Board of Directors

BOARD OF DIRECTORS Wednesday 31 January 2018 at 13:45 – 16:30 Boardroom, Level 1, Yeovil District Hospital NHS Foundation Trust AGENDA - PART 1 Action Presenter Time Enclosure

1 Welcome and Apologies for Absence Chairman 13:45 Verbal

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

3 Patient Story To Receive Shelagh Meldrum 13:50 Presentation 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 Minutes of 20 December 2017 and to Discuss To Approve Chairman 14:10 Appendix 2 Matters/Actions Arising

5 Non-Executive Director Recruitment Plan To Receive Chairman 14:15 Verbal

STRATEGY

6 Executive Director Report To Note Execs 14:20 Appendix 3

7 General Data Protection Regulation Overview To Receive Jason Maclellan 14:45 Presentation and Note

8 Results of NHS Emergency Preparedness, To Receive Yvonne Thorne 15:00 Presentation Resilience and Response Assurance Process and Note

BREAK 15:15 – 15:25

FINANCE & PERFORMANCE

9 Board Overview Quadrant and Reports Receive and Tim Newman 15:25 Appendix 4 (Inc. updates on Finance, Quality, Performance, Workforce) Note Shelagh Meldrum Simon Sethi

ITEMS TO NOTE/FOR INFORMATION

10 Items to Note/for Information: iWantGreatCare Report To Note Shelagh Meldrum 16:00 Appendix 5

Freedom to Speak-up Guardian Report To Note Shelagh Meldrum Appendix 6

Guardian of Safe Working Report To Note Tim Scull Appendix 7

Risk Management Strategy To Note Jonathan Higman Appendix 8

Q3 Corporate Risk Register To Note Jonathan Higman Appendix 9

Update from the Financial Resilience and To Note Julian Grazebrook Verbal Commercial Committee Held on 23 January 2018

Update from the Workforce Committee Held on 23 To Note Mark Saxton Verbal & January 2018 and to Note the Minutes of the Appendix 10 Meeting Held on 18 December 2017

Update from the Governance and Quality To Note Jane Henderson Verbal & Assurance Committee Held on 24 January 2018 Appendix 11 and to Note the Minutes of the Meetings Held on 16 October 2017 and 20 November 2017

Update from the Audit Committee Held on 24 To Note Caroline Moore Verbal & January 2018 and to Note the Minutes of the Appendix 12 Meeting Held on 16 October 2017

11 Any Other Business and Meeting Close Chairman 16:30 Verbal

12 Date of Next Meeting 28 February 2018 in the Boardroom, Level 1, YDH

Board of Directors – Declarations of Interest January 2018 the following table sets out the declaration of interests of the Board of Directors (voting and non-voting).

Name Position Interests Declared

Chairman and Non-Executive Directors (Voting) Paul von der Heyde Non-Executive Director -Trustee and Adviser Howlands Furniture Group, Office (Until Jan 16) Furniture Manufacturer -Sister-in-law is the sister of Dr Ali Parsa who is the Founder Chairman and Chief Executive Officer of Babylon Healthcare Services (From Jan 16) -Director and Shareholder of Herswell Consulting -Director of Bear Pit Residential Limited & Bear Pit Management Ltd -Chairman of Psoriasis and Psoriatic Arthritis Alliance & PAPAA Enterprises Ltd -Director of Silvatherm Energy Ltd Maurice Dunster Non-Executive Director -None declared Jane Henderson Non-Executive Director -None declared Julian Grazebrook Non-Executive Director -Director of Eurac ltd -Director of MAT Foundry Group ltd Caroline Moore Non-Executive Director -Director (finance and corporate services) of Yarlington Housing Group and Yarlington Homes Ltd -Member of the Pension Committee of Somerset County Council Mark Saxton Non-Executive Director -Non-Executive Director Designate for the Care Quality Commission

Executive Directors (Voting) Paul Mears Chief Executive -Director, Symphony Healthcare Services Limited (From 7 April 16) -Director, Yeovil Property Operating Company Limited -Director, Wellchester Innovation Limited - Management Board Member, Yeovil Strategic Estates Partner Board -Management Board Member Southwest Pathology Services and Facilities LLPs Jonathan Higman Director of Urgent Care -None declared and Long Term Conditions (April 12 – June 15)

Director of Strategic Development (From June 15)

Deputy Chief Executive and Director of Strategic Development (from Apr 17) Tim Newman Chief Finance & -Director, Symphony Healthcare Services Limited (from 7 Commercial Officer April 2016) -Director, Yeovil Property Operating Company Limited -Director, Wellchester Innovation Limited -Management Board Member, Yeovil Strategic Estates Partner Board -Management Board Member, Daycase UK

-Governor of the Arts University Bournemouth -Wife provides part-time finance support to Symphony Healthcare Services Limited and Yeovil District Hospital NHS Foundation Trust (from September 2017) Tim Scull Medical Director -Director of ATUM Medical Consulting Ltd. -Wife is GP Principal in Millbrook Surgery, Castle Cary. Member of the Small Practices Group. Shelagh Meldrum Director of Elective Care -Management Board Member & CQC Nominated Individual, (From Feb 16 – Apr 17) Daycase UK -Non-Executive Director, Simply Serve Limited Director of Elective Care -Husband is employed as Contract Manager at Yeovil District and Director of Nursing Hospital (From Apr 17) Simon Sethi Interim Director of Urgent -Wife is General Manager for MSK and Neurology at North Care and Long Term Bristol NHS Trust Conditions -Lecturer at Yeovil College – unpaid position (June 15 – Dec 15)

Director of Urgent Care and Long Term Conditions (From Dec 15 – Apr 17)

Director of Operations and Urgent Care (From Apr 17) Executive Directors (Non-Voting) Mandy Seymour- Managing Director of -Husband is the Managing Director of Exeter Leadership Hanbury Symphony Healthcare Consulting Services Limited -Managing Director of Symphony Healthcare Services (From 1 Dec 16) Limited Kathryn Patrick Director of Primary Care -GP Partner at Ryalls Park Medical Centre (From Jun 17) Paul Foster Deputy Medical Director -Wife is a GP Partner for Newland Medical Practice (From July 17)

APPENDIX 2 BOARD OF DIRECTORS 31 January 2018 BOARD OF DIRECTORS DRAFT Minutes of the Part 1 Board of Directors Meeting held on Wednesday 20 December 2017 at Yeovil District Hospital

Present: Paul von der Heyde Chairman Jonathan Higman Acting Chief Executive Jane Henderson Non-Executive Director Julian Grazebrook Non-Executive Director Caroline Moore Non-Executive Director Maurice Dunster Non-Executive Director Mark Saxton Non-Executive Director Shelagh Meldrum Director of Nursing and Elective Care Tim Scull Medical Director Tim Newman Finance and Commercial Officer

In Attendance: Paul Foster Deputy Medical Director Simon Sethi Director of Operations and Urgent Care Mandy Seymour-Hanbury Managing Director of SHS Simon Lilley Commercial Director Ben Edgar-Attwell Company Secretary Simon Blackburn Associate Director of Communications Mark Appleby Associate Director of HR and OD

Apologies: Kathryn Patrick Director of Primary Care Paul Mears Chief Executive

Ref: No: Action 1- 1 WELCOME AND APOLOGIES FOR ABSENCE 320/ 1.1 Paul von der Heyde welcomed everyone to the meeting giving particular 17 welcome to members observing in the audience.

1.2 Paul von der Heyde noted Paul Mears absence for the foreseeable future and passed on the Boards thoughts and best wishes. In the interim, Jonathan Higman is Acting Chief Executive.

1- 2 DECLARATIONS OF INTEREST 321/ 2.1 The register containing the declarations of interests from members (voting and 17 non-voting) of the Board was noted.

1- 4 MINUTES/ACTIONS OF THE PREVIOUS MEETING 322/ 4.1 The minutes of the previous meeting were approved as a true and accurate 17 record.

4.2 In regard to matters arising, a TrakCare and full digital strategy overview would be presented in January 2018 as a seminar session. It was confirmed that Kathryn Patrick had linked with the Head of Patient Contact regarding the miscommunication of paper referral switch off and that this had been resolved. Tim Newman confirmed that the risks relating to the estates premises assurance model had been accurately reflected on the risk register.

4.3 Upon review of the action sheet, it was agreed that the lead for the action relating to a Board seminar session on the Integrated Learning Forum is updated to Paul Foster.

1- 5 EXECUTIVE DIRECTOR REPORT 323/ 5.1 Jonathan Higman spoke to the previously circulated executive director report. 17 Letter from the Secretary of State for Health, Jeremy Hunt MP 5.2 Following the Secretary of State’s visit to the Yeovil Hospital on Thursday 23 November 2017, the Trust received a letter personally thanking the Trust and staff for continued commitment to embedding a safety culture across the whole organisation. Jonathan Higman said that this was a positive visit and the letter has been shared with the full Board and more broadly across the hospital.

Staff Survey 5.3 The Trust has received an early report for the results of this year’s NHS staff survey. The headline results are a good response rate of 58% against the national average of 44%; this compares to a 61% response rate last year. The full results with the individual department breakdown is due shortly and will be presented in January 2018’s Board meeting. There have been some positive messages with improvement in staff team working, health and wellbeing and recognition of improvements in perception that patient care is the Trust’s top priority. Maurice Dunster and Mark Saxton stated that this had been briefly discussed at the Workforce Committee and noted the quick turnaround in results this year. Following a question from Julian Grazebrook, Tim Newman confirmed that the results are accurate and the further detail relates to a breakdown in information. In response to a question from Caroline Moore, Mark Appleby advised that there were no areas which had seen a large decrease in scoring; there was no significant swing in scoring across the survey results.

Operational Update 5.4 The Trust is currently under pressure with rising demand over the winter period as predicted. The seasonal influenza vaccination programme is underway with the Trust activity working towards achieving 70% of its workforce receiving the flu vaccination; this stood at 62.2% of its workforce as at 7 December 2017 which is a significant achievement. Yeovil Hospital, along with other neighbouring organisations, has recently been affected by a norovirus outbreak which resulted in ward visitation restrictions. Thanks to the hard work and diligence of staff, patients and visitors there has been a reduction in the number of cases resulting in a relaxation of visitation restrictions. Norovirus continues to circulate in the region therefore there is a need to maintain vigilance. Mark Saxton asked Shelagh Meldrum about continued norovirus management bearing in mind previous discussions about cleaning processes at the Governance and Quality Assurance Committee and the Board of Trustee’s approval for a second ultraviolet light machine. She confirmed that this new machine has assisted in quicker thorough cleaning of wards which has helped patient flow.

Winter Monies 5.5 As part of the Autumn Budget, funds were allocated in year to help the NHS continue to provide good quality care during winter. As part of this, a bidding process was put into place for which YDH submitted three schemes. Jonathan Higman explained that additional funding has been received amounting to approximately £900k to provide additional therapy and weekend services to increase flow and further additional supporting plans.

5.6 Jane Henderson asked about the recent iCARE about Patient Time week. Simon Sethi confirmed that this went well although there was a large increase in the number of medical patients with a year-on-year increase of approximately 5%. Operational pressures increased alongside the norovirus outbreak and this pressure continues. There are some proposed changes to the second patient

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flow week planned for January 2018; this will involve a patient story each day. Tim Newman asked about current A&E performance. Simon Sethi reported that this has been challenging although current month-to-date performance is 95.22%. Julian Grazebrook asked about the acuity of patients attending A&E; Simon Sethi said that the department’s frailty team is providing help and assistance to older patients and support to get them home. A review of periods of high referrals and attendances is underway.

1- 6 FEEDBACK FROM THE CONSULTATION FOR THE TUPE OF STAFF TO 324/ SIMPLY SERVE LTD 17 6.1 Following a proposal to establish a wholly owned estates and facilities management subsidiary company, the Trust initiated a formal consultation period during the month of November 2017. Mark Appleby presented a paper outlining the feedback from this consultation period. The Trust informed the chair of the Joint Consultative and Negotiating Committee (JCNC) in July 2017 of the proposal with the JCNC formally informed of the proposal on 8 August 2017. A letter was sent to trade unions to inform them of the Trust’s proposal to establish a subsidiary company (subco) alongside information on the list of measures, roles to be transferred, outlined implications for affected employees and a draft FAQ document. Mark Appleby reported that regular meetings had taken place up to the end of November 2017 to ensure good engagement with fortnightly extra-ordinary JCNC meetings to continue throughout 2017 and in January 2018 to engage and consult with trade unions and staff side representatives.

6.2 In October 2017, all staff affected were briefed by managers and staff were also issued with a letter and FAQ document which contained trade union contact details. A room was also made available to Unison on the same day for staff to meet with a Full Time Officer with HR surgeries and drop in clinic throughout the month. Further information was provided to trade unions to include a letter regarding the proposal to establish a subco, a copy of the letter to be sent to affected staff in November 2017, consultation feedback form, information and consultation paper, FAQ document and an equality impact assessment. Formal consultation took place for the month of November 2017. Mark Appleby reported that very few staff requested one-to-one meetings. He advised that under the Transfer of Undertakings (Protection of Employment) Regulations (TUPE) the terms and conditions of affected staff cannot be changed. As part of the consultation period, the JCNC and trade unions requested that the Trust guarantee terms and conditions for affected staff for 5 years. The Trust agreed this request and also went further to guarantee any pay increases or improvements in NHS terms and conditions would be matched by the subco. Two requests were made by members of staff, relating to recognition of continuity of service should staff transfer back to the Trust and whether bank staff would have their terms and conditions protected if they transferred under TUPE. Both requests were agreed; there would be a ‘golden thread’ rule whereby pension and annual leave entitlements would remain. Mark Appleby said that all management concessions go above and beyond the Trust’s statutory duty and reflect the desire for the subco to follow the Trust’s lead in being an employer of choice.

6.3 Mark Appleby reported that feedback received from managers is that members of staff do not appear to be anxious about the proposal with very few requests or attendance at drop in sessions or to meet with HR etc. He said that Unison had held drop in sessions both on and off site from which it is understood that limited members of staff also attended. The preliminary results from the staff survey suggest that there is little anxiety from the workforce.

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6.4 Mark Appleby said that the concessions made are further than required and recommended to the Board that they are accepted. He advised that the Trust fully intends to protect terms and conditions for affected staff and that there are no grounds from a human resources perspective not to approve the establishment of a subco.

6.5 Caroline Moore asked whether the Trust had done anything different or further than the arrangements which have taken place at other organisations implementing subcos, especially referencing Gateshead Health NHS Foundation Trust. Mark Appleby advised that they also implemented the ‘golden thread’ rule however YDH has gone further with the protection offered to bank staff and also matching NHS terms and conditions for 5 years. The continuity of employment concession is also above other organisation’s arrangements. Maurice Dunster asked how long the subco at Gateshead Health NHS Foundation Trust had been in place. Mark Appleby said that it had been in place for approximately two years with improvements in staff survey feedback and a reduction in difficulties faced for recruitment of relevant staff. Mark Saxton and Caroline Moore questioned whether there had been any spikes in staff turnover or sickness since the announcement to which Mark Appleby confirmed this has not happened. It was confirmed that the FAQ document had assisted in allaying staff concerns and provided assurances.

6.6 The Board thanked Mark Appleby for presenting the feedback from the consultation period. This feedback would be considered by the Board whilst making the final decision for the creation of the subsidiary company in Part 2 Board of Directors.

1- 7 RESPONSES TO QUESTIONS RECEIVED IN ADVANCE FROM MEMBERS 325/ OF THE PUBLIC REGARDING SIMPLY SERVE LTD CONSULTATION 17 7.1 The Trust received a number of questions from members of the public in advance of the meeting regarding the Simply Serve Ltd consultation. Tim Newman read out the questions and the Trust’s response to the twenty questions received in advance of the 17:00 deadline on Friday 15 December 2017 as outlined in Annex 1 of these minutes.

7.2 Paul von der Heyde asked the Board whether any further questions, to which none were raised. The publically submitted questions would be noted and taken into discussions for the final decision in Part 2 Board of Directors.

7.3 Mark Saxton asked whether the written responses would be sent to those who submitted questions. Ben Edgar-Attwell confirmed that the responses to all BEA questions would be sent following the meeting.

1- 8 BOARD OVERVIEW QUADRANT 326/ 8.1 The Board receives a Board overview quadrant which provides oversight of 17 indicators within quality, performance, finance and workforce. Expanded reports are included as an annex to the papers to provide further insight and detail.

Quality: 8.2 Shelagh Meldrum spoke to the quality section of the Board overview quadrant where she noted that the number of complaints remains low compared to the previous year; this now averages between 4 and 6 per month. The Trust’s Friends and Family response rate is low for the month of November 2017; as such analysis is underway whether this a data anomaly. The percentage of patients likely to recommend the Trust remains high at 96% for November.

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8.3 Simon Sethi said that October’s stroke performance was good although the Trust will continue to experience challenges going forwards including in December 2017. Stroke performance remains a very high priority with a review undertaken of each and every breach. There are periods of high demand on the critical care unit and patients requiring thrombolysis.

8.4 Shelagh Meldrum advised that only one serious incident had been closed in November rather than the two reported in the performance report. This would require correction. New guidelines have been developed following this investigation with further learning to be disseminated. The actions and learning from the closed complaints were included in the performance report; this includes work regarding improving processes for the discharge of patients back to community hospitals and ensuring that the treatment escalation plan review group are made aware of learning from complaint investigations. Shelagh Meldrum said that the Trust had experienced one never event in November; the learning will be provided to the Board in due course. In response to a question from Jane Henderson, Shelagh Meldrum provided assurance that there was no harm to the patient; the outcome is likely to result in further training and alerts.

8.5 Mark Saxton enquired whether the TagCare concept, to reduce the number of patient falls, was still in place. Shelagh Meldrum confirmed that this initiative is in place which has assisted in reducing the number of patient falls. She drew attention to the point that many patients who experience falls have previously had multiple falls and are repeat fallers. Responding to a subsequent question from Mark Saxton, she advised that the Trust is continuously increasing the number of soft mattresses and landing arrangements and that there is an active falls group in place to reduce the rate further. One project the group is undertaking is a layout review of the ward toilets. There is also a campaign to personalise patient walking frames; patients consequently see the frame as theirs and this in turn reduces the number of falls experienced. Tim Scull advised that he had recently presented to the coroner on initiatives to reduce patient falls and the effects of the TagCare system. Mark Saxton stated that he had seen the TagCare in process and commended the concept.

Performance: 8.6 Simon Sethi drew attention to the continued good performance for the A&E 4 hour waiting times which was 96.7% against the 95% target for November 2017. Ambulance handover times remain consistently good with 99.6% experiencing no delays. Diagnostic waiting time performance had recovered following improvements in audiology and echo cardiology services. A recovery plan is in place due to some staff absence in certain specialties; Simon Sethi advised that performance may drop in coming months in line with this.

8.7 Speak to the cancer waiting time performance, Simon Sethi outlined the complex pathways which are susceptible to delays; one area where delays have occurred is within radiology due to staff absences. There have also been some challenges with administration support. He confirmed that an action plan was in place with additional administration support now in post. As part of winter planning, additional capacity is being provided for radiology.

8.8 Shelagh Meldrum provided a verbal update on referral to treatment incomplete waiting times performance which was at 93.3% for November 2017 against the national constitutional target of 92%. Responding to a question from Julian Grazebrook, she reported that YDH was ranked within the top 25 organisations within the country and a high performer within the region. She further commented that YDH was providing support to neighbouring organisations for

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waiting times. Caroline Moore sought clarification on the reporting processes for activity completed for neighbouring organisations; it was confirmed that these cases are not included within YDH’s data as the Trust is a sub-contractor rather than patients transferred to YDH.

8.9 Attention was drawn to the improvements in delayed transfers of care in recent months; this has been sustained through the Home First service in conjunction with the County Council. Simon Sethi added that without this service, patient flow would be in a worse position. Shelagh Meldrum explained that the Care Quality Commission (CQC) are undertaking a national review into the harm caused by delayed transfers of care; any recommendations from this will be reviewed and incorporated into process. In response to a question from Mark Saxton, Jonathan Higman confirmed that Cooksons Court, along with other nursing homes in the region, were utilised as part of the Home First service. Simon Sethi reported that the good collaborative working was taking place with the County Council, with an aligned approach and better engagement to understand what further improvements can be made or implemented.

8.10 Paul von der Heyde noted that that there had been no cases of MRSA or clostridium difficile in recent months although there had been outbreaks of norovirus within YDH and the wider community.

8.11 Jane Henderson asked whether there were any improvement updates in relation to fractured neck of femur performance. Simon Sethi confirmed that joint working was taking place within the executive team with care of the elderly as a key theme. There is the intention for further cross cover within medical staff job plans with the aim to ensure sustainable high performing services; this piece of work links to the objective of introducing a frailty unit on Ward 6b.

8.12 Jonathan Higman emphasised the good performance of the Trust across all services within the context of increasing activity and demand with work taking place across all areas to ensure high quality and performing services.

Finance: 8.13 Tim Newman spoke to the Trust’s finance position as of November 2017. He reported that the Trust’s year-to-date deficit amounted to £14million excluding sustainability and transformation funding (STF); this is £1.75million adverse to plan. The Trust was in line with the control total for November 2017 although due to being adverse to the control total in previous months, the Trust will not receive the STF.

8.14 There has been a positive variance for business as usual income in line with the increased activity. There was adverse variance for agency pay due to non- delivery of cost improvement plans (CIP). Tim Newman confirmed that there has been some allocated additional winter funding [item 5.7 refers].

8.15 Tim Newman advised that the financial figures included within the performance quadrant and performance pack exclude any risk share arrangements for the Sustainability and Transformation Partnership (STP) and it also assumes full allocation of the Vanguard funding for which negotiations are ongoing with the Clinical Commissioning Group (CCG). Discussions also continue with regard to the risk share arrangements. The contract challenges raised by the CCG are also ongoing [item 1-316/17, 10.11 refers].

8.16 Paul von der Heyde drew attention to the work underway for CIP. Tim Newman reported that current forecasts suggested that this will be in excess of £7million

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by the end of the financial year. Jonathan Higman said that are significant challenges for CIP although the Trust is mitigating the risk and identifying additional savings. The forecast highlights a potential shortfall of £1.2million against the control total for CIP. Julian Grazebrook asked whether the CIP underachievement and the agency staff overspend were a double count; Tim Newman verified that this was not a double cost and was the same; some CIP was initially allocated to pay savings. In response to a question from Caroline Moore, Jonathan Higman confirmed that CIP performance was regularly communicated to staff groups via a turnaround update.

8.17 Tim Newman provided an overview of the Department of Health loans; the Trust is awaiting confirmation for the process relating to the loan due for repayment in January 2018. He advised that it is expected that this loan would roll over. Mark Saxton queried whether the capital expenditure loan was in line with expected amounts and plans; Tim Newman confirmed.

8.18 Tim Scull commented that that it was important to review this data against the NHS Improvement Model Hospital dashboard. The results from this for YDH are much improved on the previous update. To clarify following a question from Julian Grazebrook, Tim Scull explained that the model hospital measures the efficiency of the hospital from administration to clinical. It is based on weighted activity units with key metrics. Caroline Moore and Jane Henderson asked what changes the Trust has implemented for this sudden improvement in rankings compared to other organisations. Tim Scull said that the Trust is only able to control its own methods with many initiatives for improvements in recent months; he did advise that the data within the dashboard is approximately a year behind. Paul von der Heyde said that NHSI and other external regulators use the Model Hospital Dashboard as a review and monitoring system.

Workforce: 8.19 Tim Newman drew attention to the improving vacancy position, in particular registered nursing vacancies following recent overseas nursing recruitment campaigns. The number of medical vacancies remains elevated with the financial pressure of this reflected in ongoing agency expenditure. Maurice Dunster advised that the Workforce Committee receives regular updates on recruitment; he stated that good processes are in place and assurance had been provided to the committee regarding the support arrangements for overseas staff; this is strong both in hospital and socially.

8.20 The mandatory training rates remains above the 90% target. The appraisal rate has improved in recent months following a push to encourage this, there is an action plan in place to achieve the 90% target by the end of the financial year.

8.21 The agency spend remains high against the plan however is low compared to the NHSI agency spend ceiling.

1- 9 ITEMS TO NOTE/FOR INFORMATION 327/ 17 iWantGreatCare Report 9.1 The iWantGreatCare report was reviewed where it was noted that 96% of patients in November 2017 would be likely to recommend the organisation. Shelagh Meldrum added that the Trust had recently received a number of compliments, personal thank you letters, emails and donations alongside positive comments on iWantGreatCare. There is the intention to introduce a separate outpatient report; this is not currently reported separately. In response to a question from Mark Saxton regarding displaying the results within the wards,

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Shelagh Meldrum explained that the previous reports displayed on the ward screens was not correct and was therefore removed. Work is underway to reintroduce this and also gaining feedback from patients and relatives as to the information they would like to see.

Six Monthly Establishment Review: Nursing and Midwifery Staff Report 9.2 Shelagh Meldrum spoke to the previously circulated report which provides an appraisal of the status and provision of safe staffing levels and to provide assurance on the progress to monitor and meet compliance with national requirements. The report had been discussed in detail at the Workforce Committee. The key highlights include an increase in acuity and dependency of patients and as such there have been increase in establishment across a number of areas; this increase in establishment does include uplifts in healthcare assistants (HCA). There has been a switch in the acuity of patients with a growth in more complex respiratory patients. The wards are now coming to full staff establishment for the first time in years and ward staff now feel incredibly empowered. Mark Saxton said that this reflects Shelagh Meldrum’s leadership. Paul von der Heyde said it was encouraging to hear this in light of the current financial position.

Update from the Financial Resilience and Commercial Committee Held on 18 December 2017: 9.3 Julian Grazebrook provided a brief summary of the last Financial Resilience and Commercial Committee where the financial position was reviewed in depth. He reported that an update and overview was received on the contracting arrangements and position with the main contractual partners. He advised that the CCG are only able to challenge on activity on months 6 & 7 due to missed time frames. The Trust is generally in line with expected activity. The committee had also received an update on budget setting; no guidelines have been received from NHSI however the Trust is currently reviewing capacity and demand. A summary overview of the car park KPIs where positive results was noted within the meeting.

Update from the Workforce Committee Held on 18 December 2017 and to Note the Minutes of the Meeting Held on 21 November 2017: 9.4 Maurice Dunster provide a brief summary of the discussions of the last committee meeting previous meeting; a number of items had emerged and been discussed in today’s discussions. He advised that the Guardian of Safeworking report had been deferred until January’s meeting and then presented to Board. A brief verbal update was provided whereby there was nothing outstanding to note. He advised that the committee had received an update on staff turnover where the recent hike in midwifery turnover did not raise any concerning reasons; this has since returned to normal levels. An update was received on staff retention which is high on the agenda with a number of actions in place. It is important that talent within the organisation is not suppressed and career development is available for all staff. A brief overview of the staff survey results was also received within the committee; these had been discussed as part of today’s executive report [item 5.3 refers].

1- 10 ANY OTHER BUSINESS 328/ 10.1 There were no other items of business raised. 17 1- 11 DATE OF NEXT MEETING 329/ 11.1 Wednesday 31 January 2018, Boardroom, Level 1 17

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ANNEX 1 BOD MINUTES 20 DECEMBER 17

Questions provided to the Trust Board, December 2017, re Simply Serve Ltd

1. Will the Trust now agree to provide its staff representatives with a copy of the document, described as a Report, which was used as the basis for the Trust’s decision in January to proceed with the proposal for the formation of a wholly owned company to provide the Trust with a professional property management company and associated services? This document will be provided to Unison on 21 December in response to their FOI request.

2. Will the Trust now agree that it will engage with its staff representatives about the decision to proceed with the proposal for the formation of a wholly owned company of a particular form? Firstly, it is important to recognise that there is no legal obligation upon the Trust to consult on this decision, which will be taken in the best interests of the affected staff, the wider workforce, the Trust, and the wider NHS system. We are assured that the opportunities extended to the unions to engage on the implementation of a wholly-owned subsidiary over the past five months have been ample and appropriate.

3. Will the Trusts agree to set up appropriate arrangements for the engagement of staff representatives and meaningful consultation about the most appropriate form for any wholly owned company? (See above). We are also confident that engagement with staff and with staff representatives has been ample and appropriate. We do not agree there is need for additional engagement over and above the existing arrangements. We are aware that members of the Unison decided to disengage from the engagement process, and of the reasons given. The Board is assured that the professional and legal advice and guidance received to date, together with the outcome of the staff consultation, is sufficient to enable it to make an informed decision on the implementation or otherwise of the wholly-owned subsidiary.

4. Will the Trust provide its staff representatives with a full explanation of the benefits that are being claimed for the proposal to form a wholly owned company including the financial amounts for the main benefits by future year? We are confident that this information has been offered on more than one occasion to the unions. To reiterate – setting up a wholly owned subsidiary company will: • secure the services affected by enabling them to operate as a distinct company, with opportunities for profit and investment • secure the employment of the staff working within this services • enable the Trust to provide greater flexibility for terms and conditions and pay for NEW STARTERS, which will enable us to compete more effectively within the local employment market. • enable the services to compete for new business within and external to the NHS, thereby increasing employment opportunities

5. Will the Trust provide its staff representatives with a copy of the Benefits Realisation Plan for securing the benefits claimed for the changes through formation and running of the wholly owned company? The Trust has not produced an individual realisation plan document as achieving the benefits are inherent within the project and the proposed subsidiary company. The contractual and governance arrangements along with new processes established provide oversight and accountability for achieving the objectives identified. Both a Trust and company representative have been identified whose role will be to monitor performance against plans and standards and to initiate corrective action in a timely manner as required. This structured approach will enable the achievement of benefits to be actively managed and monitored.

6. Will the Trust provide its staff representatives with a copy of the documents which set out “the adequate appraisal and approval process” as referenced in 14.1.1 of the Trusts SFIs? 14.1 of the Trust SFI’s relates to Capital Investment. The Trust has a process for appraising and prioritising capital expenditure as referred to at 14.1.1 of the trust’s SFI’s on an annual basis when determining the forthcoming years capital plans and forms part of the overall Trust’s budget setting process. This process will remain in place for the setting of future Trust capital plans which the proposed subsidiary will manage the procurement and implementation of. In addition 5.1.4 of the Trust SFI’s, Preparation and approval of business plans and budgets, require that ‘an appropriate business case should be prepared’ and an updated business case will be considered in part 2 of today’s Trust Board.

7. On what date and by what process did the Trust decide “the adequate appraisal and approval process” as referenced in 14.1.1 of the Trusts SFIs was consistent with NHS Guidance and with the Trust’s overall duty to exercise its functions effectively, efficiently and economically? 14.1 of the Trust SFI’s relates to Capital Investment. With regard to the decision whether to transfer services and staff to a wholly owned subsidiary company in order to provide effective, efficient and economical services, this will be made in part 2 of today’s Trust board meeting.

8. Why do the Trusts SFIs make no reference to the process for provision of a business case and an options appraisal to support approval of capital expenditure in line with usual model SFIs? The Trust SFI’s state that there will be an ‘appraisal and approval process in place for determining capital expenditure priorities’. The Trusts Schemes of Reservation and Delegation determine at what level decisions are to be made. In addition 5.1.4 of the Trust SFI’s, Preparation and approval of business plans and budgets, require that ‘an appropriate business case should be prepared’ and an updated business case will be considered in part 2 of today’s Trust Board.

9. What external assurance has been obtained into the proposal to form a wholly owned company? This proposal has received external assurance from NHSE, NHSI and the Somerset CCG, together with independent legal advice.

10. On what date and by what process did the Trust decide that they would not engage with staff or staff representatives over the decision to consider the formation of a wholly owned company to provide the Trust with a professional property management company and associated services? See response to questions 2 and 3.

11. On what date and by what process did the Trust decide that they would not engage with staff or staff representatives over the decision to proceed with the proposal for the formation of a wholly owned company to provide the Trust with a professional property management company and associated services? See response to questions 2 and 3.

12. On what date and by what process did the Trust approve the appointment of QE Facilities to provide services in relation to the proposal for the formation of a wholly owned company to provide the Trust with a professional property management company and associated services? QE Facilities Ltd were appointed to carry out some scoping work in 2016. As part of the Trust Board decision to progress the project in January 2017, the appointment of QE Facilities was approved on the basis that they already had significant knowledge of the Trust gained through this scoping exercise and would be able to provide the greatest continuity, knowledge, experience, and efficiency, together with access to a large amount of legal and process documentation.

This was further supported from references taken up with other Trusts who utilised QE Facilities Ltd services.

13. On what date and by what process, and in the absence of any formal procurement process and competitive tender, was due diligence applied to consideration of using the services of QE Facilities? See response to question 12.

14. On what date and by what process did the Trust decide that it would not carry out a formal business case (as defined in NHS Guidance and HM Treasury Five Case Model) in respect of the need for more professional property management? 5.1.4 of the Trust SFI’s, Preparation and approval of business plans and budgets, require that ‘an appropriate business case should be prepared’ to enable necessary decision to be made. An appropriate case was provided to the Trust Board in January 2017 which enabled the decision to proceed with the project and an updated business case will be considered in part 2 of today’s Trust Board.

15. On what date and by what process did the Trust decide that it would not carry out an Options Appraisal (as defined in NHS Guidance and HM Treasury Five Case Model) in respect of the need for more professional property management? 5.1.4 of the Trust SFI’s, Preparation and approval of business plans and budgets, require that ‘an appropriate business case should be prepared’ to enable necessary decision to be made. An appropriate case was provided to the Trust Board in January 2017 which enabled the decision to proceed with the project and an updated business case will be considered in part 2 of today’s Trust Board which identifies the key options.

16. On what date and by what process did the Trust decide that it would not carry out any baseline assessment of the quality of its current property management services? The Trust is aware of its baseline and as such this project provides a solution to enhance service delivery in a more cost effective manner whilst securing the employment of the staff working within these services and provide the additional benefits previously identified and shared.

17. On what date and by what process did the Trust decide that it would not engage with its staff and their representatives over options to improve property management services without formation of a wholly owned company? See response to questions 2 and 3.

18. The Trust claims that it has consulted with Trade Unions about the proposal to form this subsidiary company, as is required by law. Given that the Trade Unions have never received any information regarding options considered during the process of evaluating the formation of a subsidiary company (assuming that any alternative options other than “do nothing” were ever considered by anyone), this claim is demonstrably false. Will the Board now address this omission and allow for an acceptable period of meaningful consultation on this proposal, and not simply on the TUPE arrangements that must ensue if the formation of a subsidiary company is, ultimately, considered the best option? Firstly, it is important to recognise that there is no legal obligation upon the Trust to consult on this decision, which will be taken in the best interests of the affected staff, the wider workforce, the Trust, and the wider NHS system. We are assured that the opportunities extended to the unions to engage on the implementation of a wholly-owned subsidiary over the past five months have been ample and appropriate. We are also confident that engagement with staff and with staff representatives has been ample and appropriate. We do not agree there is need for additional engagement over and above the existing arrangements. The Board is assured that the professional and legal advice and guidance received to date, together with the outcome of the staff consultation, is sufficient to enable it to make an informed decision on the implementation or otherwise of the wholly-owned subsidiary.

19. I am concerned with the movement of staff from NHS pay and conditions. I am worried that this will be extended to Radiographers in the future. However, it is important to say that with iCARE values every member of the team is essential to the patient care experience and I am concerned about staff moral and retention in the vital roles such as portering. How can the Board allay our fears? Also the hospital should be making savings by changes to work practices that improve patient care not by avoiding VAT. It is important to reiterate that staff are not moving from NSH terms and conditions. The staff transferred to Simply Serve Ltd would be doing so with their existing terms and conditions, including pay and pension. One of the fundamental reasons behind establishing Simply Serve Ltd it to ensure greater job security for these roles. As you have heard, the staff consultation carried out throughout November, in which staff were encouraged to raise concerns about the transfer of employment to Simply Serve Ltd, resulted in a very small number of responses. There is no indication that staff have left or intend to leave roles as a direct result of our plans. We absolutely understand the importance of continuity amongst these core services and we can be clear that the same staff will be providing the same services, within the same teams, alongside the same NHS colleagues. We have already listed the benefits behind establishing Simply Serve Ltd earlier in a previous response.

