Agenda Solent NHS Trust In Public Board Meeting Tuesday 30th May 2017 10:30am –1:30pm Kestrel 1+2, Top Floor, Highpoint Venue, Bursledon Rd, Southampton, SO19 8BR
*Timings are tentative Item Time Dur. Title & Recommendation Exec Lead / Presenter 1 10:30 5mins Chairman’s Welcome & Update Chair • Apologies to receive To receive 2 Register of Interests & Declaration of Interests Chair To receive 3 Confirmation that meeting is Quorate Chair No business shall be transacted at meetings of the Board unless the following are present; • a minimum of two Executive Directors • at least two Non-Executive Directors including the Chair or a designated Non-Executive deputy Chair
4 *Minutes of Last Meeting and action tracker Chair To agree
5 10:35 5mins Matters Arising Chair
6 10:40 5mins Any Other Business Chair (not on the agenda but advised and agreed with the Chair for inclusion at this meeting)
7 10:45 15mins Safety and Quality First – including Chief • Six monthly Board to Floor report - To receive Executive / • Reflection on CQC current inspection – To receive Chief Nurse verbal update
Strategy & Vision 8 11:00 10mins Chief Executive’s Report Chief To receive Executive 9 11:10 5mins Summary Business Plan 2017 – 19 COO To receive Portsmouth & Commercial Director 10 11:15 10mins Quality Account Chief Nurse To approve
Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Rd, Southampton, SO19 8BR Telephone: 023 8060 8900 Fax: 023 8053 8740 Website: www.solent.nhs.uk
Programme Delivery 11 11:25 10mins Performance Report Executive • Business Plan Review Leads • Operations • Quality and Risk • Finance • Workforce To receive 12 11:35am 15mins Audit Results Report External Audit To be circulated following Audit & Risk Committee on 26th – Audit May -- To receive Director 13 Letter of Representation External Audit To be circulated following Audit & Risk Committee on 26th – Audit May -- To receive Director 14 Audit Opinion External Audit To be circulated following Audit & Risk Committee on 26th – Audit May -- To receive Director 15 11:50am 10mins Annual Accounts Director of To be circulated following Audit & Risk Committee on 26th Finance / May -- To agree Chair of Audit & Risk Committee 16 12noon 10mins Annual Report - including the Annual Governance Company Statement Secretary To agree 17 12:10pm 10min Quarterly progress on IT programme implementation Chief Medical To receive Officer
18 12:20pm 5mins Information governance Annual Report inc. Caldicott Chief Medical Guardian Report Officer / Chief To receive Nurse
**approx. 12:25pm - recess for official signings – 10mins **
External Relations 19 12:35pm 5mins Current and contemporary conversations with external All partners executives To receive verbal update *Reporting Committees 20 12:40pm 5mins *Chairs report on Members Council Chairman To receive 21 12:45pm 5mins *Charitable Funds Committee Minutes & Chairs update Committee To receive verbal update following meeting on 23rd May Chair
22 12:50pm 10mins *Assurance Committee Chair’s Update Committee To receive exception reports from April 2017 Meeting and May Chair 2017 Meeting including • Assurance Committee Annual Report –to receive
23 1pm 5mins * Mental Health Act & Deprivation of Liberty Safeguards Committee Scrutiny Committee Chairs update Chair To receive exception report from 18th May meeting and • Mental Health Act Scrutiny Committee Annual Report – to receive
------*Governance and Nominations Committee Committee No meeting held since last Chair 24 1:05pm 5mins Audit & Risk Committee Committee To receive verbal update following 26th May meeting including Chair • Freedom to Speak Up report - to receive Governance matters 25 1:10pm 5mins Governance documentation updates: Company • Board Terms of Reference Secretary • Board Code of Conduct • Remuneration Committee Terms of Reference To approve 26 1:15pm 5mins NHS Improvement – Self declaration with NHS Provider Company Licence Secretary To approve Any other business 27 1:20pm 5mins Governor comments and questions Chair
28 1:25pm 5mins Any other business & future agenda items Chair
29 1:30pm ------Close and move to Confidential meeting Chair The public and representatives of the press may attend all meetings of the Trust, but shall be required to withdraw upon the Board of Directors resolving as follows: “that representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest’” (Section 1 (2), Public Bodies (Admission to Meetings) Act 1960) ------break ------
**Supplementary papers are available on request from the Company Secretary**
Date of next meeting: Monday 31ST July 2017
Minutes Item 4.1 Solent NHS Trust In-Public Board Monday 27th March 2017 10:30-13:05 Kestrel 1 & 2, Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Rd, Southampton, SO19 8BR
Chair: Alistair Stokes, Chairman (AMS)
Members: Attendees: Sue Harriman, Chief Executive (SH) Jayne Edwards, Corporate Support Manager and Assistant Andrew Strevens, Director of Finance (AS) Company Secretary (JE) Lesley Munro, Interim - Chief Operating Officer Sam Jones, Quality and Professional Standards Team Southampton and County Services (LM) Business Support Sarah Austin, Chief Operating Officer, Portsmouth and Stephanie Clarke, Governance Lead Shadowing Mandy Commercial Director (SA) Rayani (SC) Dan Meron, Chief Medical Officer (DM) Apologies: Mandy Rayani, Chief Nurse (MR) Rachel Cheal, Associate Director of Corporate Affairs and Helen Ives Company Secretary (RC) Jon Pittam, Non-Executive Director (JPi) Mick Tutt, Non-Executive Director (MT) Jane Sansome, Non-Executive Director (JS) Francis Davis, Non-Executive Director (FD) Mike Watts, Non-Executive Director (MW)
1 Chairman’s Welcome & Update
1.1 The Chairman welcomed Helen Ives to the Board and congratulated her on her new role as Chief People Officer that will commence on 25th April 2017.
Lesley Munro was also welcomed to her first Board meeting as Interim Chief Operating Officer for Southampton and County Services.
2 Register of Interest & Declaration of Interests
2.1 There were no further updates to declare.
3 Confirmation that meeting is Quorate
3.1 The meeting was confirmed as quorate.
4 Minutes of Last Meeting and action tracker
4.1 The minutes of the meeting held on 30th January were agreed as an accurate record.
5 Matters Arising
5.1 The following actions were confirmed as complete: 547, 458, 549, 550, 551 and 540.
Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Rd, Southampton, SO19 8BR Telephone: 023 8060 8900 Fax: 023 8053 8740 Website: www.solent.nhs.uk
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6 Any Other Business
6.1 • Briefing of a London Mortality event attended by DM and MT.
7. Safety and Quality First – including feedback from recent Board to Floor Visits
7.1 It was noted that SH will brief the Confidential Board on a matter escalated during the weekend.
The Board was informed of a review being undertaken by MR and SA on Community Nursing Services within the Portsmouth City due to a number of complaints and incidents reported relating to working demand pressures.
SA informed the Board of a peak in demand and capacity during the weekend however provided assurance that the service will be on track by this evening and any appointments missed will be prioritised accordingly. It was noted that the Community Nursing Team do not have the capacity to meet care requirements within care homes following changes to contracts. SA to continue to brief the Board on updates. Action: SH
7.2 JPi asked if capacity issues are leading indicators. SA explained that there are issues when patient experience is being impacted. The lack of capacity to phone service users with regards to changes to appointments was noted.
AMS asked if service users have mobile phones in order to receive texts regarding appointment changes. SA reported that the majority of service users do not have mobile phones.
AMS asked what the current level of vacancies are for the Team. SA confirmed that Portsmouth currently has a 9% vacancy rate. LM reported that the Southampton vacancy rate is 10%.
7.3 SH highlighted the importance of understanding demand and capacity.
The Board discussed the new pressure of care provision required in order to fill gaps in care home care capabilities following discharge from hospital. SA highlighted that Portsmouth holds one of the highest waits in the country for care, nursing homes and domiciliary visits.
FD commented on the amount of time nurses spend on negotiating with agencies and highlighted the need to improve communications.
The Board discussed the importance of understanding the issues and how they can be managed short term.
7.4 MW asked how capacity requirements are understood. SA explained the breaking the block system that was designed to unpack demands however, SA reported that this has now changed. It was noted that the review being undertaken will identify system pressures.
7.5 SA informed the Board of changes to investment within community services through transformation work. It was agreed that more information will be reported to the Board on wider transformation work.
Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Rd, Southampton, SO19 8BR Telephone: 023 8060 8900 Fax: 023 8053 8740 Website: www.solent.nhs.uk
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7.6 JPi reported that the original Board to Floor visit was changed and arrangements were made to visit three teams at Westwood House with SH and RC at short notice. The following observations were made:
Community Independence Team • The team was well motivated and no safety concerns were raised. • Colocation with City Council occupational therapy staff is working well and the adaptation to small equipment efficient. Bigger equipment however required for council tenants can take up to 6 months. • IT is the main frustration for staff due to the need to work with both health and social care systems and significant slow printing issues. JPi confirmed that the matter has been escalated. • Staff commented on being given time to ensure training/mandatory training is completed and the service provides regular training sessions. • There was also evidence of good team work and motivation however staff shortages within the team are affecting assessment lists.
7.7 District Nursing Team • There were difficulties with the referral process due to communication issues with surgeries following GPs leaving. Service users were unable to contact surgeries and therefore were contacting the DN service directly. This has now been rectified. • The team has provided training to care home staff to help address peak in demand and difficulties in having a GP home visit. • Palliative Care demand is increasing and requires a degree of staffing expertise.
7.8 Sensory Service • JPi explained that the small service consisting of 3 staff members train NHS staff to provide sensory rehabilitation. The service moved to Solent in April 2016 and serves 20,000 service users. • The service helps people to cope with their disability and lead a normal life which means sensory care is no longer needed. • It was suggested that the service provide a patient story to a future Board. Action: MR
7.9 MW suggested that sensory service feedback is shared with the City Council. It was confirmed that commissioner engagement is taking place.
7.10 JS asked if the Trust ensures that staff are on comparable terms and conditions within collocated teams. It was acknowledged that there is a mismatch at all levels.
7.11 JS asked why the original visit was cancelled. MR explained that the visit was booked on a day that the service did not run.
SH commented on the visit being a very much in the moment, good visit.
MR confirmed that a Schedule of visits for the year has been circulated and MR is to conduct a visit at the Turner Centre tomorrow. The Board noted the update provided.
Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Rd, Southampton, SO19 8BR Telephone: 023 8060 8900 Fax: 023 8053 8740 Website: www.solent.nhs.uk
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Strategy & Vision
8 Chief Executive’s Report
8.1 SH referred to the publication of the clinical service review of Southern Health relating to Mental Health and DNP and expressed the importance of reading and understanding the documents. SH reported on a meeting attended with Chairs and CEOs and the Independent Chair of the Mental Health Alliance prior to the review publication where reference was made to its concept.
Southern Health believe they have a continued future with Mental Health and Learning Disabilities provision and have the ability to grow services if deemed appropriate by commissioners.
SH reported that a meeting with the Mental Health Alliance regarding the Clinical Services review has been postponed however there is to be further discussion around its provision and strategy direction.
8.2 SH reported on continued anxiety around the Acute Crisis Pathway particularly with the change in Police and Crime legislation. The need to carefully manage the 136 suite over a 24 hour period, based on current volumes was highlighted.
8.3 SH informed the Board of an STP announcement expected this week that endorses the creation of a connective Hampshire commissioning body which involves the merging of North East and Farnham, South East, Fareham and Gosport and mid Hampshire CCGs. It was noted that leadership is still awaiting approval however the Chief Officer is to be announced imminently.
It was noted that consideration is to be given on how the commissioning body will work strategically and maintain open and honest communication at senior level.
8.4 The Board discussed the Clinical Review and it was agreed that the Executive Team digest and discuss on Wednesday at the Directors meeting. Acton: Executives
8.5 SH referred to the CQC inspection update and of 7 actions identified as not been started. It was noted that MR has provided a full brief and confirmed all actions have commenced, some of which are complete.
It was noted that a CQC meeting is to be held next week with SH and MR. The Board will be briefed on discussions held. Action: SH
8.6 SH informed the Board of a £2billion Better Care fund and of work to be undertaken by Executives to understand the financial implications and opportunities. It was highlighted that NHSI have also set out indicative numbers of bed reduction requirements. SH informed the Board of a review of bed management across the whole system and it was noted that there are currently escalation beds in addition to capacity that need to be reduced to normal capacity.
It was explained that the care fund is a treasury grant however is deployed through the Better Care Fund which is a combined CCG and Council fund. It was agreed that AS feedback on the financial implications for the Trust going forward. Action: AS
Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Rd, Southampton, SO19 8BR Telephone: 023 8060 8900 Fax: 023 8053 8740 Website: www.solent.nhs.uk
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8.7 SH presented the revised Trust Management Team meeting due to a change in meeting focus.
AMS asked that all future updated documents for Board approval are presented with changes highlighted and for documents that consist of a majority change, be accompanied by an oversight paper.
8.8 The Board discussed the Terms of Reference and suggestions were made on topics for inclusion.
FD asked who was accountable for leadership and innovation. AMS explained that quality and improvement has historically been led by the Chief Nurse and research and audit through the Medical Director and Head of Research. FD suggested the need to reflect on innovation as part of a business plan.
AMS commented that attendance of Clinical Directors and Operational Directors will help embed service line leadership. SH suggested that members of the Board are invited to attend future meetings. JE to circulate a list meeting dates. Action: JE
8.9 A reduction in the number of complaints was noted. The Board noted the CEO report and further update.
9 Consideration of the Trust’s Foundation Trust application
9.1 AS reported that the FT paper was shared at the Members Council meeting.
It was noted that in order to pursue the pipeline, the Trust needs to have to achieve an outstanding or good CQC result and would need to be without a deficit plan for the next 2 years. It was acknowledged therefore not to be an appropriate time for the Trust to enter back into the FT pipeline.
9.2 AMS asked when the Board can expect to achieve a good rating by the CQC and by what process we can expect to achieve financial stability.
AS explained the deficit plan for 2017 and 2018 and reported an expectation to breakeven by 2020 onwards. AS reported on the possibility of having a credible case of financial stability by run rate and trajectory in the latter part of next year.
9.3 MR reported that the CQC are commencing return visits on 4th April and there are no expectations that the CQC will identify any queries that have not been embedded. MR indicated expectations of achieving a ‘good’ rating in 2018. It was noted that Quality insurance feedback is expected this week which forms part of the process that will provide assurance of achieving a ‘good’ position.
9.3 JS asked how long it takes to go through the FT pipeline process and suggested we pursue in order to be on track to achieve at the point of financial stability.
SH reported that timescales are unknown and it is recognised that the process can have a detrimental effect to service delivery.
The Board discussed FT consideration and it was agreed to review in 12 months. The Board noted the FT pipeline paper and further discussion.
Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Rd, Southampton, SO19 8BR Telephone: 023 8060 8900 Fax: 023 8053 8740 Website: www.solent.nhs.uk
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Programme Delivery
10 Mental Health benchmarking
10.1 MH presented the Mental Health benchmarking report. • MH explained an error in the Portsmouth data provided and how it is identified. • MH briefed the Board on admissions highlighting that Portsmouth service users are provided with beds within their area however service users in other geographical areas are required to travel further afield. • The Board was briefed on service quality and it was noted that the Trust has the lowest rate of ligature incidents, restraints and prone restraint in the region.
10.2 The Board discussed Mental Health staffing and SA suggested the need to ensure permanent posts are attractive in order to attract more agency staff. MW asked if agency staff record serious incidents. MH explained that agency companies report on behalf of the staff member on incidents that occur.
10.3 AMS asked if Solent has a predominantly high record of violent incidents in the past. MH reported that the Trust has a relatively low number.
HI reported that the Trust is low overall on staff physical violence however is also low on reporting in other areas than Mental Health.
10.4 AMS asked how many incidents of prone restraints were reported during the last year. MH reported that the information is not available however numbers are expected to be less than 15.
10.5 The Board discussed agency staffing and JS raised potential issues with contracting arrangements. MH provided assurance that staff are moved on within the service if contract requirements cannot be met. It was noted that some agency staff have indicated their interest in becoming Solent employees.
JS highlighted the importance of the Trust actively insuring against risk and seeking confirmation that agencies are independent contractors. AS confirmed insurance to be the responsibility of agency companies due to staff being provided directly by them and confirmed that contract arrangements are dealt with by the Contracting Team.
HI acknowledged the need to conduct a review of sub-contracted agencies.
10.6 AMS commented on the report providing continued assurance that the Trust is delivering a good service and powerfully illustrates the benefits of benchmarking.
10.7 SH referred to Mental Health inpatient facilities value for money and reported that the Southern Health Services review suggests an underfunding of £38m per annum for Mental Health Services and suggested that an understanding on Solent funding would be helpful. MH reported on difficulties in drawing comparisons due to a lack of understanding on how funding is defined. It was noted that differences in coding and categorising will cause an inaccurate picture. The Board noted the presentation provided and further discussion.
Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Rd, Southampton, SO19 8BR Telephone: 023 8060 8900 Fax: 023 8053 8740 Website: www.solent.nhs.uk
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11 Annual Staff Survey Feedback
10.1 • HI provided an insight on trend analysis reported and reflected on work undertaken. • It was noted that 53 measures were significantly better than last year. • The survey was promoted as a priority and managers were on board to support. • Work was undertaken to ensure the Trust is visibly addressing actions and providing feedback. • It was noted that the biggest cause for absence is stress. • Physical violence is being looked at with ‘Speak Up’ representatives to consider how to take forward. • HI explained the process of the work-stream HEART work-stream. • The Board was informed of business plans being reviewed to ensure staff engagement. • HI reported on factors affecting job satisfaction including wanting to spend more time on patient care and less time on case management and phoning around agencies.
10.2 HI distributed a copy of staff engagement scores 2015-2016 comparisons.
MW enquired as to why Children’s services West scored red for 2015 and 2016. HI explained that Children’s Services have been through an intense period of reorganisation and whilst positive results were reported, there have been difficulties in managing change.
10.3 Regarding FM and Estates, HI reported on big leadership issues that have been worked on and are to be managed through in order to commence an improvement journey. AS reported on the huge change to catering staff and a layer of management that is not up to the required level.
10.4 MW asked if the survey differentiates areas that are going through more change than others. SH reported that engagement scores are designed for Trust interpretation.
SH commented on the survey being positive information and provides evidence of recovery and progress, indicating that the Trust strategy around leadership and the great place to work programme continues to be positive.
12 Performance Report
12.1 Operations – Southampton and County Services LM highlighted the following exceptions: • There has been executive level oversight on transfers of care in South West Hampshire with a target to reduce delayed transfers to less than 100 by the end of March. AMS asked why the target is set at 100. LM confirmed target set due to trajectory.
12.2 Operations – Portsmouth SA highlighted the following exceptions: • A raising demand within Portsmouth community was noted. • It was reported that the 136 suite interim arrangements have been extended to the end of March and quality assurance is available. • The Board was informed that Substance Misuse Services are still not achieving 3 month review standard and notice to end the contract in July will not take place if there is no alternative provider. SA to provide further information at Confidential Board. AMS asked if the Trust is able to adjust the terms and conditions for AMH staff. SA confirmed this to be the case and reported on further recruitment and retention options.
Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Rd, Southampton, SO19 8BR Telephone: 023 8060 8900 Fax: 023 8053 8740 Website: www.solent.nhs.uk
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12.1 JPi asked if CQC issues identified in Child and Adolescent Mental Health (CAMHs) Team have been addressed. MR confirmed being addressed and assured the Board that issues were financial and not safety connected.
12.2 Quality and Risk • MR shared her concerns regarding the SIRI process in terms of breaches and report closures. It was noted that 4 have closed since a meeting held last week. The need for further diligence was highlighted. • Pressure ulcers continue to be monitored and best practice shared. AMS asked if a resource issue is causing the backlog. MR reported that there is no links with resource issues and confirmed that significant improvements with reporting are being seen.
12.4 Finance AS highlighted the following exceptions: • The Trust is on track to deliver the £3.2m deficit target which was reported at a providers’ conference last week. It was noted that a pound for pound bonus is likely to be available. • AS reported on conversations held with stakeholders regarding CQUINs achievements and funding arrangements for discharge to assessment. Discussions were also held with Southern Health regarding additional pharmacy provision. • AS reported that the Trust is expected to deliver within capital resource limits. • Regarding workforce, AS reported on an expected breach in agency this year. It was noted that although there will be no financial cap this year, there is a need to address going forward. • AS briefed the Board on CIP plans for the year ahead. AMS queried the reported 15% increase in turnover. AS clarified that the 15% reported represents a year average.
12.5 ICT & Transformation AMS enquired why Spinnaker Ward opted out of the trial pilot for pathology tests. MR reported the service to be too busy to take part.
DM reported on continuing issues and complexities around software compatibility particularly within Sexual Health. DM confirmed that systems are upgrading to IE11 however there remain software issues. Timescale for roll out is expected during April and May.
12.6 Infrastructure Nothing further to report.
13 Patient Experience Report
13.1 MR informed the Board that the Patient Experience report is being developed with improved triangulation. MR reported on consideration given to involve service users in the writing of the report however it was noted that further debate is on-going on how to improve engagement.
Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Rd, Southampton, SO19 8BR Telephone: 023 8060 8900 Fax: 023 8053 8740 Website: www.solent.nhs.uk
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MR reported on the good work achieved in capturing feedback from service users and informed the Board that pilot work within Sexual Health is going well. The Board noted that the monkey survey within Children’s services is also positive work.
MR highlighted 2 areas of work required to review incoming complaints of clinical areas and issues around communication to patients across all services. The Board noted the Patient Experience report and further update.
External Relations
14 Current and contemporary conversations with external partners
14.1 Nothing further to report.
*Reporting Committees
15 *Chairs report on Members Council
15.1 AMS reported that the Council discussed holding a working group to be held in May in order to agree recommendations on the future role of Governors. It was noted that initial feedback and comments have been received and RC is to meet with Lead Governor Michael North on Friday to analyse feedback in preparation for the group. The Board noted the update.
16 *Complaints Review Panel
16.1 • MR reported on the meeting held in the absence of JS as Chair. • The meeting trialled a new approach of reviewing complaints and discussed consent and how to take forward. • The management of persistent complainants was considered with regards to letter writing and complaints categorising was reviewed. The Board noted the update.
17 *Charitable Funds Committee Minutes and Chairs Update
17.1 No meeting held to report.
18 *Assurance Committee Chair’s Update
18.1 • JPi informed the Board that the new format of the Committee is working well. • The Committee was pleased with the Quality Improvement report received. • It was agreed to review internal audit to ensure fit for purpose. • The Board was informed that concern was raised regarding progress on the CQC action plan and more detailed information is to be presented to the next meeting to note.
Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Rd, Southampton, SO19 8BR Telephone: 023 8060 8900 Fax: 023 8053 8740 Website: www.solent.nhs.uk
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18.2 The Committee ratified the following policies at the February and March meetings: • Investigation Policy • Dental Radiation Policy • Emergency Lockdown Policy Chairs action was taken to ratify the following policies: • Suspension, Exclusion and Transfer Policy • Suspect Package Policy • Pay Protection Policy • Physical Security Management Policy • Suspect Package Policy The Board noted the exception report and further update.
19 *Mental Health Act Scrutiny Committee Chairs update
19.1 • JPi reported that the Committee looked at improved restraint arrangements. • An incident was highlighted and assurance provided that it would be reported through the Serious Incident process and outcomes reported to the Assurance Committee. • DoLs reporting requirements were confirmed and the reporting of training provision expectations discussed. The Board noted the exception report.
20 *Governance and Nominations Committee
20.1 There was no meeting held to report.
21 Audit and Risk Committee
21.1 JPi reported on discussions held at the February meeting: • The Committee discussed where the Trust sits with regards to being a going concern whilst running in deficit which was commented on within the Value for Money Audit. It was noted that the position would continue to be monitored. • Cyber security concerns were raised and the Committee was assured that the Trust is reasonably protected.
21.2 AMS suggested to JPi that any items needing to be raised for the Board’s attention following discussion at the Audit Committee can be presented going forward.
21.3 It was also agreed that performance achievements against any action plans be reported to the Board to gain an understanding of what the programme is and provide assurance. The Board noted the minute exceptions and approved the amended Terms of Reference.
Any other business
22 Items to cascade to other committees
22.1 There were no items for cascading.
Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Rd, Southampton, SO19 8BR Telephone: 023 8060 8900 Fax: 023 8053 8740 Website: www.solent.nhs.uk
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23 Governor comment and questions
23.1 No governors were in attendance.
24 Any other business & future agenda items
24.1 DM reported on his and MT’s attendance at a Mortality event in London, attended by NEDs, Chief Nurses and Medical Directors. DM reported that version 1 of a new policy on how to deal and learn from mortality was presented and a briefing was given on process expectations including understanding of death categories and closer links with families and carers. It was noted that from April, all Trusts will be required to publish a quarterly report to their respective Boards on deaths.
24.2 MR informed the Board of an event hosted by Solent, being held on 5th June to discuss an NHS initiative on how to involve families in incident reviews. Southern Health has also been invited to the event.
25 Close and move to Confidential meeting
25.1 There was no further business discussed and the meeting was closed.
Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Rd, Southampton, SO19 8BR Telephone: 023 8060 8900 Fax: 023 8053 8740 Website: www.solent.nhs.uk
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Actions -In Public Board
Action Agenda Exec Lead / no. Date of Meeting item ref: Concerning Action detail Manager Completion date Update for May 2017 meeting It was noted that the Community Nursing Team do not have the capacity to meet care requirements within care homes following changes to contracts. It was agreed that the Board be briefed by way of update at future meetings under May update 552 27.03.2017 7.1 Safety and Quality First matters arising. SA In progress
May update 553 27.03.2017 7.8 Sensory Service visit It was suggested that the service provide a patient story to a future Board MR Patient Experience Team will liaise with the service and arrange a mutually The Board discussed the Southern Clinical Review and it was agreed that the May update 554 27.03.2017 8.4 CEO Report Executive Team further consider implications Execs For a future meeting
SH referred to the CQC inspection update and of 7 actions identified as not been started. It was noted that MR has provided a full brief and confirmed all actions have commenced, some of which are complete. It was noted that a CQC meeting is to be held next week with SH and MR. The Board will be briefed on discussions May update 555 27.03.2017 8.5 CEO Report held. SH SH to provide update at the meeting. SH suggested that members of the Board are invited to attend future TMT May update 556 27.03.2017 8.8 CEO Report meetings. JE to circulate a list meeting dates JE Meeting dates are included on the Corporate Calendar Item 7.1
Board Report – In Public Meeting
Title of Paper Board to Floor Visits November 2016- March 2017
Author(s) Kathy Parker Quality Executive Sponsor Mandy Rayani Improvement Facilitator Chief Nurse Tracy Beck Head of Patient Safety Improving outcomes Working in partnership Ensuring sustainability Link to strategic x x x Objective(s) Link to CQC Key Safe Effective Caring Responsive Well Led x x x x x Lines of Enquiry (KLoE) Date of Paper April 2017 Committees presented Action requested To receive For decision x of the Board
Purpose
The purpose of this paper is to provide a summary of the findings, issues and good practice highlighted from the Board to Floor visits undertaken between November 2016 and March 2017.
Board to Floor visits are a way of ensuring that members of the Trust Board are informed, first hand of any potential patient safety or other issues of concern from frontline staff and often patients and visitors. The visits also provide an opportunity for staff to speak with Board members directly about their experience of working for the Trust.
After each visit onsite feedback is given directly to the clinical staff involved in the visit. This is followed up by a formal report sent to the service and service managers, including the relevant Clinical Director and Operational Director.
During the period November 2016 to March 2017 there were 7 visits scheduled with 3 visits cancelled due to availability.
Date Service Line Venue 11/11/2016 Sexual Health Royal South Hants Hospital Cancelled 14/11/2016 Child and Family Falcon House, St James Hospital 08/12/2016 Adults Southampton Rapid Response Cancelled 17/12/2016 Adults Portsmouth Spinnaker Ward rehab , St Marys Cancelled Community Campus 09/01/2017 Adults Portsmouth Spinnaker Ward rehab , St Marys Community Campus 17/02/2017 Primary Care Westwood House, Sensory Service, Community Independence Team, District Nursing 28/03/2017 Adults Portsmouth Portsmouth Rehabilitation and Re enablement Team (PRRT) , St James Hospital
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Summary of the Board to Floor visits
CAMHs Falcon House -14/11/2016
Service Challenges Identified:
• The team has been through a large transition of integrating with Community Children’s Nursing and Community Paediatric Service. • The team used the example of how managerial skills can be successfully transferred from one service to another. • There was a lot of emphasis on developing future leaders and giving staff with a leadership role the opportunity to have contact with finance and contracts teams in addition to meeting and understanding the commissioning aspects around budgeting and getting value for money.
Areas of Good Practice noted
• Team members did reflect that they have been successful in utilising transferable skills to aid the service changes. • The service in Portsmouth undertakes and has again achieved national CAMHS accreditation (QNCC) which involves peer review and monitoring against good practice guidelines. • Working closely with charitable organisations such as Portsmouth Parenting Voice has allowed access to people who need the help of this specialised service who may not have otherwise been reached. The team can therefore evidence effective preventative working across agencies. Health watch Southampton is another organisation the service is getting involved with supporting younger people.
Spinnaker Ward - rehab, St Marys Community hospital – 09/01/2017
Service Challenges Identified
• Challenges with SystmOne were identified as an area of concern on the ward. SystmOne was introduced in September 2016 and training was provided with new ways of working. In particular, there have been issues with paper records and electronic records. In addition, there have been issues accessing the records held by PHT for the same patients. • Challenges with the potential use of the gym/rehabilitation room for Acute Trust emergency patient support was highlighted as an area of concern. All patient facilities were in place in the gym/rehabilitation room to support the patient care and privacy and dignity. Staffing the area was mentioned as an issue and there is no alarm call bell system in place and hand bells were to be used.
Areas of Good Practice Identified
• The implementation of a Discharge Pack incentive which was designed on the ward which contained all the information/appointments/ contact details for the patient on transfer was highlighted as an area of good practice on the visit.
• A daily checklist of flow is commenced each day and the staff on the ward work closely with the staff from Jubilee house, to cross cover if needed.
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Westwood House – Southampton Community Independence Team - 17/02/2017 Team: Sensory Service
Service Challenges Identified
• The need for acknowledgement by commissioners with regards to the benefit of early sensory rehab being integrated into clinical pathways was highlighted.
Areas of Good Practice Identified
• It was commented that 80% of service users have no long term sensory care needs following intervention by the service. • The team now run a Sensory Rehab Clinic at the RSH for people with recent sight loss which has been well received by service users
Community Independence Team
Service Challenges Identified
• With regards to staffing, it was acknowledged that there are national shortages of physiotherapists and that the team has currently 1 wte physio vacancy. It was also commented that the shortage of Care Managers (SCC position) which is having an adverse effect on waiting lists for assessments.
Areas of Good Practice Identified
• Team commented on the benefits of integrated working and co-location between SCC staff and Solent (within the Occupational Therapy team) quoting examples of patient benefit, reduction in duplication and better connection with the falls pathway • Good example of 6C’s application and comments/compliments board
Team: District Nursing
Service Challenges Identified
• It was acknowledged that Palliative Care support demand is increasing and as such is taking more time. • Regarding staffing; the team of 17 have a significant number of staffing challenges due to a combination of sickness, vacancies, maternity leave (6 posts in all)
Areas of Good Practice Identified
• The DN team have provided innovative and un-commissioned training to Care Home staff – with a view that investment within the care homes is benefiting the DN service in the long term. Such training includes Pressure Ulcers and basic health monitoring.
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Portsmouth Rehabilitation and Reablement Team (PRRT) Portsmouth Service Line
Service Challenges Identified
• The challenges of a potential move of all staff to a different site were discussed. It was felt that a move to Portsmouth Civic offices would prove problematic due to the size of the team 100 + including OT/Physiotherapist/PCC Social Care team/Nursing staff and parking. • There were issues noted with the availability of Skyguard and lone working, with contingency plans currently in place. • There were concerns raised with the storage of equipment in the shared storage rooms. The rooms are accessible and unlocked and lead from one room to another. • The team discussed the current referral process and raised concerns with clarity. An awayday was planned for the team in April 2017 to discuss the current patient referral criteria and the referral process.
Areas of Good Practice Identified
• The PRRT spoke of the value of Integrated learning with the PCC team, Occupational Therapist, Physiotherapist and Nurses and the integrated care for the patient. The combined teamwork, support and respect of staff and colleagues were highlighted as an area of good practice within the service. • Regular team meetings are held each month on the unit and group training and clinical supervision is provided. There are plans to introduce an employee of the month scheme. The notice boards clearly show contact details of the named nurse/staff on duty and the coordinator and the escalation process. • CQC rating was good
Key Themes of the Board to Floor Visits
The top three key themes arising from the Board to Floor Visits involved:
• Staffing levels – There were concerns raised in relation to staff shortages and the retention of staff. • IT system – A number of concerns discussed related to equipment accessibility and the potential impact on services. • Lone Working – There were issues noted with the availability of Skyguard and the issue of lone working, with contingency plans currently in place eg buddy system.
Action taken
All visits are subject to an action planning process in response to any issues which arise and these are managed through service lines with an expectation that the report and the associated action is monitored through the service line governance arrangements.
The visit highlighted some very good areas of practice and no concerns although the risks associated with IT systems and Lone working issues were acknowledged. The visiting team were very grateful for the way the staff actively engaged in the visit and the patients were pleased with their treatments and commended the staff for all their hard work and care. The PRRT team spoke of the value of integrated learning with the PCC team, Occupational Therapist, Physiotherapist and Nurses
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and the integrated care for the patient. Spinnaker ward staff advised that they felt the team worked well together and were supportive of each other. The service is proud of the positive feedback they receive from their patients and the service is also proud of the low staff turnover reflecting strong team morale.
Moving forward
The Board to Floor visits enable an insight into the service line and provide an understanding of the daily challenges and the areas of good practice. The challenges that were raised recently related to staffing, IT systems and Lone working. Immediate actions have been taken to resolve these issues and service line action plans have been embedded and monitored. The outcome of the Board to Floor visits combined with the Quality Review Week report and the PLACE visits allow organisational oversight and service line engagement.
Board Recommendation
The Board is asked to receive the report and note the action being taken.
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Item 8
Title of Paper CEO Report –May 2017
Author(s) Sue Harriman, Chief Executive Officer Executive Sponsor Link to strategic x Improving outcomes x Working in partnership x Ensuring sustainability Objective(s) Link to CQC Key Safe Effective Caring Responsive Well Led x Lines of Enquiry (KLoE) Date of Paper 17th March 2017 Committees N/A presented Action requested To receive For decision X of the Board
1. Statement on quality, finance and performance This is covered in full within the integrated performance report.
2. Strategic update
Sustainability and Transformation Partnerships (STP) Sir Neil McKay has been recently appointed as the STP Chair. Sir Neil has extensive experience of healthcare operations and strategic development and has operated at the highest level in the NHS undertaking some of the most complex and demanding system leadership roles in the country. Sir Neil has held senior posts within university hospitals, a mental health trust, NHS Midlands and East, and NHS East of England as well as more recently being the Programme Chair of the West, North and East Cumbria Success Regime. A further verbal update will be provided at the meeting.
Update on Executive Team and Board We welcomed Helen Ives, Chief People Officer, into post formally on 25th April 2017.
Following the recent Assessment Centres on 26th and 27th April 2017, I am pleased to inform you of the executive team appointments as follows:
David Noyes – Chief Operating Officer for Southampton and County David is currently Director of Planning, Performance & Corporate Services at Wiltshire Clinical Commissioning Group (CCG). Prior to his life in the NHS, David spent 28 years in the Royal Navy, where his roles included being the Deputy Commander at the Joint Force Support Headquarters in Afghanistan. He was responsible for the delivery of all support related operational matters, including logistics, medical, equipment, infrastructure and corporate support functions. David also undertook a variety of strategic planning and corporate support roles in both the Ministry of Defence and Fleet Headquarters and will be joining us during the summer.
Lesley Munro – Interim Chief Nurse Lesley has been acting as the Interim Chief Operating Officer for Southampton and County Services, following Alex Whitfield’s departure in March. Recognising that the Chief Nurse is a very different role, with professional leadership requirements, the Executive Team, in discussion with Lesley, made the decision to appoint on an interim basis so as to give Lesley the opportunity to develop into the role. We will then seek to appoint to the permanent position in six months’ time.
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Lesley has been released from her current role to ensure an effective handover from Mandy Rayani, Chief Nurse, who is leaving the Trust on 9th June 2017 to join Hywel Dda University Health Board in Wales as the new Executive Director of Nursing, Quality and Patient Experience. Short term interim arrangements have been implemented within the Southampton and County Care Group prior to David Noyes starting.
Jane Sansome - Non executive director Jane Sansome’s tenure as Non-Executive Director ends on 31st May 2017 and as such will be leaving the Trust. On behalf of the Board, I would like to thank Jane for her significant contribution to the Trust and relay our good wishes to her for the future.
Southampton and County Services The number of people experiencing a delay in their care being transferred within the Southampton system continues to be higher than expected in both acute and community beds. Work continues to address this, which includes a number of approaches across both health and social care that should see a positive impact.
Community nursing continues to carry a number of vacancies, although some of these have been appointed to, as reported previously. The Chief Nurse and Chief Operating Officer have had additional discussions with the Clinical Director of the service and are currently assured that there is no evidence of a negative impact on the quality of care being delivered to patients. Work has now begun across community nursing and Solent primary care to develop integrated ways of working, which may also have a positive impact on the needs of the workforce going forward, in terms of possible career opportunities and reduced duplication.
The planned mobilisation of Sexual Health services, Southampton Healthy Living Service and the Community Wellbeing service have all taken place, and all of these services are now operational within the organisation, and were achieved by 1st April. Some final contractual issues are currently being worked through with the aim of having these resolved by the end of May.
The new Interim Operations Director for Adults Southampton has now commenced in post, which will provide additional stability and development for that area.
Progress continues to be made in relation to the integration of some children’s services, bringing together services across health, local authority and the voluntary and community sector.
The waits for General anaesthetics remains an issue within the Specialist Dental service and the service is continuing to mitigate wherever possible, by contacting a number of organisations to gain access to theatre space. Whilst not yet achieved, conversations are continuing to take place.
Portsmouth System Portsmouth Hospitals NHS Trust is seeing an increase in delayed discharges resulting in an inability to admit patients. Delays in discharge are due to social work and domiciliary care capacity and the numbers of medically fit patients are also deteriorating causing delays throughout acute and community beds as well as Portsmouth Rehabilitation and Reablement Team (PRRT). The issues have been escalated to social services colleagues to try to increase capacity for assessments, and a project to reduce the numbers of medically fit patients commences at the end of May 2017.
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There are on-going staffing challenges in adults and Adult Mental Health services although block booking agency is helping. The adult’s community team are running a ‘perfect week’ 8th May to improve processes and further analyse demand and capacity. The service is also making good progress on the complaints and Serious Incidents backlog.
Performance concerns continue with regards to Child and Adolescent Mental Health (CAMHs) waiting times – a review is underway with urgent meetings to discuss alternative referral pathways. There are also concerns in relation to forensic delays - further escalation is in progress via the Chief Executive to NHS England.
Within our children and families service the new early help service is starting, which brings together council, voluntary sector and Solent services into one new team around the family. This new service will ensure that families most in need are given the greatest support. New Key Performance Indicators (KPIs) for the service are being finalised.
Finance The Month 1 outturn is a deficit of £0.3m (plan £0.1m deficit). The adverse variance is primarily due to: - Lower activity than planned for Kite and Snowdon - Lower activity within primary care - Higher acuity of patients within mental health
More detail, including the mitigating actions to the above issues can be found within the Performance Report.
Estates The St James’/St Mary’s redevelopment has been approved as phase 1 capital for the STP submission to access the £350m capital announced in the Budget; if approved nationally, this would be received as Public Dividend Capital (PDC) rather than a loan, which would not be repayable.
ICT You will be aware of the recent NHS Cyber-attack; locally we became aware of this issue late on afternoon of 12th May, when both local incidents were reported and news coverage broke. As a precautionary measure the major incident team agreed to terminate access to both external email and the internet to prevent further contamination. Over the weekend the team worked to ensure all appropriate measures were taken to minimise the impact and risks to Solent. As of Monday 15th May at 11am, it was confirmed that all appropriate patching and security measures were as required and the decision was made to re-enable the external connections. A poster and communication campaign has been implemented reminding staff not to open suspicious emails and attachments.
3. Current news Current Trust news is available on the trust website www.solent.nhs.uk
4. Complaints A total of 7 Complaints were received in April 2017 and 8 different themes were raised in these complaints.
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Complaints per Service Line can be broken down as follows: • Adult Mental Health 1 • Primary Care 2 • Sexual Health 4
The breakdown of themes across Service Lines is detailed in the table below:
Attitude of staff 4 Clinical treatment 3 Communication 1
There has been a reduction in the number of complaints (on average the figure is between 20 to 25 a month) in addition there has been a reduction in the number of Service Concerns (16) as opposed to an average of 21. Therefore it is not possible at this stage to determine if the reduction in complaints is part of the continuing trend of less complaints being received, or whether April’s figures are an anomaly.
The Sexual Health Service which normally receives a relatively low number of complaints has received the highest proportion (in 2016/17 they received 19 over the year). There does not appear to be a trend developing as the complaints were spread across clinics and involved different aspects of treatment including test results, implant removal and initial testing. However, the situation will be monitored to ensure that there is not an increasing level of dissatisfaction with the Service.
The Complaints Team have continued to work pro-actively with the Services to reduce the number of outstanding and breaching complaints. At the end April 2017 there were 42 complaints which were open outstanding. These included complaints which had not yet reached the 30 working day response time; there were also five complaints where a local resolution meeting had been requested; this figure includes complex cases where incidents had been reported and three complaints which the Parliamentary and Health Service Ombudsman are investigating.
In April there were seventeen cases closed- 14 of these were found to be upheld or partially upheld. Learning from the complaints included one Service recognising that there is a need for greater communication between professionals as well as better provision of written information to service users. Another Service is to review their discharge process so that patients’ are fully informed as to why they have been discharged.
As reported previously, the upgraded complaints recording and reporting system is currently being trialled. The benefits of the system include allowing the current status of complaints to be reviewed by the Patient Advice and Liaison Service (PALs), Complaints Team and the Services. It is anticipated that this will result in a reduction of the number of emails and allow the services to concentrate on investigating the complaints. It was envisaged that the trial would be concluded in April 2017 and the initial response has been very positive. However, some of the Services which are part of the trial have had difficulties with the system. Additional training has been provided and the trial continues.
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5. Update from the Trust Management Team (TMT) meeting - April 18th 2017 A summary of business transacted at the 18th April 2017 meeting is below; • The committee were briefed on the financial year end position (pre-audit) • The Committee were informed of the recent Isle of Wight CQC inspection report and outcome. Updates relating to the Portsmouth and South East Hampshire system were shared. • An update was provided to the Committee regarding the work being undertaken concerning the risk register, which is included within the Trust’s ‘Wicked issue’ list. • Exception reports were presented from the reporting Groups. • An interactive session was held where Committee members were asked to focus on prompts and questions to consider in relation to one of the Trust’s priorities; ‘Great Value for Money’. Further sessions will be held at different forums focusing on the other two priorities. • There are no specific items of concern to escalate to the Board.
The May 2017 TMT meeting has been cancelled to allow colleagues to support the CQC inspection of our Substance Misuse Service and Children & Adolescent Mental Health Services.
6. Board Assurance Framework and Corporate Risk Register
Board Assurance Framework – the following table summarises the key strategic risks:
Movement since last BAF Mitigated score reported Concerning Lead exec Raw score Target score number (Current score) (and previous score) 13 ICT Dan Meron S4x L4 = 16 S4 x L3 = 12 (12) S3 X L3 = 9 Workforce capacity 55 Andrew Stevens S5 X L4 = 20 S4 X L3 =12 (12) S3 X L3= 9
Quality Governance and S4 X L3 =12 57 Mandy Rayani S4 XL4 = 16 (12) S3 x L2 = 6 quality improvement Sue Harriman 58 Future organisational function S5 X L4= 20 S4 X L4 = 16 (16) S3 X L2 = 6
Andrew Strevens 59 Business as Usual S4 XL4 = 16 S3 X L4 = 12 (12) S3 XL2 = 6
KEY: = same as previous, increase in score decrease in score
Corporate Risk Register The Risk register is a ‘live’ register of the risks identified by service lines. New risks are added to the register and existing risks and associated mitigation arrangements are reviewed each month. The risks with the greatest prevalence remain in each of the following risk groups and are detailed below: • Information Technology • Staffing • Access to Services • Estates • Contracts
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Sealings No items to report
Signings No. Date Concerning 57 04/04/2017 Alterations and Refurbishment to form new children’s hub, Thornhill clinic, Southampton 58 24/04/2017 Aldephi House, Lease
Sue Harriman Chief Executive
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Item 9.1
In Public Board Meeting Confidential Board Meeting Presentation to x Summary Business Plan 2017-19 Title of Paper How we make a difference: Our Plan 2017-19 Andrea Hewitt, Head of Sarah Austin, Commercial Director Communications and Chief Operating Officer Author(s) Becky Whale, Commercial Executive Sponsor Business Partner
9/5/2017 Reviewed at Executive Meeting Date of Paper Committees presented
Link to CQC Key Lines Safe Effective Caring Responsive Well Led of Enquiry (KLoE) Action requested of To receive For decision the Board x
The purpose of this paper is to introduce the Board to the Trust’s summary Business Plan, titled ‘How we make a difference: Our Plan 2017-19’
The document has been written for external audiences, but will also be cascaded for use internally.
The document:
- provides an overview of the challenges and opportunities for the year ahead - introduces the Trust and our purpose - outlines our vision and principles – the way we operate in Solent - outlines our quality goals and our 2017/18 quality priorities - introduces our business priorities for the year ahead - summarises the work we will undertake to achieve our priorities - summarises how we will measure our success - summarises how our priorities will benefit people, including service users and staff
The document also includes a section titled ‘Working with other organisations’. This includes information about the emerging Sustainability and Transformation Plan, what is means for Solent and how we are working with other organisations.
‘Our Plan’ will be created into an electronic interactive version. As well as used internally, it will be sent to stakeholders, including members. In addition, the top line information will be shared as a double page spread within the May edition of Shine, our magazine for staff and members. This will include a link to the full electronic booklet.
Recommendation
The Board are asked to receive the Summary Business Plan
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How we make a difference Our Plan 2017-19 Introduction About the Trust Our Plan Our priorities Working with other organisations
Introduction from our Chief Executive, Sue Harriman
I am delighted to present Our Plan. It sets out our priorities for the year ahead and how these contribute to the delivery The next two years present both opportunities of the five-year Hampshire and Isle of Wight Sustainability and challenges. We must continue to maintain our and Transformation Plan. focus on quality, whilst meeting the challenges of rising demand for healthcare services The next two years present both opportunities and challenges. We must continue to maintain our focus on quality, whilst meeting the challenges of rising demand for healthcare services. People are generally living longer We‘‘ recognise the value of an engaged workforce. If our staff are happy at and many of us are also living with lots of long-term physical and mental work, and given the right tools and skills to do their job to the best of health conditions. Whilst the demand for our services is growing, we are their ability, they will deliver great care. Our Plan has a focus being asked to provide more whilst spending every public pound wisely. on making sure we create a great place to work.
It will be more important than ever before, to work closely with other We need to live within our budget and make organisations so that care is joined up and organised around the patient. the best use of the money available to us. We will continue to work with health and care organisations across Our Plan outlines how we will support our staff, Hampshire and the Isle of Wight to help people to stay well and to make and work with other organisations, to make sure they are always provided with safe, high quality health and care. the changes that deliver this.
We will continue to take every opportunity to improve care and the outcome I hope you find this document a useful and of our Care Quality Commission (CQC) inspection will guide much of our informative summary of Our Plan and that it improvement work. Our Plan describes how we will ensure we deliver the helps you to understand how we will great care people expect of an NHS organisation. provide great care, create a great place to work and deliver great value for money.
Our Plan has a focus on making sure we create a great place to work. Sue Harriman Chief Executive 2 ‘‘Our Plan 2017-19 Introduction About the Trust Our Plan Our priorities Working with other organisations
About the Trust
We provide community and mental health services to people living in Portsmouth, Southampton and in some parts of Hampshire. Our team of over 3,500 talented staff individually make a difference to people’s lives.
We help people stay safe and well at, or close to, home. We do this by supporting families to ensure children get the best start in life, providing services for people with complex care needs and helping older people keep their independence. We also provide screening and health promotion services which support people to lead a healthier lifestyle.
We actively promote strong out of hospital services, and we work closely with other trusts, primary care, social care providers and the voluntary sector to make sure care is joined-up and organised around the individual.
Our vision and values Our shared vision is to provide great care, create a great place to work and deliver great value for money. Our HEART values guide our behaviours and actions.
Our shared vision is to provide great care, create a great place to work and deliver great value ‘‘ for money.
Our Plan 2017-19 5 Introduction About the Trust Our Plan Our priorities Working with other organisations
Our Plan
This is our summary plan for the year ahead. It outlines our quality and business priorities and how they will help us achieve our vision.
This is how we operate in Solent to ensure that we provide the best possible care and service.
This means that we: We will • design care based on peoples’ needs, using best evidence provide • support people to be safe and well in our community great care • treat people with respect, giving equal emphasis to physical and mental health • ensure services are safe and effective, and give good experience.
We will This means that we: create a • focus on employee health and wellbeing great place • behave in accordance with our core values to work • provide our staff with the opportunity to learn and develop • value staff opinion and carefully listen and respond to what staff say.
We will This means that we: deliver • deliver joined- up health and social care great value • collaborate with our partners to spend money effectively for money • involve our community in decisions about how services could be redesigned • enable services to have more time to provide care.
6 Our Plan 2017-19 Introduction About the Trust Our Plan Our priorities Working with other organisations
Our quality goals and priorities
Our quality goals and priorities describe where we will focus our improvement work to ensure that quality and safety remain at the heart of what we do every day.
Our five quality goals, which we aim to deliver in the next two years, are:
1 2 3 4 5
No avoidable To reduce To reduce To reduce To focus on deaths patient duplication variation what matters harm and eliminate and improve to our patients/ waste in the reliability service users care process and carers
Our 2017/18 quality priorities Each year we set a small number of quality priorities to help us achieve our quality goals.
We will implement the Trust’s professional frameworks so that our nurses and allied health professionals continue to deliver great care.
We will deliver the Quality Improvement Programme to enhance patient experience and make a difference to people’s health and wellbeing.
We will continue to improve our services using the learning from incidents, complaints and feedback.
We will use the Trust’s competency assessment framework to support our staff to consistently deliver safe, effective care.
We will have a consistent approach to involving people in the development of our services.
8 Our Plan 2017-19 Our Plan 2017-19 9 Introduction About the Trust Our Plan Our priorities Working with other organisations
Our 2017-19 business priorities
Every year we focus on a small number of priorities. These guide the work of our teams and are used to set individual staff objectives.
Great 1. Improve quality in line with CQC inspection care requirements 2. Provide safe staffing 3. Use technology to work differently
Great place to 4. Plan for long term sustainable staffing work 5. Enhance our leadership throughout the organisation 6. Provide training that enables us to deliver great care
Great value for 7. Further pathway integration with other providers money 8. Benchmark our services to improve productivity 9. Change front line and corporate services to live within our income
You can read more about each of these priorities, and how our service users and their families will benefit, on the following pages.
10 Our Plan 2017-19 Introduction About the Trust Our Plan Our priorities Working with other organisations
We will provide great care Our goal is to deliver care that is safe, easy to access and How will we know we have achieved our priorities? based on the best available evidence. • Through improved learning there will be even more focus on preventing safety incidents Improve quality in line with CQC inspection requirements • We will continue to shorten our waiting times 1 Our recent Care Quality Commission (CQC) inspection highlighted many areas of good practice and excellent care, • We will use even less temporary staff, this will improve quality and but also identified areas where we can improve to provide a save money good standard of care across all of our services. • Staff will be more mobile and will have more time to care This year we will implement learning from our CQC inspection, putting in place action plans and improvement projects as part • We will achieve an improvement in our CQC rating when we are revisitied of our quality improvement journey.
How will this benefit people? Provide safe staffing 2 Ensuring our services are staffed with the appropriate number • People will have more choice about how, and when, they can access and mix of clinical professionals is vital to the delivery of quality our services, and it will be easier for them to do this. care, and in keeping people safe from avoidable harm. We will make sure every service has a plan to maintain a safe level of • People will have more confidence that they are seeing the right staffing at all times. person, with the right skills, to manage their care at all times including weekends. Use technology to work differently • People will feel involved in the improvements 3 Technology can significantly improve the experience people have we make to the services they care about. of our services and the care they receive. We will use technology to make it easier for people to access our services and to give staff more time to care. For instance, we will provide more online support services and make Wi-Fi available to staff in all of our buildings.
12 Our Plan 2017-19 Our Plan 2017-19 13 Introduction About the Trust Our Plan Our priorities Working with other organisations
We will create a great place to work We have around 3,500 members of staff working in our How will we know we have achieved our priorities? organisation. Delivering great care is only possible if our staff get the practical and emotional support they need to • Our staff engagement will cotinue to increase and more staff will say that do their job well. they would recommend Solent as a great place to work
• Staff health and wellbeing will continue to improve Plan for long term sustainable staffing 4 • People will be attracted to working for Solent and will stay with us long-term We are developing new roles to support joined – up care and working together with other organisations. • We will have fewer staff vacancies
5 Enhance our leadership throughout the organisation How will this benefit people? We are focused on building a supportive, values-based, culture which enables everyone to make a difference. We will support • People will be cared for by staff that are passionate about what and develop leaders to create a work place where people can they do, happy in their work and focused on delivering the be at their best. very best care.
• People will experience better coordination between different care professionals as we join up roles Provide training that enables us all to deliver great care 6 between services and organisations. We will support people with the tools to develop themselves and take responsibility for their own learning so that they can continually progress and develop. We will support individuals to create a plan towards their preferred career or job role.
14 Our Plan 2017-19 Our Plan 2017-19 15 Introduction About the Trust Our Plan Our priorities Working with other organisations
We will deliver great value for money We want to make the best use of every pound invested in How will we know we have achieved our priorities? the NHS. The gap between the cost of providing care and the funding we receive is continuing to increase. We receive • We will deliver our financial plan, which includes finding savings of £6.5m around £178 million of funding, but have to find savings in the region of £6.5m in the next year. • Our services will be able to measure the difference they make to people’s health and wellbeing
• Our services will work even closer with other organisations 7 Further pathway integration with other providers We will further develop joined-up care with other organisations to make sure we support service users better and spend every How will this benefit people? pound wisely. This means closer working with hospital trusts, GPs, social care and the voluntary sector. • People will experience more ‘one-stop’ care. This means they will have fewer visits to different places, and their care will be provided by one team working together, no matter which organisation staff are employed by. 8 Benchmark our services to improve productivity By comparing the performance of our services with others, • People will receive care that is focussed on their overall and learning from good practice, we can make the best use of wellbeing, and they will be provided with information the money available to us. about other services which can help them if needed.
9 Change front line and corporate services to live within our income We need to do things differently to reduce costs and wastage, to make sure we live within our budgets. Every area of our organisation will have a cost improvement plan which will describe how they will make these savings over the next year.
16 Our Plan 2017-19 Our Plan 2017-19 17 Introduction About the Trust Our Plan Our priorities Working with other organisations
Working with other organisations Sustainability and Transformation Plan (STP)
What is the Hampshire and Isle of Wight STP? Over the past year, we have been working with other health and care organisations across Hampshire and the Isle of Wight to agree how we can respond to the many opportunities and challenges facing the local health and care system.
Every organisation is facing the same challenges: rising demand for services and the increasing gap between the money available to the NHS and the cost of providing services. In our area, this gap will be £577 million by 2020/21 if we do nothing. This means that we all have to do things differently and much of this can only be achieved by working together.
Hampshire and the Isle of Wight is one of 44 teams across England that are developing local Sustainability and Transformation Plans (STPs) to find ways of solving these problems. This five-year plan will change the way health and care is provided in many ways, building on the work that is already taking place in local areas and finding new ways to meet people’s needs that are safe and affordable.
What does this mean for Solent? As a large provider of community and mental health services, we have an important role in designing and delivering these changes. We are already working with local GPs, social services, the voluntary sector and other NHS providers to test ways of providing care differently to keep people safe and well, out of hospital, for as long as possible. Our Plan describes the next steps to deliver more joined-up and affordable care.
18 Our Plan 2017-19 Introduction About the Trust Our Plan Our priorities Working with other organisations
In Southampton and wider Hampshire we are:
• bringing together over 350 community and social care staff to provide a joined-up urgent response, reablement and rehabilitation service in Southampton. • putting in place a plan to bring together children’s early help and social care services. • working with GPs, across the City, to deliver joined-up care; this includes improving people’s access to primary care via local hubs and the new Wellbeing Nursing Service from April 2017. • working with University Hospitals Southampton NHS Foundation Trust (UHS) to help medically fit patients return home safely. • working with UHS to join up diabetes, respiratory care and pain management services. • working with the voluntary sector to provide care for people in the community through a new partnership with Social Care in Action (SCA) and Southampton Voluntary Services to deliver health promotion support. • working with No Limits and Terrence Higgins Trust to ensure our sexual health services support the whole community, including hard to engage groups. • working with specialist agencies, such as The Autistic Society and other learning disability groups, to promote our specialist dental service to people who have difficulty accessing dental services.
This five-year plan will change the way health and care is provided in many ways, building on the work that is already taking place in local areas and finding new ways to meet people’s needs.
20 Our Plan 2017-19 Introduction About the Trust Our Plan Our priorities Working with other organisations
In Portsmouth and South East Hampshire we are:
• working with GPs to join up how we provide urgent care response services and support for care homes. • bringing together staff working in our community nursing and adult social care teams to improve care for frail adults. • bringing together the health visiting and school nursing teams with children’s social care teams to provide more targeted support to children and families • providing a new clinical records system that can be seen by community and primary care teams, and extending this to social care teams. • working with other community providers to provide specialist services in Portsmouth Hospitals NHS Trust. Staff within this team are supporting people who attend the Emergency Department and are frail. Often these people do not need to be admitted to hospital but do need additional support at home to be safe and well. Our team make this assessment and arrange for extra support so that the person can return home safely. • providing a Discharge to Assess Service. Staff within this service are making sure people in hospital do not stay there any longer than they clinically need to, and are supported to return home, with the right care, as soon as possible. • working with a range of voluntary organisations to provide the best support and care for people in the community. In Portsmouth, this includes Solent MIND (mental health services) the Society of St James (substance misuse services) and Age UK (services for older people).
…we all have to do things differently and much of this can only be achieved by working together.
Our Plan 2017-19 23 Solent NHS Trust Highpoint Venue, Bursledon Road, Southampton, Hampshire S019 8BR www.solent.nhs.uk @SolentNHSTrust www.facebook.com/solentnhstrustnews Item 10.1
Board Report – In Public Meeting
Title of Paper Quality account
Author(s) Hilary Todd Associate Executive Sponsor Mandy Rayani, Chief Nurse Director Quality & Safety Improving outcomes Working in partnership Ensuring sustainability Link to strategic X X X Objective(s) Link to CQC Key Safe Effective Caring Responsive Well Led X x x x x Lines of Enquiry (KLoE) Date of Paper 15th May 2017
Action requested To receive For decision x of the Board
Recommendation
The Board is asked to approve the final version of the Quality Account (QA).
The QA has been developed in line with our regulatory commitments and with services, research colleagues and thematic leads.
The draft versions have been shared with the Directors and with the Assurance Committee and their amendments have been included in this final version.
The QA was also presented to the May Audit & Risk Committee.
As per the requirements the QA has also been shared with Healthwatch and our Clinical Commissioning Groups, and their statements have been included.
TP. May 2017 1
Item 10.2
Page | 1
Quality Account 2016/17 (with our priorities for quality improvement in 2017/18)
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Part 1
Page | 2 Welcome and introduction to the Quality Account
About our Trust
We are one of the largest specialist community and mental health providers in the NHS with an annual revenue of over £180m for 2016/17. Last year, we employed 3,476 clinical and non-clinical staff (including part time and bank staff) which equates to 2,833 whole time equivalents (WTE) and delivered over 800,000 service user contacts.
We help people stay safe and well at, or close to, home. We do this by supporting families and working with partners to ensure children get the best start in life, providing services for people with complex care needs and helping older people keep their independence. We also provide screening and health promotion services which support people to lead a healthier lifestyle.
We actively promote strong out of hospital services, and we work closely with other trusts, primary care, social care providers and the voluntary sector to make sure care is joined-up and organised around the individual.
Our vision and values
Last year we refreshed our vision and values. Our shared vision is to provide great care, create a great place to work and deliver great value for money.
Our ‘HEART’ values describe the way we would like our staff to work together and care for the people we serve, our patients, their families and carers.
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Page | 3
Statement of Quality from Sue Harriman, Chief Executive
Thank you for taking the time to read our 2016/17 Quality Account.
Each year all providers of NHS healthcare services are required to produce an annual Quality Account for publication. We welcome the opportunity to share how we performed during 2016/17, as well as the opportunity to reflect on the areas for further improvement. I hope that you find this report a useful guide to our performance and achievements in quality, safety and patient experience over the past year, and our plans and priorities for the year ahead.
I am proud to be the Chief Executive of a Trust that puts quality at the centre of everything we do. We have a team of dedicated and committed staff, who each make a difference and strive to deliver consistently great care.
We always endeavour to maintain our focus on providing safe, effective and quality services, whilst meeting the challenges of rising demand for healthcare services with limited financial resources. Our commitment to quality is strengthened by our Quality Improvement Programme. We are creating a culture of continuous improvement, providing our staff with the tools, capability and capacity to continuously improve to ensure we provide people with the best, and most effective, services we can.
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During 2016/17, we welcomed a team of inspectors from the Care Quality Commission who, as a result of the inspection, have helped us on our quality improvement journey. As well as highlighting areas of good practice, they also identified areas for improvement. They awarded us an overall rating of ‘Requires improvement’. However, we were delighted that Page | 4 many of our CQC domains were rated as ‘Good’ and our Learning Disability Service was rated as ‘Outstanding’. The inspection outcomes drew our attention to some areas for improvement. Whilst we have already acted to make changes, we recognise that real sustainable change will take time. Our quality priorities have been developed using the outcomes from our inspection, as well as feedback from the people who use our services and our learning from incidents and concerns.
In common with other health and care organisations, we continued to face rising demand for healthcare services as people are generally living longer and many of us are also living with long-term physical and mental health conditions. The demand for our services has continued to rise at a greater rate than the funding available.
To help us face these challenges and, in light of the Five Year Forward View, we have placed even greater emphasis on working with other organisations and are actively participating in the Sustainability and Transformation Plan for Hampshire and the Isle of Wight. Collectively we have more strength to make a difference. We continue to work with others to help people to stay well and be cared for in the community with the aim of ensuring that people only get treated and admitted into hospitals when is absolutely necessary.
I would like to reiterate our unwavering commitment to continually improving the quality and safety of the care we provide. We recognise that much of our learning can come from listening to our service users, their carers and families, and our partners and in care. A key priority going forward will be to ensure that we continue to involve people in the development and improvement of our services, and we will continue to work with other organisations to make a difference together.
I hope you will find the information in the document useful.
Sue Harriman
Chief Executive
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Some of our 2016/17 achievements:
The CQC told us that we demonstrate
compassionate care and treat people Successful Page | 5 with dignity and respect. They observed retention of us supporting patients with care and Sexual Health Learning Disability Services kindness. It was recognised that we are Services tender rated ‘Outstanding’. The CGC very focussed on bringing care closer to inspectors observed that ‘the service was focussed on the peoples’ homes, supporting early Winner of needs of the people using it interventions and promoting self- an and valued their participation management. Elizabeth 3 GP in their care’. They said that Garrett surgeries the ‘leadership within the award Nationally merged into service drove a positive, recognised as Nomination one valuing and learning culture leader in of a Nurse that staff thrive in.’ Community Leader of the 2 Older and MH Year Peoples Quality research Fellowships Improvement Integration and Programme colocation of teams successfully in Southampton and launched Portsmouth SHINE Awards Inspiring Educator of the Year Dr Lyndsey Cherry, Hearing the Patients Voice Accessible Information Awareness DVD - Keith's story:Dr Clare Mander, Public and Patient Involvement Group: for Leading on showcasing research & improvement: Ranj Parmar,
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Statement from Mandy Rayani, Chief Nurse, and Dr Dan Meron, Chief Medical Officer
Page | 6
As a Trust we are committed to providing care that is safe and effective. It is important that people are assured of the quality of our services and can see easily the ways in which we strive, year on year, to improve what we offer to those who need our services. To help us continue to improve our services we gather feedback using a variety of mechanisms, including the Friends and Family Test (FFT).
Using this feedback, we have identified a number of quality priorities for 2017/18. Some of these are new for this year and some are a continuation of our 2016/17 priorities which have been embedded into our day-to-day ways of working. The priorities we set each year are intended to help us achieve the five quality goals we set ourselves in 2016.
Looking ahead we will maintain our focus on the quality of care, safety and the wellbeing of our staff and the people who use our services. This remains our highest priority. The purpose of this Quality Account is to re-confirm this pledge and demonstrate how we have achieved this to date. It holds our organisation to account to ensure we deliver these standards across all those services we directly provide and in those services where we work in partnership with others.
Our approach to quality improvement
In May 2016 the Board agreed a three year Quality Improvement Strategic Framework. This Framework sets out our ambitions for quality improvement. We identified five quality goals which we aim to demonstrate achievement against over a three year period (2016-2019):
Quality goal 1: No avoidable deaths
Quality goal 2: To reduce patient harm
Quality goal 3: To reduce duplication and eliminate waste in the care process
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Quality goal 4: To reduce variation and improve reliability
Quality goal 5: To focus on what matters to our patients/ service users and carers
Each year we set a small number of quality priorities to help us achieve our quality goals. Page | 7 We measure achievement against the annual quality priorities, and we also reflect upon the impact our work has had on delivering our overarching quality goals. Therefore, as well as setting out our priorities for next year, this Quality Account examines our achievement against both our quality priorities and our quality goals.
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Part 2a
Looking ahead – Our Quality Priorities for Improvement 2017/18
Page | 8 How we choose our priorities We identify our priorities in partnership with staff and based on feedback from the people who use our services, their carers and families. We also use information from incidents, complaints and patient experience measures. They are developed in line with our Quality Improvement Strategic Framework and our Trust vision: to provide great care, create a great place to work and deliver great value for money.
We are fully committed to achieving our priorities. Some are similar to last year’s as many of our priorities are major areas of work which will take several years to fully implement and embed.
Priority 1: We will implement the Trust’s professional frameworks so that our nurses and allied health professionals continue to deliver great care. We will do this by: publishing both a career framework and strategies by December 2017
Priority 2: We will deliver the Quality Improvement Programme to enhance patient experience and make a difference to people’s health and wellbeing. We will do this by: having 2 groups of staff completing the programme and publishing newsletters and programme outcomes every quarter
Priority 3: We will continue to improve our services by using the learning from incidents, complaints and feedback. We will do this by: launching an Organisational Learning Framework by September 2017
Priority 4: We will implement the Trust’s competency assessment framework to support our staff to consistently deliver safe and effective care. We will do this by: developing a Trust library of competencies for Nursing and AHP workforce by July 2017
Priority 5: We will have a consistent approach to involving people in the development of our services. We will do this by: launching our volunteer strategy and web site for volunteers by December 2017
These priorities guide the work of our services and are used to set service-specific quality activities.
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Part 2b
Looking back – A review of our performance in 2016/17 against our Quality Priorities Page | 9 Our 2016/17 Quality Account included five quality priorities:
• Priority 1: Develop a culture of continuous quality improvement, building workforce capacity and capability through a focussed programme of quality improvement skills development.
• Priority 2: To provide services which ensure that mental health and physical health needs are assessed and given equality of consideration when planning and delivering care.
• Priority 3: We will create the environment in which service users/patient and carer involvement (co-production) is embedded at all levels: from individual care planning to service transformation change.
• Priority 4: To provide agreed tools for use within the Trust which enable nurses to manage staffing levels and respond to the changing complexity and levels of the care of patients on their caseload or in their ward.
• Priority 5: To support staff, within the Trust, to deliver care and services which demonstrate our values and enable clinical staff to meet the professional standards set by their regulatory body.
Details of our progress against each of our 2016/17 priorities are shown in the following tables.
Priority 1 Met Quality Domain Patient safety and effectiveness Priority for Quality Improvement (QI) Improvement Develop a culture of continuous quality improvement, building workforce capacity and capability through a focussed programme of quality improvement skills development. Aim To enable and empower staff to identify opportunities for improvement and implement changes. To enable and empower staff to demonstrate improvement via a range of formal measurement techniques. Progress During 2016/17 we implemented our Quality Improvement Programme. Seven teams (70 members of staff) joined Cohort 1 in July 2016 and seven teams joined Cohort 2 in December 2016. Continuation for In total, five cohorts of teams will participate in the Quality Improvement 2017/18 – aligned to Programme over the course of three years. This is a priority for 2017/18, Priority 2 the programme for which includes:
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• Regular “Pocket-sized Quality Improvement” training available to all • Developing a Trust quality improvement hub • Supporting teams to use the online British Medical Journal (BMJ) quality tool to publish their work Page | 10 • Developing a network of quality improvement champions, coaches and trainers.
