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© 2015 Deloitte LLP. All rights reserved.

Southend University Hospital NHS Foundation TrustIndependent Review of Governance Arrangements

FINAL report

11 January 2016

This final report is strictly private and confidential and has been prepared for the Board of Directors of Southend University Hospital NHS Foundation Trust. This report is prepared for the Board of Directors as a body alone, and our responsibility is to the full Board and not individual Directors. Only the final signed version should be taken as definitive. It should not be communicated to any third party, without our prior written permission.


Contacts and contents

1. Executive Summary 4

2. Introduction 10

3. Observations 14

Appendices:

Appendix 1: Progress against our January 2015 recommendations 32

Appendix 2: Summary of New Recommendations 39

Appendix 3: Survey Results 42

Appendix 4: Glossary 50

The contacts at Deloitte in relation to this report are:

Dr. Jay Bevington PartnerTel: 07968 [email protected]

Lucy BubbAssociate DirectorTel: 07770 [email protected]

Jess McGrathAssistant ManagerTel: 07917 [email protected]

Draft report issued: 16 December 2015 Client sponsors Chief Executive and Chair

Factual inaccuracies received:

5 January 2016 Distribution Trust Secretary, Chief Executive

Final report issued: 11 January 2016

2 Southend University Hospital NHS FT – Independent Review of Governance – FINAL REPORT © 2016 Deloitte LLP. All rights reserved


Board of DirectorsSouthend University Hospital NHS Foundation Trust Prittlewell ChaseWestcliff-on-SeaEssexSS0 0RY

11 January 2016

Dear Board of Directors

Independent Review of Governance Arrangements

In accordance with our Engagement Letter dated 27 October 2015 (the ‘Contract’), for the independent review of governance arrangements at Southend University Hospital NHS Foundation Trust (the ‘Trust’), we enclose our final report dated 11 January 2016 (the ‘Final Report’).

The Final Report is confidential to the Trust and is subject to the restrictions on use specified in the Contract. No party, except the addressee, is entitled to rely on the Final Report for any purpose whatsoever and we accept no responsibility or liability to any party in respect of the contents of this Final Report. This report is prepared for the Board of Directors as a body alone, and our responsibility is to the full Board and not individual Directors.

The Final Report must not, save as expressly provided for in the Contract (including, inter alia, in clauses 5.3 and 5.4 of the Terms of Business) be recited or referred to in any document, or copied or made available (in whole or in part) to any other person.

The Board is responsible for determining whether the scope of our work is sufficient for its purposes and we make no representation regarding the sufficiency of these procedures for the Trust’s purposes. If we were to perform additional procedures, other matters might come to our attention that would be reported to the Trust.

We have assumed that the information provided to us and management's representations are complete, accurate and reliable; we have not independently audited, verified or confirmed their accuracy, completeness or reliability. In particular, no detailed testing regarding the accuracy of the financial information has been performed.

The matters raised in this report are only those that came to our attention during the course of our work and are not necessarily a comprehensive statement of all the strengths or weaknesses that may exist or all improvements that might be made. Any recommendations for improvements should be assessed by the Trust for their full impact before they are implemented.

Yours faithfully

Deloitte LLP

Deloitte LLP2 Hardman StreetManchesterM3 3HF

Tel: +44 (0) 161 832 3555www.deloitte.co.uk

© 2016 Deloitte LLP. All rights reserved.3 Southend University Hospital NHS FT – Independent Review of Governance – FINAL REPORT


Executive Summary

© 2016 Deloitte LLP. All rights reserved.4 Southend University Hospital NHS FT – Independent Review of Governance – FINAL REPORT

© 2015 Deloitte LLP. All rights reserved.© 2015 Deloitte LLP. All rights reserved.

Key findingsExecutive summary

We have undertaken an independent review of governa nce arrangements at Southend University Hospital NHS Foundation Trust (hereafter “the Trust”) against four of the key quest ions within Monitor’s Well-Led Governance Framework. We have also reviewed progress against our recommendations made within our January 2015 report, aligning those recommendations to the framework.

Following concerns about A&E and RTT performance, M onitor launched an investigation in relation to these matt ers, an element of which was an external review of governan ce arrangements which was carried out during the summe r of 2014 and completed by us in January 2015, resulting in a series of recommendations for improvement.

Southend University Hospital NHS Foundation Trust h as undergone a period of scrutiny and personnel change within the Executive Team over the past 12 months. In add ition, the Trust has introduced a new clinical directorate str ucture.

The Trust is now emerging from this period of insta bility with a substantive Executive Team and refreshed clinical d irectorates that are having a demonstrable impact on the organi sation.

Our review findings set out within this report are groupedunder the three theme areas being assessed from within theMonitor Well-led Governance Framework, as well as a review o fprogress against previous recommendations, namely:

1. Strategy and planning;2. Capability and culture; and3. Processes and structures.

Ratings are summarised in each section and the key factorswhich have influenced the ratings in each domain are noted inthe following sections.

1. Strategy and planning1B Is the Board sufficiently aware of potential risk s to the

quality, sustainability and delivery of current and future services?

• The Board has a consistent view of the top risks to the organisation and Board members are assured that risks are appropriately identified and controlled. Through our Board Member (BM) survey we have seen a marked improvement from 2014 in BMs’ responses to risk management questions.

• Risk is regularly scrutinised at a number of forums including Corporate Management Team (CMT), Quality Assurance Committee (QAC) and at Board.

• The Board Assurance Framework (BAF) is used as a dynamic document with risk ratings changing over the year. The Board are currently reviewing the BAF and CRR (Corporate Risk Register) three times a year, to bring them in line with best practice the Board should increase this to at least quarterly.

• There is scope for further improvement of the BAF most notably: linking risks to strategic objectives; mapping assurances to the relevant control; ensuring linkage with the CRR; and including the results of real assurances obtained.

• The scope of this review did not involve meeting with front line staff in services however during interviews it was suggested that whilst risk management at Board and sub-committee level had improved, there is scope to improve risk management arrangements within the organisation.

• There is a quality impact assessment (QIA) process in place, however it is not clear how the Board are obtaining assurance over the process or are monitoring the ongoing impact to quality.

5 Southend University Hospital NHS FT – Independent Review of Governance – FINAL REPORT © 2016 Deloitte LLP. All rights reserved.


Key findings (continued)Executive summary

2. Capability and culture2B Does the Board shape an open, transparent and qua lity-

focused culture? • The Trust’s move to the directorate structure and its utilisation

of the Corporate Management Team meeting has led to increased transparency in the decision making process.

• Safe at Southend, the weekday 15 minute meeting held in the hospital restaurant, is an indicative example of the open and quality focused culture the Board are creating by providing a forum to publically discuss patient safety concerns facing the Trust each day.

• The Trust’s recently refreshed values focus on care with compassion. The Trust acknowledges the need to update its appraisal and induction documentation so that its messages are consistent with the newly established vision and values.