20. Is the Trust planning to move admin/clerical staff to work for Simply Serve? There are no plans to transfer roles beyond those already listed.

Questions received after Friday 15 December 2017 5pm deadline.

21. As the bussiness case was not presented to the unions, the trust told us that it was "sensitive information". Which is strange to say the least because the trust is establishing a company to provide non clinical services, rather than something secret and unique. What kind of corporate espionage is the trust affraid of that they would not share their plans in full, and put us all at ease? It is important to recognise that there is no legal obligation upon the Trust to share the business case, and all decision made have been taken in the best interests of the affected staff, the wider workforce, the Trust, and the wider NHS system. We feel that the opportunities extended to the unions to engage on the implementation of a wholly-owned subsidiary over the past five months have been ample and appropriate.

22. The trust claims that establishing this subsidiary will help focus on delivering healthcare - how is splitting workforce helping? You will create more structure that will need more administration, ans ultimately it will be overseen by the trust, as I am led to believe. There are benefits in Simply Serve Ltd having different terms and conditions for new staff joining the new estates and facilities company because it gives the company increased flexibility. Further benefits have been expressed in our response to questions above.

23. As we are continously assured that the trust plans to commit to keeping terms and conditions of workers who TUPE across to the subsidiary company even after the five years guarantee, would it not be easier to grant the TUPE T&Cs in perpetuity? Especially as some of the managers have been heard saying that "nothing is going to change". This would certainly make many people feel calmer about this. The 5 year guarantee was requested by Unison. Yeovil Hospital agreed to do this and then improved the concession by matching any improved benefits in the NHS for 5 years. No terms and conditions can be changed which relate to the transfer.

APPENDIX 2b BOARD OF DIRECTORS 31 January 2018

BOARD OF DIRECTORS – ACTION SHEET 31 January 2018

Minute Action Progress Due By ACTIONS FROM 27 SEPTEMBER 2017 1-286/17 Board seminar session to be scheduled to Not Yet Due March 2018 Ben Edgar-Attwell/ (7.1) review work undertaken by the new Integrated Tim Scull Learning Forum 1-287/17 A video explaining the move of the FOPAS unit Not Yet Due May 2018 Simon Sethi (8.1) to a new Frailty Unit on Level 6 to be created. ACTIONS FROM 29 NOVEMBER 2017 1-311/17 TrakCare/Digital Update to be scheduled for Schedule for Jan Jan/Feb Ben Edgar-Attwell (5.2) January/February 2018. 18 2018 1-311/17 Feedback on the paper referral switch-off and Not Yet Due March 2018 Ben Edgar-Attwell (5.4) electronic referrals to be provided to Board. ACTIONS FROM 20 DECEMBER 2017 1-325/17 Responses to questions submitted to be Complete December Ben Edgar-Attwell (7.3) circulated following the meeting. 2017

Appendix: 3 REPORT TO: Board of Directors REPORT BY: Executive Team PRESENTED BY: Executive Team TITLE: Executive Director Report DATE: 31 January 2018

Action Required (Please select any which are relevant to this paper) For Decision For Assurance For Approval For Information

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

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

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

Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) Care for our Population Develop our People We will continually seek and seize opportunities We will ensure our teams have the skills, to improve the quality, accessibility and safety of capacity and environment to enable them to our services, and the experience we provide, to provide the care that they aspire to. We will ultimately enable our local population to live support staff to innovate in order to continually healthier lives. improve the quality of our services. Pioneer the Future Put Technology at the Heart Independently and in partnership with peers and We will be at the forefront of the digital revolution global healthcare leaders, we will create in healthcare, bringing new ideas from outside replicable new models of care as an integrated the NHS to make our hospital and the local care care organisation, and develop commercial system the most technologically advanced in the partnerships which ensure a sustainable health UK. service.

Specific risks addressed by this paper (Include relevant risks and/or links to the corporate risk register/department risk register)

Implications/Requirements (Please select any which are relevant to this paper) Financial Legislation Workforce Estates

Patient Safety / ICT Quality of Care

Reference to CQC domains (Please select any which are relevant to this paper) Safe Effective Caring Responsive Well Led

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

Operational Update The Trust has had a challenging December and January with combined challenges of high demand, flu and Noro Virus, and staff sickness. Despite this, we were one of only three Trusts in the country to achieve four hours in December 2017. The January challenge with demand has been reviewed in detail and a significant part of the rise is made up of respiratory illnesses and frail elderly associated admissions with marked variation in admission rates between GP practices. Work is now underway to discuss these findings with GPs and provide support via the Symphony Programme. Rigorous infection control processes are in place to control Flu and Noro Virus but the impact on staff sickness has had a knock on effect on the hospital making it challenging particularly to staff within our escalation areas. The Trust’s performance, which is a reflection of the quality of care in the hospital, remains amongst the best in the country however the strain on staff is very real. We’d like to recognise and thank our teams for their commitment, hard work, and the great care they offer during these challenging weeks.

Relevant Committee Oversight: Board of Directors, Governance and Quality Assurance Committee

Interserve position Interserve forms part of the Trust’s Strategic Estates Partner (SEP), Interserve Prime, to provide intelligent estates strategy functions and to help the Trust deliver its estates masterplan. Following the recent news regarding the construction firm Carillion, the Trust has had assurances from Interserve regarding their financial position with expectation that “2018 operating profit [is] to be ahead of current market expectations”. Interserve is a recognised strategic supplier and they are keeping the Cabinet Office closely appraised of their progress; they are not classified on a high risk watch list. The Cabinet Office has said: "We monitor the financial health of all of our strategic suppliers, including Interserve. We are in regular discussions with all these companies regarding their financial position. We do not believe that any of our strategic suppliers are in a comparable position to Carillion."

Relevant Committee Oversight: Board of Directors

Neonatal review On the 10th January the Trust had its externally led Neonatal Intensive Care Network Review. The visiting team included a Neonatal Consultant, NHSE Quality representative, a Neonatal Unit Sister and a parent rep. Our team had prepared well for the visit and made the visiting team really welcome. The key findings included zero areas of significant concern, fantastic feedback on the environment, parent information, flexibility of staffing and parent sleeping accommodation which enables mother and baby bonding an the parents role in ward rounds. There were a few areas of improvement which included protected management time for the lead Consultant, an additional emergency phone, increased psychosocial support and resource to enable data input.

Relevant Committee Oversight: Governance & Quality Assurance Committee

CQC timescale/preparation work The Trust has received the dates for the first inspection of Daycase UK which will take place on the 23rd & 24th May 2018. This inspection will be undertaken by a team of 4 inspectors who will visit both YDH and the Yeatman Hospital. Whilst preparation is underway we are taking the approach that high standard of patient care and experience and all that goes to making this happen is business as usual. The Registered Manager of Daycase UK will be leading on preparation and the inspection days. With this in mind we are also taking the same approach to our next YDH inspection and beyond.

Relevant Committee Oversight: Board of Directors

Appendix: TbL REPORT TO: Board of Directors REPORT BY: Yvonne Thorne PRESENTED BY: Yvonne Thorne TITLE: Annual EPRR report, EPRR Assurance and Work Plan DATE: 31 January 2018

Action Required (Please select any which are relevant to this paper) For Decision For Assurance For Approval For Information x

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

There is a requirement in the EPRR assurance programme for the organisation's Accountable Emergency Officer (Mr Simon Sethi) to take the result of the 2016/17 EPRR assurance process and annual work plan to a pubic Board/Governing Body meeting for sign off.

This is a new requirement of the 2017-18 assurance and will be required to continue.

Please note annual EPRR report, Assurance programme and annual work programme for EPRR.

Yeovil District Hospital is currently assessed as Green for assurance, with further work required in business continuity to be Green across all the assurance elements.

Green signifies that YDH is meeting the requirement for emergency preparedness, resilience and response planning across the 52 assessed elements.

Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) Care for our Population Develop our People We will continually seek and seize opportunities to We will ensure our teams have the skills, capacity improve the quality, accessibility and safety of our X and environment to enable them to provide the care X services, and the experience we provide, to that they aspire to. We will support staff to innovate ultimately enable our local population to live in order to continually improve the quality of our healthier lives. services. Pioneer the Future Put Technology at the Heart Independently and in partnership with peers and We will be at the forefront of the digital revolution in global healthcare leaders, we will create healthcare, bringing new ideas from outside the replicable new models of care as an integrated NHS to make our hospital and the local care system X care organisation, and develop commercial the most technologically advanced in the UK. partnerships which ensure a sustainable health service.

Specific risks addressed by this paper (Include relevant risks and/or links to the corporate risk register/department risk register)

The risk register is available here

Page 1 of 13 Implications/Requirements (Please select any which are relevant to this paper) Financial x Legislation x Workforce x Estates x

Patient Safety / ICT x x Quality of Care

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

Safe x Effective x Caring x Responsive x Well Led x

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

Page 2 of 13

1. Executive Summary

This report identifies the work undertaken to ensure that YDH is compliant with the statutory requirements placed upon it under the Civil Contingency Act (2004), the terms and conditions of the NHS Standard Contract for Emergency Planning and the NHS Commissioning Board Standards for Emergency Preparedness, Resilience and Response (EPRR)

There is a need to provide assurance of the Trust’s state of readiness to respond to the challenges, threats, hazards and major disruptive events that may impact on the delivery of its services, or require a wider community response.

In the year September 2016 to September 2017 it was recognised internally and through external assurance that YDH had improved assurance against the core standards and October 2016 assurance registered as Green across the 1-37 core standards for EPRR.

The assurance process for CBRN undertaken by SWAST on behalf of NHS England also confirmed that YDH were meeting Standard 38-51 CBRN (and separate CBRN equipment list) and were passed as Green

The following report updates the board on progress toward achieving full statutory compliance and gives further information on work planned for 2017/18.

2. Background/Introduction

Within the Civil Contingency Act 2004, YDH is a Category 1 Responder. YDH has the following responsibilities under the Department of Health Emergency Planning Regulations:

 Carry out a risk assessment  Have plans in place to respond to emergencies  Have in place business continuity plans  Collaboration and co-operation with other agencies  Warn and inform the public and other agencies

There is a statutory obligation to train and exercise with a live exercise every three years, an annual table top exercise and a six month test of the communication cascade.

As a category 1 responder the Trust is required to fulfil the relevant legal and contractual EPRR requirements, and ensure a robust and sustainable 24/7 response to emergencies and disruptions.

3. Report

A set of core standards for EPRR have been instigated nationally since April 2013. These standards are the underpinning requirement for NHS funded organisations and assurance is monitored through the CCG (Standard contract) to NHS England. The standards are rated RED, AMBER, GREEN, this represents none, partial and full compliance.

 Standard 1-37: Core Standards  Standard 38-51: CBRN (and separate CBRN equipment list)

The trust undertook its self-assessment for these standards in September 2016. The following areas were rated AMBER and RED.

Page 3 of 13

 3. Overarching framework EPRR policy AMBER  8. Corporate and service level business Continuity AMBER  8. Mass Counter Measures RED  11. Identify organisations critical activities in event Emergency / BC event AMBER  37. On call managers / Directors training / portfolio AMBER

Following the CCG led assurance meeting and discussion at the Local Health Resilience Forum (LHRF) further actions were taken by the Accountable Officer at YDH to support the assurance process.

In October 2016 the current responsibilities of the Head of Operational Resilience were changed. 15 hours per week remain for EPRR activities with 22.5 hours within the DCUK CQC registered manager position.

The support officer role working across EPRR and transport was also reviewed and hours adjusted to support EPRR.

4. Policies and Plans

The following policies and plans were reviewed, updated and agreed in 2016-17:

 MAJAX callout plan revised and tested  Business Continuity work commenced  CBRN policy reviewed and updated  Operational winter plan reviewed  Fuel shortage plan revised and updated  Severe weather plan reviewed and updated  Loggist training planned early October 2017.  Glastonbury Festival planning

5. EPRR Activities

The following EPRR activities were undertaken in 2016-17:

 Emergency planning group membership reviewed and embedded.  Control Room Moved from level 1 to Level 4 operational room.  Director of Urgent Care (Accountable Emergency Officer) chairing EPRR meetings  Local Risk register reviewed in-line with LRF risk register  Participation in LHRP cascades and training exercises  On-call Manager / Directors training one to one and table top exercise August 2017.  Emergency planning and Manager on-call sites on Y-Cloud have been created with access to operational documents and support during EPRR and BC events.  National Threat level raised twice to Critical, all actions taken as required from national guidance.

Regular attendance:

 Local Health Resilience Partnership – EPRR Accountable Officer (SS)  Avon and Somerset LHRP tactical planning group (YT)  Avon and Somerset acute trust sub-group (YT)  YDH Emergency planning group established. (SS / YT chair)

Page 4 of 13

6. Business Continuity

The purpose of business continuity (BC) planning is to enable the Trust to continue to offer critical services in the event of a major disruption or disaster.

During 2016-17 the following BC planning has been completed (Appendix 1) further work is required for YDH to be fully compliant for BC across all trust areas.

During 2016-17 there have been two internal incidents and one external incident affecting YDH activities, all have been discussed with Directors and through HMT and any lessons learnt have been incorporated into staff training and departmental changes.

 February 2017, planned ED flooring replacement, entire ED department moved twice to facilitate replacement of flooring.  May 2017, Cyber-attack. ICC opened and virtual control team in place to cover on-going activities over weekend. Minimal disruption at YDH, report forwarded to HMT  July 2017, Electrical shutdown external to trust causing extended use of generators, need to shed load on generators to prevent overheating. External issues resolved and action not required. Guidance to be included in EFM BC plan (EFM action by end November 2017)  August 2017, Vodaphone and EE planned maintenance causing breaks in YDH service, not expected and BC plan activated. BC using EE not available. Pagers used where possible. New Vodaphone contract to address issues from this incident.

7. Training and Exercise

Please see Appendix 1.

8. Multi-Agency Working

Every opportunity is taken to be involved in multi-agency working and training. During 2016- 17 LHRP call out cascades and control room training through targeted exercises have been undertaken.

A BNSSSG Public Health England Emergotrain Mass Casualty exercise took place (September 2017). YDH activated plan within the exercise.

9. Financial Implications

There is no dedicated EPRR, BC trust budget, however when funding for training and equipment is required, (following a clear case being presented) the accountable officer and/or financial officer has made funds available.

 Training – Business continuity / Loggists  CBRN equipment maintenance  Control room equipment move

Training and equipment costs will continue into 2017-18 particularly to enable a live test of the MAJAX plan through an Emergotrain exercise in May 2018 and to ensure all on-call managers are trained in on-call, control room activities.

CBRN equipment will continue to require updating as suits / tent and pumps need replacement.

Page 5 of 13

10. Risk

Please see Appendix 2. YDH EPRR risk Register

The risk register is reviewed through the Emergency planning group and reflects the LRF Community risk register.

11. Draft Work Plan for 2017/18

A draft work plan of the EPRR and BC priorities for 2017-18 is attached at Appendix 3.

12. Recommendations

The committee is asked to receive and note this report.

Appendix 1: Training Log

Appendix 2: YDH EPRR risk register

Appendix 3: Draft work plan 2017-18

Page 6 of 13 APPENDIX 1: EPRR TRAINING PLAN

Training Course Frequency Next date Audience Delivered by

Emergency Planning Resilience & Operational Resilience As required Response Induction  All new Trust staff Team

Incident Coordination Centre Monthly  On-Call Managers and Directors. Operational Resilience (ICC) Training  Clinical Site team. Team

Loggist Training As required  Trust Loggist volunteers Public Health England

Loggist Briefing/Refresher Annually  Training Trust Loggists Operational Resilience Training Team/PHE

EPRR, IEM, Command and Control Six monthly  Directors/senior managers with a key Operational Resilience Familiarisation & Health role in emergency response Team Emergency Plans  On Call Managers with a key role in emergency response e.g. rostered for on-call.  Specific resilience staff and Incident Control Centre Admin.

CBRN Decontamination training Rolling  All new Trust HCA staff or those Operational Resilience programme requiring refresher. Team

Diploma in Health Emergency As Required  Required to have 2 employees with  External Course Planning this qualification

Page 7 of 13 EPRR EXERCISING AND TESTING PLAN

Exercise Frequency Next date Audience Delivered by

Argus Exercise As available Invited Audience Resilience Team

Resilience Team CCA Requirement Annually Invited Audience Annual EP/BCM table top Exercise

Head of Operational CCA Requirement 6 Monthly Trust wide resilience Communications exercise EFM Manager

Resilience Team CCA Requirement 3 Yearly Invited Audience LIVE Trust wide major incident exercise Resilience Team CBRN Exercise Annually Invited Audience

Fire, Health & Safety Team Lockdown Exercise Annually Trust wide

Page 8 of 13 APPENDIX 2

Risk Initial Risk Residual Title Potential Risk Identified Existing Controls and Gaps in Controls Responsibility Sub Area Reference Score Score Score Infection Control Policy / Procedures Communicable Diseases Plan (being Inability of trust to manage reviewed) capacity requirements Infectious disease Annual staff immunisation plan in place where pandemic flu Head of Operational OP006 affecting patients and 8 National immunisation programmes - GP 8 8 Emergency Planning affecting up to 50% of the Resilience staff - pandemic flu awareness campaigns population across the Business Continuity country. Staffing guidance / risk assessments for individual wards / departments Major Incident Policy annual review Mass casualty plan in place CBRN policy / training Local business Major Burns injuries / CBRN training for decontamination of Head of Operational OP007 incident (explosion, increased number of 8 8 4 Emergency Planning patients and equipment available. Resilience fire, chemical release) casualties / Annual equipment check Major Burns process available in ED / centres information made available. Loss of clinical systems / Loss of IT administrative systems / infrastructure due to communication systems Departmental business continuity plans Head of Operational OP009 8 6 6 Emergency Planning deliberate act or resulting in patient care Major Incident planning Resilience breakdown being compromised.

Significant challenge regarding training of staff across all emergency planning requirements. Current risk is CBRN and Ebola Training in ED/ICU. Failure to comply with NHS Review and Policy in place - training Civil Contingency Act Core Standards for outstanding. (CCA) Audit Self Emergency Preparedness, Head of Operational OP005 9 Ebola self audit completed and all Amber / 4 4 Emergency Planning Assessment - Resilience & Response Resilience Green Workplan link (EPRR) in line with CBRN external audit completed by SWAST contractural obligations lead with YDH Lead. Reporting through Emergency planning / BC Committee. Pandemic Flu next priority

Page 9 of 13 Risk Initial Risk Residual Title Potential Risk Identified Existing Controls and Gaps in Controls Responsibility Sub Area Reference Score Score Score Heatwave plan reviewed annually inline with DH guidance YDH risk assessment per ward / department Met Office guidance in place. indicates risk of Severe weather (floods, Severe weather plan being reviewed (Feb Head of Operational OP008 localised flooding, extreme cold, extreme 9 2015) 4 4 Emergency Planning Resilience extreme cold, extreme heat) Met Office updates daily and circulated as heat required Business Continuity Plan EFM in place Extreme weather alert system in trust through Y-Cloud Conect as required.

Page 10 of 13

APPENDIX 3

Title Action Lead Progress Details Progress Date Training - Live Exercise (3 May-18 YT/AT Plan and complete whole site Emergotrain exercise to On Going May 2018 years)Emergotrain exercise at achieve Live or Live Exercise requirement (3 yearly) YDH

Training - Table top exercise Aug-17 YT/AT Table top 35 staff, exercised all action cards, opened Complete August 2017 (Annually) ICC and used current bed state. 14 casualties over 4 hours.

Training Communications Dec-18 YT/AT Switchboard commence exercise every 6 months. On Going December 2018 Exercise Issues communicated to EPRR team to review

Training On-call Directors - Continuous training YT/AT All current staff trained, support information being On Going December 2018 Managers - Clinical Site as required developed, any new staff to rota trained.

Critical Care escalation plan For flu, mass YT/MR/JR Review current plan and update, review equipment On Going November 2017 casualty planning available following mass casualty exercise through PHE / trauma network Business Continuity Plans. All plans to be YT 2 x staff trained and members of BCi . Policy in place On Going December 2017 Audit response required reviewed and all now being reviewed. Internal Audit of IT covering BC . Extra hours confirmed and dedicated to BC, ref to separate BC plan Evacuation and Shelter plan further work ref YT requiring further review for shelter opportunities other On Going December 2017 carpark than Women’s hospital and vice-versa

Page 11 of 13 Surge and Escalation plan Complete review as YT / CW / First meetings planned, fast forward weeks identified. On Going November 2017 (formally Winter Plan) part of the Urgent KH / MC Patient flow and escalation pack in place. Care Steering Group Action Plan MI Plan Annual review core YT/AT Review, update as required following new guidance, On Going Next Review due plans exercise or incident August 2018 Mass Casualty Plan Annual review core YT/AT Review, update as required following new guidance, On Going Next Review due plans exercise or incident June 2018 CBRN Plan Annual review core YT/AT Review, update as required following new guidance, On Going Next Review due plans exercise or incident April 2018 CBRN Assurance Annual review core YT/AT Assurance visit from SWAST yet to be agreed. On Going 13 December plans 2017 Severe Weather Plan Annual review core YT/AT Review, update as required following new guidance, On Going Next Review due plans exercise or incident July 2018 Mass Countermeasures plan Annual review core YT/AT Review, update as required following new guidance, On Going Next Review due plans exercise or incident June 2018 Fuel Shortage Plan Annual review core YT/AT Review, update as required following new guidance, On Going Next Review due plans exercise or incident August 2018 Communicable Diseases Plan Annual review core YT/AT Review, update as required following new guidance, On Going Next Review due (formally Flu Plan) plans exercise or incident August 2018 Evacuation and Shelter plan Annual review core YT/AT Review, update as required following new guidance, On Going 2018 plans exercise or incident EPRR Assurance YT Prepare for Assurance On Going October 2018 The organisation's Accountable Information sent to YT Awaiting feedback from Company Secretary, currently On Going December 2017 Emergency Officer has taken the Company not a mandatory requirement therefore has not been result of the 2016/17 EPRR Secretary included before, time booked for 20th December assurance process and annual board meeting topresent annual report, assurance work plan to a pubic update and work plan Board/Governing Body meeting for sign off within the last 12 months.

Page 12 of 13 The organisation has published Information sent to YT Awaiting feedback from Company Secretary, currently Complete November 2017 the results of the 2016/17 NHS Company not a mandatory requirement therefore has not been EPRR assurance process in their Secretary included before - will be included from 2018 report annual report. The organisation has an To Identify Non- SS Non-Executive identified Caroline Moore. To be Complete November 2017 identified, active Non-executive Exec briefed Director/Governing Body Representative who formally holds the EPRR portfolio for the organisation. The organisation has an EPRR group YT EPRR group in place, Membership reviewed, Director Complete November 2017 internal EPRR oversight/delivery chairing group group that oversees and drives the internal work of the EPRR function The organisation's Accountable Meeting dates in YT AEO chairs meeting Complete October 2017 Emergency Officer regularly advance attends the organisations internal EPRR oversight/delivery group The organisation's Accountable Meeting dates in YT/SS AEO attendance encouraged Complete October 2017 Emergency Officer regularly advance attends the Local Health Resilience Partnership meetings

Page 13 of 13

Appendix: 4 REPORT TO: Board of Directors REPORT BY: Finance and Management Information Departments PRESENTED BY: Executive Directors TITLE: Board Overview Quadrant DATE: 31 January 2018

Action Required (Please select any which are relevant to this paper) For Decision For Assurance For Approval For Information

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

This Board Overview Quadrant provides an overview of the Trust’s performance on Finance, Quality, Performance and Workforce.

Due to current issues with regard to workforce reporting, data for December 2017 is not yet available. A verbal will be provided should data be available.

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

Specific risks addressed by this paper (Include relevant risks and/or links to the corporate risk register/department risk register)

The Financial, Performance, Quality and Workforce Risks are formally recorded within the Corporate and Departmental Risk Registers. The Corporate Risk Register is reviewed by Board Assurance Committees and the Board of Directors on a quarterly basis.

Implications/Requirements (Please select any which are relevant to this paper) Financial Legislation Workforce Estates

Patient Safety / ICT Quality of Care

Reference to CQC domains (Please select any which are relevant to this paper) Safe Effective Caring Responsive Well Led

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

YEOVIL DISTRICT HOSPITAL FOUNDATION TRUST PERFORMANCE QUADRANT

FINANCE Dec-17 QUALITY Dec-17

£1.4m in month £14.3m YTD £4.3m YTD adv to budget Indicators - SAFE Dec-17 Dec-16 6 Month Avg deficit deficit Mortality (No of Total Deaths) 71 73 55 Patient Falls 65 91 65 Pressure Ulcers 2 8 5 In Month (£'000s) YTD (£'000s) C.Diff (Lapse in Care) 0 0 0 Actual Variance Actual Variance MRSA 0 0 0 Control Total excl. STF (£'000s) (1,608) (439) (15,631) (2,188) Incidents reported 586 580 582 Donated Asset Adjustment 186 158 688 (14) Sustainability and Transformation Funding (STF) 0 (430) 644 (2,147) Indicators - CARING Dec-17 Dec-16 Target SOCI Position (1,422) (711) (14,299) (4,349) Complaints 6 9 Concerns - New process since Apr 17 25 86 In Month (£'000s) YTD (£'000s) Category - Core items Actual Variance Actual Variance Indicators - RESPONSIVE Dec-17 Dec-16 Target Income (BAU) 9,479 (191) 87,111 330 Inpatients Friends and Family Test Response Rate (Statutory Return) 16.0% 15.0% 40.0% STF and Donated Assets 186 (272) 1,332 (2,161) Pay (BAU) - Substantive & Bank (7,210) (334) (64,978) (1,745) Inpatients Friends and Family Test Likely to Recommend (Statutory Return) 95.0% 93.0% Pay (BAU) - Agency (374) (196) (3,651) (1,049) Non-pay (BAU) - Consumables, Other (2,662) 68 (25,072) (271) Extracted items - Drugs and Outsourced work (470) 124 (5,344) 258 Indicators - EFFECTIVE Dec-17 Dec-16 Target RAG Depreciation, interest, PDC, impairments (365) 94 (3,358) 635 Stroke BPT - 90% Stay, 4hr Direct admissions, seen by stroke consultant within 14 hours 42.9% - 45% Transformation (6) (4) (339) (346) SOCI Position (1,422) (711) (14,299) (4,349) Stroke BPT - CT scan within 12 hours 97.6% 88.5% 83%

Stroke BPT - Patients assessed for thrombolysis who also received alteplase 10.8% 15.4% 16% Additional items Actual Variance Actual Variance CIP Achievement 735 (217) (4,642) (1,164) #NOF Best Practice Achievement 29.2% 86.4% 60% CIP % achieved recurrent 71% 72% *Symphony Health Services Impact (Adult Emergency 1+LoS YTD Reduction) -2.2% - -5% Capital expenditure (317) (28) (3,867) 342 Cash balance 1,460 1,460 Total loans for Department of Health (4,834) (58,343)

PERFORMANCE Dec-17 PEOPLE Nov-17

Indicators - RESPONSIVE Actual Movement Target RAG Indicators - WELL LED Actual Target RAG A&E 4 hour Waiting Times 95.6% i 95% Turnover 18.9% 10%-15% Ambulance Handover Times 99.5% g 98% Registered Nursing Vacancies (% of Whole Time Equivalent) 7.2% 5.0% RTT - Incomplete Pathways Waiting Times 92.6% i 92% Medical & Dental Vacancies (% of Whole Time Equivalent) 5.1% 1.0% Diagnostics - 6 Weeks Waiting Times 99.2% g 99% Other vacancies (% of Whole Time Equivalent) 1.3% 2.0% Cancer - 2WeekWait - Waiting Times (Nov17) 97.1% i 93% Total Vacancies (% of Whole Time Equivalent) 3.4% 2.0% Cancer - 2WeekWait - Breast Symptoms (Nov17) 100.0% h 93% Absence Rate (month in arrears) 3.2% 3.0% Cancer - 31 day Treatment Waiting Times (Nov17) 97.7% g 96% Mandatory Training Rate 93.2% 90.0% Cancer - 62 day Standard Waiting Times (Nov17) 77.4% i 85% Staff Appraisal Rate 86.2% 90.0% Agency Spend in Month against ceiling (£000's) £399 £542 RAG Status: Target achieved, Target failed - within 1% of target, Target failed - more than 1% away from achieving target Agency Spend YTD against ceiling (£000's) £3,346 £4,332 Measurement & learning from patient feedback Continuous multi-channel data collection from all inpatients, December 2017 maternity, A&E

Exceeding FFT/CQC requirements to collect, analyse and monitor qualitative comments across all services

95% LIKELY Improvement: ward level reports assessed and shared monthly TO RECOMMEND

Average Response Rate by Care Type FFT: 95% likely to recommend

50% 80% 15% 1.5% 25% 0.5% 1% Don’t know 2 %

0% October2017 A&E Inpatient Outpatient Maternity Daycase Friends & Family Test November 2017 Average score for December 2017 Average five-star score by Care Type December 2017 5 4.93 4.93 4.97

4.83 4.81 4.87 4.86 4.90 4.89 4.87 4.87 4.9 4.82

4.75 4.72 4.67 4.76 4.8

4.7 Number of five-star compliments 639 (53% of reviews) 4.6 December 2017

4.5 A&E Inpatient Outpatient Maternity Daycase

Top 200 words used to describe Yeovil District Hospital NHS Foundation Trust

Appendix: 6 REPORT TO: Board of Directors REPORT BY: Linda Hann, Freedom to Speak up Guardian PRESENTED BY: Shelagh Meldrum, Director of Nursing & Elective Care TITLE: Freedom to Speak Up Guardian Report DATE: 31 January 2018

Action Required (Please select any which are relevant to this paper) For Decision For Assurance For Approval For Information

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

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

This report summarises the concerns raised with the Trust Freedom to Speak Up Guardian during Quarter 3 2017/2018.

Specific risks addressed by this paper (Include relevant risks and/or links to the corporate risk register/department risk register)

No corporate risks were identified.

Implications/Requirements (Please select any which are relevant to this paper) Financial Legislation Workforce Estates

Patient Safety / ICT Quality of Care

Reference to CQC domains (Please select any which are relevant to this paper) Safe Effective Caring Responsive Well Led

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

Freedom to Speak Up (F2SU) Guardian 2017/2018 Quarter 3 Report

Background

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

In his review of care concerns at Mid Staffordshire Foundation Trust, Robert Francis, QC found that staff are reluctant to raise concerns due to;

• The potential impact on their own career • The fear of being labelled a trouble maker • Loyalty to colleagues – who may be implicated • A lack of confidence that raising a concern will make a difference

QC Francis noted that the impact on those who have raised concerns has been considerable, specifically;

• Serious impact on mental health • Reduced career chances

Current Situation

Yeovil Hospital has two Freedom to Speak Up Guardians across different divisions of the Trust.

Publicising the Role

There are posters throughout the Trust inviting staff to raise concerns with the F2SU Guardian either by email or face to face.

The role is explained to all new staff at induction by the F2SU Guardian.

There is easy access to raising a concern via the Ycloud

The F2SU Guardian has a “drop in” session every Friday morning from 9am till 9.30am

Sharing learning across the organisation

The F2SU Guardian attends the Trust Wide Learning Forum and meets regularly with the Deputy Director of Nursing to ensure that wider learning from concerns raised takes place.

Measuring success

All concerns are responded to. The Chief Executive and all other relevant Directors are made aware of concerns as they are raised. Informal feedback from staff regarding the role remains very positive.

Activity To-Date

We have had 9 concerns raised via the Freedom to Speak up Guardian during quarter 3, which is a slight increase on the previous two quarters.

4 of the concerns were raised anonymously; 1 by an HCA, 2 by allied health care professionals and 2 by clerical staff.

Of the 9 concerns, 5 related to patient safety and quality. Issues raised were:

• A ward patient left in the Outpatient corridor by a porter inappropriately • Concerns regarding the location of the Rheumatology clinic • A ward patient arriving in OPD in a very distressed state • Poor communication from the Estates Department • Concerns about safety procedures with asbestos • Cleanliness in ED • Recycling issues in the canteen • Poor progression of a PALS case • The new system for ordering stationary

The following actions/changes were made as a result;

1. A revised system of taking patients to Outpatient appointments from the wards 2. Assurance given to all staff that rigorous safety procedures regarding asbestos are in place 3. Cleaning schedule in ED revised 4. Greater clarity now in place when a PALS case has been closed or passed on to another 5. team

Linda Hann Freedom To Speak Up Guardian

Appendix: 7 REPORT TO: Board of Directors REPORT BY: Nicholas Craw, Guardian of Safeworking PRESENTED BY: Tim Scull, Medical Director TITLE: Quarterly Report on Safeworking Hours DATE: 31 January 2018

Action Required (Please select any which are relevant to this paper) For Decision For Assurance For Approval For Information

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

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

The Board or a committee of the Board is required to receive a quarterly report from the GoSW and to date these have been received in the Workforce Committee and noted at the Board of Directors. In addition the Board should receive a consolidated annual report.

This report covers the period June 2017 – August 2017.

Specific risks addressed by this paper (Include relevant risks and/or links to the corporate risk register/department risk register)

The Guardian of Safe Working report links directly with: . ANA001 - Inadequate number of junior medical staff to run a closed unit (ICU / HDU) in accordance with the Faculty of Intensive Care Medicines. . M022 - Medical Patients being nursed in non-medical environments, lack of medical support and lack of medical skills in workforce. Medical team providing support across a variety of environments

Implications/Requirements (Please select any which are relevant to this paper) Financial Legislation Workforce Estates

Patient Safety / ICT Quality of Care

Reference to CQC domains (Please select any which are relevant to this paper) Safe Effective Caring Responsive Well Led

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

QUARTERLY REPORT ON SAFE WORKING HOURS: DOCTORS AND DENTISTS IN TRAINING 4th Report: September to November 2017

1. Introduction

1.1 This is the fourth quarterly report from the guardian of safe working hours regarding working hours for junior doctors on the new 2016 terms and conditions of service (T&CS). The first report covered the initial 3 months of the new T&CS: December 2016 to February 2017. The second report covered March to May 2017. The third report covered June to August 2017. This report covers the period September to November 2017

1.2 The new T&CS introduced several new practices in the way trainee doctors are employed by the trust. The 2016 T&CS introduced a new mandated role – the guardian of safe working hours. The guardian is a semi-independent role, charged with completing the specific tasks and duties set out in the T&CS.

1.3 The most significant over-arching task of the guardian is to provide the trust with information leading to an assurance that within the trust, trainee doctors’ working hours are safe. This could be defined as working hours which comply with the time limits as set out in the T&CS. The T&CS also stipulate that the guardian will provide a summary report to the trust quarterly and annually for this purpose.

1.4 The 2016 T&CS requires continuous monitoring and electronic reporting of hours worked by junior doctors, with the expectation that each and every hour worked beyond contracted hours (overtime) will be reported to the trust, and receive recognition.

1.5 Trainee doctors complete a form known as an exception report. This can be thought of as combined report of a staffing problem, and a claim for compensation/ remuneration.

