A Meeting of the Board of Directors Will Take Place on Thursday 7Th August 2014, 9Am in the Education Centre, Barnsley Hospital

A MEETING OF THE BOARD OF DIRECTORS WILL TAKE PLACE ON THURSDAY 7TH AUGUST 2014, 9AM IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL

AGENDA

No Item Sponsor Ref 1. Apologies and Welcome

2. To receive any further declarations of interests 14/08/P-02 To approve the Minutes of the meeting of the Board of 3. S Wragg, Chairman 14/08/P-03 Directors held in public on 2nd July 2014 To approve the Action Log in relation to progress to date 4. 14/08/P-04 and review any outstanding actions

Strategic Aim 1: Patients will experience safe care L Christon

5. To receive and consider a Patient’s Story Non Executive Director To receive and endorse the Medical Director’s quarterly 6. 14/08/P-06 update report. Dr J Mahajan Medical Director 7. To receive and approve the report on Doctors’ revalidation 14/08/P-07

To receive and endorse the monthly update on Nursing & A Bielby 8. 14/08/P-08 Midwifery staffing Deputy Dir of Nursing To approve the annual report on Infection Prevention & Dr J Rao 9. Director of Infection 14/08/P-09 Presentation Control Prevention & Control

To note and support progress on the Hospital @ Night A Bielby 10. 14/08/P-10 programme Deputy Dir of Nursing For the Trust’s Mortality Ratios: a) To review progress on the Trust’s Mortality Ratios Dr J Mahajan 14/08/P-11 11. b) to note the review outcomes and approve the action plan Medical Director (a-c) c) to note audit status for Sepsis Six and NEWS programmes

To receive and endorse assurance report from L Christon 12. 14/08/P-12 the Clinical Governance Committee Committee Chair

To receive and endorse assurance report from F Patton 13. 14/08/P-13 the Finance & Performance Committee Committee Chair

To receive and endorse assurance report P Spinks 14. 14/08/P-14 from the Audit Committee Committee Chair To approve the Terms or Reference for the Governance 15. 14/08/P-15 Committees A Keeney Assoc Director of To review and endorse the Board Assurance Framework Corporate Affairs 16. 14/08/P-16 (month 3 report)

Cont/…

BoD August 2014: 00 PUM Agenda

No Item Sponsor Ref Strategic Aim 2: Partnership will be our strength S Wragg 14/08/P-17 17. To note and endorse the monthly report from the Chairman Chairman D Wake, 14/08/P-18 18. To note the monthly report from Chief Executive Chief Executive To receive and endorse the quarterly marketing and E Parkes 19. Director of Marketing & 14/08/P-19 communications report Communications Strategic Aim 3: People will be proud to work for us Strategic Aim 4: Performance matters

20. To review the integrated performance report (month 3) Executive Team 14/08/P-20

21. In accordance with the Trust’s Standing Orders and Constitution, to resolve that representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted. Date of next meeting: - 4th September 2014, 9am, at Education Centre, Barnsley Hospital

Signed: ………………………….. Chairman

Please see reference section at back of papers for key to business plan and glossary of terms/acronyms

BoD August 2014: 00 PUM Agenda REF: 14/08/P/03

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT

MINUTES OF A MEETING OF THE BOARD OF DIRECTORS HELD ON 2ND JULY 2014 IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL NHSFT

PRESENT: Mrs S Brain England OBE Non Executive Director Mrs L Christon Non Executive Director Mr S Diggles Interim Director of Finance Mrs K Kelly Director of Operations Dr J Mahajan Medical Director Mrs H McNair Director of Nursing & Quality Mr P Spinks Non Executive Director Ms D Wake Chief Executive Mr S Wragg Chairman

IN ATTENDANCE: Ms L Bamford Lead Nurse, Clinical Business Unit 4 * Dr A Bowry Clinical Director, Clinical Business Unit 5 Mr J Bradley Director of ICT Ms H Brearley Director of HR & Organisational Development (OD) Mrs L Christopher Associate Director of Estates & Facilities Ms C E Dudley Secretary to the Board Ms E Foreman Clinical Nurse Lead, Deloitte (Observer) Dr K Kapur Clinical Director, Clinical Business Unit 3 Ms A Keeney Interim Assoc Director of Corporate Affairs Mr R Kirton Director of Strategy & Business Development Ms E Parkes Director of Communications & Marketing Mr M Shiwani Clinical Director, Clinical Business Unit 4 Ms A Trainer Head of Nursing, Clinical Business Unit 4 * Mr M H Wickham Clinical Director, Clinical Business Unit 5 (* attending for Minute ref 14/115)

APOLOGIES: Sir Stephen Houghton CBE Non Executive Director Mr F Patton Non Executive Director

14/111 APOLOGIES & WELCOME Members and attendees as noted above were welcomed and apologies were noted from Sir Stephen and Mr Patton. Particular welcomes were extended to Ms Foreman, attending to observe as part of the Deloitte review of the Trust’s governance arrangements, and three Clinical Directors (CDs) – Dr Bowry, Mr Shiwani and Mr Wickham. The Chairman affirmed that, following establishment of the new Clinical Business Units (CBUs), invitations had been extended to all of the CDs to attend Board meetings to provide advice directly to the Board, share updates from their CBUs and ensure timely feedback to their teams.

14/112 REGISTER OF INTERESTS AND (14/07/P-02) DECLARATION OF INTERESTS The latest Registers of Interests for the Board of Directors, the Executive Team and Clinical Directors were received and noted. Members were reminded that any changes to their entries on the Registers should be declared as soon as possible. No declarations of interest were received for any agenda items.

14/113 MINUTES OF LAST MEETING (14/07/P-03) The Minutes of the meeting of the Board of Directors held in public on 3rd June 2014 were received and approved as a true record.

14/114 ACTION LOG (14/07/P-04) The action log showing progress on matters arising from the last and previous meetings held in public was reviewed and noted.

Two of the older entries on the log were queried: • 14/10 (January 2014) – inreach model for AMU to be refined The log showed that the review had been completed but further progress would be “subject to funding”. Mrs Kelly advised that this related to funding sought as part of the 7-days working business case, a decision on which was due from the Clinical Commissioning Group (CCG) shortly.

• 13/182 (July 2013) – HSMR The log showed that the strategy would be developed after the review led by AQuA (Advanced Quality Alliance) had been completed. Dr Mahajan confirmed that the review work had now been progressed with AQuA, feedback from which had been shared at a recent workshop held with attendees from key areas across the Trust – see latest report on Mortality Ratios for more information. The action plan on mortality ratios was currently being revised building on the AQuA review and outcomes from the workshop and would be presented to the Board as soon as possible.

14/115 PATIENT ’S STORY Mrs McNair introduced Ms Trainer, one of the new Heads of Nursing, and Ms Bamford, a Lead Nurse in CBU 4, to present this month’s Patient’s Story. It comprised three accounts recently published by patients, relating to treatment received in May or June: two on the NHS Choices website and one in the Barnsley Chronicle. Each of the stories was very positive: • one from a patient who had previously used private healthcare and had been wary of using an NHS hospital. Their experience had been a positive one overall and they had appreciated the support and clear explanations given by the hospital’s caring staff; • the other case posted on NHS Choices related to a patient who had received treatment under anaesthetic for the first time in their life. They had been put at ease throughout their treatment and able to go home on the same day. They had been very impressed by both the staff, particularly those on the Surgical Admissions Unit (SAU), and the brilliant care they received pre- and post-operatively; • the third case was similarly positive and again related to the SAU.

BoD August 2014: 03_Minutes July 2014 Page 2 of 14 Ms Trainer and Ms Bamford emphasised the value of positive feedback like this being shared with the teams involved to ensure learning and further improvements. It was also a boost to staff morale. The Board agreed that the reports were a positive acknowledgement of the high standards of care provided on the SAU. Mrs Kelly endorsed this and advised that the unit worked extremely well, particularly around escalation needs with a flexible approach between day cases and in-patients, ensuring that all patients received the right care at the right time. It was recognised that the unit operated differently to other areas, with a different mix of patients and their corresponding needs. Nevertheless the unit clearly benefited from the strong clinical leadership provided by Ms Bamford and the Board suggested that it would be useful to identify learning points and good practice to be shared with other teams. Mrs Brain England also asked if some form of “buddy” mentoring could be provided so that newer lead staff could benefit from the experience of more experienced nurses such as Ms Bamford. Ms Trainer advised that she had been looking to develop this with the band 6 and 7 staff she had worked with previously and intended to revisit the possibilities in the new CBU. She would also explore other opportunities to share learning, as outlined by the Board. Dr Mahajan further commended the team and reported that junior doctors and medical trainees often commented on the learning and good experience they had benefited from when working with the SAU team. The Board appreciated the work of everyone on the SAU team and thanked Ms Trainer and Ms Bamford for their leadership and for attending the meeting as part of the Board’s approach to Patients’ Stories. The Chairman reminded members that Patients’ Stories were taken as an early agenda item to reinforce the purpose of the meeting – to support the Trust’s intention to provide top class services for patients.

14/116 NURSING & MIDWIFERY STAFFING (14/07/P-06) Mrs McNair presented the second report on monthly nursing and midwifery staffing levels against plan. The report differed slightly to the version presented last month, reflecting changes required by the Department of Health/NHS England (NHSE). The data presented in appendix 1 to the report would be posted on the national system; it now included “harm” data, as shown in the final columns. It was anticipated the published data would be accompanied by RAG (red/amber/green) ratings at some point as reporting developed further. The latest data showed that the Trust was meeting its requirement for staffing numbers, with appropriate mitigation in place where required.

The accompanying report expanded on the core data required by NHSE for publication. The additional information provided for the Board highlighted areas of shortfalls and overstaffing and the mitigating actions taken. Mrs McNair advised that one incident of harm potentially could be linked to staffing levels albeit this was a subjective assessment presently; the incident was being reviewed in more detail to identify any learning. It was acknowledged that the reported shortfalls were largely due to vacancies, maternity leave and sickness absence. A reduction in sickness absence would make an impact, as would improvements in recruitment; the latter was particularly challenging with over 500 nurse vacancies currently across the region. Work was ongoing to support recruitment and Mrs McNair outlined some initiatives being explored with the Universities to attract interest into specialist areas in particular, as these were often harder to recruit to in smaller

BoD August 2014: 03_Minutes July 2014 Page 3 of 14 general hospitals. The Board was mindful of proposals to reduce the headroom currently embedded in nurse staffing levels, from 22% to 18%. Mrs McNair also reminded the Board of the staffing ratios of registered nurses to patients applied at Barnsley (1:7 compared to the national average of 1:8), giving further support to safe care. The data return showed the Trust at 9.1% of shifts uncovered against planned rotas, which compared well with the national benchmark for staffing levels deemed unsafe (80% cover). Mrs McNair anticipated being able to provide more detailed and comparative information after a full quarter’s data had been published. Mrs Brain England welcomed the data and the extended report which, collectively, gave the Board good assurance on safe staffing levels. However, she did ask if the presentation of the report – and the data displayed on every ward – could be revised to ensure that same level of assurance was also provided for members of the public. Mr Spinks referred to previous discussions in which the Board had requested more information on the mitigating actions and emphasised that, even if national reporting was against planned staffing, the Board needed assurance on actual staffing levels on wards. Mrs McNair affirmed that a lot more data was available in detail for each ward but was difficult to present in a cohesive report format due to the volume of data available and, for accuracy, the need to take account of the acuity mix each day (one ward could be “short” of staff but with only 70% of its beds occupied, thus having more than sufficient staff to care for its patients at that time). Mrs Kelly reported on a system used in a trust she had worked with HM previously, which provided a report that in effect showed the staffing position 30 minutes into each shift, presented 24 hours retrospectively, reflecting actual staffing rather levels against plan at the start of shifts. It was agreed that this LC/HM could be useful and should be pursued. Q&G

As indicated above, it was agreed that, whilst the report met NHSE requirements, for the Board’s purpose it would be useful to revise it in terms of both format and content in order to give better assurance. This would be referred to the Quality & Governance Committee for action.

14/117 HOSPITAL STANDARDISED MORTALITY RATIO (HSMR) (14/07/P-07) & SUMMARY HOSPITAL MORALITY INIDCATORS (SHMI) Dr Mahajan presented and expanded on the latest report to May 2014, which showed progress on the agreed action plan, including the productive workshop on mortality rates held in June and continuing work to increase awareness of the Sepsis Six initiative. The report did not, however, provide an update on the Trust’s HSMR and SHMI position as no new statistics had been issued since last month: there had been a delay in issue of HSMR data nationally and SHMI statistics were only released quarterly. In terms of crude mortality rates, Dr Mahajan affirmed that the Trust had remained below mean since May 2013 and the position for May 2014 was at its lowest (best) since recording of this indicator had begun. Dr Mahajan also drew attention to the potential impact of the clinical decision unit (CDU) on mortality rates. The CDU provided a better service for patients – and their families – for end of life care but it also meant that more deaths were counted in the Trust’s mortality rates. The Executive Team were looking at the implications of this more closely.

Several members commented that, whilst it was disappointing the latest report did not provide an update on the Trust’s HSMR or SHMI positions, it would be useful if other elements of the report could also be reviewed to ensure information was current and relevant. It seemed to be growing in size but was not matched by a greater understanding of the issue. Dr Mahajan advised that

BoD August 2014: 03_Minutes July 2014 Page 4 of 14 a review of the report’s format, together with the action plan, was already in progress as mentioned earlier, linked to work progressed with the Allied Quality Alliance (AQuA). Mr Spinks also queried the SHMI position, which was reported to be within expectations but continued to show the Trust to be high compared to others, particularly against similarly sized trusts. It was clarified that (a) the statistics available to date still included the anomalous months reported previously - December 2012 and April 2013 - the impact of which was expected to lessen in future reporting, and (b) the data could not reflect the differences between the varying trusts, some of which had a very different patient and acuity mix (for instance, Airedale, which had no trauma department). It was agreed that it would be useful to include a brief explanation of such key factors where possible. Dr Mahajan affirmed that reportable progress towards the agreed JM/JB reduced target for HSMR would remain slow throughout 2014/15, with a greater impact showing towards the year end, as set out in the Trust’s Quality Strategy. It was agreed that it would be useful if the report demonstrated what was and was not working, to give assurance that the Trust continued to minimise avoidable deaths and to illustrate progress of each of the agreed actions. Ms Wake recommended that future reports should include a schedule of audits and milestones too. The need to restructure the report was acknowledged but did not undermine the work and progress ongoing:

• Ms Wake commended the work and progress to date • Dr Mahajan and Ms Wake advised that review work on all deaths had developed over the past six months. This had led to a number of mortality and morbidity reviews being undertaken to help the Trust identify any issues within each CBU. The reviews were scrutinised via the Patient Safety Steering Group. It was agreed that a succinct overview of this work would be useful to share with the Board, on a quarterly basis. JM

• Mrs McNair referred to ward by ward quality indicators, which were regularly monitored and provided more detail on issues such as compliance with the NEWS (national early warning signs) training. A ‘heat map’ was available for the latter; if required this could be reviewed at the Quality & Governance Committee, which in turn could provide assurance to the HM Board. This offer was accepted. • Dr Mahajan advised that key actions were reviewed via weekly reports at operational meetings.

• As Chair of the Clinical Governance Committee (CGC), Mrs Christon assured the Board that the CGC had spent a lot of time reviewing reports relating to mortality and would continue to do so under the new form of the Quality & Governance Committee. Dr Mahajan reconfirmed that the format report was under review. A revised version, taking account of AQuA’s recommendations and updated action plan, would be presented for the Board’s consideration shortly. Once approved by the Board, the new report and refreshed plan would be managed through the JM Trust’s Mortality Steering Group and monitored via the Quality & Governance Committee.

14/118 NON CLINICAL GOVERNANCE & RISK COMMITTEE (14/07/P-08) (NCGRC) - ASSURANCE REPORT Mrs McNair presented the assurance report on behalf of Mr Patton, NCGRC Chair, following the latest (last) meeting of the Committee held in June. She

BoD August 2014: 03_Minutes July 2014 Page 5 of 14 drew attention to the Committee’s suggested allocation of ongoing issues to the new Quality & Governance and Finance & Performance Committees, to ensure that nothing was overlooked in the transition, including: • further work required on DNAs (did not attends), assurance on which was still outstanding despite two reports commissioned by the committee, LC/ neither of which had proved satisfactory. NCGRC recommended that this Q&G be pursued through the Quality & Governance Committee. – Mrs McNair advised that the Executive Team was leading some work to take this forward. Mr Bradley and Mrs Kelly outlined key aspects being progressed with the CBUs to prevent DNAs. The links with the Trust’s

work on space utilisation were also highlighted. Mrs Kelly advised that Children’s service and Hepatology services remained the highest areas for DNAs. The former was not unexpected and needed to be managed with care. Plans were being considered for the latter services, to develop a different approach to better fit with patients’ needs;

• risks associated with the pathology systems when the current support FP/ contract expired in November (a joint risk shared with Rotherham FT). The F&P Committee recommended that this be referred to the Finance & Performance Committee for close monitoring. – Mr Bradley confirmed that work was ongoing; his team would be meeting with the current providers shortly to discuss options for support after December 2014 but the risk would remain until the situation had been fully addressed. Ms Wake advised that the issue had been discussed at the recent performance review with pathology and the CBU had been requested to provide more detail at the next meeting with a view to taking it to the CCG for support or, if necessary, looking to the small financial contingency held in the Trust’s capital programme. Mrs Christopher advised that overall costs to secure the extended support needed were estimated at £400,000 (to be shared across both trusts). • Appraisals - to be monitored via the Finance & Performance Committee. Mrs Brain England emphasised Mr Patton’s view that work now needed to FP/ focus on quality not just quantity and ensure staff’s objectives were more F&P clearly linked to the Trust’s business plan.

– Ms Brearley reminded the meeting of the new appraisal programme for all staff (other than medics) launched recently to fit better with the Trust’s business plan process and agreed values and behaviours and to enable introduction of robust performance measures as required under Agenda for Change. Whilst compliance levels stated in the report only showed 30%, the position at end of June had improved to 85.6%. This turnaround was commendable, reflecting a huge level of commitment across the Trust. In addition, a new step had been instigated through the Together We Will Make It Better initiative, learning from last year’s staff survey and the Trust now issued a personal questionnaire to all staff on completion of their appraisal. This would enable the Trust to collate more feedback on the quality of appraisals and develop further improvements. – Ms Wake advised it had been recognised that the changed process was not perfect, particularly in relation to the expectation for appraisals to be completed in the first three months of the financial year and alignment with strategic objectives. She had discussed these aspects with many staff at local level and appreciated their comments. The process was a work in progress and there were improvements to be made but the

BoD August 2014: 03_Minutes July 2014 Page 6 of 14 attainment of 85.6% – which would put the Trust in the top 20% nationally for compliance – was commendable. It was affirmed that further work on the appraisal process would be linked to the turnaround plan and Ms Parkes also advised that the communications plan would ensure continued cascade of the Trust’s objectives throughout the year. The Chairman requested further information on two other points featured in the report: • E-prescribing – it was confirmed that this had been withdrawn from the Trust’s work on its new electronic patient reporting (EPR) programme, however, the Trust continued to keep a watching brief on developments via Lorenzo, and • Re-siting of the Clinical Coding team – Mrs Christopher advised that a temporary space had been identified within O Block, so that the team could be located more centrally. The move would be completed shortly. The Board noted the Committee’s concerns, supported the processes proposed to address them and endorsed the Committee’s suggested re- allocation of identified issues for future monitoring. The Board also endorsed the NCGRC’s request that the new governance structure must be fully implemented with appropriate and robust terms of reference (next agenda item referred). As part of its usual business, the Committee had reviewed and recommended one new policy: • Governor and Members expenses policy It has also approved three amended/updated policies: • Supporting Staff involved in an accident, complaint or claim • Stress Policy • Contamination Incident Policy All of the above policies were approved and/or ratified by the Board accordingly.

14/119 GOVERNANCE RESTRUCTURE (14/07/P-09) The Board considered the proposed new governance structure presented by Ms Keeney. The new approach was intended to be more streamlined and to reflect a two-way approach with the Board and Trust being assured upwards through the organisation’s structure and also ensuring cascade back down. Ms Keeney explained that the structure had several main parts: the new committee structure – Quality & Governance, Finance & Performance and Audit – processes for reporting and assurance (using the escalation framework), a robust Board Assurance Framework and clear links to the Risk Registers.

The structure overall was welcomed and widely supported. There was a consensus that it would be simpler and would help to ensure a more comprehensive approach to governance within the Trust. It was acknowledged that there could be some overlap between the committees and it was important that the lead director for each issue was clearly identified and assigned to the right committee in the first instance. It was agreed that some further revisions would be useful for the Terms of Reference (TOR) for the three main committees to support this. Ms Keeney planned to meet with each of the committee Chairs to review the TOR (she had already commenced AK

BoD August 2014: 03_Minutes July 2014 Page 7 of 14 these discussions) to ensure they met with each committee’s needs before presenting final drafts at the Board’s next meeting, for approval. Mrs Brain England had noted in another report that it was proposed some delegated authority be given to the Finance & Performance sub-group, to facilitate approval of business cases. It was agreed that this seemed a sensible approach and, when approved, should be reflected in the TOR. Other delegated authorities would remain with the Executive Team, in accordance with the Trust’s Standing Orders and Scheme of Delegations. It was not anticipated that the committees would assume any other decision-making responsibilities and their main purpose would still be to provide assurance - or escalate risks – to the Board. This was agreed. It was also agreed that the outcomes of the governance review being led by Deloitte should be taken into account in the TOR when known.

In relation to more general points, it was agreed that (i) the TOR needed to be reviewed to eliminate any typing and grammar errors and to ensure a uniform style to the TOR and (ii) as Committees of the Board, only Executive and Non Executive Directors could be full members, with voting rights. The Chairman reported that, following discussion with the Non Executive Directors and to ensure an equitable allocation of responsibilities, the Non Executive assignments within the new structure would be: • Audit – Mr Spinks (Chair), Mrs Brain England and Sir Stephen • Finance & Performance – Mr Patton (Chair) and Mr Spinks

• Quality & Governance – Mrs Christon (Chair) and Mr Wragg

Referring to the operational groups reporting into the three committees, Ms Keeney advised that she would also be meeting with the executive leads of the groups to clarify membership and reporting systems and ensure that all groups had been identified and tied into the new structure. Mrs McNair welcomed the executive leadership at this level and emphasised the importance of ensuring that a clear focus on clinical and quality issues was maintained. The TOR for any task and finish groups would also be important and would be closely aligned to the overall structure. It was agreed that a Board workshop should be held to provide a refresher to risk assessment and risk management. HM

14/120 CHAIRMAN’S REPORT (14/07/P-10) The Chairman’s report, which provided an overview of a range of activities since the last Board meeting and reported on items of interest, was received and noted. The Chairman drew attention to the attached presentation, from the Foundation Trust Network’s (FTN) recent meeting for Chairs and Chief Executives. It outlined the FTN’s perspective of the challenging future facing the NHS and needed to be considered in the context of the Trust’s future too. The Chairman also referred to a letter from Monitor, following the latest monthly performance review meeting, copies of which would be distributed to SW Board members shortly. No further reports were received from other members of the Non Executive team.

14/121 CHIEF EXECUTIVE’S REPORT (14/07/P-11) The Chief Executive’s report on a range of activities and issues of interest arising since the last Board meeting was received and noted. Ms Wake was also pleased to report that the Trust had been highly commended for its work

BoD August 2014: 03_Minutes July 2014 Page 8 of 14 on diversity and had received an Award from NHS Employers for demonstrating ongoing commitment to personalised care and an inclusive workplace. Ms Brearley advised that the Award recognised the work of the Trust’s diversity champions, which the staff involved undertook over and above their core duties. Dr Mahajan highlighted the Clinical Teaching Award presented to Dr Eltrafi. This was an excellent recognition of his work and it was agreed that a letter of SW congratulations should be send on behalf of the Board to Dr Eltrafi.

14/122 COUNCIL OF GOVERNORS (14/07/P-12) The latest agenda (June) and approved minutes (April) from the Council of Governors’ General Meetings were received and noted. More information on the work of the Governors had also been included in the Chairman’s report.

14/123 FINANCE & PERFORMANCE COMMITTEE (14/07/P-13) The exception report from the first meeting of the Finance & Performance Committee was received and noted. The Chairman commended the Committee on being able to present the report so quickly, which was appreciated. In the absence of the Committee’s Chair (Mr Patton), Mr Diggles expanded on the report. He explained that it had been a transitional meeting. It had therefore focussed on the usual business of the Finance Committee and started to look at the new agenda of the Finance & Performance Committee. Some of the transition requirements had been progressed further outside the meeting to ensure that all aspects were addressed. Mr Spinks advised that other key issues discussed at the meeting had included consideration of how the CBUs would report in to the Committee (further work was required on this) and the proposed delegated levels of authority for approval of business cases, with the current thresholds recognised as being too low, hence the proposal to uplift these to £50,001 to £150,000 for the Committee. Mr Diggles confirmed that business cases below £50,000 would still be presented to the Committee for completeness. Ms Wake emphasised the importance of ensuring that all approved business cases approved were linked to requirements for a report on benefits realisation being presented to the Committee within six months; this was fully supported. In closing discussions, the Chairman referred to the report’s title as an “exception report”. As highlighted earlier (see new governance structure), the key role of each of the governance committees was to give assurance to the Board, not just report on exceptions, and this should be reflected in future reporting. The report was endorsed and the proposed delegated levels of authority for approval of business cases were approved.

14/124 2014/15 BUDGET REPORT (14/07/P-14) Mr Diggles presented and expanded on the draft budget for 2014/15, which formed a critical element of the two year turnaround plan submitted to Monitor on 30th June. He highlighted a number of key factors, including: • an overview of the Trust’s underlying baseline position, as shown in the report

BoD August 2014: 03_Minutes July 2014 Page 9 of 14 • the projected outcome (improvement against baseline) of -£11.9 million for 2014/15, taking account of all potential incomes, costs, assured non- recurrent income and the cost improvement plans (CIP) • the cash position, which would need careful management and continued support from the Department of Health • the reduced capital expenditure budget, with a small contingency for further demands in year. The budget had been presented in full and transparent form. It was acknowledged that any further internal and external reporting on the budget must be managed carefully to ensure that it was read correctly and not misinterpreted. Mr Spinks emphasised that the report reflected the Board’s statement in the annual accounts that it had based its going concern status on the bases outlined in the report and the reasonable assumption that central funding would be available. The Board recognised the risks associated with the budget, as was the case for any organisation at the start of the year. These included the service contract with the Trust’s main commissioners, which Ms Wake advised was still subject to final negotiations. The Board was also conscious of the Trust’s poor record on CIPs and was committed to delivering this year’s programme through close monitoring and continued development of more CIPs to meet, and if possible exceed, the £6 million target (4% of budget, 6.2% full year effect). It was also anticipated that other savings could emerge in year as planned changes progressed and the CBUs developed, which would help to improve the position. It was clarified that approval of the capital programme was integral to approval of the budget, although Mr Diggles emphasised that a prudent spending schedule had been applied. He confirmed that some expenditure on items identified as essential with regard to safety of care or future critical needs had already been progressed; they had not been held back pending finalisation of the budget. It was acknowledged that the budget was not – nor should it be – a static plan. Like the Turnaround Plan, it was a living document and the Board would expect every effort to be made to improve it in year, without putting quality at risk at any time. The Board approved the 2014/15 budget as presented.

14/125 INTEGRATED PERFORMANCE REPORT (14/07/P-15) The month 2 report on performance was received and noted. Lead Directors expanded on their respective sections:

Activity Mrs Kelly advised that the Trust had continued to meet the <4 hour A&E target since 15th April. The target for Q1 had also been met. This improvement had been well received by Monitor and the CCG, as well as the Board. The Trust was currently the second best performer in the region. Mrs Kelly believed the improvement reflected how people were working differently in the organisation and the impact of a number of schemes now coming to fruition in the Acute Medicine Unit and Emergency Department, facilitating better patient flow across the Trust. She commended the staff involved and assured the Board that more work was ongoing to ensure the trend continued and improvements were fully embedded. Ms Wake advised that central funding to support winter pressures had been declared recently (£1.8 million allocation to Barnsley community); the Trust would be working with the CCG to seek support for

BoD August 2014: 03_Minutes July 2014 Page 10 of 14 extra staffing - medical and nursing – as part of the Trust’s greater focus on flows rather than opening extra beds, although the Trust had also been clear that, if funded, it would be prepared to provide sub acute beds on site if these could not be provided in the community. Mrs Kelly reminded the Board that the national team for emergency care (ECIST) had revisited the Trust recently, to help review and refresh the emergency care pathway action plan. She was also mindful of the national proposal to reduce waiting times to 16 weeks, which would be a huge challenge for the NHS and would also need to be factored into future plans. Mr Spinks queried why the report no longer showed a breakdown of the “longest waits”. This information had provided useful indicators as to where the issues lay when delays occurred and whether or not they had been avoidable in terms of action by the Trust. The Chairman had noticed that the single longest waits were shorter than had been reported in previous months and he had taken this as a reflection of the whole system improvement. Mrs McNair and Mrs Kelly assured the Board that any issues that might cause delays would be identified in the daily operative reports reviewed by the Executive Team and would be actioned accordingly. It was agreed that further details were not necessary for the Board.

Referring to the report on performance against other national targets, it was clarified that where an ‘x’ was shown on the tables, data was not yet available – it did not imply that targets had not been achieved. Similarly some cells in the table remained blank where no data was applicable. The table would be further refined next month to make this clearer. The performance dashboard reflected a good performance against most indicators. The exceptions related to:

• M120 – diagnostic tests

This was due to the continuing national shortage of sonographers.

However the position would be supported and improved by the recent

appointment of a part-time locum and continuing work with the CCG to

limit direct referrals, to enable the department to calibrate back to

normal levels of service. Ms Wake advised that the impact of

increased referrals to these services was one of the reasons the main

service contract had not yet been signed, with a need to try to offset

penalties associated with long waits, which seemed unfair when

demand levels were outside the Trust’s control. In terms of plans to

address the shortage in the longer term, Dr Mahajan referred to work

ongoing within the Working Together workstream for radiology, to

support a regional approach. Mr Wickham also advised that the Trust

had two in-house trainees who would be qualified in September and it

was proposed to carry this programme forward to ensure newly trained

staff were always coming through. Additionally Mrs McNair reported on

plans to assess whether midwives could take on some training too,

expanding their work with baby scans.

• M210 – DNA (did not attend) rate As mentioned, work to reduce DNAs was being led by the CBUs and would be reflected in the regular CBU performance reporting. Mrs Kelly also reported on in-depth work around outpatients and clinical utilisation, and working with health visitors and community partners, to identify why patients did not attend and how/if certain services could be changed (e.g. hepatology) to better fit with patients’ needs and lifestyles. Ms Wake advised that the Trust’s approach to access was being updated to ensure it was acting appropriately with follow up ratios

BoD August 2014: 03_Minutes July 2014 Page 11 of 14 too (the Trust was currently over performing in many clinical areas compared to national benchmarks).

Quality Mrs McNair reminded the Board that most of the reported indicators in this section did not have prescribed targets, however, she had extrapolated some from the Trust’s Quality Strategy in order to give context against monthly performance. She had also applied a 50% improvement criterion across the board for the safety thermometer as a stretch target.

It was noted that the report, like the performance section, was in a new format. Any feedback on the style would be appreciated. Some anomalies had been noted (e.g. why some indicators were shown in colour – red/amber/green - but not all) and would be addressed by the next meeting. Ms Wake reiterated her Exec request that thresholds were clearly shown when rating systems were used. Team Whilst the inclusion of internal targets was appreciated, it was agreed that it would be useful to review these further at the Quality & Governance Committee and also to consider how the Patient Safety Thermometer could be improved. Initial suggestions included adding the date of the survey (it was a LC/ point prevalence report) and to add a new column to show the month’s data Q&G and/or application of a heat map on this and other indicators. HM Finance Mr Diggles expanded on the submitted report, which was set against the deficit budget for 2014/15 agreed earlier (see above). Key points included: • overall performance above plan (albeit still a significant deficit)

• a continuity of service rating of 1, which the Trust was expected to remain at throughout the year • slightly behind income due to levels of activity (down in months 1 and 2 but some retrieval in month 2) and the assumption of incurring risks and penalties subject to final contract agreement

• CIP at green, having achieved progress against plan for the first two months, although projections in Q1 were lower than later in the year • a favourable variance against pay costs, reflecting better controls on agency and bank

• higher debtors and creditors/accruals slightly down, largely reflecting a short term planned position. Mr Diggles reported that this was a positive position as it resulted from raising invoices earlier than in the past to ensure cash received earlier. It was also confirmed that the Trust was reducing its creditor balance, which meant that it was catching up with some of last year’s pressures with a controlled and managed process to ensure no adverse impact on the Trust or its suppliers • capital showing at red (behind plan) – this was, however, a positive position for the Trust reflecting the agreed restrictions on expenditure.

Workforce Ms Brearley drew attention to the sickness absence data. Although the 12 month cumulative had not reduced, the monthly rate had, reflecting the extensive work already progressed, including the impact of an escalated/rapid response programme for any stress related issues and work with the rostering team to help management of sickness. More recently an initiative had been launched to help teams understand the impact of sickness absence in their

BoD August 2014: 03_Minutes July 2014 Page 12 of 14 areas (supported by a well being programme). All of this work would continue and would be closely monitored. Mandatory training compliance remained constant and was discussed regularly in performance review meetings. The HR team would also be revisiting the corporate training programme shortly to ensure that it was being delivered as effectively as possible.

With regard to appraisals, the meeting was referred to earlier discussions (Minute 14/118 refers). Mrs Brain England welcomed the closer scrutiny of the key workforce indicators at CBU level, which would enable any issues to be reported upwards through the relevant committees. Mr Spinks suggested it would be useful and timely for the Trust’s position to be set against benchmarking data where viable - this was agreed for the next report. HB

14/126 ANY OTHER BUSINESS AND DATE OF NEXT MEETING a) Public Comments In light of the Trust’s reported deficit position, Mr Millington, member of the public, challenged assurances given by the Board and one of the Non Executive Directors in February that the Trust was a well run organisation. He stated his appreciation regarding the improvements in the A&E led by Mrs Kelly but questioned why this had not happened sooner; he also queried a perceived lack of urgency to address the Trust’s deficit position (which he calculated to be much higher than reported) and acceptance of continuing failings against certain targets, for instance 30% compliance on appraisals. The Chairman noted the points raised. Whilst he and the Chief Executive corrected several of the figures cited by Mr Millington, the Chairman also clarified that the assurances given in February had been based on the information presented to the Board at that time. When a different position had been identified at the end of March, the Board had acted swiftly to start work to address it, investigate reasons, report to Monitor and prepare an action plan, and had made a lot of progress. The Chairman was confident that the Trust would recover its position with the turnaround plan, with the support of the Board and management present at the meeting and staff across the organisation. The Chairman thanked Mr Millington for his questions but suggested it would be inappropriate to respond further as some of them were directed to individuals (the Trust operated a unitary board) and some were inaccurate. b) Mr Brannan, one of the Trust’s governors, referred to the Register of Interests for the Board of Directors. It was clarified that the Register matched the composition of the Board. One Director was currently off sick and their position was covered by an interim appointment, hence they were not shown on the Register but their declarations were still on record ad readily available. c) Mr Brannan also relayed a report presented to him by a patient. At a recent consultation, the patient had been told they had a terminal illness. This had been completely unexpected but after the consultation no-one had approached him or his wife to try to offer support or advice, or give them the opportunity to compose themselves before they left the hospital in shock. Mrs McNair asked Mr Brannan to obtain more information if possible as it was a very unusual case and was contrary to the Trust’s practice; she would like to pursue it further. When breaking bad news, patients were normally offered support, indeed another member of the

BoD August 2014: 03_Minutes July 2014 Page 13 of 14 public present also worked as a volunteer in the Trust and reported that the area she worked in had nurses specially trained to help patients in these sad situations. d) On behalf of the members he represented, Mr Jackson, a governor of the Trust and representative of the Joint Trade Unions Committee (staff side), expressed concerns regarding the closure of a ward, the potential impact on A&E and plans to reduce beds on another ward. He sought assurance that (a) these actions would not impact on the Trust’s quality of care and (b) such proposals would be better managed in future, with earlier involvement of staff side. Mrs Kelly explained the rationale for the proposed reduction in beds, which had been identified following the bed utilisation review undertaken in January. The review had shown that as many as 45% of the Trust’s patients on any one day did not need acute care. This was borne out on a daily basis by the number of empty beds identified across the site and the Trust had consequently considered changing its bed structure. Mrs Kelly emphasised that it was not just about taking beds out of the system but working differently and improving discharge practices to the advantage of our patients and without adversely affecting quality of care. Clinical teams were now involved in the planning process and a recent trial closure of one ward had demonstrated that it could be done without being detrimental to services or safety. However, it was acknowledged that staff side could and should have been involved sooner and steps had been taken to redress this and ensure co-operative working as the plans progressed. Mrs Kelly also assured Mr Jackson that the impact of any closure would be carefully monitored and actions swiftly taken if any adverse impacts on staff or patients were identified. The proposals were not final and it was more about the bed base rather than ward closures, so could still be addressed differently if it proved a better option to protect safety and quality of services for patients. Ms Wake apologised for not including staff side sooner; the Trust had been working on this and other proposals at a considerable pace but would make every effort to ensure it did not recur in future. e) Confidential matters In accordance with the Trust’s Constitution and Standing Orders, it was resolved that members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted. Due to clinical commitments, Mr Shiwani and Dr Kapur also left at this juncture. f) Date of next meeting Before moving to the business of the remainder of the meeting, the Chairman confirmed the time and date of the next Board meeting: 9am on 7th August.

BoD August 2014: 03_Minutes July 2014 Page 14 of 14

REPORT TO THE BOARD OF REF: BARNSLEY HOSPITAL NHSFT 14/08/P-04

SUBJECT: BOARD ACTION LOG

DATE: AUGUST 2014

Tick as Tick as applicable applicable

For decision/approval Assurance  PURPOSE: For review  Governance  For information  Strategy PREPARED BY: Carol Dudley, Secretary to the Board SPONSORED BY: Diane Wake, Chief Executive PRESENTED BY: Stephen Wragg, Chairman STRATEGIC CONTEXT 2-3 sentences

QUESTION(S) ADDRESSED IN THIS REPORT

CONCLUSION AND RECOMMENDATION(S)

The Board of Directors is asked to: a) note and approve reported progress to date, and b) review any outstanding actions.

BoD August 2014: 04_Action log Page 1

Subject: Board Action Log Ref: 14/07/P-04

ACTIONS ON PUBLIC AGENDA Meeting date Item Action Owner Action taken & Minute ref a) Targets to be included (or clearly stated if not applicable) against all indicators. Some elements completed in Director of July; further work requested – Operations (a) to be reviewed .

b) Proposed targets for quality Dir of Nursing Agenda items 20 and indicators to be reviewed at & Quality (b) 12 refer July 2014 Clinical Governance (CGC)/ Performance report - performance and 14/125 Quality & Governance (& June 14/109) Executive CGC assurance Committee (Q&G); options for Team (c) reports improving patient safety

thermometer to be referred to Director of the committee too. HR&OD (d) c) Thresholds for RAG rating to be clearly stated in the reports. d) Benchmarking data in next report, re workforce Terms of reference to be reviewed Interim Assoc July 2014 Governance and finalised with Chair of the new Agenda item 15 Dir of Corp 14/119 Restructure governance committees and re- refers - governance Affairs presented to Board for approval. System for appointment letters to be reviewed to ensure timely issue and reduction in DNAs (did not attend). Agenda item 12 Update: Two reports presented to Non Clinical refers July 2014 Non Clinical Governance & Risk Director of Governance & Risk (Clinical 14/118 (Feb and June), neither Operations (& Oct 13/260) Committee Governance/Q&G acceptable. Issue transferred to Committee) new Quality to Quality & Governance (Q&G) Committee in July to ensure continued progress towards resolution. a) Review of report format and action plan ongoing to reflect AQuA recommendations and to include: Medical a) Agenda item 11 - further explanation of Director (a) refers (mortality tables/data where relevant; July 2014 ratios) Mortality Ratios - schedule of audits 14/117 (& 13/182) - quarterly overview of mortality Dir of Nursing b) Agenda item 12 and morbidity reports reviewed & Quality (b) refers (CGC) by Patient Safety Steering group b) “Heat map” on NEWs training compliance to be reviewed at CGC/Q&G Content to be revised further to align with Board’s requirements on assurance as well as national Dir of Nursing reporting and improve information & Quality July 2014 Nursing & Midwifery Agenda item 8 refers to public. Considerations to 14/116 Staffing (latest monthly report) (& June 14/103) include review of system used Quality & elsewhere, reported by Dir of Ops. Governance Proposed changes to be progress via Q&G Committee.

BoD August 2014: 04_Action log Page 1

Meeting date Item Action Owner Action taken & Minute ref Revised action plan to be July 2014 Medical Mortality Ratios presented to Board as soon as 14/114 Director Agenda item 11 possible (August / September) refers (mortality ratios June 2014 Medical update) Mortality Ratios Audit date on Sepsis Six to be 14/100 confirmed. Director Process for development, approval and dissemination of policies to be reviewed (“policy on policies”) Agenda item 12 Dec 2012 NCGRC Assurance May update: work progressing, Dir of Nursing refers - CGC/Q&G 12/306 report due to be presented at NCGRC & Quality assurance report meeting June 2014 Update: redirected to Q&G July 2014

ACTIONS COMPLETED & CLOSED SINCE LAST MEETING Meeting date Item Action Owner Action taken & Minute ref CEO report July 2014 Letter of congratulations to be sent – Clinical Teaching Chairman Completed in July 14/121 to Dr Eltrafi on behalf of the Board. Award Copy of latest letter from Monitor July 2014 Completed: Chair’s report to be distributed to Board Chairman 14/120 03.07.2014 members/ June 2014 Generic issue: Guidance re cover page to be Completed: CEO/Chair 14/102 Board report format issued 10.07.2014 Funding approved; Actions to be implemented if updates on progress April 2014 business case approved: outcome Medical 7 Day services will be provided 14/65 of application to CCG to be Director through performance advised. reporting.

ROLLING TRACKER OF OUTSTANDING ACTIONS (red = overdue) Meeting date Item Action Owner Action taken & Minute Ref Refresher training for Board re risk July 2014 Governance Dir of Nursing To be included in next assessments to be scheduled at 14/119 Restructure & Quality workshop workshop session. Under the new structure, Non Clinical July 2014 transferred to Quality & Governance – DNA 14/118 Governance Committee for report monitoring and further progress a) Follow up re reporting systems a) Due at August Medical to be presented after first Board meeting. Director (a) June 2014 meeting of the R&D Strategy Deferred to allow R&D Strategy 14/99 group (due in July) first meeting of Interim Dir of R&D group b) Financial reporting to be Finance (b) reviewed b) Ongoing a) Ongoing: issues a) Concerns re potential delays addressed further on business case for at Urgent Care intermediate care to be Board and Director of June 2014 Performance report escalated to H&WB Executive Team/ Operations 14/109 - Emergency Care CCG meeting.

b) More oversight on community b) Emergency care work to be included in future report currently reporting under review with ECIST support

BoD Aug 2014: 04_Action log Page 2

Meeting date Item Action Owner Action taken & Minute Ref To be finalised and re-presented to the Board for approval. May 2014 - originally due June; deferred to Director of Patient Flow action plan 14/86 later in the year to be included Operations Ongoing with wider action plan supporting patient safety Due for next quarterly Medical Director’s Comparative data and good report (August). Due May 2014 Medical report practice re returns and compliance to timings, separate 14/82 Director – EWTR/Junior Doctors in other trusts report will be provided in September. Dir of Finance Ongoing: outcome or Review of shared pathways to be Mar 2014 Integrated performance & Info / SLA review presented when SLA review 14/54 - activity Director of anticipated July- complete. Operations August. Inreach model for AMU to be Review completed. Jan 2014 Emergency Care 4 hour Medical refined to ensure consultant 7 day services 14/10 action plan Director ownership of each patients’ care funding progressed. Will be reflected in Jan 2014 Integrated Performance Future reporting on EPR to include Dir of ICT next report on EPR 14/14 - transformation timelines - August 2014 Nov 2013 Integrated Performance Options for review of CQUINs to Dir of Finance Ongoing 13/299 - Finance be progressed with CCG & Information

BoD Aug 2014: 04_Action log Page 3

REPORT TO THE BOARD OF REF: 14/08/P-06 BARNSLEY HOSPITAL NHSFT

SUBJECT: MEDICAL DIRECTOR’S QUARTERLY REPORT

DATE: AUGUST 2014

Tick as Tick as applicable applicable

PURPOSE: For decision/approval Assurance For review Governance For information √ Strategy PREPARED BY: Dr Jugnu Mahajan, Medical Director SPONSORED BY: Dr Jugnu Mahajan, Medical Director PRESENTED BY: Dr Jugnu Mahajan, Medical Director STRATEGIC CONTEXT 2-3 sentences

To provide a brief overview on a number of the Medical Director’s activities and to record particular events, meetings or publications that the Medical Director would like to bring to the Board of Directors’ attention.

QUESTION(S) ADDRESSED IN THIS REPORT

Does this report provide an update on the Medical Directors activities in July 2014?

CONCLUSION AND RECOMMENDATION(S)

The Board is asked to accept the content of this report and note the updates.

BoD Aug 2014: 06_Medical Directors Quarterly Report

REFERENCE/CHECKLIST • Which business plan Aim 1: Patients will experience safe care objective(s) does this report Aim 4: Performance relate to? Patients BCCG Other

• Please state: Has this report considered the Staff BMBC following stakeholders? Governors Monitor

Regulators (eg Monitor / CQC)

• Has this report reviewed the Legal requirements (Acts, HSE, NHS Constitution etc) Trust’s compliance with: Equality, Diversity & Human Rights

The Trust's sustainability strategy

• Has this report Yes Quality & Governance (in draft or during • Is this report development) been supported by a Not applicable reviewed and Audit Committee

communications supported by any plan? To be developed Board or Executive Finance & Performance

committees within the Trust? ET

• Where applicable, briefly identify risk issues (including any reputation) and cross reference to risk register and governance committees • Where applicable, state Finance: resource requirements: Other:

NHS Constitution: In determining this matter, the Board should have regard to the Core principles contained in the Constitution of: • Equality of treatment and access to services • High Standards of excellence and professionalism • Service user preferences • Cross community working • Best Value • Accountability through local influence and scrutiny

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: Providing the best healthcare for all”

BoD Aug 2014: 06_Medical Directors Quarterly Report

Subject: Medical Director Quarterly Report Ref: 14/08/P-06

1. STRATEGIC CONTEXT

2. INTRODUCTION

This report outlines the activities pursued by the Medical Director in the past quarter.

3. APPRAISAL AND REVALIDATION

3.1 A full update on Appraisal and Revalidation will be presented as part of the Doctors’ Revalidation Board report.

4. E-JOB PLANNING

4.1 The focus of the E-Job Planning project has shifted from the original planned transition from paper to electronic, to the delivery of a Medical Turnaround Cost Improvement Plan (CIP) Target of £0.5m in a year. The plan is to achieve this by a reduction in Supporting Professional Activities (SPA) allocations and restriction on the maximum number of Programmed Activities (PA’s) being paid to any individual.

4.2 Review panels have been held with representatives from the executive team and each of the Clinical Directors, from which a schedule of PA reduction has been released as a CIP scheme. All panel meetings had taken place by the end of June.

4.3 Letters were sent out on 7 July 2014 to individuals affected to serve three month notice of the PA reduction.

4.4 Clinical Directors have been requested to progress the agreement of E-Job Plans and arrange meetings with all Consultants and Staff and Associate Specialist (SAS) Doctors for their areas, to be complete and Job Plans agreed by October 2014. If not possible to reach agreement then the Trust Job Plan mediation process of dispute process must begin and be progressed within the policy timeframes.

4.5 This planned completion date is in line with the start of the CIP recovery timeline and progress will be reported back to the CIP Steering Group, 14 August meeting, and to the Workforce Project Board, each month.

5. RESEARCH AND DEVELOPMENT (R&D)

5.1 RESEARCH AND DEVELOPMENT STRATEGY 5.1.1 The Strategy was approved by the Board on 5 June 2014. The Communications strategy is being developed. The first Research and Development Strategy meeting is planned for September.

5.2 LOCAL CLINICAL RESEARCH NETWORK (LCRN)

5.2.1 The funding allocation for 2014/15 has been received and is approximately the same as last year (£263,000).

BoD Aug 2014: 06_Medical Directors Quarterly Report Page 1

5.2.2 Our recruitment target for this year is 575 participants, with an aspirational target of 624. At the end of June we are at 125% of the aspirational year-to- date target. However this recruitment is predominantly the result of two trials; International Surgical Outcomes Survey (ISOS) (questionnaire study on surgical outcomes, led by Anaesthetics) and Sprint National Anaesthesia Project (SNAP-1) (questionnaire study in Surgery).

5.3 ACCRUALS 5.3.1 The accruals target for 2014/15 has not been set by the LCRN. However we are anticipating a 10% increase on the target from 2013/14, i.e. 570.

5.4 COLLABORATION FOR LEADERSHIP IN APPLIED HEALTH RESEARCH AND CARE (CLAHRC) • An update Partnership Agreement has been agreed and signed. • There are four pieces of work ongoing, which link into CLAHRC (please see below for details): Patient safety, Emergency Department (ED) Evaluation, Pressure Ulcers and Addressing Capacity in Organisations to do Research Network (ACORN).

5.5 PROJECT HIGHLIGHTS 5.5.1 Patient Safety: ‘Putting the patient at the heart of patient safety: implementing a patient measure of safety in partnership with hospital volunteers’. The first site visit has taken place. The Bradford team met with Alison Bielby, Deputy Chief Nurse and Vicky Faxon-Wastnage, Lead Nurse, Ward 19. There is a lot of enthusiasm for this work. We will be working with IT to ensure that any IT implications are anticipated. The pilot work with Ward 19, will commence in the autumn.

5.5.2 ED evaluation project. The final report was approved by the Clinical Commissioning Group (CCG), and they have also approved a dissemination budget. This work will include presentations within the Trust and CCG, posters aimed at patients, a glossy summary of the project and a formal peer reviewed publication. The CCG is interested in funding us to repeat the project in the New Year and discussions are underway.

5.5.3 The department has been approached by the CCG to work up an evaluation of patient experience in the Diabetes Pathways across Barnsley. This work will develop a diabetes questionnaire developed by South West Yorkshire Partnership Foundation Trust (SWYPFT) into a broader study of both quantitative and qualitative research that will provide the CCG with comprehensive, reliable and robust information to assist in the review of diabetes provision across Barnsley. A meeting with the CCG was scheduled to take place on 24 July.

• The meeting with the CCG went ahead, and we have agreed that R&D will produce a proposal to evaluate the patient experience of the existing Adult Diabetes Pathway. This evaluation will also include interviews with staff to explore their experience of providing care and what impacts on their capacity to provide care.

5.5.4 The CLAHRC North West London is looking for partner organisations to collaborate on a project concerning the management of Atopic Paediatric patients in the community, and focussed on asthma. This project is called

BoD Aug 2014: 06_Medical Directors Quarterly Report Page 2 of 7

‘Itchy Squeezy Sneezy’. Research and Development approached our Paediatric Department to explore and take this forward. It was agreed that this project would not go ahead, as our systems in Barnsley already incorporate many of the ideas in this initiative.