• The Board are actively engaged in visiting service areas through their Executive visibility programme and Board to Ward Programme.

• The Board have an open and well functioning relationship with the Council of Governors due to regular NED and Governor (NAG) meetings, interactions on the Board to Ward programme and an open policy for Governors to observe the QAC should they so wish.

2C Does the Board help support continuous learning a nd development across the organisation?

• The Board has set a tone of learning and development with Board meetings featuring a regular agenda item where the Board self reviews its own performance. Initiatives such as Perfect Week are used to galvanise the organisation and drive continuous improvement.

• The Trust utilises a number of mechanisms to disseminate learning from harm. The Trust should now look to monitor and provide assurance to the Board on an ongoing basis that learning has been successfully embedded. There is also scope to enhance learning from other organisations, particularly in light of closer working the success regime brings, and the Trust is fully committed to this.

• There is a focus on leadership development as demonstrated by the PULSE programme, and various other in house courses the Trust run. The Trust should ensure that all staff are aware of the opportunities available to them by increasing the publicity of these courses.

• The Trust could make increased use of both internal and external benchmarking in order to identify opportunities and drive improvement in care.

3. Structures and processes

3A Are there clear roles and accountabilities in rel ation to Board governance (including quality governance)?

• The Board has a sub-committee structure that is not dissimilar to peer Trusts in terms of number and type of sub-committees. Based on comparison against peers, the Board could consider realigning portfolios to reduce the workload of the QAC, for example, creating a Finance and Performance or Finance and Workforce Committee.




• Our review of sub-committee terms of reference found a number of improvements that could be made to ensure good practice. These included omission of terms dealing with duties.

• In our opinion, especially in light of current financial challenges, the Finance and Investment Committee (FIC), and the QAC are not meeting sufficiently regularly.

• The recent Internal Audit review of the QAC identified similar areas for improvement as our review. These included size of portfolio and lengthy meeting agenda, lengthy and detailed papers, moving agendas, inconsistent use of cover sheets and lack of member understanding of clinical audit as a means of assurance.

Review of previous recommendations

• We reviewed progress against the recommendations made during our January 2015 review. The table below shows our assessment of the implementation progress compared to the Trust’s self-assessment.

• We found that, whilst the Trust has completed the majority of actions within its action plan to address our previous recommendations, further work is required to fully implement the recommendations. The Trust should continue to progress their work and we have provided further examples of how the Trust can do so in Appendix 1.

Key Recommendations

Based on these findings we have made a number of recommendations with suggested timescales (see Appendix 2). However we would draw your attention to the following key recommendations.

R4: The Trust should:

• Review the Datix references on the BAF and ensure these map correctly across to the CRR.

• Consider whether all high level risks on the CRR are captured on the BAF.

• Align the risks to the Trust’s new strategic objectives.• Link assurances to the relevant control.• Include a target risk scoring on the trend graph and

provide data over a 12 month period. • Include milestone dates for actions. • Provide details of real assurances obtained.

R9: The integrated dashboard with results at directorate level should be presented to one of the Board’s sub-committees in order to scrutinise performance.

R14: Consider realigning the Board sub-committee portfolios to ensure each has an equitable and manageable workload and appropriate focus given to key issues

7 Southend University Hospital NHS FT – Independent Review of Governance – FINAL REPORT

Deloitte SUHFT

Implemented 11 14

Progressing 4 2

Static 0 0

Not applicable 1

Total 16 16




R16: Consider the findings of the recent Internal Audit report, views of the Chief Nurse, and the findings of this review to action changes to address the areas for improvement of the Quality Assurance Committee.

R19: The Trust should continue to make progress against the previous recommendations from January 2015.

Next steps

We suggest that the Chair and Chief Executive, in consultation withthe Board, consider the findings outlined within this report and writea management response in relation to the matters raised. Thisresponse should clearly outline how the Board proposes toimplement our various recommendations, and describe how theBoard will monitor progress going forward.



Summary of scoresExecutive summary

9

Monitor Domain Detailed Criteria Deloitte Rating

Strategy and planning

1A Does the Board have a credible strategy and robust plan to deliver? **

1B Is the Board aware of potential risks to the quality, sustainability and delivery of services?

Capability and culture

2A Does the Board have the skills and capability to lead the organisation? **

2B Does the Board shape an open, transparent, and quality focused culture?

2C Does the Board support continuous learning and development across the organisation?

Processes and structures

3A Are there clear roles and accountability in relation to board and quality governance?

3BAre there clearly defined processes for escalating and resolving issues and managing performance?

**

3C Are stakeholders actively engaged on quality, financial and operational performance? **

Measurement

4AIs appropriate information on organisational and operational performance being analysed and challenged?

**

4B Is the Board assured of the robustness of information? Not scored

Outlined below is a summary of the ratings across the key questions of the domains in the Well Led Governance framework. The summary is based on our specific review of questions 1B, 2B, 2C and 3A together with our review of implementation progress from our previous recommendations now aligned to the framework. The ratings applied to the latter (denoted by **) assumes that there has been no deterioration in areas outside the previous recommendations. A summary of the scoring criteria can be found on page 12.

Southend University Hospital NHS FT – Independent Review of Governance – FINAL REPORT © 2016 Deloitte LLP. All rights reserved.


Introduction


Introduction and review contextProject scope

• This report sets out the findings of our independent review of governance arrangements at Southend University Hospital NHS Foundation Trust (hereafter, ‘The Trust’). We would like to thank Trust Board members, staff, and other internal stakeholders for their engagement in this project.

• Our review focuses on the sub-domains of the Well-led framework which we did not explicitly cover in our previous Board Governance review. The appendix within the report provides an assessment of progress made against our January 2015 recommendations, which we have aligned to the four areas as set out in the Monitor ‘Well-Led Framework for Governance Reviews’. These are:

− Strategy and planning;

− Capability and culture;

− Processes and structures; and

− Measurement.

10

Our approach

Our approach to delivering the project scope has consisted of:

1. Conducting a desktop review of a sample of key Trust documentation ;

2. Conducting 1-1.5 hour non-attributable interviews with all Board members during November 2015;

3. Conducting 1-1.5 hour non-attributable interviews with members of staff across a range of clinical and operational roles and able to comment on governance arrangements;

4. Observation of the Corporate Management Team meeting , Audit Committee and the Quality Assurance Committee during November 2015;

5. Undertaking a Board member survey (14 responses from a total of 14 distributed surveys);

6. Feeding back emerging themes to the Chief Executive.

Observations and recommendations

• Our findings in this report are based upon the views expressed by BMs, staff across the Trust, and our own observations. We have assumed that the information provided to us and management's representations are complete, accurate and reliable; we have not independently audited, verified or confirmed their accuracy, completeness or reliability. In particular, no detailed testing regarding the accuracy of any financial information has been performed.