2. High level data

2.1 The number of doctors in training on the 2016 T&CS at YDH is 50.

Number of exception General General Orthopaedics Psychiatry Paediatrics reports received, by Medicine Surgery specialty and grade. F1 32 22 0 0 0 F2 10 0 3 3 0 CT1 or higher 0 0 0 0 2 Total 42 22 3 3 2

Total number of hours General General Orthopaedics Psychiatry Paediatrics Grand claimed on exception Medicine Surgery Total reports F1 51 30.5 1.75 0 0 83.25 F2 5.5 0 7.5 0 13 CT1 or higher 0 0 0 0 6 6 Grand Total 56.5 30.5 1.75 7.5 6 102.25 1

Method of settling General General Ortho Psychiatry Paediatrics Grand additional hours claim Medicine Surgery Total Compensation: 15 3 18 Overtime payment Compensation: Time 18 11 10 1 40 off in lieu No further action 4 1 5

Sum of Payment Due General General Ortho Psych Paeds Grand Total Medicine Surgery F1 £439.47 £115.65 £555.12 F2 £120.51 £120.51 CT 1 or higher Grand Total £559.98 £115.65 £675.63

2.2 The total number of exceptions received was 43 in the first report, 18 in the second report, 35 in the third report, and 72 in this report.

2.21 32 exceptions were received in September, 35 in October, but only 5 in November.

number of reports per month 40

0 dec jan feb mar apr may jun jul aug sept oct nov

1st report 2nd report 3rd report 4th report Number of doctors 7 4 10 13 who submitted an exception Highest number of 17 9 11 12 exceptions by single doctor Total exceptions 41 18 35 72 Wards with high 8A (17 excepts) 9A (12 excepts) 9A (11 excepts) 8B (12 excepts) numbers of 9A (14 excepts) 8B (7 excepts) 9A (11 excepts) exceptions 7A (11 excepts) Number of doctors 24 24 44 37 submitting zero reports

2.7 The only ward to routinely produce high number of reports is ward 9A (14, 12, 11 and 11 reports respectively). 2

2.8 Junior doctors can tag reports as ‘immediate safety concerns’ if they wish. One report was tagged as an ‘immediate safety concerns’. This was investigated by the guardian, the clinical director, and the governance dept. No incidents were received by governance from the relevant ward around this time. The exception concerned staffing and a late finish. Speaking to the doctor, she should have finished at 4:30pm, but did not finish until 6:15pm, due to short staffing. She requested extra help from another doctor, and did receive some, but not as much as she would have wished. She received time off in lieu. On reflection the doctor felt this was not an immediate safety concern, and it was an error to mark it as such, and the tag was withdrawn.

2.8 Intermittent working hours reporting via diary exercises continues for those trainee doctors still on the 2002 T&CS. This is overseen by the medical staffing department. There have been no diary exercises in the last quarter.

Work schedule reviews

2.9 Exception reports are designed to capture one-off occurrences – an exception to the rule of normal working hours. Where problems are recurring or part of a wider pattern, then a process known as work schedule review is undertaken. No additional work schedule reviews have been requested or required.

2.10 Junior doctors can request an appeal process (level 2 review) if they are dis-satisfied with outcomes of exception reports. There have been no appeals.

3. Locum bookings

3.1 Detailed reports on locum work carried out by trainees, in the last quarter, are already produced by the HR department. Internal locum work conducted by trainees on the new T&CS is included in maximum hour’s calculations, to ensure compliance is maintained.

3.2 Under the new T&CS YDH based trainees must inform YDH if they undertake external locums, so that safe hours can be maintained. No YDH trainees on the new T&CS have informed the trust of external locum work.

Vacancies

3.3 There were 14 vacant junior doctor posts in November 2017 The HR department had made the trust aware in advance that these posts would become vacant. Much of these are due to the deanery being unable to fill their posts and supply doctors to the trust. The trainee vacancies: September/October – 14 vacancies in total: 2x F1, 4x F2, 7x GP VTS, 1x ST3 in Medicine November – 12 vacancies in total: 3x F1, 1x F2, 7x GP VTS (2 filled with LAS posts, 5 still vacant), 1x ST3 in Medicine (filled internally). A vacant post is also a ‘Rota gap’. Increased numbers of vacancies will tend to lead to more locum spend, reduced staffing on wards, and possibly increased exception reports.

4. Fines

4.1 The T&CS require that where trainee doctors working hours exceed higher secondary limits, then in addition to payment for these hours to the doctor, a financial fine is levied on the trust.

4.2 The secondary limits which attract a fine are: a doctor working more than an average of 48 hours per week in any 3 month period, a doctor working more than an absolute maximum of 72 hours in any given week, a doctor getting less than 8 hours rest between shifts, a doctor missing more than 25% of rests breaks in any 4 week period.

4.3 There have been no breaches, and therefore no fines.

5. Qualitative information

5.1 Working with the new arrangements for doctors on the 2016 T&CS continues to embed for all those involved, having now been in use for 1 year. Junior doctors and Educational supervisors in particular continue to learn the requirements of the system. There is a move within the trust via job-planning, to specifically recognize educational supervisors’ admin time (typically 1 hour per trainee per week per educational supervisor), where otherwise the consultant’s admin time may be reduced. This may increase the popularity of the educational supervisor’s role.

5.2 A meeting between the junior doctors, guardian, director of medical education, and medical staffing, known as the ‘junior doctors forum’, is required by the 2016 T&CS. This is to enable open debate around pertinent issues. A meeting of the forum took place on the 14th September 2017. A further meeting took place on the 18th October 2017.

5.4 An issue raised at the forum was inadequate written and verbal communication from senior and middle grade surgeons to juniors. The guardian will address this.

5.5 The BMA union rep was present at the forum, and talked about changes to the junior doctors’ contract in 2018. 4

5.6 Another issue was raised by a junior who is employed by YDH, and attends our forum, but works on a psychiatry ward outside YDH, run by Somerset Partnership, due to the rotating nature of GP posts. The doctor submits exceptions which go to a different guardian employed by Somerset Partnership, and who the doctor felt was not responding properly. The contract is complex for GP trainees, and this highlighted the need for a possible SLA with SomPar on this issue.

5.7 Another issue raised was attending teaching outside on-shift hours. Junior doctors have a target to attend a high proportion of teaching sessions. When on-shift, consultants are under instruction to ensure juniors are free to attend teaching. However some teaching occurs when juniors may be off-shift i.e. doing a late shift, night shift, and timetabled rest days post nights. As hours are limited by contract, this generates a conflict as to whether a junior should or should not attend teaching when off-shift. The director of medical education is to review this.

5.8 A major issue raised was payment for completing cremation paperwork. Junior were previously paid £80 per form, with the money coming from undertakers. In the new contract, doctors should not keep money or fees earned during NHS time, it should be retained by the trust. Some junior doctors had commenced un-official industrial action by refusing to complete forms, due to this lack of payment. The medical director was present and strongly criticized any junior taking this unofficial industrial action. The guardian reminded the juniors verbally and by email that patient care must not be affected by industrial action, and that the duty of care continues for deceased patients.

5.9 A meeting between the juniors, BMA union rep, head of medical staffing, and deputy medical director subsequently took place. A provisional plan was agreed where juniors could be paid for these forms in exchange for time-shifted NHS work. That is, if a junior completes a form, and retains the fee, the junior will work one extra hour from 5pm until 6pm, and may not submit any exception reports during this time. This is a very practical solution, however, it may be very difficult to police or track these arrangements.

6. Issues arising

6.1 The single biggest issue in exception reports is that the ward was understaffed, and the doctor had to stay late to complete tasks. A description similar to this effect accounts for the majority of exception reports. The reasons given why doctors feel wards are understaffed include, Rota gaps, colleagues on night shifts, colleagues on sick leave, colleagues on annual leave, and colleagues on days off.

6.3 The number of juniors on wards is certainly better than it was in previous times. However there is no national published standard for the doctor: patient ratio for general wards. It may be useful to perform a benchmarking exercise to establish how our trust compares to other employers.

6.4 The majority of exception reports come from Foundation grade doctors. More senior trainee doctors submit few or no exception reports.

6.5 Ward 9A consistently submits higher numbers of exception reports, despite doctors changing, and therefore may represent a problem. However the closest colleague, a CT1 doctor in the same team (9A respiratory) submitted zero reports this quarter.

6.51 An F1 doctor on ward 7A submitted 11 exceptions, two other F1 doctors on the same team on 7A (surgery) submitted 6 and 5 reports respectively.

6.52 An F1 doctor on ward 8B submitted 12 reports, however the doctors F2 colleague on the same ward submitted zero reports.

6.6 The jump in unfilled posts in August, along with novice doctors commencing in August does seem to have led to an increase in exception reports. This may have settled significantly in November and December.

6.8 The actual financial cost of exception reports is small compared to current locum costs. This in turn is low compared to the implementation costs of the 2016 T&CS for regular and predicted working hours. Whilst the 2016 T&CS was stated to be intentionally cost neutral, most employers find this not to be the case.

7. Summary.

7.1 There is good evidence that working hours for trainee doctors at YDH are safe, as they relate to the 2016 T&CS, and the hour’s limits set out therein. There are several positives to be taken from this, zero confirmed immediate safety concerns, zero breaches attracting fines, and low total financial costs relating to working beyond hours.

7.2 Doctors in the foundation (F1) grade continue to generate significantly more exception reports than other grades. Some patterns such as ward 9A have emerged. However, this is not fully consistent, as doctors in the same ward teams may generate both high levels and low/zero levels of reports during the same period. Individual doctors’ behaviors seem to account in part therefore for these differences.

Dr Nick Craw Guardian of Safe Working hours. December 2017.

Appendix: 8 REPORT TO: Board of Directors REPORT BY: Trust Risk and Patient Safety Manager PRESENTED BY: Jonathan Higman, Acting Chief Executive TITLE: Risk Management Strategy DATE: 31 January 2018

Action Required (Please select any which are relevant to this paper) For Decision For Assurance For Approval For Information

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

As part of the Trust’s governance arrangements, the Risk Management Strategy outlines the risk management framework, emphasising the way that the Trust can implement its strategic objectives through an integrated risk management approach. Integrated risk management is the identification and assessment of the collective risks both corporate and clinical that affects the value and the implementation of the Trust’s strategic objectives so that risks are not seen in isolation. This risk management strategy aims to maximise the value of an integrated risk management approach by demonstrating the Trust’s risk profile and investigating mitigating actions and controls.

The Risk Management Strategy was formally approved at the Trust’s Audit Committee on 24 January 2018. The Board are asked NOTE the strategy.

Specific risks addressed by this paper (Include relevant risks and/or links to the corporate risk register/department risk register)

Implications/Requirements (Please select any which are relevant to this paper) Financial Legislation Workforce Estates

Patient Safety / ICT Quality of Care

Reference to CQC domains (Please select any which are relevant to this paper) Safe Effective Caring Responsive Well Led

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

RISK MANAGEMENT STRATEGY

Version Number 6 Version Date October 2017 Policy Owner Chief Executive Author Trust Risk and Patient Safety Manager First approval or date The Risk Management Policy was first approved in last reviewed July 2007, reviewed in September 2011 up to Version 4.1, reviewed in September 2014 (version 5)

Staff/Groups Consulted Directors and Non–Executive Directors H&S Committee Strategic Business Unit Senior Teams Maternity Risk Manager Head of Midwifery Approved by the Audit 24 January 2018 Committee on behalf of the Board of Directors Next Review Due October 2020

Equality Impact October 2017 Assessment

Table of Contents

1. INTRODUCTION ...... 5 2. PURPOSE ...... 5 3. ARRANGEMENTS FOR RISK MANAGEMENT……………………………………………..6 4. RISK REGISTER AND ASSURANCE FRAMEWORK……………………………………... 7 5. DEFINITIONS……………………………………………………………………………………9 6. ORGANISATIONAL RESPONSIBILITIES OF RISK MANAGEMENT…………………….10 7. STAFF RESPONSIBILITIES FOR MANAGEMENT OF RISK…………………………… ..12 8. OPERATIONAL RISK MANAGEMENT……………………………………………………….14 9. INCIDENT REPORTING………………………………………………………………………..18 10. APPLICABILITY………………………………………………………………………………….19 11. IMPLEMENTATION, TRAINING AND SUPPORT…………………………………………...19 12. MONITORING THE EFFECTIVENESS OF THE STRATEGY……………………………...19 13. REFERENCES…………………………………………………………………………………...20 14. ASSOCIATED POLICIES……………………………………………………………………….20 15. SUBSIDIARY COMPANIES OF YEOVIL DISTRICT HOSPITAL (YDH)…………………..21 16. EQUALITY IMPACT ASSESSMENT………………………………………………………….21

ANNEX A – RISK ASSESSMENT SCORING GUIDELINES……………………………………23 ANNEX B – EQUALITY IMPACT ASSESSMENT TOOL……………………………………….. 33 ANNEX C – MATERNITY RISK MANAGEMENT STRATEGY…………………………………TBC

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RISK MANAGEMENT STRATEGY

1 INTRODUCTION

1.1 The Chief Executive and the Board of Directors (BoD) at Yeovil District Hospital NHS Foundation Trust (Trust) is committed to a strategy, which minimises risks and achieves compliance with statutory requirements through a comprehensive system of internal controls and committees, whilst maximising the potential for flexibility, innovation and best practice in delivery of its strategic objectives. The Trust is committed to ensuring the safety of patients, staff, the public and stakeholders against risks of all kinds.

1.2 As part of governance arrangements, this strategy outlines the risk management framework, emphasising the way that the Trust can implement its strategic objectives through an integrated risk management approach. Integrated risk management is the identification and assessment of the collective risks both corporate and clinical that affects the value and the implementation of the Trust’s strategic objectives so that risks are not seen in isolation. This risk management strategy aims to maximise the value of an integrated risk management approach by demonstrating the Trust’s risk profile and investigating mitigating actions and controls.

1.3 A clear understanding of the key strategic objectives and a commitment to corporate governance will ensure that risk analysis and management are applied throughout the organisation. The Risk Management Strategy also endeavours to promote a culture whereby patient safety and quality is at the heart of all clinical practice and all staff are open to sharing learning from the experiences related to the management of risk.

1.4 The strategy will support the Trust, directly employed staff and shared service providers in managing risk through safe systems of practice, including the identification of risk and the use of clinical guidelines and protocols to minimise risk. The Assurance Committees will ensure, on behalf of the Board of Directors that safe systems and robust risk management arrangements are in place for delivering quality and safe care.

1.5 Reducing risk can lead to an improvement in patient safety and quality of care. Equally, improved quality of care may lead to a reduction of clinical risk. Risk management is therefore regarded in the Trust as an integral part of clinical governance. It is the Trust’s aim to ensure that all professionals working within the organisation know that clinical governance and patient safety is part of their daily responsibility and embedded in their working practices.

1.6 Having the capability to reduce risks does not necessarily imply that the Trust should reduce the risk. Inevitably all risk cannot be eliminated entirely and there needs to be an understanding of the levels of risk faced by the Trust to allow an assessment of which areas of risk which should be prioritised.

2 PURPOSE

2.1 The purpose of this risk management strategy is:

• to demonstrate an organisational risk management structure that details all the committees have shared responsibility for managing risk across the organisation

• to outline a process which ensures that the Board of Directors undertakes regular review of risk through the Assurance Framework and Corporate Risk Register

• to ensure demonstration of the development of a system for implementation of seamless risk management strategies in all areas of the organisation including business planning, delivery of care and planned developments

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• to identify within the strategy documentation and process, the roles and responsibilities of the key individual(s) in post with responsibility for advising on and coordinating risk management activities

• to identify the respective roles, responsibilities and accountability undertaken by the Board of Directors, members, practitioners and managers for areas of risk

• to identify the responsibilities of all managers/clinicians and staff and their authority with regard to managing risk

• to outline the process for risk assessment for all types of risk including those that relate to specific areas including projects

• to identify risks against standards set by regulators such as the Care Quality Commission and NHS Improvement

2.2 In the implementation of this strategy, the Trust will support the adoption of a no blame culture regarding the reporting of adverse incidents in line with NHS England, the National Reporting and Learning Service (NRLS) and the Serious Incident Framework – Supporting Learning to Prevent Recurrence 2015.

2.3 The Trust committed to ‘Being Open’ and the contractual ‘Duty of Candour’ applies, ensuring openness and transparency when dealing with patients and families when harm occurs.

2.4 The Trust is committed to delivering fully inclusive and accessible services and meeting the standards set out in the Equality Delivery System (EDS). The EDS is designed to help organisations review and improve their equality performance and embed equality into services through identifying future priorities and actions.

3 ARRANGEMENTS FOR RISK MANAGEMENT

3.1 Yeovil District Hospital NHS Foundation Trust will ensure that the management of risk is established throughout the organisation with guidance on roles, responsibilities, processes and procedures.

3.2 Risk may be defined as the possibility of incurring loss or the likelihood of adverse consequences arising from an event. Risk may also be described as the potential for a hazard to prevent the achievement of organisational objectives leading to a detrimental impact on patients, staff and members of the public.

3.3 Managing risk, clinical and non-clinical, is accepted as a key organisational responsibility and is an integral part of management systems and processes.

3.4 All staff have an important role in identifying, assessing and minimising risk. This can be achieved where there is a culture of openness, being ‘fair and open’ together with a willingness to admit mistakes. The organisation has a Being Open and Duty of Candour Policy in respect of communicating with patients and/or carers about patient safety incidents.

3.5 The Trust has adopted the principles of risk management, which form the basis of the risk management framework. This will assist in the identification and analysis of all risks. The risks identified may include those which adversely affect the quality of patient care, the ability to deliver services, the health, safety and welfare of patients, visitors and staff or the ability of Trust to meet service and contractual obligations.

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3.6 The following methods are to be used in the identification and management of risk:

• maintenance of Strategic Business Unit and Service risk registers

• involvement of all staff in the assessment of risk

• ongoing analysis of all clinical, financial and corporate risk

• analysis of incidents, claims and patient experience

• identifying new risks from significant events and near misses

• root cause analysis of significant events and serious incidents

• identifying new risks from national reporting through the Central Alerting System (CAS) e.g. Patient Safety Alerts issued by NHS England, Chief Medical Officer (CMO) Alerts, National Reporting Learning System (NRLS), Medicines and Healthcare Products Regulatory Agency (MHRA)

3.7 The overall Trust responsibility for risk management will rest with the Board of Directors. Other Assurance Committees with responsibility for risk management are:

• Subcommittees of the Board - Audit Committee and Governance and Quality Assurance Committee (GQAC)

• Risk Assurance Committee

• Formal Committees/Steering Groups

3.8 For an explanation of the committee responsibilities see Section 6.

3.9 Staff are involved in risk management; both through the incident reporting process and the proactive identification and management of risk in the organisation. Staff level responsibilities for risk management are detailed in Section 7.

3.10 The corporate risk register will be assessed at least quarterly in order to inform the Annual Governance Statement and when procedural, legislative or best practice changes occur.

3.11 The policy, strategy and the principle of risk management will be communicated to staff. Staff will be encouraged in the use of risk assessment to identify both immediate risks and long term risks.

4 RISK REGISTER AND ASSURANCE FRAMEWORK

Arrangements

4.1 The Strategic Business Unit and service risk registers identifies and lists the risks facing the Trust and the action being taken to mitigate them.

4.2 All Lead Directors (including Lead Clinicians responsible for specific work streams), supported by the Trust Risk and Patient Safety Manager are responsible for ensuring that risks identified through local mechanisms are included on Business Unit or service risk registers and the Corporate Risk Register for those scoring 12+ in line with the risk matrix (matrix). The Director of Nursing and Elective Care and the Head of Governance and Assurance are responsible for ensuring that Trust-wide clinical risks are included.

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4.3 The Lead Directors and Clinicians are responsible for prioritising risk treatment plans based on detailed analysis and evaluation of risks.

4.4 The Assurance Committees will review the Corporate Risk Register as part of their meetings agendas to ensure risk treatment plans are being implemented. The Board of Directors will receive the Corporate Risk Register quarterly. The Audit Committee will have overall oversight of the Assurance process.

4.5 Each risk will be scored using the matrix quantification methodology favoured by the NHS. This assigns values between 1 and 5 to both the likelihood of the risk being realised and the possible consequences of this. These are then multiplied together to give a risk rating. The matrix for assessing and rating risk is attached at Annex A.

4.6 When deciding if a risk is acceptable, the risk rating will be considered in the light of controls to reduce the risk. If significant and effective action has already been taken to minimise the adverse consequences of the risk then the risk may be termed acceptable. If further controls could be taken to reduce the risk, these will be considered in the light of the urgency of the risk, and the cost and time commitment needed to implement the control.

4.7 Within the Trust, the Business Unit and service risk registers will become an integral tool in the risk management process used actively by all Directors and their staff. Risk registers will be updated by the responsible leads set out in the risk registers supported by the Trust Risk and Patient Safety Manager, with risk information being received from a variety of sources.

Definitions of Significant and Acceptable Risk

4.8 An acceptable risk may be defined as a potential hazard that is either small enough to have an immaterial effect on the achievement of organisational objectives, or is a significant risk that has been mitigated by the establishment of effective controls. These controls may minimise the likelihood of the risk occurring, and/or minimise the adverse consequences should the risk identified occur.

4.9 A significant risk may be defined as any risk which has been identified by the Board of Directors, Business Units or Service areas as being potentially damaging to the organisation’s strategic objectives. Significant risks would be those assessed as having a risk rating of 12 (12+) or above and should be reported in accordance with the risk appetite.

4.10 Risk appetite is a threshold – the amount of risk that an organisation is prepared to accept before it takes action.

4.11 As part of the risk management process, all risks identified are evaluated and given a risk level rating. The higher the risk level, the greater the likelihood and/ or impact of that risk occurring. Annex A sets out the risk scoring and assessment guidelines.

4.12 The risk appetite for the Trust is defined as follows:

• Risk Level – Low/Green - Risk Matrix Scoring 6 or under - These represent lowest levels of opportunity/threat and actions shall be limited to contingency planning rather than active risk management action. Risks shall be recorded on the Business Units or Service risk registers. Risk level shall be monitored as part of the ‘local’ risk register review of activities such as team and senior management meetings.

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• Risk Level – Moderate/Amber – Risk Matrix Scoring between 8 and 12 - These represent moderate levels of opportunity/threat which may have a short- term impact on organisational objectives. Risks in this category shall have actions defined on the risk register or on an action plan for risk treatment. Risks shall be recorded on Business Unit or service risk registers and tabled at appropriate meetings, management meetings and relevant committees with responsibility for risk management.

• Risk level shall be monitored as part of the Business Unit or Service managers review together with the status of controls in place and risk treatment.

• Risk Level – High/Significant/Red – Risk Matrix Scoring 12+ - These represent higher levels of opportunity/threat which may have a major or long term impact on benefits realisation, organisation objectives and which may also impact on strategic objectives and outcomes positively or negatively.

• Risks in this category shall have individual action plans for risk treatment. Risks shall be proactively managed and reported on at intervals defined in the action plan but as a minimum requirement quarterly to the Assurance Committees and to the Board of Directors through the Corporate Risk Register.

The Assurance Framework

4.13 The Assurance Framework is designed to provide NHS organisations with a method for the effective and focused management of the principal risks to meeting its strategic objectives. It also provides evidence to support the Annual Governance Statement.

4.14 This is intended to simplify Board of Directors reporting and the prioritisation of action plans, which, in turn, allows for more effective performance management.

4.15 The Assurance Framework sets out the Strategic Objectives and identifies assurances on key controls, ensuring principal risks, mitigating actions and gaps in controls are documented and monitored. A lead director responsibility is identified against the objectives. The Assurance Framework is supported by the corporate risk register to identify operational risks.

4.16 The Trust will review their strategic objectives and principal risks on at least an annual basis.

4.17 The Assurance Framework will be presented to the Assurance Committees and the Board of Directors quarterly for review and proactive management of gaps in assurance about the delivery of strategic objectives.

5 DEFINITIONS

• Risk is the threat or possibility that an action or event will adversely or beneficially affect the Trust’s ability to achieve its objectives. It is measured in terms of likelihood and consequence.

• Risk management is about the Trust’s culture, processes and structures that are directed towards realising potential opportunities whilst managing adverse events. The risk management process covers all processes involved in identifying, assessing and judging risks, assigning ownership, taking action to mitigate or anticipate them, and monitoring and reviewing progress.

• Risk assessment is a systematic process of assessing the likelihood of something happening (frequency or probability) and the consequence if the risk actually happens (impact or magnitude).

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• Principle risks are those that represent a threat to achieving the Trust’s strategic objectives or to its continued existence. They also include risks that are widespread beyond the local area and risks for which the cost of control is significantly beyond the scope of the local budget holder.

• Operational risks are by-products of the day-to-day running of the Trust and include a broad spectrum of risks including clinical risk, financial risk (including fraud), legal risks (arising from employment law or health and safety regulation), regulatory risk, risk of loss or damage to assets or system failures etc. Operational risks can be managed by the Business Unit or Corporate area which is responsible for delivering services.

• Risk registers are repositories for electronically recording and dynamically managing risks that have been appropriately assessed. Risk Registers are available at different organisational levels across the Trust.

• Risk appetite is the type and amount of risk that the Trust is prepared to tolerate and explain in the context of its strategy.

• Governance is the systems and processes by which the Trust leads, directs and controls its functions in order to achieve its organisational objectives, safety, and quality of services, and in which it relates to the wider community and partner organisations.

• Internal controls are Trust policies, procedures, practices, behaviours or organisational structures to manage risks and achieve objectives.

• Assurance is the confidence the Trust has, based on sufficient evidence, that controls are in place, operating effectively and its objectives are being achieved.

• Assurance Framework: The Assurance Framework provides the organisation with a comprehensive method for the effective and focussed management of principal risks that affect the Strategic Objectives of the Trust.

6 ORGANISATIONAL RESPONSIBILITIES FOR RISK MANAGEMENT

6.1 The Board Governance Structure (the organisation’s committee structure chart) is contained on the Trust’s website under the publication section: https://www.yeovilhospital.co.uk/about-us/corporate-information/

Board of Directors

6.2 The Board of Directors are ultimately responsible and accountable for the comprehensive management of risks faced by the Trust. They will:

• agree the Strategic Objectives and review these on an annual basis

• identify the principal risks which may prevent the Trust from achieving its key objectives

• receive and review the Corporate Risk Register and the Assurance Framework quarterly, which identify the principal risks and any gaps in assurance regarding those risks

• support the Trust’s risk management programme

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• review the Risk Management Strategy at regular intervals but as a minimum once every 3 years

• approve Assurance Committee terms of reference annually

Audit Committee

6.3 The role of the Audit Committee is to provide independent verification to the Board of Directors on wider organisational controls and risk management. It is not the Audit Committee’s role to contribute to the identification and management of risks, but it will review the findings of internal (and external) audit, together with any agreed management action, with the Lead Director and Lead Clinician responsible and the internal auditors.

6.4 The Committee will:

• oversee the Risk Management Strategy and process

• review the Corporate Risk Register and Assurance Framework at their meetings

• review internal and external sources to provide adequate assurance to the Board of Directors that risks are being appropriately controlled

• receive and consider risk management reports from other committees and groups with responsibility for risk

• review the Risk Management Strategy at least annually and approve 3 yearly for ratification at the Board of Directors

• embed risk management throughout the organisation

Governance and Quality Assurance Committee (GQAC)

6.5 The GQAC act as a focus for the management of clinical, non-clinical risks receiving reports and recommendations from the Patients Safety Steering Group, Clinical Standards, Patient Experience, Risk Assurance Committee and other committees agreed through the GQAC.

Risk Assurance Committee (RAC)

6.6 The Risk Assurance Committee (RAC) reviews and tests assurance from Operational leads for topic areas on behalf of the Assurance Committees and oversees the development and delivery of key governance systems. The committee will provide exception reports directly to the Audit Committee and GQAC on topic areas to support the assurance process.

Formal Committees

6.7 There are a number of committees/groups that report to the Assurance Committees who are responsible to keep under review and manage the risks under their remit in line with their terms of reference.

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7 STAFF RESPONSIBILITIES FOR THE MANAGEMENT OF RISK

Chief Executive

7.1 The Chief Executive as the accountable officer, has overall responsibility for ensuring the implementation of risk management strategy, including organisational controls and reporting arrangements.

Director of Nursing and Elective Care

7.2 The Director Lead for Clinical Risk has overall responsibility, delegated from the Chief Executive for Quality and Patient Safety, Risk Management and Clinical Governance, including:

• ensuring implementation of risk management standards and reporting to the Assurance Committees and the Board of Directors

• providing clinical leadership for the development and implementation of the quality improvement and patient safety plan

• ensuring the effective delivery of clinical care, including clinical audit, evidence based medicine and national and local guidelines in commissioned services

• reporting to the Somerset CCG Governing Body on patient safety, safeguarding, and clinical governance

• ensuring systems for reporting incidents, investigation of serious incidents and external reporting arrangements are managed effectively

Chief Finance and Commercial Officer

7.3 Responsible for progressing financial and performance risk management. The Chief Finance and Commercial Officer is the nominated Security Management Director (SMD), the nominated Senior Information Risk Owner (SIRO) and the Executive Director responsible for Fire, Health and Safety.

Director of Strategic Performance/Deputy Chief Executive

7.4 Responsible for progressing strategic and corporate risk management. Also to ensure implementation of risk management standards and reporting to the Board of Directors.

Senior Director Risk Leads

7.5 The Senior Risk Management leads are:

• Chief Finance and Commercial Officer

• Director for Elective Care

• Director for Urgent Care and Long Term Conditions

7.6 They are responsible for:

• communicating the Risk Management Strategy

• carrying out the risk management processes set out in Section 8

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• ensuring that effective risk management processes are in place within their areas of responsibility

• initiating action within their area to prevent or reduce the adverse effects of risk

• managing the treatment of risk until it becomes acceptable to the organisation

• ensuring that learning from events and risk assessments is disseminated throughout the organization

Company Secretary

7.7 Is responsible for managing the governance arrangements at the Board of Directors level including maintaining the Assurance Framework, ensuring it drives the Board agenda with quarterly reports to the Board of Directors. The role of Company Secretary will also review the assurance and risk committees structure ensuring it meets the needs of the Trust in line with the governance arrangements.

Trust Risk and Patient Safety Manager

7.8 The Trust’s Trust Risk and Patient Safety Manager is responsible for maintaining the Trust’s risk register and risk management arrangements, working in collaboration with the Company Secretary and Director of Strategic Performance/Deputy Chief Executive for identifying corporate risks for reporting to the Board of Directors from the operational risk registers. The Trust Risk and Patient Safety Manager provides risk register arrangements for the Business Units and departments to identify and manage their risk. The Trust Risk and Patient Safety Manager is also responsible for maintaining a system for providing assurance against CQC regulations and standards.

Managers/Heads of Departments

7.9 Managers are responsible for:

• carrying out risk assessments and risk management processes, including identification, assessment and treatment of risks and communicating risk to those affected, escalating to the risk register as necessary

• maintaining Fire and Health and Safety Risk Assessments locally and developing safe systems of work when significant risks are identified that are communicated and monitored

• ensuring that staff accountable to them understand their responsibilities in respect of risk management

• ensuring incidents are reported and managed and concerns are raised where poor practice, or safety concerns are identified

All Staff

7.10 All staff are responsible for risk management from participation in risk assessment to following the safe working practices that involve their work. Staff are responsible for abiding by policies and procedures and the findings of risk assessment and may be subject to disciplinary action for non-compliance. All staff are responsible for helping to maintain a safe working environment, for using the Trust incident reporting system and for informing their line manager of issues of concern which may affect safety and quality.

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7.11 Staff should report such risks (or potential risks) to their line manager in the first instance and raise concerns as they arise.

7.12 There is a link on the YCloud site for raising views and concerns for staff to access to report their concerns.

8 OPERATIONAL RISK MANAGEMENT

8.1 Implementation of this policy and strategy is essential to achieving a robust risk management system throughout the organisation on which the quality of care to patients and the safety of staff and members of the public ultimately depends. It therefore has important and far-reaching implications. It is recognised that this requires detailed knowledge and understanding of risk management.

Risk Management Process

8.2 The Trust promotes the establishment of an open and fair, blame-free culture for reporting incidents. There will be clear guidance for all staff regarding staff roles in risk management and this will be clearly communicated at all levels.

8.3 There are many partner organisations involved in the provision of health services for the risk management strategy. These include the Local Authorities, voluntary organisations, non-statutory health service providers, patient, carer and user groups, as well as the Clinical Commissioning Group (CCG) and NHS England. Partnership working with these organisations is of key importance in terms of reporting and managing risk.

8.4 The Trust’s risk management process is based on the UK standards ISO 31000 – Application of Risk Management Standards. This model is internationally recognised and has been adopted by the Trust as a risk management model which is effective at managing risk at any level. Risk management is a continual improvement cycle where objectives are set, risk is identified, assessed and managed proactively. Fig 1 demonstrates the risk model:

Figure 1 - Risk Management Overview from ISO 31000

Establish

Context – Set Objectives ion

Identify Risks

Analyse Risks Monitor

and Review Risks

Assess Evaluate and Rank Risks Communication and Consultat Treat Risk

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8.5 The key principles of the risk management process observes the following principles:

• a culture where risk management is considered an essential and positive element in the provision of healthcare

• a risk management approach should provide a supportive structure for those involved in adverse incidents or errors by enabling a no-blame culture, openness and transparency

• processes should be strengthened and developed to allow for better identification of risk, identifying opportunities as well as threats

• managing risk is both a collective and an individual responsibility

• recognise that resources may sometimes be required to address risk and business plans should reflect this

Identifying Risk

8.6 The Trust identifies risk through both reactive and proactive methods. Reactive methods include complaints, significant events and incident reporting; proactive methods include risk assessment and implementation of recommendations arising from risk assessment and risks raised through external organisations such as the MHRA.

8.7 Risk should identify the potential risks associated with activities including, for example, delivering service targets, re-design projects, managing patient services, consultations, medicine managements, patient consent to treatment and so on.

8.8 Risk may be experienced from a variety of sources internal and external; changes in legislation; theft; losses; attack on IT systems; changes in legislation and standards etc.

8.9 Internal systems have been developed and implemented for the prevention and management of risks. For example, use checklists and protocols, significant incidents, serious untoward incidents, near miss incidents and education to raise staff awareness.

8.10 Systems for risk assessment will provide a structured method to:

• identify hazards (potential to cause harm, or losses)

• establish who will be affected by the hazard and the frequency of exposure

• establish the level of risk (likelihood of harm, or losses occurring)

• assess whether existing controls are adequate

• identify actions to meet any shortcomings

• check that controls and mitigating actions are working

8.11 Risk assessment formats and guidance is provided through the Clinical Governance team site on YCloud. For specific risks assessments such as Fire, Health and Safety refer to the appropriate YCloud page.

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Risk Assessment

8.12 The Trust will implement an approach to risk assessment with the intention that relevant members of staff are given the power and systems to deal with risks relevant to the services for which they are responsible. The Trust has designated posts with responsibilities for risk management support and advice including:

• Deputy Director of Nursing

• Head of Governance and Assurance

• Trust Risk and Patient Safety Manager

• Maternity Risk Manager

• Fire, Health and Safety Advisor

• Radiation Protection Advisor

• Local Security Management Specialist (LSMS)

• Local Counter Fraud Specialist

• Information Governance Lead

8.13 Risk assessments are the responsibility of Directors, Service leads and Managers who will keep a register of active risks managed through on-line risk registers:

• ensuring that GREEN rated risks (scoring 6 or below (Low or Moderate)) are appropriately managed at a local level

• AMBER rated risks (rated 8 to 12 (Significant)) that cannot be treated locally should be referred to the relevant Lead Director, or Service lead

• RED rated risks (rated 12+ (Significant and High Risk)) should be referred directly to the Lead Director, Service lead and Trust Risk and Patient Safety Manager for consideration and inclusion in the Corporate Risk Register

Managing Risk

8.14 Risk assessments should identify controls or mitigating actions, managed with actions as necessary to reduce risk down to an acceptable level through management teams. Action plans should be used to demonstrate key priorities against risks with delegation of actions and responsibilities identified. The manager lead should ensure these are reviewed and maintained for reference against risk mitigation.

8.15 Risks entered onto the risk registers that have been reduced where no further controls or actions can be taken to mitigate a risk may be archived on the risk register to include all evidence to demonstrate mitigating actions at a later date for inspection, or monitoring.

