Board of Directors Papers July 2015

BOARD OF DIRECTORS

Wednesday 29 July 2015 at 09:00 – 12:00 Boardroom, Level 1, Yeovil District Hospital NHS Foundation Trust

AGENDA - PART 1

Presenter Timings Enclosure

1 Welcome and Apologies for Absence PW 09:00 Verbal

2 Declarations of Interest Relating to Items on the Agenda All Verbal

3 To Hear a Patient and Receive Feedback on Actions from HR 09:05 Presentation Previous Stories The purpose of the patient story is to focus the attention of the Board on patient experiences, the learning from which is used to improve services across the organisation.

4 To Approve the Minutes of 17 June 2015 and Discuss PW 09:20 Appendix 1 Matters/Actions Arising

5 To Receive Verbal Updates from the Governance and the PvdH 09:25 Appendix 2 Audit Committees Held on 17 July 2015 and to Note the Jane H Approved Minutes from 17 April 2015 and 19 May 2015

6 To Approve the Revised Terms of Reference for: 09:40 Appendix 3 • Audit Committee PvdH • Governance Committee Jane H • Financial Resilience and Commercial Committee JG

7 To Discuss and Note the Items from the Executive PM 09:50 Appendix 4 Director Report

8 To Discuss and Note the Update on Symphony and New PM 10:10 Appendix 5 Models of Care

Break – 10:30

9 To Discuss and Note the TrakCare Highlight Report JM 10:45 Appendix 6

10 To Review and Note the Quality, Operational and Financial PM/TN 11:05 Appendix 7 Performance Report and Receive an Update on RTT HR/LA

11 To Review and Note the Safer Staffing Report HR 11:35 Appendix 8

12 Q1 Corporate Risk Register JHIG 11:45 Appendix 9

13 Any Other Business PW 11:55 Verbal

14 Exclusion of the Public To resolve that representatives of the press and other members of the public be excluded from the remainder of the meeting due to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

15 DATE AND TIME OF NEXT MEETING 26 August 2015 – Development Day – Venue TBC (Closed Session) 30 September 2015, Boardroom, Level 1, Yeovil District Hospital

APPENDIX 1 BOARD OF DIRECTORS 29 JULY 2015 BOARD OF DIRECTORS DRAFT Minutes of the meeting of the Board of Directors held on Wednesday 17 June 2015 at Yeovil District Hospital

Present: Peter Wyman Chairman Maurice Dunster Non-Executive Director Julian Grazebrook Non-Executive Director Jane Henderson Non-Executive Director Paul von der Heyde Non-Executive Director Jonathan Howes Deputy Chief Executive Mark Saxton Non-Executive Director Paul Mears Chief Executive Tim Newman Chief Finance & Commercial Officer Helen Ryan Director of Nursing & Clinical Governance Tim Scull Medical Director

In Attendance: Anne Bennett Chair of the League of Friends Simon Blackburn Associate Director of Communications Hala Hall Public Governor (Observer) Jason Maclellan Chief Information Officer [item 1-90/15] Jade Renville Company Secretary Sophie Sennett Contact Centre Manager [item 1-92/15] Simon Sethi Interim Director of Urgent Care & Long Term Conditions Apologies: Leah Allen Director of Elective Care Jonathan Higman Director of Strategic Development

Ref: No : Action 1- 1 APOLOGIES AND WELCOME 83/15 1.1 Peter Wyman welcomed everyone present to the meeting, particularly Simon Sethi as the newly appointed, Interim Director of Urgent Care and Long Term Conditions, Hala Hall, Governor Observer and Anne Bennett, Chair of the League of Friends. He also welcomed Armeta Nabahi, Paediatrics, and Simon Lilley, Commercial Director, observing in the audience. Apologies for absence were received as above.

1- 2 DECLARATIONS OF INTEREST 84/15 2.1 Peter Wyman declared that he is Treasurer and Vice-Chairman of the Council of the University of Bath. 1- 3 PATIENT STORY 85/15 3.1 Helen Ryan introduced Ali Dowding and Jo Ryan who attended the Board to give an overview of a patient’s journey from admission to discharge. Ali Dowding spoke of a patient who was admitted following a collapse at home. Having completed the initial treatment and nearing discharge, the patient’s family had some concerns about them remaining at home independently, albeit in a warden controlled environment. YDH arranged a multi- disciplinary team assessment and with an enhanced package of care the patient was able to be discharged home, an outcome that was positively received by the patient and their family. The professionals involved in the multi-disciplinary team approach included: A&E staff, doctors, health care assistants, occupational therapy, physiotherapy, the dementia team, social workers, and transport services, among others.

3.2 The Board was pleased with the positive outcome but expressed concern about the level of intervention that was required from multiple teams and the time taken to discharge (3 weeks). Ali Dowding spoke of the complexity of the case and the importance of working with the patient and their family. The Board said the development of new models of integrated care will create more opportunities to manage these complex cases in a more efficient, streamlined manner.

1- 4 MINUTES OF THE PREVIOUS MEETING 86/15 4.1 The minutes of the meeting held on 20 May 2015 were approved as a true and accurate record.

1- 5 ACTION SHEET 87/15 5.1 The Board reviewed the key outstanding actions not in progress or on the agenda, from which the Board noted that:

5.2 - 1-151/14 (NoF update), Jade Renville is liaising with Leah Allen to confirm a suitable date for the update to be presented at the Board. It was agreed this could be deferred until September 2015. 1- 6 EXECUTIVE DIRECTOR REPORT 88/15 6.1 Paul Mears presented highlights from the executive director report, from which the Board noted that:

6.2 Simon Sethi has been welcomed by the executive team as the Interim

Director of Urgent Care and Long Term Conditions. His predecessor, Jonathan Higman, has assumed his new role as the Director of Strategic Development where he will co-ordinate the Trust’s strategic planning and implementation programme and ensure the Board is appraised of progress.

6.3 Dr Alex Bickerton, consultant in diabetes and endocrinology, has been selected as one of 16 national clinical champions for Diabetes UK, for which he was congratulated by the Board. Diabetes prevalence is increasing in the UK and the work of Dr Alex Bickerton will align well with Symphony and the development of new models of integrated care.

6.4 Mr Nader Francis, Colorectal Surgeon, and three of his colleagues from YDH recently attended the European Association of Endoscopic Surgeons (EAES) Congress. Four conference papers were presented by YDH clinicians with two of the papers winning top prizes and one winning the European cup. The Board congratulated Mr Nader Francis and the team for their success and Tim Scull agreed to write to him expressing the TS congratulations of the Board.

6.5 The Dorset acute services review is ongoing and formal public consultation

will take place later in the year. Peter Wyman commented that the review

raises potential risks and opportunities for YDH. Paul Mears confirmed that YDH remains in contact with Dorset CCG and Dorset County Hospital NHS Foundation Trust to engage with the process and to consider options for greater collaboration in the future. Following a question from Julian Grazebrook, Paul Mears confirmed the process is being led by the Dorset CCG with support from McKinsey.

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6.6 An interim report by Lord Carter has been published setting out the opportunity for greater efficiency in hospitals through improved operational processes and procurement and trusts are likely to be benchmarked on delivery by the Department of Health. The Trust will review the full report when it is released in the autumn to consider learning which is applicable for YDH. The non-executive directors reflected on the work undertaken by Oliver Wyman to review the Trust’s internal efficiencies and cost improvement programme. Paul Mears said the key areas they had recommended were in connection with estates management, agency staffing and theatres. In terms of theatres, the “hospital effectiveness programme” has commenced to consider how improvements could be made in practice. The other areas identified also form part of the Trust’s 2015/16 cost improvement programme.

6.7 YDH has hosted a site visit from Monitor in order to review the Trust’s 2015/16 annual plan. The visit was constructive and Monitor spent time with the Trust’s key operational leads, the executive team and the finance department as part of the process. Monitor has also advised that they will allocate YDH a single point of contact to support the Trust with the development of new models of integrated care which was welcomed by the Board. They will also work with YDH on the development of a final business case to access transformation funding, alongside deficit support. The Board acknowledged that YDH is already incurring costs associated with the implementation of new models of care, which are being captured separately as part of the Trust’s financial reporting. They also spoke of the importance of the project being run efficiently and preventing delays wherever possible. Currently, the Monitor investigation into the Trust’s short term financial challenges is ongoing but it is expected this will soon be closed. Maurice Dunster asked of the role of the Somerset CCG in this process. Paul Mears said their key focus in this area would be the development of outcomes based commissioning, a seminar session on which would take place later this morning. Paul von der Heyde asked whether Monitor had challenged the Trust’s proposed levels of CIP. Paul Mears said YDH had planned a realistic cost improvement programme but it would be essential therefore that the full amount is achieved.

6.8 Following delay, a replacement contractor has been appointed and works have recommenced on the special care baby unit. It is hoped to recover lost production so the majority of the project is completed by December 2015. Support from the Trust’s strategic estates partner (Interserve and Prime) has been instrumental in resolving the issues.

6.9 Helen Ryan verbally updated the Board on carers week, thanking Caroline Maddams, Communications Manager, and Patricia Foers, Dementia Nurse Specialist, for their hard work in making it a success. A new carers charter has been created which recognises the value of carers and the Trust’s commitment to working with them to provide the best care possible for patients. She added that the Trust will now issue a carers pack to support them when they have contact with YDH, which will include information on car parking and a meal voucher for the canteen.

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6.10 Helen Ryan said Hala Hall, Public Governor, has completed a review on the impact for YDH of the Lampard Report into matters relating to Jimmy Savile, advising that the full report will be considered by the Governance Committee on 17 July 2015. No major issues were identified as part of the review although there are lower level actions for implementation.

1- 7 VANGUARD AND NEW MODELS OF CARE 89/15 7.1 Paul Mears provided a verbal update on progress with developing new models of integrated care, advising that the banner of Symphony will continue to be used to ensure continuity. He said the Programme Board is gaining momentum. It is chaired by Berge Balian, GP and Associate Medical Director (YDH) and membership is split 50/50 primary care/YDH. Other stakeholders, such as social care, Somerset Partnership NHS Foundation Trust and the Somerset CCG are invited to the second part of the meeting to ensure they remain involved in the programme. The working groups have also been set up. Simon Blackburn and Jason Maclellan are reviewing the need for a technology platform to keep all parties informed throughout the process. Paul Mears also advised of collaborative work with social care on the development of their “hubs”, which will work in a similar, integrated way to the complex care hubs being operated by YDH.

7.2 Paul Mears said the vanguards are being sponsored by key national agencies such as NHS England, Public Health England, Monitor and NICE who have each allocated their Chief Executive to act as a sponsor to a vanguard. YDH has been allocated the Chief Executive of Public Health England, which is a positive outcome for the Trust and brings an opportunity for greater focus on prevention.

1- 8 TRAKCARE HIGHLIGHT REPORT 90/15 8.1 Jason Maclellan presented the TrakCare highlight report which provides an overview of the implementation of the electronic health record. The project status remains amber as there have been delays in meeting the first key milestone. He confirmed these are being closely managed and are not expected to impact the overall programme delivery in terms of cost or benefits realisation.

8.2 Data migration continues to progress well and is currently ahead of schedule. Build phase has started on schedule for the key areas of PAS, ED and maternity. In terms of ED, further work is ongoing to link TrakCare with the Trust’s triage process. Mark Saxton asked whether the Trust should take the opportunity to review triage in line with the development of new care models. Jason Maclellan responded that the system is used by other trusts and it has been a clinical decision to continue using this process. In terms of maternity, further work is ongoing in connection with assessment forms. The pharmacy software solution is not yet available to view and test operationally and so a decision has been made by the Programme Board to seek a deferred date beyond the October 2015 go live. Further detailed work will continue over the summer to assess the completed product and ensure it meets the needs of the Trust’s pharmacy. There will be no financial penalty as a result of this decision.

8.3 Maurice Dunster asked about access to key supplier support which Jason Maclellan confirmed has improved in recent weeks, acknowledging the challenges for InterSystems of running three implementation programmes simultaneously.

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8.4 Following questions from the non-executive directors, Jason Maclellan said the risks presented were manageable and being mitigated.

1- 9 QUALITY, OPERATIONAL AND FINANCIAL PERFORMANCE REPORT 91/15 9.1 As a result of the timing of the Board meeting, the financial and operational performance report (May 2015) was not available and would be circulated the following week by email.

9.2 Paul Mears verbally advised that YDH is on track in month to meet the 95% target of patients seen and discharged within 4 hours and that the levels of demand are starting to decrease from the winter period.

9.3 He also said that YDH is continuing to implement its RTT backlog recovery plan which involves booking patients in chronological order according to need and treating some patients at the Shepton Mallet NHS Treatment Centre. By doing so, YDH is not meeting its performance targets in relation to RTT, although it is expected that the Trust will be back on track by Q3 of 2015/16 with the exception of orthopaedics which remains the area of greatest pressure. Paul Mears explained that changes announced nationally in relation to the RTT targets would mean in future that no penalties would be levied on failure to achieve RTT admitted and non- admitted targets, although the incomplete pathways targets for RTT would remain. Nevertheless, the non-executive directors said it would be important to maintain focus on strong RTT performance to ensure the best service provision and experience for patients.

9.4 Tim Newman summarised the Trust’s financial position, confirming the in- month deficit for May 2015 (business as usual) was £1.7m, making the year to date deficit £3.4m. The in-month position was £0.1m favourable to budget. Key overspends continue to relate to nursing, but are starting to subside as a result of focus on implementing the Trust’s nursing recruitment campaign. In terms of training and development, Tim Newman said mandatory training rates are improving but appraisal remains challenging. He said the online appraisal system had been updated and streamlined which should improve compliance. Tim Newman also advised that YDH’s occupational health supplier changed on 1 June 2015 to Optima Health. He said the new service should support managers to better manage sickness absence and improve health and wellbeing. The service will provide an employee assistance programme with a freephone hotline available to all staff, accessible 24 hours a day 365 days a year.

1- 10 PLANS TO IMPROVE DNA RATES 92/15 10.1 Following discussion at previous meetings, Simon Lilley and Sophie Sennett, Contact Centre Manager, presented an overview of plans to improve DNA (did not attend) rates. By way of context they explained performance at YDH is better than the national average but remains above the 5% target. They added that some specialities have higher volumes / percentage DNA rates and these areas will be targeted for improvement. The other short term steps will include the Trust-wide roll-out of the SMS text / outbound call reminder systems. The Board asked whether there were barriers to the reminder system being implemented quickly and Sophie Sennett confirmed a key area of focus is the collection of mobile telephone numbers. In addition, the outpatient appointment letter will be amended to explain to patients the impact of DNA.

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10.2 The non-executive directors asked whether dramatic improvement would be financially counterproductive as more capacity/planned breaks would need to be put in place. Sophie Sennett advised that the 5% target should enable optimal efficiency. Following a question from Julian Grazebrook, she also advised that in future YDH will seek feedback from patients who did not attend their appointment.

10.3 Simon Lilley spoke of longer term aims to establish an online booking and reminder service for users across primary and secondary care. Following questions from the Board, Simon Lilley confirmed alternative methods will still be available for patients unconformable using technology.

1- 11 SAFER STAFFING REPORT 93/15 11.1 Helen Ryan presented the safer staffing report which sets out the nursing and midwifery registered and unregistered staffing levels across the organisation and inpatient areas in line with NHS England/CQC guidance. She advised that there have been discussions nationally about whether the data should continue to be presented in this way. Helen Ryan said that YDH remains committed to safe staffing levels and that the Trust is undertaking a piece of work with a company to undertake computer modelling of staffing data which can be aligned to falls incidents, for example. The work produced as a result of this work will inform future reporting for the Board, which will be updated accordingly from September 2015. In terms of the ongoing nursing recruitment campaign, Helen Ryan said the recently appointed EU nurses are settling in well. Julian Grazebrook asked whether the skills of the new starters would be assessed, such as clinical capability, language competency and confidence in their role. Helen Ryan responded that the matrons are monitoring the situation closely and some nurses may be moved to areas that better suit their skill set, if required. She added that the language ability of the new EU nurses is good but they would be able to access language courses if needed. Mark Saxton asked about supervisory time and Helen Ryan confirmed that by September 2015 it is hoped that ward sisters will be 100% supervisory.

1- 12 ANNUAL SELF-CERTIFICATION DECLARATION 94/15 12.1 Jade Renville explained that as part of the annual planning process, YDH is required to submit a number of self-certifications to Monitor as set out in the enclosed paper. The Board positively confirmed statements in relation to corporate governance, AHSN and training of governors. Jade Renville illustrated some of the evidence that had been reviewed to enable the certifications to be made, such as the Trust’s reporting systems through its corporate governance structure, development and training delivered by KPMG at the Council of Governors (18 March 2015) on their role and responsibilities and a clear structure in relation to collaborative working with the AHSN. In response to a question from Mark Saxton, Jade Renville confirmed that the statement regarding training of governors is shared with them for their feedback.

1- 13 FEEDBACK FROM THE COUNCIL OF GOVERNORS – 11 JUNE 2015 95/15 13.1 Peter Wyman said the Council of Governors held on 11 June 2015 was a positive meeting attended by a number of newly elected governors. In terms of actions arising from the meeting, it was agreed in future that the length of the meeting sessions and the format of presentations would be considered.

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1- 14 ANY OTHER BUSINESS 96/15 14.1 There was no further business to discuss. 1- 15 DATE OF NEXT MEETING 97/15 15.1 The next meeting will be held on Wednesday 29 July 2015.

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APPENDIX 1b BOARD OF DIRECTORS 29 JULY 2015

BOARD OF DIRECTORS – ACTION SHEET 29 JULY 2015

Minute Action Outcome Due By ACTIONS FROM 19 NOVEMBER 2014 1-151/14 Update on NoF developments Not Yet Due Revised Leah and next steps to be presented to Date Allen & the Board. Confirmed – Matt Hall 30 Sept 15 ACTIONS FROM 28 JANUARY 2015 1-15/15 Undertake a review of staff In Progress Tim turnover. Newman & Mark Appleby ACTIONS FROM 25 MARCH 2015 1-42/15 SEP is undertaking a thorough Update review of fire, health and safety, Included in an update on which will be Executive Report presented to the Board.

ACTIONS FROM 29 APRIL 2015 1-61/15 Overview of 6 facet survey to be Update presented. Presented to the Audit Committee on 17 July 2015 ACTIONS FROM 20 MAY 2015 1-70/15 Develop a briefing note to be Complete shared with presenters of the patient story about what is expected: 5 minutes to describe the experience, 5 minutes on the lessons learned and 5 minutes on the actions for implementation.

1-74/15 Develop a briefing note explaining In progress July 2015 Paul the Trust’s strategic plans and Mears Simon Vanguard status and share with Blackburn the Somerset MPs, particularly with Marcus Fysh.

1-77/15 Leah Allen agreed to speak to Complete June 2015 Leah Berge Balian about the Allen communication she has had with the LMC regarding the Access Policy

1-79/15 Further development of the risk Complete By July Jonathan register as set out at minute item 2015 Higman 1-79/15

ACTIONS FROM 17 JUNE 2015 1-88/15 Tim Scull to write to Nadar Not Yet Due By End of Tim Scull Francis congratulating the team July 2015 on their success at the European Association of Endoscopic Surgeons Congress

CLINICAL GOVERNANCE ASSURANCE COMMITTEE (CGAC)

Minutes of a meeting of the Clinical Governance Assurance Committee held on 17 April 2015 at Yeovil District Hospital

Present: Jane Henderson (Chair) Non-executive Director Maurice Dunster Non-executive Director

In Attendance: Georgina Biggins Management Trainee (Observer) Ian Fawcett Public Governor (Observer) Jane Gifford Public Governor (Observer) (item 30/15) Hala Hall Public Governor (Observer) (item 30/15) Samantha Hann Assistant Company Secretary Paul von der Heyde Non-executive Director Jo Howarth Associate Director of Patient Safety and Quality Adrian Pickles Trust Risk Manager Jade Renville Company Secretary Helen Ryan Director of Nursing and Clinical Governance (items 15/15 – 24/15) Tim Scull Medical Director Carole Shuff Head of IT Transformation (item 30/15) Helen Williams Associate Director and Head of Midwifery

Apologies: BDO Representative Internal Auditors Anne Bennett Public Governor (Observer) Sue Bulley Public Governor (Observer) Peter Wyman Trust Chairman

Action 15/15 WELCOME AND APOLOGIES FOR ABSENCE Jane Henderson welcomed everyone present to the meeting and introduced the observers to the meeting: Public Governor Ian Fawcett and Management Trainee Georgina Biggins. Apologies for absence were received as noted above.

16/15 DECLARATIONS OF INTEREST There were no declarations of interest relating to items on the agenda.

17/15 MINUTES OF THE PREVIOUS MEETING AND MATTERS ARISING The minutes of the meeting held on 16 January 2015 were approved as a true and accurate record, subject to one amendment in relation to the SmartCare update; SH pharmacy (e-prescribing) to be replaced with pharmacy (stock control). There were no matters arising.

18/15 ACTION SHEET In relation to action 58/14, Jo Howarth confirmed the Never Events Policy Framework was issued early April 2015. Although there are no significant changes, it will impact the national reporting of serious incidents requiring investigation. Jo Howarth confirmed the Trust's procedural documents would be updated accordingly JHo and presented to CGAC in due course.

In relation to action 08/15, confirmation was provided that the Trust’s Macmillan Unit has been CHKS accredited. Samantha Hann agreed to liaise with Teresa Coombes SH to provide an update at the next meeting.

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19/15 REVISED CGAC TERMS OF REFERENCE Jane Henderson advised of proposals currently in discussion with the Chairman, non-executive and executive directors to revise the Trust’s governance structure. The proposals would be presented for approval at the Board of Directors on 29 April 2015, the key impact for CGAC of which would be its merger with NCRAC to establish an integrated “Governance Assurance Committee” to which the Quality Committee would report. Jade Renville confirmed that if the proposals are approved, she would develop terms of reference (ToR) for the Governance Assurance Committee for presentation on 17 July 2015, the date previously agreed for the next NCRAC and CGAC meetings.

CGAC said that if the merger was agreed, the length of the Governance Assurance Committee meetings would need to increase. Jade Renville added that it would continue to rely on its sub-committees to undertake detailed review against subject specific areas. Maurice Dunster questioned what was meant by section 4.2 ‘meetings may be held by electronic means’ and Jade Renville confirmed virtual meetings could be held in-between the quarterly meetings if required for any matters requiring urgent attention.

Acknowledging the proposed changes to the governance structure, CGAC nevertheless reviewed its revised ToR, which had been circulated before the meeting:

• Jane Henderson asked how the Committee could provide internal assurance to the Board of Directors on the clinical elements relating to the implementation of the electronic health record (section 2.4.3) when reports from the SmartCare Programme Board are not received at CGAC. Jo Howarth said the Programme Board is establishing a Clinical Design Authority Committee to oversee these elements as well as any risks, governance arrangements and clinical pathways. Reports from the Clinical Design Authority Committee will be cascaded to the Programme Board. In terms of the broader governance and assurance arrangements, Jade Renville confirmed they would be reviewed as well as enhancing the reporting structure to the Board of Directors. It was agreed that CGAC forms part of this assurance process and Jade Renville agreed to revise JR the wording of section 2.4.3 accordingly.