5.5.5 Evaluation of the impact of the Frail Elderly Team. This project is under discussion with Susie Orme. We have agreed to input into the analysis of the impact metrics the team is collecting, e.g. length of stay, and we will be approaching the CCG for funding to undertake a formal qualitative evaluation of the service.

5.5.6 Pressure Ulcers. A proposal has been submitted to Alison Bielby, Deputy Chief Nurse, for comment to use the Training and Action for Patients Safety (TAPS) methodology, developed by the Yorkshire Quality and Safety Research Group in Bradford, to improve our incidence of pressure ulcers through an action learning approach. This piece of work will also evaluate the TAPS approach in our Trust, to see if it can be used in the wider Trust as part of our spectrum of Service Improvement approaches.

5.5.7 The Trust is a member of the CLAHRC YH ACORN (Addressing Capacity in Organisations to do Research Network) network. The ACORN aims to develop and share good practice of building research capacity.

These projects are a good example of how the Research and Development Department can contribute both to the Trust’s Business Plan and the CLAHRC; generating research questions with our local partners, that are grounded in our priorities and then using Research and Development capacity to deliver projects that link with and utilise regional academic and clinical expertise.

6. MEDICAL EDUCATION

6.1 Undergraduate 25 3rd Year Medical Students commenced at the beginning of July 2014. These students are placed across Medical and Surgical Specialities and will be on placement at the Trust for eight weeks.

Dr Eltrafi was awarded a Clinical Teaching Award by the Medical School, University of Sheffield. This award was voted for by students. Dr Eltrafi was presented with the award at the degree ceremony at Sheffield University on 21 July.

6.2 Foundation Programme – Years 1 and 2 (F1 and F2) F1 Annual Review of Competence Progression (ARCP) was held on 11 June. 20 F1s passed and one was deferred as they are less than full time so will complete in 2015.

F2 ARCP was held on 27 June, 23 F2s passed and one F2 is deferred to 2015 due to Maternity Leave.

15 out of 18 of our new Foundation Doctors commencing in August are Sheffield Medical School graduates and have chosen Barnsley as their first job due to the excellent experience they had here as students.

6.3 Postgraduate The first successful Lap-Chole course was held at Barnsley Hospital on Friday, 20 June. Feedback was excellent and we have applied to the Royal College of

BoD Aug 2014: 06_Medical Directors Quarterly Report Page 3 of 7

Surgeons for accreditation of the course and intend to run twice yearly to trainees across the region.

The Emergency Department has been rated top in the country for the quality of training. This year’s results show that Barnsley Hospital was rated the top in the country for overall satisfaction of training.

Junior Doctors induction is due to commence on Wednesday 6 August 2014. 96 new Doctors will rotate into the Trust and a mandatory induction programme has been developed for this day.

The Deanery completed the Annual Quality Management Visit on 29 April 2014. The Trust was allocated twelve conditions all based around improving the quality of training for Trainees. Louise Pemberton, Medical Education Manager and Dr Y Myint, Consultant Anaesthetist has been working with department leads to meet the requirements of these conditions. An update meeting with the Deanery in June went well and they are pleased with the progress made so far.

6.4 Clinical Skills The Clinical Skills Team has been working on a new delivery schedule to ensure that the service being delivered fits the needs of the organisation. This will be rolled out from September 2014.

7. OTHER ACTIVITIES

7.1 Visit to Number 10 I was invited to a round the table discussion at Number 10 by Nick Seddon, the Prime Minister's special advisor. The discussion focussed on the success and next steps for Revalidation at a National Level. The Trust was chosen to represent provider Trusts from the North of England because of our good reputation in compliance with Appraisal and Revalidation.

BoD Aug 2014: 06_Medical Directors Quarterly Report Page 4 of 7

REPORT TO THE BOARD OF REF: 14/08/P-07 BARNSLEY HOSPITAL NHSFT

SUBJECT: DOCTORS’ REVALIDATION – ANNUAL REPORT

DATE: AUGUST 2014

Tick as Tick as applicable applicable

PURPOSE: For decision/approval Assurance √ For review √ Governance √ For information √ Strategy Mr Jeremy Bannister, Associate Medical Director, Appraisal and Revalidation PREPARED BY: Mr Lee Tarren, Medical Staffing Manager Mrs Jacqueline Waller, Medical Appraisal and Revalidation Support Manager SPONSORED BY: Dr Jugnu Mahajan, Medical Director PRESENTED BY: Dr Jugnu Mahajan, Medical Director STRATEGIC CONTEXT 2-3 sentences

The Framework of Quality Assurance (FQA) provides an overview of the elements defined in the Responsible Officer Regulations, along with a series of processes to support Responsible Officers and their Designated Bodies in providing the required assurance that they are discharging their respective statutory responsibilities.

QUESTION(S) ADDRESSED IN THIS REPORT

1. Does the Board receive and approve the Annual Report on the implementation of revalidation? 2. Does the Board approve the Statement of Compliance confirming that BHNFT as a Designated Body is in compliance with the regulations?

CONCLUSION AND RECOMMENDATION(S)

BHNFT as a Designated Body is in compliance with regulations as set out in the framework.

Recommendation The Board is asked to accept the report and approve the Statement of Compliance.

REFERENCE/CHECKLIST • Which business plan objective(s) does this report Aim 1: Patients will experience safe care relate to? Patients BCCG Other

• Please state: Has this report considered the Staff BMBC following stakeholders? Governors Monitor

Regulators (eg Monitor / CQC)

• Has this report reviewed the Legal requirements (Acts, HSE, NHS Constitution etc) Trust’s compliance with: Equality, Diversity & Human Rights

The Trust's sustainability strategy

• Has this report Yes Quality & Governance (in draft or during • Is this report development) been supported by a Not applicable reviewed and Audit Committee

communications supported by any plan? To be developed Board or Executive Finance & Performance

committees within the Trust? ET

• Where applicable, briefly identify risk issues (including In light of the financial difficulties they may be some constraints in any reputation) and cross developing the Team and implementing an electronic system reference to risk register and governance committees • Where applicable, state Finance: resource requirements: Other:

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: Providing the best healthcare for all”

BoD: August 2014_Doctors Revalidation

Subject: Doctors’ Revalidation – Annual Report Ref: 14/08/P/07

1. EXECUTIVE SUMMARY

BHNFT, currently, (as of 10th July 2014) have 142 doctors for whom we are the Designated Body (DB). This makes us responsible for their annual Appraisal and, if they are working here at the time of their Revalidation, responsible for making a recommendation to the General Medical Council (GMC) about their suitability for Revalidation. The numbers change as doctors move in and out of the Trust. Of the current 142 doctors, 87% have had an appraisal in the last 12 months (National Average 78%).

32 doctors had their Revalidation date from 1/4/2013 to 30/3/2014. 29 received timely recommendations for Revalidation and three were deferred for legitimate reasons.

2. PURPOSE OF THE PAPER

The purpose of this paper is to provide information to the Board of Directors to confirm that the Appraisal and Revalidation process is being carried out to a high standard. The framework for Quality Assurance for Responsible Officers (RO) and Revalidation is outlined in Appendix A.

3. BACKGROUND

Medical Revalidation was launched in 2012 to strengthen the way that doctors are regulated, with the aim of improving the quality of care provided to patients, improving patient safety and increasing public trust and confidence in the medical system.

Provider organisations have a statutory duty to support their Responsible Officers in discharging their duties under the Responsible Officer Regulations1, and it is expected that provider boards will oversee compliance by: • monitoring the frequency and quality of medical appraisals in their organisations; • checking there are effective systems in place for monitoring the conduct and performance of their doctors; • confirming that feedback from patients is sought periodically so that their views can inform the appraisal and revalidation process for their doctors; and • ensuring that appropriate pre-employment background checks (including pre-engagement for Locums) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the work performed.

4. GOVERNANCE ARRANGEMENTS

The Responsible Officer has statutory responsibility for performing the roles set out in the relevant legislation.

Quality Assurance Framework Hierarchy: Department of Health NHS England Medical Director, Sir Bruce Keogh, Responsible Officer Level 3 NHS England North Medical Director (South Yorkshire and Bassetlaw) Responsible Officer Dr Damien Riley Level 2 Designated Body (BHNFT) Responsible Officer Dr Jugnu Mahajan Level 1

1 The Medical Profession (Responsible Officers) Regulations, 2010 as amended in 2013’ and ‘The General Medical Council (License to Practice and Revalidation) Regulations Order of Council 2012’

BoD_Aug 2014: P_Doctors Revalidation.doc Page 2 of 7

Level 1 users are responsible for making recommendations to the GMC for the revalidation Cycle of all doctors who have a prescribed connection to their designated body. Level 1 users are supported by a decision support group, BHNFT is made up of the Appraisal and Revalidation Support Group (ARSG), which consists of the Medical Director, Associate Medical Director, Medical Staffing Manager and Medical Staffing and Revalidation Support Manager.

Level 2 users are responsible for making recommendations to the GMC for the revalidation Cycle of all level 1 users within their designated body. They ensure that the Responsible Officer attends 75% of all training programmes on an annual basis, has undertaken Continuing Professional Development (CPD), MSF, Reflection of Serious Incident (SI), Investigations and Complaints/compliments and that they are delivering in their responsibilities as a Responsible Officer.

The Medical Staffing Manager and the Support Manager liaise with the GMC to ensure that the list of doctors for whom we are the DB is accurate and up to date.

All Appraisal Documentation is stored on a secure server (R Drive), access being limited to the ARSG members and one admin support worker who uploads the data.

In July 2014 we started providing monthly reports to the Executive Team meetings. An update will be given in the Quarterly Medical Director’s Report. A more detailed report, Annual Doctors Revalidation Report will be presented to Board as per guidance.

5. MEDICAL APPRAISALS

5.1 Appraisal and Revalidation Performance Data This data can be found in Appendix B.

5.2 Appraisers The Trust has 35 doctors including five Staff and Associate Specialist (SAS) doctors who have gone through Appraiser training and who regularly attend Appraiser Update Meetings run by the Associate Medical Director (AMD) and Support Manager (3 per annum)

5.3 Quality Assurance All completed Appraisals are reviewed by the AMD and an Appraisee feedback form is required before a Certificate of Completed of Annual Appraisal is issued.

Every doctor undergoes a Multi Source Feedback (MSF) exercise three yearly. This involves a separate Colleague and Patient 360 Assessment. These MSFs are run and collated by an outside company. The MSFs are reviewed by the doctor and a trained appraiser to identify areas for development. Any scores of “1” (“I have real concerns”) trigger an e-mail to the AMD for investigation.

Audits are undertaken of various aspects of the Appraisal process and Appraisee feedback, leading to items for the next appraiser update meeting.

The complaints department provide a separate list of all complaints and Serious Incidents (SIs) involving an individual doctor. At the time of Revalidation this is collated with the doctor’s appraisal documentation to ensure that such cases have been discussed, reflected upon and appropriate remedial action taken.

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When a doctor is due for Revalidation the whole of their on line portfolio is reviewed and triangulated with any information or concerns gleaned by the RO from other sources within or outside the organisation. If the documentation is complete and no concerns are identified, only then are they recommended to the GMC for Revalidation.

(See Appendix C; Quality assurance audit of appraisal inputs and outputs)

5.4 Access, Security and Confidentiality Access to the Appraisal and revalidation Documentation is strictly limited to the RO, AMD, Support Manager and one Administration Assistant.

5.5 Clinical Governance There are four key pieces of information required for Revalidation, • adequate evidence of continuing professional development • quality improvement data • MSF : including colleague and patient/carer feedback • reflection of all complaints and SIs

The Quality improvement data will require evidence of performance, outcomes and audit. This information will be provided in part by the information analyst employed by each Clinical Business Unit (CBU), the outcomes of Local or National Audits and information gathered by the doctor. Each College/Faculty has a data set which it recommends should be included over a cycle of appraisal/revalidation. It is the responsibility of the Appraiser and Appraisee to cover these areas

6. REVALIDATION RECOMMENDATIONS

Out of the 32 doctors revalidated from April 2013 to March 2014, 29 completed on time and three doctors deferred with a valid reason, see Appendix D.

7. RECRUITMENT AND ENGAGEMENT BACKGROUND CHECKS

Substantive or fixed term recruitment checks: prior to any appointment being made, provisional offer letters are sent out subject to the following checks being made: Proof of Identification Checks, GMC Registration, Occupational Health Clearance, Disclosure and Barring Service (DBS), Clinical References from previous employment, and Salary information from Electronic Staff Record (ESR) or via proof of last pay slip.

If the doctor has been registered with one Designated Body prior to being offered a post, the applicant will be requested to provide the name of the responsible officer and designated body, plus provide written authorisation for BHNFT to make contact with them, this then allows for any relevant information to be shared and supports within the decision making process for the GMC.

Locums via agency: All agency workers are supplied via Holt Doctors Ltd via a Master Vendor Arrangement, (we have no off framework agencies that supply to the Trust), who have been assessed by the Crown Commercial Services (Previously GPS). As an agency they have to comply by strict pre-employment checks that cover GMC registration, right to work, DBS clearance, Occupational Health Clearance, References, Qualifications and Experience.

In addition they must also provide access to a responsible officer who can make recommendations on their fitness to practice if they are not substantively employed elsewhere, Appendix E.

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8. MONITORING PERFORMANCE

During the Annual Job Planning Cycle Clinical Directors/Leads are required to ensure that each consultant and SAS grade doctor is performing to the standards and expectations required for their position.

In addition to the annual job plan cycle each Consultant and SAS grade doctor must participate in an annual appraisal.

Utilising the e-MAG form the appraiser will assess the performance of the doctor against specific standards; this is to ensure that the individual is able to perform his or her duties safely, in line with best practice.

The appraiser participates in quality improvements and supports in effective service delivery that offers the most appropriate care for our patients. In addition the performance of the individual practitioner is assessed via a Multi Source Feedback questionnaire by their peers and patients, as well as the reflection of any complaints, Serious Incidents which enables the Practitioner and the appraiser to develop a personal development plan for the following year.

9. RESPONDING TO CONCERNS AND REMEDIATION

Concerns, identified from any source are the responsibility of all health professionals and managers. Once identified, they will be reported to the appropriate line manager and investigated under the Trust’s Policies including Maintaining High Professional Standards (MHPS) – NHS Gen 7.42, Raising Concerns – Gen 6.21 and Capability Policy Gen 7.31.

10. RISKS AND ISSUES

In light of the financial difficulties in the Trust there may be some financial constraints in developing the Team. Financial supoort may be required for an electonic revalidation system in due course.

11 ANNUAL ORGANISATION AUDIT (AOA)

At the end of year 2013/14 an audit was returned to NHS England, see Appendix F. NHS England said that, other than having an outside company quality assure our processes, we are in the top 80-100% of all respondents, and are not outlying in any areas. We will complete an internal audit by 360 assure to provide further assurance to the Board and NHS England.

12 STATEMENT OF COMPLIANCE

This Board report and attached documents support the Statement of Compliance. The designated body is in compliance with the regulation. The Statement of Compliance can be found in Appendix G.

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Appendices: Appendix A: A Framework of Quality Assurance for Responsible Officers and Revalidation Appendix B: Missed or incomplete appraisals audit Appendix C: Quality assurance audit of appraisal inputs and outputs Appendix D: Revalidation Recommendations Appendix E: Recruitment and Engagement background checks Appendix F: Annual Organisation Audit (AOA) Appendix G: Statement of Compliance

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REPORT TO THE BOARD OF REF: BARNSLEY HOSPITAL NHSFT 14/08/P-08

SUBJECT: MONTHLY UPDATE ON NURSING AND MIDWIFERY STAFFING

DATE: AUGUST 2014

Tick as Tick as applicable applicable

For decision/approval Assurance  PURPOSE: For review  Governance  For information Strategy PREPARED BY: Alison Bielby, Deputy Director of Nursing SPONSORED BY: Heather McNair, Director of Nursing and Quality PRESENTED BY: Alison Bielby, Deputy Director of Nursing and Quality STRATEGIC CONTEXT 2-3 sentences

The Trust Board is required to receive monthly information regarding the nursing and midwifery (trained and untrained) staffing levels across in patient areas of the Trust as per the guidance received from NHS England and the Care Quality Commission.

QUESTION(S) ADDRESSED IN THIS REPORT

1. Is the Trust meeting the requirements set out by NHS England and the Care Quality Commission to review nursing and midwifery staffing levels on a monthly basis?

2. What are current nursing and midwifery staffing shortfalls across the Trust and how are these being managed?

CONCLUSION AND RECOMMENDATION(S) The paper fulfils national requirements to review staffing levels across the Trust. The paper also demonstrates planned versus actual staffing levels and mitigating action where required, for Board’s information.

Recommendations The Board is asked to note the report and support on-going mitigations being put in place to manage any staffing shortfalls.

BoD Aug 2014: 08_Nursing Midwifery Staffing

REFERENCE/CHECKLIST • Which business plan objective(s) does this report Aim 1: Patients will experience safer care relate to? Patients BCCG Other

• Please state: Has this report considered the Staff BMBC following stakeholders? Governors Monitor

Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution etc) • Has this report reviewed the Trust’s compliance with: Equality, Diversity & Human Rights

The Trust's sustainability strategy

Yes CGC

• Has this report Not applicable (in draft or during NCGRC • Is this report development) been supported by a To be developed reviewed by any Audit Committee communications Board or Executive plan? committees within the Finance Commitee Trust? ET

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: Providing the best healthcare for all”

BoD Aug 2014: 08_Nursing Midwifery Staffing

Subject: Monthly update on Nursing and Midwifery Ref: 14/08/P-06

1 INTRODUCTION Barnsley Hospital NHS Foundation Trust (BHNFT) aims to provide safe, high quality care to patients, as part of the enabling this nurse staffing levels within clinical areas are continually monitored.

As reported last month the Trust is required to update the Board on a monthly basis regarding the nurse staffing levels, identifying any areas where staffing has fallen below the expected levels and the steps taken to manage this.

2. BACKGROUND BHNFT is committed to ensuring that levels of nursing staff, match the acuity and dependency needs of patients in order to provide safe and effective care. Nurse staffing includes:

• Registered Nurses • Registered Midwives • Unregistered health care/midwifery care assistants • Unregistered nursing/midwifery auxiliaries. The Trust uses an e-rostering system with duty rosters created eight weeks in advance to ensure the levels and skill mix of the nursing staff on duty are appropriate for providing safe and effective care.

This allows for contingency plans to be made where the roster identifies that the planned staffing falls short of the minimum requirement, for example where there are vacant nursing posts or staff appointed have not started in post. These contingency plans can include: moving staff from a shift which is above the minimum required level, moving staff from another ward/area which is above the minimum required level, or the use of flexible/temporary staffing from the Trust’s internal bank or via an external nursing agency.

Safe staffing levels are also monitored and managed on a daily basis by the ward Sister and Matron for that clinical area. A daily staffing situation report is currently being developed to be implemented from 1 August 2014 underpinned by an updated escalation process.

Shortfalls as a consequence of short term sickness or other unplanned leave for which cover cannot be found internally by the movement of staff or the use of the in house nurse bank staff are escalated to the Heads of Nursing for authorisation of temporary staffing via a nursing agency.

Details of the planned shift by shift versus the actual shift by shift staffing for the adult inpatient ward areas during June 2014 is found at appendix 1. (to be added)

BoD Aug 2014: 08_Nursing Midwifery Staffing

3. STAFFING REPORT The planned trust wide staffing hours for registered nurses/midwives and non-registered or care staff for days and nights in hours is summarised below.

Day Night Registered Registered Care Care midwives/ midwives Staff Staff nurses /nurses Total Total Total Total Total Total Total Total monthl monthly monthly monthly monthly monthly monthly monthly y actual planned actual planned actual planned planned actual staff staff staff staff staff staff staff hours staff hours hours hours hours hours hours hours 31595.5 38612.25 5 23169.75 22360.54 21666.5 21626.75 8352 9184.75

The average fill rates Trust-wide were as follows

Day Night

Average fill rate - Average fill Average fill rate - registered Average fill rate - registered rate - care staff nurses/midwives (%) care staff (%) nurses/midwives (%) (%)

81.8% 96.5% 99.8% 110.0%

When compared with last month the average fill rate for registered nurses/midwives shows a slight decrease during the day (0.4%) but an increase for nights (1.9%). The average fill rate for care staff increased for both days (2.7%) and nights (5.8%)

For most wards there will be a difference between the planned and actual staffing hours. Some areas will have used more hours than planned and some will have used less. The most common reason for using more staff than planned is usually related to the care needs of patients being higher than normal for that area. Using less staff than planned could be due to caring for patients who are less unwell or who have fewer care needs than those patients normally cared for on the ward.

The planned staffing level is based on optimal staffing levels and where actual staff is below this per shift the Trust has mechanisms in place to ensure that staffing on the shift remains safe. The majority of staffing shortfalls during June were due to either short term sickness or small numbers of vacant posts.

4. DATA QUALITY The data for this report has been extracted from the e-rostering system as this system should be updated and accurate. In order to confirm the accuracy of the data over the coming months a series of audits and checks will be run to validate data accuracy. Until these checks have been completed these early data need to be viewed with caution.

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5. VARIANCE REPORT For purposes of this report any deficit between planned and actual staff of greater than 20% is reported together with the reasons for the variance and any actions taken to address the cause, if appropriate.

DAY NIGHT COMMENTS /ACTION TAKEN FURTHER ACTION IDENTIFIED HARMS WARD Average fill Average Average fill Average REQUIRED rate registered fill rate rate registered fill rate nurse/midwife care nurse/midwife care staff staff An assessment of appropriate The ward has a number of In June there were 6 in patient 19 69.8% 104% 100% 100.9% nurse and care staff levels is registered nurse vacancies, in falls of which 5 resulted in no made on a shift by shift basis. the on-going bed base changes harm to the patient. All patients Care staff numbers have been these vacancies will be filled by were appropriately assessed increased to support the current Trust staff. and actions being taken. The registered nurses ward has had 4 grade 2 pressure ulcers this month the matron is currently taking a review of these to identify trends. Care staff were used to ensure enough staff on the ward when there was a reduced level of qualified staff. An assessment of appropriate The ward has a number of In June there were 5 patient 20 63.1% 97.7% 100% 108.3% nurse and care staff levels is registered nurse vacancies, in falls on the ward, 1 deemed to made on a shift by shift basis. the on-going bed base changes cause low harm and the these vacancies will be filled by remaining 4 no harm. There current Trust staff. were 6 patients who suffered a grade 2 pressure ulcer. These are currently being reviewed however all assessments had been undertaken appropriately for both the falls and tissue viability and care staff were used when qualified staff numbers fell below expected levels.

BoD Aug 2014: 08_Nursing Midwifery Staffing

The Acute Medical Unit (AMU) Although many of the posts AMU had a decrease in AMU 77.6% 90.8% 97.6% 106.7% continues to have a large have been appointed to there incidents reported this month by number of vacancies. are a number of individuals who 16. There were 6 reported are student nurses who will not incidents of grade 2 pressure The unit is being supported with qualify until September 2014 ulcers and 1 grade 3 pressure staff from other medical wards and therefore the posts will ulcer. The matron has and the use of bank and continue to be filled using conducted a review of the agency. internal bank staffing or external pressure ulcers and has This situation is monitored on a staffing via a nursing agency. identified a lack of assessments day by day basis by the Matron on admission; this has been

and the Head of Nursing to addressed with the staff ensure that the quality of care involved and also through delivered is maintained. education and training. Monitoring is on-going. The grade 3 pressure ulcer is going through the RCA process.

There were 4 falls which resulted in no harm however all assessments were in place and actions being taken.

The ward currently has 2 vacant Recruitment on going There were 9 falls on the unit band 5 posts and 2 full time which resulted in no harm; all 23 staff on long term sick. Where assessments and actions were 71.8% 103.0% 96.7% 150.0% they were unable to cover in place to try to prevent these. registered nurse shifts There were 2 grade 2 pressure additional care staff were ulcers reported but all care was utilised to support the team. in place. The ward current has 2 vacant This ward will be closed on the There were 7 falls on the ward band 5 posts and some short 1 August 2014 as part of the which resulted in no harm for 27 term sickness this month which Trust internal reconfiguration of the patients involved. All has impacted on the fill rate but beds. Staff will fill other current assessments and care plans this has been assessed on a vacant posts. were in place and being 75.4% 76.5% 96.7% 115.0% daily basis. actioned. There were 4 patients who suffered a grade 2pressure ulcer. One patient suffered a grade 3 pressure ulcer which

BoD Aug 2014: 08_Nursing Midwifery Staffing

has gone through the RCA process and found to be due to non-concordance of the patient involved. The ward currently has 2 Continued monitoring There were no incidents registered nurses on long term reported with regard to pressure 31 sick both being supported by ulcers or falls this month on the OH and HR. Two registered ward. 65.7% 118.5% 100.0% 111.8% nurses awaiting start dates, these are anticipated to be August 2014 and 1 registered nurse on maternity leave

The ward has a high level of From the 30 June 2014 there There were 4 falls reported on staff vacancies. The staffing will be 15 beds closed on ward the ward with no harm suffered 34 levels are monitored on a daily 33 and the staff will be by the patient – staffing levels basis and where registered redeployed to support ward 34. were as expected. There were 74.6% 135.9% 96.8% 153.3% nurses have not been able to two grade 2 pressure ulcers be supplied through bank and reported in June one of these agency extra care staff have occurred when staffing levels been deployed to support were less than optimal. patients. The occupancy and level of Continued monitoring No incidents reported related to ITU acuity of patients on the unit pressure ulcers or falls. 76.5% 64.3% 117.8% N/A means that not all staff planned are always required on the unit

6. CONCLUSION The wards display staffing levels of planned and actuals on a daily shift by shift basis. This is closely monitored by the Matrons and the Heads of Nursing and shortfalls are escalated appropriately. Harms are closely monitored and triangulated to staffing levels.

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Fill rate indicator return Appendix 1

Org: RFF Staffing: Nursing, midwifery and care staff

Barnsley Hospital NHS Foundation Trust

Period: June_2014-15

Please provide the URL to the page on your trust website where your staffing information is available

http://www.barnsleyhospital.nhs.uk/transparency/safe-staffing/

#REF! Day Night Day Night Registered Registered Main 2 Specialties on each ward Care Staff Care Staff midwives/nurses midwives/nurses Average fill Average fill Average Total Total Total Total Total Total Total rate - Average fill rate - Ward Total fill rate - monthly monthly monthly monthly monthly monthly monthly registered rate - care registered name monthly care staff Specialty 1 Specialty 2 planned actual planned actual planned actual planned nurses/mid staff (%) nurses/mid actual staff (%) Validation alerts (see staff staff staff staff staff staff staff wives (%) wives (%) hours control panel) hours hours hours hours hours hours hours 0 14 502 - GYNAECOLOGY 802.5 727.5 450 382.5 834 834 207 207 90.7% 85.0% 100.0% 100.0% 0 17 320 - CARDIOLOGY 1507.5 1330.76 1131.5 1005.5 690 690 345 345 88.3% 88.9% 100.0% 100.0%

18 340 - RESPIRATORY MEDICINE 1665 1344.5 1125 1000 690 690 345 345 80.8% 88.9% 100.0% 100.0% 0 2 19 430 - GERIATRIC MEDICINE 1957.5 1366.95 1575 1637.54 690 690 690 696.5 69.8% 104.0% 100.0% 100.9% 2 20 430 - GERIATRIC MEDICINE 1916.5 1209.5 1590 1553.75 690 690 690 747.5 63.1% 97.7% 100.0% 108.3% 2 AMU 300 - GENERAL MEDICINE 4147.5 3217.75 3037.5 2758.5 2415 2357.5 1380 1472 77.6% 90.8% 97.6% 106.7% 2 23 300 - GENERAL MEDICINE 1740 1248.92 1575 1621.75 690 667 345 517.5 71.8% 103.0% 96.7% 150.0% #DIV/0! 24 370 - MEDICAL ONCOLOGY 1148.5 1034.77 832.5 774.42 690 690 0 23 90.1% 93.0% 100.0% #DIV/0! 2 27 300 - GENERAL MEDICINE 1845 1390.5 2220 1699.1 690 667 690 793.5 75.4% 76.5% 96.7% 115.0% 2 28 301 - GASTROENTEROLOGY 1712.5 1449.68 1350 1285 690 693 345 401.5 84.7% 95.2% 100.4% 116.4% 2 31 100 - GENERAL SURGERY 101 - UROLOGY 1927.5 1267 1080 1280.25 690 690 690 771.25 65.7% 118.5% 100.0% 111.8% 2 32 100 - GENERAL SURGERY 120 - ENT 1462.5 1351.03 870 957.75 667 667 333.5 322 92.4% 110.1% 100.0% 96.6% 110 - TRAUMA & 33 1743 1408.93 1350 1627.48 690 690 690 793.5 80.8% 120.6% 100.0% 115.0% 2 ORTHOPAEDICS 110 - TRAUMA & 34 1672.5 1248.5 1267.5 1722.25 701 678.5 345 529 74.6% 135.9% 96.8% 153.3% 2 ORTHOPAEDICS 192 - CRITICAL CARE ITU 3622.5 2772.75 540 347 2257.5 2659.25 0 0 76.5% 64.3% 117.8% #DIV/0! #DIV/0! MEDICINE 192 - CRITICAL CARE SHDU 750 757.25 412.5 336.5 660 660 0 0 101.0% 81.6% 100.0% #DIV/0! #DIV/0! MEDICINE #DIV/0! CCU 320 - CARDIOLOGY 1507.5 1263.76 360 294.5 1035 1046.5 0 0 83.8% 81.8% 101.1% #DIV/0! 0 12 501 - OBSTETRICS 2178.25 2117 822.25 797.75 1440 1407 456 420 97.2% 97.0% 97.7% 92.1% Labour 501 - OBSTETRICS 2283 2242 394 394 2124 2040 360 360 98.2% 100.0% 96.0% 100.0% 0 Suite 0 37 171 - PAEDIATRIC SURGERY 1482.5 1397.5 635 465 1265 1196 80.5 80.5 94.3% 73.2% 94.5% 100.0% 0 15 171 - PAEDIATRIC SURGERY 1540.5 1449 552 420 1368 1224 360 360 94.1% 76.1% 89.5% 100.0% 0 TOTAL 38612.25 31595.55 23169.75 22360.54 21666.5 21626.75 8353 9184.75

REPORT TO THE BOARD OF REF: BARNSLEY HOSPITAL NHSFT 14/08/P-09

INFECTION PREVENTION AND CONTROL ANNUAL REPORT SUBJECT: 2013/2014

DATE: AUGUST 2014

Tick as Tick as applicable applicable

For decision/approval  Assurance  PURPOSE: For review Governance For information Strategy Dr Jyothi Rao, Director of Infection Prevention & Control PREPARED BY: Denise M Gibson (née Potter), Assistant Director of Infection Prevention & Control SPONSORED BY: Heather McNair, Director of Nursing & Quality Alison Bielby, Deputy Director of Nursing Dr Jyothi Rao, Director of Infection Prevention & Control PRESENTED BY: Denise M Gibson (née Potter), Assistant Director of Infection Prevention & Control STRATEGIC CONTEXT 2-3 sentences

All NHS Boards are required, within the Health and Social Care Act of 2012 and associated Hygiene Code (2010), to receive and acknowledge such annual reports prior to publically releasing them.

QUESTION(S) ADDRESSED IN THIS REPORT

Is the Trust meeting the requirements of the Health and Social Care Act?

CONCLUSION AND RECOMMENDATION(S) As demonstrated in the report the Trust is meeting the requirements of the Health and Social Care Act.

The Board of Directors is asked to receive and approve this report and subsequent publication on the hospital website.

REFERENCE/CHECKLIST • Which business plan Aim 1 – patients will experience safe care objective(s) does this report relate to? Patients BCCG Other

• Please state: Has this report considered the Staff BMBC following stakeholders? Governors Monitor

Regulators (eg Monitor / CQC)

• Has this report reviewed the Legal requirements (Acts, HSE, NHS Constitution etc) Trust’s compliance with: Equality, Diversity & Human Rights

The Trust's sustainability strategy

• Has this report Yes Quality & Governance (in draft or during • Is this report development) been supported by a Not applicable reviewed and Audit Committee

communications supported by any plan? To be developed Board or Executive Finance & Performance

committees within the Trust? ET

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: Providing the best healthcare for all”

Infection Prevention and Control Annual Report 2013/2014 And Objectives for 2014/15

The Infection Prevention & Control Team 13/14 Dr J Rao Consultant Microbiologist/DIPC Dr Y Pang Consultant Microbiologist Denise Potter Assistant Director of Infection Prevention and Control Christine Fisher Specialist Nurse Susan Burns Clinical Nurse Specialist Lynda Slater Clinical Nurse Specialist Simon Watson Data Analyst Sue Todd PA Daisy Bray Apprentice

CONTENTS PAGE

Executive Summary 5

1.0 Introduction 7

2.0 Infection Prevention & Control Arrangements 8

3.0 Saving Lives 10

4.0 Health and Social Care Act 2008 (revised 2010) 11

5.0 Policies & Procedures 11

6.0 Visits, Reports and Projects 12

7.0 Antimicrobial Prescribing 17

8.0 Audits 18

9.0 Surveillance 22

10.0 Clusters/Outbreaks 35

11.0 Complaints 35

12.0 Serious Incidents 35

13.0 Patient Assessment 35

14.0 Educational Initiatives 36

15.0 Research 37

16.0 Health Promotion 37

17.0 Capital Schemes/Estates/Equipment 38

18.0 External Visits 38

19.0 National & Regional Work 39

20.0 Objectives 39

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Appendices

Appendix 1 Lines of Communication and Accountability Appendix 2 Exception report Appendix 3 Surgical site infection surveillance Appendix 4 Control of Infection Performance indicators Appendix 5 Training

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ABBREVIATIONS

• ANTT Aseptic Non-Touch Technique • C diff Clostridium difficile • C.diff Antigen Clostridium difficile Antigen • C.diff Toxin Clostridium difficile Toxin • CCG Clinical Commissioning group • CDAD Clostridium difficile Associated Diarrhoea • CEO Chief Executive Officer • COSHH Control of Substances Hazardous to Health • CPE Carbapenemase-producing Enterobacteriacae • CQC Care Quality Commission • CSU Clinical Service Unit • CVP Central Venous Pressure • DH Department of Health • DICC District Infection Control Committee • DIPC Director of Infection Prevention & Control • GDH EIA Glutamase dehydrogenase enzyme immunoassay • HACCP Hazard Analysis of Critical Care Points • HBV Hepatitis B Virus • HCAI Health Care Associated Infection • ICD Infection Control Doctor • ICN Infection Control Nurse • IPC Infection Prevention & Control • IPCC Infection Prevention & Control Committee • IPCT Infection Prevention & Control Team • ITU Intensive Care Unit • MRSA Meticillin Resistant Staphylococcus aureus • NHSLA National Health Service Litigation Authority • NNU Neonatal Unit • PAS Patient Administration System • PEAT Patient Environment Action Team • PGD Patient Group Directive • PPE Personal Protective Equipment • RCA Root Cause Analysis • SHA Strategic Health Authority • SSD Sterile Services Department • SWYPFT South West Yorkshire Partnership Foundation Trust

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EXECUTIVE SUMMARY

Infection Prevention & Control Annual Report 2013/14 and Objectives 2014/15

The Infection Prevention and Control (IP&C) Annual Report provides a summary of all the IP&C activities and outputs across the Hospital for the year of 2013/2014. Within the Health and Social Care Act of 2012 and associated Hygiene Code (2010) requires all NHS Boards to receive and acknowledge such annual reports prior to publically releasing them.

Healthcare associated infection is of increasing media and political interest being seen as a visible and unambiguous indicator of the quality and safety of patient care. The infection prevention and control agenda faces many challenges including the ever increasing threat from antimicrobial resistant micro-organisms, the emergence of new human pathogens, growing service developments, national guidelines and targets.

Following an unannounced inspection by the Care Quality Commission (CQC) in May 2009 the Trust was found to be fully compliant against all of the duties laid down within the Hygiene Code confirming our registration without conditions. This placed the Trust within the top percentage of Trusts in England. No inspection was undertaken in 2013- 2014 however it is imperative that infection prevention and control stays as a priority in the Trusts agenda.

The Director of Infection Prevention and Control (DIPC) meets regularly with the Chief Executive (CE), the Chief Nurse, and the Medical Director and is Chair of the Trust’s Infection Prevention and Control Committee. The DIPC and Assistant DIPC are also members of the Quality and Safety Improvement and Effectiveness Board. The DIPC attends the Clinical Governance Committee and the Trust board when required.

Over the past four years the Trust has seen significant reduction in Clostridium difficile (C. difficile) associated infection and have had zero MRSA bacteraemia for the last four years. Therefore all targets have been achieved consistently but maintaining the good performance will be challenging.

The annual PLACE inspection indicates that the hospital continues to provide a clean safe environment to deliver care. However this is an ongoing process and the Trust will continue to strive for excellence. The IP&C team continues to work closely with Estates and Facilities in relation to cleanliness, environment and capital schemes. The management of Legionella prevention meets and exceeds legislation with enhanced surveillance including Pseudomonas aeroginosa control. The Sterile services department maintains all the required elements to provide sterile instruments and fulfill contractual obligations and this year has taken over the responsibility for the decontamination of endoscopes within a new decontamination facility in the SSD.

The IP&C team has continued to improve practice and facilitate change and have continued to promote ANTT (aseptic non touch technique), hand hygiene safer sharps and the principles of infection prevention & control

The team continues to teach both informally and formally and ensure that they also maintain their professional competencies. Most of the IP&C policies have been re written and are on the Trust policy warehouse and infection control intranet site.

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Considerable work has been done to improve antimicrobial prescribing within the Trust and the Consultant Microbiologists undertake teaching sessions with the medical staff. The IP&C team has undertaken a number of audits and surveillance of surgical wound infections. The Trust remains above the national average for surgical site infections and considerable work is being undertaken to address this issue.

The Trust continues to support the Saving Lives and Clean your Hands Campaign and has promoted infection prevention and control with an awareness week and a sharps prevention awareness week including the ‘Bug Herald’.

The clinical nurse specialists have continued conducting ward based practical observations of clinical practice. Working along side ward staff facilitates closer working between the IP&C team and ward staff whilst allowing closer observation of clinical practice. This is proving to be very successful and effective.

The Trust has not experienced any ward closures due to infection this year.

The Trust has an IP&C strategy for 2013 -16 which is regularly reviewed and remains on target. The Objectives for 2014/15 contain all the required elements of an annual infection control programme.

Heather Mcnair Dr Jyothi Rao Denise Potter Chief Nurse DIPC Assistant DIPC

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ANNUAL REPORT – INFECTION PREVENTION & CONTROL

1.0 Introduction

The term Healthcare Associated Infection (HCAI) encompasses any infection by any infectious agent acquired as a consequence of treatment. Micro-organisms (germs) responsible for HCAI can be viruses, fungi, parasites and, more frequently, bacteria. HCAI can be caused either by micro-organisms already present on the patient’s skin and mucosa (endogenous) or by micro-organisms transmitted from another patient or health-care worker or from the surrounding environment (exogenous).

The risk of transmission and potential harm applies at any time during health-care delivery, especially to immuno-compromised or vulnerable patients and/or in the presence of indwelling invasive devices (such as urinary catheter, intra-venous catheter, endotracheal tube, drains).

Infection prevention and control clearly has an important role to play in ensuring that patients receive a high quality of care and improved clinical outcomes. The infection prevention & control agenda faces many challenges including the ever increasing threat from antimicrobial resistant micro-organisms, the emergence of new human pathogens, growing service developments, national guidelines and very strict targets.

Healthcare associated infection is of increasing media and political interest being seen as a visible and unambiguous indicator of the quality and safety of patient care.

The foundations of infection control are built on a number of simple, well-established precautions proven to be effective and widely appreciated. “Standard Precautions” encompass the basic principles of infection control that are mandatory in all health-care facilities. Their application extends to every patient receiving care, regardless of their diagnosis, risk factors and presumed infectious status, reducing the risk to patients and staff of acquiring an infection. Hand hygiene is very much at the core of Standard Precautions and is the undisputed single most effective infection prevention control measure.

The main essential elements of controlling and preventing infections related to health care are: • Identifying risk factors and minimising their impact • Improving patients’ resistance to infection • Early identification and effective treatment of infections • Preventing transmission of micro-organisms from person to person • Maintaining a clean and fit for purpose environment including equipment with minimal levels of microbial contamination

Department of Health (DH) has continued to place infection prevention and control and health care associated infection high on the agenda. The major standards and legislation against which infection control services are judged include:

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1. The Health & Social care Act 2012 and associated Code of practise for health and adult social care on the prevention and control of infections and related guidance (revised 2010). 2. Health & Safety at work etc. Act 1974 3. COSHH 2002. 4. European legislation 2010/32/EU came in to force on 11th May 2013 as The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 This legislation has enhanced the sharps preventative work. 5. CQC Essential Standards of Quality and Safety. 6. Saving lives. 7. NHSLA. 8. Clean Your Hands Champaign

The Infection Prevention and Control Team (IPC&T) has worked hard to implement these initiatives within the Trust. The main priority this year being, delivering the IP&C strategy 2013-2016 and annual programme, exceeding national and local targets for MRSA bacteraemia, Clostridium difficile infection reduction and achievement of target, Saving Lives and continued focus on a Clean your hands Campaign.

Following an inspection by the CQC in May 2009 the Trust was found to be fully compliant with the hygiene code and therefore in the top percentage of Trusts in England with clear compliance, confirming our registration without conditions no further inspections relevant to the hygiene code have taken place. However, the annual PLACE inspection confirmed the Trust was a clean safe environment to deliver care. This is an ongoing process and the Trust will continue to strive for excellence.

This report informs on the progress made on the objectives set in last years Annual Report and also the Trusts progress in implementing national initiatives during the reporting period April 2013 to March 2014. The report also encompasses the annual programme for 2014/15 which reflects the Trusts strategic vision and commitment to the IPC agenda.

2.0 Infection Prevention & Control Arrangements

The infection control service is provided by an Infection Prevention and Control team, the Consultant Microbiologists continue to support SWYFT Community Services Unit and provide 5 sessions per week as the Infection Control Doctor. The team currently consists of;

1. Consultant Microbiologist/ DIPC / ICD 37.5 hrs weekly 2. Consultant Microbiologist 37.5 hrs weekly 3. Assistant DIPC 37.5 hrs weekly 4. 1 Specialist Infection Control Nurse 37.5 hrs weekly 5. 2 Clinical Nurse, Specialists 60 hrs weekly 6. 1 Data Analyst 37.5 hrs weekly 7. 1 Admin/Clerical support 37.5 hrs weekly 8. 1 Apprentice 37.5 hrs weekly

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Infection Control Resources

The team has a separate budget which includes the provision of patient and public information, maintenance of the infection control software, training, and other supportive material.

Reporting arrangements

• The Trust Infection Prevention and Control Committee (IP&CC) bi monthly. • The Infection Control Operational group meets bi-monthly. • The DIPC meets regularly with the CEO, Chief Nurse and is Chair of the Trust Infection Prevention & Control Committee. The DIPC also attends as required the Clinical Governance Committee and Trust board, and is a member of the Quality and Safety Improvement and Effectiveness Board. • The Matron and Clinical Director have been nominated as infection control leads within each CSU. Their main role is to deliver the IP&C Strategy, assist in delivery of the annual infection control programme and saving lives programme. The CSU’s are required to report and provide evidence of compliance with the hygiene code which is checked by the IP&CC via exception reports • The DIPC produces a monthly report to CEO and Executive Team, and bi monthly reports to IP&CC, Quality and Safety Improvement and Effectiveness Board. • The Assistant DIPC is included in the senior nursing, health & safety structure and quality agenda, meeting regularly with the Chief Nurse, matrons and AND’s. • The Decontamination Group meets quarterly and reports to the Infection Prevention & Control Committee. • The Trust has a Legionella/water safety group which meets twice yearly and reports to both IP&CC and Health & Safety. • The main alert organisms are internally scrutinised via RCA’s and MDT meetings with the clinical team. These are then externally scrutinised via a review group with SWYFT and finally by Public health and the CCG.

Current lines of accountability for infection prevention control are shown in appendix 1. However in 2014/15 the CSU’s will become Business units

The Infection Prevention and Control team continue to have a strong link with the Community Infection Control team, ensuring smooth transition of care between Health and Social Care.

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3.0 Saving Lives: A delivery programme to reduce Healthcare Associated Infection

The ‘Saving Lives’ programme launched by the Department of Health in June 2005 is designed to increase organisational focus on infection control and to reduce healthcare associated infections including MRSA. The overall aim of ‘Saving Lives’ is to ensure that all staff recognise how they can contribute to reducing infection rates and adopt best practice to achieve this.

The programme has high impact interventions which relate to specific clinical procedures which can increase the risk of infection if not performed appropriately. Each of these interventions has a simple evidence based tool that reinforces the actions that clinical staffs need to undertake every time in order to significantly reduce infection, increasing reliability and reduce unwarranted variation in care delivery. Each CSU is asked to provide exception reports where standards are less than 100% and account for the variance (appendix 2). During 13-14 an additional saving lives standard has been introduced on Enteral feeding. The scores are red however the enteral feeding policy and procedures have been updated and practise improved; further work is in progress. It is intended that in the forth coming year chronic wounds will be added. The Trusts compliance with the high impact interventions are demonstrated in table1. Data is being fed in to the Governance structure via the Infection Prevention and Control Committee and back to the Ward staff, Matrons and Clinical Leads, with exception reporting to the Trust Board via the clinical risk committee.

Table 1: Saving Lives - Compliance results Apr - Jun Jul - Sept Oct - Dec Jan - Mar Intervention 13 13 13 14 Insertion 100% 100% 100% 100% Central Venous Catheter Ongoing 100% 100% 100% 100%

Insertion 91% 94% 91% 93% Peripheral Intravenous Catheter Ongoing 92% 96% 99% 92%

Pre-op 100% 100% 100% 100%

Surgical Site Infection Intra-op 100% 100% 100% 100%

Post-op 100% 100% 100% 100% Care to Reduce Ventilation - Association 100% 100% 100% 100% Pneumonia Insertion 100% 100% 100% 100% Urinary Catheter Ongoing 99% 99% 98% 97% Suspected / Confirmed 100% HCAI Cleaning Equipment Non Infected 90% 100% 90% 100%

Enteral Feeding 50% 40% 40%

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4.0 The Health & Social Care Act 2012: Code of Practice for the control of Health care associated infection (DH Hygiene Code 2010)

The Health and Social Care Act 2012 and the related code of practice on the prevention and control of infections and related guidance better known as the hygiene code(DH 2010) has ten criterion which form the basis of the trust hygiene code registration.

The Trust is legally required to be registered with the Care Quality Commission and legal action can be taken if Trusts are found to be breaching the requirement of their registration to protect patients, workers and others from infection. The Trust successfully achieved full unconditional registration on the last inspection which was conducted on the 15th May 2009. No inspections have been undertaken in 2013/14.

To help deliver the requirements of the Hygiene Code the Trust has an Infection Prevention & Control strategy. This strategy and action plan first produced in June 2007 and updated March 2013 provides the Trust with an overarching strategic framework. This not only encompasses the Hygiene Code requirements but seeks to ensure that the Trust will be recognised as being one of the top performing NHS organisations and seeks to be first choice for patients.

5.0 Policies and Procedures

The team update the IPC policies and procedures these can be found on the Trust intranet site. The following policies and procedures have been introduced, reviewed and updated by the Infection Prevention and Control team/Estates/Occupational Health this year:

Updated Procedures

Contamination incident (needle stick injury) poster Blood and body fluid procedure Patient group directive for MRSA decolonisation Patient group directive for MSSA decolonisation (pre-assessment only)

New & updated Policies & Guidelines

PVL Guidance Legionella Children & Neonates Antimicrobial policy Contamination incidents policy Group A streptococcus MRSA Care pathways Water strategy

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6.0 Visits, Reports and Projects

The Clean Your Hand Campaign –Eighth Year

Promotional hand washing awareness campaigns have been undertaken in the Trust with every clinical area engaged with the campaign. The Clean your hands champions meet quarterly with the IP&CT and they continue to integrate the campaign into practice including participating in the delivery of hand washing training at local level and monitoring practise. The number of clean your hands champions increases year on year, as staff become more pro-active in the campaign. This year the campaign has been extended to include theatres with poster displays and champions. Surgical hand washing and gloving technique has been audited and retraining provided as required.

The fundamental principle underpinning the campaign is the focus on the hand hygiene practises of healthcare staff. Due to the nature of their work moving between different patients and different care activities with the same patient, healthcare staffs have the greatest potential to spread the microbes that cause infection.

Compliance with hand hygiene is monitored by direct weekly observation of health-care workers whilst delivering routine care. Matrons should conduct at least 10% of the observations. These are presented monthly at all the relevant committees and are displayed at ward and department level.

The Trust continues to promote “bare below the elbow” standard for all staff entering clinical environment. The compliance with this is audited regularly and reported to the Infection Prevention and Control Committee and the Trust Board.

The importance of embedding efficient and effective hand hygiene into all elements of care delivery must be kept prominent within health care and will remain a priority for the Trust.

Patient lead assessments of the care environment (PLACE)

The team work closely with Matrons, Senior Nurses and Facilities to promote cleanliness and other environmental issues. PLACE visits have been regularly conducted and additional environmental walkabouts have been undertaken with IPCT and Matrons. The team have also participated in the formal annual PLACE assessment process. A more detailed environmental inspection has been completed when two or more cases of Clostridium difficile were identified in one area within a 28 day period.

Kitchen Inspections

Standards for food hygiene within the main kitchen are regularly monitored by the facilities department and managers informed of any action required. In addition to the regular facilities inspections, infection control along with Environmental Health conduct regular kitchen inspections however none have taken place in 2013/14 Most of the ward kitchens have been updated.

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Flu

The team have been actively involved in the management and control of influenza compared to previous years the numbers were low. An extensive staff vaccination programme was also completed by the Occupational Health department and the Trust achieved 75% of all staff being vaccinated.

Decontamination

The Sterile Service Department at BHNFT continues to provide an accredited and certified service against British, European and international Standards for decontamination. Endoscopy washer disinfectors are closely monitored with weekly water quality testing. The processing of scopes has been moved from endoscopy to the sterile service department. This has improved the decontamination providing the most up to date methods with both the machinery and water treatment unit being new.

Infection prevention and control and estates have audited and inspected the external cleaning decontamination unit that cleans the Trusts specialist mattresses.

The decontamination group should meet quarterly and reports to the IP&CC.

Risk Assessments

Risk assessments have been completed and new ones continue to be developed to reduce the risks of HCAI, The team have also focused on Sharps prevention and control risk assessments in order to comply with new legislation that was introduced in May 2013. Infection control information is included on all intra/inter health-care transfer documentation and is included in the transfer & discharge policy.

Inspections

Observational visits have been completed in theatres and the theatre team is conducting more detailed specific IPC audits. The Trust laundry supplier has been audited and regular temperature checks on the washing machines are monitored.

Theatre Forum

The infection Prevention & Control Team remain active members of the forum and infection prevention and control remains an agenda item with a particular focus on surgical site infections.

