COUNCIL OF GOVERNORS
Schedule Tuesday 11 February 2020, 6:15 PM — 8:00 PM GMT Venue WILSON CARLILE CENTRE Notes for Participants Governor only pre meet 18:00 hrs to 18:15 hrs Organiser Claire Coles
Agenda
1. AGENDA 1
02~20 Agenda February 2020.doc 2
2. 18:00HRS GOVERNOR ONLY PRE-MEET 4
3. 01/20 WELCOME AND INTRODUCTION 5
4. 02/20 APOLOGIES FOR ABSENCE 6
5. 03/20 DECLARATIONS OF INTEREST 7
6. 04/20 TO RECEIVE AND AGREE THE MINUTES OF THE COUNCIL 8 MEETING HELD 12 NOVEMBER 2019 - ENC A
Enc A_Draft minutes from November 2019 V2.doc 9
7. 05/20 TO REVIEW THE ACTIONS LOG - ENC B 17
Enc B_Actions Log_February 2020.doc 18 Enc B_i_Action plan 2018-19.docx 22
8. 06/20 ENVIRONMENTAL SUSTAINABILITY PLAN - ENC C 27
Enc C_Environmental Sustainability Update COG.doc 28 Enc C_SCH SDMP with Action plan Jan 2020 Final.docx 30
9. 07/20 QUALITY REPORT - ENC D 48
Enc D_selection of quality priorities Feb COG.doc 49
10. 08/20 QUARTERLY REPORTS FROM BOARD COMMITTEES - ENC E 53 - QUALITY COMMITTEE - PEOPLE AND PERFORMANCE COMMITTEE - RISK AND AUDIT COMMITTEE
Enc E_i_QC Governors report - February 2020 (1).docx 54 Enc E_i_Governor observer - Committee feedback form Oct 2019.doc 58 Enc E_ii_PPC Governors report - February 2020.docx 59 Enc E_iii_RAC Governors report - February 2020 (1).docx 64
11. 09/20 CHAIR'S REPORT - ENC F 67 - FEEDBACK FROM BACK TO THE FLOORS
Enc F_Quarterly Report from the Chair (5).doc 68 Enc F_i_BTTF report.doc 71 Enc F_i_App A_BTTF report.docx 72
12. 10/20 DIRECTORS REPORT - ENC G 82
Enc G_Directors report Jan20.doc 83
13. 11/20 KEY MESSAGES - ENC H 90
Enc H_Key messages Feb 2020.doc 91
14. 12/20 REMUNERATION OF CHAIR AND NON-EXECUTIVES - ENC I 95
Enc I_NED Remuneration.docx 96
15. 13/20 APPOINTMENT OF NON-EXECUTIVES - ENC J 101
Enc J_NED Appointments.docx 102
16. 14/20 GOVERNOR ELECTIONS - ENC K 108
Enc K_Governor Elections.docx 109
17. 15/20 REVIEW OF WAYS OF WORKING - ENC L 111
Enc L_Ways of working.docx 112
18. 16/20 CODE OF CONDUCT - ENC M 114
Enc M_Living the Values.docx 115
19. 17/20 PROCESS FOR CHAIRING NED APPRAISALS - ENC N 121
Enc N_Chair and NED appraisal.docx 122
20. 18/20 COUNCIL OF GOVERNORS WORK PROGRAMME - ENC O 125
Enc O_WORK PROGRAMME 2020.doc 126
21. 16/20 FEEDING BACK FROM GOVERNOR ACTIVITIES 128
22. 20/20 DISCUSSION OF FUTURE TOPICS 129
23. Date of next meeting: 12 May 2020 in the Lecture Theatre, Stephenson Wing 130 1. AGENDA
COUNCILCouncil OF of GOVERNORS Governors Meeting 1. AGENDA Page 2 of 130 Tuesday 11 February 2020 18:15 – 20:00 (Governor only pre meet 18:00) Wilson Carlile Centre, 50 Cavendish Street, Sheffield, S3 7RZ Parking: There is a small off-street car park next the venue, or on-street parking around the venue: both are pay and display Elected Governors are reminded that they are deemed to have confirmed their declaration of their qualification to vote as a member of the Foundation Trust and that they are not prevented from being a member of the Council of Governors.
AGENDA
Time Item Topic Purpose Paper 18:00 GOVERNOR ONLY PRE-MEET
To review agenda items FOR COMMENT
18:15 PRELIMINARIES
01/20 Welcome & Introductions
02/20 Apologies for absence
03/20 Declarations of interest
04/20 To receive and agree the minutes of the Council meeting held 12 November 2019 Enc A To review the actions log Enc B 05/20 o RAG rated staff survey Enc Bi 18:25 STRATEGIC ISSUES
06/20 Environmental Sustainability Plan (John Williams) FOR INFORMATION Enc C
18:35 QUALITY & SAFETY PRIORITIES Quality Report - Selection of quality indicators for external audit 07/20 FOR APPROVAL Enc D (Sally Shearer)
18:45 ASSURANCE AND HOLDING TO ACCOUNT 08/20 Quarterly Reports from Board Committees: o Quality Committee (Patricia Mitchell) FOR INFORMATION Enc E i o People and Performance Committee (John Cowling) / APPROVAL Enc E ii o Risk and Audit Committee (John Cowling) Enc E iii 09/20 Chair’s Report (Sarah Jones) FOR COMMENT Enc F o Feedback from Back to the Floors Enc F i 10/20 Directors’ Report (and Governor questions on matters not otherwise FOR COMMENT Enc G covered on the agenda) (John Somers)
19:25 ENGAGING WITH THE PUBLIC 11/20 Key Messages (Communications) FOR INFORMATION Enc H 19:30 COUNCIL MATTERS - GOVERNORS ONLY
12/20 Remuneration of Chair and Non-executives (Matthew Kane) FOR APPROVAL Enc I 13/20 Appointment of Non-executives (Matthew Kane) FOR APPROVAL Enc J 14/20 Governor Elections (Matthew Kane) FOR DISCUSSION Enc K 15/20 Review of ways of working (Matthew Kane) FOR COMMENT Enc L 16/20 Code of Conduct (Matthew Kane) FOR APPROVAL Enc M 17/20 Process for chairing NED appraisals (Matthew Kane) FOR DISCUSSION Enc N COUNCIL OF GOVERNORS 1. AGENDA Page 3 of 130 18/20 Council of Governors work programme (Matthew Kane) FOR DECISION Enc O 19/20 Feeding back from Governor activities (Governors) FOR INFORMATION Verbal FUTURE AGENDA ITEMS
20/20 Discussion of future topics FOR DISCUSSION Verbal
20:00 CLOSE MEETING
Dates of next meetings: Full Council Meeting: 12 May 2020 at 18:15 in the Lecture Theatre 14 July 2020 at 18:15 in the Lecture Theatre Annual Members Meeting; Date and venue to be confirmed Full Council Meeting: 17 November 2020 at 18:15 venue TBC
2. 18:00HRS GOVERNOR ONLY PRE- MEET 3. 01/20 WELCOME AND INTRODUCTION 4. 02/20 APOLOGIES FOR ABSENCE 5. 03/20 DECLARATIONS OF INTEREST 6. 04/20 TO RECEIVE AND AGREE THE MINUTES OF THE COUNCIL MEETING HELD 12 NOVEMBER 2019 - ENC A
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Enc A Minutes of the Public Meeting of the Council of Governors
held on 12 November 2019, 18:15hrs The Helena Davies Lecture Theatre, Stephenson Wing, Sheffield Children’s Hospital
Member of the Council of Governors present:
Sarah Jones Chair Charlotte Elder Partner Governor – University of Sheffield Jack Hiscock Staff Governor – Non-Clinical Emma Packham Public Governor – Sheffield Robert Peace Public Governor- Rest of England and Wales Bethan Plant Partner Governor- Sheffield Dan White Partner Governor – Sheffield Futures Andrew Garner Staff Governor – Nursing & Midwifery Kathryn Holden Staff Governor – Other Clinical Vincent Keddie Public Governor – Sheffield Rebecca Kent Public Governor- Rest of South Yorkshire Carrie Mackenzie Staff Governor – Medical & Dental Helen Smith Public Governor - Sheffield
Also present: Andy Baker Non-Executive Director Ruth Brown Executive Director of Strategy and Operations Nick Parker Executive Director of People and OD Claire Coles Corporate Affairs Officer – Minutes John Cowling Non-Executive Director Scott Green Non-Executive Director Matthew Kane Associate Director of Corporate Affairs Jeff Perring Executive Medical Director Sally Shearer Executive Director of Nursing & Quality George Critchley Senior Communications Officer John Williams Executive Director of Finance John Somers Chief Executive Peter Lauener Non-Executive Director Patricia Mitchell Non-Executive Director
Apologies: Ruth Barley Partner Governor- Sheffield Hallam University Samantha Burns Staff Governor – Nursing & Midwifery Jackie Cole Partner Governor – YAS
COUNCIL OF GOVERNORS 6. 04/20 TO RECEIVE AND AGREE... Page 10 of 130 47/19 Welcome & Introductions The Chair welcomed Governors, and members of the Board of Directors to the meeting. Apologies for absence 48/19 Apologies were received as noted above. Declarations of interest 49/19 Governors were asked to complete any outstanding declarations of interest. Governors
50/19 Minutes of the previous meetings The minutes of the meeting held in public on 16 July 2019 were presented for consideration. The minutes were accepted as a true and accurate record of the meeting.
51/19 To review the actions log
The actions arising report were reviewed and noted. Updates against actions scheduled were noted: 20/18 to review the actions log: 48/18 vii) Reflection on matters discussed in meeting Action carried This action would remain open until Ms Burns returned from maternity leave. forward
26/19 iii) Key Messages An update would be sought from the Associate Director of Communications for the Communications action on mental health issues relating to drug use within schools.
42/19 iii) Staff Survey 2019 – Corporate Action Plan and progress update The RAG rated action plan, for the last staff survey results, would be brought to the EDPOD next meeting. STRATEGIC ISSUES
Integrated Care System (ICS) Strategic Plan 2019/24 52/19 Mr Somers, Chief Executive, and Ms Brown, Executive Director of Strategy and Operations, presented the update.
The following points and comments were noted:
i. The draft plan of the South Yorkshire and Bassetlaw response to the NHS Long
Term Plan was noted, the final version would be submitted on 15 November 2019. It was noted that although the Council meeting was within the pre-election period, a governor discussion could take place as the draft plan was already in the public domain.
ii. It was noted that agreement had been reached at both ICS and Place level on key outcomes and key areas of focus. iii. The financial plans to go alongside the trajectories set by the regulator were still being developed. Whilst the next step rules were currently unclear, the Trust’s plan was to achieve financial break even over the course of the four year plan. Discussions continued, and the complexity of the financial situation was noted. The EDOF Executive Director of Finance would brief the Council on financial mechanisms at the next meeting on the Trust positioning.
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iv. Governors raised a number of points which would be fed back to the ICS, which related to specialist commissioning of services, relationships with schools and MD education, pollution, climate change including management of waste, and also concerns around air quality. A number of these points were recognised within the Place plan. Recycling was a current hot topic and the Trust’s recycling plans would be brought to a future meeting, to provide an opportunity for governors to share experiences and shape learning. v. Mr White, Partner Governor, positively noted the inclusion of voluntary sector organisations within Place plans. The report and presentation was noted. Developing the Trust’s Strategic Direction 53/19 Ms Brown, Executive Director of Strategy and Operations, presented an update on the strategy refresh. The following points were noted:
i. The ICS Long Term Plan submission was a key driver for the Trust to refresh its
strategy to align with this plan, building on the Caring Together refresh, and on the Trust’s role in providing a healthier future for children, in addition to increased collaboration with system partners locally and nationally. ii. The plan on a page was noted, which described the Trust’s values, aims and priorities for the forthcoming year.
iii. The Council noted the timeline to develop and deliver the refresh, and that scoping the direction of travel would continue at a Board of Directors session in November. iv. A governor engagement session was being arranged for February, however there was opportunity for interested governors to be involved earlier in the process should they wish.
v. As the ICS developed its role may become reflected in legislation.
vi. The strategic objectives would inform the Trust’s priorities. The Executive Director of Strategy and Operations would share the strategy with governors. EDSO vii. In response to a question regarding the culture, the Council noted that the Trust’s aim was to be a provider of high quality care, however this had to be affordable, the Trust also had an overall aim to be a sustainable organisation, and this was challenging to balance. It noted that better quality provided income generation and efficiencies. viii. The Council was informed that current actions being taken around sustainability and improvement would be taken into account, and that the strategy would also link into the CQC action plan. The Council noted the presentation. QUALITY & SAFETY PRIORITIES
Action Planning: 54/19 The Council received an update on key action plans. The following points were noted: CQC Action Plans
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i. The first progress update against the action plan was noted. Timescales had been tight to collate and validate evidence for reporting to Quality Committee. It was
expected that a much improved position would be reported by the next meeting.
ii. The Council was informed that the action plan from the 2016 CQC inspection was now closed. Some outstanding actions from that inspection were duplicated and would be reported within the 2019 action plan. iii. Further additional updates were provided against each action reported as red on the action plan, and it was expected that a number of these actions would move off red. iv. In learning lessons on embeddedness of actions, governors were assured that ongoing monitoring of completed actions would take place and evidence was sought that actions were embedded, following concerns that some issues had been highlighted previously. v. In addition to ongoing monitoring the RAG rating used in all action plans would be reviewed for consistency. vi. Governors were assured that scoping against compliance with NHS learning disability standards had been undertaken, and an action plan would be developed. It was informed of actions identified to address areas of non-compliance against these standards. It was acknowledged that there were some areas of good practice in the Trust but this was not consistent across all services. Ms Flint, Public Governor, offered to support this work in relation to reviewing of aids for children EDNQ with autism. It was also noted that the Trust was part of a national training pilot being developed.
vii. The Council was informed that each action had an Executive and divisional accountable lead, and that the Quality Committee and Board would regularly scrutinise the action plan going forward. Progress was also showing areas that were making good progress and those that required additional support. CAMHS Transformation viii. A presentation on the CAMHS service transformation programme was provided following a request from governors to hear more about this programme. A high level overview was presented, including how the workstream fitted into the Trust’s transformation programme for the next three years. ix. Dr Bates, Partner Governor, highlighted the positive step forward by the Trust in moving to use SystmOne, and shared records across primary care, community care and acute services. x. Ms Plant noted from a partner governor perspective, that the Trust was engaged in education within schools, for example healthy minds, and that Sheffield was at the head of this successful trailblazer programme, to identify prevention need earlier. xi. The Council noted that the transformation programme was broader than CAMHS, and was a balance of what was happening in Sheffield as an integrated provider. The action planning updates were noted. Quality Report Priorities – mid-year progress review 55/19 The Council noted the mid-year update against the quality account priorities.
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ASSURANCE AND HOLDING TO ACCOUNT
Quarterly Reports from Board Committees: 56/19 The Council received a summary of work undertaken by Board Committees which provided details of the breadth and scope of issues dealt with by non-executive directors. Governor observers on the committees were invited to provide comments. Quality Committee i. Governors noted there was good triangulation with current issues being discussed at Council meetings, and it was assuring that the Committee was one of the elements to provide assurance to Board. ii. Some good areas of focus were highlighted to the Council and deep dives into specific areas and topics with push back by the Committee of areas that required additional work. iii. The Governor observer on the Committee gave assurance that the Committee was professionally managed and that each presenter provided assurance on key issues. Finance and Resources Committee iv. The financial position was highlighted. The Trust was broadly on plan at month 6. Some legitimate phasing and slippage from centrally held budgets had been transacted to achieve this position. v. The Committee had received a good deep dive presentation on the transformation of outpatients workstream, which was recommended to Governors as a potential topic of interest at a future Council meeting. vi. The renaming of the Committee was noted. vii. The Governor observer on the Committee highlighted the extent of the Committee’s seriousness and range of issues that it dealt with, and rigour with which issues were dealt with, with deep dives into specific projects. viii. The Committee’s concerns around impact of resource issues and the ability to deliver activity as well as policy updates and pressures were highlighted as an area of focus. Risk and Audit Committee ix. It was highlighted that the Committee considered deep dive presentations into Board Assurance Framework key strategic risks, with good conversations, and self- assessment on emergency planning plans and procedures. x. The Committee reaffirmed appointment of 360 Assurance as the internal audit provider, and recommended reappointment of KPMG as its external auditors. The quarterly assurance reports were noted. Recommendation from the Risk and Audit Committee on the appointment of 57/19 External Auditors Mr Kane, Associate Director of Corporate Affairs, presented the paper. The following key points were noted: i. The Council noted that a review of the external audit provider’s effectiveness had been undertaken, and that KPMG provided a strong performance.
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ii. Governors were assured that the proposed negotiated £2k uplift had been benchmarked, and was in line with any inflation uplift, and that KPMG provided value for money. iii. Governors were assured that KPMG’s previous change of opinion on the quality accounts had subsequently been subject to further discussion with the executive team. There was now clarity on timeline for future audits, by bringing these forward, in addition to the Trust ensuring 18 week wait processes were more robust. iv. Governors were also assured that KPMG would provide early details of audit partner and audit manager rotation to the Risk and Audit Committee. However it was recognised that the current partner and manager could continue in their roles for a further two years. v. The Council was informed that KPMG worked to a clear code of ethics in relation to their independence, and whilst it was important that the external auditors were independent, continuity was also valuable. vi. Governor comments would be fed back to the Risk and Audit Committee. The Council: APPROVED the reappointment of KPMG as the Trust’s external auditors for a further two years, until November 2021, at which point a competitive tender exercise would be undertaken. Governor involvement in the retender process would be sought at that time.
58/19 Chair’s Report
Ms Jones, Chair, presented the report. The following points were noted:
i. The process for feeding back from Back to the Floor visits was clarified. The aim of the visits was to take a temperature check of the department, and to triangulate against all data, these were not inspections. General comments from the feedback
form were collated into a six monthly report to the Council. In addition to completing the feedback forms, governors could also feed in their observations from visits either via Non-executive or Executives. ii. Due to volume of items on the Council agenda there was limited time to discuss Planner each visit. It was agreed that the governor WhatsApp group was not the right format to do this, and a future agenda item would be arranged. iii. It was also noted that positive comments would be fed back to teams, however a more robust process to ensure this happened was required. The update was noted.
59/19 Directors’ Report Mr Somers, Chief Executive, presented the report. The following points were noted: i. The Council noted that the Trust had achieved all core targets, however 18 weeks Referral to Treatment remained a concern, this was an area of focus by the Trust. System performance was also an issue being monitored closely by the ICS. ii. The Council noted that the impact of the national pensions issue on capacity was being looked at specialty by specialty.
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iii. The emergency department performance was highlighted as an area of concern, this was currently being reported at 80 per cent against a target of 95 per cent. It was unusual for the Trust not to achieve this target, but this was due to very high numbers of attendees to the department. iv. Areas of interest were highlighted to the Council, including showcasing of the good work of the Trust both internally and externally. The Council also noted the film from the Royal visit in July. The update was noted. ENGAGING WITH THE PUBLIC
60/19 Key Messages
Mr Critchley, Senior Communications Officer, presented the key messages for information, for sharing with constituents. Additional updates were noted: i. A number of high profile media stories impacting the Trust were noted, and governors were informed of actions being taken to support staff. ii. Governors were advised that they should not respond to any approaches by the media, and should direct all enquiries to the communications team. The key messages were noted. Directors left the meeting at this point. COUNCIL MATTERS
61/19 Feedback from October Governor Development Session
Mr Kane, Associate Director of Corporate Affairs, presented the feedback report. The following points were agreed: i. A survey monkey would be undertaken to seek feedback on the results from the session, in order to capture feedback from those governors not at the meeting, and AD-CA to identify one priority action for each section for governors to take forward.
ii. Governors discussed frequency of meetings, and how they could get richness of time together, including use of technology, to discuss or focus on specific issues. This was to get a balance on the agenda of what the Trust needed to communicate to governors, and in finding more regular quality time to discuss key issues.
iii. New governors were asked to express their interest to become a member of the Nominations and Recruitment Committee. Governors iv. New governors found the format of the agenda a lot to work through. The loss of opportunity to speak to Non-Executives before Council meetings due to the pre- meeting was noted. Further consideration would be given to the format of Council meetings. v. Governor’s feedback on start times of meetings would be sought, however it was noted that it was a challenge for governors to get to meetings before 6pm when AD-CA changes to start times had previously been tested. vi. Governors were informed that Mr Andy Baker, Non-Executive, was leaving his role with effect from 31 December 2019.
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The Council noted the report. FUTURE AGENDA ITEMS
62/19 Discussion of future topics
No additional future topics were identified, over and above those identified during the meeting.