Southend University Hospital NHS FT – Independent Review of Governance – FINAL REPORT © 2015 Deloitte LLP. All rights reserved© 2016 Deloitte LLP. All rights reserved.

Our work, which is summarised in this Report, has been limited to matters which we have identified that would appear to us to be significant within the context of the scope. In particular, this review will not identify all of the gaps that exist in relationship to the Trust’s approach to governance; rather the review will seek to consider performance against the Monitor Well-Led Governance Framework to identify the most material gaps, key exceptions or areas where insufficient evidence may give rise to the identification of material gaps in the future.

Structure of the report

• This review is not considered a Well-Led review, but the report is focused around the theme areas of the Well-Led Framework. The report is divided into two sections: an overview of our findings against four of the key questions within the Monitor ‘Well-Led Framework for Governance Reviews’ guidance; and an appendix detailing the Trust’s progression post our review finalised in January 2015. Each section in the overview of our report comprises a description of our findings and observations with recommendations for improvement where appropriate.

• To the right is an outline of the theme areas covered in this review.

• Appendix 1 provides an assessment of progress made against our January 2015 recommendations.

• New recommendations made as a result of this review are outlined in Appendix 2.

Introduction and review context (continued)

© 2015 Deloitte LLP. All rights reserved11

Key Questions within Monitor’s Well-Led Framework

Current review Recommendation Progress

2. Is the Board sufficiently aware of potential risks to the quality, sustainability and delivery of current and future services?

1. Does the Board have a credible strategy to provide high quality, sustainable services to patients and is there a robust

plan to deliver?

4. Does the Board shape an open, transparent and quality-

focused culture?

3. Does the Board have the skills and capability to lead the

organisation?

5. Does the Board support continuous learning and development across the

organisation?

7. Are there clearly defined, well-understood processes for

escalating and resolving issues and managing performance?

6. Are there clear roles and accountabilities in relation to board governance (including

quality governance)?

8. Does the Board actively engage patients, staff, governors

and other key stakeholders on quality, operational and financial

performance?

9. Is appropriate information on organisational operational

performance being analysed and challenged?

Not covered in this report

10. Is the Board assured of the robustness of information?


Risk rating Definition Evidence

Meets or exceeds expectations

Many elements of good practice and there are no major omissions

Partially meets expectations, but confident in management’s capacity to deliver green performance within a reasonable timeframe

Some elements of good practice, no major omissions and robust action plans to address perceived gaps with proven track record of delivery

Partially meets expectations, but with some concerns on capacity to deliver within a reasonable timeframe

Some elements of good practice, has no major omissions. Action plans to address perceived gaps are in early stage of development with limited evidence of track record of delivery

Does not meet expectations

Major omission in governance identified. Significant volume of action plans required and concerns about management’s capacity to deliver

Monitor scoring criteria and survey key

We have rated the review domains in line with the following:

Introduction and review context (continued)

Southend University Hospital NHS FT – Independent Review of Governance – FINAL REPORT12 © 2015 Deloitte LLP. All rights reserved

Throughout this report we have included the results of Board member surveys. The key to these graphs is as follows:

SA = Strongly agreeA = AgreeSl A = Slightly agreeSl D = Slightly disagreeD = DisagreeSD = Strongly disagreeCS = Cannot say

Non Executive Directors

Executive Directors

2014 BM survey results

2015 BM survey results



Observations



1: Strategy and planning1B Is the board sufficiently aware of potential risks to the quality, sustainability and delivery of current and future services?

Summary of our findings: Del oitte rating:• The Board has a consistent view of the top risks to the

organisation and Board members are assured that risks are appropriately identified and controlled. Through our Board Member (BM) survey we have seen a marked improvement from 2014 in BMs responses to risk management questions.

• Risk is regularly being scrutinised at a number of forums including Corporate Management Team (CMT), Quality Assurance Committee (QAC) and at Board.

• The Board Assurance Framework (BAF) is used as a dynamic document with risk ratings changing over the year. The Board are currently reviewing the BAF and Corporate Risk Register (CRR) three times a year, to bring them in line with best practice the Board should increase this to at least quarterly.

• There is scope for further improvement of the BAF most notably: linking risks to strategic objectives; mapping assurances to the relevant control; ensuring linkage with the CRR; and including the results of real assurances obtained.

• The scope of this review did not involve meeting with front line staff in services however during interviews it was suggested that whilst risk management at Board and sub-committee level had improved, there is scope to improve risk management arrangements within the organisation.

• There is a quality impact assessment (QIA) process in place, however it is not clear how the Board are obtaining assurance over the process or are monitoring the ongoing impact to quality.

• Our BM survey, see right, indicates that BMs believe they have a more consistent picture of their top risks than during our review in 2014.

• Similarly the Board has a higher level of confidence that risks are appropriately identified and controlled, as per the graph below.

• Responsibility for risk management sits within the Chief Nurse’s (CN) portfolio. Given the CN is new to the organisation and the Trust has recently appointed a new risk manager we envisage there will be a number of refinements to the risk management process over the coming months.

Key observations:Is there an effective and comprehensive process in place to identify, understand, monitor and address current and future risks?

15

02468

10

SA A SIA SID D SD CS

2015 2014

The Board has a consistent view of the top 5 risks within the organisation’s internal and external environmen t.

02468

1012


2015 2014

I am assured that risks are appropriately identifie d and controlled and can provide evidence of that assuran ce if required.




(continued)

Risk Management Policy

• The Trust has a suitable risk management policy in place which is now due for a refresh, as the review date within the document is November 2015.

• The Trust’s policy is that risks scored at less than 9 are considered low risks, rated 9-15 are moderate, and risks rated 16+ are high.

• High risks are transferred to the CRR. High risks are presented to CMT quarterly for review. High risks on the CRR were also presented for review at the QAC in July and October 2015.

• Per the policy and risk reports, risks on the CRR are reviewed monthly by the risk owner.

• Risk quality reviews are undertaken by the governance team to ensure adequate descriptions of the risks, controls and assurances are documented and that the risk is being appropriately managed.

• Our review of risk related reports demonstrated that the policy is being adhered to.

Risk Management within Directorates

• The Directorate leadership teams we interviewed reported reviewing their risk registers internally at their Directorate governance meetings.

• Risks are discussed at monthly performance reviews with the Executives. Any new emerging high risks in the directorates could then be escalated up to the Board if necessary in between the Board’s formal review of the risk register.

• We understand from our BM interviews that as part of CQC preparation it has been identified that staff are not necessarily as aware of risks in their departments as they could be and that departmental risk registers could be used more dynamically. The scope of this review has been to meet with directorate leaders and above therefore we are not in a position to triangulate this information.

• We understand that aside from training at induction it has been a number of years since the Trust has had an organisation wide risk refresher training programme in place. Given the comments above it would be an opportune time to organise risk assessment and management training.

R1: Provide risk assessment and risk management refresher training to all staff, with the content v aried according to levels of responsibility.