Cleaning/Deep Cleaning

During 2013 the Trust had very little opportunity to decant and deep clean the wards. Wards completed include 20 11,12,13,16,35,36, 37 and 38. Plus extra cleaning has been required on physio, ED and SSD. There have been improvements to the allocation of resources within the cleaning contract with a more equal distribution of resources across all wards. The provision of a steam cleaning team continues. The domestic contract is monitored by facilities with reports going to the IPCC and Infection

s:\meetings\board\2014 meetings\08 august\public\09_infection control annual report.doc 13 control is a member of the hotel services monthly monitoring contract meetings. The team have been involved with the tender, appointment and mobilisation of the new contract and new cleaning methods. Monitoring will continue with quarterly reports going to IPCC. All touch points, toys and new furniture are protected with a Nano coating to facilitate cleaning. The Pest Control is monitored by Estates and quarterly reports go to the IP&CC.

Aseptic Non Touch Technique (ANTT)

ANTT was introduced by the IP&CT as part of the Trust’s drive to improve aseptic technique Over the last year ANTT has continued to be promoted, refresher training given and reinforced by both the clinical skills facilitator and the Infection Prevention and Control team.

The intravenous aspect of the ANTT program commenced in Sept 2012, and has been part of an ongoing program over the last year, with training sessions in the pathology seminar room, at ward level, clinical skills department and by utilising cascade trainers on wards. The IP&C team has also delivered this training for new medical staff on AMU with the support of AMU consultants, this training will continue for each new intake of medical staff in AMU. ANTT training has also been delivered to the cardiology team.

Plans for ANTT over the coming year are to evaluate training and to have a relaunch of all aspects of ANTT as a focus of Infection control week.

Observation of clinical practice

During 13/14 the clinical nurse specialists have conducted 27 ward based practical observations of infection control clinical practice, observation of theatre practice has also been undertaken (Table 2). Working along side ward or department staff facilitates closer working between the IPCT and clinical staff whilst allowing closer observation of clinical practice. This is proving to be very successful and effective. Each area observed is expected to respond in writing to the actions identified in the report.

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Table 2: Practice Sharing visits April 2013-March 2014

Ward / Date Nurse Revisit Department needed visited ED 03//05/13 Sue Burns No Phlebotomy 09/05/12 Lynda Slater No Fracture clinic 15/0513 Sue Burns No Diabetic 23/05/13 Sue Burns No Centre Ward 24 06/06/13 Sue Burns Yes Audiology 20/06/13 Lynda Slater No ENT opts 27/06/13 Lynda Slater No Ward 17 02/07/13 Sue Burns No 33 Rehab/33 04/07/13 Sue Burns No Peri Ward 14 15/07/13 Sue Burns No Ward 23 17/07/13 Lynda Slater No Ward 23 20/11/13 Sue Burns No Med out pts 25/07/13 Lynda Slater No Angiogram 17/09/13 Sue Burns No PIU 25/09/13 Sue Burns No Ward 20 26/09/13 Sue Burns yes Ward 20 10/12/13 Sue Burns No Dermatology 14/10/13 Lynda Slater No Endoscopy 11/11/13 Sue Burns No Ward 27 13/11/13 Lynda Slater No Ward 18 10/01/14 Sue Burns No Ward 19 16/01/14 Sue Burns No Neonatal unit 29/01/14 Lynda Slater No CCU 26/03/14 Sue Burns No Chemotherapy 23/01/14 Lynda Slater No Unit Ward 24 12/03/14 Lynda Slater No Antenatal day 06/02/14 Lynda Slater No unit

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Infection Control Software System

The system provides notifications of patients with positive alert organisms in order that appropriate patient care is initiated as quickly as possible thereby improving efficiency and reducing the risk of infection. The infection control patient record and documentation is completed on the system which is stored against the patient’s unit number for easy access.

The system is currently been used by the IPCT, Matrons and Consultant Microbiologists.

Lead Nurses receive an E-mail alert advising them of patients who have a positive result for MRSA or Clostridium Difficile Toxin within their Ward areas.

The Following reports are available and provide up to the minute information:-

• Aspergillus report. • Blood Cultures resulting in Staphylococcus aureus, Escherichia Coli and MRSA. • Clostridium Difficile report. • Group A. Streptococcus report. • Influenza B PCR Report. • Influenza H1N1 Report. • MRSA Positive (First Isolate) report. • MRSA Screening Report. • TB Culture Report. • Case Management forms report. • Bordetella Pertussis Serology. • Faeces Culture. • Hepatitis Report. • Legionella Report. • Meningococcal Report. • Orthopaedic (Bone/Tissue) and extended culture positive results. • Vibrio Cholorae.

Additional reports built over the last year include:

• Hepatitis Report has been updated to now show results for:- . Hepatitis ‘A’ . Hepatitis ‘B’ . Hepatitis ‘C’ . Hepatitis ‘E’ • Influenza Report for Microbiologist • Pre-Assessment MRSA Screens resulting in Staphylococcus aureus • Vancomycin Resistant Enterococci Report

Further work still continues with the Data Surveillance Analyst and the Software provider regarding development issues to improve the functionality of the system. The system is due to be upgraded imminently applying completed development work carried s:\meetings\board\2014 meetings\08 august\public\09_infection control annual report.doc 16 out over the past year which will increase functionality of the system and additional security regarding E-mail Alerts.

Trials

Trials of products have included a new soap, a foam gel and a new gel dispenser. The soap and foam did not evaluate well but the dispensers were considered an improvement and cost neutral therefore the trust will install new dispensers in the next financial year. A replacement for the trusts chlorine solution has been successfully trialled and introduced resulting in a cost saving. The Team also lead the sharps prevention group and have co-ordinated several trials of safety devices.

Probiotics

The team have considered and explored the introduction of prophylactic probiotic therapy however this would prove to be too costly but may be reconsidered in the future.

7.0 Antimicrobial prescribing

There is growing concern about the increasing resistance of microorganism to antimicrobial agents. Considerable work has been done to improve antimicrobial prescribing within the Trust. The current antibiotic guideline places restrictions on the use of broad spectrum antibiotics. The microbiology department selectively report antibiotic susceptibility on clinical samples to guide appropriate choice of antibiotics. Pharmacists and microbiologist review the antibiotic prescribing on a daily basis.

Several audits been conducted and the results are fed back to the relevant clinical specialities (see under audit for detail). Overall antibiotic policy compliance rate is very good.

Each CSU receives monthly data on the antibiotic consumption and the use of cephalosporins has declined dramatically since its restriction in 2008.

Chart 1: Demonstrates 2nd and 3rd generation cephalosporin usage

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The Antibiotic share point helps the microbiologist to identify areas with inappropriate antibiotic use, who will then take necessary action to improve adherence to antibiotic guideline.

8.0 Audits

Whilst the saving lives audit tool is used to regularly monitor targeted clinical interventions the following audits have also been undertaken:

Hand Hygiene

The programme of hand hygiene observational audits of 10 per week per ward led by the matrons continues. Those areas where compliance rate is less than 100% are placed on special measures requiring daily monitoring. Results of these audits are disseminated by the matrons to the CSU’s

Chart 2: Demonstrates hand washing compliance before and after procedures during April 2013 – March 2014

Cluster One Cluster Two Surgery Elderly Critical Care General Medicine Cardiology / Theatres & Day Care Respiratory Head & Neck ED/AMU Trauma & Therapy Orthopaedics Children’s Pathology Women's Imaging Outpatients

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Central Venous Access Device - January 2013 to January 2014

The aim of the audit was to give assurance that in settings outside of critical care, compliance with national and local guidance is being achieved and patients are receiving high quality central venous access care. 125 Observations were undertaken on 50 patients. Overall compliance with guidance was good. Areas of concern were in relation to documentation, 3 patients did not have care pathways and insertion details were missing on two occasions. 4 patients exhibited localised signs of infection with poor documentation in relation to two of these patients. Work is being undertaken to improve documentation and it is anticipated that the introduction of the PICC line service will enhance this further.

Clostridium difficile - April to March 2014

All inpatients testing positive for C. difficile have a daily review undertaken by the infection prevention and control team. Blood results, dietary and fluid intake, stool type and medications are reviewed and relevant actions taken. This audit forms part of the Infection Prevention and Control annual work programme and was undertaken on all patients who had tested positive for Clostridium difficile toxin, and who were still inpatients at the time of the result. Overall the care and management of patients with C. diffcile was in accordance to Trust policies and procedures. All of the patients were on stool charts, 92% (where applicable) had commenced treatment for C. difficile and all, where appropriate, had been referred to a dietician. However, only 67.9% of patients were isolated at the time of the result and only 71.4% of patients had the correct barrier nursing signage displayed. The Infection Prevention and Control team continue to educate staff, both informally and at mandatory training with regard to the care and management of patients positive for C. difficile. Strong liaison also exists between the Infection Prevention and Control team, Matrons and Lead Nurses to ensure patients are managed safely and correctly.

Isolation Audit - July 2013.

This audit was undertaken to demonstrate compliance to Infection Prevention and Control procedures and was identified in the Infection Prevention and Control action plan 2013-2014. Standards were audited against the Isolation policy (BHNFT), Principles of care for infectious patients (BHNFT) and The Health and Social Care Act Hygiene code (DH2010).

46 patients were audited over a 4 week period, 100% of these patients were isolated appropriately, and in all instances personal protective equipment was readily available outside the room. When staff were observed entering the isolation rooms, PPE was worn when in contact with the patient and when staff were observed leaving the rooms all had removed PPE appropriately. Compliance to hand hygiene was also 100%. Areas for improvement included the management of patient observation records, these should be kept outside of the room, and this was only evident in 73% of observations. The use of the correct barrier nursing signage needs addressing with 34% of patients not having the correct barrier nursing signage displayed.

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Wards should also, whenever possible, allocate single use patient equipment. Only 23% of patients had dedicated equipment such as stethoscopes and tourniquets. Overall compliance to the principles of isolation was adhered to and room contents were kept to a minimum. However there are areas for improvement.

MRSA Screening and decolonisation - October 2013

Transmission of Meticillin Resistant Staphylococcus Aureus and the risk of MRSA infection can only be addressed effectively if measures are undertaken to identify MRSA carriers and then decolonise as required. The aim of this audit was to give assurance that BHNFT policies in relation to MRSA screening and the care and management of patients identified as having MRSA are adhered to, so ensuring a consistent approach to care based on Department of Heath recommendations.

The care and management of 57 patients were audited with the outcome that the management of patients with MRSA requires improvement. Although 53 out of the 57 patients were screened within 24 hours of admission, subsequent screening compliance was poor. Of those patients who required decolonisation, none were screened 48 hours post decolonisation according to Trust policy. Overall screening compliance was therefore only 65%. Introduction of a patient group directive for MRSA has resulted in improvements from the previous audit on ensuring that patients receive the correct duration of decolonisation. However, none of the PGD’s were completed correctly. The results of the audit were disappointing and actions have been put in place to improve compliance. The audit will be repeated

Patient Opportunities for Hand Hygiene - July - August 2013

The aim of the audit was to seek assurances that patients, who are unable to assist themselves, were offered hand hygiene facilities after toileting. 38 patients were included in the audit and information was collected face to face using a questionnaire.

The BHNFT hand hygiene policy states healthcare workers must provide hand hygiene facilities for patients. 38 patients were audited, 100% were offered hand hygiene facilities. The majority of patients were offered wipes (89%) and 24% of patients used soap and water. This audit demonstrated an 8% improvement in the number of patients being offered hand hygiene facilities after toileting from the audit undertaken in July 2011

Medical Devices

The Medical Device Coordinators' Committee has undertaken audits of medical equipment in 2013/14 as part of its work plan. Audits were undertaken on medical devices including tympanic thermometers, vital signs monitors, nebulisers, dynamaps, pulse oxymeters and electric beds. Compliance was good throughout the audits with regards to the cleanliness of equipment and knowledge of decontamination. The bi weekly PLACE inspections and infection control observational visits also include an element of medical devices cleanliness. All areas for improvement have been reported to the clinical areas. s:\meetings\board\2014 meetings\08 august\public\09_infection control annual report.doc 20

The audit of cleanliness and integrity of mattresses and trolley coverings was undertaken resulting in a number of mattresses being condemned and the procedure for checking has been reinforced. This has not yet been successfully implemented and work is on-going. The use, management and decontamination of dynamic mattresses are also a cause for concern and work is on-going to address this issue.

Environmental Audits

In addition to local PLACE inspections, the IP&CT and Matrons have undertaken local infection control audits and action plans formulated to improve areas of non compliance. Additional audits are also undertaken if two or more cases of Clostridium difficile are identified on a particular ward in a 28 day period.

Commode Audit

An external review took place on the cleanliness of commodes the results were mainly good with only minor infringements.

Intravenous Cannulae Audit

This re-audit was undertaken as part of the Infection Prevention and Control work programme. A point prevalence audit was undertaken during April – June 2013 involving 1423 cases where patients had a Cannula insitu. All aspects of the invasive connection record were audited.

97.3% of the patients with cannulae had an invasive devices record, and of these 76.9% were completed correctly. This is a significant improvement in compliance to the audit undertaken in 2012, 0.2% (3 cases) of cannulae audited were found to have local signs of infection, a decrease of 2.8% from the previous audit.

A new Cannula Audit Tool has been created allowing all wards to input their own data directly; this allows the wards to view their position in relation to compliance on a Monthly and more timely basis. Trust wide Monthly / Quarterly Audit reports are produced in order that ongoing compliance can be monitored.

Sharps Audit – January 2014

The use and management of sharps containers has been audited. Seventy five wards/ depts. were visited and a total of 683 sharps containers were inspected overall the result was very good with none being over 2/3rds full and all were correctly assembled. No containers had protruding objects however 6 were sited on the floor or at an unsuitable height. 21 were not appropriately labelled and 27 had inappropriate contents e.g. gloves, this is an increase of non compliance with correct disposal on last years audit, information has been fed back to local teams for action.

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The Use and Management of antibiotics

The pharmacy department has undertaken a three point prevalence audit of antibiotic usage. Results are overall favourable and have been presented to IP&C committee and also to the prescribers through clinical audit meetings. Audit of antibiotic prophylaxis in Gynaecological surgery was also carried out this year with the help of audit department and the results were fed back to the department.

9.0 Surveillance

The IP&C team continues to give a high priority to surveillance. In addition to the mandatory national surveillance scheme a regular cycle of other surgical intervention is monitored. The IPCT also undertake targeted and alert organism surveillance.

Meticillin Resistant Staphylococcus Aureus (MRSA)

Each new case of MRSA is followed up by the IPCT who visit all new MRSA inpatients advising on decolonisation regimes and supporting the patients, relatives and staff, including stamping the patients prescription sheet for medical staff to sign for the decolonisation regime.

All patients (elective and emergency) admitted to the Trust continue to be screened for MRSA colonisation in line with the national initiative. The number of new MRSA isolates at BHNFT, has reduced compared to last year. MRSA screening is monitored and non compliance fed back to clinical teams for checking. An audit has identified that sometimes samples are not taken at appropriate times and decolonisation is often delayed or incomplete. A new nursing PGD has been introduced and is being monitored.

Since 2001 it has been mandatory for Trusts to report MRSA bacteraemia figures to Department of Health. Results are published as MRSA bacteraemia per 100,000 occupied bed days. The Trust achieved its challenging MRSA bacteraemia target of zero for last four years placing the trust nationally in the top ten of performance in this category. Several factors have contributed to this success, including universal MRSA screening, improved decolonisation, decreased blood culture contamination rate, improved cannula care etc. However the target for the coming year is again zero which remains a challenge

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Chart 3: Number of District figures for new cases of MRSA infection colonisation by location:

Chart 4: Number of new cases of MRSA infection colonisation: District figures

Table 3: MRSA bacteraemia rate per 100,000 bed days.

No of MRSA bacteraemia BHNFT Community Target Rate per 10,000 bed days 2005/06 17 13 4 19 1.16 2006/07 16 8 8 16 1.07 2007/08 12 6 6 12 0.79 2008/09 8 3 5 11 0.53 2009/10 2 1 1 8 0.13 2010/11 0 0 0 1 0.00 2011/12 1 0 1 0 0.00 2012/13 1 0 1 0 0.00 2013/14 3 0 3 0 0.00

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Chart 5: Total number of MRSA Bacteraemia District Figures

Chart 6: Trust MRSA bacteraemia compared with Regional data.

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Meticillin Sensitive Staphylococcus aureus (MSSA) Bacteraemia

As from January 2010 it has been a requirement to report nationally all MSSA bacteraemias. It is expected that in future a target will be set to reduce the rates of MSSA bacteraemia. Out of 36 MSSA bacteraemias, 9 were hospital acquired (post 48 hr admission). The sources of these 9 bacteraemias are given in table 4. Only 5 of these bacteraemias are directly related to the health care intervention within this hospital and hence potentially avoidable. Root Cause analysis and multidisciplinary meeting has been conducted for each of these cases and action plan has been produced and monitored by the matrons

Table 4: To Identify the numbers of MSSA Bacteraemia by Month

Staphylococcus aureus Bacteraemia - Monthly Surveillance 2013/14 Month Total No. Hospital Community MVH MRSA April 3 1 2 0 0 May 2 0 2 0 0 June 3 1 2 0 0 July 4 1 2 1 0 August 2 2 0 0 0 September 5 1 4 0 0 October 7 1 6 0 1 November 0 0 0 0 0 December 4 1 3 0 1 January 2 1 1 0 0 February 0 0 0 0 0 March 4 0 4 0 1 Total 36 9 26 1 3

• Hospital = Hospital acquired (identified more than 48 hr. after admission.)

• Community = Community Acquired (identified within 48hrs of admission and not been an inpatient in the last 8 weeks.)

• All MRSA Bacteraemias are Community attributed.

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Chart 7: Demonstrates the numbers of Staphylococcus aureus bacteraemia by Month

Table 5: MSSA bacteraemia RCA findings

Case Source of Hospital Attributed MSSA Bacteraemia 1 temporary pacing wire infection 2 endocarditis 3 ?pneumonia 4 cannula site infection 5 ?pneumonia. 6 Central line infection 7 ? Skin and soft tissue 8 venflon site 9 PVC infection

Clostridium difficile

Since 2004 the reporting of C. difficile infection has been mandatory. All NHS Trusts are required to test diarrhoeal stool samples from patients over 65 years and above reporting all positive results to Public Health England. Since 2007 this has been changed to report all positive Clostridium difficile cases >2 years of age. Data is expressed as the rate per 100,000 bed days.

The end of year 2013/14 position was 20 positive cases against a trajectory of 20 therefore targets were achieved. (Table 6)

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Table 6: Clostridium difficile National Surveillance Figures (All age groups)

Number of Cases No of Cases Total Rate per 100,000 bed days (Trust (Total PCO) (Trust Apportioned cases) Apportioned) 2007/08 297 148 96.9 2008/09 194 105 67.5 2009/10 121 52 33.5 2010/11 131 49 33.2 2011/12 83 28 17.6 2012/13 64 22 14.6 2013/14 59 20 Not yet available

Chart 8: Total number of Clostridium difficile cases by location – District figures

Chart 9: Monthly new Clostridium difficile episodes against agreed trajectory

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Chart 10: Trust Clostridium difficile cases compared with Regional data.

RCA has been undertaken for all cases of C. difficile by the IPCT or Matron and an exception report is produced mainly concentrating on environmental cleanliness, if 2 or more cases are identified in a particular ward within 28 days. Antibiotic use is also monitored by the pharmacist. Actions are taken based on the results of the RCA and exception reports.

A RCA Overview Panel has been established since September 2008 involving representatives from SWYFT the monthly meeting establishes if the infection was unavoidable and what lessons can be learnt across the health economy. The cases are presented to an overview group involving commissioning, public health, SWYPFT and BHNFT.

Glycopeptide Resistant Enterococci (GRE):

The IPCT also monitor the number of cases of GRE. There were 2 cases of GRE infection /colonisation (table 7).

Table 7: Total Numbers of GRE cases by year

Year BHNFT GP KERES. KHB MVH TOTAL 2009/10 0 0 0 0 0 0 2010/11 0 0 0 0 0 0 2011/12 3 0 0 0 0 3 2012/13 0 0 0 0 0 0 2013/14 2 0 0 0 0 2

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Surveillance of Escherichia coli Bacteraemia

Since April 2011, it has become mandatory to report all cases of E.coli bacteraemia into the national database. There is no national benchmark available to compare the rate at the current time.

Table 8: Total numbers Escherichia coli Bacteraemia by Month

E Coli Bacteraemia - Monthly Surveillance 2013/14. Month Total No. Hospital Community MVH ESBL April 5 0 5 0 1 May 10 1 9 0 0 June 8 1 6 1 2 July 16 2 14 0 1 August 14 1 11 2 3 September 13 3 10 0 2 October 17 3 11 3 3 November 8 2 6 0 0 December 17 4 12 1 2 January 10 1 9 0 3 February 10 2 8 0 2 March 18 3 15 0 2 Total 146 23 116 7 21

Chart 11: Demonstrates the numbers of Escherichia coli Bacteraemia by Month

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Surveillance of blood culture contaminants

Since the introduction of monthly surveillance of blood culture contamination rates there has been significant improvement in the rate of contamination of blood culture, thus avoiding unnecessary antibiotic use and also the cost. The continued and reinforced use of ANTT to all staff saw a further reduction in the rate of contamination. A new safety blood culture collection system has been introduced. All wards receive monthly data.

Chart 12: Total blood culture contaminants by month

Surveillance of Carbapenemase- producing Enterobacteriacae (CPE)

Carbapenemases are enzymes which destroys carbapanem group of antibiotics conferring resistance to these group of antibiotics. Enterobacteriaceae (coliforms) carrying these enzymes usually are resistant to multiple other group of antibiotic making it difficult to treat. Also these organisms can cause outbreaks in institutional settings. In the UK over the last 5 years there has been rapid increase in the incidence of infections and colonisation by multi-resistant carbapenemase- producing coliforms. A number of clusters and outbreaks have also been reported. To prevent the spread of these resistant organisms DoH mandated each hospital to implement and embed Toolkit for the early detection and management and control of carbapenemase- producing Enterobacteriaceae. In BHNFT we produced guidance on CPE incorporating contents of the toolkit. This year we had 2 cases of CPE, both were acquired outside the Trust.

Table 9: Total numbers of Carbapenemase Producing Enterobacteriacae

Case Source of Carbapenemase Producing Enterobacteriacae 1 Foreign Hospital 2 Neighbouring Hospital

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Surgical Site Surveillance (appendix 3)

Orthopaedic surgical site surveillance:

The Trust is participating in the mandatory Orthopaedic wound surveillance and has been since 2001. Even though Trusts are required only to collect data on one type of orthopaedic procedure for a 3 month period, BHNFT has elected to undertake consistent surveillance of hip, knee and hip hemi-arthroplasty wound infection. The percentage of wound infections for all periods of collection are as follows: Knees 1.0% infection Hip replacement 0.9% Repair of neck of femur 0.4%. We are above national average for both Hip and Knee replacement category. A surgical site infection group has been set up and there is ongoing action plan with a number of initiatives already introduced e.g. pre and peri-operative warming. Last two quarters have seen decline in infection rate.

Post discharge surveillance continues for patients undergoing hip and knee replacement and hemi arthroplasty surgery.

Chart 13:

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Chart 14:

Chart 15:

Breast Surgery Surveillance

Breast Surgery surveillance was conducted during January – March 2014, data has been submitted to the national surveillance scheme awaiting results.

Large Bowel Surgery surveillance

Large bowel surgical site surveillance was completed for the period October – December 2013 which included post discharge surveillance. 5 wound infections were identified during this period out of 31 operations giving a percentage of 16.1%, against a national target of 10.0%. Additionally 1 patient reported case was identified through the post discharge questionnaire. More detailed results of this surveillance are shown in appendix 3.

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Chart 16:

All clinicians have been made aware notes have been reviewed by the IPCT and the colorectal nurse specialist and no obvious links found. Staff practise post operatively has been observed and staff have been re trained on ANTT. The CSU has considered the results and is aware. A number of the patients were predisposed to infection by the nature of the urgent surgery required and presenting co-morbidities.

Caesarean Section Surveillance

Caesarean section wound surveillance (including post discharge surveillance) was carried out during April – June 2013. 21 Surgical Site Infections were reported giving a percentage of 16%. All of the 21 infections were classed as superficial infections. This is an increase of 2% from the previous surveillance completed in 2012.

Table 10: The number of section operations and infections in 2010 to 2013

April – June 2010 April – June 2011 April – June 2012 April – June 2013 No. of operations 128 139 140 134 No. of SSI 13 22 20 21 % Operations infection 10% 16% 14% 16%

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Chart 17: Demonstrates Number of Caesarean Section Wound Infections

Caesarean Section Surgical Site Surveillance 18 16 16 14 14 13 13 12 10 8 8 6 4 4 4 4 3 2 1 1 0 0 0 0 0 During Admission Patient Reported Other Post Discharge March - June 2008 April - June 2010 April - June 2011 April - June 2012 April - June 2013

All clinicians are aware and the issue has been discussed at local CSU meetings. An action plan has been agreed and is in progress. The key changes will be the use of chlora prep for skin prep prior to section, Hibiscrub for three days prior to surgery for elective cases, the use of the convatec dressing for large BMI cases and patient information leaflets on wound care. The surveillance will be repeated.

Alert organism and alert conditions surveillance

Chart 18 gives the number of alert organisms identified in the laboratory. Alert organisms are those organisms that have infection control implications.

Chart 18:

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Clusters/Outbreaks

Table 11: Details of BHNFT clusters / outbreaks

Date of Ward No. of No. of No. of staff Disease Organism Cluster/ days closed patients affected Isolated Outbreak affected 26.4.13 19 2 14 5 gastroenteritis Non identified

11.4.13 28 0 11 0 gastroenteritis Non identified

Also in addition to the above clusters a further 2 wards were reviewed by the Infection Prevention and Control Team following alerts by the ward staff to an increased number of patients with symptoms. Review of 1 ward identified use of laxatives as the probable cause. The second ward reviewed also identified 2 out of the 3 patients being reported as having loose stools were on laxatives.

11.0 Complaints

The team have assisted CSU’s to answer relevant complaints

12.0 Serious incidents

Only one serious incident has been recorded and investigated one incident remains under investigation.

13.0 Patient Assessment

The team continue to support patients with infections, providing ongoing support for healthcare providers, carers, relatives and others. The team aim to visit all patients with alert conditions or alert organisms, providing individual assessments on care management and control of infection as well as providing information to patients and relatives. If the patient is unable to communicate, the team leave a compliment slip advising of the visit and our availability to relatives. Additionally the team conduct daily Clostridium difficile ward rounds visiting patients with CDAD evaluating and monitoring their progress. The microbiology consultants conduct significant micro-organism isolate ward rounds in addition to daily visits to ITU.

The Control of Infection relies on the prompt identification and management of infectious patients. Therefore the response times of the Infection Control Team are a vital element in the process to controlling risks associated with the transmission of human pathogens. The IPCT have set the following 2 target indicators against which they are performance managed

Indicator 1 - Percentage of verbal advice within 30 minutes on notification of alert organism and alert conditions. (Target 99% of in patients)

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Indicator 2 – Percentage of visits to the area within 2 working days. (Target 98% of inpatients) Summary of the results:

Indicator 1- 2970 in patient episodes of alert organism have been notified by the Infection Control team to clinical staff and verbal advice has been given. In 99.5 % of cases this was achieved within 30 minutes.

Indicator 2- 1182 initial visits have been conducted, 100% of which were done within 2 working days. The full report can be seen in appendix 4.

The team have strong working relationships with the bed management team including formal weekly meetings. Daily cubicle use continues to be monitored by the bed management and Infection Prevention and Control teams.

14.0 Educational Initiatives

The ongoing education of all staff remains a high priority for the team however; problems releasing staff continue to be experienced. The team have been actively involved in updating the corporate curriculum. E learning is available for both non clinical and clinical staff the non clinical E learning pack has been reviewed and update.

A blood borne virus study day is provided five times a year with a site specific 2½ hour update run frequently throughout the year.

The team participate in the induction programmes for new medical staff and have achieved 100% compliance with the provision of this service. The microbiologists continue to undertake targeted education of medical staff. Two mandatory consultants update have been conducted and a targeted anaesthetic team session.

The team participate in the mandatory training & induction programmes for all other staff and have achieved 100% compliance with provision of this service.

ANTT and mask fit testing training continues

Training on how to implement the MRSA decolonisation PGD has been delivered.

The team have continued to train the clean your hands champions who in turn monitor and check the hand washing technique at clinical level.

A training package has been developed for external contractors providing basic infection prevention and control advice with several sessions having been conducted and well attended.

A DVD has been introduced for the training related to urinary catheter insertion and maintenance.

Antibiotic stewardship awareness has been added to the IV additive training

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Training records can be seen in appendix 5.

14.1 Professional Development of the Infection Control Nurses

All the Infection Prevention and Control Nurses are required to provide evidence of continuing professional development as part of the requirements of the Nursing and Midwifery Council to maintain their nursing registration. Above this basic requirement there is on-going academic study and attendance at regional and national conferences to enable the nurses not only to develop professionally but also to ensure that they are able to provide the most up-to-date advice to prevent and control infection.

In the last 12 months, one Infection Control Nurse attended the National Infection Control Nurses Annual Conference and the team have attended various training days to update their knowledge. The team has continued to support and attend various committees e.g. Health & Safety, Medical Devices, COSHH and Waste, Procedures group, Advancing Nursing Practise and Senior Nurses Forum, Drugs and Therapeutics Committee, Hotel Services Forum, CQC leads, Decontamination, Legionella, Sharps Prevention, QSIEB

Additionally the team lead and chair the Infection Control Forum, the Sharps Prevention group, the urinary catheter CQUIN and the Clean Your Hands Champion meeting.

The Consultants continue to undertake CPD requirements and have attended professional study days.

15.0 Research

The team continues to evaluate current research and apply appropriately to practise.

16.0 Health Promotion (PPI/Special Projects)

The Infection Prevention & Control Team recognise the importance of working with the public to reduce healthcare associated infections and have encouraged the public to see this as a partnership. The team have promoted the principles of infection control to the general public by:

• Items in the local press. • Sharps prevention week • Infection Control week • Updated and new patient information leaflets including MRSA & your baby Group A streptococcus • Maintenance of a public display board next to the coffee shop with season related infection prevention health promotion advice e.g. preventing food poisoning, managing flu coughs colds diarrhoea etc.

The team continue to lead the sharps prevention strategy actively promoting the safe use and disposal of sharps. With the introduction of new legislation in May 2013 and subsequent Health and Safety legislation in relation to the use and management of

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sharps, a number of safety devices have been trialled and implemented. A sharps awareness week was held in April 2013.

In November the team held Infection Prevention & Control week when a number of activities to raise awareness took place including poster displays, the Bug Herald was updated and reissued, educational stands were displayed in the dining room, education centre and outpatients with staff from disciplines other than nursing e.g. Healthcare initial were available at the stands for advice. Infection Prevention and Control advice leaflets were also distributed to patients attending Outpatients, Medical Imaging and the Emergency Department.

17.0 Capital Schemes/Estates/Equipment.

The Infection Prevention & Control Team’s advice must be sought by the Trust for all service development activity including capital/building schemes, equipment procurement and contracting for services, which have implications for infection control. The Assistant DIPC and the Head of Estates (operational) have regular meetings to assist with communication and involvement. Over the last year involvement has included the Women’s and Children’s scheme, floor replacements main reception and general areas, Clinical decisions unit and new resus area, upgrades to physiotherapy, ward kitchen refurbishment, medical imagining/new MRI scanner, theatre refurbishment and theatre SSD lift links, the discharge unit, pharmacy robotics project redecoration of the restaurant, demolition of the residence blocks and Endoscopy decontamination relocation.

Additionally the IPCT have been extensively involved in the tenders, evaluation process and mobilisation of the new domestic cleaning contract. Ongoing monitoring continues with new methods of cleaning being evaluated.

A detailed risk assessment and evaluation of risk from pseudomonas in water resulted in some taps being replaced and the use of hand washing sinks being restricted. Ongoing monitoring continues and filters fitted as required to mitigate and control risk when pseudomonas is isolated.

The team have been involved in assessing the suitability of new infusion pumps and mattresses.

18.0 External Inspections

No hygiene code inspections have taken place this year however an internal audit was completed on the infection control service with some recommendations which have been actioned. An external verification of the data has also confirmed the accuracy of our statistics. The CCG commissioned an audit of the clostridium difficile investigations which agreed with the trusts outcome decisions that the cases were all unavoidable

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19.0 National & Regional Work

The team continues to forge national links and has represented the Trust at other regional meetings

20.0 OBJECTIVES FOR 2014/15

In addition to the core activities these are the specific objectives to be addressed in the year 14/15. The objectives listed below are a summary and more detailed breakdown has been issued separately.

Policies and Procedures

Policies and infection control procedures/guidelines will be reviewed. Introduce new guidance on CPE.

Audit of Policies and Procedures

Hand Washing Observational Audit The clinical environment and equipment. Use and management of sharps containers. Compliance with MRSA decolonisation and screening. Care of clostridium difficile patients including monitoring clinical care. Compliance with the correct use of cannula and maintenance of correct records. Antibiotic stewardship and management. Use of IV trays for the management of IV drugs and cannulations. Pre-operative application of Hibiscrub for MSSA positive patients under going hip or knee replacement. Cleaning of commodes. Patients being offered hand washing facilities before food and after toileting.

Education

Review training content & conduct sessions to comply with corporate curriculum Respond to adhoc training as required Focus on training for aseptic technique /ANTT Educate the patients and general public providing up to date and relevant information Develop new certificated course in infection control for HCA & Band 2’s. Raise awareness of CPE.

Projects

Clean your Hands campaign. Continue to develop information for the patients and the public. Improve and maintain the saving lives programme integrating in to practise new saving lives procedures. Promote Annual Infection Control week. Promote Annual Sharps Control week. Continue with MRSA decolonisation awareness programme.

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Targeted Theatre Infection Prevention and Control Focus. Clostridium Difficile target reduction intervention programme. Participate in the integration of the new domestic contract.

Surveillance

The routine surveillance of alert organisms, alert conditions, antibiotic resistance patterns and monitoring of all positive isolates will continue. MSSA Bacteraemia surveillance will be continued and RCA of all hospital acquired cases will be undertaken. MRSA bacteraemia surveillance will continue with root cause analysis of all cases. GRE surveillance continues. Surveillance of other resistant organisms e.g. ESBL’s. Targeted surveillance of hips knees and neck of femur repair will continue, including post charge discharge surveillance. Conduct 3 month surveillance of Caesarean section infections including post discharge surveillance. Conduct 3 months surveillance of Large Bowel surgery infections including post discharge surveillance. Continue surveillance of E Coli bacteraemia and undertake RCA.

Conduct 3 months Breast Surgery wound surveillance, including post discharge surveillance.

Clostridium difficile report monitoring continues and the root cause analysis will continue to be completed on all Clostridium difficile cases, including action during a period of increased incidence or same ribotype. Conduct focused surveillance on CPE.

Environment

Participate in new development and capital schemes. Participate in the monitoring of the cleaning contract. Upgrade treatment rooms to new drugs suites in line with the estates strategy.

All equipment and environment will be thoroughly decontaminated and cleanliness maintained to the highest level in all clinical areas according to infection prevention and control policies and procedures. On discharge of all patients thorough terminal cleaning of the room will be completed.

Other

The Infection Prevention and Control Team will be aware of and incorporate additional activity as required to meet local and national requirements as resource will allow.

Performance Management

Ensure compliance with infection control programme and hygiene code at CBU level

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Committee Structures Lines of Communication and Accountability Appendix 1

CCG & Public Health England BHNFT Board of Directors

Clinical Non-Clinical Governance Governance Committee

Public Health & CCG Post Infection Review Group

Main Alert Joint SWYPFT/BHNFT Infection Prevention & Review Committee Organism Control Committee Investigation

Decontamination BHNFT Infection Group Control Operational

CSU’s & Departments

Appendix 2

Surgical Site Infection Surveillance Appendix 3

KNEE REPLACEMENT SURVEILLANCE 2013 and Previous periods

BHNFT All Hospitals Last Period Last 4 periods Last 5 Years October – December 2013 January – December 2013 No. No. % No. No. % No. No. % Risk Index Operations SSI’s Infected Operations SSI’s Infected Operations SSI’s Infected 0 62 1 1.6% 241 2 0.8% 166423 678 0.4% 1 28 0 0.0% 97 2 2.1% 50454 452 0.9% 2 3 0 0.0% 16 0 0.0% 4934 90 1.8% 3 0 0 0.0% 0 0 0.0% 17 1 5.9% Unknown 3 0 0.0% 30 0 0.0% 11277 65 0.6% Total 96 1 1.0% 384 4 1.0% 233105 1286 0.6%

REPAIR NECK OF FEMUR SURVEILLANCE 2013 and Previous periods

BHNFT All Hospitals Last Period Last 4 periods Last 5 Years October – December 2013 January – December 2013 No. No. % No. No. % No. No. % Risk Index Operations SSI’s Infected Operations SSI’s Infected Operations SSI’s Infected 0 13 0 0.0% 45 0 0.0% 19959 214 1.1% 1 31 0 0.0% 111 0 0.0% 45015 663 1.5% 2 8 0 0.0% 42 0 0.0% 8708 232 2.7% 3 0 0 0.0% 0 0 0.0% 19 0 0.0% Unknown 12 0 0.0% 63 1 1.6% 8587 114 1.3% Total 64 0 0.0% 261 1 0.4% 82288 1223 1.5%

TOTAL HIP REPLACEMENT SURVEILLANCE 2013 and Previous periods

BHNFT All Hospitals Last Period Last 4 periods Last 5 Years October – December 2013 January – December 2013 No. No. % No. No. % No. No. % Risk Index Operations SSI’s Infected Operations SSI’s Infected Operations SSI’s Infected 0 31 0 0.0% 117 2 1.7% 154468 652 0.4% 1 19 0 0.0% 75 0 0.0% 51105 515 1.0% 2 5 0 0.0% 16 0 0.0% 7716 163 2.1% 3 0 0 0.0% 0 0 0.0% 44 1 2.3% Unknown 7 0 0.0% 25 0 0.0% 11578 74 0.6% Total 62 0 0.0% 233 2 0.9% 224911 1405 0.6%

LARGE BOWEL SURGERY 2013 and Previous periods

BHNFT All Hospitals Last Period Last 4 periods Last 5 Years October – December 2013 January – December 2013 No. No. % No. No. % No. No. % Risk Index Operations SSI’s Infected Operations SSI’s Infected Operations SSI’s Infected 0 8 0 0.0% 41 2 4.9% 5201 336 6.5% 1 10 2 20.0% 58 8 13.8% 7811 803 10.3% 2 9 1 11.1% 32 2 6.3% 3234 456 14.1% 3 0 0 0.0% 2 0 0.0% 414 90 21.7% Unknown 4 2 50.0% 18 5 27.8% 1564 144 9.2% Total 31 5 16.1% 151 17 11.3% 18224 1829 10.0%

Risk Index Definition

A Risk Index comprising data obtained from three factors – ASA score, wound classification and duration of operation – is used to assign a risk score between 0 and 3 to each operation. Operations with a risk index score of 3 have a higher risk of developing SSI than those with a score of 0. This score is used to stratify operations and enable rates of SSI to be adjusted by these risk factors.

Performance Indicators Appendix 4

PERFORMANCE INDICATOR 1 – 99.5% Total number of referrals seen/not seen by the Infection Prevention & Control

Breakdown of Total No. of referrals seen by Infection Control at BHNFT (Please note the table relates to original referral criteria not necessarily confirmed cases)

Number of Total Within 48 Total Exceeding 48 Percentage Month Assessments Hrs Hrs Compliant April 246 244 2 99.2% May 225 222 3 98.7% June 243 241 2 99.2% July 271 271 0 100.0% August 218 217 1 99.5% September 252 252 0 100.0% October 249 249 0 100.0% November 227 226 1 99.6% December 304 304 0 100.0% January 272 270 2 99.3% February 220 216 4 98.2% March 243 242 1 99.6% Total 2970 2954 16 99.5%

PERFORMANCE INDICATOR 2 Total number of referrals seen/not seen within 2 working days of notification by the Infection Prevention & Control

Number of Total Within 48 Total Exceeding 48 Percentage Month Assessments Hrs Hrs Compliant April 107 107 0 100.0% May 87 87 0 100.0% June 99 99 0 100.0% July 110 110 0 100.0% August 93 93 0 100.0% September 114 114 0 100.0% October 98 98 0 100.0% November 99 99 0 100.0% December 111 111 0 100.0% January 90 90 0 100.0% February 75 75 0 100.0% March 99 99 0 100.0% Total 1182 1182 0 100.0%

100.0% Overall for the financial year April 2013 – March 2014

PERFORMANCE INDICATOR 2 Type of Patient Alert Organism Seen

Infection: BHNFT April 13 – March 14

MRSA 761 Clostridium Difficile Toxin 28 Other 393

Total 1182

Additional Patient reviews

Type of review April 2013 – March 2014

Clostridium Difficile Ward Round 24 Diarrhoea Ward Round 289 Total 313

Training data – 01.04.2013 – 31.03.2014

Type of session Number of No of attendees

sessions

Mandatory Clinical 81 886 Mandatory – Non Clinical 43 156 Corporate Induction 44 306 Train The Trainer 10 26 Hand Hygiene By Champions 34 227 ANTT 30 146 HIV Awareness Day 3 24 HIV Awareness Update 4 19 Student Medical Induction 15 184 Doctors Induction 1 25 Contractors Induction 8 15 Clostridium difficile Training 6 29 MRSA Decolonisation 11 95 PGD Training 1 5

REPORT TO THE BOARD OF REF: BARNSLEY HOSPITAL NHSFT 14/08/P-10

SUBJECT: HOSPITAL AT NIGHT

DATE: AUGUST 2014

Tick as Tick as applicable applicable

For decision/approval Assurance  PURPOSE: For review Governance For information  Strategy PREPARED BY: Alison Bielby, Deputy Director of Nursing SPONSORED BY: Heather McNair, Director of Nursing and Quality PRESENTED BY: Alison Bielby, Deputy Director of Nursing and Quality STRATEGIC CONTEXT 2-3 sentences

Supporting the Trust’s aim of high quality care and patient safety.

QUESTION(S) ADDRESSED IN THIS REPORT

Has the project been implemented effectively?

CONCLUSION AND RECOMMENDATION(S)

Hospital at Night has been live since April 2014 and will be audited six months post project implementation to assess impact on patient safety and benefits realisation.

BoD August 2014: 10_1_Hospital at Night

REFERENCE/CHECKLIST • Which business plan objective(s) does this report Aim 1: Patients will experience safer care relate to? Patients BCCG Other

• Please state: Has this report considered the Staff BMBC following stakeholders? Governors Monitor

Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution etc) • Has this report reviewed the Trust’s compliance with: Equality, Diversity & Human Rights

The Trust's sustainability strategy

Yes CGC

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: Providing the best healthcare for all”

BoD August 2014: 10_1_Hospital at Night

Subject: Hospital At Night Ref: 14/08/P-10

1. STRATEGIC CONTEXT

1.1 This paper will summarise the work to date that has been undertaken to ensure that Hospital at Night (H@N) was safely implemented into the organisation in a way that ensures that patients receive optimal care over the night time period.

2. INTRODUCTION

2.1 The concept of H@N was introduced in pilot sites in England in 2003 to ensure compliance with European Working Time Directive (EWTD) legislation which then required doctors to work no more than 56 hours per week by August 2004. In 2009 further legislation around EWTD came into force which stated that doctors should work no more than 48 hours per week, averaged over a 6 month period. This has posed a challenge to workforce planning for trusts to provide safe and adequate healthcare.

2.2 The focus and aim of H@N is the development of competency based multidisciplinary teams to provide cover across medical and surgical specialties on the basis of being competent to provide the right care, to the right patient at the right time by the right person, rather than by virtue of belonging to a particular profession or specialty.

2.3 The H@N model has been implemented into around 85% of trusts with varying success dependent upon the capital and revenue investment, therefore Barnsley Hospital NHS Foundation Trust (BHNFT) was a late adopter of the concept.

3. DELIVERY AND IMPLEMENTATION OF HOSPITAL AT NIGHT

3.1 Hospital at night was implemented into BHNFT as part of the Transformation programme and was supported by a project manager. It was delivered in two phases: • Phase I - Acute Medical Unit (AMU) 12/7 Project - Extension of the provision of a consultant delivered service 12 hours a day 7 days a week 8am – 8pm. • Phase II - Hospital at Night Project - Transform the AMU, General Medical, General Surgery and Trauma & Orthopaedic mobile Medical and Nursing provision out of hours with the establishment of a Hospital at Night Team (H@N Team) that will provide quality care and ensure the safety of patients out of hours, 7 days a week, 8pm - 9am.

3.2 The H@N team structure was agreed and consists of Medical Staff, Nursing staff (including Advanced Nurse Practitioners) and Health Care Support Workers - see appendix 1. Following the movement and recruitment of staff the team went live on the 19 May 2014. At this point the full team had not been recruited therefore an interim team was implemented until full recruitment. The team is managed under Critical Care Outreach in CBU 2.

3.3 The Trust has recruited extra trainee ANP’s in order to ensure that there are enough for the rota. This has been supported through income from Health Education England and a bespoke course has been developed in conjunction with Sheffield Hallam University.

3.4 The team manages the clinical aspects of care over night, working closely with the night Hospital Bed Managers who focus on patient flow.

BoD August 2014: 10_1_Hospital at Night Page 1

The team aims to deliver: • An improved response time in which patients are seen and treated during the night, 7 days a week, 20:30 – 07:30 • An integrated approach to the clinical work as they are delivering it from a H@N Hub to which ensures good communication • Robust handover and escalation processes through the use of a set of Standard Operating Procedures. • Better prioritisation of work through the implementation of bleep filtering system through the H@N Coordinator. • Improved quality of patient care during the night-time out of hours period 7 days a week, 20:30 – 07:30 • Improved productivity and safety throughout the night time out of hours period 7 days a week, 20:30 – 07:30

4. SUMMARY

4.1 The implementation of Hospital at Night was undertaken using a project management approach; however going forward the team will managed by CBU 2 through their normal performance and governance structures. There are a number of safety metrics which the team are being audited against that will indicate return on investment and the impact on patient safety.

4.2 The full project report is available on request.

Appendices:

• Appendix 1 – Team structure

BoD August 2014:10_1_Hospital at Night Page 2_

Appendix 1

Exec on Call

nd 2 on call – Clinical Services Manager

New Post st 1 on call – H@N Coordinator

Existing post

1 x 1 x Cons 1 x Cons 1 x Cons ANP/H@N Med T&O G. Surg On-call On-call Coordinator On-call Band 7 - TBC * * *

1 x Reg 2 x nurses 1 x Reg 1 x Reg T&O Band 6 - Med G. Surg On-call TBC Res On-call Bed Manager *2 *

1 x HCA 3 x SHO Resident 1 x SHO 1 x SHO Band 3 - 2 x AMU T&O G. Surg

TBC + 1 x wards Resident Resident To be reviewed by * * the Corporate Matron

1 x Patient Flow/Bed Administrator Band 3 - TBC

H@N Coordinator role Work request from 1 x ANP/H@N Coordinator Acceptance of requests

Wards Band 7 - TBC Coordination of work to

H@N Team

Proposed Model – Phase II - H@N – To be agreed by the Chief Nurse

REPORT TO THE BOARD OF REF: BARNSLEY HOSPITAL NHSFT 14/08/P-11a

SUBJECT: MORTALITY RATIOS

DATE: AUGUST 2014

Tick as Tick as applicable applicable

For decision/approval Assurance PURPOSE: For review Governance For information √ Strategy PREPARED BY: Dr Jugnu Mahajan, Medical Director SPONSORED BY: Dr Jugnu Mahajan, Medical Director PRESENTED BY: Dr Jugnu Mahajan, Medical Director STRATEGIC CONTEXT 2-3 sentences

Meets the requirement to provide high quality and safe services: Strategic Objective 1c.

QUESTION(S) ADDRESSED IN THIS REPORT

1. Does the report provide an update on mortality figures for both Hospital Standardised Mortality Ratio (HSMR) and Summarised Hospital Mortality Indicator (SHMI)? 2. Does this report provide an action plan to reduce HSMR to 105 by end of the calendar year, 2014? 3. Does this report give an update on Sepsis and National Early Warning Scores (NEWS) audits?

CONCLUSION AND RECOMMENDATION(S) • 12 month rolling HSMR is 112 for February 2014 and 109.7 for the end of March 2014. This shows a significant reduction in the value of HSMR. • SHMI (pre-released) for January – December 2013 is 108 and remains in the ‘as expected’ band • Crude Mortality rates continue to fall since May 2013 with May 2014 figure being the lowest since May 2013 with May 2014 figure being the lowest since seven years on the Statistical Process Control (SPC) chart

Recommendations The Board is asked to receive the report and approve the action plan as in paper 11b.

The Board is asked to receive the report on Sepsis and update on NEWS audit as in paper 11c.

REFERENCE/CHECKLIST • Which business plan Meets the requirement to provide high quality and safe objective(s) does this report services: Strategic Objective 1c. relate to? Patients BCCG Other

• Please state: Has this report considered the Staff BMBC following stakeholders? Governors Monitor

Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution etc) • Has this report reviewed the Trust’s compliance with: Equality, Diversity & Human Rights

The Trust's sustainability strategy

Yes CGC

• Where applicable, briefly High mortality is a patient safety indicator and a risk to patient safety. High identify risk issues (including mortality may adversely affect the Trusts’ reputation. any reputation) and cross reference to risk register and governance committees • Where applicable, state Finance: resource requirements: Other:

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: Providing the best healthcare for all”

Subject: Mortality Ratios Ref: 14/08/P/11a

1 STRATEGIC CONTEXT This report covers performance on mortality ratios and action plans, which relate to Strategic Objective 1c: Patients will experience safe care.

2 INTRODUCTION 2.1 This report provides the latest available mortality figures and an update on the mortality action plan.

2.2 The mortality figures presented included • Summary Hospital Mortality Indicator values (SHMI) for January 2013 – December 2013 as pre-released by the Health and Social Care Information Centre • the current Hospital Standardised Mortality Ratio (HSMR) position including the latest month’s data for February 2014 (12 months rolling figure). HSMR data for March 2014 is not available as there has been delay in the production of Hospital Episode Statistics (HES) data, nationally. • additional information to support outstanding changes in the rolling 12 month figure, and to ensure transparency of when any individual month has a high HSMR, the monthly figures will be routinely included. • a summary of the action plan to date

3 SUMMARY HOSPITAL MORTALITY INDICATOR

3.1 Latest 12 Month Value is from January 2013 – December 2013 (pre-released)

3.2 The Trust’s SHMI position for January 2013 to December 2013 is 107.9 (89 – 113). BHNFT remains in the band two ‘as expected’ group.

3.3 BHNFT's national position for January 2013 – December 2013 will be published in August 2014.

4 HOSPITAL STANDARDISED MORTALITY RATIO 4.1 Latest Rolling 12 Month, March 2013 – March 2014, Yorkshire and Humber Non Specialist Trusts is presented. The 12 Month rolling HSMR up to the month of February 2014 is 112; a slight increase from January’s value however the 12 Month rolling HSMR for March 2014 is 109.7. Therefore the HSMR for 12 months for the financial year 2013/14 closes at a value of 109.7. This value is expected to see a continued reduction in the present financial year.