63/19 2020 Meeting dates
The meeting dates for 2020 were noted.
The meeting was closed at 20:15
Date and Time of the Next Meeting The next meeting would take place on the 11 February 2020.
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7. 05/20 TO REVIEW THE ACTIONS LOG - ENC B
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Enc B
Actions Arising Report – updated following 12 November 2019 CoG meeting
Date Target Action Progress / evidence Action ref: Action Action date to with that completed raised complete Ms Fountain would pick up 26/19 iii) Key mental health issues relating AD- Update requested 14/05/19 TBC Messages to drug use within schools, in Comms 12/11/19 for target date. terms of a public campaign. 42/19 iii) Staff RAG rated action plan would Survey 2019 – On agenda 05/20. be brought to a future Feb Corporate Action 16/07/19 EDPOD meeting which reflected 2020 Plan and Progress Action closed. progress made. Update On agenda 08/20. A separate session for EDOF to brief the Council on governors on NHS 52/19 iii) ICS financial mechanisms at the Feb Finances has been Strategic Plan 12/11/19 next meeting on the Trust EDOF 2020 scheduled for 20 April 2019/24 positioning. 2020. Action closed.
The Trust’s recycling plans The Trust’s would be brought to a future 52/19 iv) ICS environmental meeting, to provide an Feb Strategic Plan 12/11/19 EDOF sustainability plan is on opportunity for governors to 2020 2019/24 the agenda 06/20. share experiences and Action closed. shape learning.
The strategic objectives This would be done 53/19 vi) would inform the Trust’s through the joint strategy Developing the Feb 12/11/19 priorities. EDSO would EDSO session on 11/02/2020. Trust’s Strategic share the strategy with 2020 Direction governors. Action closed. Ms Flint was invited to Ms Flint, Public Governor, the LD Summit on 11 54/19 vi) Action offered to support the February and will Feb Planning: CQC 12/11/19 learning disabilities work in EDNQ feedback through 2020 Action Plans relation to reviewing of aids governors. for children with autism. Action closed.
BTTF outcomes to be On agenda 09/20. 58/19 ii) Chair’s Corp Feb 12/11/19 considered at future COG Report meeting. Affairs 2020 Action closed.
61/19 i) Feedback A survey monkey would be from October undertaken to identify one On agenda 16/20. Feb Governor 12/11/19 priority action for each AD-CA 2020 Action closed. Development development area for Session governors to take forward. 61/19 iv) Feedback Joanne Arch was duly from October Nominations for Nominations Dec appointed. Governor 12/11/19 and Recruitment Committee Governors 2019 Development role sought. Action closed. Session
Completed Actions updated following 12 November 2019 CoG meeting COUNCIL OF GOVERNORS 7. 05/20 TO REVIEW THE ACTION... Page 19 of 130 Date Target Action Progress / evidence that Action ref: Action Action date to with completed raised complete Item deferred to July. This work would be showcased at the Annual Members Meeting. Update provided November 2019: An update on the work to 06/18 Trust May Transformation work give a patient’s experience Strategy ‘Caring 20/03/18 DNQ July around “patient’s voice” within the hospital would be Together’ 2019 was showcased at the brought to a future meeting. 2018 Annual Member Meeting. The Ward Accreditation programme has now been superseded by the Pathway to Excellence. Action closed. Governors invited to Partnership Working Summit. Programme of work being scoped and will be shared back with Governors when drafted. 22/19 i) Feedback Feedback from these Update provided from the February sessions would be shared July 14/05/19 DSO November 2019: Joint Strategy at a future meeting to look 2019 Session at themes and actions. Partnership work included in the governors induction work programme, and included within strategy development. Action closed. Minute Ref: 53/19. Divisions were developing 37/19 iii) action plans which would Action closed. Outcomes from be brought to the Nov 16/07/19 EDNQ Minute Ref: 54/19. CQC Inspection November meeting for 2019 2019 information.
38/19 ii) CIO to provide a Update circulated Connecting July 12/11/19. 16/07/19 communications update on CIO Together, IM&T 2019 actions and improvements. Action closed. Strategy Clinical staff governor Staff governors were 38/19 iv) involvement in the invited to be involved in Connecting proposed Clinical Advisory Staff July the Clinical Advisory 16/07/19 Together, IM&T Forum would be key to Governors 2019 Forum on 13/09/19. Strategy providing input from a front line perspective. Action closed. Staff governor attention Staff governors were 39/19 iv) Quarterly was drawn to the request asked to champion this Reports from for support to the equality, Staff July 16/07/19 work on 13/09/19. Board diversity and inclusion Governor 2019 Committees agenda, to help champion Action closed. this work. As part of the broader 43/19 ii) Key The Council was assured of Nov Trust Strategic 16/07/19 EDOF Messages the aim to implement a 2019 Accommodation Group solution for medical day we are discussing the
care and CRF unit. potential opportunity for COUNCIL OF GOVERNORS Suitable7. 05/20 space TO wasREVIEW being THE ACTION... Sleep ServicesPage and20 of 130 explored, whilst the Medical Day Care to be outcome of the urgent care located on C Floor next to consultation was awaited, Ward 6. This is currently to understand space and with the clinical teams for accommodation priorities. review. If agreed, this An updated position would would therefore free up be provided in due course. the existing MDC facility for research purposes. Any formal recommendation will be taken to Executive Team in due course. Update provided. Action closed. The presentation would be circulated to all governors Presentation circulated on Chair / 44/19 ii) In this to reflect on the questions July 13/09/19. 16/07/19 Lead Together ahead of a session together 2019 Governor Action closed. with a message from the Chair and Lead Governor.
A governor away day would Session took place on 45/19 i) Governor July 23/10/19. 16/07/19 be added to the AD-CA Development Plan 2019 development plan. Action closed.
Governors were asked to Suggestions received and added to the development 45/19 ii) Governor provide any further July 16/07/19 Governors plan. Development Plan development suggestions 2019 to the AD-CA. Action closed. The long list of topics previously identified would Development session 46/19 Discussion be picked up at the Corp. Oct took place on 23/10/19. 16/07/19 of future topics proposed away day, and a Affairs 2019 date would be arranged for Action closed. October. The November meeting would take place on 12 November due to the Action closed. 46/19 Discussion requirement to submit the Corp. Nov 16/07/19 Minute Ref: 52/19. of future topics ICS plan by 18 November, Affairs 2019 as this required Governor approval.
A governor stall at the A ‘Bus Stop’ session Clinical Summit on 26 would take place over September 2019 would be lunch period, and a 46/19 Discussion Corp. July 16/07/19 clarified. A message would number of governors had of future topics Affairs 2019 go out to all governors who offered to be involved. were interested in running a stall. Action closed.
The infographic from the The inforgraphic will be CQC inspection which had included in the 46/19 Discussion Corp. July stakeholder newsletter 16/07/19 been circulated to of future topics constituents would be Affairs 2019 which will be circulated. circulated to members. Action closed.
Actions Scheduled updated following 12 November 2019 CoG meeting COUNCIL OF GOVERNORS 7. 05/20 TO REVIEW THE ACTION... Page 21 of 130 Date Target Progress / evidence that Action ref: Action Action Action with date to completed raised complete 50/18 to review the actions log: Ms Burns would discuss 43/18 vii) the in-house nurse Update noted 12/11/19. Reflection on 13/11/18 Ms Burns TBC counsellor initiative with Action carried forward. matters discussed the DHROD. in meeting
Governor’s feedback on start times of meetings would be sought, 61/19 vi) Feedback however it was noted This would be considered from October that it was a challenge To be as part of the next Governor 12/11/19 AD-CA for governors to get to scheduled governor effectiveness Development meetings before 6pm review. Session when changes to start times had previously been tested.
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EXECUTIVE SUMMARY
Title STAFF SURVEY ACTION PLAN - PROGRESS UPDATE
Report to Council of Governors Date 11 February 2020
Executive Sponsor Nick Parker, Executive Director of People and OD
Author Rachael Purdy, Senior HR Manager Victoria Creaser, HR Manager Purpose of report To provide the Council Of Governors with a RAG rated update on 2018 Staff Survey Results Please tick as appropriate Approval Assurance Information √
Executive summary –the key messages and issues
Please see enclosed report for a summary of progress around each theme in Staff Survey. Overall progress has been good with the majority of actions either completed or well underway. Some areas, for example the quality of appraisals need ongoing attention and will remain a focus in 2020. The Trust’s People Plan will address key areas of concern from the 2019 Staff Survey.
How this report impacts on current risks or highlights new risks
There is a proven link between colleague engagement and patient outcomes/experience and it is a key measure of employee satisfaction. Poor levels of engagement result in absenteeism, under-performance and high turnover. Empowering a motivated and compassionate workforce is a key strategic objective of the Trust as part of our organisational strategy.
Recommendations and next steps
Governors are asked to note and comment on the actions taken and ongoing actions to continue to improve engagement.
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Staff Survey Action Plan 2018 – 2019
Our purpose is to provide a healthier future for children & young people by having motivated and empowered staff
BRAG Rating: Active – Needs corrective action Active – Needs close monitoring Active – On track Complete/Embedded
Staff Engagement Score
Objective Implementation Plans Timescale BRAG Rating 1. To increase our overall Development of the Trust’s People Staff Survey 2019 engagement score Plan including new approaches to engagement to build on the current suite of engagement activities for example open meetings, back to the floors, clinical summits and quality improvement projects.
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2 Key Theme Outcomes from Staff Survey
Theme Implementation Plans Timescale BRAG 2. Quality of Appraisals The current PDR (appraisal) policy is being reviewed Ongoing Each division to have an action plan with this area being a key focus across all divisions. We have provided more appraisal training in the last 12 months than previously and the Learning and Development Team strive to meet demand, showing that appraisers and appraises want the experience to be better. The feedback from the staff survey will feed into the training delivered. Effective conversations’ training is being promoted this year which will equip appraisers with the tools to discuss important and difficult topics more effectively. The Mind Tools on-line training platform is receiving great feedback from managers and will be further promoted via targeted campaigns to increase uptake and guide colleagues to useful appraisal guidance.
3. Health and Wellbeing Wellbeing initiatives from the staff survey 17/18 implemented in By end of 18/19. Q1 19/20 Signposting colleagues to support mechanisms to encourage them to manage their own health and wellbeing H&WB group ran a wellbeing workshop at Clinical Summit to launch Mental Health First Aider role and relaunch H&WB intranet page Reviewing and developing policies that support health and wellbeing such as stress, flexible working and acceptable behaviour at work
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4. Quality of Care Pathway to Excellence programme to be implemented which will Ongoing empower colleagues to take forward quality initiatives and improve patient care. DN&Q and DDoN walkabouts listening to colleagues and their ideas for change Quality Strategy being developed - workshops at Clinical Summit for feedback
5. Safety Culture More focused approached on conflict resolution training to equip Ongoing Safe environment – colleagues with skills to avoid/deal with abuse and violence at Violence work; - Increase compliance rates - Security Manager has been proactive in providing bespoke training for teams who experience difficult patient/parent experience
6. Safe Environment – Policy to be reviewed with a focus on acceptable behaviour at By end of Q3 19/20 Bullying and work and resolving issues informally and as close as possible to Harassment. the incident. Acceptable Behaviour At Work Policy launched In December 2019
Ongoing fierce conversation training for managers which equips Ongoing managers with the skills to deal issues informally and in a timely way
7. Safety Culture Freedom to Speak up Guardian role to be fully embedded and Ongoing continue to raise the profile of Freedom to Speak Up.
Datix system implemented - focus on using management information to identify trends and patterns and establish feedback mechanisms to colleagues and teams on outcomes and learning
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8. Relationships with Implement actions resulting from recent staff survey for all services. By end of Q1 19/20 Immediate Line Managers Ensuring our managers have the tools and training to positively influence health and wellbeing and introducing key performance indicators to monitor and revise our effectiveness. Investment has been agreed for a Management and Leadership By end of Q4 19/20 post to support management and leadership development across the Trust – appointed January 2020. 8. Equality, Diversity and Workforce Race Equality Standard Action plan By end of Q4 19/20 Inclusion Workforce Disability Equality Standard Action plan Accessible Information Standard Attainment Introduce an Inclusion Strategy Establish Workplace Equality Inclusion Forums 8. Morale Divisional action plans to include actions to improve morale within teams By end of Q1 19/20 and across divisional teams
Focus on nurse retention via NHSI Nurse retention programme e.g. internal transfer process for nurses
9 Team Working Divisional action plans to include actions to improve team working within By end of Q1 19/20 teams and across divisional teams
Undertake Clinical and Corporate Summits to improve closer working By end of Q3 19/20 relationships across team boundaries
Launch of Culture and Soft implementation of Culture and Behaviour Strategy; Feel safe, team up, Ongoing Behaviour Strategy keep learning and lead collectively which underpins many of the Staff Survey themes.
This is being incorporated into team development days and there is ongoing focus to incorporate into team meetings and other operational meetings
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EXECUTIVE SUMMARY
Title Environmental Sustainability Update
Report to Council of Governors Date 11 February 2020
Executive Sponsor John Williams – Executive Director of Finance
Author Peter Knowles – Head of Estates John Williams – Executive Director of Finance Purpose of report To provide an update on our Sustainable Development Management Plan and associated 2020 action plan.
Please tick as appropriate Approval X Assurance X Information
Executive summary –the key messages and issues
1. Our Sustainable Development Management Plan (SDMP) 2019-2022 was previously approved by the Trust Board in 2019. All NHS provider organisations are required to have a Board approved SDMP under the standard contract from Commissioners. SDMP’s are considered a measure of a ‘well led organisation’ and form a key part of sustainable healthcare delivery, ensuring that services provided today are fit for purpose in the future.
2. The UK government has set a target to reduce carbon emissions by 80% by 2050. Our Carbon Footprint is approximately split; 22% Energy, 18% Travel and 60% Procurement, which will need to influence our planning in this regard.
3. This is a substantiated update of our SDMP and includes an action plan for the first 12 months key areas of focus (January 2020 to December 2020), see appendix 2. It is recommended that progress be reported to the People & Performance Committee and Trust Board on a six monthly basis.
4. We have already started to make good progress as an organisation, with developments such as LED lighting, our Combined Heating Plant and Solar Panels, but there is much more to be done. Feedback from our people is that this is an area of high interest and there is a commitment to make a difference.
5. An ‘Environmental Sustainability Steering Group’ is being created which will act as the governance for the programme of work and report through on an operational basis to the Transformation Board. The Sustainability Group will include the key corporate leads, communication, transformation and clinical representation as well as a representative from COUNCIL OF GOVERNORS 8. 06/20 ENVIRONMENTAL SUST... Page 29 of 130 our Governors.
6. It is recommended that ‘environmental sustainability’ specifically is placed as a risk on the Trust risk register given the scale of challenge ahead to meet the ambition of the government targets.
7. Given the demographic of our patients, we have a real opportunity to influence and educate the children and young people we meet in relation to sustainability. 8. There is a very clear link through the SY&B ICS Long Term Plan submission and our wider role and responsibilities as an anchor organisation within Sheffield.
9. Through discussion at the People and Performance Committee (P&PC) of this paper on the 22nd January 2020 the following themes were identified for further consideration as part of our approach. These are noted by the Executive Director of Finance and will be taken back for consideration and development within the Steering Group.
Ensure our approach to the environment is captured clearly as part of our Strategy refresh work. Further specificity of dates to be added to the action plan. Consider approach to amount of use of water within the Theatres environment. Engagement of the Youth Forum in the activities of the Steering Group Consider interdependencies with other elements of the Transformation programme e.g. Outpatients. Consider our approach to equality and diversity, with particular reference to workforce and procurement. Broader engagement with key partners e.g. Sheffield City Council.
10. The Board of Directors approved the report and action plan, noting the comments from the P&PC, at its meeting in January 2020.
How this report impacts on current risks or highlights new risks This programme of work helps to mitigate the risks associated with environmental sustainability; regulatory, reputational, financial, and the health of our people. Recommendations and next steps
Governors are asked to: i. NOTE the update and action plan ii. RAISE any questions
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January 2020 – Estates and Facilities Departments
SUSTAINABLE DEVELOPMENT MANAGEMENT PLAN (SDMP) 2020-2025
Foreword The NHS Carbon footprint is currently 21 million tonnes per year and is still increasing. The Climate Change Act requires the UK to reduce its emission by 80% by 2050 (from a 1990 baseline). As a trajectory towards 2050 we should reduce by 34% by 2020 and 64% by 2030. To this end all NHS provider organisations are required to have a Board approved SDMP under the standard contract from Commissioners. SDMP’s are considered a measure of a ‘well led organisation’ and form a key part of sustainable healthcare delivery, ensuring that services provided today are fit for purpose in the future. Sustainable Development in the context of an SDMP is based upon three core interrelated principles or areas and these are environmental, social and economic, frequently referred to as the ‘triple bottom line’. It outlines projects and activities which will evidence continual improvement in sustainability performance throughout the Trust, covering areas such as staff awareness and engagement, through to projects aimed specifically at reducing the carbon emissions associated with our service delivery and operating our estate. The SDMP details how the Trust understands, commits to, and will meet its responsibilities in relation to the sustainability agenda. This is a substantiated update of our previous plan ‘Sustainable Health care Strategy (illustrated below) which was approved by the Board in 2019. This document includes an action plan (see appendix 2), the progress of which will be reported to the Board on an annual basis. The action plan is intended to be constantly changing to reflect the continual improvement that is made. An ever changing action plan will evidence that that Trust is environmentally responsible, contributes to reducing the impact of climate change and increases the protection of natural resources. The following eleven areas of focus form the basis of our SDMP action plan: - Corporate Approach 1. Energy and Carbon Management 2. Procurement and Food 3. Travel and Transport 4. Clinical Pathways 5. Water 6. Waste 7. Climate Change Adaptation 8. The Built Environment 9. Finance 10. Workforce Development 11. Partnerships and Governance
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These are aligned with the elements of the Sustainable Development Assessment Tool (SDAT) which in the first instance will help monitor our own performance and demonstrate continual improvement but will also provide an approved process against which we can benchmark our performance against other providers.
Contents Corporate Approach ...... 3 1. Energy and Carbon Management...... 3 2. Procurement and Food ...... 3 3. Travel and Transport ...... 4 4. Clinical Pathways ...... 4 5. Water ...... 4 6. Waste ...... 4 7. Climate Change Adaptation ...... 5 8. The Built Environment ...... 5 9. Finance ...... 5 10. Workforce Development ...... 6 11. Partnerships and Governance ...... 7 Appendix 1- SCH Focus point examples ...... 8 Appendix 2 - SDMP Action Plan: January 2020 ...... 9 Appendix 3 - Single-Use Plastics Pledge Suitable product alternatives – catering consumables (attached) ...... 17
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Corporate Approach This section outlines our approach to sustainable development. It will evidence how we will communicate and engage with staff, patients and services users and will confirm how progress will be reported to the Board. It will also detail how we will benchmark ourselves against other healthcare providers. The Trust is committed to preventing pollution and reducing the environmental impact of its activities, and where reasonably practicable will comply with all relevant environmental legislation. The Trust recognises the importance of good corporate citizenship and of promoting and maintaining high standards of environmental, social and ethical conduct. We are also committed to ensuring that our suppliers and contractors adopt a similar responsible approach. We will ensure that sustainable procurement principles are considered in relevant commercial decisions based on whole life costs including value for money, resulting in a reduced impact, and ideally a positive impact. 1. Energy and Carbon Management This section addresses the management of organisational assets. This includes large assets such as buildings and critical operational plant and equipment e.g. boilers and air conditioning plant, through to smaller assets such as laptops and mobile phones. It will also include mobile assets, such as vehicles. The aim of the objectives detailed within this section will be to: • Reduce operational resource use and cost e.g. water and energy • Replace existing assets with more energy efficient and less polluting alternatives • Where possible include an energy evaluation at the business case stage
This section also considers behaviour change of our staff through targeted campaigns and modification to our current utility purchasing methodology to buy renewable sourced electricity only. 2. Procurement and Food Providing good food is an essential way for the NHS to help patients recover from illness. We continually place the dietary needs of patients first and there are no plans to remove meat from NHS menus, however we will reflect dietary trends and continue to offer healthy alternatives on our menus. This section will also encourage compliance with the Government Buying Standards for food and catering services, identifying other areas for improvement such as associated certifications and accreditations. Sustainable procurement involves taking environmental and social considerations into account alongside financial factors when deciding which product and/or service to procure. It also involves looking at the costs of a product or service over its whole life, considering running costs, lifespan and disposal costs as well as acquisition costs. It can also involve looking at the supply chain for a particular product. This involves considering the impacts of products that accrue before the product is bought and after it is disposed of, for example, manufacturing and final disposal impacts. The Government’s Sustainable Procurement Action Plan states that “Sustainable procurement is good procurement”. More specifically, it means ensuring that Government supply chains and public services will be increasingly low carbon, low
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waste and water efficient, and will respect diversity and deliver wider sustainable development goals.