Priority 2 Partially met Quality Domain Effectiveness Priority for Parity of Esteem: To provide services which ensure that mental health and Improvement physical health needs are assessed, and given equal consideration, when planning and delivering care. Aim For patients/service users to experience services which provide holistic care, ensuring that physical and psychological wellbeing needs are recognised. Progress During 2016/17 patients accessing mental health services have been screened for physical health needs and their care has been planned in-line with guidance.
Adult Mental Health wards An audit of patient records showed that, during October – December 2016, our adult mental health wards screened between 95-100 percent of patients to identify their physical health needs and care for these alongside their mental health needs.
Health and Wellbeing team (adult mental health community team) The Health and Wellbeing team includes seven nurses who monitor the physical healthcare needs of patients at specific clinics. They contact the patient’s GP if there are concerns and also undertake home visits to patients who find it difficult to attend clinics.
Through monitoring of patients, the team has detected undiagnosed hypotension, diabetes and heart problems. The team will build on this next year by working with GPs and consultants to review patients on specific medication and those living in supported accommodation.
Older Persons Mental Health wards An audit of patient records showed that, during October – December 2016, 100 percent of patients admitted to the ward were assessed for physical health needs within 48 hours of admission.
Dementia screening We have experienced a number of recording and reporting challenges
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throughout the year relating to dementia screening. The service and the performance team have made joint recommendations for improvements to the clinical templates to ensure compliance can be accurately demonstrated. The service has also identified areas where the staff could benefit from some additional training and education around screening for Page | 11 patients. Audits completed during the year have produced varied results with some localities achieving 100 percent compliance. However the most recent audit highlights the need for additional support to ensure dementia screening is part of the core offer to all eligible patients. Continuation for The physical health needs of patients will continue to be monitored within 2017/18 mental health services and this screening is being incorporated as part of our routine care for those accessing the services.
We will continue to implement the dementia screening action plan to ensure all items are implemented and an improvement can be seen in Portsmouth and Southampton during the coming year.
Priority No 3 Quality Domain Service user experience Partially met Priority for We will create the environment in which service user/patient and carer Improvement involvement (co-production) is embedded at all levels, from individual care planning to service transformation change.
We will promote a culture where the value, contribution and rights of carers are recognised and respected by our staff. Aim • To ensure that the service user/patient/carer voice is heard and used to inform service delivery • To support staff to be confident in engaging service users /patients / arers in service change • To enable patients to be equal partners in care • To have a mechanism for identifying and signposting carers so that support can be accessed
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Progress Palliative Care: One of our Community Sisters for Palliative Care was nominated for a national WOW award for her outstanding customer service and was one of 75 finalists to be shortlisted from nearly 20,000 nominations. She was selected in the Judges’ Choice Category and attended the Gala Awards Ceremony in Page | 12 November 2016.
Sexual Health Service: At the beginning of December 2016, our Sexual Health Service rolled out an email pilot for capturing patient feedback and the friends and family test (FFT) responses. December 2016 showed a 50 percent increase in responses for the service compared to November 2016. Of those responding, over 95 percent said they would recommend the service to their friends and family.
Childrens’ Services: Our Children’s Services have increased their friends and family test (FFT) response rate with the role out of ‘Monkey’, a pictorial survey specifically designed for children to encourage them to share their own views. This approach has strengthened the voice of the child/young person in their care.
Complaints regarding communication (Year To Date) We regularly review the complaints and concerns we receive looking for common themes and trends. ‘Communication / providing information to patients’ remains in the top five categories of complaints received however this reflects national trends and a slight reduction has been seen over the past three years. Where any common themes are identified within this category, learning is shared across services. A number of teams have received additional training and support to address particular areas of concern.
Continuation in During 2017/18 we will: 2017/18 – • Demonstrate the involvement of users and carers in different aspects aligned to of our work Priority 3 and 5 • Refresh the patient experience action plan • Implement recording of carer identification and signposting within our
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patient records system • Launch our volunteer strategy and a website for volunteers.
Priority 4 Page | 13 Quality Domain Patient Safety and Effectiveness Partially met Priority for To provide agreed tools for use within the Trust which enable nurses to Improvement manage staffing levels and respond to the changing complexity and levels of the care of patients on their caseload or in their ward. Aim To provide safe, effective and responsive care to patients whilst supporting staff, and reporting safe staffing levels. Progress We have piloted a workload/acuity tool within the Adult Mental Health services to support nurses to manage staffing levels within inpatient wards. An escalation framework has also been established in our Adults Portsmouth and Southampton service lines.
Reports on our staffing position continue to go to Board, however, our approach to staffing has continued to develop as new guidance and resources/tools have been published by the National Quality Board (NQB) during 2016/17.
In-line with this new guidance, we have started to benchmark our position against the duration of care we provide to patients in a day (i.e. care hours per patient day). Continuation in During 2017/18 we will: 2017/18 – linked to • Make a catalogue of acuity and dependency tools available to Priority 3 and 5 services. The tools for mental health services will be available by June 17 and the community tool will be available by September 17. • Continue to review national guidance as issued by NQB, amending our reporting/tools where applicable.
Priority 5 Quality Domain Experience Met Priority for Professional standards Improvement To support staff to deliver care and services demonstrating the Trust values, whilst enabling clinical staff to meet the professional standards set by their regulatory body. Aim • To embed our values in all aspects of work • To support clinical staff to demonstrate compliance with regulatory standards • To receive feedback from patients / service users / carers that staff have acted professionally, demonstrated honesty, valued and respected them, and engaged them in all aspects of their care and
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treatment. Progress All our clinical staff are aware of who their professional lead is with clear professional escalation routes for reporting any regulatory matters. We have also established a Professional Advisory Group which is a forum for professional leads to escalate and discuss matters associated with Page | 14 professional standards and regulations.
We have commenced the review and standardisation of nursing and allied health professionals (AHP) job descriptions.
We have created strategic frameworks for the nursing and AHP workforce which set out the contribution our nurses and allied health professionals make in delivering quality care and improving patient experience. These frameworks focus on competencies relating to interventions to ensure standardised practice within each professional group.
We have introduced tools to support nurses to revalidate, maintaining their registration with the Nursing and Midwifery Council (NMC). A series of road shows has given further support in reinforcing professional standards to clinical, and in particular nursing, teams.
We have supported students on the NMC approved return to practice course in partnership with the local universities allowing former nurses to re-join the NMC register and start working with us as qualified practitioners.
As part of their inspection, the Care Quality Commission (CQC) reflected on the caring nature of our staff commenting that we treat patients with care and kindness. Continuation in In 2017/18 we will incorporate this into our day-to-day ways of working 2017/18 and: • Continue to use the tools introduced to support revalidation • Continue to support students on the NMC approved return to practice course • Embed the Nursing and Allied Health Professionals Strategic Frameworks • Continue to review and standardise nursing and allied health professional job descriptions, developing competency frameworks to support this.
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Part 2c
Looking back – A review of our performance in 2016/17 against our Quality Goals Page | 15 The progress we have made against each of our five quality goals is shown below. For each goal we have indicated the work we will undertake in 2017/18, and the quality priority this links to, to help us further work towards achieving the goal.
No avoidable deaths What it means in We have recognised the importance of mortality reviews and are actively practice engaged in developing innovative processes for identifying, reviewing, investigating and learning from deaths. We participated in the national work led by the Care Quality Commission (CQC) which led to the production of the first national guidance on learning from deaths (National Quality Board, March 2017). In line with this report we are further developing a range of processes including the: • criteria for selecting deaths to review and investigate • recording of mortality reviews • involvement of families • extraction, dissemination, and implementation of learning • reporting on mortality in-line with latest national guidance.
The emphasis of this work is to ensure there is a culture and focus on learning, family experience and proportionality. Progress and • Our Learning Disability Service is participating in a national pilot for a successes so far Learning Disability Mortality Review process. This is coordinated by the University of Bristol and commissioned by NHS England. • In the last six months of 2016/17 every unexpected, unnatural death has been reviewed, either through the mortality review process or as a Serious / High Risk Incident (SI/HRI). • Our Chief Medical Officer is contributing to the expert team with the Department of Health and the Care Quality Commission. • Learning from serious and high risk incidents is shared every month, across all services, at Serious Incident panel meetings. Our Quality In 2017/18 we will: Improvement • Further develop Board-level leadership in the area of learning actions for 2017/18 from deaths. We will explicitly designate an executive director as (linked to Priority the patient safety director and a non-executive director to take 3): oversight of the process. • Develop and adopt a Mortality Review Policy which incorporates the National Quality Board (NQB) recommendations on learning from deaths
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• Develop our approach for engaging with bereaved families and carers to improve the experience of families who experience loss or where harm has occurred as a result of care or treatment provided by the Trust. This work will involve service users and their families, the Patient Experience team, the Trust’s legal Page | 16 services manager, clinical directors and clinical governance leads. • Further embed the principles of shared learning: we already identify learning from mortality reviews and serious incident (SI) and high risk incident investigations through the SI process; however we need to further develop processes to ensure the learning is embedded across all relevant services, and action plans are audited and delivered. This will be considered in light of the national guidance. • Develop quarterly mortality reporting in-line with national guidance.
Reducing patient harm What it We are committed to reducing patient harm and, as such, continue to develop a means in positive incident reporting culture to ensure lessons can be learned from all practice incidents and near misses and appropriate changes to practice made. Particular focus has been given to reducing unavoidable harm through improved reporting, shared learning and appropriate interventions. Further work is required to streamline the incident reporting system and strengthening the lessons learnt mechanisms. Progress so Incident Reporting: we use an electronic system to report and review incidents far and near misses. During 2015/16 we experienced significant issues with this system resulting in a reduction in the number of low harm incidents and near misses reported. Incidents resulting in harm continued to be reported during this time, either through the electronic system or via contingency arrangements. During 2016/17, with the issues having been resolved and training and support for staff re-introduced, reporting has increased.
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• Lessons Learnt: The serious incident (SI) process and panels have been further developed to ensure lessons learnt from SI and high risk incidents (HRI) are shared across the services and that staff feel able to report and learn from mistakes. Page | 17 • NHS Safety Thermometer: We have maintained 95 percent compliance in harm free care as measured by the NHS safety thermometer tool. This monitors the proportion of patients that are ‘harm free’ from pressure ulcers; falls; venous thromboembolism; and urine infections for those with a catheter. • Development of quality dashboards: This year we have further developed the monthly quality dashboards to allow service lines access to service line, sub-service line group, department and team level data within the same report through drop-down menus. These reports can be used by services individually, or in governance meetings to identify and discuss trends or outliers. Each month the reports are accompanied by raw datasets so these trends or outliers can be reviewed in detail if required. In addition, new graphs are being introduced, where applicable, to better display the data and allow more meaningful comparison, such as the number of compliments received compared to complaints, and benchmarks with similar trusts are being explored as a next step. • Service Line Quality Newsletters: Please see Appendix B for examples of quality newsletters from our service lines. • Participation in the Wessex Patient Safety Collaborative Breakthrough Series Collaborative on the (Physically) Deteriorating Patient: The aim of the collaborative is to enable all staff, involved in the pilot, to identify and recognise the deteriorating patient, to implement preventable measures and to improve outcomes. • The following Quality Improvement Projects have also contributed towards a reduction in patient harm: o Urinary catheter quality improvement project (Trust-wide). More information about this is available in Part 5, page 45. o Improving ward processes to support timely, safe and effective patient discharge within the Adults Southampton inpatient wards. Our Quality During 2017/18 we will: Improvement • Adopt the new competency framework for nurses and Allied Health actions for Professionals across all of our services 2017/18 • Complete the following quality improvement projects: (linked to o Primary Care Musculoskeletal services – ensuring the outcomes Priorities 1, 2 of all patients receiving physiotherapy treatment from the and 4): musculoskeletal services are evaluated. o Mental health services (The Limes) – reducing rates and severity of falls.
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o Mental health services (community services) – ensuring all patients prescribed olanzapine receive appropriate physical health checks. o Sexual health services – standardising brief interventions for ChemSex patients (‘ChemSex’ is a term commonly used by gay Page | 18 men and men who have sex with men to describe the use of certain drugs in a sexual context).
Reducing duplication and eliminate waste in the care process What it means in In order to reduce duplication and waste we need to empower our staff. practice Through leadership we need to build staff confidence to challenge when they can identify that a change in process is needed. Progress so far During the year we have seen a reduction in complaints regarding the efficiency of our staff and have received positive feedback, from our staff, within the staff FFT and Annual Staff Survey- 5 percent more staff said that they would recommend our services to friends or family that needed treatment than in the previous year. Services have continued to address issues of concern at an early stage to prevent escalation to a formal complaint, this resolves issues for patients more efficiently. Our latest FFT results can be found on page 37. Our Quality During 2017/18 we will: Improvement • Continue to improve upon the response rate and satisfaction actions for 2017/18 levels within our staff friends and family test (SFFT) and national (linked to priority 2) Annual Staff Survey. • Continue to reduce the number of complaints we receive about the efficiency of our staff by embedding lessons learnt • Undertake the following Quality Improvement projects o Sexual Health Services – Improving access to the Fareham and Gosport services to reduce the number of patients who do not attend appointments o Nursing – Creating effective team processes o Primary Care Musculoskeletal services - Evaluation of musculoskeletal diagnostic imaging utilisation across Musculoskeletal Specialist Services.
Reduce variation and improve reliability of care What it means in To realise this goal we need to have clear, evidence based pathways and practice models of care within each service, and to reduce variation we need to review and develop pathways and develop care bundles. Progress so far The following quality improvement projects have helped us make progress toward achieving these goals: • Specialist Dental Services – improving processes for recalling patients for follow up appointments • Children’s services – streamlining the process for health
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contributions to Education Health Care Plans Our Quality In 2017/18 we will: Improvement • Complete the following quality improvement projects: actions for 2017/18 o Adults Southampton (community neurological) – (linked to priority 2) improving the new patient referral process Page | 19 o Children’s services (looked after children’s services) – improving processes to ensure all new referrals for assessments are conducted in a timely fashion.
To focus on what matters to our patients/ service users and carers. What it means in We will seek to understand what matters to our patients, service users practice and carers so we can better meet their expectations. As well as engaging with users of our services, we will seek to involve them in service design. Progress so far • We have implemented Accessible Information (AI) standards – more information can be found in our Spotlight on AI in Part 5, page 46. • We have introduced web-based feedback in our Sexual Health Services so patients can now provide feedback online. This has seen a significant increase in response rates. • We drafted our volunteer strategic framework which will be issued for consultation in quarter 1 of 2017/18. Our Quality In 2017/18 we will: Improvement • Implement the recording of carer identification and signposting in actions for 2017/18 our electronic patient record. (linked to priority 2) • Introduce ‘Always Events’ in primary care. Always events are aspects of the patient experience that are so important to patients and family members that health care providers must aim to perform them consistently for every individual, every time. This can be linked to the quality improvement programme for rollout. • Maximise the use and development of volunteers.
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Part 2d
Openness and honesty when things go wrong
Page | 20 Duty of Candour
All healthcare professionals have a duty of candour. This is a professional responsibility to be honest when things go wrong with a patient’s treatment or care which causes, or has the potential to cause, harm or distress. This responsibility extends to service users, carers, advocates and families. Professionals are expected to:
• tell the service user or, when appropriate, the service user’s carers/advocates when something has gone wrong • apologise and offer an immediate appropriate remedy or support to put matters right (if possible) • explain fully any short or long term effects ( if appropriate).
The Duty of Candour responsibilities are explained to staff during their induction and when they start working for us. Being open and honest is an integral part of our incident reporting culture - all staff are encouraged to discuss incidents with patients, services users and carers as they occur.
In 2016-17, we have complied with the duty of candour regulation for all appropriate serious incidents (SI) and high risk incidents (HRI) reported through the SI panel in 2016/17. In those instances where the Trust has not had the appropriate contact details or patients have explicitly declined receipt of a written letter following an incident this has been clearly recorded. In addition we have:
• ensured that duty of candour is considered at every strategy meeting • ensured the duty of candour requirements have been met • considered the service user/family’s involvement in the serious incident report • shared all findings and lessons learnt from incidents across the Organisation - an example of how we have done this can be found in the Quality Newsletters in Appendix B.
Complaints
The Trust encourages the staff closest to the people receiving our services to, wherever possible and with the service user’s consent, to deal with concerns and problems as they arise so that issues can be resolved quickly and in a way that is responsive to the service user’s needs and circumstances. Timely intervention can prevent escalation of issues raised and achieve a more satisfactory outcome for all concerned. The approach to complaints handling in the Trust is based on the principles published by the Parliamentary and Health Service Ombudsman (PHSO).
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These are:
• getting it right • being customer focused • being open and accountable Page | 21 • acting fairly and proportionately • putting things right • seeking continuous improvement.
Training has been provided to staff to ensure that anyone making a complaint is supported; receives honest, timely communication; and is clear about the actions we are going to take next.
By working with staff, closest to the person receiving the service, to help them to respond to concerns and problems as they arise we have seen a reduction in the number of formal complaints received (from 290 in 2015/16 to 253 in 2016/17). We have also seen an increase in the number of issues resolved as ‘service concerns’ (from 201 in 2015/16 to 251 in 2016/17). During 2016/17 we also saw an increase in the number of people making contact with our Patient Advice and Liaison Service (PALS) for advice, signposting and general queries. We received approximately 682 calls this year compared to 479 last year.
Our Trust Board receives regular reports on the number, themes and learning from complaints and our Chief Executive personally reviews all complaint responses. In addition our quarterly patient experience report, which includes details of complaints received and the associated learning and outcomes, is made available to the public via our website.
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We strive to embed and sustain the changes made as a result of complaints and concerns to enable long term improvement. These changes are monitored within the services concerned and via our complaints review panel which was introduced to drive quality improvement and act as a mechanism for Trust-wide learning. This panel is chaired by one of our non-executive directors and our Chief Nurse with members including a Healthwatch colleague (the consumer champion for health and social care) and senior clinical representatives from each of our service lines.
Some examples of learning shared through the panel include:
• Sharing Accessible Information about the services patients are referred to • Offering a meeting with the service, known as a local resolution meeting, at the earliest opportunity after a concern is raised. This may allow concerns to be resolved early, improving both the patient and staff experience. • Terms used in complaint response letters should be clear and specific, for example, instead of stating something is ‘rare’, the letter should provide context such as the number of times this has occurred in the past year.
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Part 3
Mandatory statements relating to the Quality of NHS services provided Page | 23 Participation in clinical audits and national confidential enquires
Clinical audit
During 2016/17, we participated in 9 out of 11 national clinical audits and national confidential enquiries, covering health services that we provide. The audits and enquiries that we were eligible to participate in during 2016 /17 are included in Appendix A, together with the number of cases submitted to each audit or enquiry.
Examples of some of the outcomes of our local audits are detailed below:
Audit title Improvement as a result of the audit Re-audit: Dementia screening Improvement in assessment of memory, functioning and care needs and care plan documentation as a result of actions from previous audit. Bimanual examination prior to 100 percent compliance but further actions identified to maintain this intrauterine contraceptive device compliance. fitting Bare Below The Elbows Compliance has increased to 95 percent Since the audit was undertaken further work has been completed regarding jewellery Regional re-audit: Podiatry use of During the audit, informal training occurred as staff started to apply PGD (Patient Group Directions) for what they had learnt even before the audit was fully completed. the provision of antibiotic therapy Re-audit: Discharge and An improvement on the previous audit was seen due to child and Disengagement Pathways 2016 parent friendly discharge letters introduced by service as well as good documentation Re-audit with initial audit: Use of The use of patient ID stickers in the job book resulted in 98.5 percent patient identifiers in handover on compliance rate. rehabilitation wards Looked after Children Review Since the first re-audit in 2014, we have introduced a new consent form Audit; Consent and information for young people with capacity, and a “blue card” process. The blue card submitted prior to Initial Health captures basic consent from parent at the point of the child’s care Assessment entry. This now also includes permission for the statutory health assessment (meaning that as a team we are covered to see the child); although this doesn’t cover us for gathering and sharing information.
In addition, since the last audit, the proportion of health assessments attended by Social workers has improved significantly which means information is available to us at the appointment in more than half of cases.
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Audit title Improvement as a result of the audit Parent Experience of Therapy SPA A keyword image is generated from the comments/quotes received from parents about the service. This provides a visual ‘snap shot’ of the feedback obtained. These results demonstrate a positive response from parents participating in the audit, with the highest frequency descriptors including “helpful”, “friendly” and “happy”. Page | 24 Child Protection Case Conference An audit on the effect of service attendance at child protection case attendance conferences was undertaken. This revealed the process for inviting clinicians to the conferences had broken down. The audit also found that clinician attendance at the panel was significant to the outcome for the child. These findings resulted in a review of the administration process for inviting clinicians to conferences, not just within the department but also within Children’s Services and there is now a robust system in place. Was Not Brought (WNB) This audit found that not every parent was contacted with a WNB letter when an appointment was missed and, while most late cancellations had a further appointment arranged, not all had a reason recorded for the cancellation. However the audit also found that all patients under 18 who were noted as requiring safeguarding steps had the appropriate action recorded.
As a result of these findings a local operating procedure was written and the actions identified in the audit incorporated. A flowchart outlining the recommended steps has been sent to all clinicians. Acceptability of Digital Ano-Rectal All MSMs are now offered this as part of standard screening and the Examination (DARE) as anal cancer service has produced a leaflet to explain the benefits. screening in HIV positive Men who have Sex with Men (MSM) Re-audit: Management of Pelvic Identified that documentation was below standard, areas of concern Inflammatory Disease (PID) in GU noted-clinicians identified and messaged via their line managers; service (NICE PH 3 & BASHH standards) wide sharing of lessons learned from audit and reminder of importance (and regulatory obligation) to ensure good standard of record keeping. Management of Gonorrhoea To improve the management of Gonorrhoea guidance and training was developed to enable health advisors to undertake a test of cure. Vasectomy operations including The service is exploring a new postal method to improve the return rate failure rate of post-operative samples for analysis (to confirm the operation has been a success). The current process is too patient intensive and time consuming. It has been identified that the current failure rates are within national guidance. Impact of combined intervention of The two objectives of this audit were achieved with the result that the physical activity and cognitive ‘Ethogram’ tool is being used for all patients taking part in the group stimulation on the wellbeing of during admission as this was found to result in a higher level of patients admitted in older people engagement with tasks, more smiles and more laughter. mental health services
To date 112 local projects have been completed as a result of our service audit plans. These projects are determined by each service, based on their priorities, and are as a result of business plans, complaints investigations, and serious incident and high risk incident investigations.
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Research
The number of patients receiving NHS services provided or sub-contracted by us in 2016/17 that were recruited to participate in research approved by a research ethics committee was 1513. We have recruited to 47 studies on the National Institute of Health Research portfolio Page | 25 across a range of services. Solent NHS Trust was listed as the most research active Care Trust in the National League tables this year. The research culture and its impact on patient care was listed by the CQC this year as an area of outstanding practice.
Our research priorities:
Increasing Access Developing capability We run a number of training programmes We aim to make it easier for staff and to support research. This includes patients to be involved in research, and workshops and masterclasses, and a to work in partership with our team. clinical academic career pathway
Working in Partnership Supporting growth We work in partnership with Universities We ensure that we can continue to across the country on research studies. grow via new grants and opportunities We also have formal partnerships for to generate income. We are also research with care homes, schools and supporting staff to build an evidence charities base to support increased care in the community/ at home
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Investigating antibiotic resistance – the Solent SMART study
This year, we have worked with the University of Southampton to look at levels of Page | 26 bacterial transmission in different populations and implications for antibiotic resistance. We have taken samples from volunteers in all age groups and in a specific care home population. This has given us the opportunity not only to work on a key public health
issue, but to work with partners around Southampton and Portsmouth. We have extended
the number of homes in our Research Care Home Partnership and started to work with a number of schools and colleges. This helps us to educate young people on antibiotic use, and also on the science behind clinical research. The University have been running education workshops in schools. This is a programme we will continue to build in the next year.
Integrating clinical practice and research into dementia care
A physiotherapist working in a joint clinical and academic role(with the University of Southampton) on our Dementia ward has been supporting the team to use research to improve care. There are a range of projects. One is looking at maintaining mobility amongst older patients on acute wards, and the development of outcome measurements to track this. Another is looking at how to reduce falls amongst this group of patients. A final example is standardising the objective assessment of all the patients on the ward. This has helped the clinical team to monitor mobility and frailty of all the patients while in hospital. These projects have received national recognition, were presented at the UK Dementia congress in November 2016 and have been showcased as an example of good practice in dementia care by NHS England.
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Improving equality of access to research, Homeless Healthcare
The Homeless Healthcare team have been working with our research nurse to enable Page | 27 those who are Homeless to access research studies. Being involved in studies often requires multiple visits to a care team, on scheduled days, which can make it difficult for this group to participate. The team found ways to adjust to the needs of these patients, and this year, they have participated in a study on Hepatitis and another on antibiotic resistance. The healthcare team were recent winners of the Wessex Clinical Research Network Award for Best Clinical Team Engagement.
More information can be found on our research website pages : www.solent.nhs.uk/research. Goals agreed with commissioners
The Commission for Quality & Innovation (CQUIN) framework aims to embed quality improvement and innovation at the heart of provider commissioner discussions. It also ensures that local quality improvements are discussed and agreed at Board level, and enables commissioners to reward excellence by linking a proportion of English healthcare provider’s income to the achievement of local quality goals.
A proportion of our income in 2016/17 was conditional upon achieving quality improvement and innovation goals, agreed between ourselves and any person or body we enter into a contract, agreement or arrangement with for the provision of relevant health services, through the CQUIN payment framework. For 2016/17 the value of the CQUIN payment was £2.698 million.
We are pleased to report that we achieved a significant number of our agreed CQUIN schemes. This is a reflection of the hard work of staff across the organisation.
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The CQUIN schemes agreed with our CCG commissioners for 2016/17 are detailed below
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Registration with the Care Quality Commission (CQC)
We are required to register with the Care Quality Commission (CQC). Our current registration status is “registered without conditions”; we are therefore licenced to provide services. The Care Quality Commissioner has not taken any enforcement action against us during 2016/17. Page | 29
The CQC registers and licences us as a provider of care services as long as we meet the fundamental standards of quality and safety. In June last year we welcomed a team of inspectors from the CQC who highlighted areas of good practice and identified areas for improvement. We were awarded an overall rating of ‘Requires Improvement’, however we were delighted to be rated as ‘Good’ for providing caring and responsive services and our Learning Disability Service was rated as ‘Outstanding’. The inspectors observed that ‘the service was focussed on the needs of the people using it and valued their participation in their care’. They said that the ‘leadership within the service drove a positive, valuing and learning culture that staff thrive in.’
The CQC told us that we demonstrate compassionate care and treat people with dignity and respect. They observed many of our staff supporting patients with care and kindness. It was recognised that we are very focussed on bringing care closer to peoples’ homes, supporting early interventions and promoting self-management. The inspectors also said that we work well with people from other organisations to help keep people out of hospital. Lots of innovative practice was found across the Trust, especially in our adults and children’s community services.
During the inspection the CQC provided daily feedback on their key findings, drawing our attention to any areas requiring improvement, enabling us to take immediate action where possible. Areas requiring more detailed response and the ‘Must Do’ and ‘Should Do’ actions identified by the CQC in the final report were included in a comprehensive action plan which is embedded within services. Whilst we have already acted to make these changes, we recognise that real sustainable change will take time and this is reflected in our quality priorities.
This action plan is reviewed regularly within services and through our governance structure at the Quality Improvement and Risk Group (QIR) and our Assurance Committee, a sub-committee of our Trust Board. Actions taken to date include:
• refreshing our medicine management arrangements, including in special schools • achievement of 95 percent compliance in documenting risk assessments of children and young people within the child and adolescent mental health services (CAMHS) • completing home visits for all Substance Misuse service users with replacement drug therapy in the home who have children resident in or visiting the home • working with our commissioners to identify opportunities for improvement in the provision of the external wheelchair services • working with our commissioners and partners to ensure that the provision of the 136 Suite (a place of safety for those who have been detained under Section 136 of the Mental Health Act by the police following concerns that they are suffering from a mental disorder) is robust and accessible
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• ensuring that Substance Misuse Services have signed patient group direction forms (PGD) in place • reviewing our safeguarding training • developing our chaperone policy and training for staff in primary care • reviewing our clinical and safeguarding supervision arrangements Page | 30 • appointing a new Resuscitation Officer and reviewed the standardisation of training and equipment.
Solent community service ratings
Safe Effective Caring Responsive Well-led Overall
Community health Requires Good Good Good Good Good services for adults Improvement
Community health services for children, Requires Requires Requires Requires Inadequate Good young people and Improvement Improvement Improvement Improvement families
Community health Good Good Good Good Good Good inpatient services
End of life care Good Good Good Good Good Good
Sexual Health Good Good Good Good Good Good
Requires Overall Good Good Good Good Good Improvement
Solent mental health ratings
Safe Effective Caring Responsive Well-led Overall
Acute wards for adults of working Requires age and psychiatric Good Good Good Good Good Improvement intensive care units (PICU's) Long stay/rehabilitation Requires mental health wards Good Good Good Good Good Improvement for working age adults Wards for older Requires Requires Requires Requires Good Good people with mental improvement Improvement Improvement Improvement
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health problems Community-based mental health Good Good Good Good Good Good services for adults of working age Mental health crisis Page | 31 services and health- Requires Good Good Good Good Good based places of Improvement safety Specialist community mental Requires Requires Requires Requires health services for Inadequate Good Improvement Improvement Improvement Improvement children and young people Community-based mental health Requires Requires Inspected but Requires Requires Good services for older Improvement Improvement not rated Improvement Improvement people Community mental health services for people with a Good Outstanding Outstanding Outstanding Outstanding Outstanding learning disability or autism Community Requires Requires Requires Requires Inadequate Good Substance Misuse Improvement Improvement Improvement Improvement
Requires Requires Requires Requires Overall Good Good Improvement Improvement Improvement Improvement
Solent Primary Medical services ratings
Safe Effective Caring Responsive Well-led Overall
Portswood Solent GP Requires Good Good Good Good Good Practice improvement
Adelaide Health Good Good Good Good Good Good Centre
Royal South Hants Requires Requires Requires Hospital - Good Good Good improvement Improvement Improvement Nicholstown
Solent NHS Trust overall ratings
Requires Requires Requires Requires Overall Good Good Improvement Improvement Improvement Improvement
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Information Governance
Information Governance Toolkit attainment - the organisation has completed an annual Information Governance Toolkit Assessment achieving 70 percent compliance, which has been graded as ‘Green – Satisfactory’. Further information about the IG Toolkit can be Page | 32 found www.igt.hscic.gov.uk
Freedom of Information (FOI) Requests – the number of FOI requests received within a financial year has increased by 41percent when comparing 2016/17 to 2015/16. This year we have achieved 87.7 percent compliance with the 20 working day response target. This is a reduction on 2015/16 when we achieved 92.5 percent compliance. At this time, 10 requests are not currently due and have therefore been excluded from these figures. This reduction in compliance is due to the increasing number of requests which have also increased in complexity. The Trust will be reviewing the processing of requests to improve compliance.
Subject Access Requests (SARs) – the number of subject access requests received within a financial year has decreased slightly as the Trust no longer manages the Walk in Centre and Minor Injury Unit which were previously subject to a high volume of requests.
This year we achieved 85 percent compliance with the 40 day response target which is a slight increase on 2015/16 when we achieved 83 percent compliance. The Information Governance Team is currently reviewing the process of handling these requests to continue to increase compliance.
Clinical coding
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Clinical coding is the translation of written medical terminology into alphanumeric codes. Each code is a set of characters that classify a given entity. Clinical coders extract the relevant information from a source document and assign the appropriate codes that represent the complete picture of a patient spell in hospital. This is in accordance with the NHS Data Dictionary and World Health Page | 33 Organisation standards set out in the Clinical Coding Instruction Manual - International Classification of Diseases version 10.
Clinical coding is important for local and national monitoring of incidence of diseases and in acute trusts is used in the development of reference costing for contractual purposes. We are responsible for providing accurate, complete, timely coded clinical information to support commissioning, local information requirements and the information required for the Commissioning Data Set (CDS) and central returns.
Each year the coding process is audited by an external accredited auditor. The audit examines the quality and completeness of clinical information available for coding as well as the completeness and accuracy of the coding itself. We have achieved a top level three rating for the past two years.
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Department of Health Mandatory Quality Indicators
We have reviewed the required core set of quality indicators which we are required to report against in their Quality Accounts and are pleased to provide you with our position against all Page | 34 indicators relevant to our services for the last two reporting periods (years).
Preventing people from dying prematurely - Seven day follow-up
The data made available with regard to the percentage of patients on Care Programme Approach who were followed up within seven days after discharge from psychiatric inpatient care. This allows us to ensure our servicer users’ needs are cared for and they remain safe following discharge from hospital to community care.
NHS Organisation(s) 2015-16 2016/17 National Other Trusts – Other Trusts – Average Highest Lowest (Q2 for info awaiting year end figure)
Solent NHS Trust 99 percent 100 96.5 percent 100 percent 76.9 percent percent (Q2 16-17) (Q2 16-17) (Q2 16-17)
Enhancing quality of life for people with long-term conditions – Gatekeeping
The percentage of admissions to acute wards for which the Crisis Resolution Home Treatment team acted as a gatekeeper during the reporting period. The Crisis Resolution teams provide prompt and effective home treatment for people in mental health crisis and quickly determine whether service users should be admitted to hospital, or are suitable for home treatment. It is important to our service users that they are treated effectively and promptly in the most appropriate settings of care.
NHS Organisation(s) 2015-16 2016/17 National Other Trusts – Other Trusts – (Q2 for Average Highest Lowest info awaiting year end figure)
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Solent NHS Trust 100 100 98.2 percent 100 percent 76.0 percent percent percent (Q2 16-17) (Q2 16-17) (Q2 16-17)
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Ensuring that people have a positive experience of care – Community Mental Health Patient Survey
The Health and Social Care Information Centre (HSCIC) provides patient experience indicator data for Page | 36 the annual national Community Mental Health (CMH) Survey. The CQC does not provide a single overall rating for each trust for this survey, as it assesses a number of different aspects of people’s care and results vary across the questions and sections.
In the patient survey report published by the Care Quality Commission (CQC), the results are presented as standardised scores on a scale of 0 to 10. The higher the score for each question, the better the Trust is performing. As can be seen from the table below, the CQC have rated as ‘about the same’ as most other trusts.
We consider that this data is as described as this Care Quality Commission (CQC) national survey was developed and coordinated by the Picker Institute Europe, a charity specialising in the measurement of people’s experiences of care.
2015-16 2016/17 Survey Solent Lowest Highest CQC Solent CQC Section Patient Trust Trust Comparison Patient Comparison Responses Score Score with Other Responses with Other Trusts Trusts Health & 7.4/10 6.8 8.2 About the 7.4/10 About the social care same same workers Organising 8.4/10 7.9 9.0 About the 8.7/10 About the Care same same Planning Care 6.8/10 6.1 7.6 About the 6.8/10 About the same same Reviewing 7.3/10 6.8 8.2 About the 7.3/10 About the Care same same Changes in 5.8/10 4.7 7.3 About the 6.0/10 About the Who People same same See Crisis Care 5.8/10 5.1 7.2 About the 6.1/10 About the same same Treatments 7.0/10 6.3 7.9 About the 7.1/10 About the same same Support & 5.0/10 About the Wellbeing same Overall Views 7.2/10 6.5 7.8 About the 7.2/10 About the of Care & same same Services
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Overall 6.9/10 6.2 7.3 About the 6.8/10 About the Experience same same
We have implemented an action plan to improve the quality of our mental health service. This includes: Page | 37 • writing Care plans in the first person - care plan training commenced in March • making the CRHTT service more accessible by opening up to direct referrals from the police and ambulance services • talking about our customers in team meetings • reviewing the Friends and Family Test (FFT), analysing comments and identifying any issues requiring investigation - every month in our Governance Group, we ask a service to go through recent results and look at any issues • improving patient involvement: our Patient Forum has been running for two years providing a conduit for patient engagement in service developments and is consulted on for a number of issues such as going Smoke free • recruiting to the post of a physical health nurse to provide education and advice to service users and staff in the community teams • increasing the number of whole time equivalent (WTE) staff in our physical health and well-being team by one • ensuring all clinic rooms have physical health monitoring equipment available • co-locating Solent Mind with the community teams • continuing to review housing provision placements and the local housing available through the transformation project • reviewing the pathway for people who use our services to ensure interventions happen in a timely way
Treating and caring for people in a safe environment and protecting them from avoidable harm – Patient safety incidents The purpose of this indicator is to help monitor shifts in the risk of severe harm or death to patients and to identify new emerging risks so that we are able to proactively identify potential impacts on patient care. Trusts that have high reporting figures have a better safety culture.
Patient safety incident data is collected centrally by the National Reporting and Learning Service (NRLS). Two measures are reported below for the rate of incidents reported per 1000 bed days and the rate of incidents which are categorised as causing severe harm or death.
The NRLS considers high levels of incident reporting by Trusts to be an indicator of a positive reporting culture. Consequently, high numbers of incidents are viewed positively, particularly when the proportion of serious incidents is low and the proportion of no harm incidents is high.
Please note that the full report for April-September 2016 is not currently available due to a delay of six months from when data is submitted to the NRLS to it being published.
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October April 2015 to October 2015 April 2016 to 2014 to September –March 2016 September March 2015 2015 2016 Patient safety incidents per 1,000 provider bed days Page | 38 Solent NHS Trust 83.93 65.57 28.46 67.1 National Average (Mental Health 38.92 42.00 42.03 42.45 Trusts) Patient safety incidents resulting in severe harm or death Solent NHS Trust 1.34 percent 2.14 percent 6.01 percent 14.29 percent National Average (Mental Health Currently 1.06 percent 1.14 percent 1.14 percent Trusts) Unavailable
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Part 4
Review of Quality Performance
Page | 39 In this section we report on the quality of the service we provide.
Same sex accommodation requirements Why did we choose this measure? Reducing mixed sex accommodation is a national priority and Department of Health requirement Performance: There have been no breaches during this year.
Patient Experience Why did we choose this measure? The Friends and Family Test is a nationally mandated tool which allows services users and staff to give their feedback on NHS services Performance:
Neither Not Total Extremely Extremely Don't Recommend Likely Likely or Unlikely Recommend Responses Likely Unlikely Know Unlikely 95.79 16/17 1.65 percent 15335 11711 2978 264 96 157 129 percent 94.95 15/16 2.17 percent 13927 10474 2749 263 116 186 139 percent
The positive feedback from our service users last year has been sustained and improved this year, with an increase in the proportion of respondents who would recommend our services and a reduction in the proportion who would not recommend.
This shows that the majority of our service users are reporting a positive experience of care and the free text comments detail the complimentary feedback provided. Themes include comments related to our caring and professional staff. Services share the feedback with staff who are often personally named by service users and review comments for planning quality improvements.
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Patient Led Assessment of the Care Environment (PLACE) Why did we choose this measure? Department of Health requirements Performance:
Page | 40
As the results above show we scored highly in most categories achieving 100 percent in a number of areas such as cleanliness, ward food and condition and maintenance. It should be noted that the dementia standard was not scored fully in 2015 and the disability standard was not scored until 2016.
The majority of the patient assessors for 2016 were also part of the 2015 team and reported being extremely impressed with the services’ standards, particularly the food and cleanliness. They were pleased to see the changes that were already put into place due to their previous assessment and input.
The overall results of the PLACE visit demonstrate that there are high standards in cleanliness, condition, maintenance and food in the ward areas. There is a room for improvement in the disability and dementia scoring categories, which will be monitored. In those areas where we are tenants, or are co-located with other organisations, we work with the appropriate landlord if issues are identified and agree a joint action plan.
In order to maintain these standards, we will be re-introducing our local mini-PLACE assessments in 2017/18.
Infection control: reduction in MRSA and C. Difficile infections
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Why did we choose this measure? Department of Health requirement Performance: we are committed to a zero tolerance approach to any avoidable healthcare associated infections (HCAI’s). Achieving this vision requires planning and a systematic approach to ensure the organisation has a culture where infection prevention and control is embedded in practice. We acknowledge that every member of staff needs to be involved in the process therefore Page | 41 making infection prevention part of everyone’s job. There have been no instances of MRSA bacteraemia since 2013/14 and no instances of C. Difficile in 2016/17.
Statutory and mandatory training for 2016/17
It is important that our staff are able to learn, develop their skills, and receive the training they need to carry out their roles safely. In 2016/17 we have supported the learning and development needs of staff linked to organisational priorities. We have:
• offered clinical learning and development opportunities • delivered 20 leadership and management development programmes across our framework, with 61 members of staff achieving an accredited Institute of Leadership and Management qualification • supported our newly qualified staff to make the transition from student to clinical professional through our Preceptorship programmes • increased opportunities for our young apprentices, supporting 12 young apprentices in 2016/17 • embedded the new Practice Educator team into our service. Six Practice Educators have been helping to improve the experience placement students have whilst with us
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• supported staff development including: mentoring and the delivery of clinical skills programmes • ensured our staff are continuously developed - 91 percent of our staff have had an appraisal discussion with their manager, and have agreed a personal development plan Page | 42 • developed a career framework to support our staff in their career planning, and to provide clear information on roles and associated training and development • achieved 81 percent compliance with our Statutory and Mandatory training • achieved 95 percent compliance with Information Governance training.
Mandatory Training Course Compliance Appraisals 91.8 percent Corporate Induction 85.8 percent Dementia 72.6 percent Diversity 81.8 percent Fire Safety 72.8 percent Health & Safety 75.9 percent Infection Control 78.9 percent Information Governance 95 percent Manual Handling 84.7 percent Mental Capacity Act 72.6 percent Resuscitation 95.5 percent Safeguarding Adults 78.0 percent Safeguarding Children 80.7 percent Overall Mandatory Training 81.0 percent
Staff absence through sickness rate
Recognising that our staff are our most valuable resource, the approach we have taken to reduce sickness absence in the last year goes hand in hand with promoting staff wellbeing. In response to sickness absence data various initiatives have been implemented and evaluated to improve staff health and wellbeing. These include the increased provision of self-referral and fast track physiotherapy, emotional resilience workshops and self-care at work. These are designed to motivate and empower staff promoting self-care approaches that will help them improve their lifestyle.
Managers are supported by the human resources and occupational health teams as well as through our Employee Assistance Programme (EAP) to manage sickness absence in-line with policy supporting staff to attend work regularly. Support is also available to sustain a return to work following a period of absence.
We hold a bi-monthly health and wellbeing steering group which is attended by key stakeholders involved in supporting staff.
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In 2016, we saw our sickness absence fluctuate between 3.8 percent and 5.25 percent with usual seasonal trends occurring. Overall, the rolling sickness rate rose 0.1 percent to 4.42 percent . Stress is the main cause of sickness at 23 percent ; this is down 1 percent on the previous 12 month period.
Page | 43 The following graph shows sickness absence rates for April 2016 to March 2017. Sickness rates have fluctuated throughout the period, with a peak of 5.25 percent in November 2016. The rolling absence rate however emphasises the rate based on the preceding 12 month rolling average, and we are presently 4.42 percent , with the trend slightly rising. The average for community and mental health trusts for 12 months to April 2017 was 4.86 percent .
Staff survey
We believe that the feedback we receive from our staff plays an important part in creating a great place to work. Throughout the year we encourage our staff to share what it is like to work for the Trust through formal and informal routes.
Annually, we ask our staff to take part in the Annual Staff Survey, a national survey undertaken by all NHS trusts. Our response rate to this survey was 55.3 percent in 2016/17, an increase of 10.9 percent from last year. The national average response rate was 46.5 percent . This is a good indicator of engagement and demonstrates that our staff value the opportunity to share their views. This continues the positive trend we have seen through the quarterly Friends and Family Test (FFT) results.
Key points from the 2016/17 survey:
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• Compared to last year, we scored significantly better on 53 questions and significantly worse on only 2 questions. • Compared to other Mental Health Community (MHC) Trusts surveyed by Pickers, we scored significantly better on 29 questions, average on 53 and worse on 6. • Our overall engagement score, measured by NHS England, is 3.83 compared to 3.69 last year. Page | 44 The national average score for community trusts was 3.80.
The investment in the Great Place to Work Programme has yielded positive results with a greater focus on people through learning and development, leadership and health and wellbeing. Our collective effort to strengthen our culture through continued focus on values and behaviours is taking us in the right direction. Examples of initiatives include the Global Corporate Challenge, Dragons’ Den, leadership development programmes and improved internal communications. We will need to maintain and strengthen our efforts in order to continue the positive improvements throughout the next year.
Part 5: Quality improvement news from 2016/17
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Freedom to Speak Up
This year we appointed seven Freedom to Speak Up guardians. These guardians are a visible resource within the Trust working to the national guardian office Page | 45 recommendations on issues relating to raising concerns by NHS workers.
All guardians have undertaken training from the national guardian office to enable them to review the handling of concerns raised by NHS workers. They also review the treatment of the person, or people, who spoke up if there is cause for believing that this has not been in accordance with good practice.
Developments since the introduction of these guardians include:
• implementing an on-call rota Monday to Friday • launching a shared email account, although guardians can also be contacted on an individual basis • embedding freedom to speak up within corporate induction • raising awareness through articles in the weekly Staff News email, presentations at service line away days and at a variety of meetings including the Health Care Support Worker (HCSW) forum.
Quality Improvement Collaborative
July 2016 saw the launch of the Quality Improvement Collaborative. The programme is designed to support and encourage individuals and teams to develop the skills and capability to successfully develop and implement quality improvement projects within their workplace. Five cohorts of 7-8 teams will participate over the course of three years.
The programme comprises the following three core elements:
1. Individual team workshops to provide teams with support to carry out quality improvement projects within their workplace. 2. A series of 3 to 4 externally facilitated learning events on key quality improvement topics, delivered over eight months. 3. Optional master classes, delivered by external speakers and open to all staff, covering subjects such as Coaching for Improvement.
Seven teams joined Cohort 1 in July 2016, and a further seven teams joined Cohort 2 in December 2016. Work to date includes:
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• Improving ward processes, such as the timing of a patient’s medical review, to lower the risk of errors from rushed prescriptions so that all patients have a timely, safe and effective discharge • Improving the process of recalling patients for follow-up dental appointments to reduce the risk of patients developing associated long-term health issues – the revised process will be Page | 46 launched in 2017/18
Spotlight on Catheter Improvement Project 2016/17
Urinary Tract Infections (UTI), particularly those that relate to urinary catheters, are the second largest group of Healthcare Associated Infections (HCAI) and are responsible for approximately 17.2 percent of all HCAIs. We have been working on improving the timely removal of unnecessary catheters, associated paperwork and ensuring this area of care is as safe as possible.
Due to inconsistencies with urinary catheter documentation in inpatient and community services, the aim of the project is to ensure that every patient with a urinary catheter will have the correct paperwork accurately completed by July 2017. Expected benefits include:
• facilitating the timely removal of unnecessary urinary catheters • reducing the risk of HCAI and Sepsis • reducing the use of unnecessary antibiotics • reducing the demand on clinician’s time • reducing, pain and, increased mortality and expense.
Early in the project a baseline audit revealed that only 52 percent of patients had the correct paperwork completed accurately. For those patients assurance is provided that urinary catheters were appropriately placed. Six months into the project, the same audit was repeated and compliance was found to have risen to 80 percent , an improvement of 28 percent .
Lessons learnt, and the next steps, have been identified so we can continue to move forward and reach our aim by July 2017. This will contribute to plans from NHS England to reduce gram negative bloodstream infections by 2020, as many UTIs are caused by gram negative infections such as E.coli.
Spotlight on Accessible Information - Supporting the communication and information needs for all
Key developments with accessible information relate to the following five areas:
1. Introduction of a three-tiered accessible information training programme for staff 2. Development of an accessible information network 3. Recruitment of ‘Accessible Information Patient Volunteers’ and ‘Accessible Information Support Volunteers’ 4. Electronic recording requirements on patient records systems and data reporting
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5. Partnership working and national collaborations
Page | 47
Patient story – Dental Services
The specialist dental service had a referral for a child with autism who required an extraction under general anaesthetic (GA). The child’s mum contacted the service for help in explaining the process to
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their child. The service was able to work with the mum using the ‘At the Sleep Hospital’ storyboard to help her prepare their child for the visit. The child’s mum shared this information with their child’s school and they developed a personalised story book that incorporated some of the ‘widgets’ from our storyboard as well as those the child commonly uses. This enabled the child to be familiarised Page | 48 with the process and their story in the run up to the appointment and was very successful in preparing the child for their GA in an unfamiliar setting. The whole procedure ran very smoothly. Just before they left, the family proudly read their ‘story’. This is a section of the story (patient name removed):
This is the accessible information used by the service to explain the process of a general anaesthetic.
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Spotlight on recovery and peer workers
The Recovery Approach has contributed to substantial improvements in Adult Mental Health services. The development of a Trust–wide Thematic Lead role is designed to take this learning to other areas, working with people who have long term conditions. Page | 49 The approach promotes hope, self-management and opportunity to support people’s adjustment to a life changing event or illness. We have learnt that a key element in this is to harness the expertise of people who have themselves used the service / had similar health conditions – called ‘peers’. Using co-production to work equally with peers, we consider problems, develop solutions and deliver them together – creating a powerful, sustainable community to make improvements for individuals, services and staff. Key objectives and progress to date include:
Objective Progress to date: 1. To increase our ability to We are currently establishing a baseline, framework and learning network of learn from and work services working in this way. Our aim is to share and build best practice. with people who access A few examples are shared below: our services (Learning - Service users in Adult Mental Health have developed a training package from Lived Experience for staff about how to improve the experience of having their risk of LLE) suicide assessed. - Created a collection of films about service user’s experience of services across the Trust. - Project to identify, trial, and embed a Patient Reported Outcome measure in Adult Mental Health including service-user led training and consultation with all staff groups. - Workstream to engage adults with Learning Disabilities in recruitment of staff; service audits and evaluation. 2. To promote recovery - Re-launch of Solent Recovery College based in Portsmouth. In principles – partnership with Solent Mind and Highbury Further Education College, Hope; opportunity; self- we provide education courses about mental health for people who use management through – mental health services, carers and staff. All courses are developed and Coproduction; learning delivered by adult mental health staff and peer trainers (people who from lived experience have / have had mental health issues). We continue to host National and and recovery education International visitors wishing to learn from our model. We intend to in services working with expand this model to people with other long term conditions. people with long term - Project underway to recruit peer volunteers who live well with diabetes conditions. to work with people accessing the diabetic foot clinic. Aim to improve wellbeing though improved self-management. - Work underway with Community Nursing team to enhance methods of gaining patient experience feedback from a vulnerable and disparate client group through projects to tackle social isolation and improve wellbeing.
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Spotlight on Dementia Thematic Lead
We recognise the importance of ensuring that all our services and the environments in which we provide services are dementia aware and dementia friendly. In 2016 we introduced the role of Dementia Thematic Lead. This lead role works across the Trust in collaboration with frontline staff Page | 50 and support services teams to ensure that the necessary skills and knowledge are increased and standards are consistently achieved.
Working in partnership with Dementia UK, we began providing support and advice to a team of admiral nurses. As a consequence of our joint work, the Solent Dementia network was launched. The network is designed to give our dementia nurses and healthcare professionals easy access to quality information and support, which in turn will lead to better care for our dementia patients.
Objectives: Achievements to date:
Identify training needs for staff Dementia tier two training was sourced. A ‘train the trainers’ day and Implement tier two occurred in July 2016 and some of our clinicians are involved in rolling Dementia training for all out the training. Training on offer to clinical staff since October 2016. We relevant clinical staff. have offered 8 days so far with another 9 booked before end of March.
Network with other agencies Networking has occurred with Wessex academic health sciences and local partners to share dementia programme. Queen Alexandra Hospital dementia link workers, knowledge and expertise and Solent Mind. Southampton Dementia Action Alliance and Portsmouth look at collaborative working. Dementia Action Alliance.
Provide expertise and advice in Involvement in the development of trust guidelines for environmental Dementia care across our design for people with dementia. services
Develop a network of dementia Visits to services to offer support, including rehab wards Southampton, champions to promote high Community rehab teams Southampton and Portsmouth. District nursing quality dementia care. teams Portsmouth.
Access additional This is in the early stages. Links have been made with some services. learning/training to promote Liaison with Wessex Academic health sciences about their dementia advanced practice and leading networks. service improvements
Spotlight on Falls
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The Falls Thematic Lead is a Trust-wide role introduced in late 2016 to support frontline staff in delivering care in line with agreed standards. A particular focus of the role during the first year is to review the training made available to frontline staff as well as leading the updating of the Trust Falls policy in line with latest guidance. The post holder will also undertake a thematic review of falls that Page | 51 occur within the in-patient areas of the Trust so that further action can be identified to improve patient outcomes.
Objectives for 16/17 Achievements to date:
To establish a baseline of current Falls referral We have developed and disseminated two falls and management pathways across all adult fact sheets, and a community post-fall protocol services in both Southampton and Portsmouth To identify Falls training needs and to implement Falls training is now on the our Learning and and monitor Falls training Development Compliance Matrix for all relevant staff
Long term objectives revise into outcome Falls champions will be supporting the To reduce falls in our care by establishing Falls development of a system of cascade training for Champions, auditing the delivery of our Falls falls for staff in 2017/18 services, and provide additional information on our Intranet.
Spotlight on End of Life Care
Every year, around half a million people in England die, and two thirds of them are people over the age of 75. For most people a ‘good death’ would mean pain free, in a familiar place with close family or friends and being treated with respect. 75 percent of people say they would prefer to die at home. Recently, the number of people dying at home has increased (42 percent in 2011), but over half of deaths still occur in hospitals.
We have appointed a part-time lead in End of Life Care. The aim of the role is to provide leadership for further development and improvement of end of life care across our Trust, ensuring patients are provided with safe, effective and high quality end of life care. This will be achieved through:
Objectives Achievements to date Networking and collaboration: Scope and map Networking has taken place with wider services services and identify key stakeholders and by attending Wessex End of Life meetings. partners in relation to End of Life Care. Relationships are being built with local hospices across Portsmouth and Southampton. Network and establish relationships within the acute, primary, voluntary and private sector across the geographic areas of Portsmouth and Southampton.
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Increase understanding and awareness of End of Life Services provided through meeting with other agencies and services within our area to enhance good practice, and improve skills and Page | 52 knowledge. Training: Identify End of Life training needs and Training has been delivered in Communication in gaps by developing and collating data through Advanced Decision Making and Case means of a training needs analysis. (Linked with Management Training departmental and organisation objectives).
Rein state and roll out of End of Life Case Management training.
Introduce and roll out of the Individualised Care Individualised care plan developed and in Plan process of being rolled out. End of Life Link/expertise: To act as the link and Champions in End of Life Care identified across subject matter expert on End of Life Care by Southampton teams and wider services offering guidance on service improvement and broaden End of Life Care process exposure
Develop a network of Link Champions in End of Life Care to share practice and enhance End of Life Care
Roll out End of Life Newsletter to share practice and inform staff Policies and Audit: Identify a baseline policy for Audit aims written and audit tool developed to DNACPR and research guidance on difficult identify decisions made in relation to DNACPR. conversations in relation to CPR
Develop an End of Life framework
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Part 6: Feedback from key stakeholders
Healthwatch Southampton comment on the initial draft Account
Page | 53 Healthwatch Southampton welcomes the opportunity to make formal comment on the draft of Solent NHS Trust Quality Account 2016/17.
In Southampton, the Solent NHS Trust provides in-patient care at the Western and Royal South Hants hospitals as well as GP practice surgeries and a number of outpatient clinics and community services. Healthwatch Southampton can therefore only comment on those services that apply to Southampton.
The tables given in the review of quality goals and priorities in 2016/17 section are clear and it is pleasing to see that progress has been made. We are particularly pleased to see a reduction in the complaints regarding communication, although the way the bar chart is produced, starting with a base of 33, visually exaggerates the reduction.
However, further on in this section, the Quality Goals within the Strategic Framework are listed and include ‘Quality Improvement actions for 2017/18. This is confusing and means that the reader is having to refer back to see how statements fit with the section entitled quality priorities in 2017/18. Despite this, the information given in these sections is clear and easily understandable. We are particularly pleased to see the proposal to introduce ‘always events’.
We are pleased to see that the Trust is taking its compliance with the duty of candour very seriously and encourage an open and transparent policy.
The total number of concerns and complaints raised with the PALS and complaints service remains at about the same level, but it is pleasing to see that many of these are now resolved within the services reducing the number of formal complaints. We know from our experience, and are pleased, that the PALS service is prominently advertised. The fact that the number of general contacts with the PALs service for advice and signposting has increased is evidence of its availability. Communication and information for patients is often a major cause of complaint to Healthwatch and it is good to see that this has reduced by 10 percent for the Trust. We applaud the establishment of a complaints review panel and that is has Healthwatch amongst its members.
The fact that Solent NHS Trust continues to be at the top of the National League tables for research activity in Care Trusts is good news not just to those immediately affected by the trials but much wider. We were pleased to see this recognised by the CQC.
The CQC rating of good for Community service accords well with our experience and the trust is to be congratulated on this rating. Patient feedback on the primary medical services is also in line with the CQC findings and we have worked with the management of the Nicholstown surgery.
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Healthwatch Southampton was involved with the PLACE inspections revealing a high standard of cleanliness, and attention to patient dignity. The facility at the Royal South Hants hospital is collocated in premises managed by NHS property services and the inspection showed significant deficiencies in the maintenance of the premises controlled by them; fortunately, this does not reflect in the scoring for Solent NHS Trust. Page | 54 The improvement in staff response to the survey is encouraging as there is no doubt that the impact of staff experience can affect the delivery of care and overall patient experience.
The quality priorities for 2017/18 are welcomed but given the importance of these priorities we would have wished to see a little clearer narrative rather than the bulleted statements. We look forward to continuing an effective relationship with the Trust and will do what we can to help the Trust achieve its objectives.
H F Dymond MBE Chairman Healthwatch Southampton
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Appendix A
Eligible National Clinical Audits / Percentage Number of National Confidential Enquiries Cases Submitted Page | 55 (CQUIN 2016/17) Improving physical healthcare to reduce 109 / 110 (99 percent ) premature mortality in people with severe mental illness Child Health Clinical Outcome Review Programme: 3 cases (100 percent ) Chronic Neurodisability Child Health Clinical Outcome Review Programme: Organisational survey Young People's Mental Health completed (100 percent )
Learning Disability Mortality Review Programme (LeDeR) 14 cases (percentage rate is not applicable) National Diabetes Audit - Adults: National Core (Participating surgeries listed under Southampton CCG included: Adelaide 679 cases Health Centre, Portswood Solent, Homeless Healthcare, Nicholstown. (percentage rate is not applicable) Figures for HH were suppressed in the national report). Prescribing Observatory for Mental Health Quality Improvement Programme: 80 cases 11c - Prescribing antipsychotic medication for patients with (percentage rate is not applicable) dementia Prescribing Observatory for Mental Health Quality Improvement Programme: 8 cases 16a - Rapid tranquillisation in the context of the (percentage rate is not applicable) pharmacological management of acutely-disturbed behaviour Prescribing Observatory for Mental Health Quality Improvement Programme: 25 cases (percentage rate is not applicable) 1g and 3d - Prescribing highdose and combined antipsychotics Suicide: Suicide, Homicide and Sudden Unexplained Death (NCISH) 8 / 9 questionnaires completed (89 percent ) (remaining one in progress)
Appendix B Examples of quality newsletters used within clinical service lines to share key messages and lessons learnt
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Portsmouth Clinical Commissioning Group (Response in 16/17 Quality accounts)
NHS Portsmouth CCG supports the Trust in its publication of the 2016/17 Quality Account. Having reviewed the mandatory detail of the report, we are satisfied that the Quality Account incorporates the mandated elements required, based on available data. Page | 59 The CCG recognises the progress made on the 16/17 5 goals and the continuous development planned in 17/18.
Throughout 2016/17 the Trust made significant progress with the challenges around Community Nursing recruitment and retention. Whilst there are still a number of vacancies, the service has mitigating processes and procedures in place to address any potential areas of concern.
The recent CQC inspection awarded Solent an overall rating of Requires Improvement and the CCG acknowledge that there is a robust action plan in place to address specific areas. The progress against this is monitored at the monthly Clinical Quality Review Board. Whilst this was an overall rating, the CCG are delighted to acknowledge the rating of outstanding awarded to the learning Disability services – especially as this was one of the only LD services nationally to be rated as outstanding by the CQC.
The CCG recognises the ongoing work to embed the Patient safety agenda into practice across all its services. Work continues to build on processes to ensure compliance with the National Serious Incident Framework and in particular the CCG has seen a marked improvement to the quality and timeliness of investigations. Furthermore the impact of investigators and service line representation at the CCG SI panels has been beneficial and valuable for both provider and commissioner. It is anticipated that the Trust will now further embed the sharing of lessons across the organisation so that other areas learn and implement actions accordingly as a result.
Solent is actively engaged in the development of a robust review process for Mortality – with a focus on learning from deaths. The work undertaken by the executive team and involvement in the recent national guidance on learning is noted and welcomed by the CCG.
The Trust continues to engage positively and proactively with the CCG and has welcomed challenges posed by the CCG to ensure services are safe for patients.
The CCG applauds the Trust for the significant role it is taking in research activity.
Suzannah Rosenberg Director of Quality & Commissioning NHS Portsmouth Clinical Commissioning Group
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Southampton City Clinical Commissioning Group
Solent NHS Trust Quality Account 2016/17
Southampton City Clinical Commissioning Group is pleased to comment on Solent NHS Trust’s Page | 60 Quality Account for 2016/17. The CCG has continued to work with the Trust over the past year in monitoring the quality of care provided to the local population of Southampton in identifying areas for improvement.
There is a clear message within the Quality Account that Solent aims to provide patient centred care through continuous quality improvement and the report has highlighted some of the positive improvements made during 2016/17. These include; freedom to speak, staff survey improvements, quality improvement collaborative, accessible information and recovery and peer workers
It is disappointing to see only 2 of the 5 priorities were fully achieved during 2015/16, with a further 3 partially met. Additionally the demonstration of measures of success is not as robust in some areas as would be expected. It is recognised that priority 4 Patient Safety and Effectiveness (safe staffing), which was partially met, is reliant on guidance being issued by national bodies and it is good to note that Solent NHS Trust plans to have tools to support services during the first half of 2017/18. It is also recognised that the Trust has picked up on those indicators that were partially met in its plans for 2017/18.
A joint statement is submitted by the Chief Nurse and Chief Medical Officer which outlines continued commitment to providing care that is safe effective and provided in an efficient manner. A continued focus is for Solent to gather feedback on services, one method quoted is the Friends and Family Test and the importance of understanding whether patients would recommend the services to friends and family.
The Quality Improvement Programme provides a range of focused activities for staff training, development and a tool for reviewing capacity. Although Solent’s internal Quality Improvement Programme has been successful, both the Chief Nurse and Chief Medical Officer provide continued commitment to participate in the wider patient safety/improvement collaborative work in Wessex.
The number of formal complaints fell in 2016/17, although the number of PALS concerns rose during the same period as the organisation tried to ensure issues were dealt with more swiftly. The Chief Executive personally signs all complaint letters and a Complaints Review Panel has been developed; chaired by a Non-Executive Director and attended by Healthwatch. The aim of the Panel is to improve quality and to support organisational learning from complaints.
15 national clinical audits and confidential enquiries were reviewed by the Provider and actions appropriately identified to improve the quality of healthcare provided for the local audits. Although
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not yet finalised, there have been a total of 71 local projects completed from the service audit plans, which is to be commended.
Participation in clinical research meant that Solent were able to recruit 1181 patients into research studies. They recruited to 41 studies on the National Institute of Health Research portfolio and Page | 61 continue to be at the top of the National League tables of research activity in care trusts, which CQC stated was an area of outstanding practice, the CCG endorse this and commend the Trust for this performance.
Overall the Quality Account reflects both the challenges experienced by Solent over the last 12 months and highlights the work undertaken through Solent’s ambition to improve the quality of services. Southampton City CCG is of the view that this Quality Account presented for 2017/18 meets the mandatory national requirements.
The CCG fully supports the quality priorities for 2017/18. However Solent NHS Trust need to consider how these will be measured to ensure achievement. Southampton City CCG would expect to see in the 2017/18 Quality Account a stronger and more robust interpretation of how priorities have been achieved against the measures identified.
Southampton City CCG is satisfied with the Quality Account for 2016/17 and we look forward to continue working closely with the Trust over the coming year to further improve the quality of services for the people of Southampton.
John Richards Chief Officer Southampton CCG
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April 2017
Performance Report Part I
To provide the Trust Board with the Performance STATEMENT OF PURPOSE Report
DOCUMENT OWNER Andrew Strevens, Director of Finance & Performance
Trust Board TARGET AUDIENCE
FOR INTERNAL OR EXTERNAL External Publishing PUBLISHING
May be published via our public website: Yes
Commercial Sensitive / Confidential – for internal use MARK AS APPROPRIATE only: No
Restricted circulation: No
VERSION: V0.1
Document Control
The latest approved version of this document supersedes all other versions, upon receipt of the latest approved version all other versions should be destroyed, unless specifically stated that previous version (s) are to remain extant. If any doubt, please contact the document author.
Version Date Author / Editor Details of Change File Reference
V0.1 21/05/17 Alasdair Snell – Document R:\Provider Services\Trust Board Reports\2017‐18\M01. April Head of Creation Performance
Approval Sign-off (For formal issue)
Approver Role Signature Date Version
Alasdair Snell Head of Performance 21/05/17 V0.1
Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Road, Southampton, SO19 8BR Telephone: 023 8060 8900 Fax: 023 8053 8740 Website: www.solent.nhs.uk
Performance Report Solent NHS Trust
Table of Contents
1. 2016/17 Business Plan Review ...... 2 1.1 Introduction ...... 2 1.2 Adults Portsmouth ...... 3 1.3 Adults Southampton...... 4 1.4 Children’s and Young People ...... 5 1.5 Specialist Dental Services ...... 7 1.6 Mental Health Services ...... 8 1.7 Primary Care Services ...... 10 1.8 Sexual Health Services ...... 11 1.9 Estates and Facilities ...... 12 1.10 Finance and Performance ...... 14 1.11 Human Resources ...... 15 1.12 ICT ...... 16 1.13 Quality and Risk ...... 18 1.14 Research and Audit ...... 20
2. Operational Performance ...... 22 2.1 NHS Improvement Single Oversight Framework ...... 22 2.2 Chief Operating Officer Commentaries ...... 25 2.2.1 Portsmouth System Developments ...... 25 2.2.2 Portsmouth Care Group Hotspots ...... 25 2.2.3 Southampton System Developments ...... 25 2.2.4 Southampton & County-Wide Care Groups’ Hotspots ...... 25
3. Quality Performance ...... 26 3.1 Quality Performance ...... 26 3.2 Quality Commentary ...... 27
4. Financial Performance ...... 28 4.1 Financial Performance ...... 28 4.2 Finance Commentary ...... 29 4.2.1 Month Results ...... 29 4.2.2 CIPs ...... 29 4.2.3 Capital and Cash ...... 29 4.2.4 Aged Debt ...... 29 4.2.5 Invoices Processed via PO ...... 29
5. Workforce Performance ...... 30 5.1 Workforce Performance ...... 30 5.2 Workforce Commentary ...... 31 5.2.1 Workforce In-Month ...... 31 5.2.2 Additional Staffing ...... 31 5.2.3 Appraisal and Information Governance ...... 31 5.2.4 Learning and Development ...... 31
April 2017 Page 1 of 31 Performance Report Solent NHS Trust
1. Solent NHS Trust 2016/17 Business Plan – Year in Review
2016/17 was another year of achievement, transformation, collaborative working and a particular focus on the Trust’s Vision ‐ to provide great care, be a great place to work and deliver great value for money. All our service lines and corporate teams wrote their business plans for the start of 2016/17, ensuring every composite objective was aligned to at least one of the three key components of our vision.
Shortly after our business plans were reviewed and agreed with our Executive Team, Solent learned that they would under go a comprehensive Care Quality Commission (CQC) inspection during the summer, which would not only require significant preparation preceding this, but also identify a number of actions to implement subsequently. In addition to this, in March 2016, NHS England organised the geographical division of England into 44 Sustainability and Transformation Plan areas, which would implement the Five Year Forward View, requiring NHS organisations to work and support each other collaboratively.
Consequently, the Trust had to ensure that the strategic direction and business plans of all our service lines and corporate teams were aligned to these significant priorities and with our regional direction, schemes and initiatives. Examples of this include integration with our social care partners, collaborative services with our acute trust and GP partners to best serve our public, ease system pressures, reduce waiting times and provide better quality services.
The following report, details the significant achievements and challenges we have faced over the last year, written in collaboration with our service line and corporate leads.
Alasdair Snell Head of Performance 19/5/2017
April 2017 Page 2 of 31 Performance Report Solent NHS Trust
1.2 Adults Portsmouth 2016/17 Year in Review
Our Successes were…..
