derbyshire county pct is on journey to be a world class ... · thursday 30 june 2016 at matlock...

Derbyshire�Community�Health�Services

Board

Board�Public�Session�-�26�May�2016

26�May�2016�-�13:00

Buxton�Methodist�Church,�Chapel�Street,�Buxton�SK17�6HX

AGENDA

Spotlight�on�local�services

129 PART�2�–�Public�SessionPlease�be�aware�that�the�DCHS�Board�meeting�is�paperless�and�as�such�Board�members�will�beusing�IT�equipment�to�access�papers�for�the�duration�of�the�meeting

130 INTRODUCTORY�ITEMS

131 Introductions�and�WelcomeOwner:�Prem�Singh

Verbal

132 Apologies�for�Absence:Owner:�Prem�Singh

Verbal

133 Declarations�of�InterestOwner:�Prem�Singh

Verbal

134 Questions�from�the�PublicOwner:�Prem�Singh

Verbal�

http://www.eshareuk.com

135 Patient’s�StoryOwner:�Carolyn�White

Paper�for�Information

135�Patient�Story 6

136 Draft�Minutes�of�the�meeting�held�on�28�April�2016Owner:�Prem�Singh

Paper�for�Decision

136�Minutes�-�April�2016 11

137 Matters�ArisingOwner:�Prem�Singh

Verbal

138 Actions�MatrixOwner:�Prem�Singh

Paper�for�Information

138�Actions�Matrix 21

139 Chairman’s�ReportOwner:�Prem�Singh

Verbal

140 QUALITY�AND�GOVERNANCE

141 Quality�Service�Committee�Summary�ReportOwner:�Chris�Bentley

Paper�for�Assurance

141�QSC�Summary�Report 24141�QSC�ToR�May�2016 29

142 Quality�People�Committee�Summary�Report�including�QPC�Annual�ReportOwner:�Barbara-Anne�Walker


142�QPC�Summary�Report 36142�QPC�Annual�Report�2015�to�2016 41


143 Council�of�Governors�Summary�ReportOwner:�Barbara-Anne�Walker


143�Council�of�Governors�Summary�Report 53

144 Charitable�Funds�Committee�Summary�ReportOwner:�Prem�Singh


144�Charitable�Funds�Committee�Summary�Report 56

145 Mental�Health�Act�Committee�Summary�ReportOwner:�Barbara-Anne�Walker


145�MHAC�Summary�Report 58

146 Quality�ReportOwner:�Carolyn�White

Paper�for�Information,�Decision�and�Assurance

146�Quality�Report 65

147 Audit�and�Assurance�Committee�Terms�of�ReferenceOwner:�Kirsteen�Farrar

Paper�for�Decision�and�Assurance

147�AAC�Terms�of�Reference�May�2016 90

148 STRATEGY

149 Chief�Executive’s�ReportOwner:�Tracy�Allen

Paper�for�Information�

149�Chief�Executive�Report 96

150 PERFORMANCE

151 Quality�Business�Committee�Summary�ReportOwner:�Ian�Lichfield


151�QBC�Summary�Report 101


152 Performance�ReportOwner:�Chris�Sands/�Amanda�Rawlings/�Carolyn�White/�William�Jones


152�Performance�Report 104

153 Financial�Performance�ReportOwner:�Chris�Sands


153�Financial�Performance�Report 139

154 CONCLUDING�ITEMS

155 Any�Other�BusinessOwner:�Prem�Singh

Verbal

156 Self-Certification/Risk/Board�Assurance�FrameworkOwner:�All

Verbal

157 Questions�from�the�public�relating�to�today's�board�businessOwner:�Prem�Singh

Verbal

158 Review�of�the�Meeting�and�OutcomesOwner:�Prem�Singh

Verbal

159 Date�of�Next�MeetingOwner:�All

Thursday�30�June�2016�at�Matlock�Town�Football�Club,�Causeway�Lane,�Matlock,�DE4�3AS��Members�of�the�public�and�staff�are�invited�to�join�the�Board�for�an�informal�discussion�over�lunchfrom�12.30pm;�this�will�include�a�presentation�on�the�services�provided�in�that�area.��The�PublicBoard�meeting�will�commence�at�1.30pm


Index135�Patient�Story.docx..............................................................................................................6

136�Minutes�-�April�2016.pdf...................................................................................................11

138�Actions�Matrix.docx..........................................................................................................21

141�QSC�Summary�Report.pdf...............................................................................................24

141�QSC�ToR�May�2016.pdf.................................................................................................. 29

142�QPC�Summary�Report.pdf...............................................................................................36

142�QPC�Annual�Report�2015�to�2016.pdf............................................................................. 41

143�Council�of�Governors�Summary�Report.pdf.....................................................................53

144�Charitable�Funds�Committee�Summary�Report.pdf.........................................................56

145�MHAC�Summary�Report.docx..........................................................................................58

146�Quality�Report.docx......................................................................................................... 65

147�AAC�Terms�of�Reference�May�2016.docx....................................................................... 90

149�Chief�Executive�Report.docx............................................................................................96

151�QBC�Summary�Report.docx.......................................................................................... 101

152�Performance�Report.pdf................................................................................................ 104

153�Financial�Performance�Report.pdf................................................................................. 139


TRUST BOARDDocument Title: Patient Story

Presenter/Title: Carolyn White, Director of Quality/Chief NurseContents of Paper were previously discussed by:

Author/Title:Mr. Frank Webb, Consultant Podiatric Surgeon, Buxton Podiatric Surgery TeamSally Hadfield, High Risk Specialist Podiatrist

Contact Email and Telephone Number:

[email protected] [email protected] 01298 212264

Date of Meeting: 26 May 2016 AgendaItem No: 135/16

No of pagesinc. this one: 5

Has an Equality Impact Assessment been undertaken? Yes No X

Document is for:(more than one box can be ticked) Information X Decision Assurance

Purpose of Paper

To describe to the Board of directors the development of Podiatric surgery at Buxton Hospital for patients with high risk foot conditions.

Recommendations

That Board members note The risks and complications of diabetic foot disease the developments within Podiatric surgery and the partnership working between DCHS

and Acute hospitals. the impact of improved local services.

Board Assurance Framework Risk Reference

Not applicable

Financial Impact

Foot problems in people with diabetes have a significant financial impact on the NHS through primary care, community care, outpatient costs, increased bed occupancy and prolonged stays in hospital. A report published in 2012 by NHS Diabetes estimated that around £650 million (or £1 in every £150 the NHS spends) is spent on foot ulcers or amputations each year.

Reduced costs through admission avoidance and more appropriate antibiotic use are covered in the paper.

135�Patient�Story.docxOverall�Page�6�of�150Page�1�of�5

mailto:[email protected]



The costs to the patient of attending as an outpatient in the local hospital are compared with the cost of transport to the acute hospital.

Further Information and Appendices

Sydney’s storyBorn and bred in Macclesfield, Sydney lived there until his work brought him to live in Buxton. He worked as an auto electrician but when work hit hard times Sydney moved on to find work in Whaley Bridge at a bleach works, which he describes as taxing and very hard graft. After the first 15 years Sydney then moved to the press line in the same factory, he preferred this work as it was ‘boring, but cushy’.

Sydney was an extremely keen walker and camper. He loves the outdoors, recalling many of his trips to the Lake District and North Wales.

Sydney’s mother died at a young age after contracting TB whilst in the forces. At the age of 2 he was adopted by his grandparents. He became close to his extended family, and to this day is extremely close with his cousin Ruth. They both shared a keen interest in getting away on walking trips. Sadly as you are about to hear Sydney’s walking days have been restricted for many years.

Sydney’s medical history includes: Diabetes type 2, Asthma, Pulmonary Embolism, Diabetic Retinopathy, Bi-lateral Charcot (progressive degeneration of a weight bearing joint), amputation of 2nd toes on both feet, Osteoarthritis, Hypertension.

Sydney has been known to the community high risk foot team since the early 1990s. He has a history of diabetic foot disease due to his profound neuropathy (disease of peripheral nerves causing numbness).

Back in the summer of 2012, Sydney presented with foot ulceration. He is profoundly neuropathic; with extensive foot deformities due to bi-lateral Charcot feet (Charcot foot is a condition causing weakening of the bones in the foot that can occur in people who have significant nerve damage. The bones are weakened enough to fracture, and with continued walking the foot eventually changes shape. As the disorder progresses, the joints collapse and the foot takes on an abnormal shape, such as a rocker-bottom appearance).

Sydney had bespoke footwear, regular podiatry care and annual diabetic foot screening. He had presented in the community podiatry clinic with a left foot ulceration, tracking cellulitis and elevated temperature of 38°C. He needed the correct antibiotics, of a high dosage to prevent him from becoming systemically unwell, and monitoring of bloods and clinical appearance whilst on these antibiotics.

The ulceration became chronic, lasting three and a half years. In this period of time the patient was seen weekly for dressings and debridement and care from the shared diabetic nurse.

Sydney carried out his own daily dressings. In total he has had 2 operations, 25 X-rays, 2 MRI scans, 1 ultra sound, negative pressure wound therapy, over 5 removable casts, 4 air boots, new bespoke footwear and insoles, tissue viability shared care, and many different dressing and



wound care interventions.

Sydney became systemically unwell 3 times during this period; and he was admitted to Stepping Hill Hospital twice due to tracking cellulitis from the wound.

Understandably Sydney became fed up. He had complied with all of his treatments and yet the ulceration remained. It impacted on his quality of life, attending appointments weekly and carrying out his own daily dressings. As he doesn’t drive, the cost of taxis to weekly appointments was considerable. He would have had to have provided his own transport arrangements to attend at Stepping Hill which is over 20 miles away. We were advising him to rest his feet to aid healing; so walking to appointments was out of the question. In December 2015, when Sydney first saw us, the ulceration was deteriorating and remained chronic. We knew Sydney was reluctant to try new things as previous interventions had failed. Mr Webb discussed a total contact cast and to our surprise, Sydney accepted. After 2 weeks with the cast, improvement was remarkable. Within 3 months of casting the ulceration had healed and we were awaiting bespoke insoles. Sadly in this period of time the ulceration broke out again due to pressure over the deformity, but within 2 weeks of introducing the cast again the ulceration had healed again.

Today, Sydney has no active foot ulcerations. He is able to get into the bath and shower and get his feet wet. He has no dressing to perform daily. We are awaiting bespoke insoles and until these arrive I have requested padding remain on the post ulceration site, to prevent further break down.

Being treated by Buxton Podiatric Surgery team allowed Sydney to have regular management of his active diabetic foot disease in a setting near to home, thus improving his quality of life.

A comment that is often made by patients that attend the ‘High Risk Foot Protection Team’ is that the unit offers ‘individual personal care and that it is not like attending normal hospital appointments’.

In the last 24 months Buxton Podiatric surgery team has developed significantly to incorporate the ‘High Risk Foot Team’ alongside our Podiatric Surgery patients. Our vision is to continue developing, expanding services so as to offer on-going support to fill a necessary gap in the services provided to DCHS patients.

We feel there are still gaps in the quality of care and our vision is to develop the following: casting clinics, Home IV services to mirror other areas of DCHS, Vascular screening Peripheral Arterial Disease (Angina of the leg), High Risk Foot Protection Teams throughout all areas of DCHS.

Background on Diabetic Foot Disease and Buxton Podiatric Surgery.

The risk of foot problems in people with diabetes is increased. This is largely because of either diabetic neuropathy (nerve damage or degeneration, resulting in loss of feeling/sensation) or peripheral arterial disease (poor blood supply to vessels in the legs/feet), or both. Peripheral arterial disease affects 1 in 3 people with diabetes over the age of 50, and also increases the risk of heart attack and stroke.



Foot complications are common in people with diabetes. A foot ulcer can be defined as a localised injury to the skin and/or underlying tissue/structure. It is also known as Diabetic foot disease, due to high amputation rates and links with mortality rates. The life expectancy of people with diabetes is shortened by up to 15 years, and 75% die of macro vascular complications; such as heart disease.

Diabetic Foot disease can have extensive social, financial and personal impact to patients and their quality of life.

Many of you are aware that here in Buxton our access to the acute hospital setting is limited. Historically the complex diabetic foot patient was seen by Podiatry at Stepping Hill Hospital (21 miles away).

In the last 4 years Mr Webb has developed a ‘High Risk Foot Protection Team’ alongside podiatric surgery. The service is led by the podiatric surgery team who specialise in treating complex patients. The service allows patients to be treated in outpatient settings closer to home for complicated life threatening and changing foot conditions. The use of Patient Group Directives (PGDs) and the recent facility for podiatrists to train as independent prescribers allows acute hospital guidelines to be applied in an outpatient setting, avoiding an admission.

We are able to carry out limb salvage procedures, often impregnating the wounds with antibiotics that absorb over a 6 week period, thus reducing the usage of systemic antibiotics. We also work closely with Stepping Hill Hospital who refer patients to us for procedures. This helps Stepping Hill to reduce waiting times and reduces the usage of antibiotic therapeutic management.

Since January this year the team has mirrored the Buxton services at Whitworth Hospital with the aim of building connections and working alongside Chesterfield Royal Hospital Foundation Trust.

Monitoring Information Brief Summary

What are there Governor Involvement implications?

Public Governors are core members of groups where patient stories are shared. These include Council of Governors and Patient Experience and Engagement Group.

What are the Equality and Diversity implications?

This story focusses on the treatment of a man who has a long term condition (diabetes) and as a result has impaired mobility and vision impairment. People can expect to receive a very high standard of clinical care regardless of any protected characteristic, including a disability.

What are the Patient, Public, Staff, Member and Stakeholder Involvement implications?

Patient stories are a powerful way that the experiences of people who use our services can be shared throughout the organisation to inform learning and quality improvements.

Risk Register



Is the issue on the current Risk Register? No If yes, what is the Risk Number?

Does this update recommend a change in the current risk score? (If so, please provide your rationale below) No



Minutes of the DCHS Board Meeting held on Thursday 28 April 2016 St Thomas’ Church Centre, Chatsworth Road, Brampton, Chesterfield S40 3AW

Present Name Job title

Prem Singh PS Chairman Tracy Allen TA Chief Executive (left at 3.10pm) Chris Bentley CB Non-Executive Director Kirsteen Farrar KF Trust Secretary William Jones WJ Chief Operating Officer Ian Lichfield IL Non-Executive Director Rick Meredith RM Medical Director Amanda Rawlings AR Director of People & Organisational Effectiveness Chris Sands CS Director of Finance, Information and Strategy Nigel Smith NS Non-Executive Director Carolyn White CW Chief Nurse Barbara-Anne Walker BAW Non-Executive Director (left at 3.30pm)

Apologies John Coyne JC Non-Executive Director In Attendance Melanie Curd MC Deputy Trust Secretary

Jim Austin JA Associate Director of Transformation Tim Broadley TB Associate Director of Strategy Trish Mahon TM Matron – Tissue Viability (left after agenda item

102/16) Rachel Wilkinson RW Integrated Community Team Leader (left after

agenda item 102/16)

Item Description Action

96/16 PART 1 – PUBLIC SESSION

97/16 INTRODUCTORY ITEMS

98/16 Introductions and Welcome

99/16 Apologies for Absence Apologies were noted as above.

100/16 Declarations of Interest There were no declarations of interest.

101/16 Questions from the Public There had been no formal questions from the public received.

102/16 Patient Story CW introduced the two members of staff who had attended to tell the Patient Story.

136�Minutes�-�April�2016.pdfOverall�Page�11�of�150Page�1�of�10



TM explained the role of the Tissue Viability (TV) team within the Trust and gave the background to the story. She explained that the patient was quite mobile throughout his care and so it was quite unusual however other factors changed including his nutrition, he lost weight and he had a change in routine which meant he was sitting for long periods. The team concluded there had been missed opportunities. RW explained she completed the investigation with the team and challenged them to look at the whole person and not just as a set of clinical tasks. The Board discussed and JA gave an update on the significant investment in Smartphones to support staff in accessing specialist clinical advice quickly and efficiently. WJ explained he had been working with TM to review the authorisation of equipment as it is a significant barrier to care. TM explained about 16% of their time as a team is talking about and authorising equipment and so the new process should have a big impact on saving time. CW stated to support the TV work a “back to the floor” day is planned for all team leaders and matrons to work alongside their teams one day per week and a new CQUIN has been agreed for 2016/17 which is supporting pressure ulcer management in care homes. PS commended RW leadership style of working with her team and supporting their learning and development, he also thanked RW and TM for attending to tell the story as Board. The Board received the Patient Story.

103/16 Draft Minutes of the meeting held on 31 March 2016 The minutes of the meeting held on the 31 March 2016 were agreed as accurate. IL highlighted 70/16 had an action that had not been highlighted on the minutes or transferred to the actions matrix.

KF

104/16 Matters Arising There were no matters arising.

105/16 Actions Matrix The Board noted the actions with a deadline of April were complete.

106/16 Chairman’s Report PS stated we now embark on a new year, with many challenges and opportunities and a continued focus on our plans, both internally and system wide for the year ahead. The Chief Executive’s Report references the work colleagues are doing to finalise the year end position and today we will be looking at how we improve our performance reporting; this is building on work undertaken during the last year reshaping our Board strategic priorities, establishing Quality Committee




priorities and improving the Board Assurance Framework. Our Care Quality Commission (CQC) inspection starts on 9 May which will provide a great opportunity to demonstrate the quality of our services provided by our excellent staff. It is also an opportunity to reflect, learn and improve. Therefore, our strategic theme is our quest to build on our culture of continuous improvement, in keeping of our journey from Good to Great. With regard to building strategic relationships, PS focus has been meeting with Chair colleagues from Chesterfield Royal Hospital, Derby Teaching Hospitals and Derbyshire Healthcare Foundation Trust to continue to build our strategic thinking, discuss opportunities for collaboration and to consider stepping up our leadership contribution to the many system wide challenges we face as part of our joint responsibility for the development of the Sustainability and Transformation Plan. PS and TA have also met with Rakesh Marwaha from Erewash Clinical Commissioning Group. Within DCHS, PS had a second visit to the community teams based at Village Community Health Centre in Derby to welcome new staff to DCHS. The staff were very positive about joining DCHS; to connect and learn from elsewhere within the Trust and about migrating to our systems. We need to ensure our IT systems are being built to support our staff. Key governance and accountability activities this month have included:

• Starting new Non-Executive Director (NED) recruitment campaign. An advert went out week commencing the 11 April 2016

• Joining an extra-ordinary Quality Business Committee meeting to sign off the Operational and Financial plans ahead of the submission date of 11 April 2016

• Continuing with NED appraisals and BAW completing PS appraisal • Having meetings with the Lead Governor, as part of a regular

programme of catch up meetings • Taking part in a Board Assurance session to reflect on service quality,

improvements achieved to date and plans for the future • Governor elections; preparations are going on ahead of nominations

opening on 18 July to raise the profile of the elections and encourage people to step forward for the nine public and five staff governor posts which are available. A new web area is being launched to enable people to download nomination packs and vote online, as well as extensive newsletter coverage and leaflets to promote the opportunities on the governing body.

Other areas to note are:

• The deadline for nominations for the Extra Mile Awards has been extended to midnight on 2 May 2016.

• The Community Players held an event on 18 April 2016 to present cheques to their nominated charities following another successful year. The Players donated the sum of £6500 to 14 charities which is the money raised from this year’s pantomime of Puss in Boots that was performed over 11 performances at the Hasland Playhouse. IL was




invited to attend to present the cheques • Live online waiting times for Minor Injuries Unit and A&E to help patients

and the public to make informed choices about where to go to receive the right care

WJ added that he had been interviewed by BBC East Midlands Today regarding the waiting times at Ilkeston Community Hospital. The Board received the Chair’s Report.

107/16 QUALITY AND GOVERNANCE

108/16 Audit and Assurance Committee (AAC) Summary Report NS presented the report and stated most of the items at the meeting had received significant assurance. He wished to highlight:

• 45/16 Head of Internal Audit Opinion - provided Significant Assurance. 360 Assurance provided Significant Assurance in relation to nine reviews. There were only two reports issued with a Limited Assurance opinion with one further report of Limited Assurance (regarding agency staff) pending circulation

• 47/16 Annual Governance Statement - will remain draft until the Board approves the Financial Accounts in May 2016. There are currently no control issues that are considered significant. AAC agreed that assurance received regarding the two significant control issues reported last year could now be withdrawn

• 49/16 Mental Capacity Act (MCA) Update - Mental Health Act training; there are only seven staff remaining that are yet receive the training. On any shift there will be a qualified member of staff. MCA training; 81% of the relevant staff have now received their training against the target of 95%.

• 50/16 Data Quality Update - a huge amount of work has been undertaken to improve data quality, however the TPP project is behind schedule and the addition of new services has further added to the challenge

• 53/16 Annual Financial Accounts Progress Report – the provisional full year financial position is a surplus is £2.65m, which is an increase of £1.05m over the original planned surplus of £1.6m. One discrepancy has been identified, regarding the Gross Internal Area reported in our buildings between the District Valuer and the ERIC Return. A meeting has been arranged with the external auditors to resolve the issues

PS highlighted agenda item 46/16 Attendance at Board and Subcommittees and commended colleagues dedication and commitment. The Board received the Summary Report and the assurance it provided.

109/16 Quality Service Committee (QSC) Summary Report CB presented the Summary Report and highlighted:

• 124/16 Healthcare for All – identified DCHS compliance with the 10 Healthcare For All recommendations, as well as the six criteria in




Monitor’s Risk Assessment Framework and the plans to exceed the requirements in order to become an exemplar of good equalities practice

• 125/16 General Practices - The report reviewed the current status of the Trust’s General Practice services including the journey during the past twelve months, particularly with respect to governance arrangements. There is still work to do in streamlining our policies and procedures

• 129/16 Quality Performance Report - Pressure Ulcers; reviewed the detail of the Pressure Ulcer work commissioned by DCHS that was discussed at the March Board Development Session. Falls; the Falls Pathway Steering group has been formed and commenced its meetings. Patient Experience; very good performance of the annual Friends and Family Test (FFT) results. The overall Trust FFT was 98%

• 132/16 Divisional Governance Summary Exception Report –the organisation has committed to the Sign Up To Safety campaign to promote patient safety and reduce harm. Stay Safe Audit; reported that the Trust had achieved a 98% completion success rate for last year. Health Wellbeing and Inclusion Clinical Records Audit; 100% completion of the audit was achieved with 93% compliance against the legal questions in March 2016

• 133/16 Quality Assurance and Compliance Report - four “Inadequate” ratings found during the locality triangulations exercise. An update will be provided to QSC with proposed actions and timescale for improvement

• 140/16 Strategic Shift - the management of Derby City community services during the first 100 days post transfer. QSC reviewed the programme of work undertaken, outstanding issues, the associated risks and the ongoing mitigations. An update including action plan will be presented to the August QSC meeting

• 141/16 Integrated Sexual Health Services Update - QSC reviewed the achievement of the updated action plan for issues relating to the delivery model and associated risks of the sexual health service. A Matron and a Lead Doctor are now in place. Monthly updates are to be reported to QSC

IL highlighted the Medical Devices and podiatric surgery equipment under agenda item 136/16 and asked what the impact was on patient and staff safety. WJ explained the work that had been undertaken and that we now have information to upload from Derby Hospitals. PS highlighted the equalities monitoring challenge and stated we need to re-visit this as a Board as part of the Board commitment to the Equality, Diversity and Inclusion agenda. The Board received the Summary Report and the assurance it provided.

110/16 Quality Report CW presented the report and highlighted in response to the investigation into the deaths of people with a learning disability or mental health problem in contact with Southern Health Foundation NHS foundation Trust, the CQC has announced that it will be carrying out a review of how NHS trusts identify, report, investigate and learn from deaths of people using their services. It is likely once the final report is published DCHS will be required to review our




internal processes. The requirement for all nurses and midwives to revalidate with the Nursing and Midwifery Council (NMC) was introduced on 1st April 2016. Revalidation is a 3 yearly requirement, although it is still necessary to renew NMC registration annually. CW stated our processes are in place and working and a DCHS nurse has recently been suspended from duty for failing to revalidate with the NMC. In addition, CW added that we have introduced a new Quality Summit as part of the Quality Always process. There are two types of Quality Summit; Type One to identify the support the ward requires where the ward has taken a retrograde step and Type Two where the ward haven’t made the necessary improvements and are maintaining the same scores. CW stated we have held a Type One Summit for Hudson Ward at Bolsover as their performance has worsened on review and they have moved from one to two reds and from four to two greens, all the other areas were amber. IL highlighted Staffing for Quality and the agency spend has increased; he requested that this is included in the financial section of the report in future. The Board received the Quality Report and the assurance it provided.

CW

111/16 Board Assurance Framework (BAF) – Quarter 4 KF presented the BAF for Quarter 4 and explained it was the last time Board would see it in this format. From Quarter 1 the new BAF will be in place which has been developed following a Board Development Session in November 2015. KF stated the Quarter 4 BAF has been reviewed by AAC; there are four high risks on the BAF previously seen by Board and it is proposed to reduce the Mental Health Act Compliance risk to a low risk. The Board approved the Board Assurance Framework for Quarter 4.

112/16 Register of Board Declarations KF presented the Register of Board Declarations and explained the annual process to update the Register. She went on to explain the process for adding or amending declarations of interest during the year. The Register also contains the Fit and Proper Persons self-assessment declaration. WJ stated he would soon be stepping down as a Trustee for Helen’s Trust and will inform the Board once this role formally ends. The Board received the Register of Board Declarations and the assurance it provided.

113/16 Well-led Framework KF presented the self-assessment and action plan which she explained had been developed following a Board Development Session in November 2015.




CB requested the rationale be included for why we are judging ourselves to be green/amber as this is not consistent throughout the document. PS requested it is amended to show he regularly attends all the sub-committees of the Board, in the same way as the Chief Executive. KF to make the amendments. BAW asked RM to elaborate on the Clinical Strategy that we are developing and RM explained it will be a clinical strategy for a public health organisation in conjunction with other Foundation Trusts in the area as we are increasingly talking about patient pathways and we can’t develop the strategy in isolation. The Board received the self-assessment and action plan and the assurance they provided.

KF

114/16 Derbyshire and Derby City – Transforming Care Partnership (TCP) Plan (Learning Disabilities) WJ presented the TCP Plan and explained this was the local response to the national ambition to transform local services for people with a learning disability, and/or autism who display behaviour that challenges, including those with a mental health condition. It is anticipated that the TCP plan will form part of the learning disability component of the Sustainability and Transformation Plan to be delivered in October 2016. The Plan has been developed with stakeholders from across Derbyshire and Derby. The Board approved the TCP Plan.

115/16 STRATEGY

116/16 Chief Executive’s Report TA presented her report and highlighted that DCHS’ contracts have all been agreed and signed. She stated it was disappointing that the contracts did not reflect the local CCGs’strategy of shifting resources from in-patient provision to the community. The Trust had not been successful in securing additional investment in community nursing in the baseline contract. However, we have agreed to continue to monitor pressures through the BRAVO tool, and work with Commissioners in-year to monitor activity shifts and patient complexity. These discussions will continue through the existing contract management mechanisms. Work has been progressing on the Sustainability and Transformation Plan (STP) with a focus on defining the wellbeing, care quality and financial gaps that the system will prioritise addressing over the next 3-5 years. A 'short return' has been developed and submitted to NHS England setting out these gaps, along with the focus and approach for addressing them and the governance arrangements now agreed across the system for developing the detailed plan. This will be considered by the Board in the private session of our




meeting. With regard to 21st Century Care, the focus of work continues to be centred on developing community hubs. A very successful Assurance Panel has been held with NHS England (NHSE) this month as a gateway to the CCGs’ 'Better care closer to home' consultation. Further information is being provided to NHSE in a small number of areas to enable us to demonstrate that we have fully met their tests and we are expecting sign off to move to consultation at the beginning of May. Clear guidance has been provided that we should delay the start of the consultation due to the purdah period around the EU referendum. Therefore it will now begin at the end of June, for a period of 14 weeks until the beginning of October. The usual 12 week consultation period has been extended to take into account the holiday period over the summer. With regard to the Erewash multi-specialty community provider (MCP), the partnership has completed work on our plan for 2016/17 and submitted this to NHSE and we are awaiting confirmation of the funding that will be made available against our proposals. A financial risk share agreement between partners to deal with the recurrent implications of the investments we make against the national non recurrent money has been agreed and work is also continuing to develop and evaluate options around organisational form for the MCP going forward. The Board will be considering these developments in more detail in its private meeting. NS highlighted the Big 9 and TA confirmed this was the year-end position and the Quality Report explains why we have failed to achieve the Quality Service measures; she explained this was due in part, to how we tried to measure them. The Board received the Chief Executive’s Report.

117/16 Operational Plan 2016/2017 TB presented the final DCHS Operational Plan for 2016/17. He explained it had been developed with input from staff, governors and members. He went on to say the Plan had been updated following comments received after the presentation of the draft plan to the Board in March and in response to the changing financial context. The Board noted the content of the Operational Plan and the plans to monitor the delivery of the Plan.

118/16 PERFORMANCE

119/16 Review of Performance Reporting CS presented the report and explained this was the proposal to make performance reporting more focussed within the Trust. The idea would be to have the top 20 Key Performance Indicators (KPIs) reported to Board with more detailed KPIs reported to the Sub-Committees of Board.