8.16 Risk Assessments for health and safety, fire, security etc. should be maintained locally by the department manager with risk escalated as appropriate in line with the Red, Amber, Green (RAG) rating

8.17 The Trust has an incident reporting policy and maintains a risk management data base (Safeguard) which provides web-based reporting of clinical and non-clinical incidents and near misses.

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8.18 The Trust will upload patient safety incidents through the National Reporting and Learning System (NRLS) and Security Incidents through the Serious Incident Reporting (SIRS) system to NHS Protect.

8.19 The Trust will ensure the implementation and embedding of safe practice by:

• promoting the use of guidelines and protocols (accessed on the Policies database via the Intranet)

• ensuring safe systems of work are documented and followed when there are significant risks identified

• ensuring that staff undertake continuing professional development activity

• ensuring that the Somerset CCG Reporting and Learning from Serious Incidents (SI) Policy is followed when identifying and reporting Serious incidents externally

Minimising Risk

8.20 The Trust will ensure that learning takes place from clinical and non-clinical incidents and risk assessment findings depending on the seriousness and share learning with other services.

8.21 Safety alerts will be acted upon in line with the requirements of the alert and monitored for effectiveness.

8.22 Staff will be engaged in the learning process through governance arrangements and through raising awareness and training.

Managing Residual Risk

8.23 Residual risk represents a risk that remains after considering the controls in place to manage the risk and after further actions have been taken to reduce the risk to an acceptable level. In practice this means constantly monitoring the effectiveness of control measures. This will be achieved by:

• reviewing outcomes

• sharing best practice

• evidence based practice

• reflective practice

• clinical supervision

• appraisal

• learning from the patient experience, complaints, claims and mistakes

• inspections and monitoring

Monitoring Risks

8.24 The risk management process is monitored by the risk management committees and through the Assurance Committees reviews up to the Board of Directors.

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Quality Impact Assessments

8.25 Quality Impact Assessments (QIA) should be conducted on the same principle as risk assessment. The impact on business, finance, provision of clinical and non-clinical services and patient access to services for equality reasons should be assessed and managed. A QIA demonstrates that consideration of the wider implications to services have been considered, especially in relation to making savings through Cost Improvement Plans (CIP). The Trust has a QIA process for reference that should be used alongside the development of a QIA framework.

9 INCIDENT REPORTING

9.1 Incident reporting underpins an effective risk management strategy. The positive benefit here is that the material provides a rich source of information from which to learn and improve systems and processes and reduce risk.

9.2 A standard format for reporting all types of incidents has been implemented across the Trust. The incident on-line web based form reflects the reporting requirements of the NRLS. Staff receive training at induction and bespoke training to ensure that they are familiar with the reporting requirements. The aim is to ensure that incidents, including near misses are reported as part of routine everyday practice. The reported incidents are investigated where necessary and all the information entered onto the risk management database.

9.3 As part of the mechanism for handling the reporting of incidents and near misses there is a scoring system which enables an assessment of risk to be made as to the actual impact. This is outlined in the Incident Reporting Policy.

Serious Untoward Incident Reporting and Learning from Incidents

9.4 The Trust supports the concept of learning from incidents and sharing information in a blame free culture.

9.5 Incidents that meet the criteria of a Serious Incidents Requiring Investigation (SIRI) are reported externally.

9.6 All serious incidents requiring investigation will be escalated through the incident reporting process to be brought to the attention of the Head of Governance and Assurance who will escalate risk to the appropriate level.

9.7 Root cause investigation and analysis determines how and why adverse incidents happen, the risk management issues involved and how they can be prevented.

9.8 Changes in practice if necessary will be identified through the investigation process.

9.9 The mechanism for sharing and learning from incidents is through the reporting processes to the Patient Safety Steering Group and Integrated Learning Forum and through Strategic Business Unit and Governance meetings in line with the Incident Reporting Policy.

‘Being Open’ and ‘Duty of Candour’

9.10 The Trust will ensure through processes set out in the Being Open and Duty of Candour Policy and the Incident Reporting Policy. The Duty of Candour is a statutory and contractual requirement under Regulation 20 of the Health and Social Care Act 2008.

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Reporting to the Medicines and Healthcare Products Regulatory Agency (MHRA) and the National Reporting and Learning Service (NRLS) to NHS England

9.11 The Trust has a module on the risk management database for the distribution of the Central Alert System (CAS), Medical Device Alerts (MDAs), Patient Safety Alerts and other such clinical alert notifications in line with the Safety Alerts Management Policy. Reporting is through the CAS Liaison Officer (CASLO).

9.12 The CASLO is responsible for reporting to the MHRA, Health and Safety Executive (HSE) and NHS England using information held on the risk management database. In addition, the Trust has nominated a Medicines Safety (MSO) and a Medical Devices Safety Officer (MDSO) reporting to the Director of Nursing and Elective Care with responsibilities reported through the Patient Safety Steering Group.

10 APPLICABILITY

10.1 This strategy document applies to all staff employed by the Trust, whether on a permanent or temporary basis. Failure to comply with fundamentals of this strategy may lead to exposing the Trust and its patients, staff and the public to unnecessary risk. All staff are responsible for risk management and for reducing risks and acting upon risk assessment and following safe systems of work. Failure to carry this out may lead to disciplinary action being taken against individuals.

11 IMPLEMENTATION, TRAINING AND SUPPORT

11.1 The effective implementation of this Risk Management Strategy will facilitate the delivery of high quality service and, alongside staff training and support, will provide an awareness of the measures needed to prevent, control and contain risk. The Trust will:

• ensure all staff and stakeholders have access to a copy of this Risk Management Strategy

• produce a Corporate Risk Register which will be subject to regular review by the risk committees, Assurance Committees and the Board of Directors

• communicate to staff any action to be taken in respect of risk issues

• develop policies, procedures and guidelines based on the results of assessments and all identified risks to assist in the implementation of this Strategy

• ensure that all training programmes raise and sustain awareness throughout the Trust of the importance of identifying and managing risk. There is an internal course for managers that should be undertaken once every 5 years. All new managers should undergo induction to risk with the Trust Risk and Patient Safety Manager

• monitor and review the performance of the organisation in relation to the management of risk and the effectiveness of the systems and processes in place to manage risk

12 MONITORING THE EFFECTIVENESS OF THE STRATEGY

12.1 Reporting on the effectiveness of the risk management strategy within the Trust based on all available relevant information will be through the Head of Governance and Assurance, the Company Secretary and the Trust Risk and Patient Safety Manager.

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13 REFERENCES

• NHS Improvement Serious Incident Framework (March 2015) https://improvement.nhs.uk/uploads/documents/serious-incidnt-framwrk.pdf

• NHS Improvement Never Events https://improvement.nhs.uk/resources/never-events-policy-and-framework/

• Department of Health (February 2006) Integrated Governance Handbook: A Handbook for Executives and Non-Executives in Healthcare Organisations [Online] Department of Health. Available from: http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandst atistics/Publications/PublicationsPolicyandGuidance/DH_4128739

• NHS Foundation Trusts: Code of Governance (December 2013). Available from: https://www.gov.uk/government/publications/nhs-foundation-trusts-code-of- governance

• Department of Health (2002) Assurance: The Board Agenda Department of Health. Available from: http://webarchive.nationalarchives.gov.uk/+/http://www.dh.gov.uk/en/Publications andstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006064

• HM Treasury (March 2013) The Audit Handbook [Online] HM Treasury. Available from: https://www.gov.uk/government/publications/audit-committee-handbook

• HM Treasury (March 2016) Audit and Risk Assurance Committee Handbook https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/51 2760/PU1934_Audit_committee_handbook.pdf

• National Patient Safety Agency (2009) Being Open: Communicating Patient Safety Incidents with Patients and Carers [Online] National Patient Safety Agency. Available from: http://www.nrls.npsa.nhs.uk/resources/collections/being- open/?entryid45=83726

• National Patient Safety Agency (April 2004) Seven Steps to Patient Safety: An Overview Guide for NHS Staff [Online] National Patient Safety Agency. Available from: http://www.nrls.npsa.nhs.uk/resources/collections/seven-steps-to- patient-safety/

14 ASSOCIATED POLICIES

• Incident Reporting Policy

• Investigation Protocol

• Somerset CCG – Reporting and Learning from Serious Incident (SI) Policy

• Health and Safety Policy

• Raising Concerns (Whistleblowing) Policy

• Being Open and The Duty of Candour Policy

• Infection Prevention Control Policy

• Policy for the Development and Management of Procedural Documents

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15 SUBSIDIARY COMPANIES OF YEOVIL DISTRICT HOSPITAL (YDH)

15.1 Any employees of subsidiary companies of YDH will adhere to this policy and will receive consistent training in relation to policy implementation.

16 EQUALITY IMPACT ASSESSMENT

16.1 This policy has been assessed and implemented in line with the policy on procedural documents and an equality impact has been carried out to ensure the policy is fair and does not discriminate any staff groups. A completed Equality Impact Assessment can be found at Annex B.

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RISK ASSESSMENT SCORING GUIDELINES

1. INTRODUCTION

1.1 Risk management is a systematic and effective method of identifying risks and determining the most cost effective means to minimise or remove them. It is an essential part of any risk management programme and it encompasses the processes of risk analysis and risk evaluation.

1.2 The Board of Directors ensures that the effort and resource that is spent on managing risk is proportionate to the risk itself. The Trust has in place efficient assessment processes covering all areas of risk.

1.3 To separate those risks that are unacceptable from those that are tolerable should be evaluated in a consistent manner. Risks are assessed by combining estimates of consequence and likelihood in the context of existing control measures. The rating of a given risk is established using a two dimensional grid or matrix with consequence as one axis and likelihood as the other.

1.4 The following properties are essential for a risk assessment matrix:

• simple to use

• provides consistent results when used by staff from a variety of roles or professions

• capable of assessing a broad range of risks including clinical, health and safety, financial risk or reputation

1.5 This guidance can be used on its own as a tool for introducing risk assessment or for improving consistency or scope of risk assessments already in place within the organisation and for training purposes. In particular the organisation should use this guidance only within the framework of its strategic risk appetite and risk management decision making process.

2. GUIDANCE ON CONSEQUENCE SCORING

2.1 When undertaking a risk assessment the consequence or how bad the risk being assessed is must be measured. In this context consequence is defined as the outcome or potential outcome of an event. Clearly there may be more than one consequence of a single event.

2.2 Consequence scores can also be used to rate the severity of incidents and there are some advantages to having identical or at least parallel scoring systems for risk and incidents.

2.3 This guidance does not give detailed guidelines on incident scoring but gives a brief explanation of how this scoring system can be used for scoring incidents.

2.4 Consequences can be assessed and scored using qualitative data. Whenever possible, consequences should be assessed against objective definitions across different domains to ensure consistency in the risk assessment process. Despite defining consequence as objectively as possible it is inevitable that scoring the consequences of some risk will involve a degree of subjectivity. It is important that effective, practical based training, and use of relevant examples form part of the implementation of any assessment system to maximise consistency of scoring across the organisation.

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RISK ASSESSMENT SCORING GUIDELINES

2.5 The information in Table 1a should be used to obtain a consequence score. First define the risk explicitly in terms of the adverse consequence that might arise from the risk being assessed. Then use the table to determine the consequence score of the potential adverse outcomes relevant to the risk being evaluated. The examples given in Table1a are not exhaustive.

How To Use Consequence Table 1a

2.6 Choose the most appropriate domain for the identified risk from the left hand side of the table. Then work along the columns in the same row to assess the severity of the risk on the scale of 1-5 to determine the consequence score which is the number given at the top of the column.

Consequence scoring

1 – Negligible 2 – Minor 3 - Moderate 4 - Major 5 - Catastrophic

2.7 Many issues need to be factored into the assessment of consequence. Some of these are:

• does the organisation have a clear definition of what constitutes a minor injury

• what measures are being to determine psychological impact on individual

• what is defined as an adverse event and how many individuals may be affected

2.8 A single risk area may have multiple potential consequences and these may require separate assessment. It is also important to consider from whose perspective the risk is being assessed because this may affect the assessment of the risk itself, its consequences and the subsequent action taken.

2.9 By implementing these guidelines we will benefit from having more detailed definitions or samples for each consequence score. Table 1b shows a number of examples to use at a local level to exemplify various levels of consequence under the domain that covers the impact of the risk on the safety of patients, staff or public.

2.10 More examples have been added to the consequence categories in this revised version (Table 1b) as it is felt that extra guidance is required for risk assessment procedures and for training purposes.

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RISK ASSESSMENT SCORING GUIDELINES Table 1a – Assessment of the Severity of the Consequence of an Identified Risk: Domains, Consequence Scores and Examples of the Score Descriptors

Consequence score (severity levels) and examples of descriptors 1 2 3 4 5 Domains Negligible Minor Moderate Major Catastrophic Impact on the Minimal Minor injury Moderate injury Major injury Incident leading to safety of injury or illness requiring leading to long- death. patient, staff requiring no requiring professional term incapacity / Multiple permanent or public / minimal minor intervention. disability. injuries or (physical / intervention intervention. Requiring time off Requiring time off irreversible health psychological or Requiring work for 4-14 work for >14 effects. harm) treatment. time off work days. days. An event which No time off for <3 days. Increase in length Increase in length impacts on a large work Increase in of hospital stay of hospital stay number of patients. required. length of by 4-15 days. by >15 days. hospital stay RIDDOR/agency Mismanagement by 1-3 days. reportable of patient care incident. with long-term An event which effects. impacts on a small number of patients. Quality / Peripheral Overall Treatment or Non-compliance Incident leading to complaints / element of treatment or service has with national totally unacceptable audit treatment or service sub- significantly standards with level or quality of service sub- optimal. reduced significant risk to treatment / service. optimal. Formal effectiveness. patients if Gross failure of Informal complaint Formal complaint unresolved. patient safety if complaint / (stage 1). (stage 2). Multiple findings not acted inquiry. Local Local resolution complaints / on. resolution. (with potential to independent Inquest / Single failure go to review. ombudsman to meet independent Low performance inquiry. internal review). rating. Gross failure to standards. Repeated failure Critical report. meet national Minor to meet internal standards. implications standards. for patient Major patient safety if safety unresolved. implications if Reduced findings are not performance acted on. rating if unresolved. Human Short-term Low staffing Late delivery of Uncertain Non-delivery of key resources / low staffing level that key objectives / delivery of key objectives / service organisational levels that reduces service due to objectives / due to lack of staff. development / temporarily service lack of staff. service due to Ongoing unsafe staffing / reduces quality. Unsafe staffing lack of staff. staffing levels or competence service level or Unsafe staffing competence. quality <1 competence (>1 level or Loss of several key day day). competence (>5 staff. Low staff morale. days). No staff attending Poor staff Loss of key staff. mandatory training / attendance for Very low staff key training on an mandatory / key morale. ongoing basis. training. No staff attendance for mandatory / key training.

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RISK ASSESSMENT SCORING GUIDELINES Statutory duty No or Breech of Single breech of Enforcement Multiple breeches / inspections minimal statutory statutory duty. action. in statutory duty. impact or legislation. Challenging Multiple breeches Prosecution. breech of Reduced external in statutory duty. Complete systems guidance / performance recommendations Improvement change required. statutory rating if / improvement notices. Zero performance duty unresolved. notice. Low performance rating. rating. Severely critical Critical report. report. Adverse Rumours. Local media Local media National media National media publicity / Potential for coverage – coverage – long- coverage with <3 coverage with >3 reputation public short-term term reduction in days service well days service well concern. reduction in public below reasonable below reasonable public confidence. public public expectation. confidence. expectation. MP concerned Elements of (questions in the public House). expectation Total loss of public not being confidence. met. Business Insignificant <5 per cent 5-10 per cent Non-compliance Incident leading objectives / cost over project over project with national 10- >25 per cent over projects increase / budget. budget. 25 per cent over project budget. schedule Schedule Schedule project budget. Schedule slippage. slippage slippage. slippage. Schedule Key objectives not slippage. met. Key objectives not met. Finance Small loss. Loss of 0.1- Loss of 0.25-0.5 Uncertain Non-delivery of key including Risk of 0.25 per per cent of delivery of key objective / loss of claims claim cent of budget. objective / loss of >1 per cent of remote. budget. Claim(s) between 0.5-1.0 per cent budget. Claim less £10,000 and of budget. Failure to meet than £100,000 Claim(s) between specification / £10,000 £100,000 and £1 slippage. million. Loss of contract / Purchasers payment by results. failing to pay on Claim(s) >£1 time. million. Service / Loss / Loss / Loss / interruption Loss / Permanent loss of business interruption interruption of >1 day. interruption of >1 service or facility. interruption of >1 hour. of >8 hours. Moderate impact week. Catastrophic impact Environmental Minimal or Minor impact on environment. Major impact on on environment. impact no impact on environment. on the environment. environment

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RISK ASSESSMENT SCORING GUIDELINES Table 1b – Consequence Scores (Additional Guidance and Examples Relating to Risks Impacting on the Safety of Patients, Staff or Public)

Consequence score (severity levels) and examples of descriptors 1 2 3 4 5 Domains Negligible Minor Moderate Major Catastrophic Impact on Minimal Minor injury Moderate injury Major injury Incident leading to safety of injury or illness requiring leading to long- death. patients, staff requiring no requiring professional term incapacity / Multiple or public / minimal minor intervention. disability. permanent (physical / intervention intervention. Requiring time off Requiring time off injuries or psych-ological or Requiring work for 4-14 work for >14 irreversible health harm) treatment. time off work days. days. effects. No time off for <3 days. Increase in length Increase in length An event which work. Increase in of hospital stay by of hospital stay by impacts on a length of 4-15 days. >15 days. large number of hospital stay RIDDOR/agency Mismanage-ment patients. by 1-3 days reportable event. of patient care An event which with long-term impacts on a effects. small number of patients. Additional Incorrect Wrong drug Wrong drug or Wrong drug or Unexpected examples medication or dosage dosage dosage death. dispensed administered, administered with administered with Suicide of a but not with no potential adverse adverse effects. patient known to taken. adverse effects. Physical attack the service in the Incident effects. Physical attack resulting in past 12 months. resulting in Physical causing moderate serious injury. Homicide a bruise / attach such injury. Grade 4 pressure committed by a graze. as pushing, Self-harm ulcer. mental health Delay in shoving or requiring medical Long-term HCAI. patient. routine pinching, attention. Retained Large-scale transport causing Grade 3 pressure instruments / cervical screening for patient. minor injury. ulcer. material after errors. Grade 1 Self-harm Healthcare – surgery requiring Removal of wrong pressure resulting in acquired infection further body part leading ulcer minor (HCAI). intervention. to death or injuries. Incorrect or Haemolytic permanent Grade 2 inadequate transfusion incapacity. pressure information / reaction. Incident leading to ulcer. communication on Slip / fall resulting paralysis. Laceration, transfer of care. in injury such as Incident leading to sprain, Vehicle carrying dislocation / long-term mental anxiety patient involved in fracture / blow to health problem. requiring a road traffic the head. Rape / serious occupational accident. Loss of a limb. sexual assault. health Slip / fall resulting Post-traumatic counselling in injury such as a stress disorder. (no time off sprain. Failure to follow work up and administer required). vaccine to baby born to a mother with hepatitis B.

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RISK ASSESSMENT SCORING GUIDELINES 3. GUIDELINES ON LIKELIHOOD SCORING

3.1 Once a specific area of risk has been assessed and its consequences score agreed, the likelihood of that consequence occurring can be identified by using Table 2, Note that the Table is intended as guidance and we have attempted to populate the table with descriptions of our own probability and frequency descriptions. As with the assessment of consequence, the likelihood of a risk occurring is assigned a number from 1 to 5 the higher the number the more likely it is the consequence will occur:

Likelihood Scoring

1 - Rare 2 - Unlikely 3 - Possible 4 - Likely 5 - Almost certain

3.2 When assessing likelihood it is important to take into consideration the controls already in place. The likelihood score is a reflection of how likely it is that the adverse consequence described will occur. Likelihood can be scored by considering:

• frequency (how many times will the adverse consequence being accessed actually be realised?), or

• probability (what is the chance the adverse consequence will occur in a given reference period?)

Table 2 – Likelihood Scores (Broad Descriptors of Frequency)

Likelihood 1 2 3 4 5 Score Descriptor Rare Unlikely Possible Likely Almost Certain Frequency This will Do not Might happen or Will probably Will How often probably expect it to recur happen / undoubtedly might it/does it never happen / occasionally recur, but it is happen / happen happen / recur but it is not a recur, possibly recur possible it persisting frequently may do so issue / circumstances

Table 3 – Likelihood Scores (Time-Framed Descriptors of Frequency)

Likelihood 1 2 3 4 5 Score Descriptor Rare Unlikely Possible Likely Almost Certain Frequency Not expected Expected to Expected to Expected to Expected to to occur for occur at occur at least occur at least occur at least years least monthly weekly daily annually

3.3 It is possible to use more quantitative descriptions for frequency by considering how often the adverse consequence being assessed will be realised. A simple set of time framed definition for frequency is shown above in Table 3.

3.4 However frequency is not a useful way of scoring certain risks, especially those associated with the success of time limited of one off projects such as a new IT system

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RISK ASSESSMENT SCORING GUIDELINES that is being delivered as part of a three year programme or business objective. For these risks the likelihood score cannot be based on how often the consequence will materialise. Instead it must be based on the probability that it will occur at all in a given period. In other words a three year IT project cannot be expected to fail once a month and the likelihood score will need to be assessed on the probability of adverse consequences occurring within the project’s time frame.

3.5 With regard to achieving a national target, the risk of missing the target will be based on the time left during which the target is measured. The Trust might have assessed the probability of missing a key target as being quite high at the beginning of the year but nine months later if all the control measures have been effective, there is a much reduced probability of the target not being met.

3.6 This is why specific “probability” scores have been developed for projects and business objectives – see Table 4. Essentially, likelihood scores based on probability have been developed from project risk assessment tools from across industry. The vast majority of these agree that any project which is more likely to fail than succeed (that is, the chance of failing is greater than 50 per cent) should be assigned a score of 5.

Table 4 - Likelihood Scores (Probability Descriptors)

3.7 Table 4 can be used to assign a probability score for risks relating to time-related or one-off projects or business objectives. If it is not possible to determine a numerical probability, the probability descriptions can be used to determine the most appropriate score.

Likelihood 1 2 3 4 5 Score Descriptor Rare Unlikely Possible Likely Almost Certain Probability <0.1 per cent 0.1-1 per 1-10 per cent 10-50 per cent >50 per cent Will it happen cent or not?

4. RISK SCORING AND GRADING

4.1 Risk scoring and grading as follows:

• Define the risk(s) explicitly in terms of the adverse consequence(s) that might arise from the risk

• Use Table 1a to determine the consequence score(s) (C) for the potential adverse outcome(s) relevant to the risk being evaluated

• Use Table 2 to determine the likelihood score(s) (L) for those adverse outcomes. If possible, score the likelihood by assigning a predicted frequency of occurrence of the adverse outcome. If this is not possible, assign a probability to the adverse outcome occurring within a given time frame, such as the lifetime of a project or a patient care episode. If a numerical probability cannot be determined, use the probability descriptions to determine the most appropriate score

• Calculate the risk score by multiplying the consequence by the likelihood: C (consequence) x L (likelihood) = R (risk score)

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RISK ASSESSMENT SCORING GUIDELINES 4.2 The risk matrix in Table 5 shows both numerical scoring and colour bandings. The Trusts risk management processes are used to identify the level at which the risk will be managed in the Trust, assign priorities for remedial action, and determine whether risks are to be accepted, on the basis of the colour bandings and/or risk score.

Table 5 - Risk Matrix

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

KEY: Low Moderate Significant High risk risk risk risk

4.3 For grading risk, the scores obtained from the risk matrix are assigned grades as follows:

1-3 = Low Risk 4-6 = Moderate Risk 8-12 = Significant Risk 15-25 = High Risk

4.4 This model risk matrix has the following advantages:

• commonality across the NHS with a five by five matrix

• it is simple yet flexible and therefore lends itself to adaptability

• it is based on simple mathematical formulae and is ideal for use in spreadsheets

• equal weighting of consequence and likelihood prevents disproportionate effort directed at highly unlikely but high consequence risks. This should clearly illustrate the effectiveness of risk treatment

• there are four colour bandings for categorising risk

• even if the boundaries of risk categorisation change we are able to compare “scores” to monitor whether risks are being evaluated in a similar manner

5. RELATIONSHIP WITH INCIDENT SCORING

5.1 One of the features of the risk scoring system described here is that it includes a mechanism for directly scoring the consequence of an adverse event. When assessing risks, the consequence score is used to grade the consequence of events that might occur because of the risk in question. A certain amount of care is required when applying a score to an incident as there is danger that the incident might be given an overall actual impact score of 4 or 5 Consequence which could make the incident a “red” incident (see model risk matrix).

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RISK ASSESSMENT SCORING GUIDELINES

5.2 Refer to the Incident Reporting policy for detailed guidance.

6. CONCLUSION

6.1 As the Trust embeds risk management into respective governance arrangements. It has become more important than ever to make risk assessment easier and more consistent. It is essential that risks can be rated in a common currency within the NHS and other organisations, allowing financial, operational and clinical risks to be compared against each other and prioritised. Lastly, there needs to be confidence that tools for assessing risk can be used easily and consistently by a range of different professionals.

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EQUALITY IMPACT ASSESSMENT TOOL

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval.

Name of Document: Risk Management Strategy

1. Does the policy/guidance affect one group less or more favourably than another on the basis of: • Race No • Ethnic origins (including gypsies and travellers) No • Nationality No • Gender No • Culture No • Religion or belief No • Sexual orientation including lesbian, gay and bisexual No people • Age No • Disability No 2. Is there any evidence that some groups are affected differently? None 3. If you have identified potential discrimination, are any exceptions None Identified valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? No 5. If so can the impact be avoided? Not Applicable 6. What alternatives are there to achieving the policy/guidance Not Applicable without the impact? 7. Can we reduce the impact by taking different action? Not Applicable

For advice or if you have identified a potential discriminatory impact of this procedural document, please refer it to The Equality & Diversity Lead, Yeovil Academy, together with any suggestions as to the action required to avoid/reduce this impact.

Signed: Samantha Hann (Trust Risk and Patient Safety Manager) Date: 13th October 2017

MATERNITY RISK MANAGEMENT STRATEGY

TO BE ADDED

Appendix: 9 REPORT TO: Board of Directors REPORT BY: Trust Risk and Patient Safety Manager PRESENTED BY: Acting Chief Executive TITLE: Corporate Risk Register Report at end of Quarter 3 2017/2018 DATE: 31 January 2018

Action Required (Please select any which are relevant to this paper) For Decision For Assurance For Approval For Information

Executive Summary (Include the history, purpose of the report, any key issues to note and recommendations) This risk report aims to provide details of the key risks detailed on the Trusts risk register at the end of Quarter 3 2017/2018. The report focusses on those risks scoring Significant or Higher (12+) on the risk matrix. The top 7 risks to the organisation during Quarter 3 2017/18 are:

• Scale of current financial deficit as a proportion of turnover and non-achievement of financial control total during 2017/18 resulting in increased regulatory oversight by NHS Improvement (CR001) • Risk the Trust is unable to progress its strategy of integrated care within the desired timeframe and that the hospital becomes increasingly financially unsustainable (CR002) • Risk to delivery of Integrated Care Strategy - Closer working arrangements between MPH and Somerset Partnership resulting in decisions being made which has the potential to impact on the provision of services local to YDH and the involvement of YDH in the development of the Somerset Accountable Care System that do not align to YDH's strategy (CR007) • Risk of not being able to progress evacuation in the event of fire resulting with potential exposure to products of combustion (EFM065) • The Fire Compartmentation in Main Theatres is not of a sufficient standard to support, defend in place and aid progressive horizontal evacuation in the event of fire and smoke internal to Theatres (EFM085) • Risk to financial sustainability as a result of continuing deficits (F006) • Insufficient inpatient capacity and CAMHs support for children requiring acute admission to paediatrics (P002)

The table attached to this paper summarises the most significant risks and details the actions that are being taken to mitigate these. These have been summarised under the following headings:

• Corporate risks and risks to delivering Strategic Priorities • Risks linked to the operational pressure that the hospital has been experiencing • Clinical risks that would exist regardless of the level of pressure that the hospital is under • Trakcare risks • Symphony risks • Daycase UK risks

A full copy of the risk register can be found on YCloud Click on this link

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

Specific risks addressed by this paper (Include relevant risks and/or links to the corporate risk register/department risk register)

This risk report aims to provide details of the key risks detailed on the Trusts risk register at the end of Quarter 3 2017/2018. The report focusses on those risks scoring Significant or Higher (12+) on the risk matrix.

Implications/Requirements (Please select any which are relevant to this paper) Financial Legislation Workforce Estates

Patient Safety / ICT Quality of Care

Reference to CQC domains (Please select any which are relevant to this paper) Safe Effective Caring Responsive Well Led

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

Quarter 3 2017/18 Corporate Risk Register

Likelihood

Rare (1) Unlikely (2) Possible (3) Likely (4) Certain (5) Negligible (1) Minor (2) Moderate (3) ANA001 P002 CID001 ED001 ED018 HR002 M022 M023 MTH021 TC005 TC004 TC028

Consequence TC069 TC071 TW025 Major (4) CR003 CR001 CR004 CR002 CR008 CR007 MTH029 PH030 TC067 TW002 TW023 Catastrophic (5) EFM065 EFM085 F006

For grading risk, the scores obtained from the risk matrix are assigned grades as follows: 1-3 = Low Risk 4-6 = Moderate Risk 8-12 = Significant Risk 15-25 = High Risk

Quarter 3 2017/18 Corporate Risk Register

Q3 2017/18 Current Q3 2017/18 Residual No Risks L x C = Score L x C = Score Total number of 3 EFM085 The Fire Compartmentation in Main Theatres is not of a sufficient standard to support defend 3 x 5 = 15 1 x 3 = 3 new significant in place and aid progressive horizontal evacuation in the event of fire and smoke internal to risks added Theatres. PH030 Pharmacy Robot is now 11 years old and overdue for replacement - Failure of the pharmacy 3 x 4 = 12 3 x 4 = 12 robot would impact on ability to supply patient’s medication, Increased turnaround time for medicines and inventory and storage space issues. TC071 Risk that more local configuration results in greater downtime applying local configuration 4 x 3 = 12 3 x 3 = 9 after annual releases from Intersystems to Trakcare.Greater dependency on Trakcare Team to apply and maintain local configurations - safety risk. Total number of 2 TC005 Trakcare will go down post go-live for either necessary updates or unplanned faults. This 4 x 3 = 12 4 x 3 = 12 risks previously would impact ED and the rest of the Trust significantly as Trakcare will be the main source of scoring less information could affect patient safety and clinical decision making. than 12 which TC028 Design changes occur as part of Trakcare releases. These occur as a minimum of an annual 4 x 3 = 12 3 x 3 = 9 have increased basis. These will alter the way that the users access and enter data. within the Quarter and now form part of Corporate Risk Register Total number of 1 CR007 Risk to delivery of Integrated Care Strategy - Closer working arrangements between MPH and 4 x 4 = 16 3 x 4 = 12 risks previously Somerset Partnership resulting in decisions being made which has the potential to impact on on Corporate the provision of services local to YDH and the involvement of YDH in the development of the Risk Register Somerset Accountable Care System that do not align to YDH's strategy. which have increased from significant to high risks Total number 29 Corporate risks and risks to delivering Strategic Priorities of significant or CR001 Scale of current financial deficit as a proportion of turnover and non-achievement of financial control 4 x 4 = 16 3 x 4 = 12 high risks (12+) total during 2017/18 resulting in increased regulatory oversight by NHS Improvement CR002 Risk the Trust is unable to progress its strategy of integrated care within the desired timeframe and 4 x 4 = 16 3 x 4 = 12 that the hospital becomes increasingly financially unsustainable CR007 Risk to delivery of Integrated Care Strategy - Closer working arrangements between MPH and 4 x 4 = 16 3 x 4 = 12 Somerset Partnership resulting in decisions being made which has the potential to impact on the provision of services local to YDH and the involvement of YDH in the development of the Somerset Accountable Care System that do not align to YDH's strategy. F006 Risk to financial sustainability as a result of continuing deficits. 3 x 5 = 15 3 x 5 = 15

EFM065 The numbers and dependency of patients on wards in the main hospital plus the limiting factor of fire 3 x 5 = 15 2 x 3 = 6 sub- compartmentation increases the risk of not being able to progress evacuation in the event of fire with potential exposure to products of combustion EFM085 The Fire Compartmentation in Main Theatres is not of a sufficient standard to support defend 3 x 5 = 15 1 x 3 = 3

Likelihood – 1 = Rare, 2 = Unlikely, 3 = Possible, 4 = Likely, 5 = Certain Consequence – 1 = Negligible, 2 = Minor, 3 = Moderate, 4 = Major, 5 = Catastrophic 1-3 = Low Risk 4-6 = Moderate Risk 8-12 = Significant Risk 15-25 = High Risk Quarter 3 2017/18 Corporate Risk Register

in place and aid progressive horizontal evacuation in the event of fire and smoke internal to Theatres. CR008 Increased use of medical locums due to levels of vacancies of substantive medical workforce. 3 x 4 = 12 3 x 4 = 12 Significant financial impact for Trust which detrimentally impacts Trust's deficit and cash position. CR003 Continued high level of delayed transfers of care from YDH beds. Risk patients not cared for in the 3 x 4 = 12 2 x 4 = 8 most appropriate place, patient flow, Trust's ability to maintain performance standards, financial risk to opening additional escalation areas and risk to achievement of STF funding CR004 Risk that Symphony programme will not be sustainable and not able to identify funds to self-fund itself 3 x 4 = 12 2 x 3 = 6 and keep the programme running from April 2018. Risks linked to operational pressures that the Trust has been experiencing ED001 Overcrowding in ED at times of high demand 4 x 3 = 12 3 x 3 = 9 ED018 Partial closure of the Yeovil Health Centre Walk in Services - Risk that ED activity for minors & primary 4 x 3 = 12 3 x 3 = 9 care will increase as will the impact on capacity within ED. Additional financial & performance risks as could affect 4 hour performance & associated income. Potential overcrowding in waiting area & MIA. Potential to affect patient safety. HR002 Inability to deliver the target level of Level 3 Safeguarding mandatory training 4 x 3 = 12 3 x 3 = 9 M022 Medical patients nursed in non-medical environments 4 x 3 = 12 3 x 3 = 9 TW023 Increased emergency admissions, demand, acuity of patients, closure of community beds including 3 x 4 = 12 3 x 3 = 9 closure of Chard and Shepton Mallet Community Hospitals and problems with provision of care resulting in the opening of escalation areas, cancellation of elective activity and risks to quality of care MTH021 Lack of experienced and suitably qualified scrub staff - risk to meeting service demandswith the 4 x 3 = 12 2 x 2 = 4 potential that understaffed lists will be cancelled to ensure patient safety Clinical risks that would exist regardless of operational pressures P002 Insufficient inpatient capacity and CAMHs support for children requiring acute admission to paediatrics 5 x 3 = 15 4 x 3 = 12 PH030 Pharmacy Robot is now 11 years old and overdue for replacement - Failure of the pharmacy 3 x 4 = 12 3 x 4 = 12 robot would impact on ability to supply patient’s medication, Increased turnaround time for medicines and inventory and storage space issues. M023 Diabetes Consultant capacity insufficient to meet needs of endocrinology outpatient referrals plus 4 x 3 = 12 3 x 3 = 9 unable to provide optimum acute inpatient services TW025 Inability to retain registered nurses to adequately maintain safe staffing levels without use of 4 x 3 = 12 3 x 3 = 9 temporary staff CID001 Risk in meeting current levels of demand for echocardiography service due to inability to recruit 4 x 3 = 12 2 x 3 = 6 technicians MTH029 Theatre Services - Four sets of operating lights have been deemed obsolete following light analysis. 3 x 4 = 12 3 x 2 = 6 Spare parts are no longer supported. Repairs may not be possible. Risk to specific elective and emergency service provision if light repairs required. Risk that patients would have to be moved out of theatre to continue with procedure/surgery. TW002 Risk of patient falls resulting in moderate/major harm 3 x 4 = 12 2 x 3 = 6 ANA001 Inadequate number of junior medical staff to run a closed unit (ICU/HDU). The medical/surgical 4 x 3 = 12 2 x 2 = 4 management of Level 2 patients falls to the admitting consultant team, which could impact on the provision of care for these patients if treating teams are unable to attend the ICU. Staffing and provision of care is further impacted by the acuity of patients in the unit. TrakCare risks TC005 Trakcare will go down post go-live for either necessary updates or unplanned faults. This 4 x 3 = 12 4 x 3 = 12

would impact ED and the rest of the Trust significantly as Trakcare will be the main source of information could affect patient safety and clinical decision making. TC028 Design changes occur as part of Trakcare releases. These occur as a minimum of an annual 4 x 3 = 12 3 x 3 = 9 basis. These will alter the way that the users access and enter data. TC071 Risk that more local configuration results in greater downtime applying local configuration 4 x 3 = 12 3 x 3 = 9 after annual releases from Intersystems to Trakcare.Greater dependency on Trakcare Team to apply and maintain local configurations - safety risk. TC004 GPs not receiving information regarding patient episode due to emergency admissions discharge 4 x 3 = 12 3 x 2 = 6 summaries not being created & signed off by care provider within TrakCare. Risk GPs do not have full information and therefore unable to make accurate clinical assessments. TC067 Implementation of Phase 2 Ordercomms. Electronic results & discontinuation of paper. Risk that 3 x 4 = 12 2 x 3 = 6 patient results not viewed, actioned & signed off which could affect patient outcome TC069 Incomplete ED discharge summaries disappearing from centrally monitored outstanding discharge 4 x 3 = 12 1 x 3 = 3 summary list on TrakCare. Risk of discharge summaries not being completed and GPs not being informed of patients visit. Symphony Healthcare Services (SHS) risks There are no significant or high risks scoring 12 or above on the Corporate Risk Register for SHS Number of significant Current Risk Score Q2 17/18 Risk Score Risk (12+) that have been: L x C = L x C = Reduced 7 F006 Risk to financial sustainability as a result of continuing deficits. Although likelihood of risk reduced, 3 x 5 = 15 4 x 5 = 20 the risk is still high (15) and remains on the Corporate Risk Register CR003 Continued high level of delayed transfers of care from YDH beds. Risk patients not cared for in the 3 x 4 = 12 4 x 4 = 16 most appropriate place, patient flow, Trust's ability to maintain performance standards, financial risk to opening additional escalation areas and risk to achievement of STF funding Although likelihood of risk reduced, the risk is still significant (12) and remains on the Corporate Risk Register SHS013 Merger of Yeovil Health Centre and Oaklands Surgery by September 2017 - Lost of staff and reduced 3 x 3 = 9 4 x 3 = 12 patient lists leading to reduced service provision and income. P005 Reduced RSCN cover within the paediatric team on Ward 10 3 x 3 = 9 4 x 3 = 12 TW044 Deanery vacancies from August 2017. Risk to continued provision of quality & safe services with the 3 x 3 = 9 4 x 3 = 12 potential to delay patient treatment & outcomes. Risk to OOH service. Safe staffing levels may not be met. Financial impact of covering vacancies with locums &senior staff may have to act down. EFM048 Access to Fire Dampers. Unable to test all fire & smoke dampers thereby ensuring the integrity of fire 3 x 3 = 9 4 x 3 = 12 stopping between building compartments with risk of spread of fire and smoke in the event of a fire. Potential loss of ventilation services if dampers inaccessible. TC058 Trakcare Analytics not available for Pharmacy report generation. Unable to provide financial data, 2 x 4 = 8 3 x 4 = 12 invoice processing data & day to day operational information Archived 0 There are no significant or high risks scoring 12 or above that were archived within Quarter 3 2017/18

WORKFORCE COMMITTEE Minutes of the Workforce Committee held on 18 December 2017 at Yeovil District Hospital

Present: Maurice Dunster Non-Executive Director [Chair] Jane Henderson Non-Executive Director Mark Appleby Associate Director of HR and Organisational Development (OD) In Attendance: Paul von der Heyde Trust Chairman Ben Edgar-Attwell Company Secretary Natalie Ibrahim Staffing Manager Yvonne Thorne Staff Governor Observer Sue Bulley Public Governor Observer Shelagh Meldrum Director of Nursing and Elective Care Tracy Jones Head of Human Resources Jo Howarth Deputy Director of Nursing [items 5 – 6]

Apologies: Mark Saxton Non-Executive Director Simon Sethi Director of Operations & Urgent Care Tim Scull Medical Director Sue Oliver Head of HR – Symphony Tim Newman Chief Finance & Commercial Officer Noella Rowton Medical Workforce Manager

Action 1 WELCOME & APOLOGIES 1.1 In Mark Saxton’s absence, Maurice Dunster chaired the meeting and welcomed everyone present to the meeting. Apologies were noted as above.