3. Travel and Transport This section evaluates the impact of staff travel and transport associated with Trust activities and service provision. The Health Outcomes Travel Tool (HOTT) will be used to evaluate and report our impact from these activities and as we improve our understanding in these areas, we can consider that of our supply chain too. Much of this work will focus on moving away from fossil fuel based vehicles and increasing the number of electric or hybrid vehicles within our service fleet. There will also be a drive to reduce non-patient related business travel. Linking in with our Health and Wellbeing agenda active and sustainable travel activities and initiatives will be promoted including cycling and walking.
4. Clinical Pathways This section looks at the way clinical services are currently delivered and considers whether they make best use of our internal resources, finance and infrastructure whilst delivering the best care and outcome for our patients. Where it is identified that they do not, services can focus their efforts on creating modifications, or whole service redesign, to ensure they are fit for purpose now and also for the future. Sustainable models of care cut across organisational boundaries and look at reducing demand through healthier lifestyles as well as the redesign of service delivery. There are multiple potential benefits in efficiency, patient safety, outcomes as well as carbon savings. These include addressing skilled staff shortages through different working methods, removing barriers between organisations caring for the same patient and reduction in patient and staff travel. An example of transformative care delivery is telemedicine, which can provide face-to-face consultation for follow up appointments with no need for the patient to travel. This can reduce time pressures on staff; reduce the need for patients to travel to an appointment (which may not be local to them), reducing congestion and local air pollution in Sheffield and the surrounding areas. 5. Water We recognise the environmental impacts that result from our use of water. We are therefore committed to improve the Trust’s environmental performance relating to water use. Targeting compliance with the relevant environmental legislation is the minimum acceptable level of performance. We continually look at our approach to the use of water and will reduce our impact by managing consumption effectively. Every member of staff shall ensure water is not wasted. Leaks shall be reported as soon as practically possible to the Estates maintenance department. Refurbishment and replacement example - Low and dual-flush toilets will be considered if replacing existing units. The maximum cistern volume of new toilets is 6 litres, compared with 9 litres for older models. Existing cisterns of 9 litres or greater capacity will on a rolling program be replaced or fitted with cistern dams or blocks to reduce their capacity. 6. Waste This section looks at our approach to waste and materials. It’s purpose is to set out how we will reduce our impact by managing waste effectively in line with the waste
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hierarchy, reduce consumption of single use plastics and use locally sourced goods and services for example. Hospital kitchens will provide facilities to patients and staff for the recycling of used food and drink containers including cans, bottles, cardboard and plastics. Where food safety will not be compromised, the use of disposable cutlery, plates and cups should be avoided, and milk, condiments and sauces should be served in reusable containers. Where the use of disposable cutlery, plates and cups is unavoidable, recyclable products should be used. The disposal of food waste to landfill or incineration adds to the environmental cost. As part of a wider waste management strategy, the Trust will only work with waste management service suppliers who can demonstrate compliance with waste food and animal by-product regulations. 7. Climate Change Adaptation This section outlines the Trusts approach to climate change adaptation which will be linked directly to a Climate Change Adaptation Risk Assessment. Firstly we will consider how the practical effects of climate change, e.g. wetter winters and hotter summers, will affect demand for our services. We will also look at our building specifications to ensure that new builds and refurbishments take account of predicted changes. Secondly we will assess the readiness of our estate and infrastructure to respond to severe weather events which are also predicted to become more frequent, e.g. a heatwave, cold weather or localised flooding.
8. The Built Environment This section addresses how we will measure and report the carbon impact of our activities and services. This will include but will not be limited to emissions from: • Building energy use • Building water use • Waste generation and treatment • Travel and transport activities • Procurement • Commissioning This section addresses new build and refurbishment projects and the environment and sustainability considerations during planning, design and construction. It details our approach to the identification and implementation of resource and energy efficiency (including energy, water and waste), the use of natural materials and the redesign of space and services to support the delivery of sustainable models of care. Outlined in this section will also be our plans to deliver space utilisation and consolidation to deliver best value. Green space and Biodiversity - It is widely known and reported that green space and biodiversity play an important role in patient recovery and the overall patient experience, particularly within mental health (CAMHS). This section looks at the integration of green space into the clinical environment which will include allocating growing space along with education opportunities in this area, both of which can be used within mental health for therapeutic purposes.
9. Finance Lowering our carbon footprint and increasing sustainability can help reduce costs and improve the quality of healthcare we are able to deliver. The biggest driver for the finance community is the fact that carbon reduction should in fact help them meet
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their key challenge – the need for efficiency. The whole of the NHS is coming to terms with the size of the efficiency challenge facing it over the coming years Ask finance directors what is at the top of their organisations’ agendas at the moment and the responses are overwhelmingly, efficiency, maintaining or improving access, quality and service redesign. Specifically within finance, the overriding need to drive efficiency in the face of dramatic growth reductions dominates. But how many would identify carbon reduction as a priority? In practice very few yet carbon reduction needs to be on all NHS boards’ agendas if the exacting targets for reducing greenhouse gases set by the government and laid out in the NHS carbon reduction strategy are to be met. Even though the last target – reducing the NHS 2007 carbon footprint by 10% by 2015 – was achieved the challenge of achieving the future targets should not be underestimated. Beyond the 2020 target of 34% cut (compared with 1990 levels) we are looking at matching the UK targets of a 64% cut in carbon dioxide by 2030 and a 80% cut by 2050. The NHS Sustainable Development Unit produces regular briefings to help finance teams understand the financial benefits of sustainability; the Trust proposes to take action and guidance to ensure we make best use of such recommendations if they align to our organisational context. We intend to use such information and take action. Examples such as the "Save Money by Saving Carbon" guide looks at how a Trust can produce its own Marginal Abatement Cost (MAC) Curve and how beneficial it could be for each NHS organisation. Simply, a Marginal Abatement Cost (MAC) Curve compares different interventions and shows you which carbon reduction measures save the most money. It would enable the Trust to choose from a selection of possible measures and see which make best financial sense to invest in and which save the most carbon. It condenses complicated data into a graph showing cost effectiveness and magnitude of carbon saved. The MAC Curve Download describes how MAC Curves can be used as part of investment appraisal and can help organisations make changes to their service delivery or business activities. Sustainable development offers opportunity to see long term cost savings through avenues such as reduced energy and water consumption, reduced waste production, increased resilience to the effects of climate change both on the Trust and on the wider community. The current financial cost to the Trust of energy, waste and water is £1.8M.
Over the last two years, the Trust has invested >£4M capital funding into CO2 emission reduction projects, primarily our CEF (Carbon and Energy Fund) contract. The Trust is open to using the various routes to finance our transition towards a more sustainable future, for example the interest-free Salix loan scheme. All utilities have undergone contract reviews to ensure best value is being achieved and waste contracts are currently being retendered.
10. Workforce Development Our workforce is essential to ensuring that the Trust delivers sustainable healthcare and everyone has a part to play within this whether it is effecting large scale changes such as designing services differently or championing efficient and effective behaviours within teams. This section sets out our approach to how we do business, what our expectations of staff are, and the responsibilities placed on them and our appointed contractors in relation to this. Key to this will be the measures we take to improve staff
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understanding of the Trusts sustainability agenda through recruitment, selection, induction and appraisal. Engaging our workforce and increasing their awareness and knowledge of sustainability is key. Equipping staff with appropriate knowledge will enable them to act sustainably as an individual as well as a collective; they are in a position to shift towards sustainable behaviour within both their work and personal lives, and will be able to spot opportunities that can be implemented from the bottom up as well as the top down. There are approximately 3,300 Trust staff who are in a position to introduce simple, efficient changes to daily routines which are essential in supplementing the larger, shift changes. Every single staff member has an important role to play in helping us to improve our sustainability. The Sustainability group aim to create a platform for our departmental teams to locally deliver sustainability actions to improve: health and well-being; the patient environment and experience; and avoid unnecessary resource consumption.
11. Partnerships and Governance The Trust’s corporate vision is to become a leader in transforming the health and care system, working in partnership to connect people, services, communities and voluntary groups to meet the needs of the communities it serves. Key to realising this vision is improving the experience of patients and staff by joining up care and connecting people through clinically led transformation programmes, across the acute and community settings, which is enabled by new technology. We are well placed and supported by the introduction of our new Electronic Patient Record (EPR) system. • Removing delays • Reduce administration time and paperwork • Increase speed of decision making • Improve management of theatre and outpatient demand • Enable or clinical teams to deliver care in a very different way The Trusts carbon footprint will be calculated on an annual basis and will be published in the Trusts Annual Report.
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Appendix 1- SCH Focus point examples Anaesthetic Gases, Pharmaceuticals and Medical Devices Anaesthetic gases have extremely high global warming potential, for example 1 litre of Desflurarane has the equivalent CO2 emissions of driving a diesel car from Lands’ End to John O’Groats and back 7 times. In addition to this issue: less than 5% of inhalational anaesthetic gases are metabolised by the body. This means that 95% of the administered gas goes into the atmosphere. The Trust’s Anaesthetics team are working on several fronts to reduce this impact. Supporting NHS Pledge on Reduction of Single Use Plastics NHS Supply Chain is supporting the call by NHS chief executive Simon Stevens to dramatically cut the amount of single-use plastics in hospitals, as part of a package of measures in the NHS Long Term Plan to lessen the environmental impact of the health service. What is the Single-use plastics reduction pledge? NHS England and NHS Improvement have launched a pledge which requires NHS trusts who sign up to commit to phase out avoidable single-use plastic items which are used in catering services and office spaces. This will happen in the following stages: a) By April 2020, no longer purchase single-use plastic straws and stirrers in line with the government consultation b) By April 2021, no longer purchase single-use plastic cutlery, plates or single- use cups made of expanded polystyrene or oxo-degradable plastics c) After April 2021, go beyond these commitments in reducing single-use plastic food containers and other plastic cups for beverages – including covers and lids. d) How is NHS Supply Chain supporting the plastics pledge? NHS supply chain have alternative products available in their catalogue to help NHS trusts sign up to the pledge to phase out avoidable single-use plastic items used in catering services and office spaces. *Also see Appendix 3 attachment
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Appendix 2 - SDMP Action Plan: January 2020 Authors: Estates / Hotel Services department Board Champion: John Williams Executive Director of Finance
Trust Value Category Objective Where are we now? Specific action in 2020 Lead Timescale Resource Required Objective aligns to Corporate Report progress against Original SDMP approved Provide the Trust Executive Executive Board approval in Executive Director time Make the Trust Approach the SDMP Action Plan to by the Board in 2019. team with update. Director of Summer 2020. to present to the Board. a great place to the Board on a six Revision needed to Dates TBC Finance Dates for reporting Steering Group work monthly basis acknowledge changes to be agreed on a 6 members time to collate within the Trust and the monthly basis information and update wider health and care at scheduled meetings sector Develop a There has never been a Trust wide sustainability Communications Plan to be Utilisation of establish Through Communications Plan formalised approach to communications plan up lead with support developed by July Communications team Innovation specifically for the communicating Trust wide and operational by July from the 2020 with 6 and systems ensure we promotion of sustainable sustainable development 2020 Suitability monthly review and deliver development to staff, initiatives committee update sustainable patients and service members users Calculate carbon footprint The Trust currently does Calculate carbon footprint Head of May 2019 Need to identify Innovation , annually and report in not calculate and therefore and report in annual Trust Operations professional advice / Transformation Trusts Annual Report does not report Estates support on calculating and best Publish its Carbon and reporting to best practice Footprint. practice standards. 1. Energy and Trust wide strategy to Achieve approval of Head of Estates / April 2020 Commitment of financial Demonstrate Carbon reduce energy demand £4M investment via Carbon Estates Energy strategy Head of resources to fund energy Best Value Management through investment in and Energy Fund in This will help to improve Operations efficiency projects and/or energy saving technology Combined Heat and Power efficiency and Reduce (Estates) implement energy Plants, energy efficient Carbon emissions generating or saving boilers, LED lighting, solar Estates and technologies PV and building communications team to management controls to run campaign to inform achieve practical staff and public on how we completion in 2020 and are reducing energy, key deliver planned savings area of focus will be the
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Trust Value Category Objective Where are we now? Specific action in 2020 Lead Timescale Resource Required Objective aligns to return to Trust Carbon and Energy fund project. July 2020 Increase staff Currently no active Energy Estates and Trust April 2020 Time and engagement of Innovation , engagement in energy Campaign or communications team to communications leads. May require Transformation efficiency through an communications regarding run campaign to inform team. minimal financial and best annual Energy ‘good work’ happens. staff on how they can Supported by support. practice Awareness campaign This would provide staff contribute to saving energy Transformation with awareness of the , water and waste by ‘doing team and Estates Trusts good work and the right things’ and department. commitment. Provide staff thinking about the Possible use of support to conserve energy environment. the TLC and water and promote July 2020 campaign. resource efficient behaviours Purchase Renewable The Trust generates much Seek Board approval for Estates / Finance April 2020 Commitment financially Demonstrate Sourced electricity only of its own electricity additional spend to achieve even if the cost is slightly Best Value through our CHP plants at carbon reduction on higher. the Acute and Becton electrical supply Would require constant hospitals. We could cost review. strategically commit to buying only Renewable through our procurement – Crown commercial services. There is a relatively low cost associated but the carbon reduction implication is wholly positive and demonstrates our commitment.
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Trust Value Category Objective Where are we now? Specific action in 2020 Lead Timescale Resource Required Objective aligns to 2. Procurement Meet Government Buying Achieved compliance with Continue to develop local Associate Immediately - Annual auditing of Ways of and Food Standards for food and the objective already in model to ensure Director of Hotel Ongoing catering dept. by the Soil improving child catering services 2017 by being accredited accreditation is maintained Services Association and health with the Soil Associations, and identify elements associated cost of Food for Life within the Silver and Gold £1308.00 Standards that the Trust can work towards to further reduce child obesity and support health promotion through healthier choices. Trust ‘Fruits and veg stall, Initiative commenced in Review achievements and Associate 2020 Utilise existing High quality December 2020 identify any potential Director of Hotel resources. Possible patient additional opportunities. Services review of ‘space experience Consider further roll-out requirement, for the stall location. Healthy eating – Healthy options vending Review use and product Associate 2020 Possible cost of rental Ways of Right choice vending machine in place and range and identify any Director of Hotel for further vending improving child machines operational. potential additional Services machine units although and staff health opportunities. Consider income will cover and Traffic light food labelling We have the software and further roll-out initial cost over time. are in the process of Colour coded nutritional uploading recipes to enable and allergenic information label production for all food produced which will inform consumers at a glance if the food has high, medium or low amounts of fat, saturated fat, sugars and salt as well as calories and any allergens
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Trust Value Category Objective Where are we now? Specific action in 2020 Lead Timescale Resource Required Objective aligns to On-campus commercial All established retail outlets Continue to monitor Associate 2020 Time / capacity to review Ways of outlet restrictions, to (Costa, W H Smiths, etc) Director of Hotel and ‘audit’. improving child ensure healthy options have agreements in place Services health choices are available and to ensure any products restrict the sale of sold meet our healthy deemed unhealthy eating options choice products. Aim to requirements. contribute to a healthy lifestyle and reduce future impact on healthcare systems. Reduction of single use Disposable cutlery is being Conversations to be Associate 2020 plastic (disposable discontinued once current undertaken with waste Director of Hotel cutlery) and takeaway stock is depleted, these are contractors re compostable Services boxes being replaced with a product disposal compostable replacement. Reduction of polystyrene Recyclable items are Introduction of reusable Associate 2020 Work with comms to Innovation , takeaway boxes source able, however as takeaway containers that Director of Hotel identify if there would be Transformation these would be disposed of can be bought in the dining Services sufficient interest/ and best dirty (containing food room support of this initiative practice debris) they would contaminate the recycling waste stream – rendering the waste has not recyclable. 3. Travel and Develop a Trust Existing active / Review and updated Trusts Transformation July 2020 Time / capacity to Innovation , Transport approved sustainable travel plan sustainable travel plan team / PMO review, update and go Transformation Active/Sustainable Travel requires refreshing and through policy approvals and best Plan updating. process. Utilise existing practice team , staff resource Replace all Trust owned Existing Estates vehicles Procurement to swiftly Procurement April 2020 Cost of replacement Innovation , vehicles with Electric are circa 12 years old and conclude evaluation of team STH- vehicles, installation to Transformation (upon replacement). quickly require replacement market options and Estates and key sites of EV charging and best Install EV charging points as maintenance bills are progress purchase or rental Facilities points. practice across the Trusts sites. increasingly higher than the model of replacement EV’s. asset values.
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Trust Value Category Objective Where are we now? Specific action in 2020 Lead Timescale Resource Required Objective aligns to Procurement looking at options. Reduce business travel Currently developing Progress to completion and Human resources 2021-22 Financial costs to Innovation , claims for all non-patient Communications to raise implement ‘new plan’ team establish TBC (such as Transformation related activities. This will awareness of cost, carbon aimed to support Procurement Skype, conference and best reduce our carbon and health impact of sustainability by reduction Finance calling, technology practice footprint and reduce business travel. of business travel claims ICT solutions). business travel c02 Implementing the for all non-patient related Project needs to emissions. Trust IT Strategy to activities generate a reduction in develop infrastructure to staff / business mileage allow innovation in claims /cost. technology. Consider Implementation System used by other Evaluate if there are Human resources 2021-22 Financial costs to Innovation , of E-Community software Trusts but not SCH. deliverable benefits that we team establish TBC. Transformation for staff journey planning should further explore. Procurement Project needs to and best Consider if a system of this Finance generate efficiency practice type would be a good fit for ICT against staff / business SCH. mileage claims /cost. 4. Clinical Improve engagement There is significant Co opt 2 suitable clinical Medical Director February 2020 Staff time to attend and Ways of Pathways with Clinical staff over untapped clinical staff representatives on to the develop clinical parts of improving child sustainability issues interest in sustainability environmental work plan health issues. sustainability group. 5. Water Carry out data analysis of Generally good practice Analysis of existing data. Estates Immediately - Existing capital projects Demonstrate existing consumption and culture in place, better Further investigate of Department / Ongoing and estates teams. Best practice data to identify communications and reasons for high usage (per Head of Estates opportunities to reduce formalising how we use sqm) water consumption water will deliver positive Formalise and raise volumes through better benefits. awareness of the Trust's management and approach and commitment communication to reducing the use of water
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Trust Value Category Objective Where are we now? Specific action in 2020 Lead Timescale Resource Required Objective aligns to 6. Waste Develop a Waste The Trust has never had New appointment of Trust Associate 2020 Appointment of Demonstrate Strategy to improve an approved Waste Environmental & Director of Hotel dedicated Trust Best practice waste management and Strategy Sustainability Officer to Services Trusts Environmental & save costs lead on innovative new Environmental & Sustainability Officer ways of working to better Sustainability manage waste. Raise Officer awareness through comms and implement new waste strategy. Management of Clinical Segregation is happening Robust training across Trusts 2020 Time / capacity to review Innovation , waste across healthcare but could be better multidisciplinary teams to Environmental & and ‘audit’ Transformation sector and statutory ensure correct waste Sustainability and best responsibility for correct segregation and waste Officer practice waste segregation reduction Reduce external Procurement to identify Procurement to identify Procurement Immediately - Utilisation of existing Demonstrate packaging of items high volume products with high volume products team STH Ongoing Procurement resource Best Value purchased – including a a high packaging content with a high packaging 20% reduction in and identify if sustainable content and identify if polystyrene packaging alternatives are available sustainable alternatives are available Reduce use of single use Procurement to identify Procurement to Procurement Immediately - Utilisation of existing Demonstrate plastic items high volume products identify high volume team STH Ongoing Procurement resource Best Value sourced which are or use, products sourced which single use plastics and are or use, single use identify if sustainable plastics and identify if alternatives are available sustainable alternatives are available. Increase use of SME’s Procurement to review Procurement to review Procurement April 2020 Utilisation of existing Demonstrate (Small and Medium spend categories to identify spend categories to team STH Procurement resource Best Value Enterprises) and locally SME / local sourcing identify SME / local sourced goods and Opportunities. Make sourcing opportunities services tenders more accessible to Make tenders more SME’s and local providers accessible to SME’s and by breaking down suitable local providers by breaking tenders into smaller lots down suitable tenders into smaller lots.