The Board discussed and IL stated that we would need assurance that the sub-committees are reviewing the right KPIs in the right amount of detail to enable it to work. NS stated we need to be careful that we don’t lose the detail within the “average”. BAW asked whether we should develop a performance report for the Mental Health Act Committee (MHAC) as they are not currently included. The Board agreed to make a referral to MHAC to discuss. PS asked that we think about the impact this would have on other reports to Board, like the Quality Committee Summary Reports so we are not duplicating the information. It was agreed to try it for a period of time, starting in May and then review. The Board approved the new performance reporting process.

Referral to MHAC

120/16 Performance Report CS presented the report and stated we have been green for the Monitor indicators for the whole year. He gave his thanks to all the staff that have helped to achieve the targets. AR highlighted the absence rate and explained this is still receiving significant focus. She stated that a number of managers are coding the sickness as “not known” which does not help to understand the detail. CS suggested doing a data quality report on it – AR and CS to discuss. WJ highlighted that we have achieved 100% of our CQUIN target and gave his thanks to the CQUIN and Quality Teams within DCHS. He went on to highlight Delayed Transfer of Care which has increased to 11.2 and the Safety Express target of 94%, which we have only achieved twice during the year. NS highlighted Speech and Language Therapy (SLT) and CS explained the activity in SLT has dropped due to vacancies and it has dropped in podiatry due to staff sickness. He explained we are recruiting staff in SLT and the staff that have been unwell in podiatry are starting to return to work. NS asked whether we have an unmet demand for these services and CS stated we will have to monitor the situation carefully in months 1-3. The Board received the Performance Report and the assurance it provided.

CS/AR

121/16 Financial Performance Report CS presented the year-end report and explained the accounts are still subject to audit at this stage. They will be signed off at an extra-ordinary AAC in May and then be presented to the Private Session of Board. We have achieved a surplus of £2.65m and achieved our cost improvement programme target of £1.6m.




The Board discussed and agreed they were excellent results and thanked CS and his team for all their hard work. The Board received the Financial Performance Report and the assurance it provided.

122/16 Monitor Self Certification – Quarter 4 KF presented the Self-certification for Quarter 4 and explained it had been discussed by AAC the previous week and we were green across all the Monitor indicators. The Board approved the Self-certification for Quarter 4.

123/16 CONCLUDING ITEMS

124/16 Any Other Business AR had one item of any other business; we have been successful in three of our teams getting through to the Healthcare People Management Awards which will be held in June 2016. The projects are Leadership Development (Quality Always), Staying Safe and Equality Theatre Forum. The Board wished the teams the best of luck.

125/16 Self-Certification / Risk / Board Assurance Framework This is a standing item on the Private Session of Board to provide an opportunity to reflect on the business discussed and consider any impact on Self-certification, risk, or the Board Assurance Framework.

126/16 Questions from the Public relating to Today’s Board Business None.

127/16 Review of the Meeting The Board reflected on the new timings for Board and agreed there was a lot to fit in one day.

128/16 Date of Next meeting Thursday 26 May 2016 at Buxton Methodist Church, Chapel Street, Buxton SK17 6HX. Members of the public and staff are invited to join the Board for an informal discussion over lunch from 12.30pm; this will include a presentation on the services provided in that area. The Public Board meeting will commence at 1.30pm.



DCHS BOARD – ACTIONS MATRIX DATE: May 2016 – Public Session

Date/Item No:

Item/subject: Decision taken and/or action required:

Progress: Responsible Person:

Deadline: Outcome:

April 2016110/16

Quality Report Agency spend to be included in the financial section of the report in the future

Carolyn White

May 2016 Complete

April 2016113/16

Well-led Framework

Amendments to be made to final document

Kirsteen Farrar

May 2016 Complete

April 2016119/16

Review of Performance Reporting

A referral to be made to Mental Health Act Committee (MHAC) to discuss developing performance reporting for it.

Discussed at MHAC - 13 May 2016.

Kirsteen Farrar

May 2016 Complete

April 2016120/16

Performance Report

AR and CS to discuss doing a data quality report on absence reporting as a number of managers are coding the sickness as “not known”, which does not help to understand the detail

Lynne Shelton is completing a review.

Chris Sands/ Amanda Rawlings

June 2016

Jan 20167/16

Patient Story To discuss discharge planning with the Chief Nurse at the Acute Trust

CW to meet with the Chief Nurse at Burton Hospital on 6 May 2016. To update the Board following that meeting.

Meeting deferred until 27 May 2016, and update to be given to Board following.

Carolyn White

June 2016*Changed from Feb 2016

Mar 201689/16

Performance Report

QSC were asked to take a Deep Dive look at the reasons for the waiting times

Scheduled to go to QSC in June.

William Jones June 2016

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Date/Item No:



Deadline: Outcome:

Mar 201676/16

QSC Summary Report

KF to consider the calibration of levels of assurance and to make a recommendation; and also to review and provide direction regarding what should come out of the Deep Dive reports

Kirsteen Farrar

June 2016

Mar 201680/16

Quality Report Our services have experienced pressure from seasonal illness. The peak demand has led to a flexing up of beds and it is hoped to flex down to 16 beds in May. Analysis was requested regarding what has happened over winter and a referral to be made to QPC to look at flexing options.

A meeting is scheduled for May 2016 where key players are going to analyse our agency and flexible staffing usage over winter 2016 and plan for how we manage our workforce efficiently and proactively ahead of winter 2017. A paper has now been scheduled for July QPC to feedback on this work and provide assurance to QPC that we not only understand our winter 2016 usage, but that we are proactively planning for 2017

Amanda Rawlings

July* 2016

*Changed from May 2016

Dec 2015329/15

Quality Report The Board discussed the pros and cons of centralised teams and it was agreed that this would be discussed further at the Primary Care Development Session.

Primary Care Development Session organised for 28 July 2016

Tim Broadley Sept 2016

*changed from May 2016

Jan 201615/16

QPC Summary Report

New sentencing guidelines to be included in the Board Development Session on H&S

This session has been arranged for 29 September 2016.

Amanda Rawlings

Sept 2016



Date/Item No:



Deadline: Outcome:

Oct 2015267/15

Quality Report Derbyshire Youth Council to be invited to a future Board meeting

CW is liaising with the Council to agree the best time for them to attend.

Carolyn White

Sept 2016

*Changed from Mar 2016

Mar 201670/16

Patient Story The value of the work in Creswell to be demonstrated to GPs and an evaluation (including a cost benefit analysis) to be undertaken to produce a recommendation for future configurations of the service for the benefit of the North East Derbyshire population. This also to be included in the forthcoming Creswell and Langwith evaluation.

Tim Broadley Sept 2016



Summary Report from Quality Service Committee Report To: Board

Date: 26 May 2016

Name of Reporting Committee / Group: Quality Service Committee

Date of Meeting: 17 May 2016

Presenter: Chris Bentley, Non-Executive Director

Author: David Boddy, Corporate Governance Manager

This paper is for Assurance

Key Issues discussed at meeting: Board Assurance Framework Reference and Level of Assurance Agreed

157/16 Patient Story - The story discussed the role and impact of the Pulmonary Rehabilitation team at Clay Cross. The service transformed the quality of the patient’s final months of life. The story highlighted to the Committee the challenges faced around:

• Raising the profile and benefits of this evidence based treatment in order to increase the number of referrals into the service

• Receive the referrals early in the pathway so that the benefits on quality of life can be maximised. Faster intervention may also reduce readmissions

• Pulmonary Rehabilitation should be an essential part of the COPD pathway, and not seen as an “add on”

Although the service has tried to raise its profile, the dropout rate at referral stage indicates that conversations are insufficiently robust. The Committee noted the outstanding results of the service when compared to national average performance. The service provided is patient centred. The Committee considered the potential impact on the service should the number of referrals increase. The Committee agreed that actions within DCHS control might be:

• Link the service to our integrated teams • Change the template on Systmone

A number of actions were taken by Operations and North Derbyshire Clinical Commissioning Group to address the challenges discussed.

Paper for Information

162/16 Infection Prevention and Control: Quarter 4 and Annual Report 2015/16 - The Committee discussed compliance with the requirements of the Code of Practice for the Prevention of Infection

1.3 Significant Assurance

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incorporated within the Health & Social Care Act. 163/16 Verbal Feedback from CQC Inspection - Feedback from the clinical teams is that it has been a positive experience. The initial feedback from the CQC is overall very positive. This includes:

• Lots of excellent practice which is caring and responsive • Exceptional End of Life care delivered • Areas of concern during the last visit are now working well • Very favourable observations regarding the Learning

Disabilities service • Derby City nursing staff have reported positively about working

with DCHS • Impressive work regarding our inclusive transgender approach

The areas of challenge are areas of current DCHS focus such as:

• The work to improve the Sexual health Service as a Shared Provider

• Creswell and Langwith General Practices There was also some debate regarding the way DCHS organise the risk register. A draft report will be provided in July followed by a Quality Summit in August.

Verbal Update

165/16 Quality Performance Report - The key messages included: • Falls with harm across DCHS continue to reduce • No medication incidents resulting in significant harm were

reported in February • The Patient Experience data continues to provide appositive

story The Committee discussed the increase in Pressure Ulcer incidents reported in Derby City. The Derby City staff are experiencing a cultural change regarding incident reporting across all services. The Tissue Viability matron is meeting Derby City staff to check the accuracy of the reporting.

1.1, 1.2, 1.3, 1.4, 1.5 Significant Assurance

166/16 Risk Management Report - The Committee asked about the work to reduce the backlog of incidents that are yet to be approved. The Committee discussed the Lessons Learned. It was agreed that Lessons Learned are most relevant for reporting to QSC once the risk has been closed or reduced. The format of the report is to be reviewed and Lessons Learned might better be referred to the Learning the Lessons Group.




167/16 Divisional Operational Quality Report – the report highlighted each division in terms of quality, clinical governance, and risk management and facilitates escalation, highlighting developments and issues including.

• Planet FM - a communication has been shared with General and Business Managers detailing a timeline for reviewing medical devices, ensuring all devices are compliant with maintenance and inspection requirements and uploading amended lists to Planet FM

• Nutrition - an electronic referral form has been developed by dieticians in the south of the county to support a more streamlined referral process for community patients who require specialist advice and intervention. Dieticians in the north of the county are now considering their process and hope to align with the south in support of a consistent approach. The template will be presented to the Nutrition Group

1.5, 4.1 Significant Assurance

168/16 Quality Assurance and Compliance Report - The report regarding the assurance model development and progress was updated by the verbal report in 163/16 Feedback from Care Quality Commission (CQC) Inspection.


169/16 Annual Quality Report – The Committee was updated regarding the progress of the report. The report is being updated with final comments. Our external auditors have reviewed the report and provided detailed comments to ensure we have complied with the guidance. The Committee took Significant Assurance from the progress of the report.


170/16 Clinical Effectiveness Group (CEG) Summary Exception Report - CEG received the outcomes from a CCG commissioned report that highlighted the inappropriateness of patients undergoing catheterisation and outlined clinical issues surrounding the management of these patients. After an extended discussion a plan was outlined to improve the practices that had been identified. The Committee agreed that it should be communicated to the CCGs that patients discharged from hospital should be seen by specialists at home. The absence of a pathway means that opportunities for best practice are being missed. This is to be taken up with the CCGs. Other highlights from the report:

• Quality Always – Work is addressing long standing RAG rated amber teams

• Clinical Policies - It was reported that currently there were no policies that had a breached revision date.




The Committee reviewed the Terms of Reference and requested a number of amendments. 171/16 Clinical Safety Group Summary Report and Annual Review - The Committee reviewed the reports and:

• Requested that core strength training is included as part of the Health and Wellbeing approach to manual handling training

• Acknowledged the good triangulation that is taking place between the QSC subgroups


172/16 Patient Engagement and Experience Group Summary Exception Report - The Group was unable to take assurance from the Patient Experience Monthly Report because of the number of negative experiences reported on the Friends and Family Test in relation to using Sexual Health services. A report will be presented from the service in June to provide assurance that appropriate action is planned that will address the concerns of service users.


173/16 Safeguarding Governance Group Exception Report – The group approved the content of the Markers of Good Practice Submission (Safeguarding Children). The data highlighted that we are rated overall green. A separate general practice for Chaperoning Policy is being compiled. A check is being made to ensure that the DCHS policy is not conflicting with the new policy.


175/16 QSC Terms of Reference - The Committee approved the QSC Terms of Reference subject to a number of minor amendments. The Terms of Reference will be presented to the Board along with the Summary Report.

Paper for Decision

Board Assurance Framework Risks: 1.1 There is a risk to management capacity and overall service continuity from the process of bidding for and acquiring new services and/or the requirement to retender for existing services 1.2 There is a risk to comprehensive patient information due to discontinuity between systems employed 1.3 There is a risk to the provision of safe, effective elective care due to lack of clinical leadership and expertise 1.4 There is a risk that DCHS does not provide patient centred care due to a lack of engagement and involvement of service users and stakeholders 1.5 There is a risk that our Clinical Governance initiatives do not deliver the outcomes necessary to support our Strategy 2.5 There is a risk that the Trust fails to build cultural competence and the required level of awareness and understanding across the organisation to operate inclusively and deliver equity of access and outcomes for staff and service users 4.1 There is a risk to the organisation due to not having strong corporate governance systems in place resulting in Trust vision not being delivered 4.3 There is a risk to the organisation due to not having strong risk management controls in place resulting in failure to put effective mitigation plans in place promptly.



Policies Approved None. Issues to be escalated to Board or a Committee QSC Terms of Reference attached



DCHS Quality Service Committee

Terms of Reference

May 2016

Introduction The Quality Service Committee (QSC) is one of DCHS’ key Board sub-committees. The Board sub-committees are concerned with the governance of the organisation; that is how DCHS is structured, how it is led and how it is held to account. The Committee’s remit does not extend to the management of the organisation which is the responsibility of each Directorate. The Committee has delegated authority from the Board to approve policies and to make decisions. The Committee will support the Board in setting and ensuring that high standards of governance and behaviour are maintained in the conduct of the Trust’s business. As DCHS acquires new services and is involved in new models of care it is essential that the Committee proactively focuses on any specific risks posed by the change and provides assurance to the Board that any areas of concern identified are appropriately managed.

What The Quality Service Committee is chaired by a Non-Executive Director and is directly accountable to the Board. The Quality Service Committee will shape and influence, and is where the major decision making process will take place regarding the Quality Service domain of the DCHS Way. The Quality Service Committee will be responsible for monitoring that the controls are in place and providing assurance to the Board. The Quality Service Committee will review performance of the organisation and agree actions where required. The Quality Service Committee will delegate responsibility for specific aspects of performance and management to a number of sub-groups. These are:

• Clinical Safety Group • Clinical Effectiveness Group • Patient Experience and Engagement Group • Equality, Diversity and Inclusion Leadership Forum • Information Governance Group • Safeguarding Governance Group

QSC will ensure effective monitoring and reporting processes between frontline patient care and the Board supporting a transparent and open culture The Quality Service Committee will work in adherence to the DCHS vision and values.

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Who • Non Executive Director Chair • Non Executive Director • Chief Nurse /Director of Quality • Chief Operating Officer • Medical Director • Director of People and Organisational Effectiveness • Chair – Clinical Safety Group (Deputy Chief Nurse) • Chair – Patient Experience and Engagement Group (Assistant

Director of Quality and Professional Lead for Allied Health professions)

• Chair – Clinical Effectiveness Group (Head of Quality Governance)

• Chair – Equality, Diversity and Inclusion Leadership Forum (Director of People and Organisational Effectiveness)

• Chair – Safeguarding Governance Group (Deputy Chief Nurse)

• Trust Secretary Attendees: All Executive Directors may be in attendance at any of the meetings. Although not a member, the Chief Executive will attend the three sub-committees of the Board (Quality Service, Quality People and Quality Business Committees) on a rotational basis The Committee may require other individuals to attend as named deputies or to offer specific assurance on agenda items. The Head of Staff Partnership Committee and the Chair or Vice Chair of Front Line Care Council attend QSC to enable information sharing and assurance to and from the staff they represent. Clinical Commissioning Group colleagues may be in attendance.

Quoracy Minimum of one Non Executive Director, one Executive Director and two

other committee members, one of whom should have a clinical background.

When The Quality Service Committee will meet monthly either in person or via

conference call. Members are expected to attend at least 9 meetings in a financial year.

Where Committee meetings will be held at DCHS premises or via conference call.

Why To take responsibility, on behalf of the Board for the Governance aspects



of the Quality Service domain of the DCHS Way.

How The Quality Service Committee will shape, influence and produce overall

assurance in relation to the quality of our services. This will involve defining the scope, requirements and pace of the service plans to ensure these are aligned to the delivery of the five year Integrated Business Plan (IBP). This will incorporate the three elements of quality governance i.e. – patient safety, the patient experience and the effectiveness of care in relation to patient outcomes. This will be achieved by:

1. DCHS Quality Improvement and Assurance Framework: • Oversee the production of a Quality Strategy • Develop an annual plan for delivery of the Quality Strategy

ensuring a year on year improvement in quality service delivery

• Monitor delivery of the Annual Quality Plan • Provide assurance to the Board in relation to the delivery of

quality services • Review progress against the DCHS Quality Strategy and

refresh the strategy accordingly • ‘Horizon scan’ for best practice on an international, national

and local basis, incorporating relevant practice into quality service improvement at DCHS.

2. Compliance against regulatory requirements and external scrutiny:

• Provide assurance to the Board in relation to compliance with Care Quality Commission (CQC) requirements.

• Ensure that DCHS maintains CQC registration • Ensure compliance is maintained in relation to the Mental

Capacity Act • Ensure delivery of Deprivation of Liberty and Mental

Capacity requirements and the safeguarding of vulnerable adults

• Ensure compliance against any new regulations or statutory requirements

• Ensure compliance to relevant aspects of Health Acts in relation to :

o Infection, Prevention and Control (IP&C) o Safeguarding of children, young people and adults o Public and patient engagement • Ensure compliance against the Equality Act 2010 and the

Equality Delivery System best practice framework • Ensure compliance with the Quality aspects of Monitor’s

Regulatory Framework • Ensure compliance to the Data Protection Act 1998 and to

the NHS Regulatory Framework in relation to information governance.



3. Performance Framework:

• Maintain oversight and monitoring of quality performance in relation to commissioners

• Oversee and provide assurance to the Board in relation to the performance of DCHS in relation to patient safety, patient experience and the effectiveness of care via a suite of key performance indicators

• Ensure quality across DCHS via the Quality Assurance Framework to ensure “Front Room to Board Room” assurance throughout service delivery areas

4. Controls and Assurance:

• Oversee the controls and assurance that are and should be in place to ensure compliance and the delivery of quality services

• Identify any significant gaps and ensure corrective action • Ensure there is a risk based prioritisation and that actions

are taken to mitigate identified risk, with leads identified and that risks are addressed in a timely manner

• Have overarching responsibility for all risks and review a monthly report provided to each Committee meeting

• Review the risk register on a quarterly basis • Monitor performance against the Board Assurance

Framework for Quality Service, providing assurance to the Board

• Ensure there are effective arrangements in place for managing Serious Incidents

• Ensure there are effective arrangements in place for managing legal issues, including claims, coroners inquests, court of protection and other legal matters

• Have delegated authority from the Board to approve policies in line with the Scheme of Delegation

• Hold to account the subgroups identified by the Quality Service Committee, and commission/decommission any others as required

• Monitor the work programmes of the subgroups, receiving monthly reports

• Ensure that the Board is aware of risks in relation to the strategic delivery of quality services and provide assurance in relation to the management of clinical risk within the organisation

5. Effectiveness of care:

• Oversee the development of a Clinical Strategy which supports the effectiveness of care delivered within the organisation

• Oversee, and monitor the implementation of the Clinical Effectiveness Strategy to ensure that all Patient Outcomes



are recorded and learnt from to improve effectiveness of treatment and care

• Consider the mortality data for the Trust, ensuring any significant variance from expected performance is investigated and any associated risks are reported to the Board

• Embed the emerging Frameworks for NHS Outcomes, Public Health and Social Care within a Key Performance Indicator (KPI) framework

• Ensure that a system of ‘early warning’ is established to identify any negative impact upon the care delivered, taking corrective actions as necessary and ensuring that the Board is aware of associated risk

6. Safety:

• The Quality Service Committee provides the Board with overall assurance on the safety management systems and processes in place, to meet statutory, mandatory, legislative and best practice requirements for patient safety, and environmental and specialist prevention and protection

• The Committee has delegated responsibility from the Board to set and discharge standards of safety and behaviour (in accordance with the Health and Safety at Work Etc. Act 1974 and Health Acts) regarding the Trust business in delivering patient care across all directorates. This includes monitoring delivery of the ‘Safe Care’ agenda (Falls, Venous Thrombo Embolism, Pressure Ulcers and Catheter acquired infections)

7. Patient Experience: • Provide the Board with assurance that patients have the

opportunity to provide feedback, and that their feedback is used for learning and on which to base improvements

• Provide the Board with assurance that people using DCHS services have a positive experience and that exceptions to this are managed appropriately. For example that there is a well led complaints process.

• Provide the Board with assurance that DCHS is actively promoting the engagement and involvement of patients and service users in the work of the Trust, and that the Trust is proactive in involving service users in evaluating, reviewing, monitoring and planning services that we deliver.

8. Vulnerable patients:

• Vulnerable patients will be protected through the development of robust governance arrangements which will meet national best practice and statutory responsibilities. Routine reporting will be delivered through the Safeguarding Governance Group to QSC and the Board.



9. Information Governance:

• The committee also has a remit to provide assurance to the Board regarding information governance

• This Committee will receive reports upon on development and use of the Information Governance Toolkit through the year.

10. Assurance: • The Quality Service Committee is responsible for reviewing

the effectiveness of the controls in place relevant to the risks identified within the Quality Service section of the BAF. The number of risks may vary during the course of the year. The Committee will review and challenge the strength of the assurances that have been provided, identify any gaps in control or assurance and will confirm if the appropriate level of risk has been identified based on the information presented to the Committee.

Sub Committees • Clinical Safety Group

• Clinical Effectiveness Group • Patient Experience and Engagement Group • Information Governance Group • Safeguarding Governance Group • Equality, Diversity and Inclusion Leadership Forum

The above groups will provide a Summary Report from each of their meetings to the Quality Service Committee. Each group will also provide an annual review of performance in line with their Terms of Reference, including the Key Performance Indicators.

Communication Links

The Committee will need to ensure effective communication with the Quality People Committee and Quality Business Committee particularly in relation to risks. The Quality Service Committee will also have a relationship with the Audit and Assurance Committee in the context of its overall role in relation to assurance.

Reporting To The Quality Service Committee will report formally to DCHS Board and

provide assurance to both the Board and the Audit and Assurance Committee. The Chair of the Quality Service Committee will prepare a Summary Report after each meeting which will provide an overview of the meeting and will identify any issues or areas of risk that the DCHS Board or other Committee will need to action/note.



Key Deliverables The Quality Service Committee will also have oversight of the delivery of the following:

• Quality Service Strategy • Quality Governance Agenda • Annual Quality Account • Safety Thermometer • Annual Infection, Prevention and Control Report • Risk Management Process (including incidents) • Annual Safeguarding Report (Partnership Board) • Declaration of compliance and annual CQC registration • 360 Tracker and Delegation of Action Plans • Delivery against commissioning contract and CQUINs • Annual Patient Experience Report • DCHS Equalities Framework and Action Plan • Information Governance Toolkit • Annual Security Report • Quality Service Summary Reports to Trust Board

Review Date May 2017



Summary Report from Quality People Committee Report To: Board

Date: 26 May 2016

Name of Reporting Committee / Group: Quality People Committee


Presenter: Barbara-Anne Walker, Non-Executive Director

Author: David Boddy, Corporate Governance Manager


Key Issues discussed at meeting:

Board Assurance Framework Reference and Level of Assurance Agreed

77/16 Staff story – Organisational Change within Catering Services – the story discussed personal experience during a management of change process in Ash Green. The story illustrated that good support through a management of change process impacts positively on staff and also on patients, especially where personalised care is provided. The Committee agreed the story demonstrated really good practice and took Significant Assurance that DCHS is managing change in an appropriate and person-centred manner. The Chair requested that this story be used in conjunction with another story that was heard at the Equalities event on 16th March at a future Board meeting.


81/16 Strategic Workforce Report - AR provided QPC with an insight into national and local workforce updates including:

• Junior Doctors’ Contract • Health Care People Management Awards (HPMA) - DCHS

has been shortlisted for two awards this year • East Midlands Streamlining project • DCHS Leadership Conference.


82/16 National Staff Survey: DCHS Organisational Action Plan – The Committee discussed the Staff Survey Action Plan, worked up following agreement of the five key areas of focus at March QPC.


83/16 People Performance Report and Priority Areas of Focus - The report now includes the recent staff that TUPE transferred into DCHS i.e. Children's services from Chesterfield, Stockport and Community Services from Derby. This change impacts upon the


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overall DCHS position affecting our performance metrics - for example our appraisal completion percentage has decreased from 94 to 92%. However, the performance (for the whole organisation) in April is in fact better than (for the whole of the organisation) in March. The Committee discussed:

• Planning around agency staff requirements is underway to meet the winter pressures in quarter 4. The impact of increasingly complex ward patients has increased the demand for HCAs. A further report on this issue will be presented to the July QPC

• A review of overridden mileage claims will be undertaken to ensure that they are accurate

• The trend of increasing absence resulting from sickness. The Committee raised concern about the worsening position on this metric throughout 2015/16. The Committee noted the work already focussed on trying to improve this position, but recommended that POE invite an independent individual to review our strategy around this topic to ensure we are doing everything we can do on this matter.

The Committee took Significant Assurance from the People Performance Report with the exception of Limited Assurance regarding sickness absence.

2.1, 2.2, 2.3, 2.4, 2.5 Limited Assurance

85/16 Health and Safety Update - Health and Safety Update The committee discussed Staff Injury Incidents for the 4th Quarter January to March 2016 along with a summary of the year 2015/2016. There had been an increase in the number of RIDDORS and Near Misses reported but the numbers reported remained small. The Committee also noted the high number of incidents involving violence and aggression. The Committee was also updated regarding completed actions to effectively manage the banksman risk. The Committee took Significant Assurance from the report but Limited Assurance from the low number of Near Misses reported and the number of violence and aggression incidents.

2.3 Significant Assurance 2.3 Limited Assurance

86/16 Staffing for Quality Report - The Committee reviewed the report and discussed the future reporting requirements. It was proposed that the full report will come to QPC and that the Board will receive an exception report. Post meeting note – CW confirmed that there is a requirement for the Chief Nurse to also report the information to the Board twice yearly.




87/16 Equalities Update – Progress has been made towards achievement of the Trust’s key equalities priorities. An independent assessment has found that DCHS is achieving EDS2 level.

1.4, 2.5, 4.2 Significant Assurance

88/16 Staff Health and Wellbeing Agenda at DCHS - The work being progressed includes: • Health Needs Assessment in collaboration with Public Health in Derbyshire County Council • Appointment of new Staff Health and Wellbeing Lead • Focus on stress and anxiety The Committee discussed in detail the new national Staff Health and Wellbeing CQUIN including:

• Introduction of Health and Wellbeing initiatives for staff focusing on physical activity schemes, improved access to physiotherapy services and a range of mental health initiatives

• Healthy food for staff, patients and visitors • Improving the uptake of Flu vaccinations for frontline clinical

staff. Achievement against target by Quarter 4 will include a partial payment of 50% for achieving 65% to 74% of target. This will be tracked by reporting monthly data over 4 months from December 2016.

• All three parts of the CQUIN have an equal weighting of 0.25% of the CQUIN value. A risk has been raised regarding the Flu vaccination CQUIN.

QPC acknowledged the progress of the work but took the paper as providing Limited Assurance because of the absence of any outcomes at the present time. QPC will receive follow up reports regarding progress against the CQUIN targets.

2.3 Limited Assurance

89/16 360 Audit Report: Appraisal Management and Incremental Pay Progression - 360 Assurance reported Significant Assurance that the DCHS Appraisals Policy and supporting documentation provide a generally sound system of control but that some weakness in the design or inconsistent application of the policy put the achievement of particular controls at risk. Work to address the inconsistencies includes:

• A refresh of the Appraisals Policy to be presented to QPC • Streamlining appraisal paperwork

2.1,2.2 Significant Assurance

90/16 360 Audit Report: Bank and Agency - 360 Assurance reported Significant Assurance that the Trust has established an appropriate framework for the identification of need and booking of agency workers. However, the review did identify some gaps around compliance with the established framework and that this gap put the system’s objectives at risk and therefore, were only able to provide




Limited Assurance overall. 360 noted that in response to these findings, responsive action to address the gaps identified had been taken by DCHS immediately and thus reported at the exit meeting that control enhancements had been implemented. The Committee reviewed actions being taken to provide further assurance that the findings are being acted upon. 92/16 Staff Partnership Committee Summary Reports March and April - The Committee took Significant Assurance from the work of the committee during the March and April meetings.


93/16 Workforce Planning and Development Group Summary Reports March and April - The Committee took Significant Assurance from the work of the group during the March and April meetings. It was noted that the CQC has commended DCHS for the good work regarding Mental Health Act training.


94/16 Staff Health Wellbeing & Safety Group Summary Report - The Committee took Significant Assurance from the work of the group.


99/16 QPC Annual Review - The Committee discussed the Annual Report for the Quality People Committee (QPC) covering the work of the Committee for the period from March 2015 to March 2016. The Committee took Significant Assurance from the work of the Committee and approved the Annual Report. The Annual Report is attached to the QPC Summary Report for presentation to the Board.