• Under section 2.4.7, the Committee agreed the word ‘essential’ should be removed and replaced with ‘fundamental’.

Subject to any further comments on the ToR, which should be sent to Jade Renville, the content was accepted on the basis that it would be incorporated within the Governance Assurance Committee ToR to be approved by the Board of Directors. ALL

20/15 OVERVIEW OF MATERNITY SERVICES AND RECOMMENDATIONS FROM THE MORECOMBE BAY INVESTIGATION REPORT Helen Williams, Associate Director and Head of Midwifery, was welcomed to the meeting to provide an overview of maternity services at YDH and the recommendations arising from the Morecombe Bay Investigation Report (Furness General Hospital).

Helen Williams provided an overview of the events that took place at Furness General Hospital (FGH) between 2004-2013. In doing so she explained that when reviewing the response to the incidents it is evidenced there were a series of missed opportunities at every level of the NHS. Vital lessons can be learnt and acted upon by all Trusts. Helen Williams outlined to the Committee the findings of the report and explained that different clinical care would have prevented two thirds of the deaths.

The Committee discussed the report’s conclusions and there was a lengthy 2 | Page

discussion about the engagement between obstetrics and midwifery i.e. when midwifes should obtain advice and support for pregnant women from doctors consultants and anaesthetics. The Committee were advised the epidural rate in large teaching hospitals is between 30-40%, in America the rate is 90% and for YDH it is 20%. The differences in the rates and the possible reasons were discussed. Helen Williams said there are 4 likely reason which have been identified so far for why the epidural rate at YDH is low compared to other trusts; the women do not wish to have an epidural, diamorphine is used at YDH as an alternative to pethidine, the anaesthetics team is not based at the women’s hospital and the midwives at Yeovil are extremely supportive to the women and have the skills to guide the women through their labours. YDH provides 1:1 midwife care for women on the delivery ward and the demographic is different to other areas.

The consistency of midwifery care at YDH was discussed and Helen Williams advised the majority of midwives working at YDH, trained at the hospital and are long standing members of staff. Around 10-15% of midwifes at YDH have come from other larger trusts. The question was raised whether midwives who do train at YDH are asked why they leave at exit interviews. Helen Williams confirmed they are asked but the majority of midwives that have left the Trust have been due to retirement or emigration.

Helen Williams confirmed she has benchmarked the Trust against the 18 recommendations from the Morecombe Bay Report and has developed an action plan which was presented to the Committee. Helen Williams spoke of the parallels between YDH and FGH – rural district general hospital, similar size and demographics in terms of workforce. A self-assessment benchmarking process has been undertaken and YDH has RAG rated itself - 1 red, 6 amber and 7 green. Helen Williams confirmed YDH has clear risk assessment processes, a good multi- disciplinary team and clear clinical governance processes in maternity and Trust wide. Helen Williams provided an overview of the action plan and the Committee discussed in detail the RAG rated red action ‘recruitment and retention strategy’. The Trust has a disproportionate number of junior midwives and midwives close to retirement age. The Committee were advised of the actions in place to minimise those risks and Tim Scull confirmed this action plan will be progressed together with the Royal College of Obstetricians and Gynaecologists action plan.

Jane Henderson thanked Helen Williams for a comprehensive presentation which was formally noted by CGAC.

21/15 ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS ASSURANCE VISIT - ACTION PLAN Tim Scull confirmed progress had been made against most areas included on the action plan with the majority assessed as amber. In relation to the consultant timetables review, he said this is ongoing and that recruitment to replace the retired consultant is underway with interviews planned in June 2015. In relation to the leadership recommendation, Tim Scull advised Missak Vehouni has met with some of the Consultants to collate their views and will continue to meet with the others. These discussions will then be used to format a team building exercise to progress the recommendation.

Helen Ryan confirmed that with the successful appointment of the Head of Midwifery, reassurance can be provided that the issues identified within the original report will be addressed.

The Committee agreed the Clinical Director of obstetrics and gynaecology would reflect on the original report and provide an update to CGAC in 6 months time on the improvements made and how the Trust can evidence this.

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Helen Ryan said YDH will be inspected by the CQC within the next year and the action plan together with the CQC inspection readiness work provides the Trust with JR/SH an opportunity to further improve the maternity service and the culture of the gynaecology and obstetrics department.

Tim Scull advised the Trust’s action plan had been shared with the Royal College of Obstetricians and Gynaecologists.

22/15 UPDATE ON CQC INSPECTION READINESS Helen Ryan confirmed Price Waterhouse Cooper (PwC) have commenced their CQC readiness work programme and that a CQC inspection readiness group has been created. She said PwC have spent the week at YDH collating evidence and interviewing staff. On 19 May 2015, they will undertake a mock inspection in which 30-40 people will be involved including PwC staff, patients and carers. The mock inspection will provide a flavour of what the CQC inspection will be like for staff, heighten staff awareness and highlight areas requiring improvement. It was agreed that an update from the mock inspection would be presented to the Board of Directors on 17 June 2015.

Helen Ryan advised the Committee that the CQC will be undertaking an unannounced review of the Somerset wide safeguarding children service the week commencing 20 April 2015. The service had previously been assessed as an inadequate. As part of the review, the CQC will be visiting YDH to assess the safeguarding children service provided at A&E, Ward 10 and the Trust’s maternity service. An update would be provided at the Board of Directors on 29 April 2015. Helen Ryan also confirmed she is meeting the Trust’s new CQC inspector later today.

23/15 PATIENT SAFETY AND INFECTION CONTROL Jo Howarth presented the Quarter 4 2014/15 infection prevention and control report. Disappointingly in Quarter 4 2014/15, 2 MRSA blood stream infections occurred at the Trust. Jo Howarth provided an overview of each case and confirmed learning has been identified including improving the quality of information and hand hygiene for certain staff groups. Jo Howarth confirmed there is a specific process for hand hygiene but additional support is required to enable staff to positively re-enforce the process to other colleagues who are not following process.

Jo Howarth confirmed there is now additional resource in the infection control and prevention team.

She also said that it was a challenging quarter in relation to clostridium difficile (C.diff). Nationally, there were increases in cases of norovirus and C.diff and there were four cases of C.Diff at YDH. Full investigations have been undertaken. Helen Ryan confirmed that when the Trust has cases of norovorus, the teams test more patients for C.diff and therefore the numbers are expected to rise. Jo Howarth confirmed the Trust’s target for the number of C.diff infections is to be reduced from 10 for 2014/15 to 8 for 2015/16. The Trust is aware that this target will be increasingly challenging to achieve.

24/15 PATIENT SAFETY, QUALITY AND EXPERIENCE REPORT Jo Howarth presented the Patient Safety, Quality and Experience Report which was noted by the Committee.

Jo Howarth reported that although there was a reduction of patient falls in January 2015, due to an increase in inpatient falls over the winter, partly as a result of significant operational pressures, the Trust was unable to achieve the proposed year-end target reduction of 10%. Jo Howarth confirmed that although the number of inpatient falls increased, the number resulting in significant harm had fallen. 4 | Page

Jo Howarth said that despite an increase in Quarter 4 2014/15 of pressure ulcers, the Trust had achieved a 20% reduction across the year. YDH achieved a 40% reduction in 2013/14. She added that Grade 3 pressure ulcers are now reportable to the CCG following validation by the Tissue Viability Team.

Jo Howarth advised the Committee that HSMR mortality rates remained static despite the peak in deaths across the country in December 2014. A review of all 83 deaths at YDH in December 2014 has been undertaken and no significant issues or trends were identified. It was noted however, there has been a decline in the coding of co-morbidities. This could be due to changes in the coding team and reminders and prompts would be put in place to ensure these are captured. Paul von de Heyde questioned whether the implementation of the electronic health record would increase the coding of co-morbidites and Jo Howarth confirmed it would help to a degree that the teams also rely on input and guidance from doctors.

In terms of NICE Guidance Compliance Jane Henderson asked why there are items included within the report from a decade ago. Jo Howarth said YDH is required by the Somerset CCG to report on all identified risks, (including those of low priority) with a partial compliance status. The Trust is currently in discussions with the CCG regarding this and the issue is being debated through the national NICE Group. AP / Adrian Pickles and Jo Howarth to review and provide an update at a future meeting. JHo

Jo Howarth reported that the number of PALS enquiries had arisen, a vast number in relation to the new car parking system. There are ward level work plans which feed into the corporate work plan. Actions from complaints will be fed into ward level plans.

25/15 UPDATES FROM SUB-GROUPS

Patient Safety An update relating to patient safety had already occurred during the course of the meeting.

Clinical Standards Jo Howarth confirmed a programme of work is in place and there is representation from each directorate which will help to improve clinical engagement.

Patient Experience Maurice Dunster explained the Group is chaired by Linda Hann and monitors patient experience data. He said that at the last meeting, a key item of discussion was ensuring meaningful feedback is provided to start following the outcome of complaints. The work of the clinical standards group to improve clinical engagement should support this communication.

Quality Committee Adrian Pickles advised that the topic of complaints will be reviewed at the Quality Committee in June 2015. Paul von de Heyde asked whether areas assessed and accepted as “amber” should be moved to “blue”. Jo Howarth confirmed all areas assessed as amber have an action plan in place and the Committee have agreed on an individual basis when they are satisfied without an area should be assessed blue. Adrian Pickles confirmed each area would be reviewed annually. For some areas assessed as “amber”, the Committee felt these should be reviewed more regularly than annually.

26/15 DEVELOPMENT OF THE QUALITY ACCOUNT 2014/15 Jo Howarth confirmed work is progressing well on the 2014/15 quality accounts. The Quarter 4 2014/15 data is currently being validated and the indicators were submitted by the Information Team on 16 April 2015. She said that the draft quality 5 | Page

accounts would be submitted to the Somerset CCG, HealthWatch, Trust governors and the Overview and Scrutiny Committee for comment by the end of April 2015. A final version will be submitted to the Audit Committee on 19 May 2015. They would be circulated to CGAC members for comments when the papers are prepared for presentation at the Audit Committee and the Board of Directors on 19 and 20 May 2015.

27/15 CORPORATE RISK REGISTER Adrian Pickles confirmed there are 21 significant or high risks (12+) on the Quarter 4 2014/15 Corporate Risk Register, 14 of which are relevant to CGAC. Adrian Pickles confirmed the enclosed report provides a summary of the risks relevant to CGAC and includes a snapshot as to whether the risk is reducing, remaining static or has deteriorated. Adrian Pickles confirmed full details of the individual risks can be accessed on the Corporate Risk Register on YCloud.

The Committee reviewed the 14 risks identified in the summary report, noting in particular agency staff usage. Jo Howarth confirmed the Trust is progressing well with its nursing recruitment campaign.

28/15 ANY OTHER BUSINESS There was no further business to discuss.

29/15 DATES AND TIME OF FUTURE MEETINGS Further to the discussion in item 19/15 regarding the proposed realignment of the Governance structure, the previously agreed dates for CGAC would stand but the time was subject to change. The Committee would be advised electronically the SH confirmed time of the meetings to be held on 17 July 2015 and 14 October 2015, both of which would take place in the Boardroom on Level 1 YDH.

30/15 SMARTCARE/ELECTRONIC HEALTH RECORD (EHR) UPDATE The SmartCare update was presented jointly to CGAC and NCRAC. As such, there will be a duplication of the recording in the minutes of both meetings.

Carole Shuff presented an update on SmartCare and the planned implementation of the electronic health record (EHR) including the timeframe for each stage. Phase 1 is currently underway, the scope of which includes replacing current patient administration systems (excluding PACs, radiology, pathology and some specialised systems), supporting the evolution of the EHR system, producing clinical letters and replacing department specific systems such as A&E, maternity, pharmacy stock and theatre stock control. Representatives from departments are attending workshops to understand the system’s functionality and operational impact.

Carole Shuff advised that in phase 2, which is currently scheduled from Summer 2016, core clinical functionality will be implemented including clinical decision support, further clinical alerts, order sets, medicines management and administration, e-prescribing and further information dashboards.

Carole Shuff confirmed project managers are in place, operational assessments are underway and the system is being reviewed to assess its limitations and benefits to ensure it is used in the most effective way for the needs of the Trust. Carole Shuff confirmed the workshops, assessment, configuring, testing, and training stages will be repeated for phase 2. She added that (in terms of phase 1) staff will be trained within the 6 weeks prior to the go live date which is scheduled for October/November 2015.

The question was raised whether all new and historic patient clinical notes would be migrated onto the system. Carole Shuff said this would not be the case; only

6 | Page information held on PAS and the ED system would be migrated initially as it is a complex process to migrate all legacy information from old systems to modern electronic data systems. In phase 2, Carole Shuff confirmed clinicians may choose to add certain patient records and/or a complete a summary onto the EHR for that patient.

Mark Saxton asked whether the system is able to carry out operational assessments which Carole Shuff affirmed. Carole Shuff was asked of any system gaps and she replied that in relation to pharmacy stock goods receipting, a gap had been identified and a solution to possibly integrate this into the Trust's finance system is being explored.

The Committee asked whether YDH has met with other organisations who have implemented the system to learn from their experiences. Carole Shuff confirmed the Trust has spoken to other organisations, although there are limited mature HER systems in the UK, and that there are a team of people from Intersystems who will be available during the build.

Carole Shuff provided the Committee with an overview of the security measures available within EHR. Roles based access controls (RBAC) will be used which allow different levels of access on the system. Within phase 2, the number of passwords required by staff will be reduced as EHR is an integrated system which will streamline the authentication process will either allow staff to access the information they require. Carole Shuff confirmed the system is fully auditable and will allow different access rights, for instance read/write/view.

Tim Scull advised the Committee of ongoing information governance discussions in relation to sharing information between the Symphony Hub and EMIS. Carole Shuff confirmed e-discharge letters are currently being piloted and will remain part of the functionality.

Carole Shuff highlighted the current key programme risks:

• the resource to input into workshops and optimise opportunities • the availability of rooms to train all staff within 6 weeks • the resilience of the local network - there are currently 2 links into the Trust which share the same path – separate paths will be developed • the future changes the Trust is facing with Symphony and Vanguard and ‘pull’ on resources

The Committee also discussed the potential risks associated with ensuring all staff receive training within the 6 week period leading up to the go live date.

Adrian Pickles advised that currently the SmartCare risks are not included on the Corporate Risk Register. Carole Shuff confirmed the risks relating to EHR are currently uploaded onto a programme register on YCloud. The Committee agreed SmartCare and EHR should be included on the Corporate Risk Register and JR Jonathan Howes, Deputy Chief Executive as responsible Director for SmartCare and EHR should provide regular updates to the Board of Directors.

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NON-CLINICAL RISK ASSURANCE COMMITTEE (NCRAC)

Minutes of an NCRAC Meeting held on 17 April 2015 at Yeovil District Hospital

Present: Julian Grazebrook (Chair) Non-executive Director Mark Saxton Non-executive Director

In Attendance: Mark Appleby Head of Workforce Performance and Organisational Development (item 18/15) Georgina Biggins Management Trainee (Observer) (item 12/15) Maurice Dunster Non-executive Director (item 12/15) Ian Fawcett Public Governor (Observer) (item 12/15) Jane Gifford Public Governor (Observer) (items 12/15 - 18/15) Hala Hall Public Governor (Observer) Samantha Hann Assistant Company Secretary Jane Henderson Non-executive Director (item 12/15) Paul von der Heyde Non-executive Director Adrian Pickles Trust Risk Manager Jade Renville Company Secretary Tim Scull Medical Director (item 12/15) Carole Shuff Head of IT Transformation (item 12/15)

Apologies: BDO Representative Internal Auditors Tim Newman Chief Finance and Commercial Officer Peter Wyman Trust Chairman

Action 12/15 SMARTCARE/ELECTRONIC HEALTH RECORD (EHR) UPDATE The SmartCare update was presented jointly to NCRAC and CGAC. As such, there will be a duplication of the recording in the minutes of both meetings.

Carole Shuff advised that in phase 2, which is currently scheduled from Summer 2016,

core clinical functionality will be implemented including clinical decision support, further

clinical alerts, order sets, medicines management and administration,

e-prescribing and further information dashboards.

The question was raised whether all new and historic patient clinical notes would be migrated onto the system. Carole Shuff said this would not be the case; only information held on PAS and the ED system would be migrated initially as it is a complex process to migrate all legacy information from old systems to modern electronic data systems. In phase 2, Carole Shuff confirmed clinicians may choose to add certain patient records and/or a complete a summary onto the EHR for that patient.

explored.

Carole Shuff highlighted the current key programme risks:

The Committee also discussed the potential risks associated with ensuring all staff receive training within the 6 week period leading up to the go live date.

Adrian Pickles advised that currently the SmartCare risks are not included on the

Corporate Risk Register. Carole Shuff confirmed the risks relating to EHR are currently

uploaded onto a programme register on YCloud. The Committee agreed SmartCare

and EHR should be included on the Corporate Risk Register and Jonathan Howes,

Deputy Chief Executive as responsible Director for SmartCare and EHR should provide regular updates to the Board of Directors. JR

13/15 WELCOME AND APOLOGIES Julian Grazebrook welcomed everyone present to the meeting. Apologies for absence were received as noted above.

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14/15 DECLARATIONS OF INTEREST There were no declarations of interest relating to items on the agenda.

15/15 MINUTES OF THE PREVIOUS MEETING AND MATTERS ARISING The minutes of the meeting held on 16 January 2015 were approved as a true and accurate record, subject to one amendment in relation to the SmartCare update; SH pharmacy (e-prescribing) to be replaced with pharmacy (stock control). There were no matters arising.

16/15 ACTION SHEET Samantha Hann confirmed action 09/15 is now complete as the Information Governance Toolkit presentation had been circulated to the Committee prior to the meeting.

The Committee noted all actions were complete, on the agenda or in progress. In relation to action 19/14, Jade Renville confirmed the Audit Committee will receive an update on the current position later that day following the internal/external audit by JR/SH KPMG/BDO. The Quality Committee will review and a further update will be presented to NCRAC on 14 October 2015.

17/15 REVISED NCRAC TERMS OF REFERENCE Julian Grazebrook advised of proposals currently in discussion with the Chairman, non- executive and executive directors to revise the Trust’s governance structure. The proposals would be presented for approval at the Board of Directors on 29 April 2015, the key impact for NCRAC of which would be its merger with CGAC to establish an integrated “Governance Assurance Committee” to which the Quality Committee would report. Jade Renville confirmed that if the proposals are approved, she would develop terms of reference (ToR) for the Governance Assurance Committee for presentation on 17 July 2015, the date previously agreed for the next NCRAC and CGAC meetings. In doing so, she would take account of any non-clinical areas that could, in future, be overseen by the Audit Committee.

Acknowledging the proposed changes the governance structure, NCRAC nevertheless

reviewed its revised ToR, which had been circulated before the meeting so feedback

could be reflected within this version. The content was accepted on the basis that it would be incorporated within the Governance Assurance Committee ToR, if applicable, to be approved by the Board of Directors. Any further amendments or comments on the ToR should be sent to Jade Renville. ALL

18/15 UPDATE ON STAFF SURVEY RESULTS 2014 AND THE ACADEMY WORKPLAN 2015/16 Mark Appleby advised that the Trust undertook the staff survey in November 2014 and he provided an overview of the performance against the survey themes as an overall movement in year compared against the 2013 responses. The response rate rose from 49% in 2013 to 66% in 2014. The Committee asked whether the survey could be completed online and staff were required to complete all questions. Mark Appleby confirmed Capita, who manage the survey on the Trust’s behalf, advised against the online platform as it can reduce the response rate as some staff do not have regular access to email. The intention is to provide an online option in the next couple of years. Mark Appleby also said the questions are optional so staff are able to complete only part of the survey if they wish.

Following presentation of the key survey results, Mark Appleby explained that overall the feedback from staff has improved across the majority of sections within the survey.

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He said the Trust has already put into place since the survey was completed including the recruitment campaign for nursing staff to help relieve the pressure and work intensity on the current nursing staff and to ensure staff are released to attend mandatory training and annual appraisals. It was agreed the Trust needs to focus on improving communication and managing change. The Trust has a clear vision but it is essential managers take forward this vision and communicate this effectively with their staff. The non-executive directors commented that the response data is fairly generic and said they would welcome more detailed analysis in the future.

Mark Appleby confirmed the HR team are currently discussing with departments the survey results and the feedback, which will inform the corporate response plan. A HR helpdesk has been set up to take routine queries which will allow the HR Business Managers to focus more strategically.

Mark Appleby spoke of the Academy Education and Training 2 Year Plan. The plan identifies 7 strands – mandatory training, leadership and development, professional registration, continued professional development, vocational education, talent management and equality, diversity and inclusion. Under each strand, the plan identifies what the Trust has achieved so far and the areas of focus in the future. Mark Appleby confirmed the plan identifies new ways of improving and enhancing normal business activities. Julian Grazebrook thanked Mark Appleby for the presentation.

19/15 UPDATE FROM THE QUALITY COMMITTEE Adrian Pickles presented a report from the Quality Committee which identifies the key risk areas or compliance against legislation and CQC fundamental standards of care on an annual basis, as reviewed by the Quality Committee in 2014/15.

Adrian Pickles provided an overview of 2 significant areas of risk identified in the report. Emergency Planning: this had previously been assessed as red in September 2014 and in February 2015, but subsequently assessed as amber by the Quality Committee in response to the action plan managed by the Head of Operational Resilience. Adrian Pickles confirmed the Audit Committee will receive an update on business continuity at its meeting taking place later today. In relation to fire safety, Adrian Pickles there are systems in place and the Trust is not at any immediate risk but fire safety has been

assessed as red as there are training and educational gaps across the Trust as well as some system upgrades required, and the recording of data is not always clearly documented. A comprehensive action plan needs to be put in place and carried out. The management of fire safety is currently under review.

Adrian Pickles confirmed health records management and information governance were reviewed in February 2015 and assessed as amber. There are no areas to be brought back to the Quality Committee before the next annual review as the Information Governance Steering Group will progress the actions in 2015/16.

Samantha Hann confirmed she had presented an update regarding policy management which was assessed as amber. She added that the Trust satisfies the CQC key lines of enquiry as the Trust holds policies and procedures however there is no central record of the procedural documents, they are not always easy for staff to locate and some documents require review. An action plan is in place and will be managed by Samantha Hann. An update will be presented to the Quality Committee in July 2015.

20/15 CORPORATE RISK REGISTER - QUARTER 4 2014/15 Adrian Pickles confirmed there are 21 significant or high risks (12+) on the Quarter 4 2014/15 Corporate Risk Register, 6 of which are relevant to NCRAC. He confirmed the

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enclosed report provides a summary of the risks relevant to NCRAC and includes a snapshot as to whether the risk is reducing, remaining static or has deteriorated. Adrian Pickles confirmed full details of the individual risks can be accessed on the Corporate Risk Register on YCloud.

