12 12 12 12 12 12 8 8 Officer model in place across the two Trusts 0

Board Assurance Framework 2020-21

Strategic Objective: Innovate and Collaborate Monitoring group(s): Finance Resilience & Commercial Committee Date last reviewed: 26/04/2021 As part of a sustainable Somerset care system, and working with our partners, we will develop and deliver outstanding services, employing new models of care and innovative technology. Executive Owner(s): Director of Transformation

Strategic Priorities: P16: Complete the formal business case for collaboration with SFT P20: Support the development of local ‘Neighbourhoods’ P17: Refresh and align our digital transformation strategy with both the system digital and clinical strategy P21: Further develop virtual outpatients, virtual ward and other digital solutions developed during the pandemic P18: Implement EPMA & radiology Order Comms P22: Fully engage and collaborate in the formation of the Somerset ICS ensuring the voice of YDH and SHS is heard P19: Enhance and use our business intelligence capability to inform Trust and system planning

What is the risk to delivery? SR11: There is a risk that the volume of change activity leads to an inability to focus and deliver on priorities

What controls are in place to manage the risk to delivering the objective? What assurance do we have that our controls are working? 1) Weekly review of work programme, with escalation to Exec 3) Robust governance through Clinical Design Authority (CDA) making 1) Weekly meeting of the Transformation Leadership Team 4) Coordination of Trust wide implementations by Trust through of any issues key decisions, including go/no-go decisions on pilots, go-lives and 2) Updates to Board through Executive Director reports Emergency Planning and Business Continuity team implementations (including planned downtime) 3) Clinical oversight for key decisions impacting 5) Review of priorities by Execs to ensure number of simultaneous 4) Transformation team providing dedicated support to key projects operational/clinical areas (CDA). projects is realistic. 5) Exec oversees programme risks through dedicated Transformation sessions

Are there any gaps in our controls (and what are we doing about them)? Relate to the actions below Are there any gaps in our assurance (and what are we doing about them)? Relate them to the actions below 1) PowerHub, which will ensure greater visibility and coordination of projects, is due to be in use from May 2021

Likelihood Consequence Rationale for overall risk rating: 3: Possible 3: Moderate Overall risk rating 9: Moderate Risk Multiple go-lives or implementations can impact the ability to limit disruption to patient care. We must be careful to understand the volume of change, and the requirement on our front-line Key: Controls and Assurances Overall target risk rating 5: Low Risk staff to change aspects of their job role or responsibilities especially in the aftermath of COVID- 19 and recovery of elective services. We aspire to deliver high levels of transformation at YDH, Assurance indicates poor effectiveness of controls. Immediate action is required for ongoing Low and must not underestimate the toll that this level of change can have on our workforce. management of the risk Strength of controls Blue

Some assurances in place or controls are still maturing so effectiveness cannot be fully Medium assessed at this moment but should improve. Strength of assurance Blue Risk Appetite Low - Risks Rated 1-6 Reasonable assurance provided over the effectiveness of controls. However, there are some High issues identified that if not addressed, could increase the likelihood of the risk materialising.

Strong No gaps in controls or assurances

Change in Risk - Overall risk rating Actions to mitigate risk and to fill the gaps in controls and assurance Jan 2020 Apr 2020 Jul 2020 Oct 2020 Dec 2020 Apr 2021 6 9 9 9 9 9 Action By who? By when? Progress Implement PowerHub – cloud based programme management Associate Director November Implementation delayed by Covid. Now due for completion 1 10 solution of Transformation 2020 in May 2021 8 Establish Transformation Board to combine existing Director of September Now moving to monthly Transformation sessions with the 2 6 Improvement Board and Digital Board Transformation 2020 Execs to improve visibility and engagement. Recruitment of Digital Lead to oversee delivery against the plan, Director of 4 3 along with additional development resource and project Digital Lead in post April 2020 – COMPLETE. Transformation 2 managers, funded by HSLI fund. 9 9 6 6 9 9 9 9 9 0 4

Board Assurance Framework 2020-21

Strategic Objective: Develop a Sustainable System Monitoring group(s): Financial Resilience & Commercial Committee Date last reviewed: 15/04/2021 We will efficiently manage our resource to ensure the sustainability of our services and the local care system, whilst never compromising on safety and quality. Executive Owner(s): Chief Finance Officer

Strategic Priorities: P23: Meet our financial improvement trajectory and deliver the associated CIP and savings within the overall system P26: Maintain our focus on improving efficiency and productivity using best practice tools plan P27: Embed Improvement and change Methodology across the Trust P24: Implement and embed the YDH accountability framework P28: Position SHS as the at scale provider for primary care in Somerset and secure its sustainability within the Somerset P25: Continue to improve the culture of cost control and financial decision making system

What is the risk to delivery? SR12: There is a risk that we fail to deliver our control total and associated financial plans by not securing sufficient income for the Trust and not delivering our cost improvement and transformation plans

What controls are in place to manage the risk to delivering the objective? What assurance do we have that our controls are working? 1) Standing Financial Instructions and Scheme of Delegation 10) Effective cash management supported by ongoing monitoring of daily 1) Monthly reporting on financial position, performance 2) Robust process for development & approval of Annual Plan cash flow forecasts and forecast to FRCC and Board 3) Agreed commissioner income value reflected in the Annual 11) Planning, implementation and monitoring of plans to support savings 2) Assurance provided by Statutory Auditors and Internal Plan delivery Auditors 4) Contract management processes in place with 12) Appropriate controls across finance processes, e.g.. PTP, payroll 3) Monitored delivery of Financial Governance Review Commissioners5) Effective and accurate monthly 13) System financial planning and collaboration action plans management accounts reporting 14) Formal sign off of annual reference cost submission and active use of 4) Monthly monitoring of delivery of savings plans to 6) Monthly Executive Team Review and FRCC deep dive model hospital tool via the transformation team FRCC and through Transformation Board monitoring 15) PLICS strategic and operational delivery groups 5) Assurance Framework review meetings 7) Full engagement with System Directors of Finance Group 16) 20/21 financial plan 6) COVID-19 spend monitoring and NHSE/I review and 8) Appropriate supplier contract management 17) Financial Governance Review action plans approval 9) Approvals in respect of pay and non-pay expenditure 18) COVID-19 emergency financial arrangements for control and reporting including business cases

Are there any gaps in our controls (and what are we doing about them)? Relate to the actions below Are there any gaps in our assurance (and what are we doing about them)? Relate them to the actions below 1) Continued roll out of PLICS tool and effective use of 3) Complete review and update of governance, grip and control 1) Progress on financial governance review action plans information arrangements in line with Financial Governance Review actions has slowed due to COVID19 2) Further improvement to planning and capture of savings 4) 21/22 financial planning

Likelihood Consequence Rationale for overall risk rating: 3: Possible 4: Major Overall risk rating 12: Significant Risk Scored as possible due to continuing scale of uncertainty and complexity including unknown future NHS financial framework. Reduced from likely following confirmation of M7-12 Key: Controls and Assurances Overall target risk rating 5: Low Risk framework and H1 21/22 framework. Assurance indicates poor effectiveness of controls. Immediate action is required for ongoing Low management of the risk Strength of controls Blue

Some assurances in place or controls are still maturing so effectiveness cannot be fully Medium assessed at this moment but should improve. Strength of assurance Blue Risk Appetite Low - Risks Rated 1-6 Reasonable assurance provided over the effectiveness of controls. However, there are some High issues identified that if not addressed, could increase the likelihood of the risk materialising. Strong No gaps in controls or assurances

Change in Risk - Overall risk rating Actions to mitigate risk and to fill the gaps in controls and assurance Jan 2020 Apr 2020 Jul 2020 Oct 2020 Dec 2020 Apr 2021 12 4 16 12 12 12 Action By who? By when? Progress Oversight and delivery groups refreshed, roll out progressing 25 1 Full implementation and usage of PLICS data CFO 31 Oct 21 enhanced by speciality deep dives. Use cases and delivery plan 20 to maximise benefit in development. Slowed due to COVID19 CFO/Director of 21/22 plans in development through improved internal and 15 2 Full identification of 2021/22 savings schemes to meet gap 30 Jun 21 Transformation system process 10 21/22 H1 plan to be submitted 6/5. Awaiting national 5 20 20 16 12 4 16 12 12 12 3 Agreement of final financial plan and monitoring for 2021/22 CFO TBC confirmation of H2 planning requirements. Significant progress 0 on internal planning. 4 Delivery of financial governance review action plans CFO 31 Aug 21 Slowed due to COVID-19, actions now in progress

Board Assurance Framework 2020-21

Strategic Objective: Develop a Sustainable System Monitoring group(s): Governance and Quality Assurance Committee Date last reviewed: 22/04/2021 We will efficiently manage our resource to ensure the sustainability of our services and the local care system, whilst never compromising on safety and quality. Executive Owner(s): Chief Nurse & Chief Medical Officer

Strategic Priorities: P23: Meet our financial improvement trajectory and deliver the associated CIP and savings within the overall system P26: Maintain our focus on improving efficiency and productivity using best practice tools plan P27: Embed Improvement and change Methodology across the Trust P24: Implement and embed the YDH accountability framework P28: Position SHS as the at scale provider for primary care in Somerset and secure its sustainability within the Somerset P25: Continue to improve the culture of cost control and financial decision making system

What is the risk to delivery? SR13: There is a risk that we take decisions that compromise quality and safety in order to achieve financial balance

What controls are in place to manage the risk to delivering the objective? What assurance do we have that our controls are working? 1) Strong voice of Chief Nurse and Chief Medical Officer on 3) Quality, Outcome & Performance Monitoring 1) Quality, Outcome & Performance Monitoring 3) Patient and Staff Feedback Board & relevant committees 4) QIA's for all proposed CIP and Transformation 2) External Assurance 4) Incident and Near Miss Reporting 2) FTSU & Whistleblowing Policies 5) Clinical attendance at FRCC included as part of quorum

Are there any gaps in our controls (and what are we doing about them)? Relate to the actions below Are there any gaps in our assurance (and what are we doing about them)? Relate them to the actions below 1) Clinical input into senior system leadership structures 1) System decision making and QIAs

Likelihood Consequence Rationale for overall risk rating: 2: Unlikely 3: Moderate Overall risk rating 6: Low Risk Robust challenge welcomed and heard by Board with a commitment to protect patient and staff safety Key: Controls and Assurances Overall target risk rating 6: Low Risk Assurance indicates poor effectiveness of controls. Immediate action is required for ongoing Low management of the risk Strength of controls Green

Some assurances in place or controls are still maturing so effectiveness cannot be fully Medium assessed at this moment but should improve. Strength of assurance Green Risk Appetite Low - Risks Rated 1-6 Reasonable assurance provided over the effectiveness of controls. However, there are some High issues identified that if not addressed, could increase the likelihood of the risk materialising.

Strong No gaps in controls or assurances

Change in Risk - Overall risk rating Actions to mitigate risk and to fill the gaps in controls and assurance Jan 2020 Apr 2020 Jul 2020 Oct 2020 Dec 2020 Apr 2021 6 6 6 6 6 6 Action By who? By when? Progress Seek attendance by clinical representatives at systemwide Complete – Chief Nurse now sits on PDC and SFT/YDH 1 CEO Complete 8 meetings Programme Board Company 6 2 Chief Medical Officer & Chief Nurse to attend FRCC Ongoing Complete Secretary Add de-brief to end of Board of Directors meeting to ensure that 4 Company 3 voices have been heard and all are comfortable and in Ongoing Complete Secretary 2 agreement with decisions made. 6 6 6 6 6 6 6 6 0 4 Review and implement new Business Planning Programme CFO/DoT Ongoing In development

Board Assurance Framework 2020-21

Strategic Objective: Develop a Sustainable System Monitoring group(s): Financial Resilience and Commercial Committee Date last reviewed: 15/04/2021 We will efficiently manage our resource to ensure the sustainability of our services and the local care system, whilst never compromising on safety and quality. Executive Owner(s): Chief Financial Officer

Strategic Priorities: P23: Meet our financial improvement trajectory and deliver the associated CIP and savings within the overall system P26: Maintain our focus on improving efficiency and productivity using best practice tools plan P27: Embed Improvement and change Methodology across the Trust P24: Implement and embed the YDH accountability framework P28: Position SHS as the at scale provider for primary care in Somerset and secure its sustainability within the Somerset P25: Continue to improve the culture of cost control and financial decision making system

What is the risk to delivery? SR14: There is a risk of not delivering our strategic capital programme and therefore not continuing to develop our equipment and facilities

What controls are in place to manage the risk to delivering the objective? What assurance do we have that our controls are working? 1) Working closely with system to align objectives and agree 5) Strategic Estates Transformation Group develop and monitor 1) Reports to YEP Board on progress with major infrastructure 4) Masterplan review by Board of Directors priorities and delivery models; System estates priorities estates strategy projects and horizon scanning of opportunities; YEP Board 5) Capital Management Group quarterly reporting on delivery and agreed. 6) Managed equipment service contract in place covering diagnostic minutes to Board of Directors on a quarterly basis financials to FRCC 2) Yeovil Estates Partnership Board oversee internal major equipment replacement and development 2) Strategic Estates Transformation Group reports oversight of 6) Transformation Group oversight of digital strategy and delivery infrastructure developments 7) Capital Management Group (was Capex Group) now with focus on strategy and delivery 3) Estates Masterplan in place - updated/reviewed by Board monitoring scheme delivery and financials 3) Annual sign off of capital programme by Board of Directors, 4) Executive ownership of key initiatives 8) Transformation Group develop and monitor digital strategy following triangulation

Are there any gaps in our controls (and what are we doing about them)? Relate to the actions below Are there any gaps in our assurance (and what are we doing about them)? Relate them to the actions below 1) Refreshed capital governance structure to be taken 2) Improved planning of charitable spend on donated assets to align forward with strategic objectives

Likelihood Consequence Rationale for overall risk rating: 3: Possible 4: Major Overall risk rating 12: Significant Risk Should YDH not ensure that major capital/infrastructure developments are supported by the STP there would be significant implications for the delivery of the Trusts long-term clinical strategy Key: Controls and Assurances Overall target risk rating 6: Low Risk and maintaining delivery of core standards into the medium/long term. Assurance indicates poor effectiveness of controls. Immediate action is required for ongoing Low management of the risk Strength of controls Blue

Some assurances in place or controls are still maturing so effectiveness cannot be fully Medium assessed at this moment but should improve. Strength of assurance Blue Risk Appetite Low - Risks Rated 1-6 Reasonable assurance provided over the effectiveness of controls. However, there are some High issues identified that if not addressed, could increase the likelihood of the risk materialising.

Strong No gaps in controls or assurances

Change in Risk - Overall risk rating Actions to mitigate risk and to fill the gaps in controls and assurance Jan 2020 Apr 2020 Jul 2020 Oct-20 Dec 2020 Apr 2021 12 12 12 12 12 12 Action By who? By when? Progress Develop clear narrative to support understanding and prioritisation Chief Working with system partners as part of clinical strategy 15 1 of YDH schemes via the ICS, making explicit links to the system Operating Ongoing and aligning the YDH and SFT capital priorities strategy Officer 10 Work up outline business cases for major capital schemes YDH 2030 case under development; external support being Director of 2 (Integrated Urgent Care, Daycase Unit and Ward Redevelopment) to Ongoing pursued via SFT and the HIP2 Process; overseen by SETG Transformation 5 be ready should National capital become available Project Director appointed and workstreams progressing. Build external support from stakeholders for the YDH capital 3 CEO Ongoing Ongoing 12 9 12 12 12 12 12 12 schemes 0 4 Implement refreshed capital governance arrangements CFO/COO May 21 Proposal developed, approval - implementation in progress

Board Assurance Framework 2020-21

Strategic Objective: Develop a Sustainable System Monitoring group(s): Financial Resilience and Commercial Committee Date last reviewed: 15/04/2021 We will efficiently manage our resource to ensure the sustainability of our services and the local care system, whilst never compromising on safety and quality. Executive Owner(s): Chief Finance Officer

Strategic Priorities: P23: Meet our financial improvement trajectory and deliver the associated CIP and savings within the overall system P26: Maintain our focus on improving efficiency and productivity using best practice tools plan P27: Embed Improvement and change Methodology across the Trust P24: Implement and embed the YDH accountability framework P28: Position SHS as the at scale provider for primary care in Somerset and secure its sustainability within the Somerset P25: Continue to improve the culture of cost control and financial decision making system

What is the risk to delivery? SR15: There is a risk that the group’s subsidiary companies fail to deliver their plans which could undermine the Trust's strategic and financial plans

What controls are in place to manage the risk to delivering the objective? What assurance do we have that our controls are working? 1) Senior management teams within each subsidiary and 4) Agreement with Social Finance to support and finance SHS 1) Subsidiary level reporting to FRCC monthly clearly accountable Boards in place with NED chairs for SHS transformation 2) Quarterly scheduled updates to FRCC and SSL 5) Subsidiary financial performance reported separately to FRCC 3) Subsidiary highlight reports to Board on quarterly basis 2) Clear governance and reporting lines to YDH Board, with 6) Regular contract delivery meetings with SSL 4) Internal audit report on Subsidiary Management - areas of regular subsidiary highlight reports 7) Regular system engagement on future sustainability of SHS good practice identified. 3) Three year financial recovery plan for SHS developed and 5) Benefits realisation review of SSL agreed with Somerset CCG

Are there any gaps in our controls (and what are we doing about them)? Relate to the actions below Are there any gaps in our assurance (and what are we doing about them)? Relate them to the actions below 1) Key objectives for each subsidiary organisation not 2) Key static performance indicators for each subsidiary need for 1) Internal audit report on Subsidiary Management - 2) Benefits realisation review of SHS still to be completed formally measured against monitoring recommendations for improvements made

Likelihood Consequence Rationale for overall risk rating: 3: Possible 4: Major Overall risk rating 12: Significant Risk Scored as possible due to scale of uncertainty of costs and funding/income streams beyond H1 of 21/22. Key: Controls and Assurances Overall target risk rating 6: Low Risk Assurance indicates poor effectiveness of controls. Immediate action is required for ongoing Low management of the risk Strength of controls Blue

Some assurances in place or controls are still maturing so effectiveness cannot be fully Medium assessed at this moment but should improve. Strength of assurance Blue Risk Appetite Low - Risks Rated 1-6 Reasonable assurance provided over the effectiveness of controls. However, there are some High issues identified that if not addressed, could increase the likelihood of the risk materialising.

Strong No gaps in controls or assurances

Change in Risk - Overall risk rating Actions to mitigate risk and to fill the gaps in controls and assurance Jan 2020 Apr 2020 Jul 2020 Oct 2020 Dec 2020 Apr 2021 12 4 16 12 12 12 Action By who? By when? Progress SHS Strategic Plan to be developed which will set out how, over Plan developed but demonstrates continuing degree of risk. 20 1 the next three years, SHS becomes independently financially MD of SHS Oct 2019 Financial strategy developed and shared with system sustainable partners 15 YDH Accountability Framework approved by Board in June Recommendations identified from the BDO Internal Audit on Execs/Company 2020. Additional reporting of subsidiary company 2 Mar 2020 10 Subsidiary Management to be considered and implemented. Secretary performance and accounts to Board Assurance Committees. Annual Quality Report to be produced for SHS 5 Complete - SSL deep dive completed and assessment 3 Deep dive into SSL performance to be undertaken via FRCC CFO Sept 2020 undertaken against the original Business Case. On-going 16 16 16 12 4 16 12 12 12 0 monitoring via SSL Board and regular review by FRCC 4

Appendix: 6 REPORT TO: Board of Directors REPORT BY: Samantha Hann, Head of Risk & Litigation PRESENTED BY: Ben Edgar-Attwell, Company Secretary Jonathan Higman, Chief Executive EXEC SPONSOR: Shelagh Meldrum, Chief Nurse, Deputy Chief Executive & Director of People Corporate Risk Register Report REPORT TITLE: Quarter 4 2020/21 January – March 2021 DATE: 08 April 2021

Purpose of Paper (Please select any which are relevant to this paper)

☒ For Assurance ☐ For Approval / Recommendation ☒ For Information

The Board of Directors are ultimately responsible and accountable for the comprehensive management of risks faced by the Trust. They will: • agree the strategic objectives and review these on an annual basis • identify the principal risks which may prevent the Trust from achieving its key objectives Reason for • Presentation to receive and review the Corporate Risk Register via the Board and the Assurance Framework quarterly, which Committee / Board Assurance Committees identify the principal risks and any gaps in assurance regarding those risks • support the Trust’s risk management programme • review the Risk Management Strategy at regular intervals but as a minimum once every 3 years • approve Assurance Committee terms of reference annually Please note, this report covers corporate risks for both non-COVID19 related risks as well as COVID19 related risks.

Corporate Risk Register Reporting from April 2021

A review of the Trust’s risk reporting processes has been completed during Autumn and Winter 2020/21 to understand if further improvements could be made to ensure that all risks across the organisation and its services are appropriately managed and overseen by the various Board Assurance Committees, and ultimately by the Board of Directors. It was agreed by the Board of Directors in April 2021 that:

• Executive Committee: Following the introduction of the formal Executive Any Key Issues to Committee, the Corporate Risk Register will be scrutinised by the Note Committee prior to the end of each reporting quarter. This review will provide the opportunity for a review of all risks reaching corporate risk level, i.e. those risks scoring 12 or above using the 5x5 matrix.

• The review by the Executive Committee will include a moderation of the risk ratings provided, and provide an opportunity for the Executive Directors to highlight any significant or high risks that have not been included within the report.

• Board Assurance Committees: Each Board Assurance Committee (Governance and Quality Assurance Committee, Financial Resilience and Commercial Committee and Workforce Committee) will receive Corporate Risk Register reports with the specific risks assigned to them. The Committee will formally review and scrutinise the risks within their remit.

1

The Audit Committee will continue to receive the full Corporate Risk Register report. These reports will be received on a quarterly basis.

• To facilitate the revised arrangements outlined above the format of the Corporate Risk Register has been revised to focus on the risks specific to the reporting committee. The Executive Committee and the Audit Committee will continue to receive the report in its entirety; this is to support these Committees’ roles as defined within their individual terms of reference.

• The Board of Directors also considered the groups of risks which did not easily align with the current Board Assurance Committees. It was agreed risks scoring 12 or above which form part of the Corporate Risk Register within the following risk types would be reported through the Trust’s Governance Structure as follows:

Risk Type Designated Reporting Committee/Board Emergency Preparedness, Board of Directors Resilience & Response Fire Board of Directors Health & Safety Board of Directors Information Governance Audit Committee Sub Group (A new group to be established) Information Technology Audit Committee Sub Group (A new group to be established) Mortuary Governance & Quality Assurance Committee Patient Transport Governance & Quality Assurance Committee Procurement Financial Resilience & Commercial Committee Security Audit Committee

• In addition, the Corporate Risk Register report has introduced a second risk heat map into the report. This heat map is grouped by the Board of Directors risk categories, which were set by the Board of Directors in 2019 and provides a visual representation of the more detailed report which follows the two heat maps within the report.

Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) ☒ Care for our Population ☒ Develop our People

☒ Innovate and Collaborate ☒ Develop a Sustainable System

Implications/Requirements (Please select any which are relevant to this paper) ☒ Financial ☒ Legislation ☒ Workforce ☒ Estates ☒ ICT ☒ Patient Safety / Quality

Reference to CQC domains (Please select any which are relevant to this paper)

☐ Safe ☐ Effective ☐ Caring ☐ Responsive ☒ Well Led

Is this paper clear for release under the Freedom of Information Act 2000? ☒ Yes ☐ No

Executive Summary (Include the history, purpose of the report, any key issues to note and recommendations)

Overview

This risk report aims to provide details of the key risks within the remit of the Board of Directors detailed on the Trust’s corporate risk register (COVID19 related and non-COVID19 related) at the end of Quarter 4 2020/21. The report focuses on those risks scoring significant or higher (12+) on the risk matrix.

2

The risks to the organisation that falls within the remit of the Board of Directors during Quarter 4 2020/21 were:

• Risk 549 - Fire and smoke spread through logistics, bulk stores and the Medical Equipment library in the event of a fire with potential for loss of structural stability of upper floors. Risk Score – 12 (Significant Risk)

• Risk 584 - Uncontrolled smoke affecting Level 2 stores and Mortuary plus affecting supply to Level 3 Emergency Department causing evacuation of areas, loss of PPE storage and contamination of bulk stores stock Risk Score – 12 (Significant Risk)

Quarter 4 2020/21 Corporate Risk Register Changes

Since 1 January 2021, the changes within the Corporate Risk Register that relate to the specific risks under the remit of the Board of Directors are noted below:

Total Quarter 4 2020/21 Corporate Risk Register Update Number Risk Numbers of Risks Total number of new significant or high risks added 0 Not applicable Total number of risks previously scoring less than 12 which have increased within the Quarter & now form part 0 Not applicable of the Corporate Risk Register Total number of risks previously scoring 12 or above 0 Not applicable which have increased within the Quarter Total number of risks that have remained the same within 2 549, 584 the Quarter in terms of risk score Total number of risks which have reduced and no longer 0 Not applicable form part of the Corporate Risk Register Total number of risks which have been archived and no 0 Not applicable longer are on the live risk register

This risk report provides the necessary information for the Board of Directors that is a fundamental part of the Governance arrangements required by NHS Improvement, NHS England and the Care Quality Commission. The Board of Directors is asked to NOTE the report and the corporate risk register.

Access to the risk register on Ulysses can be found here

Quarter 4 2020/21 - Summary of the Risks

A summary of the risks detailed on the Trust’s Corporate Risk Register at the end of Quarter 4 2020/21 within the remit of the Board of Directors are detailed within this report.

3

Quarter 4 2020/21 Corporate Risk Register

Likelihood Rare (1) Unlikely (2) Possible (3) Likely (4) Certain (5)

Catastrophic (5)

549 Major (4) 584

Moderate (3)

Consequence Minor (2)

Negligible (1)

For grading risk, the scores obtained from the risk matrix are assigned grades as follows: 1-6 = Low Risk 8-10 = Moderate Risk 12-15 = Significant Risk 16-25 = High Risk

Movement Main Specialty Q4 2020/21 Q4 2020/21 of Risk / Second Current Score Target Score Total number of significant or high risks (12+) at the end of Qtr 4 2020/21 within Qtr Specialty

4 2020/21 2 Risks L x C = L x C = & Date Risk Lead & Updated Risk Owner

Continuity of Service Risks = 2 risks Risk of: Fire and Smoke spread through logistics, bulk stores and the Medical Equipment library in the event of a fire with potential for loss of structural stability of upper floors. The increase on materials to be stored due to COVID-19 has also caused overspill of storage into evacuation corridors and fire protected routes. 549 Fire / Due to: No fire barrier containment between sub compartment areas of the main bulk Procurement and logistics store areas on level 2

Resulting in: Loss of Materials Management Bulk store and Medical Equipment library Risk Lead – due to Fire with loss of equipment and service support area. Potential damage of floor 3 x 4 = 12 2 x 3 = 6 Adrian Pickles slab for Pharmacy and Pathology leading to department relocation Executive Lead Risk being managed by Simply Serve Ltd – Clive B The installation of a fire barrier in between Bulk Stores and the Equipment Library 12/03/2021 Radestock o has been placed into the Fire Capital funding for 2021-22 as part of an overall D request for significant funding for the backlog of fire safety works that is required within the hospital. The team are currently reviewing whether a water misting system can be fitted to the bulk storage areas to minimise fire damage. Risk of: Fuel loading in plant room from combustible material Due to: Bulk PPE storage in Plant room as there is no other space to hold stock Resulting in: The uncontrolled smoke affecting Level 2 stores and Mortuary plus Fire / 584 affecting supply to Level 3 Emergency Department causing evacuation of areas, loss of Procurement

PPE storage and contamination of bulk stores stock

Risk being managed by Simply Serve Ltd Risk Lead – 31/03/2021 3 x 4 = 12 2 x 3 = 6 There has been some progress within the quarter with a proportion of the PPE Adrian Pickles

having been moved off site. A shipping storage container is due to be delivered to Executive Lead B COVID19 site shortly which will store the remaining PPE. The EFM Team are erecting new – Clive o Risk plinths to allow the new unit to sit at the same level as the loading bay. As soon as Radestock D these works are finished the unit will be transported to site and installed allowing the majority of PPE to be stored effectively out of the plant room (ZPL12).

Alignment to the Board of Directors or Board Assurance Committees:

Audit Committee – AC, Board of Directors – BoD, Financial Resilience & Commercial Committee – FRCC, Governance & Quality Assurance Committee – GQAC, Workforce Committee – WC

Movement Main Specialty Current Score Quarter 3 Number of significant or high risks (12+) that have of Risk / Second on 31 March 2020/21 Risk REDUCED during Qtr 4 2020/21 within Qtr Specialty 2021 Score 4 2020/21 0 Risks and Date Risk Lead & L x C = L x C = Updated Risk Owner

There were no risks that formed part of the Corporate Risk Register which reduced during Quarter 4 2020/21 that fall within the remit of the Board of Directors.

Alignment to the Board of Directors or Board Assurance Committees:

Audit Committee – AC, Board of Directors – BoD, Financial Resilience & Commercial Committee – FRCC, Governance & Quality Assurance Committee – GQAC, Workforce Committee – WC

Risks which have been ARCHIVED during Quarter 4 2020/21 Main Specialty / Date

Second Specialty Archived 0 Risks

There were no risks that formed part of the Corporate Risk Register which were archived during Quarter 4 2020/21 that fall within the remit of the Board of Directors.

Alignment to the Board of Directors or Board Assurance Committees:

Audit Committee – AC, Board of Directors – BoD, Financial Resilience & Commercial Committee – FRCC, Governance & Quality Assurance Committee – GQAC, Workforce Committee – WC

Appendix: 7 REPORT TO: Board of Directors REPORT BY: Janet Ebdon, Learning from Deaths Manager PRESENTED BY: Meridith Kane, Chief Medical Officer EXEC SPONSOR: Meridith Kane, Chief Medical Officer REPORT TITLE: Learning from Deaths/Mortality Report DATE: 5 May 2021

Purpose of Paper (Please select any which are relevant to this paper)

☒ For Assurance ☐ For Approval / Decision ☐ For Information

Reason for Presentation to The Trust has implemented the required recommendations in Committee/Board implementing the National Guidance on Learning from Deaths. The Mortality Report includes summary tables for the Trust, which should be presented to the Board on a quarterly basis. This is a requirement of the National Quality Board Guidance on Learning from Deaths March 2017 and the NHS Improvement Implementing the Learning from Deaths framework, key requirements for Trust Boards July 2017.

Any Key Issues to Note The Quarter 4 report reflects the Medical Examiner role in identifying cases requiring further investigation through Mortality Reviews or Clinical Investigations. This allows effective feedback and sharing of learning from all sources of Mortality review. This process has also been extended to include patients with Learning Disability and those where COVID-19 has directly resulted in a patient’s death.

Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) ☒ Care for our Population ☒ Develop our People

☐ Innovate and Collaborate ☐ Develop a Sustainable System

Implications/Requirements (Please select any which are relevant to this paper) ☐ Financial ☐ Legislation ☐ Workforce ☐ Estates ☐ ICT ☒ Patient Safety / Quality

Reference to CQC domains (Please select any which are relevant to this paper)

☒ Safe ☒ Effective ☒ Caring ☐ Responsive ☒ Well Led

Is this paper clear for release under the Freedom of Information Act 2000? ☒sYe ☐ No Mortality Report Learning from Deaths

Quarter 4 2020/2021

Introduction In December 2016 the CQC report Learning, Candour and Accountability: A review of the way NHS Trusts review and investigate the deaths of patients in England, identified that learning from deaths was not given sufficient priority in some organisations and consequently valuable opportunities for improvements were being missed. In March 2017 the National Quality Board published national guidance on learning from deaths to initiate a standardised approach to learning which includes a number of recommendations to be included into Trust’s governance frameworks.

These recommendations included having a Director responsible for the learning from deaths agenda, a Non-Executive Director to take oversight of progress and implementing a systematic approach to identifying the deaths requiring review, with a robust methodology for case record reviews. Ongoing developments included specific guidance for NHS Trusts in working with families, published in July 2018 and the introduction of Medical Examiners who commenced their role in the Trust on 1st July 2020. The intention is to make sure that all deaths not investigated through the coronial process are subject to a degree of independent scrutiny, with increased transparency for the bereaved and an opportunity for them to raise concerns.

A review of the first year of NHS Trusts implementing the Learning from Deaths National Guidance was published by the CQC in March 2019. This document highlights the progress that has been made with implementation of the Learning from Deaths Programme as observed during the CQC well- led inspections. The report acknowledges the early progress and the need for cultural change in the NHS, especially in respect of engagement with families. The Trust Learning from Deaths Policy has been amended to reflect these developments and the outcomes reported within future quarterly reports.

The report highlighted several challenges for Trusts in the future. These include:

• Monitoring and evolving the role of the Medical Examiner, providing continuous safety improvement, and responding to complaints and concerns.

• Developing systems to allow learning from deaths that have occurred outside of a hospital, with effective information sharing across NHS providers.

• Improving support for staff as agreed across national bodies, including NHS Improvement and the Healthcare Safety Investigation Branch to enable them to carry out robust reviews and investigations of deaths and serious incidents.

The Trust also faces the additional challenge of setting up and maintaining additional processes to investigate and learn from cases where COVID-19 has been identified as the cause of death or a contributory factor. The Mortality processes and Medical Examiner Role link closely with the Post Infection Review (PIR) carried out for all patients with a hospital acquired COVID-19 infection confirmed by a positive test.

The South West Regional Healthcare Setting Outbreak Framework from NHS England and NHS Improvement – South West, highlights the need for formal reviews to capture learning from these cases. The guidance states that where there is any evidence that the COVID-19 infection may have been hospital-acquired and a death has resulted, there is scope for learning. If the infection was acquired due to issues in healthcare provision, such as non-compliance with IPC processes this is potentially a Serious Incident. The choice of format to capture learning remained a decision for each Trust. We have evolved a formal Post-Infection Review process, enabling inclusion of the initial review by the Medical Examiner and where required a full Mortality Review using the Structured Judgement Tool.

The Trust responded to new and emerging information and guidance as the pandemic evolved and adhered to all National Infection Prevention and Control Guidance. We adapted our practice in line with updated guidance, increasing the frequency of patient testing. Patients are now tested on day one, three and six of admission, and then weekly, or if there is a change in condition. This has changed the standard for identification of patients with a possible or definite hospital-acquired infection who require a Mortality Review.

The Quarterly Learning from Deaths report will confirm the Trust’s position in relation to these challenges as well as documenting our progress with the evolving systems used to identify and learn from a patient’s death.

The Trust Position

Mortality Rates. In hospital deaths per month

Summary Hospital-Level Mortality Indicator (SHMI)

The number of deaths in hospital is captured through the Summary Hospital-Level Mortality Indicator (SHMI). This reports mortality at Trust level using a standard and transparent methodology, which is published quarterly as a National Statistic by NHS Digital. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the Trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there. Our latest SHMI covering 12 months November 2019 to October 2020 is 86.96, which is statistically significantly lower than expected. The Trust percentage of spells with COVID-19 coding is 0.5% compared to the national average of 1.8%. This is an indication of the number of patients in hospital with a coded diagnosis of COVID-19 as a percentage of total activity. The relevance of this is the exclusion of this group of patients from the SHMI.

Hospital Standardised Mortality Ratio (HSMR)

The Trust uses Dr Foster to support analytical review of outcomes data. This includes reporting of the Hospital Standardised Mortality Ratio (HSMR), which reviews a set number of indicators to inform understanding of quality and improvements in clinical care. The Trust HSMR for the latest reporting period January to December 2020 is 91.8 remains statistically significantly lower than expected and lowest in the regional acute peer group. A weekday split shows our weekday HSMR statistically significantly lower than expected, with weekend figures within the expected range.

Dr Foster HealthCare Intelligence Mortality Data

Dr Foster provides external assurance, providing a monthly analytical review of outcomes data in respect of Mortality within the Trust. The latest Dr Foster report with a data set from January 2020 to December 2020 highlights the Trust’s position with both HSMR and SMR remaining statistically significantly low. Monitoring of our data reassures us that the reported figures are a true reflection of the current position.

The Dr Foster data also shows that we have maintained a high level of reporting of significant comorbidities. This positively affects our HSMR as this is calculated by comparing the number of expected deaths with the actual number of deaths. Patients with more comorbidities are by definition in a higher risk group for anticipated death.

There was one CUSUM Mortality alert originating in October and two in November, both reported by Dr Foster this month. CUSUM is short for cumulative sum and an alert occurs when the number of deaths, readmissions or activity within the Trust in a cohort of patients with the same coded condition, (taking account of their comorbidities) is higher than anticipated.

All mortality alerts are reviewed firstly by identifying the patients in the cohort and checking the accuracy of the code allocated to their case. If this does not show any issues an assessment of care and management from the patient records is completed. This allows us to ascertain why the alert has occurred and to identify any actions that should be taken to address any issues with the management of this group of patients. This process may result in the coding for the patient spell being amended if their main documented condition or cause of death has changed since their admission. Reviews are carried out through the Mortality Review Group or by the clinical teams involved, with the outcome fed back through the Clinical Outcomes Committee.

The CUSUM alerts in the quarter were one for occlusion or stenosis of pre-cerebral arteries and one for a statistically higher relative risk for non-hypertensive heart failure. There was also a recurrence of an alert for other perinatal conditions, last highlighted in the Dr Foster report from November 2020.

The first case from October (Occlusion of pre-cerebral arteries) was a patient who unfortunately died following a collapse at home leading to an admission of less than 24 hours. This case has been more effectively coded and had already been subject to an incident investigation.

The congestive heart failure, non-hypertensive alert showed 60 observed deaths in a 12-month period compared with an expected 44.6. The rolling trend showed a gradual increase resulting in a higher than expected relative risk. The COVID pandemic has resulted in a change in patient activity which has reduced the denominator data and the variation in the number of observed deaths in some diagnoses groups. This trend will be monitored as will the higher than expected relative risk for other perinatal conditions will also be monitored.

Learning from Deaths

The Process

In addition to the above reporting mechanisms it is important to provide a formal system to review the care and management of any patient who dies within the Trust. The Trust has appointed a Learning from Deaths Manager who holds responsibility for ensuring robust systems are used to identify and share learning form any death within the hospital.

The Structured Judgement Review Tool (SJR) from the Royal College of Physicians has been adapted to facilitate its use throughout the hospital. Formal mortality reviews are undertaken with data analysis used to inform improvements in care and provide reports to the Board.

The Mortality Review Group and the Learning from Deaths Manager oversee reviews of the management and care of all patients who have died within the hospital. A three-stage process is used with those patients requiring a formal review identified through the formal Medical Examiner interventions at the time of completing the death certification. • Mortality review 1 - An initial assessment completed by the Medical Examiner enables early identification of any case where a potential problem exists. For example, where the cause of death does not follow from the admission diagnosis or where a potential omission in care or poor management is identified. Any such case is referred to the Specialty Team or the Mortality Review group who are responsible for undertaking a detailed mortality review to identify any concerns and to ensure learning for improvement. This system ensures that all patient deaths are subject to an initial review of their management and care, with a small number going forward for a full formal Mortality or Clinical review.

• Mortality Review 2 - Cases identified for this type of review will undergo a full review via speciality Morbidity and Mortality meetings with presentation of any significant findings at local Clinical Governance Sessions. Outcomes from these meetings, in particular any learning and actions taken will be recorded through the Learning from Deaths Manager within the Structured Judgement Review tool. The SJR tool summarises each review with an avoidability score. This is used to determine whether the information identified during the review, shows any evidence that the patient’s death could have been avoided if different actions had been taken or the circumstances had been different. Any investigation undertaken outside of this process, for instance Serious Untoward Incident Investigations where death has occurred will now include an avoidability score as part of the investigation summary. This ensures all patient in hospital deaths can be categorised depending on the level of avoidability in each individual case regardless of the investigative process.

There are some groups of patient who will automatically be subject to a Mortality Review 2, regardless of any findings identified by the Medical Examiner. These are where the number of deaths in the specialty is small, where the patient had a Learning Disability and where there is evidence of a hospital acquired COVID-19 infection which has been cited as the cause or contributed to the death.

• Mortality Review 3 - The third stage of the process involves the referral of any patient whose Mortality review has identified a degree of avoidability greater than 50% to the Mortality Review Group for verification and action. The Medical Examiner may also refer cases direct for this level of review. These cases may also include those where an incident investigation has been undertaken which does not cover the patient’s death or where a case has been referred for a formal coroner’s inquest.

The current investigation processes continue where an incident has been reported, the Coroner is involved, or where other potential issues have been identified through the complaints or bereavement process. The Medical Examiners, Medical Examiner’s Officer and Learning from Deaths Manager liaise closely to avoid duplication and ensure that all deaths in hospital are reviewed at an appropriate level with outcomes, both positive and negative, recorded and shared.

The Trust’s Learning from Deaths Manager has responsibility for collating learning from all inpatient deaths whichever review method is used. Outcomes are reported through the Incident Investigation and Learning Group, Local Governance Meetings, the Mortality Review Group and the Clinical Outcomes Committee as well as being summarised within this quarterly report.

The Mortality Review Group has experienced difficulties in meeting to facilitate case reviews due to the Covid restrictions, as a formal review of records cannot be completed in a virtual setting. The group has reformed with new ways of working introduced to ensure that the quality and quantity of formal reviews is not adversely affected. Virtual meetings to provide feedback from the month’s reviews and to collate learning have been introduced.

Update from the Medical Examiner

The introduction of the Medical Examiner Role in 2020 has helped to formalise the above systems.

• Plans for all patients who die in the hospital to have a notes review by the Medical Examiner has not yet been possible due to the number of available Medical Examiner sessions. • The majority of deaths are scrutinised and assessed to identify any issues for referral. A discussion also occurs with the doctor responsible for completing the Medical Certificate of Cause of Death (MCCD). This may prompt learning for the individual doctor and can serve to reduce the possibility of the documented cause of death being rejected by the Registrar’s Office.

• There will be a conversation between the Medical Examiner Officer or Medical Examiner and the patient’s Next of Kin to explore any care concerns that they may have. This allows the team to identify any potential issues and to address these at an early stage.

Quarter 4 Review Outcomes

Quarter 4 saw 171 inpatient deaths scrutinised by the Medical Examiner. These would be classified as a Mortality Review at level 1 as described above. Of these cases 19 were referred for a full review using the Structured Judgement Tool, 9 to be completed through the Mortality Review Group and 10 by the clinical teams.

Of those cases referred to the Coroner for agreement about the cause of death, the vast majority resulting in a form 100A being issued. This means the Coroner was informed of the death but the doctor has been given permission by the coroner to issue the Medical Certificate and the Registrar is advised that the Coroner has been made aware of the death but no further investigation is necessary.

Coronial Activity There are cases where the coroner has requested investigative statements from staff in relation to the death of an inpatient or where the patient had a recent admission or procedure that could be relevant to their death. 2 new instructions were received relating to deaths in quarter 4 and one from a death in the previous quarter. One patient had an out of hospital arrest 6 days following discharge with a possible MI or Pulmonary Embolism. One was a fall at home sustaining a subdural haematoma and the third a fall sustaining fractured ribs and pneumothorax whereby the patient refused admission following initial assessment by the paramedics. Formal statements have been obtained with no omission or care problems identified that would be considered to have contributed to the death. No inquests were held in the quarter requiring Trust attendance but one complex case has been subject to an initial Pre-inquest review meeting with the Dorset Coroner.

Learning Disability Deaths

Two patients with a Learning Disability died in the quarter. These deaths have been reported in line with national requirements and will be reviewed as part of the Trust’s formal process and referred externally for a full LeDeR review. Following the changes to the current process these cases will be subject to a full Mortality Review (MR2) using the Structured Judgement Tool. No immediate actions have been identified and the deaths are not believed to be as a consequence of concerns about hospital care.

Neonatal and Maternal Deaths

CNST requires that cases and actions reviewed using the Perinatal Mortality Review Tool (PMRT) are reported to Trust Board quarterly. The PMRT facilitates a comprehensive, robust and standardised review of all perinatal deaths from 22+0 gestations (excluding terminations) to 28 days after birth; as well as babies who die after 28 days following neonatal care. Review is undertaken by a multidisciplinary panel of clinicians which has to include a panel member who is external to the unit.

The web-based tool presents a series of questions about care from pre-conception to bereavement and follow-up care. The factual information is entered in advance of a multidisciplinary panel of internal and external peers (allowing for a ‘Fresh eyes’ perspective) review of cases. The tool is used to identify required learning with action plans generated, implemented and monitored.

Two intrauterine deaths and one neonatal death occurred in quarter 4. These will be subject to PMRT panel reviews with the findings shared in future Learning from Death reports.

There has been a requirement to review one case in quarter 4; the case was an intrauterine death at 28 weeks gestation with history of prolonged rupture of membranes. PMRT findings have identified learning from this case – detailed below.

This table provides the number of deaths in month against the number reviewed using any of the investigative processes available. Please note there is a delay in accurate reporting of in-quarter reviews due to the time frames of external surveillance data from Dr Foster and the mortality review process . This table will be updated quarterly.

Green line indicates the point where the Medical Examiners process was introduced

2019/20 2020/21 and mortality review process changed. Q3 Q4 Q1 Q2 Q3 Q4 Oct Nov Dec Jan Feb Mar April May June Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Total Total Total Total Total Total deaths in the Trust (including ED 64 51 46 162 88 67 71 226 61 51 55 167 37 53 51 141 52 81 96 229 104 76 57 237 deaths) Number subject to a Level 1 N/A N/A N/A N/A N/A N/A N/A N/A N/A 33 47 51 131 49 62 58 169 85 49 37 171 Mortality Review Number subject to a Level 2/3 18 18 16 52 28 15 17 60 6 7 3 16 5 6 4 15 7 14 17 38 5 13 1 19 Mortality Review Number investigated as a 0 0 0 0 1 1 0 2 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 Serious Incident Learning Disability deaths 0 0 0 0 0 2 0 2 4 1 0 5 0 1 0 1 0 0 1 1 0 1 1 2 Bereavement concerns 2 1 2 5 4 1 0 5 0 0 2 3 0 1 0 1 0 0 0 0 0 0 0 0 Coroner’s Inquest 2 1 1 4 2 2 3 7 2 2 0 4 0 3 3 6 3 1 2 6 0 1 1 2 investigations Number thought more likely than not to be due to 0 1 1 2 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 1 problems with care

It should be noted that scrutiny of all patient deaths by the Medical Examiner and the resultant change in process means that comparative data is not yet available for all types of investigative review. Where available retrospective data has been added to the above chart.

In Q4 171 cases were reviewed by the Medical Examiner as a first level Mortality Review and 23 deaths were subject to a full case review • 19 were subject to a level 2 Mortality Review using the SJR tool • 2 cases were referred for a LeDeR review following initial local review. • No cases were reviewed where bereavement concerns were raised and 2 will be reviewed as part of the coronial process.

For those reviews undertaken using the Structured Judgement Tool in Quarter 4 (and the updated cases from the previous quarter), there was one case scoring 3 and one scoring 4 with all other cases scoring 5 or 6. The two potentially avoidable deaths have been referred back to the clinical team to provide further information and ensure actions to mitigate a recurrence have been taken.

This data is summarised in the following charts:

It should be noted that these figures relate to Level 2 case reviews performed using the Structured Judgement Tool only with the previous quarter update in place.

Overall Findings from case reviews completed using the Structured Judgement Tool

Quarter 4 2020/21- Quality of Care

Care Concerns Identified rolling year to date

Level of avoidability of death in each case reviewed - Rolling data 2019-2021

Structured Judgement Tool Avoidability Score 1 – Definitely avoidable 2 - Strong possibility of avoidability 3 – Probably avoidable greater than 50% 4 - Possibly avoidable less than 50% 5 - Slight evidence of avoidability 6 - Definitely not avoidable

All in hospital deaths can provide information about the individual patient’s care and management. Alongside the formal mortality review process learning can take many forms and be identified through many sources including those detailed above;

• Serious Incident Reviews • Complaints and bereavement concerns • Medical Examiner reviews • Coronial activity • Learning Disability Reviews (LeDeR) • Perinatal Mortality Reviews. • Child Death Review processes. • Review of COVID-19 related deaths

The Trust has developed processes to identify any care and service delivery problems within the group of patients where a COVID-19 infection has contributed to or caused their death. This is important as the number of deaths increases both nationally and within the Trust. Current data shows that in the first wave (March to June 2020) 29 patients had COVID-19 listed as a cause or contributory factor on their death certificate. With an additional 106 patients in this position since November 2020. These numbers include hospital-acquired infections and those patients admitted with a positive status. Outcomes of reviews for hospital-acquired cases will be reported in the future Learning from Deaths report.

It is important to identify themes and trends from all of the available information to enable Trust wide learning and address any issues that have been identified.

Themes from mortality reviews and investigations including Coroners referrals undertaken within the quarter:

Of the deaths reviewed using the Structured Judgement Tool so far in the quarter:

• There were no significant issues with the quality of documentation in the quarter.

• One case identified care issues and delays that may have contributed to a patient’s death (Score 3).

• The Medical Examiner role continues to allow targeted clinical reviews to take place.

• Outcomes of Clinical Notes reviews requested by the ME have been discussed at Specialty Governance Meetings

Issues positive and negative:

• Timely and appropriate DNAR discussions and decisions were made.

• Cases where a hospital acquired COVID-19 infection has been identified and linking to a patient’s death require formal review including a first level mortality review. To date our Infection Prevention and Control reviews have not identified any care and service delivery problems or any specific events where there is evidence that this would have contributed to the outcome or transmission of Covid 19

• Delays in diagnostic tests and commencement of antibiotics due to difficulties with cannulation. Not escalated in order to resolve issue.

• Surgical procedure necessitating withhold of anticoagulation with unclear plan for recommencement potentially contributed to patient death from pulmonary embolism.

• Potential delays due to COVID-19 restrictions leading to lack of management plan and ongoing treatment.

Lessons Learned:

• There is a need to provide effective formal review of patients who have died as a result of a COVID-19 infection, particularly if this is hospital-acquired. Formal SJR using retrospective review of patient records does not identify any infection control issues. Post-Infection Reviews incorporating Mortality elements have been required.

• Continued review of anticoagulation guidance is required to ensure that patients are aware of the need to recommence medication appropriately and report any complications in a timely manner.

Actions Taken:

• As a consequence of the challenges and changing guidance relating to the COVID-19 pandemic there has been increased cleaning regimes, continued access to personal protective equipment (PPE) for all staff as required, continual review of patient pathways and substantial environmental improvements.

• Development of a Post-Infection Review and Duty of Candour templates to capture and share relevant data.

• Review of patient information in relation to withholding medication to facilitate day case procedures.

• Measures are already in place to facilitate continued non-covid activity and encourage patients to report symptoms and attend the hospital.

Themes and Trends from PMRT reviews

Recent learning from previous case reviews has centred on:

• Smoking in the family home is a common theme running through PMRT outcomes with local and national drive to aid improvement. There is currently no fail safe system for partner referrals. The referral process will be amended to make sure this is followed up in the future and included in a compliance audit.

• Unit learning action plans from PMRT continue to focus on documentation. Especially documentation of routine assessments and expectations such as discussions around risk assessment for need of aspirin and enquiry about domestic abuse.

This information concludes the Quarterly Mortality and Learning from Deaths report for Quarter 4.

Appendix: 10 REPORT TO: Governance and Quality Assurance Committee REPORT BY: Freedom to Speak up Guardians Shelagh Meldrum, Deputy Chief Executive/Chief Nurse & Director of PRESENTED BY: People Shelagh Meldrum, Deputy Chief Executive/Chief Nurse & Director of EXEC SPONSOR: People REPORT TITLE: Freedom to Speak Up Guardian Q4 2020/21 Report DATE: 28 April 2021

Purpose of Paper (Please select any which are relevant to this paper)

☒ For Assurance ☐ For Approval / Decision ☒ For Information

Reason for Presentation to In February 2015, Sir Robert Francis published his final report which Committee/Board made a number of key recommendations under five overarching themes with actions for NHS organisations and professional and system regulators to help foster a culture of safety and learning in which all staff feel safe to raise a concern. One key element was the appointment of a local Guardian in each Trust.

This report summarises the concerns raised with the Trust Freedom to Speak Up Guardian during Quarter 4 2020/2021.

Any Key Issues to Note

Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) ☒ Care for our Population ☒ Develop our People

☐ Innovate and Collaborate ☐ Develop a Sustainable System

Implications/Requirements (Please select any which are relevant to this paper) ☐ Financial ☐ Legislation ☒ Workforce ☐ Estates ☐ ICT ☒ Patient Safety / Quality

Reference to CQC domains (Please select any which are relevant to this paper)

☒ Safe ☒ Effective ☒ Caring ☒ Responsive ☒ Well Led

Is this paper clear for release under the Freedom of Information Act 2000? ☒ Yes ☐ No

Freedom to Speak Up (F2SU) Guardian 2020/2021 Quarter 4 Report

Background

Freedom to Speak Up (F2SU) Guardians are staff based in local NHS Trusts. Their role is to work with Trust leaders to create effective local processes to enable staff to raise concerns about patient safety and to advise and support staff who seek to do so.

In his review of care concerns at Mid Staffordshire Foundation Trust, Robert Francis, QC found that staff are reluctant to raise concerns due to; • The potential impact on their own career • The fear of being labelled a trouble maker • Loyalty to colleagues – who may be implicated • A lack of confidence that raising a concern will make a difference

QC Francis noted that the impact on those who have raised concerns has been considerable, specifically; • Serious impact on mental health • Reduced career chances

Activity in Quarter 4

Date Theme Staff Details Actions Status (see key) Group

None

Themes Key:

Q&S = Quality & Safety, PPP = Policies, Procedures & Processes, PE = Patient Experience, A&B = Attitudes & Behaviours, SL = Staffing Levels, PC = Performance Capability, SC = Services Changes, MB = Manager Behaviour, O = Other

Reports remained open from previous period

Date Theme Staff Group Details Actions Status (see key)

30/11/2020 A&B Clinical/AHP Staff member HR Open unhappy with job Investigation role. Felt had been taken place and misled and outcome letter experiencing created for inequality in their person who role. raised concern. Unable to meet with party to ensure all concerns have been addressed.