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Trust Value Category Objective Where are we now? Specific action in 2020 Lead Timescale Resource Required Objective aligns to 7. Climate Develop a Trust wide Business Continuity Plan Undertake full climate Trust Business 2020 Utilise existing Trust Innovation , Change Climate Change Risk in place but these do not change risk assessment continuity / resource - Trust Transformation Adaptation assessment, e.g. specifically mention and place on Trusts emergency Business continuity / and best changes to service Climate Change impacts existing risk register for planning lead emergency planning lead practice demand and delivery that annual review. will likely result from climate change 8. The Built Develop a framework for Building on existing work / Develop standard Head of Capital Immediately - Existing capital projects Innovation , Environment all Capital Works (Major standard specifications to specifications include in Sustainability Ongoing and estates teams. Transformation or Minor) to Ensure agree a formalised consultancy appointment committee and best sustainable products and approach. briefings or invitation to practice services are considered tender documents on at the design stage. See defined Trust requirements. also climate change adaptation 9. Finance Work in collaboration with Current programme of Support and progress Project Continuous Project management Create long the Trusts Transformation projects identified, all at current schedule of management office (PMO) , finance term financial team on progressing different stages projects. office (PMO) lead and senior sustainability efficiency projects to Identify new ones for 2020 Finance responsible officers deliver long term and beyond. managers (SRO) sustainable change. 10. Workforce Develop staff Very limited exposure or Make all staff aware of our Sustainability June 2020 Staff time and resource, Make Trust Development Communications to communications of sustainability agenda and committee Utilisation of existing best place to improve understanding of sustainability projects and why it is so important and Communications department time and work the Trusts sustainability awareness internally of what they can do to team resources agenda through need to take action. contribute. L&OD, Human recruitment, selection, resources team induction and appraisal
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Trust Value Category Objective Where are we now? Specific action in 2020 Lead Timescale Resource Required Objective aligns to 11. Develop a strategy to Some partnership working Further develop local Executive 2020 Set up of a leadership Innovation , Partnerships and drive our sustainability on sustainability locally and relationships with partner Director of group to structure plan Transformation Governance agenda through regionally, but not organisations. Finance and programme. and best partnership working and consistently driven with a Develop a framework to Transformation Utilisation of existing practice strong governance. uncertainty on leadership. ensure sustainability links team department time directly into all work and resources streams and the associated benefits are identified and delivered through leadership and governance.
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Appendix 3 - Single-Use Plastics Pledge Suitable product alternatives – catering consumables (attached)
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9. 07/20 QUALITY REPORT - ENC D COUNCIL OF GOVERNORS 9. 07/20 QUALITY REPORT - ENC D Page 49 of 130
EXECUTIVE SUMMARY
Title QUALITY REPORT ~ SELECTION OF LOCAL INDICATOR
Report to Council of Governors Date 11 February 2020
Executive Sponsor Professor S Shearer, Executive Director of Nursing and Quality
Author Professor S Shearer, Executive Director of Nursing and Quality
Purpose of report To present to the Governors the options for selection of a local indicator. Data in relation to the selected indicator will be audited by our external auditors. Please tick as appropriate Approval X Assurance Information
Executive summary –the key messages and issues
The Annual Report is produced as part of a NHS Foundation Trust’s financial statements in order to provide assurance related to the quality of care provided within the organisation. Three of the data indicator sets reported are also required to be formally audited by the organisation’s external auditors.
Two indicators for formal reporting are mandated within the guidance issued by NHS Improvement, with the third indicator selected from a menu by the Trust’s Council of Governors. This paper presents the options available for selection.
How this report impacts on current risks or highlights new risks
The report is aligned to BAF 1 as an external assurance of care quality.
Recommendations and next steps
Governors are asked to select an indicator for testing
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COUNCIL OF GOVERNORS 9. 07/20 QUALITY REPORT - ENC D Page 50 of 130 SHEFFIELD CHILDREN’S NHS FOUNDATION TRUST QUALITY REPORT ~ SELECTION OF LOCAL INDICATOR
1. NHS IMPROVEMENT EXTERNAL ASSURRANCE FOR QUALITY REPORTS Patients want to receive assurance that they are receiving the very best quality of care. The Health Act 2009 reflects this by requiring all NHS Foundation Trusts to produce annual reports on the quality of the care that they provide as part of their annual accounts. In order to improve the quality of the data that NHS Foundation Trusts submit, NHS Improvement requires that the quality report is subject to external scrutiny. In order to comply with this requirement, some indicators will need to be checked by our external auditor, KPMG.
2. INDICATOR SELECTION
2.1 Mandatory indicator
NHS Improvement usually update the guidance for the preparation of quality accounts each year although for this review of the year 2019/20, they have suggested that the previous update of the 2010/11 guidance, issued in January 2018 should be used. This means that the selection of the local indicator by the Council of Governors follows the same process as last year. The process requires our external auditor, KPMG to undertake substantive sample testing on two mandated performance indicators and one locally selected indicator.
The guidance outlined above is developed for NHS Trusts and covers a broad range of types of provider. NHS Trusts that provide more than one type of service are advised to follow the guidance for the service from which they receive the greatest income.
Several mandated indicators are suggested in the guidance. Due to the range of providers covered by the guidance, not all indicators will be relevant to all Trusts. Therefore the indicators are placed in order of priority. Trusts are required to audit the top two indicators that are applicable to the type of service they provide.
The mandatory indicators in order of priority for testing are:
i. Percentage of patients with a total time in A&E of four hours or less from arrival to admission, transfer or discharge.
ii. Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers
iii. Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period
iv. Emergency readmissions within 28 days of discharge from hospital.
The mandatory indicators appropriate for Trust testing are therefore:
i. Percentage of patients with a total time in A&E of four hours or less from arrival to admission, transfer or discharge.
iii. Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period
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COUNCIL OF GOVERNORS 9. 07/20 QUALITY REPORT - ENC D Page 51 of 130 Governors will note that indicator ii) ii. Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers has been discarded. This is because the number of patients who wait 62 days from urgent GP referral to first treatment in the Trust is zero. In this case the guidance states that Trusts can choose to audit 31 day waits for the same indicator or move onto the next priority indicator for testing. As the Trust has 100% compliance for 31 day cancer waits, the decision was taken to use indicator (iii) for mandatory testing.
2.2 Local indicator
NHS foundation trusts must also seek assurance through substantive sample testing of one local indicator included in the quality report, as selected by the Governors.
NHSI strongly recommend that the Summary Hospital-level Mortality Indicator (SHMI) should be selected as the local indicator. The Governors of the trust may choose an alternative indicator if they consider there is already sufficient assurance in this area, or it is determined that other priorities take precedence.
The selection of Summary Hospital-level Mortality Indicator (SHMI) is not without challenge in a stand-alone Children and Young People’s integrated trust for the following reasons:
i. The mortality rate in the Trust is very low apart from areas such as haematology / oncology and PICU where data is already standardised and in the public domain from reporting across networks. ii. Mortality reaches sufficient numbers in the Emergency Department, although causation usually relates to a pre hospital event. iii. It can be challenging to find other similar Trusts to standardise against given our size and standalone status.
The guidance states that if Governors plan to select an alternative indicator, that this should be based on local priorities. However the indicator does need to be selected from a list of approved indicators within the NHSI guidance, many of which are not relevant to the services we deliver. The following are offered for discussion and selection:
2.3 The number and where available, the rate of patient safety incidents reported by the Trust, including those that result in severe harm or death.
a. Description: All patient safety incidents should be robustly investigated with lessons learned shared. Incidents resulting in severe harm or death should be reported externally and a system in place for monitoring avoidable morbidity and mortality.
b. Rationale for selection: The continuous vigilance and monitoring around this indicator is essential to protect children and young people from harm. During 2018/19 the Trust reported 4404 patient safety incidents of which 0.1% ( 4 incidents) resulted in severe harm or death.
KPMG have audited this indicator in previous periods, undertaking testing of a sample of all patient safety incidents including all those reported as resulting in severe harm or death. No issues have been identified during the testing of this indicator in previous periods.
c. Issues to be resolved:
i. Are incidents being robustly reported and investigated? ii. Are incidents being reported? Are we implementing learning to prevent recurrence? iii. Are the systems we have in place to prevent avoidable harm sufficiently robust?
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2.4 Patients readmitted to a hospital within 28 days of being discharged (0-15 years)
a. Description: This indicator is the percentage of emergency admissions aged 0-15 years, to a hospital within the Trust occurring within 28 days of being discharged from hospital which forms part of the Trust during the reporting period.
b. b. Rationale for selection: Nationally there are wide variations in readmission rates following a hospital stay, some of which are potentially avoidable. The indicator is in place to offer comparative data between organisations to prompt investigation and discussion of why readmissions occur and what steps can be taken to prevent or significantly reduce this practice.
KPMG would be able to review the reported data against patient records. However KPMG wish to highlight that they are unable to verify patients numbers who have not reported back to hospital for readmission who perhaps ought to have done.
c. Issues to be resolved:
i. Is the data accurate? ii. Are our readmission rates higher or lower than similar organisations? Iii Does the Trust need to investigate whether the initial reason for attendance has not been properly dealt with or the patient discharged too soon? Is the subsequent attendance for the same reason?
2.5 The percentage of staff employed by, or under contract to, the trust during the reporting period who would recommend the trust as a provider of care to their family or friends.
a. Description: Data is collected during the nationally mandated annual staff survey and more regular ‘pulse’ checks. Staff voluntarily answer questions regarding their experience of working within the Trust and whether, based on that knowledge and experience they would recommend the Trust as a provider of care should their family or friends require treatment.
b. Rationale for selection: The Trust has recently produced a People Strategy and a Culture and Behaviour Strategy and is seeking to improve the experience of staff working across the Trust. There is evidence to suggest that positive staff experience has a positive impact upon patient experience and outcomes.
KPMG state that reported data should be readily auditable. However, this may carry limited value to the Trust given this would be a verification of what ought to be a simple process i.e. reviewing that answers to a staff survey had been entered correctly into a database (If this is an automated survey this might further limit the value of any work undertaken).
c. Issues to be resolved: i. Are there reporting issues that impact upon the accuracy of the staff survey findings?
3. Reporting Arrangements
KPMG will take instruction from the Governors and will duly complete the audits to identify whether the processes for reporting the chosen indicators are robust, accurate and consistently applied. The audit may also suggest improvements to processes.
The result will be reported back to Governors and will feature in Annual Quality Report Review.
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10. 08/20 QUARTERLY REPORTS FROM BOARD COMMITTEES - ENC E - QUALITY COMMITTEE - PEOPLE AND PERFORMANCE COMMITTEE - RISK AND AUDIT COMMITTEE COUNCIL OF GOVERNORS 10. 08/20 QUARTERLY REPORTS FROM BOARD C... Page 54 of 130
Quality Committee Quarterly Report to Council of Governors Dated: 11 February 2020
Quality Committee Overview- Q3 2019/20 Document Purpose: For Assurance Meetings Held: 18 November 2019, 16 December 2019, 13 January 2020 Attendees All attendees were present for both sessions with no apologies received. Key Recurring Monthly Clinical Quality Dashboard Deep Dives SARC CQC Report Agenda items Update on Serious Incidents Update on out of date medical guidelines items CAMHS Transformation Deep dive into discharge summaries pilot covered Subcommittee Non-executive Feedback from Divisional Clinical Quarterly Safeguarding Report Quality Meetings Quarterly Report from the Director of CQC action plan update Infection Prevention and Control Update on operational management of central Quarterly Report form the transition database Accountable Officer for Controlled Process for reporting compliments Drugs Quarterly integrated legal and governance report Quarterly report from the mortality review panel Quarterly report mental health legislation Quarterly update on the Quality Accounts Quarterly report mental health legislation Quarterly update on restrictive interventions Quarterly update on regulation 28 action plan Quarterly CQUIN escalation report Quarterly care experience report Report from the Education Board COUNCIL OF GOVERNORS 10. 08/20 QUARTERLY REPORTS FROM BOARD C... Page 55 of 130
Update from the Antimicrobial Stewardship Group Six month update from the Medical Equipment Management Group Resuscitation Committee Annual Report Headlines 1. Note the publishing of quarterly learning from deaths report 2. Changes to governance arrangements for the CAMHS transformation programme The The following items were escalated to the board during Q3: following Education Board - The Committee received a positive six month update, which responded to a number of issues raised by items were the Committee at their last update around student nurse placements. The Education Board’s focus was across the whole Trust escalated and aligned to the People Strategy, with a lot of work being taken forward by the Learning and Organisational Development from the Team. Committee to the CAMHS Transformation Subcommittee - The Committee has overseen this subcommittee since it was established, for a Board time limited period, with a NED Chair. This period had now come to an end, and the Committee supported proposals to bring during Q3 together the governance arrangements with the operational steering group, to be overseen by the Transformation Programme for either Board. These new arrangements were approved by Board in November, with a clearly defined change programme for all escalation priorities, and Board assurance would be provided through established mechanisms, triangulated by frequent Back to the or Floor visits to the service. The Board supported the recommendation at risk due to the vulnerability of the service and awareness: patients, with a mechanism to escalate any concerns. The Board was assured that an internal audit of the service was already built into the Internal Audit plan, and that the reconfiguration of the service continued as a two to three year programme. Mortality Review Panel – The December Committee approved the quarterly learning from deaths report for publishing on the Trust website (this is a legal requirement): https://www.sheffieldchildrens.nhs.uk/download/272/publications/7901/learning- from-deaths-quarterly-review-from-mortality-review-group.pdf Medical guidelines – The Committee received an update on work to map out the process for reviewing medical guidelines. A further update would be brought back to the Committee in due course. Discharge summaries – Committee chairs have agreed that discharge summaries compliance is a quality issue and the Committee will oversee the pilot work to improve performance against this metric, and actions included a recommendation to invest in a band 3 coordinator role to help drive up performance compliance, and work with Clinical Directors in relation to the process. Quarterly CQUIN escalation report - The Committee received a report highlighting key risks. There was some learning COUNCIL OF GOVERNORS 10. 08/20 QUARTERLY REPORTS FROM BOARD C... Page 56 of 130
noted around starting projects earlier, and the Committee was assured that CQUINS for 2020/21 were already being considered. The Committee suggested consideration was given to reviewing and challenging CQUINS where the Trust could demonstrate these were unachievable, particularly those where there had been a significant increase in referrals to the service. Regulation 28 Action Plan - The Committee was informed of progress against two joint regulation 28 orders. The Committee was concerned by the lack of progress to implement a home intensive treatment (HIT) service. As this was a joint order, and a shared risk, this would be escalated with the relevant partner organisation to consider implementing a phased approach due to the patient safety concern. This was being taken forward and a progress update would be provided to the February meeting. CQC Action Plan - The quarterly progress report was scrutinised at the January meeting. Work was taking place to review criteria used for all RAG ratings used across the Trust, and progress would be reviewed against any changes in criteria. Target dates would be included in future reports, as well as narrative against those actions rated red. The final validated action plan would be shared with the CQC. Care Experience Report - The report presented the results of the children’s and young people’s patient experience survey 2018, this survey is undertaken every two years through the CQC survey coordination centre. The Trust’s response rate was 28 per cent against a national average of 26 per cent. It is a challenge to compare results with previous years due to changes to the questions, however there were some areas of improvement, and some that had stayed the same. The results showed that, overall, the Trust was a good place to have care. As a learning organisation the Committee requested that more examples where feedback had led to changes and learning was included in future care experience reports to show the development journey. Quality Impact Assessments (QIA) - The Committee had been assured that robust processes were now in place, and the team was congratulated on the improved picture, and process that worked well. Antimicrobial Stewardship - The Committee received a progress position summarising the current antimicrobial stewardship provision at the Trust. This had previously been a CQUIN project. Teams were receptive to, and learning from, reviewing use of drugs, and the work was extending areas of good practice across the Trust. Compliments – The Committee recognised the value of receiving compliments, and that compliments came into the Trust through various routes, and asked for a process to bring these together into a central process was taken forward. This was ongoing and an update would be brought back in due course. Escalations/ 1. Governors are asked to note the update. Requests 2. Raise any questions. for support COUNCIL OF GOVERNORS 10. 08/20 QUARTERLY REPORTS FROM BOARD C... Page 57 of 130
to/from the COG Summary This report covers three Committee meetings. The agenda is always full and the Committee gained assurance on a number of from the areas. Also over the reporting quarter the Committee sought improvement in a number of areas, including; the management Chair of medical guidelines and continuing oversight of management of transition plans. Report Governor Patricia Mitchell, NED Chair, Quality Committee Jackie Cole, Governor observer Author observer
Glossary: BAF – Board assurance framework - a list of strategic risks, considered by Board regularly, which threaten achievement of strategic objectives CAMHS – Child & Adolescent Mental Health Service – the name of the clinical division at the Trust dealing with young people’s mental health issues CQC – Care Quality Commission – the regulator of care quality and safety in the NHS CQUIN – Commissioning for Quality and Innovation – a regulated scheme of financial incentives for trusts provided for achievement of certain nationally agreed targets QIA – Quality impact assessments – a process of assessing the impact of changes to services on groups of people with protected characteristics COUNCIL OF GOVERNORS 10. 08/20 QUARTERLY REPORTS ... Page 58 of 130
Governor Observer – Committee Feedback Form
Committee: Quality Committee
Date(s) of Committee: 18th Nov 2019/13th Jan 20 (missed 16th Dec)
Jackie Cole, Partner Governor, and Observer on Quality Reporting Governors: Committee
Key points from committees attended in previous quarter
Full agendas for every meeting, but appropriate time allotted to discuss each item, flexibility to move things around to allow fuller discussion as and when needed. 1.
Continued evidence of progressive work at CAMHS transformational subcommittee. 2.
Care experience reports highlight that the Trust is a good place to receive care/treatment, the committee is keen to ensure there is more use of patients experience/stories to aid further/future 3. improvements.
The chair and committee members are committed to ensuring that any outstanding ations from any reports/action plans are addressed in a timely manner, with appropriate challenge given if 4. they are not addressed appropriately then escalated to board.
5.
Governor Observer: Committee Feedback form – Oct 2019
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People and Performance Committee Quarterly Report to Council of Governors Dated: 11 February 2020
People and Performance Committee Overview- Q3 2019/20 Document Purpose: For Assurance Meetings Held: 20 November 2019, 11 December 2019 (extended session), 22 January 2020 Attendees Apologies were received from: November 2019: Ruth Brown, Peter Lauener, John Somers. December 2019: John Somers, Vince Keddie, January 2020: Peter Lauener.
Key Agenda Recurring 1. Monthly Integrated Performance report Deep Dives 1. Benchmarking report items items 2. Update from Recovery & 2. Community CAMHS waiting times covered Transformation board 3. Well Prepared surgery Transformation workstream 3. Monthly finance Report 4. Trust’s five year financial plan 5. NED feedback from Divisional Board meetings 6. Capital Plan Update 7. Private Patients Initiative 8. Environmental plan 9. Transformation programme 2020-2022 10. Pathway to Excellence® 11. Impact of pensions on capacity 12. Meet and Greet the People and L&OD Teams 13. Mandatory training and PDR compliance Financial 1. The Trust reported its month 9 position with a change to its forecast outturn position to a £9.8m adverse variance to its operational Headlines plan. 2. Executives are taking forward actions to improve performance of a number of metrics reported in the IPR. 3. There was a good pre-Committee meet and greet with the People and Learning and Organisational Development team.