Board Assurance Framework Key Risks: 1.4 There is a risk that DCHS does not provide patient centred care due to a lack of engagement and involvement of service users and stakeholders 2.1 There is a risk of not being able to provide high quality care due to staff not having the appropriate skills and competencies resulting in poor patient outcomes 2.2 There is a risk to patients, service-users and employees due to staff performance and behaviours not being monitored and improved resulting in an adverse impact on the provision of high quality care and organisational reputation 2.3 There is a risk that the Trust fails to develop a proactive Health and Safety culture across the organisation, resulting in the trust not achieving zero harm to staff, visitors, contractors and members of the public 2.4 There is a risk to organisational performance due to the high volume of organisational and health system change, which is likely to continue to be a feature of our health economy for several years



2.5 There is a risk that the Trust fails to build cultural competence and the required level of awareness and understanding across the organisation to operate inclusively and deliver equity of access and outcomes for staff and service users. 3.10 There is a risk to the organisation due to lack of comprehensive data quality systems resulting in poor decisions that could affect outcomes and financial loss. 4.2 There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions

Policies Approved

• Health and Safety Policy • Waste Management Policy • Code of Conduct for Non Registered Clinical Employees

Issues to be escalated to Board or a Committee Highlighted in the Summary Report are:

• 79/16 Lessons Learnt from Organisational Change in the HWBI Division • 88/16 Details of the new national Staff Health and Wellbeing CQUIN • 99/16 QPC Annual Review



Quality People Committee

ANNUAL REPORT FOR THE PERIOD MARCH 2015 TO MARCH 2016 1. SCOPE

This is the Annual Report of the Quality People Committee. This report covers the work of the Committee for the period March 2015 to March 2016. 2. ROLE OF THE QUALITY PEOPLE COMMITTEE As one of DCHS’ key Board sub-committees, the role of the Quality People Committee is central to the good governance of the Trust. The Committee meets on a bi-monthly basis and reports directly to the Board. The membership of the Committee, for the period being reported on, consisted of two Non-Executive Directors appointed by the Board, including the Chair of the Committee and:

Director of People and Organisational Effectiveness Director of Operations/Chief Operating Officer Deputy Director of People and Organisational Effectiveness Chair of Staff Partnership Committee Chair of Workforce Planning and Development Group Chair of Staff Health Wellbeing and Safety Group Chair of Equality, Diversity and Inclusion Leadership Forum Heads of Staff Partnership Trust Secretary Chief Nurse/Director of Quality Lead for Workforce Planning

Membership (March 2015 to March 2016):

Name Title Membership Period

Barbara-Anne Walker Non-Executive Director - Chair March 2015 to March 2016

Chris Bentley Non-Executive Director March 2015 to March 2016

Amanda Rawlings

Director of People & Organisational Effectiveness, Chair of Staff Partnership Committee

March 2015 to March 2016

William Jones Director of Operations/Chief Operating Officer March 2015 to March 2016

142�QPC�Annual�Report�2015�to�Overall�Page�41�of�150Page�1�of�12


Jennifer Guiver

Deputy Director of People and Organisational Effectiveness, Chair of Staff Health Wellbeing & Safety Group


Kirsteen Farrar Trust Secretary March 2015 to March 2016

Nicky Owen / Lynn Booth Heads of Staff Partnership March 2015 to March 2016

Christine Wint/Donna Wilson

Head of Workforce Development and Education; Chair of Workforce Planning & Development Group


Karen Scott Lead for Workforce Planning March 2015 to March 2016

Sally Edwards Chair of Equality, Diversity and Inclusion Leadership Forum March 2015 to March 2016

Carolyn White Chief Nurse/Director of Quality March 2015 to March 2016

3. ATTENDANCE AT QUALITY PEOPLE COMMITTEE MEETINGS

For QPC, a quorum is not less than one Non-Executive Director, one Executive Director and two other committee members. All meetings were quorate. Attendees at the meetings are listed below (please note that Christine Wint’s lack of attendance was due to long term sickness).



The Committee has four sub groups who manage the operational delivery against the People and Organisational Effectiveness Strategy and People Objectives and identify and manage any associated risks. The sub-groups have delegated responsibility for specific aspects of performance and management to and are accountable to QPC. The groups are: Staff Partnership Committee Workforce Planning and Development Group Staff Health Wellbeing and Safety Group Equality, Diversity and Inclusion Leadership Forum

4. REVIEW OF BUSINESS 4.1 People and Organisational Effectiveness Strategy During 2015/16 the Quality People Committee has overseen the ongoing delivery of the current People and Organisational Effectiveness Strategy and provided assurance to the Board that DCHS has the right staff, in the right place, doing the right things:

• Ensuring staff are recruited, trained, qualified and retained to do the roles required • Defining the scope, requirements and pace of the developing workforce plans and staffing

for quality and ensure these are aligned to the delivery of the five year Integrated Business Plan (IBP)

Key achievements in pursuit of achieving progress on our people agenda have included:

Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Jan-16 Mar-16Barbara-Anne Walker

Non Executive Director - Chair X

Chris Bentley Non Executive Director X X X

Sally Edwards

Head of Equality Diversity and Inclusion

X X X

Kirsteen Farrar Trust Secretary X X

Jen Guiver

Deputy Director of People and Organisational Effectiveness.

William Jones Chief Operating Officer X

Nicky Owen/Lynn Booth

Heads of Staff Partnership

Amanda Rawlings

Director of People & Organisational Effectiveness and Chair of Staff Partnership Forum

X

Karen ScottLead for Workforce Planning X

Christine Wint/Donna Wilson

Head of Workforce Development and Education; Chair of Workforce Planning & Development Group

Carolyn WhiteDirector of Quality & Chief Nurse X

Quality People Committee Attendance Record

Quoracy Rules:Minimum of one Non-Executive Director, one

Executive Director & two other committee



• Development and implementation of a Recruitment and Retention Strategy for DCHS • Complete overhaul of our ‘People Report’ to allow for more detailed analysis of our people

metrics in order to support compliance.

To improve understanding of People issues across DCHS the Committee commence each meeting with a staff story. The stories this year included:

• the importance of effectiveness engagement with our bank workers • the benefits of effective appraisals • the Pulse Check Action Plan from the Finance Department as an example of good practice • Allied Health Professionals’ Experiences of undertaking basic observations for patients as

part of holistic packages of care. • experience of a staff member in returning to work following health issues • celebration of a newly qualified occupational therapist who won ‘best graduate’ at the

University of Derby and chose DCHS to commence her career.

4.2 Workforce Plans

QPC has taken a lead role in taking assurance that DCHS has appropriate workforce plans in place and is acting on these. In April 2015 the Committee received the DCHS Workforce Plan - an overview of the profile of the workforce within DCHS over 2014/15 and the workforce assumptions for 2015/2016. This was later shared with Monitor. The Committee then monitored progress against the plan using a bi-monthly Staffing for Quality report, detailing staffing in our inpatient areas (reportable to Monitor), as well as through detailed analysis of our regular People Report, especially focusing on bank and agency expenditure, time to recruit and sickness absence. In addition, a number of specific issues relating to workforce planning were discussed by the Committee, for example:

- A decision was made to trial and then implement 12 hour shifts on Fenton Ward as the People metrics supported this for quality and staff satisfaction reasons.

- The supply of staff to DCHS from agencies – a review of what checks and assurances were in place on these staff.

- Reviewing the frequency of DBS checks in response to the Saville enquiry recommendations

In addition, in April 2015, the Committee were briefed on the pioneering work that DCHS has ben doing on regional workforce planning using an innovative Workforce Planning Modelling Tool. 4.3 Monitoring and Tracking People Metrics Each meeting reviewed DCHS’ performance with respect to all People metrics and the activities to address under performances were discussed and any actions agreed. The POE team were able



to provide assurance on actions already in progress for areas of underperformance and were able to confirm priority areas of focus for the POE team. We undertook a complete overhaul of our ‘People Report’ to allow for more detailed analysis of our people metrics in order to support compliance. This report now focuses on the key people metrics and crucially, provides narrative on each area of compliance to allow the Committee to have a better view of their assurance in relation to each people metric. Implementing this new report has allowed the POE team to be able to implement a series of scheduled ‘Deep Dives’ which go into further detail on a programme of topics which was agreed at the start of the financial year. So far the Committee has received Deep Dives on:

• Sickness Absence • Protected Characteristics • Staff in post • Recruitment • Workforce Planning & Development • Benchmarking DCHS against regional Trusts • New personal file audit programme which Quality Business Services have implemented as

a result of a recommendation from 360 Assurance In October 2015 a specific paper was reviewed to provide assurance on Attendance Management in response to our declining attendance rate at the time.

4.4 Staff Involvement and Engagement The Committee has received and taken assurance on a large number of staff involvement and engagement issues and initiatives. These include:

- The Future Provision of Staff Support Services at DCHS (Resolve) where a decision was made to remodel our existing staff counseling service, rather than outsource it to an Employee Assistance programme service.

- Pulse Checks – we have both reviewed results but also taken assurance on plans to reinvigorate the Pulse Checks and to improve results.

- Staff Survey – we have received the results and Trust action plan for 2016/17. - Extra Mile Awards (EMA) 2015- Learning the Lessons ahead of the 2016 awards - Lessons learnt from the 2016 Flu Campaign and initial plans for the next campaign.

4.5 Response and compliance to external changes Each month the Committee were updated by the Director of People and Organisational Effectiveness regarding highlighted national and local issues via her Strategic Workforce Report including:

• Pensions and NI changes • National flu campaign • Junior Doctors’ contract negotiations • Monitor Agency best practice toolkit • Lord Carter – Operational Productivity and Performance in English NHS Acute Hospitals • East Midlands Streamlining project



• DCHS Staff health needs assessment 4.6 Learning and Development Arrangements The Committee received a number of updates throughout the year within a regular Learning and Education Update Paper which was implemented this year to ensure enough attention was given to this important agenda. Matters discussed included:

• Core Essential Training activity to improve compliance rates • Improvements in Safeguarding Training compliance rates • ESR2 developments for which DCHS is a pilot site • Mental Capacity Act/Deprivation of Liberty Safeguards training • Information Governance workbook • DCHS as a Centre of Excellence for Training and Education Action Plan • ICBS Leadership Development Mentoring Programme • Leadership Development Plans for DCHS • Fundamentals of Care programme • Community Nursing training • Internal coaching programme to support mentors • E-learning Update and Action Plan • Clinical Supervision including Audit Results • Information Governance Training • Gap Analysis of Essential Training. • Assessing the Trust position in relation to the risk regarding whether we have appropriate

workforce planning in place to support the changes anticipated with strategic change • CPR training • School engagement, work experience, traineeship and apprenticeships. • Quality Management Visit from Health Education England (East Midlands • Competency matrices for individual professions

The Committee also received papers in October 2015 and January 2016 from the Chief Nurse to provide assurance on the new Appraisal and Revalidation system for nurses.

4.7 Reports from Subgroups QPC received Summary Reports from its subgroups following each of their meetings. The Committee reviewed the annual performance of the QPC subgroups against their Key Performance Indicators and also agreed the changes to the Terms of Reference which improved alignment with the Board Assurance Framework and the accountability discharged through QPC. QPC significantly increased its assurance this year that these groups were operating in a way that could provide assurance on their subject areas. This was achieved through better reporting in the Summary Reports received from each sub-group. Equality, Diversity and Inclusion Leadership Forum The Equality Diversity and Inclusion Leadership Forum reports to Quality People Committee regarding People related matters and to Quality Service Committee regarding Service related



matters. EDILF ensures that DCHS has an inclusive culture. Issues reported during the year included:

• EDS2 Guidance and draft DCHS Self-Assessment • Healthcare For All (HC4A) Framework and Assurance Updates • DCHS’ plans for employing People with Learning Disabilities • Service User Equality Analysis /Clinical Records Audit Report • Board Equity Action Plan Update • Progress of the research project into the Trusts’ recruitment, selection and retention of

under-represented groups

Staff Partnership Committee The Staff Partnership Committee (SPC) is where people related business is subject to formal consultation and negotiation with the recognised trade unions, professional bodies and other committee members. Some of the issues reported to, and discussed by QPC have been:

• Changes to taxation of lease/business cars • The Staff Discussion Forum on the intranet • Management of change proposals

This group has also made significant progress this year in reviewing and updating key people policies to ensure they are as efficient and easy to use as possible. Workforce Planning and Development Group The Workforce Planning and Development Group has overseen the development and delivery of the trust’s workforce plans and education, learning and development needs, including all essential learning. Highlights from the group’s reports have been:

• Bank staff and the Fundamentals in Care programme • Learning needs analysis 2016/17 • HEEM Quality Management visit

Staff Health Wellbeing and Safety Group This sub-group is responsible for ensuring DCHS staff health, safety and wellbeing. Issues discussed have included:

• Health and Safety Annual Report • Skin Surveillance Guidance • Resolve quarterly and annual reports • Occupational Health Quarterly Reports • Staff Incidents, Near Misses and RIDDORS Report • Emotional wellbeing toolkit

4.8 Compliance to Regulatory and External Scrutiny

360 Assurance Reports The Committee receive any people-related 360 audit reports, despite these also being considered at Audit Committee. This is because QPC receive a report detailing what actions are being taken as a result of the findings and track progress against these actions accordingly. The 360 audits (with associated action plan and assurance) were:



• April 2015 E-Rostering • June 2015 Pay Expenditure • August 2015 embedding good equalities policies and practices • October 2015 Disciplinary, Grievance and Dignity at Work Case Review • October 2015 Expenses Follow Up Report

4.9 Controls and Assurance

• The Board Assurance Framework was reviewed on a quarterly basis. The Committee considered the strategic risks, controls, areas of limited assurance and how to close gaps in order to provide assurance to the Board

• QPC oversees the work of all of its subgroups, receiving regular reports, assurance and annual reports

• The Committee reviewed each paper and identified the levels of assurance and any new risks. They also undertook a Committee self-assessment at the end of each meeting.

4.10 Policies QPC has maintained its delegated responsibility for the approval of key People organisational policies throughout the year and in addition received an update on development of Quality Information Systems. Policies were considered and approved: Probationary Policy, Induction Policy, Registration and Re-registration Policy, Recruitment and Retention Premia Policy, Disciplinary Policy, Electronic Staff Record Policy, Fire Safety Policy, Waste Management Policy, Water Safety Policy, Management of Noise at Work Guidance, Hand Arm Vibration Guidance, Fleet and Transport Management Policy, Supporting Performance Policy, General Code of Conduct Policy, Supporting and Maintaining Attendance Policy, Special Leave Policy, Family Leave Policy, Registration and Re-Registration, Agile Working Policy, Updated Stress Management Policy, The Committee also approved extension of the Health and Safety Policy until October. The Committee also approved the Lone Working Guidance, Manual Handling Standard, First Aid Standards, Young Persons at Work operating standard.

4.11 Issues Escalated/ Referred with other Committees From Other Meetings: Audit Committee April 2015:

• Monitor the closure of the investigation into the supply of staff from agencies • Monitor the effective delivery of DoLS training for staff

Board August 2015: • Review the average cost to recruit people

October 2015 • Priorities for QPC for the remainder of next year and 2016/17 January 2016:



• Risk from visitors and contractors being struck by unaided reversing vehicles QSC August 2015: • Workforce Planning and Development Group to ensure that a training exercise is planned to

catch up with the rollout of IT and for QPC to report back to QSC regarding progress

• Duty of Candour - monitor the delivery of the staff training • Consider the risk to business continuity owing to insufficient staff receiving the flu

vaccination • Staff Health Wellbeing and Safety Group to check the basis of the risk regarding staff skin

health MHAC October 2015:

• Training required to be undertaken by Mental Health and Learning Disabilities staff as a result of the updated Mental Health Act Code of Practice

To Other Meetings Board briefing April 2015:

• Learning and Development Update – regarding Fundamentals of Care programme and the delivery of the Care Certificate

• Staff Health Wellbeing & Safety Group Summary Report - Skin Surveillance Guidance

October 2015: • Use of agency staff • Health & Safety Annual Report to be attached to Summary Report • Longer shifts on Fenton Ward

March 2016: • Benchmarking deep dive results

4.12 Forward Planning The Committee will continue to ensure strong governance arrangements are maintained, and enhanced in 2016/17. In addition to the routine work the Committee undertakes each year, the focus for the next 12 month period will be in the following areas, which have been agreed as the Committee’s strategic priorities for 2016/17: Strategic Priorities Associated Committee

Workstreams Controls and KPIs

1. Effectiveness workforce planning and development to meet our current and future patient needs.

• Ensure our workforce is appropriately skilled to meet the future needs of our population’s health and social care needs.

• To ensure we proactively manage

• Robust internal and external workforce planning process

• To meet the workforce plan trajectories for future staffing (e.g. ACPs)

• Essential Learning compliance • Preceptorship compliance • Care Certificate Compliance



Strategic Priorities Associated Committee Workstreams

Controls and KPIs

our required workforce supply and availability, ensuring the very best care for our patients, delivered by the most appropriate clinician.

• To provide a leadership development offer which ensures our leaders are equipped to lead on the Trust priorities and champion the DCHS Way.

• To ensure DCHS succession plans its current workforce and then manages its talent to ensure we are growing our future workforce requirements by working in collaboration with our local health and social care partners.

• To develop DCHS as a Centre of Teaching Excellence.

• Induction • Robust internal and external

workforce planning process • DCHS and Derbyshire-wide

talent mapping process • Time taken to recruit • Number of repeat

advertisements • Leadership induction • Quality Always Development

Centres • Leading the DCHS offer • DCHS and Derbyshire-wide

talent mapping process • DCHS and Derbyshire-wide

talent mapping process • Deliver on an action plan to

deliver a future pipeline of leaders (the outcome of the above process)

• Centre of Teaching Excellence Action Plan

• HEEM Quality Visit findings and resultant Action Plan.

• Grow our Primary Care training involvement following successful acquisition of a ‘training practice’.

2. Ensuring DCHS

maintains its excellent staff engagement and grows this further.

• To continuously improve staff engagement, involvement and participation in the context of our rapidly transforming health and social care environment.

• To support leaders

• Staff Forum engagement and participation

• Close Staff Partnership working • Staff engagement score • Staff Survey action planning • Pulse Check action planning • Organisational Change Policy • Dedicated POEM support to

each MOC process • Each MOC scrutinized at SPC




Controls and KPIs

and staff who are delivering and are impacted by organisation and system change

prior to commencement • Number of staff redeployed after

being put ‘at risk’ • Number of Grievances as a

result of organizational change.

3. To build cultural competence and awareness across DCHS to ensure we deliver equity of access and outcomes for staff and service users.

• Equality Action Plans • Board Equality Action Plan • People Services/Recruitment

Equality Action Plan • New Equalities Forum • EDILF • WRES compliance • DCHS demographics vs

Derbyshire-wide demographics

4. To ensure DCHS is compliant with health and safety legislation and builds a zero harm environment.

• Health and Safety strategy

• Stay Safe campaign

• Health and safety training for both staff and managers

• Safety frequency rate (FR)-This is calculated by the number of lost time accidents x 1,000,000 / total number of hours worked each month.

• Safety severity rate (SR) - This is calculated by the number of day’s lost x 100,000 / total number of hours worked each month.

• The Lost time injury cost- This is calculated by the days lost each month x by the average hourly cost in the trust.

• Zero Harm- Riddor Reportable Injuries.

• % of managers who have received Health and Safety training

5. To ensure DCHS proactively acts to understand and support the wellbeing of its

• Completion of a Health Needs Assessment of our workforce

• Achievement of the national CQUIN re:

• Health Needs Assessment findings

• Resolve Staff Support service • Occupational Health

Department




Controls and KPIs

workforce

staff wellbeing • Delivery of Health Needs Assessment findings Action Plan

5 REPORTING TO BOARD

QPC reported formally to DCHS Board and provided assurance to both the Board and the Audit and Assurance Committee. The Chair of QPC prepared a Summary Report after each meeting that provided an overview of the meeting and identified any issues or areas of risk that the DCHS Board or other Committee needed to action/note. The Annual Report demonstrates the added value that the Committee brings to the governance of the organisation. It is the Committee’s view that this added value is delivered in an efficient manner. QPC reflects on its own performance by ensuring that members self-assesses their performance at the end of each meeting. In addition continuity of events and cross referencing of important issues to and from other key committees are also considered at each meeting. 5.1 Terms of Reference The Committee reviewed and approved its Terms of Reference in January 2016. The performance of the sub groups of QPC was reviewed in October 2015 to ensure they effectively met the needs of the organisation in its quest to delivery of the People and Organisational Effectiveness (OE) Strategy. 5.2 Annual Report of the Committee This Annual Report summarises the work of the Committee for the period March 2015 to March 2016. This report will be presented to the Board.



Summary Report from Council of Governors Report To: Board

Date: 26 May 2016

Name of Reporting Committee / Group: Council of Governors


Presenter: Barbara-Anne Walker

Author: David Boddy


Key Issues discussed at meeting: Include:

• Brief summary of issue • Decision made/action to be taken • Agenda number and title of paper • Risks identified

Board Assurance Framework Reference and Level of Assurance Agreed

52/16 Patient Story - The governors discussed the positive impact of the musculo-skeletal physiotherapist in the Creswell Primary Care setting in North East Derbyshire. The meeting discussed a range of issues regarding access to services for patients living in rural communities with a low socio-economic status and made suggestions how communications to patients about our services could be improved.

The story was received for information.

54/16 Quality and Performance Report Quality Report – the Council discussed:

• The Care Quality Commission inspection • The triangulation review • The Quality reasons for the closure of the Ilkeston Endoscopy

Unit • The potential impact of the new procurement regulations on

the Vanguard initiative Regulatory Performance Report Performance against the regulatory performance indicators for the month were all RAG rated green. The position for month 12 showed that the Trust had no area of risk with a red rating. Finance Report The Trust reported a surplus position of £2.65m for the financial year, which slightly exceeds the Trust’s forecast plan of £2.6m. Subject to audit confirming the figures, the Trust has met all its statutory financial duties for the year. The Council discussed:

• The difficult national financial setting and how DCHS have

The paper was received for information.

143�Council�of�Governors�SummaOverall�Page�53�of�150Page�1�of�3


appropriately managed the year end accounts with respect to judgements about future liabilities

• Management of the slippage on the capital programme

Big 9 The Council discussed in detail the 94% completion of quality annual appraisals against the target of 100%. 55/16 Annual Quality Report Draft 9 - The Council was updated regarding the progress of the report. The governors reviewed the draft report and made recommendations. The Council also talked about the strategic thinking behind potential DCHS involvement in future Primary Care opportunities. The report was received for information


56/16 Mental Health Act Committee (MHAC) BAW described the work of MHAC including:

• The work of the Associate Mental Health Act Managers. • The work achieved by the Committee in 2015 • How DCHS compliance has been strengthened

BAW highlighted the work for 2015/16 including :

• Compliance with the new Mental Health Act Code of Practice – good progress has been made against what is a huge task

• 360 Audit – MHA compliance – the audit provided very positive results

• MHA training compliance – there are less than 12 staff that remain to be trained

• Restrictive interventions – how they are secured consistently across the Trust

BT discussed in more detail the work of the Associate Mental Health Act Managers (AMHAMs).

The content of the presentation was received by the Council

57/16 Updates from Governors Groups - The Council received the following updates: Governance Group: received observational feedback from the March Board meeting about how well the Non-Executive Directors challenged the Board; plans to attend each Board meeting and a number of Quality Committee meetings; how governors can support the governor election activities. Strategy Group: discussed Equality Diversity and Inclusion with respect to the Monitor Operational Plan guidance; the Operational Plan; and the Big 9, particularly with respect to the Information Management and Technology connectivity target.

The updates were received for information.



59/16 DCHS Operational Plan 2016/17 - The Council reviewed the Operational Plan. The Council discussed:

• Workforce plans with respect to the impact of transformation of services

• Place based care

The report was received for information

60/16 Chief Executive’s Report – highlights included: progress with transformation initiatives; system collaboration regarding tissue viability equipment ordering; and the forthcoming Extra Mile Awards.


62/16 Audit and Assurance Committee Terms of Reference - The Council of Governors was consulted on the Terms of Reference for the Audit and Assurance Committee.

The paper was received for discussion.

63/16 Nominations and Remuneration Committee Summary Report - The Council discussed and approved the proposed process for the governor membership of the Nominations and Remuneration Committee. It was agreed that in order to support the continuity of membership, the elections for the committee will arranged for November 2016 following the conclusion of the governor elections in September 2016.

Paper for decision.

64/16 Trust Secretary’s Report – the Council discussed: • The Council of Governors Self-Assessment • The updated Council of Governors Register of Interests

The paper was received for information. The Council also approved the updated Terms of Reference.


65/16 Report from the “Governor Focus” 2016 Conference – the Lead Governor shared with the meeting the experience of the National Conference for Foundation Trust including:

• Presentations reflected on the difficult economic environment that NHS Foundation Trusts currently experience

• That the DCHS Council of Governors was performing well compared to others


Policies Approved None. Issues to be escalated to Board or a Committee None.



Summary Report from Charitable Funds Committee

Report To: Board

Date: 26 May 2016

Name of Reporting Committee / Group: Charitable Funds Committee


Presenter: Prem Singh

Author: Gary Roe

Key Issues discussed at meeting Board Assurance Framework Reference and Level of Assurance Agreed

45/16 - Rhoslan, Lime Avenue, Ripley – Update - update on the developments in relation to the transfer to DCHSFT of Rhoslan, a property in Ripley. DCHSFT have now had formal notice that the property has transferred from NHSPS to DCHSFT. Rhoslan is subject to a number of constraining conditions around its use in relation to the terms of the original gift of Rhoslan. DCHS Charitable Fund Committee to take the lead responsibility for future decisions and any relevant communications in relation to the future use or disposal of Rhoslan. From a physical condition perspective, there has been a steady deterioration of the property, it is not fit for purpose and has been vacant and un-used for a number of years. These issues have been maintained as much as is practicably possible, but will continue to be an ongoing burden and cost pressure for the Trust. Legal advice to be sought from the Charities Solicitor regarding the potential to demolish the building and extend the car park. There are safety concerns over the building due to its poor condition and has been identified that the building contains levels of asbestos and it was locked down from a staff point of view. Further piece of work to undertaken regarding an options appraisal, to include detail of the cost of demolition, valuation to sell and cost of building carpark. The committee received the paper for information 46/16 Update on Communication and Marketing for DCHS Charitable Trust - communications and marketing team had been working on the following key areas and actions proposed from the Charitable Trust Committee; Screen saver, leaflet print quantity, web pages both internal and external, charitable Funds process, charitable Funds application form, inclusion of case studies in promotional material. Piece of work to be undertaken and presented to next committee around benefits of an in house electronic donation system or using a third party, i.e. just giving. The committee received the paper for information and approved the next steps

Received for information Received for information

144�Charitable�Funds�CommitteeOverall�Page�56�of�150Page�1�of�2


48/16 Financial Reporting and Investment Performance - Quarter Four - provided details of the Charity’s financial position as at 31 March 2016.

• Receipt of income totaling £34,565, with £28,846 relating to donations and legacies and £5,719 investment income.

• Expenditure in the quarter totalled £61,967, with £48,988 supporting charitable purchases.

• Expenditure exceeded income in the quarter by £27,402 in furtherance of the charity’s objectives.

• The Charity had a cash balance as at 31 March in excess of £101,000 with minimum working capital balances (to be reduced in line with approved reserves policy)

• Value of the investment portfolio reduced by £6,111 from the previous quarter’s performance.

• Year to date the total capital value of the investment portfolio has reduced by £19,090 or 3.99%.

The committee took significant assurance from the paper 50/16 Reporting Progress on Approved Funding - update the Committee on progress against the four schemes (over £10,000) approved by the committee in the last eighteen months; Refurbishment of Sensory Rooms, Ash Green – Total Spend £46,193.60, Conversion of Treatment Room, Buxton Hospital – Total Spend £20,293.38, Carers Project – Total bid approved - £54,700, Volunteers Project- Total bid approved - £58,000. Updates were positive but committee commented that that there needed to be more data and qualitative information in the updates, i.e. how many patients have been seen at Buxton Hospital that would have otherwise had to go to a different facility? The committee took significant assurance from the report, albeit with the need for future reports to contain additional qualitative and quantative information 54/16 Charitable Funds Committee Forward Planner - The committee approved the 2016/17forward planner.

Significant Assurance Significant Assurance

Policies Approved None Issues to be escalated to Board or a Committee None

144�Charitable�Funds�CommitteeOverall�Page�57�of�150Page�2�of�2


Summary Report from Mental Health Act CommitteeReport To: Board

Date: 26 May 2016

Name of Reporting Committee / Group: Mental Health Act Committee


Presenter: Barbara-Anne Walker

Author: Gary Roe



32/16 Patient Story - story explained the journey of a patient who had come into the OPMH service at Riverside Ward and how staff worked as a team, recognising their own limitations in supporting the patient to find a better solution to meet their care needs. Concerns around the 117 aftercare process, appointing appropriate Social Workers in individual cases and the impact that this has on discharging patients in a timely manner were raised. These concerns to be addressed as part of the Transformation Services workThe committee received the patient story for information

34/16 360 Assurance Audit – Mental Health Act Compliance – Action Plan - paper provided the committee with an update on the Trust response to actions arising from 360 Assurance Internal Audit and work being progressed to support this. Three outstanding actions for completion around MHA Rights and Restrictive Interventions. Work is underway on the outstanding action and they were discussed as separate agenda items at MHAC. The committee took significant assurance from the paper

35/16 MHA Rights Form – request made to the committee to approve a new MHA rights form for an initial 6 month trial period. New form details patients’ rights individually rather than generically and is in line with 360 Assurance recommendations and the revised MHA Code of Practice. The committee approved the MHA Rights form

36/16 Update on Mental Health Act Patients (MHA) in DCHS Care - outlined the use of the MHA within DCHS during quarter 4 of the financial year.Key points from the report;

There have been no lapsed Sections.