Team Development in Quarter

Guardians attending twice monthly regional catch up meetings as and when they can. Meeting arranged between YDH and Somerset guardians as merger of trusts in future. Guardians looking to reinvigorate FTSPU at YDH. Meeting to look at new recording process on Y cloud and advertise new Guardians across Trust.

Fiona Rooke, Deb Matthewson, Yvonne Thorne and Emma Symonds. Freedom to Speak up Guardians

Appendix: 9 REPORT TO: Board of Directors REPORT BY: Andrew Newton, Guardian of Safeworking PRESENTED BY: Merry Kane, Chief Medical Officer EXEC SPONSOR: Merry Kane, Chief Medical Officer REPORT TITLE: Q4 2020/21 Guardian of Safeworking Hours Report DATE: 5 May 2021

Purpose of Paper (Please select any which are relevant to this paper)

☒ For Assurance ☐ For Approval / Decision ☒ For Information

Reason for Presentation to The Guardian of Safe Working is a role required by the 2016 Junior Committee/Board Doctor Contract. The Guardian of Safe Working (GoSW) acts as a champion of safe working hours for trainees, received exception reports from doctors who have exceed their rostered hours, been unable to undertake training opportunities or have safety concerns. The GoSW works to resolve the issues raised in exceptions reports and implement and distribute fines as outlined within the Junior Doctor Contract where necessary.

The Board or a committee of the Board is required to receive a quarterly report from the GoSW and to date these have been received either in the Workforce Committee and noted at the Board of Directors or taken directly to board.

The Committee are asked to NOTE this report. Any Key Issues to Note

Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) ☒ Care for our Population ☒ Develop our People

☐ Innovate and Collaborate ☐ Develop a Sustainable System

Implications/Requirements (Please select any which are relevant to this paper) ☒ Financial ☒ Legislation ☒ Workforce ☐ Estates ☐ ICT ☒ Patient Safety / Quality

Reference to CQC domains (Please select any which are relevant to this paper)

☒ Safe ☒ Effective ☐ Caring ☒ Responsive ☒ Well Led

Is this paper clear for release under the Freedom of Information Act 2000? ☒ Yes ☐ No

YDH Guardian of Safeworking Hours Quarterly Report – October to December 2020 (Q3)

Exception Reports at YDH – Historical Perspective

• Allocate was introduced to Yeovil District Hospital NHS Foundation Trust in 2016. • From 06th December 2016 up until the reporting date we have received a total: 790 Exception Reports.

50 Exception Reports - By Type Ho 40 30

20

10

0 Jun-17 Jun-18 Jun-19 Jun-20 Oct-17 Oct-18 Oct-19 Oct-20 Apr-17 Apr-18 Apr-19 Apr-20 Feb-17 Feb-18 Feb-19 Feb-20 Feb-21 Dec-16 Dec-17 Dec-18 Dec-19 Dec-20 Aug-17 Aug-18 Aug-19 Aug-20 Hours Education Service Support

Change to Data Reporting Format

• Changes in the Allocate Software have led to a change in the Data Output Format

Exception Reports for October 2020 – December 2020 (Q3)

70

60

50

40

30

20

10

0 Oct-Dec 2019 Jan-Mar 2020 April-June 2021 July- Sept 2020 Oct-Dec 2020 Jan-Mar 2021 Total number of exception reports received Number relating to hours of working Number relating to educational opportunities Number relating to service support available to the doctor

Exception reports for October - December 2020 8

7

6

5

4

3

2

1

0 Hours Education Service Support

Jan-21 Feb-21 Mar-21

Immediate Safety Concerns

In the past three months, there have been no Exception Reports that were raised by the originator as being of “Immediate Safety Concern” (ISC).

Live Reports

• As of 1 April 2021 – 0 Reports were live

Exception Reports by Rota

Exception Reports - By Month and Rota 30

25

20

15

10

5

0 Jun-17 Jun-18 Jun-19 Jun-20 Oct-17 Oct-18 Oct-19 Oct-20 Apr-17 Apr-18 Apr-19 Apr-20 Feb-17 Feb-18 Feb-19 Feb-20 Feb-21 Dec-16 Dec-17 Dec-18 Dec-19 Dec-20 Aug-17 Aug-18 Aug-19 Aug-20

Anaes F1 ED F1 ED F2 & GP Gen Med F1 Gen Med F2 GP CT & TF Gen Med ST3+ Paeds F1 Paeds F2 & GP Paeds ST3+ Gen Surgery F1 Ortho/Surg F2/TF O+G F2/GP/TF

Exception Reports – By Rota (Q3) 2020-21

Exception Reports for the Quarter By Rota N =28 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0

Jan-21 Feb-21 Mar-21

Exception Reports – By Type 45 40 35 30 25 20 15 10 5 0 Jun-17 Jun-18 Jun-19 Jun-20 Oct-17 Oct-18 Oct-19 Oct-20 Apr-17 Apr-18 Apr-19 Apr-20 Feb-17 Feb-18 Feb-19 Feb-20 Feb-21 Dec-16 Dec-17 Dec-18 Dec-19 Dec-20 Aug-17 Aug-18 Aug-19 Aug-20 Hours Education Service Support

Report Processing Times – 2020-21 (Q2)

In the three months January – March 2021 • 2 were open for > 7 days • 15 were open for < 7 days (88%)

There has in general terms been a sustained improvement in ES/CS response times over the past two years, now the most common reason for a delay in closing an Exception Report is the time taken for the trainee to sign off any resolution that is proposed. Of the 2 reports that were open for more than 7 Days all were as a result of waiting for the Trainee to agree to the proposed actions

Trend/Themes

• The vast majority of Exception Reports raised at YDH relate to Overtime Hours. • The ‘Medical’ Teams account for the vast majority of the overtime hours claimed for. • Since COVID started having an impact the total number of claims for Overtime have dropped.

Trainee Doctors – at YDH

• Number of doctors in training (total) at YDH is 78 • Number of doctors in training at YDH on the 2016 T&CS is 78 (100%)

Rota Gaps

January: • X1 ST3 LAS Care of the Elderly

February: • X1 ST3 LAS Care of the Elderly

March: • X1 ST Paediatrics

Guardian of Safe Working Fines The secondary limits that attract a fine are • a doctor working more than an average of 48 hours per week in any 3 month period • a doctor working more than an absolute maximum of 72 hours in any given week • a doctor getting less than getting 8 hours rest between shifts • a doctor missing more than 25% of rest breaks in any 4 week period. • There have been no fines imposed at YDH in the Period January 2021 – March 2021 • (Historically there have been no fines imposed at YDH since the start of Exception Reporting)

Summary

There is consistent evidence that working hours for trainee doctors at YDH are safe, as they relate to the 2016 T&Cs and the hour’s limits set out by those T&Cs.

The vast majority of Exception Reports raised at YDH relate to Overtime Hours The ‘Medical’ Teams account for the vast majority of the overtime hours claimed for – this is still a persisting theme and remains a cause for concern.

Appendix: 10 REPORT TO: Board of Directors REPORT BY: Finance and Management Information Departments PRESENTED BY: Executive Directors EXEC SPONSOR: Executive Directors REPORT TITLE: Board Overview Quadrant DATE: 5 May 2021

Purpose of Paper (Please select any which are relevant to this paper)

☒ For Assurance ☐ For Approval / Decision ☒ For Information

Reason for Presentation to This Board Overview Quadrant provides an overview of the Trust’s Committee/Board performance on finance, quality, performance and workforce indicators, including: . Income . A&E waiting times . Top up funding from NHS . Ambulance handover times England . RTT waiting times . Pay . Diagnostic waiting times . Non-pay . Cancer waiting times . Depreciation, Interest, PDC, . Infection control Impairments . Mortality . Financial Improvement . Incidents / Never Events Trajectory basis . Complaints and concerns . Donated Assets and . Friends and Family Impairment response rate . SOCI Position . Stroke performance . CIP Achievement . Readmissions . Capital . Staff turnover . Cash Balance . Staff vacancies . Appraisal rates

Members are asked to NOTE the report for assurance and information.

Any Key Issues to Note

Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) ☒ Care for our Population ☒ Develop our People

☒ Innovate and Collaborate ☒ Develop a Sustainable System

Implications/Requirements (Please select any which are relevant to this paper) ☒ Financial ☐ Legislation ☒ Workforce ☐ Estates ☐ ICT ☒ Patient Safety / Quality

Reference to CQC domains (Please select any which are relevant to this paper)

☒ Safe ☒ Effective ☒ Caring ☒ Responsive ☒ Well Led

Is this paper clear for release under the Freedom of Information Act 2000? ☒ Yes ☐ No

YEOVIL DISTRICT HOSPITAL FOUNDATION TRUST PERFORMANCE QUADRANT

FINANCE Mar-21 SAFETY AND PATIENT EXPERIENCE Mar-21

£0.206m in £0.225m adv to £0.044m year £0.044m year end fav to Indicators Mar-21 Mar-20 6 Month Avg Movement month deficit in month plan end surplus financial trajectory HSMR (Latest available - Feb-20 to Jan-21) 0.95 0.83 -- -- Patient Falls 59 70 79.3 i Pressure Ulcers 3 7 4.3 i In Month (£'000s) YTD (£'000s) C.Diff (Lapse in Care) 0 0 0 g Variance to Variance to Trust Category - Core items Actual Actual E.Coli Gram Negative Blood Stream Infections 1 1 0.83 h Trust Plan Plan Income (Including Top funding from NHSE/I) 23,951 6,338 211,381 6,563 MRSA 0 0 0 g SIREN and COVID referred testing 177 177 889 889 Incidents reported 832 656 870 i Pay - Substantive, Bank & Agency (17,201) (5,601) (138,347) (4,583) Number of never events 0 0 0.00 g Non-pay - Consumables, Drugs, Other (6,635) (1,219) (67,594) (3,587) Number of prescribing errors causing harm 3 0 0.50 h Depreciation, Interest, PDC, Impairments (498) 79 (6,285) 762 Number of maternity serious incidents 1 0 0.16 h Financial Improvement Trajectory basis (206) (225) 44 44 VTE risk assessment completed on admission 94.59% 92.67% -- h Donated Assets and Impairment 1,982 1,995 1,945 2,031 Complaints 7 2 6 h PALS Concerns 28 47 44 i Additional items Actual Variance Actual Variance Inpatients Friends and Family Test Response Rate (Statutory Return) * -- 0.00% -- -- CIP Achievement (to draft new year budget) 407 92 2,714 353 CIP % achieved recurrent 79% Inpatients Friends and Family Test Likely to Recommend (Statutory Return) * -- 0.00% -- -- Pay - Agency (778) (85) (9,422) (669) Capital expenditure (5,014) (11,589) Rate of readmissions for the same clinical condition (% of total number of admissions) 5.35% 4.97% -- i Better Payment Practice Code (BPPC) 95%

Number of same day cancelled operations for non-clinical reasons 1 5 -- i

Safe Staffing nurse fill rate (Number of wards at < 80% establishment) 0 0 -- g * The collection of the Friends and Family test has been temporarily suspended due to the coronavirus outbreak

PERFORMANCE Mar-21 PEOPLE Mar-21

Indicators Actual Local Target National Standard Movement RAG (Local) Indicators Mar-21 Mar-20 Target Movement RAG i i A&E 4 hour Waiting Times 95.36% 95.0% 95.0% 1 Turnover 13.95% 16.40% 12%-17% Ambulance Handover Times -- 98.0% 98.0% h Registered Nursing Vacancies (% of Whole Time Equivalent) 0.00% 1.31% 5.00% i RTT - Incomplete Pathways Waiting Times 64.83% -- 92.0% h Medical & Dental Vacancies (% of Whole Time Equivalent) 2.43% 3.69% 5.00% g Diagnostics - 6 Weeks Waiting Times 93.73% 99.0% 99.0% i Other vacancies (% of Whole Time Equivalent) 2.87% 3.94% 2.00% h Cancer - 2WeekWait - Waiting Times (Feb-21) 94.46% 93.0% 93.0% h Total Vacancies (% of Whole Time Equivalent) 1.85% 3.02% 2.00% h Cancer - 2WeekWait - Breast Symptoms (Feb-21) 100.00% 93.0% 93.0% h 12 month Absence Rate (month in arrears) 3.66% 3.20% 3.00% i Cancer - 28 Day Diagnosis - 2WeekWait (Feb-21) 78.29% -- TBC h Mandatory Training Rate 88.11% 86.89% 85.00% h Cancer - 28 Day Diagnosis - Breast (Feb-21) 100.00% -- TBC h Staff Appraisal Rate 86.15% 85.32% 90.00% h Cancer - 31 day Treatment Waiting Times (Feb-21) 100.00% 96.0% 96.0% h Agency Spend in Month against ceiling (£000's) £778 £526 £470 Cancer - 62 day Standard Waiting Times (Feb-21) 89.72% 85.0% 85.0% h Agency Spend YTD against ceiling (£000's) £9,195 £6,673 £5,640

RAG Status: Local Target achieved,Target failed - within 1% of local target, Target failed - more than 1% away from achieving local target

Appendix: 11 REPORT TO: Board of Directors REPORT BY: Finance and Planning Teams PRESENTED BY: Sarah James, Chief Finance Officer EXEC SPONSOR: Sarah James, Chief Finance Officer REPORT TITLE: 2021/22 Financial Planning DATE: 5 May 2021

Purpose of Paper (Please select any which are relevant to this paper)

☐ For Assurance ☒ For Approval / Decision ☒ For Information

Reason for Presentation to This report presents to the Board the current position in respect of Committee/Board YDH and system financial planning for 2021/22.

The Board is requested to approve: • the proposed H1 system plan to be submitted on 6 May • the proposed internal budgets

Any Key Issues to Note The Board should note the level of uncertainty and risk which still exist within the plan at both system and organisational level, and the commitment to a level of cost control and savings delivery which mitigates existing risk, supports business case decisions and begins to address the underlying deficit.

Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) ☒ Care for our Population ☒ Develop our People

☒ Innovate and Collaborate ☒ Develop a Sustainable System

Implications/Requirements (Please select any which are relevant to this paper) ☒ Financial ☒ Legislation ☒ Workforce ☒ Estates ☒ ICT ☒ Patient Safety / Quality

Reference to CQC domains (Please select any which are relevant to this paper)

☒ Safe ☒ Effective ☒ Caring ☒ Responsive ☒ Well Led

Is this paper clear for release under the Freedom of Information Act 2000? ☒ Yes ☐ No

2021/22 Financial Planning

1. This paper presents to the Board the current position on system and YDH plans for the 2021/22 financial year. This follows Executive Committee endorsement of the approach taken and position reached, and confirmation of key planning decisions, and review and endorsement by the Financial Resilience and Commercial Committee. The position is presented to the Board for approval prior to submission of the system plan on 6 May and internal implementation of the new year budgets.

2. System position for H1 2021/22

Annexe 1 presents the system plan for H1 which will be submitted on 6 May. Important items to note are: • There is an outstanding difference with the regulators on the funding of c£4.3m related to dental and screening services provided by SFT. This has been treated as non-NHS income and therefore the funding is not correctly secured as NHS income going forward. If this matter is resolved favourably the system planning deficit for H1 reduces by the £4.3m • Aside from this issue, the system position for H1 is in balance including an assumption that priority business case investments (above costs already in the run rate) are supported. System savings will be required in the longer term in addition to existing CIP and QIPP plans to support this further investment and address the underlying deficit • H1 is not a good indicator of the level of financial challenge in the H2, longer term and underlying positions. NHS income settlements remain linked to covering reasonable costs of delivery but this is not guaranteed beyond H1; business case spend assumptions are partial reflecting build up of services and recruitment in H1; and savings delivery assumptions are lower than will be required in the later part of the year • The system business case process is not yet concluded to allow inclusion of fully worked up values in organisational and system plans. The system and internal YDH savings plans will not be concluded in time. This increases the level of risk in the planning assumptions

3. YDH Group position for 2021/22

The overall position for the YDH Group for H1 is as set out in the Trust specific column of the system plan. Alongside the system work, we have developed internal budget proposals for H1 and H2 of 2021/22. The principles underpinning this and proposed initial budgets are set out in Annexe 2. In the context of the recovery and staff resilience challenge, the key financial outcome for the Group for 2021/22 will be to ensure no deterioration in the underlying position and to achieve as good as possible an exit position in readiness for 2022/23. Budgets have been set for the year to aid budget holders in planning and management, recognising that review may be necessary when the H2 funding position is clarified.

Annexe 3 sets out the activity level assumptions which align with the financial planning. These have been agreed and developed at system level and in line with national restoration expectations. Separate activity modelling has been undertaken in respect of the level of recovery (i.e. reduction in backlog) achievable by the system and at organisation level, which will be funded through non-recurrent Elective Recovery Fund income above the system envelope. The financial plan does not include either income or expenditure related to recovery, which is treated separately within the national planning requirements.

Annexe 4 sets out the workforce plan which aligns with the activity and financial assumptions, on the basis of expected workforce at the end of H1.

Annexe 5 sets out the current position on business cases, summarising those submitted to the system for support, and therefore additional funding for the Trust within the overall system position, and those which are subject to internal decision and therefore internal generation of a funding source if supported. It should be noted that any cases rejected by the system for support will then need internal consideration as high priority items.

The current impact of agreeing business cases if not supported by additional system funding (i.e. value of further internal savings required to cover the costs) can be summarised as follows:

Category Unfunded Unfunded new Unfunded new Unfunded new costs in ULP costs in H1 costs in H2 full year costs £000 £000 £000 £000 High 3,493 494 991 1,957 Significant 0 112 224 444 Reasonable 0 58 118 231 Total 3,493 664 1,333 2,632

Any recurrent costs of delivering savings would also need to be covered in this way.

This excludes recovery business cases which are expected to be non-recurrent and matched by additional income from the Elective Recovery Fund.

Based on this position, we have recognised an assumption of up to £2.0m additional spend, set at the level needed to cover high priority cases should system or other external funding (e.g. Ockenden) not be secured. This would require the delivery of an equivalent value of savings in addition to CIP plans.

Annex 6 sets out the current position on CIPs. The planning and budgets for 2021/22 include an assumption of delivery of £4.3m CIPs, for which detailed plans are still being developed by teams. There is therefore a significant degree of risk at present that plans may not develop or deliver as anticipated.

Further work is in hand to agree a number of larger, potentially trustwide savings initiatives in addition to team CIP plans, which would realistically take effect in the later part of the year or in readiness for future years. A realistic and credible assessment of savings achievement will be developed and will inform the level of business case investment which can be supported.

4. Requests of the Board

The Board is requested to approve: • the proposed H1 system plan to be submitted on 6 May • the proposed internal budgets 2021/22 Financial Planning

Annexes

1 Annexe 1 H1 System Plan 2021/22

2 H1 System Position 2021/22 • Position developed jointly between system partners • Based on detailed H1 guidance, template and system envelope received 26 March • Triangulation between activity, workforce, financial and narrative submissions • Separate modelling of Mental Health and Elective Recovery Fund funding and spend plans • System business case prioritisation process nearing completion • System savings opportunities development plans in place • Continued focus on resolving dental and screening income

3 H1 System Plan 2021/22 SFT YDH CCG Total System £’000 £’000 £’000 £’000

Expenditure Run Rate 271,034 100,377 227,648 599,059

COVID Run Rate 5,586 2,067 1,605 9,258

SDF Funded Exp 3,767 - 2,298 6,065

Revised Run Rate 280,387 102,444 231,551 614,382

Inflation 2,430 1,175 2,538 6,143

Mandatory Growth - - 5,893 5,893

Other 925 681 1,743 3,349

Less CIP (1,487) (554) (1,138) (3,179)

Revised H1 Run Rate 282,255 103,746 240,587 626,588

Commissioner Income (234,500) (64,890) - (299,390)

Top Up (14,950) (18,496) - (33,446)

COVID (5,586) (2,067) (13,076) (20,729)

Other (22,972) (18,458) (228,214) (269,644)

Net (Surplus)/Deficit 4,247 (165) (703) 3,379

Business Case Investment 1,415 1,388 780 3,583

Elective Recovery Fund (1,362) (1,223) (77) (2,662)

(Surplus)Deficit 4,300 0 0) (4,300)

4 Annexe 2 YDH Group Budgets 2021/22

5 YDH Group 2021/22 Budgets – Principles (1) • Overall financial aim for the Group 21/22, in the context of recovery and staff resilience: • No deterioration in the underlying position • Best possible exit position in readiness for 22/23

• Expenditure budgets have been set on an 19/20 activity basis, including inflation and pay increments • Known cost pressures (unavoidable), e.g. O365, CNST uplift, are funded in core budgets • COVID costs are included in budgets, but subject to Exec quarterly sign off in advance • CIP delivery at the full year target value of £4.3m will be delegated to divisions/business units and corporate teams in line with agreed plans

• Formal Commissioner contract values still require further conversations within the system, however this will not directly impact operational budgets or the H1 plan • No assumption yet of top up or central support (FRF) funding for H2

6 YDH Group 2021/22 Budgets – Principles (2) • Business cases (planning treatment): • Spend already in the underlying position is included in the plan • Assumption of up to £2.0m further spend based on the position should priority cases not be supported by the system or other sources (e.g. Ockenden funding) • Will require equal value of savings delivery in addition to CIP – trustwide/large scale plans in development

• Business cases (treatment in budgets): • Where business cases have been approved in 20/21 e.g. ED, the full spend is included in the plan and allocated in the appropriate team budget • Where business cases are not yet approved but spend is already being incurred e.g. ICU, the actual spend is included in the plan but held centrally pending approval • Where business cases are not yet approved and spend will only start or increase on approval, there is no value included in the plan or budgets

7 H1 Group Budgets 2021/22 Income Expenditure CIP Final Budget Business Unit Directorate £ £ £ £ Clinical Income (86,836,010) 8,448 (86,827,562) Corporate (6,228,490) 32,795,952 (179,728) 26,387,734 Elective Care Cancer (2,160) 3,896,853 3,894,693 Elective Central (16,650) 1,773,704 (73,953) 1,683,101 Obs and Gynae (7,122) 3,858,930 3,851,808 Orthopaedics 0 3,344,451 (16,878) 3,327,573 Outpatient Services (6,984) 966,603 (5,025) 954,594 Private Patients (874,251) 783,018 (4,252) (95,485) Surgery (158,472) 5,411,634 (21,387) 5,231,775 Theatre Services (2,916) 8,207,310 8,204,394 Visiting Specialities (498) 1,371,879 (4,509) 1,366,872 Urgent Care Accident and Emergency (25,452) 6,033,936 (22,547) 5,985,937 Child Health (66,660) 2,777,244 (11,209) 2,699,375 Integrated Care (18,696) 3,899,016 (7,601) 3,872,719 Internal Medicine (243,642) 7,401,468 (30,019) 7,127,807 Pathology (206,040) 3,151,881 (4,380) 2,941,461 Patient Flow (677,658) 2,870,550 (12,626) 2,180,266 Pharmacy (3,080,778) 4,393,734 (28,473) 1,284,483 Radiology (84,864) 2,894,847 (11,338) 2,798,645 Therapists 0 2,182,974 (9,147) 2,173,827 Urgent Care Central (16,530) 493,386 (43,676) 433,180 SHS SHS (9,547,617) 10,137,672 (67,253) 522,802 (108,101,490) 108,655,490 (554,000) 0

8 H2 Group Budgets 2021/22 Income Expenditure CIP Final Budget Business Unit Directorate £ £ £ £ Clinical Income (70,144,444) 8,426 (70,136,018) Corporate (6,105,428) 32,317,816 (1,215,273) 24,997,115 Elective Care Cancer (2,165) 3,882,535 3,880,370 Elective Central (16,648) 2,511,695 (500,047) 1,995,000 Obs and Gynae (7,118) 3,858,377 3,851,259 Orthopaedics 0 3,343,923 (114,122) 3,229,801 Outpatient Services (6,991) 966,586 (33,975) 925,620 Private Patients (950,632) 803,571 (28,748) (175,809) Surgery (158,460) 5,405,531 (144,613) 5,102,458 Theatre Services (2,913) 8,205,572 8,202,659 Visiting Specialities (502) 1,369,310 (30,491) 1,338,317 Urgent Care Accident and Emergency (25,455) 6,033,257 (152,453) 5,855,349 Child Health (66,655) 2,775,867 (75,791) 2,633,421 Integrated Care (18,697) 3,888,482 (51,399) 3,818,386 Internal Medicine (243,653) 7,401,254 (202,981) 6,954,620 Pathology (206,036) 3,135,402 (29,620) 2,899,746 Patient Flow (677,670) 2,870,543 (85,374) 2,107,499 Pharmacy (3,080,775) 4,379,782 (192,527) 1,106,480 Radiology (84,871) 2,894,343 (76,662) 2,732,810 Therapists 0 2,182,958 (61,853) 2,121,105 Urgent Care Central (16,530) 557,389 (295,324) 245,535 SHS SHS (11,190,555) 11,939,432 (454,747) 294,131 (93,006,198) 110,732,051 (3,746,000) 13,979,853

9 Annexe 3 Activity Plans 2021/22

10 2021/22 Activity Plans BASED ON Definitions used in ANNUAL PLANNING and Weekly Activity Return (OP = Consultant Led Care only) excludes all Maternity, Midwifery and Nurse Led activity 2019/20 Outturn Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Total Day-cases 1,722 1,806 1,814 1,853 1,758 1,731 1,926 1,928 1,569 1,828 1,752 1,500 21,187 Inpatients 273 269 241 241 238 251 278 247 232 204 259 204 2,937 ELECTIVE - TOTAL 1,995 2,075 2,055 2,094 1,996 1,982 2,204 2,175 1,801 2,032 2,011 1,704 24,124 Non Elective 1,971 2,038 1,891 2,077 2,024 1,944 2,206 2,000 2,231 2,161 2,006 1,729 24,278 Outpatients - Procedures 2,527 2,538 2,613 2,900 2,440 2,570 2,890 2,538 1,983 2,583 2,293 1,900 29,775 Outpatients - first F2F 2,092 2,159 2,177 2,397 2,051 2,234 2,670 2,416 2,128 2,393 2,374 2,128 27,219 Outpatients - follow-up F2F 4,727 5,017 4,600 5,012 4,435 5,069 5,350 5,003 4,236 5,411 4,864 4,467 58,191 Outpatients - first virtual 209 240 201 275 214 303 367 310 310 346 315 430 3,520 Outpatients - follow-up virtual 388 453 370 493 382 494 426 333 350 376 322 306 4,693 Outpatients - FIRST TOTAL 2,301 2,399 2,378 2,672 2,265 2,537 3,037 2,726 2,438 2,739 2,689 2,558 30,739 Outpatients - FUP TOTAL 5,115 5,470 4,970 5,505 4,817 5,563 5,776 5,336 4,586 5,787 5,186 4,773 62,884 Grand Total 13,909 14,520 13,907 15,248 13,542 14,596 16,113 14,775 13,039 15,302 14,185 12,664 171,800

COVID INEFFICIENCY ACTIVITY Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22 Feb-22 Mar-22 Total Day-cases 1,498 1,571 1,578 1,612 1,529 1,506 1,676 1,677 1,365 1,590 1,524 1,305 18,433 Inpatients 246 242 217 217 214 226 250 222 209 184 233 184 2,643 ELECTIVE - TOTAL 1,736 1,805 1,788 1,822 1,737 1,724 1,917 1,892 1,567 1,768 1,750 1,482 20,988 Non Elective 1,695 1,753 1,626 1,786 1,741 1,672 1,897 1,720 1,919 1,858 1,725 1,487 20,879 Outpatients - Procedures 1,819 1,827 1,881 2,088 1,757 1,850 2,081 1,827 1,428 1,860 1,651 1,368 21,438 Outpatients - first F2F 1,464 1,511 1,524 1,678 1,436 1,564 1,869 1,691 1,490 1,675 1,662 1,490 19,053 Outpatients - follow-up F2F 2,978 3,161 2,898 3,158 2,794 3,193 3,371 3,152 2,669 3,409 3,064 2,814 36,660 Outpatients - first virtual 320 367 308 421 327 464 562 474 474 529 482 658 5,386 Outpatients - follow-up virtual 3,104 3,624 2,960 3,944 3,056 3,952 3,408 2,664 2,800 3,008 2,576 2,448 37,544 Outpatients -FIRST TOTAL 1,784 1,879 1,831 2,099 1,763 2,027 2,431 2,166 1,964 2,204 2,144 2,148 24,439 Outpatients - FUP TOTAL 6,082 6,785 5,858 7,102 5,850 7,145 6,779 5,816 5,469 6,417 5,640 5,262 74,204 Grand Total 13,116 14,049 12,985 14,896 12,847 14,419 15,104 13,421 12,346 14,107 12,910 11,747 161,948

VARIANCE April May June July AugustSeptember October November December January February March Total Day-cases (224) (235) (236) (241) (229) (225) (250) (251) (204) (238) (228) (195) (2,754) Inpatients (27) (27) (24) (24) (24) (25) (28) (25) (23) (20) (26) (20) (294) ELECTIVE - TOTAL (259) (270) (267) (272) (259) (258) (287) (283) (234) (264) (261) (222) (3,136) Non Elective (276) (285) (265) (291) (283) (272) (309) (280) (312) (303) (281) (242) (3,399) Outpatients - Procedures (708) (711) (732) (812) (683) (720) (809) (711) (555) (723) (642) (532) (8,337) Outpatients - first F2F (628) (648) (653) (719) (615) (670) (801) (725) (638) (718) (712) (638) (8,166) Outpatients - follow-up F2F (1,749) (1,856) (1,702) (1,854) (1,641) (1,876) (1,980) (1,851) (1,567) (2,002) (1,800) (1,653) (21,531) Outpatients - first virtual 111 127 107 146 113 161 195 164 164 183 167 228 1,866 Outpatients - follow-up virtual 2,716 3,171 2,590 3,451 2,674 3,458 2,982 2,331 2,450 2,632 2,254 2,142 32,851 Outpatients -FIRST TOTAL (517) (521) (547) (573) (502) (510) (606) (561) (474) (535) (545) (411) (6,300) Outpatients - FUP TOTAL 967 1,315 888 1,597 1,033 1,582 1,003 480 883 630 454 489 11,320 Grand Total (793) (472) (922) (352) (695) (177) (1,009) (1,354) (693) (1,195) (1,275) (917) (9,852)

11 2021/22 Elective Recovery Plans BASED ON Definitions used in ANNUAL PLANNING and Weekly Activity Return (OP = Consultant Led Care only) excludes all Maternity, Midwifery and Nurse Led activity

ELECTIVE RECOVERY ONLY Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22 Feb-22 Mar-22 Total Day-cases 57 57 57 57 57 57 57 57 53 57 57 57 680 Inpatients 11 11 11 11 11 11 11 11 11 11 11 11 132 ELECTIVE - TOTAL 68 68 68 68 68 68 68 68 64 68 68 68 812 Non Elective 0 0 0 0 0 0 0 0 0 0 0 0 0 Outpatients - Procedures 0 0 0 0 0 0 0 0 0 0 0 0 0 Outpatients - first F2F 68 68 68 44 44 44 44 44 44 44 44 44 600 Outpatients - follow-up F2F 0 0 0 24 24 24 24 24 24 24 24 0 192 Outpatients - first virtual 0 0 0 0 0 0 0 0 0 0 0 0 0 Outpatients - follow-up virtual 0 0 0 0 0 0 0 0 0 0 0 24 24 Outpatients -FIRST TOTAL 68 68 68 44 44 44 44 44 44 44 44 44 600 Outpatients - FUP TOTAL 0 0 0 24 24 24 24 24 24 24 24 24 216 Grand Total 136 136 136 136 136 136 136 136 132 136 136 136 1,628

12 Annexe 4 Workforce Plans 2021/22

13 Group Workforce Plan 2021/22

Planned WTE at the end of H1

Base budgets Business Case Budgeted Workforce WTE WTE WTE Additional Clinical Services 72.92 72.92 Additional Prof Sci & Tech 73.49 73.49 Admin & Clerical 504.84 3.55 508.39 Allied Health Professionals 135.18 9.70 144.88 Ancillary 244.36 1.03 245.39 Estates 35.00 35.00 Medical & Dental 317.88 5.90 323.78 Nursing & Midwifery Reg 742.37 14.72 757.09 Senior Managers 37.53 37.53 Unregistered Nurses 348.15 2.55 350.70

SHS 283.33 283.33 2,795.05 37.45 2,832.50

14 Annexe 5 YDH Business Case Position

15 Summary of Business Cases 2021/22

Category Business Cases FYE Value in Estimated H1 Estimated H2 £’000 ULP Additional Additional £’000 Impact Impact £’000 £’000 System – High Priority Urgent Care 2,474 2,079 103 209 System – High Priority Elective Care 2,976 1,414 391 782 Significant Urgent Care 167 42 84

Significant Elective Care 187 47 95

Significant Corporate 90 23 45

Reasonable Urgent Care 45 11 23

Reasonable Elective Care 163 41 83

Reasonable Corporate 23 6 12

Elective Recovery Fund Elective Care/Recovery 3,146 1,255 1,574

16 Annexe 6 YDH Group CIP Position

17 Group CIP 2021/22 – Principles

• The Trust is aiming for a challenging £4.3m Cost Improvement Programme in 21/22

• Corporate teams are set a higher percentage CIP target (3.5%) than the operational divisions

• A trust wide drugs target is set at 1.23% taking into account that pass through savings are not realised within YDH

• SHS savings are based on values agreed as per the SHS 21/22 plan signed off by the SHS Board

• SSL savings are agreed through the contract. Where costs managed by SSL are passed through to YDH e.g. consumables, the CIP target and savings benefits sit with YDH

• A small number of wholly un-influenceable costs are excluded when setting CIP targets e.g. CNST premium, external rents

• All schemes proposed to date have been reviewed by a clinical and operational scrutiny panel to identify any safety and quality impacts or risks and action required to manage

• Financial scrutiny and risk assessment of proposed schemes is to be completed

18 Summary CIP 2021/22

Target Current Plans Variance Strategic Unit £’000 £’000 £’000 Corporate 727 578 (149) Elective Care 978 404 (574) Urgent Care - Intermediate Care 200 tbc (200) Urgent Care 984 903 (81) SHS 522 522 - SSL 668 668 - Drugs – Trust wide 221 221 - Total Group CIP 4,300 3,294 (1,004)

19

Appendix: 12 REPORT TO: Board of Directors REPORT BY: Fiona Derbyshire, Corporate Accountant PRESENTED BY: Sarah James, Chief Finance Officer EXEC SPONSOR: Sarah James, Chief Finance Officer REPORT TITLE: Going Concern Assessment DATE: 5th May 2021

Purpose of Paper (Please select any which are relevant to this paper)

☐ For Assurance ☒ For Approval / Decision ☐ For Information

Reason for Presentation to The going concern assumption is a fundamental principle in the Committee/Board preparation of the year end accounts, under which the Trust is ordinarily viewed as continuing in the business of healthcare provision for the foreseeable future. The term ‘going concern’ refers to the basis of measurement of an organisation’s assets and liabilities and hence how they are included in the accounts. An organisation operating under the going concern principle will record these assets and liabilities as being able to be realised in the normal course of business. An organisation that does not prepare accounts under the going concern principle may have to record assets at a much lower break-up value and reclassify liabilities to being short term.

The HM Treasury Financial Reporting Manual (FReM) provides the basis of the financial reporting framework under which the NHS must report its financial performance. The FReM provides that the anticipated continued provision of services is a sufficient rationale for adopting a going concern basis for the preparation of the financial reports.

This means that, while management in NHS bodies will still need to document their basis for adopting the going concern basis, this assessment should be based solely on the anticipated future provision of services in the public sector.

The Trust must include within the Annual Report a disclosure detailing the judgement it has taken regarding going concern and this in turn will be subject to audit examination.

The Board is requested to CONSIDER whether it thinks it is suitable for the accounts to be prepared under the going concern basis.

Any Key Issues to Note

Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) ☐ Care for our Population ☐ Develop our People

☐ Innovate and Collaborate ☒ Develop a Sustainable System

Implications/Requirements (Please select any which are relevant to this paper) ☒ Financial ☒ Legislation ☐ Workforce ☐ Estates ☐ ICT ☐ Patient Safety / Quality

Reference to CQC domains (Please select any which are relevant to this paper)

☐ Safe ☐ Effective ☐ Caring ☐ Responsive ☒ Well Led

Is this paper clear for release under the Freedom of Information Act 2000? ☒ Yes ☐ No

Going concern assessment:

In a letter of 1 April 2021, NHS England and Improvement set out the application of the going concern principle to the NHS, as follows:

‘Local auditors conduct their work with reference to auditing standards which apply to all types of entity. Auditors are required to evaluate management’s adoption of the going concern basis and management’s assessment of any material uncertainties over that basis that may require disclosure.

The Public Audit Forum issues guidance to auditors on how auditing standards should be applied in the public sector. Its publication ‘Practice Note 10’ was revised in late 2020. This updated guidance to auditors, approved by the Financial Reporting Council, explains that where the applicable financial reporting framework provides that the anticipated continued provision of services is a sufficient basis for going concern, then this should determine the extent of the auditor’s procedures on going concern. This is the case in the NHS, with the DHSC Group Accounting Manual (GAM) and NHS foundation trust annual reporting manual (FT ARM) both based on the HM Treasury Financial Reporting Manual (FReM) where this definition applies.

This means that, for the 2020/21 year end onwards, while management in NHS bodies will still need to document their basis for adopting the going concern basis, this assessment should solely be based on the anticipated future provision of services in the public sector.’

The guidance is clear that, where this is the case, there will not be any material uncertainties over going concern requiring disclosure.

Assessment:

The application of Practice Note 10 to the NHS means that, whilst the Board will still need to document the rationale for adopting the going concern basis, the assessment should solely be based on the anticipated future provision of services in the public sector. As the Board has every expectation that the services provided by the Trust will continue to be provided in the public sector, it is appropriate to adopt the going concern basis in preparing the accounts for 2020/21. Consideration is given below to whether there are uncertainties regarding future issues which should be disclosed to enable a true and fair view.

Current year performance:

Due to the global pandemic, NHS funding for the year 2020/21 has been linked to the level of income required to cover the necessary costs of providing services including the costs of the response to the pandemic. The Trust was required to achieve breakeven control total under this arrangement, which it has achieved.

As a consequence the Trust’s 2020/21 annual accounts will report a surplus of £1.94m (before the consolidation of Charitable Funds). This is largely due to the level of income received from the centre in recognition of assets procured centrally and then donated as part of the response to the pandemic, for example ventilators and the modular CT scanner.

During 2020/21, current DHSC loans were converted to Public Dividend Capital, which has improved the liquidity and balance sheet liability position of the Trust.

2021/22 outlook:

The draft trust budget for 2021/22 is currently showing a deficit of £14m. This is broken down into a breakeven position for H1 (Half 1 April to September) and a deficit of £14m for H2, based on current system modelling The H2 position is before any assumption in relation to the level of central support funding, through the yet to be clarified income regime. The Trust continues, with system partners to develop detailed financial plans for the financial year to the end of March 2022. Based on current assumptions, including the assumed return of some form of Financial Recovery Fund (FRF) it is unlikely that the Trust will require additional cash support.

In addition there are currently on-going merger discussions between the Trust and Somerset NHS Foundation Trust, with a current target date of 1st April 2022 for the transaction.

The Boards of Directors of both organisations have agreed a Strategic Outline Case for submission to DHSC. Subject to approval of the Strategic Outline Case, further work to develop a full business case will be completed during the 2021/22 financial year for submission to DHSC to seek approval for the merger.

It is anticipated that the services provided by the Trust will continue to be provided in the public sector by the merged trust in the future.

Forecast cash flow:

At 1st April 2021

Current cash balance: £21.1m

Less commitments from 2020/21 (£5.9m) Impact of H1 funding and expenditure (Apr – Sept) - Less Pre COVID net cash outflow (Oct –Mar) (£14.0m)

Final Cash Balance £1.2m

H1 funding has been agreed with similar funding arrangements to 2020/21 continuing until 30th September 2021. The financial framework beyond this point is not yet clear, but it is expected that some form of contractual arrangement will be reintroduced, resulting in a large cash outflow later in the year when outgoing commitments remain stable but income will reduce.

The cash balance at the end of each month is expected to be at least £1.0m whilst not dropping below the minimum threshold of £1.0m at any point during the month.

The Trust expects that it can meet all of its financial obligations without requiring planned additional cash from DHSC in 2021/22. If this changes any future cash requirements are expected to be funded through additional Public Dividend Capital (PDC).

Conclusion:

The Board is asked to consider which of the following scenarios is most appropriate for the Trust:

1. The Trust is clearly a going concern and it is appropriate for the accounts to be prepared on the going concern basis; 2. The Trust is clearly a going concern but there are some uncertainties regarding future issues which should be disclosed in the accounts to ensure the true and fair view. These are not material because they do not place in doubt the application of the going concern concept

It is RECOMMENDED that scenario 2 is adopted, in recognition of the uncertainty in relation to future income, and the merger proposal merits disclosure, therefore the following disclosure would be made in the accounts:

Proposed going concern disclosure to be included within the 2020/21 annual accounts.

Going concern

In preparation of the year end accounts the Board is required to undertake an assessment as to whether the Trust will continue as a going concern.

The Trust prepares its accounts under the financial reporting framework set out for the NHS, which is based on the HM Treasury Financial Reporting Manual (FReM). The FReM provides that the anticipated continued provision of services in the public sector is a sufficient basis for preparing the accounts on a going concern basis.

As the Board has every expectation that the services provided by the Trust will continue to be provided in the public sector, it is appropriate to adopt the going concern basis in preparing the accounts for 2020/21. The Board has considered whether there are uncertainties regarding future issues which should be disclosed to enable a true and fair view.

The Trust has only had confirmation of funding arrangements for the first six months of the 2021/22 financial year. The 2021/22 financial plans and cash flow forecasts have been prepared on the assumption that any cash requirements arising will be covered in the form of Public Dividend Capital from DHSC.

The Trust is currently in merger discussions with Somerset Foundation Trust. This does not change the Board’s expectation that the services provided by the Trust will continue to be provided in the public sector.

Therefore, these accounts have been prepared under a going concern basis as set out in IAS 1.

Appendix: 13 REPORT TO: Board of Directors REPORT BY: Chair of Governance and Quality Assurance Committee (GQAC) PRESENTED BY: Chair of Governance and Quality Assurance Committee EXEC SPONSOR: Chief Nurse/Chief Medical Officer Verbal Update of Last GQAC Committee and Minutes of Meeting REPORT TITLE: Held on 28 January 2021. DATE: 5 May 2021

Purpose of Paper (Please select any which are relevant to this paper)

☐ For Assurance ☐ For Approval / Decision ☒ For Information

Reason for Presentation to The Chair of the Governance and Quality Assurance Committee will Committee/Board provide a verbal update of the previous meeting held on 28 April 2021. It was agreed during this meeting that the following items would be highlighted to the Board of Directors: • SSNAP • Long term impact/effect of COVID-19 on all services

The Board are asked to RECEIVE this verbal update and to NOTE the minutes of the meeting held on 28 January 2021. Any Key Issues to Note

Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) ☒ Care for our Population ☒ Develop our People

☒ Innovate and Collaborate ☐ Develop a Sustainable System

Implications/Requirements (Please select any which are relevant to this paper) ☐ Financial ☒ Legislation ☐ Workforce ☐ Estates ☐ ICT ☒ Patient Safety / Quality

Reference to CQC domains (Please select any which are relevant to this paper)

☒ Safe ☒ Effective ☒ Caring ☒ Responsive ☒ Well Led

Is this paper clear for release under the Freedom of Information Act 2000? ☒ Yes ☐ No

GOVERNANCE & QUALITY ASSURANCE COMMITTEE Minutes of the meeting held on Thursday 28 January 2021 at Yeovil District Hospital via MS Teams

Present: Jane Henderson [Chair] Non-Executive Director Graham Hughes Non-Executive Director Maurice Dunster Non-Executive Director Paul von der Heyde Trust Chairman Merry Kane Chief Medical Officer Shelagh Meldrum Deputy Chief Executive/Chief Nurse & Director of People Matthew Bryant Chief Operating Officer

In Attendance: Bernice Cooke Deputy Director Quality Governance & Patient Safety Sam Hann Head of Risk and Compliance Ben Edgar-Attwell Company Secretary Jan Hull Non-Executive Director – SFT Virginia Membrey Public Governor Observer

Presenters: Yvonne Thorne Deputy Director of Infection Prevention & Control Debbie Matthewson Freedom to Speak up Guardian

64- 1 WELCOME AND APOLOGIES FOR ABSENCE 2021 1.1 Jane Henderson welcomed everyone to the meeting, which included Jan Hull as NED observer. No apologies for absence were received.

65- 2 DECLARATIONS OF INTEREST 2021 2.1 There were no declarations of interest relating to items on the agenda.

66- 3 MINUTES OF PREVIOUS MEETINGS AND MATTERS ARISING 2021 3.1 The minutes of the meeting held on 22 October 2020 were approved as true and accurate record.

3.2 With regard to actions arising, Ben Edgar-Attwell advised that due to operational pressures, the presentation from the Medical Examiners had been postponed. This would be reviewed for the April 2021 meeting. Positive communications regarding the BEA SIREN trial was in hand.

3.3 Jane Henderson explained that the limited progress in collaborative working on medical electronics had been helpfully fed back to Somerset NHS FT (SFT) through David Allen. This would form part of the general work around the potential merger of the two trusts. Jane Henderson asked about the potential new structure within the Dementia Team and if this was now in place. Bernice Cooke confirmed that the new nurse manager was now in post with the post holder reporting directly to her.

3.4 Jane Henderson asked about progress in the development of system wide risk management processes. Sam Hann advised that the various Risk Managers were completing a gap analysis on this. Matthew Bryant asked who was overseeing this piece of work. Paul von der Heyde said that it was for the various executives and governance teams to work through and it was overseen through a combination of the system Programme Board and the governance committees. Jane Henderson said that bearing in mind there was an intention to move to committees in common, there would need to be consideration around the format of reports. Jan Hull said it was important to recognise the operational pressures of the executive and governance teams now although agreed the identification of common risks was needed. 1 | P a g e

67- 4 COVID-19 POSITION AND VACCINATION POSITION UPDATE 2021 4.1 Shelagh Meldrum provided an update on the current position within the hospital. The number of COVID-19 cases was starting to plateau although this was a still a higher number with around 5-6 COVID-19 patients being admitted on a daily basis. There was improved patient flow across the Somerset system, although there had been some outbreaks in the community hospitals and nursing homes, which impacts the hospital’s ability to discharge patients. The Trust was now starting to use the Exeter Nightingale Hospital. Merry Kane said she had visited the hospital the previous day; she said that this was a fantastic facility and was a result of brilliant teamwork.

4.2 The vaccination programme is showing positive results in terms of reduced numbers of staff absences. The Trust continues to learn more about the management of COVID-19 and the risk profile. This means that cohorting of positive patients and the restricting of bays, rather than entire wards, is now possible. Additional guidance is under review on both a national and local scale.

4.3 In terms of staff wellbeing, it has been hard on the teams and psychologist support is in place for affected members of staff, especially in areas such as ICU.

4.4 The environmental changes as result of COVID-19 are in a good position although there are some challenges with the windows for ventilation purposes. A programme of work to replace the windows is underway and mitigations are in place to address in the meantime using vent mechanisms that are being fitted to the windows. Additional doors have also been added within wards to assist in managing/reducing any potential outbreaks. Two enhanced respiratory bays have been created on Ward 9A to reduce pressure on ICU and create additional enhanced care capacity.

4.5 The Trust continues to monitor the nosocomial cases of COVID-19. There was also a reporting change in October 2020, which included the requirement to complete Duty of Candour processes for any probable nosocomial cases. The guidelines around this were not clear and were open to interpretation and we have taken a very open approach, which has been ratified by the CCG and CQC as being the correct approach. Duty of Candour letters have been sent to affected individuals and/or relatives. Post infection reviews are being undertaken. Graham Hughes asked about the reaction and feedback from these letters. Bernice Cooke said that to date only two responses had been received although individuals were only likely to receive their letters in the coming days. Shelagh Meldrum added that the patient experience and bereavement teams and in many cases the Medical Examiner was also in contact with relatives, and therefore we aim to ensure that the letters do not arrive unexpected.

4.6 Shelagh Meldrum provided an update on the COVID-19 vaccination programme. The work thus far has been an amazing achievement across the county, with the initial vaccinations provided within the hospitals prior to the opening of the mass vaccination centres. Further work to coordinate the various vaccination providers is underway and the second vaccinations are due to commence in the coming weeks/months. There are challenges to ensure that there is no wastage in the event of people not attending and those associated with completing both first and second vaccinations concurrently. It is important to be mindful of the impact on staff as vaccinating on mass is hard work. Due to the challenges in providing the Pfizer/BioNTech vaccination to patients on the wards, it is likely the Trust will receive delivery of the Oxford/AstraZeneca vaccination although quantities are unknown.

4.7 Jan Hull noted the previous discussions at other forums about staff recovery before work on elective recovery commences. Staff recovery is vital. Both Trusts in the county will need to give this some thought. Shelagh Meldrum said that this point was reflected on a number of national calls.

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4.8 Matthew Bryant wished to reiterate the thanks and to recognise the hard work of the various teams throughout the pandemic. Jane Henderson agreed that this had been a great team effort from all.

68- 5 INITIAL RESPONSE TO OCKENDEN REPORT 2021 5.1 Jane Henderson advised that following the publication of the Donna Ockenden report (Emerging Findings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust), YDH had been required to submit an initial response. The initial response was provided in the papers. In addition to this, a self-assessment using the Assurance Assessment Tool is to be submitted on 15 February 2021.

5.2 The initial actions taken are outlined in the initial response, a number of these were already in place and have now been formalised. One action is rated as red as the national guidance was not published at the time of submission. The submission for the 15 February 2021 will require evidence of some of these actions, along with a requirement to complete audits to ensure actions are working. It will require sign-off by the Local Maternity System. Jane Henderson and Shelagh Meldrum will review the self-assessment prior to submission. The Trust is also linking in with SFT for a joined up approach. Shelagh Meldrum said that the various actions will result in a need for additional resource and this information will be pulled into a national gap analysis. There are also potential staffing challenges as all organisations providing maternity services will be seeking additional staffing.

5.3 Jane Henderson noted the point regarding the sharing of maternity serious incidents to the Board. Shelagh Meldrum advised that further guidance and clarification was expected on the reporting processes bearing in mind investigations may be ongoing at the point when a Board meeting is held. It is likely that the requirement is to report the incidents to the Board members themselves rather than through a public Board due to investigation timings and concerns about patient identification.

5.4 Jane Henderson noted the point about a named lead consultant. She asked about occasions where women decline consultant support. Shelagh Meldrum confirmed that women could request midwife only support and in these instances, the named lead consultant may not be required.

5.5 The Committee noted the Trust’s initial response and welcomed the opportunity to review the self-assessment at Board meetings in due course.

69- 6 LEARNING FROM DEATHS Q3 REPORT 2021 6.1 Merry Kane reported that the medical examiner teams were reviewing approximately 80% of all deaths, although the aim is for 100% of deaths to be reviewed going forward. The Medical Examiners report the findings, themes and learning from these reviews to the Learning from Deaths Leads. Any reviews that flag up any concerns will require further scrutiny; they will be sent to teams for a Structured Judgement Review (SJR). Any deaths flagged as having a 50% or more chance of preventability is then referred to the Mortality Review Group. Any learning disability deaths will be reviewed by the Mortality Review Group.

6.2 Jane Henderson asked if all COVID-19 deaths would be reviewed. Merry Kane advised that a group was being created for this piece of work. No specific concerns were raised, although any potential learning would be disseminated. It is not necessary for all deaths to have a SJR, with the exception of any resulting from any outbreak.

6.3 The Trust’s Hospital Standard Mortality Ratio (HSMR) and Summary-Hospital level Mortality Indicator (SHMI) levels remain positive, i.e. lower than expected levels. One CUSUM alert was received in relation to congenital abnormalities. This was raised 3 | P a g e

from one event and the findings outlined that the case had been well managed. No concerns were raised regarding the Learning Disability Deaths and these were not believed to be as a consequence of shortcomings in hospital care.

6.4 The specific themes and learning from the reviews were outlined within the report, including maintaining a focus on ensuring that Treatment Escalation Plans and DNARs are kept up to date and audited. In terms of the Perinatal Mortality Review Tool (PMRT), there had had been one case reviewed; the findings concluded that this was a well-managed case with no concerns raised.

6.5 Matthew Bryant noted that the lessons learnt referred to liaison between the Mental Health Team and the Acute Trust. He asked if there was the right level of engagement with the various mental health services for this. Merry Kane said that there was good engagement although further improvements could be made. Bernice Cooke added that there is representation from SFT, the CCG and the psychiatric liaison services at the Trust’s Mental Health Steering Group. Learning from deaths, complaints and incidents goes to this group where relevant.

70- 7 PATIENT SAFETY, QUALITY AND EXPERIENCE REPORTS 2021 Q3 Patient Safety, Quality and Experience Report 7.2 The Committee noted the report, where the following was discussed in more detail:

7.3 There had been an increase in the number of reported incidents, although the majority were either low harm, near misses or no harm incidents. This demonstrates a good culture around patient safety and reporting.

7.4 There had been an increased number of patient falls and pressure ulcers; this is reflected nationally. Due to the pandemic, a higher number of patients are being admitted in a deconditioned state and with a higher level of acuity. Work continues in this area to reduce rates. Jane Henderson asked if that various infection control measures, such as the use of side rooms, may account for some of the challenges. It was advised that there were no themes identified from the reviews thus far. Merry Kane said that the restrictions on visitation along with reduced numbers of volunteers could account for this to some degree, as there would traditionally be more carers and relatives providing support. This impact is difficult to quantify.

7.5 Bernice Cooke drew attention to the number of post infection reviews; these required a large amount of work to pull all relevant information together, such as bed moves, swabbing dates, results timelines etc. The Trust is currently focussing on those defined as definite hospital onset infections, i.e. a positive test 15 days or more post admission. The reviews will be expanded to include all patients in addition to those resulting in a death.

7.6 The Committee noted the changes in the clinical negligence section of the report. Jane Henderson said it would be helpful for the report to outline when the events leading to potential claims occurred. Sam Hann clarified that the report was based on when claims were received, and the majority related to previous activity, sometimes a number of years ago. The incident dates could be added to the reports. Jane SH/ Henderson suggested that the pandemic could result in an increased number of BC claims going forward. Merry Kane agreed. The Trust had stood the clinical decision making team back up again bearing in mind the increased number of cases and capacity constraints. This includes out of hours cover and the various teams, such as the clinical ethics team, could be bought together at any time to support decision- making.