2 DECLARATIONS OF INTEREST 2.1 There were no declarations of interest relating to items on the agenda. Any conflicts of interest declared by the executive and non-executive directors would be contained within the register to be presented at the Board of Directors on 20 December 2017.

3 MINUTES OF THE PREVIOUS MEETING AND MATTERS ARISING 3.1 The minutes of the previous meeting were approved as a true and accurate record.

3.2 In regard to matters arising, Maurice Dunster asked Mark Appleby about recent developments regarding Simply Serve and workforce unions. Mark Appleby advised that Unison had recently started petitions regarding the proposal for the creation of the subsidiary company, Simply Serve (SSL). He explained that concessions made in relation to the TUPE of staff to SSL have been implemented and agreed by YDH management. The Trust has agreed to match agenda for change terms and conditions for 5 years including any further enhancements within the 5 years. The Trust has also agreed to implement a ‘golden thread’ rule whereby pension and annual leave entitlements would remain in the event that a member of staff voluntary changes roles within SSL. There would also be recognition for bank staff moving to SSL as they would remain on NHS terms and conditions also. Mark Appleby said that Unison have been concerned with the creation of the company; he advised that the petitions that had been started were inaccurate which had resulted in unclear messages and confusion with staff. He further said that it was understood that limited numbers of staff attended both on and off site Unison meetings. The headline results of the staff survey also show that staff largely do not have any major concerns.

3.3 Maurice Dunster asked whether there was an update on action 4.4 of the previous meeting regarding the recent high turnover of midwives. Tracy Jones explained that there were no concerning reasons for the high turnover of midwives and that the trend had not continued. She added that a recent midwifery open day had taken place whereby a number of job offers were made; the midwifery department is subsequently at full establishment. Further work is underway to review the results of a recent survey to understand further development and improvement options.

3.4 It was decided that an update on Physician Associate roles [item 4.6, 21 November 2017 refers] would be deferred to the meeting in January 2018.

3.5 In regard to item 4.12 from the previous minutes relating to the reintroduction of the contracted and temporary staff slides, Mark Appleby explained that this was anticipated to be included within the performance pack for January’s meeting. Paul von der Heyde commented that there was a need to ensure adequate oversight of the breakdown between contracted and temporary staff numbers. Tracy Jones reported that she was due to meet with the Performance and Reporting Manager to understand how the Trust can utilise the ESR staff system further including the built in reporting elements. This in turn may reduce requirements resulting data available earlier in month.

Action sheet: 3.6 It was confirmed that action 5.6 from 20 September 2017 had been addressed through additional slides within the performance report; these provide a breakdown of hot, bank and agency shifts.

3.7 Tracy Jones confirmed that the easy guide for the completion and usage of staff changes forms and ESR position numbers was currently in the testing and review phases and would be circulated across the Trust in due course. Sue Bulley asked whether the previous issues discussed by the committee in relation to the accurate completion of position numbers had been resolved. Tracy Jones reported that this had been reviewed at the Risk Assurance Committee with far greater awareness of the importance and meaning of position numbers.

3.8 It was noted that the remaining actions list within the action sheet were not yet due.

4 WORKFORCE PERFORMANCE REPORT 4.1 Mark Appleby presented the previously circulated workforce performance report, which provides an overview of the Trust’s current workforce and position. The following was discussed:

4.2 . Contracted FTE has reduced by 7 FTE compared to 12 months previous however there 5 FTE additional nursing and midwifery staff, 12 FTE additional unregistered nursing and 12 FTE additional allied health professionals.

4.3 . Labour turnover in November 2017 was 18.9% which remains high against the target of 10-15%. Mark Appleby said that a further breakdown of medical and dental turnover would be bought to the January 2018 meeting due to this rising to over 25%. Jane Henderson was concerned regarding the medical turnover noting that this was unusual. Following a question from Tracy Jones, it was agreed that the data would be checked to ensure that medical trainees on rotation and the removal of non-working bank staff from ESR were not skewing the data. It was acknowledged that turnover rates should be calculated on contracted staff data only.

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4.4 . Reporting on current nursing vacancies is now broken down into individual categories. The total number of nursing vacancies within the report as of the 30 November was 37; Mark Appleby reported that this had reduced to 22 as of Friday 15 December due to continued nursing recruitment campaigns and a recent midwifery open day where all midwifery vacancies were filled. ICU nursing staff is also now fully established. Sue Bulley asked about paediatric nurse vacancies. Shelagh Meldrum advised that the Trust has now agreed a set of competencies and a programme of training to allow for paediatric nurses to be recruited from overseas; further focus will be on reducing paediatric vacancies in the new year alongside bespoke theatre recruitment days. Yvonne Thorne said that the Trust previously had a training programme for anaesthetic roles with universities in the region and asked whether it was possible for this to be reintroduced. Natalie Ibrahim agreed to liaise with the theatres management team regarding this.

4.5 . Natalie Ibrahim reported that the attitude and arrangements for overseas staff was much improved with overseas nurses feeling more supported in their roles. Wards are working closely with all staff and induction processes have changed alongside ongoing pastoral care with the estates team providing good support for accommodation and ongoing social events. As a result, the Trust is not losing large numbers of overseas nurses except for those who have not passed their objective structured clinical examinations. This number remains low. Other successes have been realised through some bank staff moving to fixed term contracts. Maurice Dunster stated that it was reassuring to hear these developments and that a ‘turning point’ had been reached for nursing vacancies.

4.6 . Jane Henderson asked how the Trust compared to other organisations within the region. Natalie Ibrahim informed the committee that YDH was assisting neighbouring organisations in nursing recruitment with support also provided for organisations within the sustainability and transformation partnership (STP). Shelagh Meldrum provided an overview of neighbouring organisations position with regard to vacancies where high agency usage is seen; this does result in YDH having to use higher rate agencies where required due to limited availability. It is therefore beneficial for YDH to help reduce vacancies across the region.

4.7 . Mark Appleby highlighted that there had been some recent successes in medical training vacancies for which there was only one vacancy remaining.

4.8 . On review of pay expenditure, Mark Appleby described how the nursing agency spend had reduced in recent months, however this has been offset with an increase in medical locum spend due to continued vacancies and long term sickness.

4.9 . Paul von der Heyde questioned the pay expenditure and temporary staffing graph and the decision to bundle bank and locum staff together. He asked for this to be broken down separately. The graph also suggests that agency spend remaining a significant portion of pay expenditure. It was agreed that a further MA breakdown would be provided with clarity on locum and bank spend and the reasons for usage.

4.10 . Natalie Ibrahim drew attention to the newly introduced graphs within the performance pack which outlined hot, bank and agency shift usage. Hot shifts are where an additional payment is made for a shift with short notice; as such staff were reluctant to accept shifts until they were offered as a hot shift; this process has since changed with a reduction in hot shifts being offered. The

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reduction in hot shifts could result in a potential saving of £53k per quarter. The data shows that this has not had a detrimental impact on bank fill rates. Paul von der Heyde asked whether there were safety controls in place for bank staff and shifts. Natalie Ibrahim confirmed that safety controls were built within the e- rostering system where warnings are raised for excess hours.

4.11 . Maurice Dunster asked about the effect of recent increased pressures within the hospital. Natalie Ibrahim stated that the Trust had seen an increase in sickness absence due to infection outbreaks. Shelagh Meldrum advised that the Trust had been in escalation in recent weeks however agency spend continues to decrease with increasing bank fill rates.

4.12 . The committee understood that the recent increase in absence rate was due to recent infection outbreaks such as norovirus. The Trust’s rate still remains low compared to the national average.

4.13 . Tracy Jones spoke to the employee relations slide where she confirmed that a review and data cleanse had taken place for reassurance on the reported numbers. Following a request, Mark Appleby agreed to liaise with the information department to show in-month changes for reporting. MA

4.14 . Mandatory training compliance remains above the target at 93.2%.

4.15 . Appraisals compliance saw a slight increase in November 2017 to 86.2% against the 90% target. Work is ongoing to ensure the internal target is met by the end of the financial year.

4.16 . ESR data has improved with the Trust now rated as 66th out of 445 organisations in the Woven Report. There have also been further improvements in the sign up of additional departments for the Even Better Place to Work initiative. A positive review meeting also took place with Heath Education England with a statement that this is the first time they have had no negative comments from students from any trust; this in relation to non-medical training.

5 SIX MONTHLY SAFE STAFFING REVIEW REPORT AND THE NURSE AND MIDWIFERY STAFFING REPORT 5.1 Jo Howarth attended the meeting to present the safe staffing review report. This report is to provide assurance to the Workforce Committee and Trust Board that wards have been safely staffed over the last six months. The Director of Nursing and senior nurse team continues to review and monitor staffing levels in line with national guidance and principles of safe staffing.

5.2 Jo Howarth reported that there has been an increase in acuity and dependency of patients and as such there have been increase in establishment across a number of areas; this increase in establishment does include uplifts in healthcare assistants (HCA). She explained that past submissions of the national safe staffing return have included Jasmine Ward although this has been closed in recent months; therefore staffing ratios have been skewed which will affect the Model Hospital dashboard data. A request has been made to understand whether it is possible to resubmit data for affected months.

5.3 The Trust is also re-implementing SafeCare on e-roster systems to accurately report the level of care required. A visit to other exemplar organisations is planned for shared learning and to improve the Trust’s processes. Ward 9A is already utilising the SafeCare system, therefore there is the intention to roll the process out across all

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wards. Jo Howarth advised that the next report will include further developments to include incident data.

5.4 Natalie Ibrahim drew attention to a challenge with the redeployment of staff where there is no requirement to fill the shift is not adequately reflected on the system. This could then incorrectly show as a staffing gap. As such, further training is taking place with relevant staff members to ensure that this data is accurate and up to date. Maurice Dunster suggested that this would be raised at the Board of Directors meeting during the workforce committee update.

5.5 The Trust is a pilot site for A-EQUIP (advocating for education and quality improvement). The Trust has 3 Professional Midwifery Advocates (PMAs) and is in the process of increasing this number. Tracy Jones reminded the committee of the work underway regarding the midwifery score and snap surveys to ensure that support is in place. Jane Henderson asked about the results of the survey relating to why a member would leave the organisation. Tracy Jones said that this covered a range of reasons such as retirement, career progression etc. She did note that the midwifery workforce has been stable for some time although there was a sudden spike in turnover. Maurice Dunster asked that the Trust reviews and monitors midwifery turnover and to report any sudden changes to the Workforce Committee.

6 UPDATE ON STAFF RETENTION IMPROVEMENT GROUP 6.1 The Trust had recently created a Staff Retention Improvement Group in response to the continued high staff turnover rate. The Workforce Committee had previously received an overview of the group where it was requested an update would be received on a three month basis.

6.2 Jo Howarth explained that since the last update, feedback has been received from NHS Improvement; they were reassured to see the action plan in place which is both robust and achievable. A number of recommendations were provided which are to be incorporated into the action plan going forward. One action concerns holding a career development day; this will take place in January 2018 where current staff would be are able to understand opportunities available to them. A policy and application process will be implemented for staff who may wish to gain further experience in other departments.

6.3 A review is also underway regarding the creation of band 4 nursing roles. It is intended that these members of staff will have a higher competency under a transition programme of pre-registered nursing. This programme would assist in retention of staff and also in the development of in-house registered nurses. It is anticipated that these roles can be implemented within existing budgets. Maurice Dunster asked how members of staff would be identified for this programme. Jo Howarth said it would include members of staff putting themselves forward but mainly where ward sisters spot enthusiastic staff who could be developed further. As such, managers need to be aware of the programmes and staff portfolios. Yvonne Thorne agreed, suggesting staff have their own passports to outline which career pathway they are on and the options available. It was agreed that further work would take place to support existing apprenticeships and also expanding this further.

6.4 Jane Henderson suggested these new programmes are added to the discussion points for staff appraisals. There needs to be a clear outline of the different career development pathways in place. Paul von der Heyde emphasised the need for robust appraisal processes to be in place for all members of staff to ensure professional career advice and developments are discussed. Maurice Dunster approved and reiterated the importance of not squashing talent.

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7 UPDATE ON PEOPLE PLAN PROGRESS 7.1 Mark Appleby spoke to the previously circulated people plan. This outlines plans in place to improve and develop a number of departments and topics such as health and wellbeing, leadership, management, organisational structure, people engagement and workforce planning. He drew attention to the fact that the plan was coming to its natural end; as such YDH is working with counterparts in neighbouring organisations with the aim to develop a shared plan across the region with shared values in place across acute trusts.

7.2 It was highlighted that a large number of the actions have been rated as green and either completed or good progress made. Mark Appleby reported by exception for actions where progress has stalled or has been delayed. The intention to develop competency based recruitment on values and behaviours has been delayed due to staff changes and turnover within HR senior recruitment leadership. The focus has therefore revolved around overseas recruitment. There is still the intention to develop competency based recruitment and this will be the focus in the coming year. Maurice Dunster asked whether this would include assessments on attitude to which Mark Appleby confirmed this would be included with good attitude being a key attribute for leaders and managers. Paul von der Heyde pointed out the requirement for managers and ward staff to receive training on recruitment processes to ensure good values of new members of staff. Maurice Dunster understood that this was a challenge within all organisations and supported the intention to move towards this recruitment process.

7.3 Mark Appleby outlined that development of a world-class talent management programme had been rated as red. This had previously launched in 2015 however it was not particularly well managed. Further development on a talent management programme for senior staff nurses is underway.

7.4 Progress on a Board development programme has been on hold although Mark Appleby said that there may be opportunities to commence this across the sustainability and transformation partnership with joint board development. Paul von der Heyde confirmed that this is possibly on the horizon with the need to embrace the entire system. Shelagh Meldrum suggested it might be worthwhile for Mark MA Appleby to liaise with Jonathan Higman, Acting Chief Executive.

7.5 A decision had been taken not to develop the recognition, reward strategy and incentive profit share scheme further.

7.6 It was acknowledged that development of the ‘Good Managers Handbook’ had not yet started with the intention to develop an internal programme and review the success of this initially. The creation of the handbook needs to be built into other processes.

7.7 People and staff engagement has been developed further with the introduction of the Even Better Place to Work scheme as previously presented to the committee.

7.8 Paul von der Heyde asked about other organisation’s progress with their people plans. Mark Appleby said that their plans are long text documents and it is difficult to review progress with actions. Paul von der Heyde said that there is a need to liaise with STP partners prior to the development of a new plan and schemes. Mark Appleby described how an organisational development day is to be planned for the new year with staff input. Paul von der Heyde asked Shelagh Meldrum whether she was in contact with her counterparts in the region on this piece of work; She confirmed that YDH is liaising and aligning on aspects such as the quality strategy

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and further advice and support can be offered for further developments.

7.9 The committee noted the full People Plan and the progress updates included.

8 ITEMS FROM THE MEETING FOR DISCUSSION AT THE BOARD OF DIRECTORS 8.1 The Workforce Committee agreed the following items would be highlighted at the next meeting of the Board: . Staff improvement discussion . Talent management in STP context . Staff survey headline results

9 ANY OTHER BUSINESS 9.1 Mark Appleby advised that the headline results from the staff survey have recently been received. The turnaround for the results has been quicker than in previous years. The Trust’s overall response rate is 58% compared to 61% last year; this is in comparison to the national average of 44%. The headline results are encouraging bearing in mind current pressures and concepts such as the vacancy freezes and budget reductions etc. Mark Appleby explained that the majority of the responses are either in line or above the national average. The full results would be presented MA/ to the Workforce Committee and the Board in due course. BEA

9.2 Maurice Dunster asked whether good progress had been made against the actions resulting from last year’s survey. Mark Appleby advised that there has been an improvement in headline results for the areas where further action and development was highlighted; team working has increased and health and wellbeing areas have improved. Tracy Jones said that there are plans to provide further support to managers and to work within teams; the Even Better Plan to Work scheme is one method of helping managers to become better managers which is in turn key to improving staff survey results.

9.3 Sue Bulley asked whether the previous discontent within the junior doctor staff group had been resolved. Maurice Dunster said that an update provided at the previous meeting suggested that this had improved; a further update could be provided at January’s meeting during presentation of the Guardian of Safeworking report. Shelagh Meldrum confirmed that the discontent had largely been resolved.

9.4 Sue Bulley also questioned whether staff members receive training on autism and other developmental disabilities. Shelagh Meldrum confirmed that a recent equality and diversity day had focussed on autism in November 2017 and that further days are planned to raise awareness and training.

9.5 Maurice Dunster thanked staff for their hard work; this is very much appreciated and he wished everyone a good Christmas break.

10 DATE OF THE NEXT MEETING 10.1 23 January 2018, 11:30am, Boardroom, Level 1, YDH.

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GOVERNANCE & QUALITY ASSURANCE COMMITTEE Minutes of a meeting of the Governance Assurance Committee held on 16 October 2017 at Yeovil District Hospital

Present: Jane Henderson [Chair] Non-Executive Director Mark Saxton Non-Executive Director Maurice Dunster Non-Executive Director Julian Grazebrook Non-Executive Director [from item 11 onwards] Paul von der Heyde Trust Chairman and Non-Executive Director

In attendance: Sam Hann Risk Manager Sue Bulley Public Governor Observer Bernice Cooke Head of Governance and Assurance Jo Howarth Associate Director of Patient Safety and Quality Shelagh Meldrum Director of Elective Care and Nursing Tim Scull Medical Director Linda Hann Freedom to Speak up Guardian [item 11] Belinda Ockrim Lead Nurse for Cancer [item 12] Ahmar Shah Consultant [item 13]

Apologies of those Jonathan Higman Director of Strategic Development invited to attend: Simon Sethi Director of Operations and Urgent Care Paul Mears Chief Executive

Action 1 WELCOME AND APOLOGIES FOR ABSENCE 1.1 Jane Henderson welcomed everyone present to the meeting. Apologies for absence were received as indicated above.

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

3 MINUTES OF THE PREVIOUS MEETINGS AND TO NOTE ANY ACTIONS / MATTERS ARISING 3.1 The minutes of the meeting held on 2 August 2017 were approved as a true and accurate record.

Matters arising: 3.2 An update/assurance was requested on the planned workshops to assess the quality impact of the Trust’s cost improvements plans. Jo Howarth confirmed that these had been held and quality impact assessments were undertaken for all relevant cost improvement schemes.

3.3 In response to a question about progress with the action plan following the national audit of dementia care report, Jo Howarth said that this would be discussed at the Dementia Steering group prior to presentation at the Governance and Quality Assurance Committee.

Action Sheet: 3.4 Jo Howarth reported that she had met Maurice Dunster to discuss the changes in the clinical governance and patient experience departments and had suggested that Ali Male, Complaints Manager, attend a future committee. Maurice Dunster BEA noted that he had expressed a wish to attend a meeting of the integrated learning

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form, but had still had not received an invitation. Sam Hann agreed to send him all future forum dates following the meeting. SH

3.5 An update was provided on the review of the medical pro forma in the light of the results of the dementia audit. The pro forma had been forwarded to consultants for review. Current restocking orders of the existing pro forma was been limited; the new version will be implemented once finalised.

3.6 The closure of the Magnolia Ward at Summerlands Hospital run by Somerset Partnership NHS Foundation Trust (SomPar) is to be recorded on the risk register (this action sits with Simon Sethi). The Committee were informed that SomPar have established a new specialist in-reach liaison team with the aim of intervening earlier in the pathway for patients with dementia. This was seen as a potentially beneficial change as well as mitigating the impact of the closure of Magnolia.

3.7 It was confirmed that the Trust’s mortality review policy had been finalised and uploaded to the Trust’s website in line with national guidance.

4 COMMITTEE’S TERMS OF REFERENCE – ANNUAL REVIEW 4.1 Ben Edgar-Attwell spoke to the previously circulated terms of reference which had been reviewed with Jane Henderson. The terms of reference had been updated to provide for the review of annual quality report/account to be reviewed, and agreement of future year’s quality indicators to be completed via electronic means if necessary. Other changes included the additional responsibility to approve any policies from nationally mandated guidance requiring Board committee level approval, along with an additional annex within the terms of reference outlining all the reports and strategies etc. to be reviewed by the committee. This was to ensure strategic and quality overview of relevant departments and committees. The committee was also renamed the Governance and Quality Assurance Committee.

4.2 Jane Henderson invited comments on the changes made to the terms of reference. Maurice Dunster noted that the quorum requirement appeared to be lenient with only two members made up non-executive directors. Paul von der Heyde suggested that in the event the Trust has 6 or more non-executive directors, quorum could require additional non-executive director attendance. Discussions took place regarding the attendees recorded as being in regular attendance and whether this should state expected regular attendance. Jo Howarth said that she had examples of terms of reference from other organisations and agreed to send these to Ben Edgar-Attwell who would review and liaise with Jane Henderson on the final wording for committee membership, attendance and quorum. BEA

4.3 Jane Henderson sought clarification of the committee’s proposed role in relation to the Trust’s joint ventures, strategic partnerships and subsidiary organisations. Paul von der Heyde noted that the Financial Resilience and Commercial Committee had a key role with regard to Symphony Healthcare Services (SHS) and that regular updates on the various organisations are received within Part 2 Board of Directors. In addition, a non-executive director sat on each subsidiary company board to provide additional oversight. Ben Edgar-Attwell wondered if there could be a case for an additional governance committee with a specific remit to review the governance arrangements for the Trust’s joint ventures, strategic partnerships and subsidiary organisations; such a committee could receive input and expertise from the Trust’s other Board assurance committees. Paul von der Heyde said he would want to consider the viability and effectiveness of such a proposal. PvdH

4.4 It was agreed that the terms of reference would be reviewed in further detail by Paul von der Heyde, Jane Henderson and Ben Edgar-Attwell outside of the BEA/ committee and circulated to all committee members once finalised. JH/ 2 | Page

PvdH 5 RISK ASSURANCE COMMITTEE TERMS OF REFERENCE 5.1 Tim Scull gave an update and explanation of the recently revised terms of reference for the Risk Assurance Committee, formerly known as the Quality Committee. A decision had been taken to rename the committee renamed following comments made in the Trust’s recent joint NHS Improvement (NHSI) and Care Quality Commission (CQC) Well-Led review. The change provided greater clarity on the purpose of the committee and associated reporting structures.

5.2 Jane Henderson noted that the document referred to the Governance Assurance SH Committee which should be updated to reflect the updated committee and naming structure. Subject to this correction, the terms of reference were approved.

6 GOVERNANCE ITEMS RAISED IN RECENT NHSI/CQC WELL-LED INSPECTION 6.1 Ben Edgar-Attwell tabled a paper outlining the governance points raised during the recent joint NHSI and CQC Well-Led inspection. This had covered a range of topics and had highlighting some good practice in governance, recognition of risks etc. alongside some areas for improvement.

6.2 One area in which the CQC had raised concerns related to the remit of the Quality Committee (now renamed Risk Assurance Committee – see item 5 above). The report had expressed a view that the committee’s scope appeared too extensive to provide depth and also had too much focus on health and safety. Tim Scull challenged this perception: while it was the case that the agendas for the particular set of meetings that the CQC had reviewed did have a focus on health and safety, this was not necessarily representative of the Committee’s activity in the round, and there is a rotation of topics throughout the year. A number of topics had since been amalgamated. He confirmed that the committee did review in detail the risks regarding each topic, therefor it made sense to highlight risk assurance in the Committee’s title. Jo Howarth observed that the previous name of the committee may have caused some confusion as other organisations have generally named their governance committees the quality committee; as a result the Trust has reviewed committee names and addressed this accordingly.

6.3 The CQC had commented that it was important to ensure that departmental risk registers cover clinical risks, including those identified from audit or incident reporting. Jo Howarth confirmed that clinical risks arising from various incidents recorded on the Strategic Executive Information System (STEIS) would be added to the risk register. Sam Hann reported that plans were in place to meet relevant departments to review their departmental risk registers. Some risks will be relevant to a number of departments though the risk register system only allows the risk to be allocated to one lead department; the current process is to note this risk within other departmental registers. This underlined the importance of ensuring that risks are allocated to the most appropriate department while also being referenced where applicable. Jo Howarth cited the example of Trakcare, whereby the risks relating to TrakCare and the Trust’s electronic patient record system sat with the TrakCare team, although their impact may concern other departments.

6.4 Jane Henderson asked whether the Committee should be concerned about issues with the ownership of risks and their oversight by the Board and its committees? Sam Hann responded that there was clear ownership in place with relevant senior teams aware of risks concerning their departments. Departmental risks are noted and raised in departmental meetings. All risks rated 12 or above are captured on the Corporate Risk Register and reported to the Committee and Board, irrespective of which department they sit within. Risks on the Corporate Risk Register are also on departmental registers. Tim Scull confirmed that he has assurance that clinical risks are correctly scored on the register with relevant ownership of risks. 3 | Page

6.5 Maurice Dunster asked if the Trust would be able to adequately demonstrate its systems and processes to the CQC on a future inspection. Sam Hann said that the Trust has good recognition of risk and accountability and would be able to illustrate this.

6.6 The CQC report also stated that the Board needed to be informed on serious incidents and complaints and be assured that learning has been embedded. Maurice Dunster asked what is defined as a serious complaint as there is no national definition; serious incidents, in contrast, are defined nationally. Jo Howarth said that an additional slide to the Board performance pack was being developed to provide additional oversight. Shelagh Meldrum drew the Committee’s attention to the overview of recently closed complaints and incidents which she had presented at the last Board of Directors meeting. Additional changes are also to be made to the quarterly Quality Report as presented at the Governance and Quality Assurance Committee. The changes in the complaints procedures and the patient experience team had been noted since the previous inspection.

6.7 Maurice Dunster observed that a large number of complaints continue to be about communication: what was being done about this? Jo Howarth reported that the Trust had recently commissioned some advanced communications training. Bernice Cooke said that the complaint process includes conciliation meetings with complainants, from which action plans are drafted outlining where feedback and learning is required; the process is more robust than it had been previously. Shelagh Meldrum added that the action plans are then shared with the complainant. Bernice Cooke observed that one of the goals of the recently created Integrated Learning Forum was to provide additional assurance on shared learning.

6.9 Maurice Dunster said that further evidence of trust wide learning was still required. Tim Scull explained that there were a number of processes in place for shared learning, such as through trust-wide governance sessions with actions taken on common themes. He acknowledged that there were difficulties in changing existing cultures. Shelagh Meldrum agreed; it was important to review the processes that were implemented as to their suitability and whether they were working. It was agreed that feedback from trust-wide governance meetings is to be disseminated to all departments and divisions. Tim Scull and Shelagh Meldrum suggested that TS/SM departmental governance meeting minutes be reviewed within trust-wide governance.

Jane Henderson said that it was encouraging to hear that there are number of actions underway following the recent pilot Well-Led inspection. The Committee would take a continuing interest in how these were developing.

7 PATIENT SAFETY, QUALITY AND EXPERIENCE REPORT 7.1 Bernice Cooke presented the previously circulated Q2 Patient Safety, Quality and Experience Report.

7.2 Three new Patient Safety Alerts were received in quarter 2 with two of these currently open and under review. The Trust currently has 8 other Patient Safety Alerts open or under observation with 3 alerts closed in the quarter.

7.3 The Trust maintained a consistent score throughout quarter 2 for Safety Thermometer results with 96% of patients being recorded as ‘free of new harms’. The paediatric ward and maternity services use a different Safety Thermometer tool from the rest of the Trust; the Harm Free Score for maternity remained at 100% whilst the paediatric ward saw a drop in the overall score for quarter 2. Bernice Cooke said that this was under investigation with an understanding that the correct recording process may not have been completed. It was requested that this 4 | Page

explanation be included within the report. Following further discussion, it was requested that paediatrics performance be shown in graphical format going BC forward. Bernice Cooke agreed to action this for future reports.

7.4 The Trust was committed in 2017 to reducing hospital acquired pressure ulcers by 50% from the 2012/13 baseline. This was being achieved by an overall reduction of 62% in April 2017. Since this date, the Trust has utilised statistical process control to establish the average number of pressure ulcers and determine standard deviations. It was noted that a number of patients arrive at the Trust with existing skin damage; this information has been fed back to the Clinical Commissioning Group. The countywide Pressure Ulcer Collaborative have agreed regional thresholds and criteria with a Trust action place managed by the Pressure Ulcer Steering Group to achieve further reductions and prevention of pressure ulcer risks in patients. A zero tolerance approach has been adopted Trust wide.

7.5 The Trust saw 190 patient falls for quarter 2 compared to 227 for the same period last year. On a month-by-month basis, there were a number of wards which saw an increase in patient falls; further training had been provided within these areas. Bernice Cooke said that the Trust had recently procured additional falls alarms and also identified patient falls in bathrooms as an issue: a review of these environments is underway with refurbished areas having higher toilets. Following a question from Jane Henderson, Jo Howarth said that the TagCare concept was working well and had been instrumental in the Trust’s reduction in falls.

7.6 The infection control dashboard was noted. Jo Howarth said that there had been two cases of MRSA infection attributed to the Trust from the previous year.

7.7 Quarter 2 saw a total of 1697 incidents compared to 1687 incidents reported in the same period last year. All patient safety incidents are reviewed by the Incident Reporting Lead at point of notification and, where necessary, these are validated with the reporter and their Department Manager. There had been a decrease in the number of investigations commissioned for adverse (serious untoward) incidents in quarter 2 compared to this time last year. There were no apparent themes connecting these incidents. The Trust is now aligned with neighbouring organisations in terms of the number of root cause analysis investigations commissioned. The Trust is also adhering to national definitions. The Committee noted the detailed actions and learnings from incidents and reviews captured within the Quality Report.

7.8 Safeguarding activity remains constant overall. However, the number of learning disability and domestic abuse referrals is increasing, with both specialist practitioners now in post and raising awareness and providing advice. Bernice Cooke noted that there is a need to ensure that there are appropriate Deprivation of Liberties Safeguards (DoLS) in place throughout the organisation. There had been a significant increase in the number of requests, reflecting both changes in the cohort of patients and also an improvement in the knowledge of and advice by practitioners.

7.9 Safeguarding training is delivered to level 2 for all staff members, and level 3 child protection and adult safeguarding training to relevant members of staff. A review of staff groups is being undertaken as to who is eligible and requiring further training. The content of the safeguarding initiatives and dashboard as outlined within the BC report was noted.

7.10 Bernice Cooke reported that 19 formal complaints had been received in quarter 2 compared with 37 in the same quarter the previous year. A number of different process were now in place with the Trust aiming to resolve all complaints as quickly and easily for the complainant as possible. The Complaints Policy is still awaiting 5 | Page

ratification due the postponement of the last meeting. It was suggested that the policy be circulated to Governance and Quality Assurance Committee members for additional oversight and understanding. The Committee requested that further BC information be included in the report on the closed complaints; Bernice Cooke agreed to review this for future reports.