The following The following items were escalated to the board during Q3: items were escalated 1. Integrated Performance Report (IPR) from the The committee scrutinises the monthly dashboard in detail, including key achievements and areas of concern. Committee to the Board During the quarter 3 A&E performance fluctuated, and in December the trust reported that it did not meet this national target during Q3 for for the first time since 2014. This was due to sustained increase in activity during November. Contextualised with the national either position all trusts failed this target in December due to the extremely challenging month in November. The Trust remained escalation or COUNCIL OF GOVERNORS 10. 08/20 QUARTERLY REPORTS FROM BOARD C... Page 60 of 130
awareness: within the top five performers in the country. The Trust did achieve the target for January, however activity was expected to spike again during the winter period, and assurance was provided that actions to mitigate the impact of increased activity on the department would continue with primary care. The good uptake of flu vaccinations by front line staff continued, the current position was reported at 68 per cent. This was a nationally set target of 80 per cent of front line staff vaccinated. Performance was on trajectory to achieve target by the end of March 2020. 18 week wait target was not achieved in the quarter, there had been slight improvement in performance which had slowed the decline. Executives were looking at options to reduce 18 week waits within one service, with potential service models being considered. The committee was concerned that a number of core metrics on the dashboard were showing red. The dashboard enabled highlighting of these issues. Trajectories were reviewed together with work to improve ownership and accountability, and look to ensure underlying procedures were robust for areas that normally achieved target. This focussed effort was showing positive improvement for some metrics, with performance now close to target. The committee was informed of an approach being taken to reduce non consultant waiting times. The committee agreed to receive a deep dive of the issue, together with a plan to improve performance to sit alongside reporting, for transparency, and agreed ongoing close scrutiny of the issue. 2. Monthly finance report Each month the committee has scrutinised the financial position. During the reporting quarter the finance team have been undertaking detailed work with divisions to understand the Trust’s financial position, and a number of actions have been put in place. At the January meeting the committee discussed the financial position presented and the associated risks. A number of actions were agreed for the process to formally change the Trust’s forecast outturn position to a £9.8m adverse variance to its operational plan. The Committee discussed the approach to recovery and the need for a robust Financial Recovery Plan to be developed. This would be brought back to the committee later in Q4 and would require both Trust Board and regulatory/system oversight. This position has been communicated to governors following the January Board meeting. The committee was informed the trust planned to achieve its capital spend programme by year-end. Changes had been made to the Cash Committee meetings to facilitate Executive attendance, and a cash strategy to become more forward looking was approved at the January meeting. 3. Transformation Programme COUNCIL OF GOVERNORS 10. 08/20 QUARTERLY REPORTS FROM BOARD C... Page 61 of 130
The committee has received monthly highlight reports from this programme, and an outline programme for the next two years. Further detail on the programme scope would be brought to the February Board meeting. 4. Recovery and Transformation Deep Dive: Well Prepared Surgery The committee received a good update on work of the workstream, with a significant amount of work undertaken during the 18 months of the programme, however there was more to do. There were clear results made by the programme and the committee recommended that other cross cutting improvements were fed into the wider programme. 5. Benchmarking Report The committee received a paper describing extensive efficiency benchmarking information. This would be used to inform potential opportunities. A previous report by an external consultant would be reviewed and mapped across, before an update was brought back to the committee, and information would also be considered in relation to the wider system not just for internal use. 6. Community CAMHS waiting times A six month position statement was presented. This was an area highlighted by the CQC in relation to having robust processes, however since the CQC’s findings the pathway had been changed. The committee also noted there had been an increase in referrals of 46 per cent per to the service. Following national investment, three additional posts had been put in place, the impact of this additional resource would be evaluated, before considering further investment. Discussions with commissioners continued, and this phased approach would be articulated in the response to the CQC “must do”. Discussions were taking place with partners to look at; CAMHS waits, consider pathways in and out of the service and early intervention. The Trust was leading on this work in Sheffield and within the region. A six month update would be brought back to the committee. 7. Finance Long Term Plan Update Plans had been submitted on 15 November, and the committee was assured the Trust’s plan met the requirement to reach breakeven within five years, have a cost improvement plan of at least 2.5 per cent per annum, and had been triangulated with system plans. The committee noted the Trust’s gap was slightly less than previously reported due to some movement within the system. 8. Non-executive’s feedback from Divisional Board meetings Non-executives provided feedback to the committee following their attendance at each of the Clinical Divisional Board meetings. The report was shared with divisions, and Associate Directors and Clinical Directors have been invited to attend COUNCIL OF GOVERNORS 10. 08/20 QUARTERLY REPORTS FROM BOARD C... Page 62 of 130
future committee meetings in a reciprocal arrangement for cross learning. 9. Meet and greet with the People and Learning and Organisational Development Team Committee members had a useful visit to the People and Learning and Organisational Development Team at Moorfoot to talk to the team about key areas of their work. This session had been arranged to increase the visibility of the committee, and to help connect the work of the committee with what is happening on the ground. 10. People report and draft people plan The committee received an update on progress to develop the People Plan. This was the start of the work to become the best place to work. Communications out to staff would begin in due course. 11. Mandatory training and PDR compliance – update The committee received an update responding to the request to see improved mandatory training and PDR compliance. A number of actions were in place to help improve compliance, in addition to plans to move to seasonal appraisals. It was expected that improvements to the process and moving to seasonal appraisals would create better conversations between managers and their teams which would see improved mandatory training compliance. 12. Impact of Pensions issue on capacity The committee received an update which responded to its request for details to better understand the impact of this national issue on capacity. National resolution was being taken forward, and the committee would continue to oversee the impact of this issue. 13. Environmental Sustainability Plan The committee recommended the plan to Board for approval, and governor involvement. This was a good opportunity to start to influence thinking within the organisation, and as a children’s trust, to also positively influence behaviours of patients. The committee agreed to receive an update in 6 months on the basis of good progress. 14. Operational and financial planning The committee received an update on planning for 2020/21. Planning guidance was awaited and key dates were noted for submitting the draft and final plan. 15. Pathway to Excellence® The committee received an update on progress of the programme, and approved the terms of reference for the leadership council. Whilst this programme focused on nurses the approach would be extended to other professions. Staff were receptive COUNCIL OF GOVERNORS 10. 08/20 QUARTERLY REPORTS FROM BOARD C... Page 63 of 130
to this and there was enthusiasm for change. Going forward the programme would report into the Transformation Board, with progress updates reported to both the People and Performance Committee people section, and Quality Committee. Escalations/ 1. Governors are asked to note the key issues documented in this report. Requests for 2. Raise any questions. support to/from the COG Summary This report covers three committee sessions, one of which was extended to cover our people agenda. I am comfortable the meetings from the covered in suitable depth and with sufficient rigour on the key Finance, People, Performance and Transformation topics most pertinent to Chair the Trust across Q3. Report John Cowling, NED Chair, People and Performance Governor In Vince Keddie, Governor observer Author Committee support
Glossary: CQC – Care Quality Commission – the regulator for NHS safety and care in England IPR – Integrated Performance Report – the main document the Board receive that sets out the operational performance of the Trust. ICS – Integrated Care System – the arrangements that involve trusts and commissioners working together across SYB IT – Information Technology KPIs – Key performance indicators NED – Non-executive Director PDR – Performance Development Review (appraisal)
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Risk and Audit Committee Quarterly Report to Council of Governors Dated: 11 February 2020
Risk and Audit Committee Overview- Q3 2019/20 Document Purpose: For Assurance Meetings Held: 13 November 2019, 15 January 2020 Attendees Sally Shearer was absent with apologies from the 13 November meeting. Peter Lauener and Scott Green were absent with apologies on 15 January but able to send written comments. All other attendees were present for both sessions. Key Agenda Recurring 1. Board Assurance Framework Deep Dives 1. BAF (1) “Failure to effectively deliver healthcare items items 2. Internal Audit progress report impacts on the safety and quality of patient covered experience, regulatory compliance and loss of 3. External Audit plan and fees confidence of the wider community.” 4. Financial reporting 2. BAF (5) “Risk that insufficient leadership capacity and 5. Schedule for the production of the capability prevents necessary transformational change 2019/20 annual report and accounts to deliver efficient, high quality services.” 6. Well led position statement 3. BAF (7) “Failure to engage effectively with partner 7. Emergency preparedness resilience & organisations and the local community threatens the response (EPRR) update ability of the Trust to deliver its strategic ambition.” 8. Exercise Theo debrief report 4. BAF (8) “Failure to engage with our clinicians prevents the development / implementation of an effective 9. Datix implementation clinical strategy to deliver high quality services that 10. Risk Register responds to the needs of patients and other health and social care partners and prevents us from capitalising 11. Serious Incident report and Root Cause on the use of research, innovation and technology.” Analysis investigations 5. BAF (10) “Failure to develop our leadership, 12. Local Counter Fraud Specialist management and governance arrangements to ensure Progress Report delivery of sustainable high quality person-centred 13. Internal Audit Progress Report care, support learning and innovation and promote an 14. Health and Safety Strategy 2019-2022 open and fair culture prevents the Trust from demonstrating that it is a 'Well Led' organisation.” 15. Lessons Learned: External Audit Year- End Work 6. BAF (13) “Lack of operational capacity affects the Trust’s ability to lead mental health provision for young 16. Code of Governance Compliance people leading to adverse patient outcomes, negative Update impact on staff well-being and reputational damage.” 17. Board Standing Orders, Standing Financial Instructions and Scheme of COUNCIL OF GOVERNORS 10. 08/20 QUARTERLY REPORTS FROM BOARD C... Page 65 of 130
Delegation 18. KPMG technical update 19. Summary of Progress in the External Audit Planning Process 20. Financial Reporting 21. Risk and Audit Committee Training
Headlines 1. The committee scrutinised external audit performance and recommended reappointment to the Council of Governors at the November meeting. This was agreed. The following The following items were escalated to the Board during Q3: items were 1. Deep Dives: BAF 1, BAF 8 and BAF 13, BAF 5, BAF 7 and BAF 10 (the description for each of these is above) - During the reporting escalated quarter the Committee received deep dive presentations into a number of BAF risks, and gained comfort on the scoring of these. from the 2. Board Assurance Framework – The Committee reviewed the quarter 2 and quarter 3 reports, with slight updates to assurances, actions Committee to and some scoring following deep dives reviews. the Board 3. External Audit –The Committee fed back to the external auditors on the Council of Governor’s decision to reappoint them for a further during Q3 for two years. Governor feedback was also shared with KPMG. The Committee also agreed the plan for 2020/21. either 4. Internal Audit – The Committee received an update on progress against plan, and was pleased to see continued performance in the escalation or completion of audit report follow up actions. awareness: 5. Datix implementation – The Committee received a progress update on the implementation of the new risk management system within the organisation. Good progress was being made, however there were still some issues with training and how well staff used the system. 6. Emergency planning – The Committee recommended approval to Board of a number of emergency planning and EPRR procedures, and the major incident plan. There was improvement in compliance against the NHS core standards. 7. Schedule for the production of the 2019/20 annual report and accounts – The Committee approved the schedule, with work commencing in February. Governors will be asked to comment on the governor section of the annual report in due course. Escalations/ 1. Governors are asked to note the key issues documented in this report. Requests for 2. Raise any questions. support to/from the COG Summary This report covers two Committee meetings. from the Chair Report Peter Lauener, NED Chair, Risk and Audit Committee Governor In Andrew Garner, Governor observer Author support COUNCIL OF GOVERNORS 10. 08/20 QUARTERLY REPORTS FROM BOARD C... Page 66 of 130
Glossary:
BAF – Board Assurance Framework – a list of strategic risks, considered by Board regularly, which threaten achievement of strategic objectives
EPRR - Emergency Preparedness Resilience & Response – a set of national standards, used by the NHS, by which emergency planning is measured
11. 09/20 CHAIR'S REPORT - ENC F - FEEDBACK FROM BACK TO THE FLOORS COUNCIL OF GOVERNORS 11. 09/20 CHAIR'S REPORT - ENC F ... Page 68 of 130
EXECUTIVE SUMMARY
Title Quarterly Report from the Chair and Briefing on Emerging Issues
Report to Council of Governors Date 11 February 2020
Author Ms S Jones, Chair
Purpose of To present the quarterly report summarising the activity of report the Chair.
Please tick as appropriate Approval Assurance Information X
Executive summary –the key messages and issues
The report provides a briefing form the Chair on attendance at key meetings and activity since the November 2019 Council of Governors meeting.
The Chair will update on any recent activity at the meeting.
How this report impacts on current risks or highlights new risks
N/A.
Recommendations and next steps
The Council is asked to: i. NOTE the update report and additional verbal updates from the Chair on progress ii. NOTE the invitation to vote for the winner of the Governor Star Award
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Quarterly Report from the Chair – Q3
Governor update The last quarter has again been a busy time for our governors. Governor participation in Back to the Floor visits has been high. Some in depth feedback and outcomes are attached at Appendix A. Governors now have been allocated NHS email accounts. This will enable us to send you confidential or sensitive information securely, these will be used as your contact email address on the Trust website, so that members, or the public, can contact you directly. Thanks to all governors who have completed their bios for the website. These are being uploaded and can be seen here: https://www.sheffieldchildrens.nhs.uk/teams/council-of-governors/ The new Governor Whatsapp Group is working well, this has sped up information flow between governors and the corporate affairs office. I hope governors are finding it valuable and are able to share best practice and support each other. Thanks to Emma for introducing. Star awards nominations have now closed, and there have been over 800 nominations across 10 categories, this includes a separate governor award which this year is the Outstanding Colleague Award. The lead governor will be involved in the upcoming judging panel. Following the judging panel governors will then be asked to vote for their winner of the governor award, details of the nominations will be sent to you in the next couple of weeks. Following Mr Baker’s resignation at the end of December 2019, the Council of Governors Remuneration and Recruitment Committee recommended one candidate who had been appointable in the last non-executive recruitment round, and resolved to recommend him for appointment, subject to a further conversation with a small group of governors. The Committee also considered non-executive fees against a new NHS framework. It was mandatory to move non-executives’ pay onto the framework from 2022, and governors are recommending a way forward. Both of these issues are dealt with under separate reports. Charity Matters The Board was informed that The Children’s Hospital Charity had purchased their office building in December 2019. This would be a key asset for the charity. The Chief Executive and I met with The Children’s Hospital Charity Chair and Charity Director to discuss how the Trust could support the charity and develop closer working arrangements. Board development Board development continues, and an outcome of this work was to look at changes to the Board meeting format. Proposals being considered are: changes to timings of meetings, reflections on a more informal patient story, and how to create space for board learning and diversity of thought. The January Board meeting took place at the Advanced Wellbeing and Research Centre, which is a partnership collaboration hosted by Sheffield Hallam University. The Trust contributes to this partnership and it was a good opportunity for the Board to see the newly opened facilities as well as the (currently derelict) site that we hope in future will be a new Centre for Child Health Technology. COUNCIL OF GOVERNORS 11. 09/20 CHAIR'S REPORT - ENC F ... Page 70 of 130
In Partnership The Chair and Chief Executive have been proactive in the various Integrated Care System (ICS) and Accountable Care System (ACS) meetings in the quarter. Sheffield Place is looking to develop a vision for the future, before inviting commissioners to look at how we can get there. The Trust will be hosting the February Committee’s in Common meeting at the Hospital site. This is an opportunity to engage partner organisations in the future plans of the Trust, as I host a tour of some of new (and not so new) facilities. Out and About across the Trust The Trust hosted a visit from Simon Stevens, Chief Executive of the NHS. This was a really positive and engaging visit and the Trust showcased a number of services at the event. The Trust also recently hosted a visit from Lord Kerslake. As a former chief executive of the Council in Sheffield, Lord Kerslake is interested in, and supportive of the Trust and its strategic ambitions. The new safeguarding support unit was opened recently. The Trust is proud to be the only children’s hospital with a paediatrician led service. The CQC had been impressed with the new facility; and this is an opportunity to set the standard, as a service, to put the child at the centre. I attended a recent managers’ training session on mental health first aid, this approach is a shift in manager’s roles in relation to mental health of staff, and practice is evolving faster than policy. Non-executives attended the new inclusion network meetings, for gender disability, LGBT and BAME. There was an NHS England Leadership event post-election NHS provider Chair and Chief Executive workshop, hosted by NHS England, where plans of the new Government were shared, as well as national preparations for EU exit. I met with the new Chair of the CCG, Dr Terry Hudson. The Chair is a GP partner at the University medical practice and has special interests in young people’s health. This will be a key relationship to develop to support the Trust in its strategic ambitions. I attended two divisional clinical quality group meetings to observe and to help understand how information flows from Ward to Board. A Chairs and Chief Executive mental health alliance has been newly established. These meetings are already showing their value to learn from other areas. I attended the official opening of the Advanced Wellbeing Research Centre on behalf of the Trust. This is a state of the art facility dedicated to improving the health and wellbeing of the population through innovations, and is based on the Olympic Legacy Park (site of the former Don Valley Stadium). Members of the Board have also regularly supported Consultant interviews, Back to the Floors and Mental Health Reviews.
Sarah Jones Chair January 2020 COUNCIL OF GOVERNORS 11. 09/20 CHAIR'S REPORT - ENC F ... Page 71 of 130
EXECUTIVE SUMMARY
Title Feedback From Back To The Floor Visits: November 2019 to January 2020 Report to Council of Governors Date 11 February 2020
Author Claire Coles, Corporate Affairs Officer
Purpose of report This paper presents a summary of feedback from back to the floor visits undertaken November 2019 to January 2020. Please tick as appropriate Approval Assurance √ Information
Executive summary – the key messages and issues
There were 31 Back to the Floor visits undertaken by Non-executives, Executives and Governors during the reporting period. As part of their November meeting the Board undertook coordinated visits to a number of wards on the acute site, these are included within the report. Feedback from some of the visits is included within Appendix A. Any issues or concerns identified during these visits were reported back to Executives at that time. Governors are encouraged to join visits to develop their knowledge of the Trust and our services, and take a temperature check of the organisation. Visits are allocated to ensure all governors have the opportunity to join visits.
How this report impacts on current risks or highlights new risks
Key risks are identified within the report.
Recommendations and next steps
Governors are asked to: i) Review the report. ii) Recommend any management actions or identify any themes for sign off by the relevant Executive, for inclusion in an action plan. iii) Identify any areas or services for future visits.
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Back to the Floor Report November 2019 to January 2020
Date Service Area Board member / Governor Professional Visit
06/11/2019 Clinical Chemistry Sarah Jones / Joanne Arch
07/11/2019 Becton John Cowling
14/11/2019 Clinical Coding Steve Kelly
Paediatric Speech and 22/11/2019 Sarah Jones Language Therapy 25/11/2019 Theatres Vince Keddie
Andy Baker / John Cowling / 26/11/2019 Emergency Department Nick Parker Andy Baker / John Cowling / 26/11/2019 Acute Assessment Unit Nick Parker Paediatric intensive care Richard Chillery / Patricia 26/11/2019 unit Mitchell / Sally Shearer Richard Chillery / Patricia 26/11/2019 Neonatal surgical unit Mitchell / Sally Shearer Post Anaesthetic Care Peter Lauener / Jeff Perring / 26/11/2019 Unit John Somers Peter Lauener / Jeff Perring / 26/11/2019 Theatre Assessment Unit John Somers 26/11/2019 Ward 6 Scott Green / Ruth Brown
26/11/2019 Ward 3 Scott Green / Ruth Brown
Matthew Kane / Sarah Jones / 26/11/2019 Ward 5 John Williams Matthew Kane / Sarah Jones / 26/11/2019 Ward 2 John Williams 29/11/2019 Becton Richard Chillery
02/12/2019 Sustainable services Nick Parker / Emma Packham
06/12/2019 Ward 6 John Williams
04/12/2019 Cardiology Patricia Mitchell / Mark Rooker
04/12/2019 Neurology Patricia Mitchell / Jackie Griffin
Patricia Mitchell / Tracy Gill / 04/12/2019 Respiratory Sue McFarlane 11/12/2019 Theatres Ruth Brown / Richard Chillery
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12/12/2019 Clinical Genetics Ruth Brown
27/12/2019 Helena Team Sally Shearer Nick Parker / Anne-Cecile 09/01/2020 Pharmacy Hogg 10/01/2020 Embrace Ruth Brown / Scott Bailey
20/01/2020 HR and Recruitment Mark Rooker
Learning and 20/01/2020 Organisational Vince Keddie Development 30/01/2020 Communications Team Patricia Mitchell / Jack Hiscock
30/01/2020 Corporate Affairs Patricia Mitchell / Jack Hiscock
30/01/2020 Clinical Coding Patricia Mitchell / Jack Hiscock
COUNCIL OF GOVERNORS 11. 09/20 CHAIR'S REPORT - ENC F - FEEDBACK ... Page 74 of 130
Feedback
Board FEEDBACK Date Service Area member/ Matters relating to the Matters relating to staff Management Actions Governor environment The team were very proud of the fully digitised records which make a big difference to the team’s day to day work and the Patient Level Costing was mentioned during the visit, way the Trust uses it afterwards. unprompted, and whilst the Trust does not have this yet, Staff commented there is a lack discussions have recently started to accelerate. This of national steer about the new would help the Theatres management understand the SNOMED CT coding cost of a simple operation. implementation which is The coding office was supposed to be in for 2020 and very calm, clean, well It was observed that such a system may make a big 14/11/2019 Clinical Coding Steve Kelly will lead to a lot of workload. organised and welcoming. positive difference if used effectively, especially in a trust This and other questions in this Entirely digital which acknowledging they need to find more cost improvement section were not asked helped. schemes that reduce waste and unproductive work specifically, but there was a without impacting on patient care. It can be a perfect general contentment when “invest to save” project. asked if there was anything not working as well as it could. I That would help maximise the benefit of such an chose to focus on the detail of outstanding clinical coding team. the work (which I know well) to establish how high standards are (very high as it turns out). COUNCIL OF GOVERNORS 11. 09/20 CHAIR'S REPORT - ENC F - FEEDBACK ... Page 75 of 130
Board FEEDBACK Date Service Area member/ Matters relating to the Matters relating to staff Management Actions Governor environment I was struck, but not surprised, by the high level of activity in the theatres. I learned some interesting facts, for instance the complete circulation of air in theatres that is necessary to limit the risk of infection. It was worrying to learn that there had been a recent incident which had resulted in a breakdown in the air circulation One that comes to mind is the machinery. introduction of a Monday
morning meeting where theatre I was also struck by how many people are involved in an staff can voice concerns, etc. The waiting area outside operation, the length and complexity of some Asked about the use of the theatre suite is not procedures, and the number of people in the theatre Vince apprenticeships, the manager particularly attractive, but 25/11/2019 Theatres who are there as learners rather than ”doers”. Keddie confirmed the service was taking the operating suite itself is
on two apprentices to train as welcoming yet obviously a The manager mentioned the general challenge in operating department very busy area. recruiting operation theatre staff. One recent innovation practitioners. This is seen as a had been a recruitment event which had generated a fair valuable means of recruiting degree of interest in applying for posts in theatre. We staff. discussed the value of apprenticeships in attracting people into training for roles in the NHS, providing an alternative to full-time education (which can now be expensive), and one that is associated with high retention rates (which would be of value in this theatre context). COUNCIL OF GOVERNORS 11. 09/20 CHAIR'S REPORT - ENC F - FEEDBACK ... Page 76 of 130
Board FEEDBACK Date Service Area member/ Matters relating to the Matters relating to staff Management Actions Governor environment Recruitment and retention – wanted the Becton site to have equal opportunities, the AD had been discussing open days with the service and also speeding up HR process by working with the HR partner. Good example of positive recruitment given. Delightful welcome from
the front of house admin. Career trajectory – Looking at a career structure to And similarly from the retain staff. CAMHS administrator So much work had gone into who is clearly a ensuring that the young people New supervision model – early days but showed Richard foundation for the service. 29/11/2019 Becton and staff at Becton had their promise, looking at improving clinical supervision and Chillery Emerald seemed calm own Christmas light ceremony, leadership team leading on how to improve things. and normal routine was went down fantastically well. While not a significant issue will be part of the cultural being followed. work that is starting to be undertaken. The unit seemed clean Continuing to emphasise one trust, that we are an and generally well integrated provider and that opportunities are considered organised. for all sites, and use language which models the one trust approach.