The Committee further discussed the need for a risk to be included on the Corporate AP Risk Register for SmartCare and the implementation of EHR and the importance for the Board of Directors to review these risks on a regular basis.

The Committee reviewed the 6 risks identified in the summary report. Adrian Pickles advised business continuity is not on the Corporate Risk Register as this is currently captured within emergency planning. This may need to be enhanced in the future.

21/15 ANY OTHER BUSINESS There was no further business to discuss.

22/15 DATES AND TIME OF FUTURE MEETINGS Further to the discussion of item 17/15 regarding the proposed realignment of the governance structure, the previously agreed dates for NCRAC would stand but the timing is subject to change. The Committee would be advised electronically of the SH confirmed time of the meeting to be held on 17 July 2015 and 14 October 2015, both of which would take place in the Boardroom on Level 1 YDH.

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AUDIT COMMITTEE MEETING

Minutes of an Audit Committee Meeting held on 17 April 2015 at Yeovil District Hospital

Present: Paul von der Heyde (Chair) Non-executive Director Julian Grazebrook Non-executive Director Jane Henderson Non-executive Director

In attendance: Claire Baker BDO – Internal Auditors Georgina Biggins Graduate Management Trainee – Observer Jon Brown Senior Statutory Auditor, KPMG [from item 25/15] Peter Fry Income and Costing Accountant Chris Moore Senior Finance Manager [items 26/15 and 27/15] Tim Newman Chief Finance and Commercial Officer Aimee Newton Counter Fraud Service John Park Elected Public Governor - Observer Adrian Pickles Trust Risk Manager Jade Renville Company Secretary Greg Rubins BDO – Internal Auditors Mark Saxton Non-executive Director Tim Scull Medical Director [item 24/15] Dean Stevens Assistant Director of Finance Mark Thouless Financial Controller Yvonne Thorne Head of Operational Resilience [until item 22/15] Alison Whitman Elected Public Governor - Observer

Apologies: Sheena Morrow Assistant Director of Finance Tara Westcott Senior Manager, KPMG

Action 16/15 WELCOME AND APOLOGIES Paul von der Heyde welcomed everyone present to the meeting. Apologies were received as noted above.

17/15 DECLARATIONS OF INTEREST RELATING TO THE AGENDA There were no declarations of interest relating to items on the agenda.

18/15 MINUTES OF THE PREVIOUS MEETING The minutes of the meeting held on 16 January 2015 were approved as a true and accurate record. It was confirmed there were no matters arising not on the agenda. Actions would be picked up during the course of the meeting. 19/15 REVISED AUDIT COMMITTEE TERMS OF REFERENCE Paul von der Heyde advised of proposals currently in discussion with the Chairman, non-executive and executive directors to revise the Trust’s governance structure. The proposals would be presented for approval at the Board of Directors on 29 April 2015.

The impact for the Audit Committee would be minimal, but the merger of CGAC and NCRAC may mean the Audit Committee assumes oversight of some non-clinical items previously reviewed by NCRAC. Jade Renville confirmed that if the proposals are approved, she would reflect the JR changes in each of the assurance committee terms of reference (ToR). As such, it was agreed that any further comments on the draft ToR should ALL be sent to Jade Renville, in addition to inclusion of feedback from Paul von der Heyde which he had sent to Jade Renville prior to the meeting:

• The Audit Committee to have greater oversight of the appointment of the internal auditors. • In terms of 3.2.7, the word “determine” is to be removed and the paragraph is to be softened to ensure it falls within the practicable scope of the Audit Committee. • In terms of 3.3.6 and 3.2.7, the paragraph is to be clarified to note the documentation will be developed by organisational subject experts, with input from the Trust’s lawyers or other advisors if required. It is then the role of the Audit Committee to oversee the developmental process.

20/15 BDO INTERNAL AUDIT ANNUAL REPORT 2014/15 Greg Rubins spoke to the internal audit annual report which includes BDO’s audit opinion. He said BDO are able to provide a moderate assurance opinion, which is the same as issued last year. In doing so he confirmed BDO had taken account of the Trust’s financial challenges but said despite these pressures YDH is meeting the majority of its operational and quality of care targets and internal audit demonstrates that the basic controls in place are generally effective.

Commenting on the 2014/15 work plan, Greg Rubins said all audits had been completed, except for ‘complaints and incidents’ and ‘partnership working – pathology’ both of which are in the final stages of completion and CIP, the final results of which are being reviewed with management. Greg Rubins added that BDO will attempt to obtain more feedback from staff in 2015/16. Paul von der Heyde asked whether the points in the annual report can be accepted when three reports are still to be finalised. Greg Rubins said clearance meetings had been held and no major changes to the outcome of the audits are expected. Adrian Pickles said there were some inaccuracies in the draft complaints and incidents report, which would be followed up outside the meeting.

21/15 BDO INTERNAL AUDIT REPORTS TO DISCUSS AND NOTE

Business Continuity Greg Rubins presented the internal audit report into business continuity saying that BDO had identified some weaknesses in the Trust’s processes and so had made four high and two medium recommendations. Yvonne Thorne attended the Audit Committee and concurred with the statements made by BDO in their report. The non- executive directors said the issues identified were concerning and asked about the actions being taken to resolve them. Yvonne Thorne said her role had now changed to enable to her to focus on business continuity and operational resilience and that she has started to develop a plan to address the recommendations.

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She added that she will work with the IT team to update and disseminate the relevant policies and procedures. The implementation of the electronic health record will also provide the opportunity to update and formalise the Trust’s internal processes. Paul von der Heyde challenged the timescales and asked whether the actions should be implemented sooner. Yvonne Thorne said the completion of the actions would take some time, which she is working through in order of priority. She added that she will work with the SmartCare team to ensure the impact of the electronic health record implementation is reflected in business continuity and resilience planning. Greg Rubins also offered Yvonne Thorne the opportunity to meet with the IT specialist from BDO who undertook the

internal audit, which she accepted.

Risk Management and BAF BDO presented the compliance internal audit report into risk management and the Board Assurance Framework (BAF) and were able to provide moderate assurance with two medium level recommendations, which Jade Renville and Adrian Pickles said they would implement. However, in terms of the recommendation to ensure all objectives in the BAF are cross referenced to the risk register, they said that in some cases there may be no such connection if the risks in meeting a particular priority have been mitigated.

22/15 FOLLOW-UP OF RECOMMENDATIONS REPORT Claire Baker presented the follow-up of recommendations report saying that good progress has been made with one high priority and one medium recommendation still outstanding. Of these, the Audit Committee discussed the need for the estates team to carry out a secondary check of the figures for the estates return information collection (ERIC) before it is submitted. As the manager previously responsible for this action had left the Trust, this has passed to the Head of Estates who will ensure the check is undertaken at the end of May for submission in June. It was agreed BDO would follow-up and provide an update at the Audit Committee in July. The Audit Committee noted the follow-up of recommendations report.

23/15 BDO INTERNAL AUDIT PLAN 2013-16 (STRATEGIC) 2015-16 (OPERATIONAL) Greg Rubins introduced the internal audit plan saying that the operational elements have been developed with Tim Newman and Jo Howarth adding that the strategic plan remains unchanged. He listed the main items currently planned for 2015/16, as follows: • Data quality (performance indicators) • Compliance (clinical governance) • Consultant job planning • HR and training (medical and nursing workforce planning) • Budgetary control • Private patient income • Main financial systems • IT and costing developments • Information governance • Partnership working (business development)

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He added that reviews of delayed discharges and risk maturity were also possible options for audit in 2015/16. BDO urged the Audit Committee to consider the audit into delayed discharges, which is being undertaken by Somerset Partnership NHS Foundation Trust, Somerset CCG and Taunton and Somerset NHS Foundation Trust so there is comparable data across the Somerset health economy. Tim Newman said he would TN discuss this further with Jonathan Higman, Director of Urgent Care and Long Term Conditions, as he had already done significant analysis in this area and the Trust needs to ensure any internal audit would not simply be duplication; it would need to result in meaningful outcomes. Jane Henderson added that the findings from the Trust’s fastforward initiative

should be reflected within the audit if it is undertaken.

Mark Saxton questioned whether 20 days was required on HR and workforce planning given much of the analysis (such as the production of safe staffing data) is already undertaken by the Trust and scrutinised by the Board of Directors. Instead, he suggested YDH considers ‘time to recruit’. Following these comments, Tim Newman agreed he would review the number of days and scope of planned audit with the HR and TN workforce team and with BDO.

In terms of consultant job planning, Julian Grazebrook asked whether the audit should take place after the implementation of the electronic health record. Tim Newman said the processes should be broadly similar pre and post implementation but that the work specification would be reviewed prior to the start of the audit to ensure it takes account of the impact of the electronic health record.

24/15 DRAFT QUALITY COMMITTEE TERMS OF REFERENCE / WORKPLAN Tim Scull attended the Audit Committee to provide an overview of the purpose of the Quality Committee. He explained that the annual programme of work covers all service areas which are reviewed in line with the CQC standards and legal requirements. Following consideration by the Quality Committee, each service area is self-assessed using RAG scoring and an action plan is put in place to address any recommendations. Tim Scull highlighted the key areas of concern identified to date, namely fire safety (which remains red even after follow- up review), emergency planning and medical devices and clinical equipment-training and point of care testing (which have returned to amber following the implementation of recommendations although more work is to be done) and blood transfusion processes, an update on which is scheduled at HMT.

John Park commented on the importance of patient experience and that it should be reflected within the ToR and taken into account when services present to the Quality Committee. Alison Whitman asked about the number of abbreviations contained within the reports and whether they would be understood by outsiders. Tim Scull acknowledged they may not and also reflected on the challenges for the Quality Committee of overseeing such a broad range of service areas when they are not subject experts.

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The Audit Committee agreed it could not approve the ToR for the Quality Committee or confirm its reporting line to the Audit Committee as proposals to revise the Trust’s governance structure to be approved at the Board of Directors on 29 April 2015 may have an impact. For instance, if CGAC and NCRAC are merged to form a “Governance Committee”, it may be to that group which the Quality Committee reports.

25/15 2014/15 REFERENCE COSTS Peter Fry explained that reference costs are the average unit cost to the NHS of providing secondary healthcare to NHS patients and that they are used to inform prices (tariff) for NHS funded services. He added that they are collected by each trust and published annually. They are also beneficial for YDH as a measure of cost efficiency. The Audit Committee approved the process set out by Peter Fry in his tabled presentation for collecting reference costs, acknowledging that work is also ongoing to address the recommendations made during a recent audit, for which there are clear improvement plans in place with timescales. In particular, the Audit Committee said it would be important to engage more with clinicians on reference costs, which Peter Fry confirmed he would do. Tim Newman provided further assurance by advising Peter Fry is working with another trust to enable peer review on reference costs across both organisations.

26/15 GOING CONCERN Chris Moore attended the Audit Committee to give an overview of going concern, explaining its purpose in the preparation of the year-end accounts. At its meeting on 25 March 2015, the Board of Directors agreed the accounts should be prepared with the presumption of going concern, but requested the Audit Committee consider whether additional disclosures should be made. To support this aim, Chris Moore provided some examples contained within the annual reports of other trusts. On the basis that management has no intention of applying to the Secretary of State for the dissolution of YDH, the accounts would be prepared on the presumption of going concern. However, acknowledging the financial challenges faced by the Trust, including the deficit position and reducing

cash reserves, combined with the ongoing Monitor investigation, the Audit

Committee agreed disclosures should be provided in order to provide

context. In doing so, it would be made clear that the Trust has developed a strategic plan to address the challenges faced, which has been recognised nationally with the award of Vanguard status, facilitating access to transformation funding from NHS England to implement new models of care that will improve the service received by patients, whilst also delivering a sustainable financial position. The finance team would develop draft wording to be considered by Julian Grazebrook, Tim CM Newman and Paul von der Heyde prior to final agreement as part of the accounts at a meeting of the Audit Committee on 19 May 2015.

27/15 ARRANGEMENTS FOR OFF PAYROLL PAYMENTS TO STAFF POLICY Chris Moore presented the arrangements for off-payroll payments to staff to the Audit Committee for approval. In doing so he said it formalises the processes already in place to ensure any persons being paid in this way are meeting their obligations to pay the correct tax on their earnings. The Audit Committee approved the policy.

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28/15 EXTERNAL AUDIT PROGRESS REPORT AND TECHNICAL UPDATE Jon Brown presented the external audit progress report and technical update. He confirmed that since the last meeting KPMG had completed their interim audit including a review of the financial system and testing of key controls and reviewed the internal audit work papers. He added that they have agreed the final arrangements for the final year end audit, including the review of the quality report. A meeting of the Audit Committee would take place on 19 May 2015 to review the year-end accounts and associated auditor reports.

In terms of the technical update, he highlighted the changes to the annual reporting manual and detailed requirements for quality reports. John Park asked how the governor indicator (patient experience of discharge) would be measured. Jon Brown said KPMG is not required to provide an opinion on the local indicator, but said there were limitations associated with being able to validate the accuracy of the data. Jon Brown also drew attention to Monitor’s Q3 report on foundation trust performance which demonstrates the financial and operational pressures across the sector.

The Audit Committee noted the external audit progress report and technical update.

29/15 EXTERNAL AUDIT INTERIM REPORT 2014/15 In presenting the external audit interim report, Jon Brown said the year- end audit is on track and a meeting of the Audit Committee would take place on 19 May 2015 to review the year-end accounts and associated auditor reports. He added that the recommendations identified from the interim audit are of low level and actions are in place to address them. The Audit Committee noted the interim audit report 2014/15.

30/15 COUNTER FRAUD PROGRESS REPORT Aimee Newton took the report as read but highlighted the following points, which were noted by the Audit Committee:

• She is continuing to work with the Trust on the identification of data matches (i.e., duplicate invoices or invoices paid to the incorrect supplier relating to a three year period from 2010 to 2014) following the national fraud initiative. She said 19 cases have been identified resulting in overpayments of £30k, which are now being addressed. • In terms of hold to account, she listed the investigations that took place during 2014/15, saying that one case is ongoing and being actioned.

Aimee Newton also spoke of the two assessment reports which had been issued by the counter fraud service; procurement fraud [item 31/15 refers] and HR, which is currently being reviewed by Dean Stevens and Tim

Newman. Jane Henderson asked whether the counter fraud service

publishes a report on any nationwide areas of risk. Aimee Newton said an

annual report is produced which lists the key risk areas. Jon Brown added that KPMG prepares papers depicting this information, which he agreed to share by email with the Audit Committee.

31/15 PROCUREMENT FRAUD RISK ASSESSMENT FOLLOW-UP Aimee Newton provided an update on the implementation of the recommendations of the procurement fraud risk assessment.

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She said that while some progress had been made, there were a number of actions still outstanding, a plan for which would be developed by Louise Brereton, Head of Procurement, and added to the counter fraud recommendation tracker. Paul von der Heyde asked what constitutes “training” for the non-executive directors in this area. It was confirmed that the presentation delivered by Louise Brereton at a previous Audit Committee would suffice.

32/15 COUNTER FRAUD RECOMMENDATION TRACKER Dean Stevens explained that actions arising from the activities of the Trust’s counter fraud service are monitored through the recommendations tracker. He advised of progress since the last meeting saying that two recommendations had been added and one had been marked as complete. Work on the national fraud initiative data matches is ongoing, which Aimee Newton and Mark Thouless are processing. The items relating to the procurement fraud risk assessment would be added to the tracker.

33/15 COUNTER FRAUD WORK PLAN 2015-16 Aimee Newton presented the counter fraud 70 day work plan for 2015/16 which covers strategic governance, inform and involve, prevent and deter and hold to account. She explained the plan had been developed based on discussions with the Chief Financial and Commercial Officer and that it takes account of the NHS Protect standards, local proactive work, any identified risks and national work programmes and initiatives. She added that the work plan will remain flexible to ensure it meets the needs of the organisation. The Audit Committee thanked Aimee Newton for producing such a comprehensive document and approved the work plan for 2015/16.

34/15 CORPORATE RISK REGISTER Adrian Pickles presented the corporate risk register confirming there are currently 21 significant or high risks (12+) recorded, with four new risks added and one risk removed since the last review. Risks within the remit of NCRAC and CGAC had been discussed at their meetings earlier in the day. Following BDO’s recent audit, Adrian Pickles had amended the risk register report so it summarises the key information and illustrates increasing/decreasing level of risk. The Audit Committee commented positively on the revised format.

Following questions about pandemic ‘flu and Ebola and whether the actions in place reduce the levels of risk currently recorded, Adrian

Pickles agreed to undertake further review. The non-executive directors AP said the risks relating to SmartCare and the electronic health record

implementation should be captured as part of the Trust’s usual risk management processes, which Adrian Pickles agreed to follow-up with the team to ensure any risks scored at 12(+) are included on the corporate risk register. Greg Rubins and Jon Brown asked whether the corporate risk register should note the potential risk of a negative outcome to the Monitor investigation into the Trust’s finances. Tim Newman said the financial pressures and reducing cash reserves is detailed on the register and the Trust’s five year plan to address the challenges and achieving Vanguard status means any such risk is significantly mitigated.

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He added that the greater risk is the pace at which the Trust needs to progress its plans, expenditure for which may be incurred before transformation funding is received.

The Audit Committee noted the corporate risk register.

35/15 FINANCE REPORT Mark Thouless presented the finance report providing the current status for debtors, year to date losses and compensation payments. He reported the position as at 28 February 2015 which showed total debtors of £4.375m. He explained the figure is made up of NHS invoiced debt, NHS accrued income, non-NHS invoiced debt, non-NHS accrued income, accrued income (injury cost recovery scheme) and pre-paid contracts. He acknowledged NHS invoiced debt was higher than previously but said this is to be expected at year-end. He assured the Audit Committee that no queries had been raised on the invoiced debt and that it is now being received. In terms of non-NHS debt he listed details of outstanding items valued over £10k which the Trust is seeking to resolve, saying that the

largest remains Yeovil Eyecare, the supplier of which is currently in

process of CVA. Following questions from the Audit Committee regarding

loss of personal affects, Mark Thouless confirmed most costs are of low value except one item which has now been resolved. Following a request from Paul von der Heyde, Mark Thouless agreed in future to depict two MT lines for each financial year on the aged debt graphs. The Audit Committee noted the finance report, including details of aged debt, losses and special payments.

36/15 REGISTERS OF SEALINGS, HOSPITALITY AND INTERESTS The registers of sealings, hospitality and interests were noted.

37/15 ANY OTHER BUSINESS There was no further business to discuss.

38/15 MEETING WITH AUDITORS AND COUNTER FRAUD SERVICE There was an opportunity for Audit Committee members to meet with the auditors and counter fraud service in the absence of officers of the Trust.

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AUDIT COMMITTEE MEETING

Minutes of an Audit Committee Meeting held on 19 May 2015 at Yeovil District Hospital

Present: Paul von der Heyde (Chair) Non-executive Director Julian Grazebrook Non-executive Director

In attendance: Jon Brown Senior Statutory Auditor, KPMG Jo Howarth Associate Director of Patient Safety Tim Newman Chief Finance and Commercial Officer Jade Renville Company Secretary Mark Thouless Financial Controller Fiona Timmins Corporate Accountant Tara Westcott Senior Manager, KPMG

Apologies: Claire Baker BDO – Internal Auditors Jane Henderson Non-executive Director Sheena Morrow Assistant Director of Finance Aimee Newton Counter Fraud Service John Park Elected Public Governor - Observer Adrian Pickles Trust Risk Manager Greg Rubins BDO – Internal Auditors Dean Stevens Assistant Director of Finance Alison Whitman Elected Public Governor - Observer

39/15 WELCOME AND APOLOGIES Paul von der Heyde welcomed everyone present to a special meeting of the Audit Committee in order to review the annual accounts 2014/15.

40/15 DECLARATIONS OF INTEREST RELATING TO THE AGENDA There were no declarations of interest relating to items on the agenda.

41/15 KPMG ISA 260 REPORT AND PRESENTATION OF THE ANNUAL REPORT AND ACCOUNTS 2014/15 Jon Brown presented the ISA 260 report confirming that the audit had been completed in line with plan, although it was acknowledged that the timescales this year were particularly challenging for YDH. He said that KPMG had issued an unqualified opinion, subject to review by the Audit Committee and the Board, receipt of the management representation letters and some minor presentational changes.

Jon Brown advised that KPMG had found the Trust to have adequate arrangements in place to secure economy, efficiency and effectiveness in its use of resources. In doing so, he remarked upon the ongoing Monitor investigation into the Trust’s short-term financial pressures, saying that

strategic plans to create new models of care are being implemented to JR address the challenges. Wording to this effect will be included within the

annual governance statement. Following discussion at the previous meeting [item 26/15 refers] Jade Renville also confirmed the annual report had been updated to provide context to the Trust’s going concern status.

Tara Westcott commented on the audit of the 2014/15 accounts, from which it was noted that:

• The accounts have been completed in accordance with the Monitor NHS Foundation Trust Annual Reporting Manual (ARM), revisions to which had required the Trust to make additional disclosures.

• A full revaluation of Trust land and buildings was performed in-year by Gerald Eve resulting in an impairment of £5.4m. Paul von der Heyde questioned whether the property had been “devalued” as a result of any inappropriate action. Tim Newman said the recent estates facet survey identified YDH is not an outlier in terms of estates backlog and that the overview undertaken by Gerald Eve was extremely thorough. Jon Brown added that the reduction in costs is predicated on the

assumption that should the hospital need to be rebuilt it would be a

modern equivalent “out of town” at a lower price per acre.

• No significant issues were identified during the audit relating to

management override of controls.

• No significant issues were identified as a result of the work performed on the income balance. There were some differences above £250k found within the expenditure agreement of balances schedule, set out at Appendix D of the enclosed report, which are being reconciled.

• Testing has been completed on accruals at year end, which primarily relate to goods which have been received but not yet invoiced and contracted services which have not yet been billed. The balance is higher than the previous year due to increased costs relating to agency staff and consultancy for the strategic review.

• Fees for the 2014/15 audit were £63,125 + VAT. Fees for the external assurance on the 2014/15 quality report were £8,000.

• KPMG have robust procedures in place to safeguard their independence and objectivity.

Fiona Timmins summarised the key points from the 2014/15 accounts, explaining the year-end deficit for the Trust was circa £10m, total operational income was circa £120m, operating expenses totalled circa £129m, the year-end cash position was circa £2m and total losses and special payments were circa £8k. Also, the cost improvement programme delivered £2.6m and £5.5m was invested in capital developments.

The Audit Committee discussed the data analysis undertaken by KPMG of the payroll records kept by the Trust, particularly the number of employee sick days and procedures for leavers. It was agreed that a separate session should be arranged with Tim Newman, KPMG and the HR team TN to review the information in more detail and to consider ways to improve the electronic collection and reporting of this data.

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The annual report and accounts had been reviewed in detail by the non- executive directors prior to the meeting and their comments, together with some minor presentational changes identified by KPMG, would be JR incorporated within the final documentation. On this basis, the Audit Committee confirmed it would recommend to the Board of Directors that it approves the annual report and accounts 2014/15.