7.11 Bernice Cooke noted that the Friends and Family Test (FFT) response rate remains low; the Trust plans to boost the response rate through iWantGreatCare by holding meetings across departments to increase engagement. The “likely to recommend” scores remain consistently high.

7.12 The committee noted the Trust’s compliance position with regard to National Institute for Health and Care Excellence (NICE) guidance. Further detail was included in the Quality Report with none having a risk score higher than 6. The Trust’s risk scoring has been aligned with other organisations.

7.13 Tim Scull spoke to the clinical outcomes section including the Copelands Risk Adjusted Barometer (CRAB) data. Data on qualitative areas, such as readmissions, were in line with national numbers. The rates of acute kidney injury were decreasing. The Trust has remained below the normal mortality O/E (observed number of adverse outcomes/predicted number of adverse outcomes) ratio of 1.00 throughout the year.

7.14 A summary of the litigation and coronial activity was included within the quarterly report and was noted by the Committee.

7.15 Jane Henderson noted that an internal audit had been recently complete for end of life care and asked how this would be reviewed? Jo Howarth said that the End of Life Steering Group was preparing the action plan and this would be presented to the Governance and Quality Assurance Committee in due course along with BC ongoing work to be included within the Quarterly Report. BEA

8 MORTALITY REVIEW REPORT 8.1 Jo Howarth explained that mortality data had previously been included within the Quarterly Report; however bearing in mind that the national Learning from Deaths guidance states that mortality data must be reported to the Board of Directors, a decision has been taken to create a separate report. Since the last Governance and Quality Assurance Committee, the Mortality Review Policy has been approved and uploaded to the Trust’s website as per national requirements.

8.2 The Trust monitors mortality rates through the Summary Hospital-level Mortality Indicator (SHMI) as reported by NHS Digital and through the Copelands Risk Adjusted Barometer (CRAB) system. The Trust is utilising the Structured Judgement Review (SJR) from the Royal College of Physicians to undertake mortality reviews.

8.3 The Mortality Review Report reported the total number of deaths in the Trust and those in quarters 1 and 2 which were subject to a case review. Tim Scull explained that the initial intention was for all deaths to be reviewed, however the SJR tool is not as quick and easy as first believed; as such the Trust will review a representative group in line with national guidance stating that at least 25% of hospital deaths should be reviewed. The review findings revealed a need for more consistent communication with relatives, and issues around continuity of care for patients.

8.4 Two deaths had recently been reviewed under the Complaints and Concerns Management Policy. It is anticipated that further guidance in relation to deaths and bereaved relatives will be received from NHSI and NHSE; current processes may 6 | Page

be reviewed once this guidance has been received which links with ongoing work in regard to treatment escalation plans and do not attempt resuscitation forms.

8.5 Tim Scull recalled that NHSI had recently flagged that the Trust’s hospital standard mortality ratio (HSMR) had increased. Tim Scull provided an overview of the coding processes noting that further work was to be undertaken to improve this. Following a review of clinical coding procedures, he expected that the ratio would fall to more normal levels over the coming months. A retrospective audit on the coding of deaths in September was being completed. In response to a question from Jane Henderson, Tim Scull provided assurance that the cause of the increasing HSMR has been reviewed and resolved.

8.6 Jo Howarth said that the end of life care plans had been discussed at trust-wide governance sessions and further work being undertaken to ensure dissemination internally and externally. 9 RISK ASSURANCE COMMITTEE Q2 REPORT 9.1 Tim Scull spoke to the report. The following was discussed/noted:

9.2 The committee had recently reviewed and updated its terms of reference as discussed earlier. Over 40 different topics had been reviewed of which 22 topics stayed at the same rating. 6 were RAG scored as more at risk than rated on previous reviews with 10 scoring as less risky than previous. It was noted that a number of topics had moved from being RAG scored red to either blue or green; showing much improvement. A number of topics had been merged and 8 topics had been added to the topic list.

9.3 One of the topics rated as more risky included cleanliness of environment. The committee heard an overview of current cleaning procedures, and Shelagh Meldrum confirmed that, following this review, a number of risks had been identified and since been recorded on the Trust’s risk register. Diagnostic tests and imaging had also moved from a blue to an amber RAG score essentially due to an increase in radiology vacancies. Equality and diversity had also been discussed in detail at the Risk Assurance Committee where it was noted that Shelagh Meldrum had been nominated at the executive lead for this area with work being undertaken following the recent pilot Well-Led inspection. The committee discussed in detail the plans to increase awareness of various equality and diversity groups.

9.4 Tim Scull concluded that the Risk Assurance Committee was working well and becoming more knowledgeable on the topics since they were first reviewed. Paul von der Heyde asked whether Tim Scull agreed with the comments by the CQC in the recent pilot Well-Led review to which Tim Scull said that the committee is a useful tool and does indeed cover many aspects and topics throughout the Trust. He did not believe that its remit was too wide and reiterated that the Committee was reviewing the various topics in detail.

10 VERBAL UPDATE ON THE INTEGRATED LEARNING FORUM 10.1 Jo Howarth gave an oral update on the new Integrated Learning Forum which is designed to provide assurance that the Trust is meeting its obligations in relation to learning as set out in the Learning, Candour, and Accountability December 2016 and NHS England SI Framework.

10.2 The forum is to commission a deep dive and thematic review of the discharge process which will inform an improvement programme; this will have a strong focus on delayed transfers of care and complex needs alongside the new Home First project.

10.3 Jane Henderson requested that the Governance and Quality Assurance Committee 7 | Page

receive an update report from the forum at each quarterly meeting. Jo Howarth confirmed that this will be developed going forward. Mortality reviews are becoming embedded with continuous learning taking place. JHo

11 FREEDOM TO SPEAK UP GUARDIAN Q1 & Q2 REPORT (Julian Grazebrook arrived at the meeting )

11.1 Linda Hann presented the Freedom to Speak up Guardian Q1 and Q2 reports. She provided an overview of the role explaining that she had taken over the role from April 2017. Since April, the Trust had carried out communications to ensure that staff members were aware of the Freedom to Speak up Guardian.

11.3 In quarters 1 and 2, 8 concerns have been raised - a low number compared to other organisations. Following a question from Jane Henderson as to whether this role was intended to take the place of whistleblowing, Jo Howarth explained that this role and whistleblowing remain separate although they are self-eveidnetly linked in that they deal with patient concerns.

11.4 Tim Scull asked whether we knew why the Trust had a low number of concerns raised through the role as compared to other organisations. Linda Hann suggested that this could be explained by the fact that YDH promotes an open culture. Mark Saxton agreed: many members of staff raise and track concerns through their direct line manager. Maurice Dunster said that the national guidance does not appear to recognise that organisations may have strong internal processes and staff may use these to raise concerns or issues rather than escalate to the Freedom to Speak up Guardians.

11.5 Jane Henderson asked whether the remit of the role extends to the Trust’s subsidiary companies. Jo Howarth and Julian Grazebrook agreed that as part of the YDH group, the remit would extend to the subsidiary companies although it was noted that there are separate guidelines for primary care Freedom to Speak up Guardians.

11.6 Ben Edgar-Attwell reported that the Trust is also appointing a second Guardian, Fiona Rooke, who will take on this position alongside her Staff Governor role.

12 NATIONAL CANCER PATIENT EXPERIENCE SURVEY RESULTS 12.1 Belinda Ockrim, Lead Nurse for Cancer, attended the meeting to present the results of the National Cancer Patient Experience Survey (CPES).

12.2 Belinda Ockrim explained that the survey is a snap shot of cancer patients’ experience of care from visiting their GP, referral to YDH, diagnostic and treatment phases and related care for all patients aged over 16 years who had a day case or inpatient episode related to a primary cancer diagnosis. She did note that the 2016 cohort of patient was smaller than previously although there was a good response rate; only questions with 21 or more responses were able to provide further detail.

12.3 Belinda Ockrim noted that the overall score in 2016 was lower than 2015 although still higher than the national average. The Trust was a positive outlier against the national average across a number of areas such as the patient feeling that they were as soon as necessary, patients being given practical advance and support in dealing side effects of treatment, hospital staff giving information on getting financial help (which save a big drop in the national average), hospital and community staff working well together and the length of time attending clinics and appointments was right. The Trust had one negative outlier for patients being given information about what should/should not do post-discharge. The breast service saw a significant drop for this scoring compared to the 2015 results, and this required MDT review. 8 | Page

12.4 Comparing to other organisations, YDH appears in the middle group with the large majority of responses above the expected range. Belinda Ockrim said that because of the long delay between the survey and the results, it was regrettable that results from action plans do not tend to flow through in the immediate following year.

12.5 Jane Henderson asked whether the Trust was aware of the reasons for the changes in scoring compared to the previous year albeit that most of the differences were marginal. Belinda Ockrim said that because YDH’s cohort of patients was small, the scoring can be more erratic than in larger trusts. Belinda Ockrim provided examples of some of the comments from patients which covered a range of different areas and included both positive and negative aspects. Some comments related to the fact that YDH does not have radiotherapy services; there is a need to publicise what services the Trust has and also the reasons why certain services are not commissioned at YDH. Belinda Ockrim presented the 2015 action plan against the 2016 results.

12.6 In regard to the question about patients taking part in research, Belinda Ockrim said that there had been a national reduction in cancer research programmes. She assured the committee that where clinical trials are available, these are offered to patients. The wording of the question was also not clear, creating difficulties in understanding that research and clinical trials are the same thing. Support from health and social services saw more males scoring positive as opposed to females scoring negative; however the response rate was higher for females with 27 responses received in total in the 2016 cohort.

12.7 The initial thoughts for the 2016 results action plan were presented to the committee and covered a wide range of areas from data sampling to sharing the results with primary care, particularly around the referral processes.

12.8 Tim Scull asked whether the Trust was aware of the reasons for the drop in the scoring for the breast service in particular. Belinda Ockrim said that the reasons are currently unknown as the service was largely unchanged from the previous year where scoring was higher. It is important to review the actions by other Trusts and for shared learning to take place where possible.

12.9 Sue Bulley asked where the fluctuation in oncology staff and vacancies has had an adverse effect on patients. Belinda Ockrim acknowledged that this has been an issue with the service affected. The position is likely to improve now that the service was more stable although the ratings for next year could be expected to drop bearing in mind the staffing issues faced this year.

12.10 Jane Henderson thanked Belinda Ockrim for presenting and providing a position on the results. The dedication from staff members to ensure an excellent service was clear and this was evident in the Trust being largely a positive outlier across all areas surveyed.

13 VERBAL UPDATE ON THE ROYAL COLLEGE OF OBSTETRICS AND GYNAECOLOGY REVIEW 13.1 Ahmar Shah attended to give a brief verbal overview of the recent Royal College of Obstetrics and Gynaecology (RCOG) review.

13.2 The RCOG had been initially invited to review the maternity services however it was later decided to extend this review to cover gynaecology services. The main point from the review was that the RCOG has found that the Trust provided a safe and sustainable service. Some recommendations were made which included suggested improvements to the relevant dashboards and doctor job planning to 9 | Page

ensure the services were effective and efficient. The Trust had been aware that improvements were required for the relevant service dashboards however the implementation of TrakCare had stalled this piece of work; it is intended that more regular reviews of the data would be undertaken. In regard to the job planning improvements, Ahmar Shah said that a further review may be undertaken although some changes were already in place with further changes due from January 2018.

13.3 Tim Scull said that the initial verbal feedback from the review was generally positive. During the review, the team reviewed in detail the department and current processes. One viewpoint noted during the review was that that executive team needed to maintain an appropriate level of oversight and scrutiny whilst allowing the department enough space to review and resolve its own issues first. The RCOG did suggest that there needed to be further clarity of governance and a review of the current meeting structures to ensure suitable ownership of issues and actions. Jo Howarth confirmed that Bernice Cooke is to undertake a review of the governance structures and ensure that these are streamlined.

13.4 Jane Henderson said that it was good to hear that a number of issues had already been reviewed and rectified. Ahmar Shah said that the team were supportive of the suggested improvements and that it was encouraging to hear that the services are safe and sustainable. Jane Henderson and Sue Bulley said that they had recently had a walkaround of the maternity department and had been impressed with the services and the attitude within the department.

13.5 The written report is due over the next couple of months to which the Trust will have the opportunity to review for factual accuracy issues. A final version will then be received.

14 CORPORATE RISK REGISTER Q2 14.1 Sam Hann reported that questions had been raised about the circulation of the risk register and whether a high level version only should be presented at hospital management team (HMT) meetings and the Board of Directors. Paul von der Heyde said that he was of the opinion that the full version should be received to which Jane Henderson agreed. It was confirmed that the Board assurance committees will continue to receive the full register.

14.2 Sam Hann spoke to the 6 top rated risks in the organisation. The pressures on the Trust and their impact were becoming more evident; these included risks regarding the scale of the financial deficit, a risk to the Trust’s cash flow, the risk of not being able to secure an outcome based contract, continued high levels of delayed transfers of care, a risk of not being able to progress evacuation in the event of a fire and insufficient inpatient capacity and child and adolescent mental health support. More departments are raising risks in line with the increase pressure on the organisation: 7 new risks were added in quarter 2 compared to the first quarter.

14.3 A number of risks also have an increased rating. The committee discussed a risk regarding the discharge summaries to primary care not being viewable on the system. This has been raised with the software teams and suppliers to be resolved. In terms of the financial risk, the Trust’s position is currently adverse to plan although this was at the end of quarter 2 with further mitigating actions now in place.

14.4 Following a question from Jane Henderson, Sam Hann confirmed that she meets with all risk owners to review their risks and the ratings alongside these prior to the risk register report being compiled.

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15 MINUTES FROM COMMITTEE’S SUB GROUPS 15.1 The minutes of the following group meetings (which report to the Governance Committee) were noted:

. Clinical Outcomes Committee . Patient Safety Steering Group . Information Governance Steering Group . Risk Assurance Committee . Emergency Preparedness Resilience Response Group It was confirmed there were no significant items of exception for reporting.

16 KEY ITEMS TO HIGHLIGHT TO THE BOARD 16.1 It was agreed that the following items would be highlighted to the Board of Directors: 1. Mortality Report 2. Freedom to Speak up Guardian Report 3. National Cancer Experience Survey Results 4. Discussions about learning from complaints

17 ANY OTHER BUSINESS 17.1 It was confirmed that a TrakCare update would be received at the next Governance and Quality Assurance Committee.

18 DATE OF NEXT MEETING 18.1 Monday 20 November 2017, 13:30 – 17:00, MR6, Level 1, YDH

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g GOVERNANCE & QUALITY ASSURANCE COMMITTEE Minutes of a meeting of the Governance & Quality Assurance Committee held on 20 November 2017 at Yeovil District Hospital

Present: Jane Henderson [Chair] Non-Executive Director Maurice Dunster Non-Executive Director Mark Saxton Non-Executive Director

In attendance: Paul von der Heyde Trust Chairman and Non-Executive Director Shelagh Meldrum Director of Nursing and Elective Care Tim Scull Medical Director Jo Howarth Deputy Director of Nursing Bernice Cooke Head of Governance and Assurance Samantha Hann Risk Manager Ben Edgar-Attwell Company Secretary

Presenters: Specified within the minutes

Apologies BDO Representative of those Sue Bulley Public Governor Observer invited to Yvonne Thorne Head of Operation Resilience attend: Simon Sethi Director of Operations and Urgent Care

Action 1 WELCOME AND APOLOGIES FOR ABSENCE 1.1 Jane Henderson welcomed everyone present to the November meeting, whose specific purpose was to review the 2016-17 annual reports from various specialities. Apologies for absence were received as indicated above.

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

3 INFECTION PREVENTION AND CONTROL ANNUAL REPORT 3.1 Rachael Grey, Infection Control Nurse Consultant, was welcomed to the meeting to present the infection prevention and control annual report, from which the following key points were highlighted and discussed:

3.2 . The Trust continued to sustain focus and energy on the infection control agenda, sharing key learning and best practice against the need for complaint with the national targets.

3.3 . There had been two positive blood culture results for MRSA from the same patient and a single episode of infection. There was a need to review processes to ensure that such cases were correctly recorded and not attributed as two separate cases.

3.4 . The Trust had recorded nine clostridium difficile infections against a tolerance target of eight cases. Following investigation, it was determined that only three cases were attributed to a lapse in care in relation to sub-optimal antibiotic prescribing and cross infection; learning has been taken from these cases. Jane Henderson asked whether the learning is disseminated beyond the infection control department, to which it was confirmed that learning is shared within wards alongside further learning across the county.

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3.5 . 2016/17 saw successful management and maintenance of a low incidence of norovirus. The Trust has different processes now in place for the management of infections such as norovirus to ensure containment; these have proved successful with quicker turnaround times experienced.

3.6 . The Trust has implemented a new cleaning regime Trust-wide utilising innovative, evidence-based products. One example is through the use of a product called TECcare which was a superior product to standard bleach and rendered surfaces uninhabitable to bugs. YDH is one of only three hospitals using TECcare at the current time. This new regime had now been in place for over 12 months with continued monitoring of infection levels and incident rates; the Trust has seen very low levels of infection. Alongside this, the Trust has commissioned an UV Ultra machine which uses UV light as a cleaning process. Following a question from Mark Saxton, Rachael Grey said that one of the benefits of the machine is that it reduces the cleaning time resulting in a quicker turnaround time in standard cleaning processes, as well as when a deep clean is needed after an infection outbreak.

3.7 . Maurice Dunster asked whether there was a reason why antibacterial hand gel was not on the main entrances to the hospital buildings as he had observed elsewhere. Rachael Grey said that this was a considered decision: the use of gel was promoted at the point of patient care (such as at the entrance to wards); and there was a risk that if installed at hospital entry points patients might think this sufficient and believe they no longer needed to use it again upon ward or clinic entry.

3.8 . Compliance with antibiotic prescribing guidelines remains largely above 90% with anti-microbial compliance higher than the regional average (97% vs. 91%).

3.9 . Jane Henderson asked for the reason for the exemption of carbapenamase- producing enterobacteriaceae (CPE) screening within the region compared to other parts of the country. Rachael Grey said that this is because the infection is not seen within this area. The screening is invasive and uncomfortable for the patient; a risk assessment basis is in place and screening is taking place where required.

3.11 The committee thanked Rachael Grey for attending and presenting the infection prevention and control annual report.

4 MEDICINES MANAGEMENT ANNUAL REPORT 4.1 Andrew Prowse, Chief Pharmacist, and Sharon Hodges, Pharmacist, were welcomed to the meeting to present the medicines management annual report, from which the following key points were highlighted and discussed:

4.2 . The prescribing of antibiotics continues to be closely monitored by pharmacy. The Trust has a red RAG scoring against the indication for antibiotics and against stop/review date on prescription charts. The Committee were given an assurance that this position should improve once electronic prescribing is introduced with the next phase of TrakCare.

4.3 . Andrew Prowse informed the Committee that a review of committee and group structures is to be undertaken with it anticipated that some will merge with a shift in focus and to provide greater assurance.

4.4 . The number of discrepancies with drug histories remains a significant problem. The Trust has now introduced the use of EMIS viewer across the organisation, with a pharmacy enabling policy allowing pharmacists the ability to make changes as required. Andrew Prowse confirmed that the Trust is not an outlier 2 | Page

with regards to discrepancies. YDH does include every patient in KPI data whereas not all trusts do this.

4.5 . The Trust’s baseline medicines audit continues to focus on true missed doses and captures accurate information relating to the cause of the missed/omitted dose and the class missed. It was noted that there are some genuine reasons for these, such as patient declining medication. Sharon Hodges added that there is an aim for all wards to have their own drugs trolleys which should afford better access to medicines; the also has a technician whose role includes searches for misplaced medicines. Shelagh Meldrum questioned whether this SM was a good use of resources and whether other options could be pursued.

4.6 . Mark Saxton said he was surprised to see the national shortages of antibiotics and difficulties in sourcing these. Andrew Prowse said that this can happen, for example where the supply or manufacturing process is hindered. Sam Hann confirmed that this was recorded on the risk register.

4.7 . The Trust continues to reduce the number of patients with high INR levels and carries out a mini-root cause analysis for all patients with a higher INR; this information is fed back to GPs.

4.8 . An audit was conducted to assess if patients are supplied an appropriate quantity of medication on discharge. There is the intention to move towards a ward based service to aid this process and improve performance.

4.9 . An independent prescriber improvement project was conducted with the aim to reduce medicines wastage within the Trust. The project showed a significant reduction in both the value of medicines wastage and the quantity of medicines returned to pharmacy for reuse.

4.10 . The Trust continues to utilise the Yeovil Freewheelers EVS service to deliver medication to patients’ homes, with a gradual increase in the use of these volunteers. A more closely managed approach to the use of this service is currently in development including a more structured audit and follow-up process. Paul von der Heyde said it would be useful to receive further information on this service to understand whether it is a sufficient and safe SHo/ service. AP

4.11 . The pharmacy’s Aseptic Services Unit (ASU) experienced a surge in demand. ASU continues to work hard to maximise efficiency from vial sharing, resulting in savings for the organisation.

4.12 . The pharmacy team had worked closely with Boots to open the dedicated outpatient dispensary on site, improving patient experience and also allowing the ability to compete for contracts to supply other organisations.

4.13 . The Committee noted number of pharmacy interventions and wondered how these compared with rates in other trusts and in previous years. The Committee requested that data from previous years be included for comparison, and asked SHo/ whether these data could be benchmarked. Andrew Prowse said that the Trust AP was not an outlier. Following a query on the increasing number of interventions, Sharon Hodges said that there may have been underreporting previously; however, the categories had been revised and further training provided.

4.14 . The Committee discussed the future roll out of the E-Prescribing and Medicines Administration (EPMA) system via TrakCare. Tim Scull said that previous experience suggested that there would be a requirement for considerable 3 | Page

support from pharmacy for clinicians on the wards for go-live. Andrew Prowse acknowledged the concern, and explained that for this reason the new system would be rolled out of a period of time, such as one ward per month, with technical support in place to assist ward staff. Following a question from Jane Henderson, Sam Hann agreed that this needed to be added to the risk register.

4.15 • Maurice Dunster noted that the report had been reviewed at the patient safety steering group and asked whether any feedback from this group was available. Sharon Hodges agreed to review. SHo

4.16 The committee thanked Sharon Hodges and Andrew Prowse for their presentation of the Medicines Management Annual Report.

5 MATERNITY SERVICES ANNUAL REPORT 5.1 Helen Williams, Head of Midwifery, was welcomed to the meeting to present the Maternity Services annual report, from which the following key points were highlighted and discussed:

5.2 . Helen Williams noted by way of introduction that the structure of the report would be reviewed for the next year and include a wider remit.

5.3 . The Trust’s maternity department offers an integrated model of care to approximately 1500 patients in the region, which puts the department as one of the smallest within the country. Activity levels saw a slight reduction in 2016/17. The service enjoyed a raised profile both regionally and nationally through the Better Births programme and also becoming a pilot site for Professional Midwifery Advocates.

5.4 . The Trust had faced a number of challenges in the reporting year including the full Care Quality Commission (CQC) inspection where the results for the department were disappointing. An action plan was drawn up and actions implemented. A more recent joint report from the Royal College of Obstetrics and Gynaecology (RCOG) raised no significant issues and provided additional assurance on the safety and sustainability of the Trust’s maternity services .

5.5 . Following phase 1 implementation of TrakCare, the maternity dashboard has had to implement a number of work-arounds although there is the ambition to move to a daily dashboard in the near future. Helen Williams pointed out that there is no community module within TrakCare, which makes it more difficult and time-consuming to maintain keep patient records up to date; this requirement is being reviewed as part of the Better Births project in partnership with Taunton and Somerset NHS Foundation Trust.

5.6 . A risk maturity assessment had taken place of which improvements had been made to a number of processes, including a review of the risk register and merging sections of the management framework. Governance meetings had also been reviewed with action planning put in place to bring more focus and improve accountability across a mix of staff groups. The department continued to have a culture of high reporting, low harm. Maternity triggers saw a drop of 3.7%.

5.7 . 2016/17 had seen a big drive to lower avoidable repeat rates for the new-born blood spot screening programme, which peaked at 12.2%. Following further training this had reduced to 3.2%.

5.8 . Jane Henderson noted that the report stated that there was no funded specialist support for perinatal mental health. Helen William confirmed that further funding had subsequently been put into place with countywide pathways 4 | Page

working well.

5.9 . .Jane Henderson queried the uptick in non-elective caesareans. Helen Williams acknowledged that there had been a recent spike although this had since returned to normal levels. The department was reviewing this in further detail with a change in consultant presence going forward. Tim Scull commented the Trust came out better than average for caesarean section rates in the national audit for obstetrics and gynaecology.

5.10 . The department had in the past year experienced some difficulties with regard to recruitment and vacancies, but a recent recruitment open day had been most encouraging and resulted in a number of job offers being made.

5.11 . A recent score survey within the department had highlighted a feeling among some members of staff that not enough was being done to support career planning; also a general feeling that more staff were required. Helen Williams said that activity fluctuates and this latter point tends to be raised in busy periods, which are offset by quieter periods. Shelagh Meldrum said that the score survey is completed nationally and it would be useful to benchmark and feed the national data back to members of staff

5.12 . A number of changes had been made to the staffing processes with newly qualified members of staff now more integrated as a team, with regular away days to complete their various competencies and formal education. This was being monitored and management of competency had improved. A Caring for You charter had been signed in conjunction with the Royal College of Nursing, alongside a number of initiatives introduced such as Whose Shoes.

5.13 . The department has been providing a range of e-learning packages but had found that e-learning was less successful than other forms of training. An audit of the packages was underway. The packages were developed by the RCOG and were taking longer to complete than initially anticipated.

5.14 . Helen Williams acknowledged that the department’s appraisal rate was currently lower than the Trust target; it was recognised that line managers must be provided with the time to complete these with staff. Following a question from Paul von der Heyde, Helen Williams confirmed that the appraisal percentage rate was reflective of the pressures within department and the limited time frames for managers and staff to complete their appraisals.

5.15 The committee thanked Helen Williams for attending and presenting the report and noted the full report. Helen Williams said that going forward the report will be more multi-disciplinary and include more information on the obstetrics service.

6 PATIENT EXPERIENCE ANNUAL REPORT 6.1 Ali Male, Patient Experience and Engagement Manager, was welcomed to the meeting. She presented the Patient Experience annual report with Bernice Cooke, from which the following key points were highlighted and discussed:

6.2 . Ali Male said that the template of the report would be updated in futureto capture the department’s widened remit.

6.3 . In financial year 2016/17 the Trust had received a total of 153 formal complaints, a 5% increase on the previous year. It is important to note that the overall annual total for the Trust remained low compared to other organisations. The Trust saw a decrease in the number of patient advice and liaison service (PALS) contacts. The most common theme for complaints relates to communication issues. 5 | Page

6.4 . The team provides bereavement support to relatives for approximately 60 deaths a month. If any concerns regarding patient care are raised during this process, they are investigated as a PALS concern with reconciliation meetings offered. Jane Henderson noted that the national learning from deaths guidance stipulates that families should be invited to take part in any investigations and asked whether this was being applied? Ali Male confirmed that this is embedded within the department’s new processes. The new process also requires a 5 day turnaround from internal departments. The department also works closely with the Chaplaincy team.

6.5 . A new role majoring on engagement and feedback has been added to the team and an engagement strategy was under development alongside a number of teams.

6.6 . Bernice Cooke reported that the entire process for the management of formal complaints and PALS had been revised earlier this year, with the same system now being used as for incident reporting. The new system and processes are looking to be swifter than previous arrangements. She emphasised that it was important to ensure that learning is taken from all complaints etc. and that this is now embedded across the organisation. There had already been a reduction in the number of formal complaints raised. Maurice Dunster said it was encouraging to hear that progress was being made.

6.7 . Mark Saxton noted that the report referred to a “surge in referrals from the coroner” and asked for the reasons behind this increase. Tim Scull explained that this is mainly due to discussions with the coroner where advice is sought on what should be recorded on the death certificate. The process usually involves speaking with a consultant or pathologist, however due to vacancies this has proved more difficult hence an increase in contacts with the coroner.

6.8 The committee noted the progress made within the patient experience and engagement department and the changes made in process since the reporting period ended. Jane Henderson thanked Ali Male for attending to present and to continue with the evident iCARE philosophy.

7 CANCER SERVICES ANNUAL REPORT 7.1 Nicola Gowen, Business Manager for Cancer, Oncology, Haematology and Palliative Care, was welcomed to the meeting to present the Cancer, Oncology, Haematology and Palliative Care annual report, from which the following key points were highlighted and discussed:

7.2 . The business unit delivers a range of services and assures quality delivery of cancer care to YDH’s catchment population which ties in with the services provided at neighbouring organisations. The chemotherapy suite has been awarded CHKS (provider of healthcare intelligence and quality improvement services) status permitting the use of the ISO marker for quality.

7.3 . The Trust saw some challenges in 2016/17 with regard to the 2 week wait referral performance although the standard was met in quarters 1 and 4. These challenges are continuing. Performance for the 62 day wait from referral to 1st definitive treatment standard was also challenging with difficulties remaining around diagnostics. There is variability with the number of patients each month. Following a question from Mark Saxton, Nicola Gowen confirmed that there are seasonal pressures but forward planning was in place in deal with these.

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7.4 . Diagnostics pathways are under review as part of the Somerset, Wiltshire, Avon and Gloucester (SWAG) Cancer Alliance with sustained improvements across head and neck services.

7.5 . It was regrettable that the data illustrated on the new BBC NHS Tracker was incorrect due to an error in data submission – some relevant data had not been available by the deadline.

7.6 . A number key business successes were noted, including an improvement in breach reallocation performance, increase chemotherapy activity and recruitment into difficult-to-recruit roles.

7.7 . A number of business unit risks were identified including oncology consultant cover, difficulties in compliance with the CQC and national audit ‘care of the dying patient’ (this has since been addressed with the recruitment of a nurse consultant). The committee noted the other risks outlined within the report.

7.8 . The Trust took part in the QSIS national peer review of which the results were included within the annual report. The peer review highlighted a number of measures not met for the lung service; this is explained by limited physician cover for which Nicola Gowen said that additional clarity regarding the requirements is being sought in order to put the correct level in place. Tim Scull said that the Trust already has challenges in regards to the number of physicians and which could raise questions about the long-term viability of the service due to the outlined requirements.

7.9 . The Trust’s self-rating for urology had been lower than the level assessed by peer review. An action plan has been drafted. Nicola Gowen advised that the service was rated as green as no serious concerns had been raised by the national team.

7.10 . The good compliance by the colorectal services was noted with approval, and was acknowledged as is testament to the good team at YDH and the pathology cover for MDT meetings.

7.11 . End of Life Care now falls under the remit of the Deputy Director of Nursing. Training for end of life care was owned by the Academy and has proved successful. Trusts are required to provide protocols to ensure provision of patient comfort, dignity and privacy – including after the death of the patient. A number of organisational changes are underway for further improvements.

7.12 . The national Cancer Outcomes and Services Dataset (COSD) performance was 52%; this was higher than the average for the region; nevertheless further improvements are planned.

7.13 . The Trust has sustained good practice in relation to the Neutropeanic Sepsis audit with good performance for patients receiving antibiotics within the hour.

7.14 . The committee reviewed the results of the National Cancer Patient Experience Survey which had also been received at the full Governance and Quality Assurance Committee in October 2017. The Trust scored 8.8 /10 with the majority of areas positive with one negative outlier.

7.15 . A number of key priorities had been identified for 2017/18, as outlined in the report. These were outlined included: sustaining and improving the quality of care, providing accessible services, meeting financial plan and deliver efficiencies, transform models of care and recruit and develop staff. Jane Henderson asked whether there was confidence that these were still the right 7 | Page

priorities for the year. Nicola Gowen said that some additional challenges are being faced but the priorities remain current.

7.16 The committee thanked Nicola Gowen for attending and presenting the annual report and providing an impression of where pressures are being faced.

8 INTEGRATED SAFEGUARDING ANNUAL REPORT 8.1 Glen Salisbury, Head of Safeguarding, was welcomed to the meeting to present the Integrated Safeguarding annual report, from which the following key points were highlighted and discussed:

8.2 . The Trust has amalgamated the adult and child safeguarding teams with the one team now seeing a larger number of referrals than the previous teams. This is mainly due to an active promotion of the team and safeguarding.

8.3 . A data cleansing exercise and a new system review is being undertaken to ensure that relevant staff receive targeted training. Training figures are monitored at the Safeguarding Committee where improvements have been seen; further work is underway to improve compliance further.

8.4 . During 2016/17, 495 adult safeguarding referrals were made to the safeguarding team in YDH; these included domestic abuse and learning disabilities referrals. Glen Salisbury said that the numbers of domestic cases were on the increase, which reflects national trends. In discussion the committee noted that the patient group is diverse and safeguarding concerns arise in all cohorts.

8.5 . Mark Saxton spoke about the Acorn Team (vulnerable Women Maternity Services) and the previous patient story received at the Board of Directors whereby members of staff who had gone the extra mile to help a very vulnerable patient had potentially put themselves risk. Glen Salisbury said that support was in place from the community and this is reviewed on a case by case basis with advice from the security teams. The process is outlined within Trust procedures and policies such as the Lone Worker Policy.

8.6 . It was noted that the annual report on the Mental Capacity Act/Mental Health would now be reported under a separate annual report. Tim Scull said that this BEA had been reviewed at the Risk Assurance Committee. Ben Edgar-Attwell agreed to liaise with Gaynor Appleby, Mental Health Lead, regarding this report.

8.7 The committee thanked Glen Salisbury for attending and presenting the report.

9 MEDICAL DEVICES ANNUAL REPORT 9.1 Bob Perkins, Head of Clinical Engineering, was welcomed to the meeting to present the Medical Devices annual report, from which the following key points were highlighted and discussed:

9.2 . The report reflected the activities and issues relating to the management of medical devices for the period 2016/17. Representatives from the Information Technology and Symphony Healthcare Services (Trust’s primary care subsidiary company) now attended meeting to provide a robust overview of patient safety issues.

9.3 . The Committee noted with approval the appointment of the medical devices training co-ordinator, who has started in February 2016 providing additional stability. Online competencies were now being rolled out on certain wards with 99% coverage of all trained staff. Further reviews and refresher sessions were planned. Standardisation of medical devices was now in place. The 8 | Page

Committee were pleased to hear that as result of these changes the risk regarding devices training had been removed from the register.

9.4 . The Medical Electronics Department continues to maintain its ISO9001:2008 accreditation. An assessment in being made on the requirements of the new ISO9001:2015. A new standard is being developed on behalf of the NHS, ISO70000. Bob Perkin advised that the Trust has withdrawn from the pilot scheme as it was not in a position to proceed and participation would have resulted in further financial obligations.

9.5 . Jane Henderson asked about the department completing work for GP practices. Bob Perkins said that providing services for general practice had not previously been successful. However with the advent of SHS this had now become possible, including for practices not integrated into SHS.

9.6 . The department has a number of KPI against which its performance is measured. These had been reviewed and revised into an action plan with improvements in performance seen throughout the year.

9.7 . Bob Perkins said that with the proposed creation of the Trust’s subsidiary company, Simply Serve Limited, he had stepped down as the chair of the South West Medical Devices Management Group. This was in response to concerns expressed from some members of the Group about the involvement of Simply Serve Ltd. The Non-Executive Directors expressed surprise and dissatisfaction with this as Simply Serve will be a wholly-owned part of the YDH NHS group. It appeared there may have been misunderstandings and possibly misinformation about its status. Bob Perkins undertook to would review processes at other organisations.

9.8 . Bob Perkins reported that the equipment library service and activity continues to develop. The department has recently undergone refurbishment, improving the working environment for staff and improve process and storage facilities. There remains an on-going difficulty to meet the demand for some devices which is reflected in the routine reports within some Trust Patient Safety Group.