During our CQC Inspection in 2016, we achieved a rating of ‘Good’ across our Community Services in Portsmouth, in conjunction with our Adults Southampton colleagues. This reflected the hard work and commitment to deliver high quality care the service line are passionate about. In addition to this rating, our Learning Disability service received a rating of ‘Outstanding’ from the inspection, which is something the service and Trust are immensely proud of.
Through the year, our Community Nursing Service worked hard to reduce the high vacancy factor inherited from 2015/16, including recruitment drives, rolling advertisements, career development opportunities and attractive retention policies. Consequently, the service’s substantive establishment increased through the year, reducing the dependency on temporary staffing.
Our collaborative system work with our acute partners in Portsmouth has been strong, assisting with discharges from the acute sector into the community setting. We’ve been an active participant and leader in the development of the Integrated Discharge Service at Portsmouth Hospitals Trust (PHT) and the introduction of the Discharge to Assess (D2A) and Frailty Intervention Teams (FIT) models.
We strengthened our working relationships with our GP partners also, through the significant transformation work in the city, leading to their agreement to an Alliance contract with Solent NHS Trust to provide services together moving forwards. We also co‐ located with our social care partners during the year into the Civic Centre and Medina House, as part of our integration work. Consequently, there have been a number of benefits to our service users, such as a more seamless and responsive service.
Our Challenges were…..
Within our Community Nursing Services, although significant progress regarding vacancies was made during 2016/17, there remain staffing pressures in a small number of areas. Also the service struggled to embed standardised processes for visiting our service users and the management ofs Seriou Incidents (SI) and complaints. However, significant work is in progress already in 2017/18 to resolve these as quickly as possible.
Although the aforementioned co‐location with social care partners has brought benefits to our service users, our staff experience has been mixed with a number of significant estates issues that we are working to resolve together.
There were continuing pressures at Portsmouth Hospitals that have impacted the expected benefits and performance of the new D2A and FIT models (briefed above), and have
April 2017 Page 3 of 31 Performance Report Solent NHS Trust
resulted in significant pressures and risks to the safe and timely discharge of patients from Queen Alexandra (QA) Hospital.
We continue to try to mitigate against issues of single handed specialised services; vacancies and absences were difficult to cover and maintain business continuity during 2016/17. Discussions with our commissioners over long‐term models are ongoing into 2017/18.
1.3 Adults Southampton 2016/17 Year in Review
Our Successes were…..
After the CQC inspection during 2016, our services achieved a ‘good’ rating in the majority of inspected areas. This is something we are very proud of as we put quality first in all our services and the results reflected all the hard work staff have undertaken in partnership with their patients. The CQC told us that staff provided care and treatment that took account of nationally recognised evidence based guidelines and standards. They also said our staff were caring, compassionate and patient centred in their approach and that they maintained patients respect and dignity at all times.
We successfully integrated our urgent response services with our social care partners, with the aim to provide a more seamless, efficient and effective service for the people of Southampton. The identified teams were co‐located during April 2016 and have been working steadily to integrate all activities. This is exemplified by Sensory Service assessments being incorporated within the core assessments of all patients and clients within the Community Independence Services across the city, which has increased the holistic nature of these assessments. These changes have increased the quality of assessment and service provision to all patients and clients, increased the understanding of the challenges around sensory deficit to both organisations and have had a positive impact on waiting lists.
We piloted a new community based service, in collaboration with local charities, to provide access to exercises for people in the community with a neurological condition who might otherwise be unable to access these exercise classes. This NeuroFit service has been successful and we are now looking to expand it to other areas across South Hampshire.
After a review of processes in our Community Rehabilitation Services, where waits were unsatisfactorily high, we made certain changes to streamline the access to our service and this resulted in reducing waiting times significantly, consequently improving our service user outcomes and satisfaction.
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We have put significant focus on encouraging our service users to share their experiences and feedback during 2016/17, to inform and shape our delivery. This has been reflected in a 32% increase in the number or completed surveys from our surveys from our service users.
Our Challenges were…..
Our Community Nursing service faced significant challenges, such as the rising demand of our service users coupled with difficulties in recruiting to our nursing workforce due to a competitive market and the recognised national shortage of community clinical staff. Consequently, to cover any workforce gaps in the short‐term, we have utilised bank and agency staff to ensure patients’ needs are met. To address this issue long‐term, we are reviewing the appropriate workforce required to meet demand moving forwards, creating attractive new roles for prospective staff, providing development opportunities and overall, making a role in the community setting more attractive because of the opportunities to learn and develop skills.
The environment in our Neuro Behavioural Unit, following the CQC inspection in 2014, was recognised as not being as desirable as we would wish to encourage recovery of our service users. Our service line made the decision to co‐locate this service with our Snowdon Neuro Rehabilitation Unit in Southampton which will improve the environment for both our patients and staff. The mobilisation will take place during 2017/18, following consultations with our partners, public and service users.
Although the integration of services with social care has been positive for our patients, there have been significant issues integrating different IT systems, causing difficulties communicating and sharing patient records. Resolving this is a priority for our service line in 2017/18, working with our partners.
1.4 Children and Young People’s Services 2016/17 Year in Review
Our Successes were…..
2016/17 was Year 2 of our significant transformational journey to move steadily towards our ambitious goal, shared by the overwhelming majority of our staff, our service users, and other stakeholders. We seek to transform the Solent offer for children, whereby services will eventually be provided to children and families on their unique pathways towards adulthood, in an integrated, efficient and timely way, offering a good experience for families of joined up care, whilst simultaneously offering an improved experience for staff in providing that care. Examples of this during 2016/17 were with Children and Adolescent
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Mental Health Services (CAMHS) for Learning Disabilities in Portsmouth setting out to find funding for accreditation in Positive Behaviour Support and were successful in securing money through the Trust's Dragon’s Den initiative and with the support of service leads, will train every member of the Team. Also, the Family Nurse Partnership Team in Southampton began working with the Hampton Trust and the Saints Foundation to design and deliver a 7 week intervention programme working with young fathers which focuses on healthy relationships and Raising Awareness of Domestic Abuse in Relationships with Young People, with the first cohort of fathers completing at the end of the year with positive completion rates.
We introduced community staff nurses into the health visiting services across Portsmouth and Southampton to support the delivery of the Healthy Child Programme at a universal level. Tangible outcomes include reduction of caseloads for our health visitors, increasing our family facing time and over a wider coverage.
We made a targeted effort at increasing service user engagement through enhancing our current methods of receiving feedback and participation in planning of services and care planning. This includes the Autism pathway in both Portsmouth and Southampton and the introduction of Monkey Wellbeing across all our services to provide the opportunity for valuable feedback from our younger service users.
Our Challenges were…..
We faced particular vacancy challenges in our Paediatric Therapies service due to recognised national shortages of specialised staff (causing longer waits for our service users in some areas) and reduced training placements for staff to qualify. To address these issues, we are implementing new ways of working, using available capacity to meet the rising demand, such as increasing the methods of engaging with service users outside conventional face‐to‐face appointments and adjusting the workforce skill mix to support the team.
Despite these pressures, all services have received relatively few complaints and the standard of service offered has been delivered more safely, following recommendations from the CQC inspection in 2016. Two example areas of quality improvement post‐ inspection were the modernisation to the highest standards of medicines management in special schools and the comprehensive assessment, recording and communication of risks in CAMHS in both cities.
With the evolving healthcare and social landscapes, it has been a challenge to transform and shape our services to best fit our service users and families’ needs in line with our partners’ strategic directions and at the pace of change we would aspire to. However, we recognise the importance to align our services with our partners to ensure we have integrated and aligned service delivery models.
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1.5 Specialist Dental Services 2016/17 Year in Review
Our Successes were…..
During the year, we introduced laptops that were used by our clinicians remotely, enabling them to access and record patient information and records electronically, in the patients’ home. Consequently, our dentists can use their time more effectively and efficiently, increasing both the accuracy of their notes and provide better informed patient care. Our workforce have embraced this positive change and this is reflected in our staff friends and family test results and comments.
Although the Trust had a CQC inspection during 2016/17, our Dental services were not inspected on this occasion. However, the service decided to review all the CQC reports for the services that were inspected, identify key themes applicable to the Dental services, shared these with our staff, undertook a self‐assessment and no significant concerns were realised. This exercise provided a level of assurance that the service continues to provide a great quality of care.
In June 2016, we officially relocated our Somerstown Hub to a new facility that offers state of the art equipment and environment, benefiting our patients with examples such as a wheelchair recliner, enabling patients to remain in their own wheelchairs, breakleg dental chairs, allowing patients with reduced mobility easier access to our services and a best practice decontamination suite. Additionally, the entire site is wheelchair accessible with a hearing loop in reception and we are now working towards accessible signage. The environment for our staff, as well as our patients, has also greatly improved and evidenced through feedback.
Our Challenges were…..
At the start of 2016/17, the amount of available general anaesthetic (GA) theatre space, particularly for our children service users, was significantly reduced by one of our sub‐ contractors. This meant we were only able to offer half the amount of appointments from the previous year, but to reduce consequent increased waiting times, the service has worked to mitigate the impact on our service users, by finding alternative sites and putting on additional clinics where possible. Towards the end of the financial year, demand has started to exceed available capacity, and we have seen our waits begin to increase. We are working with our partners and regulatory bodies to find further theatre space for this vulnerable group of patients.
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We have found meeting our annual Units of Dental Activity (UDAs) target a challenge this year due to a number of factors including increased referrals to our services, a recognised increase in the complexity of our patients’ needs (impacting the length of time to complete individual treatments) and a mixture of natural turnover with some episodes of long‐term sickness. In order to address these challenges in 2017/18, we are looking to over‐recruit against our establishment to reduce the impact of recruitment times, start a Quality Improvement programme regarding patient recall methods that should both reduce the number of did not attends (DNAs) and vulnerable patients that were not brought, which should reduce the risk of patients not accessing timely care.
We have faced some ongoing challenges with our estates footprint, trying to reduce the number of sites we work from, creating efficiencies and improving accessibility for service users. Further work is required with our partners to get engagement and sign‐off to progress this further during 2017/18.
Despite maintaining a very good staff FFT through the year, the service are conscious there are still some areas of staff where the working environment and morale could be improved, as the aforementioned increased demand and needs of the service is putting pressure on our workforce. This is something we are conscious of and are putting a targeted bespoke engagement plan in place for each of our localities to address this in 2017/18.
1.6 Mental Health Services 2016/17 Year in Review
Our Successes were…..
Our Mental Health Services received a rating of Good from the 2016 CQC Inspection, which showed improvements from the 2014 inspection. This reflected the hard work and attention to quality in the care we provide to our service users. Significant improvements include reviewing referrals to ensure safeguarding is integrated into this process with audits now showing appropriate safeguarding referrals are now being made, resulting in increased protection and safety for our patients. Also, the number of ligature points have reduced to minimal levels and an effective working relationship with our Estates Team have resulted in a safer environment for people who use our services; and as we value our patient confidentiality and information governance, we have installed secure mechanisms to store our service users’ data.
We successfully integrated Solent’s Older Person’s Mental Health (OPMH) service into the Mental Health Service Line which provides the opportunity to allocate services to patients based on their health needs rather than an age qualification. This ensures optimum care and best outcomes for our service users.
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To improve our focussing on valuing our workforce, we developed a new framework to enable progression from Band 5 to Band 6 Mental Health Nurses who demonstrate they meet required competencies. This will ensure a well‐skilled and appropriate workforce and help attract nurse recruitment in a challenging market. This framework will be implemented during 2017.
Our Challenges were…..
Over the last 18 months, our acute patient wards have experienced an increased demand for beds and a number of service users have presented with more complex needs. This has resulted in a greater requirement for one to one care, exceeding established staffing levels. In response to these needs, the service have had to employ a greater number of staff to meet the demands, causing a significant cost pressure to the Trust. However, due to a national shortage of qualified Mental Health Nurses, this has been challenging and have had to look at temporary staffing options, skill‐mix changes and development of new roles within the workforce to address this. In addition, we experienced some unwanted delayed discharges due to the need for specialised placements for some service users. We are working with our commissioners to understand the specific levels of demand and the actions and delivery model required to meet these needs.
Both a service thematic review and the CQC inspection identified that communication methods between teams and organisations are not as robust as desired and this will be a key priority moving into 2017/18 to improve both the communication from and rto ou Mental Health Team with our partner organisations.
Due to capacity and engagement issues in both our Portsmouth and Southampton Substance Misuse Services, we were not able to meet national guidance on conducting home safety checks for service users being prescribed medications where children co‐habit. Also, although service users were being regularly reviewed by the service, this review was not always conducted by the relevant prescriber as per national guidance. New processes were introduced to ensure these standards would be improved significantly and progress and trajectories are monitored robustly.
Following reviews of our Mental Health 136 Assessment Suite, significant issues with the sub‐contractor providing the service were identified and consequently, working in conjunction with our Portsmouth commissioners, we implemented a temporary arrangement with a new sub‐contractor, working closely with our services, to deliver care that is at the expected standard, whilst a permanent delivery model is being devised across the system.
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1.7 Primary Care Services 2016/17 Year in Review
Our Successes were…..
After a 3 month tendering process for the new Behavioural Change Services in Southampton, incorporating the existing smoking cessation and health training services into one integrated service model, Solent were awarded this, in collaboration with Social Care in Action (SCA) and Southampton Voluntary Services (SVS). This redesign will extend service user coverage by members of staff being able to manage multiple issues and a new website for increased access and information.
We implemented a redesign of the Podiatry pathway in Portsmouth and Southampton, resulting in the prioritisation of high and increased risk patients who are at risk of future amputation. This work was undertaken collaboratively with our commissioning partners.
During 2016/17, our 3 separate GP surgeries across Southampton merged into one General Practice with two branches. This will be of benefit to our patients due to being able to access an 8‐8, 7 days a week, 365 days a year service, decrease our waiting times by increasing capacity of our GPs and enabling greater choice for patient appointments. This has also benefitted the Trust due to administration efficiencies.
During 2016/17, the MSK service engaged with the Portsmouth Primary Care Alliance, to help reduce demand on GPs for same day appointments by triaging MSK type conditions via the telephone. The service diverted 75% of the demand away from GP’s to alternative services or self‐management. In 2017/18, commissioners want to see this successful model as part of the Multi‐specialty Community Provider (MCP) arrangements in Portsmouth. Our service line is proactively supporting the development of this provider vehicle and also in communications with GP practices in Southampton for similar developments.
Our Challenges were…..
At the start of 2016/17, there was a backlog of 296 patients requiring podiatric surgery on our waiting list, due to limited available theatre space. As the waiting times were increasing due to higher demand than capacity, a decision was made with commissioners to not accept any further referrals, in order to treat the remaining patients as quickly as possible. A robust action plan was put into place, utilising additional theatre space at Lymington Hospital and the Spire Hospital in Portsmouth. Patients were consulted on other available providers that could shorten their waiting times and enable them to select their provider of care. The
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service set a challenging trajectory to treat and discharge all patients by April 1 and successfully achieved this, causing a significant cost pressure to the service line.
The service line suffered significant cost pressures due to the current commissioned model for diagnostics. The financial element is currently under discussion with commissioners for resolution. However, earlier in 2016/17, there were concerns over the quality of the sub‐ contract images delivered and this has subsequently improved over the year through collaborative working, improved communications and contract management. Consequently, our service users are experiencing shorter waits and greater access and this has been evidenced through a decline in complaints and incidents raised. Additionally, through the Trust’s Quality Improvement Programme, it was demonstrated that clinicians were ordering diagnostic investigations appropriately.
Our services experienced significant challenges in the recruitment of nurses in General Practice, Allied Health Professionals in Podiatry and physiotherapists in our pain services due to a competitive market and a recognised shortage of qualified personnel. The services mitigated this by implementing a number of initiatives that provide opportunities to up‐skill our current workforce and development opportunities to prospective applicants.
1.8 Sexual Health Services 2016/17 Year in Review
Our Successes were…..
After a thorough tendering process for the new Hampshire, Southampton and Portsmouth Integrated Sexual Health Services, Solent NHS Trust were awarded the initial 5 year contract, with a potential for a further two years additionally. As a consequence, the existing service will be able to further establish and strengthen relationships with our partners such as the Police and No Limits, extending our reach and coverage into the community, providing our care closer to people’s homes than ever before and increasing the public’s awareness of sexual health issues and enabling individuals to help themselves avoid ‘risky behaviours’.
Following the 2014/15 CQC inspection, Sexual Health had a number of recommendations to improve upon, which the service subsequently actioned. After the recent inspection during 2016/17, the service were proud to receive a ‘good’ rating, and were commended for the “outstanding” development of the Tulip Clinic specifically, which works with commercial sex workers and vulnerable adults.
Another accomplishment during the year was the introduction of new demand management techniques, incorporating new online booking facilities, appointments within all clinics and same day access clinics. This resulted in access to our services greatly
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improving due to scheduled appointments and this was evidenced in significant satisfaction scores from patient surveys and Friends and Family Tests.
Our Challenges were…..
Although we successfully introduced online testing for all Sexually Transmitted Infections (STI), following a transformation project with commissioners and direct feedback from our clients, enabling easy access to clients who may never have been aware of the services available or able to access the services previously, to engage and use the services available. This resulted in the online testing facility’s demand far exceeding planned activity, without the expected reduction in clinic attendances. As a consequence, this incurred significant cost pressures to the service line.
Following national guidance, 2016/17 saw the formalisation of performance metrics regarding clients receiving results of STI tests within 7 days. This was particularly challenging as our sub‐contracted providers had to work in partnership with Solent to streamline existing pathways to meet the new target. Due to unexpected equipment failures with our partners, Solent were unable to meet the target for a number of months in the first half of the year. However, performance was consistently met during the second half of the year.
One of the main objectives of the year was to consolidate resources and estates, while maintain capacity and access to patients. This was to be achieved by ensuring remaining clinics were accessible to clients within 30 minutes by public transport and 15 minutes by car. This ambitious modelling took significant time and resource to evidence the proposed model to assure commissioners and partners that clinics and availability would not be impacted and would actually improve capacity for areas of increased demand.
1.9 Estates & Facilities 2016/17 Year in Review
Our Successes were…..
The work prior to the CQC inspection during 2016/17 was reflected by few and minor concerns raised. This was a pleasing result and the one recommendation made has been addressed and will be monitored on an ongoing basis.
At the start of 2016/17, the Estates Teams were restructured to maximise delivery as efficiently as possible, ensuring both our services and patients receive the best quality care available. In conjunction with this, governance processes were strengthened by the
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implementation of a Premises Assurance Model and initial results have been positive. Early signs have shown increased engagement with our services and the establishment of strong working relationships with our partners in the STP landscape. This work is now the catalyst for driving forwards the Estates vision for 2017 and beyond.
A large piece of work was undertaken to engage and gain agreement from numerous external organisations, such as the local authority, commissioners, community groups, NHS Improvement and Department of Health, with the aim to sign‐off the large plans to facilitate the move of services from our St James’ site to St Mary’s Hospital. These plans enable us to maximise utilisation at the St Mary’s Site as well as free up land for development at St James’. The financing application is being submitted in May 2017 to NHS Improvement.
Our Challenges were…..
The Estates Team have been working with our services to improve the working environment for the Civic and Medina buildings. These service inspired moves were considered a high priority for the maximisation of the integration of social and community care. However, as these buildings are predominantly office facilities, there are issues in ensuring they are suitable for health related activities. Therefore, there are remaining issues for our staff that we are trying to tackle into 2017/18.
Working within the STP environment, it has been difficult to progress certain schemes, where many factors need to be considered. An example of this is the catering review, in which progress has been slow as we have discussed solutions with potential partners and considered a large number of options. This issue is to be resolved in Quarter 1 of 2017/18.
It was recognised during the year, that car parking is a pertinent issue for our workforce and service users. The reality of the situation is there are a limited number of car parking spaces at a number of sites and therefore some form of prioritisation is required. We are reviewing the Essential Car User Policy across the Trust and a review of the parking facilities on a site by site basis. The review of the position is being undertaken and should conclude, with recommendations to be approved by the Trust Management Team, during Quarter 1 of 2017/18.
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1.10 Finance & Performance 2016/17 Year in Review
Our Successes were…..
Following a restructure of the Finance Team in 2015/16, we were delighted to see a significant increase across the majority of responses from service lines on the service provided by the Finance Team. The Services clearly stated that the Finance Team is supportive of the aims of their services and behave in accordance with Trust Values, are accessible, contactable, and flexible and are responsive across all levels.
Based on the performance in 2016/17, where there has been clear and transparent reporting and oversight of the Trust’s finances and the delivery against its financial targets, the external auditors are recommending we have an unqualified opinion on value for money. This is something we are very proud of achieved.
Robust performance governance structures were developed by providing information in clear, transparent and understandable ways, supporting our senior leaders to make informed decisions and our public to understand the Trust’s operational performance.
The Performance Team successfully established a Corporate Management Programme Office (CPMO) in 2016/17, building a good reputation quickly across the trust. Key achievements include robust CQC Action Plan monitoring, standardised reporting templates and governance control processes.
During 2016/17, national timeframes for contract signatures were brought forward to the end of December. This accelerated process by 3 months, required successful collaborative work between corporate teams and service line as well as with our partners. We managed to complete within deadlines required.
Significant progress was made building and strengthening working relationships with our commissioners and other providers. Consequently, we were able to have honest and transparent discussions, sharing of information and best practice through the year.
There has been a real focus during the year to resolve and clear aged debt and understand why invoices are not being paid to agreed terms. The result of this is that the aged debt over s90 day overdue as at 31 March 2017 has reduced by £954k to £1.2m.
Our Challenges were…..
Following the transition of our clinical record system across most of the Trust in 2015/16, we experienced significant data quality issues in 2016/17 due to staff entry errors at the front end due to new format and system and the technical complexities for the Performance
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Team extracting this data from our new data warehouse. This has affected our operational performance, such as KPIs, waiting lists and activity, but also some national returns such as the Finance Reference Costs submissions. The Performance Team have worked hard with corporate colleagues, services and commissioners to improve the process and data outputs and saw a gradual improvement over the year. In 2017/18, we are looking at new process that will limit the number of new data quality issues and improve the overall accuracy of our outputs.
Existing finance systems have hindered productivity and timely forecasting through the year. This has been identified as a priority in 2017/18, working with our partners to find a new solution moving forwards which should improve staff satisfaction, increase productivity and first time accuracy.
Vacancies across the Finance and Performance Teams have created pressures causing the re‐prioritisation of workloads and working differently to achieve specific aims and objectives.
1.11 Human Resources 2016/17 Year in Review
Our Successes were…..
The Great Place to Work Programme was launched and is a three year programme designed to continually develop our culture and values. One element of the programme is the Senior Leadership Development Programme, which ran alongside a Board Development Programme, bringing together our top 45 leaders. The key aims were to develop values‐ based and engaging leadership, and build collaboration across the Trust with an emphasis on systems leadership. Encouraging signs that the Great Place to Work programme is having an impact was the improvement of the staff survey to a high of 3.8.
A number of internal processes were improved such as online payslips, disclosure and barring scheme (DBS) and automated online jobs, decreasing the time from job offer to start date. Our induction programme has been aligned to new starters receiving the training and equipment they require to start their roles as smoothly as possible and to make the whole on‐boarding process as efficient as possible.
Over the year, we embedded Practice Educator roles across the organisation and have improved student satisfaction and encouraged prospective students to join us, improved clinical training and introductions of initiatives such as SEPSIS. We have supported employee development in a number of areas including mentoring and the delivery of clinical skills programmes and the training of 12 young apprentices. We have also delivered 20 management training programmes, enabling 61 people to earn accredited ILM status.
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Occupational Health and Wellbeing was a key focus throughout the year, including the very successful launch of the GCC healthy steps challenge and development of OWLES (mental health and wellbeing) group.
The Trust repeated the performance from 2015/16 by having no employment tribunals during 2016/17. This is a significant achievement, signifying good people practices in place, a culture to raise issues informally before formal proceedings.
Our Challenges were…..
Although the NHS Improvement cap on agency spend was breached during the year, there was actually a £1m reduction on the previous year’s spend. Also, there were 4,000 more requests to our in‐house bank team to fill shifts than the previous year due to increased demand, and of the 45,000 requests, the team filled 75% of these with bank staff. Despite the increased demand, the workforce team running the Bank remained at the same establishment as in previous years.
Accessibility to online training has been hindered across certain areas of the Trust due to IT system and compatibility issues, particularly Adult Safeguarding Training. The consequences were a lack of confidence in the system’s provision, frustration across the workforce and impact on morale and inefficient use of time. However, most of these online issues were supplemented with opportunities for face‐to‐face training provided. Action plans are in place to resolve during 2017/18.
Workforce planning continues to be a key challenge with ongoing staffing shortages and increasing demands in care needs. To address this, we introduced the Skills for Health six step methodology and in the coming year will work with leaders to build the capability across the organisation to plan and develop the workforce. Efforts to engage with Educational providers, embed new roles and implement recruitment & retention initiatives also continue.
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1.12 Information Communications Technology Team 2016/17 Year in Review
Our Successes were…..
We successfully migrated over 3,500 staff and IT devices onto a new and fully supported IT infrastructure. This provides a stable platform to enable staff to access patient information at the point of contact, work more flexibly providing a greater value for money and a consistent and reliable service to our workforce.
The new devices provided are now capable of enabling staff access full functionality wherever they are in the community, over the mobile phone network (4G). This enables increased patient facing time and the accuracy and timing of care information.
We implemented a new communication system (Skype) to enable staff to communicate more effectively and efficiently via voice, text or video platforms. This should help reduce staff administration time and provide more opportunities for different ways of working such as clinical supervision. Forward looking, this should enable face‐to‐face consultations with service users over Skype, where appropriate, benefitting both service users and staff.
We focussed significant resources on business engagement with our staff this year, resulting in improved internal communications, information sharing, shared priorities with service lines and this was evidenced in a much improved corporate survey from the organisation.
We have increased our support to service line clinical record systems (CRS) by adding our Sexual Health Services to our support remit, providing a resilient and appropriate level of support to our service. Additionally, community hospitals are now fully using Systm1, improving the completeness and quality of the patient record and removes paper records. This enables clinicians to make more informed and appropriate clinical decisions for our service users.
To support business continuity, we developed a back‐up record system to enable our clinicians to access patient information in case of external unplanned IT failures.
The Trust maintained its Level 2 IG compliance for another year as well as introducing face to face meetings to train staff and engagement.
Our Challenges were…..
Our intention during 2016/17 was to deliver a self‐service reporting toolkit for all staff and to serve the needs of our commissioners. However, the project experienced delays due to
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difficulties with the receipt of data from systems and the development of the subsequent reporting capabilities. This has become a significant priority for delivery in 2017/18.
There were a number of significant IT incidents during the year which required contingency planning. These incidents mainly occurred on the historic infrastructure, however during quarter four of 2016/17, there were significant improvements in reliability and performance.
There were cost pressures, reliability and stability issues with the historic telephony services, causing potential poor access to services and user experience. There was a programme in place to address these issues but due to the complexity of the solution and other pressures, the resolution has been delayed into 2017/18.
A wholesale review took place of staff access to support and procurement of IT devices and services, to ensure appropriate responsiveness to requests. Agreed actions will be implemented in early 2017/18.
It was identified in 2016/17, that the existing internet browser was causing access issues to various websites, which caused particular issues to staff accessing e‐learning training and other online resources. To resolve this, it was agreed that a new internet browser was to be installed Trust‐wide. However, subsequently this caused further issues accessing critical applications for the Trust, so had to be reverted to previous versions. The new solution is being developed and tested for deployment in Quarter 1 2017/18.
1.13 Quality & Risk Team 2016/17 Year in Review
Our Successes were…..
July 2016 saw the launch of the Solent Quality Improvement Programme. The programme is designed to support and encourage individuals and teams to develop their skills and capability to successfully implement quality improvement projects within their workplace. Five cohorts of 7‐8 teams will participate over the course of three years. The programme comprises the following three core elements: Individual team workshops, a series of 3 to 4 externally facilitated learning events and optional master classes. Seven teams joined Cohort 1 in July 2016, and a further seven teams joined Cohort 2 in December 2016. Work to date includes supporting the development of the Education Health Care Plans, better management of patients with urinary catheters and improving ward processes, such as the timing of a patient’s medical review.
The Quality Team led the CQC inspection in 2016, including a range of pre‐inspection preparation activities, such as quality review visits undertaken by staff across the Trust
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including support services, Healthwatch and commissioners. The CQC inspection resulted in the Trust receiving 17 individual reports and while the Trust was rated as ‘Requires Improvement’ overall, 10 core services were rated as ‘Good’ and our Learning Disabilities service received a rating of ‘Outstanding’. The Quality Team consequently led the development of a comprehensive action plan, to address the areas requiring further improvements, providing assurances to the Trust and commissioners of progress and mitigations.
Over the year, we collaboratively produced with Solent health professionals, a Strategic Framework for Allied Health Professionals (AHPs) and a Strategic Framework for Nurses. These documents provided an opportunity to create a vision for 2016‐2019, which will progress the development of current practice and ensure quality is embedded in all patient related interventions. Both strategies are clearly linked to the national frameworks for AHPs and nurses, published in 2016.
We have increased the methods by which service users can give feedback to our services on their experience, including making it more accessible to children and young people. Examples include enabling service users to provide feedback through a web link in our Sexual Health Services and the introduction of Monkey Survey for Children and Young people. Consequently, there have been significant and encouraging increases in the volume of feedback since their introduction. We are now going to introduce these methods across further services during 2017/18.
Our Challenges were…..
Following the detailed CQC inspection in 2016, there are ongoing challenges regarding fully embedding the actions identified and incorporating them into business as usual. To address this challenge, we are further strengthening the Trust Quality Assurance Framework, which will include enhanced scrutiny and oversight, through additional observation of practice and inclusion of patient and public representation into quality reviews.
In early 2016/17, across certain areas of the Trust, there were IT system instabilities, impacting on access to the Trust incident reporting system. As a consequence, some services had to revert to business continuity plans to log incidents, including recording on paper and submitting to the Risk Team for central manual logging. Although there was no patient harm as a consequence, a significant backlog of incidents grew for uploading onto our incident reporting system. In November 2016, our incident reporting system was upgraded and outages have been minimalised since this time and the backlog has been cleared.
Meeting deadlines for completing Serious Incident (SI) investigations and submitting the associated reports and concluding complex complaint investigations within designated
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agreed timeframes have been two areas the Quality & Risk Team has worked hard to support services to improve. To address these, we have increased the available investigator resources to reduce the consequent backlog of SIs and streamlined collaborative process with our services. Additionally, we have focussed on increasing the frequency of local resolution meetings, with the intention of resolving issues of concern as early as possible and where appropriate prevent them evolving into formal complaints. We have seen service concerns increase as a result and the number of complaints decrease favourably.
1.14 Research & Audit 2016/17 Year in Review
Our Successes were…..
The Research & Clinical Audit team expanded its remit in 2016/17 and now aims to provide training and support for staff and patients to be involved in the spectrum of activities to improve our care. The core elements are now Clinical Research, Audit and Evaluation, the Trust Quality Improvement Programme (detailed in the Quality & Risk Review above), a Clinical Academic Training Programme and involvement in innovation forums. The improvements as a result of these activities were celebrated in July at our annual conference – for the first time, this was patient led.
We exceeded national targets again for research activity and remain at the top of the National League tables, and were commended by CQC for research and its impact on patient care in Solent being an area of outstanding practice. One of our ambitions is to increase the accessibility of research to staff and patients, and recently, we have launched our ‘Count Me In’ campaign. This gives patients the chance to be contacted about any trials for which they may be eligible (unless they opt out). Key studies include an Antibiotic Resistance study, Device Trial for wound healing and an award winning access trial for our Homeless Healthcare Team.
The new approach to clinical audit and evaluation focusses on learning and improvement, and this has been implemented across the Trust. Each service line now holds their own Audit and Evaluation plan. The Trust participated in all the national audits that it was required to in 2016‐17.
2016 also saw the re‐launch of a Dragon’s Den programme to support innovation – staff can now apply for small grants to set up new initiatives within their services. We supported a number of projects in 2016/17, and the feedback on how this has changed practice will be given in the summer of 2017. Projects include a lending library of sensory equipment for clients to trial (before buying) in our learning disabilities service and a mobile equipment library for specialist feeding assessment and training for families in their own homes, rather than coming into a clinical setting.
April 2017 Page 20 of 31 Performance Report Solent NHS Trust
Our Challenges were…..
We were not able to open the Clinical Trials Pharmacy as planned this year, because of delays to the building work in St Mary’s Hospital – this is now planned for 2018.
We had planned to start to use clinical and patient reported outcome measures as one indicator of clinical effectiveness – many of our clinical services collect this data, but it is not as yet integrated with the Clinical Record System and there is no central record of all the outcomes being collected. This project was not completed in 2016/17, primarily because of the roll out to Systm1 and data quality. It is included in our 2017/18 Business Plan.
April 2017 Page 21 of 31 Performance Report Solent NHS Trust
2.1 NHS Improvement Single Oversight Framework
The Single Oversight Framework is designed to help NHS providers attain, and maintain, Care Quality Commission ratings of ‘Good’ or ‘Outstanding’. The Framework was introduced on 1 October 2016, at which point the Monitor 'Risk Assessment Framework ' and the TDA's 'Accountability Framework ' no longer apply. The Framework uses five themes: 'Quality of care'; 'Finance and use of resources'; 'Operational performance'; 'Strategic change'; and 'Leadership and improvement capability'. The 'Quality of care', 'Finance and use of resources' and 'Operational performance' themes contain a list of metrics, however not all of these have nationally measured thresholds. Where internal, aspirational thresholds exist, these have been included below, highlighted in grey. The 'Operational performance' metrics do not provide a performance assessment, however NHS Improvement state that they will consider whether support is required to providers where performance against the 'Operational Performance' metrics:
● for a provider with one or more agreed Sustainability and Transformation Fund trajectories against any of the metrics: it fails to meet any trajectory for at least two consecutive months ● for a provider with no agreed Sustainability and Transformation Fund trajectory against any metrics: it fails to meet a relevant target or standard for at least two consecutive months ● where other factors (eg. a significant deterioration in a single month, or multiple support needs across other standards) indicate we need to get involved before two months have elapsed.
Providers will be placed in a segment based on NHS Improvment's assessment of the seriousness and complexity of any issues identified as per the table below:
Segment Description
Providers with maximum autonomy: no potential support needs identified. Lowest level of oversight; 1 segmentation decisions taken quarterly in the absence of any significant deterioration in performance.
Providers offered targeted support: there are concerns in relation to one or more of the themes. We've identified targeted support that the provider can access to address these concerns, but which they are not 2 obliged to take up. For some providers in segment 2, more evidence may need to be gathered to identify appropriate support.
Providers receiving mandated support for significant concerns: there is actual or suspected breach of licence, 3 and a Regional Support Group has agreed to seek formal undertakings from the provider or the Provider Regulation Committee has agreed to impose regulatory requirements.
Providers in special measures: there is actual or suspected breach of licence with very serious and/or complex 4 issues. The Provider Regulation Committee has agreed it meets the criteria to go into special measures.
Please note that Solent does not have any Sustainability and Transformation Fund trajectory metrics. For some indicators, no definition has been confirmed by NHS Improvement. Our interpretation has been applied in the below.
Current Month Performance
The Trust has continued to achieve a level 2 on the NHS Improvement scale, where level 1 is the best and level 4 the most challenged. This is a good position for the Trust.
The Organisational Health metrics continue to be the largest area of concern, with 3 out of 4 metrics above the recommended thresholds. Sickness has continued to decrease again since it peaked back in November 2016, and is achieving the internal threshold of 4%. However the proportion of Temporary Staff has reached it highest levels since monitoring began in April 2016, as a result of high levels of turnover and increased acuity of patients, particularly within our Mental Health and Community Nursing Services.
The Finance and Use of Resources indicator continues to achieve a score of 3. This score is reflective of the negative I&E margin and the declining Capital Service Capacity score. Although the overall score indicates additional support is required, the organisation is in regular communication with NHS Improvement, and the requirement for additional support has been negated.
April 2017 Page 22 of 31 Performance Report Solent NHS Trust
Quality of Care Indicators
Organisational Health Internal aspirational thresholds are highlighted in grey Indicator Description Threshold May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Staff sickness (in month) 4% 3.6% 4.0% 4.3% 4.0% 3.8% 4.4% 4.9% 4.8% 4.8% 4.4% 4.2% 4.0% Staff turnover (rolling 12 months) 12% 16.7% 16.9% 17.6% 18.1% 16.9% 15.9% 16.6% 16.3% 15.5% 15.9% 16.1% 15.2% Executive team turnover (rolling 12 months) 12% 17.4% 17.4% 17.4% 8.7% 8.8% 8.7% 0.0% 8.5% 8.5% 8.7% 18.2% 15.4% NHS Staff Survey 40% - 55.8% - - 56.7% - - - - - 61.5% - Proportion of Temporary Staff (in month) 6% 4.7% 5.3% 5.2% 5.8% 5.8% 5.5% 6.5% 6.5% 6.5% 6.2% 6.5% 6.9% Aggressive Cost Reduction Plans (YTD delivery) 100% - 69.8% - - 71.9% - - 73.4% - - 75.8% - Caring Indicator Description Threshold May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Written Complaints 23 16 37 21 16 21 20 18 25 23 20 7 Staff Friends and Family Test Percentage Recommended - Care 80% - 79.5% - - 79.5% - - - - - 81.8% - Mixed Sex Accommodation Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0 Community Scores from Friends and Family Test - % positive 95% 96.1% 96.3% 95.6% 95.5% 95.8% 95.7% 97.0% 95.5% 95.6% 96.3% 96.4% 96.9% Mental Health Scores from Friends and Family Test - % positive 95% 97.1% 91.3% 92.4% 89.7% 92.3% 86.8% 93.3% 89.7% 95.7% 89.9% 90.7% 97.2% Effective Indicator Description Threshold May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Emergency re-admissions within 30 days following an elective or 0 0 0 0 0 0 0 0 0 0 0 0 0 emergency spell at the Provider Care Programme Approach (CPA) follow up - Proportion of discharges 95% 97% 97% 100% 100% 100% 97% 100% 97% 96% 94% 100% 100% from hospital followed up within 7 days - MHMDS % clients in settled accommodation 72% 77% 72% 73% 76% 72% 71% 71% 73% 71% 70% 69% % clients in employment 5.0% 5.2% 5.0% 6.6% 5.0% 4.0% 3.1% 4.0% 3.1% 6.4% 5.9% 10.0% 5.6% Safe Indicator Description Threshold May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Occurrence of any Never Event 0 0 0 0 0 0 0 0 0 0 0 0 0 NHS England/ NHS Improvement Patient Safety Alerts outstanding 0 0 0 2 0 1 1 1 2 0 0 0 0 VTE Risk Assessment 95% 97% 94% 94% 97% 95% 89% 100% 100% 100% 97% 100% 91% Clostridium Difficile - variance from plan 0 0 0 0 0 0 0 0 0 0 0 0 0 Clostridium Difficile - infection rate 0 0 0 0 0 0 0 0 0 0 0 0 0 MRSA bacteraemias 0 0 0 0 0 0 0 0 0 0 0 0 0 Admissions to adult facilities of patients who are under 16 years of 0 0 0 0 0 0 0 0 0 0 0 0 0
April 2017 Page 23 of 31 Performance Report Solent NHS Trust
Operational Performance Indicators
Indicator Description Threshold May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Maximum time of 18 weeks from point of referral to treatment (RTT) in aggregate – patients on an incomplete pathway 92% 100.0% 99.9% 99.9% 99.5% 99.2% 99.9% 100.0% 100.0% 99.7% 100.0% 99.5% 99.3% Maximum 6-week wait for diagnostic procedures 99% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Patients requiring acute care who received a gatekeeping assessment by a crisis resolution and home treatment team in line with best practice standards 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
People with a first episode of psychosis begin treatment with a NICE- recommended package of care within 2 weeks of referral 50% 50.0% 100.0% 50.0% 50.0% NIL 88.0% 67.0% 71.0% 75.0% 100.0% 71.0% 78.0% Complete and valid submissions of metrics in the monthly Mental Health Services Data Set submissions to the HSCIC ------
- Identifier metrics 95% 95.6% 95.5% 95.6% 95.3% 95.3% 95.2% 95.0% 94.9% 94.8% 94.7% 94.5% 95.5% - Priority metrics 85% 86.6% 87.8% 86.1% 85.8% 86.6% 86.5% 83.7% 83.6% 84.5% 82.6% 82.3% 80.0% Improving Access to Psychological Therapies (IAPT) / Talking Therapies ------Proportion of people completing treatment who move to recovery 50% 51.0% 54.1% 52.9% 52.4% 52.9% 50.0% 51.2% 53.9% 56.7% 51.9% 50.0% 59.5% - Waiting time to begin treatment - within 6 weeks 75% 100.0% 96.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% - Waiting time to begin treatment - within 18 weeks 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Finance and Use of Resources Indicators
A few financial metrics will be used to assess financial performance, with a score from 1 (best) to 4 (worst) being assigned to each metric. These scores will be averaged across all metrics to derive a 'use of resources' score for the organisation. An overall score of 3 or 4 in this theme will identify a potential support need, as will providers scoring a 4 against any individual metric.
Indicator Description May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Capital service capacity Financial Sustainability 1.1 1.4 1.2 1.2 1.3 1.2 0.5 0.7 0.0 Score 4 3 4 4 3 4 4 4 4 Liquidity (days) Financial Sustainability -4.0 0.9 -4.0 -4.2 -1.0 -4.4 -4.9 -12.1 -13.0 Score 2 1 2 2 2 2 2 3 3 I&E Margin Financial Efficiency -2.3% -1.7% -1.8% -1.9% -1.8% -1.8% -1.8% -1.2% -0.02% Score 4 4 4 4 4 4 4 4 3 Distance from financial plan Financial Efficiency 0.8% 54.2% 1.5% 1.0% 0.7% 0.5% 0.3% 0.8% -0.02% Score 1 1 1 1 1 1 1 1 2 Agency spend Financial Controls -3% -12% -9% 3% 4% 4% 4% 4% 0.3% Score 1 1 1 2 2 2 2 2 2
Use of Resources Score 3 3 3 3 3 3 3 3 3 RAG R R R R R R R R R
April 2017 Page 24 of 31 Performance Report Solent NHS Trust
2.2 Chief Operating Officer Commentaries ‐ 2017/18 Month 1
2.2.1 Portsmouth System Developments
Work continues to integrate Health and Social Care services across the city, with the 0‐19 Early Help and Prevention Service bringing together a range of Childrens services.
The Alliance Programme (a transformation plan between the GP Alliance and Solent NHS Trust) is gathering pace and is the subject of a Board Seminar on 15th May.
Within the Accountable Care System (ACS) the focus for Solent remains on the Urgent Care Pathway. Our current focus is to reduce the backlog of patients medically fit for discharge (MFFD) at Portsmouth Hospitals Trust which in turn will ease the access issues to the A&E department.
2.2.2 Portsmouth Care Group Hotspots Staffing levels within Mental Health services remain higher than budgeted levels despite additional substantive recruitment. Work is ongoing with commissioners to review the staffing and delivery model.
Waiting times to the Extended Partnership Team within the Child and Adolescent Mental Health Service (CAMHS) continue to increase due to increasing levels of referrals ande acuity. Th Service is working with commissioners to review the pathways and referral criteria into the service to ensure the resource is best utilised.
2.2.3 Southampton System Developments Better Care Southampton continues to develop, and further thinking and progress will be taken to System Chiefs in early June. In addition there are ongoing developments in relation to the 0‐19 Early Help and Prevention Service in the city.
A number of clinical pathways are being reviewed, working with partners, to ensure they are delivering the best possible outcomes for patients. This includes ongoing work with Southampton Primary Care Limited and University Hospitals Southampton NHS Foundation Trust (UHS).
Within Southampton there is a continued focus on delayed transfers of care (DTOC) across the health and social care system. There are a number of system wide schemes that Solent are involved with including case management, care home support, and discharge schemes.
2.2.4 Southampton & County Wide Care Group Hotspots Vacancies within the Community Nursing workforce continue to increase with further notices received from the team. Paper shared with Chief Operating Officer and Chief Nurse to detail the extent of the situation and discussions with commissioners regarding long term plans underway. Spend on agency staffing is increasing adversely as a result.
Waiting lists for General Anaesthetics (GAs) continue to be a concern within the Special Care Dentistry service. The service continues to work with partner organisations to negotiate additional theatre space, however little movement has been seen to date. Issue escalated to commissioners to seek their support in gaining approval for additional space.
April 2017 Page 25 of 31 Performance Report Solent NHS Trust
3.1 - Quality Performance April 2017/18
Serious incidents occured in month Occured in month More than same month 16/17 Less year to date than 16/17
2 Grade 2 Healthcare Infections / Cdiff / MRSA 6 7 6 Grade 3 Grade 4 Safety complinace breaches 11 11
Responses received 2016 CQC inspection made 179 reconmendations Less than same month 16/17 MUST DO SHOULD DO Postive ratings % 86 93
Negative ratings % Of these: Have been completed
On target for delivery Complaints received in month At risk but mitigation in place Required response in month
At risk with no mitigation in place Breaches in month
April 2017 Page 26 of 31 Performance Report Solent NHS Trust
3.2 Quality Commentary
Pressure Ulcers: April 2017 saw a reduction in serious incidents (SI) from the same time last year. This has been as a result of a new pressure ulcer (PU) review process that ensures only PUs deemed avoidable or potentially avoidable by the initial pressure ulcer panel are raised as serious incidents. The increase in the reporting of Grade 2 pressure ulcers compared to April 2016 is indicative of an improvement in early identification and reporting.
Complaints: Formal complaints have been reducing as concerns are resolved as they arise by staff closest to the person receiving the service before escalation.
CQC News/Update – The CQC action plan is being routinely updated on a monthly basis and being reported on at each Care Group level. Also, we will be welcoming back the CQC to revisit our Substance Misuse Services and Children and Adolescent Mental Health Services (CAMHS) on the 23 and 24 May.
Solent’s Quality Improvement Strategic Framework sets out our ambitions for quality improvement. Five quality goals have been identified for achievement over a three year period (2016‐2019) and each year quality priorities are agreed to help us achieve these goals. Progress against these is summarised below.
Quality Goal 1: No avoidable deaths (priority 3: Continue to improve our services by using learning from incidents, complaints & feedback) Solent participated in national work led by the Care Quality Commission (CQC) to produce the first national guidance on learning from deaths. Learning from serious and high risk incidents and mortality reviews is shared each month through the SI panel meetings. Training and guidance is under development to enhance the skills of SI investigators to ensure learning is identified wherever possible.
Quality Goal 2: Reduce patient harm (priority 3: Continue to improve our services by using learning from incidents, complaints & feedback) Regular incident training has been reintroduced for staff and the incident system is being developed to streamline reporting and ensure timely review. Training for staff includes a tissue viability (TV) training module on pressure ulcers (PU) which is offered on a quarterly basis and a new foundation module has been introduced (including PU identification, prevention & management), currently running on a monthly basis.
Quality Goal 3: Reduce duplication & eliminate waste in the care process Urinary Tract Infections (UTI), particularly those relating to urinary catheters, are the second largest group of Healthcare Associated Infections (HCAI). A baseline audit revealed only 52% of patients had the correct paperwork completed accurately giving assurance that urinary catheters were appropriately placed. Six months into the project a re‐audit showed compliance at 80%. A further update will be provided on completion of the project.
Quality Goal 4: Reduce variation & improve reliability (priority 1:Implement the Trust’s professional frameworks so our nurses & allied health professionals continue to deliver great care & priority 4: Implement the Trust’s competency assessment framework to support staff to consistently deliver safe & effective care) Sepsis awareness pocket cards will be issued to staff to reinforce the new training programme for early warning scores (NEWS) compliance and promote consistent responses to patients who deteriorate.
Quality Goal 5: Focus on what matters to our patients / service users and carers (priority 2: deliver the quality improvement programme to enhance patient experience and make a difference to people’s health and wellbeing; priority 5: consistent approach to involving people in the development of services) The overall response rate of Friends and Family Tests (FFT) for inpatients has slightly exceeded the target across both cities. The number of responses from all other services has exceeded the baseline. New methods for receiving feedback have been introduced across some services including email within Sexual Health Services and Monkey Survey for Children’s Services.
April 2017 Page 27 of 31 Performance Report Solent NHS Trust
4.1 - Financial Performance April 2017/18
Deficit in Month Eligible invoices raised in month Below plan Purchase orders raised in month
Deficit YTD Purchase orders raised in month Below plan against eligible invoices
Deficit Year End Total debt month end Forecast (adj) Total debt over 90 Achieving days month end control target
Savings Target YTD Spend YTD Year end plan Savings Plan YTD 100%
Savings Savings 50% Spend against Delivered Achieved year end plan YTD 0%
April 2017 Page 28 of 31 Performance Report Solent NHS Trust 4.2 Finance Commentary
4.2.1 Month 1 Results The Trust is reporting an in month deficit of £309k for month 1, £230k adverse to plan. The adverse variance is driven by: Agency spend in Mental Health higher than vacancies. Lower than planned income in Adults Southampton due to underperformance in Kite and Snowdon. Under delivery in various CIP schemes. Unidentified CIP still existing and needs to be identified and delivered.
The following actions will be taken during May and June and mitigating actions identified to ensure delivery of control total. Mental Health Services • Business case produced and sent to Commissioners confirming the increase in acuity and more 1:1 care becoming the norm. This is causing financial pressures to the service and business case requests extra funding. Commissioners have been receptive to conversations so far and it is expected that extra funding will be secured. • Delayed access to forensic/secure/specialist mental health beds (when patient assessments indicate this) means extra staff are required until appropriate beds become available. This is being raised with NHS England. Adults Southampton • Review planned occupancy level for Kite and Snowdon, as plan seems high compared to previous periods. • Acuity of patients meant we had to run at lower levels of occupancy on Kite. Review and confirm if we can charge for higher occupancy. • Ensure checks carried out to identify appropriate patients for wards. Primary Care • Income trajectory for incisional nail surgery and other income generating schemes need urgent review and recovery plan produced. • Workshops being held to identify new CIPs to address the current unidentified CIP. Sexual Health • Pressures created due to increase in demand online with no reduction in demand in Face to Face clinics. Demand management meeting with Commissioners being held on 19 May 17 to explore options to reduce the pressures. • Deep dive into Sexual Health finances being carried out during June by DDoF with CD in attendance to review and establish what opportunities there are to reduce the unidentified CIP.
4.2.2 CIPs CIP delivery in month 1 was £138k, £80k adverse to plan. The main drivers of the adverse variance are: Primary care income generating schemes (nail incision) have not fully materialised. Work on‐going to understand trajectory. Adults Southampton and Sexual Health in month actuals estimated, awaiting confirmation of final values. ICT under delivery on telephony, scheme delayed until end of May. 4.2.3 Capital and Cash Month 1 capital expenditure is low at £0.25m; this is due to awaiting approval for the loan application to start St Marys Phase 2 work. The Capital Resource Limit is £13.28m based on approval of the loan application. The cash balance at 30 April 2017 was £3.2m. The Trust does not have a IRWCF in place and any cash support required for 2017‐18 will need to be applied for separately. 4.2.4 Aged debt Aged debt for significant customers has reduced month on month. Debt for significant customers as at 30 April is £646k compared with £735k at 31 Mach 2017.
4.2.5 Invoices processed via PO
The Trust continues to promote the use of purchase orders when ordering goods and services. In month 1 the percentage of eligible invoices processed via a PO (rather than via Non‐PO) was 85%, 5% higher than the previous month.
April 2017 Page 29 of 31 Performance Report Solent NHS Trust
5.1 Workforce Performance April 2017/18
There were FTE in post this month, YTD mandatory training compliance equivalent to 3,451 staff in post. YTD information governance training An increase of since last month completed
YTD appraisals completed
Hours requested in month
100% Hours filled by bank in month
Hours filled by agency in month 50% Sickness & absence Hours requested not filled in month 0% In month, Solent are above agency ceiling by
12 month rolling turnover is
budgeted establishment (FTE) worked in month There were new starters in month vacancy factor
FTE Posts = There were leavers in month
April 2017 Page 30 of 31 Performance Report Solent NHS Trust
5.2 ‐ Workforce Commentary
5.2.1 Workforce In‐Month
Month 1 shows that we have 2844 full time equivalent (FTE) staff and a 5.4% vacancy factor. We used 242 FTE of additional staffing across our services.
A key priority over the next few months is to work with services to establish their substantive staffing model, which will enable improved management of temporary staffing, a more stable workforce and continuous improvement in service delivery.
5.2.2 Additional Staffing
Additional staffing was high across all services due to high acuity and challenges with national staffing shortages. Agency usage has exceeded the planned expenditure in month. The highest spend continues in Adult Mental Health due to Adult Mental Health 136 suite cover and high levels of Medical and Nursing vacancies. Portsmouth Community services agency usage continues to be high due to vacancies and staffing levels continue to be reviewed weekly.
Bank continues to secure the best framework rates associated with long term planning and block bookings, with rolling recruitment in place to recruit to current vacancies. Bank fill rate is improving due to the increase of bank pay rates and lower demand is encouraging flexibility with clinical bank staff.
5.2.3 Appraisal and Information Governance
2017/18 appraisal period has commenced. All eligible staff will be having their appraisal in the first quarter; therefore compliance was returned to zero from 1st April with a target of 95% by the end of June 2017. We would expect increased appraisal activity in May and June as appraisals filter through management structures.
Likewise, Information Governance (IG) training has also been returned to 0% from 1st April, following the achievement of the required 95% compliance at the end of 16/17. Plans are in place to ensure all IG training is completed in Q1 and 2, to prevent the back ending of training in Q3 and Q4.
5.2.4 Learning & Development
The introduction of the Apprenticeship Levy has given us the opportunity to hire 80 new apprentices over the course of the year. They will be hired into clinical and non‐clinical roles and a huge amount of work has gone into setting up the learning environment and supporting infrastructure for these roles. This is a key part of our talent management and workforce development strategy.
April 2017 Page 31 of 31 SOLENT NHS Trust Audit results report
Year ended 31 March 2017 Private and Confidential 18 May 2017
Dear Board Members At the date of drafting this report, our audit of Solent NHS Trust (the Trust) for the year ended 31 March 2017 remains in progress. We will provide a verbal update at the Audit and Risk Committee meeting on 26 May. Subject to the adequate resolution of the outstanding matters listed in our report, we confirm that we anticipate being in a position to issue an unqualified audit opinion on the financial statements in the form that appears in Section 3, before the statutory deadline on 1 June 2017. We also have no matters to report about your arrangements to secure economy, efficiency and effectiveness in your use of resources.
This report is intended solely for the use of the Audit and Risk Committee, other members of the Board of Directors and senior management who are responsible for the financial statements and annual report of the Trust. This report should not be used for any other purpose nor given to any other party without our prior written consent. We would like to thank your staff for the assistance provided to us during the engagement. We look forward to the opportunity of discussing with you any aspects of this report or any other issues arising from our work.
Yours faithfully Helen Thompson Executive Director For and on behalf of Ernst & Young LLP
United Kingdom ContentsContents
Executive Areas of Audit Audit 01 Summary 02 Audit Focus 03 Report 04 Differences
Value for 06 Other 07 Appendices 05 Money Reporting Issues
In April 2015 Public Sector Audit Appointments Ltd (PSAA) issued “Statement of responsibilities of auditors and audited bodies”. It is available from the via the PSAA website (www.PSAA.co.uk). The Statement of responsibilities serves as the formal terms of engagement between appointed auditors and audited bodies. It summarises where the different responsibilities of auditors and audited bodies begin and end, and what is to be expected of the audited body in certain areas. The “Terms of Appointment (updated September 2015)” issued by the PSAA sets out additional requirements that auditors must comply with, over and above those set out in the National Audit Office Code of Audit Practice (the Code) and in legislation, and covers matters of practice and procedure which are of a recurring nature.. This report is made solely to the Audit and Risk Committee, Board of Directors and management of Solent NHS Trust in accordance with the statement of responsibilities. Our work has been undertaken so that we might state to the Audit and Risk Committee, Board of Directors and management of Solent NHS Trust those matters we are required to state to them in this report and for no other purpose. To the fullest extent permitted by law we do not accept or assume responsibility to anyone other than the Audit and Risk Committee, Board of Directors and management of Solent NHS Trust for this report or for the opinions we have formed. It should not be provided to any third-party without our prior written consent. 01 Executive Summary Executive Summary Executive summary
Scope and materiality Overview of the audit In our Audit Plan, presented at the November 2016 Audit and Risk Committee meeting, we provided you with an overview of our audit scope and approach for how we intended to carry out our responsibilities as your auditor. We carried out our audit in accordance with this plan. There were no changes to our planned scope. We planned our procedures using a materiality of £1.9 million. We have reassessed this based on the actual results for the financial year and have decreased this amount to £1.82 million. The threshold for reporting audit differences has decreased slightly from £0.095 million to £0.091 million. The basis of our assessment of materiality has remained consistent with prior years at 1% of gross revenue expenditure.
Status of the audit
Our audit is in progress and we are scheduled to complete the procedures outlined in our Audit plan to enable the audited accounts to be approved by the Board on 30 May. Subject to satisfactory completion of the following outstanding items we expect to issue an unqualified opinion on the Trust’s financial statements in the form which appears in Section 3. However, until we have completed our outstanding procedures, it is possible that further matters requiring amendment may arise. We will update the Audit and Risk Committee on 26 May 2017 with the outcome of our work.
• Testing of Income, Prepayments and Accruals • Completion of subsequent events review
• Review of Receivables, PPE, Payables, Payroll and Expenses • Completion of the NAO consistency check
• Review of some disclosure notes • Receipt and review of the signed management representation letter and review of the final version of the financial statements
1 Executive Summary Executive summary (continued)
Audit differences
As at 18 May we have identified the following audit difference which management are in the process of correcting: • Revaluation Reserve – we identified an overstatement of the Revaluation Reserve of £114,000 in the prior year due to using the incorrect useful life from the District Valuer. The current year impact on income and expenditure was below our reporting threshold and therefore not reported.
We include more detail and a full list of audit differences at Section 4.
Areas of audit focus
In our Audit Plan we identified a number of key areas of focus for our audit of the financial statements of Solent NHS Trust. This report sets out our observations and conclusions in relation to these areas. Our consideration of these matters and others identified during the period is summarised within the "Key Audit Issues" section of this report. We request that you review these and other matters set out in this report to ensure: • There are no residual further considerations or matters that could impact these issues. • You concur with the resolution of the issue. • There are no further significant issues you are aware of to be considered before the financial report is finalised. There are no matters, other than those reported by management or disclosed in this report, which we believe should be brought to the attention of the Audit and Risk Committee.
Value for money
We have considered your arrangements to take informed decisions; deploy resources in a sustainable manner; and work with partners and other third parties. In our Audit Plan we identified a significant risk in respect of delivering the year-end forecast. We have completed our planned procedures and we have no matters to report about your arrangements to secure economy efficiency and effectiveness in your use of resources. However, we have exercised our statutory duties in terms of section 30 of the Local Audit and Accountability Act 2014 to make a referral to the Secretary of State as the Trust has not met its rolling breakeven duty over the three year period from 1 April 2014 to 31 March 2017.
2 Executive Summary Executive summary (continued)
Other reporting issues
We have reviewed the information presented in the Annual Report and Annual Governance Statement for consistency with our knowledge of the Trust. We have audited the parts of the remuneration and staff report disclosures that are required to be audited. We have no matters to report as a result of this work.
We are yet to complete the procedures requested of the National Audit Office with respect to the Trust’s Whole of Government Accounts submission.
We wish to report the following matter. • We have exercised our statutory duties in terms of section 30 of the Local Audit and Accountability Act 2014 to make a referral to the Secretary of State as the Trust has not met its rolling breakeven duty over the three year period from 1 April 2014 to 31 March 2017.
Control observations
We have not identified any significant deficiencies in the design or operation of an internal control that might result in a material misstatement in your financial statements of which you are not aware.
Independence
We have nothing to update from the Audit Plan in respect of independence.
3 02 Areas of Audit Focus Areas of Audit Focus Audit issues and approach: Revenue & expenditure recognition
What judgements are we focused on? What did we do? Is the reported financial outturn materially We focused on aspects of the financial statements where • We reviewed and tested revenue and expenditure recognition policies; accurate? management could inappropriately inflate income or • We reviewed and discussed with management any accounting estimates understate expenditure, primarily: on revenue or expenditure recognition for evidence of bias; • We developed a testing strategy to test material revenue and • Material accounting estimates; expenditure streams; • We reviewed and tested revenue cut-off at the period end date; and • Revenue cut-off; • We reviewed Department of Health agreement of balances data and What is the risk? investigated significant differences (outside of DH tolerances). We also • Agreement of balances; and assessed the Trust’s controls over the coding of intra-NHS transactions and its arrangements for engaging with third parties to reach agreement Risk of fraud in revenue over intra-NHS balances. recognition • Inappropriate capitalisation of revenue. The year-end financial outturn could be manipulated based on income or expenditure being inappropriately recognised due to pressure to deliver a stated year-end financial outturn
What are our conclusions?
• Our testing has not identified any material misstatements with respect to revenue and expenditure recognition.
• Our testing of accounting estimates did not identify any evidence of management bias in relation to revenue and expenditure recognition.
• No material misstatements were identified through our testing of material revenue and expenditure streams.
• Our cut-off testing confirmed that revenue was recognised in the appropriate period.
• Following completion of our procedures on agreement of balances we have no issues to report.
5 Areas of Audit Focus Audit issues and approach: Management override of controls
What judgements are we focused on? What did we do? Is the reported financial outturn materially We focused on aspects of the financial statements where • We tested the appropriateness of journal entries recorded in the accurate? management could override controls to benefit the year- general ledger and other adjustments made in the preparation of end financial position, primarily: the financial statements; • We reviewed accounting estimates for evidence of management • Journal entries; bias; and • We identified and evaluated the business rationale for any • Material accounting estimates; and significant unusual transactions. What is the risk? • Unusual transactions. Management override of controls Management is in a unique position to perpetrate fraud because of its ability to manipulate accounting records directly or indirectly and prepare fraudulent financial statements by overriding controls that otherwise appear to be operating effectively.
What are our conclusions?
• Our review of material journals at period end and those journals made in the preparation of the financial statements did not reveal any instances of management overriding controls with the intention to misreport the financial position. We also reviewed journals throughout the period and no instances of management override were evident.
• We reviewed management judgements in relation to accounting estimates, with a specific focus on Property Plant and Equipment which we had assessed as a high risk estimate, to identify any instances of management bias or of override of controls. We have not identified any instances of inappropriate judgements being applied. A desktop review revaluation exercise was performed during the year and we satisfied ourselves that the valuer was objective and an appropriate expert for the valuations. The scope of the valuers work, the basis of valuation and the key assumptions were reasonable and management has prepared the accounts in line with the expert’s report.
• We did not identify any other transactions during our audit which appeared unusual or outside the Trust’s normal course of business. 6 Areas of Audit Focus Audit issues and approach: Accounts risk – Income and PPE
What judgements are we focused on? What did we do? Is income and PPE accounted for correctly? We focused on aspects of the financial statements where • We reviewed the working papers for both PPE and Revenue to management could incorrectly recognise income and PPE identify any issues; transactions due to the volume and complexity thereof, • We assessed the Trust’s controls over coding of revenue primarily: transactions and tested the amounts recognised back to contracts where possible; • Coding of revenue transactions and linking revenue • We developed a testing strategy around the decommissioning of recognised to the relevant contracts St James; and What is the risk? • We designed appropriate substantive procedures to validate the • Capitalisation of decommissioning cost of St James; correct classification of revenue within the accounts. and Incorrect accounting treatment for income and PPE transactions • Correct classification of revenue within the Although improvements have been made from prior years we still accounts. identified a risk in relation to the Trust’s ability to produce good quality accounts and supporting working papers in these areas.
What are our conclusions?
• Our review of PPE and Revenue working papers has not identified any significant issues
• We were able to agree material revenue transactions to the relevant contracts and reconcile these to the amounts reflected in the financial statements
• Our minute reviews and discussions with key officers in relation to St James Hospital confirmed that the work has not commenced as envisaged and that all costs have been expensed
• No material misstatements were identified through our testing of classification of revenue within the accounts.
7 03 Audit Report Audit Report
Draft audit report
Our opinion on the financial statements
INDEPENDENT AUDITOR’S REPORT TO THE DIRECTORS OF SOLENT NHS TRUST
We have audited the financial statements of Solent NHS Trust for the year ended 31 March 2017 under the Local Audit and Accountability Act 2014. The financial statements comprise the Statement of Comprehensive Income, the Statement of Financial Position, the Statement of Changes in Taxpayers’ Equity, Statement of Cash Flows and the related notes 1 to 40. The financial reporting framework that has been applied in their preparation is applicable law and International Financial Reporting Standards (IFRSs) as adopted by the European Union, and as interpreted and adapted by the 2016-17 Government Financial Reporting Manual (the 2016- 17 FReM) as contained in the Department of Health Group Accounting Manual 2016-17 and the Accounts Direction issued by the Secretary of State with the approval of HM Treasury as relevant to the National Health Service in England (the Accounts Direction). We have also audited the information in the Remuneration and Staff Report that is subject to audit, being: • the table of salaries and allowances of senior managers [and related narrative • the table of pension benefits of senior managers [and related narrative notes] on page [x] notes] on page [x];
• disclosure of payments for loss of office on page [x]; • disclosure of payments to past senior managers on page [x];
• the tables of exit packages [and related notes] on page [x]; • the analysis of staff numbers and costs [and related notes] on page [x]; and
• the table of pay multiples [and related narrative notes] on page [x]. This report is made solely to the Board of Directors of Solent NHS Trust, as a body, in accordance with Part 5 of the Local Audit and Accountability Act 2014 and as set out in paragraph 43 of the Statement of Responsibilities of Auditors and Audited Bodies published by Public Sector Audit Appointments Limited. Our audit work has been undertaken so that we might state to the Directors of the Trust those matters we are required to state to them in an auditor's report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Directors, for our audit work, for this report, or for the opinions we have formed.
9 Audit Report Draft audit report (continued)
Our opinion on the financial statements
Respective responsibilities of Directors, the Accountable Officer and auditor As explained more fully in the Statement of Directors’ Responsibilities in respect of the Accounts, set out on page [x], the Directors are responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view. Our responsibility is to audit and express an opinion on the financial statements in accordance with applicable law and International Standards on Auditing (UK and Ireland). Those standards also require us to comply with the Auditing Practices Board’s Ethical Standards for Auditors.
As explained in the statement of the Chief Executive's responsibilities, as the Accountable Officer of the Trust, the Accountable Officer is responsible for the arrangements to secure economy, efficiency and effectiveness in the use of the Trust's resources.
We are required under section 21(3)(c), as amended by schedule 13 paragraph 10(a), of the Local Audit and Accountability Act 2014 to be satisfied that the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. Section 21(5)(b) of the Local Audit and Accountability Act 2014 requires that our report must not contain our opinion if we are satisfied that proper arrangements are in place.
We are not required to consider, nor have we considered, whether all aspects of the Trust’s arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively. Scope of the audit of the financial statements An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or error. This includes an assessment of: • whether the accounting policies are appropriate to the Trust’s circumstances and have been consistently applied and adequately disclosed; • the reasonableness of significant accounting estimates made by the directors; and • the overall presentation of the financial statements. In addition we read all the financial and non-financial information in the annual report and accounts to identify material inconsistencies with the audited financial statements and to identify any information that is apparently materially incorrect based on, or materially inconsistent with, the knowledge acquired by us in the course of performing the audit. If we become aware of any apparent material misstatements or inconsistencies we consider the implications for our report.
Scope of the review of arrangements for securing economy, efficiency and effectiveness in the use of resources We have undertaken our review in accordance with the Code of Audit Practice, having regard to the guidance on the specified criterion issued by the Comptroller and Auditor General in November 2016, as to whether the Trust had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. The Comptroller and Auditor General determined this criterion as that necessary for us to consider under the Code of Audit Practice in satisfying ourselves whether the Trust put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2017.
10 Audit Report Draft audit report (continued)
Our opinion on the financial statements
We planned our work in accordance with the Code of Audit Practice. Based on our risk assessment, we undertook such work as we considered necessary to form a view on whether, in all significant respects, the Trust had put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources. Opinion on the financial statements In our opinion the financial statements: • give a true and fair view of the financial position of Solent NHS Trust as at 31 March 2017 and of its expenditure and income for the year then ended; and • have been prepared properly in accordance with the National Health Service Act 2006 and the Accounts Directions issued thereunder. Opinion on other matters In our opinion: • the parts of the Remuneration and Staff Report to be audited have been properly prepared in accordance with the Accounts Direction made under the National Health Service Act 2006; and • the other information published together with the audited financial statements in the annual report and accounts is consistent with the financial statements. Matters on which we are required to report by exception We are required to report to you if: • in our opinion the governance statement does not comply with the NHS Improvement’s guidance; or • we issue a report in the public interest under section 24 of the Local Audit and Accountability Act 2014; or • we make a written recommendation to the Trust under section 24 of the Local Audit and Accountability Act 2014. • we are not satisfied that the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2017 We have nothing to report in these respects. In respect of the following we have a matter to report by exception: • Referral to the Secretary of State We refer a matter to the Secretary of State under section 30 of the Local Audit and Accountability Act 2014 because we have reason to believe that the Trust, or an officer of the Trust, is about to make, or has made, a decision which involves or would involve the body incurring unlawful expenditure, or is about to take, or has begun to take a course of action which, if followed to its conclusion, would be unlawful and likely to cause a loss or deficiency. On 25 May 2017 we referred a matter to the Secretary of State under section 30 of the Local Audit and Accountability Act 2014. The statutory accounts indicate the Trust has a cumulative deficit at 31 March 2017 of £8.9 million over the three year period from 1 April 2014 to 31 March 2017, and therefore has not met its rolling breakeven duty.