4.4 (risk due to non-compliance of the MHA 1983 resulting in poor patient outcomes and breaches in legislation) Significant Assurance


145�MHAC�Summary�Report.docxOverall�Page�58�of�150Page�1�of�7


Section 5(2) was used once and was in place for 3 hours and 10 minutes.

One CTO patient was recalled to hospital (the CTO was subsequently revoked).

Section 62 was used twice. Once for when a T3 was not in place within the required time limit and once for a patient who had their CTO revoked whilst in hospital on recall.

There were no instances of seclusion. Ten AMHP reports were not left on the wards at the time of

a patents detention under the MHA. The MHA administration module within System One goes

live on 23rd May 2016The Committee took significant assurance from the paper but it was noted that the specific assurance regarding AMHP reports was limited

37/16 - MHA Code of Practice Update - provided an update on the work being progressed in support of ensuring that DCHS will be compliant with the revisions to the MHA 1983 Code of Practice (CoP) that came into effect on 1 April 2015. Further updates being made to the Violence, Aggression and Restraint Policy in line with guidance. The committee took significant assurance about the action plan in place and the compliance around the CoP

38/16 Update on Reporting of Restrictive Interventions - Trust are developing a governance process for the reporting of the use of restrictive interventions. In addition to localized reporting at ward/department level, the process will enable a pragmatic approach to reporting the use of restrictive interventions through to Trust Board, in accordance with the NICE guidance.Challenges around external review, in it could be challenging for the Trust to include a service user as part of a review team which may be frequently called upon to conduct such reviews. Visit to take place as soon as is practicable with a neighbouring organisation which provides similar mental health services to those of DCHS in order to share good practice ideas, to include how they manage their governance requirements in respect of the use of restrictive interventions. Trust has in place an interim approach whereby we call upon the external review of individual cases of restrictive interventions being used, being supported and undertaken by the DCHS senior Prevention Management of Violence and Aggression trainer. Information regarding restrictive interventions will be reported on at the next MHAC meeting and will subsequently be fed into the Board.The committee took significant assurance from the processes being put in place but could not be assured regarding the outcomes at this point of the work

39/16 Updated Terms of Reference - updated following discussions at the previous MHAC meeting regarding the reporting of all instances of the use of restrictive intervention. Other minor





amendments agreed at the meeting. Terms of Reference attached to the summary report.Terms of Reference were approved

40/16 Associate Mental Health Act Managers – Audit Visits - all the audits had shown good practice and care for the patients, as well as a good compliance with the MHA. Inconsistency with the striking through of out of date section 17 leaves forms. The committee took significant assurance from the audits

43/16 Legal Issues Report - update given on the one coroner’s case that is on-going. The committee took significant assurance from the paper

47/16 Matters Referred from other Committees - the committee agreed on the following KPI for Performance Reporting at Trust Board;

AMHAM Audits to be carried out twice a year to all our in-patient OPMH and LD areas

Rationale for this was that the audits cover a lot of the MHA compliance issues and if they are being completed and the wards are achieving good results then this would reflect good compliance with the MHA.

50/16 Board Assurance Framework (BAF), Risk and Self-Certification Issues - items for assurance from the previous meeting had been updated on the BAF and any items for assurance from the meeting would be added to the BAF. The Committee took significant assurance from the paper



Policies ApprovedNoneIssues to be escalated to Board or a CommitteeMHAC Terms of Reference - attached



DCHS Mental Health Act Committee

Terms of ReferenceMay 2016

What The Mental Health Act Committee (MHAC) will provide assurance to the Board that confirms the experience of all of our patients is fully compliant to the Mental Health Act 1983 (MHA).

The MHAC has delegated authority from the DCHS Board to ensure that controls are in place to support the achievement of DCHS’s business objectives and statutory responsibilities, whilst minimising its exposure to corporate, financial and clinical risks.

The MHAC will work in adherence to the DCHS vision and values.

Who The membership of the Committee will be:

Chair - Non Executive Director

Deputy Chair - Deputy Trust Secretary

Associate Mental Health Act Managers (AMHAM) The Committee may require other individuals to attend as named deputies or to offer specific assurance on agenda items:

Director of Quality/Chief Nurse

Learning Disability Services (LD) Matron

Older Peoples Mental Health Services (OPMH) Matron

General Manager - OPMH or General Manager - LD or other senior manager

Named Nurse Safeguarding Adults

Compliance Manager

Quoracy Chair (or appointed Deputy) and a minimum of two AMHAMs to be in attendance.

When The MHAC will meet 4 times times a year. Additional extraordinary meetings will be called as and when necessary.

Members are expected to attend at least 2 meetings in a financial year.

Where Committee meetings will be held at DCHS premises.



Why MHAC is integral to the DCHS governance framework and has particular responsibility to manage the risks which are associated with the organisations statutory duties under the MHA. It is important to ensure that the governance processes are linked to provide a sound framework to support the organisations activities, to provide assurance to the DCHS Board that systems and processes are in place to ensure patient safety and patient experience minimise the possibility of corporate failure and to identify and manage any potential problems at an early stage.

How The duties of the Committee are:

Mental Health Act To oversee the administration of the MHA by the Trust and its officers

(with delegated responsibilities under the 1983 ‘Act’) in accordance with the ‘Act’ and the MHA Code of Practice.

To exercise the power of review of detention of patients granted under the terms of the MHA to the ‘Managers’ of the Trust.

To exercise the powers of discharge of detained patients granted under the terms of the MHA to the ‘Managers’ of the Trust.

To ensure the organisation complies with the MHA and oversees the implementation of and subsequent ammendments to MHA legislation, guidance and best practice, in its duties as the ‘Statutory Responsible Authority’.

To be informed of all relevant visits by external bodies with regard to compliance with the MHA.

To receive an assurance that external reports and their recommendations with regard to compliance against the Mental Health Act are being implemented and performance managed.

To be responsible for the development, review, implementation and monitoring of MHA polices and procedures to support and ensure compliance with MHA legislation.

To ensure visits to the in-patient areas provided by DCHS are carried out twice a year by the Associate Mental Health Act Managers and that the visit audits/reports are received by the committee. The purpose of the visits is to ensure that there are systems and processes in place in support of the correct administration of the MHA in accordance with the ‘Act and the Code of Practice’, as well as challenging the appropriateness of the care environments and the quality of the care delivered in those environments.

To receive the reports of the visits of the Care Quality Commission (CQC) to the LD and OPMH in-patient areas and in addition, consider critically, the responses to these individual reports required to be made to the CQC by the responsible service managers and including the



formal plans showing the actions that have been taken.

To ensure there are systems in place to develop and deliver high quality care for the patients and clients of DCHS covered by the aforementioned Act, including compliance with the CQC Registration against the Essential Standards of Quality & Safety.

To review Serious Incidents (SIs) pertaining to OPMH and LD in-patient areas, highlight any areas of concern or of notable practice and review and act on summary reports of Incidents, Patient Experience, Coroner’s Inquests, Court of Protection and Claims in relation to compliance with the MHA.

To ensure that information regarding the MHA, their detention under the Act and rights of appeal is accessible for users in accordance with Section 132 of the Act.

Ensure appropriate training and support of relevant officers of the Trust (as outined in the Trust Scheme of Delegation) to enable them to carry out the duties and responsibilities delegated to them by the ‘Hospital Managers’ in accordance with the MHA Code of Practice, in order to ensure patients legal rights and safety.

To review and monitor the use of the MHA within the Trust, noting and where relevant investigating, any emerging trends in relation to service, age, gender, ethnicity and cultural background.

To receive an assurance that all restrictive interventions used within the Trust are carried out in compliance with the MHA Code of Practice and associated guidelines

Assurance:The MHAC will be responsible for monitoring that the controls are in place and providing assurance to the Board on the following Risks and Controls in the Board Assurance Framework:

“There is a risk to the organisation due to non-compliance of the administration of the MHA resulting in poor patient outcomes and breaches in legislation.”

Controls:1. A system to ensure that clinical governance controls are in place2. A system to ensure that quality governance controls are in place

Sub Committees None

Communication Links

Trust BoardQuality Service CommitteeQuality People CommitteeQuality Business Committee



Audit and Assurance CommitteeCouncil of Governors Safeguarding MeetingsOPMH and LD Governance MeetingsClinical Effectiveness Group (CEG)

Reporting To The MHAC will report formally to DCHS Board and provide assurance.

The Chair of the MHAC will prepare a Summary Report after each meeting which will provide an overview of the meeting and will identify any issues or areas of risk that the DCHS Board or other committee will need to action/note.

An annual report will be produced for the Board.

Key Performance Indicators

AMHAM Audits to be carried out twice a year to all our in-patient OPMH and LD areas

No lapses of sections for detained patients All deaths of detained patients referred to CQC Compliance with the Mental Health Act Code of Practice No unrectifiable errors on section paperwork Patient hearings are dealt with in a timely manner

Review Date September 2016



TRUST BOARDDocument Title: Quality Report

Presenter/Title: Carolyn White, Director of Quality / Chief NurseContents of Paper were previously discussed by:

Quality Service Committee (QSC) and a variety of other groups and forums across DCHS

Author Jo Hunter, Deputy Chief NurseContact Email and Telephone Number:

Carolyn White [email protected] Hunter [email protected]



Has an Equality Impact Assessment been undertaken Yes No X

Document is for:(more than one box can be ticked) Information X Decision X Assurance X

Purpose of Paper

This report is brought to Board to provide an update on key issues across the Quality agenda.

The Staffing for Quality information and exception reports can be found in Appendix 1.

Recommendations

Board is asked to receive and discuss the report and agree the levels of assurance provided across the areas of the Quality agenda covered by this report.

The Board is asked to approve the Deputy Chief Nurse providing the organisational response to the Department of Health consultation on changes to the Nursing and Midwifery Council’s (NMC) legislation.


2.1 There is a risk of not being able to provide high quality care due to staff not having the appropriate skills and competencies resulting in poor patient outcomes4.1 There is a risk to the organisation due to not having strong corporate governance systems in place resulting in Trust vision not being delivered4.2 There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions

Financial Impact

Detailed within the Safer Staffing reports is information related to additional staffing costs used for bank and agency staff on our inpatient wards.

146�Quality�Report.docxOverall�Page�65�of�150Page�1�of�25





1.0 The National Agenda

1.1. Fix Dementia Care The Alzheimer’s Society are launching a new campaign, Fix Dementia Care, after a joint survey of 285 care home managers found that 44% did not feel the NHS provided residents with dementia with adequate and timely access to secondary care, and 45% did not feel residents had adequate access to mental health care. The report found GPs were charging one in five care homes for treatment, with costs totalling up to £26m a year for care and violating the principle that NHS care should be free at the point of delivery. The Fix Dementia Care campaign is calling for an end to GPs charging care homes; the government to enforce the NHS constitution so that people with dementia in care homes have equal access to treatment; and that the government supports improvements in the availability of district and community nurses in care homes.

Implications for DCHS: DCHS provides care to a significant number of frail elderly patients many of whom have dementia and live in care homes. As the campaign gains momentum DCHS may have to consider how it could affect the care provided by the Primary Care Practices and Integrated Community Services.

1.1.2 World Health organisation (WHO) annual Clean your Hands CampaignEvery year since 2008, WHO has called out to all those working in health care across the world to demonstrate their commitment to clean hands at the point of care. The foundations are based in campaign and social marketing theory, as well as the clear evidence base on the burden of healthcare associated infections (HAI). The result is a demonstration of global solidarity that helps keep hand hygiene firmly on national and local agendas. And each year, the WHO campaign aims to target an area which remains to be an issue for high, middle and low income countries alike in terms of patient safety. This year, in 2016, the focus is slightly different as it is on the role of hand hygiene in surgical care, a very specific but important area of health care, knowing that surgical site infections are the most common HAI worldwide.

Implications for DCHS: In preparation for this day The Infection Prevention & Control team spent a full day (13th April) focussing on Surgical hand hygiene and the implications of the Code for Prevention of Infection.

1.2 Department of Health

1.2.1 Changes to the Nursing and Midwifery Council’s (NMC) legislation. The Department of Health has begun a consultation which is seeking views on changes to the Nursing and Midwifery Council’s (NMC) legislation. These changes will modernise midwifery regulation and improve the effectiveness and efficiency of fitness to practise processes. The proposed changes include the removal of the additional tier of regulation for midwifery, which is confusing for patients and the public. As you will be aware, we sought these changes following reports which confirmed that the current arrangements were not appropriate for public protection. The proposed changes will improve confidence in the system of regulation and strengthen public protection. Midwives are concerned that the NMC might be proposing to remove some of the important things that make midwifery a unique and distinctive profession. These changes do not alter the status of midwifery as a distinct profession with its own standards. There will be no change to the protected title of midwife, and delivering a baby remains a protected function for a midwife or a medical practitioner. There are also no changes to the scope of midwifery practice, which is reflected in


http://www.nationalhealthexecutive.com/News/Care-homes-call-for-more-nurses/23857

http://www.nationalhealthexecutive.com/News/Care-homes-call-for-more-nurses/23857


the Standards for competence for registered midwives and the Code.

Proposed changes to fitness to practise processes The proposed changes to NMC fitness to practise functions will provide greater flexibility in resolving cases at the end of the investigation stage of the fitness to practise process. These changes will improve the efficiency of processes and lead to the swifter resolution of complaints and investigations, whilst also improving patient protection and public confidence in nursing and midwifery regulation. The changes will enable the NMC to better balance resources between fitness to practise work and the other core functions: education, standards, registration and revalidation. The consultation closes 17 June 2016 and individual nurses/midwives and provider organisations have been asked to make comment.

Implications for DCHS: DCHS does not provide Maternity Services however a small number of Direct Entry Midwives are working as Health Visitors. The proposed changes shouldn’t affect these Midwives as the proposed changes remove Statutory Midwifery Supervision. The proposed changes to the fitness to practice processes should improve the timescales for NMC decisions regarding DCHS nursing referrals and should be welcomed.

1.3 NHS England

1.3.1 Review of Adult Intercollegiate Document This important Safeguarding Adults Document is currently being reviewed by the Royal Colleges. Once this process is completed the Statutory document will be published later in the summer.

Implications for DCHS: All the Safeguarding Adults Policies and training will require review to ensure compliance.

2.0 Local Agenda

2.1 CQC Inspection During the weeks 9-20th May 2016 CQC has visited DCHS to inspect across all services provided. Overall the inspection progressed well we had in excess of 70 inspectors who visited and revisited services across the trust. Large volumes of additional data were requested during the inspection week and continue to be received by the trust. All data request during the inspection week have been submitted within the given timescales. Generally we received positive comments regarding our services, inevitably with such a thorough inspection, areas for improvement were identified. High level verbal feedback at the end of week 1 was provided to the senior team and is reported in the Chief Executives report. Dental services were not inspected during this timeframe due to CQC being unable to filed a specialist dental advisor. Dental services inspection have been rescheduled for week commencing 23rd May 2016 and will form part of the overall report and ratings.Looking forward we will be collating feedback from staff across the organisation regarding CQC observations and endeavouring to develop an early action plan ahead of the formal report so that we can start to progress changes required. The development of the action plan has commenced and progress will be reported and monitored via QSC. The draft CQC reports are expected in early July and there will be a 10 day period for accuracy checks to be undertaken. Subsequently we will be advised of the formal date of publication. A Quality Summit is provisionally scheduled for 19th August 2016.

2.2 Reflective PracticeReflective practice is an important part of safe practice and governance for all professionals and has become a fundamental aspect of the NMC’s requirement for revalidation. A training development day on reflective practice was held by the trust on 19th May 2016 and was oversubscribed in terms of attendance. The session included presentations on clinical


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http://tools.nmc.org.uk/page/m/67afe403/5a31ada8/38faf1c2/707e5e90/198314952/VEsF/


supervision, supervision of students, support from POE and models of supervision and reflective practice.

3.0 Staffing for Quality (see Appendix 1) DCHS is currently in the process of deescalating its additional winter provision of beds. We have over the last month seen closure of beds due to outbreaks of Norovirus in some areas which has impacted on bed availability across the trust. It is worth noting that an experienced Director of Nursing acting as a specialist advisor for the CQC reviewed in detail inpatient staffing and commented on the appropriateness of the staffing ratios being utilised.


What are the Governor involvement implications?

The Chief Nurse presents a paper covering the Quality Agenda reflected in this report to the Council of Governors. Governors may be involved in some of the pieces of work reported in this paper.


Individual items within this report will have implications for Equality and Diversity. It is always possible to present the information in more accessible formats should this be required.

What are the Patient, Public, Staff, Member and Stakeholder involvement implications?

The report covers Clinical Quality which impacts on Patients, Public, staff and in many cases will have stakeholder implications.

Risk Register

Is the issue on the current Risk Register? No

Does this update recommend a change in the current risk score? (If so, please provide your rationale below) N/A



Appendix 1 Staffing for QualityAshgreen – Hillside

Now reported as site as staff work across the units dependant on bed occupancy and acuity



Ash Green – Valley View

Now reported as site as staff work across the units dependant on bed occupancy and acuity. This information should be reviewed alongside Hillside data.



Ash Green Site

Ash green has 2 wards on site, Hillside offering assessment and treatment and Valley View offering social short breaks

There is currently one ward manager at Ashgreen who covers across both wards

Due to the acuity of patients fluctuating staff are working across the site to meet patient need and bed occupancy giving consideration to skill mix required at any given time

Due to the high levels of patient acuity on Hillside this area has qualified nurses at all times and they cover valley view when required ensuring best use of staffing across the service

There has been no bank and agency use as staff work flexibly to cover demand146�Quality�Report.docxOverall�Page�71�of�150Page�7�of�25


Babington Hospital - Baron Ward

Bed occupancy has fluctuated dependant on demand .There has been some high patient acuity requiring increased staffing

Where shifts have not been filled by bank some agency support has been required .Occupancy is averaged out so there are times when it looks as if there is overstaffing but this relates to when extra support is needed for 1-1 /increased acuity and is mainly a requirement for HCA to support this demand for closer observation146�Quality�Report.docx

Overall�Page�72�of�150Page�8�of�25


Bolsover Hospital - Hudson Ward

There has been fluctuations in bed occupancy and increased beds due to demand,there is also an increased patient acuity with patients requiring extra support and some 1-1 support

Where possible these shifts have been filled with bank but some agency has been required mainly for HCA to support extra observational and care requirements



Cavendish Hospital - Fenton Ward

There has only been a very small amount of bank used in this area and no agency use

Staff in this area work long days



Cavendish – Spencer Ward



Cavendish Hospital Site

Staffing levels are dependent on patient acuity which can fluctuate Bank has been used to enable flex of staffing levels as required

There has been some HCA agency to support additional observational/care requirements



Clay Cross Hospital - Alton Ward

There has been some high patient acuity in line with seasonal demands on beds .There is also some staff vacancy within the area at present agency use has been minimal

However the ward are reporting pending vacancies



Ilkeston Hospital - Heanor Ward

There has been some bank and agency use due to vacancies which are open to recruitment and flex in beds to meet demand .Responsive workforce are providing additional cover on this ward due to increasing beds for seasonal demands.



Ilkeston Hospital - Hopewell Ward

Staff utilised across site Responsive workforce are providing additional cover on this ward due to increasing beds for seasonal cover There has been some bank and agency use



Ilkeston Hospital Site

All grades of staff work across site to provide appropriate cover especially at night the wards alternate cover to ensure one RN on each ward and an extra person across the wards

Extra staffing has been provided to meet the higher acuity of patients mainly HCA at night



Newholme Hospital - Riverside Ward



Newholme Hospital - Rowsley Ward

Due to fluctuations in bed numbers due to demand some bank and agency use has been required and is assessed dependant on acuity. There is support from responsive workforce.

Extra staffing has been used at night to ensure safety and to meet increased observational requirements



Newholme Hospital site

Due to variations in specialism on the wards at Newholme hospital staff do not work across the wards but this graph shows staffing on site for emergency planning only



Ripley Hospital – Butterley Ward

Due to vacancies with active recruitment bank and agency has been used responsive workforce are supporting in order to ensure quality and reduce agency

To to acuity extra HCA support has been required which has been met through bank and agency



St Oswald’s Hospital – Okeover Ward

There has been an increase in HCA shifts sent to bank and agency this is due to fluctuations in bed numbers and high patient acuity and some unfilled vacancies that have been advertised

There is support from responsive workforce



Walton Hospital - Linacre Ward

There are currently some HCA vacancies which are open to recruitment and maternity leave. Bank HCA were used to cover some of these shifts following review of acuity and occupancy. Some HCA Agency required.

Staff continue to flex staff across both wards to meet service and patient need

There are some RMN vacancies open to recruitment



Walton Hospital – Melbourne Ward

Due to vacancies which are open to recruitment and unavailability due to maternity leave bank staff were used to cover some of these shifts following review of acuity and occupancy. Melbourne have a number of high acuity patients. Some HCA Agency use required when unable to cover from Bank.

Staff continue to flex staff across both wards



Walton Hospital Site

All Grades of Staff flex across both wards to maintain Staffing levels. Bank is used due to patient acuity/ vacancies – however-this is HCA bank/agency only and not for RN’s. Nights when required flex 3 RN to cover both wards. There were a couple of Nights where RN numbers have been below 3 at night due to unavailability but there is always one RN on each ward . Staff flexed across site to ensure numbers at required level with HCA.

A number of HCA vacancies are open to recruitment which will reduce Bank/Agency usage. RN vacancies open to recruitment but these are hard to fill posts with rolling advert.



Whitworth Hospital – Oker Ward

Some bank use following planned increase in beds for seasonal occupancy and fluctuations in acuity

There has been a small amount of agency use mainly for HCA



TRUST BOARDDocument Title: Audit and Assurance Committee Terms of Reference

Presenter/Title: Kirsteen Farrar, Trust SecretaryContents of Paper were previously discussed by:

Audit and Assurance Committee – April 2016Council of Governors – May 2016

Author/Title: Kirsteen Farrar, Trust SecretaryDavid Boddy, Corporate Governance Manager

Contact Email and Telephone Number: [email protected]



Has an Equality Impact Assessment been undertaken Yes No XDocument is for:(more than one box can be ticked) Information Decision X Assurance

Purpose of Paper

In compliance with the NHS Foundation Trust Code of Governance (July 2014) the Audit and Assurance Committee have clearly defined Terms of Reference. The Audit Committee Handbook recommends an annual review of the Terms of Reference. This ensures that they are up to date and accurately provide assurance to the Board through the oversight, assessment, review and scrutiny of functions, process and systems within the Trust to maintain a sound system of internal control.

The Terms of Reference provide a framework for the Committee to support the Board in setting and ensuring that high standards of governance and behaviour are maintained in the conduct of the Trust’s business.

The Terms of Reference were reviewed in April by the Audit and Assurance Committee. The Committee made a number of amendments and recommended the updated Terms of Reference to the Board for approval, subject to any comments from the Council of Governors. In order to comply with the NHS Foundation Trust Code of Governance, the May Council of Governors meeting was consulted on the amended version of the Terms of Reference. The Council made no further comments.

The Terms of Reference that are presented here have been updated with the recommendations from the Audit and Assurance Committee meeting.

Recommendations

The Board are asked to review and approve the attached Terms of Reference for the Audit andAssurance Committee.


4.1 There is a risk to the organisation due to not having strong corporate governance systems in place resulting in Trust vision not being delivered.

Financial Impact

147�AAC�Terms�of�Reference�MayOverall�Page�90�of�150Page�1�of�6


No direct financial impact.


In April 2016 the Terms of Reference (ToR) were circulated to the Audit Committee and other relevant managers for comment. Taking these comments into account the Audit Committee meeting then reviewed the ToR and requested further minor amendments. These improvements included:

Reference to the system wide issues from working collaboratively with other organisations. It was recommended that paragraph 1 in the “How” section includes the words “….being mindful of the wider system changes and manages key risks facing the Trust”

Correction of a job title

The Council of Governors reviewed the Terms of Reference and made no further comment.

The Terms of Reference are attached in Appendix 1.

The Terms of Reference are recommended to the Board for consideration and approval.


What are the Governor Involvement implications?

Monitor’s code of governance states: C.3.2. The main role and responsibilities of the audit committee should be set out in publicly available, written terms of reference. The council of governors should be consulted on the terms of reference, which should be reviewed and refreshed regularly. The DCHS Council of Governors was consulted on 9 May 2016.

What are the Equality and Diversity implications? None identified.


None identified.

Risk Register

Is the issue on the current Risk Register?

No If yes, what is the Risk Number?

Does this update recommend a change in the current risk score? (If so, please provide your rationale below)



Appendix 1

Audit and Assurance Committee

Terms of ReferenceApril 2016

What To provide assurance to the Board of Directors through the oversight, assessment, review and scrutiny of functions, process and systems within the Trust to maintain a sound system of internal control.

Who The Committee shall be appointed by the Board from amongst the Non-Executive Directors (NEDs) of Trust and shall consist of not less than three NED members. One of the members will be appointed Chair of the Committee by the Board.

Attendees:Only the members of the Committee have the right to attend meetings however, the following shall generally be invited to attend routine meetings:

The Director of Finance, Information & Strategy Appropriate internal and external audit representation Either the Medical Director or the Director of Quality/Chief Nurse The Trust Secretary

A Local Counter Fraud Specialist will attend alternate meetings.

The Chief Executive will be invited, at least annually, to represent the process of assurance that supports the Annual Governance Statement.

Other directors will attend on a regular basis as determined by the committee. As a general principle Executive Directors will be invited to attend when the Committee is discussing areas or risk relating to the Directors responsibilities and at the Committee’s discretion. The Secretary of the Audit and Assurance Committee will also be in attendance to take minutes and provide appropriate support to the Chair and Committee members.

Quoracy The Audit and Assurance Committee will be quorate when two NED members are present.

The Audit and Assurance Committee can exercise the right to meet in private, which includes to exclusion of any or all of the above.

When Five meetings per annum, more frequently if deemed necessary by the committee, however there must be a minimum of four.

Where Committee meetings will be held at DCHS premises or via conference call.



Why The Trust’s Constitution requires that the Trust establish a Committee of Non- Executive Directors, excluding the Chairman, as an Audit and Assurance Committee. The Committee meets in private.

How The role of the Committee is to:

1. Review the establishment and maintenance of an effective system of integrated governance, risk management and internal control across the whole of the organisation’s activities that support the achievement of the organisation’s objectives, being mindful of the wider system changes, and manages key risks facing the Trust.

In particular, the committee shall review the adequacy and effectiveness of:

The underlying assurance processes that indicate the degree of achievement of corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements.

The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements and related reporting and self-certification.

2. Monitor the integrity of the financial statements of the NHS foundation trust, and any formal announcements relating to the trust’s financial performance, reviewing significant financial reporting judgements contained in them

3. Review and monitor the integrity of any statements that are risk and control related. These specifically include, but are not limited to, the Annual Governance Statement, the accompanying Head of Internal Audit Opinion, any external audit opinion and the financial statements of the Trust.

4. Review the Trusts internal financial controls and review the systems and controls in place to manage risk.

5. Review and make recommendations to the Trust Board on the Trust’s Annual Report, Quality Accounts and Financial Statements

6. Review any declarations for CQC registration and the assurances required for the Board.

7. Make recommendations to the Board of Directors, in relation to the appointment of the internal audit function, and to approve remuneration and terms of engagement.

8. Monitor and review the effectiveness of the NHS foundation trust's internal audit function, taking into consideration relevant UK professional and regulatory requirements



9. To report to the Council of Governors on the performance of the External Auditor and make a recommendation to the Council of Governors on the appointment, re-appointment or removal of the External Auditor and approve the remuneration and terms of engagement of the external auditor

10.Review and monitor the external auditor’s independence and objectivity and the effectiveness of the audit process, taking into consideration relevant UK professional and regulatory requirements

11.Review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications on governance of the Trust.

12.Review and monitor and ensure that the organisation has adequate arrangements in place for both preventing and countering fraud and will review the outcomes of counter fraud reports.

13.Consider and review all aspects of the Assurance Framework to ensure that the principles are embedded within the organisation.

14.Review the assurances that the Trust has an effective control system in place for ensuring good quality data.

15.Review the assurances that the Trust has an effective control system in place for the delivery of clinical audit.

16.Review arrangements that allow staff of the NHS foundation trust and other individuals where relevant, to raise, in confidence, concerns about possible improprieties in matters of financial reporting and control, clinical quality, patient safety or other matters.

17.Develop and implement policy on the engagement of the external auditor to supply non-audit services, taking into account relevant ethical guidance regarding the provision of non-audit services by the external audit firm;

18.Report to the council of governors, identifying any matters in respect of which it considers that action or improvement is needed and making recommendations as to the steps to be taken.

19.Consider and approve relevant policies, Financial Instructions and processes.