AD was introduced to the AD Medicine to discuss mental health in the acute setting.
The three things that would make a huge difference to PDR compliance is good. the service are co located services, more psychologists Mandatory training figures are and the way services are commissioned. This is a not as good as they should be Patricia community issue rather than an acute one and has to as training sessions have been Mitchell & involve GPs. Trainee GPs will be working within the 04/12/2019 Neurology cancelled. N/A Jackie service from next year which should make a difference. The service has very few Griffin Although not specific to Neurology, a concern was noted complaints and is much in relation to supporting junior doctors, there are plans to appreciated by service users address this as they are a vital part of the Trust and their families. workforce and we want them to stay with the Trust. COUNCIL OF GOVERNORS 11. 09/20 CHAIR'S REPORT - ENC F - FEEDBACK ... Page 77 of 130
Board FEEDBACK Date Service Area member/ Matters relating to the Matters relating to staff Management Actions Governor environment Within the team there is good communication with weekly team meetings at which learning from complaints is discussed to continually improve the service. In fact there are very few Patricia complaints in outpatient The service was: One issue highlighted was around booking appointments Mitchell & respiratory and the service Welcoming, Safe, Caring and most days there is a patient in clinic who should not 04/12/2019 Respiratory Tracy Gill & seems very much appreciated and involving, Well be there but this is being addressed with the booking Sue by service users and their organised and calm. team. McFarlane families. The team are aware of the Freedom to Speak up Guardian and the Duty of Candour. There are 360 degree appraisals for consultants and the team enjoys good staff retention. Strong sense of team identity The theatres consist of 9 and they were justifiably proud theatre areas and can Positive comments from parents waiting for their of what they did. They recognize which are the children, who were pleased with the care being consistently articulated that they most recently built. Suite provided. felt the culture of the with the 2 way MRI is
organisation had improved over highly specialist, state of No specific issues were raised. We did not have the the last 2/3 years (see below) – the art and valued by the opportunity to discuss the recent SI’s and Never Events Ruth Brown however, I sensed that they felt team. The other theatres – and was not sure that this was the best time to do it. 11/12/2019 Theatres & Richard slightly disconnected from the were smaller and
Chillery wider Trust – there ambition was suggested they could do I did discuss CQC, and they were proud of the good to be more specialist. with some “TLC”. rating but were “hard work” – but I am still not clear One Consultant raised they felt It is a busy environment. I about the clinical governance arrangements and CQC the unit did not publicise and could not see any specific oversight – BUT in the time I don’t think we had an “blow their own trumpet” directions and guidelines opportunity to necessary get to all this detail. enough. As a specialist service re gowning up to ensure
they were very successful in high levels of hygiene attracting medical trainees – but although lots of hand COUNCIL OF GOVERNORS 11. 09/20 CHAIR'S REPORT - ENC F - FEEDBACK ... Page 78 of 130
Board FEEDBACK Date Service Area member/ Matters relating to the Matters relating to staff Management Actions Governor environment would like to see/have the washing opportunities. opportunity for self-promotion. Storage is an issue – as They have a regional and at the service requires times national profile. (sterilised) equipment but I found all the staff friendly an as theatres have grown welcoming. Staff seemed glad there was not the space to have the opportunity to be to develop storage. The visible. All were glad to be part stores seem fairly well- of the organisation and I think I organized, despite these had a sense of being happy to challenges but still on a be part of a paediatric trust – hybrid of electronic and where CYP were the focus paper monitoring of stock rather than a clinic list in an – and so maybe an area adult focused Trust. They of development for the came across as a supportive future. team/MDT, without divisions between professions and managers, and spoke highly of their 8a manager. Some positive feedback was that 2 staff spoken to, said they could see “senior management” were reaching out to staff and having meetings where staff were listened to, including 2 clincal summits positively mentioned. The team was keen to portray what a great team they were, there was strong focus on staff and workforce development, the environment but we did not get in any great detail discussions about quality – and self- reflective practice, due to the COUNCIL OF GOVERNORS 11. 09/20 CHAIR'S REPORT - ENC F - FEEDBACK ... Page 79 of 130
Board FEEDBACK Date Service Area member/ Matters relating to the Matters relating to staff Management Actions Governor environment line of questioning. The areas is well Huge emphasis on patient Nick Parker organissed and calm but experience, and putting in place & Anne- have some building work: 09/01/2020 Pharmacy efficiency improvements to Cecile Aseptic suite not visited reduce time required to Hogg which will move to the discharge patients. new facilities. I did some research before the visit. The news sections on google when you type Embrace in brings up a tragic The service has outgrown story, dating back to last year. There is "good news" the current building. The coming out of the Embrace function, but this is not out in exciting new plans for the the public domain. Might that be worth looking in to building will bring a much promoting the work they do? needed boost to this team. I asked the team about the drivers having rest periods The team meeting was (no driving for 11hrs between shifts) but there didn't held in the main area, seem to be a consideration for the consultants - who I have nothing but admiration for whilst the call handler was could work 24hr shifts (which is commendable!) the team at Embrace and the taking calls, which isn't Ruth Brown fantastic, unseen work and the best. They said it The site is in a great location - for motorway access, 10/01/2020 Embrace & Scott logistics, that goes in to that wasn't normal practise, especially for Sheffield and Leeds hospitals. Strategic Bailey department. I was taken aback but they had 3-4 people locations across the region are also well placed. by their good nature and hard working in the same The staff are fantastic. Everyone was incredibly happy work. offices. They need and passionate about their role and working for the trust. support in how they grow I have to praise the manager who gave me a full site this function - particularly tour - what a great employee and ambassador for the as they are specialist and trust. Everyone was approachable, knew their duty and handle a vast area and roles and cared about everything. time critical needs. Storage is becoming an One item they have started to do is producing/providing issue. a "Embrace bag" for the parents. This is a really nice touch and a great initiative. They are very transparent in providing stats and figures on the website. It was mentioned that they sometimes feel a forgotten area of COUNCIL OF GOVERNORS 11. 09/20 CHAIR'S REPORT - ENC F - FEEDBACK ... Page 80 of 130
Board FEEDBACK Date Service Area member/ Matters relating to the Matters relating to staff Management Actions Governor environment the trust - as they aren't directly connected / on the same site. The ambulances and Artfelt art work is fantastic. Reliable vehicles, good specification.
On a slight downside. There was confusion that I was joining the visit. However I met with the lead consultant, who did everything he could to get over the initial confusion. I was a bit frustrated by the fact I booked an annual leave day from work to attend this. I was told it would be 10am - 5pm. I actually left at 1.15pm. Overall, the team are fantastic and are a real credit to SCH. The general feeling was they are proactive and have made some real progress with key staff I was in an office This was a very impressive visit. I was hugely impressed related issues. They were environment which was with the work to get "day one ready" and the strategy particularly proud of their efforts well kept, safe, clean and about onboarding. It's something I think the trust should to bridge nursing and doctor had some of the key take pride in as it's not always the case that large shortfall, the new erostering messages from the trust employers can do this effectively. programme and the work they displayed. There was a have done to make the positive atmosphere, a It was really interesting to learn about the work of e- onboarding experience more nice level of conversation rostering and the benefits it's likely to bring to the wider positive with the "day one ready" and good interaction trust. Clearly it’s a slow process and more work is Mark policy. between colleagues. It did needed especially to advance the reporting aspect but it 20/01/2020 HR recruitment Rooker Some of the staff feel that they feel remote from the trust has huge potential to improve efficiencies. do receive a lot of complaints (it physically is) but I from doctors in particular now wondered if more The main point that was raised seems to revolve around their contracts have changed so imagery, photos or space particularly around confidential/private space perhaps an understanding of messages could have especially at the hospital. This is delaying some aspects outside the trusts remit been displayed as many processes as there is a need to find a room at the trust would be beneficial. of the people I spoke to but a couple also admitted to having difficult All the team I spoke with talked did feel a little removed conversations in some busy areas. I wouldn't state it is a about improvements to from the care given within priority as it was such a rare event but something that mandatory training, more online the trust. perhaps could be considered. and easy accessible. They say they don't have an COUNCIL OF GOVERNORS 11. 09/20 CHAIR'S REPORT - ENC F - FEEDBACK ... Page 81 of 130
Board FEEDBACK Date Service Area member/ Matters relating to the Matters relating to staff Management Actions Governor environment issue but time at a PC was the main blocker for other areas within the trust. The team know how to raise concerns, are aware of the Freedom to Speak Up Guardian, the Duty of Candour and how to deal with complaints. The team The team are proud of the work done on the Committee are up to date with PDR’s and Assurance Reports and the improvement to are aware of and can Governance, the BAF for example. More timely reports demonstrate Trust values and would be useful for Board, Committees and Governors behaviours. meetings and there are KPIs for the team in this respect but they are dependent on Executives and Managers for In terms of knowledge of your Patricia this. Jack raised the issue of late changes in relation to work the team felt that Corporate Mitchell & proper scrutiny. This is a priority as is ensuring a fully 30/01/2020 Governors are aware of what Affairs Jack engaged Council of Governors and work is being done they and the team do as they Hiscock to promote that. work closely with them.
The work of the team included Jack mentioned that it might be helpful to have a video Strategic Governance, support on our website to showcase smaller off site services to to the Board and its raise awareness of their work for Governors and others Committees, Governors, in the Trust. Members, scrutiny of the Board Assurance Framework, monitoring Conflict of Interests and ensuring Regulatory compliance.
12. 10/20 DIRECTORS REPORT - ENC G COUNCIL OF GOVERNORS 12. 10/20 DIRECTORS REPORT -... Page 83 of 130
EXECUTIVE SUMMARY
Title Directors’ Report
Report to Council of Governors Date 11 February 2020
Author Matthew Kane, Associate Director – Corporate Affairs
Executive Sponsor John Somers, Chief Executive
Purpose of report
Please tick as appropriate Approval Assurance Information X
Executive summary –the key messages and issues
This report sets out the key messages from the Chief Executive along with highlights from the Integrated Performance Report on operational and financial performance in December 2019/January 2020.
How this report impacts on current risks or highlights new risks
As highlighted within the report.
Recommendations and next steps
Governors are asked to: i. NOTE the report ii. RAISE any questions
1
COUNCIL OF GOVERNORS 12. 10/20 DIRECTORS REPORT -... Page 84 of 130 Sheffield Children’s NHS Foundation Trust
Council of Governors
January 2020
Chief Executive’s Key Messages and Executive Team Highlights
Trust level
1. Reflecting back on 2019
2019 has been a fantastic year for the Trust. In July we were awarded a CQC rating of Good and this was followed by the official opening of the new wing by HRH Prince Harry.
We welcomed two new faces – Nick Parker and John Williams – to our executive team and made other key appointments that strengthen our senior management. As we look forwards into 2020, we will be launching a new strategy and placing culture, quality and people at the centre.
There were a number of visits during the Christmas period, amidst many switch on and panto events, one of my personal highlights is always the annual visit of Sheffield Wednesday. This year, executive team colleague and fellow Wednesday fan Nick Parker, Director of People and OD, joined me in meeting Garry Monk and the team as they went on a visit around the wards.
2. Award for Communications
Congratulations to the Communications team who have won a ‘Comms2Point0’ award for ‘Best use of Research and Evaluation’ with the Take My Place campaign. The award recognised the sterling effort of the team to bring the campaign to life, on a small budget.
The contribution of the Outpatients Team in achieving commendation for this project should also be recognised.
3. Children’s Takeover Day
My thanks to everyone who was involved in a successful Children’s Takeover Day at the end of November.
Throughout the day, I was shadowed by 17-year-old Chloe from Dinnington High School who was looking to become a social worker when she was older. We spent the day on a tour of the Hospital site and with different directors.
4. Board goes Back to the Wards
As part of November’s Board meeting, directors went back to the Back to the Floor at the Western Park site where they undertook a series of visits to clinical areas.
2
COUNCIL OF GOVERNORS 12. 10/20 DIRECTORS REPORT -... Page 85 of 130 I was joined by Medical Director, Jeff Perring, and non-executive director Peter Lauener on a visit to PACU and TAU. The photo (right) is of chair Sarah Jones and Director of Finance John Williams with ward managers Anna Leather and Lucy Dickinson on their visits to Wards 2 and 5.
The Board also celebrated 10 years of Embrace – our award winning paediatric patient transport service – on 6th December.
5. Flu update
The current flu vaccination uptake rate is 67.02% for frontline staff and 68.18% for non- frontline staff. These figures equate to 2461 vaccinations given.
The Trust took delivery of 3000 vaccines and only have 300 left. Therefore 239 vaccines are unaccounted for. The register of non vaccinated staff includes the names of some staff who we know have had the vaccine.
A data cleansing exercise is currently underway before the registers are shared with divisions for verification. Work is also underway to clean up data by removing leavers and staff known to be long term absent as well as ensuring that all externally administered vaccinations have been captured. Refreshed communications have gone out across the Trust this week.
The target is 80% by the end of March although clearly it is in everyone's interests if the target is exceeded as soon as possible.
6. Virtual reality app makes surgery a less daunting experience
A new virtual reality app is allowing children awaiting surgery to explore Sheffield Children’s – from the waiting area to the operating theatre – and get prepared for their visit all from the comfort of their own home.
The Little Journey smartphone app has animated doctors, nurses and anaesthetists to show children around the hospital and explain what happens when you come to the hospital for surgery. Characters such as a koala nurse and a rhinoceros doctor pop up to answer questions and talk through what happens in each area.
The app is available free of charge and is aimed at children, young people and their families who are due to go to the hospital for surgery. By explaining things and making the spaces more familiar, the app can make the idea of coming to hospital less daunting.
7. Gold for Sally
Following on her professorship, our executive director of nursing and quality Sally Shearer was awarded the nurses’ gold award from the chief nurse of Health Education England for her work in children’s nursing.
The Gold Award is presented to an individual who has made a significant contribution within a distinguished career in nursing and/or midwifery.
Earlier in the month, the Trust was delighted to welcome NHS Improvement/England's Deputy Chief Nurse Hilary 3
COUNCIL OF GOVERNORS 12. 10/20 DIRECTORS REPORT -... Page 86 of 130 Garratt. She met with colleagues and took a tour around our superb new Safeguarding Support Unit.
2020 is International Year of the Nurse and Midwife and we have got lots of things planned to celebrate our amazing nurses here in Sheffield!
8. Star awards nominations
Staff, patients and their families were invited to nominate their favourite doctors, nurses and other staff for a Children’s Star Award 2020. The Sheffield Children’s Star Awards have been running for more than nine years.
Anyone who has received treatment from Sheffield Children’s NHS Foundation Trust services in 2019, or staff, could make a nomination by the end of January. Winners will be announced in March.
9. Cinderella comes to Sheffield Children’s
Over Christmas, there was a lot of activity across our sites. Further highlights from my perspective included:
We worked with Sheffield Lyceum to bring Cinderella to our Outpatients Department. Executive directors Sally Shearer and Ruth Brown participated in the annual Glow Run event. Executive colleagues toured all sites to wish staff a very merry Christmas and a happy new year.
System level
10. Changes at Sheffield City Council
Following John Mothersole’s retirement, Charlie Adan will be interim CEO pending a full recruitment exercise.
11. Changes at partner organisations
Dr Richard Jenkins, Chief Executive at Barnsley NHS Foundation Trust, has taken on the role of joint Chief Executive covering Barnsley and The Rotherham NHS Foundation Trust for 12 months.
Dr Terry Hudsen has been elected as the new Chair of Sheffield CCG. Terry is a GP Principal at the University of Sheffield Health Service and has a special interest in the health and wellbeing of young adults and university students.
National level
12. Key points from Government’s manifesto
Following the election on 12th December, there was a Queen’s Speech on Thursday 19th December, in which the Government outlined its legislative agenda for the new Parliament.
The Conservatives reintroduced the two bills directly related to health and social care that featured in the October Queen’s Speech - the Health Service Safety Investigations Bill and the Medicines and Medical Devices Bill. The Conservatives will honour their manifesto 4
COUNCIL OF GOVERNORS 12. 10/20 DIRECTORS REPORT -... Page 87 of 130 commitment to seek to enshrine in law the ‘fully funded, long-term NHS plan’ in some way and reiterated their commitment to continuing to reform the current Mental Health Act. A new Immigration Bill also set out the framework for a new post-Brexit points based immigration system.
The HSJ reported that Number 10 has encouraged NHS leaders to introduce a new staff morale tracker — potentially to report every month, which could be included as part of the forthcoming People Plan.
The prime minister did not carry out a wide ranging reshuffle, and focused instead on getting his Brexit deal through Parliament. Consequently, Matt Hancock, re-elected as MP for West Suffolk, remains in place as secretary of state for health and social care for the time being.
Operational Performance – December 2019
The Integrated Performance Report (including quality, activity, workforce and performance) including a high level dashboard is structured around the organisation’s five strategic aims.
All data relates to December 2019 unless otherwise specified (e.g. sickness absence which is reported one month in arrears).
Key Achievements
After an extremely demanding November, the Trust implemented a number of actions to stabilise the position against the A&E 4 hour standard going into December. In month performance was 96.18%. Going forward additional GP shifts have been arranged at weekends from February 2020 onwards. The Trust has also secured, following a bidding process c. £200k worth of non- recurrent funding for winter pressures. The Trust continued to achieve all Cancer standards throughout December. Was Not Brought rates for both first and follow-up outpatient appointments were within the Trust’s tolerance levels. The Diagnostic standard was achieved at Trust-level with 99.8% of patients receiving their diagnostic procedure within six weeks against the national standard of 99%. This is the second month running the target has been achieved after failing the previous three months. An increased management focus within the Divisions has contributed to this performance. Following a commitment from divisions at Datix Quality Committee, the number of incidents pending investigation which are overdue continues to reduce. It is now at 293, down from 591 in September. The number of clinical guidelines and policies out of date continues to reduce.