• CMT is the forum where the directorate leadership teams interface with the Executive Directors (EDs). At the November CMT meeting we observed, the CRR was reviewed.

Risk Management at Board and Sub-Committees

• It is considered good practice for the Board to review the BAF and CRR at least quarterly. The Board have reviewed the CRR and BAF three times each throughout the last year.

• It is also considered good practice to have a standing item on the Board agenda to capture whether discussions have impacted on BAF risk ratings or whether any new risks should be added to the BAF.




(continued)

R2: The Board should aim to review the CRR and BAF at least four times a year. Further to this at each Board me eting the Board should consider whether discussions have infl uenced BAF scores.

• The Board reviewed a summary of the high graded risks on the CRR three times in January, August and October. The August and October reports provide the Board with an inherent and current rating and details of changes to the risk status. This report also provides a graph demonstrating an overview of risks by directorate and by risk level which provides the Board with insight into the spread and portfolio of risks at the directorate level.

• In line with good practice, the BAF risks are split between sub-committees: two risks are assigned to Finance and Investment Committee (FIC); four to QAC; one to Audit; and two risks are not assigned to a sub-committee and are only reviewed at Board. BAF risks are considered on a rotational basis at sub-committees, one at a time. This allows for a deep dive and consideration of that risk. During the AC we observed the discussion of the specific BAF risk included some confusion over the score. Some of the BAF risks have been covered three times at the relevant sub-committee, whereas some have only been considered once.

R3: The Trust should standardise how often sub-comm ittees review the individual BAF risks in the year. The Tr ust should allocate all BAF risks to a sub-committee for a det ailed review or should ensure there is a detailed separate revie w of these BAF risks at Board in addition to the full review o f the BAF.

The Board Assurance Framework

• The Head of Internal audit was asked to provide one on one training to executives on the BAF in 2014 in order to individually go through each of their risks with them. Following this the BAF was revised in January 2015 and reduced to amalgamate risks or remove those that were not strategic in nature. The BAF was reviewed by IA during the last financial year and it was given an amber rating identifying that the Board can take some assurance but that further improvements need to be made. Recommendations included:

• ensuring that all controls and assurances on the BAF are in place and could be evidenced;

• explicitly stating when the risk was last reviewed;

• regularly reviewing the BAF at Board as it had only been scrutinised once in 2014/15;

• Sub-committees regularly reviewing their allocated risks; and

• Increasing clarity of timeframes for actions.

• We reviewed the BAF from the Board meeting on the 7 October and there are a number of areas of good practice to highlight.

• The risk matrix used by SUHFT accompanies each issue of the BAF and clearly articulates the Trust's definitions.

• When the BAF is reviewed the Board are presented with accompanying narrative explaining any movements in the risk or why the risk rating has remained unchanged.

• A trend graph is provided showing the movement in the risk over the last 6 months. This could be improved by including a target risk and providing tracking of the risk over a longer 12 month period.




(continued)

• The date last reviewed by the relevant sub-committee and Executive lead is included showing that the BAF is a dynamic document which is continually reviewed. Our review of minutes shows that at Board and sub-committees there have been movements in risk ratings over the last year. The dates of last review, however, could be clearer, for example often the risks state last reviewed by QAC/ Board meaning it is not clear whether the date refers to the last review by QAC or the Board. There is also another date entitled last reviewed which often does not match to the last sub-committee review or to the last executive review. It would be helpful to define where or by whom the BAF risk was last reviewed.

• However there is also scope for improvement. Generally controls and assurances are not directly linked, with the exception of risk 6 which maps assurances to the relevant controls.

• The BAF includes references to the Trust’s corporate risk register however when we compared the BAF presented to the Board on the 7 October and the CRR which went to CMT on the 3 November the references did not tie through. For example Risk 5 on the BAF- Inability to recruit and retain staff-referenced risk 2030, 2035 and 2036 on the CRR however none of these risk numbers match the CRR. On the CRR risk number 2451 is the inability to recruit staff which will lead to a failure to meet expenditure targets and this is not referenced on the BAF.

• Not all high risks on the CRR are included on the BAF for example the CRR risk states that failure to meet MRSA targets has a risk rating of 20 but this particular target is not considered in the related BAF risk number 3 around targets.

• It is considered good practice to include results of real assurances in the framework for example if the assurance is an IA report to include the level of assurance provided by their latest report linked to the risk.

• The Trust include a section on actions and timeline for actions to be completed, however milestone dates for completion are not included for most risks.

• Currently the BAF is not linked to the Trust’s strategic objectives. The Trust have a session planned in January to revise the BAF and consider in light of their new strategic objectives.

R4: The Trust should complete the recommendations f rom the IA review ahead of the re-audit in 2016 and sho uld:

• Review the Datix references on the BAF and ensure these map correctly across to the CRR.

• Consider whether all high level risks on the CRR ar e captured on the BAF.

• Clarify the narrative for dates last reviewed.

• Align the risks to the Trust’s new strategic objectives.

• Link assurances to the relevant control.

• Include a target risk scoring on the trend graph an d provide data over a 12 month period.

• Include milestone dates for actions.

• Provide details of real assurances obtained.




(continued)

Incident Reporting

• The latest publically available National Reporting and Learning System (NRLS) data for the period from September 2014 to March 2015 shows that SUHFT is in the top quartile of trusts for reporting. In this period they reported 43.02 incidents per 1,000 bed days compared to the median 35.34. The Trust have a higher than average percentage of complaints relating to no or low harm at 97.5% versus 96.2% average. Demonstrating that they are a high reporter with low levels of risk.

• The Trust uses Datix to report and manage incidents; it also provides a number of other routes to report including paper based forms- which the central governance team then input into Datix- and a hotline where staff can report the incident over the phone. This facilitates reporting even if staff are struggling to access a computer.

• During divisional interviews it was noted that staff can often be frustrated by the lack of feedback from reporting incidents which can potentially be a barrier to reporting. SUHFT have recently upgraded Datix to enable the workflow within Datix to feedback to the incident reporter. At the click of a button the incident raiser can get updates on their incident whereas previously they only received a generic thank-you email.

• See section 2C for details of learning from incidents.

Triangulation of risks, incidents and complaints

• The governance team present a report to the QAC which triangulates and looks for trends in complaints, litigation, incidents and Patient Advice Liaison Service (PALS) comments.

• Currently this is a time consuming and manual process to prepare as only the risk and incident modules of Datix are web based. We understand the Governance team are considering upgrading the complaints, PALS and claims modules in order to facilitate triangulation. This would be subject to finding funding to be able to do this.

• See also discussion of triangulation of risks, incidents and complaints within section 2C.

Are service developments and efficiency changes developed and assessed with input from clinicians to understand their impact on the quality of care? Is the impact on quality and financial sustainability monitored effectively?