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7.7 Q3 Safeguarding Report The Committee noted the Q3 report. Jane Henderson noted the good references to the wider health community aspects. Bernice Cooke reported that there had been an increased rate of referrals across both adults and children, but also for learning disability patients. There were no Section 42 requests received during the reporting quarter. The report also highlights good practice in arrangements in the emergency department and the safeguarding team response. Good feedback has been received from patients.

Q3 Maternity Report 7.8 Bernice Cooke reported that maternity activity had remained consistent. There have been favourable outcomes across a number of areas, including a reduction in rates for third and fourth degree tears for normal deliveries. There was a small rise in the number of COVID-19 positive antenatal women from the previous months; these pregnancies and their outcomes are being monitored.

7.9 Bernice Cooke pointed out a small error in the report; the induction of labour was 36.2% rather than 13.5%. Jane Henderson wondered whether a deep dive into this might be worthwhile.

Q3 Infection Control Report 7.10 Yvonne Thorne joined the meeting to present the Q3 Infection Control Report. She explained that the Trust’s knowledge of COVID-19 and transmission had increased in recent months. The second wave was more impactful on the organisation than the first and the Trust continues to monitor and update processes in light of changing national guidance. Any outbreaks are reported via the national reporting criteria and the CCG and Public Health England attend all outbreak meetings.

7.11 The infection control team has increased its capacity and has additional resource. It works extremely closely with the patient flow team, which has been hugely beneficial in the management of COVID-19 and ensuring patient flow. There were a number of challenges faced by all organisations, including YDH at the outset.

7.12 Shelagh Meldrum said that the infection control team have been amazing throughout the pandemic, providing advice and support to teams and individuals. The Trust had sought an external peer review to see if there were further improvements that could be made in the management of COVID-19. This had been helpful and good practice at YDH was recognised as part of this with only the issue of swab turnaround time being raised – this has improved as a result of point of care testing.

7.13 Jane Henderson said it was important to recognise staff wellbeing; it is an unenviable job for the team to remind and instruct others of the various social distancing measures. Shelagh Meldrum agreed that this was challenging, especially where the guidance was changing. Paul Foster, Deputy Chief Medical Officer, is also working with the infection control team to support this. Yvonne Thorne said that audits have taken place on arrangements. The Committee heard about the importance of patient flow, which could be challenging with the cohorting of patients in the event of an outbreak.

7.14 Jane Henderson wished to thank Yvonne Thorne and the wider team for their excellent work throughout this period.

71- 8 RISK MANAGEMENT FRAMEWORK 2021 Q3 Board Assurance Framework (BAF) 8.1 Ben Edgar-Attwell presented the updates to the BAF, which reflected the current position in light of COVID-19. There are increasing levels of demand across the system although there are a number of schemes, controls and actions in place. The 5 | P a g e

Trust does face difficulties in achieving all nationally mandated indicators as a direct consequence of COVID-19, although the performance does remain relatively good in comparison to other organisations.

8.2 Jane Henderson noted that the scoring for the Principal Risks remained above the Risk Appetite level set by the Board; this was to be expected in the current environment although it does question if a review is required. Ben Edgar-Attwell said that this variance had been noted and had been discussed at the Executive Committee. It is intended that a session on this would be scheduled for the Board Development Day.

8.3 Matthew Bryant said that a discussion around the risk appetite would be timely. He also suggested that the assessment of some of the risks might need further review, especially those related to operational delivery, as the risk may be greater than in previous months. Jane Henderson said it was to be hoped that the risk around the adoption of new models of care would reduce in time as the development of the clinical strategy progresses. Jane Hull said it was important that strategic momentum is not lost on this workstream.

Q3 Corporate Risk Register (CRR) 8.4 The Committee reviewed the CRR as circulated. Jane Henderson said that risks 439 and 607 appeared to be very similar, if not the same. Sam Hann explained that these risks differed as one referred to nursing staff whereas the other was medical staff. This could be clarified going forward. SH

8.5 Sam Hann explained that a number of risks had increased in scoring, and that there had been a switch to an increased number of risks recorded under the category of ‘continuity of service’. This was anticipated in light of COVID-19. Maurice Dunster said that there might need to be a change in the way that risks are considered, with the COVID-19 pandemic changing the focus of previously low-scored risks.

8.6 Jane Henderson drew attention to the risk relating to the ability to safely manage the increasing numbers of mental health patients in the ED. She asked if the building works would mitigate this. Sam Hann confirmed that the risk would likely be reduced following the completion of the building works. Jane Henderson said the Trust’s view of mental health risks might change in light of the potential merger with SFT as the services are provided by SFT. Matthew Bryant said that he would hope that the Trust does not wait for any potential merger before changes take place. The changes in the facilities and environment in ED are an excellent step forward in treating this patient group.

72- 9 RISK ASSURANCE COMMITTEE (RAC) Q3 REPORT 2021 9.1 The Committee noted the RAC report. Sam Hann explained that one meeting had been stood down due to operational pressures. A number of topics had changed assurance rating as outlined in the report. One of these topics was around end of life care. The RAC had noted the exceptional work completed in this area to date, but that some additional elements had been identified which could be improved.

73- 10 FREEDOM TO SPEAK UP GUARDIAN (F2SU) Q3 REPORT 2021 10.1 Debbie Matthewson joined the meeting. She advised that only two F2SU concerns had been raised in the quarter. The first related to a staff member who had since left the organisation, feeling they had been unfairly treated in relation to promises made about career progression. The HR team are investigating this along with the Equality Diversity and Inclusion team. This relates to discussions that may have taken place upon recruitment. The second concern related to a staff member feeling there was an ongoing issue of not enough staff during winter pressures. Shelagh Meldrum explained that agency staff are sought in these circumstances, but there may be instances where staff are reallocated to ensure safe staffing levels across all wards 6 | P a g e

and departments. The reasoning for these decisions was fed back to the person raising the concern, which was then closed upon agreement of the individual.

10.2 Jane Henderson asked if an increasing number of concerns was expected following the busy winter period and the subsequent wave of COVID-19. Debbie Matthewson said the work and support provided by the HR and Health and Wellbeing Teams was being recognised by staff and it was not anticipated that there would be an increase. 74- 11 MINUTES OF COMMITTEE’S SUB-GROUPS 2021 11.1 The Committee noted the minutes of the various sub-groups.

75- 12 TO AGREE 3 KEY ITEMS TO HIGHLIGHT TO THE BOARD 2021 12.1 It was agreed that the following items would be highlighted to the Board of Directors:  Impact of COVID-19 on staff, the challenges on infection control etc.  Recognise work for Maternity Team for Ockenden Report response  Discussion around the BAF and agreement we need to review the Risk Appetite.

76- 13 ANY OTHER BUSINESS 2021 13.1 Jane Henderson explained that this was Maurice Dunster’s last meeting as NED of YDH. She wished to thank him for his input and expertise over the years; he would be greatly missed. Maurice Dunster thanked Jane and the committee and said that he would miss everyone and it was frustrating his could not say goodbye in person.

13.2 Jane Henderson thanked Jan Hull for attending and the wider teams for their time and the various reports.

77- 14 DATE OF NEXT MEETINGS 2021 14.1 28 April 2021, 09:00, Boardroom, Level 1, YDH

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Appendix: 14 REPORT TO: Board of Directors REPORT BY: Chair of Audit Committee PRESENTED BY: Chair of Audit Committee EXEC SPONSOR: Chief Finance and Commercial Officer Update of Last Audit Committee and Minutes of Meetings Held on 28 REPORT TITLE: January 2021 DATE: 5 May 2021

Purpose of Paper (Please select any which are relevant to this paper)

☐ For Assurance ☐ For Approval / Decision ☒ For Information

Reason for Presentation to The Chair of the Audit Committee will provide a verbal update of the Committee/Board previous meeting held on 28 April 2021.

The Board are asked to NOTE this update to and to NOTE the minutes of the meeting held on 28 January 2021.

Any Key Issues to Note

Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) ☐ Care for our Population ☐ Develop our People

☒ Innovate and Collaborate ☒ Develop a Sustainable System

Implications/Requirements (Please select any which are relevant to this paper) ☐ Financial ☒ Legislation ☐ Workforce ☒ Estates ☒ ICT ☒ Patient Safety / Quality

Reference to CQC domains (Please select any which are relevant to this paper)

☒ Safe ☐ Effective ☐ Caring ☒ Responsive ☒ Well Led

Is this paper clear for release under the Freedom of Information Act 2000? ☒ Yes ☐ No

AUDIT COMMITTEE Minutes of the Audit Committee held on Thursday 28 January 2021 via MS Teams at Yeovil District Hospital

Present: Paul Mapson [Chair] Non-Executive Director Jane Henderson Non-Executive Director

In Attendance: Jonathan Higman Chief Executive Sarah James Chief Finance Officer Rees Batley KPMG Rob Andrews KPMG Adam Spires BDO Kate Ball BDO Claire Baker BDO Paul von der Heyde Trust Chairman Ben Edgar-Attwell Company Secretary Sam Hann Head of Risk and Compliance Alison Whitman Public Governor Observer David Moses Public Governor Observer Barbara Gregory Non-Executive Director – Somerset NHS FT

Presenters: Jeremy Martin Director of Transformation [item 5] Dean Stevens Managing Director – SSL [item 13] Mark Thouless Head of Finance – SSL [item 13]

Apologies: Martyn Scrivens Non-Executive Director

No: Action 54- 1 WELCOME AND APOLOGIES FOR ABSENCE 2021 1.1 Paul Mapson welcomed everyone to the meeting which included Barbara Gregory from Somerset NHS Foundation Trust (SFT). No apologies for absence were noted.

55- 2 DECLARATIONS OF INTEREST 2021 2.1 There were no declarations of interest relating to items on the agenda.

56- 3 MINUTES OF THE LAST MEETING AND ACTIONS/MATTERS ARISING 2021 3.1 The minutes of the meetings held on 22 October 2020 were approved as a true and accurate record.

3.2 With regard to actions arising, it was agreed that the first action regarding the review of counter fraud referrals relating to research sessions had been completed. The Health and Safety Report had been considered by the Executive Committee and reported to the Board in November 2020. The follow up recommendation dates would continue to be set prior to Audit Committee meeting dates (in this quarter there were no outstanding or overdue actions). The action relating to business continuity was ongoing with the draft IT plan awaiting final review and sign off. The action relating to risk management monitoring and reporting was ongoing with a draft paper in place. This would be revised and in time be presented to the required committees. All other actions were either completed or not yet due.

57- 4 AUDIT COMMITTEE SCHEDULE 2021 4.1 The Committee noted the Committee scheduled; the STA and Losses and Compensations report had been added to this.

58- 5 BDO INTERNAL AUDIT/COUNTER FRAUD REPORTS 2021 Internal Audit and Counter Fraud Progress Report 5.1 Adam Spires presented the Progress Report advising that the Benefits Realisation of TrakCare, COVID-19 Governance and Key Financial Systems reports were being presented to this meeting. The Mental Health and Dementia Report was out in draft and would be presented to the next Audit Committee. The fieldwork on the Digital Security and Protection Toolkit and Risk Management follow up reviews were underway. The Therapy Services and Patient Deterioration reviews had been postponed due to ongoing COVID-19 requirements; these had been replaced with a review of Capital Governance.

5.2 With regard to the COVID-19 Governance report, Substantial Assurance was provided for both Design and Effectiveness; only one recommendation was provided which related to strengthening maintenance and updating of the master action log. Jonathan Higman advised that the recommendation had already been resolved. Paul Mapson noted the good result and wished to congratulate all staff.

5.3 The report on Key Financial Systems also provided Substantial Assurance for both Design and Effectiveness. No recommendations were made. For Trusts who utilise SBS, YDH is rated the top in the country and scores highly on the good financial control metrics. Adam Spires provided a slight caveat to the review bearing in mind the audit required the use of remote testing.

5.4 Adam Spires advised that the TrakCare review had been an advisory report and therefore no assurance ratings were provided. Three recommendations had been provided although it was recognised that significant changes had been taken in the latter part of the year. The findings outlined that there was an opportunity to ensure sufficient and robust governance and tracking processes for the implementation plan. It is important that the risk register regarding TrakCare is kept up to date and risks recorded in a timely way.

5.5 Paul Mapson said this review had been requested before he joined the organisation; he asked if the review had achieved the required objectives. Paul von der Heyde said there had been a number of personnel changes in terms of leadership for the project and therefore the recommendations were anticipated. Jonathan Higman said that the audit was for an independent review of governance processes and how improvements could be made. A significant amount of work had been completed on the renegotiation of the contract to cover what can realistically be delivered. The report would be used to ensure that robust processes and governance is in place.

5.6 Jeremy Martin agreed that the comments within the report were anticipated, but explained that there had been significant improvement in recent months and there was greater confidence of the position going forward. Paul Mapson asked about the contract renewal date. Jeremy Martin explained that the contract expired in 2025.

5.7 Claire Baker presented the Counter Fraud update. The Fraud Prevention Guidance Impact Assessment Survey had been submitted to the NHS Counter Fraud Authority (NHSCFA). Action has been taken following each piece of guidance received. One anonymous allegation had been received since the 2 | P a g e

previous meeting. The initial information was insufficient to understand the referral, or which department it related to. Further information was subsequently received which gave an indication of the department and potential concern of staff claiming additional payments they are not entitled to. Based upon the evidence available it is understood that this is potentially a cultural and procedural issue rather than a deliberate attempt by an individual or group of individuals. The controls are to be addressed and strengthened.

5.8 BDO have continued with proactive pieces of work, including a review of high supplier expenditure and COVID-19 expenditure, with support from the Procurement Team. No significant concerns or issues have been raised. Paul Mapson questioned the small contract sample size, noting the higher rate of Single Tender Actions (STAs) during the pandemic response. Claire Baker said that this was a typical amount and include a number of high expenditure suppliers. Barbara Gregory said that the number of STAs had been raised within Somerset NHS Foundation Trust (SFT).

Internal Audit Follow up of Recommendations Report 5.9 Claire Baker reported that all due recommendations had been completed. BDO had also followed up on the risk management recommendations, which were due to be considered at the next meeting. The actions relating to Health and Safety were due to be reviewed as part of the next year’s plan.

5.10 Paul Mapson asked if any of the dates were slipping. Claire Baker advised that this was not really happening and YDH has a good track record in this area compared to their other clients. Paul Mapson asked how a change in due date is authorised. Sarah James said that this is raised with her as the Trust’s Internal Audit Executive Lead. Changes come to the relevant Executive for consideration.

59- 6 DRAFT BDO INTERNAL AUDIT PLAN 2021/22 2021 6.1 Adam Spires introduced Kate Ball who was due to begin as BDO Audit Manager for YDH from April 2021. The Committee were advised that there is a requirement to set a three year internal audit plan, although recognised that this will need to be flexible in future years.

6.2 Kate Ball presented the draft Internal Audit Plan, which had been reviewed and considered by the Trust’s Executive Committee. Jonathan Higman confirmed that this review had taken place with a small number of amendments had been made in light of the COVID-19 position. The Committee considered the plan as drafted and agreed that this would be kept under review. The final plan would be presented to the meeting in April 2021 for approval. BDO

60- 7 KPMG EXTERNAL AUDIT PROGRESS REPORT AND TECHNICAL UPDATE 2021 7.1 Rob Andrews reported that since the last meeting, the audit of the Charitable Funds Accounts had been completed and submitted. The Simply Serve Limited Accounts had also been completed and were included on the agenda later in the meeting. He said that the completion of this work had come close to the final statutory deadlines.

7.2 At present, KPMG are going through the various planning aspects and the Value for Money documentation (as provided by the Trust) was being reviewed. This will provide an initial view on risks etc. For the next meeting, the fieldwork will have been completed and Month 9 sample testing would have commenced. The findings from this will be bought to a future meeting.

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7.3 Rob Andrews drew attention to Practice Note 10 as included in the Technical Update. This relates to changes in audit standards etc. This is a change in the sector and is to support consistency in the application of auditing standards. Confirmation has been received that the implementation of IFRS 16 has been deferred for a further year.

7.4 Sarah James said that the Trust needs to be alert to the potential differences and impact Practice Note 10 may have although this was not a cause for concern. Rees Batley said that there is a good template from the previous year and good steps have been made already within YDH.

7.5 Paul Mapson said that there was a risk that the Value for Money work could become overly burdensome. Rees Batley said that this was recognised although YDH had provided one of the most thorough and complete responses of all their clients. A moderation process will shortly take place and a few follow up questions may arise from this. Rob Andrews said that it had been questioned if this was the right year to introduce this review, bearing in mind the COVID-19 funding arrangements in the NHS. Sarah James said that YDH had attempted to tie in providing the information with the various evidence gathering for the due diligence work for the potential merger between YDH and SFT and that credit should be provided to the corporate services teams for this work.

Benchmarking Report 7.6 The Committee noted the benchmarking report. Sarah James noted that the creditor days within the report did not align with the Better Payment Practice Code performance for YDH. Rob Andrews advised that this data was from the provider trust NHSE/I returns. Sarah James said that this would be checked. SJ

61- 8 KPMG 2020/21 EXTERNAL AUDIT PLAN 2021 8.1 Rees Batley spoke to the circulated audit plan for 2020/21; this confirmed that the timetable for submission of the accounts had been extended until the 15 June 2021. In addition, there is no longer a requirement for external audit of the Quality Accounts for a further year. There are four key risks relating to the audit as outlined in the plan. These are consistent with the previous years and are largely driven by the auditing standards and requirements. A valuation of land and buildings had been completed in 2020 and a full revaluation is not due for 2020/21.

62- 9 PREPARATION FOR 2020/21 ANNUAL REPORT AND ACCOUNTS 2021 9.1 Sarah James advised that the report captured two aspects, the timetable for the drafting and submission of the accounts and to outline the accounting policies for this financial year. At present, there are no proposed local changes to the existing accounting policies and the Trust is not aware of any national changes, with the exception of the delay of IFRS16.

9.2 At the time of drafting the paper, discussions were taking place regarding segmental reporting and whether this should be split between urgent and elective care. Upon review of practice elsewhere and the best option for YDH, it is suggested that the segments are YDH and the two major subsidiary companies. This is not a change in policy but a change in the presentation of segments. Paul Mapson said that this appeared sensible.

9.3 Paul Mapson noted that there had been discussion at the SFT Audit Committee regarding accounting policies and the need to ensure consistent policies across both Trusts. Sarah James agreed and that this would be reviewed to ensure consistency going forward.

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9.4 Sarah James advised that the Annual Reporting Manual for 2020/21 had not been released at the time of circulating papers but that large changes were not anticipated. The paper outlined the key high level dates and deadlines for the production of the Financial Accounts and Annual Report. There is a commitment for the alignment of the production of the various subsidiary accounts. Sarah James said she would be personally writing to the Managing Directors of the subsidiary companies regarding this requirement.

63- 10 SINGLE TENDER ACTIONS REPORT 2021 10.1 Paul Mapson advised that this report had been requested for this Committee and was in line with good practice. It is important that this is kept under review bearing in mind the increased number of permissible actions during the COVID- 19 pandemic response, to ensure this practice does not unduly continue.

10.2 Sarah James agreed that it would become a regular report and that it had been drafted in line with the format presented at SFT. One additional column would be added going forward, which would capture the reason for the STA/SQA as per the provisions within the Standing Financial Instructions. Sarah James advised that the review work had commenced in May 2020 by the Estates and Facilities Directors within SSL. A number of the STAs/SQAs as reported directly relate to the urgent need in response to COVID-19; these were properly taken and were not the default tendency.

10.3 Paul Mapson welcomed the paper, which provided assurance on the work already in hand to improve processes and controls. He said further reporting to understand who has requested and approved the various actions should be included. In the event that the action does not meet any of the criteria as provided within the SFI’s, that this should be referred back to the requester.

10.4 The Committee noted the report and the proposed changes for future reports.

64- 11 LOSSES AND COMPENSATION REPORT 2021 11.1 Sarah James explained that the report was to provide the Committee with an update on the status of losses and special payments. Drug losses were now included within the report. The Committee noted the content of the report. Given the relatively low value, opinions were sought on the frequency of the report to the Committee. It was agreed that this would be reported quarterly.

65- 12 RISK MANAGEMENT FRAMEWORK (INCLUDING BAF AND CRR) 2021 Risk Assurance Committee (RAC) Report 12.1 Sam Hann advised that the report had been drafted in the same format as previous, whilst recognising that there were ongoing discussions regarding the reporting lines of certain topics. She reported that two topics had been downgraded in rag scoring. End of Life Care had been discussed at the Governance and Quality Assurance Committee (GQAC). The topic of COSHH had been downgraded due to a gap between infection control and health & safety with regards to skin surveillance and it was agreed to include skin surveillance within the next report to the RAC.

Corporate Risk Register 12.2 Sam Hann reported that there had been significant movement in risks during the quarter, largely as a result of COVID-19. There had been a shift in the categorisation of risk with a higher number of continuity of service risks reaching

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corporate level. Risks that had increased in rating related to staffing absences, staff burnout, management of outbreaks, PPE storage, patient flow etc.

12.3 Jane Henderson said that there had been substantial discussion at the GQAC meeting earlier in the day regarding risks just under the corporate level. A number of these lower rated risks were due to the mitigations put in place but that they should still be monitored going forward. A number of the solutions were on a system wide basis. Jonathan Higman agreed that a number of risks were reflected at neighbouring organisations, such as those concerning the facilities to treat mental health attendances within the emergency department. The ongoing improvement works within the department are due to mitigate this further although further work around mental health services was ongoing, to include mental health crisis services. The implementation of some of these services had been impacted by COVID-19 but that they remained a priority.

12.4 Paul von der Heyde said that he had spoken with Jane Henderson prior to the GQAC meeting about the level of risks and how this was reflected within the various reports and whether there was a need to review the Trust’s Risk Appetite. A higher level of risk is being tolerated in light of the pandemic. Jonathan Higman agreed with this point. He explained that the Executive Committee had noted this variance to the Risk Appetite and a high level mapping exercise had been completed. There was also recognition of the potential risk of staff turnover and staff burnout in the event of a national direction towards elective service recovery without a period of staff recovery.

Q3 Board Assurance Framework (BAF) 12.5 Ben Edgar-Attwell provided an overview of the BAF, which is reported to the Financial Resilience and Commercial Committee (FRCC), Workforce Committee and GQAC. Principal Risk SR8 was overseen by the Audit Committee and related to electronic systems, business continuity etc. This risk had decreased slightly in risk rating due to the actions taken.

66- 13 SIMPLY SERVE LIMITED 2021 13.1 Dean Stevens and Mark Thouless attended the meeting to provide an update on the corporation tax liability for SSL. Dean Stevens said that SSL’s tax advisors had determined that the net gain on the lease charge to the Trust constitutes taxable income which was at odds with the original advice received on establishing SSL. The paper outlined the legal advice sought on challenging the original advice received and the accounting treatment. Work continues in order to confirm future mitigation. It was confirmed that this was not material for the group accounts.

13.2 A number of actions have been identified to avoid delays in the production of the financial accounts for 2020/21 and to align the timetable with YDH. Paul von der Heyde said it was good to see the consistency in the notes within the accounts and the alignment with the drafting. He said it was important that the advice challenge around the corporation tax liability is followed up.

Annual Accounts 2019/20 13.3 The Committee noted the SSL financial accounts for 2019/20.

67- 14 EFFECTIVENESS OF COMMITTEE 2021 14.1 The Committee considered its effectiveness. It was noted that SFT produce a quarterly paper that considers the committee’s terms of reference and the work completed and actions taken against this. It was suggested that this is completed at YDH. BEA

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68- 15 ANY OTHER BUSINESS 2021 15.1 No other items of business were raised.

69- 17 DATE OF NEXT MEETING 2021 17.1 Wednesday 28 April 2021, 14:00, Boardroom, YDH

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Annex: A REPORT TO: Board of Directors REPORT BY: Samantha Hann, Head of Risk & Litigation PRESENTED BY: Ben Edgar-Attwell, Company Secretary EXEC SPONSOR: Jonathan Higman, Chief Executive REPORT TITLE: Risk Management Strategy DATE: 30 April 2021

Purpose of Paper (Please select any which are relevant to this paper)

☐ For Assurance x For Approval / Recommendation ☐ For Information

The Board of Directors are ultimately responsible and accountable for the comprehensive management of risks faced by the Trust. They will:

• agree the strategic objectives and review these on an annual basis • identify the principal risks which may prevent the Trust from achieving its key objectives • receive and review the Corporate Risk Register and the Assurance Framework quarterly, which identify the principal risks and any gaps in assurance regarding those risks • support the Trust’s risk management programme • review the Risk Management Strategy at regular intervals but as a minimum once every 3 years • approve Assurance Committee terms of reference annually

The Risk Management Strategy has been updated to include:

• inclusion of the Executive Committee and its responsibilities in Reason for Presentation to relation to risk management Committee/Board • the change of SIRO • change of name for the incident review meeting following the national requirement for patient safety alerts to be reviewed and overseen by Executive Directors • statement outlining the risk management arrangements for the subsidiary companies of YDH Trust Group • update to the terminology used for pressure ulcers within the scoring guidelines • inclusion of the risk rating definitions used by the Trust • revised job titles • updated Equality Impact Assessment

The Maternity Risk Management Strategy (Annex D) has been updated to include:

• revised job titles and roles • revised maternity triggers list • inclusion of additional departmental meetings • updated Equality Impact Assessment

The draft Risk Management Strategy was reviewed by the Audit Committee on 28 April 2021. The Audit Committee recommends that the Board of Directors approve the draft Risk Management Strategy. Risk Appetite Review

On the 7 April 2021, the Board of Directors considered the existing Risk Appetite Statement as previously set. This review was as part of good practice to review the Statement but also to ensure it is fit for purpose in light of the current environment, i.e. Any Key Issues to Note COVID19 pandemic. The Board of Directors agreed that the existing Risk Appetite levels for each of the Risk Categories should remain as they are, although a piece of work to review the Principal Risks (as monitored on the BAF) scoring would take place. It was suggested that bearing in mind there are numerous contingency plans in place for the risks, that the Consequence scoring could be lower than is currently demonstrated through the BAF.

Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) ☒ Care for our Population ☒ Develop our People

☒ Innovate and Collaborate ☒ Develop a Sustainable System

Implications/Requirements (Please select any which are relevant to this paper) ☒ Financial ☒ Legislation ☒ Workforce ☒ Estates ☒ ICT ☒ Patient Safety / Quality

Reference to CQC domains (Please select any which are relevant to this paper)

☐ Safe ☐ Effective ☐ Caring ☐ Responsive ☒ Well Led

Is this paper clear for release under the Freedom of Information Act 2000? ☒ Yes ☐ No

RISK MANAGEMENT STRATEGY

Version Number 8.1 Version Date April 2021 Policy Owner Chief Executive Author Head of Risk and Litigation First approval or date The Risk Management Policy was first approved in last reviewed July 2007, reviewed in September 2011 up to Version 4.1, reviewed in September 2014 (version 5), reviewed in October 2017 (version 6), reviewed in February 2018 (version 6.2), reviewed in July 2019 (version 7), reviewed in October 2019 (version 8) Staff/Groups Consulted Executive Directors and Non–Executive Directors Deputy Directors Company Secretary Strategic Business Unit Senior Teams Clinical Directors of Patient Safety & Governance Maternity Risk Manager Head of Midwifery Approved by the Board To be completed following approval of Directors Next Review Due October 2022 Equality Impact April 2021 Assessment

Table of Contents

1. INTRODUCTION…………………………………………………………………………………..5 2. PURPOSE………………………………………………………………………………………….5 3. ARRANGEMENTS FOR RISK MANAGEMENT…………………………………………...... 6 4. RISK REGISTER AND ASSURANCE FRAMEWORK………………………………………...7 5. DEFINITIONS……………………………………………………………………………………...9 6. ORGANISATIONAL RESPONSIBILITIES OF RISK MANAGEMENT……………………..10 7. STAFF RESPONSIBILITIES FOR MANAGEMENT OF RISK…………………………… ..12 8. OPERATIONAL RISK MANAGEMENT……………………………………………………….14 9. INCIDENT REPORTING………………………………………………………………………..19 10. APPLICABILITY………………………………………………………………………………….20 11. IMPLEMENTATION, TRAINING AND SUPPORT……………………………………………20 12. MONITORING THE EFFECTIVENESS OF THE STRATEGY……………………………...21 13. REFERENCES…………………………………………………………………………………...21 14. ASSOCIATED POLICIES……………………………………………………………………….21 15. SUBSIDIARY COMPANIES OF YEOVIL DISTRICT HOSPITAL (YDH)………………...... 22 16. EQUALITY IMPACT ASSESSMENT…………………………………………………………..22

ANNEX A – RISK APPETITE STATEMENT……………………………………………………….23 ANNEX B – RISK ASSESSMENT SCORING GUIDELINES……………………………..……..27 ANNEX C – EQUALITY IMPACT ASSESSMENT TOOL………………………………….….. ..37 ANNEX D – MATERNITY RISK MANAGEMENT STRATEGY……………………………….....40

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RISK MANAGEMENT STRATEGY

1 INTRODUCTION

1.1 The Chief Executive and the Board of Directors (BoD) at Yeovil District Hospital NHS Foundation Trust (the Trust) are committed to a strategy, which minimises risks and achieves compliance with statutory requirements through a comprehensive system of internal controls and committees, whilst maximising the potential for flexibility, innovation and best practice in delivery of its strategic objectives. The Trust is committed to ensuring the safety of patients, staff, the public and stakeholders against risks of all kinds.

1.2 As part of governance arrangements, this strategy outlines the risk management framework, emphasising the way that the Trust can implement its strategic objectives through an integrated risk management approach. Integrated risk management is the identification and assessment of the collective risks, both corporate and clinical, that affect the value and the implementation of the Trust’s strategic objectives so that risks are not seen in isolation. This Risk Management Strategy aims to maximise the value of an integrated risk management approach by demonstrating the Trust’s risk profile and investigating mitigating actions and controls.

1.3 A clear understanding of the key strategic objectives and a commitment to corporate governance will ensure that risk analysis and management are applied throughout the organisation. The Risk Management Strategy also endeavours to promote a culture whereby patient safety and quality are at the heart of all clinical practice and all staff are open to sharing learning from the experiences related to the management of risk.

1.4 The Strategy will support the Trust, directly employed staff and shared service providers in managing risk through safe systems of practice, including the identification of risk and the use of clinical guidelines and protocols to minimise risk. The Assurance Committees on behalf of the Board of Directors will ensure that safe systems and robust risk management arrangements are in place for delivering quality and safe care.

1.5 Reducing risk can lead to an improvement in patient safety and quality of care. Equally, improved quality of care may lead to a reduction of clinical risk. Risk management is therefore regarded in the Trust as an integral part of quality governance. It is the Trust’s aim to ensure that all professionals working within the organisation know that quality governance, assurance and patient safety are part of their daily responsibility and embedded in their working practices.

1.6 Having the capability to reduce risks does not necessarily imply that the Trust should reduce the risk. Inevitably all risk cannot be eliminated entirely and there needs to be an understanding of the levels of risk faced by the Trust to allow an assessment of which areas of risk which should be prioritised.

2 PURPOSE

2.1 The purpose of this Risk Management Strategy is:

• to demonstrate an organisational risk management structure in which all the Committees have shared responsibility for managing risk across the organisation

• to outline a process which ensures that the Board of Directors undertakes regular review of risk through the Assurance Framework and Corporate Risk Register

• to ensure the development of a system for implementation of seamless risk management strategies in all areas of the organisation including business planning, delivery of care and planned developments

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• to identify within the Strategy documentation and process, the roles and responsibilities of key individuals in post with responsibility for advising on and coordinating risk management activities

• to identify the respective roles, responsibilities and accountability undertaken by the Board of Directors, managers and staff for areas of risk

• to identify the responsibilities of all managers/clinicians and staff and their authority with regard to managing risk

• to outline the process for risk assessment for all types of risk including those that relate to specific areas including projects

• to identify risks against standards set by regulators such as the Care Quality Commission and NHS Improvement

2.2 In the implementation of this Strategy, the Trust will support the adoption of a no blame culture regarding the reporting of adverse incidents in line with NHS England, National Reporting and Learning Service (NRLS) and the Serious Incident Framework – Supporting Learning to Prevent Recurrence of Harm 2015.

2.3 The Trust has committed to ‘Being Open’ and the contractual ‘Duty of Candour’ applies, ensuring openness and transparency when dealing with patients and families when harm occurs.

2.4 The Trust is committed to delivering fully inclusive and accessible services and meeting the standards set out in the Equality Delivery System (EDS2). The EDS2 is designed to help organisations review and improve their equality performance and embed equality into services through identifying future priorities and actions.

3 ARRANGEMENTS FOR RISK MANAGEMENT

3.1 The Trust will ensure that the management of risk is established throughout the organisation with guidance on roles, responsibilities, processes and procedures.

3.2 Risk may be defined as the possibility of incurring loss or the likelihood of adverse consequences arising from an event. Risk may also be described as the potential for a hazard to prevent the achievement of organisational objectives leading to a detrimental impact on patients, staff and members of the public.

3.3 Managing risk, clinical and non-clinical, is accepted as a key organisational responsibility and is an integral part of management systems and processes.

3.4 All staff have an important role in identifying, assessing and minimising risk. This can be achieved where there is a culture of openness, being ‘fair and open’, together with a willingness to admit mistakes. The organisation has a Being Open and Duty of Candour Policy in respect of communicating with patients and/or carers about patient safety incidents.

3.5 The Trust has adopted the principles of risk management, which form the basis of the risk management framework. This will assist in the identification and analysis of all risks. The risks identified may include those which adversely affect the quality of patient care, the ability to deliver services, the health, safety and welfare of patients, visitors and staff or the ability of Trust to meet service and contractual obligations.

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3.6 The following methods are to be used in the identification and management of risk:

• maintenance of Strategic Business Unit and Specialty risk registers

• involvement of all staff in the assessment of risk

• ongoing analysis of all clinical, financial and corporate risk

• analysis of incidents, claims and patient experience

• identifying new risks from significant events and near misses

• root cause analysis of significant events and serious incidents

• identifying new risks from national reporting through the Central Alerting System (CAS) e.g. Patient Safety Alerts issued by NHS England, Chief Medical Officer (CMO) Alerts, National Reporting Learning System (NRLS), Medicines and Healthcare Products Regulatory Agency (MHRA)

3.7 The overall Trust responsibility for risk management will rest with the Board of Directors. Other Assurance Committees with responsibility for risk management are:

• Board Assurance Committee - Audit Committee, Governance and Quality Assurance Committee (GQAC), Workforce Committee and Financial Resilience and Commercial Committee

• Executive Committee

• Risk Assurance Committee

• Formal Committees/Steering Groups

3.8 For an explanation of the Committees responsibilities see Section 6.

3.9 Staff are involved in risk management; both through the incident reporting process and through the proactive identification and management of risk in the organisation. Staff level responsibilities for risk management are detailed in Section 7.

3.10 The corporate risk register will be assessed at least quarterly in order to inform the Annual Governance Statement and when procedural, legislative or best practice changes occur.

3.11 The policy, strategy and the principle of risk management will be communicated to staff. Staff will be encouraged in the use of risk assessment to identify both immediate risks and long term risks.

4 RISK REGISTER AND ASSURANCE FRAMEWORK

Arrangements

4.1 The Strategic Business Unit and Specialty risk registers identify and list the risks facing the Trust and the action being taken to mitigate them.

4.2 All Lead Directors (including Lead Clinicians responsible for specific work streams), supported by the Head of Risk and Litigation are responsible for ensuring that risks identified through local mechanisms are included on Strategic Business Unit and Specialty risk registers and the Corporate Risk Register for those scoring 12+ in line with the risk matrix. The Deputy Chief Executive, Chief Nurse & Director of People and

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the Deputy Director Quality Governance and Patient Safety are responsible for ensuring that Trust-wide clinical risks are included.

4.3 The Lead Directors and Clinicians are responsible for prioritising risk treatment plans based on detailed analysis and evaluation of risks.

4.4 The Executive Committee and the Assurance Committees will review the Corporate Risk Register as part of their meetings agendas to ensure risk treatment plans are being implemented. The Audit Committee will have overall oversight of the Assurance process.

4.5 Each risk will be scored using the matrix quantification methodology favoured by the NHS. This assigns values between 1 and 5 to both the likelihood of the risk being realised and the possible consequences of this. These are then multiplied together to give a risk rating. The matrix for assessing and rating risk is attached at Annex B.

4.6 When deciding if a risk is acceptable, the risk rating will be considered in the light of controls to reduce the risk and the Trust’s risk appetite. If significant and effective action has already been taken to minimise the adverse consequences of the risk, then the risk may be termed acceptable. If further controls could be taken to reduce the risk, these will be considered in the light of the urgency of the risk, and the cost and time commitment needed to implement the control.

4.7 Within the Trust, the Strategic Business Unit and Speciality risk registers will become an integral tool in the risk management process used actively by all Directors and their staff. Risk registers will be updated by the responsible leads set out in the risk registers supported by the Head of Risk and Litigation, with risk information being received from a variety of sources.

Definitions of Significant and Acceptable Risk

4.8 An acceptable risk may be defined as a potential hazard that is either small enough to have an immaterial effect on the achievement of organisational objectives, or is a significant risk that has been mitigated by the establishment of effective controls. These controls may minimise the likelihood of the risk occurring, and/or minimise the adverse consequences should the risk identified occur.

4.9 A significant or high risk may be defined as any risk which has been identified by the Board of Directors, Strategic Business Units or Speciality areas as being potentially damaging to the organisation’s strategic objectives. Significant or high risks would be those assessed as having a risk rating of 12 or above (12+) and should be reported in accordance with the risk appetite.

4.10 Risk appetite is a threshold – the amount of risk that an organisation is prepared to accept before it takes action. Annex A sets out the Trust’s Risk Appetite Statement.

4.11 As part of the risk management process, all risks identified are evaluated and given a risk level rating. The higher the risk level, the greater the likelihood and/or impact of that risk occurring. Annex B sets out the risk scoring and assessment guidelines.

4.12 The risk level ratings for the Trust are defined as follows:

• Risk Level – Low (Green) - Risk Matrix Scoring 6 or under - These represent the lowest levels of opportunity/threat and actions shall be limited to contingency planning rather than active risk management action. Risks can be recorded on the Strategic Business Units and Speciality risk registers. Risk level shall be monitored as part of the ‘local’ risk register review of activities such as team and senior management meetings.

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• Risk Level – Moderate (Yellow) – Risk Matrix Scoring between 8 and 10 These represent moderate levels of opportunity/threat. Risks in this category shall have actions defined on the risk register or on an action plan for risk treatment. Risks shall be recorded on Strategic Business Unit and Specialty risk registers and tabled at appropriate meetings, management meetings and relevant committees with responsibility for risk management.

The risk level shall be monitored as part of the Strategic Business Unit and/or Specialty managers review together with the status of controls in place and risk treatment.

• Risk Level – Significant (Amber) – Risk Matrix Scoring between 12 and 15 - These represent significant levels of opportunity/threat which may have a short or medium term impact on organisational objectives. Risks in this category shall have individual actions plans for risk treatment. Risks shall be proactively managed and reported on at intervals defined in the action plan but as a minimum requirement quarterly to the Executive Committee, Assurance Committees and to the Board of Directors through the Corporate Risk Register.

• Risk Level – High (Red) – Risk Matrix Scoring 16+ - These represent higher levels of opportunity/threat which may have a major or long term impact on benefits realisation or organisation objectives and which may also impact on strategic objectives and outcomes positively or negatively.

Risks in this category shall have individual action plans for risk treatment. Risks shall be proactively managed and reported on at intervals defined in the action plan but as a minimum requirement quarterly to the Executive Committee, Assurance Committees and to the Board of Directors through the Corporate Risk Register.

The Assurance Framework

4.13 The Assurance Framework is designed to provide NHS organisations with a method for the effective and focused management of the principal risks to meeting its strategic objectives. It also provides evidence to support the Annual Governance Statement.

4.14 This is intended to simplify Board of Directors reporting and the prioritisation of action plans, which in turn, allows for more effective performance management.

4.15 The Assurance Framework sets out the strategic objectives and identifies assurances on key controls, ensuring principal risks, mitigating actions and gaps in controls are documented and monitored. A Lead Director responsibility is identified against the objectives. The Assurance Framework is supported by the Corporate Risk Register to identify operational risks.

4.16 The Trust will review their strategic objectives and principal risks on at least an annual basis.

4.17 The Assurance Framework will be presented to the Executive Committee, the Assurance Committees and the Board of Directors quarterly for review and proactive management of gaps in assurance about the delivery of strategic objectives.

5 DEFINITIONS

• Risk is the threat or possibility that an action or event will adversely or beneficially affect the Trust’s ability to achieve its objectives. It is measured in terms of likelihood and consequence.

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• Risk management is about the Trust’s culture, processes and structures that are directed towards realising potential opportunities whilst managing adverse events. The risk management process covers all processes involved in identifying, assessing and judging risks, assigning ownership, taking action to mitigate or anticipate them, and monitoring and reviewing progress.

• Risk assessment is a systematic process of assessing the likelihood of something happening (frequency or probability) and the consequence if the risk actually happens (impact or magnitude).

• Principal risks are those that represent a threat to achieving the Trust’s strategic objectives or to its continued existence. They also include risks that are widespread beyond the local area and risks for which the cost of control is significantly beyond the scope of the local budget holder.

• Operational risks are by-products of the day-to-day running of the Trust and include a broad spectrum of risks including clinical risk, financial risk (including fraud), legal risks (arising from employment law or health and safety regulation), regulatory risk, risk of loss or damage to assets or system failures etc. Operational risks can be managed by the Strategic Business Unit or Corporate area which is responsible for delivering services.

• Risk registers are repositories for electronically recording and dynamically managing risks that have been appropriately assessed. Risk registers are available at different organisational levels across the Trust.

• Risk appetite is the type and amount of risk that the Trust is prepared to tolerate and explain in the context of its strategy.

• Risk Matrix is the mechanism through which all risks are rated and scored.

• Governance is the systems and processes by which the Trust leads, directs and controls its functions in order to achieve its organisational objectives, safety, and quality of services, and in which it relates to the wider community and partner organisations.

• Internal controls are Trust policies, procedures, practices, behaviours or organisational structures to manage risks and achieve objectives.

• Assurance is the confidence the Trust has, based on sufficient evidence, that controls are in place and operating effectively and its objectives are being achieved.

• Assurance Framework provides the organisation with a comprehensive method for the effective and focussed management of principal risks that affect the strategic objectives of the Trust.

6 ORGANISATIONAL RESPONSIBILITIES FOR RISK MANAGEMENT

6.1 The Board Governance Structure (the organisation’s Committee structure chart) is contained on the Trust’s website under the publication section: https://www.yeovilhospital.co.uk/about-us/corporate-information/

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Board of Directors

6.2 The Board of Directors are ultimately responsible and accountable for the comprehensive management of risks faced by the Trust. They will:

• agree the strategic objectives and review these on an annual basis

• identify the principal risks which may prevent the Trust from achieving its key objectives

• receive and review the Corporate Risk Register and the Assurance Framework quarterly, which identify the principal risks and any gaps in assurance regarding those risks

• support the Trust’s risk management programme

• review the Risk Management Strategy at regular intervals but as a minimum once every 3 years

• approve Assurance Committee terms of reference annually

Audit Committee

6.3 The role of the Audit Committee is to provide independent verification to the Board of Directors on wider organisational controls and risk management. It is not the Audit Committee’s role to contribute to the identification and management of risks, but it will review the findings of internal (and external) audit, together with any agreed management action, with the Lead Director and Lead Clinician responsible and the internal auditors.

6.4 The Committee will:

• oversee the Risk Management Strategy and process

• review the Corporate Risk Register and Assurance Framework at their meetings

• review internal and external sources to provide adequate assurance to the Board of Directors that risks are being appropriately controlled and risk management is embedded throughout the organisation

• receive and consider risk management reports from other Committees and Groups with responsibility for risk

• review the Risk Management Strategy at least annually and approve 3 yearly for ratification at the Board of Directors

Governance and Quality Assurance Committee (GQAC)

6.5 The GQAC acts as a focus for the management of clinical, non-clinical risks, receiving reports and recommendations from the Patients Safety Steering Group, Clinical Outcomes Committee, Patient Experience Steering Group, Risk Assurance Committee and other Committees agreed through the GQAC and included within the Trust’s Governance Structure (see Section 6.1).

Executive Committee

6.6 The Executive Committee has delegated powers from the Board of Directors to oversee the day-to-day management of an effective system of integrated governance,

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risk management and internal control across the whole organisation’s activities (both clinical and non-clinical), which also supports the achievement of the organisation’s objectives. The Committee will review the effectiveness of the management of the Principal Risks as monitored by the Assurance Framework and operational risks as monitored by the Corporate Risk Register. The Committee will also review and monitor the structures processes and responsibilities for identifying and managing key risks facing the organisation, prior to discussion at the Assurance Committees and the Board of Directors.

Risk Assurance Committee (RAC)

6.7 The Risk Assurance Committee (RAC) reviews and tests assurance from Operational Leads for topic areas on behalf of the Assurance Committees and oversees the development and delivery of key governance systems. The Committee will provide exception reports directly to the Board Assurance Committees on topic areas to support the assurance process.

Formal Committees

6.8 There are a number of Committees/Groups that report to the Assurance Committees who are responsible for reviewing and managing the risks under their remit in line with their terms of reference.

7 STAFF RESPONSIBILITIES FOR THE MANAGEMENT OF RISK

Chief Executive

7.1 The Chief Executive as the Accountable Officer has overall responsibility for ensuring the implementation of the Risk Management Strategy, including organisational controls and reporting arrangements and is the Executive Director responsible for Fire, Health and Safety.

Deputy Chief Executive, Chief Nurse and Director of People

7.2 The Director Lead for Clinical Risk has overall responsibility, delegated from the Chief Executive for Quality and Patient Safety, Risk Management and Quality Governance and Assurance, including:

• ensuring implementation of risk management standards and reporting to the Executive Committee, Assurance Committees and the Board of Directors

• providing clinical leadership for the development and implementation of the quality improvement and patient safety plan

• ensuring the effective delivery of clinical care, including clinical audit, evidence based medicine and national and local guidelines in commissioned services

• reporting to the Somerset CCG Governing Body on patient safety, safeguarding, and quality governance and assurance

• ensuring systems for reporting incidents, investigation of serious incidents and external reporting arrangements are managed effectively

7.3 The Deputy Chief Executive, Chief Nurse and Director of People is the nominated Security Management Director (SMD).

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Chief Finance Officer

7.4 The Chief Finance Officer is responsible for progressing financial risk management and is the nominated Senior Information Risk Owner (SIRO).

Chief Information Officer

7.5 The Chief Information Officer is responsible for progressing information risk management.

Senior Director Risk Leads

7.6 The Senior Risk Management leads are:

• Deputy Chief Executive, Chief Nurse and Director of People

• Chief Finance Officer

• Chief Medical Officer

• Chief Operating Officer

• Director of Operations

• Chief Information Officer

• Director of Transformation

7.7 They are responsible for:

• communicating the Risk Management Strategy

• carrying out the risk management processes set out in Section 8

• ensuring that effective risk management processes are in place within their areas of responsibility

• initiating action within their area to prevent or reduce the adverse effects of risk

• managing the treatment of risk until it becomes acceptable to the organisation

• ensuring that learning from events and risk assessments is disseminated throughout the organisation

Company Secretary

7.8 The Company Secretary is responsible for managing the governance arrangements at the Board of Directors level including maintaining the Assurance Framework, ensuring it drives the Board agenda with quarterly reports to the Board of Directors. The role of Company Secretary will also review the assurance and risk Committees structure ensuring it meets the needs of the Trust in line with the governance arrangements.

Deputy Director Quality Governance and Patient Safety

7.9 The Deputy Director Quality Governance and Patient Safety is responsible for monitoring clinical incidents, serious incidents requiring investigation and the maintenance of strategic level reporting to ensure that the Executive Team is fully aware of all clinical risks within the Trust.

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Head of Risk and Litigation

7.10 The Head of Risk and Litigation is responsible for maintaining the Trust’s risk register and risk management arrangements, working in collaboration with the Company Secretary and Chief Executive to identify corporate risks for reporting to the Board of Directors from the operational risk registers. The Head of Risk and Litigation provides risk register arrangements for the Strategic Business Units and departments to identify and manage their risks.

Managers/Heads of Departments

7.11 Managers are responsible for:

• carrying out risk assessments and risk management processes, including identification, assessment and treatment of risks and communicating risk to those affected, escalating to the risk register as necessary

• maintaining Fire and Health and Safety Risk Assessments locally and developing safe systems of work when significant or high risks are identified that are communicated and monitored

• ensuring that staff accountable to them understand their responsibilities in respect of risk management

• ensuring incidents are reported and managed, and concerns are raised where poor practice, or safety concerns are identified

All Staff

7.12 All staff are responsible for risk management from participation in risk assessment to following the safe working practices that involve their work. Staff are responsible for abiding by policies and procedures and the findings of risk assessment and may be subject to disciplinary action for non-compliance. All staff are responsible for helping to maintain a safe working environment, for using the Trust incident reporting system and for informing their line manager of issues of concern, which may affect safety and quality.

7.13 Staff should report such risks (or potential risks) to their line manager in the first instance and raise concerns as they arise.

7.14 There is a link on the YCloud site for raising views and concerns for staff to access to report their concerns.

8 OPERATIONAL RISK MANAGEMENT

8.1 Implementation of this strategy is essential to achieving a robust risk management system throughout the organisation on which the quality of care to patients and the safety of staff and members of the public ultimately depends. It therefore has important and far-reaching implications. It is recognised that this requires detailed knowledge and understanding of risk management.

Risk Management Process

8.2 The Trust promotes the establishment of an open and fair, blame-free culture for reporting incidents. There will be clear guidance for all staff regarding staff roles in risk management and this will be clearly communicated at all levels.

8.3 There are many partner organisations involved in the provision of health services for the Risk Management Strategy. These include the Local Authorities, voluntary Page 14 of 69

organisations, non-statutory health service providers, patient, carer and user groups, as well as the Clinical Commissioning Group (CCG),NHS England and NHS Improvement. Partnership working with these organisations is of key importance in terms of reporting and managing risk.

8.4 The Trust’s risk management process is based on the UK standards ISO 31000 – Application of Risk Management Standards. This model is internationally recognised and has been adopted by the Trust as a risk management model, which is effective at managing risk at any level. Risk management is a continual improvement cycle where objectives are set, risk is identified, assessed and managed proactively. Fig 1 demonstrates the risk model:

Figure 1 - Risk Management Overview from ISO 31000

8.5 The key principles of the risk management process:

• a culture where risk management is considered an essential and positive element in the provision of healthcare

• provision of a supportive structure for those involved in adverse incidents or errors by enabling a no-blame culture, openness and transparency

• processes should be strengthened and developed to allow for better identification of risk, identifying opportunities as well as threats

• managing risk is both a collective and an individual responsibility

• recognition that resources may sometimes be required to address risk and business plans should reflect this

Identifying Risk

8.6 The Trust identifies risk through both reactive and proactive methods. Reactive methods include complaints, significant events and incident reporting; proactive methods include risk assessment and implementation of recommendations arising

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from risk assessment and risks raised through external organisations such as the MHRA.

8.7 Risk should identify the potential risks associated with activities including, for example, delivering service targets redesigning projects, managing patient services, consultations, medicine managements, patient consent to treatment and so on.

8.8 Risk may be experienced from a variety of sources internal and external; changes in legislation; theft; losses; attack on IT systems; changes in legislation and standards etc.

8.9 Internal systems have been developed and implemented for the prevention and management of risks. For example, use checklists and protocols, significant incidents, serious untoward incidents, near miss incidents and education to raise staff awareness.

8.10 Systems for risk assessment will provide a structured method to:

• identify hazards (potential to cause harm, or losses)

• establish who will be affected by the hazard and the frequency of exposure

• establish the level of risk (likelihood of harm, or losses occurring)

• assess whether existing controls are adequate

• identify actions to meet any shortcomings

• check that controls and mitigating actions are working

8.11 Risk assessment formats and guidance are provided through the Quality Governance and Assurance team site on yCloud. For specific risks assessments such as Fire, Health and Safety (managed by Simply Serve Ltd) refer to the appropriate yCloud page.

Risk Assessment

8.12 The Trust will implement an approach to risk assessment with the intention that relevant members of staff are given the power and systems to deal with risks relevant to the services for which they are responsible. The Trust has designated posts with responsibilities for risk management support and advice including:

• Senior Information Risk Owner

• Deputy Chief Nurse

• Deputy Director Quality Governance and Patient Safety

• Head of Risk and Litigation

• Maternity Risk Manager

• Fire, Health and Safety Advisor

• Radiation Protection Advisor

• Local Counter Fraud Specialist

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• Data Protection Officer

8.13 Risk assessments are the responsibility of Directors, Service Leads and Managers who will keep a register of active risks managed through on-line risk registers ensuring that:

• GREEN rated risks (scoring 6 or below (Low)) are appropriately managed at a local level

• YELLOW rated risks (rated 8 – 10 (Moderate)) are appropriately managed at a local level but should be referred to the relevant Specialty Lead and if appropriate, referred to the relevant Lead Director

• AMBER rated risks (rated 12 – 15 (Significant)) should be referred directly to the Lead Director, Service Lead and Head of Risk and Litigation for consideration and inclusion in the Corporate Risk Register

• RED rated risks (rated 16+ (High Risk)) should be referred directly to the Lead Director, Service Lead and Head of Risk and Litigation for consideration and inclusion in the Corporate Risk Register

Managing Risk

8.14 Risk assessments should identify controls or mitigating actions and managed with actions as necessary to reduce risk down to an acceptable level through management teams. Action plans should be used to demonstrate key priorities against risks with delegation of actions and responsibilities identified. The Specialty Lead should ensure these are reviewed and maintained for reference against risk mitigation.

8.15 Risks entered onto the risk registers that have been reduced, where no further controls or actions can be taken to mitigate a risk, may be archived on the risk register to include all evidence to demonstrate mitigating actions at a later date for inspection, or monitoring.

8.16 Risk Assessments for health and safety, fire, security etc. should be maintained locally by the department manager with risk escalated as appropriate in line with the Red, Amber, Yellow and Green (RAG) rating.