42/15 KPMG ISA 260 REPORT – CHARITABLE FUNDS AND PRESENTATION OF THE CHARITY ACCOUNTS 2014/15 Jon Brown presented the ISA 260 report on the charitable funds confirming that the audit had been completed in line with plan and that KPMG are proposing an unqualified audit opinion. He added that no significant issues arose during the course of the audit and that no significant weaknesses in the financial systems or controls were identified.

On this basis, the Audit Committee confirmed it would recommend to the Board of Trustees that it approves the charity accounts 2014/15. Paul von der Heyde asked about the debtors value and it was confirmed that this relates to payment timing for the CT scanner.

43/15 EXTERNAL ASSURANCE ON THE QUALITY REPORT AND PRESENTATION OF THE QUALITY REPORT (ACCOUNT) 2014/15 Jon Brown presented KPMG’s external assurance on the quality report advising they had issued YDH with a limited assurance opinion. He said that the content of the quality report was accurately reported in line with regulations, but there was limited assurance over a mandatory indicator (percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period) due to unavailability of supporting documentation relating to historic patient data. This is a similar position to other trusts that use a ‘live’ system and this issue has been raised with Monitor. The Audit Committee commented on the work completed during the year by BDO to test the Trust’s RTT reporting systems, recommendations from which had been implemented.

Ongoing review of these systems would form part of BDO’s work plan

going forwards. As a result of their findings, KPMG also recommended

that YDH should introduce processes to enable identification of all RTT breaches amended post submission date that would impact the reported position on a monthly basis, which would be considered.

Jo Howarth spoke about the production of the quality report advising that its format and content is mandated by regulations. She said that feedback from Overview and Scrutiny, HealthWatch, the Somerset CCG and the Trust’s governors was expected by the end of the week, which would then be added as appendices to the report. She said that comments received from the non-executive directors during the week would be reflected in the final version. She also agreed to provide commentary to the data charts so they could be easily understood. The non-executive directors asked about the delivery of key priorities in 2015/16 and whether they could be met. Jo Howarth acknowledged that the significant and unprecedented operational pressures in 2014/15 meant YDH did not meet all its quality priorities but that additional focus on nursing recruitment, plans to build a new fabricated ward, and the implemented of actions arising from fastforward, among many others, would support YDH meet its targets in 2015/16.

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On the basis of the additional items to be incorporated within the quality Jo report, as identified by Jo Howarth (above), the Audit Committee How confirmed it would recommend its approval to the Board of Directors.

44/15 MANAGEMENT REPRESENTATION LETTERS The Audit Committee noted the draft management representation letters to be signed on behalf of the Board of Directors (for the annual report and accounts) and the Board of Trustees (for the charity accounts) once the documentation has been reviewed at those meetings.

45/15 ANY OTHER BUSINESS There was no further business to discuss.

46/15 DATE OF THE NEXT MEETING 13:30 – 15:30 on 17 July 2015 in the Boardroom, Level 1

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REPORT TO: Board of Directors

PRESENTED BY: Jane Henderson, Julian Grazebrook, Paul von der Heyde (Non-Executive Directors) and Jade Renville (Company Secretary)

TITLE: Revisions to Board Committee Terms of Reference

DATE: 29 April 2015 ______

PAPER Yes PRESENTATION No PAPER & PRESENTATION No

What is this item about? Following changes to the Trust’s governance structure (agreed by the Board of Directors in April 2015), the terms of reference for the affected Board committees have been revised accordingly.

Why is this item necessary? To support the efficient and effective governance of the organisation, particularly as YDH moves to implement a primary and acute integrated system of care following confirmation of vanguard status.

What is Board asked to do? The Board is asked to approve the revised terms of reference for the Audit Committee, the Governance Assurance Committee and the Financial Resilience and Commercial Committee, which have been reviewed in detail by each of those groups.

1. How does this paper improve patient care? By setting the governance framework in which patient care and safety is overseen and monitored.

2. How does this paper advance the Annual Plan? By setting the governance framework in which the annual plan is progressed and evaluated.

3. How does this advance our strategic objectives? By setting the governance framework in which the strategic objectives are overseen and monitored.

4. Is further information available? Refer to the Trust’s suite of constitutional documents.

Are there implications for the Trust?

• Legally? No. The proposals adhere to the Trust’s constitutional documents.

• Financially? No.

• Regarding Workforce? No

Is this paper clear for release under Freedom of Information? Yes

Board Assurance Committees Board and Committees of the Board Operational Groups and Strategic Business Units Quality Oversight Board Governance Structure Sub-Committees Working Groups Board of Board of Trustees

Directors

Operational updates provided to Remuneration Governance Audit Finance the Board via Committee Committee Committee Committee CEO Report

and Operational Report

Executive Directors*

Quality Hospital Committee Management Team (HMT)*

Patient Clinical Patient Emergency Equality Fire, Information Elective Care Urgent Care Outcomes Safety Planning & Experience Health & Governance Strategic Strategic Committee & Bus Diversity Safety & & Caldicott Business Business

Continuity Security Unit (SBU) Unit (SBU)

Nutrition and Resuscitation, Infection, Prevention & Control, Food, Patient Blood Adults at Risk, Safeguarding Data Quality -See SBU meetings matrix Patient Mgt, Drugs Children, Medical Devices, -CBU Rolling Governance Voice and Maternity Risk Mgt, Safer Therapeutics, Medicines Mgt, Harm Free Note*: Terms of Reference set out Point of Care Groups, Maternity Risk Mgt, what should be reported to HMT / Testing Obstetric Interventions Executive Directors and the relationship between them

Audit Committee – Terms of Reference

1. Establishment

1.1 The Audit Committee is established under Standing Order 6.2 of Yeovil District Hospital NHS Foundation Trust’s (“YDH” or “the Trust”) Standing Orders. The Audit Committee is constituted as a standing committee of the Trust’s Board of Directors.

2. Purpose and Authority

2.1 The Audit Committee shall provide the Board of Directors with a means of independent and objective review of financial and corporate governance, assurance processes, internal control and risk management across the Trust’s activities, including oversight of clinical and non-clinical risk, supported by the Governance Assurance Committee. In addition, the Audit Committee shall provide assurance of independence for external / internal audit and counter fraud, monitor compliance with law, guidance and codes of conduct that fall within the remit of the Audit Committee and keep under review the Trust’s procurement policy and rules.

2.2 The Audit Committee is authorised by the Board of Directors to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Audit Committee.

2.3 The Committee is authorised to obtain independent legal or professional advice and to secure the attendance of any other persons with relevant experience and expertise if it considers this necessary.

3. Duties

3.1 Internal Audit

3.1.1 Review the performance, remuneration and any proposal for change of the internal auditors. 3.1.2 Advise on the appointment of internal auditors, the audit fee and any questions of resignation or dismissal. 3.1.3 Oversee the effective operation of internal audit, including adequate resourcing, co-ordination with external audit, meeting relevant internal audit standards, and assurance of independence. 3.1.4 Review and agree the internal audit strategy and plan, ensuring it is consistent with the needs of the organisation. 3.1.5 Receive and consider the major findings of internal audit investigations, their implications and management’s response and monitor progress on the implementation of recommendations. Unless there are significant issues this will not normally include full copies of audit reports, but these must be available to any director on request. 3.1.6 Refer such reports to the Governance Assurance Committee, as appropriate, for their consideration and review. 3.1.7 Review the annual internal audit report. 3.1.8 Review the effectiveness of the internal and external auditors and their relationship. 3.1.9 Ensure that the internal audit function is adequately resourced and has appropriate standing within the organisation.

3.2 External Audit

3.2.1 Assess the external auditor’s work and fees each year and based on this assessment, make a recommendation to the Council of Governors in respect of the appointment, reappointment and removal of an external auditor. This assessment should include a review of the performance of the external auditor, their independence, objectivity and effectiveness in light of relevant professional and regulatory standards. 3.2.2 Consider and agree the external audit plan, including value for money, with the external auditor before the external audit commences. 3.2.3 Discuss problems and reservations arising from the external auditor’s work and any matters the external auditor may wish to discuss (in the absence of executive directors and other managers where necessary). 3.2.4 Consider and review external audit reports, including the annual audit letter, together with the management response, and monitor progress on the implementation of recommendations, advising the Board of Directors as appropriate. 3.2.5 Refer such reports to the Governance Assurance Committee, as appropriate, for their consideration and review. 3.2.6 Review the annual statutory accounts and annual report, including the annual governance statement, before presentation to the Board of Directors for approval, in order to obtain assurance as to their completeness, objectivity, integrity and accuracy. Review any letter of representation to the external auditors.

3.3 Internal Control and Risk Management

3.3.1 Review the scope of internal control and advise the Board of Directors on the effectiveness of the Trust’s internal control systems. 3.3.2 Review the establishment and maintenance of an effective system of internal control and risk management through use of the assurance framework. 3.3.3 Consider risk and control related disclosure statements, together with any accompanying Head of Internal Audit statement, prior to endorsement by the Board of Directors. 3.3.4 Have oversight of risk management across the Trust’s activities, including clinical and non-clinical risk, supported by the Governance Assurance Committee. 3.3.5 On behalf of the Board of Directors oversee any proposed changes made by subject level experts to the Standards of Business Conduct, Standing Orders, Standing Financial Instructions and the Scheme of Reservation and Delegation. 3.3.6 Obtain reports from the Head of Procurement or other relevant officer on probity in connection with the purchase of goods and services by the Trust and reviewing the arrangements as necessary. 3.3.7 Examine any other matter referred to the Audit Committee by the Board of Directors or a director and initiate investigation as required. 3.3.8 Review the effectiveness of the Audit Committee.

3.4 Counter Fraud

3.4.1 Review and consider the annual workplan to ensure the Trust has a provision that is proportionate to the level of risk and that the local counter fraud service has sufficient resource to deliver work in accordance with the standards issued by NHS Protect.

3.4.2 Obtain assurance that there is clear, demonstrable proactive support and strategic direction for anti-fraud, bribery and corruption work from directors and senior management within the organisation.

3.4.3 Receive and consider the recommendations made by the local counter fraud service and the associated management responses and monitor the implementation of these recommendations.

3.5 Other

3.5.1 Review and approve schedules of losses, compensation and special payments and make any recommendations to the Board of Directors. 3.5.2 Review accounting policies and any changes in accounting practice. 3.5.3 Consider the outcomes of significant reviews carried out by other bodies that fall within the remit of the Audit Committee, including, but not limited to, regulators and inspectors. 3.5.4 Keep under review key issues relating to estates, facilities, fire management and health and safety. 3.5.5 Keep under review and/or approve any annual reports or procedural documents that fall within the Committee’s remit.

4. Membership, Attendance and Quorum

4.1 The Audit Committee shall be appointed by the Board of Directors and its members shall be three non-executive directors with a quorum of two non-executive directors. The Trust Chairman shall not be a member of the Committee but may be invited to attend meetings. The Chairman of the Trust will be invited to, and be expected to attend, at least one meeting a year.

4.2 Members shall be expected to attend all meetings and the dates shall be agreed so as to enable this as far as possible.

4.3 The Chief Finance and Commercial Officer, the Head of Internal Audit, a representative of the external auditors and a representative of the local counter fraud service shall be expected to attend meetings.

4.4 The Chief Executive, and other directors, may be invited to attend meetings and shall attend if required. The Audit Committee shall have the power to require the attendance at its meetings of any member of staff. At least once a year the Audit Committee shall meet with the external and internal auditors without the Chairman of the Trust or any executive directors being present. The Chief Executive will be invited to, and shall attend, at least one meeting each year.

4.5 The Trust Risk Manager shall attend, and work with the Company Secretary to ensure matters requiring the attention of the Governance Assurance Committeeor the Hospital Management Team are referred for their attention.

4.6 The Council of Governors shall nominate two of their members to attend meetings as observers only.

4.7 The Company Secretary shall act as secretary to the Audit Committee.

5. Chairman

5.1 A non-executive director appointed by the Board of Directors will chair the Audit Committee.

6. Frequency of Meetings

6.1 A minimum of four meetings shall be held each year with at least one reserved for a meeting with the external auditors to review the end of year position, annual report, accounts and quality report.

6.2 The external auditors, Head of Internal Audit or the local counter fraud service may request a meeting if they consider that one is necessary.

7. Reporting Procedures

7.1 The minutes of each meeting will be formally recorded and reported to the Board of Directors.

7.2 The Secretary shall circulate minutes of meetings of the Audit Committee to all members and the representatives in attendance.

8. Review

8.1 These terms of reference must be reviewed at least annually, or more frequently in the event of significant political, organisational staff or policy changes.

Date Issued 29 July 2015 Review Date 29 July 2016

Governance Assurance Committee Terms of Reference

1. Establishment

1.1 The Governance Assurance Committee (“GAC”) is established under Standing Order 6.2 of Yeovil District Hospital NHS Foundation Trust’s (“YDH” or “the Trust”) Standing Orders. GAC is constituted as an assurance committee of the Trust’s Board of Directors.

2. Purpose, Authority and Duties

2.1 GAC is authorised by the Board of Directors to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by GAC.

2.2 The Committee is authorised to obtain independent legal or professional advice and to secure the attendance of any other persons with relevant experience and expertise if it considers this necessary.

2.3 The Committee’s general purpose is to provide independent, objective review and assurance to the Board of Directors that governance and risk management processes are effective, supporting the functioning of the Trust’s assurance framework and risk management systems, as overseen by the Audit Committee. GAC may also identify any gaps in control and assurance that fall within its remit and review progress in closing them.

2.4 Specifically the Committee will:

2.4.1 Review the activities of its sub-committees, including quarterly reports from the Quality Committee, ensuring strategic overview of clinical and non-clinical risk management. These committees should report to the Hospital Management Team (“HMT”) for operational matters.

2.4.2 Formally review principal risks captured within the risk register and assurance framework, as assigned to GAC. Liaise with the Audit Committee to ensure the co-ordination of internal risk assurance.

2.4.3 Seek assurance on the robustness of the governance arrangements for the implementation of the electronic health record programme.

2.4.4 Review the Care Quality Commission Intelligent Monitoring Report and any other regulatory issues and report to the Board of Directors any areas of significant impact.

2.4.5 Review clinical governance performance data to identify indicators or gaps in assurance against clinical risks and provide assurance to the Board of Directors about compliance with the Care Quality Commission essential standards, supported by the Quality Committee and the Audit Committee.

2.4.6 Review the annual quality report/account before submission to the Board of Directors, working collaboratively with the Audit Committee.

2.4.7 Keep under review and/or approve any annual reports or procedural documents that fall within the Committee’s remit.

2.4.8 Monitor and keep under review claims and litigation activity.

2.4.9 Examine any other matter referred to GAC by the Board of Directors or a director.

2.4.10 Provide reports to the Board of Directors following each meeting, making recommendations regarding the degree of assurance relating to the principal risks that fall within its remit.

3. Membership, Attendance and Quorum

3.1 The Committee shall be appointed by the Board of Directors and its members shall be two non-executive directors with a quorum of two non-executive directors. A non- executive director appointed by the Board of Directors will chair GAC. In the absence of the chair, the second non-executive member shall chair the meeting.

3.2 Notwithstanding the provision of section 3.1, all non-executive directors including the Chairman of the Trust shall be deemed members of GAC for the purposes of establishing a quorum. Where an appointed non-executive director cannot attend, another may attend in their place and shall count towards a quorum.

3.3 The Committee shall have the power to require the attendance at its meetings of any member of staff. The Trust Chairman shall not be a member of GAC but may be invited to attend meetings, together with the Chief Executive and other members of the Board of Directors as business requires. The Chairman of the Trust and the Chief Executive will be invited to, and shall attend, at least one meeting each year.

3.4 All members shall be expected to attend meetings and the dates shall be agreed so as to enable this as far as possible.

3.5 The following officers shall be in attendance:

Director of Nursing and Clinical Governance Medical Director Company Secretary Assistant Company Secretary Associate Director of Patient Safety and Quality Trust Risk Manager Directors of Elective and Urgent Care

3.6 The Trust Risk Manager shall work with the Company Secretary to ensure matters requiring the attention of the Hospital Management Team or the Audit Committee are referred for their attention.

3.7 The Council of Governors shall nominate two of their members to attend meetings as observers only.

3.8 The Assistant Company Secretary shall act as secretary to the Committee.

4. Frequency of Meetings

4.1 A minimum of four meetings shall be held each year and as often as business requires.

4.2 Meetings may be held by electronic means and their decisions accepted as valid and binding.

5. Reporting Procedures

5.1 The minutes of each meeting will be formally recorded and reported to the Board of Directors.

5.2 The Chair of the Committee shall make regular reports and, where necessary, specific recommendations to the Board of Directors.

6. Review

6.1 These Terms of Reference must be reviewed at least annually, or more frequently in the event of significant political, organisational staff or policy changes.

Date Issued: 29 July 2015 Review Date: 29 July 2016

Financial Resilience and Commercial Committee Terms of Reference

1. Formation, Accountability and Reporting Structure

1.1 The Financial Resilience and Commercial Committee (“the Committee”) is established under Standing Order 6.2 of Yeovil District Hospital NHS Foundation Trust’s (“YDH” or the “Trust”) Standing Orders. The Financial Resilience and Commercial Committee is constituted as a standing committee of the Board of Directors.

1.2 The Committee is authorised by the Board of Directors to investigate any activity within the scope of its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee.

1.3 The Committee is authorised to obtain independent legal or professional advice and to secure the attendance of any other persons with relevant expertise as necessary.

1.4 The minutes of each meeting shall be formally recorded and, once approved at the subsequent meeting, reported to the Board of Directors (Part 2). The Chair of the Committee shall also provide verbal updates from the most recent meeting, together with any specific recommendations, to the Board of Directors (Part 1).

2. Purpose, Duties and Responsibilities

2.1 The primary purpose of the Committee is to scrutinise financial and commercial matters in order to provide strategic oversight and to seek assurance on behalf of the Board of Directors.

2.2 Specifically, the Committee will:

2.2.1 Provide the Trust with the means of independent and objective review of financial resilience. 2.2.2 Undertake detailed scrutiny of the financial position (including the cash position) and performance against plan. 2.2.3 Undertake detailed scrutiny of the cost improvement programme and performance against plan. 2.2.4 Undertake detailed scrutiny of the financial forward projections to include the annual budget, 2 year and 5 year plans, and any projections or forecasts that may be prepared from time to time. 2.2.5 Review and consider the Trust’s funding plans, making recommendations for alternative solutions as appropriate. 2.2.6 Monitor performance of commercial activities. 2.2.7 Review in detail specific commercial opportunities, strategies and/or business plans, including those developed by the Strategic Estates Partner Board (where there is overlap with the scope of the Committee), making any recommendations to the Board of Directors, where required, in respect of these. 2.2.8 When reviewing commercial opportunities and activities, to ensure they deliver improved patient care and/or experience and that the Trust’s principal purpose is not jeopardised by over-development of commercial activity. 2.2.9 Keep under review key strategic, commercial contracts and seek assurance that appropriate due diligence is undertaken on any new contracts and/or renewals. 2.2.10 Maintain oversight of risk in the delivery of financial and commercial targets 2.2.11 Identify any gaps in control and assurance (financial and commercial matters) and review progress in minimising them.

3. Membership, Attendance and Quorum

3.1 The core membership of the Committee will consist of:

• Three non-executive directors, one of which will act as Chair and one of which will act as Vice-Chair • Chairman of the Trust • Chief Executive • Chief Finance and Commercial Officer (who should be in attendance at each meeting or nominate a deputy in their place) • Commercial Director

3.2 Where a member is unable to attend, they may nominate a deputy to attend in their place provided this is agreed in advance with the Chair.

3.3 The Committee may extend invitations to other personnel with the relevant skills, experience or expertise as necessary to deal with the business on the agenda or to support the delivery of particular programmes of work.

3.4 In regular attendance will be:

• Company Secretary • Assistant Director of Finance • Senior Finance Manager – Corporate • Lead Governor (Observer) • Transformation Project Manager

3.5 A quorum shall be three members, one of which must be the Chair or Vice-Chair.

4. Administration of Meetings

4.1 A minimum of 10 meetings shall be held each year, usually taking place on a monthly basis. An annual schedule of proposed dates will be prepared in advance. Extraordinary meetings may be called at the request of the Chairman.

4.2 The Company Secretary and/or Chief Finance and Commercial Officer, supported by the financial and commercial teams, will produce the agenda and all necessary papers. Subject to the availability of in-month financial data, the agenda and any supporting papers will be distributed no less than three working days prior to a meeting, wherever possible.

4.3 In agreement with the Chair or Vice-Chair, if an item needs to be raised on the day, this will be covered under Any Other Business, subject to there being available time.

4.4 The minutes of each meeting shall be formally recorded.

5. Review

5.1 These terms of reference must be reviewed at least on an annual basis, or more frequently in the event of significant political, organisational, staff or policy changes. Date Issued: 29 July 2015 Review Date: 29 July 2016

APPENDIX 4 BOARD OF DIRECTORS 29 JULY 2015

Report to: Board of Directors

Subject: Report from the Executive Team

Date: 29 July 2015

Monitor Update – Paul Mears YDH has recently received formal notice from Monitor that they have closed their investigation into the Trust’s finances and will be taking no formal enforcement action. The investigation process which Monitor has undertaken has been very thorough and assessed the reasons for the deterioration in our financial position and the plans we have in place over the coming years to return the Trust to financial surplus.

It is positive that Monitor has concluded that YDH has a robust and realistic plan to improve our financial position and that they believe the Trust has the right leadership in place to deliver this. YDH will continue to work with Monitor as we implement our strategy to integrate care through our work with primary care, community services and social care. The executive team would like to thank Tim Newman, Chris Moore, Senior Finance Manager, and Sheena Morrow, Assistant Director of Finance, in particular for their hard work through this process which has required significant efforts from the finance team.

Outcomes Based Commissioning in Somerset – Paul Mears The Board will recall the presentation at the Board on 17 June 2015 regarding the Somerset CCG’s plans to move to outcomes based commissioning. They are developing plans jointly with the NHS England Area Team and Somerset County Council and it will mean that the current contract held by YDH with the CCG will be put on notice as they move to commission a lead provider(s) to deliver a set of outcomes for the local population.

The CCG is currently proposing that the majority of health and social care services will be included in the scope of the contract and that it will focus on the whole population as opposed to selecting a segment of population (e.g. patients with >3 long term conditions). Currently there is an expectation that there will be two outcomes based contracts, one for the east of the county based around South Somerset/Mendip and one for the west of the county based around Taunton/Bridgwater.

The CCG and Somerset County Council have both agreed this approach through their internal approval processes and the plans will now move into the next phase. This will include an assessment of which provider(s) is the most ‘capable’ to deliver the outcomes based contract and the expectation is that this process will begin in the autumn. YDH is working closely with the CCG to understand the next steps in the process and also ensure that the approach from commissioners aligns to the work we are doing with local GP colleagues through the Symphony Project. An update from the CCG and Somerset County Council is attached as an appendix to this report.