In carrying out this work the Committee will primarily utilise the work of internal audit, external audit and other assurance functions, but will not be limited to these sources. It will also seek reports and assurances from directors and managers as appropriate, concentrating on the over-arching systems of integrated governance, risk management and internal control,



together with indicators for their effectiveness.

Sub Committees

The Committee has the right to request and receive reports or minutes from any other sub-committee or sub-group it feels maybe necessary and useful in discharging its duties.

Communication Links

The Committee will provide a report to the Board of Directors, at least annually, on its work and findings against the duties outlined above.

Reporting To The Summary Report of the Audit and Assurance Committee shall be formally recorded and submitted to the Board of Directors. The Chair of the Committee shall bring to the attention of the Board any issues which require any executive action.

Key Performance Indicators

Evidence of Compliance with Audit Committee Handbook requirements

True and Fair Annual Governance Statement Green Governance Risk Rating Production of Committee Annual Report to Board of Directors and

Council of Governors of work of Committee

Other Information

The Committee is authorised by the Board to investigate any activity within its Terms of Reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee. The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

Review Date April 2017



TRUST BOARD Document Title: Chief Executive’s Report

Presenter/Title: Tracy Allen, Chief ExecutiveContents of Paper were previously discussed by: n/a

Author/Title: Tracy Allen, Chief ExecutiveContact Email and Telephone Number:

Cathryn Pearson, Executive [email protected] 01629 817892



Has an Equality Impact Assessment been undertaken Yes No XDocument is for:(more than one box can be ticked) Information X Decision Assurance

Purpose of Paper

The report provides information on strategic policy, legislative and developmental issues affecting the organisation and includes:

Update on the development of the Sustainability and Transformation Plan Update on preparations for the 21st Century Better care closer to home consultation Early feedback from the Care Quality Commission Inspection DCHS Leadership Conference Long Service Tea Party Headline organisational performance – ‘the 2016/17 big 9’

Recommendations

The Board is recommended to note the report.


Not applicable

Financial Impact

None directly.

149�Chief�Executive�Report.docOverall�Page�96�of�150Page�1�of�5




Chief Executive's Report May 2016

1. Purpose of the paper

This paper is to provide the Trust Board with information about key national and local strategic issues affecting the Trust.

2. System Transformation Updates

2.1 Developing the Derbyshire/ Derby City Sustainability and Transformation Plan (STP)

Work is continuing on the development of the STP, following positive feedback from NHS England and other national bodies on the short return considered by the Board last month.

As Board members will be aware, the focus of the plan is to bridge the health and wellbeing, care quality and financial gaps that we have identified by developing integrated place based local community based teams and services, working with effective and sustainable specialist services and supported by a streamlined ‘management’ infrastructure as described in the diagram below.

Clinicians and professionals are working up detailed hypotheses about priorities for change and development in each of the areas below and four ‘big ticket’ areas have been identified as the areas where the biggest opportunities for transformation to deliver better outcomes and value for our communities exist:

The development of place-based, community focused systems of care; Prevention; Managing urgent care, and; Streamlining our ‘management infrastructure’.

DCHS directors, managers and clinicians are involved in workstreams across the board and further iterations of the plan, the key hypotheses within it, and their implications for DCHS will be considered by the Board over the coming weeks.



2.2 21st Century Joined Up Care Programme

As I reported to the Board in April, preparations are continuing to launch the ‘Better care closer to home’ consultation at the end of June.

Significant progress has also been made on the outstanding issues identified by the Board previously around the financial and commissioning framework underpinning the preferred option that will be discussed in the confidential Board session.

3. Trust highlights and key operational issues

3.1 Care Quality Commission (CQC) Inspection

The Trust welcomed a large inspection team from the CQC into the organisation during the week commencing 9th May. The team had nearly 1200 combined years of NHS experience between them and their insights and feedback will be extremely valuable.

Whilst the ‘on the ground’ inspection phase is largely complete (with the exception of unannounced visits and a review of dental services that the CQC was unable to complete during the week), the CQC will now be undertaking an intensive period of reviewing findings, seeking further evidence and information from us and triangulating their results in readiness for issuing a draft report to the Trust in July.

In this context they were only able to provide high level feedback at the end of the week.



As you'd expect from such a comprehensive and rigorous review the team identified a number of areas for improvement including:

some aspects of medicines management; improvements required within the sexual health service and general practices, largely

relating to areas we are already working on; opportunities to build on great end of life care by sharing best practice better and

measuring a wider range of outcomes, and; opportunities to strengthen the use of clinical audit to drive improvements in patient care.

They also fed back a long list of very positive organisational themes that they had observed during the week that reflect the compassion and commitment that we see across the Trust every day. These included:

Caring - overwhelmingly positive feedback with people really going the extra mile for their patients. The Head of inspection said that 'this is how it should be' and that many other organisations could learn from the way care is delivered across the core services.

Responsive – teams observed to be very responsive to people's needs with care delivered in a very personalised way.

Positive morale and strong relationships with our Staff Partnership colleagues. Strong and effective training and development. Strong practice in a number of key areas including safeguarding, consent, Mental

Capacity Act and Deprivation of Liberty work, and very impressive DNACPR records. Excellent end of life care across the Trust – describing compassionate multidisciplinary

teams including catering colleagues who provided a very high level of personalised care.

There was also some very positive service specific feedback including:

the strength of our Learning Disability community service; very impressive MIU services, and; excellent estates and integrated facilities management staff and services working

innovatively and in ways that make a really positive difference to patients.

Managing the inspection has been a major logistical exercise and I would like to thank everyone who has worked so hard on organising data submissions, inspection planning and especially to all of our colleagues who have been so open and welcoming to our inspectors. They really enjoyed the inspection and the way you shared your experiences of your services.

3.2 Leadership Conference

More than 150 colleagues from across the organisation joined Board members for our first Leadership Conference on the 6th May. The day provided a great opportunity to review what has been collectively achieved during 2015/16, recognise some particularly outstanding leaders and teams, and spend time together thinking about how we will focus on delivering our operational plan and priorities this year.

We also spent time reflecting on what great leadership looks and feels like, the growing challenges and stresses leadership responsibilities pose and the impact of our leadership both on our colleagues and on ourselves.



It was a very open and thought provoking day and has generated a commitment to further work during 2016/17 around how we continue to develop the support and development for all those of us exercising leadership responsibilities in order to continue our journey from ‘good to great’ that the whole board will want to engage with over the coming months.

Given the success of the event it is proposed to hold a similar leadership conference on an annual basis going forward.

3.3 Long Service Awards Tea Party

The Trust held its first Long Service recognition tea party on the 13th May at Newholme Hospital which provided an opportunity to recognise and celebrate more than 300 years of experience and loyalty to the NHS. Many thanks to board colleagues who supported the event and helped make it such a special afternoon. Eleven colleagues were recognised and attended with family and friends.

The next party will be held in September.

4. Organisational Performance April 2016

The ‘Big 9’ have been agreed for 2016/17. The detailed measures, and trajectories are being finalised, and these will be reported in the June reports.



Governors involved in CQC inspection and will be keen to receive the CQC inspection report and work with the Trust on monitoring the implementation of the subsequent action plan.


System transformation plans and Better Care Closer to Home consultation have equality and diversity implications that will be assessed and managed as the initiatives proceed.


As above – Better Care Closer to home consultation will require significant input from staff, patients, members and the public.

Risk Register


Does this update recommend a change in the current risk score? (If so, please provide your rationale below)



Summary Report from Quality Business CommitteeReport To: Board

Date: 26 May 2016

Name of Reporting Committee / Group: Quality Business Committee


Presenter: Ian Lichfield

Author: Gary Roe



109/16 - Strategic Priorities – The committee agreed to relook at the KPIs to add in baseline figures, targets and key dates to achieve these targets.

112/16 - Transformation Progress Report - updates on Transformation activity within the Trust. Key topics discussed were;

System Transformation – new models of care Agile working Digitisation

Significant investment in over 850 smartphones to the community teams will have many benefits and that we were beginning to see some of those already (e.g. easier access to NHS e mail and route mapping). 100 smartphone devices have been issued, with basic training being given to the users. The roll out is expected to demonstrate quicker treatment interventions, more efficient use of District Nurse time and significantly reduced travel time and expense for the Tissue Viability team. There is also likely to be a reduced cost for the line rental and number of SIM cards. March 2016 - a survey was undertaken with field-based clinical staff to establish a baseline for their perception of connectivity. which illustrated that over 50% of field based staff appear to have connectivity problems either always or very often. The transformation Team is leading on this activity and has planned a ‘connectivity summit’ in May. The committee took significant assurance from the report

114/16 - Operational Plan Delivery Group – update with regards progress in relation to the establishment of the Operational Plan Delivery Group This is a new approach to the overview of key projects and delivery of efficiencies for the Trust to include a more systematic review of service models, variation and expenditure to address the future efficiency challenge. The operational plan delivery group held its first meeting and agreed the role of the

3.1, 3.4, 3.5, 3.6, 3.7, 3.9 Significant Assurance


151�QBC�Summary�Report.docxOverall�Page�101�of�150Page�1�of�3


group and the following work it will monitor; Monitor Operational Plan Delivery Technical Efficiencies Transformation Efficiencies Variation Efficiencies

The committee took significant assurance from the report

117/16 - Performance Report - summary of DCHS’ performance against the DCHS focus area of Quality Business. The Balanced Scorecard has been reviewed to incorporate the contractual and other performance regime changes in 2016/17. The committee took significant assurance from the progress made

118/16 - Performance Reporting 2016/2017 final versionThe committee approve the measures and targets for the Board dashboard and the measures and targets for the QSC, QPC and QBC dashboard.

119/16 - Finance Report - financial performance of the Trust as at 30th April 2016. Reporting a surplus position of £0.34m at month 1, which represents a slight deficit variance of £0.02m against the planned surplus of £0.36m. The cash position is as per the plan.Year-end surplus of £3.4m is forecast, which assumes full delivery of the SQIP programme. The cash position is forecast to be £16.8 million at the end of March 2017.The committee took significant assurance from the report

120/16 - Cost Improvement Report - presented Sustainable Quality Improvement Plan (SQIP) together with updates on progress against PMO schemes and key variances with explanations. This highlighted where there was slippage against expected SQIP outturn and provided detail of any mitigation schemes or non-recurrent savings used to offset this. Noted where there was slippage in plan this would be made up and targets would remain targets. The committee took significant assurance from the report

121/16 - Annual Report - committee discussed the content of the financial performance section of the 2015/16 Annual Report.The committee took significant assurance from the report

123-16 - Business Development Report - provided information and updates across the following areas: External Business Environment, Business Opportunities and Contract UpdateThe committee took Significant Assurance from the report

125/16 - Capital & Estate Programme Group Summary Report - The Committee discussed and took Significant Assurance from the work of the Capital & Estate Programme Group

126/16 - Informatics Strategy Group: Summary Report





3.1, 3.2, 3.3, 3.4, 3.6, 3.7, 3.8, 3.12 Significant Assurance

3.1, 3.3, 3.4, 3.5, 3.6, 3.7, 3.9, 3.10, 3.12 Significant Assurance

3.9, 3.10 No Assurance



Benefits RealisationBenefits Realisation report illustrated no benefits. Needs to be revisited in order to drive through the benefits originally laid out. The committee agreed that any future request for investment will be far more rigorous. The committee took no assurance from the report

BAF Key; 3.1 There is a risk to the organisation achieving strategic objectives due to a lack of integrated planning both internally, resulting in poor outcomes across the DCHS Way and, in addition externally across the whole system3.2 There is a risk to the organisation due to not proactively managing the more competitive environment resulting in an impact on future sustainability of the Trust3.3 There is a risk to future sustainability due to change in national policy and commissioner priorities3.4 There is a risk to the effective and efficient provision of DCHS services due to the impact of funding cuts within Local Authorities resulting in greater activity being directed towards health services3.5 There is a risk to the organisation due to poor estate impacting upon patient care resulting in poor outcomes3.6 There is a risk to the organisation regarding the efficient use of resources constrained by Health Economy Plans3.7 There is a risk to the financial stability of the organisation of not meeting future Sustainable Quality Improvement Programme over the next two years3.8 There is a risk to the organisation due to the inability to meet contractual activity targets, resulting in financial risk3.9 There is a risk to the organisation due to non-delivery of elements of the IM&T strategy, resulting in objectives not being achieved3.10 There is a risk to the organisation due to lack of comprehensive data quality systems resulting in poor decisions that could affect outcomes and financial loss3.11There is a risk to the Trust’s resilience, due to an emergency or severe disruption, resulting in an impact on patient care, inability to meet targets, loss of revenue3.12 There is a risk to the organisation, due to failure to align and influence stakeholders resulting in poor relationships that impact on patient care4.1 There is a risk to the organisation due to not having strong corporate governance systems in place resulting in Trust vision not being delivered4.3 There is a risk to the organisation due to not having strong risk management controls in place resulting in failure to put effective mitigation plans in place promptly

Policies ApprovedNone.Issues to be escalated to Board or a CommitteeNone.



TRUST BOARD Document Title: Performance Report – May 2016

Presenter/Title: Chris Sands, Director of Finance, Information and Strategy Contents of Paper were previously discussed by:

Author/Title: David Caddy, Management Accountant - Performance and Costing Kate Davis – Head of Costing and Performance

Contact Email and Telephone Number: [email protected] 01246 253042

Date of Meeting: 26 May 2016 Agenda Item No: 152/16

No of pages inc. this one: 35

Has an Equality Impact Assessment been undertaken Yes No x

Document is for: (more than one box can be ticked) Information Decision Assurance x

Purpose of Paper

The Performance Report sets out a summary of DCHS’ performance against the three DCHS Way focus areas of Quality People, Quality Service and Quality Business. The Balanced Scorecard has been reviewed to incorporate the contractual and other performance regime changes in 2016/17. There are 81 green, 16 amber, 12 red, and 48 unrated indicators this month. The Overview of Measures at page 11 gives further details. The table below summarises the red rated year to date KPI’s. These are the key issues for the Quality Business Committee to focus on from a performance perspective. The benchmarking KPIs aren’t listed due to these not being specific DCHS performance measures.

Recommendations

Note and comment

Focus Area Measure Target YTD Month YTD Details Report

Quality People Training - Resuscitation (% compliance) 95% 89% 89% Page 2/13 Exception Report at page 24

Quality People New starters attending induction (compliance %) 95% 82% 82% Page 3/13 Exception Report at page 25

Quality Service Inpatient (Rehab & Urgent care) Average Length of Stay (days) 20 20.8 20.5 Page 8/15 Exception Report at page 26

Quality Service Falls resulting in severe injury or death (no.) 0 2 2 Page 9/16 Exception Report at page 27

Quality Business Speech and Language Therapy Activity (no.) 1,893 1,623 1,623 Page 9/17 Exception Report at page 28

Quality Business Health Visiting Contract (rating) Page 9/17 Exception Report at page 29

DCHS Board Performance Report

Red Rated Year to Date (YTD) Measures

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The performance framework impacts upon all risk areas in the Board Assurance Framework.

Financial Impact

The report contains a number of issues and risks that have a financial impact on the organisation. These are detailed within the report including, where appropriate, any mitigation plans and strategies that are in place.


Performance Report attached


What are there Governor Involvement implications? The Council of Governors receive performance reports


Equality and Diversity measurements are recorded in the report


The report includes measurements of service experienced by patients

Risk Register





Board Performance Report – May 2016

Background The Performance Report sets out a summary of DCHS’ performance against the three DCHS Way focus areas of Quality People, Quality Service and Quality Business. Section Index Document Page No’s Summary Document-Overview 1-3 Risk Assurance Framework Scorecard 4 Monitor Organisational Health Card 5 Summary Document-DCHS Balanced Scorecard 6-9 Overview of Measures 11 DCHS Balanced Scorecard 12-18 HCAI Scorecard 20 CQUIN Scorecard - DCHS 21 RTT Waiting Times Scorecard 22 Exception Reports 24-29 Glossary 30-32 Key for RAG, arrows and Data Quality Kitemark 33



OVERVIEW Key Issues The key issues for the Board to discuss are:

Quality People

• Attendance was 95.12% against a target of 97% and 95.56% for the average

of the past 12 months.

• There were no Riddor Zero Harm events in April against the zero harm target.

• Resuscitation compliance is a low area of compliance within the Essential Learning package. An exception report is presented at page 24.

• Induction compliance was 82% for the month against a target of 100%. An exception report is presented at page 25.

Quality Service

• Length of stay for April was 20.8 days and 20.5 days for the 3 month year to date. An exception report is presented at page 26.

• The overall occupancy rate for April was 83.3% against a target of 85%

• There were 3 avoidable grade 2,3 & 4 pressure ulcers for the month. A stretched target is being reviewed for inclusion in the next report.

• There were 2 falls in April. An exception report is presented at page 27. A stretched target will be developed for the next report.

Quality Business



• The Sustainable Quality Improvement Plan (SQIP) stood at 5.7% for April

against at target of 6%. This has been amber rated. Details have been discussed in the Finance Report.

• The majority of our activity service lines are either overperforming against their year to date profiled activity plans, or have very low and therefore recoverable levels of underperformance. An exception report for Speech and Language Therapy is presented at page 28.

• The number of mothers who have received an antenatal contact in April was 91.2% for the month. An exception report is presented at page 29.

Quality Governance

• Our Governance rating green. We are currently meeting all our Risk Assurance Framework targets and are forecasting to maintain our green rating for the year.



Monitor Risk Assurance Framework Indicators 2015 -16

Measure Measure-Sub GroupRAF

Appendix A Area

RAF Target 2016/17

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Narrative

RTT Waits - admitted patients seen within 18 weeks - 90% (target) (%)

See note 1 1 90% 92.2%

RTT Waits - non admitted patients seen within 18 weeks - 95% (target) (%)

2 95% 97.1%

RTT Waits - Incomplete pathways seen within 18 weeks - 92% (target) (%)

3 92% 97.7%

A&E 4 Hour Wait for A&E Attendances (%) 4 95.0% 100.0%

Healthcare Care Associated Infections - Clostridium difficile lapses (no.)

14Not applicable - DCHS does not have

a target

Delayed Transfer of Care for OPMH - Monitor compliance framework calculation (%)

16 7.5% 0.0% Monitor quarterly calculation.

Mental Health data completeness: identifiers 17 97% 100.0%

Certification against compliance with requirements regarding access to healthcare for people with a

learning disability19 Yes Yes

To be reported to EDS & quarterly to QSC

Data completeness: community services , comprising:referral to treatment

information %20 50% 91.9%

North East Derbyshire locality recently deployed.

Data completeness: community services , comprising: referral information % 20 50% 84.7%North East Derbyshire locality

recently deployed.

Data completeness: community services , comprising:treatment activity

information %20 50% 84.7%

North East Derbyshire locality recently deployed.

Risk Score Rating 0 0 0 0 0 0 0 0 0 0 0 0

RTT admitted and non-admitted data will no longer be collected from M4

onwards by Monitor



Monitor - Organisational Health Indicators 2016-17

NHS Derbyshire County CCGs

MeasureMeasure-Sub

GroupTarget

2016/17Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Narrative

Patient Revolution Friends & Family Test Recommended Score (%)

Patient 95% 98.3% Replaces Friends and Family score

Staff Metrics-Executive Turnover Staff2 or less in 6 months

0 Quarterly scores are quarter ending scores. Board turnover figure

Staff Metrics-Staff Satisfaction-Engagement Rates

Staff 75% 74% Quarterly scores are quarter ending scores

Staff Metrics - Pulse Check - Recommend DCHS to Friends and Family as a Place to

WorkStaff 71% 68% Quarterly scores are quarter ending

scores

Staff Metrics-Sickness Absence Rate Staff 3% 4.88% Quarterly scores are quarter ending scores

Staff Metrics-Proportion of Temporary Staff (Agency & Bank) as a % of total

workforce costsStaff 5% 0.9%

Clinical Agency & Bank now shown. Quarterly scores are quarter ending

scores

Overal Score Rating 3



Board Performance Report – May 2016

Details – DCHS Balanced Scorecard QUALITY PEOPLE HEADLINES: (pages 12 -14) Key Issues

• Total Workforce Costs (£,000) – The year to date costs for our workforce are £10,775k against our target of £10,739k and is amber rated.

• Staff Attendance (%) – In April attendance has decreased to 95.12%. The average of the last 12 months is 95.56%. The April absence rate is 4.88%. DCHS baseline Long term sickness is 2.90% and short term is 1.98% (long term is those absences over 30 days). Anxiety, Musculoskeletal and Cold and Gastrointestinal problems were the main issues this month.

• Staff Turnover (%) – This measures the movement of employees joining and leaving DCHS and can be an indication that DCHS is viewed as a good place to work. Staff turnover was 9.70% which is green rated against a plan of 14%.

• Vacancies - Average Length of Time (days) – The Average Length of Time to Recruit is 52.1 days and is green rated against a target of 60 days. The Average Length of Time from Offer to 1st Working Day is 30.6 days against a target of 40 days and in green rated. The average Length of Time for Pre Appointment checks is 15.4 days against a target of 21 days and is green rated. In March, 9.21 wte clinical posts were not filled first time due to candidates not being suitable or a limited amount of candidates being available for interview or candidates withdrawing. The Workforce Planning and Development Sub-Group review these posts in detail at their monthly meeting to ensure we are acting upon any developing patterns of hard to recruit areas.

• Essential Learning (% Compliance) – The Essential Learning day covers the key areas of Core Mandatory Learning identified by DCHS and supports compliance with the NHS Litigation Authority and CQC requirements. All staff are required to complete the Essential Learning Course every two years. 95% of staff have completed their Essential Learning within the past 2 years, as at the end of April. This is green rated.



• Information Governance Training (% Compliance) – Information

Governance Training needs to be completed annually by all staff. This training can be undertaken by completing a workbook or via e-learning. The Trust has a target that at least 95% of staff complete this training annually. As at the end of April 95% of staff were compliant with this training requirement and is green rated.

• Fire Training (% Compliance) – DCHS staff are required to complete annual Fire Training. There are a number of delivery methods for this training including e-learning. The Trust has a target that at least 95% of staff receive this training annually. The compliance rate was 94% in April. This target is amber rated.

• Staff with Appraisal Completed (% Compliance) – This figure shows the

percentage of all of our available staff who have had an Appraisal in the last 12 months ending 31st April 2016. 100% of our staff are expected to receive an annual appraisal. The aim of appraisals is to provide a comprehensive review of the performance of individual staff, identify any training and development needs and to record their overall contribution to the organisational goals of DCHS. Performance in April remained below this target, with 92% of staff having received an appraisal in the last year. An improvement target of 96% has been put in place for 2016/17. DCHS are amber rated against this target. Directorates are being reminded that they should have a robust process in place to ensure all out of date appraisals are chased and put back on track. Given the current performance, this remains a key area of focus for DCHS.

• Zero Harm - RIDDOR Reportable Injuries (no) – There were no incidences of RIDDOR injuries, diseases and dangerous occurrences in April . This has been green rated against a zero target.

• Cost of Lost Time Through Injury (£,000) – The cost of lost time through injury has been estimated as £130.87k. Further investigation into the details held on ESR will be carried out. QUALITY SERVICE HEADLINES: (pages 14 - 16) Key Issues The HCAI summary is presented at page 20.



To date there have been no positive Clostridium Difficile results reported for DCHS. Clostridium Difficile figures now include an agreed lapse count, following agreement with our Commissioners, which also stands at zero. This has been green rated.

• The CQUIN summary is presented at page 21.

• The RTT Waiting Times scorecard is presented at page 22.

• Patient Revolution – Friends and Family Test (%) – We report, to NHS England, the percentage of respondents who would recommend our services together with the total number of FFT returns. The April figure for this measure was that 98.3% would recommend our services. This has been green rated against our target of 95%.

• Complaints (no) – The number of complaints received in April was 9. This information has been reconciled to DATIX and confirmed by the Patient Support Team.

• A&E Targets (rating) – The longest time spent in our Minor Injury Units is

233 minutes at Ripley against a target of 360 minutes. This has been green rated.

• RTT Waiting Times (rating) – We are green rated for all RTT measures.

• Delayed Transfer of Care - OPMH (%) – DCHS have a target to reduce the time patients stay in an OPMH bed as a result of transfer delays. In April this was 0%. This is below the target of 7.5% and is therefore green rated.

• Inpatients Average Length of Stay (no) – DCHS have a target to reduce the average time patients stay in an inpatient bed by increasing the amount of care provided in the community. The average length of stay in April was 20.8 days and the 3 month year to date performance increased to 20.5 days. This is above the aspirational target of 20 days and is red rated. The service continues to work on reducing the average length of stay. An exception report is presented at page 26.

• Total Harm Free Care, in accordance with Safety Express (%) – The elimination of the four “harms” of Pressure Ulcers, Falls, Urinary Tract Infections and New Venous Thromboembolism fell to an amber rated score of 92.96% for April, against the Trust target of 94%. Our year to date target is also amber rated at 92.96%.

• Avoidable Grade 2, 3 & 4 Pressure Ulcers (no) – In April 3 instances were recorded. This target is red rated. QSC continue to monitor incidences of pressure damage and the implementation of actions to manage risk.



• Patients who have operations cancelled for non clinical reasons on the

day (%) – No patients had operations cancelled on the day in April. The year to date figure was 0%. This has been green rated.

• Falls resulting in severe injury or death (no.) – There were 2 falls reported on STEIS in April. This measure has been red rated. An exception report is presented at page 27.

QUALITY BUSINESS HEADLINES: (pages 17 - 18) Key Issues

• Continuity of Services Risk Rating & Capital Servicing Capacity (%) –The Continuity of Services Risk Rating is 4 & the Capital Servicing Capacity Risk Rating is 4. The will be further discussed in the Finance Report.

• Activity Performance (no.) – Speech & Language Therapy is red rated for the year to date with 1,623 contacts against a target of 1,893 contacts. An exception report is presented at page 28. The majority of service lines are either overperforming against their year to date profiled activity plans, or have very low and therefore recoverable levels of underperformance.

• FT Membership (no.) – Our Foundation Trust Membership has decreased to 12,362 members against our aspiration of 12,500 members and is amber rated.

• Health Visiting (all measures) – We screened 96.9% of babies within 10-14 days in April, against a target of 98% giving a year to date figure of 96.9% which is amber rated. In April 88.8% of babies were screened at the 2 to 2.5 year stage, giving a year to date figure of 88.8% which is red rated. The percentage of mothers who received an antenatal contact in April was 91.14% against a target of 100%. This has been red rated. The year to date measure is 94.14%, which is also red rated. An exception report is presented at page29.

.



DCHS Performance Management Reports May 2016



Month

Measure

Monitor Risk Assurance Framework Scorecard

Scorecards-Monitor Risk Assurance Framework 10 (11) 7 (10) 0 (0) 0 (0) 3 (1)

Scorecards-Monitor Organisational Health Indicators 6 (6) 3 (4) 3 (2) 0 (0) 0 (0)

Totals 16 (17) 10 (14) 3 (2) 0 (0) 3 (1)

DCHS Balanced Scorecard

Quality People 32 (32) 11 (14) 6 (7) 2 (1) 13 (10)

Quality Service - Service User Experience 22 (22) 13 (14) 0 (0) 1 (2) 8 (6)

Quality Service - Service User Safety 23 (20) 17 (15) 1 (1) 1 (2) 4 (2)

Quality Service - Clinical Effectiveness & Planning 4 (4) 0 (1) 0 (1) 1 (1) 3 (1)

Quality Business - Finance 2 (1) 0 (1) 2 (0) 0 (0) 0 (0)

Quality Business - Business & Marketing 16 (16) 7 (6) 3 (3) 2 (2) 4 (5)

Quality Business - IM&T 5 (5) 4 (5) 0 (0) 0 (0) 1 (0)

Quality Business - FT Regime 4 (4) 3 (3) 1 (1) 0 (0) 0 (0)

Totals 108 (104) 55 (59) 13 (13) 7 (8) 33 (24)

Other Scorecards

Scorecards-Healthcare Associated Infections 15 (15) 15 (15) 0 (0) 0 (0) 0 (0)

Scorecards-CQUIN 9 (11) 0 (0) 0 (0) 0 (0) 9 (11)

Integrated Wellbeing 9 (9) 1 (3) 0 (0) 5 (4) 3 (2)

Totals 33 (35) 16 (18) 0 (0) 5 (4) 12 (13)

Grand Total 157 (156) 81 (91) 16 (15) 12 (12) 48 (38)

Percentages Allocated 100% 100% 52% 58% 10% 10% 8% 8% 31% 24%

The previous month totals are shown in bracketsMeasures included:Quality PeopleAgency Costs as percentage of Paybill (%)Improved position of staff reporting incidents of violence and aggression they encounter at work (Big 9)

Quality ServiceCQC Enforcement action (including notices) currently in effect (no)Governance RatingQualified Shifts Covered (%)

Quality Business - FinanceSQIP Achieved-Non Recurrent (%)

Measures removed:Quality PeopleVacancies - Average Length of Time From Offer to 1st Working Day (days)Vacancies - Average Length of Time For Pre Appointment Checks (days)

Derbyshire Community Health Services Board Performance Overview of Measures

April-16

Total Number of YTD

Measures Rated Green

Total Number of YTD

Measures Rated Amber

Total Number of YTD Measures

Rated Red

Total Number of YTD

Unrated Measures

Total Number of Measures



Measure 2016 / 17 Full Year Target

Year to Date Target

Apr-16 Trend Year to Date Narrative

Total Workforce Cost (£000s) 12 0 10,739 10,775 10,775 Includes Agency & Bank. Plan is from QBC Finance report.