8.17 The Trust has an Incident Reporting and Investigation Management Policy and maintains a risk management database (Ulysses) which provides web-based reporting of clinical and non-clinical incidents and near misses.

8.18 The Trust will upload patient safety incidents through the National Reporting and Learning System (NRLS).

8.19 The Trust will ensure the implementation and embedding of safe practice by:

• promoting the use of guidelines and protocols (accessed on the Policies database via the Intranet)

• ensuring safe systems of work are documented and followed when there are significant risks identified

• ensuring that staff undertake continuing professional development activity

• ensuring that the Somerset CCG Reporting and Learning from Serious Incidents (SI) Policy is followed when identifying and reporting serious incidents externally

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Minimising Risk

8.20 The Trust will ensure that learning takes place from clinical and non-clinical incidents and risk assessment findings, depending on the seriousness, and share learning with other services.

8.21 Safety alerts will be acted upon in line with the requirements of the alert and monitored for effectiveness.

8.22 Staff will be engaged in the learning process through governance arrangements and through raising awareness and training.

Managing Residual Risk

8.23 Residual risk represents a risk that remains after considering the controls in place to manage the risk and after further actions have been taken to reduce the risk to an acceptable level. In practice this means constantly monitoring the effectiveness of control measures. This will be achieved by:

• reviewing outcomes

• sharing best practice

• evidence based practice

• reflective practice

• clinical supervision

• appraisal

• learning from the patient experience, complaints, claims and mistakes

• inspections and monitoring

Monitoring Risks

8.24 The risk management process is monitored by the risk management Committees and through the Executive Committee and Assurance Committees reviews up to the Board of Directors.

Quality Impact Assessments

8.25 Quality Impact Assessments (QIA) should be conducted on the same principle as risk assessment. The impact on business, finance, provision of clinical and non-clinical services and patient access to services for equality reasons should be assessed and managed. A QIA demonstrates that the wider implications to services have been considered, especially in relation to making savings through Cost Improvement Plans (CIP). The Trust has a QIA process for reference that should be used alongside the development of a QIA framework.

Data Protection Impact Assessments

8.26 The General Data Protection Regulations 2016 and Data Protection Act 2018 introduced a new obligation to undertake a Data Protection Impact Assessment (DPIA) before carrying out types of processing likely to result in high risk to individuals’ rights and freedoms. DPIAs are risk assessments that are concerned with the use of personal data within an organisation. They are designed to assist organisations to

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consider whether data is secure, whether there is or could be any risk to individuals’ privacy, and whether organisations are meeting their obligations. The focus is on the potential for harm – to individuals or to society at large, whether it is physical, material or non-material. To assess the level of risk, a DPIA must consider both the likelihood and the severity of any impact on individuals. For more information please refer to the Trust’s DPIA Policy.

9 INCIDENT REPORTING

9.1 Incident reporting underpins an effective Risk Management Strategy. The positive benefit here is that the material provides a rich source of information from which to learn and improve systems and processes and reduce risk.

9.2 A standard format for reporting all types of incidents has been implemented across the Trust. The incident on-line web based form reflects the reporting requirements of the NRLS. Staff receive training at induction and bespoke training to ensure that they are familiar with the reporting requirements. The aim is to ensure that incidents, including near misses, are reported as part of routine practice. The reported incidents are investigated where necessary and all the information entered onto the risk management database.

9.3 As part of the mechanism for handling the reporting of incidents and near misses there is a scoring system which enables an assessment of risk to be made as to the actual impact. This is outlined in the Incident Reporting and Investigation Management Policy.

Serious Untoward Incident Reporting and Learning from Incidents

9.4 The Trust supports the concept of learning from incidents and sharing information in a blame free culture.

9.5 Incidents that meet the criteria of a Serious Incidents Requiring Investigation (SIRI) are reported externally.

9.6 All SIRIs will be escalated through the incident reporting process to be brought to the attention of the Deputy Director Quality Governance and Patient Safety who will escalate risk to the appropriate level and be reviewed at the Senior Incident and Safety Review Group.

9.7 Root cause analysis investigations determines how and why adverse incidents happen, the risk management issues involved and how they can be prevented.

9.8 Changes in practice if necessary will be identified through the investigation process.

9.9 The mechanism for sharing and learning from incidents is through the reporting processes to the Patient Safety Steering Group and through Strategic Business Unit and Governance meetings in line with the Incident Reporting and Investigation Management Policy.

‘Being Open’ and ‘Duty of Candour’

9.10 The Duty of Candour is a statutory and contractual requirement under Regulation 20 of the Health and Social Care Act 2008. The Trust will ensure compliance through processes set out in the Being Open and Duty of Candour Policy and the Incident Reporting and Investigation Management Policy.

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Reporting to the Medicines and Healthcare Products Regulatory Agency (MHRA) and the National Reporting and Learning Service (NRLS) to NHS England

9.11 The Trust has a module on the risk management database for the distribution of the Central Alert System (CAS), Medical Device Alerts (MDAs), Patient Safety Alerts and other such clinical alert notifications in line with the Safety Alerts Management Policy. Reporting is through the CAS Liaison Officer (CASLO).

9.12 The CASLO is responsible for reporting to the MHRA, Health and Safety Executive (HSE) and NHS England using information held on the risk management database. In addition, the Trust has nominated a Medicines Safety Officer (MSO) and a Medical Devices Safety Officer (MDSO) reporting to the Deputy Chief Executive, Chief Nurse and Director of People with responsibilities reported through the Patient Safety Steering Group.

10 APPLICABILITY

10.1 This strategy document applies to all staff employed by the Trust, whether on a permanent or temporary basis. Failure to comply with fundamentals of this strategy may lead to exposing the Trust and its patients, staff and the public to unnecessary risk. All staff are responsible for risk management and for reducing risks and acting upon risk assessment and following safe systems of work. Failure to carry this out may lead to disciplinary action being taken against individuals.

11 IMPLEMENTATION, TRAINING AND SUPPORT

11.1 The effective implementation of this Risk Management Strategy will facilitate the delivery of high quality service and, alongside staff training and support, will provide an awareness of the measures needed to prevent, control and contain risk. The Trust will:

• ensure all staff and stakeholders have access to a copy of this Risk Management Strategy

• produce a Corporate Risk Register which will be subject to regular review by the Executive Committee, Assurance Committees and the Board of Directors

• communicate to staff any action to be taken in respect of risk issues

• develop policies, procedures and guidelines based on the results of assessments and all identified risks to assist in the implementation of this Strategy

• monitor and review the performance of the organisation in relation to the management of risk and the effectiveness of the systems and processes in place to manage risk

11.2 Training is essential for the implementation and success of the Risk Management Strategy. The Head of Risk and Litigation and Deputy Director Quality Governance and Patient Safety will work in collaboration with the Academy Team to deliver a training programme for staff with risk management responsibilities. The Head of Risk and Litigation will provide risk management advice and support to Managers and Risk Leads to facilitate local risk management. The Head of Risk and Litigation will provide ad hoc risk management support or advice to Trust staff, including staff members of YDH subsidiary companies as and when needed. All new managers should undergo induction to risk with the Head of Risk and Litigation within the first month of employment.

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12 MONITORING THE EFFECTIVENESS OF THE STRATEGY

12.1 Reporting on the effectiveness of the Risk Management Strategy within the Trust based on all available relevant information will be through the Deputy Director Quality Governance and Patient Safety the Company Secretary and the Head of Risk and Litigation.

13 REFERENCES

• NHS Improvement Serious Incident Framework (March 2015) https://improvement.nhs.uk/uploads/documents/serious-incidnt-framwrk.pdf

• NHS Improvement Never Events https://improvement.nhs.uk/resources/never-events-policy-and-framework/

• Department of Health (February 2006) Integrated Governance Handbook: A Handbook for Executives and Non-Executives in Healthcare Organisations [Online] Department of Health. Available from: http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandst atistics/Publications/PublicationsPolicyandGuidance/DH_4128739

• Good Governance Institute: The New Integrated Governance Handbook 2016 https://www.good-governance.org.uk/wp-content/uploads/2017/04/The-new- Integrated-Governance-Handbook-2016.pdf

• NHS Foundation Trusts: Code of Governance (July 2014). Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/atta chment_data/file/327068/CodeofGovernanceJuly2014.pdf

• Financial Reporting Council: The UK Corporate Governance Code (July 2018) https://www.frc.org.uk/getattachment/88bd8c45-50ea-4841-95b0- d2f4f48069a2/2018-UK-Corporate-Governance-Code-FINAL.pdf

• Department of Health (2002) Assurance: The Board Agenda Department of Health. Available from: http://webarchive.nationalarchives.gov.uk/+/http://www.dh.gov.uk/en/Publications andstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006064

• Good Governance Institute: Board Assurance Frameworks (March 2009) https://www.good-governance.org.uk/wp-content/uploads/2017/04/Board- Assurance-Framework.pdf

• HM Treasury (March 2016) Audit and Risk Assurance Committee Handbook https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/51 2760/PU1934_Audit_committee_handbook.pdf

• NHS Improvement: Learning from Patient Safety Incidents https://improvement.nhs.uk/resources/learning-from-patient-safety-incidents/

14 ASSOCIATED POLICIES

• YDH Risk Management Arrangements

• Incident Reporting and Investigation Management Policy

• Somerset CCG – Reporting and Learning from Serious Incident (SI) Policy

• Health and Safety Policy Page 21 of 69

• Raising Concerns (Whistleblowing) Policy

• Being Open and The Duty of Candour Policy

• Infection Prevention Control Policy

• Policy for the Development and Management of Procedural Documents

• Data Protection Impact Assessment Policy

15 SUBSIDIARY COMPANIES OF YEOVIL DISTRICT HOSPITAL (YDH)

15.1 The various subsidiary companies of YDH have responsibility for risk management within their entity; this will be overseen by their respective Board of Directors through their own Risk Management Strategies. YDH, as the parent company, has oversight of risk management across the Yeovil District Hospital NHS Foundation Trust Group and the subsidiary companies are responsible for providing assurance to YDH that suitable and adequate risk management processes are in place.

16 EQUALITY IMPACT ASSESSMENT

16.1 This policy has been assessed and implemented in line with the policy on procedural documents and an equality impact has been carried out to ensure the policy is fair and does not discriminate any staff groups. A completed Equality Impact Assessment can be found at Annex C.

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TRUST RISK APPETITE STATEMENT

1. Introduction

The aim of Yeovil District Hospital NHS Foundation Trust is to provide safe, high quality and effective services that improves the health, wellbeing and independence of the population it serves. The Trust’s vision statement outlines this aim:

‘To care for you as if you are one of our family’

The Board recognises that risk is inherent in the provision of healthcare, and therefore a defined approach is necessary to identify risk context, ensuring that the Trust understands and is aware of the risks it is prepared to accept in the pursuit of the delivery of the Trust’s aims and objectives. This Risk Appetite Statement sets out the Board’s strategic approach to risk-taking by defining its boundaries and risk tolerance thresholds. The Risk Appetite Statement does not negate the opportunity to potentially take decisions that result in risk- taking that is outside of the risk appetite. Where this is considered to be the case, it is proposed that these decisions will be referred to the Board.

The Trust needs to be aware of its risk appetite because if the organisation’s collective appetite is not clear and the reasons for this unknown, this may lead to erratic or inopportune risk-taking, thereby exposing the organisation to a risk it cannot tolerate. Conversely, an overly cautious approach could be taken which may stifle growth and development.

The Trust is committed to ensuring patient safety across all services provided by the organisation and therefore the Trust is strongly averse to any risk that may jeopardise it. There is recognition that the provision of healthcare services carries some risk and wherever possible, the Trust will ensure that it does all it can to deliver harm free care for every patient, every time, everywhere.

The Trust is strongly averse to any risks that could result in the non-compliance with legislation, or any frameworks provided by professional bodies.

2. Risk Appetite Categorisation

The risk appetite categories1 are as follows:

Avoid Avoidance of risk and uncertainty is a key organisational objective Minimal (as little as reasonably possible). Preference for ultra-safe Minimal delivery options that have a low degree of inherent risk and only for limited reward potential Preference for safe delivery options that have a low degree of Cautious inherent risk and may only have limited potential for reward Willing to consider all potential delivery options and choose while Open also providing an acceptable level of reward (and VfM) Eager to be innovative and choose options offering potentially higher Seek business rewards (despite greater inherent risk) Confident in setting high levels of risk appetite because of controls, Mature forward scanning and responsiveness systems are robust

1 Source: Risk Appetite for NHS Organisations (Good Governance Institute) Page 23 of 69

TRUST RISK APPETITE STATEMENT

3. Risk Appetite Statement

Key Element Risk Appetite Risk Tolerance Minimal (as little as reasonably possible) – Preference for ultra-safe Quality and Governance Low delivery options that have a (All quality related risks) (Risks rated: 1-6) low degree of inherent risk and only for limited reward potential The Trust prefers safe delivery options that have a low degree of inherent risk. The Trust is only willing to accept ultra-safe delivery options which will not adversely affect the quality and governance of services.

Cautious – Preference for Business Risk safe delivery options that (Loss of referrals, loss of Moderate have a low degree of support from CCG, (Risks rated: 8-10) inherent risk and may only Providers etc.) have limited potential for reward The Trust is eager to be innovative and to choose options offering potentially higher rewards despite greater possible inherent risks. Minimal (as little as Compliance and reasonably possible) – Performance Preference for ultra-safe Low (Risks with compliance to delivery options that have a (Risks rated: 1-6) licence requirements, data low degree of inherent risk privacy etc.) and only for limited reward potential The Trust is willing to consider all potential delivery options whilst also providing an acceptable level of reward. The Trust would want to be confident that it is able to meet any regulatory requirements and is able to demonstrate robust process underpinning its compliance. The Trust has no appetite that may result in a breach of patient confidentiality, non-compliance of the General Data Protection Regulations etc. Minimal (as little as reasonably possible) – Continuity of Service Preference for ultra-safe (Risks to the Trust being Low delivery options that have a able to provide services that (Risks rated: 1-6) low degree of inherent risk are required of it) and only for limited reward potential The Trust prefers to only accept options which have a low degree of inherent risk and will not adversely affect the ability to continue to provide the services which are required of it. Minimal (as little as reasonably possible) – Operational Risks Preference for ultra-safe (Risks covering staffing, Low delivery options that have a health and safety, security, (Risks rated: 1-6) low degree of inherent risk fire, IT, etc.) and only for limited reward potential The Trust is not willing to accept risks which will affect the operational delivery of the organisation and is committed to ensuring safe services within a robust setting.

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TRUST RISK APPETITE STATEMENT

Minimal (as little as reasonably possible) – Financial Risks Preference for ultra-safe (Accounting risk, credit risk, Low delivery options that have a market risk, liquidity risk and (Risks rated: 1-6) low degree of inherent risk budget risks) and only for limited reward potential In light of the current financial climate within the NHS and Somerset, the Trust prefers to adopt a cautious approach and only consider safe delivery options which have a low degree of inherent risk. The Trust will focus on meeting its statutory duties of maintaining expenditure within strict limited resources and adherence to financial controls. Minimal (as little as reasonably possible) – Reputation Risks Preference for ultra-safe Low (Damage to reputation delivery options that have a (Risks rated: 1-6) through bad publicity etc.) low degree of inherent risk and only for limited reward potential The Trust is willing to consider decisions that may bring scrutiny of the Trust, however the potential benefits outweighs the risks i.e. an acceptable level of reward. The Trust will always seek to have a positive reputation that aligns with its Vision Statement.

4. Review of Appetite

The Trust Board will periodically review its appetite for and attitude to risk, updating these where appropriate. This includes the setting of risk tolerances against the seven key risk categories outlined within the Trust’s Risk Management Strategy. Risks throughout the organisation should be managed within the Trust’s Risk Appetite, or where this is exceeded, action taken to reduce the risk.

The Trust’s Risk Appetite will be communicated to relevant staff involved in the management of risk.

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RISK ASSESSMENT SCORING GUIDELINES

1. INTRODUCTION

1.1 Risk management is a systematic and effective method of identifying risks and determining the most cost effective means to minimise or remove them. It is an essential part of any risk management programme and it encompasses the processes of risk analysis and risk evaluation.

1.2 The Board of Directors ensures that the effort and resource that is spent on managing risk is proportionate to the risk itself. The Trust has in place efficient assessment processes covering all areas of risk.

1.3 To separate those risks that are unacceptable from those that are tolerable should be evaluated in a consistent manner. Risks are assessed by combining estimates of consequence and likelihood in the context of existing control measures. The rating of a given risk is established using a two dimensional grid or matrix with consequence as one axis and likelihood as the other.

1.4 The following properties are essential for a risk assessment matrix:

• simple to use

• provides consistent results when used by staff from a variety of roles or professions

• capable of assessing a broad range of risks including clinical, health and safety, financial risk or reputation

1.5 This guidance can be used on its own as a tool for introducing risk assessment or for improving consistency or scope of risk assessments already in place within the organisation and for training purposes. In particular the organisation should use this guidance only within the framework of its strategic risk appetite and risk management decision making process.

2. GUIDANCE ON CONSEQUENCE SCORING

2.1 When undertaking a risk assessment the consequence or how bad the risk being assessed is must be measured. In this context, consequence is defined as the outcome or potential outcome of an event. Clearly there may be more than one consequence of a single event.

2.2 Consequence scores can also be used to rate the severity of incidents and there are some advantages to having identical or at least parallel scoring systems for risk and incidents.

2.3 This guidance does not give detailed guidelines on incident scoring but gives a brief explanation of how this scoring system can be used for scoring incidents.

2.4 Consequences can be assessed and scored using qualitative data. Whenever possible, consequences should be assessed against objective definitions across different domains to ensure consistency in the risk assessment process. Despite defining consequence as objectively as possible it is inevitable that scoring the consequences of some risk will involve a degree of subjectivity. It is important that effective, practical based training, and use of relevant examples form part of the implementation of any assessment system to maximise consistency of scoring across the organisation.

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RISK ASSESSMENT SCORING GUIDELINES

2.5 The information in Table 1a should be used to obtain a consequence score. First define the risk explicitly in terms of the adverse consequence that might arise from the risk being assessed. Then use the table to determine the consequence score of the potential adverse outcomes relevant to the risk being evaluated. The examples given in Table1a are not exhaustive.

How To Use Consequence Table 1a

2.6 Choose the most appropriate domain for the identified risk from the left hand side of the table. Then work along the columns in the same row to assess the severity of the risk on the scale of 1-5 to determine the consequence score which is the number given at the top of the column.

Consequence scoring

1 – Negligible 2 – Minor 3 - Moderate 4 - Major 5 - Catastrophic

2.7 Many issues need to be factored into the assessment of consequence. Some of these are:

• does the organisation have a clear definition of what constitutes a minor injury

• what measures are being used to determine psychological impact on individuals

• what is defined as an adverse event and how many individuals may be affected

2.8 A single risk area may have multiple potential consequences and these may require separate assessment. It is also important to consider from whose perspective the risk is being assessed because this may affect the assessment of the risk itself, its consequences and the subsequent action taken.

2.9 By implementing these guidelines we will benefit from having more detailed definitions or samples for each consequence score. Table 1b shows a number of examples to use at a local level to exemplify various levels of consequence under the domain that covers the impact of the risk on the safety of patients, staff or public.

2.10 More examples have been added to the consequence categories in this revised version (Table 1b) as it is felt that extra guidance is required for risk assessment procedures and for training purposes.

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RISK ASSESSMENT SCORING GUIDELINES Table 1a – Assessment of the Severity of the Consequence of an Identified Risk: Domains, Consequence Scores and Examples of the Score Descriptors

Consequence score (severity levels) and examples of descriptors 1 2 3 4 5 Domains Negligible Minor Moderate Major Catastrophic Impact on the Minimal Minor injury Moderate injury Major injury Incident leading to safety of injury or illness requiring leading to long- death. patient, staff requiring no requiring professional term incapacity / Multiple permanent or public / minimal minor intervention. disability. injuries or (physical / intervention intervention. Requiring time off Requiring time off irreversible health psychological or Requiring work for 7-14 work for >14 effects. harm) treatment. time off work days. days. An event which No time off for <7 days. Increase in length Increase in length impacts on a large work Increase in of hospital stay of hospital stay number of patients. required. length of by 4-15 days. by >15 days. hospital stay RIDDOR/agency Mismanagement by 1-3 days. reportable of patient care incident. with long-term An event which effects. impacts on a small number of patients. Quality / Peripheral Overall Treatment or Non-compliance Incident leading to complaints / element of treatment or service has with national totally unacceptable audit treatment or service sub- significantly standards with level or quality of service sub- optimal. reduced significant risk to treatment / service. optimal. Formal effectiveness. patients if Gross failure of Informal complaint Formal complaint unresolved. patient safety if complaint / (stage 1). (stage 2). Multiple findings not acted inquiry. Local Local resolution complaints / on. resolution. (with potential to independent Inquest / Single failure go to review. ombudsman to meet independent Low performance inquiry. internal review). rating. Gross failure to standards. Repeated failure Critical report. meet national Minor to meet internal standards. implications standards. for patient Major patient safety if safety unresolved. implications if Reduced findings are not performance acted on. rating if unresolved. Human Short-term Low staffing Late delivery of Uncertain Non-delivery of key resources / low staffing level that key objectives / delivery of key objectives / service organisational levels that reduces service due to objectives / due to lack of staff. development / temporarily service lack of staff. service due to Ongoing unsafe staffing / reduces quality. Unsafe staffing lack of staff. staffing levels or competence service level or Unsafe staffing competence. quality <1 competence (>1 level or Loss of several key day day). competence (>5 staff. Low staff morale. days). No staff attending Poor staff Loss of key staff. mandatory training / attendance for Very low staff key training on an mandatory / key morale. ongoing basis. training. No staff attendance for mandatory / key training.

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RISK ASSESSMENT SCORING GUIDELINES Statutory duty No or Breach of Single breach of Enforcement Multiple breaches / inspections minimal statutory statutory duty. action. in statutory duty. impact or legislation. Challenging Multiple breaches Prosecution. breach of Reduced external in statutory duty. Complete systems guidance / performance recommendations Improvement change required. statutory rating if / improvement notices. Zero performance duty unresolved. notice. Low performance rating. rating. Severely critical Critical report. report. Adverse Rumours. Local media Local media National media National media publicity / Potential for coverage – coverage – long- coverage with <3 coverage with >3 reputation public short-term term reduction in days service well days service well concern. reduction in public below reasonable below reasonable public confidence. public public expectation. confidence. expectation. MP concerned Elements of (questions in the public House). expectation Total loss of public not being confidence. met. Business Insignificant <5 % over 5-10 % over Non-compliance Incident leading objectives / cost project project budget. with national 10- >25 % over project projects increase / budget. Schedule 25 % over project budget. schedule Schedule slippage. budget. Schedule slippage. slippage slippage. Schedule Key objectives not slippage. met. Key objectives not met. Finance Small loss. Loss of 0.1- Loss of 0.25-0.5 Uncertain Non-delivery of key including Risk of 0.25 per per cent of delivery of key objective / loss of claims claim cent of budget. objective / loss of >1 per cent of remote. budget. Claim(s) between 0.5-1.0 per cent budget. Claim less £10,000 and of budget. Failure to meet than £100,000 Claim(s) between specification / £10,000 £100,000 and £1 slippage. million. Loss of contract / Purchasers payment by results. failing to pay on Claim(s) >£1 time. million. Service / Loss / Loss / Loss / interruption Loss / Permanent loss of business interruption interruption of >1 day. interruption of >1 service or facility. interruption of >1 hour. of >8 hours. Moderate impact week. Catastrophic impact Environmental Minimal or Minor impact on environment. Major impact on on environment. impact no impact on environment. on the environment. environment

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RISK ASSESSMENT SCORING GUIDELINES Table 1b – Consequence Scores (Additional Guidance and Examples Relating to Risks Impacting on the Safety of Patients, Staff or Public)

Consequence score (severity levels) and examples of descriptors 1 2 3 4 5 Domains Negligible Minor Moderate Major Catastrophic Impact on Minimal Minor injury Moderate injury Major injury Incident leading to safety of injury or illness requiring leading to long- death. patients, staff requiring no requiring professional term incapacity / Multiple or public / minimal minor intervention. disability. permanent (physical / intervention intervention. Requiring time off Requiring time off injuries or psych-ological or Requiring work for 7-14 work for >14 irreversible health harm) treatment. time off work days. days. effects. No time off for <7 days. Increase in length Increase in length An event which work. Increase in of hospital stay by of hospital stay by impacts on a length of 4-15 days. >15 days. large number of hospital stay RIDDOR/agency Mismanagement patients. by 1-3 days reportable event. of patient care An event which with long-term impacts on a effects. small number of patients. Additional Incorrect Wrong drug Wrong drug or Wrong drug or Unexpected examples medication or dosage dosage dosage death. dispensed administered, administered with administered with Suicide of a but not with no potential adverse adverse effects. patient known to taken. adverse effects. Physical attack the service in the Incident effects. Physical attack resulting in past 12 months. resulting in Physical causing moderate serious injury. Homicide a bruise / attack such injury. Category 4 committed by a graze. as pushing, Self-harm pressure ulcer. mental health Delay in shoving or requiring medical Long-term HCAI. patient. routine pinching, attention. Retained Large-scale transport causing Category 3 instruments / cervical screening for patient. minor injury. pressure ulcer. material after errors. Category 1 Self-harm Healthcare – surgery requiring Removal of wrong pressure resulting in acquired infection further body part leading ulcer. minor (HCAI). intervention. to death or Laceration, injuries. Incorrect or Haemolytic permanent sprain, Category 2 inadequate transfusion incapacity. anxiety pressure information / reaction. Incident leading to requiring ulcer. communication on Slip / fall resulting paralysis. occupation Slip / fall transfer of care. in permanent Incident leading to al health resulting in Vehicle carrying injury long-term mental counselling injury such patient involved in Loss of a limb. health problem. (no time off as a sprain. a road traffic Post-traumatic Rape / serious work accident. stress disorder. sexual assault. required). Slip / fall resulting Failure to follow in injury such as up and administer dislocation / vaccine to baby fracture (e.g. born to a mother #NOF) / blow to with hepatitis B. the head resulting in a bleed.

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RISK ASSESSMENT SCORING GUIDELINES

3. GUIDELINES ON LIKELIHOOD SCORING

3.1 Once a specific area of risk has been assessed and its consequences score agreed, the likelihood of that consequence occurring can be identified by using Table 2. Note that the Table is intended as guidance and we have attempted to populate the table with descriptions of our own probability and frequency descriptions. As with the assessment of consequence, the likelihood of a risk occurring is assigned a number from 1 to 5 the higher the number the more likely it is the consequence will occur:

Likelihood Scoring

1 - Rare 2 - Unlikely 3 - Possible 4 - Likely 5 - Certain

3.2 When assessing likelihood it is important to take into consideration the controls already in place. The likelihood score is a reflection of how likely it is that the adverse consequence described will occur. Likelihood can be scored by considering:

• frequency (how many times will the adverse consequence being accessed actually be realised?), or

• probability (what is the chance the adverse consequence will occur in a given reference period?)

Table 2 – Likelihood Scores (Broad Descriptors of Frequency)

Likelihood 1 2 3 4 5 Score Descriptor Rare Unlikely Possible Likely Almost Certain Frequency This will Do not Might happen or Will probably Will How often probably expect it to recur happen / undoubtedly might it/does it never happen / occasionally recur, but it is happen / happen happen / recur but it is not a recur, possibly recur possible it persisting frequently may do so issue / circumstances

Table 3 – Likelihood Scores (Time-Framed Descriptors of Frequency)

Likelihood 1 2 3 4 5 Score Descriptor Rare Unlikely Possible Likely Almost Certain Frequency Not expected Expected to Expected to Expected to Expected to to occur for occur at occur at least occur at least occur at least years least monthly weekly daily annually

3.3 It is possible to use more quantitative descriptions for frequency by considering how often the adverse consequence being assessed will be realised. A simple set of time framed definition for frequency is shown above in Table 3.

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RISK ASSESSMENT SCORING GUIDELINES 3.4 However frequency is not a useful way of scoring certain risks, especially those associated with the success of time limit or one off projects such as a new IT system that is being delivered as part of a three year programme or business objective. For these risks the likelihood score cannot be based on how often the consequence will materialise. Instead it must be based on the probability that it will occur at all in a given period. In other words, a three year IT project cannot be expected to fail once a month and the likelihood score will need to be assessed on the probability of adverse consequences occurring within the project’s time frame.

3.5 With regard to achieving a national target, the risk of missing the target will be based on the time left during which the target is measured. The Trust might have assessed the probability of missing a key target as being quite high at the beginning of the year but nine months later if all the control measures have been effective, there is a much reduced probability of the target not being met.

3.6 This is why specific “probability” scores have been developed for projects and business objectives – see Table 4. Essentially, likelihood scores based on probability have been developed from project risk assessment tools from across industry. The vast majority of these agree that any project which is more likely to fail than succeed (that is, the chance of failing is greater than 50 per cent) should be assigned a score of 5.

Table 4 - Likelihood Scores (Probability Descriptors)

3.7 Table 4 can be used to assign a probability score for risks relating to time-related or one-off projects or business objectives. If it is not possible to determine a numerical probability, the probability descriptions can be used to determine the most appropriate score.

Likelihood 1 2 3 4 5 Score Descriptor Rare Unlikely Possible Likely Almost Certain Probability <0.1 per cent 0.1-1 per 1-10 per cent 10-50 per cent >50 per cent Will it happen cent or not?

4. RISK SCORING AND GRADING

4.1 Risk scoring and grading as follows:

• Define the risk(s) explicitly in terms of the adverse consequence(s) that might arise from the risk

• Use Table 1a to determine the consequence score(s) (C) for the potential adverse outcome(s) relevant to the risk being evaluated

• Use Table 2 to determine the likelihood score(s) (L) for those adverse outcomes. If possible, score the likelihood by assigning a predicted frequency of occurrence of the adverse outcome. If this is not possible, assign a probability to the adverse outcome occurring within a given time frame, such as the lifetime of a project or a patient care episode. If a numerical probability cannot be determined, use the probability descriptions to determine the most appropriate score

• Calculate the risk score by multiplying the consequence by the likelihood: C (consequence) x L (likelihood) = R (risk score)

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RISK ASSESSMENT SCORING GUIDELINES

4.2 The risk matrix in Table 5 shows both numerical scoring and colour bandings. The Trust’s risk management processes are used to identify the level at which the risk will be managed in the Trust, assign priorities for remedial action, and determine whether risks are to be accepted, on the basis of the colour bandings and/or risk score.

Table 5 - Risk Matrix

Likelihood Consequence Rare Unlikely Possible Likely Certain 1 2 3 4 5 Negligible - 1 1 2 3 4 5 Minor - 2 2 4 6 8 10 Moderate - 3 3 6 9 12 15 Major - 4 4 8 12 16 20 Catastrophic - 5 5 10 15 20 25

KEY: Low Moderate Significant High risk risk risk risk

4.3 For grading risk, the scores obtained from the risk matrix are assigned grades as follows:

1-6 = Low Risk 8-10 = Moderate Risk 12-15 = Significant Risk 16-25 = High Risk

4.4 This model risk matrix has the following advantages:

• commonality across the NHS with a five by five matrix

• it is simple yet flexible and therefore lends itself to adaptability

• it is based on simple mathematical formulae and is ideal for use in spreadsheets

• equal weighting of consequence and likelihood prevents disproportionate effort directed at highly unlikely but high consequence risks. This should clearly illustrate the effectiveness of risk treatment

• there are four colour bandings for categorising risk

• even if the boundaries of risk categorisation change we are able to compare “scores” to monitor whether risks are being evaluated in a similar manner

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RISK ASSESSMENT SCORING GUIDELINES 5. RISK RATINGS

5.1 The Trust adopts the standard three risk ratings as described below:

INITIAL risk rating The risk score before any mitigating actions had been (also known as implemented. This would also be the score which articulates ‘inherent risk score’) how severe and likely the risk is to occur if the controls in place are found to be ineffective, or absent.

CURRENT risk This is the score at time of writing, taking account of existing rating controls and mitigating actions. (also known as the ‘residual risk score’)

TARGET risk rating The keyword here is “target”. This is the future (or prospective) risk score assigned to any risk after gaps in control measures have been addressed, and outstanding actions implemented. It is the level of risk which can be tolerated.

6. RELATIONSHIP WITH INCIDENT SCORING

6.1 One of the features of the risk scoring system described here is that it includes a mechanism for directly scoring the consequence of an adverse event. When assessing risks, the consequence score is used to grade the consequence of events that might occur because of the risk in question. A certain amount of care is required when applying a score to an incident as there is danger that the incident might be given an overall actual impact score of 4 or 5 Consequence which could make the incident a “red” incident (see model risk matrix).

6.2 Refer to the Incident Reporting and Investigation Management Policy for detailed guidance.

7. CONCLUSION

7.1 As the Trust embeds risk management into respective governance arrangements, it has become more important than ever to make risk assessment easier and more consistent. It is essential that risks can be rated in a common currency within the NHS and other organisations, allowing financial, operational and clinical risks to be compared against each other and prioritised. Lastly, there needs to be confidence that tools for assessing risk can be used easily and consistently by a range of different professionals.

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Somerset Equality Impact Assessment Before completing this EIA please ensure you have read the EIA guidance notes – available from your Equality Officer Organisation prepared for Yeovil District Hospital NHS Foundation Trust Version 1 Date Completed April 2021 Description of what is being impact assessed Policy for the Development and Management of Procedural Documents Evidence What data/information have you used to assess how this policy/service might impact on protected groups? Sources such as the Office of National Statistics, Somerset Intelligence Partnership, Somerset’s Joint Strategic Needs Analysis (JSNA), Staff and/ or area profiles,, should be detailed here No impacts on protected groups

Who have you consulted with to assess possible impact on protected groups? If you have not consulted other people, please explain why? Equality & Diversity Lead

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Analysis of impact on protected groups The Public Sector Equality Duty requires us to eliminate discrimination, advance equality of opportunity and foster good relations with protected groups. Consider how this policy/service will achieve these aims. In the table below, using the evidence outlined above and your own understanding, detail what considerations and potential impacts against each of the three aims of the Public Sector Equality Duty. Based on this information, make an assessment of the likely outcome, before you have implemented any mitigation. Negative Neutral Protected group Summary of impact Positive outcome outcome outcome • Age n/a ☐  ☐

• Disability n/a ☐  ☐

• Gender reassignment n/a ☐  ☐

• Marriage and civil n/a ☐  ☐ partnership • Pregnancy and n/a ☐  ☐ maternity • Race and ethnicity n/a ☐  ☐

• Religion or belief n/a ☐  ☐

• Sex n/a ☐  ☐

• Sexual orientation n/a ☐  ☐

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Other, e.g. carers, • n/a veterans, homeless, ☐  ☐ low income, rurality/isolation, etc. Negative outcomes action plan Where you have ascertained that there will potentially be negative outcomes, you are required to mitigate the impact of these. Please detail below the actions that you intend to take. Person How will it be Action taken/to be taken Date Action complete responsible monitored? n/a Select date ☐ Select date ☐ If negative impacts remain, please provide an explanation below. n/a

Completed by: Samantha Hann Date April 2021 Signed off by: Bernice Cooke Date April 2021 Equality Lead/Manager sign off date: Not required as no significant service change as a result of this policy To be reviewed by: (officer name) Not required as no significant service change as a result of this policy Review date: n/a

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MATERNITY DEPARTMENT RISK MANAGEMENT STRATEGY

Version Number 8.1 Version Date April 2021 Policy Owner Chief Executive Author Head of Midwifery First approval or date The Risk Management Policy was first approved in last reviewed July 2007, reviewed in September 2011 up to Version 4.1, reviewed in September 2014 (version 5), reviewed in October 2017 (version 6), reviewed in February 2018 (version 6.1), reviewed in July 2019 (version 7), reviewed October 2019 (version 8) Staff/Groups Consulted Clinical Director of Obstetrics Maternity Risk Manager Deputy Director Quality Governance and Patient Safety Head of Risk and Litigation Clinical Directors of Patient Safety & Governance Practice Educator Approved by the Audit To be completed Committee on behalf of the Board of Directors Next Review Due October 2022 Equality Impact April 2021 Assessment

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Table of Contents

1. INTRODUCTION ...... 44 2. MATERNITY DEPARTMENT RISK MANAGEMENT PHILOSOPHY ...... 44 3. MATERNITY DEPARTMENT RISK MANAGEMENT OBJECTIVES ...... 44 4. STRUCTURE LEAD ROLES AND RESPONSIBILITIES ...... 46 5. TRAINING ...... 53 6. INCIDENT / EVENT / TRIGGER REPORTING ...... 56 7. ANTENATAL & NEWBORN SCREENING INCIDENT MANAGEMENT ...... 57 8. DUTY OF CANDOUR ...... 59 9. PERINATAL MORTALITY REVIEW TOOL ...... 59 10. COMPLAINTS AND LITIGATION ...... 60 11. PEER REVIEW ...... 60 12. REFERENCES ...... 60

ANNEX 1 – Maternity Department Governance Structure ...... 61 ANNEX 2 – Clinical Incident Maternity Trigger List ...... 63 ANNEX 3 – Incident Management for Antenatal & Newborn Screening ...... 65 ANNEX 4 – Equality Impact Assessment ...... 67

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MATERNITY DEPARTMENT RISK MANAGEMENT STRATEGY

1 INTRODUCTION

1.1 The Maternity Risk Management Strategy and Framework defines how the Maternity Unit, within Yeovil District Hospital NHS Foundation Trust (the Trust), supports a systematic approach to risk management. It sets out how the Maternity Unit embeds and implements the risk management processes, with an underpinning ethos of a continuing positive learning culture (Standards for Better Health, 2004).

1.2 The Maternity Unit has a duty of care to women and their families, staff and the local population and the aim of the Strategy is to minimise risks to mothers and infants through the implementation of a risk management framework which:

• Identifies the principal risks to the achievement of the Trust's objectives for Maternity Services

• Evaluates the nature and extent of the risks

• Manages them efficiently, economically and effectively

1.3 This Strategy and Framework is an annex to the Trust’s Risk Management Strategy and should be read in conjunction with the Trust’s Incident Reporting and Investigation Management Policy, Complaints and Concerns Management Policy, Claims Management Policy and Trust HR Manual.

2 MATERNITY DEPARTMENT RISK MANAGEMENT PHILOSOPHY

2.1 The Maternity Risk Management Strategy underpins the ethos of effective risk management within the maternity services, which is seen as an integral part of quality governance and assurance. The maternity service will take all steps reasonably practicable in managing both clinical and non-clinical risks with the overall objective of protecting mothers and their babies, staff, and members of the public. The primary concern is the provision of a safe, risk free environment together with working policies and practices that take account of assessed clinical and non-clinical risks, minimise them to promote a ‘no blame, learning culture’ which encourages all team members to participate and empower others.

2.2 The Maternity Department is committed to providing a mother, baby and family centred service that is flexible and comprehensive. Excellent communication systems are vital, both verbal and written, to ensure we continue to strive to improve the care we provide for mothers, babies and their families.

2.3 A proactive approach to risk management is supported by the Clinical Directors and managers at all levels within the department. There are clear, identified links with Quality Governance team, clinical audit, the Patient Advisory Liaison Service (PALS), complaints service and legal department via the Trust Quality Governance Department.

2.4 This strategy and framework for risk management will be disseminated through the local induction process and staff briefing sessions.

3 MATERNITY DEPARTMENT RISK MANAGEMENT OBJECTIVES

3.1 These objectives are complementary to the Trust’s overall risk objectives and are supported by the recommendations of national documents and guidelines such as the

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National Institute for Health & Clinical Excellence (NICE), MBRRACE Mothers & Babies Reducing Risks through audit and confidential enquiries across the UK, Each Baby Counts and Safer Maternity Care.

3.2 The Maternity Service will:

• Promote a culture which values risk management, learns from experience and is just and supportive of staff involved in risk management issues

• Embrace a philosophy of continuous improvement in order to achieve a standard of excellence in health care and education

• Ensure all staff adopt a proactive approach to risk management within the maternity services through identification and assessment, and reporting as dictated by the Trust Incident Reporting Policy which includes:

 Identifying near misses, non-clinical and clinical risks. (Utilising the Clinical Incident Maternity Trigger List – see Annex 2)

 Reporting incidents promptly through the Trust incident reporting system ‘Ulysses’

 Being Open and following the statutory ‘Duty of Candour’

 Investigate complaints and serious incidents promptly

 Following up and acting on recommendations

 Change in policies, guidelines and practices where necessary

 Communicating changes to staff promptly

 Monitoring common trends and perform regular audits

 Providing feedback to all individuals through various mediums, encapsulating every single group

 Review and implement action plans

• Manage all risks within the maternity services emerging from various sources such as the identification and reporting process, complaints, claims or other sources. The Trust Risk Register will be the tool employed to score such risks and regular reviews are essential

• Ensure that designated individuals are responsible for areas of risk management and appropriate action plans are implemented, communicated and reviewed

• Look to embrace a philosophy of continuous improvement in order to achieve maximum patient and staff safety. This supports the Trust’s legal duty under the Health and Safety at Work Act 1974, and the Management of Health and Safety at Work Regulation 1999 in relation to risk assessment

• Educate all levels of staff in risk management and complaints, putting measures in place to ensure lessons are learnt

• Ensure that a model of clinical supervision is in place which supports midwives in practice and acts as a catalyst to improving care

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• Ensure a robust and holistic approach to risk management incorporating all relevant disciplines and departments

• Ensure that evidence based policies, guidelines and safe systems of work are in place

4 STRUCTURE LEAD ROLES AND RESPONSIBILITIES

4.1 The Chief Executive as Accountable Officer holds ultimate responsibility for all areas of risk management within the Trust. The maternity service sits within the Elective Care Strategic Business Unit led by the Deputy Chief Executive, Chief Nurse and Director of People.

4.2 The responsibilities for risk management within the maternity services rest with a number of individuals within the Department who report within an agreed framework to the Deputy Chief Executive, Chief Nurse and Director of People as a member of the Board of Directors led by the Chief Executive. They are responsible for leading and managing risk and ensuring risk management arrangements are in place across the maternity unit:

• Clinical Director for Obstetrics & Gynaecology

• Head of Midwifery

• Consultant Obstetrician with Designated Lead for Labour Ward

• Midwifery Matron

• Maternity Risk Manager

4.3 Within the maternity speciality there is a designated Maternity Risk Manager, who is responsible for leading a co-ordinated approach to managing risk in the maternity unit in conjunction with the Clinical Director for Obstetrics and Gynaecology, the Head of Midwifery and the Midwifery Matron. The Maternity Risk Manager is responsible as the chair of the Maternity Risk Management Committee for escalating issues of concern to the Clinical Director of Obstetrics and Gynaecology and the Head of Midwifery and maintaining an up to date risk register. They are in turn responsible for escalating to the Deputy Chief Executive, Chief Nurse and Director of People and the Chief Medical Officer to the Board of Directors and Chief Executive through the Governance and Quality Assurance Committee.

4.4 Other roles contributing to the maternity risk management process include:

• Clinical Director Paediatrics

• Consultant Lead for Obstetric Anaesthesia

• Head of Risk and Litigation

• Practice Educator Midwife

• Professional Midwifery Advocates

• Midwifery clinical leaders

• All other Staff

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Deputy Chief Executive, Chief Nurse and Director of People

4.5 They are responsible for:

• Communicating the Trust Risk Management Strategy

• Carrying out the risk management processes set out in Section 6 of the Trust Risk Management Strategy

• Ensures that effective risk management processes are in place within their areas of responsibility

• Initiates action within their area to prevent or reduce the adverse effects of risk

• Manages the treatment of risk until it becomes acceptable to the organisation

• Ensures that learning from events and risk assessments is disseminated throughout the organisation

Head of Midwifery (HoM):

4.6 They are responsible for:

• Ensuring that maternity services comply with legislation, Trust and Department policies and guidelines in respect of all risk management activities and the Trust Risk Management Strategy

• The implementation of this strategy, thus ensuring effective operational management of risk within the Department

• Sharing joint responsibility with the Clinical Director for Obstetrics and Gynaecology for risk management issues

• Ensuring that risks scored as significant or higher are managed and reviewed at departmental level and escalated as appropriate in the organisation

• Co-ordinating investigations into incidents and complaints

• Attending the Strategic Business Unit meeting on behalf of the Maternity Services

• Reporting directly to the Deputy Chief Executive, Chief Nurse and Director of People who is the Lead Executive at Trust Board level with responsibility for the Maternity Services

• Reporting on the Maternity RCOG dashboard and the quarterly Maternity Risk Management Report to the Strategic Business Unit

• Ensuring the completion of departmental action plans including recommendations from completed investigations, internal and external inspections

• Undertaking annual monitoring and review of this strategy in conjunction with the Clinical Director for Obstetrics and Gynaecology

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Maternity Risk Manager

4.7 They are responsible for:

• Implementation of this strategy thus ensuring effective operational management of risk within the Department

• Compliance with legislation, Trust and Department policies and guidelines in respect of all risk management activities

• Clinical risk co-ordination

• Reviewing incident forms

• Co-ordinating the undertaking of internal level 0, 1, 2 and 3 investigations liaising with the Quality Governance department as appropriate

• Provision of risk management feedback to the Patient Safety Steering Group to enable the monitoring of the maternity services

• Communicating recommendations to all staff

• Ensuring incidents are investigated and appropriate actions taken in a timely manner

• Co-ordinating the completion of the Maternity RCOG dashboard as a monitoring and reporting mechanism which informs the Maternity Risk Management Committee, Maternity Clinical Governance Meeting and the Trust Patient Safety Steering Group

• Chairing the Maternity Risk Management Committee

• Reporting to Maternity Clinical Governance Meeting and Labour Ward Council meetings

• Attending on behalf of the Maternity Risk Management Committee and reporting to the Patient Safety Steering Group

• Ensuring the Obstetric and Maternity Risk Register is constantly updated

• Ensuring the implementation of “Duty of Candour”

• Working closely with the all members of the team to reduce operational risk and complaints

• Considers recommendations and advice arising from the national confidential enquires, other national guidance (i.e. NICE) and findings from the Health Service Investigation Branch (HSIB) and health circulars, for the purpose of agreeing and ratifying implementation plans for practice, via the Maternity Clinical Governance meeting and the monthly Maternity Risk Management meeting

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Role of Maternity Risk Manager as Risk Co-ordinator

4.8 It is the responsibility of the Risk Co-ordinator to:

• Facilitate and manage an effective process for identification of hazards and other factors that have implications for clinical standards and delivery of care to women in line with national standards and legislation

• Initiate immediate action to a higher level in the Trust regarding urgent risk issues through immediate communication with the Head of Midwifery, the Deputy Chief Executive, Chief Nurse and Director of People and the Clinical Director for Obstetrics and Gynaecology

• Undertake and complete a comprehensive Maternity Service Risk Assessment, identifying risks for inclusion within the Trust Risk Register

• Ensure that individuals undertaking risk assessments are competent to do so by attendance for suitable training and guidance

• Ensure the maternity risks included on the Trust Risk Register are reviewed on a quarterly basis by the Maternity Risk Management Committee and update the register as required at other times

• Ensure risk training programmes are attended to promote risk analysis, including root cause analysis investigations

• Ensure that all incidents are graded according to severity and likelihood of recurrence and that risk assessments are reviewed after incidents

• Identify any trends in incident and near miss reporting across the Department and communicate effectively with the Head of Midwifery, consultant medical staff, clinical leads and midwives

• Instigate any reviews of identified trend analysis to provide the department with an overall view to base any recommendations in change of practice

• Delegate investigation of incident reports to clinical leads where appropriate

• Work with the Head if Risk and Litigationto identify and control risks that cannot be dealt with at department level

• Liaise with all relevant departments where incidents have been recognised as potential for litigation for the Trust

• Notify the Trust Legal Services department within 14 days of a notifiable severe brain injury incident under the Early Notification Scheme has occurred using the Early Notification report form

Clinical Director:

4.9 They are responsible for:

• Ensuring compliance with legislation, Trust and Department policies and guidelines in respect of all risk management activities

• Working with the Head of Midwifery and Maternity Risk Manager to foster a robust risk management structure

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• Sharing joint responsibility with the Head of Midwifery for risk management issues

• Being the Professional lead for obstetric and labour ward matters or delegates this role to another Consultant Obstetrician within the team

• Sharing joint responsibility for chairing the Clinical Governance Meeting with the Head of Midwifery

• Leading the formulation of, and changes to, policies and guidelines

• Ensuring that all obstetrician team members follow policies and remain competent in their roles

Consultant Obstetrician with Designated Lead for Labour Ward:

4.10 They are responsible for:

• Providing clinical leadership for all labour ward matters

• Ensuring that labour ward practice remains safe and is in line with national guidelines and recommendations

• Ensuring that all obstetrician team members follow policies and remain competent in their roles

• Leading on the review of labour ward practice and recommend subjects for audit

• Providing advice and guidance to the Maternity Risk Management Committee about unit issues

Midwifery Matron:

4.11 They are responsible for:

• Ensuring the operational implementation of risk management systems and processes in each area of responsibility

• Midwifery Matron is the professional midwifery lead for labour ward matters

• Midwifery Matron shares joint responsibility for chairing Labour Ward Council with the Consultant Labour Ward Lead

• Working closely with the Maternity Risk Manager to reduce operational risk and complaints

• Being actively involved in developing and updating maternity policies and guidelines based on current evidence

• Investigate and respond to incidents / near misses as soon as possible and, where appropriate, within 24 hours of occurrence

• Identifying resultant actions within a Department Action Plan. Any Action Plan key points will be discussed at the departmental meetings, where any change of practice / guideline will be ratified

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• Providing feedback to individuals and arrange appropriate training where need is identified

• Ensuring action guidance will be completed in accordance with the Trust Incident Reporting system

• Working with colleagues and junior doctors and midwives to ensure changes in practice and polices are complied with and are maintained

• Undertaking competency-based assessment of clinical skills for midwives

Practice Educator Midwife:

4.12 They are responsible for:

• Development and provision of Training Needs Analysis and on-going mandatory training programmes which reflect the requirements of the CQC and professional registration, taking into account training needs identified through critical incident reporting and risk management

• Working with new midwives within the clinical setting and providing training for new staff in line with Trust’s policy and CQC standards to maintain and improve standards and skills

Clinical Director Paediatrics:

4.13 They are responsible for:

• Being the Professional lead for neonatal and SCBU matters

• Providing expert advice to the maternity risk management committee for those matters linked with the management of the neonate and neonatal risks identified in pregnancy

• Ensuring all paediatric team members follow policies and remain competent in their roles

• Reviewing the paediatric guidelines that link to maternity

Consultant Lead for Obstetric Anaesthesia:

4.14 They are responsible for:

• Being the Professional lead for obstetric anaesthesia

• Providing expert advice to Labour Ward Council and the Maternity Risk Management Committee for matters relating to obstetric anaesthesia

• Co-ordinating the referral of high risk pregnant women to the anaesthetic service prior to delivery

• Ensuring that all anaesthetic team members follow policies and remain competent in their roles

• Reviewing the anaesthetic guidelines that link to maternity

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Head of Risk and Litigation:

4.15 The Head of Risk and Litigation acts as a support and advisor to the maternity services on risk management issues.

Employees

4.16 Employees at all levels of the Trust need to understand the importance of risk management and the part they play in its development and implementation. All staff have an individual responsibility and professional accountability to:

• Report near-misses, incidents and adverse events using the Trust incident reporting system ‘Ulysses’. If the impact is serious and requiring an immediate response, the incident should be reported to a member of the Maternity management team and named Consultant. Reporting will be to the Trust ‘on-call manager’ and consultant out of hours

• Actively encourage other members of staff to identify risk and assist in the risk management process. All staff are encouraged to highlight the Maternity Risk Management Strategy and Framework during local induction for new staff and to attend any relevant briefing sessions when the strategy is updated

• Be actively involved in developing and updating maternity policies and guidelines based on current evidence

• Be aware of personal responsibilities for maintaining a safe environment

• Attend all mandatory training sessions as required by the Maternity Department and Trust, keeping all relevant documentation as to their attendance

• Be aware of their legal duty to take reasonable care for their own safety and the safety of others who may be affected by their work

• Provide safe clinical practice

• Be familiar with Trust and Department policies, protocols and guidelines.

Responsibility for implementation of this strategy is shared by the Clinical Director, the Head of Midwifery and the Maternity Risk Manager:

4.17 It is their responsibility to:

• Ensure that serious risk issues are escalated in the Trust through direct reporting to the Deputy Chief Executive, Chief Nurse and Director of People (Lead Executive at Trust Board Director level with responsibility for the Maternity Services and risk management)

• Monitor the implementation of and compliance with this policy through the regular presentation of the RCOG dashboard at the monthly Risk Management meeting

• Review results of investigations and recommendations from incident reporting and monitoring the results of action plans at the Maternity Risk Management Meeting and Maternity Clinical Governance meeting

• Give expert clinical advice within the Maternity Risk Management Committee

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• Ensure that recommendations/outcomes are communicated within the Department, Labour Ward council, Maternity Clinical Governance meeting and Trust Patient Safety Steering Group

• Work in partnership to provide a co-ordinated approach across Obstetrics and Midwifery

• Ensure that all medical staff comply with appropriate risk management processes

• Liaise regularly with the Deputy Director Quality Governance and Patient Safety and Head of Risk and Litigation in order to meet the Trust and Directorate risk management objectives

4.18 Different groups have delegated responsibilities for risks with maternity services as per the Terms of Reference for these meetings:

• Maternity Risk Management Committee

• Labour Ward Council

• Rolling Maternity Clinical Governance meeting

• Friday Lunchtime Review and Education Sessions

• Obstetric Interventions

• Perinatal Mortality and Morbidity

• Senior Safety Huddle

• Avoiding Term Admission into Neonatal Unit (ATAIN)

• Saving Babies’ Lives

4.19 The maternity services recognise that in assuring effective and comprehensive risk management, there must be links between risk management and the system for legal claims, complaints management, clinical audit and clinical guideline development.

5 TRAINING

5.1 To monitor training and ensure that all staff are trained in risk management, this is done by appropriate instruction, information and teaching within Trust and local induction days. All new staff are required to attend a Trust – wide induction which includes risk management issues; at Department level, a local induction process is provided. All midwives, healthcare assistants and clerical workers undergo a period of preceptorship and receive written induction / orientation packs which include risk management information. Medical staff receive local induction training which includes consent training and information on risk management. Locum medical staff or staff beginning out of rotation will receive an induction pack prior to commencing work. In addition, further information is provided on the maternity rolling mandatory training and education programme days, medical junior staff training sessions, drills and skills training, Obstetric Intervention meetings and ad hoc meetings as appropriate.