9.9 . The capital programme for 2016/17 had been completed with the exception of the ICU ventilators, which are currently undergoing evaluation. The requirements for 2018/19 are in development and form part of a longer term programme.

9.10 . Bob Perkins provided assurance that IT patches and updates are applied to the network and medical devices to ensure that there is minimal risk of a cyber- attack. .

9.11 . The Medical Devices Committee raised two key areas of concern for further consideration: one relating to increased pressure on the supply of falls alarms and cushions, and the second related to the potential risk in the connectivity of medical devices to IT networks.

9.12 . The committee noted with approval the continued steady improvement in the department’s performance.

9.13 Jane Henderson thanked Bob Perkins for attending to present his departmental annual report.

10 EMERGENCY PLANNING AND BUSINESS CONTINUITY 10.1 In Yvonne Thorne’s absence the Emergency Planning and Business Continuity annual report was noted. 9 | Page

11 ANY OTHER BUSINESS 11.1 No other items of business were raised.

12 DATE OF NEXT MEETINGS 12.1 24 January 2018, 09:00 – 13:00, Boardroom, Level 1, YDH

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AUDIT COMMITTEE Minutes of the Audit Committee held on 16 October 2017 at Yeovil District Hospital

Present: Caroline Moore [Chair] Non-Executive Director Jane Henderson Non-Executive Director Julian Grazebrook Non-Executive Director Mark Saxton Non-Executive Director

In Attendance: Paul von der Heyde Trust Chairman Tim Newman Chief Finance and Commercial Officer Ben Edgar-Attwell Company Secretary Alison Whitman Elected Public Governor - Observer Sam Hann Risk Manager Rob Andrews KPMG Adam Spires BDO Claire Baker BDO Mark Thouless Financial Controller Tony Hall Counter Fraud Service Jo Howarth Deputy Director of Nursing [item 148/17, End of Life Care] Chris Moore Senior Finance Manager – Corporate [item 154/17 Chris England Deputy Head of Procurement [item 158/17]

Apologies: Paul Mears Chief Executive Rees Batley KPMG Dean Stevens Assistant Director of Finance Michael Clark Elected Public Governor - Observer

Action 143/ WELCOME AND APOLOGIES 17 Caroline Moore welcomed everyone to the meeting. Apologies for absence were noted as above.

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

145/ MINUTES OF THE PREVIOUS MEETING 17 The minutes of the meeting held on 17 July 2017 were reviewed; Jane Henderson stated that some grammar corrections were required. Subject to these updates, the minutes were approved as a true and accurate BEA record.

146/ REVISED TERMS OF REFERENCE 17 The committee reviewed the revised terms of reference which were in line with previous versions. Following discussions at the Governance and Quality Assurance Committee which took place earlier in the day, it was agreed that the quorum and attendance list be reviewed to highlight expected regular attendance. It was noted that the Chairman and Chief Executive is only required to attend one meeting per financial year.

Mark Saxton questioned whether it would be sensible for the chairs of relevant Board level committees to attend the Audit Committee where applicable internal audits are presented to ensure adequate input and oversight. Adam Spires confirmed that the chairs of relevant committees could be copied into the scope and results of the papers. It was noted that BDO there is a need to ensure this does not cause delay in proceedings. The internal audit plan is shared with the executive team.

147/ KPMG PROGRESS REPORT / TECHNICAL UPDATE 17 Rob Andrews presented the previously circulated KPMG progress report. Since the last Audit Committee meeting, the external audit of the Yeovil District Hospital NHS Foundation Trust Charitable Fund Accounts and Annual Report had been completed and is due for sign off by the Board of Trustees prior to submission in January 2018.

The fieldwork on the audits of Symphony Healthcare Services Limited (SHS), Yeovil Property Operating Company Limited (YPOC) and Daycase UK (DCUK) has commenced. KPMG had recently held an accounting workshop for which members of the YDH finance team attended. KPMG were also due to present to the Trust’s Council of Governors on governor

responsibilities and the role of external audit.

Rob Andrews spoke to the technical update included within the papers which outlined recent announcements and updates from NHS Improvement, NHS England, and the Department of Health along with recent publications from KPMG. This included a variety of topics such as the new Well Led Governance Framework, Cyber Security, Use of Resources Assessments, financial controls and Getting It Right First Time reports. Ben Edgar-Attwell advised that the Trust may be required to undertake an external well-led review despite being a pilot site for the new joint NHS Improvement and Care Quality Commission well-led review. He confirmed that this requirement is being investigated.

Caroline Moore questioned whether the Trust had submitted the required cyber security Trust actions template as outlined in the technical update. Tim Newman agreed to check whether this had been completed. TN

Tim Newman noted the updated guidance issued in relation to the Sustainability and Transformation Fund. This would be reviewed in further TN detail.

148/ BDO INTERNAL AUDIT REPORTS 17 Internal Audit Progress Report Adam Spires presented the internal audit progress against the 2017/18 plan. Good progress has been made with two reports presented at this meeting. It was previously requested that the scope and terms of reference for the cyber security review to be circulated to the committee. He advised that as the TrakCare pharmacy implementation dates had been delayed, a different approach had been taken to provide live assurance and spot checking at different points on an ad hoc basis.

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Caroline Moore noted that the fieldwork for a number of internal reviews had been completed and not yet reported to the Audit Committee; she asked whether any key high risks would be raised with the committee immediately prior to receiving the full report. Adam Spires confirmed that any key high risks would immediately be raised.

Following the lack of satisfaction scores being submitted, it was agreed that the executive leads would be reminded of the importance of feedback.

Agency Expenditure Report The results of the internal audit of agency expenditure outlined moderate assurance for process design and operational effectiveness. There are a number of good booking processes with consideration of bank staff usage prior to agency usage. There are two medium recommendations; the first relates to the NHS Improvement price cap where it was noted that some agency expenditure included shifts above the price cap. It was agreed that the Trust is undertaking a number of initiatives to reduce this usage and it was noted that the total expenditure for the area is below the agency ceiling. The second recommendation relates to evidence for shift approval as outlined per NHSI requirements. The evidence for approval was not always available; it was understood that this does take place although it may be through a phone call. It is recommended that processes are updated to ensure this is auditable. Caroline Moore observed that the management response to this recommendation has taken this into consideration with a review of processes. Adam Spire advised that a moderate report would not normally be presented in full to the committee but it was thought to be beneficial for the committee to have oversight.

Mark Saxton said that agency expenditure is reviewed in great detail within the workforce committee with work underway to reduce the medical spend further; he therefore said that stating the potential savings for medical staff is incorrect bearing in mind the current workforce climate and the initiatives underway. The ‘savings’ outlined in the report are not possible in the current environment. It is important to consider the acuity of patients in line with agency costs; costs should not be reviewed in isolation. Mark Saxton said it was disappointing to see that relevant members of staff were not interviewed as part of the review process which could have provided more clarity on processes etc.

Caroline Moore said that it was reassuring to hear this is being reviewed by the Workforce Committee and has adequate oversight. She noted that one recommendation was to liaise with other trusts and organisations. Mark

Saxton advised that this has since taken place with framework agreements in place.

Adam Spires advised that YDH has good processes in place with few trusts even receiving moderate assurance; this is not to be taken lightly. He said that the financial impact was included as this has been requested from a number of clients and could prove useful. A number of positives have been noted from the review with strong performance.

Paul von der Heyde said that the report currently suggests that the correct authorisation is not being provided for agency shifts above the price cap; this is not the case. It was requested that the report is updated to show that

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the correct authorisation is being received with an update of processes to capture the evidence. Adam Spires agreed to make this change. BDO

End of Life Care Report Jo Howarth attended the meeting for this agenda item. This review had taken place following a request from Shelagh Meldrum, Director of Nursing and Elective Care, to provide a forward view after it was perceived to be an area of weakness. The end of life policy is in place however there is limited awareness of the policy by members of staff and therefore some quality indicators were not necessarily monitored.

Jo Howarth said that there was an improvement programme of taking place alongside the audit. A number of recommendations were therefore completed prior to the final version of the report. The report has been helpful in addressing actions with further investment in clinical leadership and end of life care. Comprehensive training events took place with consultants and this is an ongoing process. Real time audits of all deaths take place through the bereavement office with a review of the outcomes to ensure targeted actions. Following a question from Julian Grazebrook, Jo Howarth advised that the Trust is pushing for the full use of care plans, adequate information for relatives etc. with an understanding that not all patients require palliative care at the end of their lives.

Jane Henderson said that she had attended the previous end of life steering group meeting which provided assurance that actions are taking place. Jo Howarth said that two further pieces of work are to commence; advanced communication work with consultants (this was previous standard however this is no longer in place), and also ensure usage of the ethics committee, challenging decision making where the level of care is not adequate. Following a question from Caroline Moore, Jo Howarth confirmed that the end of life steering group was a standing committee which reports to the Governance and Quality Assurance Committee.

Jane Henderson asked whether the limited assurance for design was correct and justified. Adam Spires said that this has been debated in drafting the report however there were limitations on ensuring consistent processes and questions about the right situation and criterion. Jo Howarth said that a new nurse consultant would also be raising awareness with the usage of the NHS England Last 1000 Days video during staff training.

Cyber Security Terms of Reference Adam Spires said that the terms of reference for the cyber security internal audit were included following a previous request by the committee. The review will be undertaken by an experienced IT manager; it was agreed it would be useful for him to present the final report.

Caroline Moore asked whether penetration tests would be undertaken during the review. It was confirmed that these would be discussed although they would not take place. Caroline Moore asked whether the review would also include Symphony Healthcare Services to which Adam Spires said that this is not included within the scope of the audit. It may be prudent to understand how the Trust is gaining assurance.

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149/ BDO INTERNAL AUDIT FOLLOW-UP OF RECOMMENDATIONS 17 Adam Spires and Claire Baker presented the BDO internal audit follow-up of recommendations report where it was noted that there are a total of 15 high and medium recommendations either in progress, overdue or not yet due. One high recommendation relating to ambulatory emergency care requires further workarounds due to limitations in the TrakCare system; this has since been reduced to a medium recommendation. Two overdue medium recommendations for the fixed asset audit have been chased and Mark Thouless provided assurance that they will be completed by the next committee; the delay was due to a staff member leaving and the MT recommendations not being completed prior to their leaving.

The committee noted the report.

150/ COUNTER FRAUD PROGRESS REPORT 17 Tony Hall explained that Hayley Cobb, Local Counter Fraud Specialist, was unable to attend the meeting however she had made contact with key people within the Trust including payroll, HR, E-Rostering etc. The progress report detailed the work undertaken at YDH against the 2017/18 counter fraud work plan.

Work had been undertaken on the National Fraud Initiative (NFI). This provides proactive liaison with other organisations and agencies to prevent, deter and detect fraud. A number of matches relative to potential duplicate invoices and have been reviewed by the Trust’s management accounts. Mark Thouless said that the Trust was working with tiaa in order to gain an understanding of the lessons to be learning from these ‘duplicate payments’ although it was noted that there were no concerns that they were fraudulent; they occurred due to one invoice being paid manually and one automatically. Following questions from Mark Saxton and Julian Grazebrook, Mark Thouless said that the new system in place searches for duplicate invoice numbers and is much more robust. It also requires wider usage of purchase order numbers; previously non-purchase order numbers were manually entered leaving room for error. Mark Saxton asked whether it would be prudent to check previous years for these types of errors. Mark Thouless confirmed that this had taken place with no other issues arising.

Tony Hall reported that tiaa had also worked with the company secretary, HR and procurement teams for payroll/creditor matches and procurement, payroll and company director matches. This work has now been completed with a review of the conflicts of interest register along with information on Companies House etc. It was determined that none of the YDH employees who had links with companies trading with YDH had the ability to influence a decision to award business to that company.

Tony Hall said that Ben Edgar-Attwell had sought advice from tiaa to review and make recommendations with regards to the Trust’s new draft Code of Conduct and Conflicts of Interest Policy which was in line with NHS England Guidance. Changes were suggested by tiaa. Ben Edgar-Attwell confirmed that these suggestions were incorporated into the policy.

Some further issues were raised as part of the invoice detection review whereby some invoices had duplicate payments for nursing and medical staffing agencies; this was due to human error following a requirement to

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manually input invoices; the previous system allowed duplicate invoice payments. This issue is resolved with the new Oracle system which does not allow duplicate payments. This resulted in a saving of £6,172.40.

A summary of the circulated intelligence alerts were included within the report. An e-rostering/secondary employment/timesheets review was also underway with a further report on the findings and outcomes of the work to be included at a following Audit Committee.

Tony Hall said that no reactive work was currently underway. A review would take place to understand whether this is correct and to provide further assurance.

151/ COUNTER FRAUD RECOMMENDATIONS TRACKING REPORT 17 The committee noted the Counter Fraud Recommendations Tracking Report and the progress on the recommendations which are all addressed by the new Code of Conduct and Conflicts of Interest Policy bought to this meeting for approval.

152/ Q2 CORPORATE RISK REGISTER 17 Sam Hann presented the Q2 corporate risk register which included a summary of the top 6 risks along with detailed information within the report. The pressure and impact was more evident resulting in risks relating to the scale of the current financial deficit and a risk to the Trust’s cash flow position. As a result of the increased pressure and resources and finances becoming constrained, more risks were being recorded on the register.

The corporate risk register provides a snapshot of the position as of the end of quarter 2 on which 29 risks were recorded. In regard to the financial risks, there has been further movement since the end of the quarter with further vacancy freezes and external reviews either undertaken or

underway. Other risks included not being able to secure an outcomes

based contract, continued high levels of delayed transfers of care, a risk of

not being able to progress evacuation in the event of a fire and insufficient inpatient capacity and child and adolescent mental health support.

7 new risks were added in quarter 2 compared to the first quarter. A number of the risks also increased in their rating. The risk relating to discharge summaries not being viewable on the system had been raised with the software teams and suppliers to be resolved.

Jane Henderson questioned the risk relating to the Symphony programme and ambiguity in using the word ‘sustainable’. The programme requires the identification of funding sources and Jane Henderson suggested that the moderate risk scoring was incorrect; Sam Hann agreed to liaise with Jonathan Higman, Director of Strategic Development and Jeremy Martin, SH Symphony Programme Director.

Caroline Moore asked whether there was an overall Trust risk relating to staff turnover and the loss of key staff. Sam Hann advised that there is no generic risk for the entire Trust however there are different risks within each individual specialties. Tim Newman said that there were clear risks around any consultant roles. Sam Hann agreed to note and record staff turnover SH and loss of key staff on the corporate risk register.

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153/ FINANCE REPORT 17 Mark Thouless presented the finance report which shows the status of current debtors and year-to-date losses and compensation payments. He explained that the debt is in line with the expected position. There was some aged debt which is mainly income due from Clinical Commissioning Groups (CCGs) for non-contracted activity; patient level data queries are underway.

Mark Thouless advised that NHS Shared Business Services (SBS) completes the first line of chasing debt with YDH doing the second line. Julian Grazebrook asked whether the Trust has adequate oversight of debtors. Mark Thouless said that there have been some issues with reporting although these are under review with further debt chasing to take place.

The Trust’s loses and compensations position is much reduced compared to the previous year. It is anticipated that the interface between the new TrakCare pharmacy system and the financial systems will be in place ready for the pharmacy go-live. The private patient system link is not yet in place.

Caroline Moore asked whether the new SBS system was easier and more manageable. Mark Thouless confirmed that the system is superior to the old system and the move towards a fully purchase order system has replaced the previous paper based system; approval and sign off is quicker and easier.

154/ COSTING ASSURANCE PROGRAMME 2016/17 17 Chris Moore attended the meeting to present the costing assurance programme 2016/17. The Costing Assurance Programme is divided into three workstreams and YDH is included in workstream 2.

The Trust is working to implement patient-level costing (PLICS) and the audit of 2015/16 is now complete; this review by Ernst & Young LLP provided recommendations for which the Trust has worked towards to implementing and embedding within existing processes. A clinical costing group had been initiated with new software and systems in place. A data quality group, working with the Management Information Team, was in place and meets monthly. The updated costing system now takes data outputs directly rather than a need for monthly manual inputs. This can be used to match patients far easier than previous arrangements. The new systems in place also provided the ability to incorporate and store methodologies rather than these corrections to be manually implemented.

Chris Moore explained that there are a number of documentation rules for the costing implementation programme. The Trust was one of the most compliant organisations nationally. YDH was the only Trust to date to submit a PLICS submission with the Synergy version 4 system. Tim Newman said that there is a short term challenge as the Trust had not yet been provided with the full suite of tools by the supplier. Once these have been received, further data quality improvements could be implemented.

Julian Grazebrook asked whether the finance team had adequate expertise and capacity bearing in mind recent changes in staffing. Chris Moore said that there was adequate resources and expertise in place to support this.

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Paul von der Heyde asked whether the lack of the full suite of tools was blocking the ability to implement full service line reporting. Chris Moore confirmed that this was acting as a blocker with limited outputs in place at the time. Tim Newman and Chris Moore said the Trust was close to reporting by service line although the suppliers’ resources are currently stretched. Following a question from Caroline Moore, Chris Moore confirmed that other organisations were able to review the data using other provider systems. Tim Newman said that the Trust was able to submit its PLICS data and is therefore compliant, although it causes internal reporting issues.

Chris Moore reiterated that YDH was an early adopter for PLICS however NHSI was now looking to mandate this requirement on a national basis to replace the existing reference cost submissions. Caroline Moore asked when the Trust would have service level reporting available; Chris Moore said that there was the intention for this to in place by the end of the calendar year/early next year for embedding into monthly reporting.

156/ CODE OF CONDUCT AND CONFLICTS OF INTEREST POLICY 17 Ben Edgar-Attwell explained that the previously circulated draft Code of Conduct and Conflicts of Interest Policy is intended to replace the Trust’s current Standards of Business Conduct Policy. The policy had been modelled on the guidance and templates issued by NHS England to provide standardisation across the NHS in the identification, declaration and management of conflicts of interests. The policy was circulated to key internal and external stakeholders and all feedback received was incorporated into the final draft presented. The Trust had also worked with neighbouring NHS organisations to ensure standardisation within the region. Should approval be received, an implementation and communication plan would be commenced.

Jane Henderson asked why the policy states that only gifts received over the value of £50 should be declared. Ben Edgar-Attwell confirmed that this was in line with the national guidance and the model policy.

Caroline Moore asked about instances whereby an attendee at a conference may enter a draw to win a prize, would this be expected to be declared. Tony Hall said that the policy is to raise awareness and individuals to be aware that they would need to report different interests which could include this scenario.

Alison Whitman suggested that governors should be specifically mentioned within the section defining ‘decision making staff’. Ben Edgar-Attwell agreed to add this into the policy.

Tony Hall said that the counter fraud team would review staff awareness of the policy in 4-6 months’ time.

Subject to the changes outlined above, the policy was approved by members of the Audit Committee.

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157/ MINUTES OF THE FIRE, HEALTH AND SAFETY & SECURITY 17 COMMITTEE The committee noted the minutes of the Fire, Health and Safety and Security Committee. Paul von der Heyde advised that the Board of Directors had recently received a full presentation on fire safety. Julian Grazebrook noted the gap in conflict resolution training for the emergency department; there are action plans in place to include a requirement to review contract arrangements for training.

158/ PROVISION OF AN INTERNAL AUDIT AND COUNTER FRAUD SERVICE 17 Chris England attended the meeting to provide an overview of the provision of the internal audit and counter fraud service. BDO, tiaa and KPMG were not present for this agenda item.

Chris England explained that the Trust was required to approach the market in order to ensure a robust and legally compliant contract is in place for the provision of an internal audit and counter fraud service. Existing contracts expire on 17 April 2018. The Trust has an option to undertake a local tender process however there are a number of national frameworks in place which are option to use by public sector organisations. The Audit Committee were asked to approve the commencement of this procurement process and proposed timetable. Interest had been expressed from Taunton and Somerset NHS Foundation Trust (T&S) and Somerset CCG for the procurement of the services. T&S did not require counter fraud services.

Caroline Moore asked whether the internal audit and counter fraud services can be provided by the same provider. Chris England confirmed that this is possible with many organisations doing this. Paul von der Heyde asked whether there was the possibility of having cross cover from T&S’s counter fraud service; Tim Newman said that this would be a false economy with limited cover and resource available.

Julian Grazebrook asked whether this would be an entirely joint presentation, process and appointment. Chris England said that this would be the likely outcome. Mark Saxton questioned the process should there not be agreement. Chris England said that there is unlikely to a disagreement based on the service requirements with previous countywide appointments. Caroline Moore asked who would be on the evaluation panel. Ben Edgar-Attwell suggested that it would be Tim Newman, Caroline Moore and Dean Stevens and himself.

Julian Grazebrook asked whether KPMG would be excluded from providing the services bearing in they provide external audit services. It was confirmed that this is the case; there was also a need to ensure that there are no other conflicts with T&S and the CCG.

The proposed timetable for the procurement process was reviewed. It was noted that the bidder presentations proposed date was provisionally scheduled during half term; it was agreed that this would be bought forward if possible. Ben Edgar-Attwell confirmed that as this is an internal audit procurement process, it did not require sign off by the Council of Governors. There may be the requirement for an additional Audit Committee for final approval depending on dates.

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159/ KEY ITEMS TO HIGHLIGHT TO THE BOARD 17 It was agreed that the internal audit reports on agency expenditure and end of life care would be specifically highlighted to the Board of Directors meeting alongside the internal audit and counter fraud procurement process.

160/ REGISTER OF INTERESTS, SEALINGS, GIFTS AND HOSPITALITY 17 The registers of sealings, hospitality and interests were noted.

161/ ANY OTHER BUSINESS 17 There were no other items of business raised.

162/ MEETING WITH AUDITORS AND COUNTER FRAUD SERVICE 17 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.

163/ DATE OF NEXT MEETING 17 The next meeting of the Audit Committee will be held on Wednesday 24 January 2018, 13:30 in the Boardroom, Level 1, YDH.

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YDH │ Operating and Finance Performance Overview

│ December 2017 CONTENTS

1) Safe 2) Effective 3) Responsive 4) Caring Mortality Rates Safe [1]

December 17 Latest SHMI 12 Number of Number of Mortality Rate Months to Deaths ED Deaths (Deaths/Discharges) November 17 Actual Number of Inpatient Deaths 100 0.996 71 1 2.0% 90 80 70 60 50 Additional notes Count Diff % Diff 40 30 • Number of Deaths YTD: 489 20 -52 -9.6% 10 • Number of Deaths YTD LY: 541 0

RAG status: Below National Level, Not Significant Deaths 6 Month Moving Average

Deaths in Dec were lower than Dec 16 = 73

LY=Last year YTD=Year to Date Patient Falls and Pressure Ulcers Safe [2] Patient Falls December 17 120 Patient Falls rate per 100 Patient Falls Pressure Ulcers 1000 bed days 80

65 6.7 2 60

40 December 16 20 Patient Falls rate per Patient Falls Pressure Ulcers 0 1000 bed days 91 8.8 8

Patient Falls 6 Month Moving Average Additional notes Count Diff % Diff Pressure Ulcers +2 • Patient Falls YTD: 593 -84 -12.4% 25 • Patient Falls YTD LY: 677 • Pressure Ulcers YTD: 55 20 -10 -15.4% • Pressure Ulcers YTD LY: 65 15

10 RAG status: Achieved

Improved performance compared to last year. 5 0

Pressure Ulcers +2 6 Month Moving Average C.Difficile and MRSA Cases Safe [3]

Total C Difficile Cases December 17 5 C.Diff YTD C.Diff YTD MRSA 4 (Lapses in Care) (Lapses in Care) C.Diff 3 0 0 0 0 2

December 16 1 C.Diff YTD C.Diff YTD MRSA 0 (Lapses in Care) (Lapses in Care) C.Diff 0 0 3 6

C Diff. No Lapse in Care C Diff. Due to Lapse in Care C Diff. Cases in Review Additional notes • MRSA Attributable to the Trust: 0 MRSA

• The Trust's Threshold for C/Diff cases this year is 8 3 • The Trust's Threshold for MRSA this year is 0 • There have been 2 Post 72hrs C.diff cases this year to date. One case is still under review, the other was due to 2 ‘No lapse in care’.

1 RAG status: Achieved

Targets Met. 0 Jun-17 Jun-15 Jun-16 Oct-17 Apr-17 Oct-15 Oct-16 Feb-17 Apr-15 Apr-16 Feb-16 Feb-15 Dec-17 Dec-15 Dec-16 Dec-14 Aug-17 Aug-15 Aug-16

MRSA MRSA - Not Attributable to the Trust Stroke Services Effective [1] Best Practice Achievement December 17 70% 60% Stroke BPT - Stroke BPT - Stroke BPT - High Risk TIA Direct Admit 50% Thrombolysed 12hr CT within 24hrs & Stay 40%

42.9% 10.8% 97.6% 78.6% 30%

Targets 20%

45% 16% 83% 80% 10% 0% Additional notes Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Please note that the Stroke indicators are now shown as Best Practice Achievement Financial Year 2017/18 performance against the Trust’s Best Practice Contract 80% • BPT – Stay = 4hr Direct Admission with 90% stay and Stroke Specialist assessment within 14hrs. 70% • BPT – Thrombolysed = Patients assessed for thrombosis 60% and thrombolysed with Alteplase, if clinically appropriate. 50% • BPT – 12hr CT = Patients receiving a CT scan within 12 40% hours of admission 30% 20% RAG status: Failed, close to achievement 10% Targets Failed. Reason: 0% 90% Stay on SU Direct to SU and <4hrs 14 hr Assessment The low performance on 14hr Assessment was the main reason for the lower levels of achievement in Dec. Overall BPT Measure Achievement % Overall BPT Target Fractured Neck of Femur Services Effective [2] BPT Achievement by Measure Date 2017/10 2017/11 2017/12 2016-17 2017/18 December 17 Quarter 3 3 3 YTD YTD Operated on within 36 hours 93.3% 83.3% 75.0% 75.8% 74.1% Best Practice Achievement Geriatric Assessment within 72 hours 84.6% 73.9% 65.0% 90.0% 60.7% Pre-Op AMT 100.0% 95.8% 79.2% 99.3% 97.0% 29.2% Falls Assessment 86.7% 95.8% 83.3% 95.7% 81.1% Target Bone Protection Medication 100.0% 91.7% 79.2% 100.0% 92.5% Nutritional Assessment 100.0% 95.8% 79.2% 90.0% 60% Delirium Assessment 100.0% 91.7% 79.2% 89.1% Physiotherapist on Surgery 100.0% 87.5% 79.2% 85.1% Total Activity 15 24 24 304 201 Overall BPT 66.7% 37.5% 29.2% 64.1% 40.8% Quarterly 66.7% 48.7% 41.3%

Additional notes Best Practice Achievement Financial Year 2017/18 The BPT criteria has changed from May 17: 100% • Joint Assessment Protocol → Nutrition Assessment 90% 80% • Post-Op AMTs → Delirium Assessment using 4AT 70% 60% • Rehab Assessment → Physiotherapy Assessment on 50% day/day after Surgery 40% 30% 20% 10% RAG status: Failed 0%

Targets Failed. Reason:

Delays in recording of Geriatrician Assessment and delays in Surgery were the main reasons for the low performance in Dec. Overall BPT % Achieving Each Measure Delayed Discharges Effective [3] Daily Number of Delayed Transfers of Care December 17 35 30 Lost Bed Days In Month Bed Cost 25 265 £62,540 20

December 16 15

Lost Bed Days In Month Bed Cost 10 626 £147,736 5 0 Additional notes Count Diff % Diff • Lost Bed Days YTD: 4,512 -4,482 -49.8% • Lost Bed Days YTD LY: 8,994 Monthly Split of Delayed Discharge Reasons (Bed Days) 120 • In Month Bed Cost YTD: £1,064,832 -£1,057,752 -49.8% 100 • In Month Bed Cost YTD LY: £2,122,584 80 In Month Bed Costs are calculated using an average bed cost of £236 multiplied by the number of lost Bed Days in Month. 60

RAG status: Failed, close to achievement 20 Targets Failed. Reason: 0 The very low numbers of delays in Dec were due to being Completion Public Further non Residential Nursing Car e Community Patient or Di sp utes Housing unable to report delays when Wards are under Infection of Funding acute NHS Home Home pack ag e in Equipment Family Assessment care own Home Choice Control Restrictions. 01/10/2017 01/11/2017 01/12/2017 DNA - Outpatients 0.07 Effective [4] DNA Cost

December 17 £160,000 Overall First Appointment FU Appointment OP Activity £140,000 DNA Rate Rate Rate £120,000 6.2% 4.9% 6.9% 16,665 £100,000

December 16 £80,000 Overall First Appointment FU Appointment OP Activity £60,000 DNA Rate Rate Rate 6.9% 5.6% 7.5% 17,294 £40,000

Additional notes Measure Diff % Diff DNA Admission Rates • The June 16 peak is a result of the handover to Trak Care. 12% • Total DNA Cost YTD: £858,600 -£183,825 -17.6% • Total DNA Cost YTD LY: £1,042,425 10% • Appointments cancelled by 8% 16.6% Trust %: 6% • Appointments cancelled by 12.5% 4% Patient %: 2%

RAG status: Achieved 0% Targets Met.

Overall DNA Rate First DNA Rate FUP DNA Rate Cancelled Operations Effective [5] Hospital non Clinical On the Day Cancellation of Elective Operations Dec-17 December 17 Consultant / Clinican unavailable On the Day Non- Rebooked within Total Cancelled due Emergency Intervened Clinical Reasons 28 Day Target to Lack of Beds Equipment Failure / Unavailable 15 100% 2 More urgent case too priority - elective only… No Beds Available December 16 Session cancelled On the Day Non- Rebooked within Total Cancelled due TCI / Appointment rescheduled - requires… Clinical Reasons 28 Day Target to Lack of Beds TCI / Appointment rescheduled - requires…

6 100% 1 0 1 2 3 4 5

Additional notes Hospital non Clinical On the Day Cancellation of Elective

The figure for Total Cancelled due to Lack of Beds includes Operations 2017-18 YTD cancellations with more than 1 day notice given. Administrative Reasons Consultant / Clinican unavailable Note: For any elective operation cancelled by the trust on the Equipment Failure / Unavailable day of the operation/admission, an offer of a new date must Insufficent session time / session overrun be within 28 days of the cancelled operation date. More urgent case too priority - elective only… No Beds Available Patient not sent for by administrative staff RAG Status: Achieved Requires Alternative Session/Specialty Session cancelled Targets Met. TCI / Appointment rescheduled - requires… Urgent Case Took Priority

0 2 4 6 8 10 12 14 16 Diagnostic Waits Responsive [2]

Diagnostic 6 Week Waits % December 17 100% Overall Diagnostic 6 Week 98% Waits 99.2% 96% (Target 99%) 94%

December 16 92% Overall Diagnostic 6 Week 90% Waits 99.6%

Diagnostic 6 Week Waits % Target DM01 % - Trajectory

Additional notes Diagnostic Waits by Type of Test The area with the lowest diagnostics performance was: 100% Physiological Measurement % 96.3% 95% 90% 85% 80% RAG status: Achieved 75% Targets Met. 70% 65% 60%

Imaging % Physiological Measurement % Endoscopy % RTT Pathways Responsive [1] RTT Incomplete Pathways - 18 Weeks 100% December 17 98% 96% Total Incompletes 94% 92% 92.6% 90% 88% (Target 92%) 86% 84% December 16 82% 80% Total Incompletes

91.5% RTT Incompleted Pathways - 18 Weeks Target 6 Month Moving Average

Additional Notes: Lowest RTT Perfoming Specialties Specialties with the Lowest RTT Performance (Performing 100% under 92% Target) this month: 95% • Oral Surgery 87.1% 90% 85% • Trauma & Orthopaedics 88.3% 80% 75% RAG status: Achieved 70% 65% Targets Met. 60% 55% 50% Trauma & Orthopaedics Oral Surgery ED Attendances Responsive [3]

Avg A&E Attendances per day December 17 200 A&E Average A&E Average Emergency 150 Performance Attendances per day Admissions per day 100 95.6% 144.4 39.4 50 December 16 0 A&E Average A&E Average Emergency Performance Attendances per day Admissions per day

94.0% 131.7 42.5 Avg A&E Attendances per day Avg Ambulance Arrivals per day Avg Emergency Admissions Per Day

Additional notes Count Diff % Diff A&E 4 Hour Performance - All Attendances Average Emergency Admissions excludes Paediatrics and Maternity. 100% • A&E Activity over the two month 98% +1,102 +13.9% period change: 96% 94% • A&E Attendances YTD: 37,814 +2,152 +6.0% 92% • A&E Attendances YTD LY: 35,662 90% 88% 86% RAG status: Achieved 84% 82% Targets Met. With a very difficult month of increased activity and acuity of patients, the ED team have still managed to achieve the 4hr target in Dec. Monthly Data 6 Month Moving Average Ambulance Handovers Responsive [4] Ambulance Handovers Per Month December 17 1,800 £10,000 1,600 £9,000 30 Minute Handovers Fines YTD 1,400 £8,000 £7,000 99.5% £12,800 1,200 £6,000 1,000 (Target 99%) £5,000 800 £4,000 600 December 16 £3,000 400 £2,000 30 Minute Handovers Fines YTD 200 £1,000 99.8% £18,800 0 £0

Additional notes Ambulance Handovers Ambulance Handovers - Fines • Fines YTD Diff: -£6,000 • Fines YTD % Diff: -31.9% YTD Fines Breakdown

RAG status: Achieved

Targets Met. £1,000 £1,400 £1,400 £1,000 £1,400 £2,000 £1,200 £3,200 £200

£0 £2,000 £4,000 £6,000 £8,000 £10,000 £12,000 £14,000

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Admissions and LOS Responsive [5]

Average Length of Stay (Days) December 17 6 Elective Non-Elective Average Average Non - 5 Admissions Admissions Elective LOS Elective LOS 4

1,596 2,041 2.4 4.0 3

2 December 16 1 Elective Non-Elective Average Average Non - 0 Admissions Admissions Elective LOS Elective LOS 1,617 2,135 2.4 4.8

LOS Elective LOS Non Elective

Additional notes Count Diff % Diff Admissions • Elective Admissions YTD: 16,876 +662 +4.1% 2250 • Elective Admissions YTD LY: 16,214 • Non-Elective Admissions YTD: 17,515 2000 +1,301 +8.0% • Non-Elective Admissions YTD LY: 16,214 1750 • Average Elective LOS vs LY diff: 0 0% • Average Non-Elective LOS vs LY diff: -0.8 -16.7% 1500

1250 RAG status: Achieved 1000 Targets Met.

Total Elective Admissions Non Elective Admissions Symphony Emergency Admissions Impact Responsive [6]

December 17 Emergency Admissions vs Reduction Plan Adult >1 Day LoS YTD Admissions Reduction 2,000 Admissions on Last Year 1,750 1,154 -2.2% 1,500 1,250 (Target -5%) 1,000 750 December 16 500 250 Adult >1 Day LoS 0 Admissions 1,181 >1 Day LoS Adult Emerg Adm 0 Day LoS Adult Emerg Adm Paeds Emerg Adm Reduction Plan (>1 Day LoS Adults Only)

Additional notes RAG status: Failed Count Diff % Diff • Admissions: 1,154 Targets Failed. Reason: -27 -2.3% • Admissions LY: 1,181 Whilst the level of adult 1+LoS • Admissions admissions have decreased compared 1,143 +11 +1.0% Reduction Plan: to last year, they remain higher than the • Admission YTD: 9,299 target reduction. -209 -2.2% • Admission YTD LY: 9,508 • Admissions YTD 9079 +220 +2.4% Reduction Plan Cancer 2 Week Wait Responsive [7] 2 Week Cancer Targets 100% November 17 95% 2 Week Suspected 2 Week Breast Cancer 90%

97.1% 100.0% 85%

Targets 80%

93% 93% 75%

Additional notes 2WW Breast 2WW Suspected Cancer

• YTD Avg for 2 Week Suspected Cancer: 94.6%

• YTD Avg for 2 Week Breast: 94.6% Number of Referrals Seen 1000 100 NOTE: Cancer data is now a month in arrears to allow for post-validation figures to be used. The monthly data 800 80 is not final until the Quarter End Data Submission. 600 60

400 40 Breast Symptoms Suspected Cancer Suspected -

RAG status: Achieved - 200 20 Targets Met. 0 0 No. Referrals No. referrals

2WW Exhibited Breast Symptoms 2WW Suspected Cancer Cancer 31 and 62 Day Treatment Targets Responsive [8] 31 Day Treatment First November 17 100% 31 Day Treatment 31 Day Treatment 31 Day Treatment 98% First Subsequent Surgery Subsequent Drugs 96% 97.7% 86.7% 100.0% 94% (Target 96%) (Target 94%) (Target 98%) 92% 90% 62 Day Treatment 62 Day Treatment 62 Day Treatment 88% Screening Standard Upgrades 86% 100.0% 77.4% 100.0% (Target 85%) (Target 90%) (Target 90%)

Achievement % Target 6 Month Moving Average Additional notes YTD % Target • 31 Day Treatment First YTD: 97.7% 96% 62 Day Treatment Standard • 31 Day Treatment Subsequent Surgery YTD: 95.7% 94% 100% • 31 Day Treatment Subsequent Drugs YTD: 100.0% 98% 95% • 62 Day Treatment Screening YTD: 100.0% 85% 90% • 62 Day Treatment Standard YTD: 83.2% 90% 85% • 62 Day Treatment Upgrades YTD: 92.9% 90% 80% Figures are Draft until final Quarter End Open Exeter 75% 70% RAG status: Failed, close to achievement 65% Targets Failed. Reason: 60% The 31 Day Subsequent Surgery and 62 Day Breaches were due to limited Capacity/Resource.