11 Audit Report Draft audit report (continued)
Our opinion on the financial statements
Certificate
We certify that we have completed the audit of the accounts of Solent NHS Trust in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice.
Helen Thompson for and on behalf of Ernst & Young LLP 19 Threefield Lane, Southampton SO14 3QB [Date]
12 04 Audit Differences Audit Differences Audit differences
In the normal course of any audit, we identify misstatements between amounts we believe should be recorded in the financial statements and the disclosures and amounts actually recorded. These differences are classified as ‘known’ or ‘judgemental’. Known differences represent items that can be accurately quantified and relate to a definite set of facts or circumstances. Judgemental differences generally involve estimation and relate to facts or circumstances that are uncertain or open to interpretation.
Summary of audit differences
We have included all known amounts greater than £91,000.
We highlight the following misstatement in relation to the financial statements and the disclosures that were identified during the course of our audit.
Corrected by management: Revaluation Reserve – Amended to reflect the correct useful life provided by the District Valuer. The Trust used incorrect useful life figures in 2015/16 when calculating the impact on the Revaluation Reserve for various buildings during the annual revaluation exercise which resulted in an overstatement of £114,000.
A small number of minor amendments to disclosure notes.
Uncorrected misstatements: Trade and other receivables – Provision for the impairment of receivables of £871,000 was made for various NHS bodies, however these debtors should not be provided for as they fall within the NHS resulting in an overstatement of £871,000. Trade and other payables – Dentistry work in progress was accrued for incorrectly. The accrual was incorrectly calculated resulting in an overstatement of NHS accruals and deferred income and an understatement of revenue from patient care activities of £136,000.
14 05 Value for Money Value for Money Value for Money
Economy, efficiency and effectiveness Informed decision making We are required to consider whether the Trust has put in place ‘proper arrangements’ to secure economy, efficiency and effectiveness on its use of resources. This known as our value for money conclusion.
Proper arrangements are defined by statutory guidance issued by the National Audit Office. They comprise your arrangements to: • Take informed decisions; • Deploy resources in a sustainable manner; and Proper arrangements for securing value for money • Work with partners and other third parties.
In considering your proper arrangements, we draw on the requirements of the guidance issued by NHS Sustainable Working with Improvement to ensure that our assessment is made against a framework that you are already required to resource partners and deployment third parties have in place and to report on through documents such as your annual governance statement.
Overall conclusion
We identified one significant risk in relation to these criteria and in the table below we present the findings of our work in response to the risk area in our Audit Plan. We expect having no matters to report about your arrangements to secure economy, efficiency and effectiveness in your use of resources. However, we do report that we have exercised our statutory duties in terms of section 30 of the Local Audit and Accountability Act 2014 to make a referral to the Secretary of State as the Trust has not met its rolling breakeven duty over the three year period from 1 April 2014 to 31 March 2017.
16 Value for Money VFM risks
We are only required to determine whether there are any risk that we consider significant within the Code of Audit Practice which defines as: “A matter is significant if, in the auditor’s professional view, it is reasonable to conclude that the matter would be of interest to the audited body or the wider public” Our risk assessment supports the planning of sufficient work to enable us to deliver a safe conclusion on arrangements to secure value for money and enables us to determine the nature and extent of further work that may be required. If we do not identify any significant risk there is no requirement to carry out further work. The table below presents the findings of our work in response to the risks areas in our Audit Plan.
What is the significant VFM risk? What arrangements did this impact? What are our findings?
The Trust agreed to deliver a £3.5 million deficit Deploying resources in a sustainable manner The Trust has improved its proper arrangements year on year. In for the year ended 31 March 2017. As part of this, 2015/16 we issued an ‘except for’ value for money conclusion as we the Trust needed to deliver a £14.4 million cost identified weaknesses in the Trust’s arrangements to ensure that it took improvement plan (CIP) programme, and manage properly informed decisions and deployed resources to achieve planned any emerging cost pressures. The Trust was also and sustainable outcomes. The Trust had delivered its control total for due to receive £1.14 million from the 2015/16 of £5 million deficit, but this was still a significant deficit and Sustainability and Transformation Fund (STF), the arrangements to deliver robust CIP schemes were being developed. subject to meeting the performance criteria. In 2016/17, the Trust agreed a reduced control total of £3.5 million At the end of the second quarter, the Trust was deficit, which the Trust bettered by £0.26 million and as a result performing slightly better than plan, due to some received the full STF allocation, plus additional STF funding of £1.086 slippage in the timing of redundancy payments, million which has further reduced its deficit. The reported outturn for and was expecting to receive the first three 2016/17 is £2.084 million. quarters of support from the STF. However, the financial position remained The Trust delivered a £10.9 million CIP programme, representing 76% of challenging, and the Sustainability and its planned total, and along with a number of different cost savings and Transformation Plan for Hampshire and Isle of income generation schemes implemented by management allowed the Wight was yet to be approved. Trust to bridge the gap and better its planned control total. The Trust has set a forecast deficit in 2017/18 of £1.5 million which further demonstrates that plans are in place to get back to breakeven as there is a steady decrease in the deficit control total year on year. Controls exist to quality assure plans and ensure that they are strategically aligned, plans are risk assessed and progress with delivery is monitored and reported. Based on our work performed, the Trust has deployed its resources in a sustainable manner. However, we have referred a matter to the Secretary of State under section 30 of the Local Audit and Accountability Act 2014 as the Trust has failed to achieve cumulative breakeven over the three year period 2014/15 to 2016/17. 17 06 Other reporting issues Other reporting issues Other reporting issues
Annual Report including Annual Governance Statement
We are required to give an opinion on the consistency of the Annual Report and other information published with the financial statements and the parts of the remuneration report that are required to be audited. We are also required to review the Annual Governance Statement for completeness of disclosures, consistency with other information we are aware of from our work and whether it complies with relevant guidance.
Financial information within the Annual Report and published with the financial statements was consistent with the annual accounts.
The remuneration and staff report was prepared properly and within the rules set and we had no matters to report.
We have reviewed the Annual Governance Statement and confirm that it is consistent with other information that we are aware of from our audit of the financial statements and we have no other matters to report.
Whole of Government Accounts
Alongside our work on the financial statements, we also report to the Trust on differences, within a tolerance of £250,000, between the Trust’s consolidation schedules and the audited financial statements. We also report to the NAO under its group instructions.
We have yet to complete these procedures and we will update the Audit and Risk Committee of our findings on 26 May 2017.
Financial controls
It is the responsibility of the Trust to develop and implement systems of internal financial control and to put in place proper arrangements to monitor their adequacy and effectiveness in practice. Our responsibility as your auditor is to consider whether the Trust has put adequate arrangements in place to satisfy itself that the systems of internal financial control are both adequate and effective in practice. As part of our audit of the financial statements, we obtained an understanding of internal control sufficient to plan our audit and determine the nature, timing and extent of testing performed. Although our audit was not designed to express an opinion on the effectiveness of internal control we are required to communicate to you significant deficiencies in internal control. We have not identified any significant deficiencies in the design or operation of an internal control that might result in a material misstatement in your financial statements of which you are not aware.
19 Other reporting issues Other reporting issues
Other powers and duties
We must report to the Secretary of State any matter where we believe a decision has led to, or would lead to, unlawful expenditure, or some action has been, or would be, unlawful and likely to cause a loss or deficiency. On 3 June 2015 we referred a matter to the Secretary of State under section 19 of the Audit Commission Act 1998 as we had reason to believe that the Trust was likely to breach its breakeven duty as set out in the NHS Finance Manual “Guidance on Breakeven Duty and Provisions” and at paragraph 2(1) of Schedule 5 to the National Health Services Act 2006. The financial statements for the Trust at 31 March 2017 confirm the Trust has failed to achieve cumulative breakeven over the three year period as at 31 March 2017. We therefore referred a matter to the Secretary of State under section 30 of the Local Audit and Accountability Act 2014 as the Trust has breached its rolling breakeven duty set out at paragraph 2(1) of Schedule 5 to the National Health Service Act.
We also have a duty under the Local Audit and Accountability Act 2014 to consider whether, in the public interest, to report on any matter that comes to our attention in the course of the audit in order for it to be considered by the Trust or brought to the attention of the public. We did not identify any issues which required us to issue a report in the public interest.
Other matters
As required by ISA (UK&I) 260 and other ISAs specifying communication requirements, we are required to communicate to you significant findings from the audit and other matters that are significant to your oversight of the Trust’s financial reporting process, including the following:
• Significant qualitative aspects of accounting practices including accounting policies, accounting estimates and financial statement disclosures • Significant difficulties, if any, encountered during the audit • Significant matters, if any, arising from the audit that were discussed with management • Written representations we are seeking • Expected modifications to the audit report • Other matters if any, significant to the oversight of the financial reporting process • Related parties • External confirmations • Going concern • Consideration of laws and regulation
We have no such matters to report.
20 7 Appendices Appendix A Required communications with the Audit Committee
There are certain communications that we must provide to the Audit Committees of UK clients. We have detailed these here together with a reference of when and where they were covered:
Our Reporting to you
Required communications What is reported? When and where
Terms of engagement Confirmation by the audit committee of acceptance of terms of engagement as written in The statement of responsibilities serves as the engagement letter signed by both parties. the formal terms of engagement between the PSAA’s appointed auditors and audited bodies.
Planning and audit approach Communication of the planned scope and timing of the audit, including any limitations. November 2016 Audit Plan
Significant findings from the • Our view about the significant qualitative aspects of accounting practices including 26 May 2017 audit accounting policies, accounting estimates and financial statement disclosures Audit Results Report • Significant difficulties, if any, encountered during the audit • Significant matters, if any, arising from the audit that were discussed with management • Written representations that we are seeking • Expected modifications to the audit report • Other matters if any, significant to the oversight of the financial reporting process • Findings and issues regarding the opening balance on initial audits (delete if not an initial audit)
Going concern Events or conditions identified that may cast significant doubt on the entity’s ability to No conditions or events were identified, continue as a going concern, including: either individually or in aggregate that ► Whether the events or conditions constitute a material uncertainty indicated there could be doubt about Solent NHS Trust’s ability to continue for the 12 ► Whether the use of the going concern assumption is appropriate in the preparation and presentation of the financial statements months from the date of our report ► The adequacy of related disclosures in the financial statements
22 Appendix A
Our Reporting to you
Required communications What is reported? When and where
Misstatements ► Uncorrected misstatements and their effect on our audit opinion 26 May 2017 ► The effect of uncorrected misstatements related to prior periods Audit Results Report ► A request that any uncorrected misstatement be corrected ► In writing, corrected misstatements that are significant
Fraud ► Enquiries of the audit committee to determine whether they have knowledge of any We have made enquiries of management actual, suspected or alleged fraud affecting the entity and those charged with governance. We ► Unless all of those charged with governance are involved in managing the entity, any have not become aware of any fraud or fraud that we have identified or information we have obtained that indicates that a fraud illegal acts during our audit which had a may exist involving: material impact on the financial statements. (a) management; (b) employees who have significant roles in internal control; or (c) others where the fraud results in a material misstatement in the financial statements. ► A discussion of any other matters related to fraud, relevant to audit committee responsibility.
Related parties Significant matters arising during the audit in connection with the entity’s related parties We have no matters we wish to report. including, when applicable: ► Non-disclosure by management ► Inappropriate authorisation and approval of transactions ► Disagreement over disclosures ► Non-compliance with laws and regulations ► Difficulty in identifying the party that ultimately controls the entity
Subsequent events ► Enquiry of the audit committee where appropriate regarding whether any subsequent 26 May 2017 events have occurred that might affect the financial statements. To be confirmed with Letter of Representation at Audit and Risk Committee meeting.
Other information ► Where material inconsistencies are identified in other information included in the 26 May 2017 document containing the financial statements and management refuses to make the To be confirmed with Letter of revision. Representation at Audit and Risk Committee meeting.
23 Appendix A
Our Reporting to you
Required communications What is reported? When and where
External confirmations ► Management’s refusal for us to request confirmations We have received all requested ► Inability to obtain relevant and reliable audit evidence from other procedures. confirmations
Consideration of laws ► Audit findings regarding non-compliance where the non-compliance is material and 26 May 2017 and regulations believed to be intentional. This communication is subject to compliance with legislation Audit Results Report on tipping off ► Enquiry of the audit committee into possible instances of non-compliance with laws and regulations that may have a material effect on the financial statements and that the audit committee may be aware of.
Significant deficiencies in ► Significant deficiencies in internal controls identified during the audit. 26 May 2017 internal controls identified Audit Results Report during the audit
Independence Communication of all significant facts and matters that bear on EY’s objectivity and November 2016 - Audit Plan independence. 26 May 2017 - Audit Results Report Communication of key elements of the audit engagement partner’s consideration of independence and objectivity such as: ► The principal threats ► Safeguards adopted and their effectiveness ► An overall assessment of threats and safeguards ► Information about the general policies and process within the firm to maintain objectivity and independence Communications whenever significant judgments are made about threats to objectivity and independence and the appropriateness of safeguards put in place,
Fee Reporting Breakdown of fee information at the agreement of the initial audit plan November 2016 - Audit Plan Breakdown of fee information at the completion of the audit 26 May 2017 - Audit Results Report Any non-audit work undertaken
24 Appendix B Independence
As part of our reporting on our independence, we set out below a summary of the fees you have paid us in the year ended 31 March 2017. We confirm there are no changes in our assessment of independence since our We confirm that we have undertaken non-audit work outside of the PSAA confirmation in our audit planning report dated November 2016. Code requirements on VAT compliance services. Non audit work is work not We complied with the APB Ethical Standards and the requirements of the PSAA’s carried out under the Code. We have adopted the necessary safeguards in our Terms of Appointment. In our professional judgement the firm is independent and completion of this work and complied with Auditor Guidance Note 1 issued by the objectivity of the audit engagement partner and audit staff has not been the NAO in December 2016. compromised within the meaning of regulatory and professional requirements. We consider that our independence in this context is a matter that should be reviewed by both you and ourselves. It is therefore important that you and your Audit and Risk Committee consider the facts of which you are aware and come to a view. If you wish to discuss any matters concerning our independence, we will be pleased to do so at the forthcoming meeting of the Audit and Risk Committee on 26 May 2017. We confirm we have undertaken non-audit work outside of the PSAA Code requirements in relation to our work on VAT compliance. We have adopted the necessary safeguards in our completion of this work.
25 Appendix C Management representation letter
Management Representation Letter
Addressed to EY using management’s letterhead
This letter of representations is provided in connection with your audit of the financial statements of Solent NHS Trust (“the Trust”) for the year ended 31 March 2017. We recognize that obtaining representations from us concerning the information contained in this letter is a significant procedure in enabling you to form an opinion as to whether the financial statements give a true and fair view of the financial position of the Trust as of 31 March 2017 and of its financial performance and its cash flows for the year then ended in accordance with the Department of Health Group Accounting Manual (DH GAM). We understand that the purpose of your audit of our financial statements is to express an opinion thereon and that your audit was conducted in accordance with International Standards on Auditing, which involves an examination of the accounting system, internal control and related data to the extent you considered necessary in the circumstances, and is not designed to identify - nor necessarily be expected to disclose - all fraud, shortages, errors and other irregularities, should any exist. Accordingly, we make the following representations, which are true to the best of our knowledge and belief, having made such inquiries as we considered necessary for the purpose of appropriately informing ourselves. A. Financial Statements and Financial Records 1. We have fulfilled our responsibilities, as set out in the PSAA statement of responsibilities, for the preparation of the financial statements in accordance with DH GAM. 2. We acknowledge, as members of management of the Trust, our responsibility for the fair presentation of the financial statements. We believe the financial statements referred to above give a true and fair view of the financial position, financial performance and cash flows of the trust in accordance with DH GAM and are free of material misstatements, including omissions. We have approved the financial statements. 3. The significant accounting policies adopted in the preparation of the financial statements are appropriately described in the financial statements. 4. We believe that the Trust has a system of internal controls adequate to enable the preparation of accurate financial statements in accordance with DH GAM that are free from material misstatement, whether due to fraud or error. 5. We believe that the effects of any unadjusted audit differences, summarised in the table below, accumulated during the current audit and pertaining to the latest period presented are immaterial, both individually and in the aggregate, to the financial statements taken as a whole. 6. We have not corrected these differences identified by and brought to your attention by EY because [specify reasons for not correcting misstatement].
26 Appendix C
Management Representation Letter
B. Fraud 1. We acknowledge that we are responsible for the design, implementation and maintenance of internal controls to prevent and detect fraud. 2. We have disclosed to you the results of our assessment of the risk that the financial statements may be materially misstated as a result of fraud. 3. We have no knowledge of any fraud or suspected fraud involving management or other employees who have a significant role in the Trust’s internal controls over financial reporting. In addition, we have no knowledge of any fraud or suspected fraud involving other employees in which the fraud could have a material effect on the financial statements. We have no knowledge of any allegations of financial improprieties, including fraud or suspected fraud, (regardless of the source or form and including without limitation, any allegations by “whistleblowers”) which could result in a misstatement of the financial statements or otherwise affect the financial reporting of the Trust. C. Compliance with Laws and Regulations 1. We have disclosed to you all known actual or suspected noncompliance with laws and regulations whose effects should be considered when preparing the financial statements. D. Information Provided and Completeness of Information and Transactions 1. We have provided you with: • Access to all information of which we are aware that is relevant to the preparation of the financial statements such as records, documentation and other matters as agreed in terms of the audit engagement; • Additional information that you have requested from us for the purpose of the audit; and • Unrestricted access to persons within the Trust from whom you determined it necessary to obtain audit evidence. 2. All material transactions have been recorded in the accounting records and are reflected in the financial statements. 3. We have made available to you all minutes of the meetings of the Trust Board, and committees (or summaries of actions of recent meetings for which minutes have not yet been prepared) held through the year. 4. We confirm the completeness of information provided regarding the identification of related parties. We have disclosed to you the identity of the Trust’s related parties and all related party relationships and transactions of which we are aware, including sales, purchases, loans, transfers of assets, liabilities and services, leasing arrangements, guarantees, non-monetary transactions and transactions for no consideration for the period ended, as well as related balances due to or from such parties at the year end. These transactions have been appropriately accounted for and disclosed in the financial statements. 5. We believe that the significant assumptions used in making accounting estimates, including those measured at fair value, are reasonable. 6. We have disclosed to you, and the Trust has complied with, all aspects of contractual agreements that could have a material effect on the financial statements in the event of non-compliance, including all covenants, conditions or other requirements of all outstanding debt.
27 Appendix C
Management Representation Letter
E. Liabilities and Contingencies 1. All liabilities and contingencies, including those associated with guarantees, whether written or oral, have been disclosed to you and are appropriately reflected in the financial statements. 2. We have informed you of all outstanding and possible litigation and claims, whether or not they have been discussed with legal counsel. 3. We have recorded and/or disclosed, as appropriate, all liabilities related litigation and claims, both actual and contingent, and have disclosed in the financial statements any guarantees that you have given to third parties. F. Subsequent Events 1. That there have been no events subsequent to period end which require adjustment of or disclosure in the financial statements or notes thereto. G. Agreement of balances and key judgements 1. We have disclosed to you details of all transactions and judgements that you have made on income and expenditure, payable and receivable balances with counter-parties irrespective of whether or not they have been included in the 2016/17 Agreement of Balances Exercise. 2. We have agreed balances, disputes and claims with all NHS bodies via the Agreement of Balances process and where not agreed, we have reported the matter to you. 3. We have disclosed to you all of the risks and judgements we have made in arriving at the Trust’s reported financial outturn for financial year ended 31 March 2017. H. Accounting Estimates 1. That in respect of accounting estimates recognised or disclosed in the financial statements: · We believe the measurement processes, including related assumptions and models, we used to determine the accounting estimate(s) have been consistently applied and are appropriate in the context of DH GAM. · That the disclosures relating to accounting estimates are complete and appropriate in accordance with DH GAM. · That the assumptions we used in making accounting estimates appropriately reflects our intent and ability to carry out specific courses of action on behalf of the Trust, where relevant to the accounting estimates and disclosures, · That no subsequent events require an adjustment to the accounting estimates and disclosures included in the financial statements.
28 EY | Assurance | Tax | Transactions | Advisory
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Solent NHS Trust Headquarters Highpoint Venue Helen Thompson Bursledon Rd Southampton Ernst & Young Hampshire Wessex House SO19 8BR Tel: 02380 608900 19 Threefield Lane www.solent.nhs.uk Southampton
SO14 3QB
Dear Helen 30th May 2017
Letter of Representation
This letter of representations is provided in connection with your audit of the financial statements of Solent NHS Trust (“the Trust”) for the year ended 31 March 2017. We recognise that obtaining representations from us concerning the information contained in this letter is a significant procedure in enabling you to form an opinion as to whether the financial statements give a true and fair view of the financial position of the Trust as of 31 March 2017 and of its financial performance and its cash flows for the year then ended in accordance with the Department of Health Group Accounting Manual (DH GAM).
We understand that the purpose of your audit of our financial statements is to express an opinion thereon and that your audit was conducted in accordance with International Standards on Auditing, which involves an examination of the accounting system, internal control and related data to the extent you considered necessary in the circumstances, and is not designed to identify - nor necessarily be expected to disclose - all fraud, shortages, errors and other irregularities, should any exist.
Accordingly, we make the following representations, which are true to the best of our knowledge and belief, having made such inquiries as we considered necessary for the purpose of appropriately informing ourselves.
A. Financial Statements and Financial Records
1. We have fulfilled our responsibilities, as set out in the PSAA statement of responsibilities, for the preparation of the financial statements in accordance with DH GAM.
2. We acknowledge, as members of management of the Trust, our responsibility for the fair presentation of the financial statements. We believe the financial statements referred to above give a true and fair view of the financial position, financial performance and cash flows of the trust in accordance with DH GAM and are free of material misstatements, including omissions. We have approved the financial statements.
3. The significant accounting policies adopted in the preparation of the financial statements are appropriately described in the financial statements.
Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Road, Southampton, SO19 8BR Telephone: 023 8060 8900 Fax: 023 8053 8740 (safehaven) Website: www.solent.nhs.uk Facebook: Solent NHS Trust Twitter: @SolentNHSTrust
4. We believe that the Trust has a system of internal controls adequate to enable the preparation of accurate financial statements in accordance with DH GAM that are free from material misstatement, whether due to fraud or error.
5. We believe that the effects of any unadjusted audit differences, summarised in the table below, accumulated during the current audit and pertaining to the latest period presented are immaterial, both individually and in the aggregate, to the financial statements taken as a whole.
6. We have not corrected these differences identified by and brought to your attention by EY as follows;
a. The Group Accounting Manual states that the provision for bad debts should not be made for organisations within the Department of Health accounting boundaries, i.e. NHS organisations, the Trust has taken a prudent approach. It is aware of outstanding debt with NHS organisations that is unlikely to result in future cash flows and as a result has fully provided for this debt. b. Omitting the dental work in progress error will not impact on the overall reader’s interpretation of the financial statements.
B. Fraud
1. We acknowledge that we are responsible for the design, implementation and maintenance of internal controls to prevent and detect fraud.
2. We have disclosed to you the results of our assessment of the risk that the financial statements may be materially misstated as a result of fraud.
3. We have no knowledge of any fraud or suspected fraud involving management or other employees who have a significant role in the Trust’s internal controls over financial reporting. In addition, we have no knowledge of any fraud or suspected fraud involving other employees in which the fraud could have a material effect on the financial statements. We have no knowledge of any allegations of financial improprieties, including fraud or suspected fraud, (regardless of the source or form and including without limitation, any allegations by “whistleblowers”) which could result in a misstatement of the financial statements or otherwise affect the financial reporting of the Trust.
C. Compliance with Laws and Regulations
1. We have disclosed to you all known actual or suspected noncompliance with laws and regulations whose effects should be considered when preparing the financial statements.
D. Information Provided and Completeness of Information and Transactions
1. We have provided you with: • access to all information of which we are aware that is relevant to the preparation of the financial statements such as records, documentation and other matters as agreed in terms of the audit engagement;
• additional information that you have requested from us for the purpose of the audit; and
• unrestricted access to persons within the Trust from whom you determined it necessary to obtain audit evidence. 2. All material transactions have been recorded in the accounting records and are reflected in the financial statements.
3. We have made available to you all minutes of the meetings of the Trust Board, and committees (or summaries of actions of recent meetings for which minutes have not yet been prepared) held through the year. 4. We confirm the completeness of information provided regarding the identification of related parties. We have disclosed to you the identity of the Trust’s related parties and all related party relationships and transactions of which we are aware, including sales, purchases, loans, transfers of assets, liabilities and services, leasing arrangements, guarantees, non-monetary transactions and transactions for no consideration for the period ended, as well as related balances due to or from such parties at the year end. These transactions have been appropriately accounted for and disclosed in the financial statements.
5. We believe that the significant assumptions used in making accounting estimates, including those measured at fair value, are reasonable.
6. We have disclosed to you, and the Trust has complied with, all aspects of contractual agreements that could have a material effect on the financial statements in the event of non-compliance, including all covenants, conditions or other requirements of all outstanding debt.
E. Liabilities and Contingencies
1. All liabilities and contingencies, including those associated with guarantees, whether written or oral, have been disclosed to you and are appropriately reflected in the financial statements.
2. We have informed you of all outstanding and possible litigation and claims, whether or not they have been discussed with legal counsel.
3. We have recorded and/or disclosed, as appropriate, all liabilities related litigation and claims, both actual and contingent, and have disclosed in the financial statements any guarantees that you have given to third parties.
F. Subsequent Events 1. That there have been no events subsequent to period end which require adjustment of or disclosure in the financial statements or notes thereto.
G. Agreement of balances and key judgements 1. We have disclosed to you details of all transactions and judgements that you have made on income and expenditure, payable and receivable balances with counter-parties irrespective of whether or not they have been included in the 2016/17 Agreement of Balances Exercise.
2. We have agreed balances, disputes and claims with all NHS bodies via the Agreement of Balances process and where not agreed, we have reported the matter to you.
3. We have disclosed to you all of the risks and judgements we have made in arriving at the Trust’s reported financial outturn for financial year ended 31 March 2017.
H. Accounting Estimates 1. That in respect of accounting estimates recognised or disclosed in the financial statements:
• We believe the measurement processes, including related assumptions and models, we used to determine the accounting estimate(s) have been consistently applied and are appropriate in the context of DH GAM.
• That the disclosures relating to accounting estimates are complete and appropriate in accordance with DH GAM. • That the assumptions we used in making accounting estimates appropriately reflects our intent and ability to carry out specific courses of action on behalf of the Trust, where relevant to the accounting estimates and disclosures,
• That no subsequent events require an adjustment to the accounting estimates and disclosures included in the financial statements.
Yours sincerely,
______(Director of Finance and Performance)
______(Chairman of the Audit and Risk Committee)
Independent Auditors report to the Directors of Solent NHS Trust
We have audited the financial statements of Solent NHS Trust for the year ended 31 March 2017 under the Local Audit and Accountability Act 2014. The financial statements comprise the Statement of Comprehensive Income, the Statement of Financial Position, the Statement of Changes in Taxpayers’ Equity, Statement of Cash Flows and the related notes 1 to 40. The financial reporting framework that has been applied in their preparation is applicable law and International Financial Reporting Standards (IFRSs) as adopted by the European Union, and as interpreted and adapted by the 2016-17 Government Financial Reporting Manual (the 2016-17 FReM) as contained in the Department of Health Group Accounting Manual 2016-17 and the Accounts Direction issued by the Secretary of State with the approval of HM Treasury as relevant to the National Health Service in England (the Accounts Direction).
We have also audited the information in the Remuneration and Staff Report that is subject to audit, being: • the table of salaries and allowances of senior managers and related narrative notes on page 77; • the table of pension benefits of senior managers and related narrative notes on page 79; • disclosure of payments for loss of office on page 71; • disclosure of payments to past senior managers on page 72; • the tables of exit packages and related notes on pages 74 and 75; • the analysis of staff numbers and costs and related notes on pages 82 and 83; and • the table of pay multiples and related narrative notes on page 74.
This report is made solely to the Board of Directors of Solent NHS Trust, as a body, in accordance with Part 5 of the Local Audit and Accountability Act 2014 and as set out in paragraph 43 of the Statement of Responsibilities of Auditors and Audited Bodies published by Public Sector Audit Appointments Limited. Our audit work has been undertaken so that we might state to the Directors of the Trust those matters we are required to state to them in an auditor's report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Directors, for our audit work, for this report, or for the opinions we have formed.
Respective responsibilities of Directors, the Accountable Officer and auditor As explained more fully in the Statement of Directors’ Responsibilities in respect of the Accounts, set out on page 119, the Directors are responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view. Our responsibility is to audit and express an opinion on the financial statements in accordance with applicable law and International Standards on Auditing (UK and Ireland). Those standards also require us to comply with the Auditing Practices Board’s Ethical Standards for Auditors.
As explained in the statement of the Chief Executive's responsibilities, as the Accountable Officer of the Trust, the Accountable Officer is responsible for the arrangements to secure economy, efficiency and effectiveness in the use of the Trust's resources.
We are required under section 21(3)(c), as amended by schedule 13 paragraph 10(a), of the Local Audit and Accountability Act 2014 to be satisfied that the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. Section 21(5)(b) of the Local Audit and Accountability Act 2014 requires that our report must not contain our opinion if we are satisfied that proper arrangements are in place.
We are not required to consider, nor have we considered, whether all aspects of the Trust’s arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively.
Scope of the audit of the financial statements An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or error. This includes an assessment of:
• whether the accounting policies are appropriate to the Trust’s circumstances and have been consistently applied and adequately disclosed; • the reasonableness of significant accounting estimates made by the directors; and • the overall presentation of the financial statements.
In addition we read all the financial and non-financial information in the annual report and accounts to identify material inconsistencies with the audited financial statements and to identify any information that is apparently materially incorrect based on, or materially inconsistent with, the knowledge acquired by us in the course of performing the audit. If we become aware of any apparent material misstatements or inconsistencies we consider the implications for our report.
Scope of the review of arrangements for securing economy, efficiency and effectiveness in the use of resources We have undertaken our review in accordance with the Code of Audit Practice, having regard to the guidance on the specified criterion issued by the Comptroller and Auditor General in November 2016, as to whether the Trust had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. The Comptroller and Auditor General determined this criterion as that necessary for us to consider under the Code of Audit Practice in satisfying ourselves whether the Trust put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2017.
We planned our work in accordance with the Code of Audit Practice. Based on our risk assessment, we undertook such work as we considered necessary to form a view on whether, in all significant respects, the Trust had put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources.
Opinion on the financial statements In our opinion the financial statements: • give a true and fair view of the financial position of Solent NHS Trust as at 31 March 2017 and of its expenditure and income for the year then ended; and • have been prepared properly in accordance with the National Health Service Act 2006 and the Accounts Directions issued thereunder.
Opinion on other matters In our opinion: • the parts of the Remuneration and Staff Report to be audited have been properly prepared in accordance with the Accounts Direction made under the National Health Service Act 2006; and • the other information published together with the audited financial statements in the annual report and accounts is consistent with the financial statements.
Matters on which we are required to report by exception We are required to report to you if: • in our opinion the governance statement does not comply with the NHS Improvement’s guidance; or • we issue a report in the public interest under section 24 of the Local Audit and Accountability Act 2014; or • we make a written recommendation to the Trust under section 24 of the Local Audit and Accountability Act 2014. • we are not satisfied that the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2017 We have nothing to report in these respects.
In respect of the following we have a matter to report by exception: • Referral to the Secretary of State
On 3 June 2015 we referred a matter to the Secretary of State under section 30 of the Local Audit and Accountability Act 2014. We had reason to believe that the Trust was, taking into account the NHS Finance Manual Guidance on Breakeven Duty and Provisions in the financial year ending 31 March 2015 at risk of breaching of the breakeven duty set out at paragraph 2(1) of Schedule 5 to the National Health Service Act 2006. The statutory accounts indicate the Trust has delivered a further deficit outturn for 2016/17 of £2.084 million, with a cumulative deficit at 31 March 2017 of £8.9 million, and therefore has not met its rolling breakeven duty.
Certificate We certify that we have completed the audit of the accounts of Solent NHS Trust in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice.
Helen Thompson for and on behalf of Ernst & Young LLP 19 Threefield Lane, Southampton SO14 3QB [Date]
Item 16.1
Presentation to X In Public Board Meeting Confidential Board Meeting
Title of Paper Annual Report - including the Annual Governance Statement
Sue Harriman, CEO Author(s) Rachel Cheal, AD Corporate Executive Sponsor Affairs & Company Secretary • Reviewed by executive team. • Draft Annual Governance Statement was presented to the Date of Paper 19th May 2017 Committees presented April Assurance Committee. • Annual Report and AGS presented to May 2017 Audit & Risk Committee Link to CQC Key Lines Safe Effective Caring Responsive Well Led of Enquiry (KLoE) x x x x x Action requested of To receive For decision the Board x
Every year we are required to produce an Annual Report and Annual Governance Statement (AGS), in accordance with the HM Treasury’s Finance Reporting Manual 2016-17, Department of Health Group Accounting Manual 2016-17 and guidance from NHS Improvement. The Trust also takes into consideration the NHSI’s Foundation Trust Annual Reporting Manual for the relevant good governance practice requirements.
The draft annual report has been shared with the External Auditors as part of the annual auditing process.
Matters still outstanding are highlighted in yellow – these include • consideration of the External Auditor Opinion within the Annual Governance Statement • consideration given by the Audit & Risk Committee at their meeting on 26th May with regards to the statement on pg 58) An update will be provided at the Board meeting in respect of these matters. • Section 3 the Auditors Report, Section 5 Quality Account, Appendix 1 Full Accounts - all of which will presented separately at the Board meeting
(Please note that photos have not been included at this stage and will be incorporated into the final print/designed version. Page references have also been omitted at this stage).
Board Recommendation
The Board is asked to;
• Approve the Annual Report
• Approve the Annual Governance Statement (pg 100 - 114)
The Chief Executive will be asked to separately sign the AGS at the scheduled recess during the Board meeting on 30th May 2017.
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Item 16.2
21st May v31 Page 1 of 127
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Solent NHS Trust DRAFT Annual Report and Accounts 2016/17
incorporating the Quality Account 2016/17
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Contents
Statement from the Chairman and Chief Executive Officer
Section 1: Performance Report
Section 2: Accountability and Corporate Governance Report
Section 3: The Auditors Report
Section 4: The Summary Accounts
Section 5: Quality report incorporating the Quality Account 2015/16
Appendix 1: Full Accounts
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Statement from the Chairman and Chief Executive Officer
We are delighted to present to you our Annual Report and Quality Account for the 2016/17 financial year, our sixth year of operation as Solent NHS Trust. We hope you will find the report a useful account of our year. It describes our work in 2016/17 and outlines some of our most significant achievements.
2016/17 has been another challenging year, but one in which our staff have continued to show relentless commitment to providing great care and making a difference. Within the report, you will read about the work of teams who have gone above and beyond to deliver great care, initiatives and campaigns that have helped improve the mental and physical health and wellbeing of people in the communities we serve, as well as stories of teams who have benefitted people through innovation.
During 2016/17 we continued to receive positive feedback from the people who use our services about the quality of care we provide. Providing quality, safe and effective services remained, and remains, our top priority. We are always seeking ways to improve to ensure we deliver consistently great care. In June, we welcomed a team of inspectors from the Care Quality Commission (CQC) who helped us on our improvement journey. They rated our services as ‘Requires Improvement’. Whilst we were disappointed with the overall rating, we were pleased that many of our CQC domains were rated as ‘Good’ and delighted that our Learning Disability Services were rated as ‘Outstanding’. Since the regulators visit, we have been focussed on delivering our CQC action plan and addressing the areas for improvement. You can read more about our response to the CQC inspection, our quality performance and our quality priorities for the year ahead in our Quality Account on page [n].
In common with other health and care organisations, we continued to face rising demand for healthcare services as people are generally living longer and many of us are also living with long- term physical and mental health conditions. The demand for our services has continued to rise at a greater rate than the funding available.
To help us face these challenges and, in light of the Five Year Forward View, we have placed even greater emphasis on working with other organisations and are actively participating in the Sustainability and Transformation Plan for Hampshire and the Isle of Wight. Collectively, we have more strength to make a difference. We continue to work with others to help people to stay well and be cared for in the community with the aim of ensuring that people only get treated and admitted into hospitals when is absolutely necessary. Within this report, you will read many examples of how working with others has ensured that care is joined up and is making a difference to the people who use our services.
Nationally, public sector funding continues to be limited leading to financial pressures. In response, our teams have continued to work incredibly hard, often thinking innovatively, to find savings to help us be as efficient as possible. We are pleased to report that we delivered a better position than our agreed financial control target of £3.5million deficit, with a year-end outturn of £2.1m million deficit. Whilst we have had to make some difficult decisions in the year with regards to our finances, we have continued to invest in our Information Technology (IT) infrastructure and clinical systems to support our people to work differently in a digital age – through better IT systems we can work more efficiently and our staff can have more time to provide care.
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We also continued to review our Estate, in line with our Estates Strategy. We have invested in our buildings, and divested of estate where it made sense to do so. We recognise that some of the decisions we make around our estate may not have always been popular when people have had to move their work base, or when people have had to travel to different hospitals and centres for their care. Our aim is to make more efficient use of our buildings and provide people with the best possible environment to receive care and for our staff to work in.
We would like to commend our staff and volunteers. Our achievements would not have been possible without a team of dedicated staff, many of whom often turn our challenges into opportunities. No matter what role they play, clinical or non-clinical, each member of our team makes a difference to the communities we serve and they should feel happy at work, engaged and empowered. Our dip in our staff engagement score in 2015, identified in the Annual Staff Survey, highlighted the need for us to place even more emphasis on ensuring our staff feel valued. This year we introduced our Great Place to Work Programme. We have worked hard to embed our HEART values. We have also invested in the development of our leadership team, improved our internal communications, and offered more opportunities for staff to get involved in the life of the Trust through social events and charity fundraisers. The results of the 2016 Annual Staff Survey showed that we are heading in the right direction. An improved engagement score from 3.69 in 2015, to 3.86 in 2016, told us that our people are more engaged in our Trust. You can read more about our investment in our workforce on page [n]. During 2017/18 we will continue to focus on creating a great place to work, engaging and involving staff and taking them on our journey with us.
We would like to thank our Board colleagues for their continued support. Particularly, we would like to thank Alex Whitfield and Julie Pennycook who both left the Trust during the year. Both Alex and Julie were pivotal in the creation and the work of our Trust.
Finally, it is thanks to strong leadership and our team of caring and compassionate staff, all pulling in the same direction, that we can proudly say we provide great care at the heart of the community.
Dr Alistair Stokes Sue Harriman
Chairman Chief Executive Officer
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Overview
The purpose of this section is to provide a summary of the organisation including our purpose and activities, and our principle risks and uncertainties facing us during the year head. Our Chief Executive, Sue Harriman, also reflects on how we performed over the past year. Consideration of the going concern basis can be found on pg [n]
Section 1 - Performance Report
When faced with so many challenges and uncertainties in a modern-day NHS, our focus on providing great care, creating a great place to work and delivering great value for money has helped us achieve so much. We have continued to improve quality and achieve high levels of performance. This has been achieved by excellent leadership at all levels throughout the Trust, and by individual members of staff who go above and beyond to make a difference every day.
We take pride in our unwavering focus on quality. When visited by the CQC in June we were proud to demonstrate the great care which is provided by so many of our services. Whilst we were disappointed with our overall rating of ‘Requires Improvement’ we were heartened to hear how impressed the inspectors were with the care and compassion shown by our staff and were pleased that so many of our domains were rated ‘good’. We have responded to the recommendations made by the inspectors and have a live action plan which is tracked centrally by our Corporate Performance Management Office (CPMO) and within our services. Some of the recommendations require us to work closely with partner organisations. For instance, we are working with our commissioners to improve wheelchair provision.
We finish the year financially sound and within the agreed Financial Control Target £3.5million deficit, with a year-end outturn of £2.1 million deficit. Delivering our control target and finding savings requires the input and support of all leaders and their teams. I am grateful to the many people who have seen how changes can be made without compromising patient care, and who have used innovation to do things differently. Going forward, we need to do more to involve the people who use our services in their development and transformation – engaging and working in conjunction with our communities is one of our key quality priorities for the next year.
We have had a real focus on creating a great place to work. This year’s Annual Staff Survey results were extremely pleasing, with an improved engagement score and better results across the board. I was particularly pleased that our staff told us that they would recommend our services to their friends and family if they needed treatment or care. Their testament to our services is valuable.
Whilst we see green shoots appearing across the Trust, I recognise the need to continually invest in our workforce. Our performance measures for staff sickness absence and turnover rate also provide us with a good indication about the health and wellbeing of our staff. Whilst both measures have remained fairly stable throughout the year, they are at a higher level than the targets we set ourselves. We remain committed to continually valuing, engaging and empowering our team of dedicated staff.
A number of our services experienced staffing pressures in year, which has resulted in the over reliance on agency staff. Consequently this meant that we continue to use more agency staff than our target (3%), however the safety of our services is paramount. We will continue to ensure that safe staffing and agency use remains a key focus for us in 2017/18.
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In some of our service areas we have seen some performance challenges, particularly in relation to waiting times and you can read more about this within the following section and within our Annual Governance Statement which summarises our significant issues in year.
When our performance is below expected standards, we work with our commissioners, our patients and regulatory bodies to resolve any issues as quickly and efficiently as possible. We learn so that we can do things differently in the future. Our learning is used to help set our business and quality priorities for the year ahead.
What remains clear, and I hope is evident to everyone who uses our services, is the enthusiasm and commitment of our wonderful staff. Year-on-year our people go above and beyond to dedicate themselves to the care of patients. I end 2016/17 proud of what, together, we have achieved and the hurdles we have overcome and I look forward to 2017/18.
Sue Harriman
Chief Executive
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About us
Who are we?
Solent NHS Trust was established under an Establishment Order by the Secretary of State in April 2011.
We are one of the largest specialist community and mental health providers in the NHS with an annual revenue of over £180m for 2016/17. Last year, we employed 3,476 clinical and non-clinical staff (including part time and bank staff) which equates to 2,833 whole time equivalents (WTE) and delivered over 800,000 service user contacts.
What do we do?
We provide specialist community and mental health services to local people of all ages.
We help people to stay safe and well at, or close to, home. We do this by supporting families to ensure children get the best start in life, providing services for people with complex care needs and helping older people keep their independence. We also provide screening and health promotion services which support people to lead a healthier lifestyle.
We work closely with other trusts, primary care, social care providers and the voluntary sector to make sure care is joined-up and organised around the patient.
Our services are provided from a range of locations, including community hospitals and day hospitals, as well as numerous outpatient and other settings within the community such as health centres, children’s centres and within people’s homes.
Who do we serve?
We are the main provider of community health services in Portsmouth and Southampton and the main provider of adult mental health services in Portsmouth. We also provide a number of pan- Hampshire specialist services including sexual health and specialist dentistry.
We are commissioned by NHS England, Clinical Commissioning Groups and Local Authorities in Southampton, Portsmouth and Hampshire. Southampton and Portsmouth together have more than 400,000 people resident within the cities each covering a relatively small urban geographic area with significant health inequalities, which are generally significantly worse than the England average for deprivation. Hampshire covers a wider geographical area which is predominantly more rural and affluent but also has urban areas of higher population density, significant deprivation and health need.
Our services
We are fully supportive of the need to join up health and social care services so that they work together seamlessly for local people. More support in the community will mean that people will stay healthier and maintain their independence in their own homes - avoiding hospital stays.
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We continue to work closely with primary care and adult social care and during 2016/17 we co- located a number of teams. This has helped to avoid duplication and co-ordinate care around the needs of individuals and their carers.
We have organised our clinical services into care groups aligned, or coterminous, with the geographical boundaries of our cities and the county.
The following diagram illustrates our Care Group structure:
Our values
Our shared values support the development of a strong working culture – guiding and inspiring all of our actions and decisions. They enable us to be better at what we do and create a great place for our staff to work, whilst ensuring we provide the highest quality of care to our patients.
In creating our values, we spent time listening to our employees and members. Based on what people told us, we created our HEART values to reflect the deep belief that we are a caring organisation at the centre of our community.
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How do we work together as a values-based organisation?
Our values create the foundation for everything we do – for our employees and our community. We are now working with our employees to explicitly define the behaviours and actions that we want to see in everything we do.
During the annual appraisal process, we asked people to reflect on what the values mean to them personally and how they bring them to work. We are also reshaping our recruitment and leadership practices to make HEART a part of our daily culture.
We will continue to develop ways of working that draw our values into all that we do, creating a great place to work and a great experience for our patients.
Our vision
Our shared vision includes three goals: Great care, Great place to work and Great value for money.
Many services users have complex needs that involve a number of different agencies. For most of our services it doesn’t make sense What do we mean to deliver them separately from the services provided by GPs, by 'Great care'? other NHS providers or social care.
We will deliver care that is safe, joined up, simple and easy to access, and based on the best available evidence.
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Employee experience has a direct impact on service user experience. Research shows that organisations with high
employee engagement are better for patients.
What do we mean Delivering great care is only possible if people get the practical by a 'Great place and emotional support they need. to work'? We are working to improve the development opportunities
available to our people, to improve how we communicate and engage with them, and to improve how we involve them in key
decisions that have an impact on services.
We want to make the best use of every pound invested in the NHS.
We will deliver improved value for money:
What do we mean In our own services: by making better use of our buildings and technology, ensuring we all work, together, as by 'Great value for productively as possible, and reducing waste money'? In the way the whole NHS and care system works locally: by reducing duplication and hand-offs, and by intervening earlier to avoid people requiring costly hospital care.
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Our finances
During 2016/17 we had an income of over £180 million. Our income by commissioner is illustrated below:
NHS England 16%
£7m £13m £22m Clinical Commissioning Groups £27m 58%
Local Authorities 12% £112m
Education, training and research 4%
Other income 10%
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Our objectives
In 2016/17 we developed 12 priorities to help us deliver our vision. Our goals, and the priorities below, provided the focus for our work in 2016/17.
Our performance against our objectives is detailed on pg [n]
The year in review
Summary of financial performance
A summary of financial performance can be found in Section 4.
Principle risks and uncertainties facing the organisation
Our focus during 2016/17, like the previous year, has been on maintaining service quality and sustaining financial recovery. Despite the financial challenges, service performance generally held up well throughout the year.
We finished the year with an adjusted deficit (excluding impairment) of £2.1m, a favourable £1.4m variance against our agreed Control Total of £3.5m. We received £2.2m of Sustainability and Transformation Funding from NHS Improvement, our regulator; £1.1m of this funding was as a result of improving our underlying position by £0.3m.
Our efficiency target (Cost Improvement Plan) was £14.4m, and we achieved £10.9m of this. The plan was set at an ambitious level and even though not achieved recurrently, non-recurrent schemes have been achieved which have helped us achieve better than our Control Total. The FY17/18 efficiency target has been set at a more realistic target.
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Our plan for 2017/18 is a £1.5m deficit which includes major transformation schemes and a CIP target of £6.5m. Our plan for 2018/19 is a £1.0m deficit.
Impairments of £5.8m have been recognised in 2016-17, of which £1.7m has been shown in the Statement of Comprehensive Income and the remaining £4.1m being taken to the revaluation reserve. The majority of the impairment (£5.1m) is due to a reduction in floor space valued at the St Mary’s Community Health Campus.
Our business risks
The great majority of our business is with Clinical Commissioning Groups (CCGs), NHS England, and local authorities, as commissioners for NHS patient care services and preventative services. As CCGs, NHS England and local authorities are funded by Government to buy NHS patient care and preventative services, the Trust is not exposed to the degree of financial risk faced by business entities, apart from the normal contract negotiation/renewal that is normal in any organisation. We have access to a revolving working capital facility that we can draw down as needed.
Commissioning budget reductions
There will be risks to our income in the year ahead with commissioning budgets expected to reduce further in line with the national requirement for greater efficiencies. In 2016/17, funding reductions were announced relating to public health budgets held by the Local Authorities; this has impacted on our behaviour change, health visiting and public health nursing services in the two cities, substance misuse services in Southampton, and our sexual health service across Hampshire. CCG budgets are under similar constraints and there is a risk that we will have to reduce, or stop, the provision of some services due to insufficient funds to deliver them safely and effectively. Our partner health and social care organisations are facing similar risks.
We are actively engaged with all of our commissioners to explore options that mitigate these risks; this includes looking at different clinical and workforce models which maintain good clinical outcomes, at lower cost, greater use of technology to provide services, and exploring partnerships with other health and care providers that deliver sustainable, integrated care. In the absence of additional funding, some services may have to be reduced in order to ensure care delivery that is both safe and affordable. This will have an impact on the availability of care.
Changes to the commercial environment - Sustainability and Transformation Plans
The commercial environment remains challenging. In response to the NHS Shared Planning Guidance 2016/17 -2020/21, which outlines a new approach to ensuring that health and care services are planned by place rather than around individual institutions, we are actively participating in the implementation of the Hampshire and Isle of Wight Sustainability and Transformation Plan (STP) with our partners. The STP’s aim is to ultimately deliver the Five Year Forward View vision, narrowing the gaps in quality of care and improving the health and wellbeing of our communities.
The drive towards system integration has seen a greater focus on collaborative commissioning and complex contractual arrangements that support integrated service delivery between different health and care providers, including public, private and third sector organisations.
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The Hampshire and Isle of Wight STP is establishing six Local Delivery Systems (LDS) which bring the commissioners and providers together to articulate the changes required at a local system level, and how and when they are going to be achieved. We predominately operate within the Portsmouth and South East Hampshire and the Southampton systems.
In response to the STP, discussions are taking place across the Solent wide geography regarding the development of new models of care via Accountable Care Systems (ACS) and the possible introduction of Multi-Speciality Community Provider contracts (MCP).
While the Southampton system has referenced the development of MCP contracts over the next two years it seems more likely we will first encounter this new model of contracting in the Portsmouth and South East Hampshire (PSEH) system, although dates are yet to be confirmed.
It is increasingly recognised nationally that the MCP model might not be an end in itself but rather a necessary first step on the road towards more consolidated provision with acute trusts similar to the Primary and Acute Care system (PACs) models.
These new models will require us to adopt a cross-boundary approach into wider (Southern) Hampshire and will bring health and social care staff together, under single leadership and potentially, ultimately, into a single function or organisation in the future.
We acknowledge that the future of our Trust, as it currently stands, is uncertain and presents both an opportunity and a risk for us. Whilst the front line services we offer will undoubtedly remain the same, it is likely that we will be providing these via integrated models with key partners.
Changes in delivery models and vehicles will itself bring challenges and complexities in ensuring robust clinical governance systems, processes to ensure patient safety and ensuring we respond effectively to emerging commercial models. We will, therefore, need to ensure we take our staff on the journey, ensuring that they feel involved and well informed during the changes ahead.
We recognise the wider pressures within our health economy and the need to ensure financial balance within our local health economy and will be working as a system to drive efficiencies at all levels within our STP footprint. As such, the Board have been refining our commercial strategy during the last year to ensure we maintain a sustainable cost base in response to a changing environment, including consideration of new markets and areas for potential growth.
Tenders and procurement
Other than the substantial tenders in relation to sexual health services and retaining our primary care practices in Southampton, there were fewer tender opportunities in 2016/17, but we have continued to respond to those that are aligned to our core business, including defending our existing service contracts.
A number of our services are to be re-procured in 2017/18 and 2018/19 in line with commissioning plans; this includes children’s services to the local authority in Southampton. To address this risk we are exploring innovative models of integration as a way to strengthen partnership development rather than the public sector needing to re-procure on a regular basis. This approach will strengthen new models of delivery while also reducing the risk to us of losing business through tender exercises
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– however it does not mitigate the impact of reducing budgets. We are also engaged in discussions with commissioners of specialised services to extend contracts where appropriate to deliver continuity for organisations and patients.
Any loss of key services will increase our financial pressure and also potentially destabilise other service contracts where there are significant interdependencies.
Details of our key risks in year are included within the Annual Governance Statement, page [x]
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Working with our partners and alliances (who they are, their importance)
We firmly believe that the future lies in integrated service delivery, working together with other organisations, to direct resources to the out of hospital sector in accordance with the STP for Hampshire and the Isle of Wight and developing Accountable Care Systems (ACS). Our role in this is to join with others to provide comprehensive out of hospital systems around the patient, and work closer with acute hospitals. We can act as the vehicle for change and as a stable platform to support out of hospital services.
We actively promote strong out of hospital services delivered on a local population basis, aligned and integrated with primary care, social care and the community and voluntary sector. As described earlier, we believe we have a key role to play in accelerating this model, and in providing leadership for change where appropriate.
Portsmouth and South East Hampshire
We have made good progress in our partnerships in the Portsmouth and South East Hampshire system.
During 2016, we made a number of changes, which move us towards providing even more joined up services. Some examples are illustrated;
Within social care
• We co-located community nursing with adult social care, and health visiting and school
nursing with children’s social care. This was an important milestone on the road to
more formal integration of services.
• We appointed a joint Head of Integrated Early Help and Prevention. This role brings
together all children’s early help services from the council, health and third sector.
• Our plan is to integrate adult services in a similar way.
Our preference is for single delivery structures to deliver integrated services across all ages and we benefit from joint working with our partners.
Within primary care
• We have developed a range of joint projects designed to integrate community and
primary care service provision from care home provision to urgent response services. The
total programme will come together under a new MCP contract in 2017.
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Within secondary care
• In the Autumn of 2016, we came together with other community providers to provide two key services at Portsmouth Hospitals NHS Trust: 1) A frailty interface team to ensure that frail people who attend the Emergency
Department are assessed to ensure they are only admitted to hospital when there is a clear need. If frail service users do not need to be admitted to hospital, the team ensure they are returned home, safely, with the support they need. 2) A discharge model to ensure that people do not stay in an acute hospital longer than their clinical condition requires.
Within the voluntary and community sector
• We continue to work with the voluntary and community sector in different ways: as a
subcontractor to them, sub-contracting their services to support delivery of our own contracts as well as working in partnership to deliver high quality, best value services. As an example, over the last 12 months, we have been working in partnership with the Society of St James in Portsmouth to deliver integrated substance misuse services, helping people to recover from drug and alcohol problems. We work in close
partnership with Solent Mind delivering support and recovery services, helping people accessing our mental health services to achieve improved mental health and wellbeing. We also continue to develop our close partnership working with organisations supporting children and their families.
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Southampton and County Services
Our work to provide joined up care for the citizens of Southampton has progressed during 2016/17.
Within social care
• The Integrated Southampton Response Service was launched during the year. This
brought together seven teams, from the city council and our Trust, under a single management structure. The teams provide urgent response services and reablement and rehabilitation to adults in the city. The new service includes over 350 staff who are co-located in key venues across the city. • Work has progressed with early help and children’s services, with an active working
group developing detailed plans for integrated children’s services to be launched in 2017/18.
Within primary care
• During 2016/17 significant work progressed with Southampton Primary Care Limited and Solent Medical Services. We have been working with GPs, from across the city, to further embed cluster working and join up care. During the year, we bid as a sub-contractor to primary care colleagues for the Community Wellbeing Nursing Service, a new service to
provide a proactive, preventative approach to healthcare. The service will begin on 1 April 2017.
Within secondary care
• The pressures, which have been felt in emergency care nationally, have also been felt in Southampton. The support from Southampton city teams has kept the number of medically-fit city patients in Southampton General Hospital, run by University Hospitals Southampton NHS Foundation Trust (UHS), low. However, this continues to be an area of focus for the city.
• Work has progressed to join up care pathways across diabetes, respiratory care and pain services. Our integrated Chronic Obstructive Pulmonary Disease (COPD) and respiratory service includes staff from Solent NHS Trust, Southern Health NHS
Foundation Trust and UHS work together to achieve better patient outcomes.
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Within the voluntary and community sector
We see real benefit of working with the voluntary and community sector to improve the care we are able to offer to service users. During the year, we have actively looked for opportunities to work more closely with organisations from this sector.
• Our partnership with No Limits providing school nursing services has continued to flourish and this is now considered an exemplar service.
• During the year we retendered for the Hampshire-wide sexual health service. The service, which launches on 1 April 2017, will be delivered in partnership with No Limits, the Terence Higgins Trust and through our on-going partnership with BPAS. • The health promotion service in Southampton is moving to a new service specification. We will be working in partnership with SCA and Southampton Voluntary Services to
provide this service.
Working with the community
We have continued to regularly attend scrutiny panel/committee meetings in Portsmouth, Southampton and Hampshire.
During the year we provided updates and answered questions on the following subjects:
Southampton (Health Overview and Scrutiny Panel)
• Our proposal to move the Kite Unit to the Western Community Hospital • Our Care Quality Commission inspection • Our proposal to merge GP practices in the city • Our Quality Account • The closure of the restaurant at Royal South Hants
Portsmouth (Health Overview and Scrutiny Panel)
• Our proposal to move the Kite Unit to the Western Community Hospital • Our Care Quality Commission inspection • Our proposal to move services from Falcon House to Battenburg Avenue Clinic • Phase 2 of the St James’ Hospital redevelopment
Hampshire (Health and Adult Social Care Select Committee)
• Our proposal to move the Kite Unit to the Western Community Hospital • Our Care Quality Commission inspection
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We have also engaged with the public on: • The proposed move of The Kite Unit to the Western Community hospital • The proposed move of children’s services from Falcon House to Batterburg Avenue Clinic • The merger of three GP surgeries (Adelaide, Nicholstown and Portswood) in Southampton to create Solent GP Surgery • The future of the NHS, including the creation of an MCP in Southampton • The creation of new websites including sexual health services and research • The development of online booking in sexual health services • The development of campaigns, including ‘Count me in’ our research campaign
The Board is kept informed of engagement activity via the Commercial Report which incorporates any community engagement activity which has taken place. Patients, from various services, also attend Board seminars to give their perspective on their experience of our services and the Board formally reflects on any learning.
You can also read about the work we do to engage with our members on pg [x].
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Investing in our future
Much of our investment in year has focused on improving our infrastructure, which has been in the past underfunded and in need of attention.
Over the last two years we have invested heavily in our replacing our physical IT infrastructure and clinical systems to ensure that we move into a new digital age and are beginning to see the benefits of working differently. We will continue to implement our IT Strategy over the coming years, aligning this to the Hampshire and Isle of Wight STP IT work-stream developments where this makes sense to do so.
We have made a number of estates related improvements and investments in year, including ensuring our sites comply with regulation requirements, making more efficient use of our buildings, as well as creating workspaces and facilities for our integrated teams to co-locate with colleagues from partner organisations.
During 2016/17 we also re-launched our ‘Dragons Den’ initiative, inviting staff to bid for investment to help drive innovative practice.
We value our people and recognise that an engaged workforce will deliver great care; we therefore invested significantly in our Organisational Development Programme in year, particularly focusing on our leadership capability and our ‘Leading with HEART Programme’ for our senior leaders. We recognise the importance of leadership development as being key to creating a great place to work, providing great care and ensuring great value for money – as such during the year ahead we will be extending our programme to the next tiers of leadership.
Our volunteers
We recognise the important and valuable contribution volunteers can make to us and our services. As well as benefiting patients, many volunteers can gain vital experience. They also have the opportunity to make new friends and be part of a team.
During the year, we launched our Volunteer Service and appointed a Volunteer Manager who oversees volunteer recruitment. We are now actively recruiting volunteers into both clinical and non-clinical roles and have reviewed our volunteer policy and processes, working with other Trusts to learn from best practice. Our Volunteer Manager continues to work with our services to identify any volunteer opportunities. You can find out more about volunteering opportunities on our website www.solent.nhs.uk
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Charitable funds
Beacon, Solent NHS Charity, raises money for areas not covered or fully supported by NHS funds and aims to make a difference to the experience people have when they come to us. This can be anything from improving a waiting area, buying a more comfortable chair to creating a multi-use outdoor sports area for those staying with us on a longer term basis. Sometimes it is the smallest things that can make the biggest difference.
We are immensely grateful to everyone who has donated money. The donations we received during 2016/17 amounted to £7,139.94. We are also extremely appreciative to our staff who have worked hard to raise funds for Beacon, including organising and holding fun days through to significant personal efforts such as running the London Marathon and completing the London to Brighton bike ride, both these events raised a total of £3,321.66.
During the year, we have used our charitable funds to purchase various items to enhance the care we provide to our patients. This has included purchasing a digital reminiscence therapy system that supports patients with cognitive impairment by improving patient and carer interaction. During the year ahead we will work with our services to raise the profile of Beacon further and to encourage fundraising activities and spending.
Whole system response and emergency preparedness
Our major incident policy, now entitled Solent NHS Trust Incident Response Plan, was reviewed during 2016/17. The Plan complies with current Emergency Preparedness Resilience and Response (EPRR) legislation. Our business continuity plans were also reviewed, tested and validated.
Co-operation between organisations is essential to robust emergency preparedness. We work with other organisations and Trusts to help partnership working in the event of a critical or major incident. During the year;
• our Chief Operating Officer for Southampton represented us at the Health Resilience Partnership (LHRP) • our Emergency Planning practitioner (EPP) regularly attended local health resilience meetings and provided feedback relevant information to our emergency planning group, and • our EPP worked in partnership with the local community Trusts to ensure all work undertaken is consistent across the area and that there is a greater understanding of EPRR within the organisations. Working together in this way supports the requirements of the relevant agreements and allows for joint learning and the sharing of EPRR documents and workplans.
During 2016/17 we have participated in the following exercises:
• a system wide communications test which was carried out in June 2016 • the Public Health England Emergo exercise, to test the major trauma network, in November 2016 • Exercise Asesco, a multi-agency pandemic flu exercise • an internal exercise to test the understanding and actions of staff when an incident involved full media coverage • an exercise in Portsmouth involving the acute trust and partner agencies.
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Also during the year we implemented a new training plan. All on-call staff attended at least one training session during the year.
We had four ICT incidents, graded as critical, during the year. The incident co-ordination centre was opened to facilitate appropriate ‘command and control’ during the management of these incidents and we have reflected on any learning.
Each year NHS England (NHSE) assess us for assurance against the EPRR core standards. In 2016/17, NHSE concluded that the EPRR assurance assessment was ‘substantial’ and acknowledged the work we had undertaken in year.
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News from our services
Southampton and county care group
National WOW Award Jo Harper, one of our Community Sisters for Palliative Care, was nominated for a national WOW award for her outstanding customer service. Jo was one of 75 finalists to be shortlisted from nearly 20,000 nominations. She was selected in the Judges’ Choice Category and attended the Gala Awards Ceremony in November 2016.
Matron shortlisted for national nursing award Clare Scholfield, who works as a Modern Matron for our Sexual Health Services, reached the finals at the Nursing Times Awards 2016. Clare was shortlisted in the Nurse Leader of the Year Category.
The Nursing Times Awards are considered to be highly prestigious awards amongst the nursing profession. Clare was nominated for her leadership successes.
Get me to the church on time! Our Fanshawe Ward staff won a WOW Award after pulling out all the stops so a patient could attend his daughter’s wedding. When David, one of our service users, was admitted in December, he doubted he would be well enough to make the big day. However, thanks to our amazing health care assistants, Wendy Nash and Julie Mould, David didn’t miss out on one of the most important days of his life. Not only did they arrange for him to have his hair cut, a shave and made him look dapper in a suit, they also typed up his speech in large print so he could read it.
My baby comes smokefree In February, we launched an innovative trial programme to help young mums-to-be stop smoking during pregnancy and, hopefully quit for good. As part of a research project to understand if incentives can help young women to quit smoking during pregnancy, mums-to-be under the age of 20, enrolled on the Family Nurse Partnership Programme. They were offered reward scheme vouchers alongside weekly support sessions and a range of other help.
The young mothers are asked to set a quit date at the start of the study and will be monitored regularly to verify their non-smoking status. Southampton City Council supported the study.
Homeless Healthcare team scoop award Our Homeless Healthcare team were winners at the National Institute for Health Research (NIHR) and Clinical Research Network Wessex (CRN Wessex) Awards. They received the ‘Outstanding Clinical Team’ award for the work they do to improve the health of homeless people in the city of Southampton.
Portsmouth
The Treetops Centre – 10 years of helping victims of sexual assault Treetops, our Sexual Assault Referral Centre (SARC), has been providing vital help for victims of sexual assault for 10 years. To mark the occasion, speakers from various organisations attended a networking event at Netley Police Station Headquarters in November. Staff, old and new, also reunited at a small gathering at our Treetops Centre in recognition of the service’s great achievements.
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Physiotherapist wins Patients’ Choice Award Claire Jeffries, from our Hydrotherapy and Rheumatology service, won a national Patients’ Choice Award for ‘Best Care by a Physiotherapist’. Patients with Ankylosing Spondylitis (AS), a form of arthritis which mainly affects the spine, nominated Claire for the National Ankylosing Spondylitis Society’s (NASS) award for ‘going out of her way to provide excellent care’.
Best of Health Awards 2016 The best of health awards are run every year for those healthcare professionals who have gone above and beyond in their field. Patients and colleagues are asked to nominate their hero, so to be in the running for them is an honour. The runners up were: • Hospital team of the year 2016: Colin Beevor and his team at Rheumatology Department, QA Hospital • Allied Healthworker/Team of the year 2016 Falls Prevention Exercise Team, Turner Centre, St James’ Hospital • Mental Health Worker/Team of the Year 2016 Vicky Woodhams, Adult Mental Health Nurse, St James’ Hospital • Community Nurse/Team of the Year 2016 Portsmouth Rehabilitation Team, Turner Centre, St James’ Hospital
Baby friendly initiative Our Portsmouth health visiting team and children’s centres achieved their Unicef baby friendly initiative re-accreditation. This is a result of the hard and dedication from the teams who continually strive to improve the care and support they provide to mothers and babies.
CQC rates Learning and Disability Service as ‘outstanding’ Our Learning and Disability Service were ranked as ‘outstanding’ in our Care Quality Commission (CQC) report. The service were noticed for their great focus and responsiveness to the needs of service users, development of innovative new approaches to care, on-going review of best practice and their ability to listen to the views of service users and their carers.
Preventing slips and trips Lee Henderson, Physiotherapist in our Falls Prevention Exercise team in Portsmouth, hosted our membership workshop in January 2017. As well as learning tips about how to prevent falls and what to do if you trip, people who came along to the event listened to a talk about Osteoporosis by Margo Berry of the National Osteoporosis Society. Paula Day of Portsmouth City Council’s Independence and Wellbeing team also gave advice on keeping active.
Opening of Somerstown Central Dental Clinic The Lord May of Portsmouth cut the ribbon for the official opening of our Somerstown Central Dental Clinic in August .The clinic provides specialist dental care that is not available in general practice for example, those with physical, sensory or learning disabilities.
Frailty and Interface Team celebrate one year The Frailty and Interface team (FIT) at the Queen Alexandra Hospital (QA) in Portsmouth celebrated one year of success in December. The service, which is provided by staff from several organisations including our Trust, helps to reduce the number of people who are admitted to hospital and the length of time people stay in hospital for.
The team, who work alongside the Emergency Department (ED) team at QA, see around 150 patients a week – and since June 2016 over 12,000 patients have been screened for frailty, with more than 4,000 having a positive frailty score. This means they show signs of being at a higher risk
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of a sudden deterioration in their physical and mental health which can be triggered by small events such as a minor infection. This is because as we get older our bodies gradually lose their in-built reserves.
Trust wide
Bright ideas - better services The best ideas for making service improvements almost always come from front line staff and their patients. That is why we launched our Dragons’ Den in June 2016, to provide small grants of up to £10,000 for staff to put their ideas into practice. Chaired by Sarah Williams, Associate Director for Research and Clinical Effectiveness, our Dragons have awarded over £60,000 in funding for 17 proposals. The projects which have received funding include: • new sensory equipment to support patients with autism and learning difficulties. • a Mindfulness programme on CD and the internet to support mental health recovery • a young person’s mystery shopper group in our sexual health services • equipment to support eating and swallowing assessments in children • prompt cards to help community nurses identify Sepsis , a rare condition, or deterioration in the health of patients.
Helping you stay healthy and well Occupational Health worked closely with the catering teams at the Western Community Hospital and St Mary’s Community Health Campus, to launch the Think Healthy… Choose wisely campaign in December 2016 and March 2017.
We are top of the research league tables We were named the top recruiting research Care Trust in England. The latest league tables show the number of people taking part in research with us between April 2015 and March 2016 was just over 1,800, an increase of 48% on the previous year. We also increased the number of our research studies from 42 to 47.