BoD August 2014: Mortality Ratios Page 1

4.2 This table shows the latest rolling 12 Months HSMR.

4.3 On the funnel plot BHNFT sit between the 95% and 99.8% control limit. Therefore we shouldn’t be identified as an outlier in Dr Foster Hospital Guide 2014.

BoD August 2014: Mortality Ratios Page 2

5 CRUDE MORTALITY RATES FOR BARNSLEY HOSPITAL NHSFT 5.1 Crude Mortality Rates (latest month June 2014)

No. of Crude Mortality Rate Financial Year No. of Deaths Discharges* per 1000 Discharges* 2007/08 1052 37651 27.9 2008/09 1062 40028 26.5 2009/10 1072 42583 25.2 2010/11 1051 40914 25.7 2011/12 1012 42023 24.1 2012/13 1034 42588 24.3 2013/14 1021 42551 24.0 2014/15 YTD 203 10613 19.1 * excludes Day cases unless a death

5.2 Statistical Process Control (SPC) Chart, Crude Mortality Rate, BHNFT

Crude Mortality Rate per 1000 Discharges* Mean Lower Control Limit Upper Control Limit 45 40 35 30 25 20 15 10 Jun-07 Jun-08 Jun-09 Jun-10 Jun-11 Jun-12 Jun-13 Jun-14 Oct-07 Oct-08 Oct-09 Oct-10 Oct-11 Oct-12 Oct-13 Apr-08 Apr-09 Apr-10 Apr-11 Apr-12 Apr-13 Apr-14 Feb-08 Feb-09 Feb-10 Feb-11 Feb-12 Feb-13 Feb-14 Dec-07 Dec-08 Dec-09 Dec-10 Dec-11 Dec-12 Dec-13 Aug-07 Aug-08 Aug-09 Aug-10 Aug-11 Aug-12 Aug-13

5.3 The table and the SPC chart, above shows the trends in Crude Mortality in the Trust. Since the peak in mortality in April 2013, Crude Mortality rates have been on or below the mean. Crude mortality for May 2014 is the lowest seen on this 7 year SPC chart. This low rate has continued in June.

6. PALLIATIVE CARE CODING 6.1 These charts show the variation in the prevalence of Palliative Care and Co-Morbidity coding in the HSMR Group. It is clear that Rotherham and Hull Hospitals are delivering and coding more Palliative Care than other Yorkshire and Humber Hospitals. Variation is also seen in comorbidity coding.

% of HSMR Admissions with a Palliative Care Code Highest 3 and Lowest 3 Yorks & Humber Non Specialist Trusts 4.5% 4.0% 3.5% 3.0% Rotherham NHS FT 2.5% Hull & East Yorks NHS Trust 2.0% 1.5% Barnsley NHS FT 1.0% York Teaching NHS FT 0.5% Sheffield Teaching NHS FT 0.0% Bradford Teaching NHS FT

2011/12 Q1 2011/12 Q2 2011/12 Q3 2011/12 Q4 2012/13 Q1 2012/13 Q2 2012/13 Q3 2012/13 Q4 2013/14 Q1 2013/14 Q2 2013/14 Q3

BoD August 2014: Mortality Ratios Page 3

HSMR Admissions, Average Comorbidities per Admission Highest 3 and Lowest 3 Yorks & Humber Non Specialist Trusts 7.0 6.5 6.0 Airedale NHS FT 5.5 5.0 Hull & East Yorks NHS Trust 4.5 North Lincs & Goole NHS FT 4.0 Barnsley NHS FT 3.5 Bradford Teaching NHS FT 3.0 Sheffield Teaching NHS FT

2011/12 Q1 2011/12 Q2 2011/12 Q3 2011/12 Q4 2012/13 Q1 2012/13 Q2 2012/13 Q3 2012/13 Q4 2013/14 Q1 2013/14 Q2 2013/14 Q3

7 MORTALITY REVIEWS: INDEPENDENT REVIEW OF DEATHS IN APRIL 2013 AND AQuA

7.1 A combined action plan for both the reports (AQuA & Fletcher) has been developed as part of the overall mortality action plan. A detailed report and action plan can be found in paper 11b.

8 SEPSIS AND NEWS AUDIT

8.1 Mr Julian Newell, Corporate Matron has completed a full audit on Sepsis and NEWS. The findings of these audits are documented in paper 11c.

BoD August 2014: Mortality Ratios Page 4

REPORT TO THE BOARD OF REF: BARNSLEY HOSPITAL NHSFT 14/08/P-11b

SUBJECT: MORTALITY ACTION PLAN

DATE: AUGUST 2014

Tick as Tick as applicable applicable

For decision/approval √ Assurance √ PURPOSE: For review Governance √ For information Strategy Jugnu Mahajan, Medical Director/Gill Feerick, Head of Quality & PREPARED BY: Clinical Governance SPONSORED BY: Jugnu Mahajan, Medical Director PRESENTED BY: Jugnu Mahajan, Medical Director STRATEGIC CONTEXT 2-3 sentences

The Advancing Quality Alliance (AQuA) review was undertaken as part of a formal Mortality Review agreement between the Trust and AQuA, together with discussions with the CCG. The review provided the findings and recommendations based upon AQuA’s mortality review of Barnsley Hospital NHS Foundation Trust and in wider discussions with Barnsley Clinical Commissioning Group.

QUESTION(S) ADDRESSED IN THIS REPORT

Does the Mortality Action Plan address the findings and recommendations of the AquA Mortality review and the independent Review of Deaths in April 2013 by Dr Alan Fletcher?

CONCLUSION AND RECOMMENDATION(S)

The Board is asked to:

1) approve Mortality Action Plan, which addresses the findings and recommendations of both reviews 2) approve monitoring of the Mortality action plan via the Mortality Steering Group and exceptions reported to the Quality and Governance Committee.

BoD 2014: 11b_ Mortality Action Plan

REFERENCE/CHECKLIST • Which business plan objective(s) does this report Aim 1: Patients will experience safe care relate to? Patients BCCG Other

• Please state: Has this report considered the Staff BMBC following stakeholders? Governors Monitor

Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution etc) • Has this report reviewed the Trust’s compliance with: Equality, Diversity & Human Rights

The Trust's sustainability strategy

• Has this report Quality & Governance (in draft or during Yes • Is this report development) been Audit Committee supported by a reviewed and Not applicable communications supported by any Finance & Performance plan? Board or Executive To be developed committee within the ET Trust? • Where applicable, briefly Failure to reduce HSMR and SHMI value identify risk issues (including any reputation) and cross reference to risk register and governance committees • Where applicable, state Finance: resource requirements: Other:

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: Providing the best healthcare for all”

BoD 2014: 11b_ Mortality Action Plan Subject: Mortality Action Plan Ref: 14/08/P-11b

1. STRATEGIC CONTEXT

1.1 The AQuA review was undertaken as part of a formal Mortality Review agreement between the Trust and AQuA, together with discussions with the CCG. The review provided the findings and recommendations based upon AQuA’s mortality review of Barnsley Hospital NHS Foundation Trust and in wider discussions with Barnsley Clinical Commissioning Group.

1.2 The purpose of the Review was to explore the possible contributing factors for the Trust’s perceived higher mortality rates as described by Standardised Mortality rates and to support the development of an action plan to address any identified issues.

1.3 The final report was received by the Trust in June 2014 following consultation on the draft report, which was issued earlier in May 2014. The Executive summary and recommendations of the final report are to be communicated with all staff under the direction of the Medical Director and the Director of Communications following approval of the attached action by the Board of Directors.

2. INTRODUCTION

2.1 A workshop was held on 13 June 2014 to review the recommendations of both the AQuA Mortality Review report and the report following the independent review of deaths by Dr Alan Fletcher. The workshop identified key actions for the Trust to implement in response to all recommendations made. A Trust-wide action has been developed (Appendix 1), which will be continuously monitored by the Mortality Steering Group and exceptions escalated accordingly to the Quality & Governance Committee.

2.2 In total there were 43 recommendations made within the AQuA report and five within the independent review of deaths by Dr Alan Fletcher.

2.3 The AQuA report and the recommendations were structured around AQuA’s Mortality Driver Diagram primary drivers (diagram 1). These are: • Clinical Care • Reliable Care Systems • Leadership • Documentation • End of Life Care

Appendices: Appendix 1 – Mortality Action Plan

Diagram 1: AQuA’s Mortality Driver Diagram primary drivers

Appendix 1 Draft Mortality Action Plan August 2014

Recommendations How this will be What the What evidence Who will lead Timescales Where this will RAG from AQuA achieved expected will support this this this will be be reported/ Rating Mortality Review outcome will achieved monitored: i.e be within Committee/ Group

COMPARATIVE ANALYSIS

1. Review all Review of all in-hospital To facilitate Monthly Trust Medical Director End July Monitored through comparative deaths with dissemination trust-wide, CBU wide mortality supported by 2014 and on- the Mortality analysis and of trust-wide and and speciality lessons learnt Associate Medical going. Steering Group consider the Consultant specific analysis and bulletins. Director & and CBU need for a themes and trends action plans in Corporate Matron Performance greater level of identified. the reduction of Monthly – Patient Safety. meetings. ‘drill-down’ e.g. avoidable in- Consultant at specialty or hospital patient specific mortality Clinical ward level. deaths. review feedback. Directors

CBU governance and performance meetings.

In-depth mortality reviews considered by the Mortality Steering Group.

UNDERSTANDING MORTALITY RATE DATA

2. Use internal Review of all in-hospital To facilitate Monthly Trust Medical Director End Monitored through mortality reports deaths with dissemination trust-wide, CBU wide mortality supported by September the Mortality BoD August 2014: 11b_ Mortality Action Plan Page 1

to drive forward of trust-wide and and speciality lessons learnt Associate Medical 2014 Steering Group improvement Consultant specific action plans in bulletins. Director & and CBU action plans at a themes and trends the reduction of Corporate Matron Performance speciality and identified. avoidable in- Monthly – Patient Safety. meetings. care group level. hospital patient Consultant deaths. specific mortality Clinical review feedback. Directors

CBU governance and performance meetings.

In-depth mortality reviews considered by the Mortality Steering Group.

3. Cascade Review of all in-hospital To facilitate Monthly Trust Medical Director End July Monitored through information to all deaths with dissemination trust-wide, CBU wide mortality supported by 2014 and on- the Mortality staff groups in of trust-wide themes and and speciality lessons learnt Associate Medical going. Steering Group. order to improve trends identified. action plans in bulletins. Director & staff the reduction of Corporate Matron engagement avoidable in- – Patient Safety. and hospital patient understanding. deaths and to Clinical engage staff in Directors understanding of the work being undertaken to reduce in- hospital avoidable deaths.

CLINICAL CARE

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4. Review and Review of excess deaths, Understanding Bi-monthly Medical Director Commenced Monitored through disseminate by clinical classification of the top 3 review at the supported by and on-going. the Mortality knowledge system group, by the identified Mortality Associate Medical Steering Group. about excess Mortality Steering Group. causes of death Steering Group Director. deaths by supporting the of top 3 Clinical Trust in conditions with Classification identifying any high mortality System Group. gaps of rates. assurance in 5. Focus current clinical improvement practices. activity on the conditions with the highest number of Observed deaths and those with the highest number of Excess deaths.

6. Share the Review of all in-hospital To facilitate Monthly Trust Medical Director End Monitored through findings and deaths with dissemination trust-wide, CBU wide mortality supported by September the Mortality emergent of trust-wide and and speciality lessons learnt Associate Medical 2014 Steering Group themes from the Consultant specific action plans in bulletins. Director & and CBU peer review of themes and trends the reduction of Corporate Matron Performance patient case- identified. avoidable in- Monthly – Patient Safety. meetings. notes for hospital patient Consultant patients that deaths. specific mortality Clinical have died. review feedback. Directors CBU governance and performance meetings.

In-depth mortality reviews considered by

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the Mortality Steering Group.

7. Ensure regular Review of all in-hospital To facilitate Monthly Trust Medical Director End July Monitored through mortality deaths with dissemination trust-wide, CBU wide mortality supported by 2014 the Mortality reporting is of trust-wide themes and and speciality lessons learnt Associate Medical Steering Group. accompanied trends identified. action plans in bulletins. Director & with a summary the reduction of Corporate Matron of the key avoidable in- – Patient Safety. messages and hospital patient any issues that deaths and to Clinical necessitate engage staff in Directors review/action. understanding of the work being undertaken to reduce in- hospital avoidable deaths.

8. Re-affirm the Re-launch of Care Increased Increased Medical Director End October Monitored through clinical benefits Bundles across the Trust compliance with compliance in supported by 2014 Healthcare record of Care Bundles, with agreed programmes Care Bundles in associated Clinical Directors Audits, Patient with a re-launch of clinical audit to high mortality clinical audits. & Corporate Safety and Quality to actively evidence improved areas. Matron – Patient Group, Mortality engage staff. implementation. Evidence of Safety. Steering Group appropriate and CBU 9. Ensure Care Care Bundle update implementation Performance Bundles exist training to form part of of Care Bundles meetings and are junior doctors training. in mortality implemented for reviews and SI Monitor through high mortality Compliance with RCAs. NEWS and Sepsis SMT:\Board\Templates & Agenda\11b_ Mortality Action Plan Page 4 of 24_

areas. mandatory training to be Six Audits. incorporated into 10. Continually Consultant annual monitor appraisals. compliance with Care Bundles with monthly feedback to all appropriate staff.

11. Review the To form a standing Staff trust-wide Team brief Director of End Monitored by process of agenda item on the CBU are aware of the communication. Marketing and September Executive Team celebrating monthly Governance clinical success Communications 2014 success and Meeting. stories. Confirmation that Annual good news the Director of Communications stories widely To form frequent agenda communication Nursing & Audit – Team brief throughout the items on the CEO’s team process is Quality feedback. Trust e.g. brief and other effective through supported by

reductions in communications as Quality and Head of Quality HCAIs. appropriate. Safety and Clinical Assurance Visits. Governance

RELIABLE CARE SYSTEMS

12. Ensure Implementation of 7-day Continuity in Staffing and Director of End October Monitored through continuity of working. staffing and performance Operations 2014 the Performance staffing and diagnostic data. supported by Framework& CBU diagnostic services at Medical Director Performance services at the weekends. & Clinical meetings. weekend. Directors.

13. Review ED Work with BCCG to Gain an Reduction in Director of End October Monitored through attendance data develop OOH Provision understanding Sunday ED Operations 2014 the Performance to understand utilising ED attendance of the reasons attendances. supported by Framework& CBU more fully the data to improve service for high ED Clinical Director Performance reasons for high delivery across Barnsley attendance CBU1. meetings. attendance rates Health Community. rates on a

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on Sunday. Sunday and to ensure that service provision and access to services are appropriate.

14. Review Develop and enhance in- Reduction in Performance Director of End October Monitored through admission reach services within ED. clinical risk. data Operations 2014 and on- the Performance process and demonstrating supported by going. Framework& CBU criteria in order Reduction in an improvement Clinical Director Performance to ensure that avoidable in- in quality and CBU1. meetings. patients are hospital deaths. performance admitted to the indicators and Reduction in appropriate decrease in Length of Stay ward. HSMR. (LOS).

15. Review the Implementation of 7-day Implementation Audit of Director of End Monitored through frequency, working. of routine consultant led Operations October2014 regular audits and timing and morning ward rounds. CBU Performance structure of Consultant led Medical Director meetings. Consultant ward ward rounds. supported by rounds with a Clinical Directors. view to working towards 24/7 care.

16. Continue to Develop Ambulatory Care Reduction in re- Re-admission Director of End January Monitored through work with local Services through admission performance Operations 2015 the Performance health and collaborative working with rates. data. Framework& CBU social care Barnsley Wide Urgent October 2015 Performance partners in order Care Group. Pilot of Care meetings. to improve the Coordination unscheduled Development of Care Centre care system with Coordination Centre in commencing 1st a benefit of collaboration with BCCG October 2014. reducing re- and SWYPFT. KPIs to be

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admissions. developed as part of pilot and to be evaluated in 12 months time.

17. Work with Partnership working Enhanced Pilot of Care Medical Director End July Monitored through BCCG and the between BCCG & BHNFT integrated Coordination 2015 the Performance community to deliver integrated care. approach to Centre Framework. services care provision. commencing 1st provider in order Development of Care October 2014. to deliver a more Coordination Centre in KPIs to be integrated collaboration with BCCG developed as approach to and SWYPFT. part of pilot and care provision. to be evaluated in 12 months time.

18. Review more Detailed analysis of data Provision of Re-audit of hip Medical Director End Monitored through recent data to at CBU Governance & timely care for operations being supported by November re-audit of hip understand the Performance meetings those patients carried out within Clinical Director 2014 operations being reasons behind with implementation of requiring hip 48 hours of CBU1. carried out within the apparent relevant operations. admission. 48 hours of reduction in hip corrective/improvement admission. operations being actions. carried out Monitored through within 48 hours Patient Safety & of admission Quality Group & CBU Performance meetings.

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19. Work with Partnership working with Pilot of Care Director of End July Monitored through BCCG to better BCCG to undertake a Coordination Operations 2015 the Performance understand detailed review and Centre Framework. patterns of analysis of admissions commencing 1st admissions and and re-admissions data, October 2014.

re-admissions by GP practice. KPIs to be data by GP developed as Practice. Development of Care part of pilot and Coordination Centre in to be evaluated collaboration with BCCG in 12 months and SWYPFT. time.

20. Identify actions Development and Reduction in the Development Director of End Monitored through to reduce the implementation of a number of and Operations September the Performance level of multiple proactive bed- multiple ward implementation 2014 Framework ward moves management process. moves. of a SOP.

Designation of a CBU representative to manage patient flow on a daily basis.

21. Review access Implementation of 7-day Reduction in Performance Director of End October Monitored through to senior clinical working. clinical risk. data Operations 2014 & on- the Performance decision makers demonstrating supported by going Framework& CBU both within the Reduction of an improvement Medical Director Performance trust and for avoidable in- in quality and meetings. GP’s hospital deaths. performance indicators and Reduction in decrease in Length of Stay HSMR. (LOS).

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LEADERSHIP

22. Expedite the Communication of the Trust-wide Corporate and Director of End CBU Governance completion of Quality Strategy Trust- understanding local monitoring Nursing & September meetings the Quality wide. of the quality of achievement Quality 2014. Strategy, which priorities of the of the approved supported by CBU Performance should include Quality Boards to be organisation quality targets. Head of Quality meetings. governance located on all ward and trust-wide and Clinical

expectations at landings. monitoring of Governance Clinical the progression Inclusion of the quality Business Unit towards the Director of goals, priorities and level achievement of Operations targets within the CBU the approved supported by monthly governance quality targets. CDs, HoNs & meetings. General Managers.

23. Review the Develop and Easier Exception Interim End Monitored by the length of papers communicate process for identification reporting Associate September Interim Associate for committees exception reporting and clarification template and Director of 2014 Director of in order to through the committee of the issues guidance Corporate Corporate Affairs. support effective structure. that require Affairs decision-making escalation.

Facilitate clearer and more effective discussion and support appropriate decisions and actions.

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24. Review the Understand the Presentation of Copies of the Director of End Exec Team content of information requirements mortality data relevant reports. Information September (weekly report) dashboards of the Trust and present in: Communications 2014. information/dashboards in Review of Technology CBU performance a manner that is Weekly usability of the supported by meetings meaningful, accurate, and performance information with Interim Head of Trust Board. timely and facilitates report report recipients. Information. challenge. CBU performance reports (monthly)

Trust board reports (monthly)

25. The Board Develop a small task and Enhanced Patient safety Director of HR & End October Monitored through should gain a finish group to explore the safety culture learning events Organisational 2014. performance greater training and development throughout the Development Management of understanding of regarding human factors organisation. Medical Patient Clinical Directors. the human – celebrating success, Safety Medical Director

factors agenda lessons learned, positive Ownership of Champions. supported by implementation Clinical Directors. and determine a learning from ‘near Barnsley misses’, open and honest of patient safety approach to this and ‘no blame’. and quality initiatives. 26. Re-energise the Develop an open and engagement honest culture from top to with the senior bottom and bottom to top medical (across whole workforce organisation).

27. Implement Ensure protected time is protected time considered as part of the for clinicians to Job Planning process for be involved in all Consultants. Quality and Patient Safety

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activities

28. Update the Undertake a gap analysis Coordinated Reviewed, Medical Director Completed Mortality Steering Mortality Action against the approved approach to the updated and supported by and on-going. Group Plan to include Mortality Action Plan and implementation approved action Associate Medical the any recent additional of agreed plan. Director. Patient Safety & recommendation recommendations and actions from all Quality Group. s of this review actions suggested as a internal & Continuous together with an result from external monitoring of updated driver internal/external mortality mortality updated action diagram in order reviews. reviews. plan. to determine the main priorities.

29. Increase clinical Relocate the Clinical Improved and New location of Director of End October Monitored through engagement Coding Department into timely the Clinical Information 2014 the CBU with Clinical the main hospital. engagement Coding Communications Performance Coding in order with the clinical Department. Technology meetings. to improve the staff. supported by ownership of the Head of Clinical data. Improve the Coding. clinician/coder interface.

Obtain the assurance the clinicians and coders are meeting on at least a monthly basis.

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30. Consider Where appropriate Provide input Service Director of On-going Monitored through utilising the engage with the Service and support to Improvement Business Patient Safety and improvement Improvement team in identify change involvement in Strategy Quality Group. team in the mortality/patient safety management relevant patient supported by Mortality improvement initiatives. initiatives safety/mortality Head of Business improvement ensuring improvement Change initiatives in changes, initiatives. order to provide improvements the change and initiatives management are needed. implemented and sustainable.

31. Use incidents as Lessons Learnt Bulletins Trust-wide Bi-monthly Director of End Monitored by the an opportunity following Serious learning from Lessons Learnt Marketing and September Patient Safety & for the sharing Incidents, thematic trend adverse Bulletins. Communications 2014 Quality Group. of learning e.g. analysis reviews & incidents, supported by new forum or Mortality Reviews. claims, Head of Quality & educational inquests, Clinical event complaints, Governance, Risk serious Manager & incidents & Corporate Matron unavoidable – Patient Safety. deaths.

32. Undertake in- Detailed trend analysis of Understanding Trends analysis Director of End Monitored by the depth analysis all patient safety incident of patient safety reports; Trust- Nursing & September Risk Management of the incident data over the past 12 issues across wide, CBU, Quality 2014. Group. data in order to months. the organisation speciality level. supported by establish trends and an Head of Quality & and common understanding if Triangulation Clinical areas of patient existing patient with Governance, Risk safety issues safety initiatives Safety/Quality Manager & are being Heat Maps, Corporate Matron correctly Nursing Metrics, – Patient Safety. directed. Complaints and Litigation.

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33. Clarify and re- Template TOR, agenda Coordinated Monthly CBU Interim End CBU Performance launch the and minutes from CBU governance Governance Associate September Meetings governance Governance & arrangements Meetings. Director of 2014 structures, Performance meetings. at CBU. Corporate Patient Safety & arrangements Affairs Quality Group and priorities of Monitoring Quality & the Clinical against defined Head of Quality Governance Business Units patient safety, and Clinical performance Governance. Committee. and quality

goals by each CBU.

34. Review the Full internal review of the Revised Implementation Director of End Quarterly audits internal complaints process taking complaints of new process Nursing & September by the Complaints complaints into account the findings process aligned supported by Quality 2014. Manager of process of the most recent to the new CBU education and supported by implementation of Internal Audit report. structure. training. Head of Patient the new process Experience. and quality of the complaint investigations.

35. Review the Undertake a full trust- Accurate and Completed Medical Director Commenced Monitored by medical staffing wide review of medical current gap medical staffing supported by and due for Quality and levels and staffing levels identifying analysis against reviews. Clinical Directors. completion by Governance address any any gaps in current required and end Committee & CBU shortfalls. establishment and actual medical Completed December Performance agreeing business cases staffing levels. business cases 2014. meetings. to support increase which reflect the staffing levels where results of the required. reviews to address staffing shortfalls, if any.

Contingency plans to address ongoing staffing shortfalls, if any

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Contingency plans to address short term staffing shortfalls.

36. Monitor actual Develop and implement Ensure safe Medical Director End Monitored by staff levels monitoring tools for staffing levels December Quality and alongside medical staffing levels. are in place 2014 Governance establishment across the Committee & CBU

numbers, Trust. Performance especially meetings. Daily situation report for Daily, monthly Director of End August medical and Directors on nursing and bi-annual Nursing & 2014 and on- nursing. staffing levels reports Quality going. commencing 1st August monitoring actual supported by 2014. staffing nursing Deputy Director of staffing levels Nursing Escalation plan for against nursing staffing levels. establishment numbers. Monthly Board report on nursing staffing levels and monthly upload onto UNIFY (uploaded thereafter onto NHS Choices)

Safer Nursing Care Tool bi-annually.

Implementation of Birthrate Plus and Pander

Minimum six monthly reviews of nursing establishments.

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DATA AND INFORMATION

37. Address the Relocate the Clinical Improved and New location of Director of End October Monitored through working Coding Department into timely the Clinical Information 2014 the CBU conditions and the main hospital. engagement Coding Communications Performance profile of Clinical with the clinical Department. Technology meetings. Coding. staff. supported by Increase clinical Head of Clinical engagement Improve the Coding. with Clinical clinician/coder Coding in order interface. to improve the Obtain the ownership of the assurance the data. clinicians and coders are meeting on at least a monthly basis.

38. Investigate the Improve the Improve the Communication Medical Director End Monitored through reasons for the completeness of D1s for accurateness of to medical team supported by September the CBU very high all patients and deceased all D1’s, via Medical Clinical Directors 2014. Performance proportion of patients. including Staffing & Corporate meetings and non-elective deceased D1’s. Committee, Matron – Patient mortality reviews. spells where Learning Safety. there is a Lessons change in Bulletins, primary inclusion on CBU diagnosis Governance between the first agenda. and last episode.

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All patient’s with end Improve the Communication Medical Director End Monitored through stage disease to have accurateness of to medical team supported by September the CBU palliative care section on deceased D1’s. via Medical Clinical Directors 2014. Performance D1 filled out. Staffing & Corporate meetings and Committee, Matron – Patient mortality reviews. Learning Safety. Lessons Bulletins, inclusion on CBU Governance agenda.

39. Clearly define Review Ward Clerk hours Timely and Increased Head of Health End Monitored through the responsibility together with clear accurate filing compliance in Records. September Healthcare record for filing within communication of duties within all associated 2014. Audits. case notes and of individuals with regard healthcare healthcare ensure that this to healthcare record filing. records. records audits. Patient Safety and is Quality Group. communicated to the wider workforce.

Driver 7 - END OF LIFE CARE

40. Further develop Develop link between Improved Evidence of Director of End Monitored by End joint working Care Home teams & recognition of shared planning Nursing & December of life care with EoLC secondary care teams, end of life care from D1s Quality 2014. steering group. providers, particularly frailty team. preferences and supported by specifically Extend relationships & shared planning Invitation for Deputy Director of looking at care develop positive working to meet these frailty team to Nursing. provision and with community services, attend SWYPFT preferred place with a particular focus on care home of death. nursing homes. forum.

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Engage patients and their Patient’s and Documented Medical Director End Monitored through families with realistic families have a record in supported by September Clinical Record discussion in OPD and as clearer healthcare Clinical Directors 2014. Keeping Standard part of in-patient understanding records of all & Heads of Audits assessment. of realistic discussions held Nursing. expected with patients and Patient Safety and outcomes. their families. Quality Group.

41. Review the Planned training Improved Training plan Director of End Monitored through training approach with key target knowledge and and developed Nursing & September the End of Life schedule for areas for training 2014 - skills of frontline training. Quality 2014. Care Steering EoL 2015. clinicians. supported by Group. Deputy Director of Nursing.

Improve the Improve the Communication Medical Director End Monitored through completeness of D1s for accurateness of to medical team supported by September the CBU all patients and deceased all D1’s, via Medical Clinical Directors 2014. Performance patients. including Staffing & Corporate meetings and deceased D1’s. Committee, Matron – Patient mortality reviews. Learning Safety. Lessons Bulletins, inclusion on CBU Governance agenda.

Bulletins, inclusion on CBU Governance agenda.

Recommendations How this will be What the What evidence Who will lead Timescales Where this will be RAG from Independent achieved expected will support this this this will be reported/ Rating Review of Deaths outcome will be achieved monitored: i.e in April 2013 (Dr within Committee/ Group Alan Fletcher)

1. Improve the Review and revise the Improved the Reduced number Medical End October Monitored through process for the current process for the expected of hospital Director 2014 the prescription and prescription and outcome for acquired, supported by Thromboprophylaxis administration of administration of patients preventable VTE Corporate Committee and thromboprophyl thromboprophylaxis. requiring and/or PE. Matron – Mortality Steering axis thromboprophyla Patient Safety. Group. xis.

2. Improved Re-launch the Improved the Clinical audit of the Medical End August Monitored through implementation implementation of recognition and implementation of Director 2014 and on- the Patient Safety & of the NEWS across the Trust escalation of the NEWS. supported by going Quality Group. recognition of supported by education deteriorating Head of Quality and escalation and training. patient with and Clinical of raised Early improved Governance Warning Scores expected clinical and Corporate outcomes. Matron – Patient Safety.

3. Understand the Implementation of 7-day Reduction in Performance data Director of End October Monitored through delay in working. clinical risk. demonstrating an Operations 2014 & on- the Performance assessment and improvement in supported by going Framework& CBU review, Reduction of quality and Medical Performance particularly out avoidable in- performance Director meetings. of hours and at hospital deaths. indicators and weekends decrease in Reduction in SMT:\Board\Templates & Agenda\11b_ Mortality Action Plan Page 18 of 24_

Length of Stay HSMR. (LOS).

Continuity in Staffing and Director of End October Monitored through staffing and performance data. Operations 2014 the Performance diagnostic supported by Framework& CBU services at Medical Performance weekends. Director & meetings. Clinical Directors.

Implementation Audit of consultant Director of End Monitored through of routine led ward rounds. Operations October2014 regular audits and morning CBU Performance Consultant led Medical meetings. ward rounds. Director supported by Clinical Directors.

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4. Understand the Medical Director to Support the Report the Health Medical End October Monitored through impact deaths liaise with Health & organisation in and Well-being Director 2014. Mortality Steering attributable to Well-Being Board and understanding Board by the supported by Group end stage agree a way forward to any arising Medical Director. the Palliative alcohol related address the issues of issues and allow Care Team. liver disease in end stage alcohol any appropriate Report to the the young may related liver disease in required Mortality Steering have on the the young and cancer in corrective Group from the HSMR & SHMI young patients where measure to be Palliative Care value. palliative measures had identified and Team. not been employed implemented 5. Understand the because of the sudden accordingly. impact deaths rapid progression of attributable to cancer. cancer in young patients where Medical Director to palliative liaise with the Palliative measures had Care Team via the not been Mortality Steering Group employed and request a deep dive because of the into young people with sudden rapid cancer and the palliative progression of measure applied. cancer may have on the HSMR & SHMI value.

KEY: RAG Rating

Behind plan and action needed to bring back Complete On track for delivery on target

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REPORT TO THE BOARD OF REF: BARNSLEY HOSPITAL NHSFT 14/08/P-11c

RE-AUDIT OF COMPLIANCE WITH SEPSIS SIX AND AUDIT OF SUBJECT: NEWS AND ESCALATION OF THE DETERIORATING ADULT PATIENT

DATE: AUGUST 2014

Tick as Tick as applicable applicable

For decision/approval Assurance x PURPOSE: For review x Governance For information x Strategy PREPARED BY: Julian Newell, Corporate Matron – Patient Safety SPONSORED BY: Jugnu Mahajan, Medical Director PRESENTED BY: Jugnu Mahajan, Medical Director STRATEGIC CONTEXT 2-3 sentences Sepsis Screening and treatment with Sepsis Six was introduced in August 2013 and re- launched in April 2014; a Fluids, Antibiotics, Blood Cultures, Urine, Lactate, Oxygen, Sepsis Six (FABULOS) sticker for documenting Sepsis Six completion was devised at BHNFT. An audit has been undertaken to review compliance with Sepsis Six and the FABULOS sticker following the re-launch.

National Early Warning Score (NEWS) was adopted by BHNFT in January 2014 with a revision of the escalation pathway for the deteriorating adult patient. An audit has been undertaken to review the recording of NEWS and the escalation following an elevated NEWS. QUESTION(S) ADDRESSED IN THIS REPORT

Is the BNHFT Sepsis Recognition and Treatment pathway, being followed by medical and nursing staff? Is the FABULOS sticker being used when sepsis identified? Are patients receiving all elements of Sepsis Six within the hour of recognition of sepsis? Are adult patients being assessed using NEWS? Are adult patients being escalated according to the Escalation Pathway following an elevated NEWS.

CONCLUSION AND RECOMMENDATION(S) Sepsis The audit found a 41% compliance with completion of all elements of Sepsis Six within one hour of identification and that all patients received intravenous antibiotics and intravenous fluids within the hour. The Board is asked to note this report.

National Early Warning Score (NEWS) Whilst the audit has been completed, the report on the NEWS Audit is still to be finalised. This will be completed and be available to present to September Board meeting.

BoD 2014: 11c_Sepsis_NEWS

REFERENCE/CHECKLIST • Which business plan objective(s) does this report Aim 1: Patients will experience safe care relate to? Patients BCCG Other

• Please state: Has this report considered the Staff BMBC following stakeholders? Governors Monitor

Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution etc) • Has this report reviewed the Trust’s compliance with: Equality, Diversity & Human Rights

The Trust's sustainability strategy

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: Providing the best healthcare for all”

BoD 2014: 11c_Sepsis_NEWS

Subject: SEPSIS AND NEWS AUDIT Ref: 14/08/P-11c

SEPSIS

1. STRATEGIC CONTEXT

1.1 In 2013 BHNFT implemented Sepsis Six. This is a set of six simple and effective management points for healthcare workers to work through and deliver to the patient within one hour of the recognition of sepsis: fluids, antibiotics, blood cultures, urine, lactate and oxygen.

1.2 It is recommended that all components of Sepsis Six be completed within one hour of recognition of sepsis. A Fluids, Antibiotics, Blood Cultures, Urine, Lactate, Oxygen, Sepsis Six (FABULOS) sticker was developed to act as an aide memoire and to assist in auditing compliance with Sepsis Six.

1.3 A previous audit of patients identified as having had sepsis demonstrated a poor compliance with completion of Sepsis Six. Following this audit the Sepsis Six and FABULOS sticker was re-launched; this audit is to evaluate compliance with Sepsis Six and the use of the FABULOS sticker.

2. INTRODUCTION

2.1 Adult patients coded with a diagnosis of sepsis were identified for audit.

2.2 32 patients from the Emergency Department (ED), Acute Medical Unit (AMU) and Surgical Decisions Unit (SDU), admitted between 19 May to 13 June 2014 inclusive were audited.

2.3 There was a review of case notes and Emergency Department cards.

3. CONCLUSION

3.1 The audit found a 41% compliance with completion of Sepsis Six within one hour of identification and that all patients received intravenous antibiotics and intravenous fluids within the hour.

3.2 There was a greater compliance with Sepsis Six when FABULOS stickers were used compared to when they were not.

3.3 In a number of cases, patients were treated for an infection (antibiotics and intravenous fluids) without any documentation as to whether sepsis had been considered by the nursing or medical staff. These patients had evidence of sepsis through two or more of Systemic Inflammatory Response Syndrome (SIRS) criteria being present.

3.4 This audit demonstrates that patients at BHNFT are being identified and treated for sepsis with components of Sepsis Six; however not all patient are receiving full compliance with Sepsis Six within one hour of identification of sepsis.

3.5 It is noted that following the presentation of the previous audit, there was a re-launch of the Sepsis Screening and Treatment process with the FABULOS sticker. Work undertaken to support this included education with nursing staff and junior medical staff; multiple presentations to structures within the Trust including Medical Staffing

BoD August 2014: 11c_Sepsis_NEWS Page 1

Committee, QSIEB, Senior Nurses Forum, senior nurses meetings in medicine and local governance meetings; Patient Safety Champions have been identified from medical and nursing staff in clinical areas and there have been regular Champions meetings. Although a significant improvement since the last audit there is still a poor compliance with the sepsis recognition, initiation and full completion of Sepsis Six and the use of the FABULOS sticker.

3.6 The action plan aligned to this audit will be taken to the August meeting of QSIEB and the September meeting of the Quality and Governance Committee. Thereafter implementation of the action plan will be monitored by the Patient Safety and Quality Group.

NEWS

4. STRATEGIC CONTEXT

4.1 In January 2014 BHNFT adopted the National Early Warning Score (NEWS) system to aid the identification of the deteriorating patient.

4.2 NEWS requires six parameters of clinical observations to be performed to generate a score. These are Respiratory Rate, Temperature, Oxygen saturations (including use of supplemental oxygen), Systolic Blood Pressure, Heart Rate and Level of Consciousness

4.3 BHNFT developed an Escalation pathway for the deteriorating patient to be used in conjunction with NEWS.

5. INTRODUCTION

5.1 In patients on AMU1, wards 14, 17, 18, 27, 28, 31, 32, 33 and 34 were audited.

5.2 Patients on ED and CDU were also audited.

5.3 In total 205 patients were included in the audit.

5.4 The large volume of data together with its analysis and interpretation has delayed the publication of a full report at this stage.

5.5 It is proposed that a Report on this audit will be presented to Trust Board in September.

6. PRELIMINARY FINDINGS

6.1 Preliminary findings are that patients are being assessed with NEWS, patients are having observations recorded in all six parameters of NEWS. However, not all patients are having observations and NEWS calculated at the frequency required. The audit demonstrates that patients are not always being escalated according to the Escalation Pathway in terms of frequency of observations and assessment by registered nurse and/or doctor.

7. CONCLUSION

7.1 The final report and action plan aligned to this audit will be taken to the August meeting of Quality Safety Improvement and Effectiveness Board (QSIEB) and the September meeting of the Quality and Governance Committee. Thereafter

BoD_August 2014_11c_Sepsis_NEWS Page 2 of 11

implementation of the action plan will be monitored by the Patient Safety and Quality Group.

Appendices:

• Appendix 1 – 542 ‘FABULOS audit - A review of compliance of the Sepsis Six Pathway’

BoD_August 2014_11c_Sepsis_NEWS Page 3 of 11

Appendix 1

CLINICAL AUDIT PROJECT REPORT

Audit Title 542 ‘FABULOS audit - A review of compliance of the Sepsis Six Pathway’

Re-audit

Division (specify) AMU, SDA and ED

On Clinical Audit Programme Yes No

Contact details Active Responsibility - Julian Newell and Karen Sharp Overall Responsibility - Julian Newell Clinical Effectiveness Responsibility - Jan Mathieson

RATIONALE In 2013 BHNFT implemented Sepsis Six. This is a set Why topic is being re- of six simple and effective management points for audited healthcare workers to work through and deliver to the patient within one hour of the recognition of sepsis: fluids, antibiotics, blood cultures, urine, lactate and oxygen. It is recommended that all components of Sepsis Six be completed within one hour of recognition of sepsis. A FABULOS sticker was developed to act as an aide memoir and to assist in auditing compliance with Sepsis Six.

A previous audit of patients identified as having had sepsis demonstrated a poor compliance with completion of Sepsis Six. Following this audit the Sepsis Six and FABULOS sticker was re-launched; this audit is to evaluate compliance with Sepsis Six and the use of the FABULOS sticker.

Audit initiated by Mortality Review Group

Units involved Acute

Audit Group Membership Mortality Review Group, in particular Julian Newell, Karen Sharp, Val Sutton and Jan Mathieson

METHODOLOGY

Study population Adults coded with a diagnosis of sepsis. Patients from AMU and SDA only, including via ED

Time period Patients admitted between 19 May to 13 June 2014 inclusive

BoD_August 2014_11c_Sepsis_NEWS Page 4 of 11

Source of data Review of case notes and ED cards

Sample size 32

Excluded cases None

Type of audit Retrospective

AUDIT CRITERIA AND STANDARDS As per hospital policy ‘Recognising and Source of criteria and standards responding to the Acutely Ill Adult Patient Including Sepsis Recognition and Management’. The relevant policy and standards are available Full grid below via the intranet and the clinical audit department

SUMMARY OF MAIN RESULTS n = 32

Diagnosis of sepsis?

Yes 31 97% No 1 3% Total 32 100%

No patient was excluded, as all 32 patients received intravenous fluids and intravenous antibiotics.

Is there a FABULOS sticker in the notes?

Yes 13 41% No 19 59% Total 32 100%

A majority of patients diagnosed with sepsis did not have a FABULOS sticker in the case notes; however, this is an increase from the 16% in the previous audit. The section on page four of the Observation Chart was not completed as a substitute for a FABULOS sticker.

In the absence of a FABULOS sticker, the data collectors reviewed the case notes and ICE to ascertain actions taken in treating sepsis and therefore compliance with Sepsis Six. The rationale for this being that the clinically important issue is those patients identified with sepsis receive the appropriate treatment.

Was there a delay in the recognition of sepsis?

Yes 9 28% No 23 72% Total 32 100%

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In the absence of a FABULOS sticker, the data collectors reviewed the medical notes for identification of sepsis during the medical assessment. In the majority of cases, either sepsis was identified with a FABULOS sticker or it was clearly documented in the notes.

In the nine cases identified a ‘delay in recognition’, seven of these (78%) were treated for an infection in the Emergency Department, but there was no documentation in the medical or nursing notes as to whether sepsis was considered. One patient deteriorated in the Clinical Decision Unit (CDU) and was treated for an infection, but there was no documentation in the medical or nursing notes as to whether sepsis was considered and one patient did not have signs of sepsis in the ED and deteriorated on the Acute Assessment Unit (AMU).

The data collectors did not undertake a detailed case note review and are unable to comment as to whether sepsis could have been identified earlier, for example at the point of nurse assessment in the ED or on AMU.

Was the patient on End of Life Pathway?

None of the patients in this cohort were on an End of Life Pathway, although one patient was commenced on sepsis treated and subsequently placed on End of Life Pathway.

Was the ‘sepsis six’ completed in one hour?

Is there a FABULOS Was the 'sepsis six' completed within one Total sticker in the notes? hour (with or without sticker/pathway used)? Fully 10 Yes Partially 3 Fully 3 No Partially 16 32 Compliance with Sepsis Six

Fully 13 41% Partially 19 59% Total 32 100%

Combining those with a FABULOS sticker and the case notes reviewed, 13/32 (41%) demonstrated compliance for all components of Sepsis Six within one hour of identification of sepsis.

In the cases where a FABULOS sticker was used, 10/13 (77%) of patients received full compliance with Sepsis Six compared to 3/19 (16%) when a FABULOS sticker was not used.

Where a FABULOS sticker was used; in the majority of cases it was started during the medical assessment.

Components of ‘Sepsis six’ completed within an hour of recognition of sepsis

Yes No Fluids 32 - Antibiotics 32 - Blood cultures 23 9 Urine 21 11 Lactate 24 8

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Oxygen 16 16

Fluids and Antibiotics

All patients received intravenous antibiotics and intravenous fluids on recognition of sepsis or an infection; these are the two decisively important components of the Sepsis Six bundle of care. The data collectors did not undertake case note reviews to consider whether the intravenous fluid prescribed was clinically appropriate.

Blood cultures

In the nine cases where blood cultures were not obtained, there was no documentation as to whether this had been considered.

Urine

In the absence of a FABULOS sticker, the data collectors looked for evidence of monitoring of fluid output through a Fluid Balance Chart and/or the nursing documentation. There was an absence of Fluid Balance Chart and/or nursing documentation in the ED regarding monitoring of fluid output.

Lactate

Lactate was not measured in eight patients; lactate is an important indicator of severe sepsis.

Oxygen

In the absence of a FABULOS sticker, the data collectors looked for evidence of supplemental oxygen in the NEWS chart, medical notes and/or the nursing documentation. Where oxygen was not administered, the data collectors did not find any comments in the nursing and/or medical notes as to whether supplemental oxygen had been considered and/or was not required.

Did the patient have severe sepsis?

Yes 12 38% No 20 63% Total 32 100%

The data collectors looked for evidence of severe sepsis in the medical and nursing documentation, however in the absence of lactate measurement and detailed case note review this should not be considered conclusive.

Conclusion

The audit found a 41% compliance with completion of Sepsis Six within one hour of identification and that all patients received intravenous antibiotics and intravenous fluids within the hour.

There was a greater compliance with Sepsis Six when FABULOS stickers were used compared to when they were not.

In a number of cases, patients were treated for an infection (antibiotics and intravenous fluids) without any documentation as to whether sepsis had been considered by the nursing or medical

BoD_August 2014_11c_Sepsis_NEWS Page 7 of 11

staff. These patients had evidence of sepsis through two or more of Systemic Inflammatory Response Syndrome (SIRS) criteria being present.

This audit demonstrates that patients at BHNFT are being identified and treated for sepsis with components of Sepsis Six; however not all patient are receiving full compliance with Sepsis Six within one hour of identification of sepsis.

It is noted that following the presentation of the previous audit, there was a re-launch of the Sepsis Screening and Treatment process with the FABULOS sticker. Work undertaken to support this included education with nursing staff and junior medical staff; multiple presentations to structures within the Trust including Medical Staffing Committee, QSIEB, Senior Nurses Forum, senior nurses meetings in medicine and local governance meetings; Patient Safety Champions have been identified from nursing staff in clinical areas and there have been regular Champions meetings. Despite this, there is still a poor compliance with the sepsis recognition, initiation and full completion of Sepsis Six and the use of the FABULOS sticker.

Recommendations

Risk Grading Guidance High Indicates poor compliance where immediate action is required.

Medium Indicates partial compliance but weaknesses have been identified and it is considered necessary for action to be taken.

Low Indicates significant compliance but minor weaknesses have been identified and it is considered best practice that action is taken.

1. Present the audit results at various meetings and committees (medium) 2. Review and re-evaluate the sepsis recognition and treatment pathway and associated documentation (FABULOS) including any proposal to revise any documentation (high) 3. Consider Sepsis Six documentation to be incorporated into any revisions to healthcare records 4. Continue to develop, enhance and implement a competency assessment of recognising and responding to the deteriorating patient for nursing staff including identifying sepsis (medium) 5. Consider incorporating sepsis recognition and treatment in medical staff Appraisal (medium)

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CLINICAL GOVERNANCE ISSUES

Clinical Risk Yes No

Specify issues raised

Patients are not being fully assessed for sepsis when an infection is recognised and elements of Systemic Inflammatory Response are present.

Patients are not receiving all components of Sepsis Six bundle of care when sepsis is present.

FABULOS stickers and/or page 4 of the Observation Chart are not being used in patients with sepsis and being treated for sepsis.

IM&T Yes No

Specify issued raised Training/CPD Yes No

Specify issued raised

Nursing and medical staff to continue to undertake training on sepsis.

Other

Specify issued raised

DISSEMINATION OF RESULTS

Full report available from: Clinical audit department Summary circulated to: Name Date sent Clinician(s) undertaking audit Supervising Clinician Clinical Audit Lead Medical Director Assistant Divisional Director Assistant Director of Nursing Matron Risk Department Gill Feerick Learning and Development Department Head of Department QSIEB Heather McNair

Date summary finalised: 30 July 2014

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REPORT TO THE BOARD OF REF: BARNSLEY HOSPITAL NHSFT 14/08/P-12

CLINICAL GOVERNANCE COMMITTEE (CGC) SUBJECT: HIGHLIGHT ASSURANCE REPORT

DATE: AUGUST 2014

Tick as Tick as applicable applicable

For decision/approval  Assurance  PURPOSE: For review  Governance For information Strategy PREPARED BY: Linda Christon Non Executive Director and CGC Chair SPONSORED BY: Linda Christon Non Executive Director and CGC Chair PRESENTED BY: Linda Christon Non Executive Director and CGC Chair STRATEGIC CONTEXT 2-3 sentences As this was the last meeting of the Clinical Governance Committee in its current format, the purpose of this report is to provide assurance to the Board of the smooth transition of the former Clinical Governance Committee to the new Quality & Governance Committee ensuring that all matters within its remit have been transferred and are identified on the new Board Assurance Framework (BAF), and that all matters which will become within the remit of the new Committee have been identified and a clear process established for monitoring risks under the new governance arrangements agreed by the Board.

QUESTION(S) ADDRESSED IN THIS REPORT

Are all clinical and quality risks identified and sufficiently assured?

Have all the relevant issues transferred from the former Non Clinical Governance and Risk Committee been identified and included in the work programme for the new Quality Governance Committee?

Have all the new areas of responsibility and sub committees reporting to the new committee been identified? CONCLUSION AND RECOMMENDATION(S) The Board is asked to;

1. Note the careful and detailed consideration given to ensuring the smooth transition to and implementation of the new governance arrangements. 2. Note the CGC's acknowledgement and inclusion of issues requested to be transferred from the former Non Clinical Governance Committee Board Assurance report (14/07/P-08). 3. Agree with and approve the Committee’s proposed amendment to the BAF to include BAF 1d , provision of a 7 day service, to the remit of the new Quality Governance Committee, as the Board has previously requested. 4. Approve the Policy and Procedures Framework. 5. Approve the Training Policy for Gaining Consent. 6. Note the Committee’s approval of the following revised policies; - Best Practice NICE policy - Consent policy - Clostridium difficile Policy - Hand Hygiene Policy - Isolation Policy - MRSA Screening Policy - Prevention and Control of MRSA policy - Medical Devices policy (inadvertently missed from the January assurance report)

BoD 2014: 12_1_Board Assurance Report

REFERENCE/CHECKLIST • Which business plan objective(s) does this report Aim 1: Patients will experience safer care relate to? Patients BCCG Other

• Please state: Has this report considered the Staff BMBC following stakeholders? Governors Monitor

Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution etc) • Has this report reviewed the Trust’s compliance with: Equality, Diversity & Human Rights

The Trust's sustainability strategy

• Has this report Quality & Governance (in draft or during Yes • Is this report development) been Audit Committee supported by a reviewed and Not applicable communications supported by any Finance & Performance plan? Board or Executive To be developed committee within the ET Trust? • Where applicable, briefly identify risk issues (including any reputation) and cross reference to risk register and governance committees • Where applicable, state Finance: resource requirements: Other:

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: Providing the best healthcare for all”

BoD 2014: 12_1_Board Assurance Report

CLINICAL GOVERNANCE COMMITTEE (CGC) HIGHLIGHT Subject: Ref: 14/08/P-12 ASSURANCE REPORT

1. STRATEGIC CONTEXT This was the final meeting of the Clinical Governance Committee in its current format, the meeting therefore focussed on giving detailed consideration to ensuring that all existing clinical risks and workload are transferred to the new Quality and Governance Committee. The Committee reviewed all elements of the current workload and reporting arrangements, and identified new areas of work being transferred

2. MATTERS OF NOTE 2.1 Matters delegated from the Board The Committee reviewed the draft Terms of Reference for the Quality & Governance Committee.

The Committee reviewed the Annual Forward Plan and noted that this needed to be updated to reflect new responsibilities.

The Committee referred to the Board’s request for a “Heat Map” to be produced to identify areas causing concern and was assured that work was on going to produce this for the next Monitor report.

3. BAF ASSURANCE 3.1 The Committee considered assurance updates from the existing BAF and it was confirmed that there were no urgent issues that required escalating to the Board, other than the continued concern about failure to meet stroke targets; it was agreed that stroke performance should remain on the forward plan as an area of special monitoring.