Temporary Staffing Costs - Agency (£000's) 12For

InformationFor

Information239 239 Funded by vacancies budget.

Temporary Staffing Costs - Bank (£000's) 12For

InformationFor

Information167 167 Funded by vacancies budget.

Agency Spend (Clinical) as a % of total workforce costs (%) 12 5.0% 5.0% 0.9% 0.9%

Agency Costs as percentage of Paybill (£m) 12 1.24 0.11 0.24 0.24

Total Headcount (no) 18For

InformationFor

Information5,432 5,432

Staff Attendance (%) 18 97% 97% 95.12% 95.56% Year to Date is average of past 12 months. Year to Date absence rate is 4.67%. NHS absence rate is 4.45% (4.62% East Midlands).

Improved position of staff reporting incidents of violence and aggression they encounter at work (Big 9)

28 28 48 48 Target is month in month increase

Staff Turnover (%) 18 <14% <14% 9.72% 9.72% Year to Date is average of past 12 months.

Board Turnover (no.) 12 =<2 in 6 months =<2 in 6 months 0 0

Redundancy (no.) 18For

InformationFor

Information0 0 All posts were sent to RATS for authorisation.

Vacancies - Average Length of Time To Recruit (days) 60 60 52.1 52.1 The average length of time from approved vacancy being advertised on NHS Jobs to agreed start date of employment being confirmed including pre-employment checks.

Vacancies - Average Length of Time From Offer to 1st Working Day (days) 40 40 30.6 30.6 The average length of time from an agreed offer of employment being made to the applicant commencing employment with DCHS.

Vacancies - Average Length of Time For Pre Appointment Checks (days) 21 21 15.4 15.4 The average length of time for pre-employment checks to be completed.

Vacancies - Externally Filled (no.)For

InformationFor

Information39 39

DCHS BOARD PERFORMANCE REPORT BALANCED SCORECARD 2016-17 (Derbyshire CCG Services)

Focus AreaData Quality

Score

WO

RKFO

RCE

MET

RICS




Year to Date Target




Score

Vacancies - Internally Filled (no.)For

InformationFor

Information11 11

Advertised Vacancies (no.) 18For

InformationFor

Information50 50

Essential Learning completed (% compliance) 18 95% 95% 95% 95% Year to Date is average of past 12 months-shows compliance at renewal date.

Information Governance Training (% compliance) 18 95% 95% 95% 95% Year to Date is average of past 12 months-shows compliance at renewal date.

Fire Training (% compliance) 18 95% 95% 94% 94% Year to Date is average of past 12 months-shows compliance at renewal date.

Training - Resuscitation (% compliance) 95% 95% 89% 89% Year to Date is average of past 12 months-shows compliance at renewal date.Exception report at page 24.

New starters attending induction (compliance %) 18 95% 95% 82% 82% Year to Date is rolling 12month average-shows compliance at renewal date. Exception report at page 25.

Staff with appraisal completed (% compliance) 18 97% 97% 92% 92% Year to Date is average of past 12 months-shows compliance at renewal date

Frequency Rate (no) 0.00 0.00

Severity Rate (no) 3.20 3.20 All events.

Lost time injury cost (£,000) 130.87 130.87

Zero Harm - Riddor Reportable Injuries (no) 0.00 0.00

Improvement in Staff Engagement Score (%) 75% 75% 74% 74%

Staff Survey - Recommend DCHS to Friends and Family If They Needed Care or Treatment (%)

90% 90% Annual Target - Survey is for November and is available February. Next update will be February 2017.

Staff Survey- recommend DCHS to friends and family as a place to work (%) 71% 71% Annual Target - Survey is for November and is available February. Next update will be February 2017.

Pulse Check - Recommend DCHS to Friends and Family If They Needed Care or Treatment (%)

90% 90% 90% 90%

QU

ALIT

Y PE

OPL

E

TR

AIN

ING

FEED

BACK

HEAL

TH A

ND

SAFE

TY




Year to Date Target




Score

Pulse Check - Recommend DCHS to Friends and Family as a Place to Work (%)

71% 71% 68% 68%

Patient Revolution Friends & Family Test Recommended Score (%) 98% 98% 98.3% 98.3%

Complaints Received (no.)For

InformationFor

Information9 9

PLACE (score) 95% 95% Q1-Looks at the environment in which care is provided and the quality of non-clinical services - food and privacy and dignity. Q2-Looks at cleanliness. Q3-external verification.Q4=Q1.

Certification against compliance with requirements regarding access to healthcare for people with a learning disability

Yes Yes Yes Yes

A&E A&E Targets (rating) 18

RTT Waiting Times (Scorecard) 18

E Referral Targets (rating) Choose and Book becomes e Referral

Diagnostics - Patients exceeding 6 weeks wait (%) <1% <1% 0.0% 0.0%

Patients who have operations cancelled for non clinical reasons on the day (%)

<0.8% <0.8% 0.0% 0.0%

Patients who have operations cancelled for non clinical reasons receiving treatment within 28 days (%)

100% 100% 100.0% 100.0%

Mixed Sex Accommodation Breach Rate (No) 0 0 0 0

Delayed Transfer of Care (%) <7.5% <7.5% 6.0% 6.0% Percentage of patients whose discharge is delayed for non clinical reasons (DTOC). Contract calculation for Inpatients & OPMH. Data now taken from BI.

Delayed Transfer of Care for Inpatient (Rehab & Urgent Care) - contract calculation (%)

For Information

For Information

7.8% 7.8%

Delayed Transfer of Care for OPMH - contract calculation (%) <7.5% <7.5% 0.0% 0.0%

Delayed Transfer of Care for OPMH - Monitor compliance framework calculation (%)

<7.5% <7.5% 0.0% 0.0% Year to date is the Quarterly monitor calculation.

SERV

ICE

USE

R EX

PERI

ENCE

PATI

ENT

SATI

SFAC

TIO

NRE

FERR

AL T

O T

REAT

MEN

TIN

PATI

ENT

SERV

ICES




Year to Date Target




Score

Inpatient (Rehab & Urgent care) Average Length of Stay (days) 18 20.0 20.0 20.8 20.5 Linked to achievement of IBP. Year to Date is 3 month average. Exception report at page 26.

Older Peoples Mental Health Average Length of Stay (days)For

InformationFor

Information39.9 33.7 Year to date is 3 month average.

Inpatient (RUC) Occupancy (%) 85.0% 85.0% 82.6% 82.6%

Older Peoples Mental Health Occupancy (%) 85.0% 85.0% 85.9% 85.9%

LD Occupancy (%) 85.0% 85.0% 53.1% 53.1%

Achievement of consultation /involvement/engagement inclusion priorities (%)

100% 100% 100% 100%

New or revised policies/procedures/strategies supported by EIAs (%) 87% 87% 91% 91% Percentage of Equality Impact Assessments carried out on approved policies.

CQC Registration - Overall (rating) Pilot still under development, registration with new partners being developed.

CQC Warning Notices currently in effect (no) 0 0 0 0

CQC Compliance Action Outstanding (no) 0 0 0 0

CQC Non-Compliance with Fundamental Standards resulting in Enforcement Action (no)

0 0 0 0

CQC - Moderate concerns or impacts regarding the safety of healthcare provision (as at time of submission) (no)

0 0 0 0

CQC Financial Penalties (no) 0 0 0 0

CQC Enforcement action within last 12 months (no) 0 0 0 0

CQC - Major concerns or impacts regarding the safety of healthcare provision (as at time of submission) (no)

0 0 0 0

CQC Enforcement action (including notices) currently in effect (no) Green Green Green Green

QU

ALIT

Y SE

RVIC

E

O

CCU

PAN

CYEQ

UAL

ITY

GO

VERN

ANAN

CE




Year to Date Target




Score

Governance Rating 0 0 0 0

NHS England Quality Surveillance Rating Green Green Green Green

Total Harm Free Care, in accordance with Safety Express (%) 94% 94% 93.0% 92.96%

Avoidable Grade 2, 3 & 4 Pressure Ulcers developed or deteriorated in DCHS care (no.)

16 0 0 3 3

Total Grade 3 & 4 Pressure Ulcers developed or deteriorated in DCHS care (no.)

16For

InformationFor

Information8 8

Incidence of Newly Acquired Pressure Ulcers (no.) 16For

InformationFor

Information29 29

Medication Errors causing Serious Harm (no.) 16 0 0 0 0

Falls resulting in severe injury or death (no.) 0 0 2 2 Falls reported on Steis. Exception report at page 27.

Duty of Candour - Failure to notify relevant person of a reportable incident (no)

0 0 0 0 All reportable incidents have been raised on STEIS. 7 Incidents have been completed and 3 incidences are being reviewed.

Qualified Shifts Covered (%)For

InformationFor

Information81.5% 81.5% Registered Nursing & Community Nursing

Healthcare Care Associated Infections - MRSA bacteraemia (no.) 16 0 0 0 0

Healthcare Care Associated Infections - Clostridium difficile (no.) 16 10 1 0 0

Healthcare Care Associated Infections - Clostridium difficile -lapses count (no.)

16 10 1 0 0

Healthcare Care Associated Infections - E Coli & MSSA (no) 16 0 0 0 0

Monitor Risk Assurance Framework Scorecard (RAF) (rating) 0 0 0 0

CQUIN Scorecard (rating) Quarterly reporting in 2016/17

SERV

ICE

USE

R SA

FETY

HARM

FRE

E CA

REO

THER

SAF

ETY

MEA

SURE

S

EN

ESS

& P

LAN

NIN

G




Year to Date Target




Score

Healthy Lifestyles Contract (Rating) Integrated Wellbeing Contract with DCC.

Sexual Health Contract (Rating) 12 Integrated Sexual Health Contract with DCC. Under development.

SQIP Achieved-Recurrent(%) 100% 6.4% 5.9% Discussed in the Finance Report

SQIP Achieved-Non Recurrent (%) 100% 3.2% 1.2%

Positive media stories (no.)For

InformationFor

Information24 24

MIU Activity (no.) 18 59,149 5,104 5,157 5,157

Pulmonary Rehab (no) 18 621 52 79 79

Outpatient and Daycase Activity (no.) 18 48,009 3,952 3,848 3,848

Vasectomy Service Activity (no.) 18 391 22 37 37

Podiatric Surgery Activity (no.) 18 15,790 1,272 1,265 1,265

Community Podiatry Activity-Non AQP (no.) 14 150,140 10,586 12,717 12,717

Community Podiatry Activity - AQP (no.) 4,861 352 445 445

Physiotherapy Activity (no.) 15 120,752 9,954 9,900 9,900

Speech and Language Therapy Activity (no.) 14 21,879 1,893 1,623 1,623 Exception report at page 28.

Diagnostic Imaging (no.) 3,625 302 319 319

Health Visiting Contract (rating) 18 Exception report at page 29.

5.7%

UAL

ITY

BUSI

NES

S

FIN

ANCE

BUSI

NES

S &

MAR

KETI

NG

ACTI

VITY

MET

RICS

CLIN

ICAL

EFF

ECTI

VE




Year to Date Target




Score

Health Visiting Activity (no.) 18For

InformationFor


Community Nursing Activity (no.) 10 550,592 43,595 43,634 43,634

Community Matron Activity (no.) 15For

InformationFor


Rehabilitation and Intermediate Care Activity (no.) 9For

InformationFor

Information8,088 8,088 Community Therapy activity

Community Information Dataset Completeness-Referral to treatment information (%)

>50% >50% 92% 91.9%

Community Information Dataset Completeness-Referral information (%) >50% >50% 85% 84.7%

Community Information Dataset Completeness-Treatment activity information (%)

>50% >50% 85% 84.7%

Information Governance Incidents Reported via IG toolkit - Level 2 or above (no.)

0 0 0 0

Information Governance Toolkit Achievement - measures scoring 2 or better (no)

0 0 0 Not available until June 2016

Continuity of Services-Liquidity Ratio (days.) (Monitor Shadow Format) 4 4 4 4

Continuity of Services-Capital Servicing Capacity (times.) (Monitor Shadow Format)

4 4 4 4 Discussed in the Finance Report

Continuity of Services-Risk Rating (Monitor Shadow Format) 4 4 4 4 Discussed in the Finance Report

FT Membership (no.) 12,500 12,500 12,362 12,362

QU

IM&

TFT

REG

IME



DCHS HCAI, CQUIN and RTT Waiting Times Scorecards. Pressure Ulcer Report May 2016



Measure Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 YTD

1a MRSA Infections Incidence 1 1

1b MRSA Infections Lapse in care 0 0

2a ESBL Infections Incidence 1 1

2b ESBL Infection Lapse in care 0 0

3a Norovirus outbreaks Incidence 3 3

3b Norovirus outbreaks Lapse in care 0 0

4a MRSA Bacteraemia Incidence 0 0

4b MRSA Bacteraemia Lapse in care 0 0

6a Clostridium Difficile Incidents 0 0

6b Clostridium Difficile Significant Lapse in care 0 0

6c Clostridium Difficile Minor Lapse in care 0 0

7a MSSA Bacteraemia Incidence 0 0

7b MSSA Bacteraemia Lapse in care 0 0

8a E.coli Bacteraemia Incidence 0 0

8b E.coli Bacteraemia Lapse in care 0 0

HEALTHCARE ASSOCIATED INFECTION SCORECARD 2016-17

Focus Area

ESBL/AMP C InfectionsButterley Ward, Ripley Hospital 21/04/16 (AMPC)The patient had a positive AMP C urine sample result on 21/04/16. As the patient had clinical symptoms of infection they were successfully treated with a course of Nitrofurantoin. No risk factors for the infection have been identified. All appropriate IP&C measures were in place.

MRSA InfectionsHopewell Ward, Ilkeston Hospital 06/04/16The patient had a positive MRSA wound swab result on 06/04/16. The patient has a history of colonisation with MRSA. The patient had a positive nasal swab result during their recent acute hospital admission prior to their transfer to Ilkeston Hospital. In addition, the patient has chronic leg ulcers, which when combined with the patient’s MRSA colonisation history increases the risk of wound infection or colonisation. The patient demonstrated clinical signs of infection and was treated appropriately with antibiotic therapy. The leg ulcers have responded to treatment and are no longer infected. Appropriate IP&C measures were in place.

MRSA bacteraemiaThere have been no MRSA bacteraemia reported for 2016-17 to date.

Clostridium Difficile InfectionsThere were no Clostridium difficile infections for April 2016.

Norovirus OutbreaksThere have been 3 norovirus outbreaks during April 2016.

Alton Ward, Clay Cross Hospital 04/04/16 – 11.04.168 patients and 2 staff members presented with symptoms of diarrhoea and vomiting during this period suggestive of gastrointestinal infection. One sample taken was reported as positive for Norovirus. The source of the infection has not been identified. Beds were closed to admissions for 7 days and all IP&C measures were implemented appropriately.

Heanor Ward, Ilkeston Hospital 11/04/16 – 19.4.167 patients and 5 staff members presented with symptoms of diarrhoea and vomiting during this period suggestive of gastrointestinal infection. None of the stool samples tested positive for Norovirus. The source of the outbreak has not been identifiedBeds were closed to admissions for 8 days and all IP&C measures were implemented appropriately.

Rowsley Ward, Newholme Hospital 15/04/16 –22.04.1610 patients and 4 staff members presented with symptoms of diarrhoea and vomiting during this period. 2 stool samples taken tested positive for norovirus. Beds were closed to admissions for 7 days and all IP&C measures were implemented appropriately. It has been reported that an agency nurse was symptomatic whilst on the ward 2 days prior to the outbreak commencing, it is likely that this may be the source of the infection



TypeFrequency of

Reporting2016/17 Full Year Target YTD Target Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 YTD

Forecast Outturn

Narrative

Introducing Health & Wellbeing initiatives for staff

N1aBi annually (Q1

& Q4)Delivery of health and wellbeing

initiatives by Q4 againt planBi annual report on progress

Introducing healthy food for staff, patients and visitors

N1b (i) Annually - Q4

elivery on four outcomes:- Banned price promotion of high

sugar/fat food and drink- Banned advertising of high sugar/fat

food and drink- Banning of sugary drinks and high fat/salt/sugar foods at checkouts

- Ensuring healthy options are available to all staff inc. night workers

Q4 report on progress

Introducing healthy food for staff, patients and visitors

N1b (ii) Annually - Q1Submission of national data collection

returns by July based on existing contracts with food and drink suppliers

Q1

Improving the uptake of flu vaccinations for frontline clinical

staff N1c Annually - Q4

75% of frontline clinical staff have received the flu vaccination

75%

Frailty - Delirium L1 Quarterly

Improvement in the recognition, treatment and prevention of delirium

by implementation of a clear care pathway.

Delivery against KPIs - TBC Q1

High Peak Admission Avoidance L2 QuarterlyTo improve care pathways and patient

flow across the High Peak localityDelivery against project plan -

TBC Q1

Pressure ulcer reduction L3 Quarterly

To work in partnership with nursing home staff to support a reduction in,

and improve the management of pressure ulcers across a health care

community

Delivery against KPIs - TBC Q2

Roll-out of SystmOne DOM therapy tool - County

community L4a Quarterly

Implementation of the Derby Outcomes Measure (DOM) tool across County Community services through

SystmOne

Delivery against project plan by Q4

Roll-out of SystmOne DOM therapy tool - City community

L4b Quarterly

Implementation of the Derby Outcomes Measure (DOM) in Derby

City community services through Systmone

Delivery against project plan by Q5

NHS DERBYSHIRE COUNTY CCGs AND ASSOCIATES CONTRACTCQUIN INDICATORS 2016-17



AHP-Led Referral to Treatment Schedule in Weeks (April 16) - Clocks ended in April

Service Line 0-6 7 - 12 13 - 17 18+Total

WaitersMax

Waiter>6 week

waiter total% Waiting over 6w

>13 week waiter total

% Waiting over 13w

Planned CareAVE MOPP 2345 345 5 5 2700 23 355 13.1% 10 0.4%CHE MOPP 1484 321 18 0 1823 15 339 18.6% 18 1.0%HPD MOPP 1254 132 1 0 1387 13 133 9.6% 1 0.1%Speech and Language Therapy 613 138 3 1 755 21 142 18.8% 4 0.5%

6665 33 0.5%ICBS

AV 312 45 3 2 362 83 50 13.8% 5 1.4%ERE 270 41 3 0 314 14 44 14.0% 3 1.0%SDSD 1525 264 0 1 1790 23 291 16.0% 27 1.5%CHE 204 46 2 2 254 64 50 19.7% 4 1.6%NED 430 81 8 2 521 22 91 17.5% 10 1.9%HPD 98 18 1 3 120 25 22 18.3% 4 3.3%Disability Services 10 5 2 0 17 15 7 41.2% 2 11.8%Respiratory Services 134 40 0 0 174 12 40 23.0% 0 0.0%Learning Disabilities 28 15 1 2 46 25 18 39.1% 3 6.5%

3598 58 1.6%All Services 8707 1491 47 18 10263 31.4 1582 15.4% 58 0.6%

Consultant-Led Referral to Treatment Schedule in Weeks (April 16) - Clocks ended in April - Admitted Patient Care (Part 1A - Unadjusted)

Specialty 0-6 7 - 12 13 - 17 18+Total

WaitersMax

Waiter>6 week



% Waiting over 18w

General Surgery 6 50 20 4 80 23 74 93% 4 5%Urology 0 31 6 1 38 19 38 100% 1 3%Trauma & Orthopaedics 28 19 7 6 60 34 32 53% 6 10%Ear, Nose & Throat (ENT) 0 0 0 0 0 0 0 0% 0 0%Ophthalmology 23 36 7 1 67 21 44 66% 1 1%Oral Surgery 0 0 0 0 0 0 0 0% 0 0%Neurosurgery 0 0 0 0 0 0 0 0% 0 0%Plastic Surgery 0 0 0 0 0 0 0 0% 0 0%Cardiothoracic Surgery 0 0 0 0 0 0 0 0% 0 0%General Medicine 0 0 0 0 0 0 0 0% 0 0%Gastroenterology 0 0 0 0 0 0 0 0% 0 0%Cardiology 0 0 0 0 0 0 0 0% 0 0%Dermatology 2 15 20 18 55 24 53 96% 18 33%Thoracic Medicine 0 0 0 0 0 0 0 0% 0 0%Neurology 0 0 0 0 0 0 0 0% 0 0%Rheumatology 0 0 0 0 0 0 0 0% 0 0%Geriatric Medicine 0 0 0 0 0 0 0 0% 0 0%Gynaecology 0 0 3 0 3 14 3 100% 0 0%Other 0 0 0 0 0 25 0 0% 0 0%Derbys Dental 73 17 4 1 95 25 22 0% 1 0%Leics Dental 22 28 21 6 77 22 55 0% 6 0%All Services 154 196 88 37 475 321 67.6% 37 7.8%

Consultant-Led Referral to Treatment Schedule in Weeks (April 16) - Clocks ended in April - Non-Admitted Patient Care (Part 1B)

Specialty 0-6 7 - 12 13 - 17 18+Total

WaitersMax

Waiter>6 week



% Waiting over 18w

Planned CareGeneral Surgery 16 5 2 0 23 16 7 30% 0 0%Urology 8 1 0 0 9 8 1 11% 0 0%Trauma & Orthopaedics 38 23 7 5 73 21 35 48% 5 7%Ear, Nose & Throat (ENT) 41 50 11 6 108 21 67 62% 6 6%Ophthalmology 66 17 13 1 97 20 31 32% 1 1%Oral Surgery 0 0 0 0 0 0 0 0% 0 0%Neurosurgery 0 0 0 0 0 0 0 0% 0 0%Plastic Surgery 0 0 0 0 0 0 0 0% 0 0%Cardiothoracic Surgery 0 0 0 0 0 0 0 0% 0 0%General Medicine 0 0 0 0 0 0 0 0% 0 0%Gastroenterology 10 3 1 1 15 18 5 33% 1 7%Cardiology 3 5 1 0 9 13 6 67% 0 0%Dermatology 29 55 8 0 92 17 63 68% 0 0%Thoracic Medicine 0 0 0 0 0 0 0 0% 0 0%Neurology 0 0 0 0 0 0 0 0% 0 0%Rheumatology 0 1 0 0 1 7 1 100% 0 0%Geriatric Medicine 3 4 0 0 7 9 4 57% 0 0%Gynaecology 13 14 2 0 29 13 16 55% 0 0%Other 4 6 1 1 12 22 8 67% 1 8%

Total 231 184 46 14 475 244 51.4% 14 2.9%

Consultant-Led Referral to Treatment Schedule in Weeks (April 16) - Clocks still running (Part 2)

Specialty 0-6 7 - 12 13 - 17 18+Total

WaitersMax

Waiter>6 week



% Waiting over 18w

Planned CareGeneral Surgery 89 62 8 1 160 18 71 44% 1 1%Urology 43 8 3 0 54 16 11 20% 0 0%Trauma & Orthopaedics 122 51 14 2 189 18 67 35% 2 1%Ear, Nose & Throat (ENT) 27 46 7 0 80 17 53 66% 0 0%Ophthalmology 69 74 21 5 169 19 100 59% 5 3%Oral Surgery 0 0 0 0 0 0 0 0% 0 0%Neurosurgery 0 0 0 0 0 0 0 0% 0 0%Plastic Surgery 0 0 0 0 0 0 0 0% 0 0%Cardiothoracic Surgery 0 0 0 0 0 0 0 0% 0 0%General Medicine 0 0 0 0 0 0 0 0% 0 0%Gastroenterology 21 4 1 0 26 14 5 19% 0 0%Cardiology 18 18 2 2 40 18 22 55% 2 5%Dermatology 28 43 2 1 74 18 46 62% 1 1%Thoracic Medicine 0 0 0 0 0 0 0 0% 0 0%Neurology 1 0 0 0 1 3 0 0% 0 0%Rheumatology 2 0 1 0 3 14 1 33% 0 0%Geriatric Medicine 1 3 1 0 5 13 4 80% 0 0%Gynaecology 27 12 3 0 42 17 15 36% 0 0%Other 3 9 1 1 14 24 11 79% 1 7%

Derbys Dental 62 7 1 0 70 13 8 0% 0 0%Leics Dental 129 87 13 15 244 37 115 0% 15 0%Total 642 424 78 27 1171 529 45.2% 27 2.3%



DCHS Performance Exception Reports May 2016



Measure Type Frequency Director2016/17 Full Year Target

YTD Target Q1 Apr-16 May-16 Jun-16 YTD

Resus Training (% compliance) External Monthly DoSD 95% 95% 89% 89% 89%

1-Summary of Issues:

2. Action Plan

3-Timescales

4-Effect of this Exception on the Forecast Plan (how we get to our final forecast position from here)

Exception Report Analysis

As Board are aware, DCHS is participating in a regional project to streamline the training offered to NHS staff. Therefore, resuscitation is for the first time being reported as one Essential Learning topic, rather than separately as mini topics (ILS, PBLS, CPR, mini-PBLS, mini-CPR, mini-ILS). We have also re-assessed what level of training is needed for each member of staff and are in the process of updating ESR to be able to report accurately. April's people data also now includes the ~400 staff who transferred to DCHS on 1st October 2015. Both of these issues account for the dip in performance between March and April.

It is expected that compliance will improve from next month.

It is expected that compliance will improve from next month.

QBS are currently making the required competency amendments and targetted work is ongoing in the tranferred services to reach 100% compliance and is progressing well.

89%

90% 90%

95% 95% 95% 95% 95% 95% 95% 95% 95%

84%

86%

88%

90%

92%

94%

96%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

%ag

e Co

mpl

ianc

e

Month

Resus Training (%)

Forecast (%)

Target Profile (%)

Resus Training (% Compliance) - April




YTD Target Apr-16 May-16 Jun-16 YTD

New starters attending induction (compliance %) External Monthly DoSD 95% 95% 82% 82%


2. Action Plan

3-Timescales



The low compliance this month reflects a larger than usual number of 'induction waivers' being completed by Appointing Officers. The Induction waiver exists to allow managers to delay induction for their new starter if there is a valid operational reason. All waivers are assessed by Staffing Solutions and induction booked for a later date.

Performance will improve in May and is forecast at 100% by July 2016.

Performance will improve in May and is forecast at 100% by July 2016.

Staffing Solutions will ensure waivers are only completed in exceptional circumstances.

82%

0%

20%

40%

60%

80%

100%

120%


%ag

e Co

mpl

ianc

e

Month

StartersAttendingTraining (%)

TargetProfile (%)

Forecast (%)

New Starters Attending Induction (% Compliance) - April




YTD Target Q1 Apr-16 May-16 Jun-163 month

YTD

Inpatient Average Length of Stay (days) External Monthly DoSD 20 20 16.0 20.8 20.3


2-Action Plan: (actions taken, including assignment of responsibility for this plan)

3-Timescales



During April 2016 6 community hospital wards had patients with an extended length of stay. In all, 16 patients exceeded the target of 20 days by a total 364 days. 204 days were due to a delay in accessing appropriate social care packages and 86 were attributed to patient /family choice.Regarding specific wards the details are as follows;

Babington - Patient was in for 35 days but for most of them was having rehab. At the point of discharge Medequip delivered a reclining chair which didn’t work so the discharge was delayed for 2 days while they replaced it.One patient was admitted from an acute hospital on the End of Life (EOL) pathway, and then recovered. Family had to find an appropriate nursing home which took 42 days.A patient’s family had to provide a new bed which was partly delayed by the Easter holiday period.

Alton Ward at Clay Cross - One patient waiting for an extensive, four double up calls a day care package. However an interim placement in a care home was found with Adult care in the short term which meant the patient could be discharged from a hospital bed whilst waiting for a care agency to respond.

St Oswald’s - 2 patients waiting 60 days each for packages of care and 2 others waited a further 83 days between them, also for care packages. One patient stayed for End of Life care and another waited an extra 28 days whilst family looked for a care home.

Butterley Ward at Ripley - One patient on Butterley ward was an inpatient for 96 days in total, firstly through waiting 81 days for rehousing after it was found that his home was uninhabitable. Once Adult Social Care had co-ordinated new accommodation there was a further 15 days wait for a care package to commence.Fenton Ward-Two patients waited for Continuing Care Assessments and exceeded the 20 day target by 15.4 days.

Rowsley Ward - 1 patient delayed 4 days waiting for care package and 2 patients delayed due to family objections relating to patients discharge destination.

Oker Ward - Length of stay generally related to the acuity of the patients. 3 stroke patients who will require slow rehabilitation. 2 delayed due to care package increase.

The remaining wards at Ilkeston Hospital and Bolsover had a some issues with social care package and patient/family extending the length of stay by a total 30 days.

DCHS and DCC Adult Care staff are to review some of the initiatives undertaken in the acute hospitals to help reduce Length of Stay, initially the direct reinstatement of care packages without the need for referral into Adult Care. System resilience leads to be informed of any potential LOS issues and to liaise with partner agencies in resolving delays.

All actions should be in place by May 20 2016

The last few weeks have seen less pressure in the system than over the previous 3 months, which should improve tha ability of all agencies to respond to demand. There remains a cohort of patients who need more than3 weeks to rehabilitate to the level required to go home.