Supporting young fathers and their families Our Family Nurse Partnership (FNP) worked with young fathers to raise awareness of domestic abuse and support healthy relationships. To achieve this, the team worked closely with The Hampton Trust and Saints Foundation; they met with a group of young fathers at St Mary’s Football Stadium regularly to find out their views and experiences of relationships and domestic abuse.
Solent NHS Trust and Dementia UK join forces to improve dementia care Working in partnership with Dementia UK, we began providing support and advice to a team of admiral nurses. Admiral nurses provide specialist dementia support to individuals and their families. As a consequence of our joint work, the Solent Dementia network was launched. The network is designed to give our dementia nurses and healthcare professionals easy access to quality information and support, which in turn will lead to better care for our dementia patients.
Shortlisted for national Patient Experience Network (Pen) Award
Dr Clare Mander was shortlisted for a Patient Experience Network (Pen) National Award. These awards are the first patient experience awards to celebrate best practice in health and social care in the UK.
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Clare, our Clinical Lead for Accessible Information (Ai), was shortlisted in the Accessible Information category and invited to an award ceremony at Birmingham Repertory Theatre in March for pioneering work to develop accessible information.
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Performance Analysis
Performance Governance
During 2016/17, we updated our performance governance review structure by introducing individual Performance Review Meetings with each service line where exceptions are escalated to executives for oversight, assurance and discussion. To enhance the level of oversight and assurance of clinical performance, comprehensive dashboards detailing patient care were further developed and reviewed at all Performance Review Meetings and Clinical Governance Meetings. Additionally, performance reviews of corporate services (our non-clinical support services) were performed. During the meetings, comprehensive data detailing financial, workforce, patient care, operational, contractual and regulatory performance is provided, reviewed and discussed as appropriate. The performance meetings are held monthly with formal exception reports submitted to the Trust Management Team (an executive committee).
Data Quality and Assurance
Following the implementation of a new Clinical Records System (CRS) for the majority of services in 2015, significant progress has been made in reducing the number of data quality issues during the year. Consequently the validity, accuracy and confidence in the data has increased.
A robust Data Quality Improvement Plan was in place throughout the year to structure the work required, measure the improvement and provide assurances to commissioners. Any data quality concerns were mitigated by working collaboratively with the services and keeping commissioners sighted on progress. We will continue to make further improvements during 2017/18.
Activity Review
As a result of moving to our new Clinical Records System we are reporting activity which is more reflective of the services delivered. Additionally, a combination of a reduction in activity, an increase in patient acuity, the integration of some of our services ensuring efficient patient pathways, together with increased data quality has meant that our recorded activity figures have been impacted.
Some of the services we provide jointly include
• Substance Misuse Services in Portsmouth are provided jointly with Portsmouth City Council • Substance Misuse Services in Southampton are provided jointly with a third party provider, CGL • The Integrated Crisis Response, Rehabilitation, Reablement and Hospital Discharge Team replaced several of our community services in Southampton and is now provided jointly with Southampton City Council • The Community Emergency Department Team in Portsmouth integrated with colleagues from Southern Health NHS Foundation Trust and Portsmouth Hospitals NHS Trust to provide a new Discharge to Assess Service
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A breakdown of patient contacts and occupied bed days by service line is illustrated in the following table:
Inpatient Service Line Contacts Total Occupied Bed Days
Adult Mental Health 25,220 20,318 45,538
Adult Services, Portsmouth 91,836 14,186 106,022
Adult Services, Southampton 164,987 21,589 186,576
Child and Family Services 157,785 0 157,785
Special Care Dental Services 43,739 1,210 44,949
Primary Care and Long Term Conditions Services 185,412 0 185,412
Sexual Health Services 108,608 0 108,608
Solent NHS Trust Total 777,587 57,303 834,890
Referral to Treatment Performance
We successfully achieved the national standards for Referral to Treatment (RTT) within 18 weeks for another year. Due to the diverse nature of services we provide, not all services are applicable to the national RTT standards, but a breakdown of related performance for 2016/17 is illustrated in the following table:
Number of compliant Total number of RTT standard Performance referrals referrals
Part 1B – Not Admitted 8075 8101 99.7%
Part 2 – Incomplete 13091 13123 99.8%
NHS Improvement Single Oversight Framework
NHS Improvement’s (NHSI) Single Oversight Framework provides the framework for overseeing organisations and identifying potential performance concerns. The framework covers five themes:
1. Quality of care 2. Finance and use of resources 3. Operational performance 4. Strategic change 5. Leadership and improvement capability (well-led)
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Currently NHSI has defined metrics associated with the first three themes listed above; as such our performance is summarised as follows. Thresholds highlighted in grey are internal, aspirational thresholds, whereas all others are national targets. NHSI is working to develop the performance metrics associated with the additional themes, aligning approaches to the CQC Domains where possible.
Based on data from these themes and the scale of issues faced, NHSI segments providers from 1 to 4, where ‘4’ reflects providers receiving the highest level of support from NHSI (for example, those considered in special measures) and ‘1’ reflects providers with the most autonomy. Our Trust is rated as ‘2’, largely due to our financial position, however NHSI are satisfied that we have sufficient controls in place.
Quality of Care Metrics:
The measure of ‘Quality of Care’ includes the CQC’s most recent assessment of whether our care is safe, effective, caring and responsive as well as in-year information where available. NHSI have also set some indicators under this domain and our performance is summarised as follows;
The staff sickness rate has remained fairly stable through the year, with an increase over the winter months as usual; however, we still aspire to attain an ambitious 4% sickness threshold. Further detail on how we are tackling sickness absence can be found on page [n].
Unfortunately, we did not meet our threshold (12%) for staff turnover mainly due to pressures in a few services. Turnover is monitored monthly, by service, through Performance Review Meetings, ensuring staffing levels remain safe. We are actively promoting our Great Place to Work Programme which aims to retain and support our people throughout their career with us.
We are proud that our Staff Survey results improved in year – you can find further information about this and our focus for the year ahead on page[n].
Our agency utilisation has been a particular pressure for us due to increased patient acuity and temporary vacancy cover and as such we were unable to achieve the 3% threshold required. Further detail on staffing pressures can be found within the significant issues section of the Annual Governance Statement.
Despite being unable to meet our formal savings plans, we did achieve our Financial Control Total largely due to unplanned vacancies. Further information about our financial performance can be found in section [n].
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Compliance against the Caring domain is positive overall with no significant concerns. Due to the nature of our Mental Health Services, the Friends and Family Test (FFT) scores are generally lower than Community services FFT scores but Solent benchmarks well for Mental Health provision.
The standards required to meet the metrics under the Effective domain were met in most months throughout the year.
Our performance against the Safe domain was very strong with no ongoing concerns.
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Operational Performance Metrics:
NHSI have determined a number of key metrics in accordance with NHS Constitutional standards.
Our performance against these are summarised as follows;
Overall, compliance against the Operational Performance theme is positive with the only exceptions relating to issues concerning data quality as detailed previously.
The 'Operational Performance' metrics outlined within the table do not provide an overall performance assessment for the Trust, however based on our performance against these metrics and defined thresholds, NHSI consider whether support or intervention is required. During 2016/17 we did not receive any support from NHSI in relation to our performance against these metrics.
Further information about our key performance indicators can be found on page [n].
Finance and Use of Resources Metrics:
Financial metrics are used to assess financial performance and efficiency, with a score from 1 (best) to 4 (worst) being assigned to each metric. These scores are averaged across all metrics to derive a 'use of resources' score for the organisation. An overall score of 3 or 4 in this theme will identify a potential support need, as will providers scoring a 4 against any individual metric.
Although the overall score for these metrics indicates additional support is required, the organisation is in regular communication with NHS Improvement, and the requirement for additional support has been negated.
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Key Performance Indicators (KPIs) and performance hot spots in year
Our contractual KPI performance was strong during 2016/17 across all contracts and national standards and consequently we did not receive any Contractual Performance Notices (CPNs).
We did however have a number of service performance ‘hot spots’ in year, some of which concern access to our services, system pressures and staffing, with others relating to specific CQC recommendations – these are described within the operational risks and significant issues section of the Annual Governance Statement, page [n]. Open, transparent and collaborative partnership working with our commissioners has helped improve services with performance concerns during the year.
There were no confirmed Human Rights violations by us during 2016/17.
2016-17 reflection on our business plans and achievements
Following the agreement of our 2016/17 business plans we were informed of the impending Care Quality Commission (CQC) comprehensive inspection and the implementation of the Sustainability and Transformation Plan (STP). Consequently, we reprioritised our plans.
A summary of our key achievements and challenges are summarised within the following table.
Area Successes Challenges and areas of focus for 2017/18 Adults Portsmouth • CQC ratings - ‘Good’ rating and • Standardisation of clinical governance ‘outstanding’ rating for our Learning processes within our Community Disability service Nursing teams • Community Nursing vacancy reduction • Morale and staff engagement • Positive outcomes associated with the concerning associated with estate Discharge to Assess and Frailty moves Intervention Team model introduced • Pressures within the Acute Hospital within Portsmouth Hospitals NHS Trust impacting performance of our • Partnership working with GP Alliance community services Adults Southampton • CQC rating – ‘Good’ • Vacancies within Community Nursing • Positive impact of the integration of our • Relocation of the Kite Unit from St urgent response service with social care James’ Hospital, Portsmouth, to the partners Western Community Hospital, • Introduction of the NeuroFit service Southampton • Reduction of community rehabilitation • Interfaces between different IT service waits systems used by our staff and those • Significant increase in service user using Local Authority systems feedback
Children • Successful achievement of our second • Vacancies within Paediatric Therapies year of our transformational journey • Aligning the transformation of our • Supporting Health Visitors with the services with the STP introduction of community staff nurses • Modernisation of medicines • Increased service user engagement management to ensure the highest standards Specialist Dental • Successful implementation of mobile • Limited theatre space for our General Services working practices Anaesthetic procedures • Relocation of Somerstown Hub, • Achieving our Annual Units of Dental
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Portsmouth Activity (UDA) contractual target • Completion of a comprehensive quality • Reducing our dental service estate review Estates • Limited number of recommendations • Estates related issues following staff from CQC associated with our estate relocations to the Civic offices and • Implementation of a Premises Assurance Medina House in Portsmouth Model • Progressing estate rationalisation • Significant engagement with partners to schemes aligned to the STP facilitate the relocation of services from • Ensuring suitable car parking facilities St James’ Hospital to St Mary’s for our service users and our staff Community Health Campus HR • Introduction of our Senior Leadership • Breach of the mandatory agency Development programme spend cap • Improvement of online and automated • Challenges associated with staff processes e.g. payslips and Disclosure accessing online training Baring Service checks • Workforce planning • Improved and streamlined induction process for new starters • Practice Educator Roles were embedded in year • No employment tribunals for second year running IT • Migration of all staff onto our new IT • Delayed implementation of infrastructure Viewpoint • Implementation of new staff • Number of IT related incidents in year communication system (Skype) • Telephony reliability and cost • Implementation of clinical system pressures business continuity processes • Delays associated with IT device • Maintaining our Level 2 compliance with procurement Information Governance requirements Mental Health • Integration of our Older People’s Mental • Increased demand and complexity of Health service with our Adult Mental patient needs within our Mental Health Service Health wards • Integrating safeguarding into referral • Communication methods between review process for our Adult Mental teams and our partner organisations Health Services • Provision of our Substance Misuse • Development of new framework enabling Services career development of our Mental Health • Mental Health section 136 Nurses Assessment Suite provision
Primary Care • Successfully awarded contract for a new • Significant waiting times for podiatric Services Behavioural Change Services surgery in Portsmouth • Successful redesign of podiatry pathway • Cost pressures associated with in both cities diagnostics • Merger of our three GP surgeries into • Recruitment challenges for nurses one surgery and Allied Health Professionals • Positive engagement with Portsmouth (AHPs) within Podiatry and Primary Care Alliance reducing GP based Physiotherapy MusculoSkeletal (MSK) activity Quality and Risk • Launch of Solent Quality Improvement • Fully embedding actions resulting Programme from our CQC inspection • Led the 2016 CQC inspection process • Instabilities associated with our IT • Collaborative production of strategic system causing incident reporting frameworks for Allied Health Professions challenges (AHPs) and nurses • Ensuring Serious Incident
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• Introduction of additional methods for Investigation deadlines are met capturing service user experience, including feedback from children and young people Sexual Health • CQC rating – ‘Good’ • Unanticipated activity through • Successfully awarded contract for an successful implementation of online Integrated Sexual Health Services testing • Introduction of online booking facilities • IT challenges causing difficulties in and same day access clinics achieving access metrics • Engagement with partners to rationalise estate and delivery models Finance and • Recommendation of Unqualified External • Significant expected data quality Performance Audit Opinion regarding Value for Money issues due to clinical record system • Establishment of Corporate Programme transition Management Office to provide robust • Existing finance system requiring oversight of key Trust projects upgrade to improve productivity • Meeting nationally expedited contract • Team vacancies have resulted in negotiation deadlines needing to reprioritise requests and • Reduced aged debt over 90 days by work differently £954k in year
A comprehensive review can be found within the Month 1, Board Performance Report accessible via our website.
2017/18 – A Look Forward
We will actively address all the challenges that have been identified. We will also continue to work with our partners in the evolving STP landscape as that will help ensure we achieve our financial targets. Throughout this journey, we will maintain an unwavering focus on quality and strive to deliver on our business objectives and our vision: To deliver great care, create a great place to work and deliver great value for money.
There is an exciting year ahead with the implementation of a bespoke Enterprise Data Warehouse (EDW). The aim of the Warehouse is to create a central location that stores Operational, Financial, Workforce and Quality data together, which will enable management information to be reported quicker, through self-service and be more accessible to both clinical services and corporate teams.
Environmental Responsibilities and Sustainable Development Plan
We are currently developing a Sustainable Development Management Plan that will fully align with the NHS Standard Contract, specifically the Service Contract item SC18 – Sustainable Development. Further information about our environmental responsibilities can be found within the Annual Governance Statement.
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On an annual basis we complete the Sustainable Development Unit report, supported by ERIC returns (Estates Return Information Collection). This is in line with our Carbon Reduction Action Plan, to meet our mandatory sustainability reporting requirements.
In addition, on a monthly basis, we monitor our waste disposals and utility consumptions. Our utility consumptions are compared with previous year’s usage to ensure economic efficiencies and to track consumption in line with our carbon reduction targets. Our waste disposal locations are monitored to ensure minimal waste to landfill, and to track, increasing recycling rates. We work with our waste contractor to increase segregation to improve recycling rates, and with their subcontractors to increase clinical waste residues to R1[1] recovery facilities, instead of previous landfill sites. With the agreement of the Environment Agency, the waste contractors permit has been enhanced allowing offensive waste to also be disposed of and recovered, via R1 facilities. In accordance with the HM Treasury Sustainability Reporting Guidance, our Carbon Reduction Action Plan addresses the minimum requirements concerning Green House Gasses (GHG) both Scope 1, (direct GHG emissions), and Scope 2 (energy indirect emissions), as well as Finite Resource Consumption including estates water consumption, via our ERIC return (measured in cubic meters).
We are committed to sustainable procurement practices and all new contracts are issued in accordance with NHS Terms and Conditions. By ordering our goods via a supply chain we minimise fleet mileage, deliveries, congestion and associated pollutants. During the year ahead we aspire to further analyse our environmental information and data across our estate footprint more thoroughly to support the ERIC process and requirements under the Sustainable Development Unit, as well as more broadly ensuring sustainability is embedded within business practices across the organisation.
Further information about our environmental responsibilities can be found within the Annual Governance Statement.
SIGNED BY CEO
[1] R1 recovery facilities use waste to generate energy
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Section 2: Accountability and Corporate Governance Report
Directors’ report
Governing our services
Our Board of Directors
Accountable to the Secretary of State, the Board is responsible for the effective direction of the affairs of the organisation, setting the strategic direction and appetite for risk. The Board establishes arrangements for effective governance and management as well as holding management to account for delivery, with particular emphasis on the safety and quality of the trust’s services and achievement of the required financial performance as outlined in its Terms of Reference.
The Board leads the trust by undertaking the following key roles:
• ensuring the management of staff welfare and patient safety • formulating strategy, defining the organisation’s purpose and identifying priorities • ensuring accountability by holding the organisation to account for the delivery of the strategy and scrutinising performance • seeking assurance that systems of governance and internal control are robust and reliable and to set the appetite for risk • shaping a positive culture for the Board and the organisation.
The business to be conducted by the Board and its committees is set out in the respective Terms of Reference and underpinned by the Scheme of Delegation and Reservation of Powers.
The Board meets formally every other month In-Public. Additional meetings with Board members and invited attendees are held following in-public meetings to discuss confidential matters. The Board also holds confidential seminar (briefing) meetings every other month and development days every other month. All non-executive directors take an active role at the Board and board committees.
Balance, completeness and appropriateness of the membership of the Board of Directors
The Board of Directors comprises six non-executive directors (NEDs) including the Chairman and five voting executive directors. The executives with voting rights include the Chief Executive Officer, the Director of Finance and Performance, the Chief Medical Officer, Chief Nurse and Chief Operating Officer Southampton and County Services. Together with the Chief Operating Officer Portsmouth and Commercial Director and Director of Human Resources and Organisational Development they bring a wide range of skills and experience to the Trust enabling us to achieve balance at the highest level. The structure is statutorily compliant and considered to be appropriate. The composition, balance of skills and experience of the Board is reviewed annually by the Governance and Nominations Committee.
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Appointments
Executive director appointments
There were no new Executive director appointments made in year; however the Chief Operating Officer for Southampton and County left the Trust in March 2017 and an Interim Director was appointed pending a substantive appointment being made following a formal and rigorous recruitment process.
Non-executive director appointment
During 2016/17 two Non-executive directors were appointed, supported by Odgers Berndtson, executive recruitment consultants. Interview panels were convened of representatives of NHS Improvement, an independent Trust Chair, the Lead Governor and the Trust’s Chairman.
The people
Non-executive directors
Photo Dr Alistair Stokes, Chairman
Alistair was appointed to the Trust in April 2011. He has had a wide ranging career in marketing, business development and administration in the chemical and pharmaceutical industries including working as Commercial Director with Monsanto Company and as Managing Director for UK operations and subsequently Regional Director for the Far East and South East Asia for Glaxo PLC. From 2007, Alistair served as Chairman of the Ipsen Group’s UK companies, retiring from that role in 2010. Alistair also served as Regional General Manager for the NHS in Yorkshire and for several years as a member and Vice Chairman of a District Health Authority and from 1992 until 1998 as Chairman of an NHS Trust. He is a Fellow of the Institute of Directors and a Chartered Director. Alistair is the lead NED for Health and Safety (including Local Security Management) as well as Safeguarding.
Photo Mick Tutt, Deputy Chairman
Mick was appointed to the Trust in April 2011. He has more than 40 years’ NHS experience, including 20 years in senior management and more than a decade at Executive Director (and equivalent) level. As a qualified nurse Mick has managed mental health and learning disabilities services and has overseen governance and management arrangements in a number of different Trusts and other organisations. He also has experience of working with the CQC and its predecessors, currently as a Specialist Advisor and Chair of Inspection. Mick has also acted as the Nurse/Manager representative on several independent inquiries and has undertaken many investigations into disciplinary and grievance matters and serious incidents. Mick was a former lay member of the Portsmouth Community and Mental Health Service Board before being appointed as non-executive director for Solent NHS Trust. He now acts as
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a manager for appeals against Mental Health Act detentions and also chairs the Mental Health Scrutiny Committee and Assurance Committee as well as being the Deputy Chairman.
Photo Jon Pittam, Senior Independent Director
Jon was appointed to the Trust in June 2012. Since 1997, until his retirement in 2010, Jon was the County Treasurer for Hampshire County Council as well as being Treasurer for the Hampshire Police and Fire Authorities. In these roles, Jon provided financial and strategic advice in support of the authorities' corporate strategies and was the chief financial officer for budgets approaching £2 billion. Jon was an elected council member of his chartered accountancy body and the national spending convenor for local government finance during several public expenditure rounds. Jon is the chair of the Audit & Risk Committee, is the Senior Independent Director, acts as an Associate Hospital Manager and is the lead NED for whistleblowing (Freedom to Speak Up) and procurement.
Photo Jane Sansome
Jane was appointed to the Trust in June 2015. Jane had an extensive and highly successful 21 year career in the NHS before joining the Ministry of Defence in 2000 to lead the operational planning and delivery of the strategy to transform Defence Medical Services. In 2004 with the first stage of the strategic plan delivered, Jane moved to the private sector to become the Chief Executive Officer of the project company delivering the £1.2billion redevelopment programme for Barts and the London Hospitals. In 2012 Jane joined Skanska UK as a Non-Executive Director. Jane supported the Managing Director of Skanska Facilities Services to develop the strategy, resource and contract delivery plans for the company. Jane left Skanska at the end of February 2015 to become a freelance management consultant. Jane chairs the Finance Committee and Remuneration Committee and is the lead NED for patient experience and oversight of medical fitness to practice issues.
Photo Mike Watts
Mike was appointed to the Trust in October 2016. Mike grew up and went to school in Southampton, he is a Hampshire resident and has an extensive and wide ranging track record in organisational design and development that has driven business performance. Mike is currently a consultant with Capability and Performance Improvement Ltd and was, until earlier this year, the Head of Strategic Human Resources and Organisational Development at Southampton City Council. Mike has previously held senior HR roles at the Chartered Institute of Professional Development; Cabinet Office; Lloyds TSB and Scottish Widows. During his time in the Cabinet Office, Mike was recognised by HR Magazine as one of top 30 influencers of HR practice. He has also held a previous Non- Executive Director role with the Scottish Executive.
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Photo Francis Davis
Francis was appointed to the Trust in October 2016. Francis has, for 20 years, been active in founding, chairing and supporting community groups, voluntary organisations and social enterprises in health and social care across Hampshire especially in Portsmouth, Southampton and Gosport. He helped to launch the 'Hampshire Festival of the Mind' and also the first UK 'Mental Wealth Festival'. Formerly a private sector CEO Francis has chaired industry bodies for the South and South East and also worked as a senior civil servant at Cabinet level. He is currently Professor of Communities and Public Policy at the University of Birmingham and a member of the Department of Health's cross government Independent Advisory Group on Carers. Francis chairs the Charitable Funds Committee and is an Associate Hospital Manager.
Non-executive directors who left in year
David Batters David is a Chartered Management Accountant who was appointed to the Trust in October 2015. He is the Chief Finance Officer (CFO) for the Nuclear Decommissioning Authority (NDA) which is a non- departmental-body sponsored by the Department for Energy and Climate Change (DECC). He joined the NDA in October 2010 where in addition to being the CFO he is also the Executive Director responsible for 14 nuclear sites across the UK. He is an Executive Board member of the NDA. His appointment with the NDA followed more than 20 years with BAE Systems and predecessor companies in which he held a variety of roles primarily in finance including Mergers & Acquisitions, Planning and Analysis, Reporting, Project Accounting and as a Finance Director of a number of businesses. David left on 31 July 2016.
Executive Directors
Chief Executive Officer, Sue Harriman Photo Sue is a registered nurse who trained in the Royal Navy and enjoyed a 16 year military career. Sue joined the Trust in September 2014.
Since joining the NHS over 12 years ago, Sue has worked in the primary, secondary, community and mental health care sectors. Her previous roles included being a Nurse Consultant in Infection Prevention, Director of Nursing and Allied Health Professions (AHP), Managing Director, Executive lead for performance, planning and corporate governance as well as being appointed as Deputy Chief Executive.
Photo Andrew Strevens , Director of Finance and Performance
Andrew joined the Trust in August 2015. He has worked within the
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health service since 2009 and brings a whole system view, having worked in senior positions for providers (Hampshire Community Health Care and Southern Health) and a commissioner (NHS England South Region). He also has a commercial background, having worked for KPMG and B&Q Plc.
Photo Dan Meron, Chief Medical Officer
Dan joined the Trust in January 2016. Dan studied Medicine at the University of Southampton, and completed psychiatry training in Wessex. He went on to become a consultant in general adult psychiatry in Avon & Wiltshire, where he held consultant posts in community teams, Crisis Resolution and Home Treatment, Acute Inpatient, Assertive Outreach, and Primary Care Liaison. Over the years he developed a management and leadership portfolio and continued to combine senior management roles with active front-line clinical work. He is actively engaged in research at the School of Medicine, University of Southampton, where he is currently completing a Doctor of Medicine higher research degree. He has special interest in mood and anxiety disorders, trauma, addiction, recovery, and mindfulness. Dan undertook an Executive-MBA degree at Hult International Business School and graduated with distinction in 2014. Dan believes that integration between mental and physical, primary and secondary, and between health and social care in a community-based system, is the way to improve the lives of the people we are here to serve.
Photo Mandy Rayani, Chief Nurse
Mandy trained in Swansea as a Registered Mental Health Nurse (RMN), she subsequently worked in mental health services for approximately 20 years. In 2005, Mandy became Regional Nurse for Mid and West Wales Regional Office working with the Welsh government. In 2007, Mandy took up the role of Deputy Nurse Director at Cardiff and Vale NHS Trust, one of the largest teaching hospitals in the UK. Following the NHS Wales reorganisation in 2009, she was appointed Deputy to the Executive Nurse Director of Cardiff and Vale University Health Board, a fully integrated healthcare organisation providing primary, community, secondary mental health and tertiary services. In her role, Mandy provides professional leadership to nurses and allied health professionals. She also has particular responsibility for patient experience, quality governance, risk management and regulatory compliance to ensure we continue to deliver safe, effective and sustainable services. Mandy joined the Trust in September 2014.
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Sarah Austin, Chief Operating Officer Portsmouth and Commercial Photo Director
Sarah joined Solent NHS Trust in autumn 2010 as the Transforming Community Services Programme Director before being appointed as Director of Strategy in November 2011. In December 2014 Sarah took on a wider remit for commercial activities and was appointed as the Chief Operating Officer of Portsmouth Care group and Commercial Director in July 2015. Sarah originally trained as a nurse in London, specialising in renal care in Portsmouth and has undertaken both a teaching qualification and a BSc. Her career to date includes 17 years in Portsmouth Hospitals NHS Trust latterly working as Director of Strategic Alliances which lead to the merger with Royal Hospital Haslar. Sarah also spent five years as Director of Central South Coast Cancer Network and three years in South Central Strategic Health Authority focusing on strategy, system reform and market development.
Executive directors who left in year
Julie Pennycook, Director of Human Resources and Organisational Development Having work in the independent healthcare sector for 15 years, Julie joined the NHS in Southampton in 2003 and Solent NHS Trust in April 2011. She led a comprehensive Human Resources and Organisational Development Department comprising HR Business Partners, Learning and Development, Workforce Information and Planning, Employment Administration, In-house Bank Staffing Service and Occupational Health. Julie left the Trust in December 2016. Following Julie’s departure, Andrew Strevens, Director of Finance and Performance has been providing interim leadership to the HR department. Our newly appointed Chief People Officer joins us in April 2017.
Alex Whitfield, Chief Operating Officer Southampton and County Services Alex joined the Trust in July 2012, prior to which Alex provided strong leadership as Chief Operating Officer to Winchester and Eastleigh Healthcare NHS Trust before its acquisition by Basingstoke and North Hants NHS Foundation Trust and the creation of Hampshire Hospitals FT. In her role as COO with us, Alex effectively led clinical services and had a sound understanding of the challenges faced by the local health and social care providers and actively engaged with our key partners. Alex left the Trust in March 2017 to become the Chief Executive Officer of Hampshire Hospitals NHS Foundation Trust.
Following Alex’s departure, Lesley Munro has taken the Interim Chief Operating Officer responsibilities for Southampton and County wide services and is the executive lead for charitable funds and the Making Every Contact Count initiative. Lesley is also leading on Better Care Southampton. The following summarises elements of Alex’s former role currently being led on an interim basis by the executive team prior to a substantive position being recruited to: • Dan Meron, Chief Medical Officer – interim executive lead for IT. • Andrew Strevens, Director of Finance and Performance - interim accountable officer for Emergency Planning, Resilience and Response (EPRR).
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• Mandy Rayani, Chief Nurse –interim Senior Information Risk Owner (SIRO) for the Trust
Board development and performance evaluation The Board of Directors keeps its performance and effectiveness under on-going review. The Board holds workshops every two months to focus on developmental and strategic topics. Due to a number of personnel changes the Board is planning for an external evaluation be conducted during 2017/18. The results, together with various board development activities and assessments undertaken in year via an external organisation, will inform a refresh of the Board Development Plan.
In addition, an annual governance review is conducted by the Governance and Nominations Committee and each Board committee completes a mid-year review against its agreed annual objectives and, at year end, presents an annual report to the Board on the business conducted.
The Board also reflected on the recommendations following external governance reviews including a clinical and quality governance diagnostic and a review relating to service line governance as well as internal audits concerning Risk Management. The Trust is implementing the recommendations identified.
Individual Board members are appraised annually and mid-year reviews are conducted.
Information Governance
Incidents concerning personal data related incidents are formally reported to the Information Commissioners Office, in accordance with Information Governance requirements. Further information can be found within the Annual Governance Statement, pg [n].
Statement of Accountable Officers Responsibilities
The Statement of Accountable Officers Responsibilities is located on pg [n].
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Declaration of interests and Non-Executive Director Independence The Board of Directors is satisfied that the Non-Executive Directors, who serve on the Board for the period under review, are independent, with each Non-Executive Director self-declaring against a ‘test of independence’. The Board of Directors are also satisfied that there are no relationships of circumstances likely to affect independence and all Board members are required to update their declarations in relation to their interests held in accordance with public interest, openness and transparency.
Name Interest registered Dr Alistair Stokes No interests to declare Chairman Jon Pittam No interests to declare Non-executive director Mick Tutt • Regional director – Committed Network Non-executive director • Specialist Advisor /Bank Inspector – Care Quality Commission • Pelican Consulting - sole trader offering management advice and support to health and social care organisations Jane Sansome • Director of Sansome & Co Ltd Non-executive director • Interim Managing Director of MYFM Limited. Francis Davis • Employed by University of Birmingham and St Mary’s University , Twickenham Non-executive director • Director of; Vivo Care Choices, Holocaust Memorial Day Trust, Near Neighbours, Power 2 Inspire, St Ethelburga’s Centre, Aequus International • Working with Minster of State at Department for Work and Pensions for Disabilities to enhance and develop the disability and enterprise policy. No financial interest or political affiliations. • Trustee Cathedral Innovation Centre Mike Watts • Director: Capability & Performance Improvement Ltd Non-executive director • Project work for various external clients Sue Harriman No interests to declare Chief Executive Officer Andrew Strevens No interests to declare Director of Finance and Performance Dan Meron • All non- NHS activity completed outside of NHS contracted time Chief Medical Officer • No shares, direct financial interest, involvement or investments in any pharmaceutical company. • Pinstriped Sandals Consulting Ltd - Sole director, - private practice offering consultancy, training and research services. • Honorary Deputy Medical Director at the University Hospital Southampton NHS Foundation Trust • Honorary Consultant Psychiatrist - Southern Health NHS Foundation Trust • Secondment to CQC from 7th March 2017 to 6th March 2020- occasional participation in well-led inspection teams
Mandy Rayani No interests to declare Chief Nurse Sarah Austin No interests to declare Chief Operating Officer - Portsmouth &Commercial Director Members that have left in year Julie Pennycook No interests to declare Director of HR and OD David Batters • Full time Chief Financial Officer, Nuclear Decommissioning Authority Non-executive director Alex Whitfield • Director of Wessex Academic Health Science Network (non paid) Chief Operating Officer - Southampton and County Services
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The Board’s committees
The Board has established the following committees:
Statutory committees Designated committees • Audit and Risk Committee • Assurance Committee • Governance and Nominations • Finance Committee Committee • Mental Health Act (MHA) Scrutiny • Remuneration Committee Committee • Charitable Funds Committee
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Composition of Board committees at 31 March 2017
Director Position
&
Board Funds Finance Assurance Charitable Committee Committee Committee Committee Committee Committee Committee Nominations MHA Scrutiny Audit and Risk Remuneration Governance
Alistair Stokes Chairman Chair * Member * Member Chair - - Mick Tutt Non-Executive Director Member * Member Chair Chair Member - Member Jon Pittam Non-Executive Director Member - Member Member Member Member Chair - Jane Sansome Non-Executive Director Member Chair Chair - - - Member -
Francis Davis Non-Executive Member Member Member Member Member - - Chair Started Oct 2016 Director
Mike Watts Non-Executive Member Member Member Member - - Member - Started Oct 2016 Director
Sue Harriman Chief Member Member * Member * Member * - Executive
Andrew Strevens Director of Member Member * * - - * - Finance
Dan Meron Chief Medical Member - - Member Member - - - Officer
Mandy Rayani Chief Nurse Member * - Member Member - * -
Sarah Austin COO Non – Ports and * - Member Member - - - voting Commercial Director Interim – COO Lesley Munro Southampton Member * - Member Member - - Member Started Feb 2017 and County Members that left in year Alex Whitfield COO Member * - Member Member - - Member Left March 2017 Southampton and County Julie Pennycook Director of HR Non – Left Dec 2016 and OD voting ------David Batters Non-Executive Left July 2016 Director Member Member Member - - - Member - *attends on invitation
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Membership of Board committees at 31 March 2017
Director Position
&
Board Funds meetings) meetings) meetings) Finance
Assurance Charitable Committee Committee Committee Committee Committee Committee Committee 1 (6 meetings) (7 (4 meetings) (3 (4 meetings) (4 Nominations MHA Scrutiny (11 meetings) (10 meetings) Audit and Risk Governance Remuneration
Alistair Stokes Chairman 4/6 4/11 6/7 4/10 4/4 3/3 - -
Mick Tutt Non-Executive Director 5/6 6/11 5/7 10/10 4/4 3/3 - 3/4 Jon Pittam Non-Executive 7/11 1/4 Director 6/6 6/7 8/10 3/4 3/3 4/4 ** *** Jane Sansome Non-Executive Director 6/6 9/11 7/7 - - - 4/4 - Francis Davis Non-Executive Started Oct Director 3/3 2/4 0/3 4/5 1/1 - - 1/1 2016 Mike Watts Non-Executive Started Oct Director 3/3 3/4 2/3 3/5 - - 1/1 - 2016 Sue Harriman Chief Executive 6/6 7/11 6/7 7/10 1/4 3/3 2/4 - Andrew Director of Strevens Finance 6/6 11/11 2/7 1/10 - - 3/4 -
Dan Meron Chief Medical Officer 5/6 - - 8/10 2/4 - - - Mandy Rayani Chief Nurse 6/6 3/11 - 7/10 3/4 - 1/4 - Sarah Austin COO Ports and 6/6 6/11 - 8/10 3/4 - - - Commercial Director Lesley Munro Interim – COO Started Feb Southampton 1/1 2/2 - 1/1 0/0 - - 0/0 2017 and County Members that left in year Alex Whitfield COO *Left March Southampton 5/5 7/9 - 8/9 2/4 - - 4/4 2017 and County Julie Pennycook Director of HR *Left Dec 2016 and OD 3/4 ------David Batters Non-Executive *Left July 2016 Director 2/2 2/4 2/2 - - - 1/1 -
**Previous chair of Finance Committee until end Sept 2016 ***Attended to ensure quoracy Grey shaded boxes indicate attendees
1 Remuneration Committee February 2017 was inquorate however ratification was endorsed by virtual meeting.
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Audit and Risk Committee Frequency of meeting: At least quarterly (plus private meeting with External Auditor). During 2016/176 the committee met four times and separately in private. The purpose of the Audit Committee is to provide one of the key means by which the Board of Directors ensures that effective internal control arrangements are in place. The Committee operates in accordance with Terms of Reference set by the Board, which are consistent with the NHS Audit Committee Handbook. All issues and minutes of these meetings are reported to the Board. In order to carry out its duties, Committee meetings are attended by the Chief Executive, the Director of Finance and Performance and representatives from Internal Audit, External Audit and Counter Fraud on invitation. The Committee directs and receives reports from these representatives, and seeks assurances from trust officers. The Committee’s duties can be categorised as follows: • Governance, Risk Management and Internal Control • Internal Audit • External Audit • Other Assurance Functions – including Counter Fraud • Financial Reporting In year the Committee has received progress reports against recommendations identified by Internal and External Auditors, committee specific health sector updates, and received updates on financial governance processes, including single tenders, losses and special payments, whistleblowing, as well as receiving briefings on clinical audit and counter fraud investigations. In addition, the Committee requested deep dives on cyber security and our risk management processes.
[No] significant issues in relation to the financial statements of 2016/17, operations or compliance were raised by the Audit and Risk Committee during the year however a specific request was made by the Committee regarding assurance on the Trusts risk management processes. [statement to be confirmed following Audit Committee meeting 26th May 2017]
Audit and Risk Committee composition and attendance 2016/17 is previously summarised.
Details of other committees of the Board are described in the Annual Governance Statement, page [X].
Internal audit Our Internal Auditors during 2016/17 were Pricewaterhouse Coopers, PwC, and were appointed until 31st March 2018. Internal Audit provides an independent assurance with regards to the trust’s systems of internal control to the Board. The Audit and Risk Committee considers and approves the internal audit plan and receives regular reports on progress against the plan, as well as the Head of Internal Audit Opinion which provides an opinion on the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes. The Committee also receives and considers internal audit reports on specific areas, the opinions of which are summarised in the Annual Governance Statement (page x).
The cost of the internal audit provision for 2016/17 was £55k.
External audit Our External Auditors are Ernst & Young LLP (appointed from August 2012 following the transfer of audit function from the Audit Commission to private organisations). The main responsibility of External Audit is to plan and carry out an audit that meets the requirements of The Code of Audit Practice and the NHS Manual for Accounts. External Audit is required to review and report on: • Our financial statements (our accounts)
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• Whether the trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources
The Audit and Risk Committee reviews the external audit annual audit plan at the start of the financial year and receives regular updates on progress. The Committee also receives an Annual Audit Letter. The cost of the external audit for 2016/17 was £73k.
Ernst & Young (EY) provided VAT compliance services as well as ad-hoc VAT advice in respect of the year end processes for 2015/16. This included reviewing the Trust’s VAT transactions for the financial year 2015/16 ensuring that they meet VAT compliance obligations required by HMRC. The Audit & Risk Committee considered the non-audit services conducted by the auditors and concluded that due to appropriately adopted safeguards there are no potential threats in relation to auditor independence and objectivity.
EY are appointed to 31st March 2018 and during 2017/18 a tender process will be held for external audit provision.
Counter fraud A Local Counter Fraud Specialist (LCFS) is provided by Hampshire and Isle of Wight Fraud and Security Management Service. The role of the LCFS is to assist in creating an anti-fraud, corruption and bribery culture within the Trust; to deter, prevent and detect fraud, to investigate suspicions that arise, to seek to apply appropriate sanctions; and to seek redress in respect of monies obtained through fraud. The Audit and Risk Committee receives regular progress reports from the LCFS during the course of the year and also receives an annual report. Our Counter Fraud provision has received an overall rating of Green (the highest possible rating) from NHS Protect. We have implemented agreed policies and procedures, such as the Fraud, Corruption and Anti- bribery Policy as well as a Freedom to Speak Up (Whistleblowing) Policy and issues of concern are referred to the LCFS for investigation.
Remuneration Full details of remuneration are given in the remuneration report on page [x].
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Members Council
Elections to our inaugural Council of Governors were announced in August 2013, however further to the announcement to step off the Foundation Trust pipeline back in December 2015, the Governors and Board took the opportunity to review their Terms of Reference. Under the revised Terms of Reference the name of the Council was amended to reflect the strengthening engagement with the membership to ‘Members Council’.
The responsibilities of the Members Council and Governors are to: • act as a critical friend and advisor, representing the interests of the organisation, staff, members and wider public • support the Board in the development of the organisation’s strategic plans (including the Annual Plan) seeking assurance and continued transparency on its delivery and implementation • play a role in promoting integrated and partnership working and in assessing its effects • provide third party expertise and advice, on invitation from Officers of the Trust • be an advocate for the Trust providing support and bringing to the attention of the Trust any matters of broad concern (not individual cases) raised by constituent members in relation to standards of care, safety, performance, value for money or any matter contrary to the Trust’s values and in the spirit of the ‘See something, say something’ campaign. • contribute to the development of; and approve the Membership Engagement Strategy • work with the Board to establish a process for handling issues such as; the removal of Council members, dealing with disputes, tenure and other ‘constitutional’ matters
In addition, Governors are invited to participate in the Board level appointments process and observe a number of Board Committees.
The Council comprises 14 publicly elected governors and five staff elected governors representing the constituencies of Portsmouth, Southampton and Hampshire, as well as six appointed governors from partner organisations. However, the Council does have a number of vacancies as highlighted in the following table, which are currently being held.
In early 2017/18 the Council together with Board members will be reconsidering the role of governors in light of the changing external context and Sustainability and Transformation Plans. As part of this review the current vacancies will also be considered.
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Composition of Members Council Constituency Name Staff Southampton Debra O’Brien Sarah Oborne Portsmouth Jenny Ford Vacancy Hampshire Lucy Foord Public Southampton Clive Clifford Jon Clark Vacancy Vacancy Vacancy Portsmouth Narcisse Kamga Michael North Sharon Ward David Stephen Butler Vacancy Hampshire Sharon Collins Harry Hellier Robert Blackman Vacancy Nominated Governors Portsmouth City Council David Williams Southampton City Council Cllr. Warwick Payne Hampshire County Council Cllr. Peter Latham NHS Southampton City CCG Beccy Willis University of Southampton * Prof. Paul Roderick NHS Portsmouth City CCG Vacancy *(rotational seat with University of Portsmouth)
Michael North, Portsmouth Public Governor, is the current Lead Governor serving his third term (term ends 31st March 2017). The Lead Governor acts as the central point of engagement between the Trust and the Council.
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Council attendance 2016/17
Governor 15/04/2016 12/07/2016 12/10/2016 10/03/2017
Christine Cassell Apologies Resigned 1st Feb 2017 Clive Clifford Apologies Hope Jackman Apologies Resigned 26th May 2016 David Lickman Apologies Apologies * Jon Clark Narcisse Kamga Michael North Apologies Graham Cox Resigned 3rd Oct 2016 Sharon Ward Apologies Apologies Apologies Apologies David Stephen Butler Sharon Collins Apologies Apologies Harry Hellier Robert Blackman Debra O’Brien Apologies Apologies Apologies Sarah Oborne Apologies Apologies Jenny Ford Apologies Apologies Apologies Apologies Fran Williams Apologies Apologies Resigned Dec 2016 Lucy Foord Apologies Apologies Apologies Apologies David Williams – Apologies Apologies Apologies Apologies Portsmouth City Council Councillor Dave Shields – Resigned 15th June 2016 Southampton City Council Councillor Peter Latham – Apologies Apologies Apologies Hampshire County Council Professor Paul Roderick, Apologies Apologies Apologies University of Southampton Warwick Payne – Nominated June Apologies Southampton City Council 2016 Beccy Willis – Apologies Apologies Apologies Apologies Southampton City Clinical Commissioning Group *Dave Lickman sadly passed away in December 2016.
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Declarations of interest
Name Interest registered Debra O’Brien • Nil Sarah Oborne • Member of St John Ambulance Jenny Ford • Nil Lucy Foord • Nil Clive Clifford • Nil Jon Clark • Wife works for Faculty of Medicine at the University of Southampton Narcisse Kamga • The Sickle Cell Society • MENCAP Michael North • Chair of a Patients Participation Group – Drayton, Portsmouth • Chair of a Patients Participation Group – Wootton Street Surgery, Cosham Sharon Ward • Nil David Stephen Butler • Portsmouth Royal Dockyard Historical Trust
Sharon Collins • Director – Collins Corporate Solutions Ltd • Director – Shared Ventures Ltd, and facilitator of Solent Region Collaboration Hub – enabling conversations and collaboration opportunities across health, housing and social care across Hampshire, Portsmouth, Southampton and the Isle of Wight • Volunteer on the Committee of Hampshire Hornets Wheelchair Basketball (a fully constituted, not-for-profit accessible basketball club with charitable aims) Harry Hellier • Nil Robert Blackman • Nil David Williams • Board member of Portsmouth CCG • Director of University Technical College Portsmouth (UTC Portsmouth) Cllr Warwick Payne • Labour Party membership Cllr Peter Latham • Member of Conservative Party Professor Paul Roderick • Wife is the Director of Public Health for Hampshire HCC Beccy Willis • Partner works for Southampton City Clinical Commissioning Group and is involved in the Solent contract
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Our membership
Defining the membership constituencies
We have two membership constituencies as follows:
• Public constituency – people aged over 14 based in Southampton, Portsmouth and wider Hampshire and includes patients, service users and carers. We have a total of 7,144 public members. • Staff constituency –all permanent members of staff, as well as bank staff over 12 months and temporary staff on a contract of over 12 months, unless they opt out. We have a total of 3,464 staff members.
The public constituency
The public constituency consists of three distinct constituencies, with no further subdivisions:
• Portsmouth city: 1,846 • Southampton city: 2,057 • Hampshire : 3,241
Staff constituency Consistent with our values, it is assumed that all staff will be members, unless they choose to opt out. Staff members include all those who have worked with us for a period of 12 months or more, on a fixed term contract or as bank staff.
The staff constituency is subdivided into geographical constituencies to ensure a practical working link between members and governors.
The three staff constituencies are: • Staff predominantly based in Portsmouth • Staff predominantly based in Southampton • Staff whose focus is in Hampshire
Membership targets
When we were actively part of the Foundation Trust pipeline, we had an agreed target for membership being 1% of the Portsmouth and Southampton populations and 0.25% of the Hampshire population. However, since the decision was made to step off the FT pipeline back in December 2015 we shifted our focus from recruitment to membership engagement. In 2016/17 we reviewed our strategy for engagement whilst continuing to undertake membership engagement activity with our governors.
Membership engagement We continued to explore opportunities to engage with our members during 2016/17.
During the year we: • Continued with our programme of Health and Mind events with topics focussing on falls awareness, patient experience, diabetes and blood pressure.
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• Held an event for members about the changes in the NHS and how we are working with other organisations to deliver great care.
• Involved members in the creation of our values, both online and via a targeted event.
• Published four, quarterly editions of Shine, our newsletter for both staff and public members. The quarterly publication keeps our members up to date with the latest news from the Trust and the wider NHS.
• Reinstated our monthly Members’ Update – our e-newsletter for those members who have shared their email address with us.
• Invited members to attend our Annual General Meeting 2016.
• Asked members for feedback on a number of topics including: the proposal to move the Kite Unit to the Western Community Hospital and our Access Policy.
• Invited members to attend our Research Conference and take part in research.
• Share information on key topics including our Care Quality Commission inspection and Sustainability and Transformation Plans.
• Shared information about various health campaigns including Sepsis, Cervical Cancer and Smokefree, amongst others. We have recently produced a Membership Engagement Framework for the year ahead building upon the work of our former Membership Strategy. The Framework sets out how we will engage with our current membership to ensure they are informed and involved in a planned and sustainable way. The Framework will be refined following any changes to the role of our governors pending review in early 2017/18.
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Remuneration Report
Remuneration of the Chief Executive and Directors accountable to the Chief Executive is determined by the Remuneration Committee. The terms of reference of this Committee comply with the Secretary of State's "Code of Conduct and Accountability for NHS Boards".
The Remuneration Committee met seven times during 2016/17.
The committee considers the terms and conditions of appointment of all Executive Directors, and the appointment of the Chief Executive and other Executive Directors.
All Non Executive Directors and the Chairman are members of the Committee. Although the Chief Executive, Director of Human Resources, and Director of Finance & Performance attend the meetings by invitation, they are not members of the Committee.
The attendance by members is detailed below:
2
Member 27/06/2016 25/07/2016 14/11/2016 6 20/12/201 20/01/2017 27/03/2017 21/02/2017
Jane Sansome (Chair) David Batters - Resigned 31/07/16 Alistair Stokes X
Jonathan Pittam X
Mick Tutt X X Francis Davis – X X X Appointed 01/10/16 Michael Watts – X Appointed 01/10/16 = Attended meeting X= Apologies received
Although the Remuneration Committee has a general oversight of the Trust's pay policies, it determines the reward package of Senior Managers only. All Senior Managers are Executive Directors. Other staff are covered either by the national NHS Agenda for Change pay terms or the national Medical and Dental pay terms.
In year the Committee;
• re-evaluated a number of the executive team’s remuneration as a consequence of individuals taking on additional responsibilities and as a consequence of an external benchmarking report
2 Although the meeting was non quorate views from members were sought via email exchange prior to the committee meeting.
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• considered and approved proposals concerning Mutually Agreed Resignation Schemes (MARS). Assurance was given to the Committee concerning the governance processes surrounding the MARS. • supported nominations with regards to the Queen’s Birthday Honours • considered remuneration arrangements for individuals in interim executive positions and new appointees • ratified the recommendations made by the Clinical Excellence Awards Panel
Senior Managers Remuneration Policy
Our policy on the remuneration of senior managers for the current and future financial year is based on principles agreed nationally by the Department of Health taking into account market forces and benchmarking. During 2016/17 GatenbySanderson undertook a benchmarking exercise on Executive Director and Non-Executive Director pay, which has been used to review the remuneration of the Chief Executive and Executive Directors.
Senior managers pay includes the following elements as set out by the Department of Health: Basic Pay, Additional Payments in respect of Recruitment and Retention, and Additional Responsibilities. All Recruitment and Retention additions are subject to benchmarking, whilst additional responsibilities additions are awarded in line with the requirements of the Pay Framework for Very Senior Managers in Strategic and Special Health Authorities, Primary Care Trusts and Ambulance Trusts. All elements of the executive directors' remuneration package are subject to performance conditions and achievement of specific targets. There are no Directors currently being paid a performance bonus.
Two Directors’ receive a salary in excess of £142,500. Paying a salary above this threshold has been agreed by our Remuneration Committee and the NHS Improvement Remuneration Committee for one Director. The other Director is paid in accordance with the relevant national Medical and Dental terms as they also perform clinical duties.
Individual annual appraisals assess achievements and performance of Executive Directors. Directors are appraised by the Chief Executive and the outcome fed back to the Remuneration Committee. Individual executive performance appraisals and development plans are well established within the Trust and follow our agreed procedures. This is in line with both Trust and national strategy.
The Chairman undertakes the performance review of the Chief Executive and non-executive directors. Feedback is provided to our Regulator, NHSI, regarding the completion and outcome of annual appraisals concerning the Non-Executive Directors and the Chief Executive.
Our Non-Executive Directors, including the Chairman, are paid the rates set by the Secretary of State and NHS Improvement.
Service Contract Obligations
All senior manager contracts require them to meet the Fit and Proper Persons requirements specified in Section 7 of the Health and Social Care Act 2008. Failure to do so would be considered a breach of their contractual terms.
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Loss of office payments for Senior Managers is determined in accordance with Sections 14-16 and 20 of the NHS Terms and Conditions of Employment. During 2016/17 there was one loss of office payment, details of which are included within the following section.
Duration of Contracts
All Executive Directors are employed without term in accordance with our Recruitment and Selection Policy.
All Executive Directors are required to give six months’ notice in order to terminate their contract. Termination payments are on the grounds of ill health retirement, early retirement, or redundancy are on the same basis as for all other NHS employees as laid down in the National Terms and Conditions of Employment and the NHS Pension scheme procedures.
Within the 2016-17 financial year there were two early Executive Director terminations, one of whom received a non-contractual MARS payment of £42k. The MARS payment is calculated in accordance with Section 20 of the National Terms and Conditions as well as the Trust’s MARs Policy and is shown on the following pages within the Exit Packages and Salaries and Allowances tables. No other termination payments were made to Executive Directors.
The tenure of the Chairperson and Non-Executive Directors are set by the Secretary of State. They are office holders and as such are not employees, so are not entitled to any notice periods or termination payments.
Awards Made to Previous Senior Managers
There have been no awards made to past Senior Managers in the last year and therefore no provisions were necessary.
The Trust’s liability in the event of an early termination will be in accordance with the senior managers’ terms and conditions.
Off payroll engagements
Following the Review of Tax Arrangements of Public Sector Appointees published by the Chief Secretary to the Treasury on 23 May 2012, Trusts must publish information on their highly paid and or senior off-payroll engagements
In accordance with the Manual of Accounts Annual Reporting Guidance 2016-17, all public bodies are required to publish the following information within their 2016-17Annual Report.
Off payroll engagements in place as at 31/03/17, for more than £220 per day that last longer than six months Total number of off pay scale engagements in place as at 31st March 2017 3 Of which, the number that have existed for: less than one year at the time of reporting 3 between one and two years at the time of reporting 0 between two and three years at the time of reporting 0
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between three and four years at the time of reporting 0 four or more years at the time of reporting 0 A review of all off-payroll engagements has been undertaken, and assurance has been sought on all contracts to ensure the individual is paying the right amount of tax. As a result we believe we are fully compliant with the requirements.
All new off-payroll engagements or those that reached six months in duration between 01/04/16 31/03/17, at a rate of £220 or more per day and that last longer than 6 months Number new engagements, or those that reached six months in duration, 3 between 1st April 2016 and 31st March 2017 Number of new engagements which include contractual clauses giving the Trust the right to request assurance in relation to the contractors Income 3 Tax and National Insurance obligations Number for whom assurance has been requested 3 Of which assurance has been received 3 assurance has not been received 0 Engagements terminated as a result of assurance not being received. 0
Notes: In any case where, exceptionally, the Trust has engaged without including a contractual clause allowing the Trust to seek assurance as to their tax obligations – or where assurance has been requested and not received, without a contract termination – the Trust has set out the reasons for this.
When an individual leaves after assistance is requested but before assurance is received it has been included within the “No” for whom assurance has not been received.
Personal details for all engagements where assurance is requested but not received within the deadlines, have been passed to the HMRC tax evasion hotline.
If at the time of reporting the Trust is still awaiting information from the individual, it has been reported as “No” for whom assurance has not been received
Instances where the Trust is awaiting information from the individual at the time of reporting has been reported as not received.
Off payroll engagements of board members, and/or, senior officials with significant financial responsibility, between 01/04/16 and 31/03/17. Number of off-payroll engagements of board members, and or senior 0 officers with significant financial responsibility, during the year Number of individuals on payroll and off-payroll that have been deemed “board members, and/or senior officers with significant financial 14 responsibility during the financial year. This figure includes both payroll and off-payroll engagements Period and details of the exceptional circumstances that led to this appointment and period of appointment: There were no off payroll engagements of board members and or senior managers.
Expenditure on Consultancy
During the 2016/17 financial year £120k was sent on consultancy.
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Expenses
During the 2015/16 financial year, subsistence and travel costs were paid as follows:
Number making a 2015-2016 2016-2017 Number claim £00 £00 Executive Directors 8 8 70-80 80-90 Non Executive Directors 7 3 40-50 30-40 Shadow Governors 24 3 8-9 8-9 Total 39 1 132,133 131-132 The salary, emoluments, allowances, exit packages, and pension entitlements of the Trust's Senior Managers are detailed in the following sections.
Fair Pay Multiples
Reporting bodies are required to disclose the relationship between the remuneration of the highest paid director/Member in their organisation and the median remuneration of the organisation’s workforce.
The banded remuneration of the highest paid director/Member in Solent NHS Trust in the financial year, 2016/17 was £155k-£160k (2015/16, £165k–£170k). This was 5 times (2015/16, x5) the median remuneration of the workforce (£28,101), (2015/16, £27,901).
In the 2016/17 two (2015/16, nil) employees received remuneration in excess of the highest paid director/member. Remuneration ranged from £15k to £180k (2015/16, £15k-£167k)
Total remuneration includes salary, non-consolidated performance related pay, and benefits in kind, but does not include severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions.
When calculating the median figure, individuals employed via a bank contract who did not work in March 2017 have been excluded; as are those with honorary appointments, Non-executive directors who receive allowances only, and individuals who were not directly employed by the Trust.
Exit Packages
Changes have continued to take place within the organisation in the 2016/2017 financial year and whilst we endeavour to do all we can to ensure the continued employment of our staff there have been 42 severance payments totalling £737k made in the year. Eight of these payments relate to compulsory redundancies, and thirty-four have been due to other payments. One payment relates to a senior manager as detailed in the accounts and all payments have been made in accordance with the NHS Pension Scheme procedures and National Terms and Conditions, as a result Treasury Approval has not been required.
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Number of Cost of Number Cost of Total Total compulsory compulsory of other other number cost of Exit Package cost band (including Redundancie redundancie departure departure of exit exit any special payment element) s s s agreed s agreed packages package s Number £'s Number £s Number £s Less than £10,000 1 4957 19 88,901 20 93,858 £10,000 - £25,000 4 63,504 7 123,088 11 186,593 £25,001 - £50,000 3 118,083 6 222,949 9 341,032 £50,001 - £100,000 2 115,908 2 115,906 Total number of exit packages by type 8 186.545 34 550,844 42 737,389
This note provides an analysis of Exit Packages agreed during the year. Redundancy and other departure costs have been paid in accordance with the provisions of the NHS redundancy arrangements. Exit costs in this note are accounted for in full in the year of departure. Other departures have been paid in accordance with the Mutually Agreed Resignation Scheme (MARS). Where the Trust has agreed early retirements, the additional costs are met by the Trust and not by the NHS Pensions Scheme. Ill-health retirement costs are met by the NHS Pensions Scheme and are not included in the table. Ill health retirement costs are met by the NHS Pensions Scheme and are not included in this table.
This disclosure reports the number and value of exit packages agreed in the year. Note: The expense associated with these departures may have been recognised in part or in full in a previous period. The following table reports the number and value of exit packages agreed in the year.
Number of exit Total Value of Other Departures package agreements agreements
Number £000s Mutually agreed resignations (MARS) contractual costs 34 551 Total 34 551
As single exit packages can be made up of several components each of which will be counted separately in this note, the total number above may not necessarily match the total number in table 1 which will be the number of individuals.
*: Any non contractual payments in lieu of notice are disclosed under “non contractual payments requiring HMT approval”
**: includes any non-contractual severance payment made following judicial mediation, and no amount relating to non-contractual payments in lieu of notice.
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No non contractual payments were made to individuals where the payment value was more than 12 months of their annual salary. The Remuneration Report includes disclosure of exit payments payable to individuals named in the Report.
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Salaries and Allowances (subject to audit):
Name and Title 2016 - 2017
(a) (b) (c) (d) (e) (f) Total
Salary and Expense Performance Long term 0ther All pension- (a to f) fees Payments Pay and performance payments related (bands of including (taxable) bonuses pay and (bands of benefits £5,000) R&R (bands (total to (bands of bonuses £5,000) (bands of of £5,000) nearest £100 £5,000) (bands of £2,500) £5,000)
£000 £000 £000 £000 £000 £000 £000
S Harriman – Chief Executive 155-160 0.2-0.3 0 0 0 20-22. 5 175-180
J Pennycook- Director of Human Resources & 75-80 0-0.1 0 0 40-45 10-12.5 125-130 Organisational Development Resigned 31/12/16 A Strevens – Director of 100-105 0.1-0.2 0 0 0 12.5-15 115-120 Finance and Performance D Meron – Chief Medical 135-140 0.2-0.3 0 0 0 17.5-20 155-160 Officer* A Whitfield – Chief Operating Officer Southampton and 100-105 0.1-0.2 0 0 0 12.5-15 115-120 Hampshire Wide Resigned 12/03/17
M Rayani – Chief Nurse 105-110 0.2-0.3 0 0 0 15-17.5 120-125
S Austin – Chief Operating 105-110 0 0 0 0 15-17.5 120-125 Officer Portsmouth
A Stokes – Chairman 15-20 0 0 0 0 0 15-20
D Batters – Non Executive Director 0 0 0 0 0 0 0 Resigned 31/07/16 F Davis – Non Executive Director Commenced – 0-5 0 0 0 0 0 0-5 01/10/16 J Pittam – Non Executive 5-10 0.2-0.3 0 0 0 0 5-10 Director J Sansome – Non Executive 5-10 0-0.1 0 0 0 0 5-10 Director M Tutt – Non Executive 5-10 0.4-0.5 0 0 0 0 5-10 Director M Watts – Non Executive Director 0-5 0 0 0 0 0 0-5 Commenced – 01/10/16
For individuals who joined or left the Trust part way through the year, the full time equivalent salary plus any additional remuneration, excluding severance payments have been used to calculate the rate of payment.
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The expenses shown column (b) are different to those shown in the Expenses section as column (b) relates solely to taxable expenses, compared to all expenses shown in the Expenses Section.
* The Chief Medical officer role is combined with clinical duties. These figures include £45k-50k (expressed in bands of £5,000) relating to clinical duties.
** The Director of Human Resources and Organisation Development received a non contractual payment which is shown in column (e)
Previous year Salary and Allowances
Name and Title 2015 - 2016
(d) (e) (b) (c) (a) Long term Expense Performance Total performance All pension-related payments Pay and (a to e) Salary (bands pay and benefits (bands of (taxable) total bonuses (bands of of £5,000) bonuses £2,500) to nearest (bands of £5,000) (bands of £100 £5,000) £5,000)
£000 £000 £000 £000 £000 £000
S Harriman – Chief Executive 155-160 0.2-0.3 0 0 20-22.5 175-180
J Pennycook- Director of 105-110 Human Resources & 90-95 0-0.1 0 0 12.5-15
Organisational Development A Strevens – Director of 70-75 Finance and Performance 60-65 0-0.1 0 0 7.5-10
Commenced – 24/08/15 D Meron – Chief Medical 0-2.5 Officer 15-20 0-0.1 0 0 15-20
Commenced – 25/01/16 * A Snell – Medical Director 55-60 0.1-0.2 0 0 0 55-60 Retired – 31/08/15 A Whitfield – Chief Operating 105-110 0.1-0.2 0 0 15-17.5 120-125 Officer
M Rayani – Chief Nurse 85-90 0.3-0.4 0 0 12.5-15 105-110
S Austin – Director of Strategy 95-100 0-0.1 0 0 12.5-15 110-115
R Steele – Director of Estates 55-60 0.1-0.2 0 0 7.5-10 65-70 Resigned – 01/11/15
A Stokes – Chairman 15-20 0 0 0 0 15-20
D Batters – Non Executive Director 0 0 0 0 0 0 Commenced 05/10/15 A Cameron – Non Executive Director Commenced – 5-10 0.1-0.2 0 0 0 5-10 01/06/15 Passed away - 22/03/16 B Neaves - Non Executive Director 0-5 0.1-0.2 0 0 0 0-5 Resigned 30/09/15
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J Pittam – Non Executive 5-10 0.2-0.3 0 0 0 5-10 Director B Roynon – Non Executive Director 0-5 0 0 0 0 0-5 Resigned 31/05/15 J Sansome – Non Executive Director Commenced – 5-10 0-0.1 0 0 0 5-10 01/06/15 M Tutt – Non Executive 5-10 0.3-0.4 0 0 0 5-10 Director
Pension Benefits (Subject to Audit ) 2016-17
Real increase Real increase Total accrued Lump sum at Cash Cash Real increase Employers in pension at in pension pension at age 60 related equivalent equivalent in Cash Contribution to age 60 (bands lump sum at age 60 at 31 to accrued Transfer Value Transfer Value Equivalent Stakeholder Name and title of £2,500) aged 60 March 2017 pension at 31 at 31 March at 31 March Transfer Value Pension to (bands of (bands of March 2017 2016 2017 nearest £100 £2,500) £5,000) (bands of £5,000) £000 £000 £000 £000 £000 £000 £000 £000 S Harriman 2.5 - 5.0 (2.5) - 0.0 25 - 30 70 - 75 427 489 61 J Pennycook - Director of Human Resources and Organisational Development 0.0 - 2.5 2.0 - 2.5 15 - 20 45 - 50 269 295 26 A Strevens - Director of Finance and Performance 0.0 - 2.5 0 10 - 15 0 133 151 18 D Meron - Chief Medical Officer 0.0 - 2.5 2.5 - 5.0 30 - 35 95 - 100 568 612 45 A Whitfield - Chief Operating Officer Southampton & Hampshire Wide 0.0 - 2.5 (2.5) - 0.0 15 - 20 35 - 40 216 242 26 M Rayani - Chief Nurse 7.5 - 10.0 22.5 - 25.0 45 - 50 135 - 140 685 852 167 S Austin - Chief Operating Officer Portsmouth 2.5 - 5.0 5.0 - 7.5 50 - 55 95 - 100 690 784 95 As Non-Executive members do not receive pensionable remuneration, there will be no entries in respect of pensions for Non-Executive members.
Cash Equivalent Transfer Values A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member’s accrued benefits and any contingent spouse’s (or other allowable beneficiary’s) pension payable from the scheme. CETVs are calculated in accordance with the Occupational Pension Schemes (transfer Values) Regulations 2008.
Real Increase in CETV
This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end of the period.
[SIGNED]
Sue Harriman
Chief Executive Officer
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Staff Report
Our Staff
Last year, we employed 3,476 clinical and non-clinical staff (including part time and bank staff) which equates to 2,833 whole time equivalents (WTE), all of whom contribute to providing high quality patient care across our local communities. Our staff work hard to improve efficiency, to meet national and local quality targets and to bring innovations in care to our patients.
The majority of our staff are permanently employed clinical staff directly involved in delivering patient care. We also employ a significant number of scientific, technical and administrative staff who also provide vital expertise and support. The following table provides a breakdown of our workforce at the end of the year (March 2017).
Staff Group Permanently Permanently Total employed employed March Female Male 2017 WTE WTE WTE Admin & Estates 511.98 82.96 594.94 3 Directors 3.00 2.00 5.00 Healthcare Assistants and Other Support Staff 545.14 132.37 677.51 Managers and Senior Managers 40.43 25.50 65.93 Medical & Dental 101.94 35.01 136.95 Nursing & Midwives 710.61 69.56 780.17 Scientific, Therapeutic & Technical 510.45 62.37 572.82 TOTAL 2423.55 409.77 2833.32
Our workforce is predominately female (86%) and this is the predominant gender in all of the staff groups, with a split in our staff usage as above. Males are markedly higher in the Manager group (39%).
3 At 31st March 2017 the Executive Team had 2 vacancies.
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The following tables provide detail on staff numbers and expenditure. The staff expenditure is for the full year, the staff numbers represent average figures for the year as opposed to the month 12 (March 2017) position.
Permanent Other Total Employee Benefits - Gross Expenditure Agency £000s £000s £000s Salaries and wages 92,777 4,706 97,483 Social security costs 8,536 8,536 Employer Contributions to NHS BSA - Pensions Division 11,760 11,760 Other pension costs 4 4 Termination benefits 63 63 Total employee benefits 113,140 4,706 117,846
Employee costs capitalised 216 216 Gross Employee Benefits excluding capitalised costs 112,924 4,706 117,630
Permanent Other Total Average Staff Numbers Agency Number Number Number Medical and dental 137 2 139 Administration and estates 593 42 635 Healthcare assistants and other support staff 664 75 739 Nursing, midwifery and health visiting staff 72 42 114 Nursing, midwifery and health visiting learners 790 790 Scientific, therapeutic and technical staff 551 12 563 Other 1 1 TOTAL 2,808 173 2,981
Of the above - staff engaged on capital projects 5 5
Despite on-going challenges with regards to recruitment in certain professional disciplines and particular areas such as community nursing and mental health nurses, the overall level of vacancies are around 3% of the total workforce. The amount spent on bank and agency staff also remains a challenge with increasing demand for bank workers. The amount of spend on bank and agency staff is between 6 - 7% of the total pay bill; this is reflective of demand on our Mental Health and Community services and the national difficulty in recruiting to these posts.
New rules with regard to expenditure on agency staff were implemented this year and the Trust was allocated a ceiling of £3.5 million in relation to expenditure on agency usage. Performance remained within our set financial envelope until December 2016, whereby the increasing challenge of recruiting mental health and community nurses, has unfortunately increased our spend beyond our threshold and our closing spend on agency was £4.7 million.
However, workforce controls have been introduced internally to ensure that the vast majority of temporary staff are sourced through our in house bank, which has provided additional assurance in terms of the quality of temporary staff supply and an overall cost saving of £1 million of agency spend compared to 2015/16 spend.
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The introduction of our Recruitment and Retention strategy provided both a long term and short term view of how we can recruit and retain key staff. This year we have introduced a dedicated recruitment lead to ensure a proactive and rapid response to demand and to manage bulk recruitment drives. Our presence at university recruitment fairs, business talent opportunities and our own open day events has enabled us to maximise our opportunities to recruit.
When advertising nursing vacancies, our primary advertising media is NHS Jobs, where there is a link to other social media platforms such as Facebook with a dedicated nursing recruitment site. In partnership with our Communications Team, we have designed innovative advertising materials, which reflect both our overarching values and a brand specific to Solent.
Equality and Diversity
Every effort is made to ensure that all our staff are treated fairly, inclusively and equitably regardless of their individual characteristics and circumstances. All new employees are given training in relation to our values and the principles of treating others with dignity and respect. Robust arrangements are also in place to deal with any reports of non-compliance and we continue to monitor trends and take action where necessary.
With regards to disabled employees or those who become disabled whilst working for us, we provide support, training and make reasonable adjustments as necessary to ensure our staff can enjoy a fulfilling career with us. We are also registered as a “Mindful Employer” and accredited with the Two Ticks disability symbol. We continue to encourage and support applications for employment from all individuals. For applicants who disclose a disability reasonable adjustments are put in place upon request and all applicants are selected on merit and performance.