South Petherton Community Hospital – Paul Mears Following discussions at the Board and between this trust, the CCG and Somerset Partnership I met recently with Edward Colgan, CEO of Somerset Partnership, and David Slack, Managing Director of the CCG, to discuss the situation with South Petherton Community Hospital. At this meeting Edward Colgan confirmed that it is the intention of Somerset Partnership to re-open the eight beds which were temporarily closed last winter and that these will be available for general medical patients. This is positive news and we have reaffirmed our commitment to work in collaboration with Somerset Partnership to make the best use of the community hospital beds in the local area.

Health and Safety and Fire Management – Tim Newman Adrian Pickles has taken over as the Fire, Health and Safety Manager and the team structure is changing with the recruitment of a Fire, Health and Safety Adviser to provide support to safety management. Fire safety arrangements for responding to fire alarms are being updated and communicated with fire plans and signage and evacuation procedures are being updated.

The fire alarm system upgrade project is being externally reviewed to identify priorities going forward to reduce faults and increase fire detection coverage. A report will be prepared and shared with the Audit Committee following this review. Fire stopping surveys have taken place and remedial work is underway. Fire damper inspections are taking place, including removal and replacement of fire doors containing asbestos through a planned programme of work identified through risk assessment. There remains a considerable amount of work required to update health and safety management arrangements and to improve department risk assessment procedures. Introducing an audit process to identify and target areas for safety improvement will be a key area going forward to target resources and to support managers. The Trust is also introducing a number of manual handling safety improvements including a powered bed mover and handling equipment for main theatres. New ergonomic patient handling chairs are being introduced and lone working devices fitted into the mortuary with other locations planned.

The Local Security Management Specialist (LSMS) support is being provided through NHS Secure to take forward compliance with NHS standards and to lead on key policies aimed at reducing violence and aggression to staff and develop lockdown procedures. Conflict resolution training for all frontline staff will be an area of work required to ensure they have the confidence and skills in dealing with violence and aggression, a plan for which will be developed and rolled out.

Nursing – Helen Ryan Following a helpful forum meeting with nursing support staff, Helen Ryan has requested a full review of the roles and competencies for nursing support roles band 1 – 4, including benchmarking with surrounding trusts. Maddie Groves will lead on this work supported by Debbie Matthewson and Mark Appleby. The completion date is the end of March 2016.

The Director of Nursing at Taunton and Somerset NHS Foundation Trust, Carol Dight, is leaving the Trust at the end of September. Carol has been a good and supportive colleague and she will be missed by both organisations. The executive team would like to wish Carol well in her new role.

YDH is interviewing for a second senior post in the clinical governance team to support Jo Howarth. The post holder will lead on CQC readiness, among other key workstreams, and will deputise for Jo Howarth when she is away which will strengthen the governance team. Rachel Grey, Nurse Consultant for Infection Control, has returned from maternity leave and so Wendy Grey, who covered the role on an interim basis, now assumes a new role leading the nursing developments for Symphony and Vanguard.

Last week Helen Ryan attended the Regional Directors of Nursing meeting for the South of England and was asked to present our new models of care work. This was well received and an excellent opportunity to network and share learning with other organisations. Network for the Major Trauma Peer Review – Simon Sethi YDH continues to see a high volume of complex major trauma and provides good outcomes. Following recent peer review, YDH has achieved the best results across the regional network for its major trauma care, a great achievement for all clinical teams involved.

W51 Somerset County Council Somerset Clinical Commissioning Group 20 July 2015

Sam Barrell, Chief Executive Taunton and Somerset NHS Foundation Trust

Edward Colgan, Chief Executive Somerset Partnership NHS Foundation Trust

Paul Mears, Chief Executive Yeovil District Hospital NHS Foundation Trust

Dear Colleague

We are writing to update you on recent decisions taken by the Somerset CCG Governing Body, the Cabinet of Somerset County Council and endorsed by the NHS England Southwest subregional team, collectively referred to in this letter as 'the Commissioners'.

You are aware of the process followed by the Commissioners over the past six months to consider a move to an Outcomes Based Commissioning ('OBC ') approach. The process has involved the creation of a high-level business case and consideration of a number of key questions regarding implementation and next steps. The process has also involved consultation with your organisations, with primary care, Healthwatch and patient participation groups.

At the CCG Governing Body meeting on 16 July1, the following recommendations were agreed:

1. Approve in principle a move to a capitated outcomes-based and incentivised Commissioning approach for health and social care services in Somerset 2. Agree that the CCG via the Managing Director and Senior Leadership team engages with Somerset County Council and NHS England on closer integration of health and social care commissioning 3. Agree in principle to future discussions to pool budgets for health and social care, subject to these proposals being reviewed and agreed at a future meeting 4. Support the development of a full business case for the re-commissioning of health and in scope social care services in Somerset to be brought to a future meeting 5. Agree that the CCG engages with the Council and NHS England in the process of re-commissioning health and social care services subject to the agreement of any full business case.

Ihtt p:// www.50 mersetccg.nhs. uk/ about-us/governing-body/ meetings-a nd-papers/ These recommendations were adapted in mirror form for agreement at the County Council Cabinet meeting on 29 June":

1. Provide support for the move to an Outcome Based Commissioning (OBC) contract approach for social services in Somerset 2. Agree that the Council via the Chief Executive engages with Somerset CCG and NHS England on closer integration of health and social care commissioning 3. Agree in principle to future discussions to pool budgets for health and social care, subject to these proposals being reviewed and agreed at a future cabinet meeting 4. Support the development of a full business case for the re-commissioning of health and in scope social care services in Somerset to be brought to a future Cabinet meeting 5. Agree that the Council engages with the CCG and NHS England in the process of re-commissioning health and social care services subject to the agreement of any full business case.

In addition, at the CCG Governing Body meeting two further recommendations were adopted:

1. Approve the use of 'Capability' as part of an assessment criteria to identify which providers might be 'most capable' for the purposes of OBC 2. Agree that the CCG via the Clinical Operations Group engages further with primary care providers and NHS England to develop detailed options for practices to participate in Outcome Based Commissioning

The additional recommendations allow the CCG to being a process of identifying 'Capable Providers' to be invited to join a process of selection for OBC, leading - if successful - to the appointment of one or more Most Capable Providers to lead the delivery of health and certain social care services under the OBC approach. More detail on this process will be circulated in due course.

The Commissioners also acknowledge the importance of further engaging with and involving Primary Care in the move to an OBC approach. We recognise a number of specific contractual considerations which apply to Primary Care which could affect the extent of its participation in future lead provider structures. In any event, we expect providers selected through the Most Capable Provider route to demonstrate the engagement and involvement of Primary Care.

The online copy of the business case can be accessed through the Governing Body papers section of the NHS Somerset CCG website . We received external support from PWC and Cobic Ltd and the document sets out a number of ambitious key recommendations which will be tested over the next six months:

• We are aiming to take a 'whole population' approach to OBC, with an initial focus on those people with long-term conditions • We want to encourage a collaborative approach from our provider community through the adoption of the 'Most Capable Provider' rather than competitive, open procurement

2 http://www1.somerset.gov.uk/cou nci I/board3d/Cabinet%20Agenda%20290615. pdf • We have intending to incentivise providers to deliver to long term outcomes using a combination of key indicators focused on long-term outcomes • Primary care is encouraged to be a central part of the new provider leadership structure .

The aim is to have OBC contracts in place by April 2017 , but we would hope to be realising benefits from a new way of working focused on outcomes from April 2016.

We will be issuing more detail on our plans in due course , and we look forward to discussing the next steps to implementation with you.

Yours sincerely

David Slack Pat Flaherty Managing Director Chief Executive Somerset CGG Somerset County Council

Copy:

Anthony Farnsworth , Director of Commissioning Operations, NHS England South Region, South West

Federation Contact Rachel Stark, Bridgwater Bay Health Federation Dr Geoff Sharp, Central Mendip Federation Dr Emeline Dean, Chard, Crewkerne and Ilminster Federation Dr Helen Kingston, East Mendip Federation Dr Carol Reynolds , North Sedgemoor Federation Dr David Cripps, South Somerset Healthcare Federation Dr William Chandler, Taunton Deane General Practice Federation Dr Mike Pearce, West Mendip Federation Dr David Davies, West Somerset Federation

Local Implementation Group Chairs (UG) Dr Steven Gardiner, Somerset Coast Dr Mike Gorman, Taunton Dr Geoff Sharp, Mendip Dr lain Phillips, South Somerset

Local Providers James Scott, Chief Executive, Royal United Hospitals Bath NHS Foundation Trust Rob Little, Interim Chief Executive, Weston Area Health NHS Trust Ken Wenman, South Western Ambulance Services NHS Foundation Trust Chester Barnes, Hospital Director, Shepton Mallet NHS Treatment Centre Mel Lock, Adults and Health Operation Director, Somerset County Council Dr Sue Roberts, Somerset Local Medical Committee

APPENDIX 5 BOARD OF DIRECTORS 29 JULY 2015

Report to: Board of Directors

Report from: Paul Mears

Subject: Symphony Update

Date: 29 July 2015

This is a regular monthly report updating the Board on progress with the Symphony Programme in South Somerset. South Somerset was selected in March 2015 as one of 29 sites nationally to become a Vanguard for the development of new care models and new ways of working.

Programme Board and Structure

The Programme Board has met three times and also held an Away Day to develop the vision for the care models and joint venture, as well as the communications strategy.

The Complex Care and Enhanced Primary Care Working Groups are now well established, and are making good progress. The Complex Care Working Group has been focussing on addressing operational issues resulting from new ways of working, as well as undertaking a systematic stocktake of the model and its implementation. Meanwhile the hub is now fully staffed and the team is focussing on standardising and documenting its processes to ensure these can be rolled-out to the other two hubs later in the year.

The Enhanced Primary Care Working Group is working with the three pilot practices, Buttercross in Somerton, Millbrook in Castle Cary and Hendford Lodge in Yeovil, to develop the model and make some early changes. Castle Cary has been trialling the weekly “huddle” of all staff to review their most complex patients, and Buttercross has been developing new roles for therapists and pharmacists in the practice.

The Elective and Urgent Care Groups are now being established, and the business case for Systematised Surgery, the major workstream of the Elective Group, is well advanced.

The two Joint Venture Working Groups have been meeting together to develop the broad JV model and establish the work programme. Consensus is emerging on the favoured JV structure, and the detailed work programme is now underway. Discussions have taken place with NHS England and Monitor about the national support required, and a meeting is being set up during August to agree how the local and national teams will work together.

The Programme Board has decided to purchase the Jive communications platform, which will enable much easier and more interactive communications between those involved in the programme and includes elements of social networking, file-sharing, blogging, messaging, polls and many other features. This will become the principle communications platform within the programme and will enable all involved in the programme to get updates on the areas which interest them and be involved in discussions as the work develops.

APPENDIX 6 BOARD OF DIRECTORS 29 JULY 2015

Report to: Board of Directors

Report from: Jason Maclellan and Jonathan Howes

Subject: Electronic Health Record (TrakCare) Update

Date: 29 July 2015

Summary The aim of this monthly highlight report is to provide the Board with an update on progress and to provide assurance on the actions and controls in place to ensure successful implementation of the electronic health record system (TrakCare).

Executive Summary

The overall programme status for July remains unchanged at AMBER.

The programme continues to make progress towards implementation. At the last meeting of the Steering Board, it was agreed to set the phase 1 go-live date as 16 November 2015. This will provide the team with some contingency and allow maximum time to complete the build, test and train elements prior to go-live.

The date and timeline remains challenging but plans are in place to mitigate the risks.

Software and System Set-Up Good progress has been made in maternity and ED. InterSystems are developing elements of their solution to fit the needs of YDH and/or national standards. For example, this will include the use of Manchester triage protocol (ED) and additional data to comply with national standards for English maternity data sets (Maternity).

Pharmacy remains under development as InterSystems develop and amend functionality and interfaces to fit YDH’s requirements. Risks to the timetable have been mitigated as it has been agreed the pharmacy system will go-live in February 2016.

A major task for YDH is the build of the outpatient clinics, letters and various rules and workflows. The staff currently building PAS clinics are being seconded to the project to do this. There are over 3000 clinics to build and this will be a key task over the coming two months so that all patient visits at and beyond go-live remain established, accurate and efficient.

Data and Data Migration Data migration which had been running smoothly has experienced some delays this month. Trial data has been extracted from legacy systems and code tables within the new system are being set up. InterSystems experts were on site the week commencing 20 July 2015 to resolve some table issues that were preventing the test loads of data. Data tables are needed to underpin the build activity and the loading of legacy data.

Testing and Training The programme team has been joined by a Test and Training Manager. They have commenced the detailed planning to schedule test and train phases, looking at materials and staffing. Facilities for this will be confirmed shortly as quotes are being received for temporary accommodation compared to relocating elements of the Academy training capability offsite. Engagement has commenced with managers across YDH about the planning to backfill staff for training and testing.

Business Change As well as direct engagement with staff within the areas in scope of phase 1, during July a TrakCare Operational Group was established with the YDH operational directors and business managers. This is starting to plan for the go-live cut over and the period beyond to look at staff, performance and operational impacts and planning mitigations for these, such as backfill. Additionally this group will oversee the work to develop the future state processes and future ways of working using the new system.

IT and Infrastructure Work has commenced to link the InterSystems data centre to YDH. This includes a full second line network link with full diversity, mitigating the previous network issues. An audit is underway to review PCs, monitors, printers etc to ensure as YDH moves towards digital records that staff have sufficient equipment to operate TrakCare.

Communications An increased focus has now been placed on communications, with additional staff being recruited to deliver the communications plan with new materials, packs and videos being created. Countdown posters are in positon around the Trust, weekly updates are sent to staff in the e-newsletter and a managers presentation pack has been distributed.

YDH │Quality, Operational and Financial Performance Overview

Month 3 – June 2015

1 CONTENTS

1 Safe 2 Effective 3 Responsive 4 Caring 5 Well-led – Staffing 6 Well-led - Financial Performance

2 Safe Mortality Rates [1]

Latest HSMR 12 June Number of Months to Mar 15 Deaths 98.3 42

Hospital Standardised Mortality Ratio (HSMR) Actual number of deaths 120 100

100 80 80 60 60 40 40 20 20

0 0

Jul-12 Jul-13 Jul-14

Jan-13 Jan-14 Jan-15

Sep-12 Sep-13 Sep-14

Nov-12 Nov-13 Nov-14

Mar-13 Mar-14 Mar-15

Jun-12 Jun-13 Jun-14 Jun-15

Oct-12 Oct-13 Oct-14

May-12 May-13 May-14

Apr-14 Apr-15 Apr-12 Apr-13

Feb-13 Feb-14 Feb-15

Dec-14 Dec-12 Dec-13

Aug-14 Aug-12 Aug-13

Monthly data 6 month moving average Monthly data 6 month moving average

RAG Status: Significantly better than national average, Within expected range, Significantly higher than national average.

3 Patient Falls and Pressure Ulcers Safe [2]

Patient Falls Pressure Ulcers 81 18 (67 in June 14) (10 in June 14)

Patient falls Pressure ulcers +2 140 25 120 20 100 80 15 60 10 40 5 20

0 0

Jun-13 Jun-12 Jun-14 Jun-15 Jun-12 Jun-13 Jun-14 Jun-15

Oct-14 Oct-12 Oct-13 Oct-12 Oct-13 Oct-14

Apr-13 Apr-12 Apr-14 Apr-15 Apr-12 Apr-13 Apr-14 Apr-15

Feb-14 Feb-13 Feb-14 Feb-15 Feb-13 Feb-15

Dec-14 Dec-12 Dec-13 Dec-12 Dec-13 Dec-14

Aug-12 Aug-12 Aug-13 Aug-14 Aug-13 Aug-14

Monthly data 6 month moving average Monthly data 6 month moving average

4 Safe C.Difficile and MRSA cases [3]

June C.Diff June MRSA 0 0 (1 in June 14) (0 in June 14)

MRSA C difficile cases 2 4 3 3 2 1 2 1 1

0 0

Jul-12 Jul-13 Jul-14

Jan-14 Jan-15 Jan-13

Oct-12 Oct-14 Oct-13

Apr-13 Apr-14 Apr-15 Apr-12

Monthly data 6 month moving average Monthly data 6 month moving average

From Apr 15, Figures and any targets for C.Diff relate to due to lapses in care only

5 Effective Stroke Services [1]

June 15 4Hr Direct Admission

90% Stay on Stroke Admission Direct 100% Unit within 4hrs 80% 77% 58% 60% (Target: 80%) (Target: 90%) 40% 20% High Risk TIA CT Scan in 1hr 0%

80% 46%

Jun-12 Jun-13 Jun-14 Jun-15

Oct-12 Oct-13 Oct-14

Apr-12 Apr-13 Apr-14 Apr-15

Feb-13 Feb-14 Feb-15

Dec-12 Dec-13 Dec-14

Aug-13 Aug-14 (Target: 80%) (Target: 50%) Aug-12 4Hr Direct Admission Target Achievement 1HrCTScan Additional Notes 70% 60% SSNAP Published figures for Q3 Oct-Dec14: 50% National Average 4hr to Stroke Unit : 56.9% 40% National Average 90% Stay on Stroke Unit: 82.2% 30% 20% 10%

Jun-12 Jun-13 Jun-14 Jun-15

Oct-12 Oct-14 Oct-13

Apr-12 Apr-13 Apr-14 Apr-15

Feb-13 Feb-14 Feb-15

Dec-13 Dec-14 Dec-12

Aug-12 Aug-13 Aug-14

6 Effective Fractured Neck of Femur Services [2]

June 15 Average Length of Stay - #NOF patients Best Practice 35.0 Achievement 30.0 0% 25.0 (Target: 60%) 20.0 15.0 YTD AvLoS Direct admission: Trauma ward 10.0 12.9 days 5.0 0.0

(vs 17.3 days Other wards)

Jul-14

Jan-15

Jun-14 Jun-15

Oct-14

Apr-14 Apr-15

Sep-14 Feb-15

Dec-14

Aug-14

Nov-14

Mar-15

May-15 May-14 Trauma Ward Admission Other Admissions

Best Practice Achievement - #NOF 15/16 YTD Additional Notes 100.0% 80.0% Best Practice achievement in Financial Year 14/15 : 37.5% 60.0% Poor performance in April, continues into May and June due to 40.0% the loss of our Orthopaedic Geriatrician in March and resulting 20.0% in low numbers of patients assessed within 72 hours and 0.0% meeting MDT requirements. Operated Geriatric Pre-op AMT Post-op Falls Bone Post-op on within Assessment AMT Assessment Protection MDT A new Orthopaedic Geriatrician has now been appointed. 36 hours within 72 Medication June’s ‘Other Admissions’ were low numbers hence the LOS hours being lower than Trauma Ward Admissions Overall BPT % Achieving each measure Trauma Ward direct Admissions BPT

7 Effective Delayed Discharges [3]

Number of Inpatients Medically Fit for Discharge 70 June 15 60 50

40 Lost Bed Days Average Bed Cost 356 £84,016 30 (639 June 14) (£150,804 June 14) 20

Monthly Split of Delayed Discharge Reasons (Bed Days)

180 Additional Notes 160 140 The number of lost beddays due to delays in further NHS 120 100 Non-Acute Care and Care Packages in own home have 80 reduced since April but Nursing Home delays have increased 60 in June compared to previous months. 40 20 Overall, the number of lost beddays compared to the same 0 time last year has reduced by 44%. Completion Public Further non Residential Nursing Care Community Patient or Disputes Housing of Funding acute NHS Home Home package in Equipment Family Assessment care own Home Choice 04/2015 05/2015 06/2015

8 Effective DNA - Outpatients [4]

DNA Cost £120 Overall DNA Rate £110 8.5% £100

Thousands £90 £80 £70 st 1 Appointment Rate FU Appointment Rate £60

6.0% 9.6%

Jun-13 Jun-14

Oct-14 Oct-13

Apr-13 Apr-14 Apr-15

Feb-14 Feb-15

Dec-13 Dec-14

Aug-14 Aug-13

DNA Cost

DNA Rate 11.0% Additional Notes 10.0% 9.0% Published National DNA rates for 13/14 were 7.0%. (Source HSCIC) 8.0%

7.0% The DNA cost is based on the average New appointment 6.0% costing £150 and the average FUP appointment costing £75 5.0%

4.0%

Jun-13 Jun-14 Jun-15

Oct-13 Oct-14

Apr-13 Apr-14 Apr-15

Feb-15 Feb-14

Dec-13 Dec-14

Aug-14 Aug-13 Overall DNA rate First DNA rate Follow up DNA rate

RAG Status: Less than 5%, 5-7%, Over 7%.

9 Effective Cancelled Operations [5]

Hospital Non-clinical Cancellations of Elective Operations 2015 - 16 YTD June 15 Equipment Failure/Unavailable On the Day Non- Requires Alternative Session/Specialty Rebooked within 28 Clinical Reasons Day Target Date Bought Forward 12 11 Session Cancelled (3 - June 15) Administrative Reasons No Beds Available Total Cancelled due Urgent Case took Priority to Lack of Beds Insufficient Session Time 4 Consultant/Clinican Unavailable

0 10 20 30 40 50 60 70 80 90

Hospital Non-clinical On the Day Cancellations of Elective Additional Notes Operations - June 2015 The one patient not rebooked within 28 Day Target declined Requires Alternative Session/Specialty any future dates.

Administrative Reasons The figure for Total Cancelled due to Lack of Beds includes cancellations with more than 1 day notice given. No Beds Available Note: For any elective operation cancelled by the trust on the Insufficient Session Time day of the operation/admission, an offer of a new date must be made within 5 calendar days, and the newly offered date must Equipment Failure/Unavailable be within 28 days of the cancelled operation date. 0 1 2 3 4 5

RAG Status: <=15 Cancellations, 16-24 Cancellations, >=25 Cancellations

10 Effective First to Follow-up Ratio [6]

New:Follow Ratio 2.9 June 15 2.7 2.5 2.3 6 Month Rolling New to FU Ratio 2.1 Average 1:2.3 1:2.4 1.9 1.7

1.5

Jun-13 Jun-15 Jun-12 Jun-14

Oct-12 Oct-13 Oct-14

Apr-13 Apr-14 Apr-15 Apr-12

Feb-13 Feb-14 Feb-15

Dec-12 Dec-13 Dec-14

Aug-12 Aug-13 Aug-14

New:Follow Ratio 6 month moving average April 2015 - March 2016 1st to Follow Up Ratio by Speciality 4000 8 Additional Notes 3500 7

3000 6 National Average ratio: 1:2.35 2500 5

2000 4 1500 3 rate Bristol and Somerset Area Team ratio : 1:1.89 attendances 1000 2 (HSCIC Source 13/14) 500 1 0 0

1st Follow Up Rate

11 Responsive RTT Pathways [1]

May Admitted May Non-Admitted April Incompletes 72.4% 94.2% 88.9% (Target: 90%) (Target: 95%) (Target: 92%)

RTT Completed Pathways - Admitted RTT Completed Pathways - Non admitted

Monthly data RTT target 6 Month Moving Average Monthly data RTT target 6 Month Moving Average

100.0% 100% 95.0% 97% 90.0% 94% 85.0% 91% 80.0% 75.0% 88%

70.0% 85%

Jun-12 Jun-13 Jun-14 Jun-15

Oct-12 Oct-13 Oct-14

Oct-12 Oct-14 Oct-13

Apr-12 Apr-13 Apr-14 Apr-15

Apr-13 Apr-14 Apr-12 Apr-15

Feb-13 Feb-14 Feb-15

Feb-13 Feb-15 Feb-14

Dec-12 Dec-13 Dec-14

Aug-12 Aug-13 Aug-14

Aug-13 Aug-14 Aug-12

RTT Incomplete Pathways Additional Notes Monthly data RTT target 6 Month Moving Average 100.0% Following on from the recent letter from Simon Stevens outlining proposed changes in RTT Wait times, there will 95.0% be no penalties levied on failure to achieve RTT Admitted 90.0% and Non-Admitted Targets from April 2015 onwards. The 85.0% Incomplete Pathways targets for RTT will remain.