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Maternity Mandatory Training

5.2 The maternity training needs analysis sets out the specialist training required for each staff group and the frequency of the training. The training needs analysis informs the Staff Passport which incorporates both Trust and specialist requirements.

Responsibilities

5.3 Head of Midwifery is accountable for:

• Ensuring that all permanent and temporary staff attend the training appropriate to their role as set out in the training needs analysis

• Informing in writing by the practice educator if a staff member is out of date for training by 3 months

• Receiving a copy of the action plan drawn up by the staff member and the line manager if the staff member is out of date for training for more than 3 months

• Taking whatever action is considered appropriate if a staff member does not comply with repeated requests to attend or complete mandatory training

5.4 Line Managers are responsible for:

• Assisting the Head of Midwifery in the achievement of their role to ensure that all staff attend specialist mandatory training as identified in the maternity training needs analysis, and that this links to the staff personal development plan and appraisal

• Informing in writing by the practice educator within 1 month if a staff member is out of date with their mandatory training. They will be expected to contact the staff member and ensure that the training needs are addressed

• Line managers will be informing in writing by the practice educator if the staff member is still out of date after 3 months. They will be expected to meet with the staff member and draw up an action plan with a copy to the Head of Midwifery and practice educator to ensure that training is given priority

5.5 The staff are responsible for ensuring that they attend all training for their staff group as determined by the maternity training needs analysis, and as identified in the Staff Passport. Bank and temporary staff are personally responsible for ensuring they attend all training required by the Trust and the maternity training needs analysis as identified in the Staff Passport. All staff will be issued with a Staff Passport detailing the Trust and Departmental mandatory training specific to their post. The Staff Passport will include the frequency of the training requirement and will encourage the staff member to record their training attendance. This passport will be used as evidence, in association with electronic attendance records held by the Yeovil Academy and HR, for the purposes of staff appraisal.

5.6 The Midwifery Practice Educator is responsible for:

• Developing and delivering a programme of training as identified in the maternity training needs analysis that reflects the needs of the different staff groups

• Collaborating with the consultant obstetrician responsible for training and education and the Clinical Lead for Obstetrics to ensure that such a programme is wherever possible and appropriately delivered in a multi-professional setting

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• Maintaining accurate records of attendance and non-attendance, identifying when staff members are due for their training and those who are out of date

• Informing the staff member and their line manager within 1 month if they are out of date

• Informing the line manager and Head of Midwifery if a staff member is 3 months out of date

• Publishing lists of training dates in sufficient time to allow managers to plan attendance

• Providing monthly reports to the Maternity Risk Manager detailing the training status of all staff

Attendance Standard

5.7 The Trust Maternity Department expects all staff to comply with mandatory training requirements. For the purpose of the Royal College of Obstetricians and Gynaecologists (RCOG) maternity dashboard the standards are set as follows:

• Green 90% • Amber 80% • Red 65%

5.8 Maternity and Trust mandatory training will be considered together and reported to the Maternity Risk Manager on a monthly basis.

5.9 Wherever possible staff will be allocated protected paid time to attend mandatory training. If staff are nominated to attend and fail to do so, the midwifery practice educator will inform their line manager in writing. The staff member must make every effort to attend the next appropriate training session. It is inevitable that some members of staff will be unable to attend through sickness and annual leave. In these circumstances it remains the responsibility of the individual to ensure that they make a specific request for study leave for the following training session.

5.10 It is occasionally necessary to withdraw staff from training for purposes of providing cover for clinical areas. In this case the staff member must be given priority on the following session and should not be withdrawn on consecutive training sessions. Line managers will be notified in writing within 1 month of members of staff who do not attend planned training or who are out of date.

5.11 Staff will be provided with 7.5 hours protected time a year to complete their mandatory e-learning package. Staff will be rostered this time and can be completed at home with the use of an external link, however evidence must be provided to the Practice Educators detailing the modules completed.

5.12 The Trust fully supports continuing professional development and lifelong learning for all staff. Individual midwives may identify post registration training needs through appraisal. Line managers may help identify specific course or study days that meet the individual’s needs, however all final decisions regarding training allocation should be referred to the Head of Midwifery and funding for agreed training will be sought via a training funding application form to the Yeovil Academy.

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5.13 All new members of staff are met during the induction process, training requirements are assessed and training plans will be implemented in accordance with the individual’s needs.

6 INCIDENT / EVENT / TRIGGER REPORTING

6.1 All staff are to follow the Trust incident management process as outlined in the Trust Risk Management Strategy and Incident Reporting and Investigation Management Policy (accessible on the Trust intranet). All staff are to be made aware of this strategy though various means:

• Newsletter

• Induction for new staff

• Near miss, Labour Ward Council, and Obstetric Intervention meetings

• Intranet

• Personal Email

• Notice Boards and focus board on labour ward

6.2 The risk management process must be followed for all incidents, whether clinical or non-clinical. Report the incident and maintain safety in the situation.

6.3 Maternity ‘Triggers’ are used for the identification of specific maternity orientated clinical risks, which are reported on the Trust Incident Form as per the Trust Risk Management Strategy with all other identified incidents and near misses. Access to the Trust incident reporting system ‘Ulysses’ is available in all work areas. All incident forms are reviewed for the purpose of trend analysis with the aim of identifying areas of practice for review and to provide an overview of the incidents reported. This involves scoring each incident in line with the Trust Risk Management Strategy using the Likelihood versus Consequence scoring method. The list of triggers is included as Annex 2.

6.4 The Maternity Risk Management Committee meets monthly to review reported incidents from Ulysses and to review the maternity dashboard. This review group identifies and instigates follow up action to manage and reduce risk. The outcomes of the Maternity Risk Management Committee are reported to the Trust Patient Safety Steering Group addressing any emerging themes or trends and learning. This wider group will also review investigations from incidents and near misses and monitors progress on action plans. The department participates in the quarterly Trust Wide Governance Agenda when appropriate to enable sharing of lessons learned in maternity across the organisation.

Serious Incidents Requiring Investigation (SIRI)

6.5 SIRIs in line with the National framework for reporting and learning from serious incidents requiring investigation (for example, unexpected deaths or actual injury to a patient) must be reported immediately to:

• The Head of Midwifery

• Clinical Director of Obstetrics & Gynaecology

• Midwifery Matrons

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• On call Consultant Obstetrician

• Clinical Site Manager, who will inform the Manager on call who in turn will inform the Director on call for the Trust if the event occurs out of hours and some of the above personnel are not immediately available

6.6 Such incidents are communicated as soon as reasonably practicable to the Deputy Chief Executive, Chief Nurse and Director of People and the Chief Medical Officer. Investigation into adverse events is carried out using the Serious Incident Framework 2015. A Trust wide register of all investigations is maintained by the Quality Governance Department and monthly reports are made to the Trust Patient Safety Steering Group.

6.7 Direct lines of communication exist between this Department and the Trust Quality Governance department, and Patient Advisory and Liaison services.

6.8 Serious Incidents should be reported to Somerset Clinical Commissioning Group (CCG) and through to NHS England by the Quality Governance Department if appropriate through STEIS reporting. As a Foundation Trust, Yeovil District Hospital is also ultimately responsible to NHS England and Improvement.

6.9 Initial risk assessment is carried out on receipt of an incident form. The Clinical Director, Head of Midwifery, Obstetric Labour Ward Lead, Maternity Matron and Maternity Risk Manager meet to make an initial assessment of any immediate action required and further risk assessment of near miss and harm level of 3 incident reports at a weekly Senior Safety Huddle. The Serious Incident and Safety Review Group will nominate an independent investigator(s) to undertake the investigation if required. However, this will also include specialist Maternity personnel, as maternity is a highly specialised area. Other specialist personnel are asked to advise on investigation of incidents as appropriate, for example the infection control team.

6.10 The investigation and resulting action plan is presented at the Maternity Clinical Governance Meeting or appropriate departmental meeting. This approach enables learning for those involved in the incident as well as the rest of the department and allows more in depth analysis of events. It is envisaged that this will also prevent a repetition of the incident. In some cases, a Trust wide approach is advocated, thereby sharing the learning from an incident that may have wider implications to the Trust.

6.11 The investigation action plan is incorporated into the Departmental action plan monitored by the Clinical Director and Head of Midwifery.

7 ANTENATAL & NEWBORN SCREENING INCIDENT MANAGEMENT

7.1 National screening programmes are public health interventions, which aim to identify disease or conditions in defined populations in order to reduce incidence, or morbidity, or mortality from that disease/condition, or to provide improved choice and information to individuals and families. The characteristics specific to screening programmes mean that incidents require special attention and management:

• There is potential for incidents in screening programmes to affect a large number of individuals/users of the service. This means that seemingly minor local incidents can have a major service and population impact

• As individuals respond to an offer of screening in the expectation that it will be beneficial, there is an added ethical imperative to prevent and respond effectively to quality problems

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• Poor quality screening can do more harm than good – it can harm individuals and /or have no benefit to the population

• Incidents often affect the whole screening pathway and not just the local department or provider organisation in which the problem occurred

• Local incidents can affect public confidence in a screening programme beyond the immediate area involved

• Investigation and dissemination of learning from local incidents, “potential” incidents and near misses should be shared with the rest of the national screening programme in order to help prevent incidents elsewhere

Definition of a Screening Incident

• A screening incident is any unintended or unexpected incident(s) that could have or did lead to harm to one or more persons who are eligible for NHS screening; or to staff working in the screening programme. A screening incident can affect populations as well as individuals

• It is an actual or possible failure in the screening pathway and at the interface between screening and the next stage of care

• Although the level of risk to an individual in an incident may be low, because of the large numbers of people offered screening, this may equate to a high corporate risk. It is important to ensure that there is a proportionate response based on an accurate investigation and assessment of the risk of harm. Due to the public interest in screening, the likelihood of adverse media coverage with resulting public concern is high even if no harm occurs

Definition of a Serious Screening Incident

7.2 Whether a “serious incident” should be declared is a matter of professional judgement on a case by case basis. It should be a joint decision by the key stakeholders informed by QA advice. In distinguishing between a screening incident and a serious screening incident, consideration should be given to whether individuals, the public or staff would suffer avoidable severe (ie permanent) harm or death if the problem is unresolved. “A serious incident is an incident that occurred during NHS funded healthcare (including in the community), which resulted in one or more of the following:

• Unexpected or avoidable death or severe harm of one or more patients, staff or members of the public

• A never event – all never events are defined as serious incidents although not all never events necessarily result in severe harm or death

• A scenario that prevents, or threatens to prevent, an organisation’s ability to continue to deliver healthcare services including data loss, property

7.3 The stimulus to declare a serious screening incident can come from a number of organisations such as the provider, NHS England and QA. A serious incident can be declared at the outset and scaled down as appropriate.

7.4 Please see Annex 3 for a flow chart determining the management of antenatal and newborn screening incidents.

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8 BEING OPEN AND DUTY OF CANDOUR

8.1 The ethical responsibility of the NHS to acknowledge failings and resolve them openly is emphasised in the NHS Constitution. From April 2013, the NHS standard contract includes a duty of candour. The Francis Report emphasised the need to put NHS users at the centre of services, have effective governance and investigate quality problems rigorously. The Trust will ensure this takes place through processes set out in the ‘Being Open’ and Duty of Candour Policy and the Incident Reporting and Investigation Management Policy, the Head of Midwifery will ensure this takes place within maternity. The Duty of Candour is a contractual requirement coming from the recommendations from the Mid Staffs Enquiry http://www.midstaffspublicinquiry.com/report

9 PERINATAL MORTALITY REVIEW TOOL

9.1 MBRRACE-UK were appointed by the Healthcare Quality Improvement Partnership (HQIP) to develop and establish a national standardised Perinatal Mortality Review Tool (PMRT) building on the work of the DH/Sands Perinatal Mortality Review ‘Task and Finish Group’. The PMRT programme was commissioned by HQIP on behalf of the Department of Health (England) and the Welsh and Scottish Governments; as a consequence the tool is free for use by Trusts and Health Boards in England, Wales and Scotland.

9.2 The PMRT had been designed with user and parent involvement to support high quality standardised perinatal reviews on the principle of ‘review once, review well’.

9.3 The aim of the PMRT programme is to introduce the PMRT to support standardised perinatal mortality reviews across NHS maternity and neonatal units in England, Scotland and Wales. The tool supports:

• Systematic, multidisciplinary, high quality reviews of the circumstances and care leading up to and surrounding each stillbirth and neonatal death from 22 weeks gestation, and the deaths of babies who die in the post-neonatal period having received neonatal care;

• Active communication with parents to ensure they are told that a review of their care and that of their baby will be carried out and how they can contribute to the process;

• A structured process of review, learning, reporting and actions to improve future care;

• Coming to a clear understanding of why each baby died, accepting that this may not always be possible even when full clinical investigations have been undertaken; this will involve a grading of the care provided;

• Production of a report for parents which includes a meaningful, plain English explanation of why their baby died and whether, with different actions, the death of their baby might have been prevented;

• Other reports from the tool which will enable organisations providing and commissioning care to identify emerging themes across a number of deaths to support learning and changes in the delivery and commissioning of care to improve future care and prevent the future deaths which are avoidable;

• Production of national reports of the themes and trends associated with perinatal deaths to enable national lessons to be learned from the nation-wide system of reviews

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• Parents whose baby has died have the greatest interest of all in the review of their baby’s death. Alongside the national annual reports, a lay summary of the main technical report will be written specifically for families and the wider public. This will help local NHS services and baby loss charities to help parents engage with the local review process and improvements in care

10 COMPLAINTS AND LITIGATION

10.1 All complaints are centrally managed under the Trust’s Complaints and Concerns Management policy but locally investigated. This process encourages local ownership of complaints and ensures local implementation of service improvements.

10.2 Any litigation claims are managed centrally and investigated in conjunction with the Quality Governance Department under the Trust’s Claims Management process.

10.3 Any identified learning will be incorporated into an action plan discussed at the maternity bi monthly rolling Clinical Governance Meeting where any relevant action is agreed.

11 PEER REVIEW

11.1 The clinical areas have a system of peer review. This uses a ward monitoring tool that includes assessing and reporting on a range of quality criteria. It is informed by the Trust iCARE (communication, attitude, respect & environment) philosophy and objectives and provides a specific yet dynamic assessment of care delivery and standards. Through this process, opportunities for learning from the information collected and reviewed are provided and implemented. These reports are presented at Maternity Clinical Governance meetings.

12 REFERENCES

• Department of Health Nov 2017 Safer Maternity Care - The National Maternity Safety Strategy - Progress and Next Steps • Trust Risk Management Strategy for which the Maternity Risk Management Strategy is an appendix to • Trust Incident Reporting and Investigation Management Policy • Complaints Policy • Trust HR Manual which includes Training Policy • MBRRACE-UK Saving Lives, Improving Mothers’ Care - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2013–15, December 2017 • Fundamental Standards of Care • Maternity Dashboard Clinical Performance and Governance Score Card Royal College of Obstetricians and Gynaecologists (RCOG) Good Practice No: 7 January 2008 • Perinatal Mortality Review Tool

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MATERNITY DEPARTMENT GOVERNANCE STRUCTURE

Board of Directors

Governance & Quality Assurance Sub-Committee

Maternity Risk Patient Safety Steering Group Core Service

Management Steering Clinical Governance Group Steering Group Incident, Investigation and Learning Group

Obstetrics &

Gynaecology Clinical Obstetrics & Labour Perinatal Senior Avoiding Term Saving Governance Intervention Ward Morbidity Safety Admission into Babies’ Meeting Council & Mortality Huddle Neonatal Unit Lives Meeting Meeting Meeting Meeting Meeting

Clinical Director & Clinical Leaders Consultant Meeting Senior Midwifery Team Meetings Head of Midwifery Meeting Management Meeting Meeting

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Please complete a Trust incident form for the following maternity related issues:

• Anaesthetic complications • Baby born below 10th centile • Baby temperature recorded below 35.5 • Birth injury • Born before arrival • Calling in on-call midwives • Closure of the unit • Concerns about management of labour • Congenital anomalies (as per EUROCAT definition) • Cord accident/prolapse • Cord Ph below 7.1 • Delay in carrying out emergency LSCS • Eclampsia • Hysterectomy • In-utero transfer out • Inadequate staffing levels for workload • Laceration to baby at caesarean section • Loss of clinical materials eg. Swab • Low apgars <7 at 5 minutes • Maternal death • Maternal resuscitation • Maternal transfer to intensive care • Maternity positive COVID 19 test • Misdiagnosis of antenatal screening test • Missed antennal /neonatal screening test • Neonatal death • Neonatal seizures • Noncompliance of electronic/maternity trilogy recording • Pulmonary embolism (PE) • Postpartum haemorrhage 1000-1499mls • Postpartum haemorrhage >1499mls • Premature deliveries up to 36+6 • Readmission of baby • Readmission of mother • Return to theatre • Seriously ill patient • Shoulder dystocia • Significant infection • Stillbirth • Term baby admitted to SCBU • Third & forth degree tear • Transfer in from homebirth • Trauma to bladder or other organs • Unavailability of any facility or equipment • Unavailability of healthcare record • Undiagnosed breech • Unplanned homebirth • Unsuccessful forceps ventouse • Uterine rupture • VTE • Working environment of 30+ for over 3 hours

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NB:

• Drug errors should be recorded under main Trust category of medication incidents

• Communication issues should be listed separately in addition to the maternity trigger incident form as these will be recorded under the main Trust category of communication incident

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INCIDENT MANAGEMENT FOR ANTENATAL & NEWBORN SCREENING

1. Screening incident suspected

2. Provider seeks advice from SQAS Serious incident may be declared immediately SIAF required SIAF not required

3. SIAF completed and 4. Follow internal incident classification governance process; agreed no SQAS involvement

5. Serious incident 9. Safety incident declared declared

6. 72 hour report 10. Managing and produced investigating

7. Managing and investigating 4. Incident report produced and reviewed

8. Serious incident report produced and incidents safety screening for Actions reviewed

Actions for screening serious incidents serious screening for Actions

12. Incident closure

Consider whether 13. Lessons identified escalation or de- and action taken escalation is appropriate, at all times

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EQUALITY IMPACT ASSESSMENT TOOL

Somerset Equality Impact Assessment Before completing this EIA please ensure you have read the EIA guidance notes – available from your Equality Officer Organisation prepared for Yeovil District Hospital NHS Foundation Trust Version 1 Date Completed April 2021 Description of what is being impact assessed Policy for the Development and Management of Procedural Documents Evidence What data/information have you used to assess how this policy/service might impact on protected groups? Sources such as the Office of National Statistics, Somerset Intelligence Partnership, Somerset’s Joint Strategic Needs Analysis (JSNA), Staff and/ or area profiles,, should be detailed here No impacts on protected groups

Who have you consulted with to assess possible impact on protected groups? If you have not consulted other people, please explain why? Equality & Diversity Lead

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EQUALITY IMPACT ASSESSMENT TOOL

Analysis of impact on protected groups The Public Sector Equality Duty requires us to eliminate discrimination, advance equality of opportunity and foster good relations with protected groups. Consider how this policy/service will achieve these aims. In the table below, using the evidence outlined above and your own understanding, detail what considerations and potential impacts against each of the three aims of the Public Sector Equality Duty. Based on this information, make an assessment of the likely outcome, before you have implemented any mitigation. Negative Neutral Protected group Summary of impact Positive outcome outcome outcome • Age n/a ☐  ☐

• Disability n/a ☐  ☐

• Gender reassignment n/a ☐  ☐

• Marriage and civil n/a ☐  ☐ partnership • Pregnancy and n/a ☐  ☐ maternity • Race and ethnicity n/a ☐  ☐

• Religion or belief n/a ☐  ☐

• Sex n/a ☐  ☐

• Sexual orientation n/a ☐  ☐

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EQUALITY IMPACT ASSESSMENT TOOL

Other, e.g. carers, • n/a veterans, homeless, ☐  ☐ low income, rurality/isolation, etc. Negative outcomes action plan Where you have ascertained that there will potentially be negative outcomes, you are required to mitigate the impact of these. Please detail below the actions that you intend to take. Person How will it be Action taken/to be taken Date Action complete responsible monitored? n/a Select date ☐ Select date ☐ If negative impacts remain, please provide an explanation below. n/a

Completed by: Nicola Crouch Date April 2021 Signed off by: Sallyann Batstone Date April 2021 Equality Lead/Manager sign off date: Not required as no significant service change as a result of this policy To be reviewed by: (officer name) Not required as no significant service change as a result of this policy Review date: n/a

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Annex: B REPORT TO: Board of Directors Ben Edgar-Attwell, Company Secretary REPORT BY: Sarah James, Chief Finance Officer Ben Edgar-Attwell, Company Secretary PRESENTED BY: Sarah James, Chief Finance Officer Ben Edgar-Attwell, Company Secretary EXEC SPONSOR: Sarah James, Chief Finance Officer REPORT TITLE: Summary of Constitutional Documents Review and Updates DATE: 5 May 2021

Purpose of Paper (Please select any which are relevant to this paper)

☐ For Assurance ☒ For Approval / Decision ☐ For Information

Reason for Presentation to To accompany the Trust’s Constitution, the Trust has a suite of Committee/Board documents outlining the formal framework for the conduct of Trust business and affairs.

In line with best practice, the suite of documents should be reviewed on a regular basis, and at least on an annual basis.

The following documents have been reviewed and updates made as outlined below.

• Standing Financial Instructions (SFI’s) • Standing Orders for the Practice and Procedure of the Board of Directors and the Council of Governors (SO’s) • Scheme of Reservation and Delegation (SRD)

In light of the work towards a merger with Somerset NHS Foundation Trust (SFT), this review and the updates have been completed to provide consistency across the organisations where this is appropriate.

The main/wholesale changes to the documents include revisions/strengthening of the following: • SFI’s – Allocations, Business Planning, Budgets, Budgetary Control and Monitoring • SFI’s – Tendering and Contract Procedure • SFI’s – Disposals • SRD – Delegation Limits (within table of document)

In addition, there have been other smaller changes, such as grammar and titles, movement of responsibilities to align with current arrangements etc. A high-level summary of the wholesale changes are outlined below.

A ‘clean’ copy of the documents have been provided below.

The Audit Committee considered the updated documents on 28 April 2021. The Committee recommended the Board approve the updated documents.

Any Key Issues to Note

Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) ☒ Care for our Population ☒ Develop our People

☒ Innovate and Collaborate ☒ Develop a Sustainable System

Implications/Requirements (Please select any which are relevant to this paper) ☒ Financial ☒ Legislation ☒ Workforce ☒ Estates ☒ ICT ☒ Patient Safety / Quality

Reference to CQC domains (Please select any which are relevant to this paper)

☒ Safe ☒ Effective ☒ Caring ☒ Responsive ☒ Well Led

Is this paper clear for release under the Freedom of Information Act 2000? ☒ Yes ☐ No

Standing Financial Instructions Changes

Ref: Change Throughout Grammar, spelling and title changes document 1.6 Additional wording relating to wholly and partially owned corporate entities to maintain adequate governance arrangements 4.1.4 Additional wording where any ultra vires transactions, evidence of improper acts etc. relate to the CFO, that these matters should be raised with the Chief Executive. 4.5 Amendments to reflect oversight of security management is the responsibility of the Chief Nurse & Director of People. Section 5 Business Operational Planning and Budget section required strengthening/clarifying. Section redrafted in line with SFT SFI’s – Section 5 covers allocations, business planning, budgets, budgetary control and monitoring. 8.2 Additional wording relating to Fees and Charges – CFO responsible for approving and reviewing level of all fees and charges other than those determined by DoH or by Statute. 8.3 Additional wording relating to Income in Dispute/in Error – clarification of only cancelled by a credit note. 8.4 Additional wording to strengthen arrangements and oversight of Debt Recovery. Section 10 Section for Tendering and Contract Procedures redrafted to clarify and strengthen arrangements. Wording aligned with SFT. Section 11 Section for Disposals in relation to competitive tendering and quotation procedures added to strengthen arrangements. Wording aligned with SFT. 13.2 Additional wording clarifying the definition of funded establishment and the variation of establishment within existing funding. 13.4 Amendments to reflect oversight of payroll is the responsibility of the Director of Human Resources and Organisational Development. 13.4.3 Additional wording clarifying the arrangements regarding pay advances and outlining that loans to employees are not permitted under any circumstance. 14.2.4- Strengthening/redrafting of wording relating to any proposed prepayments and 14.2.5 contracts, leases etc. must be approved by the CFO. 15.2-15.3 Borrowing procedures wording redrafted in line with national practice, i.e. in accordance with its Licence and the Prudential Borrowing Code for NHS Foundation Trusts. Removal of wording relating to investment of money in bodies corporate and giving financial assistance to any person for the purposes of or in connection with its functions or principal purposes. Strengthening of wording relating to the holding of temporary cash surpluses within in such public and private sector investment as notified by NHS Improvement and/or the Secretary of State and in accordance with the Treasury Management Policy. 16.1.1 Removal of the reference to the operation of the Construction Industry Scheme. 16.4.1 Addition of CFO issuing control procedures in relation to assets 16.4.5 Addition of requirement for any damage, or loss of equipment, stores or supplies to be reported to Board members and officers in accordance with the procedures for reporting losses. 17.1.1- Strengthening/redrafting of section and definition of stocks and stores and the 17.1.2 requirement to set out procedures for the regulation, control and security of stocks and stores. 18.1 Section on disposals and condemnations redrafted and strengthened. Aligned to SFT. 18.2 Section on losses and special payments redrafted and strengthened. Aligned to SFT. Annex A Annex A – Tendering Procedure section removed – incorporated into Section 10 outlined above.

Standing Orders for the Practice and Procedure of the Board of Directors and the Council of Governors

Ref: Change Throughout Grammar, spelling and title changes document 5.3.1 Change of notice period and the confirmation of the business proposed to be transacted at a meeting of the Board or Council from fourteen to four days written notice in line with current practice. Removed requirement for this notice to be signed by the Chairman or the Secretary 7.2.2 Addition of Financial Resilience and Commercial Committee to list of committees established by the Board. 8.5 Updated wording relating to gifts and hospitality declarations – removed reference to specific systems and value – reference added to relevant policy.

Scheme of Reservation and Delegation

Ref/Section: Change Throughout Grammar, spelling and title changes document Decisions Movement of approval of Capital plan from Regulations and Control to reserved to the Strategy, Business Plans and Budgets. Board Authorities/Duties Removal of the following: Approve commitment of expenditure in excess delegated or of that which has been allocated by the Trust and which is not in reserved to the accordance with the standing financial instructions. Chief Executive Addition of the following: Taking of urgent decisions (with the Chairman), that the Board has retained to itself within the Standing Orders, after having consulted at least two Non-Executive Directors Authorities/Duties Removed the redundant reference to authority to approve of delegated or expenditure limits per Table A reserved to the Simplification of section relating to the management of banking Chief Finance arrangements and operational of bank accounts. Previous wording Officer longwinded. Simplification of section relating to the implementation and maintenance of financial record keeping and system of internal financial control. Previous wording longwinded. Simplification of section relating to the ensuring sufficient and independent Internal Audit functions are in place. Previous wording longwinded. Amendments to reflect oversight of security management is the responsibility of the Chief Nurse & Director of People. Amendments to reflect oversight of payroll is the responsibility of the Director of Human Resources and Organisational Development Removal of section detailing system of verification, recording and payment of amounts payable, handling and payment of accounts and payment for goods and services. Covered by overall responsibility for financial systems, processes and controls. Simplification of section relating to proposed prepayments. Previous wording longwinded. Alignment with SFIs. Addition of approval of proposed repayment plans outside of Trust policy. Alignment with SFIs. Redrafted wording relating to the development and implementation of a capital investment programme Removal of assessment of requirement for the operation of the construction industry taxation deduction scheme. Simplification of wording relating to ensuring appropriate risk pooling and insurance arrangements. Previous wording longwinded. Authorities/Duties Addition of responsibility for payroll. Moved from CFO responsibilities. delegated or reserved to the Director Of HR And OD Authorities/Duties Clarification of the duties for overseeing and approving booking delegated or processes for bank or agency medical staff within budget and for reserved to the exceptional approval of high cost usage. Chief Medical Officer Authorities/Duties Removal of authority to approve outline and final business cases for delegated or capital investment reserved to Clarification of the duties for overseeing and approving booking Executive processes for bank or agency staff within budget and for exceptional Directors approval of high cost usage with the relevant directorates. Removal of authority to review and approve business cases for any new staff position resulting in costs over and above allocated budgets and/or where there is a material change to service provision. Addition of authority to instigate additional cost control measures in the recruitment of vacant posts during period of significant financial challenge. Authorities/Duties Addition of duty to identify overseas visitors or service users who are delegated or required to pay for the treatment they receive and ensure action is taken reserved to all for the invoicing of any services provided. Officers Simplification of wording relating to investment and business case approval process. Authorities/Duties Clarification of the duties for overseeing and approving booking delegated or processes for bank or agency nursing staff within budget and for reserved to Chief exceptional approval of high cost usage. Nurse & Director Addition of responsibilities for security management matters and of People measures. Table A Amendment that in urgent or exceptional circumstances, the Executive Delegation of Directors, Chief Executive or Chief Finance Officer may vary financial expenditure limits or authorisation arrangements, such variation to be approved at the next meeting of the Board. Amendment and simplification to the delegated limits as outlined within table. In line with current practice. Losses and special payments £50k and above moved from Board to Audit Committee.

STANDING FINANCIAL INSTRUCTIONS

Version Number 2.1 Version Date March 2021 Owner Chief Finance Officer Deputy Chief Finance Officer Author Company Secretary

Staff/Groups Procurement Consulted Finance

Approved by Board of TBC Directors Next Review Due TBC

CONTENTS

Item

1 Introduction 2 Interpretation 3 3 Responsibilities and delegation 6 4 Audit 9 5 Allocations, business planning, budgets, budgetary control and monitoring 12 6 Annual Accounts and Reports 14 7 Bank accounts 15 8 Income, fees and charges and security of cash and other negotiable 15 instruments 9 Agreements for provision of services 16 10 Tendering and contract procedure 17 11 Disposals 28 12 In-house Services 28 13 Terms of service, allowances and payment of members of the board and 28 employees 14 Non-pay expenditure 30 15 External borrowing and investments 32 16 Capital investment, private financing, asset registers and security of assets 32 17 Stock, stores and receipt of goods 33 18 Disposals and condemnations, insurance, losses and special payments 34 19 Information technology 35 20 Patients' property 35 21 Acceptance of gifts and hospitality by officers 36 22 Records management 36 23 Freedom of Information and information data requests 36 24 Risk management 36 25 Insurance 37 26 Funds held on trust 37

1 INTRODUCTION

1.1 Yeovil District Hospital NHS Foundation Trust (the "Trust") is a Public Benefit Corporation following Authorisation by Monitor pursuant to the 2006 Act.

1.2 The principal place of business of the Trust is at Yeovil District Hospital, Higher Kingston, Yeovil, Somerset, BA21 4AT ("Trust Headquarters").

1.3 The Trust is governed by the Regulatory Framework which requires the Trust to adopt Standing Financial Instructions ("SFIs") for the regulation of the conduct of the Directors and Officers in relation to financial matters. These SFIs shall have effect as if incorporated in the Standing Orders but, for the avoidance of doubt, these SFIs do not form part of the Constitution.

1.4 These SFIs together with the Standing Orders and the Scheme of Delegation provide a framework for the administration of the Trust's affairs. All Directors and Officers should be aware of the existence of these documents and, where necessary, be familiar with the detailed provisions contained within them.

1.5 These SFIs identify the financial responsibilities, which apply to everyone working for the Trust and its constituent organisations including trading units. They do not provide detailed procedural advice. These statements should therefore be read in conjunction with any relevant detailed departmental and financial procedures and notes published by the Trust. All financial procedures must be approved by the Chief Finance Officer.

1.6 The Trust has a number of wholly and partially owned corporate entities. These corporate entities are separate, distinct legal entities for commercial purposes and have distinct taxation, regulatory and liability obligations. As separate, independent corporate entities, they are subject to their own governance arrangements, which are the responsibility of the relevant entity’s management structure, and therefore these Standing Financial Instructions are not applicable. For avoidance of doubt, any matter reserved to the Trust in relation to such corporate entities will be treated as an item of the Trust and will be considered in accordance with these Standing Financial Instructions. The Group expects that wholly and partially owned corporate entities will maintain adequate governance arrangements to at least an equivalent standard as those maintained by the Trust.

1.7 Should any difficulties arise regarding the interpretation or application of any of the SFIs then the advice of the Chief Finance Officer must be sought before acting. The user of these SFIs should also be familiar with and comply with the provisions of the Standing Orders and the Scheme of Delegation.

1.8 All Directors and Officers have a duty to disclose any non-compliance with these SFIs to the Chief Finance Officer as soon as possible. The Chief Finance and may report the non- compliance to the Trust's Audit Committee for referring action or ratification.

1.9 Failure to comply with these SFIs may be regarded as a disciplinary matter that could result in dismissal from employment with the Trust.

2 INTERPRETATION

2.1 Save as otherwise permitted by law, at any meeting of the Board the Chairman of the Trust (or the person presiding over the meeting) shall be the final authority on the interpretation of the SFIs (on which he should be advised by the Chief Executive or the Chief Finance Officer and his decision shall be final and binding except in the case of manifest error. 3

2.2 Wherever a financial limit is stipulated in these SFIs but no value is given, reference should be made to the Trust’s Financial Limits contained within the Scheme of Delegation, which shall be issued to accompany the SFIs and Standing Orders. The Board should periodically review the Financial Limits.

2.3 Unless a contrary intention is evident or the context requires otherwise, words or expressions contained in these SFIs shall bear the same meaning as in the Constitution. In these SFIs:

"the 2006 Act” means the National Health Service Act 2006 (as amended);

“the 2012 Act” means the Health and Social Care Act 2012;

"Accounting Officer" means a person who from time to time discharges the functions specified in paragraph 25(5) of Schedule 7 of the 2006 Act. The Chief Executive of the Trust is the Accounting Officer;

"Annual Accounts" means those accounts prepared by the Trust pursuant to paragraph 25 of Schedule 7 to the 2006 Act;

"Annual Operational Plan" shall have the meaning ascribed to it in SFI 5.1.1;

"Annual Report" means a report prepared by the Trust pursuant to paragraph 26 of Schedule 7 to the 2006 Act;

"Auditor" means the Auditor of the Trust appointed by the Council of Governors pursuant to paragraph 13 of the Constitution;

"Audit Committee" means a committee of the Board as established pursuant to paragraph 8.7.4 of the Constitution;

“Authorisation” means the authorisation issued to the Trust by Monitor under section 35 of the 2006 Act;

“Board” means the Board of Directors as constituted in accordance with the Constitution;

"Board of Trustees" means a meeting of the Board of Trustees for the Yeovil District Hospital Charitable Fund;

"Budget" means a resource, expressed in financial terms, proposed by the Board for the purpose of carrying out, for a specific period, any or all of the business functions of the Trust;

"Budget Holder" means the Director or Officer with delegated authority to manage business activity for a specific area of the Trust;

“Budget Manager” means the officer who has daily operational responsibility for the management of the Budget;

"Capital Investment Manual" means the guidance of that name issued by the Department of Health, as may be amended from time to time;

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"Chairman" means the Chairman of the Trust;

“Council of Governors” means the Council of Governors as constituted in accordance with the Constitution;

"Chief Executive" means the Chief Executive of the Trust;

"Committee of Public Accounts" means the committee appointed by the House of Commons under Commons Standing Order 148 (or otherwise) to examine the accounts showing the appropriation of the sums granted by Parliament to meet public expenditure and of such other accounts laid before Parliament as the committee may think fit;

“Constitution” means the Constitution of the Trust together with the annexes;

“Director” means a member of the Board who has voting rights;

“Executive Director" means an executive voting member of the Board of the Trust;

"Chief Finance Officer" means the Chief Finance Officer of the Trust;

"Financial Limits" means the financial limits set out in the Scheme of Delegation;

“Financial Year” means each successive period of twelve months beginning with 1 April;

"Funds held on Trust" means those funds which the Trust holds at the date of incorporation, receives on distribution by statutory instrument, or chooses subsequently to accept under powers gained under the 2006 Act and shall include the income and interest derived from the holding of such funds all or some of which may or may not be charitable;

"Local Counter Fraud Specialist" means the person appointed by the Trust pursuant to SFI 4.4.3 to carry out the responsibilities and functions set out in the Secretary of State for Health's Directions to NHS Bodies on Counter Fraud Measures 2004, as amended from time to time;

"Local Security Management Specialist" means the person appointed by the Trust pursuant to SFI 4.5.2 to carry out the responsibilities and functions set out in the Secretary of State for Health's Directions to NHS Bodies on Security Management Measures 2004, as amended from time to time;

“Member” means a member of the Trust;

“Monitor” means the body corporate known as Monitor, as provided by section 61 of the 2012 Act;

“NHS Improvement” or “NHSI” is the operational name for an organisation that brings together Monitor and the NHS Trust Development Authority;

“NHS Counter Fraud Authority” means the organisation established and constituted by Statutory Instrument 2017 No 958 and sponsored by the Department of Health and Social Care Anti-Fraud Unit;

"Non-Executive Director" means a non-executive member of the Board of the Trust including the Chairman; 5

"Officer" means an employee of the Trust and for the avoidance of doubt does not include Non-Executive Directors;

“Property” is land and buildings owned or leased by the Trust;

"Records Management Code" shall have the meaning ascribed to it in SFI 20.2;

"Remuneration Committee" shall have the meaning ascribed to it in SFI 11.1;

“Secretary” means the Secretary of the Trust or any other person or body corporate appointed to perform the duties of the Secretary of the Trust, including a joint, assistant or deputy secretary;

“Simply Serve Limited” means the Yeovil District Hospital NHS Foundation Trust wholly owned estates and facilities management company.

“Standing Financial Instructions” "SFIs" means these Standing Financial Instructions which regulate the conduct of the Trust's financial matters;

“Standing Orders” "SOs" means the Standing Orders for the Council of Governors and the Standing Orders for the Board; and

"Trust" means Yeovil District Hospital NHS Foundation Trust;

"Virement" means the agreed transfer of money from one Budget head to another, within a Financial Year.

3 RESPONSIBILITIES AND DELEGATION

3.1 The Board

3.1.1 The Board exercises financial supervision and control by:

(a) formulating the financial strategy of the Trust;

(b) requiring the submission and approval of Budgets within approved allocations and overall income;

(c) defining and approving essential features in respect of important procedures and financial systems, (including (but not limited to) the need to obtain value for money) and the Trust's statutory duty under Section 63 of the 2006 Act (General duty of NHS foundation trusts) to exercise its functions effectively, efficiently and economically; and

(d) defining specific responsibilities placed on the Board and Nominated Officers as indicated in the Scheme of Delegation;

3.1.2 The Board has resolved that certain powers and decisions may only be exercised by the Board in formal session. These are set out in the Scheme of Delegation.

3.1.3 The Board will delegate responsibility for the performance of its functions in accordance with the Regulatory Framework and the Scheme of Delegation.

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3.2 The Chief Executive

3.2.1 Within these SFIs, it is acknowledged that the Chief Executive is ultimately accountable to the Board and, as Accounting Officer, to NHSI and the Committee of Public Accounts, for the overall organisation, management and staffing of the Trust and for its procedures in financial and other matters.

3.2.2 The Accounting Officer is responsible for ensuring that:

(a) there is a high standard of financial management in the Trust as a whole;

(b) the Trust's financial systems and procedures promote the efficient and economical conduct of business, and safeguard financial propriety and regularity throughout the Trust; and

(c) financial considerations are fully taken into account in decisions on Trust policy proposals.

3.2.3 Subject to SFI 3.2.2 above, the Accounting Officer, must at all times comply with the NHS Foundation Trust Accounting Officer Memorandum. 3.2.4 The Accounting Officer has overall responsibility for the Trust's activities and is responsible for ensuring that the Trust's financial obligations and targets are met, and has overall responsibility for the Trust’s system of internal control.

3.2.5 The Accounting Officer has personal responsibility for:

(a) the propriety and regularity of the public finances for which he is accountable;

(b) the keeping of proper accounts, in accordance with the Constitution;

(c) prudent and economical administration of the Trust's affairs; and

(d) the efficient and effective use of all the resources (financial or otherwise) in his charge.

3.2.6 It is a duty of the Chief Executive to ensure that existing Directors and Officers and all new appointees are notified of and put in a position to understand their responsibilities within these SFIs.

3.3 Chief Finance Officer

3.3.1 The Chief Finance Officer is responsible for:

(a) implementing the Trust’s financial policies and for coordinating any corrective action necessary to further these policies;

(c) the provision of financial advice to the Board and the Officers;

(d) maintaining an effective system of internal financial control including, designing, implementing and supervising appropriate financial procedures and systems incorporating the principles of separation of duties and internal checks;

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(e) the preparation and maintenance of such accounts, certificates, estimates, records and reports as the Board may require for the purpose of carrying out its statutory duties;

(f) ensuring that sufficient records are maintained to show and explain the Trust’s transactions, in order to disclose, with reasonable accuracy, the financial position of the Trust at any time;

(g) ensuring there are arrangements to review, evaluate and report on the effectiveness of internal financial control including the establishment of an effective Internal Audit function;

(h) deciding at what stage to involve the police in cases of misappropriation and other irregularities not involving fraud or corruption and liaising with Monitor as appropriate;

(i) ensuring that an annual Internal Audit report is prepared for the consideration of the Audit Committee and the Board. The report must cover:

i. a clear opinion on the effectiveness of internal control in accordance with any controls assurance guidance or best practice advice issued by NHSI;

ii. major internal financial control weaknesses discovered;

iii. progress on the implementation of any Internal Audit recommendations;

iv. progress against plan over the previous year;

v. a strategic audit plan covering the coming three years; and

vi. a detailed plan for the coming year.

3.3.2 The Chief Finance Officer or designated internal auditors are entitled without necessarily giving prior notice to require and receive:

(a) access to all records, documents and correspondence relating to any financial or other relevant transactions, including documents of a confidential nature;

(b) access at all reasonable times to any land, premises, or Directors or Officers, of the Trust;

(c) the production of any cash, stores or other property of the Trust under the control of either a member of the Board or an Officer; and

(d) explanations concerning any matter under investigation.

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4 AUDIT

4.1 Audit Committee

4.1.1 In accordance with the Constitution and the Standing Orders, the Board must formally establish a committee of a minimum of two (2) non-executive directors (excluding the Chairman) as an Audit Committee with clearly defined terms of reference to perform such monitoring, reviewing and other functions as is appropriate.

4.1.2 In establishing the Audit Committee, the Board shall satisfy itself that at least one member of the Audit Committee has recent and relevant financial experience.

4.1.3 In establishing the terms of reference of the Audit Committee, the Board will ensure that the Audit Committee will:

(a) review the financial information systems and monitor the integrity of the financial statements of the Trust and any formal announcements relating to the Trust's financial performance, and review significant financial reporting judgments contained in them;

(b) review the Trust's internal financial controls, internal control and risk management systems;

(c) monitor and review the effectiveness of the Trust's Internal Audit function and ensure it is adequate and meets any mandatory standards set by NHSI;

(d) review and monitor the Auditor's independence and objectivity and the effectiveness of the audit process, taking into consideration relevant UK professional and regulatory requirements;

(e) provide reports to the Council of Governors, identifying any matters in respect of which it considers that action or improvement is needed and making recommendations as to the steps to be taken;

(f) review arrangements by which Officers may raise, in confidence, concerns about possible improprieties in matters of:

(i) financial reporting and control;

(ii) clinical quality;

(iii) patient safety; or

(iv) other matters;

(g) agree with the Council of Governors the criteria for appointing, reappointing and removing Auditors;

(h) make recommendations to the Council of Governors in relation to the appointment, re-appointment and removal of the Auditor and approve the remuneration and terms of engagement of the Auditor; 9

(i) make a report to the Council of Governors in relation to the performance of the Auditor, including detail such as the quality and value of the work, and the timeliness of reporting and fees; and

(j) monitor compliance with the Standing Orders, these SFIs and the Scheme of Delegation.

4.1.4 Where the Audit Committee feels there is evidence of ultra vires transactions, evidence of improper acts, or if there are other important matters that the Audit Committee wishes to raise, the chairman of the Audit Committee should raise the matter with the Chief Finance Officer in the first instance. In the event the matter relates to the Chief Finance Officer, the matter should be raised with the Chief Executive.

4.2 Role of Internal Audit

4.2.1 Internal Audit will review, appraise and report upon:

(a) the extent of compliance with, and the financial effect of, relevant established policies, plans and procedures;

(b) the adequacy and application of financial and other related management controls;

4.2.2 The Head of Internal Audit will normally attend the meetings of the Audit Committee and has a right of access to all Audit Committee members, the Chairman and Chief Executive.

4.2.3 The Head of Internal Audit shall be accountable to the Chief Finance Officer.

4.2.4 Officers in receipt of audit reports referred to them, have a duty to take appropriate remedial action, if any, within the agreed time-scales specified within the audit reports.

4.3 External Audit

4.3.1 The Trust shall provide to the Auditor every facility and all information which they may reasonably require for the purposes of their functions under paragraph 23 of Schedule 7 of the 2006 Act.

4.4 Fraud and Corruption

4.4.1 In line with their responsibilities, the Chief Executive and Chief Finance Officer shall monitor and ensure compliance with any relevant guidance issued by NHSI or the NHS Counter Fraud Authority on fraud and corruption.

4.4.2 The Chief Finance Officer is responsible for the promotion of counter fraud measures within the Trust and, in that capacity, they will ensure that the Trust co- operates with NHSI and the NHS Counter Fraud Authority to enable them to efficiently and effectively carry out their respective functions in relation to the prevention, detection and investigation of fraud in the NHS. This also relates to the UK Bribery Act 2010 and the Criminal Finances Act 2017 Sections 45-46 in relation to the prevention of the facilitation of tax evasion. The Chief Finance 10

Officer must notify the NHS Counter Fraud Authority and the Auditor of all frauds.

4.4.3 The Trust will appoint at least one person (who may be either an Officer or a person whose services are supplied to the Trust by an outside organisation) as a Local Counter Fraud Specialist, in accordance with any guidance issued by NHSI or the NHS Counter Fraud Authority on the suitability criteria for such appointees.

4.4.4 The Local Counter Fraud Specialist shall report directly to the Chief Finance Officer and shall work with NHSI and the NHS Counter Fraud Authority.

4.4.5 The Local Counter Fraud Specialist and the Chief Finance Officer will, at the beginning of each Financial Year, prepare a written work plan outlining the Local Counter Fraud Specialist's projected work for that Financial Year.

4.4.6 The Local Counter Fraud Specialist will provide a written report, at least annually, on counter fraud work within the Trust.

4.4.7 The Local Counter Fraud Specialist shall be afforded the opportunity to attend meetings of the Audit Committee and other meetings of the Board, or its committees, as required.

4.4.8 The Local Counter Fraud Specialist shall:

(a) keep full and accurate records of any instances of fraud and suspected fraud;

(b) report to the Audit Committee any weaknesses in fraud-related systems and any other matters which may have fraud-related implications for the Trust;

(c) request from the Chief Finance Officer all necessary support to enable them to efficiently, effectively and promptly carry out their functions and responsibilities, including working conditions of sufficient security and privacy to protect the confidentiality of their work;

(d) request from the Chief Finance Officer all appropriate training and support, as recommended by the NHS Counter Fraud Authority; and

(e) participate in activities which NHSI directs, or in which the NHS Counter Fraud Authority is engaged, including national anti-fraud measures.

4.4.9 Any Officer discovering or suspecting a loss of any kind must immediately inform the Chief Executive and the Chief Finance Officer or the Local Counter Fraud Specialist.

4.5 Security management

4.5.1 The Deputy Chief Executive, Chief Nurse and Director of People is responsible for security management matters and the promotion of security management measures within the Trust.

4.5.2 The Trust will appoint at least one person as a Local Security Management Specialist, in accordance with any guidance issued by NHSI or the NHS Counter Fraud Authority on suitability criteria for such appointees.

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4.5.3 The Local Security Management Specialist will report directly to the Deputy Chief Executive, Chief Executive and Director of People and will work with NHSI and the NHS Counter Fraud Authority.

4.5.4 The Local Security Management Specialist will, at the beginning of each Financial Year, prepare a written work plan outlining the Local Security Management Specialist's projected work for that Financial Year.

4.5.5 The Local Security Management Specialist shall be afforded the opportunity to attend Audit Committee meetings and other meetings of the Board, or its committees, as required.

5. ALLOCATIONS, BUSINESS PLANNING, BUDGETS, BUDGETARY CONTROL AND MONITORING

5.1 Preparation and approval of business plans and budgets:

5.1.1 The Chief Executive will compile and submit to the Board an annual business plan which takes into account financial targets and forecast limits of available resources. The annual business plan will contain a statement of the significant assumptions on which the plan is based and details of major changes in workload, delivery of services or resources required to achieve the plan.

5.1.2 Prior to the start of the financial year, the Chief Finance Officer will, on behalf of the Chief Executive, prepare and submit budgets for approval by the Board. Such budgets will be in accordance with the aims and objectives set out in the Trust’s Annual Business Plan and;

• accord with workload and manpower plans; • be produced following discussion with appropriate budget holders; • be prepared within the limits of available funds and identify potential risks.

5.1.3 The Chief Finance Officer shall monitor financial performance against budget and business plan, periodically review them, and report to the committee responsible for monitoring financial performance and the Board.

5.1.4 All budget holders must provide information as required by the Chief Finance Officer to enable budgets to be complied with.

5.1.5 The Chief Finance Officer has a responsibility to ensure that adequate training is delivered on an on-going basis to budget holders to help them manage successfully.

5.2 Budgetary delegation

5.2.1 The Chief Executive may delegate the management of a budget to permit the performance of a defined range of activities including pooled budget arrangements under section 75 of the NHS Act 2006.

5.2.2 This delegation must be in writing and be accompanied by a clear definition of:

• the amount of the budget; 12

• the purpose(s) of each budget heading;

• individual and group responsibilities;

• authority to exercise virement;

• achievement of planned levels of service; and

• the provision of regular reports.

5.2.3 The Chief Executive and delegated budget holders must not exceed the budgetary total or virement limits set by the Board.

5.2.4 Any budgeted funds not required for their designated purpose(s) revert to the immediate control of the Chief Executive and Chief Finance Officer, subject to any authorised use of virement.

5.2.5 Non-recurring budgets should not be used to finance recurring expenditure without the authority in writing of the Chief Finance Officer or Chief Executive.

5.3 Budgetary control and reporting

5.3.1 The Chief Finance Officer will devise and maintain systems of budgetary control. These will include:

• monthly financial reports to the Board in a form approved by the Board containing income and expenditure to date showing trends and forecast year end position;

• movements in working capital;

• capital project spend and projected outturn;

• explanations of any material variances from plan;

• details of any corrective action where necessary and the Chief Executive’s and/or the Chief Finance Officer’s views of whether such actions are sufficient to correct the situation;

• the issue of timely, accurate and comprehensible advice and financial reports to each budget holder, covering the areas for which they are responsible;

• Investigation and reporting of variances from budgets. These reports will be monitored by the committee responsible for monitoring financial performance who will report to the Board on matters arising from their review.

5.4 Each budget holder is responsible for ensuring that:

5.4.1 Any likely overspending or reduction of income which cannot be met by virement is not incurred without the prior consent of the Board.

5.4.2 The amount provided in the approved budget is not used in whole or in part for any 13

purpose other than that specifically authorised subject to the rules of virement as set put in the Scheme of Delegation.

5.4.3 No permanent Officers are appointed outside of the agreed funded establishment without prior approval from the Executive Team.

5.4.4 The Chief Executive is responsible for identifying and implementing cost improvements and income generation initiatives in accordance with the requirements of the Annual Business Plan and a balance budget.

5.5 Capital expenditure

5.5.1 The general rules applying to delegation and reporting shall also apply to capital expenditure. (The particular applications relating to capital are contained in SFI 16.

5.6 Monitoring Returns

5.6.1 The Chief Executive is responsible for ensuring that the appropriate monitoring forms are submitted to NHS Improvement and any other requisite monitoring organisation.

6 ANNUAL ACCOUNTS AND REPORTS

6.1 The Chief Finance Officer, on behalf of the Trust, will keep accounts in such form as NHSI may direct.

6.2 The Chief Finance Officer is responsible for ensuring that the Trust complies with any directions given by NHSI as to:

6.2.1 the methods and principles according to which the accounts are to be prepared; and

6.2.2 the information to be given in the accounts.

6.3 The Accounting Officer is responsible for the preparation and submission of the Annual Accounts in each Financial Year in such form as NHSI may direct.

6.4 For the purposes of SFIs 6.1 to 6.3 above, the Chief Finance Officer and the Accounting Officer shall comply with:

6.4.1 the directions of NHSI as laid down in the annual reporting guidance for NHS foundation trusts as set out in the NHS Foundation Trust Annual Reporting Manual and the Operational Planning guidance that is in force for the relevant Financial Year; and

6.4.2 international financial reporting standards unless directed otherwise by NHSI.

6.5 The Trust will prepare an Annual Report, in accordance with the Constitution and the SFI 6.4 above.

6.6 The Trust will prepare an annual Quality Report to meet the requirement to publish annual Quality Accounts in accordance with the directions issued by NHSI as laid down in the annual reporting guidance for NHS foundation trusts set out in the NHS Foundation Trust Annual Reporting Manual. 14

6.7 For the purposes of SFI 6.6 above:

6.7.1 "Quality Accounts" means a document which the Trust must publish under Section 8(1) of the Health Act 2009; and

6.7.2 "Quality Report" means the report on the Trust's quality of care which forms a part of the Trust's Annual Report.

7 BANK ACCOUNTS

7.1 The Chief Finance Officer is responsible for managing the Trust's banking arrangements and the operation of accounts. This advice will take into account any relevant guidance issued by NHSI from time to time.

7.2 The Chief Finance Officer is responsible for reporting to the Board all arrangements in respect of the Trust's banking arrangements including arrangements made with the Trust's bankers for accounts to be overdrawn (together with remedial action taken).