Areas for Improvement
The percentage of patients on an 18-week RTT incomplete pathway was not achieved at Trust-level for the eighth consecutive month. The closing month-end position was a deteriorating position at 86.27% against the national standard of 92%. o There are currently 1275 patients waiting over 18 weeks for treatment. 61% of these are on surgical pathways, 35% on medical pathways and the reminder within clinical genetics. o From a surgical perspective, medium term solutions exist in the form of other Trusts assisting with capacity. There is ongoing dialogue across the ICS in relation to this. o From a medicine perspective, the principal areas of concern are sleep and Neurodisability. A business case was approved in December to provide capacity 5
COUNCIL OF GOVERNORS 12. 10/20 DIRECTORS REPORT -... Page 88 of 130 for the former and a Steering Group has been established, led by the Deputy Chief Executive for the latter. o A full waiting list diagnostic will occur within January by the North East Commissioning Support Unit. This will provide assurance as to the accuracy of the Trust waiting list position and identify actions to be taken where appropriate. It should be noted that this may improve, maintain or worsen the current performance levels.
Referral to Treatment within CAMHS remains challenging. Referrals year to date are up 47% compared to last year. A recovery plan is in place and external funding of £250k has just been secured. The number of overdue follow up patients increased to over 9,000 for the first time. Whilst there was a significant reduction in the number of patients cancelled on the day (9) three of these were not treated within 28 days. All of these were within Neurosurgery that is reliant on fixed job plans from STH.
There was significant underperformance against the activity plan in December (as there was for August).
Financial Performance – January 2020
1. For the period April to December 2019, on a Control Total basis (excluding PSF), the financial position is a deficit of £7.61m against a planned deficit of £4.54m, an adverse variance to plan of £3.07m. Taking away non-recurrent in year transactions our underlying position is a £9.35m deficit year to date. As a result we are not able to access our Q3 PSF funding, worth £0.5m.
2. As a consequence to our quarter three position, we have reviewed the forecast outturn (FOT) for the Trust. Our FOT position is potentially a £9.8m adverse variance to plan, noting there are a number of predominantly system based mitigations that are to be explored which could reduce this to a c£7.2m adverse variance.
3. The FOT (£9.8m) position is driven by our ongoing shortfall against our activity plan income targets in both planned and unplanned care (£3.6m), contracting risks (£0.9m), and whilst CIP is planned to be delivered (of the internal £5.5m plan), other cost pressures are causing an overspend position across both pay and non-pay (£2.9m) which includes a reduction in contribution against plan for our Genetics Laboratory. In addition there is realised risk against support from within the system and nationally (£2.4m) as included in our initial Operational Plan.
4. The Director of Finance recommended through the People and Performance Committee on the 22nd January 2020 that the Trust formally goes through the forecast outturn change protocol, including Board Assurance Statement, with our ICS partners and regulator NHSI, which was approved and later ratified at the Trust Board on the 28th January 2020. This process will create the need for a formal recovery plan which will be produced over the course of the next couple of months and brought back to Executive Team and ultimately the Board of Directors for approval. This will also be required go through the appropriate ICS and regulatory channels for approval.
5. The Trust will continue to strive to achieve the best possible financial position for the year- ending 2019/20, with enhanced financial grip and control mechanisms in place from December relating to vacancies, agency spend and non-pay and where applicable working capital/cash management, including capital programme review, being scrutinised and control measures implemented. The Executive team will ensure that this does not compromise on the quality of service delivery or to the detriment of patient care.
6
COUNCIL OF GOVERNORS 12. 10/20 DIRECTORS REPORT -... Page 89 of 130 6. The Trust Board should be aware of the regulatory and system scrutiny, and the potential reputational damage.
7. The impact on the Trusts Long Term Financial plan has not yet been fully quantified, however there is now clearly additional pressure placed on our recovery back to a break- even position by the end of 2023/24 and against the regulatory Financial Improvement Trajectory for 2020/21.
8. The impact on the Trusts cash position is a major concern. Further work is ongoing to clarify at what point in time cash support will be required. This is inevitable and will in all likelihood be sooner than the original estimates contained in the LTP. The cash strategy has now been agreed by the Cash Committee and is being brought to P&PC in January for approval, which creates a framework for effective cash management.
9. There is still an opportunity, even with this potential FOT, for the Trust to receive its PSF for Q3 and Q4 (£1.2m) and the System to achieve System PSF (£2m), if the ICS balances as a system at the year-end. Work is going on within the system to review all organisations FOT in this context.
10. Given the performance to date and the significant work undertaken to validate the forecast outturn position. At their January 2020 meeting the Board;
Noted and discussed the financial position presented and the associated risks. Accepted the recommendation of the People and Performance Committee to a forecast outturn change position of £9.8m away from control total. Supported the development of a Financial Recovery Plan, which is to be brought back to future Trust Board meetings for approval and oversight.
7
13. 11/20 KEY MESSAGES - ENC H COUNCIL OF GOVERNORS 13. 11/20 KEY MESSAGES - ENC H Page 91 of 130
EXECUTIVE SUMMARY
Title Key Messages for Governors Report to Council of Governors Date 11 February 2020
Executive Sponsor Nick Parker, Executive Director of People and OD
Author Lea Fountain, Associate Director of Communications
Purpose of report To present to governors
Please tick as appropriate Approval Assurance √ Information
Executive summary –the key messages and issues
1. Preparing families to come to Sheffield Children’s - Families can be nervous coming to hospital for the first time. They may be having a major procedure, or simply be worried about coming to an unfamiliar environment. Teams across Sheffield Children’s are taking action to help families prepare and get a better understanding of what to expect, including development of a new Theatres app and Outpatient videos. Help us spread the word!
2. Christmas at Sheffield Children’s – A round up of the many visits to the hospital and Becton, helping give more fun opportunities to patients and their families than ever before
3. Summary of national media and awards
4. Charity update and events How this report impacts on current risks or highlights new risks
N/A
Recommendations and next steps
Governors are asked to: i) Note the report ii) Share information within their constituencies
COUNCIL OF GOVERNORS 13. 11/20 KEY MESSAGES - ENC H Page 92 of 130
GOVERNORS - KEY MESSAGES February 2020
1. PREPARING FAMILIES TO COME TO SHEFFIELD CHILDREN’S
Families can be nervous coming to hospital for the first time. They may be having a major procedure, or simply be worried about coming to an unfamiliar environment. Teams across Sheffield Children’s are taking action to help families prepare and get a better understanding of what to expect.
This includes:
Little journey app
A new virtual reality app launched this month which is allowing children awaiting surgery to explore Sheffield Children’s – from the waiting area to the operating theatre – and get prepared for their visit all from the comfort of their own home.
The Little Journey smartphone app has animated doctors, nurses and anaesthetists to show children around the hospital and explain what happens when you come to the hospital for surgery. Characters such as a koala nurse and a rhinoceros doctor pop up to answer questions and talk through what happens in each area.
The app is available free of charge and is aimed at children, young people and their families who are due to go to the hospital for surgery. By explaining things and making the spaces more familiar, the app can make the idea of coming to hospital more manageable.
Coming to outpatients
A series of videos have been produced to help families coming to Sheffield Children’s for an outpatient appointment. In the videos, patients Molly and Tendo share what happens in each section of their hospital visit.
Each video includes signing throughout thanks to our volunteer Chris.
These videos aim to help patients and families prepare for their appointments and reduce any anxiety about coming to hospital. They were created as part of the Modernising Outpatients Programme, which seeks to improve the quality and efficiency of the service delivered to patients and families.
Videos include: arriving and checking in at the appointment, height and weight tests, urine test and blood test.
Governors - These new tools are being shared through media, social media, the website, employee channels and referenced on patient letters. Governor support in helping get the word out about these tools would be hugely beneficial.
COUNCIL OF GOVERNORS 13. 11/20 KEY MESSAGES - ENC H Page 93 of 130 2. CHRISTMAS TIME AT SHEFFIELD CHILDREN’S
Throughout the festive period colleagues facilitated and supported a number of visits across the Trust. Patients, parents and staff engaged with the visits, ensuring patients at all sites enjoyed more entertainment at Christmas than ever before.
The visits ranged from pantomime cast, Salvation Army band and sport groups such as Sheffield United and the Sheffield Steelers. It also involved the first live streaming of a pantomime performance at the Crucible direct to the atrium at the hospital for patients and families.
Pictures and videos from the visits were shared on social media and received great feedback about both the visits and the wider work the Trust does to care for children and young people.
Visits included:
Salvation Army Band – Children’s hospital
Sheffield Steelers – Becton
Children’s Hospital Pyjamas donation – Children’s hospital
Sheffield United – Children’s hospital and Becton
Sheffield Theatres Panto – Children’s hospital
Live streaming of Sheffield Theatres pantomime - Children’s hospital and Becton
Santa visit – Ward 6
Jess Ennis – Children’s hospital
Sheffield Steelers – Becton
3. NATIONAL AND INTERNATIONAL COVERAGE
Widespread national coverage - Button battery dangers awareness - Warning about the danger of the batteries just before Christmas as they’re often found in toys. Sheffield Children’s worked with NHS England to develop the message, which included a case study of a child who was treated at Sheffield Children’s after she swallowed a button battery.
BBC Inside Out – Awareness piece about uses with adrenaline pens for allergies. Allergy Consultant Nicola Jay explained the issue, and patients showed how Sheffield Children’s works with them to ensure they know how to use pens safely.
Digital Health, Health Technology News – Sheffield Children’s launches Little Journey App.
4. AWARDS Comms2Point0 Award – The communications team have been awarded ‘Best Use of Research and Evaluation’ for the Take My Place Campaign.
COUNCIL OF GOVERNORS 13. 11/20 KEY MESSAGES - ENC H Page 94 of 130 5. THE CHILDREN’S HOSPITAL CHARITY
In the first year of the appeal, thanks the support received The Children’s Hospital Charity has raised an incredible £2,825,995 - which means the appeal is now 14% of the way there.
Whilst fundraising for the appeal is well on the way, other areas in the hospital also received support from the charity funds. Here are a few items which were funded over the last few months:
£2,067 Narcolepsy Family Day 2020 £1,300 Ward 4 adolescent room furniture £331 PCCU Play Materials £3,053 Specialist chair for patients on haematology and oncology grant programme £129 Emergency Department Play materials £529 television for Ryegate House £1,259 electronic devices for adolescents on Ward 1
Upcoming charity events
29 March – Sheffield Half Marathon 12 April – East Egg Run 18 April – Skydive 19 April – Hull Half Marathon 26 April – London Marathon
14. 12/20 REMUNERATION OF CHAIR AND NON-EXECUTIVES - ENC I COUNCIL OF GOVERNORS 14. 12/20 REMUNERATION OF CH... Page 96 of 130
EXECUTIVE SUMMARY
Title Remuneration of Chair and Non-executive Directors
Report to Council of Governors Date 11 February 2020
Author Matthew Kane, Associate Director – Corporate Affairs
Purpose of report
Please tick as appropriate Approval X Assurance Information
Executive summary –the key messages and issues It is the Council’s role to approve the remuneration of the chair and non-executive directors on the Board of Directors, taking account of guidance and recommendations from the Remuneration and Recruitment Committee of the Council of Governors.
On 26 September, the Trust’s regulator NHS Improvement issued new guidance covering three areas, one of which included a single approach towards the remuneration for chairs and non-executives of NHS foundation trusts and NHS trusts.
A copy of the full documentation can be found at: https://improvement.nhs.uk/resources/remuneration-structure-nhs-provider-chairs-and-non- executive-directors/
The other two pieces of guidance from NHSI were around providing a standard job description and appraisal format for the chair. The latter is explored in a further report on this agenda.
Background
Within foundation trusts, the Council of Governors has the freedom to decide the remuneration of its chair and non-executives. This is not the case in NHS trusts where chairs are paid in accordance a banding system depending on the trust’s size. Non-executives in an NHS trust are paid a flat rate of £6,157.
At Sheffield Children’s, the chair’s remuneration is £48k per annum and the non- executive remuneration is £14,352. This was last reviewed in May 2017 with no increase recommended at that time. Both payments are ‘within range’ when compared with Foundation Trust neighbours (see figure 1 below). COUNCIL OF GOVERNORS 14. 12/20 REMUNERATION OF CH... Page 97 of 130
Chair Non-executives Barnsley £47,500 £13,200
Calderdale and Huddersfield £50,136 £13,137
Chesterfield £49,990 £14,607
Derbyshire Community Health £50,000 £13,000
Derbyshire Healthcare £50,000 £13,888
Doncaster and Bassetlaw £50,000 £12,302
Harrogate and District £48,985 £13,261
Sheffield Children’s £48,000 £14,352 (11th out of 15) (4th out of 15)
Sheffield Health and Social Care £40,000 £13,888
Sherwood Forest £50,000 £12,641
Sheffield Teaching £58,000 £15,500-19,000
South West Yorkshire £42,420 £13,584
RDaSH £42,202 £12,250
Rotherham £50,000 £16,653
University of Derby and Burton £50,000 £15,000
Issue
While the remuneration of chairs and non-executives in the NHS is well below those seen in the corporate sector, there is a view that the current system lacks transparency and parity and results in NHS trusts potentially having a smaller pool of high-calibre chairs and non-executive directors from which to choose, due to the lack of discretion they have over what they pay. There is also a risk that higher payments in the system could result in an ‘upward ratchet’ that is disproportionate to the levels pay for staff across the NHS.
NHSI has therefore introduced a new framework within the guidance that aligns the remuneration of chairs and non-executives within Foundation Trusts and NHS trusts. There is no new funding to support these changes and no formal consultation was undertaken prior to introduction.
The framework for the chair is tiered depending on Trust turnover and the skills and experience of the respective post-holder (see figure 3 below): COUNCIL OF GOVERNORS 14. 12/20 REMUNERATION OF CH... Page 98 of 130
The guidance also recommends that the remuneration for non-executives is a flat rate of £13,000, with the option of a £2k supplement for up to two individuals for extra responsibility. In larger trusts, three individuals may be given a supplement.
The new framework applies from now, so a decision is required prior to the Trust advertising any new non-executive roles. The framework is phased so that each chair/non-executive remains on their existing remuneration for the remaining portion of their present term with new appointments and reappointments moving on to the framework. It is envisaged that all roles are on the new framework by 2022.
Despite this being central guidance, foundation trusts retain the prerogative to operate outside of the framework on a ‘comply or explain’ basis. However, there need to be “compelling reasons” to step outside the framework and such divergences may be questioned by NHSI.
Compliance will be monitored centrally. This monitoring is likely to take the form of spot audits and declarations of compliance/non-compliance in the annual report, similar to the approach taken in respect of conflicts of interest. The lead governor, especially, needs to be comfortable with explaining the decisions governors have made.
Options considered
The Remuneration and Recruitment Committee met on 10 December to consider the issues. The key issues considered were:
1. Should the Trust adopt the framework in its proposed form then it will have the consequence of a reduction in remuneration in relation to both the chair’s role (by £2,900 if the upper quartile is adopted) and non-executive directors’ role (by £1,352). It should, however, be noted that if the Trust increases its turnover to >£200m by 2022 (which is almost certain) then the upper quartile for the chair is £50k. COUNCIL OF GOVERNORS 14. 12/20 REMUNERATION OF CH... Page 99 of 130
2. If the Trust decides to step outside the framework then it will need to consider its justification as it is likely to be questioned by NHSI. One such justification might be ‘market forces’ given the remuneration currently offered within other foundation trusts in the area.
3. Another option would be for all reappointments of existing non-executives to be in line with current remuneration levels with all new appointments moving to the new framework. Such an approach takes account of the knowledge, skills and experience already accumulated.
Recommendations
The Committee, led by the Lead Governor and without the Chair in the room, debated the proposals at length.
Two options were explored in depth:
1. To adopt the new NHSI framework for all appointments and reappointments with immediate effect.
2. To stage payments in such a way that all serving non-executive directors remain on their existing level of remuneration for the remainder of their present term, and any subsequent reappointment approved before 2022 when they would then move to the NHSI framework.
The Committee recommended option 2 to this Council meeting, as it would meet the intention of the regulator by the required date (with the exception of the newly appointed non-executive director who would align with the framework a year later), whilst mitigating the impact on people from a reduction in remuneration.
The issue of the Chair’s remuneration and the two supplementary payments would both be explored at a later date which, logically, would be 2021/22 when the Chair’s term ends and when the new framework must be operating for all roles.
How this report impacts on current risks or highlights new risks
Key risks from the options outlined include:
- Impact on morale from proposed reduction in remuneration.
- Scrutiny from regulators from not aligning to the framework immediately.
- Potential for NHS trusts to compete against FTs like ourselves for non- executives as both types of trust will pay a flat rate.
- Potential for high-paying local FTs to not follow the guidance putting the Trust at a competitive disadvantage.
COUNCIL OF GOVERNORS 14. 12/20 REMUNERATION OF CH... Page 100 of 130
Recommendations and next steps Council is asked to:
1. Note the new guidance.
2. Approve that any new appointments made before 31 March 2020 remain on the existing level of remuneration (£14,352) with any new appointments made from 1 April 2020 being aligned with the NHSI framework (£13,000).
3. Approve that all serving non-executive directors remain on their existing level of remuneration for the remainder of their present term, and any subsequent reappointment approved before 2022 when they would then move to the NHSI framework, e.g.
Current term Possible term Last date to move ends extensions on to new framework current remuneration Peter Lauener 31 August N/A 1 September 2022 2022 John Cowling 30 September 1 October 2020 & 1 October 2022 2020 1 October 2021 Jon Eggleton 10 February N/A 11 February 2023 (if appointed) 2023 Richard 30 May 2022 N/A 1 June 2022 Chillery Scott Green 31 March 2021 1 April 2021 1 April 2022 (single-year extension only) Patricia 30 September 1 October 2020 & 4 October 2022 Mitchell 2020 1 October 2021
4. Approve that the Chair remains on her existing level of remuneration until the end of her current term when the remuneration for the role will be reviewed, taking account of changes in Trust turnover.
5. Defer consideration of the two supplemental payments for non-executive directors until a later date.
15. 13/20 APPOINTMENT OF NON- EXECUTIVES - ENC J COUNCIL OF GOVERNORS 15. 13/20 APPOINTMENT OF NON... Page 102 of 130
EXECUTIVE SUMMARY
Title Appointment of Non-executive Director
Report to Council of Governors Date 11 February 2020
Author Matthew Kane, Associate Director – Corporate Affairs
Purpose of report
Please tick as appropriate Approval X Assurance Information
Executive summary –the key messages and issues
The Chair received the resignation of Andy Baker from his role as non-executive director following a change in employment situation and he left the Trust at the end of 2019.
It is the Council’s role to appoint, reappoint and remove non-executive directors of the Board of Directors, following consideration by the Remuneration and Recruitment Committee of the Council of Governors.
The Committee met on 10 December 2019 to consider the issues. In respect of the immediate vacancy on the Board, three options were considered:
1. During the most recent recruitment exercise that concluded May 2019 the committee deliberated between two candidates that were deemed ‘appointable’, choosing the candidate with the clinical skill-set over the one with commercial experience. The commercial candidate was Jon Eggleton, a former marketing director and chief executive in a major private sector company who possessed many of the qualities that the departing non- executive director brought to the Board including marketing experience. Despite not being selected, Mr Eggleton showed a continued interest and commitment to the Trust and has recently become a Trustee of The Children’s Hospital Charity. The Council may reasonably decide to recommend him for the position without need for a further recruitment round. Governors should note that Jon lives in Hertfordshire but has indicated that this is not a barrier to his involvement with the Trust. COUNCIL OF GOVERNORS 15. 13/20 APPOINTMENT OF NON... Page 103 of 130
2. Commence an immediate recruitment round, using external recruitment consultants or by carrying out the search ‘in house’. In the last recruitment round the Trust took a different approach from previous exercises, undertaking it in house. The process attracted 21 applications with a number of high-quality candidates and strong long-list and short-list processes which included a number of BAME candidates reaching the final stages. Alternatively, the committee is entitled to utilise recruitment consultants. The approximate cost would be circa. £25k. Board diversity (particularly in relation to protected characteristics) is an area that the Trust has identified that it needs to strengthen. There is also a regulatory standard with regards to having a 50:50 gender split on NHS boards by 2020 (which the Trust is not on course to meet). Council should also note that successive studies have established a link between diversity and good performance1 2.
3. The Trust could decide to hold the vacancy pending any further vacancies. The Trust would be non-compliant with the NHS code of governance which requires that at least half the board, excluding the chairperson, should comprise non-executive directors determined by the board to be independent. The code requirement is ‘comply or explain’ so this would need to be declared in the annual report.
Having considered the report, the Committee recommended option 1 (appointment of Mr Eggleton) to this Council meeting. Some of those Committee members who had not been involved in the original recruitment round met with Mr Eggleton in December and endorsed the Committee’s recommendation. Two references have since been received for Mr Eggleton, both of which endorse him for the role.
For governors’ information, the attached appendix sets out the skill set of existing non-executive directors along with the skill gaps since Mr Baker’s departure.