Progress continues with the implementation of our Equality and Diversity Strategy including embedding our Equality Impact Group and staff engagement forums. We continually review our effectiveness alongside the diversity agenda ensuring that we are managing employee relations concerns appropriately. Our on-going campaign to ‘Spot It, Stop It Anti bullying’ addresses both patients and services users and internal issues regarding bullying and harassment aligned to our Dignity at Work policy. Our policies are developed with equality and diversity as one of the main considerations.
Partnership Working
We pride ourselves on having developed excellent partnership arrangements with our staff and staff side representatives. This is formally supported within the Joint Consultative Committee (JCC) and the local Doctors and Dentists Negotiating Committee (DDNC) that specifically deals with matters associated to medical staff. We also have a Policy Steering Group to ensure that we continue to develop partnership arrangements when renewing policies that affect the workforce to ensure fairness and equity.
Reducing Sickness Absence
Recognising that our staff are our most valuable resource, the approach that we have taken to reduce sickness absence in the last year goes hand in hand with promoting staff wellbeing.
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In 2016, we saw our sickness absence fluctuate between 3.92% and 5.25% with usual seasonal trends occurring. Overall, the rolling sickness rate rose 0.11% to 4.43%. Stress is the main cause of sickness at 23%; this is down 0.5% on the previous 12 month period.
The following graph shows sickness absence rates for April 2016 to March 2017. Sickness rates have fluctuated throughout the period, with a peak of 5.25% in November 2016. The rolling absence rate however emphasises the rate based on the preceding 12 month rolling average, and we are presently 4.43%, with the trend slightly rising. The average for community and mental health trusts for 12 months to April 2017 was 4.86%.
In response to sickness absence data, various initiatives have been implemented and evaluated to improve staff health and wellbeing. These include the increased provision of self-referral and fast track physiotherapy. Emotional resilience workshops and self-care at work designed and developed to motivate and empower staff to promote self-care approaches that will help them to improve their lifestyle.
Managers are supported by HR and Occupational health and our Employee Assistance Programme (EAP) to manage sickness absence in line with our policy and supporting staff to attend work regularly or sustain a return to work following a period of absence.
Our Health and Wellbeing Steering Group is held bi-monthly and is attended by key stakeholders involved in supporting staff.
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Employee Engagement
There is a clear relationship between employee satisfaction and patient satisfaction and we recognise that the highest quality of care for patients is delivered through a high quality and engaged workforce where staff feel empowered to really make a difference. Within Solent we operate a number of employee engagement and patient care measures throughout the year as demonstrated in figure [n] below, all with the primary purpose of measuring and enhancing employee engagement.
Figure [n]: Annual Engagement Cycle
We have a variety of employee engagement initiatives in place within our Great Place to Work programme shown in the following illustration, figure [n].
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Figure [n]: Great Place to Work Programme
A summary of each element is outlined as follows;
Leading with Heart • Leading with Heart Senior Leadership and Board development programme • Management development programmes and workshops • Back to the Floor – members of the Board spend time working with teams • Director drop ins – Executive Directors join teams informally to listen and learn
At the Heart • Engagement Forums – organised by Occupational Group to explore key workforce issues • Focus Groups – in response to specific concerns raised by employees • At the Heart team sessions – team engagement programme to strengthen the Heart values • Communications Champions – employee communication and engagement network • Power Hours – hour-long webinars to share knowledge and expertise • Social Committee – charity fundraising and social events such as the Summer Party
The Way Forward • Strategy communications - connecting employees with our vision, priorities and progress • Monthly “Ask Sue” forums – staff are invited to contact the CEO in an online Q&A
The Difference • Communication and Engagement programme – using the power of storytelling to involve people and recognise the difference our care makes • Weekly Employee newsletter and regular Manager newsletter
People First • We are working to continually improve our employee experience (see Diagram [n]) from the moment people express an interest in joining Solent throughout their entire career with us.
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Figure [n]: Employee Experience
• In support of employee experience, we have a robust Occupational Health and Wellbeing programme in place that proactively supports the health of our employees through initiatives such as the Global Corporate Challenge (GCC), which is a 100 day step challenge and the Optimising Wellbeing & Lived Experience of Staff (OWLES) group aimed at spreading the word on mental health.
Being Agile
• Continual quality improvement and innovation are supported through Dragon’s Den (where staff can apply for funds to fast track new initiatives) and the Quality Improvement (QI) Programme (development to support teams on their own quality improvement projects). • Involvement and consultation with employees facing or affected by change is integral to the way we lead the organisation. With adherence to our Organisational Change Policy we seek to ensure our consultations are meaningful, fair, transparent and consistent. Our consultations are carried out in partnership with our staff side colleagues and we adhere to our policies throughout. • Consultations completed this year have included changes to Band 5 and 6 notice periods, the merging of our three GP practices and service specific consultations concerning delivery contractual changes.
Staff Survey
The 2016 Annual Staff Survey was carried out by Pickers Institute Europe. 1,784 out of 3,225 eligible employees completed the survey. Our response rate was 55.3% compared to last year’s rate of
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44.4%, which is a 10.9% increase. The national average response rate for combined Mental Health, Learning Disabilities and Community Trusts was 46.5%.
In the 2016 Annual Staff survey, the Trust engagement score was 3.83 which has increased from 3.69 since 2015. The national average score for community trusts was 3.80 as demonstrated below.
Figure [n]. Overall Staff Engagement
Table [n]. Top 5 ranking scores compared with combined Mental Health, Learning Disabilities and Community Trusts in England
Average Key Findings Solent 2016 MH/Comm Trusts Staff confidence and security in reporting unsafe clinical 3.89 3.71 practice Percentage of staff experiencing physical violence from 9% 15% patients, relatives or the public in last 12 months Percentage of staff experiencing harassment, bullying or 22% 28% abuse from patients, relatives or the public in last 12 months Percentage of staff appraised in last 12 months 96% 92%
Fairness and effectiveness of procedures for reporting errors, 3.86 3.77 near misses and incidents
It is positive that people feel well able to report unsafe clinical practice and that procedures for reporting errors are considered to be fair and effective. Taken together, there is a strong indicator that we have an open and transparent climate for matters of patient quality and care. Harassment and bullying from patients, relatives or the public is 6% lower than the national average. Appraisal completion is 4% higher than the national average.
We have a low % of staff experiencing physical violence; however, from Table [n], we can also see that we have a low score on % of staff reporting the last incidence of violence. The same can be said of harassment and bullying. We have appointed Freedom to Speak Up Guardians across our Service Lines and early feedback indicates that this is a good opportunity to engage with employees.
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Table [n]. Bottom 5 ranking scores compared with combined Mental Health, Learning Disabilities and Community Trusts in England
Average Key Findings Solent 2016 MH/Comm Trusts Percentage of staff/ colleagues reporting most recent 74% 88% experience of violence Staff satisfaction with resourcing and support 3.28 3.33
Staff satisfaction with the quality of work and care they are 3.81 3.89 able to deliver Percentage of staff/ colleagues reporting most recent 57% 58% experience of harassment, bullying or abuse Effective team working 3.86 3.87
There is an opportunity to improve staff satisfaction with resourcing and support, which may also be linked to effective team working and staff satisfaction with the quality of work and care they are able to deliver. Our organisational priorities for this year include safe staffing and productivity improvement. Each service line business plan has clear deliverables against these priority areas and will be monitored through the Board Performance Reporting process.
In response to this years’ feedback from the survey, during the coming 12 months our focus will be on the following areas: • Great Place to Work programme - development of leaders, teams and our culture through the HEART values • Health & Wellbeing • Learning and development • Involvement and empowerment • Internal communications
A new approach to action planning has been developed, which involves employees in setting their ‘Top 3’ for the team and the organisation. Progress against our organisational action plan will be monitored quarterly at the People & Organisational Development Group.
Exit Packages
Details of exit packages can be found on page [n]
Off Payroll engagement
Off Payroll engagements can be found on page [n]
Information on policies and procedures with respect to countering fraud and corruption
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One of the basic principles of the NHS is the proper use of public funds. It is, therefore, important that all staff working for us and with us are aware of the risk of fraud, corruption, theft, and other illegal acts involving dishonesty. The ultimate aim of all counter fraud work is to support improved NHS services and ensure that fraud within the NHS is clearly seen as being unacceptable. All fraud, bribery and corruption (collectively referred to as economic crime) in the NHS is unacceptable and we are committed to supporting anti-bribery and corruption initiatives and recognise the importance of having appropriate policies and procedures in place to ensure that all staff are aware of their responsibilities.
We have anti-fraud and anti-bribery policies and we are committed to the elimination of fraud and illegal acts within our Trust; we ensure rigorous investigation, disciplinary and criminal sanctions as appropriate. We also ensure that there are various routes through which staff can raise any concerns or suspicions.
External Consultancy
At times it is necessary for us to make use of the skills of external consultants and at these times, we ensure that the arrangements comply with our standing financial instructions and offer good value for money. External consultancy is used within the Trust when we require objective advice and assistance relating to strategy, structure, management of our organisation, for example. This year we have sought advice and assistance from external consultants relating to Organisation Development and property related issues. The cost associated with consultancy can be found within the Remuneration Report.
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Occupational Health & Wellbeing Service
Our Occupational Health & Wellbeing team assists staff and managers to create a safe and healthy work environment where the health and wellbeing of employees is highly valued and encourages and supports staff to maintain and adopt healthy lifestyles.
Our team offers a comprehensive Occupational Health and Wellbeing service and was SEQOHS accredited (Safe, Effective, Quality Occupational Health Service) in 2014. We have successfully maintained our accreditation as part of the annual review process in 2016.
We continue to focus on our staff health and wellbeing and with the additional support of CQUIN (Commissioning for Quality and Innovation) funds in 2016, we have seen significant improvements towards achieving our Staff Health & Wellbeing Strategy objectives. We have developed a number of new health and wellbeing schemes and been able to further develop existing ones to support our staff, some of which are summarised as follows;
• Our OWLES group was launched in April 2016. OWLES stands for ‘Optimising the Wellbeing and Lived Experience of Staff’. The group is attended by people that are passionate about making a positive difference for their colleagues in the working environment, tackling stigma and raising awareness in support of staff mental wellbeing. • A staff health and wellbeing calendar was produced and launched in January 2017. The calendar contains top tips and resources which aim to provide inspiration and health and wellbeing information as well as links to further resources. Its focus is on promoting a self-help approach. • A programme of support was initiated to support staff musculoskeletal health. We recognise that our staff have busy and often physically demanding jobs which require extra care to avoid injury. The introduction of mobile working devices has also required staff to think and work differently. The programme is tailored to provide advice and support for those working in different working environments, from hospital, to clinics and patients’ homes. We have also increased our physiotherapy capacity to support preventative programmes and a quick response when problems do arise. • Our `think healthy, choose wisely’ food campaign was launched in November at the Western Community Hospital. This included the introduction of Rude Food vending machines that offer healthier options and our restaurant now provides daily healthier choices. This is part of an on- going programme to encourage healthy food and lifestyle choices, which we will be rolling out further during 2017/18. • In May 2016 we set 63 staff teams off on a virtual journey to improve their health and wellbeing and work productivity. Virgin Pulse (formally GCC) supported us on this 100 day journey which focused on physical activity, healthy eating, mental wellbeing and sleep. Participants had great success as well as a lot of fun which was a great morale booster. Together we achieved the following: o A total of 425,785,481 steps o We walked, cycled or swam 272,503 miles – the equivalent of walking around the world 6.8 times o We burned 16,478,667 calories, adding up to 34,494 hamburgers o The total reported weight loss was 250kg o 61% of us exceeded 10,000 steps per day vs 12% Pre-GCC
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o 74% of staff are now getting the recommend 7 hours of sleep, 74% are feeling less stressed and 67% are concentrating better or feeling more productive
Our efforts will continue into 2017/18, taking even more steps to support staff health & wellbeing and deliver our Strategy.
Health and Safety
We are committed to the health, safety and welfare of our colleagues, and third parties that work within our operational footprint and have remained compliant with Health and Safety legislation in year. We have not been inspected or investigated by external authorities such as the Health and Safety Executive, Fire Authority or Environmental Officer as a result of any specific incidents or concerns.
The Chief Nurse is the executive lead for the Health and Safety agenda and chairs the Health and Safety Group, which meets quarterly.
NHS Constitution
The NHS Constitution was established in 2009 and revised in summer 2015. The constitution sets out the principles and values of the NHS. It also sets out the rights to which patients, service users, the public and staff are entitled, a range of pledges to achieve and the responsibilities which patients, service users, the public and staff owe to one another to ensure that the NHS operates fairly and effectively. We operate in accordance with the principles and pledges as set out in the NHS Constitution and undertake an annual review of our compliance, which is reported to our In-public Board meeting.
Enhanced quality governance reporting
CQC Comprehensive Inspection
In June 2016 we received a comprehensive Care Quality Commission (CQC) inspection, the overall outcome rating from which was ‘Requires Improvement’. Whilst many of the services provided received separate ratings, the majority of which were rated as ‘good’ there were also three inadequate ratings and one outstanding rating. These ratings have been published and are clearly displayed within service areas.
The preparation for the CQC inspection enabled us to test our quality governance arrangements, seeking fresh assurance that the arrangements in place to govern quality and safety of services were fit for purpose, responsive and effective. This enabled us to prioritise governance activities and together with the outcome of the inspection itself, we have taken additional steps to strengthen our quality governance arrangements. The quality assurance scrutiny and reporting arrangements have been further developed with greater alignment to the CQC inspection standards so that at team, service and corporate level, compliance with the CQC five domains; safe, caring, responsive, effective and well-led, can be clearly articulated and evidenced.
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Our Corporate Performance Management Office (CPMO) is supporting the quality team to monitor performance against the action plans developed in response to the CQC inspection findings, enabling escalation to executives and the Assurance Committee and through to Board as necessary.
Quality governance reporting
The Quality Improvement and Risk Group, established last year, has been reviewed, together with the Terms of Reference for the Assurance Committee, with the aim of providing a greater emphasis on shared learning and outcomes from actions taken to improve quality. Risks identified through the Quality Improvement and Risk Group are escalated through to the Assurance Committee and then onto Board, as appropriate. The quality dashboards developed last year to support monitoring of key quality and safety indicators at service and corporate level have been embedded and are considered at service level performance meetings. The Quality Improvement and Risk Group also considers themes and risks identified through the review of the quality dashboards and the Trust Risk Register.
The Quality Account provides more detail of the governance arrangements in place and reflects the achievements against the quality priorities set for 2016/2017. The Quality Account also sets out the annual quality priorities identified for 2017/2018 which are intended to support the delivery of the Quality Goals outlined in the our Quality Improvement Strategic Framework.
The Quality Account can be found on page [n].
Quality Improvement
2016/2017 has seen a high level of activity focused on improving patient/service user experience and outcomes. Implementation of the Friends and Family Test (FFT) has continued to be supported across all of our service lines and a new approach using e-mail has also been piloted in one of our service areas with initial success. The overall feedback received through FFT and other local feedback mechanisms has been positive. In addition, feedback received through the formal complaints process has been used to inform further improvement initiatives such as a review of our Customer Care Training programme.
Other developments as a result of feedback include improvements in patient information and changes to appointment arrangements. Recognition of carers has been a key piece of work undertaken within the Trust, including the publication of the Trust Carer’s pledge, so that carers are signposted to assessment and supported when necessary - this work will continue throughout the coming year. 2017/2018 will also see a further focus on co-production: a genuine involvement of patients and carers in designing, developing and evaluation services building on the work started by services as part of our Quality Improvement Programme.
A number of our teams and individual staff members have once again received recognition for their work in supporting patient care and progress has also continued to be made against clinical audit, research and development plans at service and corporate levels; the details of which are outlined in the Quality Account.
It is particularly pleasing to note that we have continued to be an exemplar organisation in the level and quality of research and development activity being undertaken with contribution recognised through national publications.
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NHS Foundation Trust Code of Governance
Although as an NHS Trust, the NHS Foundation Trust Code of Governance does not directly apply, the principles are seen as good governance practice. Solent NHS Trust has, therefore, applied the principles of the NHS Foundation Trust Code of Governance on a comply or explain basis, where applicable. The NHS Foundation Trust Code of Governance, most recently revised in July 2014, is based on the principles of the UK Corporate Governance Code issued in 2012.
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Statement of Chief Executive’s responsibilities as the Accountable Officer of Solent NHS Trust
The Secretary of State has designated the Chief Executive as Accountable Officer of Solent NHS Trust. The relevant responsibilities of the Accountable Officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in Managing Public Money published by the HM Treasury.
Under the NHS Act 2006, the Secretary of State has directed Solent NHS Trust to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of Solent NHS Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year.
In preparing the accounts, the Accountable Officer is required to comply with the requirements of the Department of Health Group Accounting Manual and in particular to: • observe the Accounts Direction issued by the Secretary of State including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; • make judgements and estimates on a reasonable basis; • state whether applicable accounting standards as set out in the Department of Health Group Accounting Manual have been followed, and disclose and explain any material departures in the financial statements; • ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance; and • prepare the financial statements on a going concern basis.
The Accountable Officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the Trust and to enable them to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accountable Officer is also responsible for safeguarding the assets of the Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities.
The directors consider the annual report and accounts, taken as a whole, is fair, balanced and understandable and provides the information necessary for patients, regulators and stakeholders to assess the trust’s performance, business model and strategy.
Disclosure of information to auditors The directors and I confirm that, so far as we are aware, there is no relevant audit information of which the trust’s external auditors are unaware. We also confirm that we have taken all steps that we ought to have taken as directors in order to make ourselves aware of any relevant audit information and to establish that the auditors are aware of that information.
To the best of my knowledge and belief, I have properly discharged the responsibilities set out in the Accountable Officer Memorandum .
[signed] Sue Harriman Chief Executive Officer
Date: xxxxx
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Annual Governance Statement
Scope of responsibility As Accountable Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the Trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the Trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the Accountable Officer Memorandum.
The purpose of the system of internal control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of Solent NHS Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in Solent NHS Trust for the year ended 31 March 2017 and up to the date of approval of the annual report and accounts.
The governance framework of the organisation The role of the Board and its duties are explained on page [n] of the Annual Report. The individuals who serve on the Board and changes to appointments can be found on pg [n] of the Annual Report.
Figure 1 illustrates the Committees of the Board. Figure 1
A summary of the role of the Audit & Risk Committee is found on page [n] of the Annual Report and internal audit opinions for the audits carried out in year are as follows:
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Audit title Opinion Risk Management Medium risk Key Financial Systems Low risk - General Ledger Low risk – invoicing and accounts receivable Low risk – Payroll, HR & Expenses Low risk – Purchasing and accounts payable Nursing staff arrangements and workforce capacity Medium risk Information Governance Toolkit 2016/17 Low risk IT Risk Assessment No risk rating given
Governance and Nominations Committee Frequency of meeting: At least twice a year and as required. During 2016-17 the Committee met three times. The Committee’s main purpose is to lead in the identification and recommendation of candidates to Executive vacancies to the Trust Board. The Committee also considers and keeps under review governance arrangements for the Trust including, Fit and Proper Person processes, Committee Structure and Committee Terms of Reference and to make proposals to Trust Board as appropriate.
The Committee is responsible for assessing the size, structure and skill requirements of the Board, and for considering any changes necessary or new appointments. If a need is identified, the Committee will consider if external recruitment consultants are required to assist in the process and instruct the selected agency, shortlist and interview candidates. If the vacancy is for a Non-Executive Director the recruitment process is handled by NHS Improvement. The Chairman, Non-Executive Directors and the Chief Executive (except in the case of the appointment of a new Chief Executive) are responsible for deciding the appointment of Executive Directors. The Chairman and the Non- Executive Directors are responsible for the appointment and removal of the Chief Executive. All new appointees received an appropriate induction.
Remuneration Committee Frequency of meeting: At least annually and as required. During 2016-17 the Committee met seven times. The Remuneration Committee is comprised of the Non-Executive Directors (and others by invitation). The Committee reports to Confidential Board meetings regarding recommendations and the basis for its decisions. The Committee makes decisions on behalf of the Board about appropriate remuneration (including consideration of performance related pay and to ratify decisions of the Clinical Excellence Awards Panel), allowances and terms of service for the Chief Executive and other Executive Directors.
Charitable Funds Committee Frequency of meeting: Quarterly (or as required). During 2016-17 the Committee met four times. The Corporate Trustee (Solent NHS Trust), through its Board, has delegated day to day management of the charity (Solent NHS Charity) to the Committee. The Committee ensures that funds are spent in accordance with the original intention of the donor (where specified), oversees and reviews the strategic and operational management of the Charitable Trust Fund as well as ensuring legislative requirements in accordance with the Charity Commission are met. The Committee is also responsible for developing and managing policies and procedures in relation to the management of Charitable Funds, monitoring the investment portfolio and the development of the fundraising strategy.
Assurance Committee Frequency of meeting: Ten times a year. During 2016-17 the Committee met ten times.
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Following the successful development of the Quality Improvement & Risk Group, the Assurance Committee amended its terms of reference in year. The Committee is responsible for providing the Trust Board with assurance on all aspects of quality of care. This includes quality governance systems, ensuring regulatory standards of quality and safety are met and that risk across the organisation is mitigated. In particular the Committee provides assurance to the Board regarding: • Regulatory compliance (including Safeguarding) and the provision of services in accordance with statute, best practice and guidance • High standards of healthcare governance and high quality service provision. • Risk – ensuring that risks are identified, prioritised and appropriately managed. • a culture of continuous improvement across the Trust exists and learning is shared and embedded The Committee also seeks assurance that the development of all clinical governance activities within the service lines improve the quality of care throughout the Trust. A programme of annual assurance reporting and deep dives are scheduled annually.
Finance Committee Frequency of meeting: At least six times a year. During 2016-17 the Committee met eleven times. The Finance Committee is responsible for ensuring appropriate financial frameworks are in place to drive the financial strategy, and provide assurance to the Board on financial matters as directed. The Committee focuses on the following areas; strategic financial planning, business planning processes, annual budget setting and monitoring, treasury management and financial control, business management as well as conducting in depth reviews of aspects of financial performance as directed by the Board. The Finance Committee has been integral to the Board in providing scrutiny and oversight concerning the delivery of the financial plan.
Mental Health Act Scrutiny Committee (MHAS Committee) Frequency of meeting: Quarterly. During 2016-17 the Committee met four times. The central purpose of the Committee is to oversee the implementation of the Mental Health Act (MHA) 1983 functions within the Trust principally within Adult and Older Persons Mental Health, and Learning Disabilities services. The Committee has primary responsibility for seeing that the requirements of the Act are followed. In particular, to seek assurance that service users are detained only as the Mental Health Act 1983 allows, that their treatment and care accord fully with its provisions, and that they are fully informed of, and are supported in exercising, their statutory rights. In addition, on an annual basis the Trusts external legal advisors provide update training in relation to the Mental Health Act. In year the Committee expanded its remit to seeking assurance concerning appropriate application for Deprivation of Liberties Safeguards (DoLS) as well as seeking assurance regarding adequacy of training and development opportunities provided for front-line practitioners and of the monitoring of competence regarding the application of the MHA and DoLS.
Attendance records at the Board and its committees are included within the Annual Report pg [n].
Highlights of Board Committee Reports The Board has an agreed annual cycle of business and receives monthly exception reports via the relevant Chair in relation to recent meetings of its Committees. The Board, as a standing item at each meeting, also considers whether additional assurance is sought from its Committees on any items of concern. The Chief Executive Report to Board includes commentary on significant changes recorded in the Board Assurance Framework and Corporate Risk Register. Progress on corporate and strategic objectives is reported quarterly within the performance report. In addition, a number of internal audits were completed, as described on page [n] and annually each Board Committee presents an annual report to the Board detailing a summary of business transacted and
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achievements against the agreed Committee objectives. The Committee annual reports will be available via the Trust website.
Performance Evaluation of Board Details can be found within the Annual Report of the processes undertaken in year in relation to Board Effectiveness, pg [n].
Capacity to handle risk Risk management and quality governance accountability and leadership As Chief Executive, I am ultimately accountable for governance and risks relating to the operational delivery of all clinical and non-clinical services provided by the Trust including its subcontracts. The Board sets the Trust’s risk appetite and is briefed through the monthly CEO report on all significant risks. Key roles in relation to risk management and quality governance include; • Chief Nurse - nominated Executive Lead Director for risk management, quality governance and health and safety compliance • The Head of Patient Safety working with the Clinical Risk Manager is responsible for ensuring the development and oversight of implementation of the Trust Risk Management Framework, risk procedures and administration of the Corporate Risk Register • Clinical Directors - accountable for risk and clinical governance within their respective service lines, supported by the Operational Directors and Clinical Governance Leads. • Service Line Clinical Governance Groups, chaired by the Clinical Director - responsible for the oversight of quality and risks, triangulating performance information to monitor and address service quality. The groups provide exception reporting to the Quality Improvement and Risk Group which is chaired by the Chief Nurse and these are then scrutinised at the Assurance Committee. A rolling programme of service line deep dive reports are also scheduled. The service line structure provides high levels of autonomy increasing the effectiveness and accountability of the clinical services. • Care Group Meetings , chaired by Chief Operating Officers, general performance of quality and other operational issues • Operational Directors and Heads of Service – responsible for managing operational risks originating within their service areas. • Trust Management Team - oversees operational responses to risks contained in the Corporate Risk Register. The roles of the Assurance Committee and Audit and Risk Committee are described previously. • Executive oversight ensuring emergency planning and disaster recovery plans are established and regularly tested. • Performance reviews are held with care groups and corporate teams to seek assurance regarding the management of operational risk • Each service line has a documented local Annual Governance Statement which outlines the internal control and risk management processes under the leadership of each Clinical Director. The Service Line Annual Governance Statements are presented annually to the Assurance Committee and underpin assurance to the overarching Annual Governance Statement with regard to the internal control and clinical governance processes within our clinical services.
The Trust has established processes to formally assess all Cost Improvement Plans (CIPs) and other transformation schemes through a Quality Impact Assessment (QIA) process. Within the QIA process, foreseeable or potential risks which could impact on quality are considered and key leading indicators are identified to help highlight the realisation of any actual risks. A gateway approach to the agreement of CIPs and QIAs has been embedded with sign-off by the applicable service line Clinical and Operational Directors in consultation with services prior to review by the Chief Medical
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Officer and Chief Nurse. The Service Line Clinical Governance Groups are responsible for the management and monitoring of the leading indicators identified within signed off QIAs and for ensuring that in collaboration with the Chief Medical Officer and Chief Nurse, risks associated with QIAs are escalated to the Assurance Committee.
Risk management training An introduction to risk management, Serious Incidents (SI) and Duty of Candour is provided at every Corporate Induction. A two day training package for SI Investigators is now provided in collaboration with neighbouring organisations. This training provides in depth training on root cause analysis, identification of hazards and the SI process.
Formal training is also provided for staff through the Risk Management and Learning and Development Teams to ensure staff are equipped to manage risk appropriately. Training includes; the legal framework, risk management principles, escalation processes, accountabilities, risk assessment, hazard identification, root cause analysis, investigator training, risk management and the principles of being open/duty of candour.
Risk assurance The Board Assurance Framework (BAF) provides me with evidence that the effectiveness of controls that manage the risks to the organisation achieving its principal objectives have been identified and where gaps exist, that appropriate mitigating actions are in place to reduce the risk to a tolerable level. The Audit and Risk Committee tests the effectiveness of this system annually.
The risk and control framework I am assured that risk management processes are becoming increasingly embedded within the Trust and incident reporting is openly and actively encouraged to ensure a culture of continuous improvement and learning. I am also assured that there are appropriate deterrents in place concerning fraud and corruption. The organisation understands that successful risk management requires participation, commitment and collaboration from all staff.
The Risk Management Framework (including strategy, policy and processes) provides an overarching framework for the management of internal and external risk and describes the accountability arrangements, processes and the Trust’s risk tolerance. The Trust’s approach to risk management encompasses the breadth of the organisation by considering financial, organisational, reputational and project risks, both clinical and non-clinical. This is achieved through: • an appropriate framework; delegating authority, seeking competent advice and assurance • a clear risk appetite, risk culture, philosophy and resources for risk management • the integration of risk management into all strategic and operational activities • the identification and analysis, active management, monitoring and reporting of risk across the Trust • the appropriate and timely escalation of risks • an environment of continuous learning from risks, complaints and incidents in a fair blame/non-punitive culture underpinned by open communication • consistent compliance with relevant standards, targets and best practice • business continuity plans and recovery plans that are established and regularly tested; and • Fraud deterrence including the proactive work conducted by the Local Counter Fraud Service, policies on Fraud, Corruption and Anti-bribery , debt recovery and the threat of prosecution. Fraud deterrence is integral to the management of risk across the organisation especially as there could be clinical or health and safety implications which could then impact upon the organisation. Staff are encouraged to report any potential fraud using the online incident reporting process appropriately including anonymous reporting if necessary.
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We are not aware of any specific areas within the organisation that are at risk of fraud, however we cannot be complacent. Notifications from the Counter Fraud team improve our knowledge and awareness of the risk of fraud. The wider public via their elected governors, can raise concerns or issues concerning risk via the various meetings the governors attend and observe and via the established communication channels.
Equality impact assessments are carried out to assess the impact of the Trust’s decisions and design of services as part of the Trust’s legal duty under the Equality Act 2010. The Trust also considers how using the assessments, Trust policies, procedures and service planning supports us to take into account the diverse needs of those intended to benefit from them. Following the completion of the equality impact assessment any issues identified would be appropriately reported through the risk management process.
Risk assessment process The organisation has structured risk assessment and management processes in place. This also includes having trained, service-based risk assessors in place to undertake assessment to support local management. Service Managers are responsible for managing action planning against identified risks and for escalating those risks with additional resource implications via service risk registers. The Risk Management Team receives and centrally records risk assessments to identify commonalities for organisational risk treatment and escalation. Risk registers operate at service line level for all identified risks. Risks assessed as scoring 12 or above are escalated to the corporate risk register, in accordance with the risk appetite, agreed by Board. Figure 2 illustrates the risk reporting structure. The management of Risk Registers at service and corporate levels is currently under review and any revisions will be reflected in an update to the Trust Risk Management Policy.
Figure 2
Risk identification and measurement Risk identification establishes the organisation’s exposure to risk and uncertainty. The processes used by the Trust include, but is not limited to; risk assessments, adverse event reports including trends and data analysis, Serious Incidents requiring investigation (SI), claims and complaints data, business decision making and project planning, strategy and policy development analysis, external/internal audit findings /recommendations and whistle blowing in accordance with the Trusts Freedom to Speak Up policy.
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As the organisation has implemented online web incident and risk reporting, this has provided the ability for real time reporting and escalation and aligns existing systems used for incident, complaints and claims reporting. In turn this has enabled the Risk Team (and service managers) to provide swift response and support to services. The use of the online system supports the triangulation of data from incidents, claims and complaints for further analysis and assurance.
The Trust uses the National Patient Safety Agency likelihood and severity matrix to assign a risk score and we recognise that in all cases it is vital to set the risk into context for evaluation. Risks which fall outside of the remit of routine clinical assessment or are potentially significant for the organisation are approached and managed in line with the Risk Management Framework. The Trust is aware and encourages a proactive safety culture, good communication and teamwork, all of which are inherent in the improvement of risk and the implementation of good clinical risk assessments. To ensure clinical risk assessments are appropriate they are always reviewed as part of all serious or high risk investigations so that lessons can be learnt and assessments improved if necessary. The positive risk management culture and risk management processes have enabled the Trust to proactively identify, assess, treat and monitor significant risks in year.
The organisations strategic risks (scoring 12 or over), at the end of the current financial year and as detailed within the Board Assurance Framework relate to: • Future organisational function – clarification on structure, leadership and multi-agency accountability will be required as the organisation responds to the Sustainability & Transformation Plan and associated work streams as well as the rapidly changing external environment. • Information Management and Technology - as described within the operational risk context. • Workforce Capacity – as described within the operational context. In addition, work is progressing to further understand the workforce baseline as well as plans to progress and develop staff, aligned to our Recruitment and Retention strategy. • Quality Governance and quality improvement – the Trust continues to implement action plans to address issues raised as a consequence of the comprehensive CQC inspection and further embed the Solent Quality Improvement Programme. • Business as Usual - in periods of such complex change, it is essential that the Trust is sighted on maintaining safe and effective services. There is a risk that the Trust fails to evidence valid activity and performance due to deficiencies in data quality. To mitigate this a data assurance programme continues to be implemented.
There is clear alignment between the Board Assurance Framework and operational risks.
The highest operational risks in year concern:
• Staffing – we have continued to experience staffing pressures across a number of our service lines, and in particular within our Mental Health services and Community Nursing teams risking impact on patient experience and safety. Whilst teams remain under significant pressure due to vacancies (including nationally recognised shortages in some staffing groups) and sickness, the services continue to address the staffing challenge with comprehensive action plans including recruitment, retention, staff engagement and service redesign. The risk to patient safety is managed daily; however at times we have had to exceed the NHS Improvement Agency ceiling4 to ensure quality and safety are maintained.
4 NHS Improvement implemented a set of rules to support Trusts to reduce their agency expenditure. Further information is available at:
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• Information Management and Technology – whilst we have seen significant improvement in the stability of our network and have successfully migrated our staff onto new devices, we acknowledge that IT still causes frustrations for some of our colleagues. The majority of disruption experienced in the last 12 months has been caused by network stability issues which have impacted the ability of clinicians to readily access and update information – mitigations have been implemented when these incidents occurred. Work to migrate to the fully managed Solent network is now largely complete with any remaining dependencies on other partners being identified and documented to optimise response times. Improving data quality has also been a focus for the Trust to ensure management information is complete and valid, to assist with reporting against contractual performance. The Data Assurance Programme will continue to be implemented during 2017/18.
• Our electronic Patient Systems - part of our 2015/16 plan when migrating from BT RiO (our previous patient system) to TPP SystmOne (our new patient system) was to ensure existing information reporting was ready for the new financial year of 16/17 onwards. A statutory reporting service commenced as planned, but local information reporting requirements were not delivered. It took us much longer than anticipated to understand the nature of the SystmOne data and this therefore impacted on our ability to provide data returns to commissioners; there were delays in providing contractual activity and performance information. Commissioners were notified in advance and clauses in contracts were put in place to manage this during this financial year. This did not impact the use of SystmOne from a user’s perspective, but has delayed our plans to present management information to clinical services.
• Service specific risks concerning access, for example within our dental general anaesthetic lists, podiatric surgery and speech and language therapy. However, we have seen improvements in year concerning our Paediatric therapy and continence waits. Further details of operational issues of significance can be found on pg [n].
We will continue to monitor and mitigate all significant risks associated with Cost Improvement Plans identified via the Quality Impact Assessment process.
Serious Incidents Requiring Investigation and incidents involving Information Governance (IG) matters A total of 216 Serious incidents requiring Investigation (SI) were raised 133 of which related to incidents concerning pressure ulcer management/care. Other SIs concerned unexpected deaths (41), suboptimal care (2), patient accident (2), Slips/Trips and Falls (6), as well as delayed diagnosis, treatment delays, concerning communication, safeguarding adults, Venous thromboembolism (VTE).
We also investigated and responded to eleven Information Governance SIs, all of which are categorised as:
• Contractor Breach • Personally Identifiable Data sent to wrong person / address • Security of information – change in processes required
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/510391/agency_rules__23_ March_2016.pdf
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Our commissioners provide scrutiny to our SI process and confirm closure on investigations once appropriate assurance has been sought.
Our Caldicott Guardian and Senior Information Risk Officer are consulted with whenever there is an Information Governance Serious Incident.
Information Governance Toolkit and data security In March 2017 the Trust achieved Level 2 or above standard in relation to the forty-five requirements outlined in the national Information Governance Toolkit, which requires a considerable number of requirements and arrangements which must be achieved. This includes ensuring that at least 95% of staff have completed Information Governance Training annually, which is nationally recognised as an extremely challenging standard. Data Security is a significant part of the IG Toolkit in terms of providing assurance and compliance at a Level 2. All Information Governance SIRI’s, which includes personal data incidents, are also reported and monitored using the IG Toolkit, which automatically reports these incidents to the Information Commissioner’s Office, for investigation. The IG Toolkit and all risks/incidents are closely monitored by the Trust’s Senior Information Risk Owner (SIRO) and the Trust’s Caldicott Guardian5.
Care Quality Commission (CQC) Compliance The Trust has reported full compliance with the registration requirements of the Care Quality Commission through the year and routinely receives visits and inspections from the CQC. There are no outstanding issues recorded against the Trust. The Trust is fully compliant with the registration requirements of the Care Quality Commission.
The CQC undertook a comprehensive inspection of the Trust in June 2016, the outcome of which was a ‘Requires Improvement’ rating. Whilst a number of core services were rated as ‘Good’ and the Learning Disability service was rated as ‘Outstanding’ an action plan is being implemented to address the key ‘must do’ and ‘should do’ areas identified for improvement. A number of actions identified by the CQC require the Trust to work collaboratively with commissioners and other organisations, these are: • Work with NHS England to agree a formal escalation policy for patients who require mental health forensic services • Work with the local authority takes place to improve access to social work support • Work with the external provider of wheelchairs to provide a more responsive and timely service and that this service is appropriately monitored to reduce risk to patients.
Monitoring the implementation of the actions taken within service lines is via the individual service line governance groups, Quality Improvement & Risk Group through to the Assurance Committee. This is supplemented by Board oversight through activities such as Board to Floor visits, Quality Review Visits, review of performance management information and Friends and Family Test feedback.
Quality Governance Arrangements The Trust has a range of arrangements in place which provide monitoring and assurance on matters relating to quality, safety and regulatory matters. Each Service Line has an identified lead for Clinical Governance who is responsible for supporting the Service Line Clinical Director in the delivery of the quality, safety and governance agenda. The Clinical Governance leads also liaise with the Trust Quality Risk and Professional Standards team to support cross organisational work streams and
5 The SIRO was Alex Whitfield until March 2017, after which Mandy Rayani, Chief Nurse, became the interim SIRO. The Trust’s Caldicott Guardian is Dr. Dan Meron, Chief Medical Officer.
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learning arising from incidents. Each Service Line has a governance structure in place which reports through to a newly established Quality Improvement & Risk Group and the Assurance Committee. Specific Trust wide arrangements are in place which support robust quality governance and assurance include: • A Quality Impact Assessment process- for all CIP schemes and service changes/reconfiguration • SI (Serious Incident requiring investigation) process including Root Cause Analysis (RCA) investigation and SIRI panel arrangement • Mortality Review process for unexpected deaths • CQRM (Contract, Quality & Risk Management Meeting) monthly meetings with commissioners • An audit programme (Trust wide and Service level covering standards and topic specific issues) • Board to Floor visits ( includes Executives, Non-Executives and Governors) to engage with frontline staff and patients • Service review visits by Commissioners • Announced and unannounced visits to clinical areas/teams by the Quality Risk & Professional Standards team • Patient and service user feedback (Friends and Family Test and other local mechanisms) • Patient-Led Assessments of the Care Environments • Patient and carer stories to Board • Monthly reporting and publication of safe staffing status (with sign off by Matrons and oversight by the Quality Risk and Professional Standards Team) • Monitoring of quality indicators through the Service Line performance sub-committee meetings • Monthly review of the Corporate Risk Register • Care Group level performance review meetings. In addition the Board is apprised of any key quality and safety matters at the beginning of each Board meeting.
The Patient Experience Strategy was approved following consultation with a wide range of service users and partner agencies. The Trust Patient Experience forum continues to meet quarterly and oversees the delivery and implementation of the strategy.
A Quality Account is produced annually which outlines the progress made and action taken to improve and maintain quality and safety within and across Trust services. The Annual Quality Account is developed in consultation with key stakeholders and serves as an additional validation mechanism for determining the quality of services. More information on the Quality Account is provided on page[n] (of the Annual Report)
NHS pension scheme As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employers contributions and payments into the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations.
Equality, Diversity and Human Rights Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with.
Environmental responsibilities We undertook a review of the impacts of climate change for delivering our services back in 2015/16 and in response to the Sustainable Development Unit guidance implemented a Sustainability and Carbon Management Strategy. The strategy incorporates a Sustainable Development Management
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Action Plan and a Carbon Reduction Action Plan, which are reviewed at least annually to ensure they remain relevant and reflect the changing estate.
We are now currently developing a Sustainable Development Management Plan that will fully align with the NHS Standard Contract, specifically Service Contract item SC18 – Sustainable Development. This plan recognises the challenge in meeting our carbon reduction targets and sets out the measures to be taken and establishes our commitment in meeting carbon reduction obligations. A number of initiatives are already in place delivering improvements with new measures in progress as part of our management plan and regular monitoring against our baseline is in place to record the achieved reductions against target. This also accords with the emergency preparedness and civil contingency requirements ensuring that this organisation’s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with.
Review of economy, efficiency and effectiveness of the use of resources The following key processes are in place to ensure that resources are used economically, efficiently and effectively: • Scheme of Delegation and Reservation of Powers, Standing Orders and Standing Financial Instructions approved by the Board and were refreshed in 2016/17. These key governance documents include explicit arrangements for: o Setting and monitoring financial budgets; o Delegation of authority; o Performance management; and o Achieving value for money in procurement. • A financial plan approved and monitored by the Board. • The Trust operates a hierarchy of control, commencing at the Board and cascading downwards to Budget managers in relation to budgetary control, balance sheet reconciliations, and periodic review of Service Level income with commissioners. In addition, the Finance Committee provides scrutiny and oversight which has been supplemented this year by independent commissioned reviews. • Robust competitive processes used for procuring non-staff expenditure items. Above £5,000 procurement involves competitive tendering. The Trust has agreed procedures to override internal controls in relation to competitive tendering in exceptional circumstances and with prior approval obtained. • Cost Improvement Plans (CIPs), which are assessed for their impact on quality with local clinical ownership and accountability • Strict controls on vacancy management and recruitment • Devolved financial management with the continuation of service line reporting and service line management • The Trust participated in the National Benchmarking Network’s Children’s & Adolescent Mental Health Services (CAMHS), Corporate Services, Learning Disabilities, Intermediate Care (NAIC), Mental Health, and Pathology projects during 2016/17. In addition to this, we have been a stakeholder in the development of the NHS Improvement Community Indicator Benchmarking Programme and the aspirant community foundation trust network.
The Trust Board gains assurance from the Finance Committee in respect of ensuring appropriate financial frameworks are in place to drive the financial strategy and provide assurance to the Board on financial matters as directed, including to review the impact of CIPs on forward financial planning. The Audit and Risk Committee also receives reports regarding Losses and Compensations, SFI breaches, financial adjustments and single tender waivers. The Board gains assurance from the Assurance Committee regarding the quality of services and compliance with regulatory control. The Audit & Risk Committee test the effectiveness of these systems.
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Performance reporting During 2016/17, the performance governance structure was refreshed to optimise escalations of significant performance to the senior leadership team and Trust Board. This required a two tiered meeting structure where the Chief Operating Officers meet with their service line senior managers on a monthly basis and review performance against quality, workforce, finance, business plans, operations, data quality and any other issues pertinent at that time. The exceptions from that meeting form the agenda at a later monthly meeting chaired by the Director of Finance and Performance where these are discussed in-depth and necessary mitigations implemented, and assurance sought where appropriate.
We also have established a Corporate Performance Subcommittee which convenes on a monthly basis. At this meeting Executives review and scrutinise the performance under their respective areas of responsibility. A summary of all operational and corporate exceptions are then submitted through to the monthly Trust Management Team Meeting ensuring oversight. In addition to standard performance monitoring, other significant areas of risk can be requested for review at the performance meetings, for example, progress against the CQC Action Plan, agency spend and contract performance notice remedial action plans. Similarly, the Chief Operating Officers and Director of Finance and Performance have discretion to include agenda items, where appropriate, to ensure all necessary and required items for performance assurance are considered. Star Chambers are also held periodically to provide additional scrutiny and support to managers where escalation is required.
We have implemented an internal waiting list tool across our services allowing us to have visibility of our elective waiting times; however it is acknowledged that there are issues associated with data quality as stated within the section detailing our operational risks.
Link to External Auditors opinion
Annual Quality Report The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended) to prepare Quality Accounts for each financial year. NHS Improvement has issued guidance to Trust Boards on the form and content of annual Quality Reports which incorporate the above legal requirements in the NHS Foundation Trust Annual Reporting Manual.
Solent NHS Trust has produced its annual Quality Account in compliance with these requirements, and in doing so has consulted with our membership and key stakeholders.
The Account includes a summary of the arrangements in place to assure the Board that the reporting of quality presents a balanced view and that appropriate controls are in place to ensure the accuracy of data.
The Trust has in place a number of systems and processes to ensure that we are focusing upon the right quality indicators and that quality reports are integral to the overall performance monitoring of the Trust. This is led by executive leadership to ensure that quality and other performance information is triangulated and presented in a balanced view.
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Quality indicators are based upon a range of sources, including regulatory, national, best practice and locally agreed improvement targets. Many indicators are established internally in collaboration with clinical services to help achieve the highest possible standards of quality and care.
All quality metrics have systems to appropriately capture the information, analyse and onward reporting to the applicable stakeholders, including internally (the Board, Care Group Performance Subcommittees) or externally (for example the Trust Development Authority and local commissioners). A copy of the Quality Account is available on page [n] of the Annual Report.
The Quality Improvement Strategy is currently being reviewed to reflect the refreshed value statements being developed within the Trust and the work planned for 2016/17 in supporting an enhanced focus on quality improvement linked to embedding cultural change.
Significant issues during 2016/17 As part of its role in ensuring effective direction of the Trust, the Board continuously seeks assurances on the detection and management of significant issues. As Accountable Officer, I ensure that Board members are apprised of real or potential significant issues on a no-surprises basis, both within formal Board meetings and as required between meetings. Electronic briefings are circulated to Non-Executive Directors to inform them of any emerging issues in between Board meetings. The Board Assurance Framework is updated to reflect significant issues and the mitigation thereof. In year the following significant issues occurred: • As previously identified in relation to our operational risks a number of our services experienced staffing pressures due to sickness, vacancies and difficulties recruiting due to national staff shortages, such as paediatric occupational therapists and community and mental health nurses, which has resulted in the over reliance on agency staff. As a consequence we continue to actively recruit to our in-house bank service although this is proving more problematic in Portsmouth, we are progressing with ways to recruit and retain our staff and where necessary liaise, with commissioners to review service specifications. • Problems in recruitment and retention in community nursing Portsmouth have been mainly resolved with vacancies now running at single figures and the workforce gradually returning to a more stable position. • Staffing issues have been exacerbated in acute mental health wards by an increase in acuity, and delays in transferring to secure beds. These matters are under active discussion with local and national commissioners. • Following our CQC comprehensive inspection we actively implemented action plans to address priority areas including medicines management practices in some of our services and ensuring consistent risk assessment approaches are applied within our Community Mental Health Services for Children and Young People. We have also reviewed with our Commissioner colleagues the future provision of our Substance Misuse Service in Southampton – we remain in discussion with regards to the best approach • The IT infrastructure has been identified as a high risk to us for some time, to mitigate this, we have been working with CGI, our IT partner, to implement a managed IT service to include network, telephone, server and upgrading the hardware and devices our staff use. Our legacy infrastructure is vulnerable to failure due to its age and complexity. Over the last 12 months there have been a number of server and network failures which have resulted in the loss of access to various systems and telephones. We are not aware of any patient harm occurrences as a result of these incidents. The first phase of the transition, which was to replace the application servers and IT hardware/devices was completed in 2016 and the network migration was fully completed February 2017; this has increased our resilience and stability. The final phase of the infrastructure refresh is to replace the telephony system, this work is underway at the moment.
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• We continued to constructively support system working, and have developed in partnership both the frailty interface and discharge to assess services. At this early stage of implementation, pressure continues to reduce the backlog of medically fit patients and at the same time prioritise admission avoidance. The system is not yet in balance resulting in acute pressures in some community services. • In addition, our Delayed Transfers of Care (DTOCs) were higher than forecasted in Quarter 4 2016/17 predominantly due to delays in social care support and domiciliary care across both Southampton and Portsmouth. • Serious Incident reporting arrangements have been reviewed during the last year in line with emerging guidance and national report. Whilst the Trust identified a backlog and issues concerning the timeliness of serious incident investigation closures, the standard of investigation has consistently improved. The number of serious incident investigation reports that breach the closure deadline has significantly reduced. • In response to concerns with the provider of section 136 services, the contract was terminated and a new provider selected following a rigorous quality assurance process. The short term contract with the new provider will be followed by a substantive contract during 2017/18. • The implementation of our new Clinical Record System compromised the validity of our management data, and subsequently a programme of Data Assurance has been implemented. • Budget reductions by our Local Authority partners planned for implementation during 2017/18, which will undoubtedly affect our service users and our services provided • Operational performance was also impacted in year as summarised as follows: o Dental General Anaesthetic List – due to a reduction in theatre lists at University Hospital Southampton NHS Foundation Trust, we have had to reduce the number of theatre lists we run and consequently children that cannot be treated in Southampton are being referred to our clinic in Portsmouth. The theatre list reductions are also impacting adult waiting times. o Podiatric Surgery – Due to limited available theatre space, the service stopped accepting new referrals. All patients remaining on the waiting list were then prioritised for treatment, with patients under the block contract arrangement with Portsmouth City CCG treated by April 2017 and any patients under the chose and book element from other CCGs will be treated during Q1/Q2 2016-17. All patients were offered alternatives arrangements or providers to reduce waiting times. o Children’s Therapy Waits ‐ Our service across Hampshire continues to work on reducing the number of children waiting over 18 weeks for appointments and the numbers waiting, and length of waits have improved overall in recent months. o Changes over the last few years to school nursing budgets have undermined this service and in Portsmouth this has impacted on delivery. Recruitment planned will assist the position to an extent from March 2017, but the service remains vulnerable until a complete redesign is in place. o Our Adults Speech and Language Therapies service in West Hampshire had insufficient capacity to manage high levels of referrals and waiting times increased. Following extensive discussions with commissioners we gave notice on the service and handed over provision in November 2016.
We will participate in the development of associated governance frameworks to ensure appropriate risk management and internal control arrangements are established relating to the Hampshire and Isle of Wight Sustainability and Transformation Plan.
Review of effectiveness As Accountable Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of
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the internal auditors, clinical audit and the executive managers and clinical leads within the Trust who have responsibility for the development and maintenance of the internal control framework.
I have drawn on the content of the Quality Account and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Board, the Audit & Risk Committee, Assurance Committee and a plan to address weaknesses and ensure continuous improvement of the system is in place.
The following key processes have been applied in maintaining and reviewing the effectiveness of the system of internal control: • a review of Committee governance by the Governance and Nominations Committee. The Board consider recommendations made by the Committee and is ultimately responsible for approving and monitoring systems to ensure proper governance and the management of risk • reviews of key governance documentation such as Standing Orders, SFIs, Scheme of Delegation and the Board Assurance Framework • the oversight by the Audit & Risk Committee of the effectiveness of the Trust’s systems for internal control, including the Board Assurance Framework (BAF). In discharging their duties the Committee takes independent advice from the Trust’s internal auditors (PwC) and external auditors (Ernst & Young). The BAF is also reviewed and challenged by the Board and updates are presented monthly via the Chief Executive’s report to the Board • the internal audit plan, which has been adapted in year to address areas of potential weakness in order that the Trust can benefit from insight and the implementation of best practice recommendations • the findings of relevant internal audits, including an assessment of significant assurance with minor improvement opportunities concerning the effectiveness of our governance processes in a recent audit. • the scrutiny given to the Clinical Audit programme by the Audit and Risk Committee • the periodic review of the Well Led Framework and associated action plan • the scrutiny given by the Mental Health Act Scrutiny Committee in relation to the implementation of the Mental Health Act and • the review of serious untoward incidents and learning by SIRI Panel and Service Line Clinical Governance Groups.
The Head of Internal Audit Opinion (HOIA) concluded an opinion of ‘general satisfaction with some improvements required’ and that governance, risk management and controls in relation to business critical areas is generally satisfactory. It was noted however that there are some areas of weakness and as such the Trust is actively addressing these; particularly concerning those raised within the Risk Management audit report.
I therefore believe that the necessary arrangements are in place for the discharge of statutory functions, that the Trust is legally compliant and there are no irregularities.
Conclusion In conclusion, I believe Solent NHS Trust has a generally sound system of internal controls that supports the achievement of its objectives.
Sue Harriman Chief Executive Officer Date
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Section 3: The Auditors Report
Independent Auditors report to the Directors of Solent NHS Trust
[to be inserted once received by the Board – separate document]
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Section 4: The Accounts
Foreword and Statement on Financial Performance
We have ended 2016-17 by achieving three of our four financial statutory duties:
• External Financing Limit (EFL) which is an overall cash management control. The Trust was set an EFL of £7.8m cash outflow for 2016-17, actual EFL was £2.4m cash outflow and therefore the Trust achieved the EFL target with a positive variance of £5.4m.
• Capital Cost absorption rate is based on actual (rather than forecast) average net relevant assets and therefore the actual capital cost absorption rate is automatically 3.5%.
• Capital Resource Limit (CRL) which represents investments in fixed assets throughout the year. The Trusts fixed asset investment for 2016-17 was £4.1m a £0.8m underspend against the target of £4.9m.
The Trust did not achieve its breakeven duty, a measure of financial stability, with an adjusted retained deficit of £2.1m reported in 2016-17.
The 2016-17 financial statements have been prepared in accordance with the Department of Health Group Manual for Accounts 2016-17. The accounting policies contained in that manual follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to the NHS. Where the Manual for Accounts permits choice of accounting policy, the accounting policy which is judged to be the most appropriate to the particular circumstances of the Trust for the purpose of giving a true and fair view has been selected.
[insert signature]
Sue Harriman
Chief Executive
[insert date]
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Financial Review & Statutory Duties in relation to the Accounts
Directors’ responsibility statement in relation to the accounts
The Directors are required under the National Health Service Act 2006 to prepare financial statements for each financial year. The Secretary of State, with the approval of the Treasury, directs that these financial statements give a true and fair view of the state of affairs of the NHS Trust and of the income and expenditure of the NHS Trust for that period. In preparing those financial statements, the Directors are required to apply on a consistent basis accounting policies laid down by the Secretary of State with the approval of the Treasury; make judgements and estimates which are reasonable and prudent; and state whether applicable International Financial Reporting Standards have been followed, as detailed in the Statement of Accountable Officers Responsibilities on page [x], subject to any material departures disclosed and explained in the financial statements.
We have complied with HM Treasury’s guidance on cost allocation and setting charges for information as required
The Directors confirm to the best of their knowledge and belief that they have complied with the above requirements in preparing the financial statements.
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Financial Review & Statutory Duties in relation to the Accounts
Break-even position (a measure of financial stability)
The Trust has a statutory duty to achieve break-even in the year. The Trust has not achieved this as it reported an adjusted deficit of £2.1m in 2016-17. Our regulators were aware of this position and continue to support us in our delivery of key community and mental health local services.
Capital Costs Absorption Rate (a measure of Statement of Financial Position Management)
The Trust is required to absorb the cost of capital at a rate of 3.5% of actual average relevant net assets. The average net relevant assets exclude balances held in the Government Banking Service bank accounts. The dividend payable on public dividend capital is based on actual (rather than forecast) average relevant net assets and therefore the actual cost absorption rate is automatically 3.5%.
External Financing Limit (an overall cash management control)
The Trust was set an External Finance Limit of £7.8m cash outflow for 2016-17 which it is permitted to undershoot. Actual external financing requirements for 2016-17 were £2.4m cash outflow and therefore the Trust achieved the target with a positive variance of £5.4m.
Capital Resource Limit (Investment in fixed assets during the year)
The Capital Resource Limit is the amount that the Trust can invest in fixed assets during the year; a target with the Trust is not permitted to overspend. The Trust was set a capital resource limit of £4.9m for 2016-17. Its actual fixed asset investment was £4.1m, an £0.8m underspend against target.
Want to find out more?
Included on these pages are the 'summary accounts' of the Trust and an overall picture of our fiscal performance.
A copy of our full accounts are available in Appendix [X]
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Financial Statements
Statement of Comprehensive Income for year ended 31 March 2017
2016-17 2015-16 £000 £000 Employee benefits (117,630) (118,911) Other costs (64,454) (71,662) Revenue from patient care activities 162,140 161,968 Other Operating revenue 18,535 16,886 Operating surplus/(deficit) (1,409) (11,719)
Investment revenue 23 21 Other gains and (losses) (11) (94) Finance costs (159) (133) Surplus/(deficit) for the financial year (1,556) (11,925) Public dividend capital dividends payable (2,314) (3,239) Retained surplus/(deficit) for the year (3,870) (15,164)
Impairments and reversals taken to the revaluation reserve (4,032) (17,207) Net gain/(loss) on revaluation of property, plant & equipment 0 419 Total comprehensive income for the year (7,902) (31,952)
Financial performance for the year Retained surplus/(deficit) for the year (3,870) (15,164) Impairments (excluding IFRIC 12 impairments) 1,740 10,165 Adjustments in respect of donated asset respect elimination 46 (63) Adjusted retained surplus/(deficit) (2,084) (5,062)
Statement of Financial Position as at 31 March 2017
31 March 2017 31 March 2016 £000 £000 Non-current assets 82,958 88,721 Current assets 19,909 17,038 Current liabilities (24,213) (18,019) NET CURRENT ASSETS / (LIABILITIES) (4,304) (981)
TOTAL ASSETS LESS CURRENT LIABILITIES 78,654 87,740 Non-current liabilities (4,126) (5,310) TOTAL ASSETS EMPLOYED 74,528 82,430
FINANCED BY TAXPAYERS' EQUITY 74,528 82,430
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Statement of Changes in Taxpayers' Equity for year ended 31 March 2017
Public Dividend Retained Revaluation Total capital earnings reserve reserves £000 £000 £000 £000 Balance at 1 April 2016 6,435 63,438 12,557 82,430 Changes in taxpayers' equity for 2016-17 Retained surplus/(deficit) for the year (3,870) (3,870) Impairments and reversals (4,032) (4,032) Transfers between reserves 248 (248) 0 Net recognised revenue/(expense) for the year 0 (3,622) (4,280) (7,902)
Balance at 31 March 2017 6,435 59,816 8,277 74,528
Balance at 1 April 2015 6,435 77,690 30,257 114,382 Changes in taxpayers' equity for 2015-16 Retained surplus/(deficit) for the year (15,164) (15,164) Net gain / (loss) on revaluation of property, plant, equipment 419 419 Impairments and reversals (17,207) (17,207) Transfers between reserves 912 (912) 0 Net recognised revenue/(expense) for the year 0 (14,252) (17,700) (31,952)
Balance at 31 March 2016 6,435 63,438 12,557 82,430
Statement of cash flows for the year ended 31 March 2017
2016-17 2015-16 £000 £000 Net cash inflow/(outflow) from operating activities 4,308 10,500 Net cash inflow/(outflow) from investing activities (4,002) (6,523) NET CASH INFLOW/(OUTFLOW) BEFORE FINANCING 306 3,977 Net cash inflow/(outflow) from financing activities 410 813 INCREASE / (DECREASE) IN CASH 716 4,790
Cash at the beginning of the period 5,575 785 Cash at year end 6,291 5,575
Better Payment Practice Code : Measure of Compliance 31 March 2017
2016-17 2015-16 Number £000 Number £000 Total non-NHS trade invoices paid in the year 28,529 56,003 26,399 51,159 Total non-NHS trade invoices paid within target 26,648 48,637 24,109 46,770 % non-NHS trade invoices paid within target 93% 87% 91% 91% Total NHS trade invoices paid in the year 1,912 22,404 1,395 18,376 Total NHS trade invoices paid within target 1,589 19,915 1,196 14,778 Percentage of NHS trade invoices paid within target 83% 89% 86% 80%
The Better Payment Practice Code requires the Trust to aim to pay all undisputed invoices by the due date, or within 30 days of receipt of goods or a valid invoice, whichever is later.
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Challenges ahead
The challenges we face as we head in to the new financial year are continuing to improve our financial strength, service quality and performance within a financial envelope subject to year on year cost reductions.
We ended 2016-17 reporting an adjusted deficit of £2.1m with Board recognition that there are more challenging years ahead. We delivered cost savings of £10.9m in the year and we acknowledge that it will be necessary for some service areas to transform and redesign the way services are provided, without compromising quality in order to achieve future cost saving targets.
The key challenges we face in 2017-18 are as follows: • Delivery of the deficit target of £1.5m • Delivery of the efficiency savings programme • Delivery of key programmes including estates rationalisation • Working within the Sustainability and Transformation Programme, Local Delivery Systems and Accountable Care System
The internal control processes for managing risks are outlined in the Annual Governance Statement found on page [n].
Going concern The 2016/17 deficit is an agreed and expected deficit and the financial statements will be prepared on a going concern basis, as management have no significant reasons to believe otherwise. This is supported by the recent contract negations with NHS and Local Authority organisations to provide continuing services throughout 2017/18 within an agreed Control Total.
In conclusion, having considered the challenges we face, particularly with reference to our operating plan for the next twelve months, and having reviewed with our external auditors, the Board has a reasonable expectation that the Trust has access to adequate resources to continue in operational existence in the foreseeable future. For this reason the Trust continues to adopt the going concern basis in preparing the annual accounts. However, as the Trust has not achieved a cumulative breakeven position over the last three years, it is acknowledged that our Auditors have referred a matter to the Secretary of State in accordance with Section 30 of the Local Audit and Accountability Act 2014.
The financial statements included within Section 4 were approved by the Trust Board and signed on its behalf by
[insert signature] Sue Harriman Chief Executive [insert date]
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Section 5: Quality report incorporating the Quality Account 2015/16
[to be inserted once approved by the Board – separate document]
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Appendix 1 – Full Accounts
[to be included post audit completion]
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Item 17
X In Public Board Meeting Confidential Board Meeting
Title of Paper Quarterly ICT Trust Report Simon Sturgeon Dan Meron Author(s) Executive Sponsor
Date of Paper 15 May 2017 Committees presented Trust Board Link to CQC Key Lines Safe Effective Caring Responsive Well Led of Enquiry (KLoE) X X X Action requested of To receive For decision the Board X
Transition from legacy to new world.
During 2016 Solent, with their ICT supplier (CGi), successfully completed the transition of all Solent users and devices onto the new Solent network and server infrastructure. The new network, (SOLNHS), is one shared network that can reliably be accessed from any Trust location and via a new remote connectivity solution (VPN) from non Solent sites. This process involved moving over 4000 users from multiple legacy domains (networks) in different locations to the new SOLNHS domain, which is controlled and maintained by CGi from their datacentre. As part of this process all locally hosted applications were also relocated to the data centre, this included services such as; e-mail, the risk management system and the Dental applications. File storage for individual users was also migrated at this time but shared folders were left to be included as part of the Sharepoint project which is covered later in this document.
To facilitate this transition every machine was rebuilt incorporating the build which allows users to access SOLNHS. Every laptop is 3/4G enabled to support mobile working. This function means that clinical teams working in the community can access and update patient records in real time, leading to more effective and timely patient care. The project also delivered a standard suite of fully supported applications, ensuring proper version control and complete support from the ICT supplier. In support of the above circa 4000 end user devices were deployed to Solent staff in less than 9 months.
A number of lessons were learnt from this work. First was that the project was based on services, and not geographical location. This caused some issues during roll out as most services are spread over a wide geographic area. Future projects take the geographical spread into consideration alongside service set up to ensure the optimal roll out plan is identified to facilitate pace and minimise any negative impacts. This project also gave the ICT team a wider appreciation of the restraints in relation to user availability and technical knowledge. As a result we have planned more support, training and communication for future projects.
Enhance Projects
Telephony/ Unified Communications
Following transition of the legacy IT infrastructure the next priority for the trust is to implement a replacement for the ageing telephony infrastructure which had been inherited, like the IT infrastructure from multiple legacy organisations. The old solution is expensive and complicated to support due to its age and make up (several disparate systems that have been merged together as organisational boundaries changes to form Solent NHS).
The Solent ICT team worked with Bittern Health Centre to pilot the migration to the new Skype and Mitel telephony solutions (Unified Comms). This technology is intended to replace the multiple legacy telephony solutions with a streamlined Mitel switchboard solution where fixed phones are required (reception desks, consulting rooms etc.). The Skype element will provide telephony to other team members via their laptop or PC and will be fully integrated with the existing Skype functionality so will support instant messaging, video conferencing etc. Skype offers huge benefits to the Trust as it enables meetings to take place virtually, cutting out the need to travel and allowing more time to focus on patient care.
Everyone in the Trust has now been allocated with their own Skype telephone number; this is attached to their PC, enabling calls to be handled wherever they login. Enrolling everyone at the start of the project ensures that all the teams have access to a telephone, regardless of which site they are working from.
All the telephones at Bitterne Health Centre have now been transitioned into the new world, with non-geographic 0300 numbers being allocated to 6 patient facing services. The Trust has also ensured that non-Solent users within the building have access to telephony, staying with the traditional style of telephone in some of the clinics.
As a result of this project all telephone numbers will be changing across the Trust, to ensure the patient impact is as minimal as possible 0300 numbers have been handed out to over 100 different patient facing teams. These 0300 numbers work in both the old and new world, allowing more time for the patients to digest and act on the changes. Once a phone line is ceased a message will be left stating the new number for the patient to dial.
The lessons learnt from the pilot site are now being used to support the plan for the roll out of this functionality to the rest of the organisation over the next 3 months. The Unified Comms team is working with Services to define their public facing telephone numbers and the call handling needs ahead of their transition. This will enable all staff to access their phone calls via their PC, enabling a more mobile workforce with the ability to share calls much more easily.
SharePoint
The SharePoint project, which will ultimately provide a replacement for the Trust’s internal facing intranet site and file management solution, has formally been initiated. The new SharePoint will extend collaboration across services and provide a structured electronic storage facility to govern our organisation.
The Project team has engaged with each of the services and key stakeholders attended a SharePoint online WebEx on 30th March which provided a demonstration of a demo SharePoint site for staff to see how it could look and work. Following the WebEx, the same key stakeholders from each service attended an on-site workshop on 3rd and 4th May to feed in specific requirements into the build. Cloud2 have now started configuring the site which will be launched from July 2017. Over the next 3 months, the focus will be on training Site Owners to manage the site long-term and also staff on how to save documents in the next system. Housekeeping activities on shared drives including archiving and removing duplicates continues to be a priority for this project. This work is essential to ensure the migration to the new solution is as efficient as possible.
Transition into BAU / Service Improvement
Over the last quarter, the stabilisation of the network has seen a natural reduction in the number of tickets being raised and the volume has dropped 16%. There is an additional plan to reduce the amount of tickets further, with the rollout of SRM/Self Help, user password reset/unlock
SRM/Self Help is providing staff with direct access into the Helpdesk ticket logging system, meaning that staff can log their tickets directly on the system and look up their own updates. The rollout to the first 50 pilot users is already complete and 120 additional users have since been added with another 500 hundred planned from May onwards. This is initially aimed at “super users” but will ultimately be available to all staff. Initial feedback from the pilot users is encouraging.
The number one reason for calling the helpdesk is to reset forgotten passwords (this accounts for up to 50% of all calls with approx. 3000 calls per month). User Password Reset/Unlock will provide staff with the ability to reset their own logon passwords without the need of call the Helpdesk. The pilot testing will be in place by the end of May with a planned roll out by the end of the summer.
The vast majority of the migration from the legacy network infrastructure was completed by the end of March. Following this work, there has been a marked improvement in network stability. Three sites are still awaiting the final stages of their migration to the new network environment; these are due for completion in May.
Increasing Helpdesk First Time Fix Rate: This is the rate in which the Helpdesk are resolving tickets with the member of staff at the first point of contact. Over the last quarter has increased from 42% to 54%. This improvement is encouraging and has been the result of increased skill sharing between the desktop support and help desk teams as well as improvements in their ability to remotely access end user devices to resolve issues remotely.
Due to the risk associated with the legacy file store and the timescales of the Sharepoint project, it has been agreed that all legacy share drives will be migrated into the CGi data centre temporarily. The migration of the main drives was completed in early May and the remaining drives are scheduled for completion shortly. This alongside the go live of the new Sharepoint intranet site will remove the final piece of the legacy infrastructure and the associated risks.
Recommendation
The Board are asked to receive the update. Item 18.1
Board Report – In Public Meeting Title of Paper Information Governance Annual Report inc. Caldicott Guardian Annual Activity/Assurance Reports Author(s) Sadie Bell, Head of Executive Sponsor Mandy Rayani, Chief Nurse Information Governance Dr Daniel Meron, Chief Medical Officer Improving outcomes Working in partnership Ensuring sustainability Link to strategic X X Objective(s) Date of Paper 12TH May 2017 Committees N/A presented Action requested To receive For decision X of the Board Information Governance Annual Report has also been presented at the May 2017 References Assurance Committee
Information Governance Annual Report: The purpose of this paper is to provide the Board with assurance that the Trust submitted a compliant IG Toolkit Submission for 2016/17 and identify current compliance with legal Requirements outlined in the Freedom of Information Act 2000 and data Protection Act 1998 (Subject Access Requests). The other purpose of this report is to identify the Trusts current level of IG incidents and the impact of this, within the Trust.