7.3 The Chief Finance Officer is responsible for ensuring payments made from bank or G overnment Banking Service (GBS) accounts do not exceed the amount credited to the account except where prior arrangements have been made.

7.4 The Board shall approve the Trust's banking arrangements.

7.5 All accounts should be held in the name of the Trust. No Officer other than the Chief Finance Officer shall open any account in the name of the Trust or for the purpose of furthering the Trust's activities.

7.6 The Chief Finance Officer will review the banking arrangements of the Trust at regular intervals to ensure they reflect best practice and represent good value for money.

8 INCOME, FEES AND CHARGES AND SECURITY OF CASH AND OTHER NEGOTIABLE INSTRUMENTS

8.1.1 The Chief Finance Officer is responsible for the prompt banking of all monies received.

8.1.2 Official money shall not under any circumstances be used for the encashment of private cheques, or IOUs.

8.1.3 All cheques, postal orders, cash etc., shall be banked promptly and intact. Disbursements shall not be made from cash received, except under arrangements approved by the Chief Finance Officer.

8.1.4 All Officers who hold cash will be provided with a safe or a lockable cash box which shall normally be deposited in a safe.

8.1.5 The holders of safe keys shall not accept unofficial funds for depositing in their safes unless in exceptional circumstances, and such deposits are in appropriate sealed envelopes or locked containers. It shall be made clear to the depositors that the Trust is not to be held liable for any loss, and written indemnities must be obtained from the depositors absolving the Trust from responsibility for any such loss.

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8.1.6 In the event of incoming post, that does not have a designated addressee (e.g. the Finance Department) or which is not personally addressed to an individual, which contains cash, cheques, postal orders or other forms of payment, the Company Secretary should be notified immediately who will retain an electronic register and advise accordingly.

8.1.7 An official receipt will be made out for all cash receipts when requested, showing the type of remittance and the reasons for payment.

8.1.8 Any loss or shortfall of cash, cheques or other negotiable instruments, however occasioned, shall be reported to the Chief Finance Officer.

8.2 Fees and charges

8.2.1 The Chief Finance Officer is responsible for approving and regularly reviewing the level of all fees and charges other than those determined by the Department of Health or by Statute. Independent professional advice on matters of valuation should be taken as necessary. Where sponsorship income (including items in kind such as subsidised goods or loans of equipment) is considered the guidance in the Department of Health’s Commercial Sponsorship – Ethical Standards in the NHS (Contained within the Code of Conduct & Managing Conflict of Interest and Personal Conduct Policy) shall be followed.

8.2.2 All employees must inform the Chief Finance Officer promptly of money due arising from transactions which they initiate/deal with, including all contracts, leases, tenancy agreements, private patient undertakings and other transactions.

8.3 Income in Dispute/in Error

8.3.1 Where an invoice is raised in error, it can only be cancelled by a credit note, appropriately authorised.

8.4 Debt recovery

8.4.1 The Chief Finance Officer is responsible for the appropriate recovery of all monies due, including the use of debt recovery agencies where appropriate.

8.4.2 Income not received will be dealt with in accordance with losses procedures.

8.4.3 Overpayments should be detected (or preferably prevented) and recovery initiated.

8.4.4 The Chief Finance Officer shall approve any repayment plans outside of the agreed Trust policy.

8.4.5 Any losses identified resulting from Fraud or bribery will be notified by the LCFM to Finance and robust action will be taken to ensure any loss is recovered in full

9 AGREEMENTS FOR PROVISION OF SERVICES

9.1 The Chief Executive is responsible for ensuring the Trust enters into suitable legally binding agreements with service commissioners for the provision of NHS services. All 16

agreements should aim to implement the agreed priorities contained within the relevant plans and wherever possible, be based upon integrated care pathways to reflect expected patient experience.

9.2 Where the Trust makes arrangements for the provision of services by non-NHS providers, the Chief Executive is responsible for ensuring that the agreements put in place have due regard to the quality and the cost-effectiveness of the services provided.

9.3 Where the Trust enters into a relationship with another organisation for the supply or receipt of other services (clinical or non-clinical), the responsible Officer should ensure that an appropriate contract is present and signed by both parties. The Head of Procurement and/or Head of Contracting will provide professional advice on the structure and content of this type of contract and should approve the contract before being signed by the delegated Officer.

9.4 Contracts should be reviewed and agreed on an annual basis or as determined by the term of the agreement so as to ensure value for money and minimise any potential loss of income.

10. TENDERING AND CONTRACT PROCEDURE

10.1. Duty to comply with Standing Orders

10.1.1. The procedure for making all contracts by or on behalf of the Trust shall comply with the Trust’s Standing Orders and these SFIs.

10.2. EU Directives and Acts Governing Public Procurement

10.2.1. Directives by the World Trade Organisation Government Procurement Agreement promulgated by the Department of Health (DH) prescribing procedures for awarding all forms of contracts shall have effect as if incorporated in these SFIs.

10.2.2. The Bribery Act 2010, which came into effect on 1 July 2011, makes it a criminal offence to give promise or offer a bribe, and to request, agree to receive or accept a bribe, either at home or abroad. The Bribery Act 2010 shall have effect as if incorporated in these SFIs.

10.2.3. The Trust shall adopt as good practice the requirements of the NHS England Business Case Approvals Process for Capital Investment, Property, Equipment and ICT 23 October 2018 Publications Gateway Reference: 08130 and Health Building Note 00-08 Part A: Strategic framework for the efficient management of healthcare estates and facilities and associated relevant guidance issued by NHS Improvement in respect of capital investment and estate and property transactions, including the “Capital Regime, Investment and Property Business Case Approval Guidance for NHS Trusts and Foundation Trusts.

10.2.4. In the case of management consultancy contracts the Trust shall adopt, as far as is practicable, the NHS Executive guidance "The Procurement and Management of Consultants within the NHS". The Trust will also comply with the Guidance from NHS Improvement entitled “Best Practice in Making Investments” and the Regulatory Framework.

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10.2.5. The Trust should have policies and procedures in place for the control of all tendering activity.

10.3. Formal Competitive Tendering

10.3.1. The Trust shall ensure that competitive tenders are invited for the supply of goods, materials and manufactured articles and for the rendering of services including all forms of management consultancy services (other than specialised services sought from or provided by the Department of Health or other regulatory organisations); for the design, construction and maintenance of building and engineering works (including construction and concession contracts); and for disposals.

10.3.2. Formal tendering procedures may be waived by officers to whom powers have been delegated by the Chief Executive without reference to the Chief Executive where:

10.3.2.1. the estimated expenditure or income does not, or is not reasonably expected to, exceed £50,000 excl VAT (this figure to be reviewed annually); or

10.3.2.2. the supply is proposed under special arrangements negotiated by the Department of Health in which event the said special arrangements must be complied with;

10.3.2.3. where the requirement is covered by an existing national, regional or local contract or framework

10.3.2.4. where provided for in regulatory guidance.

10.3.3. Formal tendering procedures may be waived by Officers to whom powers have been delegated by the Chief Executive:

10.3.3.1. in very exceptional circumstances where the Chief Executive decides that formal tendering procedures would not be practicable or the estimated expenditure or income would not warrant formal tendering procedures, and the circumstance are detailed in an appropriate Trust record;

10.3.3.2. where the timescale genuinely precludes competitive tendering (failure to plan the work properly is not a justification for single tender);

10.3.3.3. where it is apparent from the specification that specialist expertise is required to meet it and the expertise is only available from one source;

10.3.3.4. where the task is essential to complete the project, and arises as a consequence of a recently completed assignment and engaging different consultants for the new task would be inappropriate; or

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10.3.3.5. where there is a clear benefit to be gained from maintaining continuity with an earlier project. However in such cases the benefits of such continuity must outweigh any potential financial advantage to be gained by competitive tendering;

10.3.4. The waiving of competitive tendering procedures should not be used:

10.3.4.1. to avoid competition or for administrative convenience or to award further work to a consultant originally appointed through a competitive procedure;

10.3.4.2. for building and engineering construction works, and maintenance (other than in accordance with Concode or other relevant regulatory guidance) without Department of Health approval.

10.3.5. Where it is decided that competitive tendering is not applicable and should be waived by virtue of SFI 10.3.3.1 to SFI 10.3.3.4 above the fact of the waiver and the reasons should be documented and recorded in an appropriate Trust record and reported by the Chief Executive to the Audit Committee.

10.3.6. Except where SFI 10.3.2 and SFI 10.3.3, or a requirement under SFI 10.2, applies, the Board shall ensure that invitations to tender are sent to a sufficient number of firms/individuals to provide fair and adequate competition as appropriate, and where possible, no less than three firms/individuals, having regard to their capacity to supply the goods or materials or to undertake the services or works required.

10.3.7. Items estimated to be below the limit set in this SFI for which formal tendering procedures are not used which subsequently prove to have a value above such limits shall be reported to the Chief Executive, and be recorded in an appropriate Trust record.

10.3.8. The Board shall review the Tendering Procedure at least every two years.

10.4. Invitation to tender

10.4.1. All invitations to tender shall state the date and time as being the latest time for the receipt of tenders.

10.4.2. All invitations to tender shall be by an e-tendering software package. The supplier’s response shall be completed on-line and uploaded into a secure electronic mailbox until the opening time.

10.4.3. Every tender for goods, materials, manufactured articles supplied as part of a works contract and services shall embody such of the main contract conditions as may be appropriate in accordance with the contract forms described in SFI 10.4.2.2 and 10.4.3 below.

10.4.4. Every tender for goods, materials, services or disposals shall embody such of the NHS Standard Contract Conditions as are applicable. Every tenderer must have 19

given or give a written undertaking not to engage in collusive tendering or other restrictive practice.

10.4.5. Every tender for building or engineering works (except for maintenance work, when Estatecode or other relevant regulatory guidance shall be followed) shall embody or be in the terms of the current edition of one of the Joint Contracts Tribunal Standard Forms of Building Contract or Department of the Environment (GC/Wks) Standard forms of contract amended to comply with Concode; or to include other approved partnering contract types, such as NEC or PPC2000 or, when the content of the work is primarily engineering, the General Conditions of Contract recommended by the Institution of Mechanical and Electrical Engineers and the Association of Consulting Engineers (Form A), or (in the case of civil engineering work) the General Conditions of Contract recommended by the Institute of Civil Engineers, the Association of Consulting Engineers and the Federation of Civil Engineering Contractors. The standard documents should be amended to comply with Concode and, in minor respects, to cover special features of individual projects. Tendering based on other forms of contract may be used only after prior consultation with the DH or modified and/or amplified to accord with guidance issued by NHS Improvement (Monitor) and the Department of Health and, in minor respects, to cover special features of individual projects.

10.4.6. Each significant member of Trust staff involved in the tendering process must declare any interests relating to the project they are engaged in.

10.5. Receipt and safe custody of Formal tenders

10.5.1. The tender documents will be stored in the electronic mailbox until the closing date and time. An audit log within the e- tendering system will record the data and time the offer documents are received.

10.6. Opening Formal tenders

10.6.1. Where an electronic tendering package is used the tender documents will be opened electronically by two independent professionals from the procurement service.

10.6.2. Where an electronic tendering package is used the details of the persons opening the documents will be recorded in the audit trail on the portal together with the date and time of the document opening.

10.6.3. All actions by both procurement staff and suppliers shall be recorded within the system audit reports.

10.7. Admissibility

10.7.1. If for any reason the designated officers are of the opinion that the tenders received are not strictly competitive (for example, because their numbers are insufficient or any are amended, incomplete or qualified) no contract shall be awarded without the approval of the Chief Executive. 20

10.7.2. Where only one tender is sought and/or received, the Chief Executive and Chief Finance Officer shall, as far practicable, ensure that the price to be paid is fair and reasonable and will ensure value for money for the Trust.

10.8. Late tenders

10.8.1. Tenders received after the due time and date, but before the opening of the other tenders, may be considered only if the Chief Executive or their Nominated Officer decides that there are exceptional circumstances, e.g. where significant financial, technical or delivery advantages would accrue, and is satisfied that there is no reason to doubt the bona fides of the tenders concerned.

10.8.1.1. The Chief Executive or Nominated Officer shall decide whether such tenders are admissible and whether re-tendering is desirable. Re- tendering may be limited to those tenders reasonably in the field of consideration in the original competition. If the tender is accepted the late arrival of the tender shall be reported to the Board at its next meeting.

10.8.1.2. Technically late tenders (i.e. those despatched in good time but delayed through no fault of the tenderer) may at the discretion of the Chief Executive be regarded as having arrived in due time.

10.8.1.3. Incomplete tenders (i.e. those from which information necessary for the adjudication of the tender is missing) and amended tenders (i.e .those amended by the tenderer upon their own initiative either orally or in writing after the due time for receipt) will be dealt with in the same way as late tenders. Where examination of tenders reveals errors or incompleteness which would affect the tender figure, the tenderer is to be given details of such errors and afforded the opportunity of confirming or withdrawing their offer.

10.8.1.4. While decisions as to the admissibility of late, incomplete or amended tenders are under consideration, the tender documents shall be kept strictly confidential, and the process of evaluation shall not be started.

10.9. Acceptance of formal tenders

10.9.1. Any discussions with a tenderer which are deemed necessary to clarify technical aspects of their tender before the award of a contract will not disqualify the tender.

10.9.2. A tender other than the lowest whole life cost (if payment is to be made by the Trust), or other than the highest (if payment is to be received by the Trust) shall not be accepted unless for good and sufficient reason and the decision and reason recorded as a written record using the appropriate Tender Acceptance Authorisation Form, an approved Contract Award Recommendation Report or an approved Board recommendation paper.

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10.9.3. Where other factors are taken into account in selecting a tenderer, these must be clearly recorded and documented in the contract file, and the reason(s) for not accepting the lowest tender clearly stated.

10.9.4. No tender shall be accepted which will commit expenditure in excess of that which has been allocated by the Trust and which is not in accordance with these instructions except with the authorisation of the Chief Executive.

10.9.5. The use of these procedures must demonstrate that the award of the contract:

10.9.5.1. was not in excess of the going market rate/price current at the time the contract was awarded, and

10.9.5.2. achieved best value for money;

10.9.6. In considering which tender to recommend, if any, the designated officers shall have regard to whether value for money will be obtained by the Trust and whether the number of tenders received provides adequate competition. This will take the form of an official evaluation process involving a consideration of both commercial and technical aspects, any key stakeholders involved in the tender process. In cases of doubt they shall consult the Chief Executive via the completion of a Recommendation Report. The Chief Executive or Chief Finance Officer shall approve acceptance of the tender in writing to the responsible officer. (Larger tenders i.e. those exceeding a total value of £500,000 (inc Vat) shall be referred to the Board for approval).

10.9.7. Where the form of contract includes a fluctuation clause all applications for price variations must be submitted in writing by the tenderer and shall be approved by the Chief Executive or nominated officer.

10.9.8. All tenders shall be treated as confidential and shall be retained for inspection.

10.10. Tender reports to the Trust Board

10.10.1. Reports to the Board will be made on an exceptional circumstance basis only.

10.11. List of approved firms

10.11.1. Building and Engineering Construction Works

10.11.1.1. Invitations to tender shall be made only to firms included on either an approved list of tenderers compiled by the Trust or by neighbouring Trusts or on the Construction Line, NHS Supply Chain or other national or regional purchasing framework list.

10.11.1.2. Firms included on approved list of tenderers shall ensure that when engaging, training, promoting or dismissing employees or in any conditions of employment, shall not discriminate against any person and

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shall act in accordance with all relevant employment legislation and guidance.

10.11.1.3. Firms shall conform at least with the requirements of the Health and Safety at Work Act 1974 (as amended) and any amending and/or other related legislation concerned with the health, safety and welfare of workers and other persons, and to any relevant British standard code of practice issued by the British Standard Institution. Firms must provide to the appropriate Officer a copy of its safety policy and evidence of the safety of plant and equipment, when requested.

10.11.2. Financial Standing and Technical Competence of Contractors 10.11.2.1. The Chief Finance Officer may make or institute any enquiries they deem appropriate concerning the financial standing and financial suitability of approved contractors. The Director with lead responsibility for clinical governance will similarly make such enquiries as is felt appropriate to be satisfied as to their technical/medical competence.

10.12. Exceptions to using approved contractors

10.12.1. If in the opinion of the Chief Executive and the Chief Finance Officer or the Director with lead responsibility for clinical governance it is impractical to use a potential contractor from a list of approved firms/individuals (for example where specialist services or skills are required and there are insufficient suitable potential contractors on a list), or where a list for whatever reason has not been prepared, the Chief Executive shall ensure that appropriate checks are carried out as to the technical and financial capability of those firms that are invited to tender or quote.

10.12.2. An appropriate record in the contract file shall be made of the reasons for inviting a tender or quote other than from an approved list.

10.13. Competitive Quotations

10.13.1. The Trust shall use National Contracts awarded by such Government Bodies as Crown Commercial Services or NHS Supply Chain (Supply Chain Coordination Ltd (SCCL) for the procurement of all goods and services unless the Chief Executive or nominated officers deem it inappropriate. The decision to use alternative sources must be documented.

10.13.2. Quotations are required to be obtained where formal tendering procedures have been waived under SFIs 10.3.2 or 10.3.3 and where the intended expenditure or income exceeds, or is reasonably expected to exceed the limits defined in the Scheme of Delegation.

10.13.3. Where quotations are obtained under SFI 10.14 they shall be obtained from at least three firms/individuals based on specifications or terms of reference prepared by, or on behalf of, the Board.

10.13.4. Quotations shall be in writing. 23

10.13.5. All quotations shall be treated as confidential and shall be retained for inspection.

10.13.6. The Chief Executive or their Nominated Officer shall evaluate the quotations and select the one which gives value for money. If this is not the lowest quotation then this fact and the reasons why the lowest quotation was not chosen shall be recorded in a permanent record and a Quotation Acceptance Authorisation Form completed.

10.14. Non-Competitive Quotations

10.14.1. Non-competitive quotations in writing may be obtained, in exceptional circumstances, for the following purposes:

10.14.1.1. where the timescale genuinely precludes competitive quotations (failure to plan the work properly is not a justification for single quotation);

10.14.1.2. the supply of goods/services of a special character for which it is not, in the opinion of the Chief Executive or their Nominated Officer, possible or desirable to obtain competitive quotations;

10.14.1.3. where the task is essential to complete a project, and arises as a consequence of a recently completed assignment and engaging different consultants for the new task would be inappropriate; or

10.14.1.4. where there is a clear benefit to be gained from maintaining continuity with an earlier project. However in such cases the benefits of such continuity must outweigh any potential financial advantage to be gained by competitive quotations;

10.14.1.5. where tenders or quotations are not required, because expenditure is below the limits set in the Scheme of Delegation, the Trust shall procure goods and services in accordance with procurement procedures approved by the Board.

10.15. Quotations to be within Financial Limits

10.15.1. No quotation shall be accepted which will commit expenditure in excess of that which has been allocated by the Trust and which is not in accordance with these SFIs except with the authorisation of either the Chief Executive or Chief Finance Officer.

10.16. Authorisation of Tenders and Competitive Quotations

10.16.1. Providing all the conditions and circumstances set out in these SFIs have been fully complied with, formal authorisation and awarding of a contract may be decided by the following staff to the value of the contract as follows:

10.16.1.1. Contracts awarded to the lowest bidder. 24

10.16.1.1.1. Below £5,000 – Budget Holder 10.16.1.1.2. £5,000 - £49,999 – Deputy Director and Senior Finance Manager 10.16.1.1.3. £50,000 - £99,999 – Executive Director and Deputy Chief Finance Officer 10.16.1.1.4. £100,000 - £499,999 – Chief Executive and Chief Finance Officer 10.16.1.1.5. Above £500,000 – Trust Board – to be recorded in minutes.

10.16.1.2. The Chief Finance Officer must approve any contracts not awarded to the lowest bidder, with additional approval as follows:

10.16.1.2.1. £50,000 - £499,999 Chief Executive

10.16.1.2.2. Above £500,000 – Trust Board – to be recorded in minutes.

10.16.2. These levels of authorisation may be varied or changed from time to time by the Board and need to be read in conjunction with the Scheme of Delegation.

10.16.3. Formal authorisation must be put in writing. In the case of authorisation by the Board this shall be recorded in the minutes.

10.17. Instances where formal competitive tendering or competitive quotation is not required

10.17.1. Where competitive tendering or a competitive quotation is not required, the Trust should adopt one of the following alternatives:

10.17.1.1. the Trust shall use the NHS Supply Chain for procurement of all goods and services unless the Chief Executive or their Nominated Officer deem it inappropriate. The decision to use alternative sources must be documented;

10.17.1.2. if the Trust does not use the NHS Supply Chain (where tenders or quotations are not required, because expenditure is below £5,000), the Trust shall procure goods and services in accordance with procurement procedures approved by the Chief Finance Officer.

10.18. Private Partnership

10.18.1. The Trust should normally market-test for "Private Partnership" funding when considering a capital procurement. When the Board proposes, or is required, to use finance provided by the private sector the following shall apply:

10.18.1.1. The Chief Executive and Chief Finance Officer shall demonstrate that the use of private finance represents value for money and genuinely transfers risk to the private sector.

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10.18.1.2. Where the sum exceeds delegated limits, a business case must be referred to NHS Improvement (Monitor) and/or Department of Health for approval or treated as per current guidelines.

10.18.1.3. The proposal must be specifically agreed by the Board in the light of such professional advice as should reasonably be sought in particular with regard to vires.

10.18.1.4. The selection of a contractor/finance company must be on the basis of competitive tendering or quotations.

10.19. Compliance Requirements for all Contracts (including lease contracts)

10.19.1. The Board may only enter into contracts on behalf of the Trust within its statutory powers and within the Regulatory Framework and shall comply with:

10.19.1.1. Standing Orders;

10.19.1.2. these SFIs;

10.19.1.3. the Trust’s Provider Licence;

10.19.1.4. statutory provisions including those giving effect to EU Directives;

10.19.1.5. such of the NHS Standard Contract Conditions as are applicable;

10.19.1.6. appropriate NHS guidance;

10.19.2. Where appropriate, contracts shall be in or embody the same terms and conditions of contract as was the basis on which tenders or quotations were invited.

10.19.3. Contracts shall include lease and hire purchase agreements.

10.19.4. In all contracts made by the Trust, the Board shall endeavour to obtain value for money by use of all systems in place. The Chief Executive shall nominate an Officer who shall oversee and manage each contract on behalf of the Trust.

10.20. Personnel and Agency or Temporary Staff Contracts

10.20.1. The Chief Executive shall nominate Officers with delegated authority to enter into contracts for the employment of other Officers and to enter into contracts for the employment of agency staff or temporary staff service contracts.

10.21. Healthcare Services Agreements

10.21.1. Healthcare Services contracts made between two Health Service Bodies for the supply of healthcare services, will be legally binding contracts and are subject to the provisions of the 2006 Act and any other relevant legislation.

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10.21.2. The Chief Executive shall nominate Officers with power to negotiate for the provision of healthcare services from providers of healthcare services.

10.22. Cancellation of Contracts

10.22.1. Except where specific provision is made in model forms of contracts or standard schedules of conditions approved for use within the NHS, there shall be inserted in every written contract a clause empowering the Trust to cancel the contract and to recover from the contractor the amount of any loss resulting from such cancellation, if:

10.22.1.1. the contractor has offered, or given or agreed to give, any person any gift or consideration of any kind as an inducement or reward for doing or forbearing to do or for having done or forborne to do any action in relation to the obtaining or execution of the contract or any other contract with the Trust; or

10.22.1.2. the contractor has shown or forborne favour or disfavour to any person in relation to the contracts or any other contract with the Trust, or if the like acts shall have been done by any person employed by them or acting on their behalf (whether with or without the knowledge of the contractor); or

10.22.1.3. in relation to any contract with the Trust the contractor or any person employed by them or acting on their behalf shall have committed any offence under the Prevention of Corruption Acts 1989 and 1916,the Prevention of Corruption (Amendment) Act 2018, Bribery Act 2010, and other appropriate legislation.

10.23. Determination of Contracts for Failure to Deliver Goods or Materials

10.23.1. There shall be inserted in every written contract for the supply of goods or materials entered into by the Trust a clause to secure that, should the contractor fail to deliver the goods or materials or any portion thereof within the time or times specified in the contract, the Trust may (without prejudice) determine the contract either wholly or to the extent of such default and purchase other goods, or material of similar description to make good such default.

10.23.2. The clause referred to at 10.23.1 shall further secure that the amount by which the cost of so purchasing other goods or materials exceeds the amount which would have been payable to the contractor in respect of the goods or materials shall be recoverable from the contractor.

10.24. Contracts Involving Charitable Funds 10.24.1. Contracts involving Charitable Funds shall do so individually to a specific named fund. Such contracts involving charitable funds shall comply with the requirements of the Charities Acts.

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10.24.2. SFI 10.24.1 shall not only apply to expenditure from Exchequer funds but also to works, services and goods purchased from the Trust’s trust funds and private resources.

11. DISPOSALS

11.1. Competitive Tendering or Quotation procedures shall not apply to the disposal of:

11.1.1. any matter in respect of which a fair price can be obtained only by negotiation or sale by auction as determined (or pre- determined in a reserve) by the Chief Executive or their Nominated Officer;

11.1.2. obsolete or condemned articles and stores, which may be disposed of in accordance with the supplies policy of the Trust;

11.1.3. items to be disposed of with an estimated sale value below the limit at which a tender or quotation is required;

11.1.4. items arising from works of construction, demolition or site clearance, which should be dealt with in accordance with the relevant contract; or

11.1.5. land or buildings concerning which Department of Health guidance has been issued but subject to compliance with such guidance; or

11.1.6. any matter which NHS Improvement (Monitor) has issued alternate specific guidance and/or best practice advice in relation to.

12. IN-HOUSE SERVICES

12.1. The Chief Executive shall be responsible for ensuring that best value for money can be demonstrated for all services provided on an in-house basis. The Trust may also determine from time to time that in- house services should be market tested by competitive tendering.

12.2. In all cases where the Trust determines that in-house services should be subject to competitive tendering arrangements shall be made to ensure appropriate segregation of interests and responsibilities.

13. TERMS OF SERVICE, ALLOWANCES AND PAYMENT OF MEMBERS OF THE BOARD AND EMPLOYEES

13.1. Remuneration Committee

13.1.1. In accordance with Standing Orders the Board shall establish a Remuneration Committee, with clearly defined terms of reference, specifying which posts fall within its area of responsibility, its composition, and the arrangements for reporting.

13.1.2. The Remuneration Committee will:

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(a) advise and make recommendations to the Board about appropriate remuneration and terms of service for the Chief Executive and other Executive Directors (and other senior Officers), including but not limited to:

(i) all aspects of salary (including any performance related elements and/or bonuses);

(ii) provisions for other benefits, including pensions and cars;

(iii) arrangements for termination of employment and other contractual terms;

(b) make such recommendations to the Board on the remuneration, allowances and other terms and conditions of the Chief Executive and other Executive Directors and senior Officers to ensure they are fairly rewarded for their individual contribution to the Trust having proper regard to the Trust's circumstances and performance and to the provisions of any national arrangements where appropriate;

(c) monitor and evaluate the performance of individual Executive Directors and some senior Officers; and

(d) decide on and oversee appropriate contractual arrangements for all Executive Directors and senior Officers, including the proper calculation and scrutiny of termination payments taking account of such guidance and/or best practice issued by NHSI, as is appropriate.

13.1.3. The Board will review and approve proposals presented by the Chief Executive for setting of remuneration and conditions of service for those Officers not covered by the Remuneration Committee.

13.1.4. The Trust will pay remuneration and allowances to the Chairman and other non- executive Directors in accordance with the decisions of the Council of Governors in accordance with the Constitution.

13.2. Funded establishment

13.2.1. The manpower plans incorporated within the annual budget will form the funded establishment.

13.2.2. The funded establishment of any department may be varied within the existing funding available.

13.3. Appointments

13.3.1. No Director or Officer may engage, re-engage, or re-grade Officers, re-deploy either on a permanent or temporary nature, or hire agency staff, or agree to changes in any aspect of remuneration:

(a) unless authorised to do so by the Chief Executive or the Chief Finance Officer; or

(b) within the limit of their approved Budget and funded establishment as defined in the Scheme of Delegation. 29

13.3.2. The Board will approve procedures presented by the Chief Executive for the determination of commencing pay rates, conditions of service, etc., for Officers.

13.3.3. The Trust will apply the rules of "Agenda for Change" in determining pay rates, conditions of service, etc., for Trust Officers.

13.4. Processing of the payroll

13.4.1. The Director of Human Resources and Organisational Development is responsible for:

(a) specifying timetables for submission of properly authorised time records and other notifications; and

(b) making payment on the agreed dates

(c) ensuring appropriate arrangements for the reclaiming of business mileage and expenses.

13.4.2. The Director of Human Resources and Organisational Development will ensure that payroll provisions are supported by appropriate terms and conditions, adequate internal controls and audit review procedures, adequate provisions for the security and confidentiality of payroll data, and that suitable arrangements are made for the collection of payroll deductions and payment of these to appropriate bodies.

13.4.3. Pay advances are only permitted in exceptional circumstances and with appropriate consideration of risk should any element of an advance not be due to the employee at the time of payment. Loans to employees are not permitted under any circumstances.

13.5. Contracts of employment

13.5.1. The Director of Human Resources and Organisational Development, or Chief Nurse and Director of People in their absence, is responsible for: (a) ensuring that all Officers are issued with a contract of employment in a form approved by the Board and which complies with employment legislation; and

(b) dealing with variations to, or termination of, contracts of employment.

14. NON-PAY EXPENDITURE

14.1. Delegation of authority

14.1.1. The Chief Executive will set out:

(a) the list of Officers who are authorised to place requisitions for the supply of goods and services which should be updated and reviewed on an annual basis by the Finance Department, and

(b) the maximum level of each requisition and the system for authorisation above that level.

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14.2. Choice, requisitioning, ordering, receipt and payment for goods and services

14.2.1. The requisitioner, in choosing the item to be supplied (or the service to be performed) shall always seek to obtain the best value for money for the Trust. In so doing, the advice of the Trust's procurement service should be sought where it is deemed that additional support or guidance is required.

14.2.2. The Chief Finance Officer shall be responsible for the prompt payment of properly authorised accounts and claims in accordance with the Better Payment Practice Code (BPPC).

14.2.3. The Chief Finance Officer will be responsible for designing and maintaining a system of verification, recording and payment of all amounts payable, including applicable VAT.

14.2.4. The Chief Finance Officer shall approve any proposed prepayment outside of normal commercial arrangements, e.g. telephone rental, annual subscriptions. Other prepayments are only permitted in exceptional circumstances:

• prepayments are only permitted where the financial advantages outweigh the disadvantages (i.e. cash flows must be discounted to Net Present Value using an appropriate rate); • the appropriate Officer must confirm in writing the case for prepayment, including the implications if the supplier is at some time during the course of the prepayment agreement unable to meet their commitments; • the budget holder is responsible for ensuring that all items due under a prepayment contract are received and they must immediately inform the appropriate Director or Chief Executive if problems are encountered.

14.2.5. Officers must ensure that they comply fully with any guidance issued by the Chief Finance Officer and that

• all contracts ( other than for a simple purchase, as permitted within these SFIs, the Scheme of Delegation or delegated Budget) leases, tenancy agreements and other commitments which may result in a liability must be approved by the Chief Finance Officer in advance of any commitment being made • where consultancy advice is being obtained, the procurement of such advice must be in accordance with guidance issued by NHS Improvement • no requisition/order is placed for any item or items for which there is no budget provision unless authorised by the Chief Finance Officer on behalf of the Chief Executive • all goods, services, or works are ordered on an official order except works and services executed in accordance with a contract and purchases by purchase card or from petty cash • orders are not split or otherwise placed in a manner devised so as to avoid the financial thresholds • goods are not taken on trial or loan in circumstances that could commit the Trust to a future uncompetitive purchase • changes to the list of Directors/Officers authorised to certify invoices are notified to the Chief Finance Officer • purchases from petty cash or on purchase cards are restricted in value and by 31

type of purchase in accordance with instructions issued by the Chief Finance Officer

14.2.6. Under no circumstances should goods be ordered through the Trust for personal or private use.

14.3. Joint finance arrangements with local authorities and Voluntary Organisation

14.3.1. Payments to local authorities and Voluntary Organisations made under the powers of section 75 of the 2006 Act must comply with procedures laid down by the Chief Finance Officer which should be in accordance with the provisions of the 2006 Act and the relevant local authority partnership agreement.

15. EXTERNAL BORROWING AND INVESTMENTS

15.1. Public Dividend Capital

15.1.1. The Accounting Officer is responsible for ensuring that the Trust pays annually to the Department of Health a dividend on its Public Dividend Capital at a rate to be determined from time to time by the Secretary of State in accordance with the 2006 Act and the Regulatory Framework.

15.2. Borrowing procedures

15.2.1. The Trust may borrow money in accordance with its Licence and with the Prudential Borrowing Code for NHS Foundation Trusts.

15.2.2. All borrowing must be approved by the Board. The Board must be made aware of any short-term borrowings made at its next ensuing meeting.

15.3. Investments

15.3.1. Temporary cash surpluses must be held only in such public and private sector investments as notified by NHS Improvement and/or the Secretary of State and in accordance with the Treasury Management policy..

16. CAPITAL INVESTMENT, PRIVATE FINANCING, ASSET REGISTERS AND SECURITY OF ASSETS

16.1. Capital investment

16.1.1. The Chief Finance Officer:

(a) will ensure that there is an adequate appraisal and approval process in place for determining capital expenditure priorities and the effect of each proposal upon business plans;

(b) is responsible for ensuring appropriate procedures the management of all stages of capital schemes from initial business case to completion and for ensuring that schemes are delivered on time and to cost; and

(c) will issue procedures for the regular reporting of expenditure and commitment against authorised expenditure. 32

16.2. Private finance

16.2.1. When the Board proposes to use finance for capital schemes other than through its allocations it should be satisfied that the use of such finance represents value for money and genuinely transfers risk t as appropriate.

16.3. Asset registers

16.3.1. The Trust will maintain an asset register recording fixed assets. As a minimum, the data set to be held within these registers shall be as specified in the Capital Accounting Manual as issued by NHSI.

16.3.2. Where capital assets are sold, scrapped, lost or otherwise disposed of, their value must be removed from the accounting records and each disposal must be validated by reference to authorisation documents and invoices (where appropriate).

16.4. Security of assets

16.4.1. The Chief Finance Officer shall issue control procedures in relation to assets.

16.4.2. All significant discrepancies revealed by verification of physical assets to fixed asset registers shall be notified to the Chief Finance Officer.

16.4.3. Whilst each Officer has a responsibility for the security of property of the Trust, it is the responsibility of Directors and senior Officers in all disciplines to apply appropriate routine security practices in relation to Trust property.

16.4.4. Where practical, assets should be marked as "Trust Property".

16.4.5. Any damage to the Trust's premises, vehicles and equipment, or any loss of equipment, stores or supplies must be reported by Board members and Officers in accordance with the procedure for reporting losses.

17. STOCK, STORES AND RECEIPT OF GOODS

17.1. Stocks and stores

17.1.1. Stores, defined in terms of controlled stores and departmental stores (for immediate use) should be:

• kept to a minimum;

• subjected to annual stock take;

• valued at the lower of cost and net realisable value

17.1.2. The Chief Executive Officer shall set out procedures for the regulation, control and security of stocks and stores, including an annual physical check and the designation of an Officer with responsibility to review slow moving and obsolete items and report to the Chief Finance Officer any evidence of significant overstocking and of any negligence or malpractice. 33

17.2. Receipt of Goods

17.2.1. A delivery note shall be obtained from the supplier at the time of delivery and shall be signed by the person receiving the goods. All goods received shall be checked, by the appropriate department or delegated department, as regards quantity and/or weight and inspected as to quality and specification.

17.3. Issue of Stocks

17.3.1. The issue of stocks shall be supplied by an authorised requisition note and a receipt for the stock issued shall be returned to the designated Officer. Where a 'twin-bin' system is used, a record of orders and consumption shall be maintained as approved by the Chief Finance Officer.

18. DISPOSALS AND CONDEMNATIONS, INSURANCE, LOSSES AND SPECIAL PAYMENTS

18.1. Disposals and Condemnations

18.1.1. The Chief Finance Officer must prepare detailed procedures for the disposal of assets in accordance with the Regulatory Framework and guidance issued by NHS Improvement, including condemnations, and ensure that these are notified to managers.

18.1.2. When it is decided to dispose of a Trust asset, the Head of Facilities or Head of Procurement within Simply Serve Limited will determine and advise the Chief Finance Officer of the estimated market value of the item, taking account of professional advice where appropriate.

18.1.3. All unserviceable articles shall be condemned or otherwise disposed of by an Officer authorised for that purpose by the Chief Finance Officer.

18.1.4. All disposals will be recorded by the condemning Officer in a form approved by the Chief Finance Officer which will indicate whether the articles are to be converted, destroyed or otherwise disposed of.

18.1.5. The condemning Officer shall satisfy him/herself as to whether or not there is evidence of negligence in use and shall report any such evidence to the Chief Finance Officer who will take the appropriate action.

18.2. Losses and Special Payments

18.2.1. The Chief Finance Officer must prepare procedural instructions on the recording of and accounting for condemnations, losses, and special payments.

18.2.2. Within limits delegated to it by NHS Improvement, and the Treasury, the Audit Committee shall approve the writing-off of losses above the level delegated to nominated Executive Directors or other senior Officers contained in the Financial Limits.

18.2.3. The Chief Finance Officer shall be authorised to take any necessary steps to safeguard the Trust’s interests in bankruptcies and company liquidations.

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18.2.4. For any loss, the Chief Finance Officer should consider whether any insurance claim can be made.

18.2.5. The Chief Finance Officer shall maintain a Losses and Special Payments Register in which write-off action is recorded, which shall be presented to the Audit Committee on a regular basis.

18.2.6. No special payments exceeding delegated limits shall be made without the prior approval of NHS Improvement/Treasury.

19. INFORMATION TECHNOLOGY

19.1.1. The Chief Finance Officer is responsible for the accuracy and security of the computerised financial data of the Trust. The Chief Finance Officer will:

(a) devise and implement any necessary procedures to ensure reasonable protection of the Trust's financial data, programs and computer hardware from accidental or intentional disclosure to unauthorised persons, deletion or modification, theft or damage, having due regard for the General Data Protection Regulations and Data Protection Act 2018 and any other relevant legislation;

(b) ensure that reasonable controls exist over data entry, processing, storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system;

(c) ensure that adequate controls exist to maintain the security, privacy, accuracy and completeness of financial data sent via transmission networks; and

(d) ensure that an adequate audit trail exists through the computerised system and that such computer audit reviews as he may consider necessary are being carried out.

20. PATIENTS' PROPERTY

20.1. The Trust has a responsibility to provide safe custody for money and other personal property (hereafter referred to as "property") handed in by patients, in the possession of unconscious or confused patients, or found in the possession of patients dying in hospital or dead on arrival.

20.2. The Trust will not accept responsibility or liability for patients’ property brought into Trust premises (including ambulances and other patient transport vehicles), unless it is handed in for safe custody by the Trust and a copy of an official patients' property record is obtained as a receipt.

20.3. In all cases where property of a deceased patient is of a total value in excess of £5,000 (or such other amount as may be prescribed by the Administration of Estates (Small Payments) Act 1965 (as amended)), the production of probate or letters of administration shall be required before any of the property is released. Where the total value of property is £5,000 or less, forms of indemnity shall be obtained before any of the property is released.

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20.4. Where patients' property or income is received for specific purposes and held for safekeeping the property or income shall be used only for that purpose, unless any variation is approved by the donor or patient in writing.

21. ACCEPTANCE OF GIFTS AND HOSPITALITY BY OFFICERS

21.1. The Chief Executive shall ensure that all Officers are made aware of the Trust's policy on acceptance of gifts and other benefits in kind by Officers. This policy should contain provisions of the Bribery Act 2010.

22. RECORDS MANAGEMENT

22.1. The Chief Executive shall ensure that the Trust adopts information governance arrangements which comply with the principles and guidelines contained in the Department of Health's 'Records Management: NHS Code of Practice Parts 1 and 2 (Part 1, April 2006, and Part 2, 8 January 2009) as may be varied from time to time (the "Records Management Code").

22.2. The records held in archives shall be capable of retrieval by authorised persons in accordance with the provisions of the Records Management Code.

22.3. Records held by the Trust under the Records Management Code shall only be destroyed in accordance with the schedule of disposals and with the express authority of the Chief Executive. The Chief Executive shall ensure that records are maintained of documents so destroyed.

23. FREEDOM OF INFORMATION AND INFORMATION DATA REQUESTS

23.1. The Trust's Secretary shall publish and maintain a "freedom of information publication scheme", or adopt a model publication scheme approved by the Information Commissioner. The Chief Executive will be responsible for ensuring that the Trust complies with the guidance issued by NHSI regarding the collection, synthesis and processing of information as set out in "Information Data Requests: Guidance for NHS Foundation Trusts and Sponsors", as varied from time to time.

24. RISK MANAGEMENT

24.1. The Chief Executive shall ensure that the Trust has a programme of risk management, in accordance with any relevant guidance as issued by NHSI which must be approved and monitored by the Board.

24.2. The programme of risk management shall include:

24.2.1. a process for identifying and quantifying risks and potential liabilities;

24.2.2. engendering among all Trust Officers a positive attitude towards the control of risk;

24.2.3. management processes to ensure all significant risks and potential liabilities are addressed, including effective systems of internal control, cost effective insurance cover, and decisions on the acceptable level of retained risk;

24.2.4. contingency plans to offset the impact of adverse events; 36

24.2.5. audit arrangements; and

24.2.6. decisions on which risks shall be insured.

25. INSURANCE

25.1. Risk pooling schemes administered by the NHS Resolution

25.1.1. The Board shall decide if the Trust will insure through the risk pooling schemes administered by the NHS Resolution under Section 71 (Schemes for meeting losses and liabilities, etc. of certain health service bodies) of the 2006 Act (the "Schemes") for some or all of the risks covered by the Schemes. If the Board decides not to use the Schemes for any of the risk areas covered by the Schemes, this decision shall be reviewed annually.

25.1.2. Where the Board decides not to use the Schemes for one or other of the risks covered by the Schemes, the Chief Finance Officer shall ensure that the Board is informed of the nature and extent of the risks that are to be insured under alternative arrangements (if any) as a result of this decision. The Chief Finance Officer will draw up formal documented procedures for the management of any claims arising from third parties and payments in respect of losses that will not be reimbursed.

25.1.3. Where the Board decides to use the Schemes for one or other of the risks covered by the Schemes, the Chief Finance Officer shall ensure that the arrangements entered into are appropriate and complementary to the Trust's risk management programme.

25.2. Insurance arrangements with commercial insurers and self-insurance

25.2.1. The Trust may enter into insurance arrangements with commercial insurers on the open market for one or other of the risks covered by the Schemes, or for any risks not covered by the Schemes.

25.2.2. The Trust may self-insure either on an individual basis or as part of a risk-pooling scheme with other organisations for one or other of the risks covered by the Schemes, or for any risks not covered by the Schemes.

26. FUNDS HELD ON TRUST

26.1. As management processes overlap most of the sections of these SFIs will apply to the management of Funds held on Trust.

26.2. Corporate Trustee

26.2.1. The discharge of the Trust's corporate trustee responsibilities are exercised separately and distinctly from its powers exercised as the Trust, and therefore these powers may not necessarily be discharged in the same manner. Nevertheless, there must still be adherence to the overriding general principles of financial regularity, prudence and propriety. The Trustees responsibilities cover both charitable and non-charitable purposes.

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26.2.2. The Chief Finance Officer shall ensure that each Fund held on Trust which the Trust is responsible for managing is managed appropriately with regard to its purpose and to its requirements. The Chief Finance Officer shall, in exercising their responsibilities set out in this SFI 24, have regard to appropriate and independent legal advice, as and when required.

26.2.3. Oversight of the management of Funds held on Trust is delegated to the Board of Trustees which will act as sub-committee of the Board chaired by a Non-Executive Director.

26.3. Accountability to Charity Commissioning and NHSI

26.3.1. Accountability for charitable Funds held on Trust is to the Charity Commission.

26.3.2. Accountability for non-charitable Funds held on Trust is to NHSI.

26.3.3. Directors and Officers must take account of the provisions of the Scheme of Delegation before taking action.

26.4. Applicability of SFIs to Funds Held on Trust

26.4.1. The overriding principle in managing Funds held on Trust is that the integrity of each trust fund must be maintained and all statutory and Trust obligations must be satisfied.

26.4.2. Charitable Funds held on Trust are those gifts, donations and endowments made under the relevant charities legislation and held on trust for purposes relating to the Trust and the objectives of which are for the benefit of the NHS in England. They are administered by the Board acting as Trustees for the Trust.

26.4.3. The Chief Finance Officer shall maintain such accounts and records as may be necessary to record and protect all transactions and funds of the Trust as trustees of non-exchequer funds, including an Investment Register.

26.4.4. The Chief Finance Officer shall arrange for the administration of all existing charitable Funds held on Trust. A “Deed of Establishment” must exist for every trust fund and detailed codes of procedure shall be produced covering every aspect of the financial management of charitable Funds held on Trust, for the guidance of all Officers. The Deed of Establishment shall identify the restricted nature of certain funds, and it is the responsibility of fund managers, within their delegated authority, and the Board of Trustees, to ensure that funds are utilised in accordance with the terms of the Deed of Establishment.

26.4.5. The Chief Finance Officer shall ensure that all charitable Funds held on Trust are currently registered with the Charities Commission in accordance with the Charities Act 2011 or subsequent legislation.

26.4.6. The Chief Finance Officer shall recommend the creation of a new charitable fund where funds and/or other assets, received in accordance with the Trust's policies cannot adequately be managed as part of an existing fund. All new funds must be covered by a Deed of Establishment and must be formally approved by the Board.

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26.4.7. The Deed of Establishment for any new charitable Funds held on Trust shall clearly identify, inter alia, the objects of the new fund, the capacity of the Trust to delegate powers to manage the fund and the power to assign the residue of the charitable fund to another fund contingent upon certain conditions (e.g. discharge of original objects).

26.4.8. All gifts accepted shall be received and held in the name of the Trust and administered in accordance with the Trust’s policy, subject to the terms of specific funds. As the Trust can accept gifts only for all or any purposes relating to the NHS, Officers (including Directors) shall, in cases of doubt, consult the Chief Finance Officer before accepting any gifts.

26.4.9. All gifts, donations and proceeds of fund-raising activities, which are intended for the Trust’s use, must be handed immediately to the Chief Finance Officer via the approved route to be banked directly to the charitable funds bank account.

26.4.10. In respect of donations, the Chief Finance Officer shall provide:-

(a) guidelines to Officers as to how to proceed when offered funds. These are to include:-

(i) the identification of the donors' intentions;

(ii) where possible, the avoidance of new trusts; the avoidance of impossible, undesirable or administratively difficult objects;

(iii) sources of immediate further advice; and

(iv) treatment of offers for personal gifts;

(b) secure and appropriate receipting arrangements, which will indicate that funds have been accepted directly into the Trust's donated funds and that the donor’s intentions have been noted and accepted.

26.4.11. In respect of legacies and bequests, the Chief Finance Officer, shall where required, after the death of a testator ensure that:

(a) all correspondence concerning a legacy is dealt with on behalf of the Trust. Only the Chief Finance Officer shall be empowered to give an executor a good discharge;

(b) where necessary, grant of probate is obtained or apply for a grant of letters of administration, where the Trust is the beneficiary; and

(c) arrangements regarding the administration of a will are negotiated with executors and to discharge them from their duty.

26.4.12. In respect of fund-raising, the final approval for major appeals will be given by the Board of Trustees.

26.5. Investment Management 39

26.5.1. The Board of Trustees shall be responsible for all aspects of the management of the investment of Funds held on Trust.

26.5.2. The Chief Finance Officer shall be responsible for the appropriate treatment of all investment income including all dividends, interest and other receipts.

26.6. Expenditure management

26.6.1. The exercise of expenditure discretion (including dispositions) shall be managed by the Board of Trustees. Day to day management may be delegated to the Chief Finance Officer. In so doing the Board of Trustees shall be aware of the following:-

(a) the objects of various trust funds and the designated objectives;

(b) the availability of liquid funds within each trust fund;

(c) the powers of delegation available to commit resources;

(d) the avoidance of the use of exchequer funds to discharge trust fund liabilities (except where administratively unavoidable), and to ensure that any indebtedness to the Exchequer shall be discharged by trust funds at the earliest possible time;

(e) that trust funds are to be spent rather than preserved, subject to the wishes of the donor and the needs of the Trust; and

(f) the definitions of “charitable purposes” as agreed by the Charity Commission.

26.7. Banking Services

26.7.1. The Chief Finance Officer shall advise the Board of Trustees and, with its approval, shall ensure that appropriate banking services are available to the Trust as corporate trustee. These bank accounts should permit the separate identification of liquid funds to each trust where this is deemed necessary by NHSI or the Charity Commission.

26.8. Asset Management 26.8.1. Assets in the ownership of or used by the Trust as corporate trustee, shall be maintained along with the general estate and inventory of assets of the Trust. The Chief Finance Officer shall ensure that:-

(a) appropriate records of all donated assets owned by the Trust are maintained, and that all assets, at agreed valuations are brought to account;

(b) appropriate measures are taken to protect and/or to replace assets. These to include decisions regarding insurance, inventory control, and the reporting of losses;

(c) donated assets received on trust shall be accounted for appropriately; 40

(d) all assets acquired from charitable Funds held on Trust which are intended to be retained within the trust funds are appropriately accounted for.

26.9. Reporting, Accounting and Audit

26.9.1. The Chief Finance Officer shall ensure that regular reports are made to the Board of Trustees with regard to, inter alia, the receipt of Funds held on Trust, investments of these trust funds and the disposition of resources.

26.9.2. The Chief Finance Officer shall prepare annual accounts in the required manner, which shall be submitted to the Board within agreed timescales.

26.9.3. The Chief Finance Officer shall:

(a) in relation to the non-charitable trust funds prepare any required returns to NHSI; and (b) prepare an annual trustees report regarding charitable trust funds and make the required return to the Charity Commission

for adoption by the Board of Trustees as required.

Accounting and Audit

26.9.4. The Chief Finance Officer shall maintain all financial records to enable the production of reports as above and to the satisfaction of internal and external audit.

26.9.5. Distribution of investment income to the charitable Funds held on Trust and the recovery of administration costs shall be performed on a basis determined by the Chief Finance Officer.

26.9.6. The Chief Finance Officer shall ensure that the records, accounts and returns receive adequate scrutiny by the Trust's Internal Audit during the year. They will liaise with the Internal Auditor and provide them with all necessary information.

26.9.7. The Board of Trustees shall be advised by the Chief Finance Officer on the outcome of the annual audit.

26.10. Administration Costs

26.10.1. The Chief Finance Officer shall identify all costs directly incurred in the administration of all Funds held on Trust, and subject to any legal restrictions, and with the agreement of the Board, shall charge such costs to the appropriate trust accounts.

26.11. Taxation and Excise Duty

26.11.1. The Chief Finance Officer shall ensure that the Trust’s liability to taxation and excise duty is managed appropriately, taking full advantage of available concessions, through the maintenance of appropriate records, the preparation and submission of all required returns, and the recovery of deductions at source.

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42

Standing Orders for the Practice and Procedure of the Board of Directors and the Council of Governors

Version Number 2.1 Version Date March 2021 Owner Company Secretary Author Company Secretary Company Secretary Staff/Groups Chief Finance Officer Consulted Chairman Approved by Board of Directors Next Review Due March 2022

1 Yeovil District Hospital NHS Foundation Trust (January 2019)

Yeovil District Hospital NHS Foundation Trust Standing Orders for the Practice and Procedure of the Board of Directors and the Council of Governors

1 INTRODUCTION

1.1 Standing Orders provide a formal framework for the conduct of a Trust’s business but it is not their function to define the corporate nature of the Trust Board directorship, which requires Directors to participate objectives and to have collective responsibility for its decisions and, since the Trust as an agent of the Secretary of State, to accept the constraints of national policies and priorities and to have concern for the common interests of the NHS.

1.2 Yeovil District Hospital NHS Foundation Trust (the “Trust”) was established in accordance with the Health and Social Care (Community Health and Standards) Act 2003 (the “Act”). Authorisation commenced from 1 June 2006 and subject to provisions of Sections 25 and 26 of the Act, this Authorisation is of unlimited duration.

1.3 The Trust applies the principles of the NHS Foundation Trust Code of Governance, most recently revised in July 2014, which is based upon the principles of the UK Corporate Governance Code issues in 2012.

1.4 These Standing Orders together with the Standing Financial Instructions and the Scheme of Reservation and Delegation provide a framework for the administration of the Trust’s affairs. All Directors and Officers should be aware of the existence of these documents and, where necessary, be familiar with the detail provisions contained within them.

1.5 The Trust has a number of wholly and partially owned corporate entities. These corporate entities are separate, distinct legal entities for commercial purposes and have distinct taxation, regulatory and liability obligations. As separate, independent corporate entities, they are subject to their own governance arrangements, which are the responsibility of the relevant entity’s management structure, and therefore these Standing Orders are not applicable. For avoidance of doubt, any matter reserved to the Trust in relation to such corporate entitles will be treated as an item of the Trust and will be considered in accordance with these Standing Orders.

2 INTERPRETATION

2.1 Unless a contrary intention is evident or the context requires otherwise, words or expressions contained in these SOs shall bear the same meaning as in the Constitution.

2.2 For the purposes of these SOs, the "Board" means the Board of Directors and the "Council" means the Council of Governors.

3 THE BOARD

3.1 All business shall be conducted in the name of the Trust.

3.2 All funds received in trust shall be in the name of the Trust as corporate trustee. Directors acting on behalf of the Trust as corporate trustees are acting as quasi-trustees.

3.3 In relation to Funds held on Trust, powers exercised by the Trust as corporate trustee shall be exercised separately and distinctly from those powers exercised as the Foundation Trust. Accountability for charitable Funds held on Trust is to the Charity Commission. Accountability for non- charitable Funds held on Trust is only to NHS Improvement (NHSI).

3.4 The Trust has the functions conferred on it by the Regulatory Framework.

2 Yeovil District Hospital NHS Foundation Trust (January 2019) 3.5 All powers of the Trust shall be exercised by the Board meeting either in public session except as otherwise provided for in SO 5 below.