• The Trust’s 2015/16 transformation programmes were developed by the directorates, with assistance from an external adviser using capacity and demand analysis. These were presented to the Board in March 2015.

• This session was designed for the Board to challenge the transformation programme. During our interviews BMs commented that this was also an opportunity for the Board to challenge the quality impact of schemes. The presentations however focused more on risks to achievement of the improvement programmes rather than risks to quality.

• Each scheme within the transformation programme should have an associated Quality Impact Assessment (QIA). We reviewed the Trust’s QIA template. This considers the impact of quality on patient safety, clinical effectiveness and patient experience. Each scheme has its own risk register and includes risks to quality.




(continued)

• In line with good practice the CN and MD are required to review, sign off and approve QIAs. From our review of documents these reviews occur separately. It can often be useful for the MD and CN to arrange sessions to discuss QIAs and jointly sign off post this discussion.

• The Trust has a QIA policy which is in date and is due for review in February 2016. This states that the Clinical Assurance Committee (CAC), which reports to QAC, is responsible for assurance that QIAs have been completed in line with the policy. Per QAC’s terms of reference (ToR) this sub-committee should be informed of compliance and receive assurance for the Trust Board. From our review of QAC minutes and agendas, including review of minutes from CAC meetings, we could not see evidence of QAC receiving assurance over the QIA process.

R5: At least annually the QAC should receive assura nce that the QIA process is effective. This should include d etails of percentage of schemes that have a QIA in place, det ails of schemes which have been rejected and assurance that schemes are being monitored on an ongoing basis.

• Of the sample of QIAs we reviewed these were lacking in SMART KPIs to monitor the quality impact of schemes.

• Currently the ongoing monitoring of transformation programmes at Board and sub-committee level is in relation to financial achievement rather than the quality impact. Good practice is for each scheme to have a quality dashboard. This should then feed into the directorate’s quality dashboard and be challenged during performance reviews and presented to the Board or one of its sub-committees to scrutinise.

The BM survey graph below demonstrates that not all BMs are confident in the QIA process. This is one area where there has been very little progress when we compare with 2014 results.

R6: QIAs should have SMART quality KPIs identified to enable the monitoring of impact. The QAC should mon itor the ongoing impact on quality of transformation sch emes.

20

01234567


ED NED

2015 Results: There are clear mechanisms in place t o monitor the impact of CIPs on quality throughout th e life of a scheme.



2B Does the Board shape an open, transparent and quality-focused culture?

Summary of our findings: Del oitte rating:

• The Trust’s move to the directorate structure and its utilisation of the Corporate Management Team meeting has led to increased transparency in the decision making process.

• Safe at Southend, the weekday 15 minute meeting held in the hospital restaurant, is an indicative example of the open and quality focused culture the Board are creating by providing a forum to publically discuss patient safety concerns facing the Trust each day.

• The Trust’s recently refreshed values focus on care with compassion. The Trust acknowledges the need to update its appraisal and induction documentation so that its messages are consistent with the newly established vision and values.

• The Board are actively engaged in visiting service areas through their Executive visibility programme and Board to Ward Programme.

• The Board have an open and well functioning relationship with the Council of Governors due to regular NAG meetings, interactions on the Board to Ward programme and an open policy for Governors to observe the QAC should they so wish.

• their appraisal about how they will live the new values.

• The Trust has a Non Executive Director (NED) who is appointed as the equality and diversity champion. In line with good practice Board report cover sheets include a section on the impact on equality and diversity. However sub-committee reports have variable use of these cover sheets. During our observation of QAC the equality and diversity champion challenged papers if the impact on equality or diversity had not been sufficiently considered.

Are candour, openness, honesty and transparency and challenges to poor practice are the norm? Is behaviour and performance inconsistent with the values is identified and dealt with swiftly and effectively, regardless of seniority?

• In response to our survey, see graph below, BMs are comfortable openly expressing their views.

• The Trust has recently refreshed and approved their values. A bottom up approach was used whereby the Trust canvassed opinions on what the values should be through roaming reporters with iPads, online surveys, focus groups and text messages. The Human Resources (HR) team gained input from governors, patients, staff and carers and generated 3,000 values which were distilled into themes.

Do leaders at every level prioritise safe, high quality, compassionate care and promote equality and diversity?

• The Trust’s induction process includes a presentation from an ED on the Trust’s strategy, vision, values and expected behaviours. The induction materials are being revised in light of the new values which centre around compassionate care.

• Similarly the appraisal documentation assesses staff on their delivery of the values. There are plans to revise this documentation with every staff member to have a pledge in

2: Capability and culture

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2015 Results: As a Board member I feel able to say w hat I am thinking and can openly express my doubts, uncertainties or lack of understanding of an issue.



2: Capability and culture2B Does the Board shape an open, transparent and quality-focused culture? (continued)

• The CMT agreed the values at their away day, and the Board ratified them in November.

• It was commented during our interviews with both Board Members and Directorate leadership teams that the Corporate Management team meeting has increased the transparency of decision making as Clinical Directors now sign off on key decisions, with Associate Directors also being involved in the process.

• The Trust invite Governors to the QAC as observers, again demonstrating openness and transparency.

• In line with requirements the Trust has a Senior Independent Director (SID).

Does the leadership actively shapes the culture through effective engagement with staff, people who use the services, their representatives and stakeholders. Do leaders model and encourage co-operative, supportive relationships among staff so that feel respected, valued and supported?

• The Trust have a number of programmes in place to ensure that the Board are visible and engage with staff throughout the organisation.

• Every two weeks the Executive team have two hours blocked out in their diary in order to visit services.

• The Trust also have a Board to Ward programme in place where both NEDs and EDs are assigned areas with which they have an ongoing relationship with. Governors are invited to attend the Board to Ward visits with the NEDs. In line with good practice the Board visit both clinical and non-clinical areas.

• We understand from staff interviews that the feedback from these Board to Ward visits was not being systematically captured and so there are plans for the EDs to complete the 15 steps challenge with iPads to instantly capture outputs from these visits.

• We understand that the Board does not currently publicise their visits on a regular basis although they are sometimes referred to within the CEO’s Blog.

R7: The Trust should develop a structured communica tion plan to inform staff of their visits to service are as and insights gained through these.

• In addition to these events the Trust run a morning meeting every week day called Safe at Southend. This focuses on any patient safety issues that need to be immediately dealt with and then follows up on actions captured the day before. This is led by an ED and it rotates each week which ED facilitates this session. This session is open to all staff with representation from each directorate required. This initiative is an example of the Trust’s approach to transparency as it is held publically within the Trust restaurant.

• It was evident from our interviews with NEDs and a representative of the CoG that the NEDs and the Governors have a strong working relationship. This is fostered through NED and Governor (NAG) meetings during which NEDs report to Governors on their activities.

Are there mechanisms in place to support staff and promote their positive wellbeing?