3.2 The Committee also considered the revised BAF presented to Board and identified that one area of work, the 7 day service, specifically allocated to this committee previously by the Board was not assigned to the Quality & Governance Committee. It was agreed that this would be raised through the assurance report.

4. ADDITIONAL REPORTS 4.1 The Committee considered an updated Nursing Staffing report and agreed that, accepting the limitations of the national reporting format, there was a case for reporting the link between nursing figures and harm and that this would provide assurance to the Board.

4.2 The Committee approved the annual Infection Prevention and Control report and recommended that it be received by Board in the form of a short presentation.

4.3 The Committee received a presentation of the outcome of the Advancing Quality Alliance (AQuA) Mortality Review and agreed that, while the findings were quite general it was important to weave it into our on-going work. A formal launch day of the updated action plan will be held.

4.4 The Last Days of Life Care Plan was presented for information. This will begin to be implemented throughout the Trust from the end of July.

BoD August 2014: 12_1_Board Assurance Report Page 1

4.5 The Hospital at Night end of project report was tabled and it was agreed that this should be presented to the Board.

5. OTHER MATTERS 5.1 Safeguarding Children: It was noted that Ofsted had made a return visit to the Trust and a report was expected.

5.2 It was noted that the Dementia Commissioning for Quality and Innovation (CQUIN) had achieved the first quarter target.

6. POLICIES 6.1 The following policies were reviewed, supported and are recommended to Board for approval; - Policy and Procedures Framework, - Training Policy for Gaining Consent

6.2 The following policies were reviewed and approved for the Board to note; - Best Practice NICE policy - Consent policy

6.3 The following IP&C policies were reviewed and approved, for the Board to note; - C Diff Policy - Hand Hygiene Policy - Isolation Policy - MRSA Screening Policy - Prevention and Control of MRSA policy

Appendices:

• Appendix 1- Chair’s log

• Appendix 2 - Policy and Procedures Framework

• Appendix 3 - Training Policy for Gaining Consent

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Chairs Key Issues and Assurance Model (Chair’s Log)

Committee / Group Date Chair

Clinical Governance Committee (final meeting to be 17 July 2014 Linda Christon replaced with the Quality and Governance Committee).

Agenda Item Issue and Lead Officer Receiving Body e.g. Recommendation/ Assurance/ Board or Committee mandate to receiving body

Matters delegated from the Board Terms of Reference Review deferred by the Committee. Board of Directors Refer to separate agenda item.

Forward plan Requires update to reflect new Board of Directors To note, following the Board’s request for responsibilities. assurance

On-going delivery of the The Quality and Governance Committee Board of Directors To note, following the Board’s request for Risk Register would receive assurance on this from the assurance Risk Management Group. Lead officer: Mrs McNair

Work is on-going. Heat map sent to Heat Map Monitor by Wednesday 23 July 2014. Board of Directors To note, following the Board’s request for Completed assurance Lead officer: Mrs McNair

In progress. Would be reviewed by the NEWS score and sepsis Quality & Governance Committee in future. The Board of Directors For review by Board of Directors, via the bundle However, to ensure this is reviewed in a HSMR paper timely manner, it was agreed it should be reviewed by the Board of Directors in this instance. Lead officer: Dr Mahajan, via the HSMR paper

Nurse Staffing Accepting the limitations of the national Board of Directors The report will be presented to the Board of reporting format, there was a ase for Directors by Dr Rao, Director of Infection reporting the link between nursing figures Prevention and Control. and harm and that this would provide assurance to the Board.

Infection Prevention and For Approval at by the Board of Directors Board of Directors The report will be presented to the Board of Control Annual Report Directors by Dr Rao, Director of Infection The Committee acknowledged the on- Prevention and Control. going vigilance of the Infection Prevention and Control Team. Lead officer: Mrs McNair

Serious Incidents The Committee acknowledged the on- Board of Directors To note. going work to improve pressure ulcers.

The Committee requested that Mrs McNair liaise with the CG, for assurance in relation to work in the community.

AQuA report The AQuA mortality review was received Board of Directors To note. on 20 June 2014; subsequently an action plan has been developed. A launch day will be arranged to promote this. Lead officer: Dr Mahajan

Amber Care Bundle The positive work undertaken by Diane Board of Directors To note. report. Steele in relation to the Amber Care Bundle was acknowledged. Lead officer: Heather McNair

Last Days of Life Care This will begin to be implemented Board of Directors For information Plan throughout the Trust from the end of July.

Existing BAF Stroke Performance To continually monitor stroke performance. To remain on the forward plan as an area of special monitoring. To note Board of Directors

Revised BAF Was specifically allocated to the Seven day service Committee previously by the Board. Was Enquiry to be approved by Board. not assigned to the Quality & Governance Board of Directors Committee.

Safeguarding Children Ofsted had made a return visit to the Trust, Board of Directors For information a report is expected.

CQUINs The Dementia CQUIN had achieved the Board of Directors For information first quarter target.

Hospital at Night report The Hospital at Night end of project report Board of Directors. For information, see separate agenda item. is to be itemised on the Board of Director’s agenda, for their review. Lead officer: Heather McNair

Policies for approval Policy on Policies Policies endorsed by the Committee and to Board of Directors. Board of Directors to approve. be presented to the Board for approval Training Policy for Lead officer: Heather McNair Gaining Consent. Policies approved by the The following revised policies were Board of Directors For information and to ratify. Committee approved by the Clinical Governance Committee (to become Quality and Governance Committee) • C diff policy • Hand Hygiene policy • Isolation policy • MRSA Screening policy • Prevention and Control of MRSA policy • Best Practice NICE policy • Consent Policy

Appendix 2

POLICY/PROCEDURE CONTROL SHEET

Policy/Procedure Title GEN 7.32 Policies and Procedures Framework and ID number: Sponsoring Director: Heather Mcnair, Director of Nursing and Quality Implementation Lead: Gill Feerick, Head of Quality and Clinical Governance (a) To patients Yes (b) To Staff Yes (c) Financial No Impact: (d) Equality Impact Assessment (EIA) Completed: Yes / No (e) Counter Fraud assessed Completed: Yes / No (e) Other Training implications: To be incorporated into induction: No Approval Process Date Local Consultation Date Quality, Safety, April Executive Led Committee/Board Improvement & 2014 Effectiveness Board Board Committee: July • Quality & Governance 2014 • Audit Committee Date of consultation: • Finance & Performance • RATS Aug Trust Board Approval / Ratification 2014 Other:

Approval/Ratification at Trust Board: Version Number: 1 Date on Policy Warehouse: Team Brief Date: Circulation Date: Date of next review: July 2017

For completion by ET for new policies only: Revenue or Budget Code: Non Revenue (a) Training £ Additional Costs (b) Implementation £ (c) Capital £ (d) Other £

Policy and Procedures Framework, V1.0, July2014 Page 1 of 34

Appendix 2

Policies and Procedures Framework v1.0

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Table of Contents

Page 1. Policy 4 2. Circulation 4 3. Scope 4 4. Definitions 4 5. Aims and Objectives 5 6. Standards 5 7. Responsibilities 6 7.1 Individual Responsibilities 7.1.1 Chief Executive 7 7.1.2 Head of Quality and Clinical Governance 7 7.1.3 Executive Directors 7 7.1.4 Policy Authors 7 7.1.5 Gatekeeper 7 7.1.6 Quality and Governance Team 8 7.2 Board and Committee Responsibilities 7 7.2.1 Trust Board 7 7.2.2 Quality and Governance Committee 8 7.2.3 All Trust Committees 8 8. Training Requirements 9 9. Monitoring and Compliance 9 10 References 9 11. Attachments 9

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1. Policy Statement

All Barnsley Hospital NHS Foundation Trust Policies and Procedures must be developed, ratified, implemented, monitored, reviewed and archived in line with this Policy.

2. Circulation

• This Policy should be read by all Barnsley Hospital NHS Foundation Trust (BHNFT) staff responsible for the development, ratification, implementation, monitoring, review or archiving of policies or procedures. • This Policy applies equally to staff in a permanent, temporary, voluntary or contractor role acting for or on behalf of BHNFT.

3. Scope

Includes:

• This Policy applies to new and revised Trust Policies and Procedures across all locations and services.

Excludes:

• Whilst this Policy should be considered as good practice for all controlled documents it does not apply to strategies, clinical guidelines or patient information leaflets.

4. Definitions

For the purpose of this Policy, the following definitions apply:

• Policy: A policy is an approved document which outlines the overall intentions and direction of the organisation related to a particular subject or topic matter, as formally expressed by the senior management of the Trust. In general terms any policy document is consistent with the overall policy of the organisation and provides a framework for the setting of relevant and appropriate objectives. A policy is a principle to guide decisions and achieve rational outcomes. A policy is a statement of intent, and is implemented as a procedure.

• Procedure: A procedure is an approved document which clearly specifies ways in which a certain activity or process should be carried out. It is also the document which defines a series of steps in a regular definite order. A well-defined procedure controls a well-defined process or activity. A procedure defines the work that should be done, and explains how it should be done, who should do it, and under what circumstances. In addition, it explains what authority and what responsibility has

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been allocated, which supplies and materials should be used, and which documents and records must be used to carry out the work.

• Policy/Procedure Lifecycle: Each document has a lifecycle through which it is developed, ratified, implemented, monitored, reviewed and archived.

• Policy/Procedure Ratification/Approval: An interchangeable term for the process of agreeing that a policy or procedure can become active.

A summary procedure outlining the stages in the policy/procedure lifecycle is included in Attachment 1.

5. Aims and Objectives

The aims and objectives of this Policy are to: • Define a systematic approach for the development, ratification, implementation control and archive of trust policies and procedures. • Provide a framework for ensuring that all BHNFT Policies and Procedures are developed to a consistently high standard, as required by internal standards and external regulation. • Define standards to ensure good quality, current information is easily available to all appropriate Trust staff and is used to effectively inform their practice. • Use version control and archiving processes to eliminate the risks associated with duplicate, out of date or conflicting documents.

6. Standards

Policies and procedures will be developed and managed in line with the following standards:

a) The style and format of all policies will be based upon the template (Attachment 5) which reflects BHNFTs corporate style and also with the following: • Frontage title in Arial 26 font, bold and centred. • Arial 12 font for content • Bold type Arial 14 for headings • Single line spacing with clear spaces between paragraphs • Bullet points for lists • Set out text in numbered sections with clear headings • Footer used to confirm title of document, month and year of development and page number, Page 1 of 1 format right aligned line after title etc - the footer must be in Arial 10 font, please see footer of this policy as an example. • No italics • No underlining

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• No Block Capitals – the only exception is Abbreviations, which should be in full on first mention and the abbreviation following in brackets and thereafter just the abbreviation is permissible. e.g. Barnsley Hospital NHS Foundation Trust (BHNFT).

b) Policies and procedures should include a definition of terms used (section 3 of Attachment 5). c) All new and revised policies and procedures should be subject to appropriate consultation (section 2 of Attachment 1). d) All new and revised policies and procedures should be ratified/approved by a the Trust Board, an appropriate committee or Executive Director (section 3 of Attachment 1). e) All policies and procedures should have a review date (section 6 of Attachment 1). f) New or reviewed policies and procedures should be uploaded to the Trust’s sharepoint site by the Gatekeeper. Superseded versions of policies and procedures should not be deleted, they should be moved to the sharepoint archive by the Gatekeeper (section 7 of Attachment 1). g) Documents associated with each policy or procedure should be listed in the document. h) Full citation details of any reference source that is used in developing the policy or procedure should be included (section 10 of Attachment 5). i) Policies and procedures must include details of how the standards within the policy or procedure will be monitored and how compliance or non compliance will be reported and acted upon (section 9 of Attachment 5). j) All new and revised policies and procedures must include details of training requirements (section 8 of Attachment 5). k) An equality impact assessment must be completed during the development of new and reviewed policies and procedures. l) A launch and implementation plan (Attachment 4), outlining how the policy or procedure will be communicated and implemented across the Trust should be completed for all new policies and procedures. 7. Responsibilities

The Trust Board, managers and staff are responsible for establishing, maintaining and supporting a coordinated approach to policy and procedure lifecycle management in all areas of their responsibility which does not discriminate against any member of staff, patients or the public on the grounds of age, gender, disability, race, religion or sexual orientation. Some members of staff and Committees have particular specialist functions in relation to policy lifecycle as described below:

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7.1 Individual Responsibilities

7.1.1 Chief Executive

The Chief Executive retains overall responsibility to the Trust Board for overseeing an appropriate infrastructure to support the implementation of this policy and supporting procedures. He/she delegates operational responsibility to the Head of Quality and Clinical Governance.

7.1.2 Head of Quality and Clinical Governance

The Head of Quality and Clinical Governance is responsible for the development and review and monitoring of this policy. They will oversee the implementation of this policy and supporting procedure and provide reports, as required, to the Trust Board, in this regard.

7.1.3 Executive Directors

Each Executive Director is responsible for ensuring the implementation of this policy through their operational management teams.

7.1.4 Policy Authors

All staff involved with the development/review of a policy and procedure have a responsibility to:

• Understand and comply with this policy. • Undertake any research required to ensure that the policy or procedure is based on and compliant with available legislation, national requirements, evidence or best practice. • Undertake appropriate consultation to ensure that the policy or procedure is achievable and adequately supported.

7.1.5 Gatekeeper

The nominated Gatekeeper for BHNFT is the Risk and Governance Administrator, situated within the Risk Management Department. The Gatekeeper has the responsibility to:

• Ensure the quality assurance (Ratification and Equality Impact Assessment) checks have taken place.

• Upload the document for storage on the central sharepoint site.

• Maintain and monitor a schedule of policies and notify policy authors when a policy is due to be reviewed according to the review date.

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• Ensure the latest version of all policies and procedures are provided to the Communications function, who will then be responsible for timely communication to a central point. 7.1.6 Quality and Governance Team

The Quality and Governance Team has a joint responsibility to support the implementation of this policy, in particular:

• Support Clinical Business Units in their role and advise Clinical Business Units in Policy and Procedure development. 7.2 Board and Committee Responsibilities

7.2.1 Trust Board

The Trust Board is responsible for ensuring that the organisation has appropriate governance systems in place to enable it to deliver its objectives, statutory requirements and policy commitments. It delegates operational responsibility to the Quality and Governance Committee.

7.2.2 Quality and Governance Committee

The Quality and Governance Committee is responsible for approving this Policy.

The Committee is responsible for monitoring the ongoing implementation of the policy.

7.2.3 All Trust Committees

All Trust Committees involved in any aspect of a Policy and Procedure lifecycle, have particular responsibility in relation to:

• Approving and monitoring implementation of and compliance with Policies and Procedures which fall within their areas of expertise or responsibility.

• Ensuring compliance with this Policy by use of the consultation/approval checklist before approval.

• Applying appropriate scrutiny to Policies and Procedures for technical content and compliance with appropriate National standards/requirements, seeking comment from other experts/committees as required, before ratification.

• Ensuring that the Trust Gatekeeper is notified when a new or revised Policy or Procedure is ratified.

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• Monitor implementation of and compliance with Policies and Procedures through the mechanisms and standards defined in the Policy

8. Training Requirements

There are no mandatory training requirements associated with this Policy.

9. Monitoring and Compliance

The monitoring of compliance with this policy will be the responsibility of the Head of Quality & Governance through annual trust wide audits. The results of the audit will be reviewed by the Patient Safety & Quality Group and monitoring of implementation of any actions will be undertaken by the Patient Safety & Quality Group and Quality and Governance Committee. 10. References

NHS Records Management Code of Practice, March 2006 ISO, 9001Quality Management.

11. Attachments

Attachment 1 – Procedure for Developing and Managing Policies and Procedures Attachment 2 – Consultation and Ratification Checklist Attachment 3 – Equality Impact Assessment Attachment 4 – Launch and Implementation Plan Attachment 5 – Policy/Procedure Template

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Attachment 1: Procedure for Developing and Managing Policies and Procedures

1. Develop Policy/Procedure Authors must identify who will be affected by new policies/procedures and consult with them early in the policy/procedure development.

2. Consultation An Equality Impact Assessment, Launch Plan and Ratification Checklist should also be completed for new policies & procedures.

3. Ratification/Approval Ratification (or approval) is completed by the Trust Board, an appropriate Committee or Executive Director. New or reviewed Polices/Procedures will not be ‘active’ until ratification or approval has been obtained. The ratifying board/group/committee or Executive Director is responsible for ensuring that ratification/approval is documented; there is a launch / implementation plan in place and an Equality Impact Assessment has been completed

4. Implement and Communicate Ratified/approved polices/procedures are forwarded to the Trust Gatekeeper. The Gatekeeper should upload the document for storage on the central Sharepoint site. All new policies and procedures must include a launch and implementation plan. Reviewed policies and procedures may include a launch and implementation plan as appropriate. Local records must be kept by Clinical Business Units demonstrating circulation and understanding of new or revised policies and procedures by those staff to whom the policy or procedure is applicable.

5. Monitor and Compliance How, when and who will monitor the standards in the policy/procedure must be detailed together with who will review the results of the monitoring process and who will be responsible for monitoring the implementation of any actions.

6. Review Policies/Procedures must be reviewed every 3 years, at a minimum, or following a change in service, evidence, guideline or statute. Review dates are completion dates not when reviews begin. Reviews should be timely and begun in sufficient time before the review date to ensure they are ratified and fit for implementation. Revised policies/procedures can be ratified by an appropriate committee or Executive Director unless it is a policy which is subject to significant revision. In this instance the revised policy will be subject to ratification/approval by the Trust Board. The Trust Gatekeeper is the overseer of Policy/Procedure lifecycles, acting as the trigger mechanism for authors to review and revise Policies and Procedures.

7. Control and Archive New and revised policies/procedures will be published on sharepoint by the Trust Gatekeeper. Any superseded documents will not be deleted, they will be saved to the sharepoint archive by the Trust Gatekeeper.

This procedure should be read in conjunction with the Policy and Procedures Framework.

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1. Development of Policies or Procedures

• New policies and procedures should consider appropriate legislation and national best practice / evidence (e.g. Royal colleges and professional bodies, Care Quality Commission, Department of Health, and Monitor).

• Version control will be strictly applied throughout the lifecycle of policies and procedures. The process of version control is as follows:

New policies/procedures Title, version, month and year ratified e.g. Policy and Procedures Framework, v1, January 2011

Revised policies/procedures after full review with changes Title, version, month and year ratified e.g. Policy and Procedures Framework, v2, January 2014

Revised policies/procedures after full review with no changes Title, version, month and year ratified Policy and Procedures Framework, v1, January 2014

Revised policies/procedures prior to full review with changes Title, version, month and year ratified Policy and Procedures Framework, v1.1, January 2012

2. Consultation

• Appropriate consultation should be undertaken with all key stakeholders, including external stakeholders, where appropriate, for all new policies and procedures.

• The policy/procedure author is responsible for ensuring that the relevant committees and groups, service users and carers and Trust solicitors, where necessary, are consulted about the draft policy and procedures.

3. Ratification/Approval of Policies

• New policies are subject to ratification/approval by the Trust Board. • When ratifying/approving a new policy this must be documented on the ratification checklist. • The ratification checklists will be retained electronically by the Trusts nominated Gatekeeper and stored on the central Sharepoint site. • Revised policies may be ratified/approved by a relevant group/committee or an appropriate Executive Director unless the policy is subject to significant revision. In

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this instance the revised policy will be subject to ratification/approval by the Trust Board. • Where a revised policy is ratified/approved, a record should be made of the group/committee or Executive Director who have undertaken ratification on the ratification checklist. • Policies will not be considered “active” until they have been ratified/approved.

4. Ratification/Approval of Procedures

• New procedures are subject to ratification/approval by an appropriate group or committee. • The named sponsoring Director of the procedure is responsible for deciding which group/committee is most appropriate for ratifying/approving a new procedure. • When ratifying/approving a new procedure this must be documented on the ratification checklist. • The ratification checklists will be retained electronically by the Trusts nominated Gatekeeper and stored on the central Sharepoint site. • Revised procedures may be ratified/approved by a relevant group/committee or an appropriate Executive Director. • Where a revised procedure is ratified/approved, a record should be made of the group/committee or Executive Director who have undertaken ratification on the ratification checklist. • Procedures will not be considered “active” until they have been ratified/approved.

5. Implementation and Communication

• All new policies and procedures must include a launch and implementation plan.

• Reviewed policies and procedures may include a launch and implementation plan as appropriate identifying those areas of change.

• All Clinical Business units must have processes in place to manage the risks associated with the introduction of new or revised policies and procedures. Local records must be kept by Clinical Business Units demonstrating circulation and understanding of new or revised policies and procedures by those staff to whom the policy or procedure is applicable.

6. Monitoring and Compliance

• Each policy and procedure must include details of how the standards within the policy / procedure will be monitored and how compliance or non compliance will be reported and managed.

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7. Review

• Policies and procedures are subject to review every three years as a minimum or following a significant change in service, evidence, national guideline or statute, if earlier. • The review date of a policy or procedure is the date on which the review should be complete and not the date on which the review should begin. If a policy or procedure becomes “out-of-date” because a review has not taken place, this will be termed non- compliant. • The Trust Gatekeeper is the overseer of policy and procedure lifecycles, acting as the trigger mechanism for authors to review and revise these in a timely fashion. • Appropriate consultation must be undertaken with all key stakeholders, following any significant change to standards, responsibilities or process. • Reviewed policies can be ratified by an appropriate committee or Executive Director.

8. Control and Archiving

• New or reviewed policies should be uploaded to the Trust’s sharepoint site by the Trust Gatekeeper.

• The Trusts Records Management Policy, Corporate Records Management Policy outlines the scheduling of the retention and disposal of corporate and clinical documents, in line with Department of Health guidance.

• Superseded versions of policies and procedures should be moved to the sharepoint archive by the Trust Gatekeeper.

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Attachment 2: Consultation and Ratification Checklist

Title Policy and Procedures Framework, v 1.0, January 2014

Ratification checklist Details

1 Revised or New

2 Format complies with Policies and Procedures Template? Yes No Consultation with range of internal /external groups/ 3 Yes No individuals has taken place? 4 Equality Impact Assessment completed and attached? Yes No

Yes No

If Yes please provide details Are there any governance or risk implications? (e.g. 5 patient safety, clinical effectiveness, compliance with or deviation from National guidance or legislation etc)

Yes No

If Yes please provide details

6 Are there any operational implications?

Yes No

If Yes please provide details

7 Are there any educational or training implications?

Yes No

8 Are there any clinical implications? If Yes please provide details

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Yes No

If Yes please provide details

9 Does the document have financial implications?

Yes No

If Yes please provide details

10 Does the document have HR implications?

Launch and Implementation Plan completed and 11 Yes No attached? Does the document have a review date in line with the 12 Yes No Policies and Procedures Framework?

Yes No

Date: ..………………………………………

Name of Committee or Executive Director: Has the document been approved/ratified by an 13 appropriate Committee or Executive Director? ………………………………………………..

Signature of Chair of Committee or Executive Director:

……………………………………………….

Yes 14 Reviewed by Local Counter Fraud Specialist Date: …………………………………………

Yes No

15 Consultation and ratification checklist approved? Date: …………………………………………

Name of Trust Gatekeeper:

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………………………………………………..

Signature of Trust Gatekeeper:

……………………………………………….

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Attachment 3: Equality Impact Assessment

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Attachment 4: Launch and Implementation Plan

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

Action Who When How Identify key users / Quality & Prior to Through consultation of policy writers Governance ratification document identify key stakeholders and users. Present Policy to key Quality & Following Presentation of Policy to user groups Governance ratification Safety & Governance Team Cascade communication of new policy via Patient Safety and Quality Group. Cascade communication of new policy via senior Clinical Business Unit Leads & Managers Add to Sharepoint Gatekeeper Following As per Gatekeeper process. ratification Monitor implementation Head of 6 months Audit led by Clinical Quality & following Effectiveness Team. Governance ratification

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Attachment 5: Policy/Procedure Template

POLICY/PROCEDURE CONTROL SHEET

Policy/Procedure Title INSERT TITLE OF POLICY and ID number: Sponsoring Director: NAME & TITLE Of SPONSORING DIRECTOR Implementation Lead: NAME & TIATLE OF IMPLEMENTATION LEAD (a) To patients Yes/No (b) To Staff Yes/No (c) Financial Yes/No Impact: (d) Equality Impact Assessment (EIA) Completed: Yes / No (e) Counter Fraud assessed Completed: Yes / No (e) Other Training implications: To be incorporated into induction: Yes/No Approval Process Date Local Consultation Date Insert names of local Executive Led Committee/Board groups/committees where Insert date of consultation by consultation has taken relevant Executive led place together with date of Committee/Board consultation Board Committee: • Quality & Governance Date of consultation: • Audit Committee • Finance & Performance • RATS Trust Board Approval / Ratification Other:

Insert Version Approval/Ratification at Trust Board: Insert date Version Number: Number Date on Policy Warehouse: Insert date Team Brief Date: Insert date Circulation Date: Insert date Date of next review: Insert date

For completion by ET for new policies only: Revenue or Budget Code: Non Revenue (a) Training £ Additional Costs (b) Implementation £ (c) Capital £ (d) Other £

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Insert name of Policy/Procedure

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List of Contents

For ease of reference each policy or procedure should include a list of contents that lists the main headings and attachments with the page numbers where each section can be found.

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1. Circulation

Define precisely who this document applies to / needs to be read by. 2. Scope

Includes: In this section you should make it clear what the document applies to.

Excludes: Insert details of any exclusion to the policy or procedure.

3. Definitions

Provide definitions of key words/terms that are particularly relevant and may need clarification. These should be the local definitions which you wish to apply rather than dictionary definitions. The purpose of this is to ensure all of the users of the document have a common understanding. If there is only a small number of definitions these may be included at the start of the document.

4. Aims and Objectives

In this section break down the overall aim of the document into specific outcomes that implementing the policy and or procedure should achieve, use bullet points and keep the objectives realistic and measurable.

5. Standards (for Policies) / Process (for Procedure) (delete as applicable)

Clearly set out in a logical order the standards that must be achieved or process that must be followed. Include as many sub headings as you need to make the body of the document easily understood.

6. Responsibilities

For Policies clearly state who is responsible for infrastructure, implementation, monitoring and review of this document.

For Procedures focus on individuals and staff groups responsible for the key steps in the process.

6.1 Individual Responsibilities

In this section you should provide an explanation of responsibilities of individuals or staff groups in relation to the document. This should focus on the individuals responsible for developing the policy or procedure, developing supporting infrastructure, implementing and monitoring. Examples include:

Chief Executive

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Where appropriate, this section should provide an explanation of the role of the Chief Executive in reference to the document.

Executive Directors In this section you should provide an explanation of Executive Directors responsibilities in reference to the document.

Individual Staff Responsibilities In this section you should provide an explanation of responsibilities of staff who are responsible for establishing, enforcing and supporting the policy/procedure.

6.2 Committee Responsibilities

Ratifying Board and Committee Responsibilities Where appropriate, Name the Committee who ratify the document and say what the responsibilities of that group are.

If the document has been approved by an Executive lead, then this responsibility should be included under section 7.1.

Operational Committees Name Board/Committees/Groups and state responsibilities to develop monitor, review and report on the application of the document. Also state format and frequency of such reports.

If the policy or procedure defines an operational responsibility for a committee include how failures / breaches of the standards will be followed through.

7. Training Requirements

In this section provide plans for appropriate training required to implement the document, achieve and maintain the required standards. There should be a cross reference made to the Trusts Corporate Curriculum which outlines the training requirements for all staff.

If training is considered to be mandatory for any staff group, consultation with Employee Development must be undertaken to ensure that the training requirements can be met.

8. Monitoring and Compliance

In this section provide details of how the standards within this Policy / Procedure will be monitored and how compliance or non compliance will be reported and acted upon.

9. References

Where appropriate, full details should be included that clearly identifies the source of any materials that the policy or procedure makes reference to. All BHNFT Policies and

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Procedures should include full details of any reference source that is used in developing the Policy or Procedure.

10. Attachments

Add attachments starting a new page for each attachment

The following attachments must be included:

Ratification Checklist (mandatory for all new policies and procedures and as appropriate for revised policies and procedures).

This details how stakeholders and service users have been involved in development and dissemination of the document and describes how the document will be launched and monitored. It is recommended that ratifying committees use this document to establish that appropriate procedures have been followed.

Equality Impact Assessment (EIA) (mandatory for all policies and procedures)

Include the Equality Impact Assessment

Launch and Implementation Plan (mandatory for all new policies and procedures and as appropriate for revised policies and procedures.

This provides a checklist for communication and implementation of the policy or procedure.

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Attachment xx: Consultation and Ratification Checklist

Title Title of Policy or Procedure, version number, month & year of development

Consultation and Ratification Checklist Details

1 Revised or New

Yes No

If Yes please provide details Are there any governance or risk implications? (e.g.

5 patient safety, clinical effectiveness, compliance with or

deviation from National guidance or legislation etc)

Yes No

If Yes please provide details

6 Are there any operational implications?

Yes No

If Yes please provide details

7 Are there any educational or training implications?

Yes No 8 Are there any clinical implications? If Yes please provide details

Policies and Procedures Framework v 1.0

Yes No

If Yes please provide details

9 Does the document have financial implications?

Yes No

If Yes please provide details

10 Does the document have HR implications?

Launch and Implementation Plan completed and 11 Yes No attached? Does the document have a review date in line with the 12 Yes No Policies and Procedures Framework?

Yes No

Date: ..………………………………………

Name of Committee or Executive Director: Has the document been approved/ratified by an 13 appropriate Committee or Executive Director? ………………………………………………..

Signature of Chair of Committee or Executive Director:

……………………………………………….

Yes 14 Reviewed by Local Counter Fraud Specialist Date: …………………………………………

Yes No

Date: ………………………………………… 15 Consultation and ratification checklist approved? Name of Trust Gatekeeper:

………………………………………………..

Policies and Procedures Framework v 1.0

Signature of Trust Gatekeeper:

……………………………………………….

Attachment xx: Equality Impact Assessment

Policies and Procedures Framework v 1.0

Attachment xx: Launch and Implementation Plan

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

Action Who When How Identify actions for the Identify who Determine Explain how actions will be launch and is when implemented implementation of the responsible actions new or revised policy or for are procedure implementing required identified actions

Appendix 1

Equality Impact Analysis

The purpose of Equality Analysis is to ensure that the Trust does not unwittingly discriminate against any groups recognised under the Equality Act 2010. These are: Age, Disability, Gender reassignment, Sexual Orientation, Race, Religion or Belief, Sex, Sexual orientation, Marriage & Civil partnership, Pregnancy and Maternity. An EqIA is a process which ensures the Trust eliminate unlawful discrimination, foster good relations between others and promote equality of opportunity in the take up of its services and employment practices.

Division/Department Quality and Governance

Policy/Service Policy; Policy and Procedures Framework Is this policy/service Existing/Revised New/Existing

Name of Assessor(s) Gill Feerick

Date of EqIA 07/04/14

Aims/Objectives/ To ensure that all Barnsley Purpose Of Hospital NHS Foundation Policy/Service Trust Policies and Procedures are developed, ratified, implemented, monitored, reviewed and archived in line with Trust Policy.

Associated Objectives Equality Act, 2010 for this Service e.g. National frameworks, Equality Act.

Does this policy/service Workforce and patients – this Affect patients or the policy ensures good workforce? governance around the development, implementation and control of Trust policy and procedures; clinical and non clinical. What outcomes do you To ensure that the Trust has

want to achieve from this a systematic approved

process? process for the development of all policies and procedures and to ensure that there is good governance arrangements in place in association with policies and procedures. What factors could Contribute Detract contribute/detract from the effective delivery of N/A N/A this policy/service?

Are there any concerns Race No What existing equality that this service or policy evidence either presumed or could have a differential otherwise do you have for impact on or due to the this response? following: All future policies and procedures written and managed under the guidance of this framework document will be developed, consulted, implemented, reviewed and controlled in a manner which will have no differential impact on or due to race. All approved documents will be managed under the governance arrangements of the organisation. All documents will be consulted upon by relevant groups and committees before approval and ratification is sought. Age No All future policies and procedures written and managed under the guidance of this framework document will be developed, consulted, implemented, reviewed and controlled in a manner which will have no differential impact on or due to age. All approved documents will be managed under the governance arrangements of the

organisation. All documents will be consulted upon by relevant groups and committees before approval and ratification is sought. Disability No All future policies and procedures written and managed under the guidance of this framework document will be developed, consulted, implemented, reviewed and controlled in a manner which will have no differential impact on or due to disability. All approved documents will be managed under the governance arrangements of the organisation. All documents will be consulted upon by relevant groups and committees before approval and ratification is sought. Gender Reassignment No All future policies and procedures written and managed under the guidance of this framework document will be developed, consulted, implemented, reviewed and controlled in a manner which will have no differential impact on or due to gender re-assignment. All approved documents will be managed under the governance arrangements of the organisation. All documents will be consulted upon by relevant groups and committees before approval and ratification is sought. Religion/Belief No All future policies and procedures written and managed under the guidance of this framework document will be developed, consulted, implemented, reviewed and controlled in a

manner which will have no differential impact on or due to religion/belief. All approved documents will be managed under the governance arrangements of the organisation. All documents will be consulted upon by relevant groups and committees before approval and ratification is sought. Sexual Orientation No All future policies and procedures written and managed under the guidance of this framework document will be developed, consulted, implemented, reviewed and controlled in a manner which will have no differential impact on or due to sexual orientation. All approved documents will be managed under the governance arrangements of the organisation. All documents will be consulted upon by relevant groups and committees before approval and ratification is sought. Pregnancy Maternity No All future policies and procedures written and managed under the guidance of this framework document will be developed, consulted, implemented, reviewed and controlled in a manner which will have no differential impact on or due to pregnancy/maternity. All approved documents will be managed under the governance arrangements of the organisation. All documents will be consulted upon by relevant groups and committees before approval and ratification is sought.

Marriage Civil Partnership No All future policies and procedures written and managed under the guidance of this framework document will be developed, consulted, implemented, reviewed and controlled in a manner which will have no differential impact on or due to marriage/civil partnership. All approved documents will be managed under the governance arrangements of the organisation. All documents will be consulted upon by relevant groups and committees before approval and ratification is sought. Sex No All future policies and procedures written and managed under the guidance of this framework document will be developed, consulted, implemented, reviewed and controlled in a manner which will have no differential impact on or due to sex. All approved documents will be managed under the governance arrangements of the organisation. All documents will be consulted upon by relevant groups and committees before approval and ratification is sought. Human Rights No All future policies and procedures written and managed under the guidance of this framework document will be developed, consulted, implemented, reviewed and controlled in a manner which will have no differential impact on or due to human rights. All approved documents will be managed under the

governance arrangements of the organisation. All documents will be consulted upon by relevant groups and committees before approval and ratification is sought. If you have answered yes to any of the above, please describe or attach any evidence of action which will mitigate your EqIA and ensure your policy/service will be able to show: • Eliminate discrimination • Promote equal opportunities • Foster good relations between others

Should the EqIA proceed Yes No Comments to a full EqIA for the areas identified for No attention? Comments

Send to: Equality and Diversity Beverley Powell, Equality and Diversity Advisor Advisor for signature and authorisation Send to: Line Manager for signature and Heather Mcnair, Director of Nursing and Quality authorisation

Head of Department Responsible for policy or Gill Feerick, Head of Quality and Clinical Governance service

When is the next review (please note review should be immediate on any amendments to your policy etc)

1 Year N/A 2 Year N/A

3 Year April 2017

Appendix 3

POLICY CONTROL SHEET (updated January 2014)

Policy Title and ID number: TRAINING POLICY FOR OBTAINING CONSENT GEN 7.27 Sponsoring Director: MEDICAL DIRECTOR Implementation Lead: Head of Quality & Clinical Governance (a) To patients Yes / No (b) To Staff Yes / No (c) Financial Yes / No Impact: (d) Equality Impact Assessment (EIA) Completed: Yes / No (e) Counter Fraud assessed Completed: Yes / No (f) Other Training implications: To be incorporated into induction: Yes / No

Local Approval Process Date Consultation

Executive Led Committee/Board Joint Partnership Forum Local Negotiating Board Committee: Committee

Infection Control • Clinical Governance / Committee: Date of consultation: • Non Clinical Governance & Risk Health & Safety Board • Audit Committee Quality Safety 07.05.14 Improvements & • Finance Committee Effectiveness Board • RATS Investment Board Patients Experience Trust Board Approval / Ratification Board Information Governance Other: Board Workforce Board Approval/Ratification at Trust Board: Version Number: Date on Policy Warehouse: Team Brief Date: Circulation Date: Date of next review:

For completion by ET for new policies only: Revenue or Non Budget Code: Revenue (a) Training £ Additional Costs (b) Implementation £ (c) Capital £ (d) Other £

Barnsley Hospital NHS Foundation Trust

TRAINING POLICY FOR OBTAINING CONSENT Policy ID number: GEN 7.27

Author: Head of Quality and Clinical Governance

Consent Training Policy CONTENTS

1. INTRODUCTION……………………………………………………………. Page 3 1.1 Purpose………………………………………………………………… Page 3 1.2 Scope…………………………………………………………………… Page 3 1.3 Definitions……………………………………………………………… Page 3

2. CONSENT TRAINING POLICY…………………………………………… Page 4 2.1 Process for identifying staff authorised to consent……………….. Page 4 2.2 Professional training and competence……………………………… Page 5 2.3 Consent training……………………………………………………….. Page 5 2.3.1 General principles of consent…………………………………. Page 5 2.4 Delegate consent training…………………………………………….. Page 5 2.4.1 General principles of consent…………………………………. Page 5 2.4.2 Procedure specific elements of consent…………………….. Page 5 2.4.3 Post mortem consent training…………………………………. Page 6 2.5 Records training and competence…………………………………... Page 6 2.5.1 General consent training………………………………………. Page 7 2.5.2 Procedure specific consent training………………………….. Page 7 2.5.3 Post mortem consent training…………………………………. Page 7 2.6 Unauthorised consent………………………………………………… Page 7 3. ROLES AND RESPONSIBILITIES……………………………………….. Page 7 3.1 Chief Executive………………………………………………………... Page 7 3.2 The Board of Directors………………………………………………... Page 8 3.3 Head of Quality and Governance…………………………………… Page 8 3.4 Clinical Directors………………………………………………………. Page 8 3.5 Speciality Leads……………………………………………………….. Page 8 3.6 Consultants/Senior Nursing staff……………………………………. Page 8 3.7 Patient Safety and Quality Group……………………………………. Page 8 3.8 Human Tissue Act (HTA) Designated individual…………………… Page 8 4. MONITORING COMPLIANCE……………………………………………. Page 9 4.1 Process…………………………………………………………………. Page 9 4.1.1 Monitoring ………………………………………………………. Page 9 4.1.2 Audit………………………………………………………………. Page 9

5. REFERENCE DOCUMENTS………………………………………………. Page 9 6. ASSOCIATED DOCUMENTATION……………………………………….. Page 9 7. APPENDICES……………………………………………………………….. Page 9 7.1 Example of Procedure Specific Consent Training Record………… Page 10 7.2 Procedure Specific Consent Training and Competence Record….. Page 11

1. INTRODUCTION 1.1. Purpose Patients have a legal and ethical right to determine what happens to their own bodies.

Barnsley Hospital NHS Foundation Trust (BHNFT) is committed to ensuring that consent should only be taken by health professionals who have a thorough knowledge of the procedure, and the implications of the procedure that the patient is undergoing. This is to ensure that the patient has received appropriate information to make an informed choice.

Full and complete details of relevant consent processes are available in the BHNFT Consent Policy and the Post Mortem Consent : Standard Operating Procedure SOP-CP-MORT-D-6.

The aims of this training policy are:

1. To clarify who can seek consent for procedures and post-mortems at BHNFT. 2. To outline the process for ensuring that all appropriate staff are competent and are equipped with the knowledge, skills and attitudes essential for obtaining informed consent. 3. To describe the evidence that will be required to demonstrate competence and training in relation to consent.

1.2. Scope Consent is a patient’s agreement for a health professional to provide care at all levels. This policy therefore applies to all staff employed by BHNFT who have a role in information provision to patients, carers and relatives and who are involved in direct patient care. Patients may indicate consent non-verbally (for example by presenting their arm for their pulse to be taken), orally or in writing. For obtaining consent from Children and Young People please see BHNFT Seeking Consent: Working With Children for guidance.

For the consent to be valid, the patient consenting must have the relevant mental capacity to do so : • be able to receive and retain treatment information • to believe it • to weigh the information in order to reach a decision • to communicate his/her decision.

The provision of information during the consent process must cover not only the proposed procedure, and associated risks and benefits, and alternatives but also any consequences of that procedure..

1.3. Definitions Procedure - an activity directed at or performed on an individual with the object of improving health, treating disease or injury, or making a diagnosis by a clinician (e.g. doctor, nurse or other allied health professional) who is trained and competent in that procedure.

Consent - a patient’s agreement for a health professional to provide care, or agreement for a health professional to undertake a procedure, including post mortem.

Delegated consent - the taking of consent by a professional other than the person who will perform the procedure.

2. CONSENT TRAINING POLICY The health professional providing the treatment or investigation is responsible for ensuring that the person has given valid consent before treatment begins. In most cases consent will be sought by the health professional carrying out a procedure on a patient. However, in certain circumstances where written consent is being sought it may be appropriate for other members of the clinical team to participate in the process of seeking consent.

The GMC guidance states that the task of seeking consent may be delegated to another person, as long as they are suitably trained and qualified. In particular, they must have sufficient knowledge of the proposed investigation or treatment, and understand the risks involved, in order to be able to provide any information the patient may require. Thus, pre-op assessment or specialist nurses, who would not perform a procedure themselves, may still be trained to take consent for the procedure.

There are specific requirements under the Human Tissue Act for consent for a post mortem examination, as it is unusual for the patient to have given consent before their death. See section 2.4.3 below.

2.1. Process for identifying staff authorised to consent Within BHNFT, the person seeking consent for a procedure will be either:

a. The person performing that procedure b. Sufficiently trained and experienced staff confident, competent and capable of seeking delegated consent for the procedure.

If a specialty feels that an individual needs specific training to take delegated consent for a particular procedure, the is required to provide that training and be assured that the individual is competent before they seek consent for that procedure.

In order for a specialty or to delegate the taking of consent to other staff for specified procedures other than those trained to perform the procedures, the following must be available:

• The procedure is on a list of procedures suitable for delegated consent, approved by the Clinical Lead for the specialty, and published on the intranet. It is expected that these procedures will be relatively common and generally lower risk. Procedures that are more complex and higher risk would not be suitable for delegated consent and the person performing the procedure would be expected to consent the patient personally.

• There is, whenever possible, written patient information available specific to that procedure. • There is a customised consent form specific to that procedure detailing the specific risks, benefits and the written patient information to be provided. • There are procedure specific consent training materials and a specialty training programme detailing who will provide the training AND • The person to whom the seeking of consent is delegated has completed general and procedure specific consent training, and who are up to date with refresher training or competency assessments when relevant.

This policy outlines the processes in place to ensure that these elements can be managed effectively.

2.2. Professional training and competence Healthcare staff are professionally trained to undertake many simple or complex procedures for which they seek implied, verbal or written consent. Consent training is an integral part of that professional training. Consent competence in this situation is part of the professional competence of the person to perform the procedure and is outside the remit of this policy.

2.3. Consent Training A corporate curriculum has been developed within the Trust. Staff are expected to refer to the corporate curriculum to identify the training needs of relevant groups of staff with regard to consent training.

2.3.1. General principles of consent All staff involved in seeking consent for procedures including post mortems, must ensure that their knowledge of consent remains up to date as this subject is influenced by case law. Guidance and recommendations will inevitably change over time.

All clinical staff will have training on the general principles of consent as part of their corporate induction. The organisation will provide updated training to relevant staff when guidance and recommendations change significantly. Senior clinicians will be required to ensure that this information is cascaded appropriately to relevant staff.

2.4. Delegated Consent Training Clinical staff may be trained to seek consent for the approved list of procedures in their specialty. Training must ensure these staff have sufficient understanding and knowledge of the process of consent and the procedure, in order to provide complete and accurate information, appropriate to the needs of the individual patient and are therefore competent to seek informed consent.

2.4.1. General principles of consent Staff being trained to seek delegated consent must have completed general consent training within the previous 12 months. See section 2.3

2.4.2. Procedure specific elements of consent Details of specialty consent training will be required before the specialty or is authorised to train staff to seek delegated consent. Procedure specific consent training will be delivered by senior clinicians within the specialty, as specified in the specialty consent training register submitted to The Patient Safety & Quality Group.

Procedure specific training materials will include the following elements:

1. Procedure specific information a. What is involved, before, during and after the procedure b. Risks, benefits and alternatives to the procedure c. Additional procedures that might be necessary e.g. blood transfusion 2. Customised consent form for the procedure 3. Information for patients and carers about the procedure and anaesthetic

Procedure specific consent training programmes will include:

1. Observation of senior clinical staff consent practice 2. Supervised practice by senior clinical staff 3. Assessment of competence by senior clinician

The precise training requirements for observation, supervised practice and assessment of competence will depend on the previous experience of the practitioner.

When the training, and any period of observation and supervised practice has been completed, a senior clinician is required to confirm that the trainee practitioner has been trained and is competent to seek consent for the specified procedure/s (see 2.5.2). The record of competence must be held locally within the speciality or by the most senior clinician.

Staff may bring evidence of consent training during previous employment. The senior clinician or trainer within the specialty should assess this, and confirm competence to seek consent for the relevant procedures.

2.4.3. Post mortem consent training Specific training in seeking consent for post mortem from relatives will be required for all staff seeking that consent. The training programme will be developed and approved by the HTA designated lead.

Training will cover the following elements:

1. Coroner system 2. Death certificate completion 3. Post Mortem Consent: Standard Operating Procedure 4. Bereavement support and information 5. HTA standards regarding consent

2.5. Records of training and competence Attendance at all consent training, and any competence assessments must be recorded. All attendance records and records of completion of consent training, excluding post mortem consent training, must be held locally within the speciality or by the most senior clinician.

2.5.1. General consent training An attendance record of those attending any general consent training, will be recorded on the ESR by Learning and Development.

2.5.2. Procedure specific consent training A record of completion of procedure specific training and competence on “Procedure Specific Consent Training and Competence” (see 7.2) is required as evidence. As procedure specific consent training may occur over a period of time, there is a Consent Training Record sheet (see 7.1) for trainee practitioners to collect the evidence of their training if required.

The Clinical Director of the Clinical Business Unit will be responsible for ensuring that all procedure specific consent training records are maintained within the specialty or by the most senior clinician. The Clinical Director will record the specified procedures agreed as suitable for delegated consent for each specialty or within the Clinical Business Unit authorised to use delegated consent by the Patient Safety and Quality Group.

2.5.3. Post mortem consent training An attendance record of those attending post mortem consent training is required, and is held by the HTA designated lead.

2.6. Unauthorised Consent Regular audits by the Quality Assurance and Effectiveness team will identify any staff who have obtained consent for a procedure that they have not performed. The requirements of section 2.1 will then be sought for the procedures and staff identified. Any staff who are identified as having obtained consent without apparently being authorised to do so, will initially be discussed with the clinical leads to check whether they are actually capable of performing the relevant procedure.

The findings will be shared with the relevant Clinical Director and the Patient Safety and Quality Group, and appropriate action will be taken to ensure that any unauthorised consent is effectively addressed within the relevant specialty. If unauthorised consent continues to be identified, the

authority to delegate consent within that specialty will be reviewed by the Patient Safety and Quality Group.

Informing the GMC of unauthorised consent will be the decision and responsibility of the Medical Director.

3. ROLES AND RESPONSIBILITIES

3.1. Chief Executive The Chief executive is accountable for all consent processes.

3.2. The Board of Directors The Board of Directors is responsible for ratifying the Consent Policy

3.3. Head of Quality & Clinical Governance The Head of Quality & Clinical Governance is responsible for ensuring that the policies and forms for consent are kept up to date with changing legislature. He/she is also available to give advice. He/she will be responsible for ensuring the continued availability of general consent training. He/she will ensure that the organisation provides training updates to specialty leads when national guidance regarding consent is significantly changed.

3.4. Clinical Directors Clinical Directors are responsible for ensuring that the Consent Training Policy is followed and that only appropriately trained personnel take consent in their Clinical Business Unit. They are responsible for identifying the consultant and senior nursing staff who will provide procedure specific delegated consent training and assessment within the relevant speciality.

3.5. Specialty Leads Specialty leads will be responsible for identifying the procedures suitable for delegated consent. They will develop or approve the procedure specific consent training for staff required to seek delegated consent within their specialty.

3.6. Consultants / Senior Nursing Staff / Senior Allied Health Professionals Consultants and Senior Nursing Staff will be responsible for ensuring that their junior staff are appropriately trained in general and procedure specific consent, before they are asked to seek consent from patients, and that this will only be for procedures approved for delegated consent.

3.7 Doctors, nurses and other allied health professionals

Doctors, nurses and other allied health professionals are appropriately trained in general and procedure specific consent, before they are asked to seek consent from patients, and that this will only be for procedures approved for delegated consent.

3.7. Patient Safety and Quality Group The Patient Safety and Quality Group, is responsible for approving the Consent Training Policy and will receive audits and monitoring reports. The Board will authorise specialties to train staff in delegated consent once they are satisfied that the requirements of this policy have been met.

The Board will review consent audit results and consider actions to be taken to address any identified unauthorised delegated consent.

3.8. Human Tissue Act (HTA) Designated Individual The HTA designated individual is responsible for providing training in consent for post mortems and for maintaining appropriate training records.

4. MONITORING COMPLIANCE AND EFFECTIVENESS 4.1. Process for Monitoring Compliance

4.1.1. Monitoring Training figures will be monitored as specified in the Training Needs Analysis Policy.

4.1.2. Audit There are regular audits of the consent process, undertaken by Quality Assurance and Effectiveness team. These monitor compliance with the documentation of the consent process and compliance with the Consent Training Policy. The audits aim to confirm that consent is only taken by staff authorised to do so.

Evidence of post-mortem consent training will be required from the HTA designated individual.

5. REFERENCE DOCUMENTS Department of Health: Reference Guide to consent for examination or treatment. Second Edition 2009

Department of Health: Mental Health Act 1983

Mental Capacity Act 2005

Human Tissue Authority Code of Practice 1: Consent July 2006

General Medical Council: Consent: Patients and Doctors Making Decisions Together June 2008

6. ASSOCIATED DOCUMENTATION

Barnsley Hospital NHS Foundation Trust Consent Policy

BHNFT Seeking Consent: Working With Children

BHNFT Customised Consent Forms

BHNFT Consent Patient Information

BHNFT Post Mortem Consent : Standard Operating Procedure SOP-CP- MORT-D-6

Appendices 7.1 Example of Procedure Specific Consent Training Record 7.2 Procedure Specific Consent Training and Competence Record

7.1. Example of Procedure Specific Consent Training Record

CONSENT TRAINING RECORD

Name…………………………………………..………………………………………………………

Specialty………………..……………………………………………………………………………..

Job Title......

Date General Consent Training Completed (must be within last 12 months) ..…./..…./…….. ______

Procedure for which training is taking place…………………………………….

Observation of senior clinical staff consent practice:

Dates

Procedure specific consent training by senior clinician:

Date Signed by trainer ………………......