80.0%

75.0%

Jun-12 Jun-13 Jun-15 Jun-14

Oct-12 Oct-13 Oct-14

Apr-13 Apr-14 Apr-15 Apr-12

Feb-13 Feb-14 Feb-15

Dec-12 Dec-13 Dec-14

Aug-13 Aug-14 Aug-12

12 Responsive RTT Incomplete Pathways [2]

RTT Incomplete Pathways with All Stops June 15 9,000 8,000 Admitted Patients over Non-Admitted Patients 7,000 18 Weeks over 18 Weeks 6,000 5,000 471 361 4,000 3,000 2,000 1,000 Patients over 26 Patients over 52 0

Weeks Weeks

Jun-12 Jun-13 Jun-14 Jun-15

Oct-13 Oct-14 Oct-12

Apr-12 Apr-13 Apr-14 Apr-15

Feb-13 Feb-14 Feb-15

Dec-14 Dec-12 Dec-13

Aug-13 Aug-14 260 0 Aug-12 RTT Incomplete Pathways RTT incomplete pathways > 18 weeks Number of Stops RTT Incomplete pathways - Aging Additional Notes 500 400 The significant increase in incomplete pathways can be attributed to the high level of elective cancellations during December - 300 March. 200 100 Patients that delay treatment through choice are counted as an 0 incomplete pathways until they receive their treatment, or it is decided that they don’t need treatment. Patient choice only adjusts the wait time once they have received an admitted

treatment (non-admitted stops are not adjusted for patient choice)

>18 weeks >19 weeks >21 weeks >22 weeks >23 weeks >24 weeks >26 weeks >20 weeks >25 Weeks

Non Admitted Admitted

13 Responsive Inpatient and Outpatient Waiters [3]

IP/DC Waiting List June 15 2500 2000 Outpatient GP/DP Inpatient & Day Case 1500 Waiting List Waiting List 1000 3176 2081 (+17.8% vs last FY) (+21.1% vs last FY) 500

Jul-12 Jul-13 Jul-14

Jan-13 Jan-14 Jan-15

Oct-12 Oct-13 Oct-14

Apr-12 Apr-13 Apr-14 Apr-15

OP Waiting List Notes 3500 The IP/DC growth compared to last year is primarily due to an increase in patients waiting for General Surgery, 3000 Trauma and Orthopaedics and Ophthalmology. 2500

2000

1500

Jul-12 Jul-13 Jul-14

Jan-13 Jan-14 Jan-15

Oct-12 Oct-13 Oct-14

Apr-12 Apr-13 Apr-14 Apr-15

14 Responsive ED Attendances [4]

June 15 A&E 4 hour performance - All Attendances 98% Average Breaches A&E Performance per Day 96% 95.04% 6.5 (95.8% June 14) 94% (5.9 June 14) 92%

Average A&E Average Ambulance 90% Attendances per day Arrivals per day 130.9 40.6 88%

(139 June 14) (41.7 June 14)

Jun-14 Jun-15 Jun-12 Jun-13

Oct-12 Oct-13 Oct-14

Apr-12 Apr-13 Apr-14 Apr-15

Feb-13 Feb-14 Feb-15

Dec-13 Dec-14 Dec-12

Aug-12 Aug-13 Aug-14

Avg A&E Attendances per Day Monthly data 6 month moving average 160 Additional Notes 140 120 100 A&E activity over the two month period May and June was 80 down by -7.6% vs last year (-627 attendances). 60 40 YTD attendances (11510) vs last FY YTD (12086). 20

Jun-13 Jun-14 Jun-15 Jun-12

Oct-12 Oct-14 Oct-13

Apr-12 Apr-13 Apr-14 Apr-15

Feb-13 Feb-14 Feb-15

Dec-12 Dec-13 Dec-14

Aug-13 Aug-14 Aug-12 Avg A&E attendances per day Avg ambulance arrivals per day

15 Responsive Ambulance Handovers [5]

30 Minute Handover YTD Fines Target 99.6% £2000 (£1200 YTD 14/15) (99.9% June 14)

Ambulance Handovers Per Month 1,600 £18,000 1,400 £16,000 1,200 £14,000 £12,000 1,000 £10,000 800 £8,000 600 £6,000 400 £4,000 200 £2,000

0 £0

Jul-13 Jul-12 Jul-14

Jan-13 Jan-15 Jan-14

Jun-12 Jun-14 Jun-13 Jun-15

Oct-12 Oct-14 Oct-13

Apr-12 Apr-14 Apr-13 Apr-15

Sep-13 Feb-14 Sep-12 Feb-13 Sep-14 Feb-15

Dec-12 Dec-13 Dec-14

Aug-12 Aug-14 Aug-13

Nov-12 Nov-13 Nov-14

Mar-13 Mar-15 Mar-14

May-13 May-15 May-12 May-14

Ambulance Handovers Fines

£400 £600 £1,000

Fines

Ambulance handovers -

£0 £500 £1,000 £1,500 £2,000 £2,500 Apr-15 May-15 Jun-15

16 Responsive Cancer 2 Week Wait [6] Draft Data 2 Week Cancer Targets 100.0%

95.0% June 15 90.0% 85.0% 2 Week Suspected 2 Week Breast Cancer 80.0%

91.3% 84.9% 75.0%

Jun-12 Jun-13 Jun-15 Jun-14

Oct-12 Oct-13 Oct-14

Apr-12 Apr-13 Apr-15 Apr-14

Feb-13 Feb-14 Feb-15

Dec-12 Dec-13 Dec-14

Aug-12 Aug-13 Aug-14 2WW Suspected Cancer 2WW Breast

Number of Referrals Seen Additional Notes 600 100

500 80 Draft Data for June indicates that the trust did not achieve 400 60 the 2 Week Wait Cancer Targets. 300 40

200 All breaches of the target were due to patient choice.

breast symptons suspected cancer

20 - - 100

0 0

Jun-12 Jun-13 Jun-15 Jun-14

Oct-13 Oct-14 Oct-12

Apr-12 Apr-13 Apr-15 Apr-14

Feb-13 Feb-14 Feb-15

Dec-12 Dec-13 Dec-14

Aug-13 Aug-14 Aug-12

no. referrals No. No. referrals 2WW Suspected Cancer 2WW Exhibited Breast Symptoms

17 Responsive Cancer 31 and 62 Day Targets [7] Draft Data

31 Day Treatment 62 Day Treatment 31 Day Treatment First First Standard 101.0% 100% 87.4% 99.0% 97.0% 95.0% 31 Day Treatment 62 Day Treatment 93.0% Subsequent Surgery Screening 91.0% 100% 100% 89.0% 87.0% 85.0% 31 Day Treatment 62 Day Treatment

Subsequent Drugs Upgrades

Jun-12 Jun-13 Jun-15 Jun-14

Oct-13 Oct-14 Oct-12

Apr-13 Apr-14 Apr-12 Apr-15

Feb-13 Feb-14 Feb-15

Dec-12 Dec-13 Dec-14

Aug-12 Aug-14 100% 92.9% Aug-13 Achievement % Target % 6 month rolling %

62 Day Treatment Standard Additional Notes 100.0%

90.0% Draft data for June indicates that the Trust achieved all 31 80.0% Day and 62 Day related Cancer Targets.

70.0%

60.0%

50.0%

Jun-12 Jun-14 Jun-15 Jun-13

Oct-12 Oct-13 Oct-14

Apr-12 Apr-14 Apr-15 Apr-13

Feb-13 Feb-14 Feb-15

Dec-12 Dec-13 Dec-14

Aug-12 Aug-13 Aug-14

Achievement % 6 Month Rolling % Target %

18 Responsive Admissions and LOS [8]

Average Length of Stay (Days) June 15 7.0 6.0 5.0 Elective Admissions Non-Elective Admissions 4.0 1,707 1,750 3.0 (1,775 June 14) (1,547 June 14) 2.0 1.0 Elective LOS Non-Elective LOS 0.0

3.5 Days 4.9 Days

Jun-12 Jun-13 Jun-14 Jun-15

Oct-12 Oct-14 Oct-13

Apr-12 Apr-14 Apr-15 Apr-13

Feb-13 Feb-14 Feb-15

Dec-12 Dec-13

(+1.3 vs June 14) (+0.3 vs June 14) Dec-14

Aug-12 Aug-13 Aug-14

LOS Elective LOS Non Elective Admissions 2,500 Additional Notes

2,000 1,500 Following the peak in elective length of stay in January, the elective length of stay had dropped back to levels 1,000 comparable to last May. However June saw an increase in 500 the Elective average length of stay.

Jun-12 Jun-13 Jun-15 Jun-14

Oct-12 Oct-13 Oct-14

Apr-12 Apr-13 Apr-14 Apr-15

Feb-14 Feb-15 Feb-13

Dec-13 Dec-14 Dec-12

Aug-12 Aug-13 Aug-14 Total Elective admissions Non Elective admissions

19 Caring Friends and Family Test [1]

Friends and Family Test % of Inpatient / ED / Maternity Responses

June 15 6000 30%

5000 25% Overall Rate Outpatients 4000 20% 19.4% 36 Reponses 3000 15% (22.2% June 14) (n/a June 14) 4071 3493 3588 3449 3641 3480 3277 3482 3239 3380 3202 2990 3190 3119 2000 2808 10%

Inpatients A&E Maternity 1000 5% 878 887 806 813 814 46.0% 4.9% 45.7% 726 773 735 576 462 451 601 705 694 758 0 0%

(41.4% June 14) (13.3% June 14) (24.6% June 14)

Jul-14

Jan-15

Jun-14 Jun-15

Oct-14

Apr-14 Apr-15

Feb-15 Sep-14

Dec-14

Aug-14

Nov-14

Mar-15

May-14 May-15 No of Respondants No of eligible Patients % of responses Friends and Family Test Inpatient / ED / Maternity Response to 'extremely likely' and 'likely' to recommend YDH

100.0% Additional Notes 90.0% 20.0% 21.4% 20.4% 21.6% 21.6% 23.1% 80.0% 26.0% 25.2% 24.6% 23.9% 24.6% 20.1% 23.8% 26.3% 21.8% The low performance in A&E is in part due to a decrease in 70.0% the supply of paper versions of the question to hand out to 60.0% patients. This supply issue has now been resolved. 50.0% 40.0% 73.8% 68.5% 68.1% 69.9% 68.0% 68.9% 72.7% 72.1% 72.6% 69.3% 68.1% 72.9% 72.6% 71.9% 30.0% 64.9% The Friends and Family Test has been extended into 20.0% Outpatient areas (only capturing Response numbers rather 10.0% than percentage) and the returns have been expanded to 0.0% include children accessing our services and their

carers/parents.

Jul-14

Jan-15

Jun-15 Jun-14

Oct-14

Apr-15 Apr-14

Sep-14 Feb-15

Dec-14

Aug-14

Nov-14

Mar-15

May-14 May-15 % Extremely Likely % Likely

20 Monitor Well Led

FY Jun-15 Q1 to Target Period Apr-15 May-15 Indicators 14/15 (Draft) Date

RTT 18 week RTT admitted wait - All specialties 90% M 88.6% 74.3% 77.0% 72.4% 74.5%

RTT 18 week RTT non-admitted wait - All specialties 95% M 95.6% 92.7% 93.8% 94.2% 93.6%

RTT 18 week RTT Incomplete pathways - All Specialties 92% M 93.9% 89.6% 89.8% 88.9% 89.6%

A&E A&E Clinical Quality: Total time of 4 hours in A&E 95% M 95.2% 95.5% 95.8% 95.0% 95.7%

Cancer Max waiting time of 2 weeks from urgent suspect cancer GP referral to first outpatient appt 93% Q 92.4% 90.9% 92.6% 91.3% 91.6%

Cancer Max waiting time of 2 weeks for symptomatic breast patients (cancer not initially suspected) 93% Q 93.03% 94.8% 88.9% 84.9% 89.6%

Cancer Max waiting time of 31 days from diagnosis to first treatment for all cancers 96% Q 97.8% 96.8% 100.0% 100.0% 99.1%

Cancer Max waiting time of 31 days for subsequent DRUG treatments for all cancers 98% Q 100.0% 100.0% 100.0% 100.0% 100.0%

Cancer Max waiting time of 31 days for subsequent SURGICAL treatments for all cancers 94% Q 94.1% 100.0% 90.9% 100.0% 97.7%

Cancer Max waiting time of 62 days from urgent GP referral to first treatment for all cancers 85% Q 87.3% 95.2% 88.6% 87.4% 90.0%

Cancer Max waiting time of 62 days from consultant screening service referral for all cancers 90% Q 100.0% 100.0% 100.0% 100.0% 100.0%

Safety C.Diff year on year reduction (lapses in care only) 8 pa Q 3 0 1 0 1

21 YDH │Workforce

Well Led - Staffing

Month 3 – June 2015

22 Well Led Contracted & Temporary FTE [1]

June 15

Total FTE 1929 (June 14 – 1825)

Additional Notes Total FTE has increased by 104 FTE compared to June 14.

23 Well Led Contracted FTE [2]

June 15

Contracted FTE 1766 (June 14 – 1652)

Additional Notes Contracted FTE has increased by 114 FTE compared to June 14.

The vacancy percentage for June 15 is 13% compared to 10% in June 14.

24 Well Led Temporary FTE [3]

June 15

Total FTE 163 (June 14 – 173.1)

Additional Notes Temporary FTE has reduced by 10 FTE compared to June14.

The increase in temporary nursing staff is due to covering vacancies and is being addressed by the Nursing Recruitment Plan.

The reduction in ancillary staff is due to an increase in permanent housekeepers being appointed.

25 Well Led Comparison to 2014 [4]

Jun-14 Jun-15 Contracted Temporary Temporary Contracted Temporary Temporary Skills Groups Total FTE Total FTE FTE FTE % FTE FTE % Additional Clinical Services 42 9 50 17% 45 11 56 20% Additional Prof Scientific & Technical 48 0 48 0% 45 2 48 5% Admin & Clerical 334 11 345 3% 387 15 403 4% Allied Health Professionals 80 2 82 2% 93 2 95 3% Ancillary 143 43 186 23% 153 28 181 16% Estates 21 - 21 0% 21 2 23 9% Medical & Dental 209 35 244 14% 211 17 228 7% Nursing & Midwifery Reg 508 42 550 8% 495 53 548 10% Senior Managers 66 - 66 0% 82 - 82 0% HCA's 201 32 233 14% 232 32 264 12% Total 1,652 173 1,825 9% 1,766 163 1,929 8%

26 Well Led Staff Turnover [5]

Percentage 13.5% (June 14 – 13.9)

Staff Turnover 16.0%

14.0%

12.0%

10.0%

8.0%

6.0%

4.0%

2.0%

0.0%

Jun-14 Jun-12 Jun-13 Jun-15

Oct-12 Oct-13 Oct-14

Apr-12 Apr-13 Apr-14 Apr-15

Feb-13 Feb-14 Feb-15

Dec-12 Dec-13 Dec-14

Aug-12 Aug-13 Aug-14

Actual Target Lower Limit Target Upper Limit

27 Well Led Leavers [6]

June 15 Rolling Year Resignations

Adult Dependants Better Reward Package Child Dependants Incompatible Working Relationships Number of Leavers Health 16 Promotion (May 14 – 27) To undertake further education or training Lack of Opportunities Work Life Balance Relocation Rolling Year Leavers by Reason Other/Not Known 0 20 40 60 80 100 120 Transfer Additional Notes Death in service The number of staff leaving the Trust for unknown reasons is Dismissal being reviewed so that we understand better the reasons why staff are leaving. Redundancy The main skills group of the leavers in June 15 were Medical & Retirement Dental and Admin & Clerical. End of Fixed Term Resignation

0 20 40 60 80 100 120 140 160 180 200 220

28 Well Led Sickness [7]

June 15 Sickness Absence vs Target 5.0%

4.0%

3.0%

Percentage 2.0% 3.3% (June 14 – 3.4%) 1.0%

0.0%

Jun-12 Jun-13 Jun-14

Oct-12 Oct-13 Oct-14

Apr-12 Apr-13 Apr-14 Apr-15

Feb-13 Feb-14 Feb-15

Dec-12 Dec-13 Dec-14

Aug-12 Aug-13 Aug-14

Total for YDH Target

Additional Notes

Sickness is reported one month in arrears. The Sickness Absence Rate for May 15 (M2) was 3.3%, representing an adverse variance against target and an increase in month of 0.6%. The rolling 12 month sickness percentage is 3.5%

The number of employees on Long Term Sickness (>28 Days) March 15 - 25 April 15 -19 May 15 - 29

29 Well Led Mandatory Training [8]

June 15 Mandatory Training Compliance vs Target 100.0% 80.0% 60.0% Compliance Percentage 40.0% 88% 20.0% (June 14 – 82%)

0.0%

Jun-12 Jun-13 Jun-14 Jun-15

Oct-12 Oct-13 Oct-14

Apr-12 Apr-13 Apr-14 Apr-15

Feb-13 Feb-14 Feb-15

Dec-12 Dec-13 Dec-14

Aug-12 Aug-13 Aug-14

Mandatory Training by Skills Group - % Compliant Total for YDH Target HCA's Senior Managers Additional Notes Nursing & Midwifery Reg The percentage of staff up to date with their Mandatory Training Medical & Dental has remained at 86%, against a target of 90%. Estates Ancillary Allied Health Professionals Admin & Clerical Additional Prof Scientific &… Additional Clinical Services

0% 20% 40% 60% 80% 100% Apr-15 May-15 Jun-15

30 Well Led Appraisals [9]

June 15 Appraisal vs Target 100.0% 80.0% 60.0% Compliance 40.0% Percentage 77% 20.0% (June 14 – 81%)

0.0%

Jun-12 Jun-13 Jun-14 Jun-15

Oct-12 Oct-13 Oct-14

Apr-12 Apr-13 Apr-14 Apr-15

Feb-13 Feb-14 Feb-15

Dec-12 Dec-13 Dec-14

Aug-14 Aug-12 Aug-13

Annual Appraisal by Skills Group - % Compliant Total for YDH Target

HCA's Additional Notes Senior Managers Nursing & Midwifery Reg The percentage of staff remaining in date for their Annual Medical & Dental Appraisal decreased from 78% to 77% in May 15, against a target Estates of 90%. Ancillary Allied Health Professionals Admin & Clerical Additional Prof Scientific & Technical Additional Clinical Services

0% 20% 40% 60% 80% 100%

Apr-15 May-15 Jun-15

31 Well Led Workforce Assurance [10]

Trustwide Additional Add'l Prof Admin & Allied Health Medical & Nursing & Senior Jun-15 Target Clinical Scientific & Ancillary Estates HCA's Jun-15 Jun-14 Clerical Professional Dental Midwifery Managers Services Technical

Workforce FTE 1976 55 55 397 103 163 31 221 505 92 242 1866 1652 Vacancy Rate 10% 3% 15% 5% 11% 17% 9% 20% 19% 18% -1% 13% 10%

Turnover Turnover * 10% to 15% TBC TBC TBC TBC TBC TBC TBC TBC TBC TBC 13% 14%

Sickness Absence Sickness Absence (May-15) 3.0% 5.2% 1.8% 1.9% 2.9% 6.6% 1.4% 0.6% 3.7% 0.1% 6.0% 3.3% 2.9% Sickness Absence (YTD) 3.0% 4.2% 1.1% 2.0% 2.2% 5.2% 0.7% 0.6% 3.6% 0.1% 5.5% 3.0% 3.2%

Performance Compliance Mandatory Training 90% 82% 93% 87% 83% 85% 99% 90% 89% 97% 88% 88% 82% Appraisal 90% 73% 86% 82% 69% 69% 82% 90% 72% 80% 73% 77% 81%

* excludes Jnr M & D

32 Well Led Workforce Assurance [11]

Registered Nursing All Staff

Budgeted Contracted Vacancy Budgeted Contracted Vacancy Average Turnover Sickness Mandatory Jun-15 Appraisal % FFT * Pals Complaints Grievances FTE FTE Rate % FTE FTE Rate % Fill Rate % % Absence % Training %

Trauma & Orthopaedics 23 12 48% 38 32 18% 92% 16% 5.6% 47% 86% 100% 1 0 0 Surgery & Gynae 17 11 32% 28 24 14% 105% 30% 1.5% 84% 88% 95% 2 0 0 Kingston Wing 13 10 18% 31 29 7% 96% 8% 4.4% 69% 92% 95% 0 0 0 ICU 45 39 14% 46 41 12% 82% 7% 6.7% 79% 91% 100% 2 0 0

Elective Care Elective Midwifery 56 54 4% 74 72 3% 89% 10% 8.6% 73% 92% 96% 3 0 0 Elective Ward 14 10 26% 26 23 11% 94% 16% 5.0% 95% 95% 95% 3 2 0

Emergency Admisssions Unit 22 17 21% 37 34 8% 105% 23% 5.7% 58% 80% 93% 5 0 0 Ward 8A - Medicine 17 12 30% 28 29 -1% 104% 9% 5.1% 42% 83% 100% 2 0 0 Stroke & Elderley Care 15 10 32% 30 24 19% 98% 23% 2.2% 95% 95% 100% 0 0 0 Ward 9A - Medicine 19 16 18% 31 31 -1% 99% 31% 4.1% 68% 90% 92% 3 1 0

Ward 9B - Medicine 17 10 38% 28 25 10% 99% 43% 6.6% 85% 90% 92% 5 0 0 Urgent Care Urgent Ward 10 16 15 8% 20 18 11% 96% 20% 6.2% 85% 82% 95% 2 2 0 CCU 18 14 23% 18 14 23% 101% 29% 1.3% 100% 79% 100% 0 0 0 SCBU 11 10 9% 17 14 16% 91% 11% 1.8% 70% 93% N/A 0 0 0

Total Vacancies 302 241 20%

* Extremely Likely and Likely to recommend

33 YDH │Financial Performance

Month 3 – June 2015

34 Executive Summary Business as usual (BAU) excluding transformation. All variances reported are for BAU hospital operations.