• The Trust periodically runs well-being days. As part of their well-being programme they offer childcare vouchers, discounted gym memberships, a money advice service and yoga sessions. The Trust has an employee assistance programme in place which offers access to online counselling. During BM interviews it was commented that this could benefit from increased advertising. Currently this is promoted at induction and on the staff well-being section of the intranet.



2: Capability and culture2B Does the Board shape an open, transparent and quality-focused culture? (continued)

• We are aware that the Communications team are developing the idea of a staff council. This would be a positive forum for staff to express their views.

Is there a culture of collective responsibility between teams and services?

• The Board recognises the success and achievement of its staff on an ongoing basis. SUHFT has a “Hospital Heroes programme” where each month a member of staff is awarded this title and presented their award by the Board at the start of the Board meeting. This is an example of good practice as often staff achievement awards are only an annual event.

• The Trust also has an annual awards ceremony which recognises staff over the following categories:

• Quality care

• Outstanding leadership

• Team of the year

• Employee of the year

• Innovation

• Outstanding achievement

• Unsung Hero

• Lifetime achievement

• The Trust also has a very successful Patients’ choice award which is publicised through the local paper.

Does the leadership actively promotes staff empowerment to drive improvement and a culture where the benefit of raising concerns is valued?

• The Trust have recently refreshed their Raising Concerns Policy. In addition to the Freedom to Speak up Guardian and the SID, the Trust also have Freedom to Speak up Champions within each of the directorates. The Trust asked for volunteers for this role and those appointed are a mixture of grades.

• We understand from our BM interviews that the Trust log lessons learned from concerns and have plans to share the learning from these with the CEO’s blog. This demonstrates both a transparency and a desire to learn from concerns in a constructive manner.



2C Does the board help support continuous learning and development across the organisation?


• The Board has set a tone of learning and development with Board meetings featuring a regular agenda item where the Board self reviews its own performance. Initiatives such as Perfect Week are used to galvanise the organisation and drive continuous improvement.

• The Trust utilises a number of mechanisms to disseminate learning from harm. The Trust should now look to monitor and provide assurance to the Board on an ongoing basis that learning has been successfully embedded. There is also scope to enhance learning from other organisations, particularly in light of closer working the success regime brings, and the Trust is fully committed to this.

• There is a focus on leadership development as demonstrated by the PULSE programme, and various other in house courses the Trust run. The Trust should ensure that all staff are aware of the opportunities available to them by increasing the publicity of these courses.

• The Trust could make increased use of both internal and external benchmarking in order to identify opportunities and drive improvement in care.

• nurse vacancies with local trusts as part of the assessment of the achievement of one of the Trust’s Quality Accounts’ priorities. These were one off examples of benchmarking, some of which were in response to specific requests from the NEDs as opposed to a standing item in the reports. Our review of Board papers also identified a limited use of benchmarking against external providers.

R8: The Trust should consider how it can incorporat e regular internal and external benchmarking to drive improvement and provide assurance to the Board.

• From our review of reports to QAC the Trust internally benchmarks quality performance between directorates therefore allowing the Board to identify areas of underperformance. This internal benchmarking has been used for risks (at the last three QAC meetings), SIs, complaints, claims, and PALS within the complaints report (at the last two QAC meetings). At QAC the complaints report (as of the last two meetings) triangulates activity with complaints, PALS, incidents and claims. An analysis of the directorate with the poorest results is provided within the report.

• Whilst within the quality reports discussed above there is benchmarking of directorate performance, there is a lack of directorate benchmarking in the integrated performance report (IPR). It is best practice for one of the sub-committees to receive a more granular performance report showing results at least to a directorate level. Without this granularity green metrics may mask areas of underperformance at a directorate level.

R9: The integrated dashboard with results at directo rate level should be presented to one of the Board’s sub -committees in order to scrutinise performance.

Key observations:Is information and analysis used proactively to identify opportunities to drive improvement in care?

• Benchmarking against other providers is a useful tool to identify opportunities for improvement. During our observation of the QAC we noted the following benchmarking comparisons within reports: a comparison of the number of Serious Incidents (SIs) with local Trusts; a comparison of health and safety metrics with other localproviders; and a comparison of registered




2C Does the board help support continuous learning and development across the organisation? (continued)

Does the Board promote a strong focus on continuous learning, improvement and empowerment at all levels of the Trust?

• The Board sets a culture of learning and improvement through their self- reflection at the end of the private Board and QAC meetings. This is good practice and sets the tone of learning and improvement from the top, however it does not occur at the Finance and Investment Committee or at the Audit Committee.

R10: Evaluation of the effectiveness of sub-committ ee meetings should be a standing item on the agenda of all sub-committees.

• The Board’s IPR includes a section on lessons learnt. During interviews and observation of the QAC NEDs commented that rather than receiving details of the actions taken to learn from incidents they would like assurance that the lessons have been learned, for example demonstrated by a downward trend in incidents following the issuance of specific learning. If there is a downward trend this provides evidence the learning has been embedded if it remains stable or increases the governance team should find alternative ways and forums to disseminate the learning.

R11: The governance team should track the efficacy of learning from harm events and bulletins by tracking the level of similar incidents post a learning campaign.

understand if all of the training currently grouped under this heading is necessary.

Learning and Development

• The Trust provided leadership training to the clinical directorate leadership teams through the PULSE programme when they took on the role. The programme was open to the Clinical Directors (CDs) and one other member of the team, we observed that most CDs chose to take their AssociateDirector (AD) with them rather than the Head of Nursing.

• Coaching was also offered on an individual basis to CDs and ADs. It is clear the Trust is committed to supporting the directorate leadership teams in their new roles.

• The Trust assessed the success of the PULSE programme through a survey. From the sample of directorates we interviewed generally staff were positive about the programme however there were some comments that for those who were experienced leaders this covered old ground and could have been more stretching.

• We understand that the Trust is planning to run the course for clinical leads. This is a good example of the Trust investing to develop the tier below the directorate leadership team. The Trust should consider whether this should also be open to matrons and general managers.

Training

• The Trust are failing to meet their 85% target for statutory and mandatory training. As of the report that went to the October QAC only 68% of Trust staff had completed all of their statutoryand mandatory training. The Trust are taking steps to address; an action plan was agreed by CMT and then presented to QAC in October. As part of this the HR department are reviewing what is included within statutory and mandatory training to





• We saw evidence that leadership development courses are also offered to more junior members of staff. These include:

• The Edward Jenner Programme which is open to all staff;

• -The Ernest Shackleton Programme for aspiring leaders and those newly appointed to a leadership role; and

• -The Ellen MacArthur Programme targeted at experienced service leaders looking to develop strategic awareness and shape higher level healthcare.

• During interviews it was commented that these courses could benefit from increased advertising.

R12: Develop a communication plan to highlight the developmental opportunities available to staff.