Supervised practice by senior clinical staff:

Dates Signed by supervisor…………………………………

Signed by supervisor…………………………………

Procedure for which training is taking place…………………………………….

Observation of senior clinical staff consent practice:

Dates

Procedure specific consent training by senior clinician:

Date Signed by trainer ………………......

Supervised practice by senior clinical staff:

Dates Signed by supervisor…………………………………

Signed by supervisor…………………………………

This record may be used to collect evidence of procedure specific consent training and if used, should be presented to the senior member of the clinical team who will complete the PROCEDURE SPECIFIC CONSENT TRAINING AND COMPETENCE

7.2. Procedure Specific Consent Training and Competence Record

PROCEDURE SPECIFIC CONSENT TRAINING AND COMPETENCE

Name……………………………………………………………………………………………………

Specialty……………….………………..……………………………………………………………..

Job Title......

Date General Consent Training Completed (must be within last 12 months) ..…./..…./…….. ______

I have completed training in the general and specific principles of consent relevant to the following specialty procedures approved for delegated consent:

1. ……………………………………………………………………………..

2. ……………………………………………………………………………….

3. ……………………………………………………………………………….

4. ………………………………………………………………………………...

5. …………………………………………………………………………………

6. …………………………………………………………………………………

I understand that I am not able to seek consent for any other procedures that I am unable to perform without completing additional procedure specific consent training.

Signature…...... Date…………………………………..

Assessment of Competence by senior member of Clinical team: For the above specified procedures, the named practitioner has provided evidence of previous training and competence, or has completed training and demonstrated competence in relation to:

1. A good working knowledge of the policies and practice guidelines in relation to obtaining consent. 2. An understanding of the process of obtaining consent. 3. An ability to provide a comprehensive explanation and education to the patient about the procedure, risks, benefits and alternative options. 4. An understanding of the possible problems encountered when obtaining consent and is able to describe the appropriate action to be taken. 5. An understanding of the importance of accurate and complete documentation of information provision and consent. 6. An ability to identify appropriately when to refer the consent to a more experienced practitioner.

Signature………………………………………………………. Date……………………………

Name (print)…………………………………………………… Job Title……………………….

Equality Impact Analysis Template

Division/Department Quality and Governance

Policy/Service TRAINING POLICY FOR OBTAINING CONSENT Is this policy/service New/Existing New

Name of Assessor(s) Julian Newell

Date of EqIA 2/5/2014

Aims/Objectives/ To clarify who can seek Purpose Of consent for procedures and

Policy/Service post-mortems at BHNFT and to outline the process for obtaining consent Associated Objectives Department of Health: for this Service e.g. Reference Guide to consent National frameworks, for examination or treatment. Equality Act. Second Edition 2009

Department of Health: Mental

Health Act 1983

Mental Capacity Act 2005

Human Tissue Authority Code of Practice 1: Consent

1 Revised version February 2013

July 2006

General Medical Council: Consent: Patients and Doctors Making Decisions Together June 2008

Does this policy/service Workforce

Affect patients or the workforce?

What outcomes do you Improved safety and quality want to achieve from this assurance for obtaining process? consent for procedures at BHNFT What factors could Contribute Detract contribute/detract from the effective delivery of this policy/service? Implementation of this policy Failure to follow the policy

Are there any concerns What existing equality that this service or policy Race no evidence either presumed or could have a differential otherwise do you have for impact on or due to the this response? following: This policy has been written to ensure that all staff being asked to take consent for a procedure are trained and competent to do so. There has been wide consultation with all nursing, AHP and clinical leads. Age no This policy has been written to ensure that all staff being asked to take consent for a procedure are trained and competent to do so. There has been wide consultation with all nursing, AHP and clinical leads.

2 Revised version February 2013

Disability no This policy has been written to ensure that all staff being asked to take consent for a procedure are trained and competent to do so. There has been wide consultation with all nursing, AHP and clinical leads. Gender Reassignment no This policy has been written to ensure that all staff being asked to take consent for a procedure are trained and competent to do so. There has been wide consultation with all nursing, AHP and clinical leads. Religion/Belief no This policy has been written to ensure that all staff being asked to take consent for a procedure are trained and competent to do so. There has been wide consultation with all nursing, AHP and clinical leads. Sexual Orientation no This policy has been written to ensure that all staff being asked to take consent for a procedure are trained and competent to do so. There has been wide consultation with all nursing, AHP and clinical leads. Pregnancy Maternity no This policy has been written to ensure that all staff being asked to take consent for a procedure are trained and competent to do so. There has been wide consultation with all nursing, AHP and clinical leads. Marriage Civil Partnership no This policy has been written to ensure that all staff being asked to take consent for a procedure are trained and competent to do so. There has been wide consultation

3 Revised version February 2013

with all nursing, AHP and clinical leads.

Sex no This policy has been written to ensure that all staff being asked to take consent for a procedure are trained and competent to do so. There has been wide consultation with all nursing, AHP and clinical leads. Human Rights no This policy has been written to ensure that all staff being asked to take consent for a procedure are trained and competent to do so. There has been wide consultation with all nursing, AHP and clinical leads. If you have answered yes to any of the above, please describe or attach any evidence of action which will mitigate your EqIA and ensure your policy/service will be able to show: • Eliminate discrimination • Promore equal opportunities • Foster good relations between others

Should the EqIA proceed Yes No Comments to a full EqIA for the areas identified for X attention? Comments

Send to: Equality and Diversity Advisor for signature and authorisation

4 Revised version February 2013

Send to: Line Manager for signature and authorisation

Head of Department Responsible for policy or service

When is the next review (please note review should be immediate on any amendments to your policy etc)

1 Year

2 Year

3 Year

5 Revised version February 2013

REPORT TO THE BOARD OF REF: BARNSLEY HOSPITAL NHSFT 14/08/P-13

SUBJECT: FINANCE & PERFORMANCE ASSURANCE REPORT DATE: AUGUST 2014 Tick as Tick as applicable applicable

For decision/approval √ Assurance √ PURPOSE: For review Governance For information Strategy Francis Patton, Non Executive Director, Chair Finance & PREPARED BY: Performance Committee Francis Patton, Non Executive Director, Chair Finance & SPONSORED BY: Performance Committee Francis Patton, Non Executive Director, Chair Finance & PRESENTED BY: Performance Committee STRATEGIC CONTEXT 2-3 sentences The current financial environment for the Trust is extremely challenging and it is essential that the Board is assured that both financial and general performance of the Trust is effectively managed and that the Trust remains viable.

The Finance & Performance Committee has been put in place under the new Governance structure to provide assurance to the Board of Directors in relation to complex financial and operational matters following detailed analysis and challenge of both the financial and operational reports received.

QUESTION(S) ADDRESSED IN THIS REPORT Is the F&P Committee fully up and running in its new format?

What issues need escalating from F&P to full board?

CONCLUSION AND RECOMMENDATION(S) The Finance & Performance Committee is still in transition with the structure, attendance and format of reports still in development however it has made good advances in its first two meetings.

Issues that need escalating to Board are:- • Timing of meetings needs review. • Board assurance for BHSS. • Radiology management • Capital programme. • EPR Updates on:- • Terms of reference • Finance reporting to Board • Business cases • Advisory reports

The Board is asked to accept this report, note progress and agree to review the sequence of meetings leading up to Board (for 2015).

BoD August 2014: 13F&P Assurance report

REFERENCE/CHECKLIST • Which business plan objective(s) does this report relate to? Patients BCCG Other

• Please state: Has this report considered the Staff BMBC following stakeholders? Governors Monitor

Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution etc) • Has this report reviewed the Trust’s compliance with: Equality, Diversity & Human Rights

The Trust's sustainability strategy

• Has this report Quality & Governance (in draft or during Yes • Is this report development) been Audit Committee supported by a reviewed and Not applicable communications supported by any Finance & Performance plan? Board or Executive To be developed committee within the ET Trust? • Where applicable, briefly identify risk issues (including any reputation) and cross reference to risk register and governance committees • Where applicable, state Finance: resource requirements: Other:

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: Providing the best healthcare for all”

BoD August 2014: 13F&P Assurance report

Subject: Finance & Performance Committee Assurance Report Ref: 14/08/C/-13

CHAIR’S LOG: Chair’s Key Issues and Assurance Model Committee / Group Date Chair Finance and Performance Committee 24th July 2014 Francis Patton, Non Executive Director

Agenda Item Issue and Lead Officer Receiving Body, i.e. Board or Recommendation/ Assurance/ Committee mandate to receiving body Timing of meetings It has become apparent that the Reported to Board of Directors It is recommended that the Board timings and flow of meetings – F&P Chair’s Log August reviews meeting dates to improve the needed to provide assurance to 2014 assurance provided to Board Board don’t work under the new structure and need reviewing. Board Assurance With assurance for BHSS Reported to Board of Directors The F&P Committee has agreed that with reference to coming through F&P and the – F&P Chair’s Log August the Deputy Chair (DOF) will take the BHSS Chair of F&P also being Chair of 2014 Chair when BHSS is on the agenda. BHSS the Board needs assurance that governance is in place. CBU 5 Radiology The Radiology Manager has Reported to Board of Directors The F&P Committee will keep this area Manager handed in his notice and the – F&P Chair’s Log August under review but will also be pushing Deputy post is also vacant 2014 for full succession plan development creating a significant risk to the throughout the Trust. The committee organisation. will keep the Board informed of progress in both areas. Capital Programme With the necessary restrictions Reported to Board of Directors The F&P Committee will keep this area on capital expenditure for the – F&P Chair’s Log August under review updating the board as present financial situation, 2014 and when required. questions were raised as to the Trust’s ability to deal with any emergencies arising on essential maintenance. It was confirmed that there was no spare in the budget.

BoD August 2014: 13_F & P Assurance report Page 1 of 3

Agenda Item Issue and Lead Officer Receiving Body, i.e. Board or Recommendation/ Assurance/ Committee mandate to receiving body EPR Whilst the Director of ICT was Reported to Board of Directors The F&P Committee has sought confident in the EPR – F&P Chair’s Log August assurance from the Director of ICT for programme plan and delivery a 2014 the next meeting of F&P that he has number of the CBUs were spoken to and dealt with issues flagged flagging issues with its by the CBUs. This will be triangulated implementation. through the CBU reports. Terms of Reference Assurance on finance Reported to Board of Directors CBUs attended F&P for the first time in and Committee /performance to be gained from – F&P Chair’s Log July 2014 July. Only two CBUs were represented Membership/ CBU/departments. CBUs to and reports needed developing. The Attendance attend Committee meetings to Chair of F&P will meet with the General discuss CBU performance. Managers from CBUs to brief them on the committee’s requirements. Directors required to send well briefed Deputies in their Agreed by Directors. absence. A number of minor changes will need F&P TOR to be finalised by to be made to TOR for F&P, these will Assoc Dir of Corp Affairs. be confirmed at the August meeting and recommended to September board. Reporting to the Director of Finance to provide Reported to Board of Directors F&P Committee requested sight of Board (Finance) financial detail to Board within – F&P Chair’s Log July 2014 Creditors and Debtors. This was integrated performance report reviewed in detail and a summary will supplemented by F&P Chair’s now form part of the Finance Report to log and/or escalation report to Board. be used to provide further detail if required.

Page 2 of 3 BoD August 2014: 13_F & P Assurance report

Agenda Item Issue and Lead Officer Receiving Body, i.e. Board or Recommendation/ Assurance/ Committee mandate to receiving body Business Case New process approved. Reported to Board of Directors Implemented Approval Process Changes to delegated authority – F&P Chair’s Log July 2014 for approval for business cases proposed: - Exec team up to £50,000 - F&P from £50,001 to £150,000. Larger cases to be endorsed by F&P subject to Board No cases this month. ratification. Advisory Reports – F&P to receive a tracker on all Reported to Board of Directors Project Allerton remains the only Allerton external and internal reports – F&P Chair’s Log July 2014 advisory report and no areas need providing an update on actions flagging to board. and any issues identified. Currently this is only Project Allerton.

Page 3 of 3 BoD August 2014: 13_F & P Assurance report

REPORT TO THE BOARD OF BARNSLEY REF: HOSPITAL NHSFT 14/08/P-14

SUBJECT: AUDIT COMMITTEE – CHAIR’S LOG

DATE: AUGUST 2014

Tick as Tick as applicable applicable For decision/approval Assurance  PURPOSE: For review  Governance  For information Strategy PREPARED BY: Paul Spinks, Non Exec Director & Audit Committee Chair SPONSORED BY: Paul Spinks, Non Exec Director & Audit Committee Chair PRESENTED BY: Paul Spinks, Non Exec Director & Audit Committee Chair STRATEGIC CONTEXT 2-3 sentences

Integral to the Trust’s governance arrangements.

QUESTION(S) ADDRESSED IN THIS REPORT

Has the Committee identified any issues to report to bring to the attention of the Board?

CONCLUSION AND RECOMMENDATION(S)

The Board is asked to note this report and respond to the issues referred for escalation.

BoD Aug 2014: 14_Audit Committee REFERENCE/CHECKLIST • Which business plan objective(s) does this report relate to? Patients BCCG Other

• Please state: Has this report considered the Staff BMBC following stakeholders? Governors Monitor

Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution etc) • Has this report reviewed the Trust’s compliance with: Equality, Diversity & Human Rights

The Trust's sustainability strategy

• Has this report Quality & Governance (in draft or during • Yes Is this report development) been Audit Committee supported by a reviewed and Not applicable communications supported by any Finance & Performance plan? Board or Executive To be developed committee within the ET Trust? • Where applicable, briefly identify risk issues (including any reputation) and cross reference to risk register and governance committees • Where applicable, state Finance: resource requirements: Other:

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: Providing the best healthcare for all”

BoD Aug 2014: 14_Audit Committee CHAIR’S LOG: Chair’s Key Issues and Assurance Model Committee / Group Date Chair Other Attendees Audit Committee 17July 2014 Paul Spinks Suzy Brain England

Agenda Item Issue and Lead Officer Receiving Recommendation/ Assurance/ Body, i.e. mandate to receiving body Board or Committee Terms of Reference Angela Keeney Main Board The final revised Terms of Reference will need to be approved We made a significant number of requests for by Board as part of its overall amendment or clarification to the Terms of Governance arrangements. Reference that had previously been presented to the Board. Internal Audit Diane Wake Main Board The Board is asked to ensure that Progress Report – appropriate action is taken to ensure Recommendations We expressed concern at the number of actions that agreed recommendations are Tracker were shown as overdue. The Committee agreed that implemented. rather than discussing individual reports at this stage we would include this in our escalation report to the Board on the need for executive leads to ensure that agreed action plans are implemented. Internal Audit Angela Keeney / Jugnu Mahajan Main Board We are drawing the Board's attention to the risks associated with We expressed concern on the results of the the number of Job Plans that have Consultant Job Plans audit and requested that an still to be agreed and the lack of executive lead attend to present an update of procedures for monitoring actions taken at a future Audit Committee. performance against these Plans. External Audit ISA Steve Wragg / Francis Patton Main Board We require clarification on our 260 Report on BHSS BHSS responsibilities for BHSS. We were unable to provide external audit with the requested assurances as no members of the Audit Committee were on the Board of BHSS.

BoD Aug 2014: 14_Audit Committee p1 of 2

Agenda Item Issue and Lead Officer Receiving Recommendation/ Assurance/ Body, i.e. mandate to receiving body Board or Committee Single Tenders Stuart Diggles / Tim Spensley Main Board The Board is asked to note our request for a review of this contract. We requested a review of the procurement process on the KPMG contract from procurement in view of the very significant amount involved.

BoD Aug 2014: 14_Audit Committee p2 of 2

REPORT TO THE BOARD OF REF: 14/08/P-15 BARNSLEY HOSPITAL NHSFT

TERMS OF REFERENCE FOR GOVERNANCE COMMITTEES - SUBJECT: PROPOSED GOVERNANCE STRUCTURE DATE: AUGUST 2014

Tick as Tick as applicable applicable

For decision/approval  Assurance  PURPOSE: For review Governance  For information Strategy PREPARED BY: Angela Keeney, Interim Assoc Director of Corporate Affairs SPONSORED BY: Diane Wake, Chief Executive PRESENTED BY: Angela Keeney, Assoc Interim Director of Corporate Affairs STRATEGIC CONTEXT 2-3 sentences

To build on the Trust’s governance structure to ensure clear and robust governance reporting and escalation arrangements are in place, supporting all aspects of the Trust’s service delivery.

QUESTION(S) ADDRESSED IN THIS REPORT

Do the amended Terms of Reference (TOR) for the Board’s governance committees sufficiently address the points raised by the Board in July 2014 and support the role of the Committees?

CONCLUSION AND RECOMMENDATION(S) The governance committees have each taken steps to review and revise their respective TOR to ensure that they fully support the committees’ role in giving assurance (or otherwise) to the Board on issues under their remit: • the Audit Committee reviewed and amended its TOR at its meeting on 17th July; • the Finance & Performance Committee reviewed its TORs in both June (as the last meeting of the Finance Committee) and July. Due to time constraints in July, members were asked to comment further outside the meeting to the Committee’s Chair. • The Quality & Governance has not yet had opportunity to receive and revise its TOR (July meeting was the final meeting of the Clinical Governance Committee, focused on close down and handover of its work). They have been reviewed by the Chair and Executive Lead of the Committee but will be subject to further discussion at the Committee’s next meeting. The attached drafts have been revised in accordance with the Board’s comments at the last meeting and feedback from each of the governance committees, as above. The governance structure has also been updated to reflect the Committees’ needs and comments (e.g. Research & Development reporting to Finance & Performance rather than Quality & Governance). The Board is asked to: • review the attached report • approve the proposed structure, amended terms of reference and escalation framework – subject to any final changes from the Committee Chairs, and • delegate authority to the Chairman and Chief Executive to give further and final approval on behalf of the Board in the event that any material changes are requested from the Committees following their next meetings.

BoD Aug2014: ToR cover sheet Page 1

REFERENCE/CHECKLIST • Which business plan objective(s) does this report relate to? Patients BCCG Other

• Please state: Has this report considered the Staff BMBC following stakeholders? Governors Monitor

Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution etc) • Has this report reviewed the Trust’s compliance with: Equality, Diversity & Human Rights

The Trust's sustainability strategy

• Has this report Quality & Governance (in draft or during Yes • Is this report development) been Audit Committee supported by a reviewed and Not applicable communications supported by any Finance & Performance plan? Board or Executive To be developed committee within the ET Trust? • Where applicable, briefly identify risk issues (including any reputation) and cross reference to risk register and governance committees • Where applicable, state Finance: resource requirements: Other:

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: Providing the best healthcare for all”

BoD Aug2014: ToR cover sheet Page 2

Governance Structure

Barnsley Hospital NHS Foundation Trust

Assurance and Escalation Framework

1.0 Introduction / Background

The Trust acknowledges governance as an integral process to services which ensure that there are demonstrable systems in place. This links strategic and operational activities and supports on-going critical appraisal and review.

It is important that the Board of Directors has processes in place to monitor the implementation of strategic objectives set out in its business plan.

To ensure it receives assurances through its Committee Structures that the strategic goals are being met or concerns are escalated.

The Governance Structure described in this framework aligns quality, risk and performance and how they are monitored

2.0 Content of framework

2.1 Organisational governance structure (Appendix A)

Within the governance structure there are committees and groups, each having a delegated responsibility to deliver the Trust’s strategic goals and objectives, via compliance with performance and quality indicators and monitoring of associated risks.

The governance structure clearly demonstrates the reporting and accountability mechanisms ie task and finish groups report to groups, groups report to committees and committees report to the Board.

This is supported in all of the Terms of Reference and outlined in Table 1. Terms of reference for all committees are available through the Chair of the relevant Committee.

Table 1: Accountability arrangements within the corporate governance arrangements

Committee Groups Task & Finish Groups Reporting to Board Committee Groups

Terms of Reference reviewed Annually Annually On establishment

Membership must Membership Membership will include executive should include be relevant staff Membership directors, non executive co-opted to executive directors, clinical deliver specific directors, clinical staff, senior time limited staff, senior managers, pieces of work managers

Annual work plan Progress against Measured by the informed by key the Committee specific Performance performance work plan deliverable for the indicators/evidence work stream and risks against strategic objectives

Responsible for Responsible for Need to report the performance the performance specific Accountability management of management of deliverables to the group the Task and appropriate Group structure and their Finish groups, work plans

Reporting Minutes and Minutes and Progress reports Chairs log to Board Chairs Log to to appropriate mechanism of Directors - risks Committees – groups. against work reported to Risk risks reported to plan Management Risk Management Group for inclusion for inclusion on 5

on the BAF the Risk Register

There is a demonstrable inter- relationship between the committees, via sharing of minutes and the production of a Chair’s log, which outlines key issues being discussed at committee meetings. The Chair’s log is a standing agenda item on all governance meetings, at all levels, reporting up to the Board of Directors.

During Board meetings there are discussions with challenge regarding the data produced and the reports by the Non Executive and Executive team members. This is recorded through minutes of the committees and references in the chairs log.

2.2 Escalation of Key Issues through the Governance Structure (Chair’s Log - Appendix C)

All committees will use the Chair’s Key Issues (Chair’s Log) model to:

• Escalate risk over the threshold delegated to the committee (in accordance with delegation or identified through other issues presented at the committee)

• Escalate decisions outside the delegated authority of the committee

• Communicate positive assurance and gaps in assurance

• Commission tasks for groups

• Integrate issues which cross the Terms of Reference of different committees

• Forward plan

Chairs’ Key Issues will be reported to the next meeting of the committee / Board and will be presented by the Chair of the reporting committee.

3.0 Trust Monitoring / Assurance Processes

3.1 Board Assurance Framework

The Board Assurance Framework (BAF) is the Board’s ‘tool‘ for the management and monitoring of the strategic risk. Having identified the Trust’s strategic objectives, the Board will identify the key risks to the delivery of the strategic plan and the key controls in place to manage the risk, The BAF will be managed in a quarterly cycle,

• Associate Director of Corporate Affairs will have oversight of the BAF; ensuring risks are assigned to each Board Committee.

• Each Committee will review the BAF at formal meetings and provide update assurances on assurance/gaps on control and positive/gaps in assurance

• Updates sent to Risk Management, for revision of the Corporate BAF,

• BAF risks greater than 15 will be presented to Board of Directors

The Audit Committee will review the controls involved in the management and monitoring of the BAF in order to provide assurance of effectiveness to the Board.

The BAF is audited by Internal Audit on an annual basis.

3.1.1 The key features of the BAF are described in the table overleaf.

Assurance Obtained on Controls Board Action Plan

Year Priority Responsible 6 month Ob. Key Positive Gaps in Gaps in End Principal Risk Action Plan Director & forecast No Likelihood/ Controls Assurance Control Assurance foreca Committee (Sept 14) Impact st

(what is the (what (Where are we likelihood of controls/ (what evidence (where are we failing to put (what should the risk systems do shows the risks failing to gain controls in prevent this occurring we have in are being evidence that place? Where objective being and place to managed and our are we failing achieved) consequen ensure we objectives are systems/are to make them ce/ impact deliver our being delivered effective) effective) if it occurs) objectives)

3.1.2 Sources of Assurance

The Board of Directors gain its assurance from the internal and external sources listed below, this is not an exhaustive list.

Internal External assessments, reviews and benchmarking

Board Performance Report Health and Safety inspections

Performance Reviews External Audit Reports

Key Performance Indicators Patient Related Outcome Measures

Chair’s Logs – Key Issues CQUINS (Commissioning for Quality and Innovation)

Minutes - Board Governance Committees External Accreditation and individual CBU Governance meetings

Clinical Business Units governance and Independent Reviews risk reports

Risk Register CQC assessments

Quality Accounts Clinical Specialty Peer Reviews

Internal staff survey National Audits

Local Counter Fraud Reports National Staff Surveys

Staff Survey Results Patient Choices

Patient Satisfaction Surveys Friends and Family Test

Staff Survey Results Specialist External Reviews

Safeguarding Serious Case Reviews National patient surveys

Serious Incidents Investigations MHRA Inspections

Clinical Audit Internal Audit Reports

Clinical Presentations

Complaints, litigation reports through the Risk Management Group

Nursing Indicators and Nursing Quality Audits

Compliments

Policies and Procedures – monitoring of compliance

Key Performance Indicators

Compliance Reports

Information Governance Toolkit

Corporate Performance Report

Mock CQC inspection reports

Executive/ NED walk rounds

Internal staff survey

3.2 Risk Register

The Risk Management Strategy sets out how risks are identified at all levels of the Trust. It describes in detail how risks are escalated through the Clinical Business Units (CBU) and Corporate Governance Structures. A summary of the process is detailed below:

Each CBU/ department and Corporate Services Department will be aware of the detail of the risks that would prevent them meeting their or the Trust’s objectives. CBU level risks are managed at a local level and monitored at the CBU Performance Review and at the Corporate Operations Group.

CBUs and Corporate Services/ Departments will present their full risks register on a six monthly basis to the Risk Management Group.

The Director of Nursing & Quality and Medical Director sit on the Risk Management Group where risks are discussed and reviewed and are supported by the Risk Manager.

During this review the Risk Management Group will consider:

• Mitigating actions and timescales to determine whether the risk score is appropriate • Whether additional mitigations are required to manage a risk • Whether there are links between identified risks, which point to broader corporate issues • Whether identified risks represent risks to the Trust’s strategic aims and should therefore be escalated to the BAF (Board of Directors) Risk Management Group’s observations and required actions will be communicated to the committee / Board via the Chair’s Key Issue Model as assurance, escalation, integration (through inter disciplinary work) or the commissioning of additional actions or monitoring by a specific group.

Following the review by the Risk Management Group, reporting to Board of Directors will be based on any rating >15.

The Audit Committee will review the controls involved in the management and monitoring of the BAF in order to provide assurance of effectiveness to the Board.

3.3 Internal and External Sources of Assessment / Assurance (Internal Audit, Clinical Audit, Peer Review)

The Trust has internal structure in place to ensure reporting on progress or concerns. This ensures clear two way communication or information and identifies the systems in place to escalate concerns and ensure that they are responded to and, where required, challenged.

Internal and external sources of assessment/ assurance cover the range of the Trust’s activities and include:

• Care Quality Commission (CQC) Inspections • Internal/External Audit • Independent Reviews • External Accreditations

The Trust also commissions external reviews of its activities where the needs for additional independent assessments /assurances are identified.

3.4 Quality Strategy

The quality goals set out in the strategy have objectives which reflect and support the Trust’s strategic objectives.

The Quality Strategy is aligned with Governance Assurance Framework

The Quality Strategy is aligned to the Trust’s strategic objectives and support the vision and values by ensuring that clear performance indicators which are measurable and reported monthly through the Integrated Performance Report to the Board of Directors.

3.5 The Trust Cost Improvement Programme

3.5.1 Weekly Review process for CIPs

Each CBU is responsible for the monitoring and delivery of their CIP schemes. All schemes are subject to a weekly review process. The review is undertaken by members of the Executive Team, including the Chief Executive, Director of Nursing & Quality, Director of Operations, Director of Finance and Director of Strategy. Each CBU is represented by the General Manager, Head of Nursing and appropriate members of the team from within the CBU structure.

Schemes are assessed at the outset for any potential impact on quality and throughout the scheme whenever there is a change. Each CBU has support from the PMO in delivering and maintaining traction with each scheme.

3.5.2 Finance and Performance Committee

The progress of all schemes is reported to the Finance & Performance Committee on a monthly basis and through the Turnaround Tracker.

The Tracker reports progress against plan for the year to date position and the forecast outturn. Each CBU has a deliverable RAG rating system.

3.6 Key Performance Indicators

In holding the Executive Team and the CBUs to account for the delivery of the strategic objectives and the operational performance of the Trust, the Board will oversee a range of Key Performance Indicators (KPIs). The KPIs will cover the 12

breadth of the Trust activities. The Board KPIs are determined in part by external regulatory framework, eg CQC Essential Standards.

More granular reports are reviewed by committees, groups, and individual CBUs.

The Board may also identify and monitor KPIs associated with the delivery of the strategy or the monitoring of identified risk. These indicators may change over time as particular issues come to the fore for the Trust.

The Board may also assign monitoring of a particular KPI to a committee. If the Board does assign the monitoring of a specific KPI there will be explicit concerning the conditions for escalation back to the Board.

3.7 Culture

The Trust is developing an open and learning culture and encourages monitoring of, and comments and concerns about its performance from a wide range of internal and external sources. These sources include:

• Staff

• Patient / Carers

• Internal and external sources of assessment/assurances ( internal audit, clinical audit peer review)

• The Trust’s monitoring/ assurances processes

• Regulatory Bodies

• The Trust’s Council of Governors

3.8 Staff

The Trust has a number of policies and systems which encourage staff at all levels to be involved in performance monitoring and to raise concerns about any risk issues. These include

• HR policies such as Grievance and Disciplinary • Safeguarding Policy (Children and Adults) • Line Management Processes

• Executive and Non Executive Walkabouts • Staff Surveys • Governance Policies • Risk Management Strategy and Risk Assessment methodology • Joint Partnership Forum • Induction Programme • Mandatory Training • Risk Assessment Procedures • Raising Concerns Policy

4.0 Associated Documents

The framework sets out or signposts the Trust’s policies, systems and process and should in particular be read in conjunction with the Trust’s:

Terms of Reference for:

The Executive Management Team

The Finance & Performance Committee

The Audit Committee

The Quality & Governance Committee

Trust Strategies:

Quality Strategy

Risk Management Strategy

Trust Processes:

Performance Management Framework

Board of Directors

Audit Finance & Performance Quality & Governance Remuneration Committee Committee Committee Committee

Equality & Diversity Workforce Patient Safety & Quality Mortality Resus Education / Mandatory training Group Group Quality Policy SI Reviews Record management Dementia Medicines Mgm't VTE Capital Operations Patient Experience CQC Safeguarding Group Group Learning from Experience Frients & Family Test CIP Steering Health & Safety Patient Information Group Group Radiation Fire Medical Devices Sharps Decontaminations Waste Mgmt Sustainability Estates & Procurement Risk Management Medical Gases Theatre User Procurement Group Group Moving & Handling group Space Utilisation Catering Litigation review group Cleaning Corporate Operations Organ Donation Consent Group Group Risk registers Resilience & Emergency Planning

Information Governance Data security / Cyber Group FOI

Research & Development Group Committee of the Board

Groups (direct reports to Board Committees) Infection Prevention & Control Working Groups/Task & Finish Groups Group (not exhaustive) Template for all Trust Action Plans – Appendix B

Aims/ How this will What What Who will Timescales this Where this RAG rating Targets/ be achieved expected evidence will lead this will be will be Objectives outcome will support this achieved within reported/ be monitored to - i.e. Committee/ Group

KEY RAG Rating Green Complete Amber On track for delivery Red Behind plan and action needed to bring back on target

CHAIR’S LOG: Chair’s Key Issues and Assurance Model – Appendix C Committee / Group Date Chair

Agenda Item Issue and Lead Officer Receiving Body, i.e. Board or Recommendation/ Assurance/ Committee mandate to receiving body

TERMS OF REFERENCE FINANCE AND PERFORMANCE COMMITTEE

1. CONSTITUTION

The Board of Directors approved the establishment of the Finance and Performance Committee (known as “the Committee” in these terms of reference) for the purpose of: a) providing detailed scrutiny of financial matters and operational performance in order to provide assurance and raise concerns (if appropriate) to the Board of Directors. b) making recommendations, as appropriate, on financial and performance matters to the Board of Directors. The Committee is accountable to the Board of Directors and any changes to these terms of reference must be approved by the Board of Directors

2. DUTIES

In particular the Committee will provide assurance, raise concerns (if appropriate) and make recommendations to the Board of Directors in respect of the Committee’s role in: Financial matters a) undertaking detailed scrutiny of monthly, quarterly and year to date financial information, including performance against the cost improvement programme; b) undertaking detailed scrutiny of the financial forward projections; c) considering proposal for financial plans and estimates; d) considering the annual budget for the Trust e) approving business cases Performance management f) receiving assurance from the Executive Directors in respect of Clinical Business Units (CBU) performance against: • annual budgets, capital plans and the cost improvement programme, • quality, innovation, productivity and prevention plans, • commissioning for quality and innovation plans (CQUIN), • clinical activity and key performance indicators, • corporate governance activities and responsibilities; Contract negotiation and performance g) overseeing the negotiation of contracts with the organisation’s commissioners; h) receiving assurance from the Executive Directors in respect of the organisation: • meeting the contractual requirements and expectations of commissioners;

F&P July 2014: ToR Finance & Perf 22072014 1 • meeting the legislative / regulatory requirements of regulators and other bodies; • ensuring best value for money at all times Risk management and internal control i) receive the corporate risk register and take lead responsibility for identified risks in respect of non-clinical matters and standards: • receiving reports and assurance from the Executive Directors in respect of risks, considering the recommendations as appropriate from the Executive Directors as to those risks which are strategically significant and need to be included in the Board’s Assurance Framework, • overseeing the Executive Directors’ role in ensuring CBU Action Plans to mitigate risks and gaps in controls and assurance are implemented, • liaise with the Quality & Governance Committee to consider the impact of these non-clinical risks against all the risks facing the organisation; j) agreeing, with the Executive Directors, the annual programme of work of the Executive Team; j) work with the Audit Committee and the Quality & Governance Committee advising on the non-clinical aspects of the Risk Management Group k) liaising with the Risk Management Group to ensure compliance with the organisation’s risk management systems and processes and to identify those risks (and risk mitigation action plans) which need to be brought to the attention of the Board of Directors; Business cases l) considering the recommendations of the Executive Directors when considering business cases in respect of: • major service and strategic developments from the Executive Directors • new consultant or senior clinical posts submitted by the appropriate Executive Director. Human Resources and Organisational Development m) consider, advise and make appropriate recommendations to the Board of Directors on all aspects of HR Strategy, including policy and procedures: • monitor the organisation staff profile and trends, including sickness absence and appraisal completion • monitor progress against HR Plans in relation to recruitment, leadership and professional development, performance management and employment policies and procedures.

3. MEMBERSHIP

a) The Committee will include the following members: a. Non Executive Director (Chair); b. Non Executive Director c. Chief Executive

F&P July 2014: ToR Finance & Perf 22072014 2 d. Director of Finance (Deputy Chair) e. Director of Strategy & Business Development f. Director of Nursing & Quality g. Director of Operations h. Medical Director i. Director of Human Resources j. Director of ICT k. Associate Director of Estates & Facilities b) All Non Executive and Executive Directors listed above have voting rights • the Medical Director will nominate a Deputy Medical Director to attend on their behalf fully briefed. A Deputy Medical Director attending in such circumstances will not have the right to vote. • the Director of Nursing & Quality will nominate the Deputy Director of Nursing to attend on their behalf fully briefed. The Deputy Director of Nursing attending in such circumstances will not have the right to vote. • the Director or Finance will nominate the Deputy Director of Finance to attend on their behalf fully briefed. The Deputy Director of Finance attending in such circumstances will not have the right to vote. • the Director of Operations will nominate a Deputy to attend on their behalf fully briefed. The Deputy attending in such circumstances will not have the right to vote c) The Chair of the Committee is the Non Executive Director appointed by the Chair of Barnsley Hospital NHS Foundation Trust. If the Chair is not present, then the Deputy Chair shall chair the meeting. In the absence of both the Chair and Deputy Chair, and provided the meeting is quorate, the Chair of the meeting shall be appointed from the membership present.

4. ATTENDANCE

a) CBU representation through General Manager or Clinical Director, with relevant CBU finance officer. b) Other members may also nominate a deputy. Such deputies will be in attendance and will not have voting rights. c) The Chair of the Committee may also extend invitations to other persons with relevant skills, experience or expertise as necessary to deal with the business on the agenda. Such personnel will be in attendance and will have no voting rights.

5. RESPONSIBILITY OF MEMBERS

Members of the Committee have a responsibility to: a) attend at least 80% of meetings each year, having read all papers beforehand; b) act as ‘champions’, disseminating information and good practice as appropriate;

F&P July 2014: ToR Finance & Perf 22072014 3 c) identify agenda items, for consideration by the Chair, to the Lead Director / Secretary at least 10 days before the meeting; d) prepare and submit papers for a meeting, at least 8 days before the meeting; e) if unable to attend, send their apologies to the Chair and Secretary prior to the meeting and identify their deputy where applicable. f) when matters are discussed in confidence at the meeting, to maintain such confidences; g) declare any conflicts of interest / potential conflicts of interest in accordance with the Barnsley Hospital NHS Foundation Trust’s policies and procedures; h) at the start of the meeting, declare any conflicts of interest / potential conflicts of interest with the Barnsley Hospital NHS Foundation Trust’s policies and procedures.

6. QUORUM

a) A quorum will normally be four members. Of these members, there should be: • at least one Non-Executive Director; and • at least one Executive Director. b) When considering if the meeting is quorate, only those individuals who are members can be counted. Deputies and attendees cannot be considered as contributing to the quorum.

7. FREQUENCY

a) Meetings will normally take place monthly, allowing for this Committee to report to the Board of Directors. b) The business of each meeting will be transacted within a maximum of three hours.

8. AUTHORITY

The Committee is authorised by the Board of Directors: a) to investigate any activity within its terms of reference and produce an annual work program or forward plan; b) to approve or ratify (as appropriate) those policies and procedures for which it has responsibility; c) to promote a learning organisation and culture, which is open and transparent; d) to establish and approve the terms of reference of such sub-committeees, groups or task and finish groups as it believes are necessary to fulfil its terms of reference; e) to approve business cases and financial commitments within limits agreed by the Board of Directors.

9. DECISION MAKING

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

F&P July 2014: ToR Finance & Perf 22072014 4 b) Where this is not possible then the Chair of the meeting will ask for members to vote using a show of hands, provided that nothing in the way of business is conducted is prohibited by the standing orders of the Barnsley Hospital NHS Foundation Trust. c) In the event of a formal vote the Chair will clarify what members are being asked to vote on – the ‘motion’. Subject to meeting being quorate a simple majority of members present will prevail. In the event of a tied vote, the Chair of the meeting will have a second and deciding vote. d) Only the members of the Committee present at the meeting will be eligible to vote. Members not present, deputies and attendees will not be permitted to vote nor will proxy voting be permitted. The outcome of the vote, including the details of those members who voted in favour or against the motion and those who abstained, shall be recorded in the minutes of the meeting.

10. REPORTING

The Committee will have the following reporting responsibilities: a) to ensure that the minutes of its meetings are formally recorded and provided to the Board of Directors. b) to present the Chair’s Log to the Board of Directors at the Board’s meetings regularly. The Log shall be prepared by the Chair of the Committee, outlining the key issues discussed at the meeting and those issues that need to be brought to the attention of the Board of Directors; c) to produce those assurance and performance management reports listed in the Committee’s annual work programme which has been agreed with, and are required by, the Board of Directors; d) any items of specific concern, or which require the Board of Directors’ approval, will be subject to a separate report to accompany the Chair’s Log; e) to produce an annual report for the Board of Directors setting out: i. the role and the main responsibilities of the committee ii. membership of the committee iii. number of meetings and attendance iv. a description of the main activities during the year v. a completed annual self-assessment (format to be approved by the Audit Committee) and the identification of any development needs for the Committee

11 REPORTING GROUPS

a) The groups identified below will be required to submit the following information to the Committee: • their terms or reference for formal approval and review; • the minutes of their meetings, together with Chair’s Key Issues Log (Chair’s Log) prepared by the Chair of that group, outlining the key issues discussed at the meeting and those issues that need to be brought to the attention of this Committee;

F&P July 2014: ToR Finance & Perf 22072014 5 • to produce those assurance and performance management reports listed in the individual group’s annual work programmes which have been agreed with, and are required by, this Committee; • an annual report setting out the progress they have made and future development; and • any report or briefing requested by this Committee. b) The groups are: • the Executive Team (re relevant issues) • the CIP Steering Group • the Capital Operations Group • the Workforce Group • any Task and Finish Group set up by the Committee to assist them in carrying out their duties

12. ADMINISTRATIVE ARRANGEMENTS

a) The Lead Director - the Director of Finance - is a member of the Committee and has corporate responsibility for: i liaising with the Chair on all aspects of the work of the Committee, including providing advice; ii ensuring the Committee acts in accordance with the Trust’s standing orders and the scheme of reservation and delegation; iii identifying an officer to undertake the role of Secretary; iv overseeing the delivery of the Secretary’s duties. b) The Secretary of the Committee will be responsible for: i attending the meeting; ii ensuring correct and formal minutes are taken in the format prescribed in the Governance Strategy and, once agreed by the Chair, distributing minutes to the members iii distribution of approved minutes to the Board of Directors iv keeping a record of matters arising and issues to be carried forward via an action log; v producing an action log following each meeting and ensuring any outstanding action is carried forward on the action list until complete; vi producing a schedule of meetings to be agreed for each calendar year and making the necessary arrangements for confirming these dates and booking appropriate rooms and facilities; vii providing appropriate support to the Chair, Lead Director and Committee members; viii providing notice of each meeting and requesting agenda items no later than 14 days before a meeting;

F&P July 2014: ToR Finance & Perf 22072014 6 ix agreeing the agenda with the Chair and Lead Director prior to sending the agenda and papers to members no later than 7 5 days before the meeting; x ensuring the Annual Work Programme is up to date and distributed at each meeting; xi ensuring the papers of the Committee are filed in accordance with Barnsley Hospital NHS Foundation Trust’s policies and procedures.

13. REVIEW

Terms of Reference will normally be reviewed annually, with recommendations on changes submitted to the Board of Directors for approval.

Date Approved: August 2014 (o/s) Version Number: v3 Next Review August 2015 To be reviewed by: Finance & Performance Committee To be approved by: Board of Directors Executive Responsibility: Director of Finance & Information

F&P July 2014: ToR Finance & Perf 22072014 7

TERMS OF REFERENCE

QUALITY & GOVERNANCE COMMITTEE

1. CONSTITUTION

The purpose of the Quality & Governance Committee is to assist the Board in obtaining assurance that high standards of care are provided and any potential or actual risks to quality are identified and robustly addressed at an early stage.

The committee will work with the Audit Committee to ensure that there are adequate and appropriate quality governance structures, processes and controls in place throughout the Trust to:

• Promote safety and excellence in patient care Identity, priorities and manage risk arising from clinical care • Ensure efficient and effective use of resources through evidence based clinical practice The Committee is responsible for the following;

• Receiving assurance that robust Quality and Governance structures are in place Scrutinising and challenging quality indicators and ensuring that themes and organisation wide learning and improvement are taking place. • Ensuring that potential and actual risks to quality are proactively identified and robust action plans are in place and implemented to address these, providing assurance to the Board. • Authenticating the information to the Board, in the case of in depth reviews, staff from the locality could be invited to attend • Demonstrating direct dialogue with patients • Ensuring implementation of the National Patient Safety Agency Reporting requirements to achieve the standards of compliance • Compliance with statutory and regulatory requirements e.g. CQC, NHSLA and Health & Safety. Overseeing the development and the implementation of the Quality Strategy and achievement of quality indicators.

2 DUTIES

2.1 To ensure that there are robust systems in place across all services and all levels within the Trust, to enable the Trust to effectively monitor quality performance and to have an assurance process to improve the quality of care.

Gov/Drafts/ToR Quality Gov 25072014 p1 of 7

2.2 To ensure that the Trust's Quality Governance system is in line with Monitor's Risk Assessment Framework and the Governance Quality Framework and that this is reviewed annually or in line with any updates.

2.3 To oversee the system within the Trust for obtaining and maintaining any licences relevant to clinical activity in the Trust.

2.4 To scrutinise, robustly discuss and challenge information and reports in relation to quality to ensure that themes, organisation wide learning I improvement are being addressed

2.5 To approve the Trust's Quality Reports before submission to the Board, this will include areas such as Safeguarding, Records Management, SI review, Medicines Management, VTE, Mortality and Dementia

2.6 To ensure that all statutory quality governance requirements are adhered to within the Trust including the requirement of our regulators, Monitor and the Care Quality Commission.

2.7 To promote within the Trust a culture of open and honest reporting of any situation that may threaten the quality of patient care in accordance with the relevant policies.

2.8 To seek assurance that robust and timely systems and processes are in place to proactively ensure compliance with the CQC essential standards of Quality and Safety and that any remedial action is taken in a timely and outcome focused way.

2.9 To ensure the delivery of the Trust strategies relating to Clinical Effectiveness, Patient and Public Involvement and the Trust agreed priorities published in the Trust Quality Account.

2.10 To oversee the Trust's policies and procedures with respect to the use of clinical data and patient identifiable information, to ensure that this is in accordance with all relevant legislation and guidance including the Caldicott Guidelines and the Data Protection Act 1998

2.11 To seek assurance that robust and timely systems or programmes are in place in respect of Patient Safety, including:

• Effective systems for the reporting, scrutiny and implementation of actions arising out of adverse incident and external enquires • Safeguarding (Children and Adults) including training and lessons learnt and action plans implemented • Infection Control including policies, training, audit and inspection • Procurement, management and maintenance of Medical devices monitoring and compliance with national patient safety, medical device and drug alerts effective management and learning from clinical claims/complaints/SIs • Early Warning Trigger tool exception report

Gov/Drafts/ToR Quality Gov 25072014 p2 of 7

• Annual review of the Health & Safety report

2.12 To seek assurance that robust and timely systems or programmes are in place in respect of Clinical Effectiveness, including:

• Effective Medicines Management • Timely review of NICE Guidance, technology appraisals and other national guidelines or regulations and the implementation of action plans • Effective delivery of the Trust Annual Clinical Audit programme and the implementation of actions to improve standards and quality effectively • Development and implementation of Clinical outcome measures and care pathways • To approve deviation from Nice Guidance where it is deemed appropriate and necessary to do so • To agree annual clinical audit programme including the risk based approach those pertaining to NICE Guidance and to ensure this is a continuing cycle.

2.13 To identify potential risks to quality and ensure that these are being reported via the risk register and that there are robust plans to mitigate the risk

2.14 To regularly review risk register items pertaining to Quality, Clinical Governance

2.15 To ensure the delivery of the Trust priorities published in the Quality Account

2.16 To provide assurance to the Audit Committee on the management of key quality and governance risks and issues to ensure an integrated approach to governance.

2.17 To oversee the process for developing and implementing quality priorities.

2.18 To seek assurance on the Trust's arrangements for actively engaging patients, staff, or members and key stakeholders on quality, including their patient experience.

3.0 MEMBERSHIP

3.1 The membership of the committee will consist of: • Non Executive Directors (2) (one of whom will chair the committee) Medical Director • Director of Nursing and Quality

4. ATTENDANCE

• Deputy Director of Nursing • Head of Quality and Clinical Governance

Gov/Drafts/ToR Quality Gov 25072014 p3 of 7

• Director of Operations • Senior Representation from each Clinical Business Unit, eg General Manager, Clinical Director and Head of Nursing The Chair of the Committee may extend invitations to other persons with relevant skills, experience or expertise as necessary to deal with the business on the agenda. Such persons will be in attendance and will have no voting rights.

5 RESPONSIBILITY OF MEMBERS

Members of the Committee have a responsibility to: • attend at least 80% of meetings, having read all papers beforehand; act as 'champions', disseminating information and good practice as appropriate; • identify agenda items, for consideration by the Chair, to the Lead Director I Secretary at least 10 days before the meeting; • prepare and submit papers for a meeting, at least 8 days before the meeting; • if unable to attend, send their apologies to the Chair and Secretary prior to the meeting • when matters are discussed in confidence at the meeting, to maintain such confidences; • declare any conflicts of interest I potential conflicts of interest in accordance with the Barnsley Hospitals NHS Foundation Trust's policies and procedures; • at the start of the meeting, declare any conflicts of interest I potential conflicts of interest with the Barnsley Hospitals NHS Foundation Trust's policies and procedures.

6.0 QUORUM

The Committee will be deemed quorate to the extent that the following are present: • At least one Non Executive Director • Medical Director or their representatives • Director of Nursing or a representative

As a Board Committee, only Non Executive Directors or Executive Directors have the delegated authority to make decisions

7.0 FREQUENCY OF MEETINGS

The Committee shall meet monthly

8.0 AUTHORITY

The Committee is authorised by the Board of Directors:

Gov/Drafts/ToR Quality Gov 25072014 p4 of 7

• to investigate any activity within its terms of reference and produce an annual work program or forward plan;

• to approve or ratify (as appropriate) those policies and procedures for which it has responsibility • to promote a learning organisation and culture, which is open and transparent; • to establish and approve the terms of reference of such sub-committees, groups or task and finish groups as it believes are necessary to fulfil its terms of reference

9.0 DECISION MAKING

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

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

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

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

10 REPORTING ARRANGEMENTS INTO THE BOARD

The Committee will have the following reporting responsibilities: • to ensure that the minutes of its meetings are recorded and provided to the Board of Directors. • to present the Chair’s Log to the Board of Directors at the Board’s meetings regularly. The Log shall be prepared by the Chair of the Committee, outlining the key issues discussed at the meeting and those issues that need to be brought to the attention of the Board of Directors; • to produce those assurance and performance management reports listed in the Committee's annual work programme which has been agreed with, and are required by, the Board of Directors; • any items of specific concern, or which require the Board of Directors' approval, will be subject to a separate report; • to provide exception reports via the Chairs Log to the Board of

Gov/Drafts/ToR Quality Gov 25072014 p5 of 7

Directors highlighting key developments I achievements or potential issues; • to produce an annual report for the Board of Directors setting out: i the role and the main responsibilities of the committee ii membership of the committee iii number of meetings and attendance iv a description of the main activities during the year

11 REPORTING GROUPS The groups identified below will be required to submit the following information to the Committee: • their terms or reference for formal approval and review; • the minutes of their meetings, together with a Chairs Log prepared by the chair outlining the key issues discussed at the meeting and those issues that need to be brought to the attention of this Committee; • to produce those assurance and performance management reports listed in the individual group's annual work programmes which have been agreed with, and are required by, this Committee; • an annual report setting out the progress they have made and future development; and • any report or briefing requested by this Committee.

The groups are: • Patient Safety & Quality Group • Patient Experience Group • Health & Safety Group • Risk Management Group • Organ Donation Group • Information Governance Group • Research & Development • Infection Prevention & Control Group

12 MONITORING COMPLIANCE, EFFECTIVENESS AND REVIEW DATE

12.1 The Committee shall, at least once a year, review its own performance against the agreed terms of reference to ensure it is operating at maximum effectiveness, complying with NHSLA Standards and recommend any changes it considers necessary to the Board for approval.

Gov/Drafts/ToR Quality Gov 25072014 p6 of 7

12.2 The Committee will provide an Annual Report to the Trust Board, which will summarise its performance against the delivery of its work programme setting out the challenges and successes over the year, it will also report on attendance during the year. It will provide an annual plan for the programme of work for the forthcoming year. In particular, the annual programme coverage will incorporate all key areas within the Committee's duties, as set out in section 2 of its Terms of Reference.

Date Approved: ______2014

Version Number :

Next Review:

To be reviewed by: Quality & Governance Committee To be approved by: Board of Directors

Executive Responsibility: Director of Nursing & Quality

Gov/Drafts/ToR Quality Gov 25072014 p7 of 7

TERMS OF REFERENCE AUDIT COMMITTEE

1 Constitution

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

2 Duties

2.1 The Committee is responsible for the following aspects of Risk Management a) to review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the Organisation's activities (both clinical and non-clinical), that supports the achievement of the Organisation's objectives. b) the Audit Committee provides an oversight of the activities of internal audit, external audit and the local counter fraud service and the assurance on internal control, including compliance with the law and regulations governing the Trust's activities.