How this report impacts on current risks or highlights new risks
There is a risk that, without an effective Board that includes relevant skills, experience, independence and diversity, the Trust fails to meet its requirements in relation to its Provider Licence as well as regulatory and NHS Constitution standards.
This is mitigated through a timely approach towards succession planning and the filling of vacancies, which is led by the Chair and supported by the Director of People and OD and Trust Secretary.
1 West, Dawson and Kaur, Making the difference: Diversity and inclusion in the NHS, 2015 2 Sealy, R., NHS Women on Boards 50:50 by 2020, NHS Employers and NHSI, 2017 COUNCIL OF GOVERNORS 15. 13/20 APPOINTMENT OF NON... Page 104 of 130
Recommendations and next steps
Governors approve the appointment of Jon Eggleton as non-executive director with effect from 12 February 2020 for an initial period of three years, subject to Fit and Proper Person checks.
COUNCIL OF GOVERNORS 15. 13/20 APPOINTMENT OF NON-EXECUTIVES - ENC J Page 105 of 130
APPENDIX A – NON-EXECUTIVE DIRECTOR SKILL-SET
Start date Expiry of Time at Skill set current term expiry of current term Sarah Jones 1 Sept 2016 31 Aug 2022 6 years Leadership Chair Change management and transformation Project management Strategic thinking Stakeholder management
Peter Lauener 1 Sept 2016 31 Aug 2022 6 years Governance Non-executive Director & How central and local government works Deputy Chair Strategy development Policy framework for children’s welfare Workforce and skills development
John Cowling 1 Oct 2014 30 Sept 2020 6 years Strategy and leadership Non-executive Director & People management Senior Independent Director Risk management and governance Finance and regulation Business development, marketing and consultative selling
Richard Chillery 1 June 2019 30 May 2022 3 years Clinical experience – CAMHS, mental health Non-executive Director NHS, social care and third sector children’s services Universities and education Leadership: operational, clinical and at strategic level Public Health England children’s services experience
COUNCIL OF GOVERNORS 15. 13/20 APPOINTMENT OF NON-EXECUTIVES - ENC J Page 106 of 130
Scott Green 1 Apr 2018 31 Mar 2021 3 years Policing Non-executive Director Safeguarding Leadership Governance/Accountability Charity sector Partnership working
Patricia Mitchell 1 Oct 2014 30 Sept 2020 6 years Commercial Litigation Non-executive Director Charity including governance, fundraising and charity law Human resources Change management
Vacancy w/e/f 1 January 2020 Skills gaps:
Commercial, finance and economics Technology Delivery and operations Marketing Procurement
COUNCIL OF GOVERNORS 15. 13/20 APPOINTMENT OF NON... Page 107 of 130
16. 14/20 GOVERNOR ELECTIONS - ENC K COUNCIL OF GOVERNORS 16. 14/20 GOVERNOR ELECTIONS ... Page 109 of 130
EXECUTIVE SUMMARY
Title Governor elections
Report to Council of Governors Date 11 February 2020
Author Matthew Kane, Associate Director – Corporate Affairs
Purpose of report
Please tick as appropriate Approval X Assurance Information
Executive summary –the key messages and issues Elections for seven governor seats will take place in 2020. These are as follows:
Constituency Area Current governor Terms completed Public Rest of England & Wales Robert Peace One Public Rest of South Yorkshire Rebecca Kent Two Public Sheffield Debbie Mander One Helen Smith Two Staff Medical and Dental Carrie MacKenzie Two Staff Nursing Samantha Burns One Staff Other Clinical Healthcare Kathryn Holden Two
All existing governors are eligible for re-election. The proposed timetable provides for maximum engagement with members and time for nominations.
ELECTION STAGE DATE Notice of Election / nomination open Friday, 15 May 2020 Nominations deadline Monday, 15 Jun 2020 Summary of valid nominated candidates published Tuesday, 16 Jun 2020 Final date for candidate withdrawal Thursday, 18 Jun 2020 Notice of Poll published Monday, 6 Jul 2020 Voting packs despatched Tuesday, 7 Jul 2020 Close of election Thursday, 30 Jul 2020 Declaration of results Friday, 31 Jul 2020 New governors commence in role Date of AMM
COUNCIL OF GOVERNORS 16. 14/20 GOVERNOR ELECTIONS ... Page 110 of 130
Current membership totals for the Trust are as follows:
Member Type Constituency Email Postal Total Seats PUBLIC North Derbyshire 110 302 412 1 PUBLIC Rest of England & Wales 147 418 565 2 PUBLIC Rest of South Yorkshire 293 1,015 1,308 3 PUBLIC Sheffield 1,544 3,771 5,315 12 STAFF Medical and Dental 369 62 431 1 STAFF Non-Clinical Staff 737 314 1,051 2 STAFF Nursing and Midwifery 863 121 984 2 STAFF Other clinical staff 330 792 1,122 2
In addition, two governors who still have 18 months left to run on their existing terms have not attended a meeting of the Council of Governors for a substantial period of time. The Constitution allows that where a governor has not attended for three meetings without reasonable excuse they may be removed from the Council.
It is proposed to write to the governors concerned and see what support the Trust could give to enable them to attend meetings, or whether they would wish to resign. If no response is required it is proposed to bring a motion to the next Council of Governors removing them from the Council. This would require three-quarters of governors to vote for the motion.
This would then allow the vacancies to be wrapped up into the 2020 elections process.
How this report impacts on current risks or highlights new risks
N/A
Recommendations and next steps
Governors are asked to:
1. Note the 2020 elections process.
2. Agree the approach proposed in relation to the two governors who are not attending meetings.
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EXECUTIVE SUMMARY
Title Review of ways of working
Report to Council of Governors Date 11 February 2020
Author Matthew Kane, Associate Director – Corporate Affairs
Purpose of report
Please tick as appropriate Approval X Assurance Information
Executive summary –the key messages and issues
At the meeting in November, it was agreed that a survey monkey be undertaken to decide one priority action from eac of the development areas identified following the development day on 23 October. A total of 12 responses were received when the priorities identified were as follows:
Under the "Understand our role and responsibilities" heading: Hold session with governors on how to be heard / escalate issues Under the "Expanding our Knowledge" heading: Hold quarterly/six monthly briefings on 'hot' topics Under the “Getting involved in the Trust” heading: Having more information about Back to the Floors before they take place Under the “Communicating with our constituents” heading: Consider better use of the Annual Members' Meeting
Additional comments made as part of the survey were:
Things are definitely better than previously in terms of Governor activity and interest in what goes on.
End of year surveys for govs on how they are experiencing their role, what could motivate them to be more involved, reasons they’ve found engagement tricky, what would improve their experience, what areas they are least confident on etc could be very insightful for you / help get govs get heard.
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The governor whatsapp group is helpful. Perhaps more opportunities for gathering governors together, whether in person or via technological conference to identify specific tasks / issues / areas that we could address together and create a stronger driving force in serving the trust together and promote helpful and effective change.
Plans will now be taken forward on these four areas. In addition, separate discussions over the WhatApp group have highlighted the need for a specific focussed session for governors on NHS finance. This is provisionally taking place on:
Monday 20 April, 4-5.30pm, Boardroom
Governors should note the date in their diairies.
Governors also considered how they could get richness of time together, including use of technology, to discuss or focus on specific issues. The Chair has therefore offered to trial an opportunity for governors to meet or telephone 1 - 2pm each month on the Thursday following Board meetings when there is not a Council of Governors meeting the following month. Provisionally the dates suggested are:
Thursday 27 February 2020 Thursday 2 April 2020 Thursday 21 May 2020 Thursday 30 July 2020
How this report impacts on current risks or highlights new risks
N/A
Recommendations and next steps
Governors are asked to endorse the priority areas for further working and plans for regular catch ups.
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EXECUTIVE SUMMARY
Title Living the Values
Report to Council of Governors Date 11 February 2020
Author Matthew Kane, Associate Director – Corporate Affairs
Purpose of report
Please tick as appropriate Approval X Assurance Information
Executive summary –the key messages and issues
Over the past year governors have been exploring how the Trust’s values and culture and behaviours work can be applied in their work. This has involved items at meetings in May and July 2019 and at the Governor Development Session in October 2019.
During those sessions, Governors felt that there was a case for ensuring that consistent standards for governors and staff should be applied across the Trust. Accordingly, work has taken place on devising a code of conduct for governors in line with what is in place at most trusts.
The proposed code integrates the We Care and Nolan principles of public life and sets out a standard framework so that the Council of Governors is fair, transparent, responsible and accountable in its dealings with one another and the public. It also sets out a process through which any breaches may be addressed.
How this report impacts on current risks or highlights new risks
N/A
Recommendations and next steps
That the attached ‘Living the Values’ document be formally adopted as the Trust’s code of conduct for governors.
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Code of Conduct for Governors
Positive and constructive behaviour is crucial to effective teamwork. Sheffield Children’s has an agreed set of values and our Council of Governors acts as a role model for the rest of the organisation. They recognise, therefore, the importance of ‘living the values’.
This code of conduct builds on the Trust’s constitution which embodies the legal requirements for governors. The code should also be read in conjunction with NHS Improvement’s code of governance and guidance for governors and the Trust’s constitution. Once elected, governors will be required to sign a declaration to confirm that they will comply with the requirements of this code.
Governors must continue to comply with the qualifications required to hold office, throughout their period of tenure, as defined in the constitution. The Associate Director – Corporate Affairs and Trust Secretary must be advised of any changes in circumstances that may disqualify a governor from continuing in office.
Key values and principles
The Trust’s values are:
Committed to Excellence Teamwork Accountability Compassion Integrity
Governors are ambassadors of Trust members and the public and are therefore bound by the principles established by the Nolan Committee as ‘principles of public life’. By taking on the role of governor and operating in public life, governors agree to these seven principles:
Selflessness - Holders of public office should act solely in terms of the public interest.
Integrity - Holders of public office must avoid placing themselves under any obligation to people or organisations that might try inappropriately to influence them in their work. They should not act or take decisions in order to gain financial or other material benefits for themselves, their family, or their friends. They must declare and resolve any interests and relationships.
Objectivity - Holders of public office must act and take decisions impartially, fairly and on merit, using the best evidence and without discrimination or bias.
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Accountability - Holders of public office are accountable to the public for their decisions and actions and must submit themselves to the scrutiny necessary to ensure this.
Openness- Holders of public office should act and take decisions in an open and transparent manner. Information should not be withheld from the public unless there are clear and lawful reasons for so doing.
Honesty- Holders of public office should be truthful.
Leadership - Holders of public office should exhibit these principles in their own behaviour. They should actively promote and robustly support the principles and be willing to challenge poor behaviour wherever it occurs.
Behaviours
Together, the Trust’s values and the Nolan principles represent a shared set of standards for the Trust. They can be articulated in terms of the Trust’s culture and behaviour values:
Feeling Safe means that, as a governor, I:
Communicate and ask for help when I am uncertain Listen and be aware of the effects on others of my body language Not become personally involved in patient matters that should rightly be handled by the appropriate members of staff Follow relevant Trust procedures when visiting patient areas, and agree the format of any such visits with the relevant manager Treat colleagues with dignity and respect at all times by ensuring all contributions are heard and considered Take account of safety and quality of care to patients at all times Ensure that support to staff and a feeling of being valued and cared for is part of the culture of the Trust ‘Call out’ unacceptable behaviour through the proper procedures Ensure that what is agreed as confidential remains confidential and is not shared outside the organisation Ensure that I understand what information and parts of discussions can be shared Never undermine colleagues or my collective responsibility Feedback any issues of concern to the Chair, Vice Chair, Chief Executive or Trust Secretary
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Teaming Up means that, as a governor, I:
Respect the Chair’s role and responsibilities in meetings Contribute to the clarity of decision making of the team Understand that the role of governors is apolitical Welcome diversity of opinion and membership and use this as a strength in decision making Not seek to undermine the collective decision-making of the Council of Governors Seek to improve partnership working in and outside the organisation Understand that the Council of Governors acts as a whole and no one governor or group of governors can act in the name of the Trust Keep the relevant people in the Trust up to date with key issues I am dealing with, recognising their interests and needs as well as their assigned responsibilities Am on time for meetings and stay in them showing respect for the agenda (unless there is a valid reason which has been communicated to the Chair) Maintain high standards of timekeeping and attendance and demand the same from others Respect an individual’s right to be different but in the context of maintaining high standards expected of a governor Accept and receive feedback when collective decisions are made and move on Do what is necessary to change processes within the governor remit where something does not work and remove unnecessary obstacles to achieve success Celebrate success and achievement so that this, in turn, breeds further success
Keeping Learning means that, as a governor, I:
Feedback on performance and challenge with a constructive purpose Celebrate success and achievement with teams, participating in lessons learned when things go wrong Commit to learning and development activities that are provided by the Trust Be prepared to state what I do not know and learn from this Take responsibility to understand the Trust’s position Ensure that I participate in the Chair and NED appraisals by giving constructive feedback
Leading Collectively means that, as a governor, I:
Ensure the Trust is always portrayed to others in a positive and constructive manner including outside the organisation and on social media
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Am accountable to the membership who elected me or the organisation who appointed me Use ‘My name is …’ when first meeting patients or members of the public at the Trust Behave with honesty and integrity to maintain the reputation of the Trust and confidence of the Council of Governors Declare any interests in line with the Standing Orders and take the necessary action to resolve those conflicts Conduct myself in a manner which reflects positively on the Trust when attending external meetings or any other events Comply with all legal obligations
Dealing with a breach of this code of conduct
Where a complaint is received alleging that misconduct has taken place, the Chair will consider how best to deal with it and may take such action as may be immediately required. This may include exclusion of the governor from a meeting or having a private discussion with a governor. The Chair may decide that the Chief Executive, Deputy Chief Executive, Trust Secretary or someone else may be best placed to have this discussion.
Examples of a minor issue for a private word might be persistently turning up for meetings late without reasonable excuse or criticising the Trust publicly, over social media for example. Examples of more serious breaches where the conduct committee would be used might be, for example, seeking to speak on behalf of the Trust to the media in a way that is contrary to Trust policy, putting staff under pressure to change procedures for their own or a family member’s benefit or misusing Trust equipment in a deliberate way.
Any decision to invoke the code must be reasonable. If the governor is considered to have acted in a manner that is in breach of this code of conduct then a panel (known as a conduct committee) consisting of the Chair, Deputy Chair and a governor with no prior involvement in the case will consider the alleged breach and decide whether a sanction should be applied.
This will be a committee of the Council of Governors and is to ensure the matter is dealt with fairly. The committee will be advised by the Executive Director of People and Organisational Development and Trust Secretary (or their representative). The governor subject to the complaint may be represented at the committee. Sanctions may include recommending to a Part 2 session of the Council of Governors that:
The governor issues a letter or statement of apology to the Council of Governors or someone else The governor attends a relevant training session The governor is removed from a particular committee or role at the Trust The governor is removed from the Council of Governors Other action takes place, such as mediation between governor and complainant
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All recommendations will be decided on a simple majority except for where consideration is given to the removal of a governor from the Council of Governors which requires 75% of governors present and voting. If a governor fails within two months to carry out the requested action then they may be subject to a further sanction.
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EXECUTIVE SUMMARY
Title Chair and NED performance evaluation process
Report to Council of Governors Date 11 February 2020
Author Matthew Kane, Associate Director – Corporate Affairs
Purpose of report
Please tick as appropriate Approval X Assurance Information
Executive summary –the key messages and issues The Foundation Trust code of governance states:
The council of governors, which is responsible for the appointment and re- appointment of non-executive directors, should take the lead on agreeing a process for the evaluation of the chairperson and the non-executives, with the chairperson and the non-executives. The outcomes of the evaluation of the non- executive directors should be agreed with them by the chairperson. The outcomes of the evaluation of the chairperson should be agreed by him or her with the senior independent director. The outcomes of the evaluation of the non- executive directors and the chairperson should be reported to the governors. The governors should bear in mind that it may be desirable to use the senior independent director to lead the evaluation of the chairperson.
The senior independent director should lead the performance evaluation of the chairperson, within a framework agreed by the council of governors and taking into account the views of directors and governors.
As per the process above, the performance evaluation process for non-executive directors will be led by the chair, with the chair’s performance evaluation led by the Senior Independent Director (John Cowling). Standard templates for the NED appraisal will used as per last year’s process. Appraisals of both chair and NEDs will be informed by feedback from EDs, other NEDs and governors. For the chair, it will also include system wide chairs and ICS colleagues. The outcomes (in general terms) of the performance evaluations will be shared with the Council of Governors in May 2020.
One key change to the process this year is the introduction of a standard framework for NHS provider chair’s appraisals that was introduced by NHS Improvement / England in November 2019. The full guidance can be found at: COUNCIL OF GOVERNORS 19. 17/20 PROCESS FOR CHAIRI... Page 123 of 130
https://improvement.nhs.uk/documents/6107/Provider_Chair_Appraisal_Framework_ 1nov
The guidance states that the national framework outlined is not prescriptive, although there are two required elements:
to consult with the NHSI regional director as to whether there are any areas of competency in the chair’s performance evaluation that should receive particular focus
to send the Appraisal Reporting Template (Appendix 3 in the guidance) to NHSI’s Chair and COO and the relevant regional director.
Provided it can be shown that local variations are consistent with the broad principles established by the framework and include mechanisms for adequate multi-source assessment against the components of the provider chair competency framework, “context-specific flexibility” can be maintained.
A flow-chart showing the process is attached as an appendix to this report.
It is proposed that the Chair and SID meet prior to the chair’s performance evaluation to discuss how best to integrate the national framework within the existing Sheffield Children’s process.
How this report impacts on current risks or highlights new risks
N/A
Recommendations and next steps
Governors are asked to approve:
1. the proposed process for chair and non-executive director appraisals
2. the proposal as to how to integrate the new NHSI framework into existing SCH processes.
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Appendix
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GOVERNORS’ WORK PROGRAMME FOR NEXT 12 MONTHS – Items relating to statutory duties
Meeting Agenda item Lead Comments For approval: Governors to note timetable and select Quality Report DNQ 11 February quality indicators for external audit. 2020 For approval: To propose next steps following Review of ways of working Chair development session and survey monkey. Corporate For approval: Governors to agree agenda planner for Council of Governors Work Programme Affairs Office year ahead. Corporate Governor Elections For information: To note process for 2020 elections. Affairs Office Recommendation from the Recruitment and For comment & decision: Governors to review Remuneration Committee re: Chair / Lead recommendations from the Recruitment and Chair & NED remuneration Governor Remuneration Committee. Appointment of NED For information: Review of Back to the Floors Overview of Back to the Floors (6 monthly) NED QC Chair undertaken
Meeting Agenda item Lead Comments 12 May 2020 For information: Governors asked to review the Self- Self-certification Chair certification prior to consideration by Board. Quality Report DNQ For information: Governors to comment on draft. Corporate Annual Report preparation of Governor Section For information: Governors to comment on draft. Affairs Office For approval: Governors to agree the Governor who will Appointment of Lead Governor Chair act as Lead Governor for 2020/21. Review of register of interests and fit and proper Corporate For action: Governors to complete annual declarations. persons declarations Affairs Office COUNCIL OF GOVERNORS 20. 18/20 COUNCIL OF GOVERNORS WORK PROG... Page 127 of 130
Meeting Agenda item Lead Comments
Report from the Risk & Audit Committee on the For approval: Governors to confirm reappointment of NED Chair 14 July 2020 performance of the external auditor the external auditor. Recommendation from the Recruitment and Chair / Lead For approval: as required, likely to include decisions on Remuneration Committee (as necessary) Governor two NED reappointments / appointments. For information: Governors to note the outcomes of the External Audit Letter DNQ external audit work relating to the quality report. For information: Review of Back to the Floors Overview of Back to the Floors (6 monthly) NED QC Chair undertaken.
Meeting Agenda item Lead Lead For noting: Governors are presented with the annual September report and accounts (for noting, In line with their statutory (Date to be Annual Members’ Meeting – presentation of the role), the final Quality Report and the outcomes of the Chair confirmed) annual report and accounts external audit work undertaken during the last year. This meeting also formally records any annual election results and marks the end / start of terms of office.
Meeting Agenda item Lead Comments
17 Nov 2020 Strategic Direction COO / CFO For information.
For assurance: Governors to review a mid-year Quality Report Priorities – mid-year progress report DNQ progress report on quality priorities. For approval: Governors are asked to nominate Governors to work with the Risk and Audit Committee to External Auditor procurement NED Chair commence procurement of external auditor for cycle 2020/21.
21. 16/20 FEEDING BACK FROM GOVERNOR ACTIVITIES 22. 20/20 DISCUSSION OF FUTURE TOPICS 23. Date of next meeting: 12 May 2020 in the Lecture Theatre, Stephenson Wing