The report outlines a number of recommendations, under each section of the report
Caldicott Guardian Annual Report: Activity and plan to be noted and assurance provided that standards re being meet.
Board Recommendation The Board is asked to review all reports and consider assurance the recommendations made, to assess if it feels that these are adequate enough to improve compliance.
In addition to this though there are three key considers for the Board, within the Information Governance Annual Report.
Subject Access Requests; consider the three options available with regards to the governance and processing of requests and the administrative burden this would have on clinical service lines. Identify a supported option
IG Toolkit; As Solent NHS Trust is now an established organisation it should be aiming to achieve Level 3 in the majority of, if not all, requirements of the IG Toolkit. This will ensure that the Trust is compliant with Caldicott 2 and prepared for the higher standards of compliance which come with the General Data Protection Regulations (2018). The Trust needs to make a decision if this is something they feel should be undertaken in 2017/18. A resource review will need to be undertaken to see what Solent NHS Trust can achieve with current IG resources and where not possible to achieve with current resources what is needed to achieve this. This will directly link with the General Data Protection Regulations (GDPR) IG Resource review
GDPR; The Data Protection Officer will need to undertake an IG Resource Review, to assess if adequate resources are available to successfully implement the Regulations and other requirements outlined in this report (IG Toolkit & Subject Access Requests). This report will be presented to Board at a later date.
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Summary information and key points for the IG Annual Report
Please note Pg 3 – 10 of this report is content and pg 11 – 19 is the supporting data
IG Toolkit • Solent NHS Trust declared at the end of the financial year that it was at least level 2 compliant with all requirements • The Trust’s compliance with regards to the 12 requirements linked to the Caldicott 2 Report, identify that the Trust is working towards the implantation of the Caldicott 2 Report, as the Trust has only reached the minimum requirement of Level 2 compliance.
IG Incidents • In 2016/17, 310 IG Incidents were reported; of which 41 were HRIs and 12 SIRIs • The top three reported Information Governance Breaches in 2016/17 were; o PID sent to wrong address / person o PID in wrong record o PID saved / sent insecurely • The number of incidents reported has decreased each quarter and the impact of the incidents has reduced, due to measures put in place. • Due to the success of bespoke training, monthly communications through the IG Newsletter and fortnightly IG scenarios sent to all staff, has had in reducing the number of Information Governance incidents reported each quarter and heightened awareness of Information Governance in working practices, Solent NHS Trust will continue with this type of awareness and have designed a new refreshed Information Governance Training programme.
Subject Access Requests • Current compliance over the last four quarters currently ranges between 80%-90%. • The IG Team hope to achieve an overall year compliance level of at least 85% once the remaining requests have been closed. • The Trust has undertaken one SIRI investigation relating to the processing of a subject access request, which has also highlighted complaints that have been received by the IG Team, with regards to requests being sent incomplete by service lines.
FOI Requests • The ICO have stated that compliance on FOI’s should not fall below 85%. • Solent NHS Trust’s overall compliance to date is 87.3% (to date)
GDPR • The Trust is currently working towards appointing a Data Protection Officer, who will undertake the implementation of the GDPR Action Plan and once implemented enforce the Regulations within the Trust. • The Data Protection Officer will need to undertake an IG Resource Review, to assess if adequate resources are available to successfully implement the Regulations and other requirements outlined in this report (IG Toolkit & Subject Access Requests).
All embedded documents within the Caldicott Guardian Annual Report and Plan 2016/2017 are available via the Supplementary Papers pack.
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Item 18.2
Information Governance
Information Governance Assurance Report Quarter 4 – End of Year Submission Report 2016/17
Author: Sadie Bell Head of Information Governance Page 1 of 19 R:\IG Solent\Reports\2016-17\201605\ 20150427_IGAssuranceReport_2015-16_ V1_SBe.doc
Contents
1. Purpose ...... 3
2. Information Governance Toolkit Submission 2016/17 ...... 3 2.1 Summary of Results: ...... 3 2.2 IG Toolkit and the Caldicott 2 Report ...... 4 2.3 Overall Compliance Statement ...... 4 2.4 Next Steps ...... 4
3. Information Governance Incidents ...... 5 3.1 IG Incident Trends ...... 5 3.2 High Risk Incidents and Serious Incidents Requiring Investigation ...... 6 3.3 Summary ...... 6 3.4 Recommendations ...... 6
4. Summary of Information Governance’s Legal Requirements Compliance ...... 7
5. General Data Protection Implementation ...... 10
Appendix A: IG Toolkit Compliance Breakdown ...... 11 Appendix B: Incidents broken down by Service Line Management ...... 13 Appendix C: GDPR Action Plan ...... 14
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1. Purpose
1.1 The purpose of this report is to provide the Trust with a detailed report of the Trust’s current Information Governance compliance, with both Law and National Requirements.
1.2 Solent NHS Trust believes that it is essential to the delivery of the highest quality of health care for all relevant information to be accurate complete, timely and secure. As such it is the responsibility of all staff or contractors working on our behalf to ensure and promote a high quality of reliable information to underpin decision making.
1.3 Information Governance promotes good practice requirements and guidance to ensure information is handled by organisations and staff legally, securely, efficiently and effectively to deliver the highest care standards. Information Governance also plays a key role as the foundation for all governance areas, supporting integrated governance within Solent NHS Trust.
1.4 This reports covers Solent NHS Trust’s Information Governance’s Activity; , • Information Governance Toolkit Submission, V14, 2016/17 • Incidents • Subject Access Requests (Requests for personal information / records) compliance • FOI compliance • Implementation of the new General Data Protection Regulations (to be fully implemented by May 2018)
2. Information Governance Toolkit Submission 2016/17 In order to be compliant within the Information Governance Toolkit, Solent NHS Trust must achieve Level 2 or above in all 45 requirements. Solent NHS Trust declared at the end of the financial year that it was at least level 2 compliant with all requirements.
A full breakdown of the Trust’s compliance can be found in Appendix A.
2.1 Summary of Results: Requirement Section Total No. No. Requirements No. Requirements Requirements Level 2 Level 3 Information Governance Management (100’s) 5 3 2 Confidentiality & Data Protection (200’s) 9 9 0 Information Security Assurance (300’s) 15 14 1 Clinical Information assurance (400’s) 5 4 1 Secondary user Assurance (500’s) 8 7 1 Corporate Information Assurance (600’s) 3 3 0 Totals 45 40 5
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2.2 IG Toolkit and the Caldicott 2 Report The Caldicott 2 Report has been incorporated into the IG Toolkit.
Caldicott 2 is requirements are covered within 12 key requirements of the IG Toolkit. In order to be fully compliant with Caldicott 2, the Trust must achieve Level 3 in all 12 of these requirements.
The achievement levels are;
• Has fully implemented a Caldicott 2 recommendation - level 3. • Is working towards implementation of a Caldicott 2 recommendation - level 1 or 2 • Has not started implementing a Caldicott 2recommendation - level 0.
Compliance with Caldicott 2 IG Toolkit Requirements – V14, 2016/17
Req Current Compliance Level Req Current Compliance Level 101 2 206 2 200 2 207 2 201 2 300 2 202 2 302 2 203 2 307 1 205 2 400 2
2.3 Overall Compliance Statement Solent NHS Trust’s overall Information Governance IG Toolkit compliancy score for 2016/17 was 70% and was graded as Green – Satisfactory. This is a slight decrease compared to 2015/16’s compliance score of 73%.
The Trust’s compliance with regards to the 12 requirements linked to the Caldicott 2 Report, identify that the Trust is working towards the implantation of the Caldicott 2 Report, as the Trust has only reached the minimum requirement of Level 2 compliance.
2.4 Next Steps As Solent NHS Trust is now an established organisation it should be aiming to achieve Level 3 in the majority of, if not all, requirements of the IG Toolkit. This will ensure that the Trust is compliant with Caldicott 2 and prepared for the higher standards of compliance which come with the General Data Protection Regulations (2018). In addition to this, being Level 3 compliant will ensure that the Trust is able to demonstrate a higher level of compliance, which will provide patients with greater trust that Solent NHS Trust ensure that their information is kept secure and appropriately used. This will also provide the Trust with a competitive advantage, as a fully compliant Trust, with regards to Law and National Requirements.
Level 2 = Implementation of standards Level 3 = Assessment, Review and Testing of implementation, to provide assurance that standards are not only implemented, but abided by.
A resource review will need to be undertaken to see what Solent NHS Trust can achieve with current IG resources and where not possible to achieve with current resources what is needed to achieve this. This will directly link with the General Data Protection Regulations (GDPR) IG Resource review, which has been identified as part of the Trust’s GDPR action plan.
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3. Information Governance Incidents 3.1 IG Incident Trends
Comparing the number of incidents reported in 2015/16 (222, average of 56 per quarter) to the number of incidents reported in 2016/17 (310, average of 78 incidents per quarter), it identifies that the Trust has increased the number of incidents reported by 40%. However the number of incidents reported each quarter is decreasing.
Trends: IG Incidents – Main Issues Q1 Q2 Q3 Q4 Total Stolen Notes/PID 1 1 0 0 2 Lost Notes/PID 9 9 5 6 29 PID sent to wrong address / person 24 22 22 16 84 PID in wrong record 12 12 9 5 38 Records Error 5 9 7 5 26 PID Saved / Stored Insecurely 11 7 8 9 35 NHSMail not used for PID 1 0 0 5 6 Post Issues (way in sent/received) 3 1 0 4 8 PID found in public place 1 0 1 0 2 Breach by staff - Deliberate 0 0 0 1 1 Breach by staff - Unintentional 2 7 3 6 18 Printing Issues (left on printer / wrong printer) 3 7 4 2 16 Cyber Security 0 0 0 0 0 Other 12 10 10 13 45 Total 84 85 69 72 310
An additional 197 incidents with a minimal impact or out of Solent NHS Trust’s control were also reported in 2016/17. Although these incidents are considered to be out of Solent NHS Trust’s control they are still reported and monitored, as they could impact upon our data, patients and care provided.
IG Incident – Low Risk Incidents Q1 Q2 Q3 Q4 Total Lost Smart Card / ID Badge 6 6 6 8 26 System Error 42 17 20 27 106 Out of our control 14 23 16 12 65 Total 62 46 42 47 197
Appendix B: Service Line Breakdown
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3.2 High Risk Incidents and Serious Incidents Requiring Investigation
High Risk Incidents (HRI): There were Serious Incidents Requiring forty-one HRI’s this financial year. This a Investigation (SIRI): There were twelve double the number of incidents reported SIRI’s this financial year, which is a slight in 2015/16; increase of one, when compared to 2015/16; • Adult Mental Health – 2 • Adults Portsmouth – 3 • Adult Mental Health – 3 • Adults Southampton – 6 • Adult Services Portsmouth – 1 • Child & Family – 17 • Child & Family – 6 • Corporate – 3 • Corporate – 1 • Dental – 1 • Primary Care – 1 • Primary Care – 8 • Sexual Health – 1
3.3 Summary Information Governance incidents is a topic that Solent NHS Trust monitors closely and respond to in accordance to trends; As a result of this the Information Governance Team introduced bespoke tailored Information Governance Training in 2016/17, delivered through a mixture of online training and face-to-face training. This training heightened staff’s awareness of how Information Governance effects staff’s work at a service level, what to do to prevent incidents and also what type of incidents to report, this lead to spikes in reporting.
Information Governance Breaches have declined quarter on quarter, with the exception of Q4, which saw a slight spike, associated with an increase in incidents reported by Primary Care Services, where the majority of staff were trained in IG within Q4; therefore we would expect to see a spike in reporting.
The top three reported Information Governance Breaches in 2016/17 were; • PID sent to wrong address / person • PID in wrong record • PID saved / sent insecurely
Although with all three of these categories, the number of incidents reported decreased each quarter and the impact of the incidents have reduced due to measures put in place.
The main areas of concern for both HRI’s and SIRI’s are; • The secure transferring, sending and storage of Personally Identifiable Data (PID) • Staff Breaches, both intentional and unintentional • Records Management
Due to the success of bespoke training, monthly communications through the IG Newsletter and fortnightly IG scenarios sent to all staff, has had in reducing the number of Information Governance incidents reported each quarter and heightened awareness of Information Governance in working practices, Solent NHS Trust will continue with this type of awareness and have designed a new refreshed Information Governance Training programme.
3.4 Recommendations • IG Team to continue to undertake o quarterly IG incident trending and assess the best way to prevent reoccurrence o provide bespoke IG Training & Awareness, as this has proved to be successful in raising staff awareness. o with lesson learnt based IG scenarios in Staff News and IG Newsletter • IG Team to assess different ways of ensuring shared learning from incidents is cascaded to staff. Page 6 of 19 R:\IG Solent\Reports\2016-17\201605\ 20150427_IGAssuranceReport_2015-16_ V1_SBe.doc
4. Summary of Information Governance’s Legal Requirements Compliance
4.1 Subject Access Requests / Request for Personal Information Compliance Overview: Performance:
Year Total Q2, 2016/17 Q3, 2016/17 Q4, 2016/17 Q1, 2016/17 to date *TBC *TBC *TBC 2016/17 Number of requests 191 160 170 187 708 received Number of requests responded to within 21 101 (53%) 94 (59%) 105 (61%) 94 (50%) 394 (55.7%) days (best practice) Number of requests responded to within 40 51 (27%) 39 (24%) 40 (24%) 17 (9%) 147 (20.8%) days Number of breaches (in 39 (20%) 25 (16%) 22 (13%) 6 (3%) 92 (12.9%) excess of 40 days) Number of breaches 0 (0%) 0 (0%) 0 (0%) 1 (1%) 1 (0.1%) (RECORDS LOST) Not Due 0 (0%) 2 (1%) 3 (2%) 69 (37%) 74 (10.5%) * final figures are subject to change, as some requests are currently not due to date.
2016/17** 2015/16 Total 634 881 Total Compliance 541 (85%) 731 (83%) No. breaches (in excess of 40 days) 94 (15%) 150 (17%) **figures are total number of requests, minus those requests who are currently not due, to show current level of compliance. Final figures are subject to change once outstanding requests are closed.
Service Line Management No. Request Breaches 2016-2017 % 2015-2016 % Compliance*** Compliance Adult Services – Portsmouth 16 4 75% 80% Adult Services – Southampton 27 5 81% 84% Adult Mental Health 91 11 88% 84% Children Services 107 16 85% 78% Dental 14 0 100% 90% Primary Care 222 45 80% 82% Sexual Health 42 1 98% 80% Coporate 21 3 86% 86% Redirected Requests 94 7 90% 94% Total 634 94 85% 83% ***figures are total number of requests, minus those requests who are currently not due, to show current level of compliance. Final figures are subject to change once outstanding requests are closed.
Summary: The number of SAR Requests received within in a financial year has decreased slightly, however this will be due to Solent NHS Trust no longer receiving requests (or at least very rarely) for Walk- in Centre and Minor Injury Unit requests, which previously contributed to a large number of requests.
Current compliance over the last four quarters currently ranges between 80%-90%. The IG Team hope to achieve an overall year compliance level of at least 85%% once the remaining requests have been closed. Q4’s compliance currently sits at the highest it has been in the last year, at 94% and overall compliance to date has increased, when compared to 2015/16; this is evidence that the Subject Access Request monitoring process is working.
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In terms of Service Line Management (SLM) compliance, in most service lines, compliance levels are increasing. When compared to 2015/16. However some Service Lines compliance has decreased slightly; • Adult Services Portsmouth • Adult Services Southampton • Primary Care • Corporate
It is important to note that the Trust has undertaken one SIRI investigation relating to the processing of a subject access request, which has also highlighted complaints that have been received by the IG Team, with regards to requests being sent incomplete by service lines.
The Trust needs to consider if the current process for governing and responding to requests, is adequate or if the process needs to be changed, to increase compliance and reduce the administrative burdening on clinical services. It is also important to note that from May 2018 the Trust will have less time to respond to requests (currently 40days and will reduce down to 30days) and will become free (the Trust should expect an increase in requests), it is therefore expected that without changes to process, compliance levels will decrease.
There are three options available;
1. No change required; compliance is currently 85% and therefore this is not an adequate position or option 2. Service Lines who are not fully compliant are to identify adequate resources within the service line to process requests. Staff responsible for processing and / or signing off requests are provided additional training. Escalation of breaches are to be escalated to Operational and Clinical Directors. This option is still an administrative burden on clinical services and will require extra resources within Service Lines, to ensure compliance levels increase. 3. Centralise the Subject Access Request process within the IG Team. The IG Team currently provide the governance and monitoring aspects of this process and offer expert advice. By centralising the process within the IG Team the Trust will benefit further from this expert advice, control the time taken to respond to the request, ensure all information releasable under the law is collated, redacted and prepped ready for sign-off by a clinician. The IG Team will also be able to triage the request and advise the clinician of how much time needs to be set aside to sign off a case e.g. a direct patient request with no redaction – small amount of time; a complex case with multiple redactions and parent responsibility issues – additional amount of time required. This option will reduce the administrative burden with the clinical services. However for this option to be viable and absorbed within the IG Team, resources and allocation of work will need to be reviewed within the IG Team and included as part of the GDPR IG Resource Review, as indicated in the GDPR Action Plan.
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4.2 Freedom of Information Compliance Overview: In 2016/17 the Trust received a total of three hundred and three, with thirty-eight requests breaching (to date – four are currently not due); processes are continuously monitored and amended to reduce the risk of further breaches.
The number of FOI Requests received within in a financial year has increased by 41%, when comparing 2016/17 to 2015/16.
Month April May June July August Sept No. Requests 26 24 26 30 32 24 No. Breaches 3 3 3 2 4 2 No. Not Due 0 0 0 0 0 0 % Compliance 88% 88% 85% 93% 87.5% 91.6%
Month Oct Nov Dec Jan Feb* Mar* No. Requests 26 16 19 24 27 29 No. Breaches 7 3 4 2 1 4 No. Not Due 0 0 0 0 1 3 % Compliance 73% 81.3% 79% 91.6% 96.2% 84.6% *March’s figures have are subject to change, due to requests currently not being due
The ICO have stated that compliance on FOI’s should not fall below 85%. Solent NHS Trust’s overall compliance to date is 87.3%. Last year’s compliance 2015/16 was 92.5%, therefore the Trust’s compliance has decreased.
The Information Governance Team continues to work on reducing the burden of FOI’s requests on services and reduce breaches by; • the IG Team will also be requesting confirmation from services within two working days, that information is held and identifying if clarity on the request is required • identifying the Frequently Asked Questions/Requests • working with the services to see if we can annually publish data • refer requestors to already published data
However as a result of the number of requests received continuing to increase; this has made little impact on improving compliance; although there are other factors that continue to impact the Trusts ability to improve compliance, e.g. • Service sending incomplete responses back to the IG Team • IAO’s not approving responses prior to them being sent to the IG Team, so requests are being sent back • Delays in the sign-off process
Recommendations: The IG Team have will undertake the following actions to increase compliance to 100%; • Request handlers to ensure that FOI disclosure being submitted to the IG Team is the full disclosure and not part disclosure • Request handlers to ensure IAO has approved FOI disclosure prior to disclosure being submitted to the IG Team • Ensuring that reminder emails and communications are sent • Publication scheme and public facing website to be updated to allow similar requests to be populated by the IG team or redirected to the website, relieving pressure off services where applicable. • Continued work with service lines to ensure that appropriate IAO’s and request handlers are identified to receive requests within two working days. • IG Team to review sign off process, to ensure it is sufficient and deadlines are met.
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5. General Data Protection Implementation In May 2018 the new General Data Protection Regulations will come into force.
What has changed? 1. Data Subjects will notice more empowerment: • Wider rights of subject access and information about processing • Greater transparency about processing, and, • Stricter conditions for consent and right to object
2. Organisations will notice the focus on increased accountability and pro-active, evidence-based compliance • Thorough risk assessments, and the principles of ‘privacy by design’ and ‘data protection by default’ • Requirement to maintain accurate records of all data processing activities, • Increased regulatory enforcement powers and penalties • Stricter breach notification to regulators and to individuals affected
What actions have been undertaken and next steps? The Trust has placed the implementation of these new Regulations on the Trust’s Risk Register and identified an action plan to mitigate this risk.
See Appendix C – GDPR Action Plan & Updates
The Trust is currently working towards appointing a Data Protection Officer, who will undertake the implementation of the GDPR Action Plan and once implemented enforce the Regulations within the Trust.
Once this step has been completed, the Data Protection Officer will need to undertake an IG Resource Review, to assess if adequate resources are available to successfully implement the Regulations and other requirements outlined in this report (IG Toolkit & Subject Access Requests). The paper will identify the standard of compliance that can be achieved with current resources e.g. satisfactory / adequate, excellent, outstanding, etc…; the Trust would need to make a decision on the standard of compliance it is happy to accept. Although the standard of compliance is optional, the implementation of the Regulations is not and additional resources to implement the GDPR may be required.
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Appendix A: IG Toolkit Compliance Breakdown Req Description Attainment No Level Information Governance Management 101 There is an adequate Information Governance Management Framework to support the current and Level 2 evolving Information Governance agenda 105 There are approved and comprehensive Information Governance Policies with associated strategies Level 2 and/or improvement plans 110 Formal contractual arrangements that include compliance with information governance requirements, Level 2 are in place with all contractors and support organisations 111 Employment contracts which include compliance with information governance standards are in place Level 3 for all individuals carrying out work on behalf of the organisation 112 Information Governance awareness and mandatory training procedures are in place and all staff are Level 3 appropriately trained Confidentiality and Data Protection Assurance 200 The Information Governance agenda is supported by adequate confidentiality and data protection Level 2 skills, knowledge and experience which meet the organisation’s assessed needs 201 Staff are provided with clear guidance on keeping personal information secure and on respecting the Level 2 confidentiality of service users 202 Personal information is only used in ways that do not directly contribute to the delivery of care Level 2 services where there is a lawful basis to do so and objections to the disclosure of confidential personal information are appropriately respected 203 Individuals are informed about the proposed uses of their personal information Level 2 205 There are appropriate procedures for recognising and responding to individuals’ requests for access Level 2 to their personal data 206 There are appropriate confidentiality audit procedures to monitor access to confidential personal Level 2 information 207 Where required, protocols governing the routine sharing of personal information have been agreed Level 2 with other organisations 209 All person identifiable data processed outside of the UK complies with the Data Protection Act 1998 Level 2 and Department of Health guidelines 210 All new processes, services, information systems, and other relevant information assets are Level 2 developed and implemented in a secure and structured manner, and comply with IG security accreditation, information quality and confidentiality and data protection requirements Information Security Assurance 300 The Information Governance agenda is supported by adequate information security skills, knowledge Level 2 and experience which meet the organisation’s assessed needs 301 A formal information security risk assessment and management programme for key Information Level 2 Assets has been documented, implemented and reviewed 302 There are documented information security incident / event reporting and management procedures Level 3 that are accessible to all staff 303 There are established business processes and procedures that satisfy the organisation’s obligations Level 2 as a Registration Authority 304 Monitoring and enforcement processes are in place to ensure NHS national application Smartcard Level 2 users comply with the terms and conditions of use 305 Operating and application information systems (under the organisation’s control) support appropriate Level 2 access control functionality and documented and managed access rights are in place for all users of these systems 307 An effectively supported Senior Information Risk Owner takes ownership of the organisation’s Level 2 information risk policy and information risk management strategy
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308 All transfers of hardcopy and digital person identifiable and sensitive information have been identified, Level 2 mapped and risk assessed; technical and organisational measures adequately secure these transfers 309 Business continuity plans are up to date and tested for all critical information assets (data processing Level 2 facilities, communications services and data) and service - specific measures are in place 310 Procedures are in place to prevent information processing being interrupted or disrupted through Level 2 equipment failure, environmental hazard or human error 311 Information Assets with computer components are capable of the rapid detection, isolation and Level 2 removal of malicious code and unauthorised mobile code 313 Policy and procedures are in place to ensure that Information Communication Technology (ICT) Level 2 networks operate securely 314 Policy and procedures ensure that mobile computing and teleworking are secure Level 2 323 All information assets that hold, or are, personal data are protected by appropriate organisational and Level 2 technical measures 324 The confidentiality of service user information is protected through use of pseudonymisation and Level 2 anonymisation techniques where appropriate Clinical Information Assurance 400 The Information Governance agenda is supported by adequate information quality and records Level 2 management skills, knowledge and experience 401 There is consistent and comprehensive use of the NHS Number in line with National Patient Safety Level 2 Agency requirements 402 Procedures are in place to ensure the accuracy of service user information on all systems and /or Level 2 records that support the provision of care 404 A multi-professional audit of clinical records across all specialties has been undertaken Level 2 406 Procedures are in place for monitoring the availability of paper health/care records and tracing Level 3 missing records Secondary Use Assurance 501 National data definitions, standards, values and validation programmes are incorporated within key Level 2 systems and local documentation is updated as standards develop 502 External data quality reports are used for monitoring and improving data quality Level 2 504 Documented procedures are in place for using both local and national benchmarking to identify data Level 2 quality issues and analyse trends in information over time, ensuring that large changes are investigated and explained 506 A documented procedure and a regular audit cycle for accuracy checks on service user data is in Level 2 place 507 The Completeness and Validity check for data has been completed and passed Level 2 508 Clinical/care staff are involved in validating information derived from the recording of clinical/care Level 2 activity 514 An audit of clinical coding, based on national standards, has been undertaken by a NHS Level 3 Classifications Service approved clinical coding auditor within the last 12 months 516 Training programmes for clinical coding staff entering coded clinical data are comprehensive and Level 2 conform to national standards Corporate Information Assurance 601 Documented and implemented procedures are in place for the effective management of corporate Level 2 records 603 Documented and publicly available procedures are in place to ensure compliance with the Freedom Level 2 of Information Act 2000 604 As part of the information lifecycle management strategy, an audit of corporate records has been Level 2 undertaken
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Appendix B: Incidents broken down by Service Line Management
Adult Mental Adults, Adults, Children Dental Primary Care Sexual Health Corporate Health Portsmouth Southampton Services Q1 7 6 12 29 3 9 9 9 Q2 8 9 9 33 2 14 4 6 Q3 5 8 5 24 3 8 7 9 Q4 1 7 6 19 2 18 11 8 Total 21 30 32 105 10 49 31 32 * Minus minor IG issues
In 2016/17 the main service line who reported the most Information Governance incidents was Children Services (105 incidents). The remaining service lines averaged approx. 30 incidents, with Dental and AMH being below average.
Children Services: The main Information Governance Breaches are PID sent to the wrong address / person. The service line have introduced processes and procedures, to reduce the number of these incidents reported, but further documentation, communication and awareness of these processes are required.
Q1 Q2 Q3 Q4 Total Lost Notes/PID 1 3 1 5 PID sent to wrong address / person 14 13 11 5 43 PID in wrong record 5 7 1 3 16 Records Error 1 1 3 2 7 PID Saved/ Stored insecurely 3 2 4 2 11 NHS Mail not used for PID 2 2 Post Issues (way in sent/received) 1 3 4 PID found in public place 1 1 Breach by Staff - Unintentional 2 2 1 1 6 Printing Issues (left on printer / wrong printer) 1 1 Other 2 4 2 1 9 Total 29 33 24 19 105
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Appendix C: GDPR Action Plan
Action Required Linked to ICO’s Supporting Time Frame Person Accountable Status 12 Steps Information Assurance Committee & Board to be Awareness This paper will act as January 17 Head of Information Completed made aware of the new Regulations, awareness to Governance what has changed, what the impact Assurance Committee is, any resource implications. and Board
The GDPR should be placed on the Awareness Jan 17 – Apr 18 Head of Information Completed Trust’s Risk Register, until actions are Governance completed and updates on progress reported to Assurance Committee & Board on a monthly basis Appointment of the Data Protection Data Protection This role needs to be Jan 17 – Apr 17 Chief Executive In Progress – Job Officer Role, with the appropriate Officer reported to ahead of Description is accountability and responsibility. May 2018, as they will currently awaiting be mandated to banding and sign- The role will have professional undertake all the off accountability to the CEO and Board preparation work for and will need to advise Board on all the organisation, to decisions that may directly or ensure that they are indirectly impact upon personally fully compliant with identifiable or special category data. this action plan and the GDPR no later than May 2018 Review of Corporate Record Information You Existing Corporate Apr 17 – Dec Data Protection In Progress – Inventory and a documented list of all Hold Record Inventory in 17 Officer (once Collection of information held on our Network place, but these are appointed) information has Drives to be undertaken. Ensuring Data Protection not necessarily commenced. The retention dates are associated with all by Design comprehensive IG Team / documents. SharePoint Project Work on Network Manager are Review of resources required for Drives being currently this piece of work will need to be undertaken in requesting Bank undertaken in advance to this preparation for Staff to undertake SharePoint, but the Network Drive Page 14 of 19 R:\IG Solent\Reports\2016-17\201605\ 20150427_IGAssuranceReport_2015-16_ V1_SBe.doc
retention dates have work not been assigned to archived data Tighter monitoring of IG incidents Data Breaches IG Risk Policy in Apr 17 – May Data Protection To Commence – required and reporting to Board place 17 Officer (once A review of the IG appointed) Risk Policy and Review of the IG Risk Policy SIRI process has not yet All SIRI Breaches to be reported to commenced. ICO within 72hrs In Progress - IG Incidents and key summary information on IG incidents will form part of the IG update on the CEO report that goes to Trust Board.
Completed - A detailed annual report will be submitted to Board Review of all Existing Information Legal Basis for Information Sharing June 17 – Aug Data Protection Sharing Agreements, to ensure that Processing Agreement and 17 Officer (once information sharing arrangements Personal Data Privacy Notices appointed) comply with the new requirements already in place and restrictions of the GDPR. Ensuring that all legal basis(s) are documented.
In particular assess any data sharing that is currently undertaken without consent and under “best interest” to
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ensure it meets the new requirement of “vital interest”.
Revised agreements to be put in place and signed off by all parties PIA Procedure needs to be tightened Data Protection Privacy Impact Apr 17 – Dec Data Protection To commence and this made Policy. Need to embed by Design and Assessment 17 Officer (once a culture that these are undertaken as Data Protection Procedure in place appointed) routine and presented to the Data Impact Protection Officer for Implementation. Assessments Early involvement and sign off by the Data Protection Officer is key
Data Protection Officer to attend Service Line Governance Meetings and Board to advice on all decisions that may directly or indirectly impact upon personally identifiable or special category data.
Review of PIA Template required All Contracts for data processing are Legal Basis for Jul 17 – Sept Data Protection to be reviewed, to ensure that the Processing 17 Officer (once legal basis is documented and Personal Data appointed) Information Sharing Agreements are included, outlining every step of data processing and the returning / destruction of data, when contract is terminated All Contractors, contracted for data Legal Basis for Some evidence is Jul 17 – Sept Data Protection processing are to have their Data Processing currently collected, 17 Officer (once Protection Compliance and evidence Personal Data but this needs to be appointed) reviewed in line with the new GDPR strengthened and compliance where not available, the organisation
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needs to consider terminating the contracts Preventative work needs to be Data Breaches May 17 – May Data Protection planned and implemented. 18 Officer (once appointed) Resources need to be reviewed to ensure that the Trust has adequate resources to prevent Data Breaches Review of all consent processes, to Consent May 17 – May Data Protection ensure that consent is freely given, 18 Officer (once specific, informed and unambiguous. appointed)
Implied consent is no longer Head of Information acceptable. Systems
The GDPR is also clear that controllers must be able to demonstrate that consent was given – review processes in terms of verbal consent
New consent processes need to be fully embedded within organisational culture by May 18 Review Data Flow Mapping and Information You Existing reviews in Aug 17 – Oct Data Protection Information Sharing Review, to Hold place, but these are 17 Officer (once ensure that all data held, transferred not necessarily appointed) and shared are documented and Legal Basis for comprehensive appropriate legal arrangements, Processing processes and agreements are in Personal Data place. Where not in place these need to be implemented Assess Subject Access Request Individuals Subject Access Jul 17 – Aug 17 Data Protection processes, and the suspected Rights Request processes Officer (once increase in demand, to ensure the already in place, but appointed) Trust can comply and has adequate Subject Access need to be amended
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resources Requests to reflect changes, such as demand, time Ensure that all our patients and staff to process requests are aware they can access their reduced, cost records for free from May 18 removed, etc… Expand upon Privacy Notice, to Legal Basis for Privacy Notices January 18 Data Protection ensure that it meets the new legal Processing already in place Officer (once requirements Personal Data appointed)
Ensure that the Privacy Notice is Children written in a language that children will understand (Children aged 13+ can Communicating give consent, where deemed capable) Privacy Information Must document all data held, for what purpose, whom it is shared with, how it is stored, who has access to it and how long it is held for. This is to be made public
Create an Internet Page “Your Information, Your Rights” Assess processes in place regards Individuals Jan 18 – Mar Data Protection perceived “inaccuracies of data” and Rights 18 Officer (once how these can be “corrected” appointed)
Implement processes to comply with Individuals Jan 18 – Mar Data Protection the “Right to be forgotten – erased” Rights 18 Officer (once appointed) Review all IG policies in line with the Data Protection Jan 18 – Apr 18 Data Protection GDPR by Design Officer (once appointed) Implement new Subject Access Individuals Mar 18 – May Data Protection Request Processes and Resources Rights 18 Officer (once required to ensure compliance appointed) Subject Access Requests Page 18 of 19 R:\IG Solent\Reports\2016-17\201605\ 20150427_IGAssuranceReport_2015-16_ V1_SBe.doc
Ensure that data is portable and Individuals Mar 18 – May Data Protection available in an electronic format and Rights 18 Officer (once easily transferable to new providers appointed) on request of a data subject Subject Access Requests Head of Information Systems Embed a culture within the Trust Data Protection Mar 18 – May Data Protection where the Data Protection Officer is by Design 18 Officer (once seen as central to the working appointed) practices of the Trust, with regards to any change or addition, which directly or indirectly affects personally identifiable and/or special category data. E.g.
• Contract Review • Information Sharing Agreements • Privacy Impact Assessments • IG Audits • IG Training
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Caldicott Guardian Annual Report and Plan 2016/2017 Item 18.3
1. Introduction Within Solent NHS Trust Daniel Meron, Chief Medical Officer is the Caldicott Guardian and is responsible for protecting the confidentiality of patient and service user information and enabling appropriate information sharing. Ensuring that Solent NHS Trust in liaison with local Councils, Social Services and partner organisations satisfy the highest practicable standards for handling patient identifiable data.
2. Scope This report covers several aspects of the Caldicott Guardian’s role, identifying the activities that have been undertaken throughout the financial year. The Caldicott Guardian Issue Log provides evidence of the requests and additional considerations a Caldicott Guardian is required to provide.
The Caldicott Guardian is also key in ensuring that all confidential and personally identifiable data shared, is done so in the best interest of the patient and in line with the Caldicott Principles, therefore the Caldicott Guardian must sign off on all Information Sharing Agreements, Transfer of Service Agreements and Privacy Impact Assessments.
The Caldicott Guardian Annual Work Plan sets out the key objectives for the Caldicott Guardian for the forthcoming financial year, which includes the implementation of recommendations made in the Caldicott 2 Review.
3. Caldicott 3 Report In July 2016, Dame Fiona Caldicott, the National Data Guardian for Health and Care, published her findings on a review of Data Security and Consent. The report proposes new measures to strengthen security of health and care information and help people make informed choices about how their data is used.
The report made twenty recommendations and an additional ten Security Standards. Nine of these recommendations are linked to Data Security, nine are linked to Consent and two are linked to the next steps.
The findings of the report then went out to public consultation from July 2016 – September 2017. The final Government response is still awaited. However the Head of IG did review the Caldicott 3 Report and assessed Solent’s compliance against these, in preparation to the final report. This review identified that the Trust has mechanisms in place to ensure compliance with the recommendations that directly effect it, some of these however may need strengthening.
4. Caldicott Guardian Issue Log Throughout the year various issues and concerns are raised with the Caldicott Guardian with regards to patient confidentiality and security of information. These issues are logged centrally by the IG Team and reviewed and approved by the Caldicott Guardian.
In 2016/17, forty-three items added to the Caldicott Guardian Issue Log, all of which have been considered by the Caldicott. Items logged for Caldicott Guardian consideration are in relation to the following subjects: Page 1 of 4 R:\IG Solent\IG Structure\Caldicott Guardian\Annual Report\2015-16 20160323_ CaldicottGuardianAnnualReport_2015-16_V1_IGT
Subject Total Access Controls 16 Information Governance Breach / Incidents 1 Logical Deletion and/or Reversal 7 Other 2 Process Change 4 Records Management 2 Removal of Sensitive Information 3 Research / Audits / Surveys 3 Subject Access Request 4 SystmOne issues / controls 1 Total 43
The Caldicott Guardian Issue Log is to be authorised and by the Caldicott Guardian. This report will act as official sign-off from the Caldicott Guardian on all issues and concerns raised in 2016/17.
April16-March17_ Caldicott Issue Log
5. Information Sharing Agreements and Privacy Impact Assessment Tables: The Caldicott Guardian must counter-sign all Information Sharing Protocols/Agreements, Transfer of Service Agreements and Privacy Impact Assessments with the SIRO and draw awareness to the Chief Executive outlining rules relating to the sharing of information with other organisations and provides guidance to staff in relation to sharing confidential information (Requirement 207).
Below is a list of all Information Sharing Protocols/Agreements that are currently in place, which includes who approved the agreement, when it was approved and when it is due for renewal.
Information Sharing Protocol - Agreement
Below is a list of all Privacy Impact Assessments that have been approved, which includes who approved the agreement and when it was approved.
PIA Log.pdf
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6. Caldicott Guardian Annual Work Plan: At Solent NHS Trust, the Caldicott Work Plan is incorporated into the Trust’s Information Governance Improvement Plan. The IG improvement programme will be managed by the Head of Information Governance and overseen by the Caldicott and the Quality Improvement and Risk Committee. The Head of Information Governance provides a quarterly report of assurance directly to the Assurance Committee.
20170512_Caldicott WorkPlan_2017-18_V
This report will act as official sign-off from the Caldicott Guardian for the 2017/18 Caldicott Guardian Work Plan.
7. General Data Protection Regulations (GDPR) In May 2018 the new General Data Protection Regulations will come into force.
What has changed? Data Subjects will notice more empowerment: • Wider rights of subject access and information about processing • Greater transparency about processing, and, • Stricter conditions for consent and right to object
Organisations will notice the focus on increased accountability and pro- active, evidence-based compliance • Thorough risk assessments, and the principles of ‘privacy by design’ and ‘data protection by default’ • Requirement to maintain accurate records of all data processing activities, • Increased regulatory enforcement powers and penalties • Stricter breach notification to regulators and to individuals affected
The Trust has placed the implementation of these new Regulations on the Trust’s Risk Register and identified an action plan to mitigate this risk.
Detailed report on the implementation of these regulations and the actions required are identified in the report below.
20170420_IntroGDP R_V1.1_SBe.docx
8. Conclusion It is felt that continual awareness of Information Governance and the Caldicott Guardian’s role means that staff are aware of maintaining confidentiality and the implementation of the Caldicott Principles and where necessary will raise issues with the Caldicott Guardian, questioning practice to ensure it meets Information Governance standards.
Further work on IG compliance needs to be undertaken, as identified in the Caldicott Guardian’s work plan; mainly around ensuring adequate Information Sharing Agreements and Consent Processes are in place and continual staff
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awareness on patient confidentiality. This work will be undertaken throughout 2017/18 and closely links to the implementation of the new General Data Protection Regulations, with the aim to provide greater accountability, openness and transparency. Regular updates will be provided to the Caldicott Guardian, as well as the SIRO, Assurance Committee and Board.
9. Approval: Name: Daniel Meron
Signed:
Designation: Chief Medical Officer / Caldicott Guardian
Date:
Report by: Sadie Bell – Head of Information Governance Danielle Reddy – Information Governance Officer
Report date: 24th April 2017
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Board Report – In Public Meeting
Title of Paper Chairman’s report on Members Council
Author(s) Jayne Edwards, Corporate Executive Sponsor Dr. Alistair Stokes, Chairman Support Manager/Assistant Company Secretary Date of Paper 15th May 2017 Committees n/a presented Action requested To receive For decision x of the Board Link to CQC Key Safe Effective Caring Responsive Well Led
Lines of Enquiry x (KLoE)
Since the report to the March 2017 Board, the following governor activities have taken place:
Following the Members Council meeting on 10th March where it was agreed that a working group be established to consider the role of the Council, the following representatives met on 5th May 2017; o Michael North – Lead Governor, Public Governor Portsmouth o Sharon Collins – Public Governor Hampshire o Harry Hellier – Public Governor Hampshire o Bob Blackman – Public Governor Hampshire o Mandy Rayani – Chief Nurse o Lesley Munro – Interim Chief Operating Officer Southampton and County o Lauren Riddle – Membership Manager o Jayne Edwards – Corporate Services Manager & Ass. Company Secretary o Rachel Cheal - Ass. Director Corporate Affairs & Company Secretary • The Group discussed and suggested proposals concerning the following; o Key roles o What ‘good’ would look like o Changes to the ‘name’ o Composition, tenure and vacancies • An indicative phased plan, associated with any changes, is also proposed and consideration is to be given concerning the Trust’s current public membership. • The output of the working group is to be refined before being presented for discussion with the Board and wider current Members’ Council.
Forthcoming meetings • Following the Members’ Council in June, the Communications Team will be holding a Membership Recruitment and Engagement Group (name to be revised). The meeting will focus on the renewed direction for membership.
There are no other matters concerning the Members Council to be brought to the attention of the Board.
Recommendation
• The Board is asked to receive the update above in relation to Members Council activities.
Item 22.1 Exception and recommendation report
Committee Assurance committee Date of 18th April & 16th May /Subgroup meetings 2017 name
Chair Report to Trust Board Mick tutt
Key issues to be escalated We received a verbal up-date on the Trust’s Mortality Review process at the April meeting, noting the requirements set out in the ‘Learning from Deaths...new responsibilities for board members’ report launched on 21st March 2017. Four key actions were reported as ‘in hand’:-
i) identification of an existing Executive Director as Patient Safety Director ii) identification of an existing Non-Executive Director to take oversight of the arrangements iii) a process for – formally – reporting on action taken for all deaths occurring for people accessing Solent services iv) a revised Mortality Review policy
We noted that the first, substantive quarterly ‘deep dive’ was scheduled for the June meeting The requirement for iii) is that a process is in place by June 2017 and should include quarterly reporting to the Board. Given the Board and Assurance meeting frequency and current escalation arrangements, it was agreed that the quarterly reports should be received by the Assurance committee (June & September ‘17, January & March ’18) and be escalated to the Board via this Exception & Recommendation route. The Board’s agreement to this ‘work around’ is sought The requirement for iv) is for a revised policy to be ratified by September 2017 and we were assured the arrangements were in hand to comply with this
Having been informed of short-notice re-Inspections of our Substance Misuse (SMS) and Children & Adolescent Mental Health (CAMHS) services, by the CQC; to take place week commencing 22nd May, we used our May meeting to seek assurance that the action taken, in response to the concerns raised by the CQC in their Comprehensive Inspection last June, would be sufficient to provide evidence of progress The Clinical Directors (CDs) for both services and the interim Governance Lead for CAMHS joined our Chief Operating Officers (COOs) in providing that assurance; where we looked, in detail, at both the actions the CQC had asked for and the rational underlying the concerns that were prompting these actions. Whilst we received assurance that the majority of actions had, or were, being addressed it was noted that prescribing reviews in SMS had still not met national or local expectation and the CD outlined the further steps he had requested to address this. The CD for CAMHS confirmed that the service yet to implement a way of establishing how to manage waiting times, after an initial options assessment had been conducted. He outlined the reasons why this remained an issue and identified the further steps the service were planning to take to address this We concluded the discussion by noting that the CQC re-Inspection would be before the Board and, therefore, initial feedback from the CQC should be available, verbally, to the Board at the meeting
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Consideration of the assurances regarding action taken to address the concerns raised by the CQC had been preceded by receipt of a first draft of a proposed Quality Assurance Monitoring & Reporting process. It was clear that the proposal would enable more robust assurance of the issues discussed with SMS and CAMHS and the committee approved the direction of travel, but asked for further management action to be taken to ensure operational effectiveness
In addition to the introduction of mandatory reporting and monitoring for the Mortality Review process, two further areas of activity are also associated with that requirement and we received reports on both of these in this reporting period:-
The first is now that associated with the introduction of the Freedom to Speak Up Guardian and we received a first quarterly ‘deep dive’ from the designated Guardian at the April meeting. We were briefed about the arrangements for ensuring access to the function, within Care Groups; current activity and linkages to the designated Non Executive Director and Chief Executive Officer We were briefed, at our May meeting, about concerns raised by a group of practitioners (through their trade association); which had been addressed and were within the remit of the Freedom to Speak Up arrangements
The second related to Information Governance (IG) and we received an Annual Report on the Trust compliance with IG expectations at our May meeting. This demonstrated that the Trust met the requirements for compliance during 2016/7 and outlined a number of measures to be taken for this current year, to both continue with that compliance and address newly-introduced further requirements. The full Report is available, if required
The April meeting received the Annual Report from the Wessex Speciality Doctors & Associate Specialists (SAS), working with Solent. The committee agreed that this cohort of practitioners make a significant and valued contribution to the Trust’s activity and we were, therefore, disappointed that:-
a) the Tutor (author of the Report) had noted that, nationally, this group of practitioners felt undervalued by senior managers b) engagement, in formal educational activity, appeared to have diminished considerably since the previous year – although feedback from those attending appeared to suggest satisfaction with the content
The committee discussed various ways these concerns might be mitigated (through engagement with future Quality Improvement projects and a potential Conference) and the full Report is available, if required
The May meeting received a Thematic Review, conducted by the Governance Lead for Mental Health, into the provision of care and treatment for people admitted to Brooker ward, at the Limes, Portsmouth. The Review was acknowledged to be comprehensive, with a number of action points identified from the issues raised and conclusions reached. It was noted that these would be monitored by the relevant Governance group and reported through to QIR, for escalation to the committee if felt necessary Comment was made regarding the absence of external peer review to the work, and the CD
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explained the reasons why this planned activity had not taken place. In discussion it was confirmed that external peers would be asked to contribute to the audits to be undertaken to assess the effectiveness and embeddedness of the actions identified The, wider, principle of external peer review was however highlighted and services were to be encouraged to ensure this occurred, whenever possible
The May meeting also received the quarterly up-date on the activity associated with Serious Incidents Requiring Investigation. Whilst the total number of Incidents had risen, slightly, compared to the previous year this was not felt to be significant – but we requested some alternative mechanisms for tracking trends, over time; to provide assurance that this assumption was accurate. The report contained a synopsis of the learning from Incidents investigated and the Chief Nurse outlined the various mechanisms available for dissemination of this learning across the Trust
An Annual Report regarding achievements associated with the Making Every Contact Count initiative was received at the May meeting. This was commissioned by Public Health Southampton and we were reminded that the initiative was part of all NHS contracts and was mandated. We sought to understand why the initiative was not commissioned in Portsmouth and the COO undertook to explore this with relevant colleagues, with a view to up-dating the committee when we receive a further up-date, in the Autumn
We looked to our COOs to identify the major risks to high quality services and continued compliance with regulatory requirement, in the two Care Groups and for the Quality Improvement & Risk group (QIR) to both underpin and enhance the assurance received from the COOs, and we received reports which continued to both:-
collaborate some of the issues raised by COOs, particularly of an operational nature raised other issues, largely of a strategic or ‘cross-cutting’ nature
Significant issues included:-
continued challenges associated with recruitment of practitioners, across the Trust – with particular ‘hot-spots’ in Community Nursing and Speech & Language Therapists, Southampton and Adult Mental Health wards (mitigated by the ‘block-booking’ of agency staff), Portsmouth a first outline, at the April meeting, of the quality and governance issues associated with the Trust’s wider engagement in the Urgent Care system across Portsmouth & South East Hampshire – which led to a discussion regarding the most appropriate forum for this to be considered. Further consideration by the Board was advocated, with continued focus at the Assurance committee as an interim (as least) measure continued concerns that workforce issues – including the ability to attract, recruit and retain appropriately qualified and experienced people, and the provision of suitable and effective learning & development for all staff (including essential recording of training received) – were not, currently, being overseen by a Non Executive Director- led committee. It was agreed, at the April meeting, that the Board would be asked to review this the May meeting developed this theme, further; in that we received a status report on the ‘fitness-for-purpose’ of the electronic system which should identify the learning & development required for individual practitioners – in order that we can
acexceptionandrecommendationsreportaprilmay17 page 3
be assured that they have the skills and experience required to undertake their role, and record the receipt of this learning, in an accurate and timely manner. We heard that the electronic system, currently, does not always enable managers to be confident that all necessary and relevant opportunities are identified for all practitioners and that managers cannot be confident that all learning & development activity is recorded accurately. We were given assurances regarding the measures being taken, at an operational level, to mitigate the risks these shortfalls pose and an outline of the programme to ensure the electronic system was ‘fit-for-purpose’. Again, oversight of the implementation and achievements of this programme should be within the remit of the Non Executive Director-led committee, noted above the May meeting also received an up-date, with regard to a specific aspect of this shortfall in confidence with the electronic recording system; that of Level 3 Safeguarding training. This was the issue, first raised at our January meeting, which alerted us to the potential shortfalls and risks. The up-date provided us with assurance of the process, through the provision of supervision, which would enable confidence to be achieved, that relevant practitioners received – and had been able to put into practice – the appropriate learning, in this instance we received up-dates on the action taken to address the concerns raised by the CQC with regard to the provision (by a 3rd party) of wheelchairs for people in receipt of our services, and of efforts to obtain the formal findings from a joint CQC/OFSTED Inspection, last autumn; which involved some of our services. Both these issues had been on-going for some time and we requested some focussed management attention, in order to attempt to reach resolution
We have received drafts of both the Annual Governance Statement (AGS) and Quality Account, in preparation for their inclusion with the Trust Annual Accounts, over several months and members were asked for final comments on the drafts at the April meeting, ahead of formal receipt by the Board The May meeting received a draft of the Annual Report for the committee’s activity during 2016/7, again ahead of formal receipt by the Board. In consideration of this item we reviewed the – perceived – effectiveness of the committee, particularly the changed arrangements for exception reporting from the COOs and QIR, since the revised Terms of Reference were adopted in January. We concluded that the arrangements did offer confidence that we could provide adequate assurance – or escalate issues of concern to us – to the Board; but that we would ask for an Internal Audit assessment, later this year; to offer a more independent judgement
We noted a recent Supreme Court Judgment, detailing that a hospital smoking ban had infringed the Appellant’s Human Rights; because there had been reliance (by the Scottish Health Board involved) on the blanket restrictions invoked under the powers of the Mental Health Act 1983, at our May meeting. We were informed of the action taken to seek legal advice; which confirmed that this Judgement did not affect Solent policies. We did, however, ask for further consideration to be given to the detail of implementation within our Mental Health services, and asked for further clarification
We recorded out formal thanks to the Chief Nurse at our May meeting, for her contributions to quality and regulatory compliance within the Trust
acexceptionandrecommendationsreportaprilmay17 page 4
Decisions made at the meeting
The April meeting received a report from our Contracts team, which outlined the risk management process now applied to all known sub-contracts. This had arisen as a consequence of historic requests for assurance of the quality and regulatory compliance of those who provided sub-contracted services for us, and we agreed that this report provided a useful first step – which would now be followed, on a quarterly basis, by more focussed exception reporting on those 10/12 sub-contracts assessed as posing the highest risks. We also noted that both Finance (re operational risks) and Audit & Risk (for governance) committees would be involved which monitoring this activity
At the April meeting we ratified the following policies:-
• IPC09 TSE CID Policy • IG09 Registration Authority Smart Card • RK08 Fire Safety Policy • MMT03 Medicine Policy
We also noted the CLS11 Seclusion Policy following minor amendments made to the appendix, which was approved by Chairs’ action on 18th March
Ratified by Chair’s Action • IG08 Policy for Surveillance Camera System (CCTV) • RK05 Physical Security Management Policy
At the May meeting we ratified the following policies:-
• GO10 Managing Conflict of Interest Policy • HR05 Bank, Agency and Locum Workers Policy And following minor amendments, we ratified changes to the following • RK01 Serious incidents requiring investigation (SI) policy • RK04 Investigation Policy • DA01 Waiting Times and Patients Access Policy
Ratified by Chair’s Action: • HS05 Slips Trips and Falls Policy (Patients) • GO09 Anti-Fraud, Corruption & Bribery Policy
• RK08 Fire Safety Policy Recommendations to the Trust Board The Board are asked to:-
agree that the quarterly Mortality Review reports should be received by the Assurance committee (June & September ‘17, January & March ’18) and be escalated to the Board via this Exception & Recommendation route
consider how the quality and governance issues associated with the Trust’s wider engagement in the Urgent Care system across Portsmouth & South East Hampshire might most appropriately be monitored
consider whether workforce issues should be overseen by a seperate Non Executive Director-led committee
acexceptionandrecommendationsreportaprilmay17 page 5
note the other issues set out above
Other risks to highlight (not previously mentioned)
none of note
acexceptionandrecommendationsreportaprilmay17 page 6
Item 22.2 Assurance Committee Annual Report 2016-17
Introduction The Assurance Committee is a formal Committee of the Solent NHS Trust Board with defined Terms of Reference and as such is required to prepare an Annual Report on its work and performance in the preceding year for consideration by the Trust Board. This report summarises the Committee’s activity for the year to 31st March 2017. Meetings During 2016-17 the following meetings were held:
• 19th April 2016 • 22nd November 2016 • 17th May 2016 • 17th January 2017 • 21st June 2016 • 14th February 2017 • 19th July 2016 • 14th March 2017 • 20th September 2016 • th 25 October 2016 Membership & Attendance Attendance by members is outlined as follows:
Meeting
mber % May June April July January March
th th st th th th nd th th th attendance attendance 19 21 20 19 Septe 25 October 22 November 17 14 February 14 NAME 17 Mick Tutt – Chair P P P P P P P P P P 100% Non Executive Director *Mike Watts n/a n/a n/a n/a n/a A P P A P 60% Non Executive Director *Francis Davis n/a n/a n/a n/a n/a P A P P P 80% Non Executive Director Jon Pittam n/a P P P P n/a P P P P 89% Non Executive Director Sue Harriman P A P P A P P P A P 70% Chief Executive Officer Mandy Rayani P A P P P P P A P A 70% Chief Nurse Sarah Austin P P P P P P A P A P 80% Chief Operating Officer *Alex Whitfield P P P P P A P P P n/a 89% Chief Operating Officer Dan Meron P P P A P P P P A P 80% Chief Medical Officer Lesley Munro n/a n/a n/a n/a n/a n/a n/a n/a P P 100% Interim Chief Operating Officer Rachel Cheal n/a n/a n/a n/a n/a n/a n/a P P P 100% Associate Director of Corporate Affairs and Company Secretary P= Present A= Apologies
*Alex Whitfield left the Trust and Lesley Munro took the role of Interim Chief Operating Officer in March 2017. *Mike Watts and Francis Davis joined the Trust in October 2016.
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Terms of Reference ToR The ToR were amended in June 2016 to reflect that the Audit & Risk Committee Chair could be a member of the Assurance Committee. Revised ToR were presented to the November 2016 meeting, following reflection on governance reviews undertaken by Internal Auditors KPMG, External Consultant Julie Jones and the CQC. It was agreed to commence the revised arrangements in January 2017.
Status against the achievement of the Committee’s Objectives
Objectives Year end
Any urgent matters of safety will be reported to Agenda planned accordingly for every meeting the Committee, at the commencement of each meeting.
A review of the frequency of meetings, duration Review delayed – because of delay in receiving CQC and remit (including membership) will take draft report. Draft report received late October and place during August 2016 – following discussion regarding frequency of meetings, duration and remit took place at November meeting… with consideration of recent external reviews, agreed changes taking place from January 2017. including the CQC Comprehensive Inspection at the end of June 2016
Clinical ownership of quality governance and The process of ‘deep dives’ and exception reporting regulatory compliance will continue to be re- enabled extremely detailed discussion of governance enforced and monitored through the focus on issues experienced by service lines to be discussed. exception and ‘deep dive’ reporting from each Clinical Directors (CDs) and Governance Leads(GLs) service line, with a positive encouragement for made candidness a virtue – a situation much candidness from CDs and others attending. appreciated by the Chair, as this enabled full feedback to be provided for the full Board.
The process for ‘deep dives’ changed from January 2017 – when CDs and GLs no longer, routinely, attended the Committee – but attended the Quality Improvement & Risk (QIR) group, as part of the revised ToR
Chief Operating Officers (COOs) and the chair of QIR provide exception reports, reflecting the content previously provided by CDs and GLs and a revised series of ‘deep dives’ into specific areas of Governance and Regulatory Compliance has been established
Safe Staffing will be monitored through the On-going and noted to remain a significant risk in receipt of the monthly service line updates and almost all service lines. quarterly corporate reporting.
The Committee will continue to receive, review On-going and comment upon the Corporate Risk Register
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(CRR) to accurately reflect the service lines’ perceptions of risks and mitigations. The parallel process of Trust Management Team review will continue to be considered to ensure there are no duplications or omissions.
The use of dashboards, reflecting performance Dashboards received for meetings from September will be received once deemed ‘fit for purpose’ 2016 onwards. The September meeting agreed to and used by Committee members to interrogate receive dashboards through to November 2016 and then consider future use. assurance provided from service lines. The COO and QIR exception reports have replaced the function partly envisaged of dashboards
The Committee will receive a report at each Verbal reports received, together with minutes from meeting of the Quality Improvement and Risk ‘historic’ QIR meetings were received at most Group and from other groups by exception Committee meetings, prior to January 2017. Subsequently, written reports were received for 2 of which will assist in the achievement of objective the 3 meetings held. 2.
Serious Incidents Requiring Investigations (SIRI) SIRI Panel including monthly mortality review including mortality will continue to be information received at each meeting, until January monitored through receipt of an exception 2017, and scrutinised as necessary. Since January 2017 SIR and Mortality Reviews have report from the Panel Chair and minutes been developed as ‘deep dives’ available on request.
Other reports will be received, following Other reports were received as requested and agreement by the Chair, CMO and CN required.
Summary of business conducted in year Highlights of the main business conducted by the Committee for the period April 2016 to and including November 2016 are summarised as follows;
Quality • The Committee were alerted to any Urgent Matters of Safety at each meeting. • Quality matters were reported as part of individual service line updates. • The Committee noted the Wessex Trust SAS Development Annual Report at the April 2016 meeting. • The draft Quality Accounts were presented for comment at the April 2016 meeting and final version was agreed for Board endorsement in May. • Mortality review updates were presented at each meeting including position updates on work to review policies and practices. The June 2016 meeting was informed of a revised interim process in place as part of the overall implementation plan. • The Chief Medical Officer provided a verbal update on the Homicide Review at the April 2016 Committee. A copy of the report and action plan was circulated with the minutes of the meeting. • The Recruitment and Retention Strategy was presented to the September 2016 meeting and it was noted that a Workforce and Performance sub-committee were to monitor the position going forward and the Assurance Committee would reflect on issues not being effectively addressed.
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Regulatory Compliance • 2014 CQC inspection ’Must’, ‘Should...’ and ‘Could do’ action positions were presented, prior to the June 2016 Inspection; to ensure the original recommendations were effectively closed off. • Initial feedback from the 2016 CQC Inspection, and arrangements for the Quality Summit were shared at the July 2016 meeting. • CQC Inspection outcomes and key findings for each Core Service were presented in detail to the November 2016 meeting.
Risk Assurance • The Committee received monthly updates on risks, via the QIR updates. • The Committee received a monthly SIRI (and HIgh Risk Incident (HIRI)) update, by way of an exception report. Challenges with the lack of investigators were highlighted. • The Health and Safety annual report for 15/16 was presented in July 2016 for onward reporting via exception to the September 2016 Board. • The Safeguarding annual report was presented.
Operational Policies • A list of the policies ratified by the Committee is appended to this report (see Appendix 1)
Assurances from Service Lines
Adult Mental Health Substance Misuse and Pharmacy • The Committee were alerted to staffing issues impacting on the service and of additional rostering oversight being implemented. The October 2016 Committee were informed of a key nursing tool in place to help address staffing pressures. • Issues with the s136 suite were noted and it was agreed that the Mental Health Act Scrutiny Committee (MHASC) would discuss further. • A deep dive was conducted in June 2016 and included a briefing on the March 2016 homicide investigation report under the new investigation regime. Assurance was also provided that all mixed sex accommodation issues were mitigated and ligature issues identified with action plans in place. • The Committee was informed of issues identified by the CQC of the Substance Misuse Service (SMS) and assurance was given of a comprehensive action plan in place. • Significant IT issues within the Crisis Resolution Home Treatment Team were highlighted. • A further deep dive was provided in September 2016 and third party provider data challenges with regards to the 136 suite were highlighted. An update was also provided on issues with prescription care planning within SMS and of sustainable changes in place to address.
Adults Services, Southampton • The April 2016 meeting received an update on the Health and Social Care Integration project. • The October 2016 Committee was briefed on risks associated with the Speech and Language Therapy service, post contract and of a response to a Trust letter sent, still awaited by commissioners. CEO involvement was agreed as a duty of care to service users, if deemed necessary.
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• The Committee was informed of significant staffing issues on Snowdon Ward and bed closure potential. It was agreed that Adults Portsmouth share techniques of their recruitment successes.
Adults Services, Portsmouth • A deep dive was conducted at the May 2016 meeting and an update was presented on the workforce review undertaken due to increasing staffing pressures. The Committee was assured of work being undertaken to mitigate risks and change working methods. The Committee was updated on staffing challenges throughout the year. • The Committee was informed of accommodation challenges at Medina House and the escalation of issues was confirmed. Updates were provided at subsequent meetings. • A second deep dive was conducted in October 2016 and context was provided on caseload numbers and activities. A pressure ulcer review process was explained. The Committee noted that additional incident information was being requested by CCGs and of work in progress on earlier CCG involvement with incident reporting.
Child & Family • Concern was raised regarding Personal Identifiable Data (PID) sent in error and the Committee considered different thresholds of accountability from clinical incidents and incidents within corporate supporting services. The matter was escalated to Executives for discussion and resolution. • The Committee was informed of Solent Bank Administration support challenges and of an increase in Information Governance incidents during times of temporary cover. • The Committee was assured of lessons learnt with regards to deaths and areas of improvement were identified. • Benefits of engagement with young people accessing the service during a membership event were highlighted. • Staff morale concerns due to transformation challenges were highlighted. • The Committee was informed of on-going work to focus on learning awareness of reported risks and of a database that triangulated incidents, SIRI, HRIs and plaudits.
Dental Services • A deep dive was presented at the April 2016 meeting where the Committee was updated on prison complaint issues and of a leaflet created to provide information to prisoners on treatment provision to ensure expectations were realistic. Annual staff survey results were shared and key issues highlighted. Contextual information was also provided on incidents and action plans in place. • Regular updates were provided on significant IT issues within the service line. The October 2016 Committee was informed of a spike in radiography IT issues. • Lift issues at the Eastleigh Health Centre, and increase in the number of home visits undertaken as a consequence were noted. • An additional day for General Anaesthesia had been reported to commence with UHS. • Safeguarding Training was noted to have failed to upload onto the Learning and Development system in August 2016.
Primary & Urgent Care • The Committee received a briefing on an in-health review being undertaken including issues relating to transport collection, waiting times being unacceptable.
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• Issues with spinal surgery and pressures within the Musculoskeletal Service were highlighted. Regular updates were provided. • The Committee was informed of continuity plans in place in readiness for the retirement of the Clinical Director, Dr Cliff Howells. • The Committee received a deep dive from the service line in July 2016 and was updated on improvements with IT connectivity. A briefing was provided on the recent 3 day CQC intensive inspections. • The successful recruitment of Accredited Nurse Practitioners and additional sessions of GP cover were noted at the September meeting. • Estates strategy with regards to aiding lift repairs was discussed at the October 2016 due to 4 lifts across sites in need of repair. The matter was escalated to Directors to consider and resolve.
Sexual Health Services • The Committee were made aware of access issues across the service and of a pilot being conducted to provide a same-day service, 2 days per week. Regular updates were to be provided. • IT issues were reported regularly. • Problems associated with the electronic Care Record system were noted and it was confirmed that the matter had been escalated and entered onto the Corporate Risk Register (CRR). • Accurate data reporting was discussed at the July 2016 meeting. It was confirmed that data checks had been carried out at the QIR Group meeting and it was agreed to continue with the reporting of dashboard and review at a later date. • The Committee were informed of a major incident relating to IT that involved an external organisation. IT was confirmed that a SIRI had been launched to investigate. • The October 2016 Committee were informed of the successful tender of the service. It was noted that issues with telephony and difficulties in reaching the service had been resolved.
Quality Improvement and Risk (QIR) Group Updates • The QIR received exception reports from each service line. Information Governance provided regular update reports. SIRIs, risks and complaint updates were also provided on a monthly basis. Verbal updates of the QIR were reported to Assurance Committees during meeting quick turnarounds. Historic and current exception reports were noted.
Other Matters • The Committee noted the Annual Governance Statement at the April 2016 meeting. • National changes to the clinical research approval process at the April 2016 meeting was explained. It was also noted that the Trust had been asked to sponsor Medicines and Healthcare Products Regulatory Agency (MHRA) registered study which was endorsed in principle pending further governance discussions. • The Safeguarding Adults and Children’s Annual Report and Infection Control Annual Report were noted at the July 2016 meeting. • The Clinical Audit and Effectiveness six monthly update was provided at the November 2016 meeting. • The Committee received the IG Compliance report, including national reviews and new General Data Protection Regulations.
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The format of the Committee changed from January 2017 following agreement of the revised Terms of Reference. Service line reports were presented via the QIR Group exception updates as well as, SIRIs, risks and complaints. From January, the Committee received Chief Operating Officer exception reports from Southampton and Hampshire Care Groups and Portsmouth Care Group.
Highlights of the main business conducted by the Committee for the period January 2017 to and including March 2017 are summarised as follows; • The January Committee received a Health and Safety update regarding improvements to Legionella prevention, ligature risk actions, lone working arrangements and workplace safety inspections. The Committee was assured that Health and Safety matters fulfilled statutory responsibilities. • CQC oversight updates were provided at each meeting and a deep dive presentation was provided at the March meeting, • The Committee received a deep dive from the Safeguarding Team and it was noted that the Trust was compliant with statutory duties and actions were being taken to address any deficits in relation to level 3 safeguarding training. • The Committee was updated on Freedom to Speak Up matters at each meeting. • An update on third party contracting and sub-contracting was provided at the January meeting. • The March 2017 Committee received a six monthly Medicines Management report. • Each meeting received a report from COOs to identify major risks to services and continued compliance with regulatory requirements. • An overview of programmes and deep dives were provided by Thematic Leads for Falls and Dementia at the January 2016 meeting. • Service Line Annual Governance Statements were presented to the February Committee for inclusion in the main Trust Annual Report. • The March meeting received a quarterly review of achievements against Quality priorities for noting.
A committee exception report was presented to the Board following each meeting.
Objectives for 2017-18
1. Any urgent matters of safety or concerns raised through the Freedom to Speak Up Guardian will be reported to the Committee, at the commencement of each meeting.
2. An Internal Audit review of the changes made, as a consequence of the revised ToR, will be sought during 2017/8 – to provide Assurance that the changes have not diluted the effectiveness of the work of the Committee
3. Exception reports, from the COOs and the chair of QIR, will be received at each meeting. the precise format of these may change, through-out the year; as the changes in arrangement become embedded
4. A series of ‘deep dives’, into specific areas of Governance and Regulatory Compliance, will be received at each meeting
5. Safe Staffing will be monitored through the receipt of the regular report from the Chief Nurse and, where necessary, by exception
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6. Other reports will be received, following agreement by the Chair, CMO and CN
Conclusion
The Committee has complied with its Terms of Reference during the period under review.