Achievement % Target 6 Month Moving Average Cancer 62 Day Urgent GP Referral Pathway Responsive [9]

62 Day Site Breakdown - 3 Month Review Achievement, Referrals and Breaches November 17 Cancer Site September 17 October 17 November 17 2017/18 YTD

Target: 85% Brain 0 0 0 0 0 0 0 0 Breast 83.3% 6 1 100.0% 6 0 100.0% 11 0 95.7% 69 3 Gynaecology 100.0% 2.5 0 57.1% 3.5 1.5 66.7% 3 1 73.8% 21 5.5 Haematology 0 0 66.7% 3 1 0.0% 2 2 69.6% 11.5 3.5 Head and Neck 50.0% 1 0.5 66.7% 1.5 0.5 50.0% 1 0.5 69.2% 6.5 2 Lower GI 40.0% 2.5 1.5 9.1% 5.5 5 61.5% 6.5 2.5 51.9% 39.5 19 Lung 40.0% 2.5 1.5 40.0% 2.5 1.5 50.0% 4 2 63.0% 23 8.5 Sarcoma 0 0 0 0 0 0 100.0% 1 0 Skin 94.4% 18 1 100.0% 12 0 96.3% 27 1 98.5% 133.5 2 Upper GI 85.7% 7 1 100.0% 4 0 0 0 88.9% 22.5 2.5 Urology 93.8% 8 0.5 52.6% 9.5 4.5 52.2% 11.5 5.5 72.2% 79 22 Other 0 0 100.0% 1 0 0.0% 0.5 0.5 75.0% 6 1.5 All 85.3% 47.5 7.0 71.1% 48.5 14.0 77.4% 66.5 15.0 83.2% 412.5 69.5

Additional notes Number of 62 Day Patients Seen Note that shared breaches with other organisations show 160 140 as 0.5 on the table above. 120 100 80 RAG status: Failed 60 Targets Failed. Reason: 40 20 The 62 Day Breaches were mainly in Urology patients and 0 were due to limited Capacity/Resource. Patient Compliments and Complaints Caring [1]

December 17 Number of Compliments and Complaints 120

Compliments Complaints PALs 100 52 6 63 80 60 December 16 40 20 Compliments Complaints PALs 0 43 9 86

Compliments Complaints Additional notes

• Compliments YTD: 422 +41 +10.8% • Compliments YTD LY: 381 Highest Departments - Compliments YTD • Complaints YTD: 59 -57 -49.1% • Complaints YTD LY: 116 Kingston Wing • PALs YTD: 659 -398 -37.7% Ambulatory Care • PALs YTD LY: 1057 Surgical Team

Radiology RAG status: Achieved General YDH Compliments Targets Met. Emergency Department From the 1st September 2017 the compliments recording system changed. Compliments are now registered against Ward 6A a department including when a compliment is received for 0 10 20 30 40 50 60 70 an individual member of staff. Learning from Complaints and Incidents Caring [2]

December 17

Number of Serious Number of Incident Investigations Complaints closed closed

0 6

Actions and Learning

Main Actions:

• Effective communication with patient /relatives regarding the risks and benefits of using a falls alarms so that expectations are appropriately managed

• Clinical Director for Obstetrics to develop an appropriate training/update programme

• To develop information leaflet regarding the role of Paediatrics in the diagnostic process to establish a cause of behavioural/developmental issues NHS Improvement Indicators Well Led

December 17 12 Month Review

RTT Yearly Averages 18 week RTT Incomplete pathways - All Specialties Trend

Target Period 2016/17 2017/18 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 92% M 90.8% 93.8% 92.3% 92.3% 93.1% 93.3% 94.6% 94.6% 94.3% 94.3% 93.6% 93.4% 93.3% 92.6%

A&E Yearly Averages A&E Clinical Quality: Total time of 4 hours in A&E Trend

Target Period 2016/17 2017/18 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 95% M 93.9% 97.6% 95.8% 96.1% 98.4% 98.1% 98.7% 97.6% 97.8% 98.2% 97.7% 98.1% 96.7% 95.6%

Cancer Yearly Averages Max waiting time of 62 days from urgent GP referral to first treatment for all cancers Trend

Target Period 2016/17 2017/18 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 85% Q 86.5% 83.2% 91.0% 90.1% 93.3% 85.9% 88.6% 92.3% 84.6% 80.6% 85.3% 71.1% 77.4%

Diagnostics Yearly Averages Diagnostic 6 Week Waits Trend

Target Period 2016/17 2017/18 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 99% M 99.2% 98.9% 99.5% 99.5% 99.6% 98.5% 98.1% 99.4% 99.2% 99.6% 98.7% 97.9% 99.2% 99.2%

Safety Yearly Averages C.Diff year on year reduction (lapses in care only) Trend

Target Period 2016/17 2017/18 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 8 pa Q 3 0 0 0 0 0 0 0 0 0 0 0 0 0 YDH │Financial Performance

Month 9 – December 2017

Variance to forecast – BAU & Transformation excl. donated assets In month £102k adverse to forecast, £3k adverse YTD.

£000's Dec-17 YTD Actual Forecast Variance Actual Forecast Variance Notes NHS Clinical Income 8,674 9,168 (495) 82,601 82,254 347 Offset by drugs, YTD favourable. Other income 1,642 1,572 70 14,343 14,338 5 Non NHS Clinical income 143 231 (88) 1,570 1,817 (247) Offset by non pay (Trakcare)

Total income 10,458 10,971 (513) 98,514 98,409 106

Other Pay (2,599) (2,624) 24 (23,625) (23,606) (19) Nursing Pay (2,760) (2,742) (18) (25,370) (25,171) (199) Sickness & escalation Medical Pay (2,417) (2,306) (110) (21,539) (21,124) (415) Vacancy cover Total Pay (7,776) (7,672) (104) (70,534) (69,901) (634)

Drugs (909) (1,207) 297 (11,056) (11,236) 180 Offsetting income Consumables Non Pay (868) (936) 68 (8,190) (8,168) (22) Other Non Pay (2,146) (2,274) 128 (21,009) (21,199) 190 Cost savings Total Non Pay (3,924) (4,417) 493 (40,255) (40,603) 349

Total Expenditure (11,700) (12,089) 389 (110,789) (110,504) (285)

Below EBITDA (366) (388) 22 (3,357) (3,533) 177 Interest lower than forecast Control Total Surplus / (1,608) (1,506) (102) (15,631) (15,629) (3) (Deficit) Quarterly change in financial performance (BAU)* In 2017/18 improvement each quarter on underlying run rate, Q1 adverse variance to Q4 prior year caused by change to tariff, seasonality in income and pay inflation.

*Graphs exclude, one off items in 2016/17 MSCP income, 2017/18 Q1 A/L accrual. Clinical Negligence (£1.1m increase YoY), STF Income, Donated Assets, Impairment, All drugs spend and high cost drugs income (£3.1m 16/17 £3.1m 17/18). Overview of key variances to prior year YTD

(10,000)

(10,500)

(11,000) Excluded from adjusted control total (11,500) (13,276) (12,000) (14,299) 684 (12,500) (182) 400 (357) 543 (13,000) 200 (888) 847 (2,270) £’000 (Deficit) / Surplus (13,500)

(14,000)

Favourable Adverse Technical – variance due to interest payable lower than plan November position vs budget Reported in month deficit £1.4m, £712k adverse to plan. £439k adverse to the control total. STF not earned in month YTD £2.19m adverse to control total excluding STF, in line with forecast.

Performance against control total Financial Summary In Month Year to Date (excluding STF) Variance Variance 0.00 Actual to Actual to (0.50) £000's Budget Budget

(1.00)

Total Trust Deficit (1,421) (712) (14,300) (4,350) Which Includes £’m Donated Items 186 158 688 (14) (1.50) Control total (1,608) (869) (14,987) (4,335) (2.00) (Including STF) ** STF* 0 (430) 644 (2,147) (2.50) Control total (1,608) (439) (15,631) (2,188) (Excluding STF) Actual 17/18 Plan 17/18

*STF – Sustainability & Transformation Funding – ED 4 hr wait performance in month was 95.6% (target achieved). STF income not recognised in month however as the control YTD was not achieved.

Overview of key variances to budget in month

(200)

(710) (400) Excluded from adjusted control (600) total 57 (1,421) (800) (425) (1,000) Separated 234 out for (410) 157 comparison (4) (1,200) 95 (430)

£’000 (Deficit) / Surplus (120) 135 (1,400)

(1,600)

Favourable Adverse

Technical – variance due to interest adjustment as interest rate now confirmed lower than accrued rate. Overview of key variances to budget YTD YTD £2,203k adverse to plan excluding STF CIP unachieved YTD £1.2m

(7,500) Separated out for (8,500) (9,950) comparison

(9,500) 88 1,067 Excluded from (736) (10,500) (2,030) adjusted control total (14,300)

(11,500) (764) (346) 632 (14) (12,500) (100)

£’000 (Deficit) / Surplus (2,147) (13,500)

(14,500)

Favourable Adverse Technical – variance due to interest payable lower than plan Drugs Drugs in month net position of £57k favourable(23%),YTD £88k favourable(4%)

Variance YTD is 1,500 £88k favourable

1,000 £’000

500

Drugs expenditure Drugs Income In tariff drugs budget indication (above income)

Notes • Drugs spend YTD of £11.1m, offset by £8.8m. Net spend of £2.3m, which relates to in tariff drug spend. • In tariff drugs are funded through activity, unlike pass through income for high cost drugs from NHS England, Cancer Drug Fund and Somerset CCG. • In month position is estimated due to the implementation of Trak in Pharmacy. We have also removed the process of accruing homecare drugs but gives an equal reduction in both income and expenditure in month. Income summary excluding STF & drugs In month £191k adverse (2%), £330k favourable YTD (1%)

In month In month YTD Notes – In month variances Clinical Income Source Actuals Variance Variance • Somerset in month adverse to plan due to lower than planned elective Somerset CCG 6,125 (382) (361) activity (including daycases). Somerset CCG Overperformance 0 (84) (750) Dorset CCG 1,197 (38) 413 Specialist Commission Grp 362 59 430 Public Health Clinical Income 68 8 (16) Private Patients 133 (24) (258) Other (incl. NCAs, ICRS) 316 36 (194) Total 8,201 (425) (736)

In month In month YTD Non Clinical Income Source Notes – In month variances Actuals Variance Variance • Trakcare – offsetting non pay R&D Income 59 (6) (20) underspend, timing of implementation Education & Training 318 8 55 costs.

Trakcare 0 (84) 70 • Other – including £172k winter Pharmacy & Maintenance Contracts 124 6 89 pressures funding. £39k CIP overachievement offset by pay Catering 63 4 24 underachievement. £60k One off Car Parking 89 (16) (87) benefit. Other 626 322 936 Total (excl. donated asset inc.) 1,278 234 1,066 Pay expenditure & temporary staffing YTD £645k overspent plus central CIP unachieved £2m, total £2.8m YTD (4%)

8,000

7,500 Variance Underlying position 50 9 (100) 14 (11) (31) 7,000 21 0 (29) £’000 6,500 (60) £’000 (50)

6,000 (100)

5,500 Variance to Budget (150) in Month (187) £146k Adv Agency Bank & Locum Substantive Substantive Budget Central CIP target (200) excl central CIP

(250) Notes (275) • Nursing & medical - see later analysis (300) • S,T&T – £60k adverse - £49k CIP savings target not delivered. Theatre Services £32k over for ODP posts (funded by nursing budget). Vacancies in Therapies causing agency spend.

• Ancillary – £29k offset in admin & clerical. Pay expenditure & temporary staffing Nursing staff (registered and unregistered) - £187k overspend (7%), £1,148k overspend YTD (5%) 2,900 400

350 2,700

300 2,500 250

£’000 2,300 200

2,100 150 Bed Days Occupied

1,900 100

Agency Bank Substantive Average Occupied Bed Days (exc Cookson Court) Nursing Agency Spend £000s Area Apr May June Jul Aug Sep Oct Nov Dec Notes Wards 119 98 90 9 35 72 47 15 37 • Substantive costs have decreased by £20k ED 62 35 36 12 21 17 18 9 15 from last month, to £2,404k in month.

Theatres 34 52 54 52 16 29 59 39 36 • Agency costs have increased by £21k from Midwifery 0 0 0 0 0 0 0 1 2 last month, to £103k in month. ICU 23 6 26 36 21 42 25 15 11 • Bank costs have decreased by £18k from Outpatients 0 0 0 0 0 0 2 2 1 last month, to £205k in month. Other 0 0 0 0 1 -1 0 1 2 Total 238 191 206 110 94 160 151 82 103 Pay expenditure & temporary staffing Nursing staff (registered and unregistered) – in month and YTD variance

Reason for Variance In Month YTD Comments Variance Variance £’000 £’000 Budget assumed escalation costs of £0.1k in Escalation (5) (7) month, however actual costs were £5.7k in month. Budget for closure of space set here, achieved by CIP DTOC 5 (80) increased income from Somerset County Council and closure of Jasmine beds.

Supernumerary 0 0 £14k spent in month, within allocated risk budget

Specialing 0 0 £5k spend in month, within allocated risk budget

Notable overspends on 9B and 9A. Underspends Wards & ICU 11 (143) include 6B and Kingston Wing.

Workforce CIP (200) (1,102) Underachievement of general CIP schemes

Overspends in Specialist Nursing & ED, partially Other 2 184 offset by underspend in Theatre Services

Total (187) (1,148) Pay expenditure & temporary staffing Medical staffing pressures remain across a number of specialities 2600 2400 2200 2000 1800

£’000 1600 1400 1200 1000 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17

Regular payroll Additional payroll Agency Budget Pay expenditure & temporary staffing Medical staff – pressures across a broad range of specialities

Pay expenditure & temporary staffing Annual NHSI ceiling £6.5m. Agency YTD £3.7m, £1.2m (25%) below ceiling, £1,049k (40%) above plan. £’000

% of total pay Staff Group M1 M2 M3 M4 M5 M6 M7 M8 M9 in month Notes

Medical 234 129 345 91 189 124 193 222 205 8% Further agency Nursing 238 191 206 110 94 160 151 82 103 4% costs will be added Housekeeping & 16 12 18 20 15 12 15 16 20 to this when the Domestics YDH group is fully Therapy 6 30 14 19 11 4 21 18 11 consolidated. YTD Catering 3 7 5 7 4 6 3 3 1 3% costs in SHS are Audiology 3 2 15 9 6 2 (2) 13 (3) £875k. Finance 2 8 1 9 7 14 24 33 19 Other 13 21 23 9 14 12 1 9 19 Total 569 400 627 274 339 334 407 395 374 5% Non pay expenditure – medical consumables & referred tests

1,200

1,000

800

600

400 £’000

200

- Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Referred Tests High Cost Consumables Other Medical Consumables Medical Consumables Notes Business Unit In month In month YTD YTD Medical Consumables Actual Variance Actual Variance • Long Term Conditions – Adult diabetes Internal Medicine 60 6 540 50 • Facilities – increase in bulk store spend. • Other –Central budgets risk for higher activity Long Term Conditions 18 (11) 106 (41) offset by lower income (£61k in month, £625k Facilities 64 (12) 480 (46) YTD). Theatres 256 (1) 2,457 (89) Referred Tests Other 206 64 1,670 827 • Pathology – One off favourable adjustment of Consumables Total 605 46 5,255 700 £40k Pathology 253 36 2,770 (173) Radiology 11 0 154 (45) Other 0 3 11 9 Referred Tests Total 264 39 2,935 (209)

Other Medical Consumables – Medical & Surgical Equipment High Cost Consumables – Includes high cost prostheses Other non pay

2,500 In Month In Month YTD 2,000 Other Non Pay Category Actual Variance Variance £'000 £’000 £’000 1,500 Catering (83) (1) 8 Cleaning, Linen, Laundry & (115) (5) 82 1,000 Uniforms £’000 Equipment, Leases & 500 (31) 2 66 Maintenance

- Insurances (334) 1 (10) Medical Equipment (179) 8 87 Office Expenses (10) (3) (26) Other Non Pay Actual Other Non Pay Budget Other (70) 10 113 Patient & Staff Travel (63) 13 20 Notes – In month variances Patient Appliances (67) (15) (15) Postage, Phones & Calls (33) 20 (19) • Patient Appliances – high spends in Audiology (£9k overspent) and Printing & Photocopiers (33) 2 1 Orthotics (£5k overspent) Professional & Consultancy (114) (55) (9) • Professional & Consultancy – £46k 16/17feasibility studies for estates Fees projects not progressed and PWC costs. Property, Rates & Utilities (229) (7) (29) • Rent – Unachieved CIP related to consolidation of space back to YDH. Property - ext. contracts (24) 3 (31) • Software – Trakcare favourable offset by reduced income. Recruitment & Redundancy (47) 3 (396) Rent (212) (60) (412) Software (123) 55 (223) Training (27) 12 30 Total (1,794) (17) (763) Outsourced costs

NHS Recharges Summary In month In month YTD variance Outsourced NHS variance Notes £000's £000's £000's Taunton & Somerset (143) (29) 60 Medical staff recharges and SPS price gain premium Dorset County (10) 18 57 ENT Medical staff and Orthotic therapists Royal Devon & Exeter (15) 1 (20) Medical staff recharges

Torbay & Southern (18) (1) (42) Payroll

Other (70) 7 (7) Incl. Som Par, UHB medstaff, Maternity pathway providers Total (257) (4) 48

In month YTD In month Outsourced Non NHS variance variance Notes £000's £000's £000's Boots Outpatient Pharmacy (29) (1) (15) Service charge Cookson Court Beds (3) 0 0 STP Contribution (24) (16) (13) Non Pay costs element only

Other 33 89 151 £57k CIP for nursing home bed savings in month.

Total (23) 71 123 Capital YTD Spend £3.9m, £342k favourable to plan.

800 Actual 700 Plan 600 Forecast 500 400 £’000 300 200 100 0 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Capital Expenditure In Month Year to Date Notes Actual Variance Actual Variance (ADV)/FAV (ADV)/FAV • General Site capex, underspent YTD by £224k

• Medical Equipment underspent YTD by £338k due to timing, Operational Capital Spend items are now being purchased. Total General Site Capex 6 60 1,205 224 • IT underspent YTD £262k – timing difference. Medical Equipment 1 59 243 338 Radiology 0 0 0 200 • Major Developments relates to ward refurbishments

IT Upgrades/ Developments 2 101 331 262 • Donated Schemes include L7 DDA toilet, lift lobby and lighting Strategic Developments Major Developments 27 14 222 531 IT - Trakcare 90 (80) 748 (169) Donated Schemes in Year 191 (182) 1,119 (1,044) Total 317 (28) 3,867 342 Cash Cash balance at 31 December 2017; £1.5m

5,000 2017/18 Loan support Actual Cash Planned cash 17,000 received 4,000

16,000 16,559 3,000 £’000 15,000 2,000 14,000 1,000 £’000 13,000 0 12,000 -1,000 11,000 10,993 10,000

9,000 Schedule of loan support received Actual Loan Planned Loan Loan Name Loan Value Annual Interest Principal Drawdown YTD Drawdown YTD 2017 2017 £m Rate repayment date Revenue – 2015/16 17.5 1.5% Jan 2018 0-30 31-60 61-90 Over 90 Capital – 2015/16 5.3 1.97% Feb 2033 Aged Debtors Total days days days days Revenue – 2016/17 17.0 1.5% Feb 2021 £'000 £'000 £'000 £'000 £'000 Capital – 2016/17 1.9 0.45% tbc Receivables non NHS 1,219 516 464 0 239 Receivables NHS 11,864 10,834 196 0 834 Revenue – 2017/18 16.6 1.5% tbc Bad debt provision as at 31 Dec is £217k vs £239k over 90 days aged Total 58.3 debtors (excl NHS & Private Patients). I&E impact YTD of £40k. Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Creditors Days 43.5 48.4 46.2 40.4 48.9 49.4 55.9 48.4 55.5 39.5 58.5 54.5 34.6 Summary Trust Turnaround Highlight Report December 2017

TARGET FORECAST GAP Narrative by exception (INCL PIPELINE) Project Headline £8.7M £7.2M £1.5M Forecast outturn risk of £1.1m has been mitigated, however additional risks emerging and pipeline schemes not materialising Scheme Development Status Progress last month Plans in Identified Unidentified SBU Target Pipeline In delivery Divisional Support now in place with regular reviews being Development total Gap undertaken Corporate 2,918 25 0 2,423 2,448 471 Elective Care 2,805 - 249 999 1,248 1,556 Key activities this week Urgent Care 2,907 54 221 2,255 2,530 377 Further review / challenge to ensure forecast values are Transformation ------deliverable Trust wide 1,146 57 - 935 992 154 Central - 1,064 - - - - - 1,064 Risks & Issues Mitigating Actions

Total 8,712 136 470 6,612 7,218 1,494 1) Delivery of forecast savings 1) Regular reviews of progress Monthly progress on CIP development 2) Level of unidentified savings 2)Review of forecast outturn to target challenge to reduce costs

Recurrent vs Non Recurrent Savings Type 5 | Appendices

1 Statement of Comprehensive Income

2 Balance Sheet

3 13 week cash flow

4 Monthly cash flow

Summary Statement of Comprehensive Income For whole trust including business as usual operations and transformation. Financial Summary Prior Months Actuals In Month - Dec 17 Year to Date Variance Annual Variance to to Budget £000's Oct-17 Nov-17 Actual Budget % var Actual Budget % var 2017/18

Income Clinical Income 9,441 10,346 8,953 (533) 6.0% 85,229 196 (0.2%) 113,012 Non NHS Clinical Income 228 173 143 (62) 43.5% 1,570 (442) 28.2% 2,672 Other Income 1,302 1,350 1,570 (123) 7.8% 13,245 (1,275) 9.6% 19,832 Total Income 10,971 11,870 10,666 (718) 6.7% 100,044 (1,521) 1.5% 135,515

Pay Registered Nursing (2,226) (2,170) (2,149) (24) (1.1%) (19,785) 193 1.0% (26,451) Unregistered Nursing (635) (623) (611) (147) (24.1%) (5,586) (1,255) (22.5%) (5,741) Medical Staff (2,409) (2,493) (2,417) (272) (11.3%) (21,539) (1,562) (7.3%) (26,388) Estates, Admin & Clerical (1,491) (1,520) (1,474) 33 2.2% (13,462) 486 3.6% (18,468) Pay - Scientific, Therapeutic & Technical (756) (781) (763) (59) (7.8%) (6,812) (185) (2.7%) (8,738) Pay - Ancillary (364) (365) (362) (29) (8.0%) (3,351) (375) (11.2%) (3,972) Total Pay Expenditure (7,881) (7,953) (7,776) (499) (6.4%) (70,534) (2,698) (3.8%) (89,759) Pay % of revenue 71.8% 67.0% 72.9% 70.5% 66.2% Non Pay Drugs (1,085) (1,275) (909) 231 25.4% (11,056) (637) (5.8%) (13,828) Consumable M&SE (404) (378) (403) 83 20.6% (3,346) 676 20.2% (5,295) High Cost M&SE (283) (281) (201) (37) (18.1%) (1,909) 24 1.3% (2,531) Other (2,572) (2,642) (2,411) 135 5.6% (23,943) (816) (3.4%) (30,761) Total Non Pay Expenditure (4,345) (4,576) (3,924) 413 10.5% (40,255) (754) (1.9%) (52,414) Non pay % of revenue 39.6% 38.5% 36.8% 40.2% 38.7% EBITDA (1,255) (658) (1,034) (804) (77.8%) (10,745) (4,972) (46.3%) (6,657) Other Technical (418) (262) (388) 93 23.9% (3,554) 622 17.5% (5,646) Surplus / (Deficit) (1,673) (920) (1,421) (712) (14,300) (4,350) (12,303) Surplus/Deficit % of revenue 15.3% 7.8% 13.3% 14.3% 9.1% Summary Statement of Comprehensive Income For business as usual operations Financial Summary Prior Months Actuals In Month - Dec 17 Year to Date Variance Annual Variance to to Budget £000's Oct-17 Nov-17 Actual Budget % var Actual Budget % var 2017/18 Income Clinical Income 9,122 10,138 8,674 (529) 6.1% 82,601 153 (0.2%) 109,577 Non NHS Clinical Income 228 173 143 (62) 43.5% 1,570 (442) 28.2% 2,672 Other Income 1,302 1,489 1,593 (46) 2.9% 13,242 (806) 6.1% 19,195 Total Income 10,652 11,800 10,409 (637) 6.1% 97,413 (1,095) 1.1% 131,443 Pay Registered Nursing (2,191) (2,118) (2,113) (38) (1.8%) (19,409) 122 0.6% (25,855) Unregistered Nursing (614) (611) (599) (149) (24.8%) (5,475) (1,270) (23.2%) (5,574) Medical Staff (2,370) (2,438) (2,369) (275) (11.6%) (21,006) (1,481) (7.1%) (25,785) Estates, Admin & Clerical (1,403) (1,441) (1,399) 21 1.5% (12,713) 456 3.6% (17,430) Pay - Scientific, Therapeutic & Technical (740) (763) (742) (60) (8.1%) (6,674) (246) (3.7%) (8,473) Pay - Ancillary (364) (365) (362) (29) (8.0%) (3,351) (375) (11.2%) (3,972) Total Pay Expenditure (7,683) (7,735) (7,584) (530) (7.0%) (68,629) (2,794) (4.1%) (87,089) Pay % of revenue 72.1% 65.5% 72.9% 70.5% 66.3% Non Pay Drugs (1,085) (1,275) (909) 231 25.4% (11,055) (636) (5.8%) (13,828) Consumable M&SE (404) (378) (403) 83 20.6% (3,345) 676 20.2% (5,295) High Cost M&SE (283) (281) (201) (37) (18.1%) (1,909) 24 1.3% (2,531) Other (2,412) (2,488) (2,339) 89 3.8% (22,881) (801) (3.5%) (29,358) Total Non Pay Expenditure (4,184) (4,421) (3,852) 366 9.5% (39,191) (737) (1.9%) (51,011) Non pay % of revenue 39.3% 37.5% 37.0% 40.2% 38.8% EBITDA (1,216) (356) (1,027) (801) (77.9%) (10,406) (4,626) (44.5%) (6,657) Other Technical (418) (262) (388) 93 23.9% (3,554) 622 17.5% (5,646) Surplus / (Deficit) (1,634) (618) (1,415) (708) (13,961) (4,004) (12,303) Surplus/Deficit % of revenue 15.3% 5.2% 13.6% 14.3% 9.4% Balance Sheet Nov 17 Dec 17 Mvt In Mth Dec 16 Mvt In Yr Non Current Assets 60,869 60,867 (2) 59,188 1,679 Current Assets Stock 2,031 1,982 (49) 2,183 (201) NHS Trade Debtors 11,261 12,090 829 1,592 10,498 Non NHS Trade Debtors 1,238 1,169 (69) 979 190 Accrued Income 3,930 3,498 (432) 4,625 (1,127) Prepaid Contracts 1,755 2,102 347 1,338 764 Cash in Hand and at Bank (901) 1,460 2,361 1,981 (521) Total Current assets 19,314 22,301 2,987 12,698 9,603 Current Liabilities Trade Creditors (4,990) (2,359) 2,631 (2,194) (165) Other Creditors (2,082) (2,047) 35 (3,377) 1,330 PDC Dividend Creditor 0 0 0 (119) 119 Capital Creditor (753) (536) 217 (1,083) 547 Accruals (15,454) (18,037) (2,583) (9,422) (8,615) Borrowings <1yr (18,269) (18,269) 0 (456) (17,813) Interest Payable 0 0 0 (254) 254 Deferred Income (175) (84) 91 (636) 552 Current Liabilities (41,723) (41,332) 391 (17,541) (23,791)

Net Current Assets (22,409) (19,031) 3,378 (4,843) (14,188) Total Assets less Current Liabilities 38,460 41,836 3,376 54,345 (12,509) Trade and other Payables >1yr 0 0 0 0 0 Borrowings> 1yr (36,661) (41,458) (4,797) (40,083) (1,376) Provisions >1yr (1,033) (1,033) 0 (959) (74) Net Assets employed 766 (655) (1,421) 13,303 (13,959) Financed by: I&E Reserve Current year (27,502) (28,923) (1,421) (13,276) (15,648) Public Dividend Capital 42,089 42,089 0 41,823 266 I&E Reserve Previous year (23,223) (23,223) 0 (23,223) 0 Revaluation Reserve 9,402 9,402 0 7,978 1,424 Total Financed 766 (655) (1,421) 13,303 (13,958) 13 Week Cash Flow Summary

Week ending 05-Jan-18 12-Jan-18 19-Jan-18 26-Jan-18 02-Feb-18 09-Feb-18 16-Feb-18 23-Feb-18 02-Mar-18 09-Mar-18 16-Mar-18 23-Mar-18 30-Mar-18 Month Jan-18 Jan-18 Jan-18 Jan-18 Feb-18 Feb-18 Feb-18 Feb-18 Mar-18 Mar-18 Mar-18 Mar-18 Mar-18 Opening Cash 3,310 11,477 10,754 7,089 1,746 10,109 9,036 9,979 1,000 9,456 8,781 6,751 5,984 Clinical Income 9,178 23 23 23 9,178 23 23 23 9,178 23 23 23 23 Other receipts 101 191 862 101 101 101 920 133 101 101 830 133 101 Transformation Income 0 0 0 0 0 0 795 0 0 0 795 0 0 Deficit Support Loan - DoH - Revenue 0 0 0 0 0 0 228 0 0 0 860 0 0 Deficit Support Loan - DoH - Capital 0 0 0 0 0 0 0 0 0 0 0 0 0 Payroll costs 0 0 (2,987) (4,680) 0 0 0 (7,667) 0 0 (2,987) 0 (4,212) Non pay costs (1,027) (852) (1,477) (702) (852) (1,127) (952) (1,147) (852) (829) (1,580) (952) (923) PDC Dividend 0 0 0 0 0 0 0 0 0 0 0 0 0 Loan repayments and interest 0 0 0 0 0 0 0 (250) 0 0 0 0 0 Other payments 0 0 0 0 0 0 0 0 0 0 0 0 0 Capex (81) (81) (81) (81) (64) (92) (92) (92) (101) (101) (101) (101) (103) Capital creditors (5) (5) (5) (5) 0 21 21 21 129 129 129 129 129 Closing Cash 11,477 10,754 7,089 1,746 10,109 9,036 9,979 1,000 9,456 8,781 6,751 5,984 1,000

Notes

Vanguard receipt for Q3 confirmed for receipt in February Capex broadly in line with plan. Monthly Cash Flow Summary Month Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 £m £m £m £m £m £m £m £m £m £m £m £m Pay costs (7.3) (7.3) (7.3) (7.4) (7.6) (7.4) (7.4) (7.7) (7.7) (7.7) (7.7) (7.7)

Non pay Non pay costs incl Capital and Stores . (2.7) (5.5) (7.3) (4.2) (4.9) (6.2) (3.7) (2.9) (3.8) (3.4) (3.7) (4.3) NHS bodies (0.3) (0.9) 0.0 (1.0) (1.0) (0.8) (1.3) (1.0) (1.3) (1.1) (1.1) (1.3) CNST (0.4) (0.4) (0.4) (0.4) (0.4) (0.4) (0.4) (0.4) (0.4) (0.4) 0.0 0.0 Loan repayments and PDC Dividend 0.0 0.0 0.0 0.0 (0.2) (0.3) 0.0 0.0 0.0 0.0 (0.3) 0.0

Income Somerset and Dorset Contract Income 8.2 8.0 8.0 8.0 8.4 8.0 8.2 8.2 8.2 8.2 8.2 8.2 NHS England 1.1 1.5 0.7 0.2 1.7 0.9 1.1 1.1 1.1 1.1 1.1 1.1 Transformation Income Vanguard and STF 0.0 0.0 0.9 3.1 0.0 0.6 (0.6) 0.0 0.0 0.8 0.0 0.8 Other NHS Income 0.5 0.2 1.6 0.8 0.6 1.6 0.9 0.5 0.5 0.5 0.5 1.0 Heath Education England 0.3 0.0 0.6 0.0 0.6 0.3 0.3 0.3 0.3 0.3 0.3 0.3 VAT income 0.1 0.2 0.2 0.2 0.4 0.1 0.1 0.1 0.1 0.1 0.1 0.1 Other non NHS income 0.5 0.6 1.2 0.6 0.8 1.2 0.7 0.7 0.8 0.8 0.8 0.8

Net cash flow generated from operations (0.0) (3.6) (1.8) (0.1) (1.6) (2.4) (2.1) (1.1) (2.2) (0.8) (1.8) (1.0)

Opening Cash Balance 1.1 2.4 0.9 1.2 2.5 1.9 1.7 1.0 1.0 1.0 1.0 1.0 Deficit Support Loan - Revenue 1.2 2.2 2.3 1.1 1.0 2.1 1.4 1.1 2.2 0.8 1.8 1.0 Deficit Support Loan - Capital 0.0 0.0 0.0 0.3 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Closing Cash 2.3 1.0 1.4 2.5 2.0 1.6 1.0 1.0 1.0 1.0 1.0 1.0

Loan Note Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Original loan requirement as per NHSI template 1.8 2.1 1.0 1.3 1.9 0.7 0.7 0.9 0.5 1.2 0.0 0.8 12.9 Revised loan requirement as per revised cash flow 1.2 2.2 2.3 1.1 1.0 2.1 1.4 1.1 2.2 0.8 1.8 1.0 18.1

Variance 0.6 (0.1) (1.3) 0.1 0.9 (1.4) (0.7) (0.2) (1.7) 0.4 (1.8) (0.2) (5.2)

Reconcilliation of original loan to revised loan

Original loan requirement 12.9

STF not received 3.7 additional ~I & E deficit above plan 1.9 Less STF Q4 from 1617 (2.0) Q1 reduction in Annual leave accrual still a cash requirement 0.4 CQUIN loss 0.5 Additional March cash deficit 0.8

Requirement for loan in 1718 18.1