Appraisals

• The current appraisal form includes required objectives on improving quality in the Trust and in delivering patient safety. There is also a section on personal development. We are aware that the HR department are going to undertake a review of appraisal documentation to link to the new Trust values and to streamline the form, with the intention that all staff will have a development plan.

Ongoing Learning

• There is a weekly incident round up to capture learning from incidents.

• There have been a number of learning from harm events we were provided with evidence of events hosted in September 2014, May 2015, and September 2015. The latest event in September during one of the 2 hospital wide clinical audit days a year was attended by over 160 clinicians. The governance team have issued a survey to check that the learning has been

• embedded from this event. This is an example of good practice which the Trust should continue to utilise, as it closes the loop on learning and provides assurance that the session was successful.

• Directorate leadership teams informed us that learning from other organisations or external inquiries would be captured in the Chief Executive’s blog or included in core brief.

• Directorates we spoke with were pursuing various ways to share lessons locally such as within newsletters.

• We were also informed that learning from harm is part of standardised directorate governance agendas. This is then shared between directorates at the CAC meetings where each directorate presents their governance report. During interviews there was some scepticism about whether directorates were currently paying lip service to this part of the agenda and whether there could be a more comprehensive round up of learning.

• Whilst there are a number of methods the Trust uses to share learning from harm, during our interviews with staff it was commented that there were a number of other opportunities that could be exploited including;

• increased sharing of learning with other providers in the local health economy such as Basildon and Thurrock University Hospitals NHS FT and Mid Essex Hospital Services NHS Trust; and

• more content issued centrally on lessons learned externally from other providers and national inquiries.

R13: The Governance team should consider and formal ise a plan for how they can capture and disseminate learn ing both from other providers in the local health econo my and national NHS learning.





• During our review the Trust were undertaking the “Perfect Week” initiative focused on breaking the cycle and learning what the Trust could do differently. This is the second such event the Trust have undertaken in the last 18 months demonstrating their commitment to improve the quality of patient care.

Are staff encouraged to use information regularly and to take time out to review performance and make improvements?

• The Trust uses Medway Business Intelligence and all staff have access to performance information dashboards covering for example the Emergency department, Cancer waiting times and Referral to treatment times.

• Weekly the central governance team issue a report to directorates which highlights overdue incidents, SIs, risk assessments, legal reports and complaints. This benchmarks the directorates against each other.

• The Trust’s monthly core brief includes information on Trust wide performance.




3A Are there clear roles and accountabilities in relation to board governance (including quality governance)?


• The Board has a sub-committee structure that is not dissimilar to peer Trusts in terms of number and type of sub-committees.Based on comparison against peers, the Board could consider realigning portfolios to reduce the workload of the QAC, for example, creating a Finance and Performance or Finance and Workforce Committee.

• Our review of sub-committee terms of reference found a number of improvements that could be made to ensure good practice. These included omission of terms dealing with duties.

• In our opinion, especially in light of current financial challenges, the FIC, and the QAC are not meeting sufficiently regularly.

• The recent Internal Audit review of the QAC identified similar areas for improvement as our review. These included size of portfolio and lengthy meeting agenda, lengthy and detailed papers, moving agendas, inconsistent use of cover sheets and lack of member understanding of clinical audit as a means of assurance.

• The Trust also has a Charitable Funds Committee and a Nominations and Remuneration Committee, both of which have NED membership.

• The number and type of sub-committees are similar to that of other Trusts (see Figure 2 below).

• During our interviews many commented about the large size of the QAC portfolio, which includes performance and workforce. In our experience, and shown in Figure 2 below, many FTs separate assurance focus of performance or workforce from the quality-focused sub-committee. There are a number of variations to do this, for example having a Finance and Performance Committee or Finance and Workforce Committee or Performance Committee that focuses on performance in its widest sense.

R14: Consider realigning the Board sub-committee portfolios to ensure each has an equitable and mana geable workload and appropriate focus given to key issues.

Key observations:Are there clear structures supporting the work of the Board?

Board sub-committees

• The Trust currently has three key Board sub-committees, all with NED membership and chairmanship:

• Audit Committee (AC);• Quality Assurance Committee (QAC); and• Finance and Investment Committee (FIC).

3: Structure and processes


Fig 2. Comparison of Board sub-committees



3: Structure and processes3A Are there clear roles and accountabilities in relation to board governance (including quality governance)? (continued)

• All of the sub-committees are chaired by NEDs and there is a matrix of NED shared membership. The shared membership enables issues to be escalated between sub-committees, when appropriate, and is considered good practice.

• We note that the NED membership of the AC includes the Chairs of all the key Board sub-committees, which we consider to be good practice. We also note that the AC terms of reference specifically states that the QAC Chair should be a member, and vice versa.

• In general, BMs felt that the sub-committee structure provides the Board with assurance without straying into managing the business, as highlighted by the graph below. The graph also shows the improvement from 2014.

Committee terms of reference

• Each of the sub-committees have agreed ToR that include the purpose, duties, membership, frequency, and reporting arrangements.

• When reviewing the duties of the QAC, we noted a number of significant omissions, based on good practice. These include:• its role in reviewing QIAs and monitoring the on-going

impact of CIPs to quality; and• its role in developing quality indicators throughout the

Trust.

Committee Meeting Frequency

• The frequency of meetings of the FIC and the QAC specified within the terms of references are currently outliers when compared to good practice.

• The FIC meets four times per year. Based on good practice we would expect this sub-committee to meet more frequently,particularly given the financial position of the Trust.

• The terms of reference state that the members should review the monthly financial performance against income, expenditure and capital budgets and review progress against efficiency programmes.

• As the financial position of the Trust is deteriorating due to a number of reasons including slippage on efficiency programmes, we would expect the FIC to meet on a monthly or at least bi-monthly basis.

• The QAC meets at least four times per year. During our interviews, BMs commented that the frequency had reduced when the terms of reference were reviewed at the beginning of the year.

• Based on good practice, we would expect this sub-committee to meet at least every six weeks if not on a monthly basis. An increased frequency should also help with the workload of the QAC and enable members to recall and follow up actions in a timely manner.


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The Board’s committees provide the Board with assur ance and do not stray into managing the business.




R15: Increase the frequency of meetings of both the Financeand Investment Committee and the Quality Assurance Committee to reflect good practice.

Quality Assurance Committee

• During the time of our review, the Trust’s Internal Auditors were also undertaking a specific review of the QAC, seeking to provide assurance that the QAC is assigned the right responsibilities, deals with the right issues and escalates the right matters for the attention of the Trust Board.

• Furthermore, we are aware that the recently appointed Chief Nurse, as lead ED for the QAC, was reviewing how the QAC works with insight from other Trusts.