Report Mick Tutt, Non Executive Director and Assurance Committee Chair Author(s) Jayne Edwards, Corporate Support Manager and Assistant Company Secretary
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Appendix 1 – List of Policies agreed by Assurance Committee 2016-17
APRIL 2016 MAY 2016 • Policy for the Development and • Clinical Audit and Service Evaluation Policy Implementation of Procedural Documents • Management of Resuscitation Policy • Induction and Essential Training Policy • MRSA Policy • Records Management and Information • Fundraising Events Management Policy Lifecycle Management Policy for Clinical and • Donation and Charitable Gifts Policy Corporate Records • Policy for Self Administration of Medicines • Policy for Managing Performance of Medical on Inpatient Wards and Dental Staff • Hand Hygiene Policy • Safe Use of Display Screen Equipment and • Policy for Infection Prevention and Control Mobile Devices Policy Standards Precautions
JUNE 2016 JULY 2016 • Verification of Expected Death Policy • Policy for the Safe Handling and Disposal of • Uniform Policy Healthcare Waste • Clinical Risk Assessment and • Control of Substances Hazardous to Health Management Policy and Procedure (COSHH) Policy • Supporting Learning in Practice Policy • Overarching IV Policy • Management of Medical Devices • Long Term Segregation and Blanket (Equipment) Policy Restrictions Policy • Pay Protection Policy • DBS Check Policy • Dignity at Work Policy • Grievance Policy • Investigation Policy • Performance Management Policy • Suspension, Exclusion and Transfer Policy • Reporting Adverse Incidents • Tissue Viability Policy
SEPTEMBER 2016 OCTOBER 2016 • Operational Policy for the Use of Seclusion • Ligature Risk Assessment Policy Suite within Maple Ward • Registration of Professional Staff Policy • Standards of Business Conduct – Register of Interest, Gift and Hospitality Policy • Complaints Policy • Policy on Policies • Child and Young Person’s Advance Care Plan Policy • Equality, Diversity and Human Rights Policy • Preloading of Insulin Policy NOVEMBER 2016 JANUARY 2017 • Claim Management Policy • Isolation Policy • Mobile Working Policy • Staff Reward and Recognition Policy • Disciplinary Policy • Organisation Change and Consultation Policy • Chaperone Policy • Policy on Obtaining and Providing References • Anti-Fraud, Corruption and Bribery Policy • Urinary Catheter Policy
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• Management of Allegations of Abuse Against Staff Under Safeguarding Procedure • Consent to Examination and Treatment Policy • Information Governance Policy FEBRUARY 2017 MARCH 2017 • Dental Radiation Policy • Investigation Policy • Emergency Lockdown Policy • Suspect Package Policy • Pay Protection Policy • Suspension, Exclusion and Transfer Policy
10 Item 23.1 Exception and recommendation report
Committee Mental Health Act & Deprivation of Date of /Subgroup Liberty Safeguards Scrutiny Committee 18th May 2017 meeting name
Chair Report to Trust Board Mick Tutt
Key issues to be escalated This meeting took place at the Civic Offices in Portsmouth, for the first time; meaning that we have now ceased to meet within the old hospital buildings at St James we received an up-date from the Clinical Director (CD) for Children & Families services – who had been attempting to investigate an incident involving a young person under 18 years of age who had been taken to the s136 suite, last summer. He informed us of the limited progress made, because of the absence of information from the (then) 3rd party provider. He suggested that, within the revised arrangements for the operation of the suite, this situation was less likely to occur again and that, rather than continuing to pursue an historic matter, services should look to ensure more robust arrangements in future. In discussion committee members agreed that this was the most pragmatic way forward
also received a summary of the historic governance arrangements for the suite, during the time direct provision was from a 3rd party provider, from the Clinical Director (CD). This, again, emphasised the lack of robustness overall and suggested that both the 3rd party provider and Solent should accept responsibility for this – which we accepted we did so on the basis of receipt of a second set of improved data, which was necessary for the committee to scrutinise that the use of the suite fell within the expectations of the Code of Practice
also noted an up-date regarding the anticipated up-grade to the physical environment of the suite. We were informed that some, minor, improvements had been undertaken and others were programmed to take place, but that a date for the substantive renovation to the environment still had to be agreed with commissioners and Southern Health Foundation Trust – because of the requirement to provide sufficient facilities across Hampshire during the building works
received a draft Memorandum of Understanding, with Hampshire police, which provided local operational detail of expectations announced earlier this year for the role of the police within Solent services
received confirmation that the Service User Group had considered our request to receive copies of the minutes of their meetings and agreed to this, from the next (August) meeting
heard about good practice in the application of s4 (urgent admission on the recommendation of only one doctor) and admission of a young person aged under 18 years and that the improvement in compliance with the expectations of s132 (ensuring people were ‘read their rights’), and documentation generally, noted at the last meeting, appeared to have continued mhascexceptionreportmay17 Page 1
noted, however, that one person had continued to be held after the s5:2 (doctors holding power) had lapsed and that one person’s treatment had taken place without valid Consent. We heard management explanations for these exceptions and received assurances of the action being taken to minimise the risk of further occurrence
noted apparent variations in the application of s62 (provision of urgent treatment) and the management proposals to address this
were informed that the use of Community Treatment Orders had resumed and noted the continued use of long-term s17 leave. We received assurances from the Mental Capacity & Mental Health Act (MCA&MHA) lead and the CD that each individual application was appropriate and would be reviewed in accordance with overall arrangements for reviewing detention – including referral to a Managers’ (Associate Hospital Managers (AHM)) Hearing and/or Tribunal
received a first set of data related to the application of Deprivation of Liberty Safeguards (DoLS) across the Trust – as required by the revised Terms of Reference and as discussed at the last meeting. Receipt identified some learning needs for some committee members; in order to, appropriately, scrutinise the information and the MCA&MHA lead agreed that he would arrange this for the next (August) meeting It was noted that the area using DoLS most was Jubilee House in Portsmouth and the MCA&MHA lead outlined the reasons why this might be so. It was also noted that all three Local Authorities (LAs) (Hampshire County Council, Portsmouth City Council and Southampton City Council) had outstanding Applications for Authorisation and the MCA&MHA lead assured us of the process for reminding of their responsibilities
received reports of management action taken to review the use of restraint and seclusion. These contained confirmation that the use of both restraint and seclusion had been within the expectations of the Code of Practice, within mental health services As noted previously, the Kite Unit does not use seclusion, but we received a report of management action taken to review the use of restraint – which confirmed that this was within the expectations of the Code of Practice. We were also informed of the action taken, following the request of the Chief Nurse, to review the method of restraint used; to become compatible with that used within mental health services
received a draft of the Annual Report for the committee’s activity during 2016/7, ahead of formal receipt by the Board
received a proposal for the provision of learning and development opportunities to enable practitioners to work, appropriately, with people diagnosed with autism. We noted that further work was, probably, necessary – but supported the general direction of travel
noted the short summary of the implications of the publication from the Law Commission for the reform of Mental Capacity and Deprivation of Liberty, but decided to await any further indication of any change in the Mental Health Act 1983 and likely time-frames for progress through Parliament
mhascexceptionreportmay17 Page 2
Decisions made at the meeting
We agreed that
the report, from the CD, which recommended that the interim arrangement for the main door to Hawthorns ward remained locked, should be supported. We acknowledged that this action constituted a ‘blanket ban’, within the definition contained in the Code of Practice, but noted
i) the measures in place to enable those assessed as not at risk to leave the ward ii) the reported absence of adverse comment from people on the ward iii) that such a blanket ban was in keeping with ‘...the national trend...’
there needed to be an urgent consideration of the mechanisms management colleagues needed to utilise in order for the committee to discharge its duty, within the revised Terms of Reference, for oversight of the learning and development opportunities available for practitioners applying either the Mental Capacity Act 2005 or the Mental Health Act 1983. It was agreed that the Chair would be able to take Chair’s Action, ahead of the next meeting; to ensure the committee received some information to consider
the Fact Sheet for prospective AHM should be circulated to all existing AHM and other committee members
future meetings would alternate between the Civic Offices and the Trust Headquarters
the new (CQC) Mental Health Act Reviewer should be provided with full sets of documentation from the meetings and have an open invitation to attend
Recommendations to the Trust Board
the Board are asked to note the issues set out above
Other risks to highlight (not previously mentioned)
mhascexceptionreportmay17 Page 3
Mental Health Act Scrutiny Committee Annual Report 2016-17 Item 23.2
Introduction The Mental Health Act Scrutiny Committee (MHASC) is a formal Committee of the Solent NHS Trust Board with defined Terms of Reference (ToR) and as such is required to prepare an Annual Report on its work and performance in the preceding year for consideration by the Trust Board. This report summarises the Committee’s activity for the year to 31st March 2017.
Meetings During 2016-17 the following meetings were held:
• 19th May 2016 • 17th November 2016
• 18th August 2016 • 16th February 2017
Membership & Attendance Attendance by members is outlined as follows:
% attendance
May
August
th February 201 6 2016 201 7 201 6
November November th
th 19 th 18 16
NAME 17
Mick Tutt – Chair P P P P 100% Non Executive Director Jon Pittam P A P P 75% Non Executive Director Alistair Stokes P P P P 100% Trust Chairman Mandy Rayani P P A P 75% Chief Nurse Dr Dan Meron P A P A 50% Chief Medical Officer Alex Whitfield A A P P 50% Chief Operating Officer, Southampton Sarah Austin A P P P 75% Chief Operating Officer, Portsmouth *Francis Davis n/a n/a n/a P 100% Non Executive Director
P= Present A= Apologies
*Francis Davis joined the Trust in October 2016 and expressed an interest in becoming an Associate Hospital Manager (AHM) prior to the February ’17 meeting.
Terms of Reference The ToR were reviewed at the November 2016 meeting and consideration was given to the Committee’s role and the attendance of Associate Hospital Managers going forward. The revised ToR (to incorporate the application of Deprivation of Liberty Safeguards (DoLS) and training provision for both the Mental Capacity Act 2005 (MCA) and the Mental Health Act 1983 (MHA)) were endorsed by
1 the committee and ratified by the Board in January ‘17 Status against the achievement of the Committee’s Objectives
Objectives for 2016-17 Year end position
To continue to utilise the Mental Health Act Presented by the MCA&MHA Lead at every lead Report as a main vehicle for scrutinising meeting and matters of exception highlighted for compliance with the expectations of the Act. discussion / challenge / action.
This will continue to seek assurance in the Status: ongoing light of internal and external inspections, audits, reporting and national changes in policy, research and law.
To continue scrutiny of the use of seclusion, There is a standing item for reports to be restraint, seeking assurance from provided. Further refinement, to ensure full management reviews that the expectations assurance of compliance, must continue during 2017/8 of the Act and Code of Practice are adhered Status: ongoing with.
To re-consider the past decision to separate See note, regarding ToR above – the committee’s scrutiny of the application of the Mental remit was extended to incorporate the DoLS Capacity Act 2005 from the application of aspect of the MCA and further extended to include consideration of training for practitioners the Mental Health Act 1983, in the context in both MCA and MHA, for the February 2017 of the increasing convergence lead by case- meeting. Consideration of how appropriate law and the Law Commission Review 2015. arrangements to provide assurance on these aspects was commenced at the February ’17 meeting and is anticipated to be concluded at the May ’17 meeting With regard to AHM: • to continue the process of reflective Training provided at each meeting. Paul Barber training sessions at part B of the provided the annual MHA law update in January meeting, including at annual up-date ’16, and Simon Lindsey provided a further session from our solicitors in November ‘16
• to formally conduct a third round of Conducted during q1, with the decision to reviews/appraisals for AHM based recommend, to the Governance & Nominations on previous recommendations to the committee, the re-appointment of Pam Coen & Governance and Nominations Jon Pittam for 3 years and the re-appointment of Committee, reinforcing the Liz Burden, Richard Hibbert, Irene Jackson, Brian importance of attendance at both Mansbridge, Jackie Powell and Sue Rennison for parts of the quarterly committee 1 year with Tom Morton continuing to sit until meetings. suitable alternative arrangements were complete Both Richard Hibbert & Tom Morton stood down within the year 2016/7
• to engage a further round of Zenna Hopkins recommended, to the Governance
2 recruitment for additional AHM, & Nominations committee, for appointment in with the expectation being that at November ’16 for 3 years least one will be a person who has Francis Davis expressed an interest in becoming accessed services – liaising with the an AHM after commencing as a Non Executive Governance and Nominations Director and has undertaken the usual training in Committee regarding those to be preparation for the role appointed. A community venue for community hearings was offered in each case. This was confirmed for the • to continue to advocate for a choice Committee of venues for community hearings Status: ongoing Each service user was requested to give feedback on hearings. This was shared at Part B of the meeting. Status: ongoing
• to continue to review reasons for non–attendance (by those detained) at hearings
Summary of business conducted in year The majority of business conducted at the meetings was through the Mental Health Act Scrutiny Report; co-ordinated by the MCA&MHA Lead, with contributions from relevant clinical and service leads and seclusion reviews.
The report included an executive summary which highlighted key issues and guided committee members to more detail within the body of the document, as well as appendixes where necessary.
Governors attended the Committee, when available; to observe. There was also an opportunity to engage with the business of the Committee, through a specific agenda item. Governors were also encouraged to attend Part B.
Training sessions were provided during Part B of the meeting and psychiatrists as well as Executive Directors and other management colleagues were invited to attend, if the training was considered to be of value.
Following notification received, from the CQC; that Board endorsement of ‘Blanket Ban’ practice would be scrutinised, to ensure due process followed the Code of Practice 2016 for people detained under the MHA, services provided a list of items for inclusion within blanket bans which was reported onto the Board for approval, prior to the comprehensive (CQC) Inspection in June ‘16.
An update on plans to implement a Smoke Free Environment policy was provided at the August 2016 meeting.
Exception reports of the MHASC were presented to the Board following each meeting.
3 Part B training sessions provided 19th May 2016 Mental Health Act and Mental Capacity Act Update (from Paul Barber’s presentation January 2016) 18th August 2016 Physical Health Care in Mental Health – Jacqui Young
17th November 2015 Current service provision – operational arrangements for residential and community services
18th February 2016 Information Governance Training
Objectives for 2017-18 1. To continue to utilise the MCA&MHA lead Report as a main vehicle for scrutinising compliance with the expectations of the MHA. This will continue to seek assurance in the light of internal and external inspections, audits, reporting and national changes in policy, research and law.
2. To continue scrutiny of the use of seclusion, restraint, seeking assurance from management reviews that the expectations of the Act and Code of Practice are adhered with.
3. To refine the scrutiny of the application of DoLS, across the Trust and the outcomes of training provided for practitioners on the MCA and MHA
4. With regard to AHM:-
• to continue the process of reflective training sessions at part B of the meeting, including at annual up-date from our solicitors • to formally conduct a fourth round of reviews/appraisals for AHM, based on previous recommendations to the Governance and Nominations Committee • to continue to advocate for a choice of venues for community hearings • to continue to review reasons for non–attendance (by those detained) at hearings
Conclusion The Committee has complied with its Terms of Reference, including those revised after November ’16, during the period under review. Report Mick Tutt, Non Executive Director and Assurance Committee Chair Author(s) Jayne Edwards, Corporate Support Manager, Assistant Company Secretary
4 Item 24
In Public Board Meeting Confidential Board Meeting Presentation to X
Title of Paper Freedom To Speak Up
Author(s) Mandy Sambrook, Freedom to Executive Sponsor Speak Up Guardian Date of Paper 12TH May 2017 Committees presented Link to CQC Key Lines Safe Effective Caring Responsive Well Led of Enquiry (KLoE) / / / / Action requested of To receive For decision the Board / We have made progress in a number of areas and this report describes these achievements to date as well as some of the challenges encountered. While there is good progress in the NHS there is still a distance to go to create a universally open and honest culture.
Within Solent, the Freedom to Speak up Guardian programme is being delivered with a Lead Guardian appointed, along with six guardians working within each care group.
The Freedom to Speak Up Steering Group has been established, the composition of which includes;
• Chief Executive: Sue Harriman
• Jon Pitman: Non-Executive Director:
• Lead Guardian: Mandy Sambrook BSC RSCN Public Health
The role of the Freedom to Speak up Guardian
The lead guardian is working within a national framework along with professional bodies and systems regulators to ensure that there is a process;
- for staff to raise concerns - to ensure that issues are acted upon in a timely way - to ensure that staff are not penalised as a result and that - feedback is provided to staff on actions taken.
Additional Lead Guardian duties include; - Commence facilitation of discussion between staff and management, not to solve concerns raised - Promotion of the role - Further develop a culture of openness and freedom for staff to raise concerns to their managers that will be explored and resolved and lessons shared - Escalate and Support
The Freedom to Speak up Team is providing support to ensure that their role meets the needs of staff and will support the cultural change that we wish to see across England. Freedom to Speak Up Guardians are already making themselves available to all staff, including new starters at induction. They are also attending team meetings, proactively promoting speaking up, and being contacted by staff who want to speak up.
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All guardians have received Innovative training, supported by Health Education England and Public Concern at Work.
Policy and Reporting
The Trusts Whistle Blowing Policy has been updated to identify a lead Freedom to Speak Up Non- Executive Director as well as the Freedom to Speak up Guardians. The pathway for raising Freedom To Speak up issues has also been included.
Current Cases
There are currently 10 cases being considered. All cases are confidential and independent of our HR processes. A summary of these is outlined below;
- 3 x Attitudes and Behaviours - 2 x Policies and Procedures - 1 x Quality and Safety: Entered 28.02.17 - 2 x Service Changes - 1 x Patient Experience One case currently under review.
National Guardianship
The Freedom to Speak up Report, published in February 2015, describes the functions of the National Guardian office as follows:
- Support Freedom to Speak up Guardians in NHS Trusts and Foundation Trusts - Provide national leadership on issues relating to raising concerns by NHS workers - Review the handling of concerns raised by NHS workers, and/or the treatment of the person or people who spoke up where there is cause for believing that this has not been in accordance with good practice - Advise NHS organisations to take appropriate action where they have failed to follow good practice, or advise the relevant systems regulator to make a direction to that effect - Offer guidance on good practice about handling concerns - Ensure transparency and publish reports on the activities of this office.
There are challenges ahead to ensure all NHS Trusts and Foundations Trusts have effective and thriving freedom to speak up cultures within their respective organisations. Despite the good work being implemented, there are currently inconsistencies across England and it is acknowledged that there is much to learn and improve upon.
Board Recommendation
The Board is asked to receive the update.
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Item 25.1
In Public Board Meeting Confidential Board Meeting Presentation to x Governance documentation updates – amendments to key documents Title of Paper
Rachel Cheal, Associate Dir. Sue Harriman, Chief Executive Author(s) Corporate Affairs & Company Executive Sponsor Secretary Date of Paper 12th May 2017 Committees presented Link to CQC Key Lines Safe Effective Caring Responsive Well Led of Enquiry (KLoE) X Action requested of To receive For decision the Board X
The following governance documentation has been reviewed and updated (changes tracked in red font):
• Board Terms of Reference (TOR) - the TORs have been reviewed to reference the Hampshire and Isle of Wight Sustainability & Transformation Plan, Control Total and notably proposed changes to the voting executive members. Current executive voting members include: the Chief Executive Officer, Director of Finance & Performance, Chief Medical Officer, Chief Nurse with the final executive vote previously residing with the Chief Operating Officer Southampton and County. In light of the recent changes to executive personnel at the Board and to ensure there is no disparity between the Operating Officers, it is recommended that the final executive vote resides with the Chief People Officer. • Board Code of Conduct – the Code of Conduct has been reviewed; there are no material changes to note. References to Foundation Trust/ Monitor and the Model Constitution have been deleted and reference to Freedom to Speak Up included. • Remuneration Committee Terms of Reference (TOR) – the TORs have been refreshed, amending reference from the Trust Development Authority (TDA) to NHS Improvement (NHSI). Changes to the new title of Chief People Officer (as opposed to the Director of HR and OD) have also been included.
Recommendation:
The Board is asked to:
• Approve the changes to the Board Terms of Reference (Item 25.2) • Approve the changes to the Board Code of Conduct (Item 25.3) • Approve the changes to the Remuneration Committee Terms of Reference (Item 25.4)
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Solent NHS Trust Item 25.2 Trust Board Terms of Reference
Reference to “the Board” shall mean the Trust Board
1 Constitution 1.1 The Board is accountable to the Secretary of State for the effective direction of the affairs of Solent NHS Trust, setting the strategic direction and appetite for risk of the Trust, establishing arrangements for effective governance and management and holding management to account for delivery, with particular emphasis on the safety and quality of the Trust’s services and achievement of the required financial performance
1.2 The Board has established the following Committees: • Audit & Risk Committee • Governance & Nominations Committee • Remuneration Committee • Mental Health Act Scrutiny Committee • Assurance Committee • Finance Committee • Charitable Funds Committee
2. Purpose 2.1 The purpose of the Trust Board is to govern the organisation effectively and ensure that the Trust is providing safe, high quality, patient-centred care.
The Board leads the Trust by undertaking the following key roles: 2.2 • Ensure the management of staff welfare and patient safety • Formulating Strategy, defining the organisations purpose and identifying priorities • Ensuring accountability by holding the organisation to account for the delivery of the strategy and scrutinising performance • Seeking assurance that systems of governance and internal control are robust and reliable and to set the appetite for risk • Shaping a positive culture for the board and the organisation.
3 Duties 3.1 Clinical Standards and Patient Safety 3.1.1 To receive reports which provide assurance of the quality and safety of healthcare services, education, training and research delivered by Solent NHS Trust, by applying the principles and standards of clinical governance set out by the Department of Health, the Care Quality Commission and other relevant NHS bodies and assure the Board that areas of concern are being monitored.
3.1.2 To ensure compliance with all legal and regulatory requirements and clinical guidance monitoring performance against the Care Quality Commission requirements and ensuring that effective systems operate for the dissemination of National Guidance and directives
3.1.3 To oversee the risk management strategy implementation of Solent NHS Trust, and ensure appropriate action in relation to adverse events that occur.
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3.1.4 To ensure a focus on quality at strategic and operational levels including patient safety (including Healthcare Associated Infections), effectiveness and patient experience as well as the promotion of health and wellbeing
3.1.5 To be responsible for overseeing the development and implementation of a workforce strategy, ensuring the workforce meets the needs of the organisation and is fit for purpose.
3.2 Formulate Strategy 3.2.1 To set the strategic direction to be pursued by the Trust being cognisant of the Sustainability and Transformation Plan for Hampshire and the Isle of Wight
3.2.3 To develop and approve a long term clinically informed Trust Strategy which is designed to bring healthcare benefit to the population, build reputation and ensure the sustained success of Solent NHS Trust enabling the organisation to compete effectively in the healthcare market.
3.2.4 To oversee the implementation of the long term financial model (LTFM) to deliver the long term success of Solent NHS Trust as well as oversight of the achievement of the Trust’s Control Total.
3.2.5 To ensure the necessary financial and human resources are in place to meet strategic objectives and review management performance.
3.2.6 To approve business cases and new business opportunities as recommended by the Chief Executive, Trust Management Team Meeting (TMT) and Finance Committee and in accordance with the Trust’s SFI’s and Scheme of Delegation
3.2.7 To approve the development of innovative models of service delivery and redesign proposed by the Chief Executive and TMT
3.2.8 To ensure that a Board development and organisational development plans are in place to support the Trust’s delivery of the strategic direction.
3.3 Shape Culture & Partnership Working 3.3.1 To foster positive and productive external relationships with partners and stakeholders in the local health economy, in particular with patient/user groups and forums; Local Authority, Health and Wellbeing Board, Sustainability & Transformation Plan partners, Healthwatch and Primary Care.
3.3.2 To maintain public and staff confidence and engagement with Solent NHS Trust and facilitate the effective involvement of the public
3.3.3 To ensure that the culture of the organisation reflects NHS values as reflected in the NHS Constitution, namely: respect and dignity; commitment to quality of care; compassion; improving lives; working together for patients and everyone counts.
3.4 Performance Management 3.4.1 To continuously monitor and respond to performance of all Solent NHS Trust services ensuring close links to operational plan objectives and vital signs.
3.4.2 To agree and approve SLAs with NHS providers.
3.4.3 To consider directives, comments and recommendations from the Board’s committees and take
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the appropriate action.
3.5 Governance 3.5.1 To be assured that an appropriate governance framework of prudent and effective controls is in operation which enables resources and risk to be assessed and managed allowing transparency, probity, integrity and the efficient use of resources.
3.5.2 To deliver financial balance/surplus and continuously monitor the organisations viability as a going concern
3.5.3 To approve the Annual Report, Quality Account and Annual Accounts
3.5.4 To be responsible for ensuring the effective stewardship of assets
3.5.5 To provide advice concerning action against litigation.
3.5.6 To receive and review the Board Assurance Framework and request the presentation of reports where additional assurance is required.
3.5.7 To embed the Learning Organisation and Quality Improvement ethos into all activities.
4 Membership 4.1 The Trust Board will comprise the following: Voting members: • Independent Chair (Chairperson) • Five Non-Executive Members • Chief Executive • Chief Nurse • Director of Finance & Performance • Chief Medical Officer • Chief People Officer
Non voting members: • Chief Operating Officer Portsmouth and Commercial Strategy • Chief Operating Officer Southampton and County
4.2 In the case of the number of votes for and against a motion being equal, the Chair of the Board will have a second, casting vote.
4.3 A manager who has been appointed formally to act up for an officer member during a period of incapacity or temporarily to fill an officer member vacancy, shall be entitled to exercise the voting rights of the officer member.
4.4 Members will be expected to attend at least 75% of meetings.
4.5 When an executive director member is unable to attend a meeting, a nominated deputy must be identified. The nominated deputy must be a direct report to the Board member.
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5 Attendees 5.1 The following will be attendees at the meeting; • Associate Director of Corporate Affairs and Company Secretary • Corporate Support Manager and Assistant Company Secretary
5.2 In addition, lead officers representing other services/departments may attend when required or at the invitation of the Chair.
6 Secretary 6.1 The Corporate Support Manager or their nominee shall act as the secretary of the committee.
6.2 The administration of the meeting shall be supported by the Corporate Support Manager who will arrange to take minutes of the meeting and provide appropriate support to the Chairman and committee members.
The agenda and any working papers shall be circulated to members five working days before the date of the meeting.
7 Quorum 7.1 No business shall be transacted at meetings of the Board unless the following are present; • a minimum of two Executive Directors • at least two Non-Executive Directors including the Chair or a designated Non- Executive deputy Chair
8 Frequency 8.1 Meetings will be held every other month or more frequently if required, under the Chairmanship of the Solent NHS Trust Chair.
8.2 The following meetings will be held: • Seminar (to brief the Board on current issues) • In Public Meeting • Confidential Meeting
8.3 Additional Board Development Workshops will be scheduled throughout the year as appropriate to support Board development and strategic planning.
9 Notice of meetings 9.1 Meetings shall be summoned by the secretary at the request of the Chairman.
9.2 Unless otherwise agreed, notice of each meeting confirming the venue, time and date together with an agenda of items to be discussed, shall be forwarded to each member and any other person required to attend, no later than 5 working days before the date of the meeting. Supporting papers shall be sent to members and to other attendees as appropriate, at the same time.
10 Minutes of meetings 10.1 The secretary shall minute the proceedings of all meetings, including recording the names of those present and in attendance.
10.2 The secretary shall ascertain, at the beginning of each meeting, the existence of any conflicts of
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interest and minute them accordingly.
10.3 Minutes of meetings shall be circulated promptly to all members once agreed.
10.4 Minutes will be available under the Freedom of Information Act 2000.
11 Authority 11.1 The Board may : • seek any information it requires from any employee of the Trust in order to perform its duties • obtain, at the Trust’s expense, outside legal or other professional advice on any matter within its terms of reference, and • call any employee to be questioned at a meeting of the Board as and when required.
12 Reporting 12.1 The Board will develop an Annual Cycle of Business where scheduled items throughout the year will be presented.
12.2 The Board will receive copies of minutes, and updates (including exception reporting) from its reporting Committees via the relevant Committee Chairs
12.3 The Chairs of Committees will also be responsible for ensuring relevant information and decisions are reported and cascaded back through the appropriate communication channels.
12.4 The Board will receive project reports on an ad-hoc basis.
12.5 Member’s attendance at meetings will be disclosed in the Trust’s Annual Report.
Version 7 Agreed at Trust Board May 2017
Date of Next Review May 2018
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Item 25.3 Board of Directors: Code of Conduct
To outline the behaviours and Purpose of Agreement requirements expected of the Board
Reference Number Solent/Corporate / BoDCoC/01 Version Version 4 Name of Approving Board of Directors Committees/Groups Operational Date May 2017 Document Review Date May 2018
Document Sponsor (Name & Job Alistair Stokes, Chairman Title) Document Manager (Name & Job Rachel Cheal, Company Secretary Title)
Version Summary of amendments 2 Overall document review and incorporation of Regulation 5 Fit and Proper Person requirements – amended Appendix 2. 3 Annual Review- updated section 3.1 to reflect new organisational values, changes made to reference ‘Members Council’ throughout, no other material amendments required 4 Annual Review
Foreword – this Code of Conduct applies specifically to the Board of Directors (as defined below); however the principles described equally apply to all members of staff.
1. Introduction
1.1 High standards of corporate and personal conduct are an essential component of public services. Solent NHS Trust is required to comply with the principles of best practice applicable to corporate governance in the NHS/health sector and with any relevant Code of practice.
1.2 The purpose of this Code is to provide clear guidance on the standards of conduct and behaviour expected of the 1Board of Directors.
1.3 This Code, with the NHS Constitution (and the Code of Conduct for the Members Council) forms part of the framework designed to promote the highest possible standards of conduct and behaviour within the Trust.
1.4 The Code is intended to operate in conjunction with the Standing Orders. The Code applies at all times when the Board are carrying out the business of the Trust or representing the Trust.
1.5 The Board must also comply with the statutory and general duties requirements conferred by legislation as set out in the NHS Act 2006 (“NHS Act”), as amended by the Health & Social Care Act 2012 (“HSCA”). 1.6 The Board must also comply with the following;
• Standards for NHS Board Members 2012 • Code of Conduct - Code of Accountability in the NHS 2004
2. Principles of public life
All Directors are expected to abide by the Nolan principles of: selflessness, integrity, objectivity, accountability, honesty, transparency and leadership:
2.1 Selflessness: Holders of public office should act solely in terms of the public interest: they should not do so in order to gain financial or other benefits for themselves, their family or their friends.
2.2 Integrity: Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties.
2.3 Objectivity: In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit alone.
1 For the purpose of this document the Board of Directors/ Directors means, Board members (voting) and non-voting (i.e. other executive directors and lay members)
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2.4 Accountability: Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office.
2.5 Openness: Holders of public office should be as open as possible about all the decisions and actions they take: they should give reasons for their decisions and restrict information only when the wider public interest clearly demands.
2.6 Honesty: Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.
2.7 Leadership: Holders of public office should promote and support these principles by leadership and example.
3. Corporate vision & values
3.1 Solent NHS Trust Board of Directors will also adhere to the following organisational values developed with staff and the Board:
4. General Principles
4.1 The Board of Directors has a duty to conduct business with probity, to respond to staff, patients and suppliers impartially, to achieve value for money from the public funds with which they are entrusted and to demonstrate high ethical standards of personal conduct.
4.2 The general duty of the Board of Directors and of each Director individually, is to act with a view to promoting the success of the Trust so as to maximise the benefits for service users and for the public.
4.3 The Board of Directors therefore undertakes to set an example in the conduct of its business and to promote the highest corporate standards of conduct. The Board of Directors will lead in ensuring that the provisions of the Standing Orders, Financial Standing Orders and an accompanying Scheme of Delegation conform to best practice and serve to enhance standards of conduct.
4.4 The Board of Directors expects that this Code will inform and govern the decisions and conduct of all Directors.
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5. Confidentiality and Access to Information
5.1 Directors must comply with the Trust’s confidentiality policies and procedures.
5.2 Directors must not disclose any confidential information, except in specified lawful circumstances.
5.3 Information on decisions made by the Board of Directors and information supporting those decisions should be made available in a way that is understandable.
5.4 Positive responses should be given to reasonable requests for information and in accordance with the Freedom of Information Act 2000 and other applicable legislation and Directors must not seek to prevent a person from gaining access to information to which they are legally entitled.
5.5 The Trust has adopted policies and procedures to protect confidentiality of personal information and to ensure compliance with the Data Protection Act, the Freedom of Information Act and other relevant legislation which will be followed at all times by Board of Directors and all staff.
5.6 As part of this Code of Conduct, the Board are asked to confirm their agreement with the Non-Disclosure Agreement, located in Appendix 1.
6. Register of Interests
6.1 Directors are required to register all relevant interests on the Trust’s register of interests in accordance with the provisions of the Standing Orders.
6.2 It is the responsibility of each Director to update the register entry if their interests change.
6.3 A pro forma is available from the Company Secretary - failure to register a relevant interest in a timely manner may constitute a breach of this Code.
7. Conflicts of Interest
7.1 Directors have a statutory duty to avoid a situation in which they have (or can have) a direct or indirect interest that conflicts (or possibly may conflict) with the interests of the Trust.
7.2 Directors have a further statutory duty not to accept a benefit from a third party by reason of being a Director or for doing (or not doing) anything in that capacity.
7.3 If a Director has in any way a direct or indirect interest in a proposed transaction or arrangement with the corporation, the Director must declare the nature and extent of that interest to the other Directors. It is equally important to register any potential conflicts.
7.4 If such a declaration proves to be, or becomes, inaccurate or incomplete, a further declaration must be made. Any such declaration must be made at the earliest opportunity and before the Trust enters into the transaction or arrangement.
7.5 The Chair will advise directors in respect of any conflicts of interest that arise during Board of Directors meetings, including whether the interest is such that the Director should withdraw from the meeting for the period of the discussion.
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7.6 In the event of disagreement it is for the Board of Directors to decide whether a Director must withdraw from the meeting. The Company Secretary will provide advice on any conflicts that arise between meetings.
7.7 Further information can be found within the Standing Orders.
8. Gifts and Hospitality
8.1 The Board of Directors will set an example in the use of public funds and the need for good value in incurring public expenditure.
8.2 The use of the Trust for hospitality and entertainment, including hospitality at conferences or seminars, will be carefully considered.
8.3 All expenditure on these items should be capable of justification as reasonable in the light of the general practice in the public sector. The Board of Directors is conscious of the fact that expenditure on hospitality or entertainment is the responsibility of management and is open to be challenged by the internal and external auditors and that ill-considered actions can damage the reputation of the Trust in the eyes of the community.
8.4 The Board of Directors has adopted a Standards of Business Conduct – Register of Interests, Gifts and Hospitality Policy which will be followed at all times by Directors and all employees. Directors and employees must not accept gifts or hospitality other than in compliance with this policy.
9. Freedom to Speak Up /Whistle – Blowing
9.1 The Board of Directors acknowledges that staff must have a proper and widely publicised procedure for voicing complaints or concerns about maladministration, malpractice, breaches of this Code and other concerns of an ethical nature.
9.2 The Board of Directors has adopted a Freedom to Speak Up Policy (whistle-blowing policy) on raising matters of concern which will be followed at all times by Directors and all staff. The policy sets out the arrangements and procedures to be followed in situations where staff wish to raise a concern, the document also outlines the scrutiny and oversight by the Audit & Risk Committee.
10. Personal Conduct
10.1 Directors are expected to conduct themselves in a manner that reflects positively on the Trust and not to conduct themselves in a manner that could reasonably be regarded as bringing their office or the Trust into disrepute.
10.2 Specifically Directors must:
• Act in the best interests of the Trust and adhere to its values and this Code of Conduct
• Respect others and treat them with dignity and fairness
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• Seek to ensure that no one is unlawfully discriminated against and promote equal opportunities and social inclusion
• Be honest and act with integrity and probity
• Contribute to the workings of the Board of Directors as a Board member in order for it to fulfil its role and functions
• Recognise that the Board of Directors is collectively responsible for the exercise of its powers and the performance of the Trust
• Raise concerns and provide appropriate challenge regarding the running of the Trust or a proposed action where appropriate
• Recognise the differing roles of the Chair, Deputy Chair, Senior Independent Director, Chief Executive, Executive Directors and Non-Executive Directors
• Make every effort to attend meetings where practicable
• Adhere to good practice in respect of the conduct of meetings and respect the views of others
• Take and consider advice on issues where appropriate
• Acknowledge the responsibility of the Members Council to represent the interests of the Trust’s members and partner organisations in the governance and performance of the Trust, and to have regard to the views of the Members Council
• Not use their position for personal advantage or seek to gain preferential treatment; nor seek improperly to confer an advantage or disadvantage on any other person
• Accept responsibility for their performance, learning and development.
11. Fit and Proper Person Requirements
11.1 In accordance with Monitor’s NHS Provider Licence Condition G4 and Regulation 5 of the Regulated Activities Regulations, Health & Social Care Act 2008, Directors are asked to confirm their compliance with the Fit and Proper Persons Test as outlined in Appendix 2. Although the Fit and Proper Person requirements of Regulation 5 do not apply to the Members Council, the Trust has implemented its own governance procedures, including reference to Fit and Proper Person requirements within the draft constitution (as per Monitor’s model template), the introduction of standard DBS checks, and Companies House checks.
12. Fraud, Corruption and Bribery
12.1 In accordance with the Bribery Act 2010 and the Trust’s ‘Fraud, Corruption & Anti –Bribery Policy’, Solent NHS Trust is committed to supporting anti-bribery and corruption initiatives and recognises the importance of ensuring that there are appropriate policies and procedures in place to ensure that all staff are aware of their responsibilities. Solent NHS
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Trust is absolutely committed to maintaining an honest, open and well-intentioned atmosphere. It is also committed to the elimination of any fraud within the Trust and to the rigorous investigation of any such cases. The Board of Directors will comply with the Trust’s policy.
13. Board Principles regarding meeting etiquette and administration
14.1 Principles of meeting etiquette and administration are summarised in Appendix 3.
14. Compliance
14.1 The members of the Board of Directors will satisfy themselves that the actions of the Board of Directors in conducting Board business fully reflect the values, general principles and provisions in this Code and, as far as is reasonably practicable, that concerns expressed by staff or others are fully investigated and acted upon.
14.2 All directors, on appointment, will be required to give an undertaking to abide by the provisions of this Code of conduct.
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Appendix 1 - Non Disclosure Agreement
Dear Director
As a member of the Board of Directors, you will hold a valued and trusted position within our organisation. In the course of discharging your role, you will receive Confidential Information (please see further below). To protect the interests of the Trust and its service users, the Code of Conduct expects you to agree to respect the confidentiality of such information.
Please confirm your agreement to do so by signing and returning to the Trust the enclosed compliance form. Please direct any questions you may have to the Trust Secretary.
For the purposes of this commitment, “Confidential Information” means:
(a) all information (whether communicated orally or in writing) relating to the business, financial, staff or other affairs of the Trust disclosed to you in your capacity as a Director of the Trust (including, without limitation, agendas and minutes relating to meetings); but excluding any information already in the public domain (for example, Part 1 In Public Board agendas and associated papers) and
(b) all notes, memoranda or other documents prepared by you which contain, reflect or are generated from the information referred to in (a) above.
If you are in any doubt as to whether particular information is Confidential Information, please check with the Trust Secretary.
It is worth emphasising that the Trust is committed to transparency and openness, as well as to meeting its statutory obligations. To be clear, nothing in this letter or the commitment which it seeks from you shall prejudice any rights that you may have under the Public Interest Disclosure Act 1998 and/or any obligations that you have or may have to raise concerns about patient safety and care with regulatory or other appropriate statutory bodies pursuant to applicable professional and ethical obligations (including those obligations set out in guidance issued by regulatory or other appropriate statutory bodies from time to time).
Yours sincerely
Rachel Cheal, Associate Director of Corporate Affairs & Company Secretary, on behalf of Solent NHS Trust.
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Appendix 2 - Fit and Proper Person Declaration
Pre-employment and annual declaration for Director and
Director-equivalent posts
Solent NHS Trust (“the Trust”)
1. It is a condition of employment that those holding director and director-equivalent posts provide confirmation in writing, on appointment and thereafter on demand, of their fitness to hold such posts. Your post has been designated as being such a post. Fitness to hold such a post is determined in a number of ways, including (but not exclusively) by Monitors NHS Provider Licence Condition G4, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2008 (“the Regulated Activities Regulations”), and the Trust’s draft constitution (which will come into force at the point of being licenced).
2. By signing the declaration below, you are confirming that you do not fall within the definition of an “unfit person” or any other criteria set out below, and that you are not aware of any pending proceedings or matters which may call such a declaration into question.
Monitors NHS Provider Licence Condition G4,
3. Condition G4 provides that the Licensee shall not appoint as a director any person who is an unfit person, except with the approval in writing of Monitor.
4. Directors contracts contain a provision permitting summary termination in the event of a director being or becoming an unfit person. The Trust shall also ensure that it enforces that provision promptly upon discovering any director to be an unfit person, except with the approval in writing of Monitor.
(Regarding governors, no person who is unfit may become or continue as a governor, except with the approval in writing from Monitor).
If Monitor has given approval in relation to any person in accordance with the above the Trust shall notify Monitor promptly in writing of any material change in the role required or performance by that person.
5. An “unfit person” is defined at condition G4 as:
(a) an individual:
(i) who has been adjudged bankrupt or whose estate has been sequestrated and (in either case) has not been discharged; or
(ii) who has made a composition or arrangement with, or granted a trust deed for, his creditors and has not been discharged in respect of it; or
(iii) who within the preceding five years has been convicted in the British Islands of any offence and a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on him; or
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(iv) who is subject to an unexpired disqualification order made under the Company Directors’ Disqualification Act 1986; or
(b) a body corporate, or a body corporate with a parent body corporate:
(i) where one or more of the Directors of the body corporate or of its parent body corporate is an unfit person under the provisions of sub-paragraph (a) of this paragraph, or
(ii) in relation to which a voluntary arrangement is proposed under section 1 of the Insolvency Act 1986, or
(iii) which has a receiver (including an administrative receiver within the meaning of section 29(2) of the 1986 Act) appointed for the whole or any material part of its assets or undertaking, or (iv) which has an administrator appointed to manage its affairs, business and property in accordance with Schedule B1 to the 1986 Act, or
(v) which passes any resolution for winding up, or
(vi) which becomes subject to an order of a Court for winding up.
Regulated Activities Regulations
6. Regulation 5 of the Regulated Activities Regulations states that the Trust must not appoint or have in place an individual as a director, or performing the functions of or equivalent or similar to the functions of, such a director, if they do not satisfy all the requirements set out in paragraph 3 of that Regulation.
7. The requirements of paragraph 3 of Regulation 5 of the Regulated Activities Regulations are that:
(a) the individual is of good character;
(b) the individual has the qualifications, competence, skills and experience which are necessary for the relevant office or position or the work for which they are employed;
(c) the individual is able by reason of their health, after reasonable adjustments are made, of properly performing tasks which are intrinsic to the office or position for which they are appointed or to the work for which they are employed;
(d) the individual has not been responsible for, privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity or providing a service elsewhere which, if provided in England, would be a regulated activity; and
(e) none of the grounds of unfitness specified in Part 1 of Schedule 4 apply to the individual.
8. The grounds of unfitness specified in Part 1 of Schedule 4 to the Regulated Activities Regulations are:
(a) the person is an undischarged bankrupt or a person whose estate has had sequestration awarded in respect of it and who has not been discharged;
(b) the person is the subject of a bankruptcy restrictions order or an interim bankruptcy restrictions order or an order to like effect made in Scotland or Northern Ireland;
(c) the person is a person to whom a moratorium period under a debt relief order applies under Part VIIA (debt relief orders) of the Insolvency Act 1986;
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(d) the person has made a composition or arrangement with, or granted a trust deed for, creditors and not been discharged in respect of it;
(e) the person is included in the children’s barred list or the adults’ barred list maintained under section 2 of the Safeguarding Vulnerable Groups Act 2006, or in any corresponding list maintained under an equivalent enactment in force in Scotland or Northern Ireland;
(f) the person is prohibited from holding the relevant office or position, or in the case of an individual for carrying on the regulated activity, by or under any enactment.
Trust’s draft constitution
9. The Trust’s constitution (section 35) places a number of restrictions on an individual’s ability to become or continue as a director. A person may not become or continue as a director of the Trust if:
• a person who has been adjudged bankrupt or whose estate has been sequestrated and (in either case) has not been discharged.
• a person who has made a composition or arrangement with, or granted a trust deed for, his creditors and has not been discharged in respect of it.
• a person who within the preceding five years has been convicted in the British Islands of any offence if a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on him;
• a person who, in the case of a non executive director other than the initial non-executive directors, no longer satisfies paragraph 29 (if applicable);
• a person whose tenure of office as a chairman or as a member or Director of a health service body has been terminated on the grounds that his appointment is not in the interests of public service, for non-attendance at meetings, or for non-disclosure of a pecuniary interest;
• a person who has had their name removed from a list maintained by a direction under any NHS act or has otherwise been disqualified or suspended from any healthcare profession, and has not subsequently had their name included in such a list or had their qualification re-instated or suspension lifted (as applicable), and due to such reasons is considered by the Trust to be unsuitable to be a Director;
• a person who by reference to information revealed by a disclosure and barring service (established under section 87 of the Protection of Freedoms Act 2012) check is considered by the chief executive to be inappropriate on the grounds that their appointment may adversely affect public confidence in the Trust or otherwise bring the Trust into disrepute;
• a person who has, or has been in the last five years prior to their application to be a member, been involved as a perpetrator in a serious incident of assault or violence, or in one or more incidents of harassment, against any of the Trust’s employees or other persons who exercise functions for the purposes of the Trust (including volunteers), and following such behaviour has been asked to leave, has been removed or excluded from any hospital, premises or establishment, in accordance with the relevant Trust policy for withholding treatment from violent / aggressive patients;
• a person who has within the preceding two years been dismissed, otherwise than by reason of redundancy, from any paid employment with a health service body;
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• a person who is a governor of the Trust or an executive or non-executive director or a governor of another NHS foundation trust, an executive or non-executive director, chair, chief executive officer of another Health Service Body or a body corporate whose business includes the provision of health care services, or which includes the provision of any service to the Trust;
• a person who is a member of a local authority health overview and scrutiny committee;
• a person who is a subject of a disqualification order made under the Company Directors' Disqualification Act 1986;
• a person who has failed without reasonable cause to fulfil any training requirement established by the Board of Directors;
• a person who has failed to sign and deliver to the Secretary a statement in the form required by the Board of Directors confirming acceptance of the Directors’ Code of Conduct;
• a person who has knowingly or recklessly made a false declaration for any purpose provided for under this constitution or in the 2006 Act;
• a person who is the spouse, partner, parent or child of a member of the Board of Directors (including the chairman) of the Trust; or
• a person who is the subject of a sex offenders order and/or his name in included in the sex offenders register.
I declare that I have not been at any time responsible for, privy to, contributed to, or facilitated, any serious misconduct or mismanagement in the carrying out of a regulated activity in any former roles. If the Trust discovers information, after appointment, that suggests an individual is not of good character, or if concerns or findings regarding misconduct or mismanagement under the Fit and Proper Person requirements are made, these will be shared with Regulators as appropriate and may lead to action in accordance with the Trust’s disciplinary policy.
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Appendix 3 - Solent NHS Trust Board Principles
The members of Board of Directors hereby agree to follow the below principles:
1. Apologies sent to the Company Secretary ASAP
2. Agenda items to be agreed by Chair and Chief Executive Officer at least 2 weeks prior to meeting
3. In accordance with the Intelligent Board Recommendations, every member of the Board needs sufficient information at a high enough level to be confident that the organisation is well run. Papers must be presented in accordance with the ‘Board Report Guidance’ The submitted board paper while succinct must contain sufficient information to act as a stand-alone paper without reference to any additional papers which may be made available outside the formal board papers. Executive sponsors must not rely upon board members reading additional papers as a means of communicating critical information.
4. Papers received after the deadline stipulated will not be accepted and will be deferred, unless with express permission from the Chair.
5. Authors of papers to ensure that they are sponsored by the relevant Executive Lead, prior to being submitted for circulation to the Board with the agenda
6. Agendas and papers to be circulated 5 working days prior to meeting
7. All papers to be read prior to meeting
8. A.O.B to be agreed at the start of the meeting
9. A Register of Interests will be maintained and all members will separately declare any interests in agenda items at the start of the meeting, which will then be recorded in the minutes.
10. Throughout the meeting Members will address the Chairperson as ‘Chair’.
11. Attendance at the meeting should take priority over other meetings, however it is recognised that on occasions there will be competing priorities. In these circumstances the Board Member shall negotiate with the Chair/Chief Executive Officer regarding attendance
12. Mobile phones and blackberries will be switched off during the meeting and not used (except in the case where the attendee is on-call. The Chair should be notified at the start of the meeting in such cases). Use of laptops/ ipads is only permitted for the sole purpose of supporting the meeting.
13. These principles are extended to Board Committees.
14. An annual agenda cycle will be maintained by the Secretary to the Board and will include the standing items that are required to be presented each month.
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Annual Declaration of Compliance with Code of Conduct
1. I confirm that I have received and read the Code of Conduct for the Board of Directors. I confirm that I have complied with the Code to date and I agree to comply with it in the future in carrying out my role as a Director of Solent NHS Trust.
In doing so, I also;
2. confirm my agreement to preserve the confidentiality of confidential information, as outlined in the Non Disclosure Agreement, Appendix 1
3. acknowledge the extracts from Monitors Provider Licence, Regulated Activities Regulations and the Trust’s draft constitution concerning Fit and Proper Persons requirements as outlined in Appendix 2. I confirm that I do not fit within the definition of an “unfit person” as listed and that there are no other grounds under which I would be ineligible to continue in post. I undertake to notify the Trust immediately if I no longer satisfy the criteria to be a “fit and proper person” or other grounds under which I would be ineligible to continue in post.
4. confirm I understand and respect the details outlined in Solent NHS Trust Board principles, Appendix 3.
Name (please print)
Signature
Date
Please return this completed signed form to: - Company Secretary, Solent NHS Trust, Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Rd, Southampton, SO19 8BR
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Solent NHS Trust Remuneration Committee Terms of Reference Item 25.4
The Solent NHS Trust Board hereby establishes a Committee of the Board to be known as the Remuneration Committee (‘the Committee’) in accordance with its Standing Orders and Scheme of Delegation.
The Committee is a Non-Executive Committee of the Board and has no executive powers, other than those specifically delegated by the Board in these Terms of Reference which are incorporated within the Trust’s Standing Orders.
1. Membership
1.1 Membership of the Remuneration Committee will comprise: • The Non-Executive members of Solent NHS Trust • The Trust Chair
1.2 One of the members of the Remuneration Committee will be appointed as Chair of the Committee by the Chair of Solent NHS Trust Board. In the absence of the Committee Chairman and/or an appointed deputy, the remaining members present shall elect one of themselves to chair the meeting.
1.3 The Trust Chair shall not be the Chair of the Committee.
1.4 The composition of the Committee will be disclosed in the Solent NHS Trust Annual Report.
2. Purpose
2.1 The Committee makes decisions on behalf of the Board regarding remuneration and terms of office relating to the Chief Executive and other Executive Directors and also agrees/oversees Clinical Excellence Awards as well as overseeing severance payments over £50k.
3. Duties
The committee will:
3.1 Be responsible for aligning the Trust’s Remuneration Policy for Directors with national Very Senior Management (VSM) terms.
3.2 Make decisions on behalf of Solent NHS Trust Board and where necessary make recommendations to NHS Improvements about appropriate remuneration, allowances and terms of service for the Chief Executive, and other Executive Directors, to include:-
o Salary o Pensions o Performance related pay [and whether Directors are eligible for annual bonuses] o Provision of other contractual terms and benefits o Approval of settlement agreements/severance pay or other occasional payments to individuals and out of court settlements, taking account of national guidance o Receive and note decisions of the Clinical Excellence Awards (CEA) panel
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3.3 Within the constraints of national frameworks, the Committee will agree the remuneration package, allowances and terms of service of the Trust’s executive directors. No executive director shall be involved in any decisions as to their own remuneration
3.4 Monitor and oversee the evaluation of the performance of the Chief Executive and other individual Executive Directors
3.5. Approve participation in any performance related pay schemes, where operated by the Trust, and approve the total annual payments made under such schemes. The Committee will ensure: • that any pay-outs or grants under any incentive schemes are subject to challenging performance criteria reflecting the objectives of the Trust. • that any performance criteria and upper pay limits for annual bonuses and incentive schemes are disclosed
3.6 Ensure that contractual terms on termination, and any payments made, are fair to the individual, and the NHS, aligned with the interests of the patients, that failure is not rewarded and that the duty to mitigate loss is fully recognised, in line with national guidance where appropriate.
3.7 The Committee will refer the following matters to the NHS Improvements (NHSI) in accordance with Deleted: Trust Development the ‘NHS TDA Guidance for NHS Trusts on processes for making severance payments1’; Authority
• All severance payments (contractual or non-contractual) to Chief Executives and Directors of NHS Trusts. For these purposes, “Director” means any Director reporting to the Chief Executive whether or not an executive member of the Board.
• Non-contractual severance payments to all staff (including to Chief Executives and Directors as defined in 2.1).
• Contractual payments over £50,000 to all staff (including to Chief Executives and Directors as defined in 2.1)
3.8 Be responsible for establishing the selection criteria, selecting, appointing and setting the terms of reference for any Remuneration Consultants who advise the committee, and to obtain reliable, up-to- date information about remuneration in other Trusts. Where Remuneration Consultants are appointed, a statement will be made available of whether they have any other connection with the Trust or conflicts of interest.
3.9 Consider any pension consequences and associated costs to the Trust of basic salary increases and other changes in pensionable remuneration.
3.10 Ensure that levels of remuneration for the Chair and other non-executive directors reflect the national terms
3.11 Consult the Chair and/or the Chief Executive concerning proposals relating to the remuneration of other Executive Directors
3.12 Recommend and monitor the level and structure of remuneration for Senior Management (the definition of Senior Management to be determined by the Trust Board, but will normally include the first layer of management below Board level).
1 It is acknowledged that the title of this document may be amended in the future to acknowledge NHSIs new title Page 2 of 4
3.13 Disclose in the Annual report, where the Trust releases an Executive Director, for example to serve as a Non-Executive Director elsewhere, whether or not the Director will retain such earnings.
3.14 To have oversight of Mutually Agreed Resignation Schemes (MARs) and to approve schemes as necessary.
4. Attendance
4.1 The Chief Executive, Chief People Officer and Director of Finance and Performance will be invited to Deleted: Director of HR & OD attend the meeting as required to provide advice but will not be in attendance for discussions concerning their own remuneration and/or terms of service, and will therefore withdraw from those parts of the meeting.
5. Secretary
5.1 The Secretary to the Committee will be coordinated by the Chief People Officer with the Committee Deleted: Director of HR & OD Chair.
6 Quorum
6.1 The quorum necessary for the transaction of business shall be three members. A duly convened meeting of the committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the committee.
7 Notice of meetings
7.1 The Chair or their deputy shall summon the meeting.
7.2 Whenever possible, members will be given 5 working days’ notice before the date of the paper and associated supporting papers will be circulated in advance of the meeting. However, it is acknowledged that it may be necessary to convene a meeting (or virtual meeting) at short notice and members will be informed accordingly.
8 Minutes of meetings
8.1 The secretary shall minute the proceedings and resolutions of all committee meetings, including the names of those members present and those in attendance. In the case of virtual meetings, a written confirmation of the meeting and agreements will follow as soon as practically possible.
8.2 Minutes of committee meetings shall be circulated promptly to all members of the committee
9. AGM attendance
9.1 The Chair of the Committee shall attend the Annual General Meeting prepared to respond to any stakeholder queries in relation to the committee activity.
10. Authority
10.1 The Committee is authorised by the Board to review and approve any activity within its Terms of Reference. In so doing, the Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.
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10.2 The Committee will make satisfactory arrangements to ensure it receives adequate independent advice on remuneration levels elsewhere in the NHS, with due reference to national policy and guidance, as well as trends and developments in areas of benefits and terms and conditions of employment.
11. Frequency of Meetings
11.1 The Committee shall meet at least annually and at such other times as the Chair of the committee shall require.
12 Reporting responsibilities
12.1 The Committee shall report formally to Solent NHS Trust Confidential Board meeting, the basis for its Deleted: Part 2 (private) decisions and recommendations. The Chair of the Committee shall draw to the attention of the Board any significant issues that require specific consideration or action by the Board. Minutes of the Trust Board’s meetings will record receipt of the report of the Remuneration Committee and the decisions of the Board.
12.2 Notes for each meeting, including decisions and actions, will be recorded and retained by the Chief Deleted: Director of HR & OD. People Officer.
12.3 The Committee shall produce an annual statement of the Trust’s remuneration policy and practices which will form part of the Trust’s Annual Report, including: . the disclosure of any remuneration received by an Executive Director serving as a Non-Executive Director elsewhere and whether this is retained or not by the Executive Director . membership of the Remuneration Committee, this means the names of the Chair and members of the Remuneration Committee . the number of meetings and individual’s attendance at each . the name of any person (and in particular any director of the Trust who was not a member of the committee) who provided advice or services to the committee that materially assisted the committee in their consideration of any matter. Where such a person is not a director of the Trust: a description of the nature of any other services that person has provided to the Trust during the financial year and whether that person was appointed by the committee
12.4 Members attendance at Committee meetings will be disclosed in the Trust’s Annual Report
Version 6 Deleted: 5 Date of Next Review Date: June 2017 Deleted: July 2017
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Item 26
Board Report – In Public Meeting Title of Paper NHS Improvement : Self Certification against NHS Provider Licence (Single Oversight Framework requirement)
Author(s) Rachel Cheal, Associate Director of Corporate Affairs and Company Secretary
Date of Paper 10th May 2017 Committees n/a presented
Action requested x of the Board To receive For decision Link to CQC Key Safe Effective Caring Responsive Well Led
Lines of Enquiry x (KLoE)
The requirement From April 2017, NHS Improvement introduced a new requirement on all NHS Trusts for 2017/18 whereby each Trust is asked to self-certify in accordance with the NHS Provider Licence. Although NHS Trusts are exempt from needing the provider licence, directions from the Secretary of State require the NHS Trust Development Authority to ensure that NHS Trusts comply with conditions equivalent to the licence as it deems appropriate. The Single Oversight Framework (SOF), bases its oversight on the NHS provider licence. NHS Trusts are therefore legally subject to the equivalent of certain provider licence conditions (including Condition G6 and Condition FT4) and must self-certify under these licence provisions.
Solent NHS Trust, is therefore required to self-certify that we meet the obligations set out in the NHS provider licence (which itself includes requirements to comply with the National Health Service Act 2006, the Health and Social Care Act 2008, the Health Act 2009 and the Health and Social Care Act 2012, and to have regard to the NHS Constitution) and that we have complied with governance requirements. The Trust completed a similar exercise (in shadow) when it was actively pursuing Foundation Trust status.
The process NHS Providers are asked to self-certify the following after the financial year-end:
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A template has been provided by NHSI to capture Trust responses on a ‘comply or explain’ basis, which has been adapted for internal use to capture assurance.
There is no set process for assurance or how conditions are met, which is reflective of autonomy - each Trust is therefore required to determine how compliance is met (or otherwise). NHSI also requires each Board to formally ‘sign’ in agreement of compliance against the conditions.
Providers are required to have effective systems and processes in place to ensure compliance; to identify risks to compliance and take reasonable mitigating actions to prevent those risks/or compliance failures.
Compliance with the conditions must be published (via the website) and can be spot audited by NHSI post July 2017. Evidence must therefore be collected to support each condition compliance.
A copy of Solent NHS Trust’s compliance with these conditions are found on pg 3.
A copy of the full Licence Conditions for G6 and FT4 are found in Appendix 1, pg 7.
Recommendations:
The Board is asked to confirm its agreement with the responses outlined against each of the Provider Licence requirements; or provide alternative responses as agreed. Representatives of the Board (e.g. the Chairman and the CEO) are asked for formally sign in agreement.
As NHSI are conducting spot audits it is recommended that the Board reconsiders compliance at each meeting. It is therefore suggested that in future, compliance is included within the Single Oversight Framework reporting requirements incorporated within the Performance Report. The Board are asked to agree with this approach.
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Self-Certification 2017/18 – NHS Provider Licence
No. Requirement Response (Confirmed Assurance (or in the case of non-compliance, the reasons why) Risk and mitigating actions to /not confirmed) ensure full compliance
Condition G6 – Systems for compliance with licence conditions 1 Following a review for the purpose of paragraph 2(b) of Confirmed The Board is not aware of any departures or deviations with licence condition G6, the Directors of the Licensee are Licence conditions requirements. The effectiveness of internal satisfied that, in the Financial Year most recently ended, the control systems and processes are reviewed on an annual basis Licensee took all such precautions as were necessary in and documented within the Annual Governance Statement as order to comply with the conditions of the licence, any presented to the Audit & Risk Committee and incorporated within requirements imposed on it under the NHS Acts and have the Annual Report. In addition, assurance to the Board is had regard to the NHS Constitution. supported by opinions from Internal Auditors and External Auditors. Condition FT4 – Governance Arrangements 1 The Board is satisfied that the Licensee applies those Confirmed The Board is not aware of any departures from the requirements principles, systems and standards of good corporate of this condition. governance which reasonably would be regarded as The Board considers and adopts corporate governance standards, appropriate for a supplier of health care services to the guidance and best practice as appropriate. NHS.
2 The Board has regard to such guidance on good corporate Confirmed The Board is not aware of any departures from the requirements governance as may be issued by NHS Improvement from of this condition. time to time. The Board considers and adopts corporate governance standards, guidance and best practice as appropriate, including that issued by NHSI.
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3 The Board is satisfied that the Licensee has established and Confirmed The Board is not aware of any departures from the requirements implements: of this condition. (a) Effective board and committee structures; On an annual basis the Trust has implemented a process of (b) Clear responsibilities for its Board, for committees governance reviews (via the Governance and Nominations reporting to the Board and for staff reporting to the Board Committee) including; and those committees; and - Reviewing composition, skill and balance of the Board and its (c) Clear reporting lines and accountabilities throughout its Committees organisation - Reviewing Terms of Reference - The completion of an Annual Report for each Board Committee incorporating a reflection on the achievement of objectives and business conducted in year. A mid-year review of each Committee is also conducted. The Composition of Committees is also kept under constant review to take into consideration and periods of unscheduled /planned leave or the impact of vacancies effecting quoracy. The Trust’s wider governance structure is also regularly considered and refreshed to ensure efficiency and clear lines of reporting.
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4 The Board is satisfied that the Licensee has established and Confirmed The Board is not aware of any departures from the requirements Concerning CQC compliance: A effectively implements systems and/or processes: of this condition. comprehensive action plan is in place and being monitored (a) To ensure compliance with the Licensee’s duty to Internal control processes has been established and are embedded in response to the CQC operate efficiently, economically and effectively; across the organisation as outlined within the Annual Governance comprehensive inspection (b) For timely and effective scrutiny and oversight by the Statement. The agreed annual Internal Audit programme during 2016. Board of the Licensee’s operations; deliberately focuses on key areas where testing may identify the (c) To ensure compliance with health care standards binding need for strengthened controls. The external auditors are in on the Licensee including but not restricted to standards the process of finalising their specified by the Secretary of State, the Care Quality VFM opinion. The draft Commission, the NHS Commissioning Board and statutory opinion shared with Solent is regulators of health care professions; that the accounts for 2016/17 (d) For effective financial decision-making, management will be unqualified on this and control (including but not restricted to appropriate point. systems and/or processes to ensure the Licensee’s ability to continue as a going concern); (e) To obtain and disseminate accurate, comprehensive, timely and up to date information for Board and Committee decision-making; (f) To identify and manage (including but not restricted to manage through forward plans) material risks to compliance with the Conditions of its Licence; (g) To generate and monitor delivery of business plans (including any changes to such plans) and to receive internal and where appropriate external assurance on such plans and their delivery; and (h) To ensure compliance with all applicable legal requirements.
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5 The Board is satisfied that the systems and/or processes Confirmed The Board is not aware of any departures from the requirements Concerning Board level referred to in paragraph 4 (above) should include but not of this condition. capability- appointment has be restricted to systems and/or processes to ensure: been made to the Chief Nurse The Trusts’ goals; Great Care, Great Place to Work and Great Value position and COO (a) That there is sufficient capability at Board level to for money, demonstrate the organisations focus and emphasis on Southampton and County and provide effective organisational leadership on the quality of ‘quality’ being the overriding principle for everything we do. transition arrangements/ care provided; handovers are being (b) That the Board’s planning and decision-making The Board’s agenda has a notable weight towards quality of care, implemented. processes take timely and appropriate account of quality of supported by data and information owned and presented by the care considerations; Executive Directors. (c) The collection of accurate, comprehensive, timely and The Board will also actively up to date information on quality of care; There is clear accountability for quality of care throughout the recruiting to a NED vacancy (d) That the Board receives and takes into account accurate, organisation from executive leadership by the Chief Nurse working with support from the NHSI, comprehensive, timely and up to date information on with the Chief Medical Officer. post purdah as the current quality of care; NED post holder leaves at the (e) That the Licensee, including its Board, actively engages Established escalation processes allow staff to raise concerns as end of May 2017. on quality of care with patients, staff and other relevant appropriate. stakeholders and takes into account as appropriate views and information from these sources; and (f) That there is clear accountability for quality of care throughout the Licensee including but not restricted to systems and/or processes for escalating and resolving quality issues including escalating them to the Board where appropriate. 6 The Board is satisfied that there are systems to ensure that Confirmed The Board is not aware of any departures from the requirements the Licensee has in place personnel on the Board, reporting of this condition. to the Board and within the rest of the organisation who Details of the composition of the Board can be found within the are sufficient in number and appropriately qualified to public website. ensure compliance with the conditions of its NHS provider Qualifications, skills and experience are taken into consideration, licence. along with behavioural competencies as part of any recruitment exercise for Board vacancies. Signed on behalf of the Board of Directors; Signature Signature
Title Title Date Date
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Appendix 1 – details of full relevant Licence conditions:
Condition G6 – Systems for compliance with licence conditions and related obligations 1. The Licensee shall take all reasonable precautions against the risk of failure to comply with: (a) the Conditions of this Licence, (b) any requirements imposed on it under the NHS Acts, and (c) the requirement to have regard to the NHS Constitution in providing health care services for the purposes of the NHS.
2. Without prejudice to the generality of paragraph 1, the steps that the Licensee must take pursuant to that paragraph shall include: (a) the establishment and implementation of processes and systems to identify risks and guard against their occurrence; and (b) regular review of whether those processes and systems have been implemented and of their effectiveness.
3. Not later than two months from the end of each Financial Year, the Licensee shall prepare and submit to Monitor a certificate to the effect that, following a review for the purpose of paragraph 2(b) the Directors of the Licensee are or are not satisfied, as the case may be that, in the Financial Year most recently ended, the Licensee took all such precautions as were necessary in order to comply with this Condition.
4. The Licensee shall publish each certificate submitted for the purpose of this Condition within one month of its submission to Monitor in such manner as is likely to bring it to the attention of such persons who reasonably can be expected to have an interest in it.
Condition FT4 – NHS foundation trust governance arrangements 1. This condition shall apply if the Licensee is an NHS foundation trust, without prejudice to the generality of the other conditions in this Licence.
2. The Licensee shall apply those principles, systems and standards of good corporate governance which reasonably would be regarded as appropriate for a supplier of health care services to the NHS.
3. Without prejudice to the generality of paragraph 2 and to the generality of General Condition 5, the Licensee shall: (a) have regard to such guidance on good corporate governance as may be issued by Monitor from time to time; and (b) comply with the following paragraphs of this Condition.
4. The Licensee shall establish and implement: (a) effective board and committee structures; (b) clear responsibilities for its Board, for committees reporting to the Board and for staff reporting to the Board and those committees; and (c) clear reporting lines and accountabilities throughout its organisation.
5. The Licensee shall establish and effectively implement systems and/or processes: (a) to ensure compliance with the Licensee’s duty to operate efficiently, economically and effectively; (b) for timely and effective scrutiny and oversight by the Board of the Licensee’s operations;
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(c) to ensure compliance with health care standards binding on the Licensee including but not restricted to standards specified by the Secretary of State, the Care Quality Commission, the NHS Commissioning Board and statutory regulators of health care professions; d) for effective financial decision-making, management and control (including but not restricted to appropriate systems and/or processes to ensure the Licensee’s ability to continue as a going concern); (e) to obtain and disseminate accurate, comprehensive, timely and up to date information for Board and Committee decision-making; (f) to identify and manage (including but not restricted to manage through forward plans) material risks to compliance with the Conditions of its Licence; (g) to generate and monitor delivery of business plans (including any changes to such plans) and to receive internal and where appropriate external assurance on such plans and their delivery; and (h) to ensure compliance with all applicable legal requirements.
6. The systems and/or processes referred to in paragraph 5 should include but not be restricted to systems and/or processes to ensure: (a) that there is sufficient capability at Board level to provide effective organisational leadership on the quality of care provided; (b) that the Board’s planning and decision-making processes take timely and appropriate account of quality of care considerations; (c) the collection of accurate, comprehensive, timely and up to date information on quality of care; (d) that the Board receives and takes into account accurate, comprehensive, timely and up to date information on quality of care; (e) that the Licensee including its Board actively engages on quality of care with patients, staff and other relevant stakeholders and takes into account as appropriate views and information from these sources; and (f) that there is clear accountability for quality of care throughout the Licensee’s organisation including but not restricted to systems and/or processes for escalating and resolving quality issues including escalating them to the Board where appropriate.
7. The Licensee shall ensure the existence and effective operation of systems to ensure that it has in place personnel on the Board, reporting to the Board and within the rest of the Licensee’s organisation who are sufficient in number and appropriately qualified to ensure compliance with the Conditions of this Licence.
8. The Licensee shall submit to Monitor within three months of the end of each financial year: (a) a corporate governance statement by and on behalf of its Board confirming compliance with this Condition as at the date of the statement and anticipated compliance with this Condition for the next financial year, specifying any risks to compliance with this Condition in the next financial year and any actions it proposes to take to manage such risks; and (b) if required in writing by Monitor, a statement from its auditors either: (i) confirming that, in their view, after making reasonable enquiries, the Licensee has taken all the actions set out in its corporate governance statement applicable to the past financial year, or (ii) setting out the areas where, in their view, after making reasonable enquiries, the Licensee has failed to take the actions set out in its corporate governance statement applicable to the past financial year.
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