2.2 In particular, the Committee will review the adequacy and effectiveness of: a) All risk and control related disclosure statements (in particular the Annual Governance Statement and declarations of compliance with the Care Quality Commission's Core Standards), together with any accompanying Head of Internal Audit statement, external audit opinion or other appropriate independent assurances, prior to endorsement by the Board. b) The underlying assurance processes that indicate the degree of the achievement of corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements. c) The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements. d) The policies and procedures for all work related to fraud and corruption as required by NHS Protect

2.3 In carrying out this work the Committee will primarily utilise the work of Internal Audit, External Audit and other assurance functions, but will not be limited to these audit functions. It will also seek reports and assurances from Directors and Managers as appropriate, concentrating on the overarching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness.

Audit: ToR Audit 23072014 1 2.4 This will be evidenced through the Committee's use of an effective Assurance Framework to guide its work and that of the audit and assurance functions that report to it.

2.5 Internal Audit The Committee shall ensure that there is an effective internal audit function established by management that meets mandatory NHS Internal Audit Standards and provides appropriate independent assurance to the Audit Committee, Chief Executive and Board. This will be achieved by: a) Consideration of the provision of the Internal Audit service, the cost of the audit and any questions of resignation and dismissal. b) Review and approval of the Internal Audit strategy, operational plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the Organisation as identified in the Assurance Framework. c) Consideration of the major findings of internal audit work (and management's response), and ensure co-ordination between the Internal and External Auditors to optimise audit resources. d) Ensuring that the Internal Audit function is adequately resourced and has appropriate standing within the organisation. e) Annual review of the effectiveness of internal audit. The Head of Internal Audit shall have a direct reporting line to the Committee and its Chair.

2.6 External Audit The Committee shall review the work and findings of the External Auditor appointed by the Trust and consider the implications and management's responses to their work. This will be achieved by: a) Consideration of the appointment and performance of the External Auditor. b) Discussion and agreement with the External Auditor, before the audit commences, of the nature and scope of the audit as set out in the Annual Plan. c) Discussion with the External Auditors of their local evaluation of audit risks and assessment of the Trust and associated impact on the audit fee. d) Review all External Audit reports, including agreement of the annual audit letter before submission to the Board and any work carried outside the annual audit plan, together with the appropriateness of management responses. The External Auditor shall have a direct reporting line to the Committee and its Chair. The Council of Governors has the responsibility to appoint or remove the Foundation Trust's External Auditors.

Audit: ToR Audit 23072014 2 2.7 Standing Orders, Standing Financial Instructions and Standards of Business Conduct a) To review on behalf of the Board of Directors the operation of, and proposed changes to the Standing Orders and Standing Financial Instructions, Codes of Conduct and Standards of Business Conduct; including maintenance of registers of interest. b) To examine the circumstances of any significant departure from the requirements of any of the foregoing. c) To review the Scheme of Delegation.

2.8 Financial Reporting

a) The Committee shall have annual overview of the financial statements of the organisation. b) The Committee should ensure that the systems for financial reporting to the Board include those of budgetary control are subject to review as to the completeness and accuracy of the information provided c) The Committee shall review the annual report and financial statements before submission to the Board, focussing particularly on • The wording in the Annual Governance Statement • Changes in and compliance with accounting policies, practices and estimation techniques • Unadjusted mis-statements in the financial statements • Significant judgements in preparation of the financial statements • Letters of representation • Explanation from significant variances

2.9 Other audit related issues a) To review performance indicators relevant to the Committee. b) To examine any other matter referred to the Committee by the Board of Directors and to initiate investigation as determined by the Committee. c) To annually review the accounting policies of the Trust and make appropriate recommendations to the Board of Directors. d) Identify annual objectives of the Committee, produce an annual work plan in the agreed Trust format, measure performance at the end of the year and produce an annual report.

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

Audit: ToR Audit 23072014 3 3 Membership Full membership of the Committee is limited to Non-Executive Directors, whom the Board appoints on the recommendation of the Chairman of the Trust. The Chairman may not be a member of the Committee. At least one of the Non-executive Directors should have recent and relevant financial experience. The formal membership of the committee shall comprise the following core members: • Chairman of the Committee, Non-executive Director • Two other Non-executive Directors The Director of Finance & Information, Associate Director of Corporate Affairs, Internal and External Auditors shall generally be in attendance at routine meetings of the Audit Committee. In line with best practice the Chairman of the Board of Directors is not a formal member but may be in attendance at committee meetings The Audit Committee may sit privately without any non-members present for all or part of the meeting if they so decide.

4. Attendance It is expected that all members will attend 3 out of 5 committee meetings per financial year . An attendance record will be held for each meeting. The Chief Executive and other Executive Directors should be invited to attend when the Committee is discussing areas of risk or operation that are the responsibility of that Director. The Chief Executive should be invited to attend, at least annually, to discuss with the Audit Committee the process for assurance that supports the Annual Governance Statement.

5 Quorum A quorum for any meeting of the Committee shall be attendance by two core members of Non-executive Directors. In the absence of the Committee Chair, one of the other core members shall assume the Chair for that meeting.

6 Frequency of meetings Meetings of the Audit Committee shall be held at least five times per year and at such other times as the Chairman of the Committee shall require, subject to agreement with the Chairman of the Trust and the Chief Executive. The External Auditors shall be afforded the opportunity at least once per year to meet with the Committee without Executive Directors present.

Audit: ToR Audit 23072014 4 7 Authority The Committee is authorised by the Board of Directors to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to cooperate with any request made by the Committee. The Committee is authorised by the Board of Directors to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it is considered necessary,

8 Reporting Arrangements into Board of Directors

8.1 The Committee will have the following reporting responsibilities: a) to ensure that the minutes of its meetings are formally recorded and submitted to the Board of Directors. These minutes shall be accompanied by a Chairs Log prepared by the chair of the meeting, outlining the key issues discussed at the meeting and those issues that need to be brought to the attention of the Board of Directors; b) to produce those assurance and performance management reports listed in the Committee’s annual work programme which has been agreed with, and are required by, the Board of Directors; c) any items of specific concern, or which require the Board of Directors’ approval, will be subject to a separate report; d) to produce an annual report for the Board of Directors setting out: i. the role and the main responsibilities of the committee ii. membership of the committee iii. number of meetings and attendance iv. a description of the main activities during the year v. a completed annual self-assessment (the format to be approved by the Audit Committee) and the identification of any development needs for the Committee

8.2 The Chair of the Committee will report to the Board at least annually on the completion of its work in support of the Annual Governance Statement.

9 Administration

9.1 The Audit Committee will be supported by a nominated lead Executive Director, who will facilitate administrative support. a) liaising with the Chair on all aspects of the work of the Committee, including providing advice; b) ensuring the Committee acts in accordance with standing orders and the scheme of reservation and delegation; c) identifying an officer to undertake the role of Secretary; d) overseeing the delivery of the Secretary’s duties.

Audit: ToR Audit 23072014 5 9.2 The Secretary of the Committee will be responsible for: a) attending the meeting; b) ensuring correct and formal minutes are taken in the format prescribed in the Governance Strategy and, once agreed by the Chair, distributing minutes to the members c) keeping a record of matters arising and issues to be carried forward via an action log; d) producing an action log following each meeting and ensuring any outstanding action is carried forward on the action list until complete; e) producing a schedule of meetings to be agreed for each calendar year and making the necessary arrangements for confirming these dates and booking appropriate rooms and facilities; f) providing appropriate support to the Chair, Lead Director and Committee members; g) providing notice of each meeting and requesting agenda items no later than 14 days before a meeting; h) agreeing the agenda with the Chair and Lead Director prior to sending the agenda and papers to members no later than 7 days before the meeting; i) ensuring the Annual Work Programme is up to date and distributed at each meeting; j) ensuring the papers of the Committee are filed in accordance with Barnsley Hospital NHS Foundation Trust’s policies and procedures

10. Review Terms of Reference will normally be reviewed annually, with recommendations on changes submitted to the Board of Directors for approval.

Date Approved: August 2014 Version Number: Next Review: August 2015 To be reviewed by: Audit Committee To be approved by: Board of Directors Executive Responsibility: Director of Finance

Audit: ToR Audit 23072014 6

REPORT TO THE BOARD OF REF: BARNSLEY HOSPITAL NHSFT 14/08/P-16

SUBJECT: BOARD ASSURANCE FRAMEWORK

DATE: AUGUST 2014

Tick as Tick as applicable applicable

For decision/approval  Assurance PURPOSE: For review Governance  For information Strategy PREPARED BY: Angela Keeney, Interim Associate Director of Corporate Affairs SPONSORED BY: Diane Wake, Chief Executive PRESENTED BY: Angela Keeney, Interim Associate Director of Corporate Affairs STRATEGIC CONTEXT 2-3 sentences

The Board Assurance Framework (BAF) enables the Board to monitor how the internal governance arrangements are supporting the achievement and delivery of the Trust’s strategic objectives and aids in identifying risks. The attached version has been updated for the Board by the Executive Directors

QUESTION(S) ADDRESSED IN THIS REPORT

Does this BAF provide the Board requirements in the monitoring of risks and assurance throughout the year?

CONCLUSION AND RECOMMENDATION(S)

This BAF would allow for assurances and risks to be identified by the Board.

Following the recommendations from the Board in July 2014, Q1 update will be provided in September 2014 report to Board.

BoD Aug 2014: BAF Front Cover August 2014

REFERENCE/CHECKLIST • Which business plan objective(s) does this report relate to? Patients BCCG Other

• Please state: Has this report considered the Staff BMBC following stakeholders? Governors Monitor

Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution etc) • Has this report reviewed the Trust’s compliance with: Equality, Diversity & Human Rights

The Trust's sustainability strategy

• Has this report Quality & Governance (in draft or during Yes • Is this report development) been Audit Committee supported by a reviewed and Not applicable communications supported by any Finance & Performance plan? Board or Executive To be developed committee within the ET Trust? • Where applicable, briefly identify risk issues (including any reputation) and cross reference to risk register and governance committees • Where applicable, state Finance: resource requirements: Other:

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: Providing the best healthcare for all”

BoD 2014: BAF Front Cover August 2014

Subject: Board Assurance Framework Ref: 14/08/P-16

1. STRATEGIC CONTEXT

1.1 With financial and quality challenges facing the Trust, the Board members must be clear how the internal governance arrangements are supporting the achievement and delivery of strategic objectives.

2. INTRODUCTION

2.1 Whilst the term ‘Board Assurance Framework’ should refer to the wide systems and processes of governance which are in place to provide the Board with assurance regarding the achievements of its strategic objectives, the phrase has become synonymous with the document or report generated to capture these assurances.

3. BOARD ASSURANCE FRAMEWORK

3.1 The amount of information which is generated and which informs the on-going but ever changing, confidence levels of the Board with regard to achieving strategic objectives, cannot solely be captured in one single document. The BAF should record the Board’s confidence in achievement of each strategic objective at any given point in time, given all the information that has been available to them.

3.2 In this way it is believed the BAF will remain a ‘live’ document in supporting effective decision making and providing evidence and justification for the decision making process.

3.3 Any piece of information the Board receives may affect the members’ confidence about the likely achievement of a strategic objective.

3.4 The BAF can be used dynamically to capture these changes as a result of new information, rather than attempting to replicate all the detailed information actually received by the Board.

Appendices:

• Appendix 1 – Board Assurance Framework (July 14 v5)

BoD Aug 2014: BAF Front Cover August 2014 Page 1

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5)

Board Assurance Framework 2014/2015 TRUST BOARD: July 2014

Executive Summary

The format of the Board Assurance Framework (BAF) is reviewed and approved annually by the Board and the Audit Committee. The format for the 2014/2015 provides greater visibility for each of the annual objectives and where the full measures are listed and monitored. The BAF remains a live document with on-going work to continue to ensure the strategic risks are appropriately identified, documented and mitigated. There is on-going work to strengthen the controls, actions and links to known future sources of internal and independent assurance.

The BAF will continue to be reviewed and updated with Executive directors at least quarterly and then reported to the Quality and Governance Committee and Board for scrutiny and assurance. The Associate Director of Corporate Affairs retains core oversight of the document. In addition, further updates relating to areas led by the Executive Team will be incorporated.

The Board Assurance Framework contains the principal risks associated to the achievement and delivery of the Trusts Annual Strategic Aims and Objectives. The Strategic Aims, from which the 2014/15 annual objectives have been framed, build on the previous work of the Trust and support the delivery of the Trust’s vision and values.

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5)

Strategic Aims 2014

1. Patients will experience safe care: to continuously improve the quality of our services in order to provide the best care and optimise health outcomes for each individual accessing our services.

2. Partnership will be our strength: to be an effective member of the local health community, working as a key member in the Working together programme. To excel at customer service, achieving outstanding levels of communication with patient, carers and the local health community.

3. People will be proud to work for us: to be an employer of choice, providing staff a workplace were they are supported by skilful leadership.

4. Performance matters: we will utilise the new Trust performance framework to ensure we achieve key targets in operational matters, finance and quality.

The risk traffic light definitions are:

• Red: A significant failure to mitigate a risk either through lack of controls identified (or poorly framed controls) with a high likelihood of the risk being realised in the short term.

• Amber: On course to be mitigated, given the controls identified, but further work required in delivering the agreed actions

• Green: The risk has been mitigated as defined by the controls and actions identified. These risks will continue to be displayed on the framework so that assurance can be received and kept up to date

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5)

Table format for BAF

Assurance Obtained on Controls Board Action Plan

Priority Responsible 6 month Year Ob. Key Positive Gaps in Gaps in Principal Risk Likelihood/ Action Plan Director & forecast End No Controls Assurance Control Assurance Impact Committee (Sept 14) f/cast

(what is the (what (Where are we likelihood of controls/ (what evidence (where are we failing to put (what should the risk systems do shows the risks failing to gain controls in Identify executive prevent this occurring we have in are being evidence that place? Where lead and appropriate objective being and place to managed and our are we failing lead committee achieved) consequen ensure we objectives are systems/are to make them ce/ impact deliver our being delivered effective) effective) if it occurs) objectives)

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5)

TRUST STRATEGIC OBJECTIVE 1: PATIENTS WILL EXPERIENCE SAFE CARE RAG Rating per Quarter Trust Annual Objective 2014/15 Measures Q1 Q2 Q3 Q4 a) In 2014/15 we will provide high quality care for patients, ensuring all our patients have a positive experience of care through us better understanding what Reports made to Quality &

patients want, measuring our performance and improving the way we work. We Governance Committee will achieve agreed milestones and targets for the friends and family test (FFT). including: 1.a Reporting patient experience in all i) implement improvements to our complaint investigation processes CBUs -actions to be tracked ii) Improve the experience of patients with dementia and their carers Measure and benchmark patient experience using core dataset. iii) implement the NHS Friend and Family Test throughout the hospital b) In 2014/15 we will deliver consistently safe care: taking action to reduce harm to patients in our care and protecting the most vulnerable including a reduction in hospital acquired harms and a 50% reduction in inpatient falls. Reports made to Quality & Governance Committee i) reduce hospital acquired harms in relation to VTE, Catheter Acquired Urinary Tract including: 1.b Infections & Pressure Ulcers NHS Safety Thermometer ii) reduce the number of inpatient falls by 50% by April 2015(baseline value will be Participation in National Clinical

number reported in 2013/14) Note Keeping Audit measuring 75% compliance by end of year iii) to improve clinical note keeping, ensuring robust patient assessment and

management plans. c) To deliver consistently effective care throughout 2014/15: The Trust will achieve Reports made to Quality & improved health outcomes through delivery of safe, effective and evidence- Governance Committee

based care, this will delivered through agreed levels of compliance and a including: continuous improvement in our HSMR value. National Benchmarking & monthly 1.c data analysis i) reduce HSMR target 110 by February 2015/ 100 by February 2016 Demonstrate 95% compliance ii) improve recognition & management of the adult deteriorating patient with NEWS &Sepsis Screening Tool by year end iii) improve sepsis recognition and response d) Delivery of prioritised 7 day services in 2014/15 to support the needs of our patients increasing the availability of: medical decision makers, radiology cover, Delivery of 7 day working plan.

therapy support and pharmacy services. We will deliver our 7 day action plan to CQUIN dashboard support us in the achievement of Keogh's 10 standards. 1.d i) extended clinical services ii) enhanced Hospital at Night services iii) achievement of CQUIN standard

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5)

Assurance Obtained on Controls Board Action Plan

Priority Responsible 6 month Year Ob. Key Positive Gaps in Gaps in Principal Risk Action Plan Director & forecast End No Likelihood/ Controls Assurance Control Assurance Impact Committee (Sept 14) forecast 1a Inability to Link to Risk Quality & Reported to Robust Appointment of Chief Executive / meet Monitor / Register Safety Board: governance governance Chairman CQC regulatory Strategy systems in facilitators requirements Risk 1155 Quality & CBUs Finance inc Governance Implementation of CIP and Committee CBU governance Board of Deficit Nursing meetings Directors (4x5 = 20) Strategy Audit (July 2014 Committee Risk 1002 review Four Hour underway) Integrated Target performance (4x4 = 16) report to Board

Risk 1463 Gov. Annual Structure Governance (3x2 = 6) Account Risk 1227 Annual Health CQUINS & Safety (5x2 = 10) Report

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5) Assurance Obtained on Controls Board Action Plan

Priority Responsible 6 month Year Ob. Key Positive Gaps in Gaps in Principal Risk Action Plan Director & forecast End No Likelihood/ Controls Assurance Control Assurance Impact Committee (Sept 14) forecast 1b Failure to deliver Link to Risk Quality Reported to Current Monitor delivery Director of effective, safe Register metrics in Board: information against known Operations/ care monthly CBU system/process CQUIN element Director of Risk 1226 reports Integrated es may not and strive to Nursing Nursing: performance support robust improve Staffing & Safety report monitoring in performance Quality & Thermometer Skill Mix CBUs Governance (3x3 = 9) data Reports from

Quality & Risk 1201 Patient Governance Advancing Quality feedback via HR: Non Committee Triangulation of Action Plan (being complaints & recruitment/ claims data implemented) Vacancies. QIA Tracker (3x3 = 9) Friends

&Family Test data

Incident reporting

CQUIN & contracting monitoring process

Benchmarked outcome data

Monthly Report on Nurse Staffing levels

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5) Assurance Obtained on Controls Board Action Plan

Priority Responsible 6 month Year Ob. Key Positive Gaps in Gaps in Principal Risk Action Plan Director & forecast End No Likelihood/ Controls Assurance Control Assurance Impact Committee (Sept 14) forecast 1c Failure to Link to Risk Monitoring of Healthcare HSMR action plan Medical Director improve levels Register mortality at Evaluation and service of compliance Trust, Data pathways review and Risk 1221 Divisional Quality & improvement in HMSR and HSMR Continued Governance HSMR value compliance Consultant benchmarking monitoring of levels Level. reports. mortality rates (5x4 = 20) against Regular Mortality outlier benchmarks reports to investigation Quality & reports Enhanced Governance implementation of CQC Mortality Committee & care bundles (May Outlier alerts Trust Board. 2014) Short and In Clinical Audit Introduction of depth Mortality Programme. specific CBU action MDT reviews plans if required Monthly taking place, Coding with learning Clinical Coding Mortality disseminated audit by Internal Report. Trustwide Audit diarised in (ongoing annual work Specialist monthly) programme Palliative Care Team, in place

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5) Assurance Obtained on Controls Board Action Plan

Priority Responsible 6 month Year Ob. Key Positive Gaps in Gaps in Principal Risk Action Plan Director & forecast End No Likelihood/ Controls Assurance Control Assurance Impact Committee (Sept 14) forecast 1d Compromised Link to Risk Quality An agreement Payment for Action Plan to Director of services if Register Strategy has been future years. implement 7 day Strategy/Director unable to design reached with working & Keogh of Operations/ recommendations Medical Director and introduce 7 Risk 1201 the CCG on HR: Non day services payment for Finance & recruitment/ these services Performance Vacancies for the next (3x3 = 9) year.

Risk 1484 ANP Night Service provision (4x4 = 16)

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5)

Quarterly Trust Board Progress Reports ( Executive Director Lead)

(include progress on meeting the objective and the management of the principle risk)

1b ) Advancing Quality Action Plan – implementation underway

Q1: Progress Report

Q2: Progress Report

Q3: Progress Report

Q4: Progress Report

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5)

TRUST STRATEGIC OBJECTIVE 2: PARTNERSHIP WILL BE OUR STRENGTH

RAG Rating per Quarter Trust Annual Objectives 2014/15 Measures Q1 Q2 Q3 Q4

BHNFT Strategic a) We will continue to be open and inclusive with our patients, our partners and the public Communications 2.a and provide information about their care and our services. and Engagement Framework

Delivery of the b) To be an effective partner on the Health & Well Being Board (HWB) allowing for 2.b Health and improvement in the services we provide and the way we work with others Wellbeing strategy

c) We will be a key partner in the Working Together Programme supporting the delivery of Working Together 2.c the programmes aims and outcomes Strategy

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5)

Assurance Obtained on Controls Board Action Plan

Priority Responsible 6 month Year Ob. Positive Gaps in Gaps in Principal Risk Key Controls Action Plan Director & forecast End No Likelihood/ Assurance Control Assurance Impact Committee (Sept 14) forecast 2a Damage to Link to Risk Strategic Quarterly None identified Communication Director of organisational Register Communications report to Annual Action Plan Communications reputation & Engagement Board (August ( August 2014) & Marketing Framework 2014)

None FFT measures Quality & Executive NHS Choices Governance Summary for ( monitored turnaround Plan monthly) – Internal & External Social Media Stakeholders Feedback – monitored ( July 2014) daily

External stakeholder Breach of communicatio Licence - n being Communications launched Framework (August 2014 - bimonthly) ( August 2014) MPs briefing

quarterly (July Trust Branding 2014) Guidelines Board to ( April 2014) Board meetings with CCG

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5) Assurance Obtained on Controls Board Action Plan

Priority Responsible 6 month Year Ob. Positive Gaps in Gaps in Principal Risk Key Controls Action Plan Director & forecast End No Likelihood/ Assurance Control Assurance Impact Committee (Sept 14) forecast 2b Inability to Link to Risk CCG/Trust Introduction of The Trust is Increased Work with CCG to Director of manage Register commissioning CBUs, with not acuity of deliver robust plans Operations/Direct increased contract lead clinical responsible patients for activity of Strategy demand for Not been monitoring directors for the attending A&E reductions and Emergency identified meetings - ensuring activity monitor through Services monthly significant reductions contract meetings. Finance & clinical but provides Quality and Performance engagement input Performance through the

meetings with CCG to the CCG deliver the

planned Activity and reductions. demand reports to Finance and Performance Committee

Local Urgent Care Board

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5) Assurance Obtained on Controls Board Action Plan

Priority Responsible 6 month Year Ob. Positive Gaps in Gaps in Principal Risk Key Controls Action Plan Director & forecast End No Likelihood/ Assurance Control Assurance Impact Committee (Sept 14) forecast 2c Failure to Link to Risk Joint working Report to None None Director of release benefits Register with partner Board from identified identified Strategy/Chief from Working organisations Chief Executive Together Not been Executive/Dire Programme identified Engagement ctor Finance & agreement Performance signed

Overall benefits not been identified per organisation

Clinical workstreams ongoing

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5)

Quarterly Trust Board Progress Reports ( Executive Director Lead)

(include progress on meeting the objective and the management of the principle risk)

2a) Chief Executive monthly column in Barnsley Chronicle

Q1: Progress Report

Q2: Progress Report

Q3: Progress Report

Q4: Progress Report

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5)

TRUST OBJECTIVE 3: PEOPLE WILL BE PROUD TO WORK FOR US

RAG Rating per Quarter Trust Annual Objectives 2014/15 Measures Q1 Q2 Q3 Q4

Performance a) A new Clinical Business Unit structure will be fully implemented. Delivering leadership and 3.a Management accountability across the organisation. Framework

Workforce plan May 2014 Resourcing plan b) Recruit, retain and develop a highly skilled workforce. Reduce the time taken to recruit 3.b by June 2014 staff Annual Training plan by April 2015

c) Proactively improve the health and well being of our employees. This will be done through Quarterly/Annual 3.c supportive and skilful leadership working with the Trusts Healthy Workplace Group staff survey

d) To create an engaged and motivated workforce whose achievements are recognised at all Quarterly/ Annual 3.d levels and support the Trusts aims and values. staff survey

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5)

Assurance Obtained on Controls Board Action Plan

Priority Responsible 6 month Year Ob. Key Positive Gaps in Gaps in Principal Risk Action Plan Director & forecast End No Likelihood/ Controls Assurance Control Assurance Impact Committee (Sept 14) forecast 3a Embedding new Link to Risk Monthly Workforce data Programmes Staff Statutory & Director of HR & CBU structure Register performance reported via for leadership perception of Mandatory Training Organisational and engage reports from Workforce to be gaps following plan & trajectory Development workforce to Not been CBUs Group developed Francis Report deliver 2 and identified? Finance & 5year plans, Monthly Performance impacting on Nursing Organisation quality, finance Workforce al and service Report Development delivery Strategy

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5) Assurance Obtained on Controls Board Action Plan

Priority Responsible 6 month Year Ob. Key Positive Gaps in Gaps in Principal Risk Action Plan Director & forecast End No Likelihood/ Controls Assurance Control Assurance Impact Committee (Sept 14) forecast 3b Failure to Link to Risk Workforce Monitored Excessive use Current Review data and Director of HR & develop and Register report to through CBU of bank and vacancy rate develop future Organisational implement a Trust Board performance agency staff and unfilled workforce plans Development workforce Risk 1201 via Finance reports posts across all CBUs strategy HR: Non & recruitment/ Performance Reports to ( clinical staff) Vacancies Finance and Finance & (3x3 = 9) Performance Length of Performance committee recruitment Monthly process (KPI Continue to nurse average 56 streamline staffing days) recruitment process levels report as appropriate to Board Nurse Education Strategy not in place

Further roll out of e-roster programme

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5) Assurance Obtained on Controls Board Action Plan

Priority Responsible 6 month Year Ob. Key Positive Gaps in Gaps in Principal Risk Action Plan Director & forecast End No Likelihood/ Controls Assurance Control Assurance Impact Committee (Sept 14) forecast 3c Inability to Link to Risk Workforce data Not meeting all Health & Well Being Director of HR & reduce absence Register reported via workforce Plan ( 2013/14) Organisational rates and Workforce targets Development enable return to Risk 1197 Group and Staff Survey employment Absence & Finance & Investors in People sooner after Stress Performance Action Plan Finance & period of (3x3 =9) Committee Performance sickness

Friends &

Family Test to include staff, key measures of staff survey (reported bi- monthly)

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5) Assurance Obtained on Controls Board Action Plan

Priority Responsible 6 month Year Ob. Key Positive Gaps in Gaps in Principal Risk Action Plan Director & forecast End No Likelihood/ Controls Assurance Control Assurance Impact Committee (Sept 14) forecast 3d Failure to Link to Risk Performance Report to Recruitment BHNFTH Strategic Director of HR & engage & Register reports from Board from gaps Communications Organisational motivate our CBU related Director of HR and Engagement Development workforce Risk 1200 to sickness, Framework Generic vacancy rate

Risk as etc. described – Finance & no detail Implementati Together We Will Performance (3x4 = 12) on of Make it Better- Together We linked to staff Will Make it survey themes Better

Health & Well Being Strategy

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5) Quarterly Trust Board Progress Reports ( Executive Director Lead)

(include progress on meeting the objective and the management of the principle risk)

3a)CBU structure almost complete, shadowing process underway Q1: Progress Report 3d) Staff engagement: ‘Join the Conversation’ commenced. Team Brief by CE reintroduced

Q2: Progress Report

Q3: Progress Report

Q4: Progress Report

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5)

TRUST OBJECTIVE 4: PERFORMANCE MATTERS Measures RAG Rating per Quarter Trust Annual Objectives 2014/15 Q1 Q2 Q3 Q4 Performance Framework & a) We will improve performance through embedding a new performance framework supporting the 4.a Board CBUs. This will support achieving the operational, quality, financial and delivery targets. Performance Report

5 year IM&T 4.b b) The EPR will launch in September 2014 offering a benefit from the investment Strategy

c) Optimise the use of the estate to use space efficiently, improve the environment and identify cost 5 year Estates 4.c reductions. Projects will be identified and managed in line with the capital expenditure and Strategy availability of funds

d) We will secure the most cost effective goods and services BHSS business 4.d plan

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5)

Assurance Obtained on Controls Board Action Plan

Priority Responsible 6 month Year Ob. Key Positive Gaps in Gaps in Principal Risk Action Plan Director & forecast End No Likelihood/ Controls Assurance Control Assurance Impact Committee (Sept 14) forecast 4a Failure to deliver Link to Risk BHNFT Reports to Ensuring Maturity of Action plans in Chief Executive/ Turnaround Plan Register Turnaround Board: registration schemes Place for targets and Director of Plan including: standards at risk of Finance/ Director Director of standards are Risk 1155 Future schemes not performing within of Strategy Finance Report embedded Finance inc Rolling CIP to be identified the ‘achieved’ programme across CBUs thresholds. CIP and Finance & Performance Deficit CBU Committee Monthly review of (4x5 = 20) ownership of Report Quality & schemes Performance Reports CQC compliance and other external & Robust at Band 6- ( July internal information to Performance 2014) target areas at Management Evidence log for potential risk of non Regime in CQC outcome, compliance. place internal review of And patient stories. all outcomes. Budget setting & Business NHSLA level 1 planning Quality Accounts Internal audit processes 2013/Internal programme 2014/15

Audits - QIA Governance Clinical audit

/Performance programme 2014/15 Trust Weekly report to Performance Executive Team , Framework with narrative on performance Monthly budget Reporting reporting mechanisms in place for each CBU through the Performance Framework

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5) Assurance Obtained on Controls Board Action Plan

Priority Responsible 6 month Year Ob. Key Positive Gaps in Gaps in Principal Risk Action Plan Director & forecast End No Likelihood/ Controls Assurance Control Assurance Impact Committee (Sept 14) forecast 4b Failure to deliver Link to Risk Reports to Assurance for 5year IM&T Director of IM&T Strategy Register Board , EPR being Strategy Finance/ Director including EPR Finance & obtained of ICT Performance externally Risk 1150 Committee Finance & EPR Performance (3x3 = 9) ICT Strategy approved Risk 1151 2013 Systems outwith IT Business strategy case for EPR (4x2 = 8)

Risk 1469 Pathology System (5x4 = 20)

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5) Assurance Obtained on Controls Board Action Plan

Priority Responsible 6 month Year Ob. Key Positive Gaps in Gaps in Principal Risk Action Plan Director & forecast End No Likelihood/ Controls Assurance Control Assurance Impact Committee (Sept 14) forecast 4c Risk of access Link to Risk Robust Strong Board Availability of Ensure each Associate Director to Capital Register process for with clear the level of scheme has full of Facilities/ through Trust development strategy and finance business case and Director of Capital Risk 1155 and approval process for available implementation Strategy/ Director Programme and Finance inc of business prioritisation through the monitored through of Operations/ of competing CIP and cases capital project group. Director of service delivery programme Finance/ Deficit programmes Board (4x5 = 20) prioritisation Finance & through Performance Weekly Executive Team Meeting

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5) Assurance Obtained on Controls Board Action Plan

Priority Responsible 6 month Year Ob. Key Positive Gaps in Gaps in Principal Risk Action Plan Director & forecast End No Likelihood/ Controls Assurance Control Assurance Impact Committee (Sept 14) forecast 4d Developing Link to Risk Reports BHSS Risk log being Director of agreed Register prepared for Business Plan developed Finance/Director commercial Board (August 2014) of Strategy & partnerships None Business identified Development

BOARD ASSURANCE FRAMEWORK 2014/15 (JULY V5)

Quarterly Trust Board Progress Reports ( Executive Director Lead)

(include progress on meeting the objective and the management of the principle risk)

Introduction of weekly performance reports to ET - commenced

Introduction of monthly CBU performance meetings with clinical engagement - commenced Q1: Progress Report Senior Operational & Performance meetings led by Director of Operations (frequency to be determined) – agreed and to be implemented shortly

Q2: Progress Report

Q3: Progress Report

Q4: Progress Report

REPORT TO THE BOARD OF REF: BARNSLEY HOSPITAL NHSFT 14/08/P-17

SUBJECT: CHAIRMAN’S REPORT

DATE: AUGUST 2014

Tick as Tick as applicable applicable

For decision/approval Assurance PURPOSE: For review Governance For information  Strategy PREPARED BY: Stephen Wragg, Chairman SPONSORED BY: PRESENTED BY: Stephen Wragg, Chairman STRATEGIC CONTEXT 2-3 sentences

QUESTION(S) ADDRESSED IN THIS REPORT

CONCLUSION AND RECOMMENDATION(S)

The Board of Directors is asked to: a) receive, note and support this report b) invite and note any further reports on their activities from the wider Non Executive team. c) support the recommendation regarding the Foundation Trust Governors Association

BoD Aug: 2014: 17_Chairs report

REFERENCE/CHECKLIST • Which business plan objective(s) does this report relate to? Patients BCCG Other

• Please state: Has this report considered the Staff BMBC following stakeholders? Governors Monitor

Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution etc) • Has this report reviewed the Trust’s compliance with: Equality, Diversity & Human Rights

The Trust's sustainability strategy

• Has this report Quality & Governance (in draft or during Yes • Is this report development) been Audit Committee supported by a reviewed and Not applicable communications supported by any Finance & Performance plan? Board or Executive To be developed committee within the ET Trust? • Where applicable, briefly identify risk issues (including any reputation) and cross reference to risk register and governance committees • Where applicable, state Finance: resource requirements: Other:

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: Providing the best healthcare for all”

Bod Aug 2014: 17_Chairs report

Subject: CHAIRMAN’S REPORT Ref: 14/08/P-17

1. INTRODUCTION 1.1 This report is intended to give a brief outline of some of the work and activities undertaken as Trust Chairman over the past month and highlight a number of items of interest. 1.2 The items reported are not shown in any order of priority.

2. TRUST POSITION

2.1 As is reported in other papers in this Board meeting, work to stabilise our position continues at pace. Our turnaround plan has been submitted to Monitor and they will continue to review our progress against the plan until we are able to satisfy them that we are no longer in breach of our licence.

2.2 Whilst we remain in breach it is fitting for me to comment in this report about our current situation. Other reports will detail the progress made against the plan, but I am pleased to note that we are currently performing slightly ahead of our plan and that it appears to me the Trust as a whole is galvanised to ensure the delivery of the plan.

2.3 Our internal governance structure review is now complete and the changes to that have begun to strengthen the way that assurance is provided, not only to the Board, but to staff, patients and stakeholders throughout the borough.

2.4 We must continue to give confidence to the population of Barnsley and our key stakeholders that care will not be compromised and we will turn this current situation around. I will reiterate the message from previous meetings as I think it should be constantly in people’s minds. Whilst we are bringing about our return to stability, we must not compromise on quality of care and patient safety.

2.5 Once again I would like to thank everyone for the excellent support we are receiving inside and outside the Trust, but we must continue to deliver to earn that ongoing support and recognise that this is the start of a long journey; while progress has been made it must be sustained.

3. COUNCIL OF GOVERNORS 3.1 This month has seen two sub group meetings. Strategy & Performance heard from Debbie Myers on our membership strategy and were impressed with the work she has been able to do since she arrived. The strategy gave Governors a focus for how we will develop this area over the coming years. Focus was also given to the monthly board reports on performance and a discussion on how the Governors would hold NEDs to account following Monitor guidance being issued on the subject. 3.2 The Staff & Environment sub group heard from Hilary Brearley on staff morale, and how the HR team is aiming to monitor and understand that through the turnaround period. Hilary also gave a detailed explanation on the recruitment process and how that is measured, and giving details of improvements that are being made in that area of work. In addition we heard from Jason Bradley on the EPR implementation and

BoD August 2014: 17_Chairs report p1 of 3

how the IT team is mitigating the risks to the organisation while the system is being implemented. 3.3 I also met with staff governors in the month, who are able to raise issues with me to be passed on in the organisation and give me a sense of how things are in the Trust from their perspective.

4. FOUNDATION TRUST NETWORK (FTN) / FOUNDATION TRUST GOVERNORS’ ASSOCIATION (FTGA)

4.1 As some people may be aware, work has been progressed on bringing the FTGA under the arm of the FTN, and as a member of the FTGA, the Trust has been asked to vote on this issue. It seems a sensible move, combining their strengths and knowledge and is strongly supported by both organisations.

4.2 The end of August coincides with the end of the FTGA’s current hosting arrangements with Capita and the terms of office of most of its Board, making 1st September a convenient date to set up the new arrangement.

4.3 In terms of financial prudence, a recent communication from the FTN states the following:

“Subscriptions The intention is that the transaction will be cost neutral and that operational costs for the rest of the FTN’s financial year 2014/15 will be met from existing resources. This means that those trusts that are existing FTGA members will not be invoiced in the autumn of 2014 and there will be no other costs passed on to members in respect of the governor offer in 2014/15. We have not yet started to work on subscriptions for future years, but as always there will be a frank and open dialogue with members via the FTN board.”

4.4 It is equally important that the Governors’ voice continues to be heard at national level and the FTGA and FTN have given assurance that steps have been taken to enhance and preserve this. As part of this, the FTN has agreed to form a Governor Policy Board to represent Governor interests, membership of which will include representatives from foundation trust Governors as well as the FTN Board.

4.5 Voting must be received on or before 14th August, in writing, and I would propose that we vote in favour of the proposal that the FTGA merges with the FTN.

5. NEWS & EVENTS 5.1 On 1 July, I attended the FTN Annual Governance conference where I heard about a number of presentations on governance matters, including a significant one on Board challenge delivered by DAC Beachcroft. 5.2 On 10th July, Katie Cartwright and I attended a meeting of the Rockley and Stainborough Rotary club under the Presidency of Trevor Smith, our Deputy Lead Governor, to talk to them about the Tiny Hearts Appeal, the reason we need it and try gain their support for the appeal. I felt that we were received very well and we were able to pass on a number of messages about the Trust and how we operate. 5.3 On 16th July I was pleased to be able to support the Acute Medical Unit’s marathon challenge by walking on the treadmill for a short distance and helping in a small way to them achieving their overall target. Later that afternoon I attended the local

Bod Aug 2014: 17_Chairs report p2 of 3 strategic partnership on behalf of the Trust, the minutes of which will be attached when they become available. 5.4 On 21st July I attended a meeting at Sheffield College to support their application to build a University Training College, which will have a healthcare focus. This is mainly a vocational college working with employers to develop students’ ability to fill the future needs of employers. 5.5 On 23 July, along with the Trust team, I attended Monitor for our monthly performance review meeting, more on which is reported elsewhere in this Board meeting. 5.6 The CEO, Emma Parkes and I met with our local MPs on 25 July. Unsurprisingly the focus of the meeting was our current situation, which we described as well as we are able to, and gave the MPs some assurance that we are in control of the current situation. 5.7 On 28 July I was pleased to attend a reception with the Deputy Mayor, where he presented a cheque raised in his mayoral year to our charity. We received just over £4,000, which we are extremely grateful for, and this will be used to support cancer services in the Trust. I was pleased to be joined at the event by Alison Bennett and Sara Andrews (specialist cancer nurses at the Trust), as well as Emma Parkes and Katie Cartwright.

6. BARNSLEY HOSPITAL CHARITY

6.1 Donations to the Charity in June, totalled over £15,700 and in mid July were at just over £4,000, not including the mayoral donation reported above. As always, the generosity of our supporters is tremendous.

6.2 In terms Charity activities: • August sees the “Underneath the Stars Festival” at Cannon Hall – a 3 day music festival. Tiny Hearts has been chosen as their charity and volunteers will be going to the event to collect donations. • As part of the Alhambra Charity of the Year activity, the team will be hosting a “Princess Party” at the shopping centre shortly. All monies raised will be donated to the Tiny Hearts Appeal • The Zombie Run website is now live and preparations are well under way for the event. 114 runners have registered to date and over 100 zombies signed up as volunteers. • Barnsley Council has given approval for the Rainbow Run to be held at Locke Park again in 2015. Dates will be announced soon. • Filming has started for The Tiny Hearts Appeal DVD and merchandise for the “Born in Barnsley” range has been ordered. The Charity will be retailing this in the charity shop, Sainsbury’s and the Alhambra shopping centre • The Charity’s 2014 Christmas cards will be available from September, from the charity shop, Sainsbury’s and Alhambra shopping centre.

Stephen Wragg CHAIRMAN August 2014

Bod Aug 2014: 17_Chairs report p3 of 3

REPORT TO THE BOARD OF REF: BARNSLEY HOSPITAL NHSFT 14/08/P-18

SUBJECT: CHIEF EXECUTIVE’S REPORT

DATE: AUGUST 2014

Tick as Tick as applicable applicable

For decision/approval Assurance PURPOSE: For review Governance For information  Strategy PREPARED BY: Diane Wake, Chief Executive SPONSORED BY: Diane Wake, Chief Executive PRESENTED BY: Diane Wake, Chief Executive STRATEGIC CONTEXT 2-3 sentences

To report particular events, meetings or publications that the Chief Executive would like to bring to the Board’s attention.

QUESTION(S) ADDRESSED IN THIS REPORT

CONCLUSION AND RECOMMENDATION(S)

The Board of Directors is asked to receive and note this report.

BoD August 2014: 18_CEO Report

REFERENCE/CHECKLIST • Which business plan objective(s) does this report relate to? Patients BCCG Other

• Please state: Has this report considered the Staff BMBC following stakeholders? Governors Monitor

Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution etc) • Has this report reviewed the Trust’s compliance with: Equality, Diversity & Human Rights

The Trust's sustainability strategy

Yes • Quality & Governance Has this report (in draft or during • Is this report Not applicable development) been Finance & Performance supported by a reviewed by any communications To be developed Board or Executive Audit Committee plan? committees within the Trust? ET

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: Providing the best healthcare for all”

BoD August 2014: 18_CEO Report

Subject: CHIEF EXECUTIVE’S REPORT Ref: 14/08/P-18

1. INTRODUCTION

1.1 This report is intended to give a brief outline of some of the key activities undertaken as Chief Executive since last month’s report and highlight a number of items of interest.

1.2 The items below are not reported in any order of priority. 2. WORKING TOGETHER PROGRAMME EXECUTIVE UPDATE 2.1 David Peverelle, Chief Operating Officer attended the Executive Meeting of the Working Together Programme on 7 July 2014 on behalf of the Chief Executive. The Key points of the meeting are summarised below:

• HR support for the programme. The meeting considered future arrangements to support the programme which was important in particular for potential HR related issues to future service changes as a consequence of the programme.

• Medicines Management. A new area of work being considered is the feasibility of reviewing medicines management across the provider trusts. This includes collaboration on formularies, with some work already being undertaken by the CCGs, centralisation of storage and VAT recovery.

2.2 The Executive meeting had a monthly update on each of the key programme areas.

• Informatics. Good progress being made on a number of key elements of the programme, which included integrated information networks across the providers which was important in relation to both clinical activity and the information sharing.

• Speciality Collaborative Working particular focus being given on Ear Nose and Throat (ENT), ophthalmology and Oral Maxillo Facial Surgery (OMFS). A number of clinical meetings being held that week with emerging options about potential service reconfiguration being made available in August.

• Radiology. A clinical workshop was held in June scoping the remit of the project and Task and Finish Groups are being established. These will cover interventional radiology, radiographer and radiologist capacity and a review of demand and efficiency. Focus was also being given to a regional approach to enhanced training programmes for radiographers and radiologists.

• Children’s Services. Two key areas – continuing review of paediatric services and anaesthesia and the Children’s Urgent Emergency Care Pathways. A joint core group has been established between providers and commissioners. On 9th September the Yorkshire and Humber Children’s and Maternity Strategic Clinical Network are holding their first meeting and the core group was linking into the work being undertaken by the programme. The Trusts have also completed an updated gap analysis previously undertaken in 2012. • GI Bleeds. A meeting was being held the following day. Key drivers for change included particular out of hours cover and identifying solutions to cross-Trust cover.

BoD August 2014:CEO Report Page 1

• Procurement. Work continuing on five main product areas, however, progress slower than anticipated due to incomplete data fields. These include examination gloves, dressings, bandages, needles and syringes.

• Shared Services. A meeting was scheduled for 1st July to identify areas currently being scoped with a paper being produced outlining the opportunities and benefits to be considered by Directors of Finance with a view to updating the Programme Executive in September.

• Draft governance arrangements for joint projects. The meeting considered an outline of the governance arrangements for the programme and particularly interface with the work being undertaken by commissioners which has then to be considered by its South Yorkshire commissioners with a view to confirming a proposed framework by the end of July.

• Communications and Engagement. A Communications and Engagement Strategy is being drafted with the aim of supporting the delivery of the programme areas and objectives. This will include more detail on where public consultation was required and the level of engagement needed with key stakeholders.

• Future meeting arrangements. It is planned to have a joint meeting between the Programme Executive and the Trust Chairs on 4th August. The Executive meeting planned for 1st September has been cancelled in view of a planned Programme Executive and Commissioning meeting on Friday, 5th September.

• Attendance at Trust meetings. The Programme Director and Medical Director for the Working Together Programme extended an offer to attend Trust meetings if they felt that would be useful

3. NATIONAL ACUTE MEDICINE AWARENESS WEEK

3.1 The staff on the Acute Medical Unit (AMU) undertook a virtual marathon on 16 July 2014 as part of the National Acute Medicine Awareness Week initiative.

3.2 The first mile was undertaken by Lead Nurse, Louise Sharp and throughout the day medical and nursing staff, managers and governors as well as the Chairman added to the mileage following a virtual route around the borough. The final 2.5 miles was completed by AMU Lead Consultant Dr Rana by 18:00. This was a great achievement by all concerned.

3.3 The virtual marathon raised £128.00 which will be used towards further enhancing the ‘Dignity Room’ on AMU for patients and their families.

3.4 Pictures and a report will be sent to the National Society for Acute Medicine (SAM) and will be published via the network along with news letters from across the country.

4. HOSPITAL ATTACHMENT FOR MA STUDENTS IN HOSPITAL MANAGEMENT

4.1 The Trust has received a certificate and a letter of thanks from the University of Leeds, Nuffield Centre, following the three-week attachment of one of their international students. 4.2 Over the years, students who have been placed in the Trust have repeatedly stated how valuable and educationally beneficial their experience has been to them.

BoD August 2014:CEO Report Page 2

5. SIGN UP TO SAFETY

5.1 The Trust has signed up to “Sign up to Safety” campaign with Julian Newell, Corporate Matron – Patient Safety leading the campaign. The “Sign up to Safety” campaign’s key elements are:

• put Safety First. Commit to reduce avoidable harm in the NHS by half and make public the goals and plans developed locally. • place patent safety at the heart of the Trust’s Quality Strategy. With the setting of goals on patient safety issues such as National Early Warning Scores (NEWs) and sepsis. • continually learn. Make the organisation more resilient to risks, by acting on the feedback from patients and by constantly measuring and monitoring how safe the services are • complaints. Actively investigate and respond to all complaints and concerns in a timely manner • deaths. Review all deaths in the Trust in a uniform and systematic way • patient safety. Monitoring patient safety through traingulation of information (Quality Impact Monitoring, Clinical Audit) in oder to analyse, improve and learn • honesty. Be transparent with people about progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong. Actively pursue a policy of candour in the circumstances of something going wrong. • collaborate. Take a leading role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use. • support. Help understand why things go wrong and how to put them right. Give staff the time and support to improve and celebrate the progress. Ensure staff is informed about patient safety issues and support staff so that changes and improvements are made in ways which are effective and sustainable.

Diane Wake Chief Executive August 2014

BoD August 2014:CEO Report Page 3

REF: 14/08/P-19

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT

SUBJECT: QUARTERLY COMMUNICATIONS UPDATE

DATE: AUGUST 2014

Tick as Tick as applicable applicable

For decision/approval Assurance X PURPOSE: For review X Governance For information X Strategy EMMA PARKES PREPARED BY: DIRECTOR OF MARKETING AND COMMUNICATIONS DIANE WAKE SPONSORED BY: CHIEF EXECUTIVE EMMA PARKES PRESENTED BY: DIRECTOR OF MARKETING AND COMMUNICATIONS STRATEGIC CONTEXT 2-3 sentences

To provide an assurance on progress against the Trust’s Strategic Communications and Engagement Strategy 2013 – 2016 and to report on associated communications activity within the previous quarter.

QUESTION(S) ADDRESSED IN THIS REPORT

1. Does the Communications function have an annual action plan for 2014/5, which links to and delivers the Trust’s Strategic Communications and Engagement Framework? 2. Have the actions taken in the past quarter built positive perceptions of the Trust? 3. Has the Communications function taken the necessary and relevant steps to ensure the reputation of the Trust is managed effectively?

CONCLUSION AND RECOMMENDATION(S)

1. The Board is asked to note the Communications Annual Action Plan 2014/15, provided as Appendix 2. 2. Actions taken by the Communications function in the last quarter have continued to build a positive reputation for the Trust with over 32 positive media stories proactively placed during the quarter. 3. The Communications function has ensured balanced coverage with opportunity to comment on 23 reactive media requests in order to maintain the Trust’s reputation.

BoD month 2014: 19_Comms Board report August 2014

REFERENCE/CHECKLIST The report contributes to the Trust’s Strategic Aims (below) and supports the delivery of all Strategic Objectives: • Which business plan • Patients will experience safe care objective(s) does this report • Partnerships will be our strength relate to? • People will be proud to work for us • Performance matters Patients BCCG Other

• Please state: Has this report considered the Staff BMBC following stakeholders? Media Governors Monitor

Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution etc) • Has this report reviewed the Trust’s compliance with: Equality, Diversity & Human Rights

The Trust's sustainability strategy

• Where applicable, briefly N/A identify risk issues (including any reputation) and cross reference to risk register and governance committees • Where applicable, state Finance: N/A resource requirements: Other: N/A

The Board will also have regard to the Trust’s core vision statement: “To be the best integrated healthcare organisation of choice for our local communities and beyond”

BoD month 2014: 19_Comms Board report August 2014

Subject: QUARTERLY COMMUNICATIONS UPDATE Ref: 14/08/P-19

1. STRATEGIC CONTEXT

1.1 This report provides the Board with assurance on actions that will be taken during 2014/15 to support the delivery of the Strategic Communications and Engagement Framework 2013-2016 and the Trust's strategic objectives.

1.2 Furthermore, this report provides an overview of communications, media and social media activity within Quarter 1 of the 2014/15 financial year.

2. STRATEGIC COMMUNICATIONS AND ENGAGEMENT

2.1 Staffing Changes

The substantive Director of Marketing & Communications will take up a period of maternity leave on 8 August 2014, returning on 11 May 2015. During the period, an Interim Director of Marketing & Communications will fulfil the role.

The Digital Communications Officer is now in post and has impacted positively on social media activity in the quarter, increasing the number of followers on both Facebook and Twitter. This replaces the previous Web Manager position within the communications function.

2.2 Annual Action Plan

The Annual Action Plan 2014/15, which supports the delivery of the Trust’s Strategic Communications and Engagement Framework 2013 – 2016, was received at Non- Clinical Governance Committee on 16 June 2014. This is attached as Appendix 2.