£1.3m in £4.7m £0.2 m YTD month YTD favourable vs deficit deficit budget Trend in month surplus / deficit 0

-0.2

-0.4 -0.6 -0.8 -1 -1.2

Surplus/ (Deficit) £m -1.4 -1.6 -1.8 -2 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Budget 15/16 Actual 15/16 Actual 14/15

35 Executive Summary In month June 2015 BAU favourable variance to budget £47k. Whole trust including transformation £26k favourable to budget (1,200)

(1,220)

(1,240) (1,277)

(1,260) (1,324)

(1,280)

32 (1,300)

7 9 (1,320) 5 5 (35) Underspend 24 Overspend Surplus/ (Deficit) £’000 (1,340) 1.1 1.2 1.3 2.1 2.2 2.3 2.3 (1,360)

Presentation ref – see section for more details

36 Executive Summary – Year to date summary Year to date £4.7m deficit; £0.2m favourable to budget Focus Point -Income is £86k (0.3%) adverse to budget. Clinical income is £100k favourable due to additional cancer drug Income fund income received offset by costs. 1 Private patients £37k adverse and RTA income £69k adverse. Other income £80k adverse, £147k timing on donated asset income offset by additional facilities contracts and education income.

-Expenditure is £160k (0.5%) favourable to budget. Pay is £20k overspent, £294k overspend on nursing staff is offset by 2 Expenditure underspends in medical, admin and other staff groups. Non pay is £180k underspent, £266k lower expenditure on consumable items mainly in theatres is offset by an overspend on drugs, covered by additional income.

-Capital is £1,394k (64%) underspent against plan. The main variances are due to the purchase of medical equipment, Capital taking place later than planned, and timing variance on costs for the 3 modular ward construction.

-Cash at 30th June is £5.8m. This is in line with plan and continues to be monitored weekly. 4 Cash Awaiting documentation from Monitor to enable first planned drawdown of cash support in September.

37 Contents

1.1 NHS Clinical Income 1 Income 1.2 Non NHS Clinical Income 1.3 Other Income

2.1 Pay Expenditure and Temporary Staffing 2.2 Drugs 2 Expenditure 2.3 Other Non Pay Expenditure 2.4 CIP (Cost Improvement Programmes) 2.5 Transformation Budget

Capital 3 3.1 Capital Projects

4.1 Cash Flow 4 Cash 4.2 Balance Sheet

38 1.1 | NHS clinical income 1 2 3 4 YTD £100k & £5k in month favourable variance.

June 2015 June 2015 Actual Budget 9,350 9,000 £8.60m £8.60m 9,150 8,950

8,500 235 243 8,750 430 495 8,550 8,000 £’000 8,350 337 297 7,500 8,150 7,950 7,000 1,168 1,162 7,750

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

6,500 15/16 Budget 15/16 Actual 14/15 Actual £’000 6,000 Notes • In month less income was received for high cost 5,500 pass through drugs offset by lower expenditure. 6,433 6,404 5,000 • Specialised Commissioning contract £40k 4,500 favourable in month following adjustment to SCBU activity estimated lower in M2, contract £37k 4,000 Other High Cost Drugs adverse YTD. Specialised Commissioning Dorset CCG Somerset CCG Other includes- Overseas patients, Local Authority, Military, Public Health & NCA

39 1.2 | Non NHS clinical income - 1.3 | Other non clinical income 1 2 3 4 Favourable variance in month £21k, adverse by £159k YTD

1,600 June 2015 June 2015 Actual Budget £1.48m £1.47m 1,500 1,450 1,500 1,400 1,350

1,300 1,400 1,250 209 194 £’000 1,200 1,150 1,300 1,100

1,050

35 44 1,000 ’000

£ Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 1,200 15/16 Budget 15/16 Actual 14/15 Actual

Notes 1,100 1,236 1,229 • £15k favourable in month on private patients, £37k adverse year to date. 1,000 • £9k adverse Other Non NHS Clinical Income due to lower Injury Cost Recovery Scheme, variable income stream YTD £49k lower than prior year. 900 • Other Non Clinical Income £7k favourable in month, Private Patients Other Non NHS Clinical Income £131k timing variance on donated asset income Other Non Clinical Income offset by additional facilities contracts income and a Other non clinical includes: R&D, education and training, catering, car rebate received from SPS. parking, commercial contracts, donated asset income.

40 2.1 | Pay expenditure & temporary staffing 1 2 3 4 Pay YTD is £20k overspent & £35k in month, additional costs for nursing staff offset by underspend on medical and admin 8,000 100

7,500

7,000

6,500

£’000 £’000 6,000 22 0 12 5,500 (24)

5,000 (50) (92)

Agency Actual Bank & Locum Actual Substantive Actual Agency Budget Bank & Locum Budget Substantive Budget Notes (100) Variance to Budget in Month • Nursing pay is overspent due to additional premium being paid for agency staff. See separate slide for further detail on nursing pay. £35K Adv (150) • Medical staff pay is in underspent against budget, see separate slide for further detail on medical pay.

• Ancillary are overspent in pharmacy, radiology and catering due to additional workload across the hospital.

41 2.1 | Pay expenditure & temporary staffing 1 2 3 4 Nursing Staff - £92k overspent in month, £294k YTD.

2,800 350

2,600 300 2,400

250

2,200

2,000

200 £’000 1,800 150 1,600

1,400 100

Agency Actual Bank Actual Substantive Actual Agency Premium Budget

Bank Budget Substantive Budget Prior Month Budget Average Occupied Bed Days

Notes • Substantive expenditure increased in month offset by a reduction in bank. Agency expenditure stayed fairly consistent to give an overall reduction in nursing costs in month of £23k. • Additional duties have been worked in month to cover the supernumerary status of the newly appointed registered nurses and untrained support workers. There were also additional shifts to cover requirements of one to one nursing care for higher acuity patients. • The main variances in month were incurred against the adult IP ward budgets

42 Recruitment Position – June 1 2 3 4

Overview Notes

Total starters 23 • Staff Nurse Campaign - 23 more staff nurses Total leavers 16 arrived in July, bringing the total recruited since January to 66. Vacancies Medical Non-training -43 • Medical Campaign – 8 of 10 SHO vacancies, 13 of 15 Middle Grade vacancies, and 5 of 14 Medical Training -3 Consultant vacancies are on track to be filled. Nursing (band 5 only) -29 • Both campaigns have clear project plans and Total -75 are actively being progressed.

Offers • 73 medical training allocations from the Deanery Medical Non-training 11 are being processed and the national rotation start date for these posts is 5 August. Medical Training 73 Nursing (band 5 only) 10 • Additional information will available next month

Total 94*

* 18 offers have also been made for other clinical and corporate posts

43 Nursing Vacancies 1 2 3 4 Forecast net vacancy/over established closing monthly position Vacancy = negative, over establishment = positive

30 New ward opens, 15 wte increase in required 36 15 20 15 nursing establishment 15 18 10 20 0

-10

-20 23 -30 18 Leavers assumed to be -40 21 Number of starters 6 per month based on 14/15 average -50 Total Jan’15 - Dec’16 -60 =203

Apr'15 projection Jul'15 projection

44 Recruitment Position – June 1 2 3 4

Notes

• We have recruited 66 staff nurses since January.

• Since January, staff nurse leavers have been 32 compared to plan of 36, joiners have been 66 compared to plan of 43.

• In July 23 more staff nurses arrived from Italy.

• In August 6 staff nurses will join from the UK.

• In September 18 staff nurses will join from Spain and Italy, 16 preceptorship nurses, 1 international (requiring visa and OSCE), and 2 from the UK.

• Due to potential problems with the limited number of Tier 2 visas we are investigating whether the trip to India planned for September should be postponed. We are therefore continuing to recruit 24 EU nurses, this will also ensure we are fully staffed for the new modular ward.

45 2.1 | Pay expenditure & temporary staffing 1 2 3 4 Medical Staff Analysis - £47k underspent in month, £125k YTD. Agency spend in month £205k, YTD £684k. 2600

2400

2200

2000

1800

£’000 1600

1400

1200

1000 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Regular payroll Additional payroll Bought in services Agency Budget 2015/16 incl risk budget Budget 2015/16 excl risk budget

Notes Urgent Care - £61k fav due to Symphony Hub underspend (offset by income) and vacancy in Radiology (offset with non pay costs for reporting) and un-utilised risk budget. Elective Care - £9k fav due to un-utilised risk budget Corporate - £9k adv due to expenditure within Somerset Academy and Maternity pay costs Central - £13k adv due to commitments against central budgets. Agency Spend Total agency spend in month £205k; £684k ytd. 53% (£109k) of in month spend relates to 4 consultant vacancies – Stroke, Respiratory, Care of the Elderly and Gynaecology

46 2.2 | Drugs 1 2 3 4 £24k underspent in month; £72k overspent YTD, this is partially offset by additional income for high cost pass through drugs. YTD High Cost Drugs Income

1,400 June 2015 June 2015 2,500 Actual Budget 1,200 £2.03m £2.02m 1,000 2,000 406 312 800

1,500 600

£’000 938 999 £’000 400 1,000 200 500 - 683 691 0 CDF - Actual Spec Comm - Actual All other drugs - Actual Cancer Drugs Fund CDF - Budget Spec Comm - Budget All other drugs - Budget Specialised Commisioning Somerset & Dorset CCG Notes • From April – June £3.3m has been spent on drugs and £2.0m of income received to directly pay for high cost items.

• In month the trust is underspent by £24k against budget, but overspent by £72k YTD.

• The £72k YTD overspend is offset by £24k of additional income for high cost drugs consisting of; £93k greater than plan from the Cancer Drugs fund, £61k less from Specialised Commissioning, and £9k less from CCG contracts.

• YTD the marginal rate payment for Specialised Commissioning drugs has reduced income by approximately £50k, under the contract the Trust only receives income to cover 70% of drug costs above plan.

47 2.3 | Other non pay expenditure 1 2 3 4 Underspent by £10k in month, £251k YTD. 3,750 40

3,250

2,750 30

2,250

£’000 1,750 £’000 28 1,250 10 12 750

0 High Cost Consumables Actual Consumable M&SE Actual Other Non Pay Actual High Cost Consumables Budget Consumable M&SE Budget Other Non Pay Budget (10) Notes Variance to (30) • Consumable M&SE underspent by £12k in month, £117k YTD. Underspend on Budget in Month theatres consumables offset by additional radiology costs for service to review scans (20) £10K Fav following a staff vacancy.

• High cost consumables are underspend by £28k in month, £149k YTD, mostly in (30) orthopaedic theatres.

• Other non pay is overspent by £30k in month, £15k YTD. Additional costs for set up of nursing rental accommodation and extra costs for hearing aids, offset by various (40) underspends. Consumable High Cost Other Non M&SE Consumable Pay

Consumable M&SE – Medical & Surgical Equipment High Cost Consumables – Includes high cost prostheses 48 2.4 | CIP Achievement 1 2 3 4 In month £255k achieved against plan of £217k. YTD £504k achieved against plan of £561k. 350 300 250

200

£’000 150 100 50 0 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 CIP Recurrent CIP Non Recurrent CIP Plan Year to Date

Actual Acutal Non Total Annual Project Recurrent Recurrent Achieved Plan Variance Plan Procurement 12 2 14 37 (24) 229 1% Items 54 155 209 202 6 1,102 Facilities 19 0 19 30 (11) 157 Corporate 62 0 62 25 37 100 Energy 35 0 35 31 4 125 Commercial 25 0 25 29 (4) 104 CNST 16 0 16 16 0 63 Non Pay Inflation 66 0 66 66 0 362 Elective Care 0 0 0 75 (75) 300 Urgent Care 50 10 59 50 10 386 Total 338 166 504 561 (57) 2,928

49 2.5 | Transformation Budget 1 2 3 4 Overspent by £22k in month, £109k YTD due to less YTD YTD Expenditure Income income received than plan. 300 £0.26m £0.15m 800 700 250

600

200

500 120 £’000 £’000 400 All expenditure is planned to be 150 300 offset by income 200 100 100 139 150 0 50

0 Pay Non Pay Income Planned Income & Expenditure Actual Expenditure Actual income

Notes

• Transformation budgets cover new models of care included in the business case presented to the Department of Health. The planned expenditure for the year is budgeted to be paid for by income from the transformation fund and other sources.

• The overspend in month relates to pay expense being incurred for project staff working on initial implementation and the extended FOPAS service, only partially offset by £150k of income received.

• Future month plans for pay and non pay incorporate expansion of new models of care in hubs and extensivist care models.

50 3.1 | Capital 1 2 3 4 Underspent by £817k in month, YTD £1,394k underspent

1400 Plan 1200 Actual

1000

800 £’000 600

400

200

0 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Capital Expenditure In Month Year to Date Notes Actual Variance Actual Variance Operational Capital Spend • General site capex is underspent due to SCBU Total General Site Capex 157 179 311 258 works now scheduled later in the year.

Medical Equipment 0 184 0 396 • Medical equipment scheduled to be purchased later Radiology 0 165 1 164 this year. IT Upgrad / Replacement 24 (9) 24 6 IT / Developments 1 24 1 49 • Radiology equipment now being funded via a lease Major Developments agreement. Energy Project 44 91 101 169 New Ward 34 116 74 126 • New ward, planning permission has been submitted, further costs expected later in the year. IT - Smartcare 112 55 259 190 Donated Schemes in Year 0 12 0 37 Total 373 817 772 1,394

51 4.2 | Cash 1 2 3 4 Outflow in month was £516k, cash balance at 30th June; £5,750k

Total planned cash support of £24.3m to 10,000 cover revenue and capital. 8,000

6,000

£’000 4,000

2,000

Actual Cash Planned Cash Support Planned cash Revised forecast

Notes • At end of June 2015 cash balance was inline with plan.

• £9m drawdown planned for September 2015 awaiting documentation required from Monitor to facilitate this- £6m of this is to repay prepayment to Somerset CCG.

• Creditors continue to be monitored weekly.

52 4.2 | Balance Sheet 1 2 3 4 May 15 June Mvt In Mth Notes Non Current Assets 51,720 51,770 50 Current Assets • Current assets have decreased Stock 2,012 2,074 62 due to cash balance reducing, NHS Trade Debtors 1,298 1,713 415 quarterly invoices have been raised Non NHS Trade Debtors 859 645 (214) Accrued Income 1,211 1,431 220 awaiting payment increasing NHS Prepaid Contracts 1,587 1,548 (39) debtors. Cash in Hand and at Bank 6,266 5,750 (516) Total Current assets 13,233 13,161 (72) • Current liabilities have increased by Current Liabilities £1.3m following payments being Trade Creditors (2,349) (2,624) (275) Other Creditors (2,853) (2,955) (102) received in advance. PDC creditor PDC Dividend Creditor (209) (326) (117) increases prior to cash payment in Capital Creditor (810) (1,061) (251) September. Accruals (6,838) (6,984) (146) Borrowings <1yr (130) (130) 0 Deferred Income (7,432) (7,816) (384) Current Liabilities (20,621) (21,896) (1,275)

Net Current Assets (7,388) (8,735) (1,347) Total Assets less Current Liabilities 44,332 43,035 (1,297) Trade and other Payables >1yr (11) (11) 0 Borrowings> 1yr (1,626) (1,626) 0 Provisions >1yr (1,047) (1,049) (2) Net Assets employed 41,648 40,349 (1,299) Financed by: I&E Reserve Current year (3,535) (4,834) (1,299) Public Dividend Capital 41,823 41,823 0 I&E Reserve Previous year (4,638) (4,638) 0 Revaluation Reserve 7,998 7,998 0 Total Financed 41,648 40,349 (1,299)

53 Summary Statement of Comprehensive Income 1 2 3 4 For business as usual operations – excluding transformation. Financial Summary Prior Months Actuals In Month - June -15 Year to Date Variance Annual Variance to to Budget £000's Apr-15 May-15 Actual Budget % var Actual Budget % var 2015/16

Income Clinical Income 8,225 8,117 8,603 5 (0.1%) 24,946 100 (0.4%) 104,174 Non NHS Clinical Income 176 174 244 5 (2.1%) 593 (106) 17.9% 2,891 Other Income 1,107 1,088 1,236 7 (0.5%) 3,430 (80) 2.3% 14,067 Total Income 9,507 9,379 10,083 16 (0.2%) 28,969 (86) 0.3% 121,132

Pay Nursing (2,701) (2,663) (2,639) (92) (3.5%) (8,003) (294) (3.7%) (30,171) Medical Staff (2,322) (2,257) (2,290) 47 2.1% (6,869) 125 1.8% (26,918) Estates, Admin & Clerical (1,253) (1,252) (1,306) 12 0.9% (3,810) 137 3.6% (15,626) Pay - Scientific, Therapeutic & Technical (628) (614) (629) 22 3.4% (1,871) 72 3.9% (7,891) Pay - Ancillary (357) (355) (365) (24) (6.6%) (1,077) (61) (5.6%) (4,061) Total Pay Expenditure (7,261) (7,141) (7,228) (35) (0.5%) (21,630) (20) (0.1%) (84,667)

Non Pay Drugs (1,119) (1,054) (1,115) 24 2.2% (3,288) (72) (2.2%) (13,666) Consumable M&SE (615) (614) (682) 12 1.8% (1,911) 117 6.1% (7,949) High Cost M&SE (270) (190) (261) 28 10.6% (721) 149 20.7% (3,023) Other (1,542) (1,679) (1,652) (30) (1.8%) (4,873) (15) (0.3%) (24,859) Total Non Pay Expenditure (3,545) (3,537) (3,711) 34 0.9% (10,793) 180 1.7% (49,497) EBITDA (1,299) (1,299) (856) 15 1.8% (3,454) 74 2.1% (13,032) Other Technical (428) (421) (421) 32 7.6% (1,270) 89 7.0% (5,399) Surplus / (Deficit) (1,727) (1,721) (1,277) 47 (4,724) 163 (18,431)

54 Summary Statement of Comprehensive Income 1 2 3 4 For whole trust including business as usual operations and transformation. Financial Summary Prior Months Actuals In Month - June -15 Year to Date Variance Annual Variance to to Budget £000's Apr-15 May-15 Actual Budget % var Actual Budget % var 2015/16

Income Clinical Income 8,225 8,117 8,753 (369) 4.2% 25,096 (567) 2.3% 109,729 Non NHS Clinical Income 176 174 244 5 (2.1%) 593 (106) 17.9% 2,891 Other Income 1,107 1,088 1,236 7 (0.5%) 3,430 (80) 2.3% 13,946 Total Income 9,507 9,379 10,233 (357) 3.5% 29,119 (753) 2.6% 126,566

Pay Nursing (2,701) (2,676) (2,647) (65) (2.4%) (8,024) (234) (2.9%) (31,784) Medical Staff (2,322) (2,264) (2,299) 95 4.1% (6,884) 252 3.7% (28,761) Estates, Admin & Clerical (1,280) (1,292) (1,339) 94 7.0% (3,912) 284 7.3% (17,462) Pay - Scientific, Therapeutic & Technical (628) (615) (630) 29 4.6% (1,873) 96 5.1% (8,336) Pay - Ancillary (357) (355) (365) (24) (6.6%) (1,077) (61) (5.6%) (4,135) Total Pay Expenditure (7,288) (7,202) (7,280) 129 1.8% (21,770) 338 1.6% (90,479)

Non Pay Drugs (1,119) (1,054) (1,115) 24 2.2% (3,288) (72) (2.2%) (13,929) Consumable M&SE (615) (614) (682) 12 1.8% (1,911) 117 6.1% (8,158) High Cost M&SE (270) (190) (261) 28 10.6% (721) 149 20.7% (3,471) Other (1,542) (1,679) (1,772) 158 8.9% (4,993) 185 3.7% (23,396) Total Non Pay Expenditure (3,545) (3,537) (3,830) 222 5.8% (10,913) 380 3.5% (48,955) EBITDA (1,326) (1,360) (877) (6) (0.7%) (3,563) (35) (1.0%) (12,868) Other Technical (428) (421) (421) 32 7.6% (1,270) 89 7.0% (5,563) Surplus / (Deficit) (1,754) (1,781) (1,298) 26 (4,834) 54 (18,431)

Board of Directors Meeting July 2015

Director of Nursing Report

Monthly Report of Nurse/Midwifery Staffing Levels

1 June 2015 - 30 June 2015

EXECUTIVE SUMMARY

The NHS National Quality Board published a new guidance in November 2013 to support providers and commissioners to make the right decisions about nursing, midwifery and care staffing capacity and capability “How to ensure the right people with the right skills are in the right place at the right time”: A Guide to Nursing, Midwifery and Care Staff Capacity and Capability.

There are nine key expectations that apply to the Trust:

1. Boards take full responsibility for the quality of care provided. 2. Processes are to be in place to enable staffing establishments to be met on a shift by shift basis. 3. Evidence based tools to be used. 4. Clinical and managerial leaders foster a culture of professionalism and responsiveness where staff feel able to raise concerns. 5. Multi-professional approach is taken when setting staffing establishments. 6. Sufficient time to undertake care and duties in practice. 7. Boards receive monthly updates on workforce information and staffing capacity and capability and is discussed at public Board meetings every six months. 8. Clearly display information about the nursing and care staff present on each ward, clinical setting or service on each shift. 9. Provider to take an active role in securing staff in line with their workforce requirements.

PURPOSE

The purpose of this report is to provide the Board of Directors with monthly information regarding the nursing and midwifery registered and unregistered staffing levels on a shift by shift basis of the planned and actual nurse staffing levels across the organisation and across inpatient areas of the Trust as per the guidance received from NHS England and the Care Quality Commission.

METHODOLOGY AND SCOPE FOR REVIEW

This report focusses on all adult inpatient areas including Critical Care, inpatient maternity wards and inpatient paediatric wards. With the Trust working towards the 1:8 ratio as recommended in the National Safe Staffing Alliance for relevant adult wards. For the purpose of this report non inpatient areas such as the operating theatres, day theatre, endoscopy and emergency department are currently excluded.