20.8

20.3 15.0

16.0

17.0

18.0

19.0

20.0

21.0

22.0


Days

Month

Monthly Length ofStay (days)

Average Length ofStay - 3 monthrolling ave (days)

Monthly Length ofStay Forecast (days)

Target (days)

Inpatient Average Length of Stay (days) - April



Measure Type Frequency Director

2015/16 Full Year Target

YTD Target Q3 Jan-16 Feb-16 Mar-16 YTD

Falls resulting in severe injury or death (no.) External Monthly DoNQ 0 0 15 1 1 3 20



3-Timescales



W59130 - A 90 year old female patient was found on the floor in the toilet of Baron Ward,. Patient reported that they had bumped right side of head and right shoulder. ANP present and correct protocols followed to ensure post fall assessment completed correctly. potential injuries seen, emergency ambulance transfer to Royal Derby Hospital. CT scan confirmed small subdural haemotoma (no skull fracture) and right scapula fracture. Patient currently being treated for an infection (source unknown) on an Orthopaedic ward awaiting decision regarding management of fractured scapula. No current treatment required for subdural bleed W58245- An 84 year old female patient found on her back on the floor on Melbourne ward corridor. Curtains and curtain rail found to be on floor next to patient. assessed by doctor following incident at 11am, subsequent examination at 13.45 detected possible shoulder injury, sent for x-ray. fracture of Right shoulder identified. Patient returned to ward for conservative management (sling provided) W58404 - A 92 year old female patient on Riverside ward was walking on the corridor, she stepped backwards and tripped over her own feet, she then attempted to grab the hand rail and missed it ,then she fell backwards onto the floor. Patient's Early Warning Score and neurological observations taken. Patient was encouraged to try and get up independently she half turned around but could not fully get up staff assisted. Patient's Left leg had no swelling or redness or shortening she could lift it a small amount at that time. Patient assisted into a wheelchair and taken to her room on standing she favoured her Right leg and had problems with her Left to put it fully on the floor to weight bear as she was assisted into bed. 999 called due to suspected left leg injury. Attended Chesterfield Royal Hospital, fracture seen, left hip fracture.

W59130 - Duty of Candour notification letter delivered to daughter. RCA in progress W58245 - Duty of Candour completed on the 29/02/16. Ward Manager notified the Patient's husband. RCA in progress. W58404 - Duty of Candour discussed with the Patient's daughter on the 3rd March 2016. RCA in progress.

W59130 - Duty of Candour notification letter delivered to daughter. RCA in progress

W58245 - Duty of Candour completed on the 29/02/16. Ward Manager notified the Patient's husband. RCA in progress.

W58404 - Duty of Candour discussed with the Patient's daughter on the 3rd March 2016. RCA in progress.

0

1

2

3

4

5

6


No

Month

Falls Resulting in Severe Injury or Death - March

Falls Resulting inSevere Injury(no)




YTD Target Q1 Apr-16 May-16 Jun-16 YTD

Speech and Language Therapy Activity (no.) External Monthly DoSD 21,879 1,893 1,623 1,623 1,623



3-Timescales



The service there have been 4 long term absences in the children's team during April and 1 long term absence in the adult team, this will have impacted on the activity in the service. Additionally there has been vacancy in the children's team during April, and 2 maternity leaves. New starters have come into post during April.

At this stage in the year we expect to recover this position and meet the overall activity for the year end.

On going recruitment should impact positively on activity moving through the next 2-3 months with expected increases in contacts demonstarted.

Some long term absence remains in the service , but some staff on long term absences have returned to their posts now.We are proactive in managing absence in the service and utilise OH support to facilitate return to work as effectively as possible. We have recruited to cover for maternity leave and some of the vacancy in the children's service, these staff have been following DCHS and SLT service induction during April and picking up a caseload, which will now be in place for May. recruitment to vacancies in the service continues.

1,623

1,893 3,573

5,614 7,297

8,599 10,421

12,320

14,439 15,817

17,936 19,835

21,879

0

5,000

10,000

15,000

20,000

25,000


Activ

ity (

no)

Month

Activity Actual(no)

Activity Target(no)

ActivityForecast (no)

Speech and Language Therapy Activity (no) Cumulative - April



Measure Type Frequency Director2016/17 Full Year

TargetYTD Target Q1 Apr-16 May-16 Jun-16 YTD

Health Visiting New Birth Visits within Contract Terms-10-14 days (%) External Monthly DoSD 98% 98% 95.0% 96.9% 96.9%

Health Visiting 2-2.5 year Development Assessment Completed (%) External Monthly DoSD 93% 93% 93.0% 88.8% 88.8%

Health Visiting - Number of mothers who have received a first face to face antenatal contact (%) External Monthly DoSD 93% 98% 91.2% 91.2% 91.2%



3-Timescales

The revised activity reporting process will provide an accurate figure of the number birth visits undertaken each month and how many of these recieved an Antenatal contact and reflect the increased performance figures towards target.

8

July 1st -Recruitment to vacancies will be complete by end of May.


1 New Birth Visits - In April there were 552 birth visits due, 504 of these births received a visit within 10 - 14 days (91.3%), 48 were completed late or outstanding. DCHS have agreed the exceptions with the DCC Commissioners which include babies in Neonatal units and transfer in and outs, there were 31 exceptions ( 10 in NNU, 1 mothers & baby in hospital, and 1 late referral from child health Dept, 12 completed in timescale but documented date late, 1 visit late on day 15 due to continuity of care, 3 no access after 2 appointments, 1 transfer in and 1 transfer out which gives a revised performance figure of 96.92%. Of the remaining 17 visits there were 6 No Access visits, 8 visits under taken after 14 days, 4 visits cancelled at short notice by mother.

2 Antenatal Contacts - In April there were 531 births, 385 of these births received an Antenatal contact which is 73% achieved. DCHS have agreed the exceptions with the DCC Commissioners which include babies born premature, mothers seen by FNP, no maternity referral received, mothers who actively refuse the visit and transfer ins and out of area. There were 108 mothers who did not receive an antenatal contact, valid and agreed exceptions account for 99, which gives a revised performance of 91.15%. Reasons for the remaining 31 AN visits not being undertaken include , 7 no access visits, 1 cancelled by mother, 15 not scheduled for appointment as many of these transferred late in pregnancy from Derby City and Staffordshire to DCHS due to changes in commissioning from registered to resident population from 1st April.

1. New Birth Visits - additional HV resource moved to Erewash and SDDD where they have recieved over 600 children transfer into each locality as a result of bulk transfer of children from Derby City and Staffordshire due to changes in commissioning from GP registered to LA resident population for children 0-5 years. Working closely with Midwifery providers to ensure we recieve antenatal referrals based on residency. Continue to audit records monthly to identify any team/practitioner appointment scheduling processes that need improvement.

2. Antenatal Contacts - Management support to a teams in Erewash and SDDD to mobilise wider workforce support to help with processing the 1600 additional children recieved as a result of boundary changes and support to achieve all core contacts within timeframe. A new SystmOne template has been added to care plans to capture exceptions and support reporting of performance. Continue to audit births monthly of all mothers who do not recieve an Antenatal contact. Team leaders to identify capacity or scheduling issues in teams to try to improve the number of women offerred an antenatal appointment, work with Midwifery providers where referrals not recieved and evidence via DATIX. SystmOne Admin Coordinator supporting and offering 1:1 training for practitioners to correct any data quality issues.Healthy Child Programme Lead and Quality Professional Lead will review these reports monthly to identify any data quality and workforce capacity issues.

96.9%

88.8%

91.2%

40%

50%

60%

70%

80%

90%

100%

110%

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15

Perc

enta

ge o

f co

ntac

ts

Month

No. of Actual Visits 10-14days (%)

Health Visiting 2-2.5 YearDevelopment AssessmentCompleted (%)

Actual First Face to FaceAntenatal Contacts (%)

Target (%)

Forecast - Overall (%)

Health Visiting (%) - April



Main QBC and Board Reports

QBC Board Comm Measure Description

Total Workforce Cost (£000s) Includes agency & bank. Plan revised to match QBC Finance report

Temporary Staffing Costs - Agency (£000's) Agency costs, usually funded by vacancies budget

Temporary Staffing Costs - Bank (£000's) Bank costs, usually funded by vacancies budget

Agency & Bank Spend as a % of Turnover (%) Agency & bank costs / Income

Agency & Bank Spend (Clinical) as a % of total workforce costs (%)

Total WTE - Contracted - All Assignments (no)

Total Headcount (no)

Health Visitor WTE (no.) Health visitors as reported by POEP within ESR

Staff Attendance (%) Staff attendance in month and on a ytd 12 month average

Staff Turnover (%) Staff turnover in month and on a ytd 12 month average

Board Turnover (no.)

Redundancy (no.) All posts made redundant to RATs for authorisation

Vacancies - Average Length of Time To Recruit (days)The average length of time from an approved vacancy being advertised on NHS Jobs to an agreed start date of employment being confirmed including time taken to complete pre-employment checks.

Vacancies - Average Length of Time From Offer to 1st Working Day (days) The average length of time from an agreed offer of employment being made to the applicant commencing employment with DCHS.

Vacancies - Average Length of Time For Pre Appointment Checks (days) The average length of time for pre-employment checks to be completed.

Vacancies - Externally Filled (no.) New measure

Vacancies - Internally Filled (no.) New measure

Advertised Vacancies (no.)

Essential Learning completed (% compliance) Year to Date is rolling 12month average - wte data

Information Governance Training (% compliance) Year to Date is rolling 12 month average-assignment data

Fire Training (% compliance) Year to Date is rolling 12 month average-assignment data

New starters attending induction (compliance %) New starters attending induction within 3 months / new starters requiring induction

Training - Resuscitation (% compliance)

Training - Safeguarding Children L2 (% compliance)

Training - Safeguarding Children L3 (% compliance)

Training - Safeguarding Adults L2 (% compliance)

Staff with appraisal completed (% compliance) Staff who have a current completed appraisal

Injury Frequency Rate (no)

Injury Severity Rate (no)

Lost time Injury cost (£)

Zero Harm - Riddor Reportable Injurys (no)

Improvement in Staff Engagement Score (%) Total staff participating / Total staff

Staff Survey - Recommend DCHS to Friends and Family If They Needed Care or Treatment (%)

Staff Survey- recommend DCHS to friends and family as a place to work (%)

Staff Survey - Participation Rates (%)

Pulse Check - Participation Rate (%)

Pulse Check - Recommend DCHS to Friends and Family If They Needed Care or Treatment (%) Quarterly survey score

Pulse Check - Recommend DCHS to Friends and Family as a Place to Work (%) Quarterly survey score

Patient Revolution Friends & Family Test Recommended Score (%) Service scores by patients

Complaints Received (no.) Level 2 and above complaints

PLACE (score)Q1-Looks at the environment in which care is provided and the quality of non-clinical services - food and privacy and dignity. Q2-Looks at cleanliness. Q3-external verification.Q4-PLACE

Certification against compliance with requirements regarding access to healthcare for people with a learning disability

To be reported to EDS & quarterly to QSC

A&E Targets (rating) Composite A&E targets measure

A&E 4 Hour Wait for A&E Attendances (%) The percentage of people who are seen within A&E in under 4 hours

A&E Unplanned Re-attendance Rate (%) Unplanned attendances within 7 days of discharge / total attendances

A&E Left Without Being Seen Rate (%) The percentage of people who leave the A&E without being seen

A&E Time to Initial Assessment - 95th percentile (mins) The time below which 95% of patients arriving by emergency ambulance are assessed

A&E Time to Treatment - Median (mins) The time below which 50% of attendances were treated

A&E Total Time in the A&E Department (non admitted) - Longest (mins) Single longest time recorded from arrival at A&E to transfer or discharge

A&E Total Time in the A&E Department (non admitted)-95th percentile (mins) 95% of patients have spent up to this time in the A&E Department

RTT Targets (rating) RTT composite measure

RTT Waits - incomplete pathway 92nd percentile (weeks) 92nd percentile of incomplete pathways whose clocks stopped during the period on an adjusted basis

RTT Waits - admitted patients 90th percentile (weeks) 90th percentile time waited for admitted patients whose clocks stopped during the period on an adjusted basis

RTT Waits - non admitted patients 95th percentile (weeks) 95th percentile time waited for admitted patients whose clocks stopped during the period on an adjusted basis

RTT Waits - admitted patients seen within 18 weeks - 90% (target) (1A) 90% target for admitted patients

RTT Waits - admitted patients seen within 18 weeks - 90% (target) (1A) - Planned Care

RTT Waits - admitted patients seen within 18 weeks - 90% (target) (1A) - DCHS Dental

RTT Waits - admitted patients seen within 18 weeks - 90% (target) (1A) - Leicestershire Dental

RTT Waits - non admitted patients seen within 18 weeks - 95% (target) (1B) 95% target for non admitted patients

RTT Waits - Incomplete pathway - 92% (target) (2)

RTT Waits - pathways greater than 52 weeks for completed admitted pathways (un-adjusted), completed non-admitted pathways and incomplete pathways.

Patient pathways greeter than 52 weeks

RTT Waiting Times (Scorecard)

Diagnostics - Patients exceeding 6 weeks wait (%)

Choose and Book Targets (rating) Composite of Choose and Book targets

Choose & Book - Appointment slots available - no of patients unable to book (%)

Focus Area

DCHS BOARD PERFORMANCE REPORT BALANCED SCORECARD

A&E

REFE

RRAL

TO

TRE

ATM

ENT

HEA

LTH

AN

D S

AFET

Y

QU

ALIT

Y PE

OPL

E

SERV

ICE

USE

R EX

PERI

ENCE

WO

RKFO

RCE

MET

RICS

TRAI

NIN

G A

ND

APR

AISA

LFE

EDBA

CKPA

TIEN

T SA

TISF

ACTI

ON




QBC Board Comm Measure DescriptionFocus Area


Choose & Book - Eligible Services Directly Bookable (%)

Choose & Book-Unpublished Services in Directory of Services (%)

Choose & Book-Minimise Number of "Do Not Use" or "Test" Services in Directory Of Services (No)

Choose & Book-Age range added to all services in the Directory Of Services (%)

Choose & Book-Provide advice & guidance for all included services (%)

Choose & Book - Patients Contacted Within 3 days of Being Reported on ASI (%)

Patients who have operations cancelled for non clinical reasons on the day (%)

Patients who have operations cancelled for non clinical reasons receiving treatment within 28 days (%)

Mixed Sex Accommodation Breach Rate (No)

Delayed Transfer of Care (%) Number of breaches / number of Finished Consultant Episodes

Delayed Transfer of Care for Inpatient (Rehab & Urgent Care) - contract calculation (%) Number of delayed transfers of care as a proportion of the number of occupied beds

Delayed Transfer of Care for OPMH - contract calculation (%) Delayed patient transfers from DCHS to other organisations

Delayed Transfer of Care for OPMH - Monitor compliance framework calculation (%) Delayed patient transfers from DCHS to other organisations

Inpatient (Rehab & Urgent care) Average Length of Stay (days) Composite of Rehab and Urgent Care length of stay

Older Peoples Mental Health Average Length of Stay (days) Average time in Urgent Care wards

Inpatient and Older Peoples Mental Health Occupancy (%) Bed Occupancy rates

Inpatient (RUC) Occupancy (%)

Older Peoples Mental Health Occupancy (%) Bed Occupancy rates

LD Occupancy (%) Bed Occupancy rates

Achievement of consultation /involvement/engagement inclusion priorities (%) Bed Occupancy rates

New or revised policies/procedures/strategies supported by EIAs (%) Equality and diversity measure

CQC Registration - Overall (rating) Equality and diversity measure

CQC Warning Notices currently in effect (no)

CQC Compliance Action Outstanding (no)

CQC Non-Compliance with Essential Standards resulting in Enforcement Action (no)

CQC - Moderate concerns or impacts regarding the safety of healthcare provision (as at time of submission) (no)

Internal rating against CQC measures

CQC Financial Penalties (no)

CQC Enforcement action within last 12 months (no)

CQC - Major concerns or impacts regarding the safety of healthcare provision (as at time of submission) (no)

CQC Enforcement action (including notices) currently in effect (no)

Total Harm Free Care, in accordance with Safety Express (%)

Inpatients who have harm free care, in accordance with Safety Express (%)

LD patients who have harm free care, in accordance with Safety Express (%)

Community Nursing patients who have harm free care, in accordance with Safety Express (%)

Avoidable Grade 2, 3 & 4 Pressure Ulcers developed or deteriorated in DCHS care (no.)

Total Grade 3 & 4 Pressure Ulcers developed or deteriorated in DCHS care (no.)

Incidence of Newly Acquired Pressure Ulcers (no.)

Medication Errors causing Serious Harm (no.)

NHSLA Rating (no.)

Open Serious Incidents Requiring Investigation (SIRI) (no.)

Never Events (no.)

Falls resulting in severe injury or death (no.)

Open Central Alert System (CAS) Alerts (No.)

100% compliance with WHO surgical checklist (Yes/No) Total number of alerts open on final day on month

Venous Thromboembolism (VTE) Screening (%)

Incidence of health care-related Venous Thromboembolism (No.)

Duty of Candour - Failure to notify relevant person of a reportable incident (no)

Crude Mortality Rate (%)

Healthcare Care Associated Infections - Targets (ratings)

Healthcare Care Associated Infections - MRSA bacteraemia (no.)

Healthcare Care Associated Infections - Clostridium difficile (no.)

Healthcare Care Associated Infections - E Coli & MSSA (no)

Healthcare Care Associated Infections - Clostridium difficile -lapses count (no.)

Breastfeeding sustainment from 10 days to 6-8 weeks after birth (%) Number of partially and fully breastfed infants / total infants due a 6-8 week check

Smoking Quitter Targets Number of partially, fully and none breastfed infants / total infants due a 6-8 week check

CQUIN Scorecard (rating)

Monitor Risk Assurance Framework Scorecard (RAF) (rating)

IWB Overall Measures (rating)

ISH Overall Measures (rating) Composite of quit smoking targets

CIP Achieved-Recurrent(%)

CIP Achieved-Non Recurrent (%) CIP Achieved / Total CIP required

Continuity of Services-Liquidity Ratio (days.) (Monitor Shadow Format)

Continuity of Services-Capital Servicing Capacity (times.) (Monitor Shadow Format)

Continuity of Services-Risk Rating (Monitor Shadow Format)

FT Membership (no.)

SERV

ICE

USE

R SA

FETY

CQC

HAR

M F

REE

CARE

PRES

SURE

ULC

ERS

FIN

ANCE

FT R

EGIM

ECL

INIC

AL E

FFEC

TIVE

NES

S &

PLA

NN

ING

EQU

ALIT

Y &

D

IVER

SITY

CHO

OSE

& B

OO

KIN

PATI

ENTS

QU

ALIT

Y SE

RVIC

E

OCC

UPA

NCY

HCA

IO

THER

SAF

ETY

MEA

SURE

S




QBC Board Comm Measure DescriptionFocus Area


Positive media stories (no.)

Available Bed Days-Inpatients (RUC) (no.)The number of positive media stories reported for DCHS across all media outlets. A positive media story is classed as one that enhances the reputation of DCHS

Available Bed Days-OPMH (no.)

Occupied Bed Days-Inpatients (RUC) (no.)

Occupied Bed Days-OPMH (no.)

Available Beds-Inpatients (RUC) (no.)

Available Beds-OPMH (no.)

MIU Activity (no.) All contract activity, compared against profiled activity plan

Community Beds -Discharged Occupied Bed Days (no) All contract activity, compared against profiled activity plan

Clinical Navigation Service Contacts & Service Outcome (no.)

In-Reach Service Contacts & Service Outcome (no.)

Outpatient and Daycase Activity (no.) All contract activity, compared against profiled activity plan

Vasectomy Service Activity (no.) All contract activity, compared against profiled activity plan

Podiatric Surgery Activity (no.) All contract activity, compared against profiled activity plan

Community Podiatry Activity (no.)

Community Podiatry Activity-Non AQP (no.) All contract activity, compared against profiled activity plan

Community Podiatry Activity - AQP (no.) All contract activity, compared against profiled activity plan

Physiotherapy Activity (no.) All contract activity, compared against profiled activity plan

Speech and Language Therapy Activity (no.) All contract activity, compared against profiled activity plan

Diagnostic Imaging (no.) All contract activity, compared against profiled activity plan

Pulmonary Rehab (no)

Rehabilitation and Intermediate Care Activity (no.) All contract activity, compared against profiled activity plan

Health Visiting Activity (no.)

Health Visiting Contract (Rating)

Health Visiting New Birth Visits within Contract Terms-10-14 days (%)

Health Visiting 2-2.5 year Development Assessment Completed (%)

Health Visiting - Number of mothers who have received a first face to face antenatal contact (%)

Community Nursing Activity (no.)

Community Matron Activity (no.)

Community Information Dataset Completeness-Referral to treatment information (%)

Community Information Dataset Completeness-Referral information (%)

Community Information Dataset Completeness-Treatment activity information (%)

Mental Health Data Completeness - identifiers %

Information Governance Incidents Reported via IG toolkit - Level 2 or above (no.)

Information Governance Toolkit Achievement - measures scoring 2 or better (no)

SUS Dataset Validation (%)

SUS / SLAM Variation (%)

SUS Dataset Altered Between 5 days After Month End & Inclusion Point (%)

Sickness & Absence Rates - Long Term Absence (%)

Sickness & Absence Rates - Short Term Absence (%)

Turnover - Planned (%) DCHS planned turnover changes

Turnover - Unplanned (%) Employee generated turnover changes

New SIRIs reported per month (excluding pressure ulcers) (no.)

Percentage of deaths in community hospitals (expected and unexpected) compared to all discharges (excl Palliative Care and End of Life)

Injurous Falls per 1,000 inpatient occupied bed days (no.)

Injurious and non Injurious Falls per 1,000 Inpatient Occupied Bed Days

Number of incidents (causing harm or otherwise) per 1,000 WTE budgeted staff (no)

Number of Formal Complaints Reported per 1,000 WTE Budgeted Staff

Safety Thermometer - Percentage of 'Harm Free' Care (New harms only)

Face to face contacts per whole time equivalent (wte) community nurse per working day (no.)

Total pay cost per wte community nurse (£)

Face to face contacts per whole time equivalent (wte) health visitor per working day (no.)

Total pay cost per wte health visitor (£)

Average length of stay (days)

Percentage occupancy of community hospital beds (%)

Data Completeness-NHS Number (%)

Data Completeness-Ethnicity code (%)

Data Completeness-Postcode (%)

Data Completeness-GP Practice code (%)

INFO

RMAT

ION

QU

ALIT

Y BU

SIN

ESS

QU

ALIT

Y BU

SIN

ESS

CAPA

CITY

COM

M

NU

RSIN

G

QU

ALIT

Y SE

RVIC

E

INFO

RMAT

ION

QU

ALIT

Y BU

SIN

ESS

QAU

ALIT

Y PE

OPL

E

CON

TRAC

T AC

TIVI

TYH

EALT

H V

ISIT

ING

BUSI

NES

S &

MAR

KETI

NG



KEY TO COLOUR CODINGS

Indicator / Measure has met or exceeded targetIndicator / Measure has not met target but is within acceptable tolerances. An action plan is in place and is being monitoredIndicator / Measure has not met target and is beyond accepted tolerances. Immediate action and investigation has been instigated. An action plan is in place and is being monitored. Indicator / Measure is not available or in development

KEY TO SYMBOLS

↑ Performance has improved / is above target

↓ Performance has declined / is below target

↔ Performance is stable and on target to be delivered

Data Quality Kitemark scoring

Using data collected interview sessions with service staff; each system has been marked on the criteria of Audit, Timeliness, Sign off, Granularity, Completeness and Source/Process. A system can score as Not Sufficient, Sufficient or Exemplary in each of the six areas. These areas make up the outer segments of the Data Quality Kitemark Shield eg: A score of Sufficient or Exemplary marks the system as Green on the Kitemark Shield for that section and a score of Not Sufficient marks the system as red.

Data Confidence Score Each system will receive a Data Confidence Score calculated by the total overall scoring given by four key members of staff relating to the specified system from Information, Performance and within the service. Each contact is asked to give the system a confidence rating out of 5 to state how accurately the system data reflects service activity, where 5 is Complete Confidence and 1 No Confidence. The total of the four scorings will be displayed in the centre of the Data Quality Kitemark Shield.

Timeliness

Source/process

Sign off

Completeness

Granularity

Audit

12



TRUST BOARD Document Title: Financial Performance Report

Presenter/Title: Chris Sands, Director of Finance, Information and Strategy Contents of Paper were previously discussed by: Quality Business Committee held on Wednesday 18 May 2016

Author/Title: David Gray, Head of Financial Management Contact Email and Telephone Number: [email protected] 01246 253046

Date of Meeting: 26 May 2016 Agenda Item No: 153/16

No of pages inc. this one: 12

Has an Equality Impact Assessment been undertaken Yes No X

Document is for: (more than one box can be ticked) Information Decision Assurance X

Purpose of Paper

The paper sets out the financial performance of the Trust as at 30th April 2016. The report details performance against statutory and internal targets. The Trust is reporting a surplus position of £0.34m at month 1, which represents a slight deficit variance of £0.02m against the planned surplus of £0.36m. The cash position is as per the plan A year end surplus of £3.4m is forecast, which assumes full delivery of the SQIP programme. The cash position is forecast to be £16.8 million at the end of March 2017. The Trust is forecasting that it will meet all its statutory financial duties for the year

Recommendations

Board Member are asked to receive the Report for Information.


3.7 There is a risk to the financial stability of the organisation of not meeting future Sustainable Quality Improvement Programme over the next two years

Financial Impact

The report contains a number of issues and risks that have a financial impact on the organisation.


Financial Performance Report attached

153�Financial�Performance�RepoOverall�Page�139�of�150Page�1�of�12





Governors will hold the Board to account around its financial position

What are the Equality and Diversity implications? None


None

Risk Register





WORKING CAPITAL13.65 G 16.85 G2.37 G 0.05 G

£m % £m % % £m % £m % £m % (3.17) G 0.60 GEBITDA (0.89) (5.74) (0.86) (5.50) (4.04) (9.83) (5.26) (9.42) (5.04) 0.40 (4.12)

Net (surplus)/deficit (0.36) (2.30) (0.33) (2.14) (6.70) (3.42) (1.83) (3.42) (1.83) 0.00 (0.12) RISK RATINGSFinancial Sustainability Rating - Liquidity (days) 15.78 G 26.68 G

I&E SURPLUS (excl. IMPAIRMENT) I&E SUMMARY AS AT 30 APRIL 2016 Financial Sustainability Rating - Liquidity 4 G 4 GFinancial Sustainability Rating - Capital Servicing (x times) 4.12 G 4.00 G

APRIL 2016

YTD

FOTYTD

VAR

ACTU

AL

PLAN

Current Liabilities Variance (£m)£m

VAR

FOT

PLAN

FULL YEAR

0.02

0.04

DERBYSHIRE COMMUNITY HEALTH SERVICES NHS FOUNDATION TRUST FINANCIAL PERFORMANCE REPORT

PLAN ACTUAL VARIANCE PLAN FOT VARIANCE

APRIL 2016 KEY FINANCIAL INDICATORS

EBITDA AND SURPLUS AS AT 30 APRIL 2016YTD 2016/17 FULL YEAR

APRIL 2016

FOTYTD

Current Assets Variance (£m)Cash at bank as per the ledger (£m)

Financial Sustainability Rating - Capital Servicing 4 G 4 GFinancial Sustainability Rating - I&E margin (%) 2.14 G 1.83 GFinancial Sustainability Rating - I&E margin 4 G 4 G

(£m) (£m) (£m) (£m) (£m) (£m) Financial Sustainability Rating - I&E margin variance (%) -0.16% G 0.00% G(15.54) (15.58) (0.04) (186.86) (187.01) (0.15) Financial Sustainability Rating - I&E margin variance 3 G 4 G

PAY 10.74 10.78 0.04 130.45 129.79 (0.66) Overall Financial Sustainability rating 4 G 4 GNON-PAY 3.91 3.95 0.03 46.58 47.80 1.22 Agency spend (£m) 0.24 A 1.46 GOTHER 0.53 0.52 (0.01) 6.41 6.00 (0.41)

(0.36) (0.33) 0.02 (3.42) (3.43) (0.01) PERFORMANCE AND CIP YTD FOTContract over/(under) performance (£m) 0.00 G 0.00 G

CAPITAL PROGRAMME MONTH END CASH BALANCE Over/(under)achievement of CIP target (£m) (0.04) G 0.00 G(Over)/underspend against investments (£m) G GNet impact of CIP/investments/NR savings (£m) (0.04) G 0.00 G

ADDITIONAL TRIGGERS YTD FOTReceivables aged over 90 days (%) 5.0 30.8 R 5.0 GPayables aged over 90 days (%) 5.0 22.5 R 5.0 GChange in Finance Director in last year 2 0 G 0 GInterim Finance Director in place over QE 2 0 G 0 GDays expenditure covered by QE cash 10 31.7 G 34.6 GCapital Expenditure % of plan (%) 75.0 95.7 G 100.0 G

INCOME

TOTAL

APRIL 2016 VA

R

ACTU

AL

PLAN

VAR

FOT

PLAN

0.00.51.01.52.02.53.03.54.0

Cum

ulat

ive

surp

lus

(£m

)

Plan Actual Forecast

0.0

5.0

10.0

15.0

20.0

Cas

h at

mon

th e

nd (£

m)


0.01.02.03.04.05.06.07.0

Cum

ulat

ive

capi

tal s

pend

(£

m)




DERBYSHIRE COMMUNITY HEALTH SERVICES NHS FOUNDATION TRUST

MONTHLY FINANCIAL PERFORMANCE REPORT FOR TRUST BOARD AS AT 30TH APRIL 2016

1. Introduction

The purpose of this report is to update and inform the Board on performance against key financial criteria for month 1 of the current financial year, 2016/17. The Trust is reporting a surplus position of £0.34m at month 1, which represents a £0.02m deficit variance against the planned surplus of £0.36m. It should be noted that as this is only month 1 of the new financial year the position still requires tight financial control. A year end surplus of £3.4m is forecast, which assumes full delivery of the SQIP Programme. The general mitigation reserve of £1.3m remains uncommitted and unallocated at Month 1.