2.3 Brand Management

The Trust’s new brand was launched on 30 April 2014. The brand is focused around the strapline ‘Quality in Care’ and the colour palette was selected so that each of the Trust’s Clinical Business Units (CBUs) has its own colour and sub-identity, invoking a sense of ‘ownership’ from staff in these areas. Brand Guidelines, a Corporate house Style, Key Messages and template materials are available to ensure staff are using branded materials, embedding the brand within the organisation. Feedback has been positive from internal and external stakeholders.

2.4 Reputation Management

The Communications function has continued to issue timely internal and external briefings on financial and operational performance. In addition to proactively briefing local media, the function has worked to minimise negative media coverage of the Trust’s position by managing 23 reactive media requests relating to the issue during the quarter, with the provision of a range of statements in order to provide context and balance to resulting articles. Diane Wake’s monthly column in the Barnsley Chronicle has been used to reinforce key messages.

During the quarter, a total of 32 proactive articles have been secured about the Trust’s activities and services in order to offset the inevitable negative coverage received.

3. INTERNAL COMMUNICATIONS AND STAFF ENGAGEMENT

Key activity in the quarter has included:

3.1 Delivery of the HEART Awards 2014. This year’s event saw a rebranding, becoming the Barnsley Hospital Charity HEART Awards for the first time. Nearly 300 guests attended the awards, the highest ever, with over 100 nominations made. Nominations have also been submitted to the Hospital Worker category in the Proud of Barnsley Awards, managed by the Barnsley Chronicle.

3.2 Delivery of a security campaign themed ‘Every Day in May’. On each day in May a different message was posted on the intranet and reinforced in the e-bulletin every Monday, promoting a different key message related to security around the hospital, including tips on how to keep staff areas secure.

3.3 Supporting the reduction in sickness absence. A programme of communications designed to help reduce sickness absence has included publishing sickness absence rates by CBU in Team Brief, posters distributed around the Trust detailing the cost of sickness absence and others delivering key health and wellbeing messages and promotion of a Health and Wellbeing app for staff.

3.4 The establishment of a “You Said, We’ve Done” section of the intranet, to act as a hub for staff feedback and what the Trust is doing in response. The section includes feedback from the Join the Conversation Roadshows, efficiency ideas, Together We Will Make it Better, and Open and Honest Care. The section will be updated with new ideas, and the Trust’s actions in response, as they develop.

3.5 Continued delivery of the Join the Conversation events with the Chief Executive. These continue to be well attended and feedback from staff is posted on the intranet after every event.

4. EXTERNAL COMMUNICATIONS

4.1 A new, bi-monthly, external e-magazine communication called ‘Quality Matters’ will be launched on 4 August 2014. The publication aims to keep external stakeholders and partners up-to-date with important information about the Trust whilst raising awareness of services and key acheivements.

5. ANNUAL REPORT 2013/14

5.1 The Annual Report and Financial Accounts for the period 1 April 2013 to 31 March 2014 were laid before Parliament, as required, on 3 July. The report will be presented at the Annual General and Public Members Meeting on 11 September 2014.

6. MEMBERSHIP COMMUNICATIONS

6.1 Membership – membership continues to grow, with 12,516 eligible members comprising 9,064 public members and 3,452 staff members. Under-represented sections of the community are proactively targeted in order to encourage them to be actively involved in making decisions about current and future services.

6.2 Voluntary Youth Ambassador Scheme – the scheme, developed in collaboration with Barnsley College, aims to encourage young people (16 and 18 year old) to become

involved in the Trust. The aim is to recruit three Youth Ambassadors during 2014/15 who will support the Trust in growing membership levels among 16 to 18 year olds.

6.3 Data validation – in order to generate further efficiencies, members are being encouraged to change their communication preference from post to email. Barnsley Hospital Charity is supporting the initiative with the donation of a prize to be drawn in Quarter 3 2014/15.

7. BARNSLEY HOSPITAL CHARITY

7.1 Tiny Hearts, the capital appeal to raise £1million for the Trust’s Special Care Baby Unit (SCBU), is expected to launch in August 2014. Louis Tomlinson of the band One Direction is supporting the appeal and will be the face of the direct giving social media campaign, which is branded ‘One in a Million’. The branding for the appeal is complete and an accompanying DVD is in production featuring local families, celebrities and experts. A schools programme is being created in partnership with The Civic and a corporate and community pack has been produced to encourage full engagement with local communities. Merchandise is in production and will be sold in Sainsburys stores across the town, The Alhambra Centre and the Charity office.

7.2 The Zombie Run 2014 currently has over 100 registered runners. It has attracted positive media coverage in the Barnsley Chronicle, The Barnsley Independent and We Are Barnsley. The target for the event is to increase the runners from 560 in 2013 to 1,000 this year, with an income generation target of £25,000, £5,000 more than in 2013.

7.3 The Rainbow Run was a success with over 600 runners taking part. The event has raised approximately £13,000 for the Charity and has secured multiple opportunities for positive media coverage and increased awareness.

8. CONCLUSION

8.1 The Communications function has continued to deliver timely and appropriate messages in line with the Trust’s priorities during the quarter. Internally, staff have been kept up-to-date with key events via a range of methods from face-to-face to email in order to reach as wide an audience as possible. Externally, partners have been briefed proactively and the launch of Quality matters in August will support this approach.

8.2 Proactive reputation management has again been important this quarter. Relationships with the Barnsley Chronicle continue to be positive, with the publication affording the Trust the opportunity to provide comment on all related articles.

8.3 Barnsley Hospital Charity continues to raise awareness and funds to support all services across the Trust.

Appendices:

• Appendix 1 – Communications and Media Dashboard Quarter 1 2014 • Appendix 2 – Annual Action plan 2014/15

APPENDIX 1 - COMMUNICATIONS AND MEDIA DASHBOARD QUARTER 1 2014

1. MEDIA AND REPUTATION MANAGEMENT

1.1 Positive Opportunities to View (OTV) – Print

Opportunities to view have fallen this quarter, primarily due to coverage of the Trust’s financial and operational performance and Monitor’s investigation, which has dominated coverage, especially in April, and has limited the number of published positive articles. However, positive articles increased in May and June, with May seeing more positive articles in the Barnsley Chronicle than in any other month in the past year. Such articles included pieces on the Trust’s involvement in Dementia Awareness Week, Barnsley Hospital Charity’s Rainbow Run and the opening of the Barnsley Birthing Centre.

Month Number of Articles Publication OTV April 2014 2 Barnsley Chronicle 152,504 1 Barnsley Independent 148,508 Total opportunities to view in April 301,012 May 2014 13 Barnsley Chronicle 991,276 5 The Sheffield Star 319,300 1 Barnsley Independent 148,508 Total opportunities to view in May 1,459,084 June 2014 9 Barnsley Chronicle 686,268 1 The Sheffield Star 63,860 Total opportunities to view in June 750,128

Total positive opportunities to view for the quarter 2,510,224

1.2 Positive Opportunities to Hear (OTH)

Quarterly opportunities to hear were high due to an item about Barnsley Hospital Charity’s Rainbow Run on BBC Radio 1 in May. This alone made OTH for the quarter the second highest in the last year. Aside from this, OTH were affected by the coverage of the financial position, which dominated radio coverage at the expense of more positive items.

Month Number of Articles Radio Station OTH April 2014 0 - 0 Total opportunities to hear in April 0 May 2014 1 BBC Radio 1 10,532,000 Total opportunities to hear in May 10,532,000 June 2014 0 - 0 Total opportunities to hear in June 0

Total positive opportunities to hear for the quarter 10,532,000

1.3 Media Coverage by Tone

Media coverage has been mixed in tone, with a large number of balanced and neutral articles. This was particularly the case in April, when the media began covering the Trust’s financial and operational performance and Monitor’s subsequent investigation.

Many articles that would otherwise have been negative were counter-balanced by statements and context that were provided, helping to give a balanced tone to articles.

May saw a significant increase in the number of positive articles published as proactive stories were pushed out to help rebalance the Trust’s reputation. Stories included the Trust’s involvement in Dementia Awareness Week, Barnsley Hospital Charity’s Rainbow Run, a new one-stop clinic for falls patients and the opening of the Barnsley Birthing Centre to patients. June’s coverage and tone was again affected by the financial and operational position, particularly by coverage of Monitor’s announcement.

Media coverage by tone

80 60 Positive 40 Neutral 20 % of articles % of 0 Negative Apr-14 May-14 Jun-14

2. SOCIAL MEDIA

2.1 The Twitter following continues to grow. The last quarter has seen the development of links on Twitter with key organisations including The Barnsley Chronicle, We Are Barnsley, Barnsley College and Healthwatch Barnsley, who have all retweeted us. Twitter activity compares favourably with regional Trusts, with the Trust having more than twice as many followers as Doncaster & Bassetlaw Hospitals.

2.2 Facebook Engagement has been exceptionally strong. Our following on Facebook continues to grow steadily, with a particularly strong increase of 55 fans between May and June. Total reach is more than double that of quarter 4 2013/14. This has been achieved through consistent interaction with followers and use of imagery and informative stories. Posts with particularly high reach included the first baby born in the Barnsley Birthing Centre, reaching 12,164 people, and a post about members of the Maternity Department in the Lord Mayor’s Parade, reaching over 3,000 people. For the last quarter, the total reach each month was:

Measure April May June Total Facebook Total Reach 371 19,469 18,932 38,799 Facebook: No of Fans 854 872 927 927 (June 2014) Twitter Followers 2,374 2,417 2,477 2,477 (June 2014)

3. ONLINE ACTIVITY

Website visits totalled 62,129 in the quarter, significantly higher than the 55,633 visits in the equivalent quarter last year, evidencing the increasing popularity of the website year- on-year. The news section of the website received 1,649 visits, up from 1,384 in the previous quarter, as more people are being driven to news content via avenues such as social media feeds. The top five most popular pages in the quarter were:

Page Number of Hits Home page 19,294 Job vacancies 14,874

Contact 14,683 Work for us 5,943 Services list 5,635

APPENDIX 2 - Communications Annual Action Plan 2014/15

The following actions reflect the 2014/15 objectives of the Trust’s Communications function, encompassing; communications and engagement, public relations, media and reputation management, Trust membership and Barnsley Hospital Charity.

Achievement of the objectives will be measured using one of more of the following evaluation methods, together with clear evidence of the outcome for each specific objective.

1. Staff Survey Results 2. Outcomes of Together We Will Make It better work streams 3. Internal Communications Audit 4. External Communications Audit 5. Inpatient and Outpatient survey results 6. Complaints and compliments 7. Anecdotal feedback from Stakeholders via communication channels 8. Regular measurement of positive and negative media coverage, combined with opportunities to view and hear positive information about the Trust 9. Analysis of potential negative stories deflected or transformed into balanced coverage 10. Website user statistics 11. Social media activity 12. Charity income generation, supporter statistics and media coverage analysis. 13. Anecdotal feedback from Governors and the Trust’s membership. 14. FFT Data

Communication Objectives Strategic Core Area SMART Objective Outcome Measure Status Aim of Focus All Strategic Throughout 2014/15, we will be open and inclusive with our System and process in place to ensure 1, 2, 3, 4, On- Comms patients, our partners and the public and provide them with regular review of stakeholder feedback, 5, 6, 7, going. information about their care and our services. By July 2014, leading to better engagement overall and 11, 13, we will put in place systems to enable us to proactively seek a greater understanding of stakeholder 14 July the views of patients, relatives, visitors, the general public, views, together with data to influence 2014 our partners and our staff and to use this feedback to help us service provision. Target improve services. complete Performance Strategic By July 2014, to undertake a review of all media and Strategic management of 3, 7, 8, Complete Matters Comms communications related protocols and policies to ensure they communications, leading to a greater 10, 11 continue to meet business need. impact of activity Performance External By August 2014, to have launched a formal external To build a positive reputation among our 4, 7 Complete Matters Comms communication to the Trust’s external stakeholders in order to external stakeholders, leading to stronger increase awareness and understanding activities/services. partnerships and greater awareness. Performance Online By August 2014, to have undertaken a comprehensive review Up-to-date, accessible information for our 3, 7, 10, On Matters Activity of the staff Intranet site to ensure content is up-to-date, staff, leading to better informed and 11 Target relevant and as accessible as possible, within the technical engaged staff, with the Intranet being a and financial constraints. central source of information. Performance Branding By October 2014, to ensure that the new brand is embedded Consistent usage across the Trust 3, 5, 7 On target Matters across the Trust and is being utilised on internal and external leading to consistently high quality communications and to have produced supporting information communications, positively impacting on including a Corporate House Style Guide. reputation. Performance Online By November 2014, to have undertaken a comprehensive Up-to-date information readily available 4, 7, 10, On Matters Activity review of the Trust’s external website in order to ensure the for patients and the public, leading to 11 Target content is up-to-date, relevant and accessible, within the increased understanding and awareness, technical and financial constraints. positive impact on reputation. Performance Social By March 2015, to improve engagement with patients and the Increased external engagement, leading 4, 7, 11 On target Matters Media public via social media channels by increasing the number of to richer feedback and a positive impact followers for the Facebook and Twitter accounts by 50% on reputation. based on figures for March 2014. Performance Media By March 2015, to achieve a 5% increase in the number of Reputation management, leading to 8, 9, 12 In Matters positive stories about the Trust in comparison to 2013/14. repaired public trust and confidence. progress People will Staff Eng By March 2015, to have contributed to increased staff Increased engagement and 1, 2, 3, 7 On target be Proud to engagement by achieving a 10% increase in the number of communication of key messages, leading Work for us staff who receive a Team Brief regularly, and a 5% increase to a better informed and up-to-date in the number of weekly bulletin readers, based on in workforce. comparison of October 2013 Audit figures. 2

Membership Objectives Strategic Core Area of SMART Objective Outcome Measure Status Aim Focus Partnerships Partnership By August 2014, to produce an events calendar designed Targeted recruitment and awareness 7, 13 On target will be our Community to target specific community groups and increase raising activity, utilising Governor Strength Links membership and awareness of Trust activities. support, leading to increased community activity and stronger partnerships. Performance Membership By August 2014, to review and update the Membership Alignment of strategic direction and 7, 13 On target Matters Comms and Engagement Strategy, recruitment information and activity, leading to a better informed develop a range of tiered membership levels to enable membership. better targeting of membership. Performance Efficient By December 2014, to have implemented a robust process Reduced printed copes leading to more 7, 13 and On target matters Comms for capturing email addresses from current and new efficient and effective communications quality of members in order to reduce the number of printed with the membership. email communications and increase email communication. address Performance Membership By March 2015, to identify under-represented groups A representative membership of the 7, 13 On target Matters Development within the wider membership and develop a targeted population, leading to better engagement approach for proactive recruitment to each. on service developments.

Barnsley Hospital Charity Objectives Strategic Core Area SMART Objective Outcome Measure Status Aim of Focus Performance Income By July 2014, to create a targeted communications plan, Effective management of the capital 12 Complete Matters Generation with clearly defined milestones in order to manage the campaign project, leading to delivery of operational delivery of the Tiny Hearts capital appeal, the overall target of £1m through 2014/15 and 2015/16. Partnerships Effective By August 2014, to develop a Charity Fundraising Pack to Target to attract 10 new business 12 On target will be our Corporate enable effective targeting of corporate sponsorship and partners in 2014/15, leading to stronger Strength Partnerships corporate fundraising with clear targets and aims. external relationships, increased reputational and fundraising activity. People will be Staff Eng By August 2014 to produce an internal Engagement Plan Identification of a new department to 12 On target Proud to designed to increase staff awareness of the Charity. To benefit from charitable funds on a Work for us include a regular staff update. quarterly basis, leading to increased staff engagement and increased fundraising. Partnership Supporter By September 2014, to develop and launch a social media Target of £100,000 income generation by 12 On target will be our Engagement campaign, ‘One in a Million’, designed to support the Tiny July 2016, leading to stronger external Strength Hearts appeal by engaging donors in the core social media relationships, increased reputational demographic of under 25 years. impact and increased fundraising.

REPORT TO THE BOARD OF REF: BARNSLEY HOSPITAL NHSFT 14/08/P-20

MONTHLY INTEGRATED TRUST BOARD REPORT – SUBJECT: REPORT PERIOD MONTH 3

DATE: AUGUST 2014

Tick as Tick as applicable applicable

For decision/approval Assurance  PURPOSE: For review  Governance  For information  Strategy PREPARED BY: Stuart Diggles, Interim Director of Finance David Peverelle, Chief Operating Officer SPONSORED BY: Heather McNair, Director of Nursing & Quality Hilary Brearley, Director of Human Resources & Organisational Development Stuart Diggles, Interim Director of Finance Heather McNair, Director of Nursing & Quality PRESENTED BY: David Peverelle, Chief Operating Officer Hilary Brearley, Director of Human Resources & Organisational Development STRATEGIC CONTEXT 2-3 sentences

To provide an overview of the Trust’s performance in terms of quality, activity, workforce and finance for July 2014.

To provide positive assurance against the following Trust business objectives: 1a, 1b, 2c, 3c, 5b. To provide an update on the Trust’s Emergency Care 4 Hour Pathway Action Plan.

QUESTION(S) ADDRESSED IN THIS REPORT

How has the Trust performed in month 3 and year to date? Are sufficient actions in place to address any areas of concern?

CONCLUSION AND RECOMMENDATION(S)

The Board of Directors is asked to receive and consider the contents of the report.

BoD Aug 2014: P20_Integrated Board Report_1

REFERENCE/CHECKLIST • Which business plan objective(s) does this report relate to? Patients BCCG Other

• Please state: Has this report considered the Staff BMBC following stakeholders? Governors Monitor

Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution etc) • Has this report reviewed the Trust’s compliance with: Equality, Diversity & Human Rights

The Trust's sustainability strategy

• Has this report Quality & Governance (in draft or during Yes • Is this report development) been Audit Committee supported by a reviewed and Not applicable communications supported by any Finance & Performance plan? Board or Executive To be developed committee within the ET Trust? • Where applicable, briefly Inherent within the report. identify risk issues (including any reputation) and cross reference to risk register and governance committees • Where applicable, state Finance: resource requirements: Other:

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: Providing the best healthcare for all”

BoD Aug 2014: P20_Integrated Board Report_1

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Summary of Actions by the Imaging Department Reducing the 6 weeks access Waiting Times. Andy Hardy July 2014

Waiting Times & Actions:

 MRI: o currently at around 6.5 weeks wait o Trust approved the use of mobile MRI towards the end of June – sessions booked as soon as available. nd o 6 consecutive days of mobile MRI booked from 22 August 2014 – this should reduce wait to 5 weeks, potentially less than this dependent on demand. o Future use of mobile MRI does have some funding within budget – however, our own MRI scanner will be commencing some weekend service from late September/early October and will have some positive impact on weekly elective activity. Therefore no further mobile planned at this stage but finance available to support if required. o Assessment of the waiting time trajectory is being undertaken , focussing on volume of patients waiting 3-4 weeks and assessing if in-house MRI service has appropriate capacity to maintain sub-6-week wait. If not, then mobile will be booked at an earlier stage to prevent breaches and avoid a backlog.

 Ultrasound: o MSK Ultrasound – locum (private sector) sessions now running – has seen reduction from 13 weeks peak to just over 8 weeks (the latter figure being for patients who are to be booked next from the waiting list). . Still tracking to achieve a sub 6 week wait by October. Plan to review MSK position at end of August to try and gauge on-going requirements for private sector support, or whether demand can be managed with in-house capacity. o Soft-Tissue, Lumps, Hernias – 9 week wait as these have historically been Radiologist examinations only. . 6 locum sessions booked through August with (based on demand up until July) projection to a 6 week wait in September. As with MSK, the Department will review the position and assess any future support required or whether stable position can be held in-house. o General Ultrasound – some patients experiencing access time of around 4 weeks at present (range 4-6 weeks) for Sonographer lists. o Obs/Gynae Ultrasound – 6 week wait at present for routine cases. . Fetal Anomaly back within target after lengthy period of breaches following 18hpw locum support from 2nd July .

 CT: o Most patients, including routine cases, have access to CT within 2 weeks at present. o 2ww patients well managed (concern with reporting turnaround, but access generally of no concern at present). o Weekend elective capacity will expand slightly in Autumn – 7 day working agenda.

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= target not achived Green = on target Improvement in performance Amber = under performance (within 5% of target) Deterioration in performance Red = fail (>5% target) No change in performance

Page 12 of 25 Green = on target Improvement in performance Amber = under performance (within 5% of target) Deterioration in performance Red = fail (>5% target) No change in performance

Page 13 of 25 Green = on target Improvement in performance Amber = under performance (within 5% of target) Deterioration in performance Red = fail (>5% target) No change in performance

Page 14 of 25 Green = on target Improvement in performance Amber = under performance (within 5% of target) Deterioration in performance Red = fail (>5% target) No change in performance

Page 15 of 25 Green = on target Improvement in performance Amber = under performance (within 5% of target) Deterioration in performance Red = fail (>5% target) No change in performance

Page 16 of 25 Green = on target Improvement in performance Amber = under performance (within 5% of target) Deterioration in performance Red = fail (>5% target) No change in performance

Page 17 of 25

Page 18 of 25

EXECUTIVE SUMMARY

Key Issue RAG Trend Financial Performance Summary Appendix

The RAG Rating applied to financial commentary is based the on following criteria Key to RAG Rating • Green equating to on or exceeding plan. • Amber behind plan by up to 5%. • Red greater than 5% behind plan.

Financial The Trust’s continuity of service rating exclusive of working capital facility at month 3 is 1. In line Appendix 1 Reporting Indices Green with expectations, a number of indicators of forward financial risk have been triggered. Liquidity is -25 days, and the capital servicing capacity defined as revenue available for capital service over annual debt service is -7.

The outturn for capital expenditure is 47.6% of plan.

Statement of The consolidated overall position for month 3 is a £4.98m deficit, against a plan position of Appendix 2 Green Comprehensive £5.29m deficit, a favourable variance of £0.31m. (A deficit of £3.37m was reported for month 2 Income against a plan deficit of £3.64m.) EBITDA is -£3.158m against a planned position of -£3.39m, which is favourable.

Income Amber Contract income Appendix 2a £0.93m behind plan at month 3, of this £0.28m is due to risks and penalties. (Month 2 £0.55m behind). The significant variance relates to CBU 1 (Emergencies, Orthopaedics and Care Services).

Other Income £0.63m ahead of plan at month 3, (£0.12m ahead of plan at month 2).

Cost Achievement at month 3 is £0.81m which is £0.05m ahead of plan, although there are variances Appendix 3 Improvement Green at scheme level. The current position includes significant achievements, for example, the Programmes closure of ward 29.

Pay Green Total pay expense is showing a favourable variance of £0.6m. The agency run rate has increased in month (£0.5m in June, £0.48m in May), with particular pressures in CBU 1 (Emergencies, Orthopaedics and Care Services) and CBU 3 (General & Specialist Medicine).

Page 20 of 25

Key Issue RAG Trend Financial Performance Summary Appendix

Statement of The principal variances at month 3 are total debtors, which are higher than plan by £1.43m, Appendix 4 & Financial Position Amber Overdue debtors (31- 90 days plus) stand at £1.01m. Total creditors including accruals are 4a lower than plan by £0.77 million. Deferred income is £1.11m ahead of plan due to the receipt of business case income. Overall, total assets employed are £0.12m favourable to plan.

Cash Green Cash is £0.68m ahead of plan. Cash flow has been micromanaged over the previous 3 months Appendix 5 with particular attention given to the payment of creditors.

Capital Capital expenditure is £0.58m year to date, £0.63m behind plan, being principally VDI, O Block Appendix 6 Red and Intelligent drug cabinets.

Appendix 1

Indicators of Forward Financial Risk - Consolidated accounts

Risk Actual

Unplanned decrease in EBITDA margin in two consecutive quarters No

Quarterly self-certification by trust that the continuity of service rating (COSR) may be less than 3 in the next 12 months Yes

Working capital facility used in pervious quarter No

Debtors > 90 days past due account for more than 5% of total debtor balances Yes 8.85%

Creditors > 90 days past due account for more than 5% of total creditor balances Yes 9.87%

Two or more changes in Finance Director in a twelve month period No

Interim Finance Director in place over more than one quarter end No

Quarter end cash balance < 10 days of operating expenses No 15

Capital expenditure < 75% of plan for the year to date Yes 47.56%

Continuity of Service Rating Metric Weight Definition Rating Categories Score Rating 1 2 3 4 Liquidity ratio (days) 50% Working capital balance * 360 Annual operating expenses <- -14 -14 -7 0 -25.0 1

Capital Servicing capacity (times) 50% Revenue available for capital service < 1.25 1.25 1.75 2.5 -7 1 Annual debt service

Overall rating 1

Appendix 2 Consolidated Statement of Comprehensive Income

Performance against plan @ Month 3

Statement of Comprehensive Income Draft Month Month Cumulative Cumulative Performance against draft plan/budget at Month 3 FY2014/15 Budget Plan Actual Variance Plan Actual Variance Full Year Jun-14 Jun-14 YTD YTD YTD YTD £'000 £'000 £'000 £'000 £'000 £'000 £'000 NHS Clinical Income Elective Long Stay 10,867 901 860 -41 2,621 2,303 -318 Non Elective 49,406 4,035 4,141 106 12,209 12,391 182 Planned Same Day 14,310 1,184 1,143 -41 3,456 3,414 -42 Out-patients 25,748 2,140 2,080 -60 6,210 6,066 -144 A & E 7,368 625 613 -12 1,875 1,832 -43 Other 35,730 3,246 2,618 -628 8,850 8,537 -313 Business Cases 4,818 271 565 294 816 565 -251 Total 148,247 12,403 12,020 -383 36,037 35,108 -929

Non NHS Clinical Income Private patients 13 1 0 -1 3 1 -2 Other Non Protected Clinical Income (RTA) 1,088 90 93 3 272 446 174 Total 1,100 91 93 2 275 447 172

Other income Research and development 545 46 56 10 136 141 5 Education and Training 4,098 343 372 29 1,029 1,070 41 Other income 10,709 521 992 471 2,467 2,879 412 PFI specific income 0 7 2 -5 7 7 0 Total 15,351 917 1,422 505 3,639 4,097 458 Total income 164,698 13,411 13,535 125 39,951 39,652 -299 Costs Employee benefits expenses (Pay) & Agency costs -118,554 -9,900 -9,746 154 -29,800 -29,191 609 Drug costs -11,710 -948 -965 -17 -2,900 -2,955 -55 Clinical supplies and services -17,548 -1,176 -1,257 -81 -3,542 -3,258 284 Misc other operating expenses (excl Dep'n) -20,846 -2,420 -2,571 -151 -7,101 -7,406 -305

Total costs -168,657 -14,443 -14,539 -96 -43,343 -42,810 533 EBITDA -3,959 -1,033 -1,004 29 -3,392 -3,158 234

Depreciation & Amortisation - owned assets -5,723 -436 -452 -16 -1,336 -1,355 -19 Depreciation & Amortisation - PFI assets -48 -4 -4 0 -12 -12 0 Interest Income 20 2 1 -1 6 7 1 Restructuring Costs -350 -29 0 29 -87 0 87 PFI Interest Expense 0 -4 -4 0 -12 -12 0 PFI Specific Costs 0 -12 -12 0 -34 -34 0 PDC Dividend expense -1,884 -141 -139 2 -425 -418 7 Net Surplus/(Deficit) -11,945 -1,657 -1,614 43 -5,292 -4,982 310

Appendix 2a

Current Month - June-14 Year To Date - June-14 Activity £'000 Activity £'000 POD Analysis Plan Actual Variance Plan Actual Variance Plan Actual Variance Plan Actual Variance 01 - Elective Inpatients 371 342 -29 893 846 -47 1,079 966 -113 2,596 2,273 -323 02 - Elective Daycases 1,906 1,906 -0 1,185 1,124 -61 5,554 5,644 90 3,456 3,414 -43 03 - Non Elective 2,743 2,641 -102 3,715 3,803 88 8,329 8,359 30 11,279 11,635 356 03 - Non Elective (CDU) 247 271 24 135 148 13 742 714 -28 404 389 -15 04a - Excess Beddays (Non Elective) 741 279 -462 167 67 -101 2,250 1,646 -604 508 364 -144 04b - Excess Beddays (Elective) 37 32 -5 9 7 -2 107 135 28 25 30 5 05 - Outpatients New Att. 5,686 5,615 -71 874 843 -32 16,481 16,657 176 2,536 2,499 -37 06 - Outpatients F/up Att 18,265 16,414 -1,851 1,266 1,243 -23 52,988 50,179 -2,809 3,675 3,675 1 08 - A&E Attendances 6,810 6,876 66 625 614 -11 20,429 20,397 -32 1,875 1,833 -42 09 - Critical Care 641 575 -66 478 427 -51 1,944 2,084 140 1,451 1,516 65 10 - Maternity Pathway Tariff 501 450 -51 469 386 -83 1,521 1,417 -104 1,421 1,314 -108 11 - Direct Access Tests 220,163 225,835 5,672 352 350 -2 639,500 653,682 14,182 1,019 1,024 5 12 - High cost drugs revenue 0 0 0 613 568 -46 0 0 0 1,839 1,719 -121 12a - Unbundled Radiology 1,460 1,372 -88 147 145 -2 4,242 4,301 59 427 443 16 13 - Other non-tariff revenue 4,344 3,240 -1,104 333 324 -9 12,627 10,734 -1,893 1,027 1,035 8 14 - Schedule of Service Fee Items 0 0 0 16 16 0 0 0 0 47 47 0 15 - Community Paediatrics 0 0 0 88 88 0 0 0 0 263 263 0 16 - Business Cases 0 0 0 44 44 0 0 0 0 132 132 0 17 - Therapy Services 2,765 2,439 -326 99 95 -4 8,032 7,256 -776 288 279 -9 18 - Specialist Nursing 952 1,019 67 46 44 -3 2,765 3,014 249 134 126 -8 TOTAL 11,553 11,180 -374 34,403 34,010 -393

Current Month - June-14 Year To Date - June-14 Activity £'000 Activity £'000 CBU Analysis Plan Actual Variance Plan Actual Variance Plan Actual Variance Plan Actual Variance CBU 1 - Emergencies, Orthopaedics & Care Services 2,336 2,285 -51 6,910 6,502 -407 CBU 2 - Theatres, Anaesthetics & Critical Care 309 307 -1 936 951 14 CBU 3 - General & Specialist Medicine 3,655 3,587 -68 10,911 11,111 200 CBU 4 - General & Specialist Surgery 1,902 1,878 -24 5,628 5,644 16 CBU 5 - Diagnostics & Clinical Support Services 552 551 -1 1,631 1,660 29 CBU 6 - Women, Children's & GUM 2,167 1,984 -183 6,492 6,356 -136 CBU 7 - Corporate 632 586 -46 1,896 1,786 -110 TOTAL 11,553 11,180 -374 34,403 34,010 -393

CQUINs (1/12 of total) 267 267 0 802 802 0

Risks & Penalties Current Month Year To Date Contract Risks & Adjustments (e.g N:F Ratios) 20 -18 -38 20 -104 -124 Quality Schedule (RTT, Diagnostics & D1) 0 -77 -77 0 -164 -164 2014/15 CQUINs (Dementia - 1/12 of declared risk) 0 0 0 0 0 0 TOTAL 20 -95 -115 20 -268 -288 Risk Adjusted Total 11,841 11,352 -489 35,225 34,544 -681

Appendix 3

Efficiency Plan 2014-15

CBU summary Full Year Month 3 Month 3 Month 3 Target Target Actual Variance £1000's £1000's £1000's £1000's Emerency Medicine, Trauma & Orthopaedics, Care of the Elderly, Therapy Services 367 58 66 8 Theatres, Anaesthetics and Crtical Care Services 242 27 10 (18) General and Specialist Medicine 260 32 11 (21) General and Specialist Surgery 835 172 155 (17) Diagnostic and Clinical Support Services 782 154 202 47 Women's, Children's and GUM Services 279 36 36 (1) Estates & Facilities 84 21 31 10 Corporate 3,465 256 302 46 Total 6,316 757 812 54

Income, Pay, Non-Pay summary Full Year Month 3 Month 3 Month 3 Target Target Actual Variance £1000's £1000's £1000's £1000's Income 310 42 55 12 Pay 5,038 495 592 98 Drugs 100 25 33 8 Clinical Supplies 513 107 71 (35) Non-Clinical Supplies 0 0 0 0 Miscellaneous Other Expenses 355 89 61 (28) Total 6,316 757 812 54

Scheme summary Full Year Month 3 Month 3 Month 3 Target Target Actual Variance £1000's £1000's £1000's £1000's CI001 - Endoscopy Consumable Budget Reduction 15 0 0 0 CI002 - 5% Reduction on Printing Budgets 22 5 0 (5) CI003 - 5% Reduction on Travel Budgets 12 3 0 (3) CI004 - Savings on Prosthetics 30 8 0 (8) CI005 - Savings on PACS System Costs 78 20 20 0 CI006 - Reduce Computer Maintenance Budgets 162 41 41 1 CI007 - Savings Projects Continuing From 13/14 144 48 48 0 CI008 - Renewal of Contracts Ending in Year 18 0 0 0 CI009 - New Saving Initiatives 150 12 12 0 CI010 - Buying Team Transactional Savings 156 39 11 (28) CI011 - Income Generation 32 8 7 (1) CI012 - EPR System Benefits 140 0 0 0 CI013 - Reduce Interpreter Budgets 15 4 0 (4) CI014 - Removal of Budget for Counselling Services for the Hospice 16 4 0 (4) CI015 - Medicine Management Savings 100 25 33 8 CI016 - Working Together 50 13 0 (13) CI017 - Closure of Ward 29 600 150 150 0 CI018 - Closure of 2 Further Wards 702 0 0 0 CI019 - 1% Vacancy Factor on all Pay Budgets 1,000 250 248 (2) CI020 - Reduction in 2nd On Call Budgets 25 0 0 0 CI021 - Reduction of hours for A&C Staff (37.5 to 35) 58 14 0 (14) CI022 - Reduction of SPAs to 1.5 per Consultant 250 0 0 0 CI023 - Capping Maximum number of PAs to 12 250 0 0 0 CI024 - Radiology Skill Mix Review 135 26 26 0 CI025 - Cardio Respiratory Skill Mix Review 15 4 4 0 CI026 - Restructure Bed Management Team 50 0 0 0 CI027 - 2.5% Reduction of Back Office Functions 952 0 114 114 CI028 - Pathology Partnership Savings 202 50 50 0 CI029 - Increase Salary Sacrifice Income 50 12 16 4 CI030 - Increase Patient Car Parking Charges 10 2 2 0 CI031 - Increase Staff Car Parking Charges 38 10 20 10 CI032 - Increase SLA for Telecommunications Services to SWYPT 40 10 10 0 CI034 - CBU 1 CIP Target £200K Full Year but not to start until August 133 0 0 0 CI035 - CBU 2 CIP Target £200K Full Year but not to start until August 133 0 0 0 CI036 - CBU 3 CIP Target £200K Full Year but not to start until August 133 0 0 0 CI037 - CBU 4 CIP Target £200K Full Year but not to start until August 133 0 0 0 CI038 - CBU 5 CIP Target £200K Full Year but not to start until August 133 0 0 0 CI039 - CBU 6 CIP Target £200K Full Year but not to start until August 133 0 0 0 6,316 757 812 54

Appendix 4

Consolidated Statement of Position

2013/14 2013/14 Plan Actual Variance June June £'000 £'000 £'000 NON CURRENT ASSETS 72,238 71,235 -1,003 CURRENT ASSETS Inventories 1,379 1,269 -110 NHS Trade Receivables Current 1,367 2,837 1,470 Non NHS Receivables Current 550 574 24 Other Receivables Current 1,301 975 -326 Prepayments Current 1,117 882 -235 Cash 6,547 7,223 676 Assets Current Total 12,261 13,760 1,499 CURRENT LIABILITIES (< one year) Trade Payables Current -5,571 -4,784 787 Other Payables Current -10,116 -6,997 3,119 PFI Leases Current -181 -187 -6 Social Security Creditors Current -3,644 -3,555 89 Accruals Current -3,371 -6,552 -3,181 Provisions current -683 -693 -10 Deferred Income Current -491 -1,599 -1,108 Total Current Liabilities -24,057 -24,367 -310

NET CURRENT ASSETS (LIABILITIES) -11,796 -10,607 1,189 Other Receivables Non current 624 657 33 PFI Leases Non Current -484 -471 13 Other non current -282 -282 0 Total Non Current -142 -96 46

TOTAL ASSETS EMPLOYED 60,300 60,532 232 TAXPAYERS' AND OTHERS' EQUITY Public dividend capital 56,558 56,558 0 Retained earnings -529 -297 232 Revaluation reserve 4,271 4,271 0 TAXPAYERS EQUITY TOTAL 60,300 60,532 232

Appendix 4a

Aged Debt at 30/6/2014 Not due 1-30 31-60 61-90 91+ balance Total 13,948,895.28 382,944.56 585,237.52 114,893.37 308,435.46 15,340,406.19 Cash received 30/6/2014 (123,181.41) Period 3 invoices raised post 30/6/14 630,188.59 Total invoiced position 15,847,413.37 Adjusted for Period 4 invoices raised (11,644,725.38) Invoiced Ledger position 4,202,687.99 Accrual for advanced invoicing (1,010,898.71) Debtor element of VAT 212,941.24 Debtor element of Social Security costs 52,894.05 Debtor Charitable Funds 28,807.34 Debtor Other (7,188.50) BHSS debtors 549,480.98 Consolidation adjustments (249,320.48) Bad Debt Provision (368,243.21)

Trade & Other Debtors at 30/6/14 3,411,160.70

Aged Credit at 30/6/2014 Not due 1-30 31-60 61-90 91+ balance Total (511,361.54) (2,226,823.34) (2,118,480.80) (1,510,764.96) (968,942.58) (7,336,373.22) Period 3 invoices posted after 30/6/14 (200,830.04) Total ledger position (7,537,203.26) Invoiced & accrued (10,484,132.20) Creditor element of VAT (33,583.87) PDC Dividend payable (76,500.00) BHSS Creditors (446,277.19) Consolidation adjustments 249,320.48 BHSS Corporation tax payable (4,676.00)

Trade & Other Creditors at 30/6/14 (18,333,052.04)

Appendix 5

Consolidated Statement of Cashflows

DRAFT DRAFT DRAFT Budget Budget Actual Variance Budget Actual Variance £'000s £'000s £'000s £'000s £'000s £'000s £'000s Annual Jun-14 Jun-14 Jun-14 YTD YTD YTD Cashflows from Operating Activities Operating Surplus/(Loss) -11,945 -1,657 -1,614 43 -5,292 -4,982 310 Non-cash Income & Expenses/ movements in Working Capital Depreciation & Amortisation 5,771 454 456 2 1,362 1,367 5 PDC Dividend 1,884 141 139 -2 425 418 -7 PFI Interest 0 16 16 0 46 46 0 Interest Received -20 -2 -1 1 -6 -7 -1 Decrease/(Increase) in Trade & Other Receivables 579 160 1,211 1,051 1,915 1,348 -567 Decrease/(Increase) in Inventories 0 0 -84 -84 0 299 299 (Decrease)/Increase in Trade & Other Payables -8,325 -1,939 -2,175 -236 -1,726 -4,307 -2,581 (Decrease)/Increase in Other Liabilities -4,140 -372 0 372 -991 0 991 (Decrease)/Increase in Deferred Income -218 -18 -276 -258 -54 1,054 1,108 (Decrease)/Increase in Provisions 0 0 -6 -6 0 10 10 Other Movements 424 -122 34 156 -366 -7 359 NET CASH INFLOW FROM OPERATING ACTIVITIES -15,988 -3,339 -2,300 1,039 -4,687 -4,761 -74 Cash Flows from Investing Activities Interest received 20 2 1 -1 6 7 1 Purchase of Property Plant & Equipment -3,476 -301 -186 115 -1,209 -540 669 Net Cash Outflow from Investing Activities -3,456 -299 -185 114 -1,203 -533 670 Cash flows from Financing Activities PDC Received 0 0 0 0 9,955 9,955 0 Capital Element of Private Finance Initiative Obligations -180 -15 -20 -5 -45 -58 -13 Interest Element of Private Finance Initiative Obligations 0 0 2 2 0 6 6 PDC Dividend Paid -1,884 0 0 0 0 0 0 Net Cash Outflow from Financing Activities -2,064 -15 -18 -3 9,910 9,903 -7

Increase/(Decrease) in Cash and Cash Equivalents -21,508 -3,653 -2,503 1,150 4,020 4,609 589 Cash and Cash Equivalents at 1 April 2,527 10,200 9,726 -474 2,527 2,614 87 Cash and Cash Equivalents at 30 June -18,981 6,547 7,223 676 6,547 7,223 676 -21,508 -3,653 -2,503 1,150 4,020 4,609 589

Appendix 6

Capital Programme 2014/15 Annual Budget Actual Variance Budget to date to date £'000s £'000s £'000s £'000s 2013-14 Deferred Schemes Electrical Testing 9 9 0 -9 Maternity Birthing Unit 266 266 291 25 Kitchens AB/KL 35 35 31 -4 O Block 613 200 44 -156 Pharmacy Robot - Inpatients 18 18 18 -0 OT Kitchen Refurbishment 5 5 4 -1 Urgent Care 7 7 32 25 Hospital Contact Centre 7 7 4 -3 Replace Theatre Chiller Plant 40 40 15 -25 Ceiling Tracking Hoist 2 2 2 1 Estates Deferred 2013-14 1,002 589 441 -148 Digital Dictation 6 0 0 0 Intelligent Drug Cabinets 6 6 0 -6 Intelligent Drug Cabinets (AMU) 48 48 3 -45 IM&T Deferred 2013-14 60 54 3 -51 Ceiling Tracking Hoist 17 17 0 -17 Winpath POCT Interface Blood Gas Analyser 1 1 0 -1 M&S Equipment Deferred 2012-13 19 19 0 -19 Total Deferred 2013-14 1,081 661 444 -217 Electrical Infrastructure 360 0 0 0 Escape Lighting 50 15 0 -15 Security - JAG Accreditation 20 18 15 -3 Air Tube Upgrade 50 0 0 0 H&S Barriers 35 10 0 -10 HV Switchgear (Sub 3) 40 0 0 0 Asbestos Enabling 30 0 3 3 Day Case Chiller 50 0 0 0 KL Condensate Tanks 45 0 0 0 FRA Upgrades 50 0 0 0 ESTATES Backlog Maintenance 2014/15 730 43 18 -25 VDI 445 445 69 -376 Replace Wireless AP's 5 0 0 0 Colposcopy Database 40 0 0 0 IM&T 2014/15 490 445 69 -376 Medical & Surgical Equipment 0 0 0 0 M&S Equipment 2014/15 0 0 0 0 EPR 605 60 37 -24 O Block - Neonatal Unit 100 0 0 0 Pathology Autoclave 70 0 0 0 STRATEGIC SCHEMES 2014/15 775 60 37 -24 Contingency 400 0 8 8 TOTAL CAPITAL PROGRAMME 3,476 1,209 575 -634

REFERENCE SECTION

BoD: XX Reference - August 2014

SCHEDULE OF ACRONYMS

Additional acronyms may be added as appropriate/on request

A Control of Substances Hazardous to COSHH A&E Accident and Emergency Health A4C / AfC Agenda for Change CPA Clinical Pathology Accreditation Awards Committee for Clinical CPD Continuing Professional Development ACCEA Excellence Awards CPE Clinical Performance & Effectiveness ACE Acute Care of the Eldery Clinical Performance & Effectiveness CPEC ACS Additional Clinical Services Committee AEC Ambulatory Emergency Care CPMS Central Portfolio Management System AHP Allied Health Professions CPT Capital Planning Team AHSN Academic Health Science Network CQC Care Quality Commission AMU Acute Medical Unit Commissioning for Quality and CQUIN ANP Advance Nurse Practitioner Innovation AOA Annual Organisational Audit CRS Commissioner Requested Services AQuA Advancing Quality Alliance CSSD Central Sterile Services Department Annual Review of Competence CSU Clinical Service Units ARCP Progression D AUP Acceptable Use Policy DB Designated Body B DDA Disability Discrimination Act British Association of Emergency Do ICT Director of ICT BAEM Medicines DoH Department of Health BBE Bare below the elbows Director of Human Resourses and DoHR&OD BCCG Barnsley Clinical Commissioning Group Organisational Development Barnsley Hospital NHS Foundation Do N&Q Director of Nursing and Quality BHNFT Trust DHSC Directorate of Health & Social Care BMA British Medical Association DH / DoH Department of Health BMBC Barnsley Metropolitan Borough Council Director of Infection Prevention & DIPC BMJ British Medical Journal Control BoD Board of Directors DMD Divisional Medical Director BWCC Barnsley Women and Children’s Centre DNA Did Not Attend C DNAR Do Not Attempt Resusitation CAP Community Acquired Pneumonia DPM Department of Psychological Medicine CASU Controls Assurance Support Unit DNR Do Not Resusitate CAUTI Catheter-Associated Urinary Tract DSEU Day Surgery & Endoscopy Unit Infection E CBU Clinical Business Unit Earnings before interest, taxes, EBITDA CCG Clinical Commissioning Group depreciation and amortisation CCU Coronary Care Unit Emergency Care Intensive Support ECIST C. diff Clostridium Difficile Team CDU Clinical Decision Unit ECN Emergency Care Network CE / CEO Chief Executive / Chief Executive Officer ED Emergency Department Confidential Enquiry into Maternal and EDD Estimated Date of Discharge CEMACH Child Health EDS2 Equality Delivery System Commission for Health Audit and ENT Ear, Nose & Throat CHAI Improvement EPAP Emergency Pathway Action Plan CHD Coronary Heart Disease EPR Electronic Patient Records CHI Commission for Health Improvement EqIA Equality Impact Assessment CHKS – name of company providing ESR Electronic Staff Record CHKS statistical/benchmarking data ET Executive Team Cost Improvement Programme (also EWS Early Warning Score CIP known as efficiency programme) EWTR European Working Time Regulation Collaboration for Leadership in Applied CLAHRC F Health Research and Care Fluids, Antibiotics, Blood Cultures, FABULOS CLAUDE Clinical Audit Data Base Urine, Lactate, Oxygen, Sepsis Six CMO Chief Medical Officer FBC Full Business Case CMT Clinical Management Team FCE/FCSE Finished Consultant Episode CNST Clinical Negligence Scheme for Trusts FFCE First Finished Consultant Episode COG Council of Governors FFT Friends and Family Testing COO Chief Operating Officer FT Foundation Trust COPD Chronic Obstructive Pulmonary Disease FTN Foundation Trust Network

BoD:XX Reference - August 2014

FQA Framework of Quality Assurance MTAS Medical Training Application Service G N GMC General Medical Council National Confidential Enquiry into NCEPOD GP General Practitioner Perioperative Deaths GUM / NED Non Executive Director Genito-Urinary Medicine GU Med NEWS National Early Warning Score H NHS National Health Service Harmonised Approval Process Pan NHSE National Health Service England HAPPY Yorkshire NHSE National Health & Safety Executive HCA Health Care Assistant National Health Service Litigation NHSLA HES Hospital Episode Statistics Authority HSE Health & Safety Executive North Derbyshire, South Yorkshire and NORCOM H&S Health & Safety Bassetlaw Commissioning Consortium HDU High Dependency Unit National Confidential Inquiry into Suicide NCISH HR Human Resources and Homicide HRG Health Resource Group (finance) NICE National Institute for Clinical Excellence HSC Health Service Circular NIMG NICE Initiation and Monitoring Group HSMR Hospital Standardised Mortality Ratio NIHR National Institute for Health Research I NPAT National Patients Access Team I&E Income and Expenditure NPSA National Patient Safety Agency ICU Intensive Care Unit (also known as ITU) NRLS National Reporting & Learning System International Financial Reporting NSF National Service Framework IFRS Standards O IIP Investors in People OBC Outline Business Case IHP Improving Hospital Partnerships OH Occupational Health IPC Infection Prevention & Contr Official Journal of the European OJEC IR1 Incident Reporting form Communities Ionising Radiation - Medical Exposure Older Persons Early Rehabilitation IRMER OPERA Regulations Assessment ISS Mediclean – cleaning contractors at OPT Operational Performance Team ISS the Trust OT Occupatinal Therapy IT Information Technology PQ Intensive Therapy Unit (also known as PA Professional Activities (4 hours) ITU ICU) Picture Archiving & Communications PACS IV Intravenous Systems IWL Improving Working Lives PALS Patient Advice & Liaison Services J PAS Patient Administration System Joint Negotiating and Consultation PBR / PbR Payment by results (tariff system) JNCC Committee PCT Primary Care Trust JTUC Joint Trade Union Committee PEAT Patient Environment Action Team KL PGME Post Graduate Medical Education KPI Key Performance Indicator PIU Planned Investigation Unit LA Local Authority Patient Led Assessment of the Care PLACE LCRN Local Clinical Research Network Environment LAC Local Awards Committee PMG Performance Management Group LDP Local Development Plan PPG Patient Participation Group LHC Local Health Community PPI Public & Patient Involvement LIFT Local Improvement Finance Trust PR Public Relations LINks Local Involvement Networks PROMS Patient Reported Outcome Measures LOS Length of Stay PSM Patient Services Manager LPMS Local Portfolio Management System PTS Patient transport services LRC Learning and Resource Centre QA Quality Assurance LTC Long Term Conditions Quality Innovation Prevention & QIPP M Productivity Quality and Safety Improvement & M&S Medical & Surgical QSIEB MAG Model Appraisal Guide Effectiveness Board MDA Medical Devices Agency R MDT Multi-Disciplinary Team R&D Research and Development ME Management Executive RAF Risk Assessment Framework Medicines &Medical Healthcare Remuneration and Terms of Service MHRA RATS Regulatory Agency Myocardial Infarction National Audit Royal College of Paediatrics and Child MINAP RCPCH Programme Health MRI Magnetic Resonance Imaging RCP Royal College of Physicians

Bod: XX Reference - August 2014

Rotherham Hospital NHS Foundation SPC Statistical Process Control RFT Trust SpR Specialist Registrar ROCA Register of Controls Assurance SSD Sterile Services Department RPST Risk Pooling Assessment for Trusts Sheffield Teaching Hospitals NHS STH RST Revalidation Support Team Foundation Trust RTT Referral to Treatment Strategic Health Authority Executive STEIS S Information System SABS Safety Alert Broadcast System South Yorkshire Strategic Health SYSHA SALT Speech and Language Therapy Authority South West Yorkshire Partnership SAS Staff and Associate Specialist SWYPFT SAU Surgical Administration Unit Foundation Trust Sheffield Children’s Hospital NHS TUV SCH The Information Governance Education Foundation Trust TIGER SDA Surgical Decision Area Recognition Award SHA Strategic Health Authority TWWMIB Together We Will Make It Better SHMI Standardise Hospital Mortality Indicators VDI Virtual Desktop Infrastructure SHO Senior House Officer VTE VenousThrombo-Embolism SI Serious Incident WXYZ SIFT Service Increment for Training WCA Wider Controls Assurance SLA / Service Level Agreements / Service WLI Waiting List Initiative SLAM Level Agreement Monitoring Wte whole time equivalent SOA Strategic Options Analysis Y&H Yorkshire & the Humber SUI Serious Untoward Incident YTD Year to Date SoS Secretary of State SPA Supporting Professional Activities

Bod: XX Reference - August 2014