KEY POINTS

. National Unify Returns . Safer Nursing Indicator . Safer Staffing: A Guide to Care Contact Time . Recruitment, the recruitment drive is ongoing . e-Rostering and Implementation of Bank Booking System . Temporary Staffing . Bank and Agency usage, noticeable reduction in use of agency staff . Unfilled Shifts . Supervisory Status

Unify Return

Day Night Day Night

Registered Registered Care Staff Care Staff midwives/nurses midwives/nurses Average Average fill Average fill rate - Average rate - fill rate - Ward registered fill rate - registered care

name nurses/ care staff nurses/

staff midwives (%) midwives (%)

(%) (%)

hours hours hours hours hours hours

actual staff staff actual staff actual staff actual

planned staff staff planned staff planned staff planned

Total monthly monthly Total monthly Total monthly Total monthly Total monthly Total monthly Total

Total monthly monthly Total staff planned hours monthly Total staff actual hours

61.7% 96.2% 100.0% 100.0% JW 739 456 1170 1125 750 750 375 375 KW 690 690 690 631.5 690 690 345 310.5 100.0% 91.5% 100.0% 90.0% 6A 1045.5 920 1440 1408 690 644 690 575 88.0% 97.8% 93.3% 83.3% 6B 1012.5 845.5 1436 1369 690 678.5 570 604.5 83.5% 95.3% 98.3% 106.1% 7A 1102.5 1102 935 1110.5 690 690 690 678.5 100.0% 118.8% 100.0% 98.3% EAU 1266.5 1237.5 1545 1682 1035 1081 690 782 97.7% 108.9% 104.4% 113.3% 8A 904.5 854.5 1260 1432 690 724.5 690 678.5 94.5% 113.7% 105.0% 98.3% 8B 1228 1128 1260 1272 690 690 690 701.5 91.9% 101.0% 100.0% 101.7% 9A 967 906 1215 1247 690 690 690 690 93.7% 102.6% 100.0% 100.0% 9B 984.5 888 1168 1241 690 690 690 690 90.2% 106.3% 100.0% 100.0% 10 1029.5 1007 345 328.5 1023.5 966 0 0 97.8% 95.2% 94.4% - ICU 2415 2020.5 150 42 2415 2035.5 0 0 83.7% 28.0% 84.3% - CCU 1332 1326.5 0 0.5 820.5 820.5 0 34.5 99.6% - 100.0% - Freya 2767.5 2338 967.5 822 1890 1825.5 630 567 84.5% 85.0% 96.6% 90.0%

SCBU 900 892.5 450 345 285 256.5 285 247 99.2% 76.7% 90.0% 86.7%

Safer Staffing Indicators

As recommended by the guidance the safe nursing indicators of falls, pressure ulcers and medication administration errors are measured. The following tables indicate the staffing levels in relation to the safety outcome measure for each ward.

Both Wards 8A and 8B demonstrate a noticeable direct correlation between reduced staffing and increased incidents in safe nursing indicators.

Safe Staffing: A Guide to Care Contact Time

The publication of Safe Staffing: A Guide to Care Contact Time: A Guide to Care Contact Time acknowledges that safe staffing was more than just looking at numbers on a ward. Both Bournemouth and Plymouth Universities have agreed for us to utilise students to collect this data. The data collection tool is now on iteration three and being trialled by the students.

Recruitment

Registered Nurses: The rolling fortnightly interviews continue with successful candidates being offered positions on the day. Candidates are both UK and EU of origin.

May Cohort: The EU registered nurses that commenced in May have completed their four week supported induction programme at the beginning of June. Their PIN applications are gradually being processed by the NMC and as soon as they receive it they are included in the registered nurse number. There is a current attrition rate of two nurses for this cohort, which is not expected to rise.

English Language Controls

The NMC has launched a 12 week consultation on English Language requirements and the registration process. New legislation that is coming into effect will enable the NMC to put in place language controls for applicants from the European Economic Area (EEA). It is recommended that all candidates pass the International English Language Testing System (IELTS) achieving a score of at least seven in each section and seven overall. The introduction of this may have a negative impact on recruitment from within the EU, due to the challenge of achieving an adequate score.

The following graph indicates our current recruitment position and going forward as of 17 July 2015:

NB: It should be noted this is only accurate on the day it is calculated due to the fluidity of recruitment but an over recruitment position is predicted towards the latter part of the year; this will enable the staffing of the modular ward. In order to ensure this the cohort for September and November have been increased

Non EU Recruitment: Recruitment in India continues to be actively explored but there is currently a potential problem with the issuing of Tier 2 visas that is currently being investigated by Human Resources. It should be noted that from April 2016, due to registered nurses not being included on the Shortage Occupational List (SOL), they will need to earn at least £35,000 to qualify for settlement in the UK, which may have an impact on retention. e-Rostering

The planned implementation of e-rostering continues with the wards in the tower block now complete and being paid by e-roster. All other departments are now included in the project plan to be moved over to e-rostering on a phased change over.

Temporary Staffing

Due to the continuing high vacancy rate, although the position has significantly improved since January 2015, ensuring safe staffing levels continues to be a challenge. The skill mix of every ward is reviewed daily by the Matrons and flexing of staff across all wards continues to ensure the provision of safe care including mitigating the risk of the unavailability of a registered nurse by using a health care assistant. Vacant shifts are escalated to the agencies as soon as the Staffing Solutions Office receives them. In addition, the Associate Director of Nursing reviews all shifts and escalates to Thornbury a week in advance in order to maintain safe staffing levels. There is a continued replacement of bank and less expensive agencies into shifts already filled by the more expensive agencies in order to reduce the financial risk to the organisation. An enhanced rate of pay is offered to registered nurses when necessary to maintain our staffing levels. The following table indicates the number of bank / agency used during June 2015.

Bank and Agency Usage

9A 9B 8A 8B 7A 6A 6B

ICU

EAU

SCBU

ACCU

TOTAL

FREYA Labour

Registered 5 33 36 47 65 13 56 99 91 43 13 24 3 5 533 Bank Unregistered 25 45 10 56 2 18 42 6 42 1 10 20 1 1 3 282 Bank Total Bank 5 58 81 57 121 15 74 141 6 133 44 23 44 4 1 8 815 Registered 3 16 11 8 9 14 14 6 29 9 4 14 1 1 139 Agency Unregistered 5 4 3 13 5 2 5 11 1 2 1 52 Agency

Total Agency 3 21 15 11 22 5 16 19 6 40 9 5 16 1 2 0 191 TOTAL 8 79 96 68 143 20 90 160 12 173 53 28 60 5 3 8 1006 Bank/Agency

The number of registered agency shifts has reduced dramatically from 478 in May to 139 in June; the same trend can be seen for agency unregistered with a reduction from 244 in May to 52 in June.

Unfilled Shifts

The following table indicates the number of unfilled shifts across the ward areas for June 2015. During this time a total of 255 registered nurses and 110 unregistered nurse shifts were unfilled using professional judgement.

A total of 24 registered nurse shifts were not filled due to the unavailability of staff and a total of 51 unregistered shifts. The wards would have been working with less than the recommended number and the staff will have been required to prioritise the care they give in order to ensure a safe provision of service.

The number of time shifts fell below the agreed staffing levels continues to be collected manually and therefore there may be inaccuracies in the data. The new bank booking system has now been implemented and the reports available are currently being explored.

When registered nurse shifts were unfilled by using professional judgement the shift will have been filled with an unregistered nurse where possible so that the number of staff on duty was sufficient, although the skill mix did not meet the 1:8 ratio.

In Maternity and SCBU, 64 registered midwife shifts were uncovered and 40 unregistered shifts uncovered due to the unavailability of staff.

9A 9B 8A 8B 7A 6A 6B

ICU

EAU

SCBU

ACCU

TOTAL

FREYA

Registered 12 8 18 7 17 1 2 5 24 43 68 0 50 255 Using Professional Judgement Unregistered 5 9 2 1 5 0 1 0 22 20 18 16 11 110

Registered 1 3 1 1 3 1 60 4 74 Nurse unavailable Unregistered 5 4 1 1 22 18 51

TOTAL 17 22 20 12 22 2 6 6 47 65 89 17 61 82 22 490

Supervisory Status

The vacancy rate continues to decrease and the ward sisters are increasing their supervisory time in their clinical areas.

SUPERVISORY STATUS REPORT (% calculated on number of days available to work)

Ward April May June

10 46% 46% 100%

9A 55% 52% 100%

9B 18% 0 Sister Chell covering Level 9

8A 14% 38% 100%

CCU 5% 0 23%

8B 0 29% 95%

7A 0 5% 32%

EAU 95% 67% 100%

T&O 118% 64% 86%

Elective 0 10% 52%

MFFD 0 10% 68%

KW 0 0 Has dedicated Matron

ICU 23% 38% 33%

RECOMMENDATIONS

The Board of Directors is asked to note the information contained in this summary report and the actions currently in place.

REPORT TO: Board of Directors

PRESENTED BY: Director of Strategic Development

TITLE: Corporate Risk Register Report

DATE: 29 July 2015 ______

PAPER Yes PRESENTATION No PAPER & PRESENTATION No

What is this item about? The risk report aims to provide The Board of Directors (BoD) with detail of the key operational risks being faced by the Trust, scoring Significant or Higher (12+) on the risk matrix.

Why is this item necessary? The risk report provides the necessary information for the Assurance Committees and the Board of Directors that is a fundamental part of the Governance arrangements required by Monitor and the Care Quality Commission.

What is BoD asked to do? The Board of Directors is asked to NOTE the report and corporate risk register.

1. How does this paper improve patient care? This report and attachments highlight the key operational risks facing the Trust to achieve its Strategic Objectives of Patient Safety and Quality. Prompt 2 under KLOE Well led = Does the Governance framework ensure that responsibilities are clear and that quality, performance and risks are understood and managed?

2. How does this paper advance the Annual Plan? The report is an essential part of the work towards the Annual Report and the Annual Governance Statement.

3. How does this advance our strategic objectives? The report identifies key areas of operational risks that are fundamentally part of the Trust’s governance arrangements.

4. Is further information available? Risk registers are on YCloud with the Risk Management Strategy approved in December 2014. The Board Assurance Framework (BAF) has links to operational risks where relevant.

Are there implications for the Trust?

• Legally? No

• Financially? Yes. Some of the issues discussed reflect the current position against Trust performance

• Regarding Workforce? No

Is this paper clear for release under Freedom of Information? YES

1. SUMMARY OF RISKS

1.1 This report presents the Corporate Risk Register as at the 6 July 2015. Since the last update to the Board of Directors in May 2015, the following is noted:

• There are 19 Significant or High risks (12+) recorded at the time of this report on the Corporate Risk Register; • One new risks were added in Qtr 4 – 2014/15, and; • Three risks have been reduced in score.

1.2 To aid interpretation of the risks they have been grouped into three broad areas under the following headings:

• Risks that are linked to the level of operational pressure that the Trust has been experiencing.

• A set of other clinical risks that would exist regardless of operational pressures.

• The remaining corporate risks.

1.3 The table attached to this paper summarises the most significant risks and details the actions that are being taken to mitigate these. A full copy of the risk register can be found on YCloud – Click on this link.

1.4 The hospital has experienced a significant increase in pressure over the Winter of 2014/15. This is manifesting itself in a set of risks that are linked to these. Broadly, these are:

• The pressure on the hospital bed stock • The risk associated with the current level of agency staff usage to staff areas of escalation capacity • The risk associated with the delivery of RTT standards, resulting from the cancellation of elective surgery • The clinical risk associated with the achievement of a reduction in pressure ulcers • The risk of serious harm as a result of patent falls

1.5 There are a series of other clinical risks that are not specifically linked to the operational pressures. These are:

• The consistent management of inpatients with diabetes • Recruitment and retention of nursing staff in Gynaecology • Senior medical cover to support frail elderly patients following orthopaedic trauma • Delays in treatment as a result of National problems with Homecare service provision

1.6 The key corporate risk areas are as follows:

• Staff shortages within the payroll department, potentially leading to delays in staff being paid • The ageing fire alarm system • Security management • Medical devices training • A number of risks relating to the Trusts Emergency preparedness • Implementation of the Trakcare Electronic Health Record system

1.7 The mitigating actions being taken to address each of these risks are detailed in the table below.

2. RECOMMENDATION The Board of Directors is asked to NOTE the risks included in the corporate risk register together with the mitigating actions.

Risks that have increased as a consequence of the increased operational pressures being experienced by the Trust:

Risk Risk Description Risk Action / Progress Has Where Residual No Score deteriorated Reviewed Risk Static

Moving towards risk reduction

- Increased TW023 Clinical Trust-wide Capacity Modeling undertaken with the Academic demand during winter 14/15 resulting in 16 = HMT 9 = Health Science Network predicts a shortfall of 40- escalation areas open, elective activity High Significant 50 beds across the Trust for Winter 2015/16. Plans and quality of care; Major risks include are being developed, linked to this year’s Falls, Pressure Ulcers, Medication Operational Resilience Funding to close this gap. errors, Staffing risks and inability to These are under discussion with Somerset CCG maintain quality of care and include a 24 bed modular ward, new assessment processes and partnerships with Nursing Home and Domiciliary Care providers to deliver new models which aim to reduce the pressure on hospital beds. In addition the ‘Fastforward’ project to assist discharges and identify flow issues took place before Easter 15 with action plan as a result to address flow issues. 6A / 6B swop taking place in May 2015 to assist flow and capacity.

During Quarter 4 - RTT team has been developed RTT - Insufficient capacity to prevent ST010 20 = and now has an operational support manager Elective Care 12 – breach of RTT targets from December High owning RTT in order for the RTT performance Business Unit / Significant 2014, resulting in specialty and HMT manager to concentrate on assurance. Currently aggregate breach and significant bed pressures inhibit full booking of lists. Waiting numbers of patients waiting over 18 list funding in negation in order to address the weeks. Risk has increased as a result backlog. Plan to address the backlog of patients of significant level of cancelled waiting being developed via the Elective Care SBU. operations over Winter 2014/15 Trajectory model developed with CCG – aim to

deliver all speciality other than T&O by end of Qtr 3 15/16. Action plan developed alongside this with all business managers and costed

Risk Risk Description Risk Action / Progress Has Where Residual No Score deteriorated Reviewed Risk Static

Moving towards risk reduction

UC006 Urgent Care – Nurse Staffing 20 = Out to recruit 40 + Nurses from Italy and Spain Urgent Care 12 = Vacancies. Risk to the continued High during April 15. RACE course developed. Second Business Unit Significant provision of quality services as a result cohort being planned. E-rostering system in place; of increased agency spend to maintain incentive scheme developed to support recruitment escalation capacity; financial risk above and retention. budget of circa £100k per month.

Orthopaedics - Lack of capacity to Raised risk possible to likely due to sustained OTH001 Elective Care meet the LDP contract, local 17 week 12 = reduction in elective orthopaedic bed capacity early 6 = Signific Business Unit Moderate and National 18 week RTT Targets in December 2014 and continuing late Feb 15, with ant our admitted pathway. no real indication of any sustained improvement in bed flow. 6A / 6B ward moves in April will assist flow

Clinical Trustwide - Inability to recruit Nursing recruitment events overseas in March and TW025 HMT experienced registered nurses and 12 = April and Return to the Acute Care Environment 6 = newly qualified due to reduced numbers Signific (RACE) course commenced for HCA’s. Further Moderate

of registered nurses available in the ant overseas trips planned May. Over recruitment of UK. unregistered staff. Number of European Nurses have commenced employment within the Trust

Clinical Trustwide - Failure to Regular reviewed at Pressure Ulcer Steering TW003 Pressure Ulcer implement actions for patients at risk of 12 = Group. Mattress and Equipment changes being 6 = Signific identified as part of risk reduction work. Auditing Steering Group Moderate developing pressures ulcers whilst in ant reporting to the hospital resulting in skin deterioration, use or pressure ulcer relieving equipment Adhering Patient Safety extended length of stay and expose to to Tissue Viability Risk assessment is part of the Steering Group infection control risk Fundamentals of Care Audit Monitoring prevalence and continuing reduction in line with CQUIN Target another reduction of 20% end of year Target 2015/16 = 75. Current PU Action Plan being updated with some slippage due to pressures and a short term reduction in staffing resources.

Risk Risk Description Risk Action / Progress Has Where Residual No Score deteriorated Reviewed Risk Static

Moving towards risk reduction

Review RCA's and monitor falls for trends through - Serious injury to TW002 Clinical Trustwide 12 = the Falls Prevention Group with Corporate action Falls Prevention 6 = patients at high risk of falls resulting in Signific plan developed through the falls prevention lead. Working Group / Moderate major harm PSSG ant New multifactorial falls risk assessment has now

been rolled out Trust wide which is NICE compliant

Other Clinical Risks:

Risk Risk Description Risk Progress Has Where Residual No Score deteriorated Reviewed Risk Static

Moving towards risk reduction

UC005 Urgent Care – Consultant and Middle Appointed long term NHS Locums to cover FOPAS Urgent Care 9 = Grade Medical Staffing Vacancies 16 = and Respiratory Medicine and reviewing Business Unit Significant High alternative staffing models Recruited to vacant posts in ED and EAU, SBU manager for Emergency Medicine Reviewing additional costs in Urology and Dermatology

Action plan in place to address to address - Failure of Nursing TW019 Clinical Trustwide 16 = actions.Serious incident investigations being Diabetes 6 = and Medical staff to accurately record Steering Group High reviewed, implemented e-learning programs for Moderate and respond to poor control of diabetes registered nurses. Business case agreed via HMT in April to increase the specialist nurse hours for in-

patient care. Workplan in place to include focused and targeted training, trustwide governance session, Thematic review of investigations. Diabetic steering group continues to meet bi- monthly, action plan in place

Risk Risk Description Risk Progress Has Where Residual No Score deteriorated Reviewed Risk Static

Moving towards risk reduction

OG020 Gynaecology - Unable to recruit A ward staffing risk assessment has taken place. nursing staff to EPAC/GAU 12 = OBS & Gynae 4 = Admission protocol developed for Jasmine ward. Business Unit Gynaecology ward, or retain staff with Signific Review of skill mix within Gynaecology dept. to Moderate ant skills and knowledge. Financial risk of determine ability to run a Gynae ward/EPAC/GAU covering Gynaecology ward with bank as cross cover for existing staff. Risk score nursing staff upgraded due to timescales

Increase of awareness of both medical and nursing OTH009 - Inadequate levels of Elective Care Orthopaedics 12 = vacancies. Speciality doctor for Ortho/Geriatrics 6 = Consultant medical cover on the Business Unit Signific leaves her post on 25th Feb 2015. This post has Moderate Orthopaedic ward to support the long ant been advertised, and the advert extended due to term conditions of frail elderly patients lack of suitable candidates. Plans being worked on with reduced medical leadership. This to cover this vacancy with an additional Trust risk has increased in Likelihood Fellow based on 6A. Multiple actions on risk impacting on length of Stay and register to address risk. Fracture NOF pathway is Patient Outcomes. Risk Increased to part of Orthopaedic CIP/Redesign work streams 12 (Significant) with task and finish groups reporting into Orthopaedic Steering Group during 2015/16

Business model being developed through Chief PH009 Pharmacy Clinical Trustwide - Delays Pharmacy Lead 12 = Pharmacist, Commercial Director and Assistant 6 = to patient treatment due to Homecare Moderate Signific Director of Finance for an Outpatient Pharmacy service failures resulting in medication ant solution, wholly owned subsidiary, 3rd party not being received on time. provider. This in effect would reduce the risk as this could be brought under control of the Trust

Corporate Risks:

Risk Risk Description Risk Action / Progress Has Where Residual No Score deteriorated Reviewed Risk Static

Moving towards risk reduction

HR013 Finance - Staff not being paid correctly 2 permanent staff now recruited and Payroll Finance team 6 = 15 = Manager recruitment underway after which closer and / or on time High Moderate working with HR will be embedded and the risk will reduce significantly. New payroll manager starting mid-August 2015

EFM046 Estates and Facilities - Ageing Fire 15 = Working with Strategic Partner to survey L2 Fire Health and 5 = Alarm Systems and building High Stopping. Fire doors replaced on L2 £182,000 Safety Moderate engineering systems do not prevent the allocated 15/16 for Fire Alarm upgrade. Fire Committee spread of fire and smoke in an stopping checks completed on L2, training emergency which leads to evacuation increased for Fire wardens and key staff. Fire delay and potential for evacuation alarm upgrade plan being reviewed. Prioritised areas to be compromised. plans in place to mitigate risk. Following assurance meeting with CCG / NHS OP006 Emergency Planning - Inability of trust 12 = England - risk amended to reflect trust resilience Emergency 12 = to manage capacity requirements Signific issues if up to 50% of staff unable to attend site Planning Significant where pandemic flu affecting up to 50% ant due to sickness or family sickness / school Committee of the population across the country. closures. Also expected increase in patient activity, critical care capacity constraints with plans to be updated. Risk will remain high nationally and within YDH. Staffing plan being updated.

Emergency Planning - Risk of patient Action work plan in place, all currently Amber / Emergency 12 = OP010 presenting with Ebola at YDH exposing 12 = Green. Current risk relates to releasing staff across Planning Significant Committee staff and others to the virus leading to Signific ICU / ED for training in PPE use.

exposure and cross contamination ant Protocol has been developed for patients presenting with symptoms with trained staff

EHR Project - Failure to realise and Agree a risk reporting process to Board level EHR001 agree the risks associated with 12 = EHR Project 6 = committee to communicate risk and agree level of implementation of the EHR project Signific Group Moderate acceptable risk as implementation goes forward for (Smartcare) to allow management ant Assurance decisions to be made on high risk areas Risk Risk Description Risk Action / Progress Has Where Residual No Score deteriorated Reviewed Risk Static

Moving towards risk reduction

New outsourced Security contract due to be EFM031 Security - NHS Protect Standards self- 12 = mobilised with effect from 1 June 15. Additional Security 3 = Low Committee review tool completed and has Signific hours to be provided: 1 officer 24 hours per day,

identified overall Trust risk as Amber. ant plus a second officer 18:00 - 06:00 daily Increased awareness of incidents and preventative actions taken through LSMS. Security Camera review taking place. Conflict Resolution Training levels to be agreed

Improvement in availability with training with HR009 - Insufficient Medical Devices 4 = Human Resources 12 = records being recorded on completion. OLM assurance around Medical Devices Signific Committee Moderate training records updated and devices being linked training which demonstrates staff ant to staff training record – Policy and procedures competency to deliver safe patient care remain to be updated but progress is good with a dedicated trainer EHR00 Electronic Health Record Trust wide Agree a risk reporting process to Board level EHR Team 1 – Failure to realise and agree the risk 16 = committee to communicate risk and agree level of New July 6 = associated with implementation of the Signifi acceptable risk as implementation progress goes 2015 Moderate EHR project (Smartcare) to allow cant forward management decisions to be made on high risk areas

Risks Reduced from the Risk Register since last Board review:

Risk Risk Description Risk Action / Progress Has Where Residual No Score deteriorated Reviewed Risk Static

Moving towards risk reduction RA008 Radiology - Loss of Consultant Breast 12 = Locum in place until June 2013. Radiology 6 = Radiologists due to them being called back Signific Recruitment taking place Moderate to MPH and MPH advertising for Consultant ant Breast radiologists. Without a breast radiologist we would not be able to support the symptomatic breast service. Loss of income.

OP005 Emergency Planning - Failure to comply 12 = Good progress - Assurance process through CCG / NHS Emergency 6 = with NHS Core Standards for Emergency Signific England, Quality Committee has supported review of Planning Moderate Preparedness, Resilience & Response ant risk. CBRN plan ratified / Severe Weather plan and Fuel Committee (EPRR) in line with contractual obligations plan awaiting HMT ratification. Lockdown plan to be developed

TW017 Finance - Failure to deliver the CQUIN 12 = Continued performance reporting monitoring through CQUIN Steering 6 = programme for 2014/15 results in loss of Signific HMT and Board. Plans in place for 2015/16 in Group Moderate payments ant negotiation with CCG