3.6 The Board has resolved that certain powers and decisions may only be exercised or made by the Board in formal session. These powers and decisions are set out in the Scheme of Reservation and Delegation.

3.7 The Board and each Director individually shall at all times seek to comply with the Trust’s Code of Governance and the Code of Conduct for the Board.

3.8 The Board shall appoint one of the Non-Executive Directors to be the Senior Independent Director, in consultation with the Council. The Senior Independent Director may also be the Non-Executive Director appointed as Vice-Chairman of the Board. The Senior Independent Director shall be available to Members and Governors if they have concerns which contact through the normal channels of Chairman, Chief Executive or Chief Finance Officer has failed to resolve or for which such contact is inappropriate. The Senior Independent Director shall hold a meeting at least annually with the other Non-Executive Directors in the absence of the Chairman.

4 THE COUNCIL

4.1 The roles and responsibilities of the Council are to be carried out in accordance with the Regulatory Framework include the following:

4.1.1 to hold the Board to account for the performance of the Trust;

4.1.2 to respond as appropriate when consulted by the Board in accordance with the Constitution; and

4.1.3 to prepare and from time to time review the Trust’s membership strategy.

4.2 Certain powers and decisions may only be exercised by the Council in formal session.

4.3 The Council and each Governor individually shall at all times seek to comply with the Trust’s Code of Governance and the Code of Conduct for the Council.

4.4 The Council is required to nominate one of the members of the Council as the Lead Governor. The Lead Governor shall provide a single point of contact on all Governors' issues and be the primary contact for NHSI when communicating directly to the Governors.

5 MEETINGS OF THE BOARD AND THE COUNCIL

5.1 Admission of the public

5.1.1 Meetings of the Council and the Board are to be open to members of the public, but the members of the public may be excluded from all or any part of the meeting of the Council or the Board on the grounds that publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution of the Council or the Board (as relevant), and arising from the nature of the business or of the proceedings.

5.1.2 The Chairman shall give such directions as he thinks fit (including a decision to expel or exclude any member of the public and/or press if the individual in question is interfering with or preventing the proper conduct of the meeting).

5.1.3 Nothing in these SOs shall require the Board or the Council (as relevant) to allow members of the public or representative of the press to record proceedings in any manner whatsoever, other than writing, or to make any oral report of proceedings as they take place without the prior agreement of the person chairing the meeting.

3 Yeovil District Hospital NHS Foundation Trust (January 2019) 5.1.4 Matters to be dealt with by the Board or the Council following the exclusion of the public and representatives of the press under SO 5.1.2 above shall be confidential to the Directors or the Governors (as relevant). Members of the Board or the Council (as relevant) and others in attendance at the request of the person chairing the meeting shall not reveal or disclose the content of papers or reports presented, or any discussion on these generally, which take place while the public and press are excluded, without the express permission of the Chairman.

5.1.5 The Chairman (or Vice Chairman) will decide what arrangements and terms and conditions he feels are appropriate to offer in extending an invitation to observers, advisors and others to attend and address any meeting of the Board or the Council (as relevant), and may change, alter or vary these terms and conditions as it deems fit.

5.1.6 The Council may invite the Chief Executive or any other member(s) of the Board, or a representative of the Auditor or other advisors of the Trust to attend a meeting of the Council.

5.1.7 The Board may invite Officers of the Trust to attend meetings of the Board either generally or for specific items to be discussed at the meeting of the Board. For the avoidance of doubt, such Officers of the Trust shall not have voting rights and will be recorded as being 'in attendance' for the purposes of the minutes of the meeting of the Board.

5.2 Calling meetings

5.2.1 Meetings of the Board and the Council shall be held at such times and places as the Board or the Council (as relevant) may determine.

5.2.2 The Chairman may call a meeting of the Board or the Council at any time.

5.2.3 Members of the Council may, in writing signed by at least eight members of the Council, request a meeting of the Council, and the members of the Board may, in writing signed by at least one-third of the members of the Board may request a meeting of the Board. If the Chairman refuses to call a meeting after a requisition for that purpose signed by at least eight members of the Council, or at least one-third of the members of the Board (as relevant), has been presented to him specifying the business to be carried out, the Secretary shall call a meeting on at least fourteen (14) days but not more than twenty-eight (28) days' written notice to discuss the specified business.

5.2.4 If the Secretary fails to call a meeting as set out in SO 5.2.3 above, the eight members of the Council or the one-third members of the Board (as relevant) shall call such a meeting for the purpose for the purpose of conducting that business. No business shall be conducted at such a meeting other than that specified in the notice of the meeting.

5.3 Notice of meetings

5.3.1 Save in an emergency or the need to conduct urgent business, the Secretary shall give at least four (4) days written notice of the date and place of each meeting of the Board or the Council (as relevant). The notice shall specify the business proposed to be transacted at the meeting of the Board or the Council.

5.3.2 The notice shall be emailed to every Director or Governor (as relevant) to the email address provided by each Director or Governor (as relevant) so as to be available to him at least four (4) days before the meeting. A notice shall be presumed to have been served at the time at the same time the email has been delivered unless an error or an undelivered receipt is received.

5.3.3 A public notice of the time and place of the meeting of the Board or the Council, and the agenda, shall be published on the Trust's website.

4 Yeovil District Hospital NHS Foundation Trust (January 2019) 5.3.4 Lack of service of the notice on any member of the Board or the Council (as relevant) shall not affect the validity of a meeting, but failure to serve such a notice on more than three Directors (at least one executive director and one non-executive director) or Governors (as relevant) will invalidate the meeting of the Board or the Council (as relevant).

5.3.5 In the case of a meeting called in default of the Chairman, in accordance with SO 5.2.3 above, the notice shall be signed by those Directors or Governors (as relevant) who called the meeting and no business shall be transacted at the meeting other than that specified in the notice.

5.3.6 In the event of an emergency giving rise to the need for an immediate meeting, failure to comply with the notice periods referred to in SOs 5.3.1 and 5.3.3 above shall not prevent the calling of or invalidate such meeting provided that every effort is made to make personal contact with every Director or Governor (as relevant) and the agenda for the meeting is restricted to matters arising in that emergency.

5.4 Agendas and supporting papers

5.4.1 The Board and the Council may determine that certain matters shall appear on every agenda for a meeting and shall be addressed prior to any other business being conducted ("Standing Items").

5.4.2 Agendas will be sent to members of the Board or the Council (as relevant) four (4) days before the meeting and supporting papers, shall accompany the agenda, save in an emergency giving rise to the need for an immediate meeting as set out in SO 5.3.6 above, or as otherwise agreed with the Chairman. Failure to serve the agenda and (where relevant) supporting papers on more than three members of the Board or the Council (as relevant) will invalidate the meeting. The agenda and supporting papers shall be presumed to have been served one day after posting, or in the case of a notice being sent electronically, on the date of transmission.

5.4.3 Subject to SO 5.2.3, a Director or a Governor desiring a matter to be included on an agenda other than a Standing Item or a motion under SO 5.5 below, shall make his request in writing to the Chairman at least ten (10) days before the meeting is notified to the Governors or Directors (as relevant). The request should state whether the item of business is proposed to be transacted in the presence of the public and should include appropriate supporting information. Requests made less than ten (10) days before a meeting may be included on the agenda at the discretion of the Chairman.

5.4.4 No business may be transacted at any meeting of the Board or the Council which is not specified in the notice of that meeting unless the Chairman, in his absolute discretion, agrees that the item and (where relevant) any supporting papers should be considered by the Board or the Council (as relevant) as a matter of urgency. A decision by the Chairman to permit consideration of the item in question and (where relevant) the supporting papers shall be recorded in the minutes of that meeting.

5.5 Notices of motions

5.5.1 A Governor or Director desiring to move or amend a motion shall send a written notice, to the Chairman, thereof at least ten (10) days before the meeting of the Council or the Board (as relevant) is notified to Governors or the Directors, who shall insert in the agenda for the meeting of the Council or the Board (as relevant) all notices so received subject to the notice being permissible under the appropriate regulations. This SO shall not prevent any motion being moved during the meeting of the Council or the Director, without notice on any business mentioned on the agenda.

5.5.2 A motion or amendment once moved and seconded may be withdrawn by the proposer with the concurrence of the seconder and the consent of the Chairman.

5 Yeovil District Hospital NHS Foundation Trust (January 2019) 5.5.3 Notice of motion to amend or rescind any resolution (or the general substance of any resolution) which has been passed within the preceding six (6) calendar months shall bear the signature of the Governor or Director who gives it and also the signature of four (4) other Governors or Directors . When any such motion has been disposed of by the Council or the Board, it shall not be competent for any Governor or Director other than the Chairman to propose a motion to the same effect within six (6) months, however the Chairman may do so if he considers it appropriate.

5.5.4 The mover of a motion shall have a right of reply at the close of any discussion on the motion or any amendment thereto.

5.5.5 When a motion is under discussion or immediately prior to discussion it shall be open to a Governor or Director (as relevant) to move:

(a) an amendment to the motion.

(b) the adjournment of the discussion or the meeting.

(c) that the meeting proceed to the next business (*)

(d) the appointment of an ad hoc committee to deal with a specific item of business.

(e) that the motion be now put to a vote (*)

(f) In the case of SOs denoted by (*) above, to ensure objectivity motions may only be put by a Governor or a Director who has not previously taken part in the debate.

5.5.6 No amendment to the motion shall be admitted if, in the opinion of the Chairman of the meeting, the amendment negates the substance of the motion.

5.6 Chairman of meetings

5.6.1 Details in respect of the chair of the meeting of the Board and the Council are set out in the Constitution.

5.6.2 If the Chairman and the Deputy Chairman are absent from a meeting of the Board, or are absent temporarily on the grounds of a declared conflict of interest, such Non-Executive Director as the members of the Board present and voting at the meeting choose shall preside during that period.

5.6.3 If the Chairman and the Deputy Chairman are absent from a meeting of the Council, or are absent temporarily on the grounds of a declared conflict of interest, one of the Non- Executive Directors is to preside at the meeting of the Council. If the person at any such meeting has a conflict of interest in relation to the business being discussed, a Governor appointed by the Council will chair that part of the meeting.

5.6.4 All meetings shall be controlled by the person chairing the meeting and any ruling of the person chairing the meeting in relation to the conduct of the meeting shall be final.

5.7 Chairman's ruling

5.7.1 All meetings shall be controlled by the person chairing the meeting and any ruling of the person chairing the meeting in relation to the conduct of the meeting shall be final.

5.7.2 The decision of the person chairing the meeting on questions of order, relevancy and regularity (including procedure on handling motions) and the individual's interpretation of the SOs, at the meeting, shall be final.

6 Yeovil District Hospital NHS Foundation Trust (January 2019) 5.7.3 In respect of meetings of the Board, statements of Directors made at meetings of the Board shall be relevant to the matter under discussion at the material time and the decision of the Chairman of the meeting on questions of order, relevancy, regularity and any other matters shall be observed at the meeting of the Board.

5.8 Conduct at meetings

5.8.1 The decision of the person chairing the meeting on questions of order, relevance, regularity, appropriateness and any other matters shall be observed at the meeting.

5.8.2 Approval to speak will be given by the person chairing the meeting.

5.8.3 The Council or the Board may agree that its members can participate in the meetings of the Council or the Board (as relevant) by telephone, video or computer link. Participation in a meeting in this manner shall be deemed to constitute presence in person at a meeting of the Council or the Board.

5.9 Voting

5.9.1 When an issue or question at a Board meeting requires a vote, each Director shall have one vote. When an issue or question at a Council meeting requires a vote, each Governor shall have one vote.

5.9.2 Subject to SO 5.9.3 below, every question at a meeting of the Board or the Council shall be determined by a majority of the votes of the Chairman and the Directors or Governors (as relevant) present and voting on the question.

5.9.3 Unless otherwise specified in the Constitution, the person chairing the meeting of the Board or the Council (as relevant) shall not have a vote except in the case of an equality of votes of any question of proposition, when the person chairing the meeting of the Board or the Council shall have a casting vote.

5.9.4 All questions put to the vote shall, at the discretion of the person chairing the meeting, be determined by oral expression or by a show of hands (if all Directors or Governors (as relevant) are present in person). A paper ballot may also be used if a majority of the Directors or Governors (as relevant) present so request.

5.9.5 If at least one-third of the Directors or Governors (as relevant) present so request, the voting (other than by paper ballot) on any question may be recorded to show how each Director or Governor (as relevant) present voted or abstained.

5.9.6 If a Director or Governor (as relevant) so requests, the individual’s vote shall be recorded by name upon any vote (other than by paper ballot).

5.9.7 A Director or Governor (as relevant) may only vote if present at the time of the vote on which the question is to be decided. In no circumstances may an absent Governor or Director (as relevant) vote by proxy. Absence is defined as being absent at the time of the vote. In respect of Directors or Governors (as relevant) participating in the meeting of the Board or the Council (as relevant) by telephone, video or computer link, those Directors or Governors (as relevant) shall have a vote by oral expression or email confirmation.

5.9.8 In respect of meetings of the Board, no resolution of the Board shall be passed if it is opposed by all of the Non-Executive Directors present or by all of the Executive Directors present at a meeting of the Board.

5.9.9 Every Governor must make an annual declaration that he is qualified to vote at meetings of the Council. Such declaration shall be in the form specified at SO 8.8.2 below that they are a member of the constituency which elected them and are not prevented from being a member of the Council by paragraph 8 of Schedule 7 to the 2006 Act or under the Constitution.

7 Yeovil District Hospital NHS Foundation Trust (January 2019) 5.9.10 A Governor may not vote at a meeting of the Council unless, prior to the meeting, he has made the declaration referred to in SO 5.9.9 above.

5.9.11 Each Governor must also notify the Secretary as soon as possible and provide a further declaration at any subsequent meeting if his circumstances have changed.

5.9.12 All Governors shall be deemed to have confirmed the declaration upon attending any subsequent meeting of the Council, and every agenda for meetings of the Council will draw this to the attention of Governors.

5.9.13 If any matter for consideration at a meeting of the Board relates to the interests of the Chairman or the Non-Executive Directors as a class, neither the Chairman nor any of the Non-Executive Directors shall preside over the period of the meeting during which the matter is under discussion. The Directors (excluding the Chairman and the Non-Executive Directors) shall elect one of the number to preside during that period and that person shall exercise all the rights and obligations of the Chairman, including (for the avoidance of doubt) the right to exercise a casting vote where the numbers of votes for and against a motion is equal.

5.9.14 An Officer who has been appointed formally by the Board to act up for an Executive Director during a period of incapacity or temporarily to fill an Executive Director vacancy, shall be entitled to exercise the voting rights of the Executive Director. An Officer attending the Board to represent an Executive Director during a period of incapacity or temporary absence without formal acting up status may not exercise the voting rights of the Executive Director. An Officer's status when attending a meeting shall be recorded in the minutes.

5.10 Minutes

5.10.1 The minutes of the proceedings of a meeting of the Board or the Council (as relevant) shall be drawn up and submitted for agreement at the next ensuing meeting of the Board or the Council (as relevant).

5.10.2 No discussion shall take place upon the minutes except upon their accuracy or where the person chairing the meeting considers discussion appropriate. Any amendment to the minutes shall be agreed and recorded at the next meeting of the Board or the Council (as relevant).

5.10.3 Subject to SO 5.10.4, minutes of the proceedings of a meeting of the Council or the Board shall be circulated in accordance with the Governor's or Director's wishes (as relevant).

5.10.4 Minutes of meetings shall be made available to the public except for minutes relating to business conducted when members of the public are excluded under the terms of SO 5.1.1 above.

5.11 Record of attendance

5.11.1 The names of the Chairman and Directors or Governors (as relevant) present at the meeting shall be recorded in the minutes.

5.12 Quorum

5.12.1 At a Board meeting, no business shall be transacted unless at least one third of the total number of Directors, including at least one Executive Director and one Non-Executive Director are present. For the avoidance of doubt, an officer in attendance for an Executive Director but without formal acting up status may not count towards the quorum.

5.12.2 At a Council meeting, no business shall be transacted unless at least thirteen members of the Governors is present and the majority of those Governors present are members of the Public Constituency of the Trust.

8 Yeovil District Hospital NHS Foundation Trust (January 2019) 5.12.3 If at any Board or Council meeting (as relevant) there is no quorum present within thirty minutes of the time fixed for the start of the meeting, the Board or Council meeting (as relevant) shall stand adjourned for a number of days to be fixed by the Chairman and in any event not exceeding thirty days and upon reconvening, those present shall constitute a quorum.

5.12.4 If a Director or Governor (as relevant) has been disqualified from participating in the discussion on any matter and/or from voting on any resolution by reason of the declaration of a conflict of interest the individual shall no longer count towards the quorum. If a quorum is then not available for the discussion and/or the passing of a resolution on any matter, that matter may not be discussed further or voted upon at that Board or Council meeting (as relevant). Such a position shall be recorded in the minutes of the Board or Council meeting (as relevant). The Board or Council meeting (as relevant) must then proceed to the next business.

5.13 Decisions without meetings (Board only)

5.13.1 The Board may make decisions without meetings of the Board.

5.13.2 The Board may hold meetings by telephone or electronic means. Such meetings shall be conducted under the relevant provisions of the SOs as though an ordinary meeting of the Board was being held.

5.13.3 Authority to employ the provisions of SOs 5.13.1 and 5.13.2 shall be consistent with SO 5.2 and SO 5.4.

5.13.4 Business conducted under the provisions of SOs 5.13.1 and 5.13.2 shall have the same effect and authority as business conducted at an ordinary meeting of the Board.

5.14 Meetings: electronic communication

5.14.1 In this SO “communication” and “electronic communication” shall have the meanings set out in the Electronic Communications Act 2000 or any statutory modification or re- enactment thereof.

5.14.2 A Director or Governor (as relevant) in electronic communication with the Chairman and all other parties to a meeting of the Board or the Council (as relevant) or a committee or subcommittee of the Directors or the Governors (as relevant) shall be regarded for all purposes as personally attending such a meeting provided that, but only for so long as, at such a meeting he has the ability to communicate interactively and simultaneously with all other parties attending the meeting including all persons attending by way of electronic communication.

5.14.3 A meeting at which one or more of the Directors or the Governors (as relevant) attends by way of electronic communication is deemed to be held at such a place as the Directors or the Governors (as relevant) shall at the said meeting resolve. In the absence of such a resolution, the meeting shall be deemed to be held at the place (if any) where a majority of the Directors or the Governors (as relevant) attending the meeting are physically present, or in default of such a majority, the place at which the Chairman of the meeting is physically present.

5.14.4 Meetings of the Board or the Council (as relevant) held in accordance with this SO are subject to SO 5.12 (Quorum). For such a meeting to be valid, a quorum must be present and maintained throughout the meeting.

5.14.5 The minutes of a meeting of the Board or the Council (as relevant) held in this way must state that it was held by electronic communication and that the Directors or the Governors (as relevant) were all able to hear each other and were present throughout the meeting.

5.15 Repeat Considerations

9 Yeovil District Hospital NHS Foundation Trust (January 2019) 5.15.1 When any issue has been dealt with by the Board or the Council (as relevant), it shall not be competent for any member of the Board or the Council (as relevant) other than the Chairman to propose a motion to the same effect within six months. This SO shall not apply to motions moved in pursuance of a report or recommendations of a committee of the Board or the Council (as relevant) or the Chief Executive.

5.16 Reports from the Executive Directors (Board only)

5.16.1 At any meeting of the Board, a Director may ask any question through the Chairman without notice on any report by an Executive Director, or other Officer of the Trust, after that report has been received by or while such report is under consideration by the Board at the meeting. The Chairman may, in his absolute discretion, reject any question which is substantially the same and related to the same subject matter as a question which has already been put to that meeting or a previous meeting.

5.17 Joint Directors

5.17.1 Where a post of Executive Director is shared by more than one person:

(a) both persons shall be entitled to attend meetings of the Board;

(b) either of those persons shall be eligible to vote in the case of an agreement between them;

(c) in the case of disagreements between them no vote shall be cast; and

(d) the presence of either or both of those person shall count as one person for the purposes of SO 5.12.

6 ARRANGEMENT FOR THE EXERCISE OF FUNCTIONS BY DELEGATION (BOARD ONLY)

6.1 Delegation of functions

6.1.1 Subject to the Regulatory Framework and such guidance, if any, as may be given by NHSI, the Board may make arrangements for the exercise, on behalf of the Board, of any of its functions by a committee of Directors or sub-committee appointed by virtue of SO 7 below or by a Director or an officer of the Trust, in each case subject to such restrictions and conditions as the Board thinks fit.

6.2 Emergency powers

6.2.1 The powers which the Board has reserved to itself within these SOs and the Scheme of Reservation and Delegation may in emergency or for an urgent decision be exercised by the Chief Executive and the Chairman after having consulted at least two Non-Executive Directors. The exercise of such powers by the Chief Executive and Chairman shall be reported to the next formal meeting of the Board for ratification.

6.3 Delegation to committees

6.3.1 The Board shall agree from time to time to the delegation of executive powers to be exercised by other committees or joint-committees, which it has formally constituted and which are made up of Directors. The Constitution and terms of reference of these committees and their specific powers shall be approved by the Board.

6.3.2 When the Board are not meeting as the Board, they shall operate as a committee and may only exercise such powers as have been delegated to them by the Board in public session.

6.4 Delegation to an Executive Director

10 Yeovil District Hospital NHS Foundation Trust (January 2019) 6.4.1 Those functions of the Trust which have not been retained as reserved by the Board, or delegated to a committee or sub-committee, shall be exercised on behalf of the Board by the Chief Executive. The Chief Executive shall determine which functions he will perform personally and shall nominate officers to undertake the remaining functions for which they will retain accountability to the Board.

6.4.2 The Chief Executive shall prepare a Scheme of Reservation and Delegation identifying the individual proposals which shall be considered and approved by the Board, subject to any amendment agreed during the discussion. The Chief Executive may from time to time propose amendments to the Scheme of Reservation and Delegation which shall be considered and approved by the Board.

6.4.3 Nothing in these SOs or the Scheme of Reservation and Delegation shall impair the discharge of the direct accountability to the Board or the Chief Finance Officer or other Executive Director to provide information and advise the Board in accordance with statutory requirements or any requirements of NHSI. For all other functions which do not form part of these requirements, the Chief Finance Officer shall be accountable to the Chief Executive.

6.5 Schedule of matters reserved to the Board and Scheme of Reservation and Delegation

6.5.1 The arrangements made by the Board as set out in the Scheme of Reservation and Delegation shall have effect as if incorporated in these SOs.

7 COMMITTEES

7.1 Committees of the Council

7.1.1 The Council may not delegate any of its powers to a committee or sub-committee, but it may appoint committees consisting of its members, Directors, and other persons to assist the Council in carrying out its functions. The Council may, through the Secretary, request that advisors assist them or any committee they appoint in carrying out its duties. All decisions taken in good faith at a meeting of the Council or of any committee of the Council shall be valid even if it is discovered subsequently that there was a defect in the calling of the meeting, or the appointment of the Governors attending the meeting.

7.1.2 In making any recommendations, a committee of the Council must have due regard to the established policies of the Council and shall not depart from them without due reason and consideration. Any such departure and the reason for it shall be drawn to the attention of the Council at the earliest opportunity. The Council requires its committee to refer back to them for a decision.

7.1.3 In consideration of any recommendation a committee of the Council must comply with:

(a) the Trust’s Standing Financial Instructions, SOs and written procedures and specific reference to the relevant sections of these documents, should be made, and

(b) any statutory provisions or requirements.

7.2 Committees of the Board

7.2.1 Subject to directions as may be given by NHSI, the Board may appoint committees of the Board, consisting wholly or partly of Directors, or wholly or partly of persons who are not Directors.

7.2.2 The committees established by the Board shall include:

(a) Audit Committee;

11 Yeovil District Hospital NHS Foundation Trust (January 2019) (b) Governance and Quality Assurance Committee;

(c) Financial Resilience and Commercial Committee;

(d) Board of Trustees of the Yeovil District Hospital Charitable Fund;

(e) Remuneration Committee; and

(f) any other successor committees to those listed above or any other committees as the Board deem it necessary or appropriate to establish from time to time.

7.2.3 The Board may also establish and dissolve such other committees as required to discharge the responsibilities of the Board.

7.2.4 The Board may appoint committees of the Board consisting wholly or partly of Directors.

7.3 Appointment of Committees

7.3.1 A committee appointed under this SO may, subject to such directions and guidance as may be given by NHSI or the Board or the Council (as relevant), appoint sub-committees consisting wholly or partly of members of the committee, or wholly of persons who are not members of the committee .

7.3.2 Where committees are authorised to establish sub-committees they may not delegate their powers to the sub-committee unless expressly authorised by the Board or the Council (as relevant).

7.3.3 Where the Council determines that persons, who are neither Governors nor members of the Board nor Officers of the Trust shall be appointed to a committee of the Council, the terms of such appointment shall be determined by the Council subject to the payment of travelling expenses and other allowances being in accordance with such sum as may be determined by the Board.

7.3.4 Where the Board determines, and legislation, regulations and directions or guidance issued by NHSI permit that persons who are not Directors of the Trust shall be appointed to a committee of the Board, the terms of such appointment shall be determined by the Board. The Board shall define the powers of such appointees and shall agree allowances, including reimbursement for loss of earnings, and/or expenses.

7.3.5 Where the Board is required to appoint a person to a committee and/or to undertake functions as required by NHSI, and where such appointments are to operate independently of the Board of Directors, such appointment shall be made in accordance with regulations laid down by NHSI.

7.3.6 Committees will normally only make recommendations and provide advice to the Board or the Council unless the Board or the Council (as relevant) has specifically delegated powers to the committee.

7.4 Terms of Reference of Committees

7.4.1 Each such committee shall have such terms of reference and powers and be subject to such conditions the Board or the Council (as relevant) shall decide. Such terms of reference shall be in accordance with the Regulatory Framework and any directions and guidance issued by NHSI, but the Council shall not delegate to any committee any of the powers or responsibilities which are to be exercised by the Council at a general meeting. The terms of reference shall have effect as if incorporated into these SOs.

7.5 Approval of appointments to Committees

12 Yeovil District Hospital NHS Foundation Trust (January 2019)

7.5.1 The Board or the Council (as relevant) shall approve the appointments of each of the committees which it has formally constituted.

7.5.2 Except in relation to the Appointment Committee each committee of the Council shall elect its own chairman.

7.5.3 The Board of Directors shall appoint one of the Directors to chair each of its committees.

7.6 Appointments for statutory functions

7.6.1 Where the Board or the Council (as relevant) is required by the Constitution, by any applicable statute or regulations or by any directions or guidance issued by NHSI to appoint persons to a committee to undertake statutory functions, and where such appointments are to operate independently of the Board or the Council (as relevant), such appointments shall be made in accordance with the Constitution or such applicable statute or regulations or such directions or guidance issued by NHSI.

7.7 Applicability of SOs and Standing Financial Instructions to committees and sub-committees

7.7.1 The SOs and Standing Financial Instructions of the Trust, as far as they are applicable, shall as appropriate apply to meetings and any committees and sub-committees established by the Board or the Council. In which case the term “Chairman” is to be read as a reference to the chairman of the committee or sub-committee as the context permits, and the term “member of the Board” or "member of the Council" (as relevant) is to be read as a reference to a member of the committee or sub-committee also as the context permits.

7.8 Confidentiality

7.8.1 A member of a committee shall not disclose a matter dealt with by, or brought before, the committee without its permission until the committee shall have reported to the Board or the Council (as relevant) or shall otherwise have concluded on that matter.

7.8.2 A Director or Governor member of a committee shall not disclose any matter reported to the Board or the Council (as relevant) or otherwise dealt with by the committee, notwithstanding that the matter has been reported or action has been concluded, if the Board or the Council (as relevant) or committee shall resolve that it is confidential.

8 DECLARATION OF INTEREST

8.1 Interests

8.1.1 Interests which should be regarded as relevant and material for the purposes of this SO are:

(a) Directorships, including non-executive directorships held in private companies or listed companies (with the exception of those of dormant companies).

8.1.2

(a) Ownership or part-ownership or directorship of private companies, businesses or consultancies likely or possibly seeking to do business with the NHS.

(b) Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS.

(c) A position of authority in a charity or voluntary organisation in the field of health and social care.

13 Yeovil District Hospital NHS Foundation Trust (January 2019) (d) Any connection with a voluntary or other organisation contracting for NHS services or commissioning NHS services.

(e) Any connection with an organisation, entity or company considering entering into or having entered into a financial arrangement with the Trust, including but not limited to, lenders or banks.

(f) Any pecuniary interest, direct or indirect in a contract which the Trust has entered into or proposed to enter into.

(g) Any direct or indirect interest in a proposed transaction or arrangement with the Trust.

(h) Any relationship, or of a cohabiting spouse or partner, that conflicts, or might reasonably be predicted could conflict with the interests of the Trust.

8.1.3 For the avoidance of doubt, the following shall not be considered relevant and material for the purposes of these SOs:

(a) Shares not exceeding 2% of the total share in issue held in any company whose shares are listed on any public exchange;

(b) An employment contract held by Staff Governors;

(c) An employment contract with the relevant local authority held by a Local Authority Governor;

(d) An employment contract with a Partnership Organisation held by a Partnership Governor.

8.2 A Director or a Governor shall not be treated as having a pecuniary interest in any contract, proposed contract or other matter by reason only:

8.2.1 of his membership of a company or other body, if he has no beneficial interest in any securities of that company or other body; or

8.2.2 of an interest in any company, body or person with which he is connected which is so remote or insignificant that it cannot reasonably be regarded as likely to influence a Director or a Governor (as relevant) in the consideration or discussion of or in voting on, any question with respect to that contract or matter.

8.3 Where a Director or a Governor:

8.3.1 has an indirect pecuniary interest in a contract, proposed contract or other matter by reason only of a beneficial interest in securities of a company or other body, and

8.3.2 the total nominal value of those securities does not exceed £5,000 or one-hundredth of the total nominal value of the issued share capital of the company of body, whichever it the less, and

8.3.3 if the share capital is of more than one class, the total nominal value of shares of any one class in which he has a beneficial interest does not exceed one-hundredth of the total issued share capital of that clause,

8.4 This SO 8 shall not prohibit him from taking part in the consideration or discussion of the contract or other matter or from voting on any question with respect to it without prejudice however to his duty to disclose his interest.

14 Yeovil District Hospital NHS Foundation Trust (January 2019) 8.5 All individuals in their capacity as a Governor or a Director of the Trust shall be required to report to the Secretary all gifts, hospitality and conflicts of interest in line with the Trust’s relevant policy.

8.6 Directorship by a Director or Governor of companies likely to or possibly seeking to do business with the NHS should be published in the Trust's Annual Report. This information should be kept up to date for inclusion in succeeding Annual Reports.

8.7 This SO 8 applies to a committee or sub-committee of the Board or the Council as it applies to the Board and the Council and applies to any member of such committees or sub-committees (whether or not he is also a Director or Governor) as it applies to a Director or a Governor.

8.8 Declarations by Governors

8.8.1 All Governors must declare any actual or potential interest, direct or indirect, which is relevant and material to the business of the Trust, or proposed transaction involving the Trust (before the Trust enters into the transaction or arrangement).

8.8.2 Any relevant and material interests shall be declared either at the time of the Governor's election or appointment or as soon as thereafter as the interest arises, but within five (5) days of the Governor becoming aware of the existence of that interest. The declaration upon appointment or election shall be in the following form:

To the Secretary of Yeovil District Hospitals NHS Foundation Trust:

I hereby declare that I am at the date of this declaration a member of the [Public/Staff Constituency], and I am not prevented from being a member of the Council of Governors by reason of any provision in the Constitution.

8.8.3 In addition, if a Governor is present at a meeting of the Council and has an interest of any sort in any matter which is the subject of consideration, he shall at the meeting and as soon as practicable after its commencement, disclose the fact and shall:

(a) withdraw from the meeting and play no part in the relevant discussion or decision; and

(b) shall not vote on the issues (and if by advertence they do remain and vote, their vote shall not be counted).

8.8.4 At the time the interest is declared, it should be recorded in the minutes of the Council meeting. Any changes in interests should be officially declared at the next relevant meeting of the Council following the change occurring.

8.8.5 The Secretary shall be responsible for compiling and maintaining the register of interests of Governors in accordance with the Constitution. In establishing, maintaining, updating and publicising the register of interest, the Trust shall comply with all guidance issued from time to time by NHSI. The details of the Governors' interests recorded in the register of interests of Governors will be kept up to date by means of a regular review as necessary.

8.8.6 The above list of potential interests applies to the Governors, their partner, and to their immediate family (parent, spouse, child or sibling).

8.8.7 If a Governor fails to declare an interest required to be disclosed in accordance with the Constitution and the provisions of this SO 8.8, the Governor shall permanently vacate their office if required to do so by 75% of the remaining Governors present and voting at a meeting of the Council.

8.8.8 If a Governor has any doubt about the relevant of an interest then they should discuss it with the Secretary.

15 Yeovil District Hospital NHS Foundation Trust (January 2019) 8.9 Declaration by Directors

8.9.1 All Directors of the Trust are under the following duties:

(a) A duty to avoid a situation in which the Director has (or can have) a direct or indirect interest that conflicts (or possibly may conflict) with the interests of the Trust; and

(b) A duty not to accept a benefit from a third party by reason of being a Director or doing (or not doing) anything in that capacity.

8.9.2 At the time Directors' interests are declared, they should be recorded in the minutes of the Board meeting. Any changes in interests should be officially declared at the next Board meeting following the change occurring. It is the obligation of the Director to inform the Secretary in writing within seven (7) days of becoming aware of the existence of a relevant or material interest.

8.9.3 Directors' directorships of companies in SO 8.1.1 above likely or possibly seeking to do business with the NHS (SO 7.1.2 above) should be published in the Board's Annual Report. The information should be kept up to date for inclusion in succeeding Annual Reports.

8.9.4 During the course of a Board meeting, if a conflict of interest is established, the Director concerned should withdraw from the meeting and play no part in the relevant discussion or decision. For the avoidance of doubt, this includes voting on such an issue where a conflict is established. If there is a dispute as to whether a conflict of interest does exist, a majority will resolve the issue with the Chairman having the casting vote.

8.9.5 The Secretary shall be responsible for compiling and maintaining the register of interests of Directors. In establishing, maintaining, updating and publicising the register of interest, the Trust shall comply with all guidance issued from time to time by NHSI. The details of the Directors' interests recorded in the register of interests of Directors will be kept up to date by means of a regular review as necessary.

8.9.6 If Directors have any doubt about the relevance or materiality of an interest, this should be discussed with the Chairman.

8.10 Canvassing of, and recommendations by, Directors or Governors in relation to appointments

8.10.1 Canvassing of Directors, Governors or members of any committee, sub-committee or joint committee of the Board or the Council directly or indirectly for any appointment under the Trust shall disqualify the candidate for such appointment. The contents of this SO 8.10.1 shall be included in application forms or otherwise brought to the attention of candidates.

8.10.2 A Director or a Governor (as appropriate) shall not solicit for any person any appointment under the Trust or recommend any person for such appointment; but this SO 8.10.2 shall not preclude a Director or a Governor (as appropriate) from giving written testimonial of a candidate's ability, experience or character for submission to the Trust in relation to any appointment.

8.10.3 Informal discussions outside appointments panels or committees, whether solicited or unsolicited, should be declared to the panel or committee in question.

8.11 Registers of Interests

8.11.1 Registers of Interests shall be maintained in accordance with paragraph 20 of Schedule 7 of the 2006 Act to first record formally declarations of interests of Directors and secondly to record formally the interests of Governors. The Register of Interests will include details of all directorships and other relevant and material interests which have been declared by both Executive and Non-Executive Directors and by all Governors.

16 Yeovil District Hospital NHS Foundation Trust (January 2019) 8.11.2 The details set at SO 8.11.1 will be kept up to date by means of an annual review of the Register of Interests in which any changes to interests declared during the preceding twelve (12) months will be incorporated.

8.11.3 The Register of Interests will be available for public inspection in accordance with the Constitution.

9 SUSPENSION OF SOs

Suspending SOs for practice and procedure of the Board

9.1 Except where this would contravene any statutory provision or guidance issued by NHSI or the rules relating to the quorum, any one or more of the SOs may be suspended at any meeting of the Board, provided that at least two-thirds of the whole number of the members of the Board are present, including one Executive Director and one Non-Executive Director, and that a majority of those present vote in favour of suspension. The decision and reason to suspend the SOs shall be recorded in the minutes of the Board meeting.

Suspending SOs for practice and procedure of the Council

9.2 Except where this would contravene any statutory provision or guidance issued by NHSI or the rules relating to the quorum, any one or more of the SOs may be suspended at any meeting of the Council, provided that at least two-thirds of the whole number of the members of the Council are present, including one Public Governor and one Staff Governor, and that a majority of those present vote in favour of suspension. The decision and reason for the suspension shall be recorded in the minutes of the Council meeting.

SOs applicable to both the Board and the Council

9.3 A separate record of matters discussed by the Board or the Council (as relevant) during the suspension of SOs shall be made and shall be available to the Chairman and members of the Board or Governors (as relevant).

9.4 No formal business may be transacted while the SOs are suspended.

9.5 The Audit Committee shall review every decision to suspend SOs.

10 CUSTODY OF SEAL AND SEALING OF DOCUMENTS (BOARD ONLY)

10.1 Custody of seal

10.1.1 The common seal of the Trust shall be kept by the Secretary in a secure place.

10.2 Sealing of Documents

10.2.1 The common seal of the Trust shall not be fixed to any documents unless the sealing has been authorised by a resolution of the Board, or of a committee thereof or where the Board has delegated its powers.

10.2.2 Before any building, engineering, property or capital document is sealed it must be approved and signed by the Chief Finance Officer (or an Officer nominated by them) and authorised and countersigned by the Chief Executive (or an Officer nominated by them) provided that any Officer nominated is not from the same directorate as the person nominating them.

10.3 Register of sealing

10.3.1 An entry of every sealing shall be made and numbered consecutively in a book provided for that purpose. A report of all sealings shall be made to the Board at least once a year.

17 Yeovil District Hospital NHS Foundation Trust (January 2019) The report shall contain details of the seal number, the description of the document and date of sealing.

10.4 Signature of documents

10.4.1 Where the signature of any document will be a necessary step in legal proceedings involving the Trust, it shall be signed by the Chief Executive, unless any enactment otherwise requires or authorises, or the Board shall have given the necessary authority to some other person for the purpose of such proceedings.

10.4.2 The Chief Executive or nominated Officers shall be authorised, by resolution of the Board, to sign on behalf of the Trust any agreement or other document not requested to be executed as a deed, the subject matter of which has been approved by the Board or any committee or sub-committee to which the Board has delegated appropriate authority.

11 TRUST SECRETARY

11.1 The Trust shall have a Secretary who may be an employee, but may not be a Governor, or the Chief Executive or the Chief Finance Officer. The Secretary shall be appointed and removed by the Board.

11.2 The Secretary's functions shall include:

11.2.1 acting as Secretary to the Council and the Board, and any committees of the Council or the Board;

11.2.2 summoning and attending all meetings of the Council and the Board, and keeping the minutes of those meetings;

11.2.3 keeping the register of members and other registers and books required by the Constitution to be kept;

11.2.4 having charge of the Trust's seal;

11.2.5 publishing to Members in an appropriate form information which they should have about the Trust's affairs; and

11.2.6 oversight of the preparation and sending to NHSI and any other statutory body all returns which are required to be made in conjunction with the Management Information Team and Finance Department.

12 MISCELLANEOUS

12.1 SOs to be given to members of the Board and Governors

12.1.1 It is the duty of the Chief Executive to ensure that existing members of the Board and the Council and all new appointees are notified of and understand their responsibilities within the SOs and the SFIs. Updated copies shall be issued to staff designated by the Chief Executive.

12.1.2 New Designated Officers shall be informed in writing and shall receive copies where appropriate of the SOs.

12.2 The Trust's SFI and Scheme of Reservation and Delegation to the Board shall have the effect as if incorporated into the SOs.

12.3 Amendment of the SOs

18 Yeovil District Hospital NHS Foundation Trust (January 2019) 12.3.1 The SOs may only be amended in accordance with paragraph 20 of the Constitution (Amendment of the Constitution).

12.4 Duty to report non-compliance with the SOs

12.4.1 If for any reason these SOs are not complied with, full details of the non-compliance and any justification for non-compliance, and the circumstances around the non-compliance, shall be reported to the next formal meeting of the Board or the Council (as relevant) for action or ratification. All members of the Board or the Council (as relevant) and Officers have a duty to disclose any non-compliance with these SOs to the Secretary as soon as possible.

19 Yeovil District Hospital NHS Foundation Trust (January 2019)

SCHEME OF RESERVATION AND DELEGATION

Version Number 2.1 Version Date March 2021 Owner Chief Finance Officer Chief Finance Officer Author Deputy Chief Finance Officer Company Secretary Company Secretary Staff/Groups Consulted Procurement Finance Approved by Board of TBC Directors Next Review Due TBC

1 9253587 YEOVIL DISTRICT HOSPITAL NHS FOUNDATION TRUST SCHEME OF RESERVATION AND DELEGATION

Introduction

This document sets out the powers of the Trust ("the Powers") reserved to the Board of Directors ("the Board") and the Scheme of Delegation.

All Powers which have not been retained by the Board or delegated to a committee of the Board shall be exercised on behalf of the Board by the Chief Executive. All powers delegated by the Chief Executive can be reassumed by him/her should the need arise. If the Chief Executive is absent powers delegated to him may be exercised by a nominated Officer after taking appropriate advice from the Chief Finance Officer.

The Board remains accountable for all of its functions, including those which have been delegated. The Board may request at any time information about the exercise of delegated functions to enable it to maintain its monitoring role. In the absence of a Director or Officer to whom powers have been delegated those powers shall be exercised by that Director's or Officer's superior.

The tables below show the scheme of reservation and delegation.

DECISIONS RESERVED TO THE BOARD

General Enabling Provision The Board may determine any matter, for which it has delegated or statutory authority, in full session within its statutory powers. Regulations and Control 1. Approve, suspend, vary or amend the Standing Orders (SOs), a schedule of matters reserved to the Board and Standing Financial Instructions (SFIs) for the regulation of its proceedings and business. 2. Ratify any urgent decisions taken by the Chairman and Chief Executive. 3. Approve a scheme of delegation of powers from the Board to committees, Officers or other bodies. 4. Require and receive the declaration of Board members’ interests that may conflict with those of the Trust and determining the extent to which that member of the Board may remain involved with the matter under consideration. 5. Require and receive the declaration of Officers’ interests that may conflict with those of the Trust. 6. Declare relevant and material interests and any pecuniary interest in any contract, proposed contract or other matter under consideration by the Board. 7. Approve arrangements for dealing with complaints. 8. Adopt the organisation structures, processes and procedures to facilitate the discharge of business by the Trust and to agree modifications thereto. For clarity this would comprise details of the structure of the Board and its sub-committees and the Directorate structure of the Trust. Organisational structures below Executive and Clinical Director are the responsibility of the Chief Executive. 9. Establish terms of reference and reporting arrangements of all committees and sub- committees (and other committees if required) that are established by the Board. 10. Formal delegation of powers to sub committees or joint committees and approval of appointments to such Committees, their constitution and terms of reference. (Constitution and terms of reference of sub committees may be approved by the

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DECISIONS RESERVED TO THE BOARD Board.) 11. Receive reports from committees and to take action on them. 12. Confirm the recommendations of the Trust’s committees where the committees do not have executive powers. 13. Approval of arrangements relating to the discharge of the Trust’s responsibilities as a corporate trustee for Funds held on Trust. 14. Approval and authorisation of institutions with which temporary cash surpluses may be held. 15. Authorise use of the seal. 16. Ratify or otherwise instances of failure to comply with Standing Orders brought to the Chief Executive’s attention. 17. Approval of the disciplinary procedure for Officers of the Trust. 18. Discipline members of the Board or Officers who are in breach of statutory requirements, Standing Orders or the Code of Conduct for Directors. 19. Approve the incorporation of new subsidiaries, to include the terms of articles of association and standing financial instructions.

Appointments/ Dismissal 1. Appoint the Deputy Chairman of the Board. 2. Appoint and dismiss committees (and individual members) that are directly accountable to the Board. 3. Through the Remuneration Committee, appoint, discipline and dismiss Executive Directors. 4. Appoint, appraise, discipline and dismiss the Secretary. 5. Approve proposals of the Remuneration Committee regarding Executive Directors, the Chief Executive and senior employees. Note: (1) The Chief Executive is to be appointed (and removed) by the Non-Executive Directors, subject to the approval of a majority of the members of the Council of Governors present and voting at a meeting of the Council of Governors. (2) The Executive Directors are to be appointed (and removed) by a Committee consisting of the Chairman, the Chief Executive and the other Non-Executive Directors. Strategy, Business Plans and Budgets 1. Define the strategic aims and objectives of the Trust. 2. Identify the key strategic risks, evaluate them and ensure adequate responses are in place and are monitored. 3. Approve proposals for ensuring quality and developing clinical governance, risk management in services provided by the Trust. 4. Approve and monitor the Trust’s policies and procedures for the management of risk. 5. Approve the Trust's proposed business plan, budgets and annual financial plans. 6. Ratify proposals for acquisition, disposal or change of use of land and/or buildings. 7. Approve PFI proposals. 8. Approve the opening and closing of any bank or investment accounts. 9. Approve proposals on individual contracts, including purchase orders (other than NHS commissioning contracts) of a capital or revenue nature above the limits of delegation to the Chief Executive and Chief Finance Officer. 10. Approve proposals in individual cases for the write off of losses or making of special payments above the limits of delegation to the Chief Executive and Chief Finance Officer. 11. Approve individual compensation payments made outside of legal / statutory or mandatory requirements.

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DECISIONS RESERVED TO THE BOARD

12. Approve proposals for action on litigation against or on behalf of the Trust where the likely financial impact is expected to exceed £10,000 or is contentious or novel or likely to lead to adverse publicity, excluding claims covered by the NHS risk pooling schemes. 13. Decide whether the Trust will insure through the risk pooling schemes administered by NHS Resolution or self-insure for some or all of the risks covered by the risk pooling scheme. Decisions to self-insure should be reviewed annually. 14. Review use of NHSLA risk pooling schemes. 15. Approve the annual Capital Plan and delegation of scheme budgets. Policy Determination 1. Approve Trust's management policies including personnel policies incorporating the arrangements for the appointment, removal and remuneration of staff. Audit Arrangements 1. Receive the annual management letter received from the Auditor and agreement of proposed action, taking account of the advice, where appropriate, for the Audit Committee. Note: The appointment or dismissal of the Auditor is reserved to the Council of Governors. 2. Approve the appointment or dismissal of the internal auditor. 3. Receive an annual report from the internal auditor and agree action on recommendations where appropriate of the Audit Committee. Annual Reports and Accounts 1. Receive and approve the Trust's Annual Report and Annual Accounts prior to the submission to NHS Improvement and Parliament and presentation to the Council of Governors and subsequently, the Members of the Trust. Monitoring 1. Receive such reports as the Board sees fit from committees in respect of their exercise of powers delegated or from Directors and Officers of the Trust. 2. Make such monitoring returns required by the Department of Health and/or NHS Improvement (NHSI) and the Charity Commission where Board certification is required. Agree a list of Officers authorised to make short term borrowings on behalf of the Trust.

Granting and termination of all leases with annual rent above the limits of delegation to the Chief Executive or Chief Finance Officer.

SFI/SO REF AUTHORITIES/DUTIES DELEGATED OR RESERVED TO THE CHIEF EXECUTIVE SFI 3.2.6 Notify Directors and Officers of their responsibilities within the Standing Orders and Standing Financial Instructions and ensuring that they understand the responsibilities. SFI 3.2.2 Responsibility for security of the Trust's property, avoiding loss, exercising economy and efficiency in using resources and confirming with SOs and the SFIs. SFI 10 Approval of the tendering and contract procedure. SFI 10.8 Responsible for treatment of ‘late tenders’. SFI 10.18.1.1 Demonstrate that the use of private finance represents value for money and genuinely transfers risk to the private sector. SFI 12.1 Ensure that the best value for money can be demonstrated for all services provided under contract or in-house.

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SFI/SO REF AUTHORITIES/DUTIES DELEGATED OR RESERVED TO THE CHIEF EXECUTIVE SFI 3.2.4 Responsible as the Accountable Officer to ensure that the Board meets its obligations to perform its functions within the available financial resources, and has overall executive responsibility for the Trusts’ activities, and has overall responsibility for the System of Internal Control. SFI 14.1.1 Approve the list of Officers authorised to place requisitions for supply of goods and services and the maximum level of each requisition and the system for authorisation above that level and nominate Officers to oversee and manage contracts. Ensure that any Officer including a contractor or employee of a contractor who is empowered by the Trust to commit the Trust to expenditure or who is authorised to obtain income are made aware of these SFIs and their requirement to comply. SFI 13.1.3 Prepare proposals for setting the remuneration and conditions of service for those officers not covered by the Remuneration Committee. SFI 13.2.2 Prepare procedure for the determination of commencing pay rates, conditions of service etc. for Officers. SFI 6.4.1 Compile and submit to the Board an annual business plan which takes into account financial targets and forecast limits of available resources. SFI 15.1 Ensure the Trust pays annually to the Department of Health a dividend on its public dividend capital. SFI 6.5 Preparation of the Annual Report in each financial year to HM Treasury and to NHSEI as necessary. SFI 9.1 Ensure the Trust enters into suitable legally binding agreements with service commissioners for the provision of NHS services. SFI 9.2 Ensure agreements have due regard to the quality and the cost-effectiveness of the services provided where the Trust makes arrangements for the provision of services by non- NHS providers. SFI 22.3 Authorise the destruction of documents and ensure that records are maintained of documents so destroyed. Review of the Trust's compliance with the Caldicott report on protecting patient's confidentiality in the NHS. SFI 22.2 Ensure compliance with the guidance issued by NHSI regarding the collection, synthesis and processing of information.

SFI 24.1 Ensure that the Trust has a risk management programme, in accordance with any relevant guidance as issued by NHSI. Overall responsibility for ensuring that all complaints by patients or relatives of patients are dealt with effectively. Review of the Trust's compliance with the General Data Protection Regulations (GDPR) and the Data Protection Act 2018.

SFI 21.1 Ensure all Officers are made aware of the Trust policy on the acceptance of gifts and other benefits in kind by Officers. Taking of urgent decisions (with the Chairman), that the Board has retained to itself within the Standing Orders, after having consulted at least two Non-Executive Directors

SFI/SO REF AUTHORITIES/DUTIES DELEGATED OR RESERVED TO THE CHAIRMAN SFI 2.1 Final authority in interpretation of Standing Orders (SOs). SO 5.2.2 Call meetings of the Trust. SO 5.9.3 Having a casting vote.

5 9253587 Taking of urgent decisions (with the Chief Executive), that the Board has retained to itself within the Standing Orders, after having consulted at least two Non-Executive Directors.

SFI/SO REF AUTHORITIES/DUTIES DELEGATED OR RESERVED TO THE CHIEF FINANCE OFFICER Report waivers of tendering procedures in accordance with SFIs. Approval of staff additional to the agreed establishment, in or over the budget SFI 1.5 Maintenance, update and approval of all financial procedures. SFI 1.7 Advice on interpretation or application of SFIs. SFI 26.1 Ensure that the Funds held on Trust are managed appropriately. Maintain an up to date list of nominated fund holders. SFI 7.1 Operation of Bank Accounts: • Managing banking arrangements and operation of bank accounts • Opening bank accounts SFI 26.4.5 Registration of Funds held on Trust with Charities Commission SFI 3.3.1 Responsible for implementation and maintenance of financial record keeping and systems of internal financial control SFI 3.3.1 Responsible for ensuring a sufficient and independent Internal Audit function SFI 4.4.5 Preparation of the Fraud Response Plan. SFI 5.1.2 Lead the Trust's financial planning and budgeting exercise. Submit budgets to the Board for approval. Monitor performance against budget and the Business Plan; periodically review them and report to the Board of Directors. Submit financial estimate and forecasts to the Board. Provide guidance and training to budget holders.

SFI 5.1.3 Monitor performance against budget on a current and projection basis. Setting of fees and charges for overseas visitors, other patient related services and non- patient income, if different from national tariff. SFI 6.1 Preparation of financial returns, annual accounts and reports to HM Treasury and NHSI and other regulators as necessary. SFI 6.2 Ensure that the Trust complies with any directions given by NHSI as to: (a) the methods and principles according to which the accounts are to be prepared; and (b) the information to be given in the accounts. SFI 4.4.2 Immediately inform the police if theft or arson is involved but in the case of fraud or corruption will determine the appropriate stage in which to involve the police based on the facts of the case. Notify NHSI and the Auditor of all frauds. Notify the Board and the Auditor of losses apparently caused by theft, fraud, arson, neglect of duty or gross carelessness except if trivial and where fraud is not suspected. SFI 14.2.2 Shall be responsible for the prompt payment of accounts and claims in accordance with the Better Payment Practice Code (BPPC). SFI 14.2.4 Approve any proposed prepayments outside of normal commercial arrangements SFI 8.4.4 Approve any proposed repayment plans outside of Trust policy SFI 14.2.5 Approve and advise on all lease, tenancy agreements and other commitments which may result in a liability for the Trust. SFI 14.3.1 Lay down procedures for payments to local authorities and voluntary organisations made under the powers of section 75 of the NHS Act 2006. Investment of surplus funds in accordance with the Trust's Operating Cash Management Policy. 6 9253587 Ensure arrangements are in place for the development and implementation of a capital investment programme.