2. Summary Financial Position The financial risk of the Trust is measured by the Financial Sustainability Rating as part of the provider license. A rating of 4 is low risk, whilst a rating of 1 is high risk. The Trust is forecasting a rating of 4 at the year-end. This reflects the strong balance sheet of the Trust and the forecast surplus position. The Trust is forecasting a surplus of £3.4m. This is supported by £1 million non-recurrent income, and £0.21m non recurrent efficiencies. Therefore the underlying forecast outturn surplus position of the Trust is £2.2m surplus. Table One – Financial Sustainability Rating The Trust’s Performance against the new Financial Sustainability ratings is detailed in the table below. The Trust achieved a rating of 4 at year-end. This reflects the strong balance sheet of the Trust.

Measure Indicator Weight Year to date Year End Outturn Value Rating Value Rating

Liquidity Days Number of days operating expenditure covered by current working capital balances

25% 15.63 4 27.55 4

Capital Servicing

Revenue cover available to service debt repayments

25% 4.12

4 4.00 4



I&E Margin (%)

Year to date I&E margin as a % of total income

25% 2.14 4 1.83 4

I&E Margin Variance (%)

Year to date variance from plan

25% 0.49 4 0.49 4

Overall Rating 4 4

Table Two – “Agency Spend” metrics The Trust’s performance against the Agency Spend metric is detailed below which shows our spend is behind the submitted planned run rate due to the impact of Flexing the number of beds DCHS have open and the complexity of patients currently in the beds and out in the Community.

Measure Indicator Year to date Year End Outturn Actual

£m Target

£m Actual

£m Target

£m Agency Spend Spend against

Planned Trajectory

0.24 0.11 1.46 1.46

3. Income & Expenditure Appendix 1 details the Income & Expenditure Statement as at month 1. More detail on the income and expenditure position is provided below.

3.1 Clinical Income As at month 1 the clinical income position is showing break even against plan. Activity monitoring for month1 is not currently available and therefore for all services, activity and income is anticipated to be in line with plan. The 16/17 activity plans have been developed by services following a robust process and therefore there is no reason to expect that activity should be significantly different from plan at this point of the year. Activity against plans will be closely monitored throughout the year to ensure early identification of under / over –performance and any associated risks to income.

3.2 Non-Clinical and Other Income

Following the realignment of Budgets as part of the Annual Budget Setting Process overall across all Services and Divisions Other Income is ahead of plan by £0.04m.

3.3 Expenditure



Overall, the Trust is reporting a slight overspend against the expenditure plan of £0.06m at month 1. Overall Pay costs are overspent compared to plan by £0.04m predominantly due mostly to the level of Bank and Agency Spend across Integrated Care Services, however the continued vacancies within Health and Wellbeing, Facilities Management and Corporate Divisions are helping to offset the overspend. Total Agency and Flexible Workforce (DCHS Bank Staff) costs have reduced by £0.1m compared to March 2016 and combined together overall represent 3.8% of the Total Pay Spend to date. Agency Spend during April 2016 reduced by £0.038m when compared to March 2016 with costs incurred during the month of £0.24m representing 2.2% of the Total Pay Spend to date. Non-pay Costs are overall showing a slight overspend against plan of £0.02m. There has been an adverse movement in Bad Debt Provision during the month (£0.13m), this is in relation to Non-NHS debt over 90 days, which is expected to be recovered during May. Due to the overspend against plan and as its very early on in the financial year, Services and Divisions are asked to be mindful of the position when committing expenditure. The sustainable quality improvement plan (SQIP) is slightly under plan at month 1 showing an underperformance of £0.04m. It is expected that the initial slippage in some schemes can be recovered by year end. 3.4 Cost Improvements Plan The Trust has a SQIP target of £5.0m for 2016/17. As at month 1 there is an underachievement against the planned schemes of £0.03m, however the plan is forecast to fully achieve by year end. Further detail of the SQIP position can be found in Appendix 2.

4.0 Statement of Financial Position Appendix 3 sets out the Statement of Financial Position.

4.1 Cash At the end of April the cash balance matched the plan (actual: £13.7m, plan £13.7m). The Trust continues to actively manage working capital in line with the Working Capital Framework. Further detail can be found in Appendix 4 attached.

5. Capital Plans and Expenditure

The Trust’s capital plan for 2016-17 totals £5,893k.



Year-to-date spend is £594k against a plan of £620k, an under-spend of £26k. This is principally caused by variance on the phasing of the IM&T expenditure. Further detail can be found in Appendix 5 attached.

6. Risks The main risk carried forward from the previous financial year is the delivery of activity targets in the sexual health service. The activity targets have been recast in consultation with the service to reflect 2015/16 outturn. We will continue to closely monitor performance with the service.

7. Summary

Board Members are asked to note the month 1 position against the financial targets. Chris Sands Director of Finance, Information and Strategy



1 2 3 4 5 6 7 8 9 10 11 12

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

Actual Plan Variance Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Outturn Plan

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

OPERATINGIncome

Clinical Income -14,814 -14,814 0 -14,814 -14,814 -14,814 -14,814 -14,814 -14,814 -14,814 -14,840 -14,914 -14,914 -14,914 -14,914 -178,194 -178,236

Other NHS Income -500 -426 -74 -500 -439 -439 -439 -439 -439 -439 -439 -439 -439 -439 -439 -5,329 -5,075

Education and Training -53 -69 16 -53 -68 -68 -68 -68 -68 -68 -68 -68 -68 -68 -68 -801 -815

Other Income -209 -232 23 -209 -225 -225 -225 -225 -225 -225 -225 -225 -225 -225 -225 -2,684 -2,731

INCOME TOTAL -15,576 -15,541 -35 -15,576 -15,546 -15,546 -15,546 -15,546 -15,546 -15,546 -15,572 -15,646 -15,646 -15,646 -15,646 -187,008 -186,857

Operating ExpensesEmployee Benefit Expenses 10,775 10,739 36 10,775 10,687 10,675 10,793 10,993 10,825 10,634 10,757 10,982 10,794 10,917 10,957 129,789 130,452

Drugs 97 110 -13 97 115 115 115 115 115 115 115 115 115 115 115 1,362 1,313

Clinical Supplies and Services 782 804 -22 782 763 762 762 762 762 762 762 762 762 762 762 9,165 9,408

Other Costs 3,066 2,996 70 3,066 3,145 3,105 2,986 3,235 3,204 2,933 3,078 3,331 3,143 3,034 3,009 37,269 35,856

OPERATING EXPENSES TOTAL 14,720 14,649 71 14,720 14,710 14,657 14,656 15,105 14,906 14,444 14,712 15,190 14,814 14,828 14,843 177,585 177,029

OPERATING (PROFIT) / LOSS EBITDA -856 -892 36 -856 -836 -889 -890 -441 -640 -1,102 -860 -456 -832 -818 -803 -9,423 -9,828

NON OPERATINGLoss / (Profit) on Asset Disposal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Impairment of non-current assets 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Depreciation / Amortisation 317 330 -13 317 307 307 307 307 307 307 307 307 307 307 307 3,694 3,958

Interest (Receivable) / Payable -3 -4 1 -3 -4 -4 -5 -4 -4 -5 -4 -4 -5 -4 -4 -50 -50

Public Dividend Capital 208 208 0 208 195 195 195 195 195 195 195 195 195 195 195 2,353 2,500

NON OPERATING TOTAL 522 534 -12 522 498 498 497 498 498 497 498 498 497 498 498 5,997 6,408

RETAINED (SURPLUS) / DEFICIT -334 -358 24 -334 -338 -391 -393 57 -142 -605 -362 42 -335 -320 -305 -3,426 -3,420

ADJUSTMENTS TO RETAINED SURPLUSDonated Asset Income 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Donated Asset Depreciation 11 0 11 11 11 11 11 11 11 11 11 11 10 10 10 129 120

Impairment of non-current assets 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL ADJUSTMENTS 11 0 11 11 11 11 11 11 11 11 11 11 10 10 10 129 120

ADJUSTED RETAINED (SURPLUS) / DEFICIT -323 -358 35 -323 -327 -380 -382 68 -131 -594 -351 53 -325 -310 -295 -3,297 -3,300

STATEMENT OF INCOME & EXPENDITUREAPRIL 2016

Category

Year to Date Monthly Actual / Forecast

As at 30 April 2016



Appendix 2

R / NR Plan Actual Variance Risk Rating

Plan Out-turn Actual Variance Risk Rating

FYE Forecast

£'s % £'s %

Total CIP 16/17 £300,467 6.4% £272,950 5.8% -£27,517 -9% £4,684,600 £4,684,600 £0 0% £4,684,600Recurrent CIP R £293,800 £270,450 -£23,350 £4,474,600 £4,474,600 £0 £4,474,600Non Recurrent CIP NR £6,667 £2,500 -£4,167 £210,000 £210,000 £0 £210,000

R / NR Plan Actual Variance Risk Rating

Plan Out-turn Actual Variance Risk Rating

FYE Forecast

£'s % £'s %

Integrated Community Based Services15/16 Schemes – (Bolsover Ward and Management Post) R £2,750 8.3% £2,750 8.3% £0 0% £33,000 £33,000 £0 0% £33,000OPMH/LD Medical Contract R £4,167 8.3% £0 0.0% -£4,167 -100% £50,000 £50,000 £0 0% £50,000Management cost savings R £14,167 8.3% £14,167 8.3% £0 0% £170,000 £170,000 £0 0% £170,000Inpatient Budget Consolidation R £7,500 8.3% £7,500 8.3% £0 0% £90,000 £90,000 £0 0% £90,000Babington seasonal bed flex NR £0 0.0% £0 0.0% £0 0% £94,000 £94,000 £0 0% £0Buxton (Fenton Ward) seasonal bed flex NR £0 0.0% £0 0.0% £0 0% £36,000 £36,000 £0 0% £0Medical Staffing Review R £0 0.0% £0 0.0% £0 0% £79,000 £79,000 £0 0% £79,000MARS - ICBS R £9,342 8.3% £9,342 8.3% £0 0% £112,100 £112,100 £0 0% £112,100Health, Wellbeing and InclusionChildren’s Reconfiguration School Nursing - County R £25,000 8.3% £25,000 8.3% £0 0% £300,000 £300,000 £0 0% £300,000Children’s Reconfiguration Health Visiting - County R £4,167 8.3% £4,167 8.3% £0 0% £50,000 £50,000 £0 0% £50,000(Connecting for Health) - Sexual Health R £8,333 8.3% £8,333 8.3% £0 0% £100,000 £100,000 £0 0%Staff vacant posts - apprentice R £1,667 8.3% £1,667 8.3% £0 0% £20,000 £20,000 £0 0% £20,000Planned Care and Outpatient ServicesSavings through procurement – Dentistry & Podiatry R £3,333 8.3% £1,667 4.2% -£1,666 -50% £40,000 £40,000 £0 0% £40,000MARS – Planned Care R £1,808 8.3% £1,808 8.3% £0 0% £21,700 £21,700 £0 0% £21,700Integrated Facilities ManagementReduction in accommodation expenses - St Marys Ct R £9,417 8.3% £9,417 8.3% £0 0% £113,000 £113,000 £0 0% £113,000Reduction in cost of utilities; increased income from solar R £4,167 8.3% £4,167 8.3% £0 0% £50,000 £50,000 £0 0% £50,000Room rental - price increase R £4,167 8.3% £0 0.0% -£4,167 -100% £50,000 £50,000 £0 0% £50,000Catering income - vending & coffee machines, menus R £4,167 8.3% £1,083 2.2% -£3,084 -74% £50,000 £13,000 -£37,000 -74% £13,000IFM Catering Income Mitigations R £0 0.0% £2,233 0.0% £2,233 0% £0 £37,000 £37,000 0% £37,000IFM Procurement - e auction R £4,167 8.3% £0 0.0% -£4,167 -100% £50,000 £50,000 £0 0% £50,000MARS – IFM R £26,758 8.3% £26,758 8.3% £0 0% £321,100 £321,100 £0 0% £321,100EstatesStaff vacant posts R £11,250 8.3% £11,250 8.3% £0 0% £135,000 £135,000 £0 0% £135,000MARS - Estates R £4,208 8.3% £4,208 8.3% £0 0% £50,500 £50,500 £0 0% £50,500Corporate15/16 Non recurrent schemes - recurrent effect R £33,333 8.3% £33,333 8.3% £0 0% £400,000 £400,000 £0 0% £400,000Corporate SQIP Target R £28,500 8.3% £28,500 8.3% £0 0% £342,000 £342,000 £0 0% £342,000Non Pay Inflation Reserve release R £41,667 8.3% £41,667 8.3% £0 0% £500,000 £500,000 £0 0% £500,000MARS - Strategy R £2,533 8.3% £2,533 8.3% £0 0% £30,400 £30,400 £0 0% £30,400MARS - POE R £4,150 8.3% £4,150 8.3% £0 0% £49,800 £49,800 £0 0% £49,800Capital Charges Review - Asset Lives R £0 0.0% £0 0.0% £0 0% £140,000 £140,000 £0 0% £280,000Agile Working R £8,333 8.3% £0 0.0% -£8,333 -100% £100,000 £100,000 £0 0% £100,000Digitilisation Opportunities R £0 0.0% £0 0.0% £0 0% £50,000 £50,000 £0 0% £66,667Telecoms Review NR £6,667 8.3% £2,500 3.1% -£4,167 -63% £80,000 £80,000 £0 0% £0OtherPharmacy Services Review R £0 0.0% £0 0.0% £0 0% £50,000 £50,000 £0 0% £100,000Babington Office Moves R £0 0.0% £0 0.0% £0 0% £30,000 £30,000 £0 0% £30,000Primary Care Contribution R £8,083 8.3% £8,083 8.3% £0 0% £97,000 £97,000 £0 0% £97,000Mitigation Reserve Reduction R £16,667 8.3% £16,667 8.3% £0 0% £200,000 £200,000 £0 0% £200,000

Total £300,467 £272,950 -£27,517 £4,084,600 £4,084,600 £0 £3,981,267

OtherHR - Travel Renegotiation Review R £0 0.0% £0 0.0% £0 0% £100,000 £100,000 £0 0%Capital Charges Valuation R £0 0.0% £0 0.0% £0 0% £250,000 £250,000 £0 0%VOIP Implementation R £0 0.0% £0 0.0% £0 0% £100,000 £100,000 £0 0%Procurement - Utilities R £0 0.0% £0 0.0% £0 0% £50,000 £50,000 £0 0%LD Short Break Service R £0 0.0% £0 0.0% £0 0% £200,000 £200,000 £0 0%(Connecting for Health) - Care Home Support R £0 0.0% £0 0.0% £0 0% £105,400 £105,400 £0 0%(Connecting for Health) - Stroke Services R £0 0.0% £0 0.0% £0 0% £60,000 £60,000 £0 0%(Connecting for Health) - Pul Rehab North R £0 0.0% £0 0.0% £0 0% £50,000 £50,000 £0 0%

Total £0 £0 £0 £915,400 £915,400 £0

£300,467 £272,950 -£27,517 £5,000,000 £5,000,000 £0 £3,981,267

SQIP Monitoring 2016/17 April 2016

Summary of Overall SQIP Monitoring 2016/17

TO BE CONFIRMED SCHEMES

Year to Date Annual

Plan % of Annual

Actual % of Annual

Year to Date Annual

Plan % of Annual

Actual % of Annual

SQIP Schemes 2016/17

Scheme R / NR

Scheme



Appendix 3

1 2 3 4 5 6 7 8 9 10 11 122015-16 Annual Annual

Year Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Outturn PlanEnd Actual Plan Variance Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Outturn

£'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s

ASSETSNon Current

Tangible Assets 82,396 82,701 82,194 507 82,701 82,809 82,635 82,640 82,682 82,839 82,966 83,061 79,438 79,914 80,578 81,707 82,788

Intangible Assets 1,604 1,564 1,299 265 1,564 1,272 1,245 1,218 1,191 1,164 1,137 1,110 1,083 1,056 1,029 1,002 1,002

Total Non Current Assets 84,000 84,265 83,493 772 84,265 84,081 83,880 83,858 83,873 84,003 84,103 84,171 80,521 80,970 81,607 82,709 83,790

CurrentInventories 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NHS Trade Receivabes 2,017 2,427 2,031 396 2,427 2,025 2,042 2,041 2,021 2,037 2,038 2,038 2,020 2,038 2,033 2,036 2,036

Non NHS Trade Receivabes 1,963 991 2,390 (1,399) 991 2,390 2,390 2,380 2,380 2,380 2,370 2,370 2,370 2,360 2,360 2,360 2,360

PDC Dividend Receivable 141 141 141 0 141 141 141 0 0 0 0 0 0 0 0 0 0

Bad Debt Provision (176) (311) (180) (131) (311) (180) (180) (170) (170) (170) (160) (160) (160) (150) (150) (150) (150)

Capital Receivables 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Accrued Income 2,258 4,856 1,803 3,053 4,856 1,333 1,633 1,423 1,373 1,823 2,623 2,798 2,498 2,248 2,348 1,798 1,798

Prepayments 945 1,326 745 581 1,326 445 745 595 795 545 845 795 995 835 1,165 1,225 1,225

Other Receivables 858 790 844 (54) 790 944 1,228 1,065 1,043 1,286 1,018 1,115 1,169 1,028 828 1,003 1,003

Land Held For Sale 0 0 0 0 0 0 0 0 0 0 0 0 4,100 4,100 4,100 0 0

Cash and Cash Equivalents 16,974 13,654 13,727 (73) 13,654 14,816 15,329 16,906 17,568 15,099 14,449 14,961 15,403 13,028 13,262 16,853 16,802

Total Current Assets 24,980 23,874 21,501 2,373 23,874 21,914 23,328 24,240 25,010 23,000 23,183 23,917 28,395 25,487 25,946 25,125 25,074

TOTAL ASSETS 108,980 108,139 104,994 3,145 108,139 105,995 107,208 108,098 108,883 107,003 107,286 108,088 108,916 106,457 107,553 107,834 108,864

LIABILITIESCurrent

Trade Payables (8,193) (5,750) (3,864) (1,886) (5,750) (3,863) (3,861) (3,870) (3,873) (3,874) (3,871) (3,872) (3,873) (3,873) (3,869) (3,269) (3,869)

Other Payables (3,754) (4,147) (4,054) (93) (4,147) (4,130) (4,085) (4,173) (4,118) (4,157) (4,094) (4,089) (4,136) (4,121) (4,224) (5,482) (5,482)

Public Dividend Capital Payable 0 (208) (196) (12) (208) (403) (598) (793) (988) 0 (195) (390) (585) (780) (975) 0 0

Capital Payables (853) (558) (153) (405) (558) (203) (253) (153) (361) (569) (153) (361) (569) (153) (653) (153) (153)

Accrued Expenditure (3,036) (3,739) (3,367) (372) (3,739) (3,702) (4,380) (4,744) (5,294) (4,066) (4,090) (4,190) (4,240) (1,740) (1,780) (2,345) (2,345)

Annual Leave Accrual (535) (535) (535) 0 (535) (535) (535) (535) (535) (535) (535) (535) (535) (535) (535) (495) (495)

Deferred Income, Current (570) (844) (522) (322) (844) (474) (426) (378) (330) (282) (234) (186) (138) (90) (42) 0 0

Provisions, Current (465) (454) (379) (75) (454) (454) (459) (384) (384) (389) (389) (389) (394) (394) (394) (399) (399)

Other Liabilities 0 0 0 0 0 0 0 0 0 0 0 0 (1,383) (1,383) (1,383) 0 0

Total Current Liabilities (17,406) (16,235) (13,070) (3,165) (16,235) (13,764) (14,597) (15,030) (15,883) (13,872) (13,561) (14,012) (14,470) (11,686) (12,472) (12,143) (12,743)

Non CurrentDeferred Income, Non Current 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Provisions, Non Current (20) (30) (105) 75 (30) (30) (30) (105) (105) (105) (105) (105) (105) (105) (105) (105) (105)

Total Non Current Liabilities (20) (30) (105) 75 (30) (30) (30) (105) (105) (105) (105) (105) (105) (105) (105) (105) (105)

TOTAL LIABILITIES (17,426) (16,265) (13,175) (3,090) (16,265) (13,794) (14,627) (15,135) (15,988) (13,977) (13,666) (14,117) (14,575) (11,791) (12,577) (12,248) (12,848)

TOTAL ASSET EMPLOYED 91,554 91,874 91,819 55 91,874 92,201 92,581 92,963 92,895 93,026 93,620 93,971 94,341 94,666 94,976 95,586 96,016

TAXPAYERS' EQUITYPublic Dividend Capital 243 243 243 0 243 243 243 243 243 243 243 243 243 243 243 243 243

Retained Earnings 69,759 70,079 70,024 55 70,079 70,406 70,786 71,168 71,100 71,231 71,825 72,176 72,123 72,448 72,758 73,053 73,483

Revaluation Reserve 21,552 21,552 21,552 0 21,552 21,552 21,552 21,552 21,552 21,552 21,552 21,552 21,975 21,975 21,975 22,290 22,290

TOTAL TAXPAYERS EQUITY 91,554 91,874 91,819 55 91,874 92,201 92,581 92,963 92,895 93,026 93,620 93,971 94,341 94,666 94,976 95,586 96,016

Year to DateAs at 30 April 2016

Monthly Actual / Forecast

STATEMENT OF FINANCIAL POSITION 2016-1730 APRIL 2016



Appendix 41 2 3 4 5 6 7 8 9 10 11 12

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

Actual Plan Variance Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Outturn£'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s

SURPLUS / (DEFICIT) 323 261 62 323 327 380 382 (68) 131 594 351 (53) 325 310 295 3,297 3,251

Less Non Operating Income / ExpenditureFinance Income / Charges (3) (3) 0 (3) (4) (4) (5) (4) (4) (5) (4) (4) (5) (4) (4) (50) (50)

Depreciation and Amortisation 328 339 (11) 328 318 318 318 318 318 318 318 318 317 317 317 3,823 3,824

PDC Dividend Expense 208 208 0 208 195 195 195 195 195 195 195 195 195 195 195 2,353 2,350

Impairment Losses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

OPERATING CASHFLOWS BEFORE MOVEMENTS IN WORKING CAPITAL 856 805 51 856 836 889 890 441 640 1,102 860 456 832 818 803 9,423 9,375

Inventories 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NHS Trade Receivabes (412) (14) (398) (412) 401 (17) 1 20 (23) (1) 0 18 (18) 5 (3) (29) (19)

Non NHS Trade Receivabes 1,107 (423) 1,530 1,107 (1,530) 0 0 0 0 0 0 0 0 0 0 (423) (423)

Accrued Income (2,598) 455 (3,053) (2,598) 3,523 (300) 210 50 (450) (800) (175) 300 250 (100) 550 460 460

Prepayments (381) 200 (581) (381) 881 (300) 150 (200) 250 (300) 50 (200) 160 (330) (60) (280) (280)

Other Receivables 68 14 54 68 (154) (284) 163 22 (243) 268 (97) (54) 141 200 (175) (145) (145)

Trade Payables (2,443) (4,349) 1,906 (2,443) (1,887) (2) 9 3 1 (3) 1 1 0 (4) (600) (4,924) (2,922)

Other Payables 393 300 93 393 (17) (45) 88 (55) 39 (63) (5) 47 (15) 103 1,258 1,728 (1,038)

Accrued Expenditure 703 331 372 703 (37) 678 364 550 (1,228) 24 100 50 (2,500) 40 565 (691) (691)

Annual Leave Accrual 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (40) (40) (40)

Deferred Income, Current & Non Current 274 (48) 322 274 (370) (48) (48) (48) (48) (48) (48) (48) (48) (48) (42) (570) (570)

Provisions, Current & Non Current (1) (1) 0 (1) 0 5 0 0 5 0 0 5 0 0 5 19 19

Increase / (Decrease) in working capital (3,290) (3,535) 245 (3,290) 810 (313) 937 342 (1,697) (923) (174) 119 (2,030) (134) 1,458 (4,895) (5,649)

NET CASHFLOW FROM OPERATIONS (2,434) (2,730) 296 (2,434) 1,646 576 1,827 783 (1,057) 179 686 575 (1,198) 684 2,261 4,528 3,726

Property, Plant & Equipment Expenditure (594) (620) 26 (594) (133) (117) (296) (333) (448) (418) (386) (345) (766) (954) (1,104) (5,893) (5,893)

Proceeds on Disposal of Property, Plant & Equipment 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4,100 4,100 4,100

(Increase) / Decrease in Capital Receivables 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Increase / (Decrease) in Capital Payables (295) 100 (395) (295) (355) 50 (100) 208 208 (416) 208 208 (416) 500 (500) (700) 100

NET CASHFLOW FROM INVESTING ACTIVITIES (889) (520) (369) (889) (488) (67) (396) (125) (240) (834) (178) (137) (1,182) (454) 2,496 (2,493) (1,693)

PDC Dividends Paid 0 0 0 0 0 0 0 0 (1,176) 0 0 0 0 0 (1,170) (2,346) (2,352)

PDC Received 0 0 0 0 0 0 141 0 0 0 0 0 0 0 0 141 141

Interest Received on Cash and Cash Equivalents 3 3 0 3 4 4 5 4 4 5 4 4 5 4 4 50 50

NET CASHFLOW FROM FINANCING ACTIVITIES 3 3 0 3 4 4 146 4 (1,172) 5 4 4 5 4 (1,166) (2,155) (2,161)

NET CASH INFLOW / (OUTFLOW) (3,320) (3,247) (73) (3,320) 1,162 513 1,577 662 (2,469) (650) 512 442 (2,375) 234 3,591 (120) (128)

Opening Cash Balance 16,974 16,974 0 16,974 13,654 14,816 15,329 16,906 17,568 15,099 14,449 14,961 15,403 13,028 13,262 16,974 16,974

Net Cash Inflow / (Outflow) (3,320) (3,247) (73) (3,320) 1,162 513 1,577 662 (2,469) (650) 512 442 (2,375) 234 3,591 (120) (128)

CLOSING CASH BALANCE 13,654 13,727 (73) 13,654 14,816 15,329 16,906 17,568 15,099 14,449 14,961 15,403 13,028 13,262 16,853 16,854 16,846

OPERATING ACTIVITIES

INVESTING ACTIVITES

FINANCING ACTIVITES

CASHFLOW STATEMENT 2015/1630 APRIL 2016

As at 30 April 2016Monthly Actual / ForecastYear to Date



Appendix 5

1 2 3 4 5 6 7 8 9 10 11 12Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

A5047 Walton Hospital Site Development Estates 765.0 12.2 179.1 191.3 191.3 191.1 765.0A5050 Heanor Site Development Estates 1,958.0 -15.3 100.0 100.0 150.0 150.0 350.0 500.0 623.3 1,958.0A5105 Buxton Site Development Feasibility Fees Estates 10.0 10.0 10.0A5107 Ilkeston Hospital Upgrade Main Reception & Entrance Estates 65.0 25.0 40.0 65.0A5057 Belper Provision of Health Facilities Estates 208.0 69.3 69.3 69.4 208.0A5103 London Road Community Hospital Microscopy Lab & Accommodation Estates 90.0 36.5 53.5 90.0A5108 Ripley Hospital Upgrade Security - Lighting/CCTV Estates 9.0 9.0 9.0

Purchase of Castle Street Medical Practice Estates 510.0 510.0 510.0

A5473 IM&T - Mobile working IM&T 750.0 51.8 62.5 62.5 62.5 62.5 62.5 62.5 62.5 62.5 62.5 62.5 73.2 750.0A5432 IM&T - Desktop renewal and local infrastructure IM&T 450.0 -12.5 37.5 37.5 37.5 37.5 37.5 37.5 37.5 37.5 75.0 87.5 450.0A5433 IM&T - System procurement IM&T 75.0 25.0 25.0 25.0 75.0A5434 IM&T - LAN/WAN Infrastructure IM&T 85.0 28.3 28.3 28.4 85.0A5435 IM&T - PAS Replacement IM&T 225.0 2.9 17.0 17.0 17.0 17.0 17.0 17.0 17.0 17.0 25.0 25.0 36.1 225.0

Equipment Equipment 343.0 68.6 68.6 68.6 68.6 68.6 343.0

A5106 Theatre - Air Handling Unit/Upgrade Ventilation Plant Backlog 50.0 50.0 50.0

CONT Contingency Contingency 300.0 100.0 100.0 92.0 292.0 8.0

MISC Expenditure relating to all other Axxxx schemes Other 8.0 8.0 -8.0

Capital Programme Expenditure 5,893.0 593.6 133.0 117.0 296.1 333.3 448.3 418.1 385.6 344.6 766.2 953.7 1,103.5 5,893.0

CAPITAL PROGRAMME 2016-1730 APRIL 2016

Scheme Number Scheme Description Category 2016-17

PlanPlan v

ForecastFull Year Forecast



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