Maintenance of asset registers and arranging for a physical check of assets against the asset register to be conducted once a year. Responsibility for purchasing systems, stock control systems and ensuring procedures are in place for the control over stores and receipt of goods, issues and returns. Take the necessary steps to safeguard the Trust’s interests in bankruptcies and company liquidations SFI 18.2.4 Consider whether any insurance claim can be made. Responsibility for the accuracy and security of computerised financial data and ensuring that the adequate controls, procedures and management trails are in place. Ensure that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Ensure that each trust fund which the Trust is responsible for managing is managed appropriately with regard to its purpose and to its requirements. SFI 25.1 Ensure the Trust enters into appropriate risk pooling and insurance arrangements

SFI/SO REF AUTHORITIES/DUTIES DELEGATED OR RESERVED TO THE CHIEF EXECUTIVE AND THE CHIEF FINANCE OFFICER SFI 10.3.2 Waive formal tendering procedures. Where only one tender is sought and/or received shall as far as practicable ensure that the price to be paid is fair and reasonable and will ensure value for money for the Trust. Shall ensure that appropriate checks are carried out as to the technical and financial capability of those firms that are invited to tender or quote where it is impractical to use a potential contractor from a list of approved firms/individuals or where a list has not been prepared. Monitor and ensure compliance with the guidance issued by the DOH and NHSI on fraud and corruption including the appointment of the Local Counter Fraud Specialist. Immediately inform the LCFS and Operational Fraud Team on receipt of information concerning the discovery or suspicion of fraud. Ensure that the arrangements for financial control and financial audit of building and engineering contracts and property transactions comply with relevant guidance. The technical audit of these contracts shall be the responsibility of the relevant Executive Director. SO 10.2.2 Approve and sign all building, engineering, property or capital documents before sealing.

SFI/SO REF AUTHORITIES/DUTIES DELEGATED OR RESERVED TO THE CHIEF FINANCE OFFICER AND THE CHIEF NURSE & DIRECTOR OF PEOPLE The granting of additional increments to staff within budget (other than automatic increments) as per Agenda for Change and Medical staff terms and conditions.

SFI/SO REF AUTHORITIES/DUTIES DELEGATED OR RESERVED TO THE SECRETARY SO 11.2.3 Maintain Register(s) of Interests. SO 11.2.2 Summoning and attending all meetings of the Council and the Board, and keeping the minutes of those meetings. SO 11.2.4 Keep seal in safe place and maintain register of sealing. Keep a register of hospitality.

7 9253587 SFI 23.1 Maintain a Freedom of Information Publication Scheme in accordance with the requirements of the Information Commissioner.

SFI/SO REF AUTHORITIES/DUTIES DELEGATED OR RESERVED TO THE DIRECTOR OF HR AND OD Ensure that all Officers are issued with a Contract of Employment and any variation to or termination of, contracts of employment. Authority to enter into and manage contracts for the employment of agency staff or temporary staff or service contracts. All requests for upgrading/re-grading major skill mix changes, in accordance with Agenda for Change and Medical staff terms and conditions, in consultation with the Chief Nurse & Director of People Authority to complete standing data forms affecting pay of new starters, variations to employment terms and conditions, and leavers. Authorisation of payment of removal expenses incurred by Officers taking up new appointments as per policy. Review of grievances in accordance with the Grievance Policy. Implementation of the staff Retirement Policy, in consultation with the Chief Nurse & Director of People: • Authorisation of extensions of contract beyond normal retirement age • Authorisation of return to work in part time capacity under the flexible retirement scheme • Redundancy • Ill health retirement Application of disciplinary procedures as per Disciplinary Policy and Medical Staffing Policy

SFI 13.4.1 Payroll: a) specifying timetables for submission of properly authorised time records and other notifications; b) final determination of pay and allowances; c) making payments on agreed dates; d) agreeing method of payment;

SFI/SO REF AUTHORITIES/DUTIES DELEGATED OR RESERVED TO THE CHIEF MEDICAL OFFICER Oversee and approve the booking processes for bank or agency (locum) medical staff within budget and for exceptional approval of high cost usage Authorisation of Clinical trials. Authorisation of Research projects.

SFI/SO REF AUTHORITIES/DUTIES DELEGATED OR RESERVED TO EXECUTIVE DIRECTORS Authority to fill funded posts on the establishment with permanent staff. Approve carry forward of annual leave up to a maximum of 5 days for relevant staff. Confirm appointment of member of any committee of the Trust as representative on outside bodies. Maintaining archives for all documents in accordance with the Records Management Code. Sign on behalf of the Trust any agreement or document not requested to be executed as a deed. Approve and sign all documents which will be necessary in legal proceedings. Approve arrangements relating to the discharge of the Trust's responsibilities as a bailer for patients' property.

Approve the Trust's major incident plan. 8 9253587 Oversee and approve the booking processes, within their relevant directorates, for bank or agency staff within budget and for exceptional approval of high cost usage..

During periods of significant financial challenge on the organisation, the Executive Directors (via the Executive Committee or by Chair’s Action through Huddle meetings) may instigate additional cost control measures in the recruitment of vacant posts. This may include additional controls of any underspends against existing budgets.

SFI/SO REF AUTHORITIES/DUTIES DELEGATED OR RESERVED TO ALL DIRECTORS AND HEADS OF DEPARTMENTS Pay and expenses • Authority to authorise overtime • Authority to authorise travel and subsistence expenses Family leave as per the Trust's policy • Bereavement leave • Special leave for family and domestic reasons • Paternity or maternity or parental leave

Special Leave as per the Trust's policy • Jury service • Armed service • Short term unpaid leave • Employment break leave • Medical staff leave of absence – paid and unpaid Sick leave per the Trust's Attendance Management Policy: • Phased return to work part-time on full pay to assist recovery • Extension of sick leave on full or half pay Study and professional leave Duty to disclose any non-compliance with these Standing Financial Instructions to the Chief Finance Officer as soon as possible together with full details of the non- compliance and the circumstances around non-compliance.

SFI/SO REF AUTHORITIES/DUTIES DELEGATED OR RESERVED TO ALL OFFICERS Identify overseas visitors or services users who are required to pay for the treatment they receive and ensure action is taken for the invoicing of any services provided. Comply with guidance contained in the YDH Code of Conduct and Conflicts of Interest policy. Immediately inform their Head of Department on the discovery or suspicion of any loss. Immediately inform the Chief Executive and Chief Finance Officer or an Officer charged with investigating loss or fraud or confidentiality on receipt of any information concerning the discovery of or suspicion of fraud. Informing the Chief Finance Officer of monies due to the Trust. Completion of time records in accordance with the Chief Finance Officer’s instructions. Submitting termination forms to the HR department in the prescribed form immediately upon knowing the effective date of an Officer’s resignation, termination or retirement.

Notifying the HR Director immediately where an Officer fails to report for duty or to fulfil obligations in circumstances that suggest they have left without notice. Ensure that they comply fully with the guidance and limits specified by the Trust.

9 9253587 Responsibility for security of Trust assets including notifying discrepancies to the Chief Finance and Commercial Officer and reporting losses in accordance with Trust procedures. Responsibility to apply routine security practices in relation to Trust property as may be determined by the Board. Any breach should be reported in accordance with agreed procedures. Responsibility for defining in writing the security arrangements relating to the custody of keys for all stores and locations. Operate a system to identify and deal with slow moving and obsolete stock, for condemnation, disposal and replacement of unserviceable articles and report to the Chief Finance Officer evidence of significant overstocking and any negligence or malpractice. Submit proposals for investment, specifying the details of the outline design and operational requirements in the cases, through the relevant business case approval process. Responsible for ensuring patients and guardians are informed before or at admission either by notices or information booklets or orally that the Trust will generally not accept responsibility or liability for patients’ property unless it is deposited for safe custody and a copy of the patient’s property record is obtained as a receipt. Follow the Trust's policy for the collection, custody, investment, recording, safekeeping, and disposal of patients' property (including the property of deceased patients and of patients transferred to other premises). Declare to the Secretary details of any individual or collective hospitality receipt items in excess of £50. Disclosure of non-compliance with SOs to the Chief Executive.

Disclose to line manager any relationship with a candidate for a staff appointment.

SFI/SO REF AUTHORITIES/DUTIES DELEGATED OR RESERVED TO BUDGET HOLDERS Ensure that all items due under a prepayment contract are received. SFI 5.2.4 Any funds from a Budget not required for their designated purpose(s) revert to the immediate control of the Chief Finance Officer, subject to any authorised Virement. SFI 5.2.3 Ensure that spend is within budget, subject to authorised Virement. SFI 5.2.5 Ensure that non-recurring Budgets are not used to finance recurring expenditure without the authority in writing of the Chief Finance Officer.

SFI/SO REF AUTHORITIES/DUTIES DELEGATED OR RESERVED TO THE CHIEF NURSE AND DIRECTOR OF PEOPLE Inform Officers on appointment of their responsibilities and duties for the administration of the property of patients, and to investigate any related complaints. Oversee and approve the booking processes for bank or agency nursing staff within budget and for exceptional approval of high cost usage Responsible for security management matters and the management of security management measures within the Trust. DECISIONS/DUTIES DELEGATED BY THE BOARD TO COMMITTEES

COMMITTEE DUTIES DELEGATED BY THE BOARD TO COMMITTEES Audit Committee See Terms of Reference, Annex A Remuneration Committee See Terms of Reference, Annex B Board of Trustees See Terms of Reference, Annex C Governance and Quality Assurance Committee See Terms of Reference, Annex D Financial Resilience and Commercial Committee See Terms of Reference, Annex E Workforce Committee See Terms of Reference, Annex F Executive Committee See Terms of Reference, Annex G 10 9253587 The terms of reference will be attached as separate Annexes in the final version of the document following approval. Table A – Delegation of expenditure

All thresholds are inclusive of VAT irrespective of recovery arrangements.

In the interests of business continuity, in the case of absence of the Chief Finance Officer, the Deputy Chief Finance Officer is authorised to deputise per the limits applicable for the Chief Finance Officer in the following table.

In urgent or exceptional circumstances the Executive Directors, Chief Executive or Chief Finance Officer may vary financial limits or authorisation arrangements, such variation to be approved at the next meeting of the Board.

Purchase Orders must be raised for all non-pay expenditure except for the following exclusions:

• All temporary staff including Nursing, Med Locums • Catering • Pharmacy – specialist PO system in place • Utilities i.e. gas, electric, water • Rent & rates • Banking & insurance services • Cross charges/payments between NHS organisations

DELEGATED MATTER DELEGATED LIMIT DELEGATED TO 1. Virement of pay and non-pay expenditure Authorisation of Virement (the transfer £25,000 and above* Chief Finance of budget from one cost code to Officer another, to facilitate activities not originally budgeted)

*Business cases may be required to the Deputy Chief Finance Officer satisfaction of the Chief Finance Officer Up to £24,999*

2. Petty cash disbursements Claims of over £100 will only be £100 up to £200 Deputy Chief Finance Officer considered on an exceptional basis and will not exceed £200 up to £99 Petty Cash Imprest Holder

3. Approval of business cases for new or materially changed investment Business cases for expenditure not £500,000 and above Board approved through the annual planning process.

Business cases for use of monies £250,000 to £499,999 Financial Resilience and earmarked though the annual planning Commercial Committee process in advance of a fully worked up case

Business cases for materially different £50,000 to £249,999 Executive Committee use of an agreed budget

The Chief Executive or Chief Finance Officer may determine that fundamental, high risk or high profile Up to £49,999 Chief Executive and Chief Finance changes to previously Board approved Officer spend plans require a higher level of approval irrespective of financial value

Make decisions within delegated Delegated budget budget envelope to deliver agreed envelope to deliver Budget holder services agreed schemes (Board approved plan)

DELEGATED MATTER DELEGATED LIMIT DELEGATED TO 4. Non pay (purchase orders and invoice authorisation) Requisitioning stock and non-stock £500,000 and above Board items or services within allocated budget which have been subjected to competitive tender or 3 quotations have £100,000 to £499,999 Chief Executive & Chief Finance been obtained (NB EU Directives must Officer be complied with) £50,000 to £99,999 Executive Director & Deputy Chief *Note Chief Executive or Chief Finance Finance Officer Officer must approve all expenditure on consultancy advice in advance of any £5,000 to £49,999 Deputy Director & Senior Finance commitment. Manager

Any spend not budgeted not covered Up to £4,999 Budget Holder by Virement (see 1 above) must be approved by the Chief Finance Officer in advance of any commitment and a business case will be required.

5. Capital expenditure, all limits are per project Annual Capital Plan to be approved by Board of Directors. Capital Budget holder to have authority to spend up to the budget in line with the original purpose. Any expenditure changes and/or a material change will require approval via the following: Approve changes above £500,000 £500,000 and above Board and/or fundamental, high risk or high profile changes to agreed schemes

Approve changes £250,000 to £250,000 to £499,999 Financial Resilience and £499,999 and/or material change to Commercial Committee the agreed schemes

Approve changes £50,000 to £50,000 to £249,999 Executive Committee £249,999 and/or material change to the agreed schemes

Approve changes up to £49,999 within Up to £49,999 Capital Management Group overall budget in line with agreed schemes or to accommodate urgent spend

Decisions within delegated budget Delegated budget Individuals with delegated authority envelope envelope to deliver for projects agreed schemes (Board approved plan)

6. Contracts, all limits are values per annum unless otherwise stated Non-property related Contract value: £500,000 and above pa Board

Board (through Financial Resilience and Commercial Committee) to £100,000 to £499,999 pa Chief Executive & Chief Finance approve any non-property related Officer contract with commitments exceeding 3 years unless the total £50,000 to £99,999 pa Executive Director & Deputy Chief contract value is less than £750,000 Finance Officer £5,000 to £49,999 pa Within existing budget provision or Deputy Director & Senior Finance approved business case and subject Up to £4,999 pa Manager to tendering and contracting Budget Holder procedures

Additional approval is required for contracts not awarded to the lowest bidder

DELEGATED MATTER DELEGATED LIMIT DELEGATED TO New property leases or extension of Rental value: existing lease commitment over 1 Over £150,000 pa Board year Up to £149,999 pa Chief Executive and Chief Finance Officer

1 Year Tenancy Arrangements Up to £14,999 pa per Facilities Manager & Deputy Chief tenancy. Finance Officer

7. Approval of single tender or single quotation action Approval of use of single tender or £50,000 and above Chief Finance Officer single quotation waiver in accordance with Tendering and Up to £49,999 Deputy Chief Finance Officer Contracting procedure (SFIs)

8. Trust fund expenditure all limits are per project The Trustees may, in their discretion, £5,000 and above Board of Trustees approve a block of funding to be spent on a series of projects, delegating final £500 up to £4,999 Executive Director (or nominated approval to the Chief Finance Officer Deputy) responsible for service area of spend

Up to £499 Nominated Fund Holder 9. Disposal and condemnations all limits are per project Budget holders should seek advice £50,000 and above Chief Finance from Procurement within SSL before Officer any disposal or condemnation is up to £49,999 actioned. Deputy Chief Finance Officer With current replacement value of: 10. Losses and special payments all limits are per project or case Abandoned capital schemes £50,000 and above Audit Committee

£5,000 up to £49,999 Chief Executive or Chief Finance Officer

up to £4,999 Deputy Chief Finance Officer

Losses of cash due to theft, fraud, £50,000 and above Audit Committee overpayment & others

Bad debts and claims abandoned £5,000 up to £49,999 Chief Executive or Chief Finance Officer

up to £4,999 Deputy Chief Finance Officer

Compensation payments by court order £50,000 and above Audit Committee

up to £49,999 Chief Executive and Chief Finance Officer All ex-gratia payments £50,000 and above Audit Committee

up to £49,999 Chief Executive and Chief Finance Officer

YDH │ Operating and Finance Performance Overview

│ March 21

1 CONTENTS

1) Safe 2) Effective 3) Responsive 4) Caring

2 Safe Mortality Rates Number of Inpatient Deaths 120 110 100 March 21 90 80 Weekend Number of Crude Mortality Latest HSMR 70 Mortality Trustwide Rate (Deaths / 60 Feb-20 to Jan-21 Relative Risk Deaths Discharges) 50 40 0.951 0.941 60 1.48% 30 20 10 March 20 0 Weekend Number of Crude Mortality HSMR Mortality Trustwide Rate (Deaths / Feb-19 to Jan-20 -3σ Centre Line +3σ Number of Deaths Relative Risk Deaths Discharges) 0.839 0.915 69 1.92% HSMR Trend (Rolling 12 Month Periods) 1.30

1.20

1.10 RAG status: Achieved 1.00 The trust's HSMR was 95.1 in for the 12 month period up to

January 2021. The Trust continues to perform significantly better Risk Relative 0.90 than the National Average. The total number of deaths for 2020 0.80 of 743 is not significantly higher than the previous year 2 year average of 735 deaths. 0.70

Further information is available in the quarterly mortality report.

3 Patient Falls and Pressure Ulcers Safe Patient Falls 120 March 21 14 days Bed 1000 per Rate 100 Patient Falls Patient Falls rate Pressure 12 Patient Falls Causing Harm per 1000 bed days Ulcers 80 10 59 3 6.60 3 60 8 6 40 March 20 ofNumber Falls 4 20 2 Patient Falls Patient Falls rate Pressure Patient Falls 0 0 Causing Harm per 1000 bed days Ulcers 70 4 8.09 7

Additional notes Patient Falls Patient Falls per 1000 Bed Days Count Diff % Diff • Patient Falls YTD: 857 61 +7.66% Pressure Ulcers +2 • Patient Falls YTD LY: 796 12 3 • Pressure Ulcers YTD: 56 Days Bed 1000 per Rate -1 -1.75% • Pressure Ulcers YTD LY: 57 10 2.5 • Pressure Ulcers 6M Avg: 4.3 8 2 -1.3 -23.53% • Pressure Ulcers 6M Avg LY: 5.7 6 1.5

4 1 RAG status: Failed, close to achievement 2 0.5 Targets Failed. Reason: Number of PressureUlcers 0 0 A review of patient falls is being undertaken to identify any specific areas of learning.

The numbers of reported pressure ulcers per 1000 bed days has Pressure Ulcers Pressure Ulcers per 1000 Bed Days remained consistent over the last 3 months.

4 Safe Infection Control Gram Negative Bloodstream Infections 9 8 March 21 7 6 MRSA C.Diff YTD C.Diff YTD C.Diff 5 Bacteremia (Lapses in Care) (Lapses in Care) 4 0 0 1 10 3 2 Positive Covid-19 1 E.Coli P.Aeruginosa Klebsiella spp. Cases 0 1 0 0 10

Additional notes E.Coli Infections Klebsiella Infections P.Aeruginosa Infections C.Diff MRSA

• The Trust's Threshold for C/Diff cases this year is TBC February 2021 Trust infection rate per 100,000 bed days; YDH Hospital Onset BSI Infection rate per 100,000 bed days E.Coli - 0.00, P.Aeruginosa - 12.69, Klebsiella - 12.69 50

40 February 2021 National infection rate per 100,000 bed days;

E.Coli - 18.75, P.Aeruginosa - 5.99, Klebsiella - 14.44 30

(All rates shown above are for hospital onset infections only) 20

10 RAG status: Achieved Rate per 100,000 bed days Targets Met. 0 There have been 10 reported C.Diff cases this financial year. The trust's C.Diff threshold for 20/21 is yet to be confirmed. Further information is available in the quarterly quality report. YDH E.Coli YDH Klebsiella Ecoli National Benchmark Klebsiella National Benchmark

5 Stroke Services Effective 90% Stroke Unit Stay Achievement

100% March 21 80% YDH SSNAP Level YDH SSNAP Score 90% Stay on 12hr CT Scan (Jul-20 to Sep-20) (Jul-20 to Sep-20) Stroke Unit 60%

B 71 73.53% 96.30% 40%

Targets 20% B 70 83.3% 83% 0%

Additional notes Stroke Performance national benchmarks from 18/19 Stroke Audit: SSNAP Levels/Scores - Peer Trust Comparison 4hr Direct Admission = 58.40% 100 12hr CT Scan = 95.20% 90 90% Stay = 84.40% 80 Thombolysed = 11.90% 70 Consultant 24hr Review = 83.90% 60 50 MPH 40 DCH RAG status: Achieved 30 YDH 20 Targets Met. 10 The 90% Stay Stroke performance has been affected by changes in 0 patient flows to support Covid 19 related Infection Control Jul-19 to Oct-19 to Jan-20 to Apr-20 to Jul-20 to measures. Sep-19 Dec-19 Mar-20 Jun-20 Sep-20 SSNAP Data Release Period

6 Admissions and LOS Responsive Average Length of Stay (Days) 6 March 21 5 Elective Non-Elective Average Average Non - Admissions Admissions Elective LOS Elective LOS 4 1,830 2,228 2.13 4.00 3 2

March 20 1

Elective Non-Elective Average Average Non - 0 Admissions Admissions Elective LOS Elective LOS 1,681 1,919 2.05 5.20 LOS Elective LOS Non-Elective Additional notes Count Diff % Diff • Elective Admissions YTD: 16,855 Admissions -7,065 -29.54% • Elective Admissions YTD LY: 23,920 2500 • Non-Elective Admissions YTD: 22,430 2250 -3,887 -14.77% • Non-Elective Admissions YTD LY: 26,317 2000 • Average Elective LOS vs LY diff: +0.1 +4.15% 1750 • Average Non-Elective LOS vs LY diff: -1.2 -23.11% 1500 1250 RAG status: Achieved 1000 750 Targets Met. 500

Total Elective Admissions Non-Elective Admissions

7 Covid-19 Elective Recovery Responsive Somerset FT & Yeovil FT - RTT New Clocks % Re-Start Somerset FT and YDH FT >52 Week RTT Waits 100.00% 3600 3200 80.00% 2800 2400 60.00% 2000 40.00% 1600 1200 20.00% 800 400 0.00% 0

SFT RTT New Clocks % Re-Start YDH RTT New Clocks % Re-Start SF T RTT Incomplete Pathways >52 Weeks YDH RTT Incomplete Pathways >52 Weeks

Somerset FT & Yeovil FT Elective % Re-Start Somerset FT and Yeovil FT- Diagnostic Activity 140.00% 100.00% 120.00% 80.00% 100.00% 80.00% 60.00%

60.00% 40.00% 40.00% 20.00% 20.00% 0.00% 0.00%

SFT Elective % Re-Start YDH Elective % Re-Start SFT Diagnostics % Re-S tar t YDH Diagnostics % Re-S tar t

8 Readmissions Responsive Number of Readmissions

500 15% March 21 400 Readmission Rate Related Unrelated Number of 10% readmissions (Exc 0 day LOS) Readmission Rate Readmission Rate 300

414 9.31% 5.35% 4.85% 200 5% 100 March 20 Number of Readmission Rate Related Unrelated 0 0% readmissions (Exc 0 day LOS) Readmission Rate Readmission Rate 357 9.28% 4.97% 4.94% Readmissions Readmission Rate (exc 0 day)

Additional notes Number of Related/Unrelated Readmissions Count Diff % Diff • Readmissions YTD: 3,960 500 -1,016 -20.42% • Readmissions YTD LY: 4,976 400 • Related Readmissions 217 38 +21.23% • Related Readmission LY: 179 300 • Readmissions Rate (All) 9.39% 0.29% -- 200 • Readmissions Rate (All) LY: 9.10% 100 RAG status: Achieved 0 Targets Met.

Related Readmissions Unrelated Readmissions

9 Effective Criteria to Reside Beddays that do not meet the 'criteria to reside' 2000

March 21 1500 Bedays that do not Number of Stranded 40% meet the criteria to Patients (21+ Days LOS) - Reduction 1000 reside as at month end Ambition 1,315 32 24 500

March 20 0 Bedays that do not Number of Stranded 40% meet the criteria to Patients (21+ Days LOS) - Reduction reside as at month end Ambition 819 24 24 Number of Stranded Patients (as at the end of the reporting month) 120

100

RAG status: Achieved 80 60 Targets Met. 40

20

0

Stranded Patients (14-20 Day LOS) Stranded Patients (21+Day LOS) Reduction Ambition (21+Day LOS Only)

10 Responsive Cancelled Operations Hospital non Clinical On the Day Cancellation of Elective Operations Mar-21 March 21 On the Day YTD On the Day Rebooked Urgent Non-Clinical Non-Clinical within 28 Day Cancellations Reasons Reasons Target 1 34 100.00% 6 TCI / Appointment rescheduled - requires alternative session / clinic

March 20 On the Day YTD On the Day Rebooked Urgent Non-Clinical Non-Clinical within 28 Day Cancellations Reasons Reasons Target 0 2 5 69 100.00% 2 Number of Cancelled Operations Additional notes 30

Note: For any elective operation cancelled by the trust on the 25

day of the operation/admission, an offer of a new date must be 20 within 28 days of the cancelled operation date. 15

RAG Status: Achieved 10 5 Targets Met. 0

On the Day - Cancelled Operations

11 Diagnostic Waits Responsive Diagnostic 6 Week Waits % 100% March 21 80% Overall Diagnostic 6 Week Waits 60%

93.73% 40% (Target 99.0%) 20%

0%

Additional notes The area with the lowest diagnostics performance was: Diagnostic 6 Week Waits % Target DM01 % - Trajectory Endoscopy % 78.50% Diagnostic Waits by Type of Test 100%

RAG status: Failed 80%

Targets Failed. Reason: 60% The diagnostic waiting times continue to improve following the impact of Covid 19. Staff sickness has 40% impacted the pace of physiological and endoscopy 20% recovery. 0%

Imaging % Physiological Measurement % Endoscopy %

12 Responsive RTT Performance RTT Incomplete Pathways - 18 Weeks 100%

March 21 90%

18 Week Incomplete Pathways > 52 Week Waits 80%

64.83% 746 70%

TBC 60% March 20 50%

18 Week Incomplete Pathways > 52 Week Waits 40% 85.38% 2 RTT Incomplete Pathways - 18 Weeks Constitutional Standard Additional Notes: 6 Month Moving Average RTT Incomplete Pathways with All Stops Specialties with the Lowest RTT Performance this month: 12,000

Neurology - 33.56% 10,000 ENT - 38.67% 8,000

6,000 RAG status: Failed 4,000

Targets Failed. 2,000 The waiting list remains a consistent level, however the 0 pathways continue to age at an increasing rate.

Number of Stops Number of Incomplete Pathways

13 RTT Pathways Responsive

RTT Incomplete Pathways (total waiting list size) March 21 11,000 Incomplete Pathways waiting Pathways waiting 10,000 Pathways > 18 Weeks > 40 Weeks 9,000 9803 3448 985 8,000 7,000

6,000 March 20 5,000 Incomplete Pathways waiting Pathways waiting Pathways > 18 Weeks > 40 Weeks 9486 1387 24 Number of Incomplete Pathways RTT Incomplete Pathways - Aging 2500 Additional notes Diff % Diff 2000 • Number of 317 3.34% Incomplete Pathways 1500

1000 RAG status: Achieved 500 Targets Met. The waiting list size continues to increase and is expected to 0 rise back to 90% of pre-Covid levels by March 21. >18 >19 >20 >21 >22 >23 >24 >25 >26 >30 >40 52+ weeks weeks weeks weeks weeks weeks weeks Weeks weeks weeks weeks Weeks

Admitted Non Admitted

14 Responsive Cancer Performance 2 Week Cancer Targets 100% 95% February 21 90% 2 Week Exhibited Breast 85% 2 Week Suspected Cancer Cancer Symptoms 80% 94.46% 100.00% 75% 70% (National Target - 93.00%) (National Target - 93.00%) 65% 60%

31 Day Treatment First 62 Day Treatment Standard

2WW Breast 2WW Suspected Cancer 100.00% 89.72% 62 Day Treatment Standard (National Target - 96.00%) (National Target - 85.00%) 100% 95% 90% 85% RAG status: Achieved 80%

Targets Met. 75% 70% 65% 60%

62 Day Treatment Standard

15 Cancer 62 Day Urgent GP Referral Pathway Responsive 62 Day Site Breakdown - 3 Month Review Achievement, Referrals and Breaches February 21 Cancer Site December 20 January 21 February 21 2020/21 YTD Target: 85% Brain 0 0 0 0 0 0 0 0 Breast 92.3% 13 1 100.0% 7 0 100.0% 6 0 96.5% 85 3 Gynaecology 0 0 100.0% 1.5 0 100.0% 4.5 0 84.2% 28.5 4.5 Haematology 100.0% 2 0 100.0% 2 0 100.0% 3 0 81.0% 21 4 Head and Neck 0.0% 0.5 0.5 100.0% 0.5 0 0 0 57.1% 3.5 1.5 Lower GI 50.0% 3 1.5 50.0% 6 3 50.0% 5 2.5 60.4% 55.5 22 Lung 77.8% 4.5 1 100.0% 1 0 100.0% 3 0 71.2% 26 7.5 Sarcoma 0 0 0 0 0 0 0 0 Skin 100.0% 14 0 94.4% 18 1 95.0% 20 1 96.4% 222 8 Upper GI 60.0% 5 2 53.9% 6.5 3 66.7% 3 1 71.4% 45.5 13 Urology 88.2% 8.5 1 77.8% 9 2 87.5% 8 1 69.4% 103 31.5 Other 100.0% 1 0 100.0% 2 0 100.0% 1 0 100.0% 13 0 All 86.41% 51.5 7.0 83.18% 53.5 9.0 89.72% 53.5 5.5 84.25% 603.0 95.0

Number of 62 Day Patients Seen - YTD Additional notes 240 Please note that a shared breach with another organisation 200 will show as 0.5 on the table above. 160 120 RAG status: Achieved 80 Targets Met. 40 The figures above are reflective of the February 21 CWT 0 submission and are subject to change until the final quarter end CWT submission.

16 Outpatients Transformation Responsive Number of Outpatient Attendances 2020/21 YTD 24000

Total Outpatients Outpatient Procedures Virtual Clinic Activity 20000 Activity Proportion Proportion 16000 214282 11.50% 25.5% 12000 Average Wait to First ASI Rate DNA Rate 8000 OP (Weeks) 94.13% 13.62 4.66% 4000 0 All Appointment Patient Cancellations Trust Cancellations Cancellations

26.84% 6.51% 20.33% New OP Attendances Follow-Up OP Attendances

Proportion of Virtual Clinic Activity Comments 60.0% Please note that 'Virtual' Clinic activity includes Telephone follow-up clinics. - Patient Initiated Follow-Ups (PIFU) now in place for all specialities & being 50.0% reported on. - Demonstrations and Action Planning sessions held with Synertec, Dr Doctor & 40.0% Medio to progress the initiatives that will be part of the Digital Roadmap 2020/21. 30.0% - On-site review of check-in kiosks and their use & identification of future enhancements, held with Jayex. 20.0% - Further enhancements made to Dr Doctor service to enable 100% text/email confirmation & reminder messages to be sent along with the launch of an 10.0% improved Empty Slot Report to improve utilisation rate. − Review of Polling Ranges, Wait Times and the DOS, to reduce ASI rate. All plans 0.0% and initiatives to compliment the Trust’s Digital Strategy and vice-versa. − Expand the scope of the Dr Doctor functionality e.g. short notice cancellations (coverage of reminder and confirmation messages now at 100%). Virtual Clinic Activity %

17 ED Transformation Responsive A&E 4 Hour Performance - All Attendances

100% March 21 98% A&E 4 Hour Average A&E Total A&E Attendances 96% Performance Attendances per day 94% 95.36% 4225 136.29 92% Year on Year Attendances resulting in 90% 12 Hour Trolley Waits A&E Growth an Inpatient stay 88% -20.75% 35.48% 1 86%

Median Time to Triage Median Time to Median Time in Emergency (hh:mm) Treatment (hh:mm) Department (hh:mm) 4Hr Performance 6 Month Moving Average 00:10 00:41 02:44 Avg A&E Attendances per day Ambulance Handovers Number of Ambulance Average Ambulance 200 Performance Handovers Arrivals per day -- -- 44.84 150

100 Comments

The A&E 4 hour target has been impacted by high levels of patient acuity and 50 an increase in Mental Health presentations. 0

Avg A&E Attendances per day Avg Ambulance Arrivals per day Avg Emergency Admissions Per Day

18 Patient Complaints and PALS Caring

Number of Complaints March 21 10 PALS PALS Complaints PALs 8 Concerns Enquiries 7 124 29 95 6 4 March 20 2 PALS PALS Complaints PALs Concerns Enquiries 0 2 114 46 68

Additional notes Complaints

• Complaints YTD: 53 +2 +3.92% PALS Breakdown • Complaints YTD LY: 51 180 • PALs YTD: 1444 +160 +12.46% 160 • PALs YTD LY: 1284 140 120 100 RAG status: Achieved 80 Targets Met. 60 40 20 0

PALS Concerns PALS Enquiries

19 YDH Group │ Workforce Report Well Led - Staffing

│ March 21

20 Workforce Assurance Well Led

March 21 Workforce Assurance - YDH Only

Workforce Monthly Position Contracted FTE Additional Additional Prof Admin & Allied Health Medical & Nursing & Senior Non-Registered Ancillary Mar-20 Mar-21 Clinical Services Sci & Tech Clerical Professionals Dental Midwifery Reg Managers Nursing 1893.5 2031.7 70.9 63.1 411.4 132.0 34.5 267.2 679.2 34.9 338.6

Workforce Monthly Position Labour Turnover Rolling 12 Month Trend Additional Additional Prof Admin & Allied Health Medical & Nursing & Senior Non-Registered Target Ancillary Mar-20 Mar-21 Clinical Services Sci & Tech Clerical Professionals Dental Midwifery Reg Managers Nursing 12% - 17% 16.71% 15.36% 18.89% 9.02% 15.06% 14.19% 10.00% 20.92% 12.20% 11.59% 21.13%

Workforce Monthly Position Sickness Absence - In Month Rolling 12 Month Trend Additional Additional Prof Admin & Allied Health Medical & Nursing & Senior Non-Registered Target Ancillary Feb-20 Feb-21 Clinical Services Sci & Tech Clerical Professionals Dental Midwifery Reg Managers Nursing 3% 3.22% 3.61% 7.92% 1.11% 2.93% 2.98% 8.54% 0.60% 4.46% 0.00% 4.82%

Workforce Monthly Position Mandatory Training Rolling 12 Month Trend Additional Additional Prof Admin & Allied Health Medical & Nursing & Senior Non-Registered Target Ancillary Mar-20 Mar-21 Clinical Services Sci & Tech Clerical Professionals Dental Midwifery Reg Managers Nursing 85% 89.46% 88.41% 90.58% 93.41% 91.22% 88.15% 93.22% 80.29% 89.50% 79.09% 88.10%

Workforce Monthly Position Appraisals Rolling 12 Month Trend Additional Additional Prof Admin & Allied Health Medical & Nursing & Senior Non-Registered Target Ancillary Mar-20 Mar-21 Clinical Services Sci & Tech Clerical Professionals Dental Midwifery Reg Managers Nursing 90% 85.35% 84.60% 86.90% 80.60% 79.15% 77.33% 82.05% 85.13% 87.31% 67.74% 90.76%

Please note that the trust's internal targets for Labour Turnover and Mandatory Training have been changed from July 2019. Historic data from before this point will be RAG rated against the prior set of targets for these measures.

21 Well Led Contracted FTE Contracted FTE 2700 March 21 2500 2300 YDH Group YDH DCUK SHS SSL 2100 2540.5 2031.7 -- 238.3 270.4 1900 March 20 1700 1500 YDH Group YDH DCUK SHS SSL

2369.3 1893.5 0.0 222.3 253.6 YDH SSL DCUK SHS

Additional notes Count Diff % Diff Contracted FTE - 3 Year Trend • Group FTE: 2540.5 Additional Clinical Services +171 +7.22% • Group FTE LY: 2369.3 Additional Prof Sci & Tech • Group FTE (Excl SHS): 2302.1 Admin & Clerical +155 +7.22% • Group FTE (Excl SHS) LY: 2147.0 Allied Health Professionals Ancillary Comments Medical & Dental Non-Registered Nursing YDH has seen a growth in the following areas: Nursing & Midwifery Reg • Medical posts as vacant posts have been filled • Nursing and HCA posts for safer staffing reasons Senior Managers • Admin posts to support expansion of services SSL • SHS as new practices have joined SHS • SSL as new contracts are won • All of this growth is planned & expected 0 100 200 300 400 500 600 Mar-19 Mar-20 Mar-21

22 Well Led Turnover Labour Turnover - YDH Only 20.0% March 21 15.0% YDH Group YDH DCUK SHS SSL 10.0% 13.95% 15.36% -- 6.41% 12.83% 5.0% March 20 0.0% YDH Group YDH DCUK SHS SSL

16.40% 16.71% 0.00% 14.93% 15.87% YDH Turnover Target Lower Limit Target Upper Limit

Additional notes Rolling Turnover by Skills Group Achievement Diff • Group Turnover: 13.95% Additional Clinical Services -2.45% Additional Prof Sci & Tech • Group Turnover LY: 16.40% Admin & Clerical • YDH Turnover: 15.36% -1.35% Allied Health Professionals • YDH Turnover LY: 16.71% Ancillary Medical & Dental Comments Non-Registered Nursing Nursing & Midwifery Reg Turnover remain low although increased slightly in February. Senior Managers From July 2019 onwards, the trust's internal labour turnover SSL target has changed to be within 12% - 17%. SHS Please note that DCUK ceased to exist as of March 2020. 0% 5% 10% 15% 20% 25% 30% Mar-19 Mar-20 Mar-21

23 Leaving Reasons - YDH Well Led YDH Rolling Year Leavers by Reason

Death in service March 21 Dismissal Number of Leavers Number of Resignations - Rolling Year - Rolling Year End of Fixed Term 320 221 Pregnancy

Redundancy March 20 Resignation Number of Leavers Number of Resignations - Rolling Year - Rolling Year Retirement

316 247 0 50 100 150 200 250 300 Mar-19 Mar-20 Mar-21

Additional notes Count Diff % Diff YDH Rolling Year Leavers - Resignations • Rolling Year Leavers: 320 +4 +1.27% Adult Dependants • Rolling Year Leavers LY: 316 Better Reward Package Child Dependants Further education or training Comments Hea lth Incompatible Working Relationships Big reduction in work life balance as a reason for leaving Lack of Opportunities which hopefully is beginning to show the benefits of the Other/Not Known work we are doing around flexible working. Promotion Promotion continues to increase as a reason which needs a deep dive Relocation along with lack of opportunity for SSL. Work Life Bala nce Figures exclude junior doctors rotations and internal 0 25 50 75 100 transfers and are based on a rolling 12 month period. Mar-19 Mar-20 Mar-21

24 Leaving Reasons - SSL Well Led SSL - Rolling Year Leavers by Reason

Death in service March 21 Number of Leavers Number of Resignations Dismissal - Rolling Year - Rolling Year End of Fixed Term 38 25 Redundancy

March 20 Resignation Number of Leavers Number of Resignations Retirement - Rolling Year - Rolling Year

43 29 0 5 10 15 20 25 30 35 Mar-19 Mar-20 Mar-21

Additional notes Count Diff % Diff SSL - Rolling Year Leavers - Resignations • Rolling Year Leavers: 38 -5 -11.6% Better Reward Package • Rolling Year Leavers LY: 43 Child Dependants Further education or training Hea lth Incompatible Working Relationships Comments Lack of Opportunities Other/Not Known The number of leavers is in-line with expectations. Promotion Relocation Work Life Bala nce

0 2 4 6 8 10

Mar-19 Mar-20 Mar-21

25 Leaving Reasons - SHS Well Led SHS - Rolling Year Leavers by Reason

March 21 Dismissal

Number of Leavers Number of Resignations End of Fixed Term - Rolling Year - Rolling Year Redundancy 71 7 Resignation

March 20 Retirement Number of Leavers Number of Resignations - Rolling Year - Rolling Year No Category Recorded

92 62 0 10 20 30 40 50 60 70 Mar-19 Mar-20 Mar-21

Additional notes Count Diff % Diff SHS - Rolling Year Leavers - Resignations • Rolling Year Leavers: 71 -21 -22.8% Better Reward Package • Rolling Year Leavers LY: 92 Hea lth Incompatible Working Relationships Lack of Opportunities Other/Not Known Comments Promotion Number of leavers is in line with expectations. Relocation Resignation Work Life Bala nce

0 5 10 15 20 25 Mar-19 Mar-20 Mar-21

26 Well Led Leavers in Month Length of Service Skills Group Less than 1 Yr 1 to 3 Yrs Over 3 Yrs Total Additional Clinical Services 1 2 0 3 March 21 Additional Prof Sci & Tech 0 0 0 0 Admin & Clerical 0 1 3 4 YDH Group YDH DCUK SSL SHS Allied Health Professionals 0 0 3 3 Ancillary 0 0 0 0 46 30 0 4 12 Estates 0 0 0 0 Medical & Dental 3 1 0 4 Non-Registered Nursing 2 1 2 5 March 20 Nursing & Midwifery Reg 0 4 6 10 Senior Managers 0 0 1 1 YDH Group YDH DCUK SSL SHS DCUK ------0 SHS ------12 28 23 0 4 1 SSL 0 3 1 4 Total 6 12 16 46

Additional notes In Month Leavers by Skills Group Count Diff % Diff • In Month Leavers: 46 Additional Clinical Services +18 +64.29% Additional Prof Sci & Tech • In Month Leavers LY: 28 Admin & Clerical Allied Health Professionals Ancillary Medical & Dental Non-Registered Nursing Comments Nursing & Midwifery Reg 39.1% of the leavers have less than 3 years service. Senior Managers All nurse leavers have a ‘stay’ or ‘exit’ interview as DCUK SHS appropriate. SSL Covid-19 appears to have reduced the number of staff leaving. 0 2 4 6 8 10 12 14 Mar-19 Mar-20 Mar-21

27 Vacancies Being Recruited to - YDH Group Well Led

Vacancies being recruited to (FTE) Jan-21 Feb-21 Mar-21 Additional Clinical Services 2.0 1.0 0.0 Additional Prof Scientific & Technical 3.0 0.0 4.6 Admin & Clerical 11.2 10.9 13.3 Allied Health Professionals 4.3 2.6 4.8 Ancillary 0.0 0.0 0.0 Estates 0.0 0.0 0.0 HCA's 22.0 0.0 2.0 Medical 8.0 6.5 6.5 Medical Training 0.0 1.0 1.0 Senior Managers 0.0 0.0 0.0 SSL 4.0 2.0 1.0 DCUK 0.0 0.0 0.0 Specialist Nursing / Band 6 9.5 4.0 4.5 Nursing and Midwifery Qualified - Childrens 1.0 0.0 0.0 Nursing and Midwifery Qualified - Ward Areas 0.0 0.0 0.0 Nursing and Midwifery Qualified - EAU / ED 0.0 0.0 0.0 Nursing and Midwifery Qualified - ICU 0.0 0.0 0.0 Nursing and Midwifery Qualified - Outpatients 2.0 1.6 0.0 Nursing and Midwifery Qualified - Midwifery 0.0 0.0 0.0 Nursing and Midwifery Qualified - Theatres 2.0 0.0 0.0 Nursing and Midwifery Qualified - Total 5.0 1.6 0.0 Total 69.0 29.6 37.7

28 Well Led Sickness Absence Absence vs Target 5.0%

February 21 4.0%

YDH Group YDH DCUK SHS SSL 3.0%

3.66% 3.61% -- 1.86% 5.62% 2.0%

February 20 1.0% 0.0% YDH Group YDH DCUK SHS SSL

3.20% 3.22% 5.66% 2.94% 2.75% YDH Absence Target

Additional notes Count Diff Absence by Skills Group • Group Absence: 3.66% Additional Clinical Services 0.46% • Group Absence LY: 3.20% Additional Prof Sci & Tech • Group 12 month sickness absence: 3.43% Admin & Clerical 0.72% • Group 12 month sickness absence LY: 2.71% Allied Health Professionals Ancillary Comments Medical & Dental Non-Registered Nursing There has been a spike in absence levels but a review of Nursing & Midwifery Reg reasons show there is no cause for concern. Resilience levels Senior Managers among staff seem high and good support measures are in SSL place. SHS Please note that the Absence figures only relate to sickness 0% 2% 4% 6% 8% 10% absence, and is reported one month in arrears. Feb-19 Feb-20 Feb-21

29 Well Led Statutory Training Mandatory Training vs Target - YDH Only 100%

March 21 90%

YDH Group YDH DCUK SHS SSL 80%

88.11% 88.41% -- 86.80% 87.44% 70%

March 20 60% 50% YDH Group YDH DCUK SHS SSL

86.89% 89.46% 0.00% 76.04% 80.09% YDH Mandatory Training Target

Additional notes Mandatory Training Nonachievement by Skills Group Count Diff Additional Clinical Services • Group Mandatory Training: 88.11% 1.22% Additional Prof Sci & Tech • Group Mandatory Training 86.89% Admin & Clerical • YDH Mandatory Training: 88.41% -1.05% Allied Health Professionals • YDH Mandatory Training LY: 89.46% Ancillary Medical & Dental Comments Non-Registered Nursing Nursing & Midwifery Reg Remains over target, however Infection Control, Information Senior Managers Governance, and Resus remain a focus. Additional training SSL sessions are being provided and performance is likely to SHS improve. 0% 5% 10% 15% 20% 25% 30% Mar-19 Mar-20 Mar-21

30 Statutory Training Elements Well Led

Statutory Training Elements vs Target - YDH Only March 21 Overall Conflict Equality Achievement Conflict 88.11% 92.18% 92.46% Equality Information Fire Infection Control Governance Fire 93.06% 84.40% 75.98% Infection Control Manual Handling Prevent Resus

88.83% 89.50% 78.93% Information Governance

Childrens Adults Safeguarding Manual Handling Safeguarding 90.60% 92.25% Prevent

Comments Resus Please note that the trust's target for statutory training is 85%, with the safeguarding elements benchmarked against a 90% Adults Safeguarding target.

Childrens Safeguarding

50% 60% 70% 80% 90% 100% Mar-20 Mar-21

31 Safeguarding Training Well Led Childrens Safeguarding Achievement vs Target - YDH Only 100%

March 21 90% Childrens Adults Safeguarding Safeguarding 80%

90.60% 92.25% 70% Childrens Childrens Childrens 60% Safeguarding - Safeguarding - Safeguarding - Level 1 Level 2 Level 3 50% 90.38% 91.53% 91.28%

YDH Childrens Safeguarding Achievement Target

Additional notes Achievement Adults Safeguarding Achievement vs Target - YDH Only • Childrens Safeguarding Level 1 - YDH 92.50% 100% • Childrens Safeguarding Level 2 - YDH 91.53% • Childrens Safeguarding Level 3 - YDH 91.28% 90% • Childrens Safeguarding Level 1 - DCUK -- • Childrens Safeguarding Level 2 - DCUK -- 80% • Adults Safeguarding - YDH 93.99% 70% • Adults Safeguarding - DCUK -- 60%

Comments 50% Please note that the trusts contractual target for safeguarding training compliance is 90%. YDH Adults Safeguarding Achievement Target

32 Well Led Appraisals Appraisals vs Target - YDH Only 100%

March 21 90%

YDH Group YDH DCUK SHS SSL 80%

86.15% 84.60% -- 92.11% 90.67% 70%

March 20 60% 50% YDH Group YDH DCUK SHS SSL

85.32% 85.35% 0.00% 87.30% 0.00% YDH Appraisals Achievement Target

Additional notes Appraisals by Skills Group Count Diff Additional Clinical Services • Group Appraisals: 86.15% 0.83% Additional Prof Sci & Tech • Group Appraisals LY: 85.32% Admin & Clerical • YDH Appraisals: 84.60% -0.75% Allied Health Professionals • YDH Appraisals LY: 85.35% Ancillary Medical & Dental Comments Non-Registered Nursing Nursing & Midwifery Reg The YDH Group 12 month appraisals achievement in March Senior Managers was 69.6%. Appraisal performance is below target as SSL expected because of Covid, however there is now a real focus SHS on improving this over the following few months. 0% 20% 40% 60% 80% 100% Mar-19 Mar-20 Mar-21

33 Appendix A - Slide Index Appendix

Slide Index - Performance 1) Performance Section Title Slide 16) Cancer 62 Day Urgent GP Referral Pathway 2) Contents 17) Outpatients Transformation 3) Mortality Rates 18) ED Transformation 4) Patient Falls and Pressure Ulcers 19) Patient Complaints and PALS 5) Infection Control 6) Stroke Services 7) Admissions and Length of Stay 8) Covid-19 Elective Recovery 9) Readmissions 10) Criteria to Reside 11) Cancelled Operations 12) Diagnostic Waits 13) RTT Performance 14) RTT Pathways 15) Cancer Performance

34 Appendix A - Slide Index Appendix

Slide Index - Workforce 20) Workforce Section Title Slide 21) Workforce Assurance 22) Contracted FTE 23) Staff Turnover 24) Leaving Reasons - YDH 25) Leaving Reasons - SSL 26) Leaving Reasons - SHS 27) Leavers in Month 28) Vacancies Being Recruited to - YDH Group 29) Sickness Absence 30) Mandatory Training 31) Mandatory Training Elements 32) Safeguarding Training 33) Appraisals

35 YDH │ ConsolidatedOperating and Financial Finance Performance

│ Month 12 - March 2021 Month 12 Contents

1 Group I&E 2 Group agency expenditure Group I&E - Summary

March 2021 £'000' YTD Trust Variance Variance Actual Trust plan Actual Trust plan Annual Plan fav/(adv) fav/(adv) 24,128 17,613 6,515 Income 212,270 204,818 7,452 204,818

(17,201) (11,601) (5,601) Pay (138,347) (133,764) (4,583) (133,764)

(6,635) (5,416) (1,219) Non Pay (67,594) (64,007) (3,587) (64,007)

292 596 (305) EBITDA 6,329 7,047 (718) 7,047

(498) (577) 79 Below EBITDA (6,285) (7,047) 762 (7,047)

(206) 20 (225) BAU - on Financial Improvement Trajectory Basis 44 (0) 44 (0)

(472) (83) (389) Annual Leave Provision (2,230) (500) (1,730) (500)

2,230 0 2,230 Annual Leave Provision - funding recognised 2,230 0 2,230 0

1,552 (62) 1,614 BAU - I&E surplus/(deficit) 44 (500) 544 (500)

1,982 (14) 1,995 Donated Assets 1,945 (87) 2,031 (87)

0 0 0 PSF/FRF/MRET 0 0 0 0

3,533 (76) 3,609 Accounts - I&E surplus/(deficit) 1,989 (587) 2,575 (587)

Key headlines: Income - key favourable variances in month were seen in overseas recruitment and finalised HEE allocation. Clinical income recognises notional income accounted in M12 and offsetting expenditure as per national guidance - £4.240m for central employer pension contributions. In month position includes £0.177m reimbursement of COVID-19 costs incurred outside of the system funding envelope and £1.093m of financial regime additional income. Year to date key favourable variances include overperformance of overseas recruitment, private patients and HEE education and training income. Pay - key variances in month within medical and nursing, other pay includes employer pension contributions offset by income. Continued higher spend on agency of £0.085m in month (£0.669m YTD). Gross incremental COVID-19 costs of £0.426m in month (£7.148m YTD) have been incurred. Non Pay/EBITDA - higher spend in month on drugs, consumables, recharges, professional fees and maintenance, and increase in provisions. Underspends were seen on equipment, IT, training, LLP and CNST costs. Includes COVID-19 costs of £0.221m in month (£2.280m YTD). Donated assets recognise equipment and consumables from DHSC/ NHSE for COVID response and is excluded from performance on a financial trajectory basis. Group I&E - Detail

March 2021 £'000' YTD Variance Variance Actual Trust plan Actual Trust plan fav/(adv) fav/(adv) 20,078 16,037 4,041 NHS Clinical Income 171,933 170,114 1,819 123 146 (23) Non NHS Clinical Income 1,355 1,254 101 2,657 1,430 1,226 Other Income 20,902 17,351 3,550 1,270 0 1,270 Top Up income 18,080 16,098 1,982 24,128 17,613 6,515 Total Income 212,270 204,818 7,452 (4,633) (3,580) (1,053) Medical Pay (42,528) (41,872) (656) (4,750) (4,509) (241) Nursing Pay (50,093) (50,485) 391 (7,818) (3,511) (4,307) Other Pay (45,725) (41,407) (4,318)

(17,201) (11,601) (5,601) Total Pay (138,347) (133,764) (4,583) (2,031) (1,549) (482) Drugs (20,864) (19,002) (1,862) (865) (595) (269) Consumables Non Pay (6,671) (6,483) (188) (3,739) (3,272) (467) Other Non Pay (40,060) (38,522) (1,538) (6,635) (5,416) (1,219) Total Non Pay (67,594) (64,007) (3,587) 292 596 (305) EBITDA 6,329 7,047 (718) (498) (577) 79 Below EBITDA (6,285) (7,047) 762 (206) 20 (225) BAU - on Financial Improvement Trajectory Basis 44 (0) 44 (472) (83) (389) Annual Leave Provision (2,230) (500) (1,730) 2,230 0 2,230 Annual Leave Provision - funding recognised 2,230 0 2,230 1,552 (62) 1,614 BAU - I&E surplus/(deficit) 44 (500) 544 1,982 (14) 1,995 Donated Assets 1,945 (87) 2,031 0 0 0 PSF/FRF/MRET 0 0 0 3,533 (76) 3,609 Accounts - I&E surplus/(deficit) 1,989 (587) 2,575 Group agency expenditure

Mar-21 £'000' YTD Forecast Variance Variance Actual Trust Plan Actual Trust Plan Outturn fav/(adv) fav/(adv) 467 466 (1) Medical 5,105 5,380 275 5,089 46 63 17 Nursing 672 455 (216) 886 22 39 17 Other Pay 359 454 95 366 535 568 33 YDH total 6,136 6,290 154 6,341 81 60 (20) Other Pay 994 773 (221) 1,042 81 60 (20) SSL total 994 773 (221) 1,042 114 50 (64) Medical 1,833 1,361 (472) 1,878 48 15 (33) Nursing 453 324 (128) 430 1 0 (0) Other Pay 7 5 (2) 7 162 65 (97) SHS total 2,292 1,691 (602) 2,315 778 693 (85) Group Total 9,422 8,753 (669) 9,698

Key headlines relating to forecast variance: Increased staffing levels were implemented from April 2020 and have continued to support requirements for COVID 19 management. Escalation areas have been opened more frequently to maximise the provision of care for acutely ill patients. Establishments have increased during the pandemic to manage the changes in patient flow, PPE management, acuity and number of admissions. This has impacted the Trust's ability to cover vacant shifts with bank staff, with an increased reliance on nurse agencies outside of national frameworks. The lock down, need for some staff to shield and COVID related sickness have also had a significant impact. Sickness rates in nursing have been consistently high ranging between 5.2% to 7.5%. SHS agency spend continues at a high rate due to vacancies, which albeit considerably lower than the start of the year, are measured against a budget containing very aggressive CIP targets. In addition demand levels in most practices are at exceptionally high levels meaning any GP or nursing holiday or sickness needs to be covered by agency staff rather than a proportion being absorbed internally as is the budget assumption. A decrease in locum spend is reflected in the 21/22 budget but remains a key risk for SHS.