• We have reviewed a draft copy of the Internal Audit report and confirm that our findings had also been identified within the report. The areas for improvement mainly focused on the following areas:

• significant portfolio and lengthy meeting agendas;

• lack of timings allocated to each agenda item, consequently the agenda moves around significantly during the meetings;

• papers received that are long and detailed;

• inconsistent use of cover sheets with purpose clearly stated, e.g. for assurance, for information. We also identified this as an areas for improvement in the other key sub-committees; and

• lack of members’ understanding about clinical audit and its role in providing assurance about quality improvement to the QAC. This was particularly noticeable as the terms of reference clearly states the QAC responsibility around clinical audit.

R16: Consider the findings of the recent Internal A udit report, views of the Chief Nurse, and the findings o f this review to action changes to address the areas for improvement of the Quality Assurance Committee.

• It is considered good practice to have a NED with a clinical background on the Board and for that individual to be the Chair or a member of the quality-focused assurance Board sub-committee.

• The Trust does not currently have a NED with a clinical background; however, there is a recruitment campaign to appoint two NEDs (one vacant post and one NED at the end of their term of office). As part of this campaign, the Trust is seeking a NED with a clinical background as a suitable candidate was not available during previous recruitment campaigns.

• If appointed, the Trust should ensure this individual is becomes a member of the QAC.

R17: Ensure that, if appointed, the NED with a clin icalbackground becomes a member of the Quality Assuranc e Committee.

Committee reporting to the Board

• The sub-committee Chairs of all Board sub-committees provide a written report to the Board.

• The responses from our BM survey suggests that BMs continue to be satisfied with the effectiveness of the process to highlight key issues and escalate decisions to the Board (see graph overleaf).




Is there sufficient focus on quality in Board, committee and sub-committee meetings?

• The QAC is responsible for providing assurance to the Board that there is an effective system of quality governance, risk management and internal control for the three broad areas of patient experience, clinical effectiveness and the safety of patients.

• The sub-committee receives a variety of quality-focused reports, some of which are also presented to the Board.

• The Board makes use of patient stories at every other Board meeting (three times per year) and BMs commented that they found these very useful.

• The clinical directorates have a governance structure that includes representatives as members of the CAC that reports to QAC. Some of those staff and BMs interviewed felt that there is a lack of consistent governance support for the clinical directorates, which was impacting on directorate ownership of governance matters.

R18: Review the level of, and need for, governance s upport across the clinical directorates to address any inconsistencies.


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The process by which committees highlight key issue s and escalate decisions to be made to the Board is effective.



Appendix 1: Progress against our January 2015 recommendations


Southend University Hospital NHS FT – Independent Review of Governance – FINAL REPORT

Recommendation (January 2015)

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Comments on Progress

1A. Does the board have a credible strategy to provi de high quality, sustainable services to patients a nd is there a robust plan to deliver?

Agree overarching strategy demonstrating clinical leadership in this process and develop enabling strategies to support implementation.

The formulation of the strategy was driven by CMT. A long list of options was produced by CMT during a workshop in early January 2015 and was followed up be a second workshop where ideas were shortlisted. As part of the original workshop CMT collectively decided upon the evaluation criteria.

During a Board workshop in February 2015 the Board then carried out an options appraisal on each of the shortlisted strategies provided by CMT.

During our interviews with BMs, Heads of Departments and Directorate leadership teams it was repeatedly stated that this was a fundamental change in approach to formulation of strategy which had moved the Trust from a top down approach to a clinically led bottom up approach.

The Trust also appointed Clinical Directors to the Transformation Board in April 2015 ensuring that Clinicians are involved in strategic development on an ongoing basis.

Continue to embed the revised annual planning process, and to ensure that there are clear mechanisms for monitoring progress against key objectives at the Board.

The Trust now have an established timeline for development of the Trust wide plan. This was revised again in the year and now involves directorates producing draft plans for January, agreeing these at CMT in February before the Trust wide plan is signed off by the Board in March.

The Board should factor into its forward plans clear agenda slots to monitor progress against objectives to ensure that all BMs understand current progress against key objectives.

Continue work to understand the impact of engagement activities with external stakeholders in order to focus and prioritise future work.

During the development of the strategy the Trust engaged external stakeholders to shape it in a number of ways. The external strategy consultant which the Trust appointed attended other providers strategy events.

The Trust held an external stakeholder event in June 2015 and invited members of the local health economy including other providers, CCGs and the local authority. This session was designed to share the strategy and obtain input from external stakeholders. The Executives presented the strategy, which was followed by facilitated feedback workshops to gather input.

Appendix 1.1 Strategy

33 © 2015 Deloitte LLP. All rights reserved.© 2016 Deloitte LLP. All rights reserved.


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2A. Does the board have the skills and capability t o lead the organisation?

Further refine the Board appraisal process ensuring that feedback is sought from Board members and where relevant stakeholders and senior staff.

The Chair has appraised the NEDs and the Chief Executive has appraised the EDs. The EDs had a 360 degree review which was externally facilitated. From our interviews, we understand that the EDs were not invited to provide feedback to the NEDs as part of their appraisal process. All Governors were asked to provide feedback for the NED appraisal process, although we understand that the number of Governors providing feedback could be improved.

The Chair was appraised by the SID with input from the Lead Governor.

The Trust plan for the whole Board including the NEDs to have a 360 degree review in 2016/17.

2C. Does the Board support continuous learning and development across the organisation?

Close the loop with learning rather than focusing on delivering the action plan e.g. SIs/Clinical audit.

During the February 2015 QAC a sub group was formed to review the reporting of SIs. As a result of this the SI report became part of the Integrated performance report from May 2015 onwards and now includes a section on lessons learned and practices changed.

The SI management process has been reviewed and as part of that there s an emphasis on providing assurance through audit. This has been incorporated into the clinical audit plan. However the Trust acknowledge they are not yet in a position where the learning loop is continuously and consistently closed through audit. See section 2C of our report.

Continue to focus on embedding the new directorate structures and using them to share learning across the Trust.

The directorate reporting template for CAC now includes a section on lessons learned. See commentary in Section 2C of the main report.

Appendix 1.2 Capabilities and Culture

34 Southend University Hospital NHS FT – Independent Review of Governance – FINAL REPORT © 2015 Deloitte LLP. All rights reserved.© 2016 Deloitte LLP. All rights reserved.


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3B. Are there clearly defined, well understood proc esses for escalating and resolving issues and manag ing performance?

Embed the changes to the Clinical Directorate structure and the performance management framework.

The Board have established a clear performance framework and this was approved on 25 February 2015 on the Board Development Day. Performance review meetings under this framework commenced in April 2015.

The performance management process is still evolving and we understand that a new reporting template is being implemented based on one directorate’s good practice example. This template will be structured around the CQC domains.

During our interviews with a sample of directorate leadership teams there were variable comments about the level of challenge at Performance review meetings. Two of the three directorates felt there should be increased holding to account in these meetings. Comments were also made that attendance from Executives was variable which led to an inconsistent process depending on who was present.

The Trust have planned an internal audit of the performance framework which is due to commence in February 2016.

Following the change to the Clinical Directorate structure, the Executive team need to be able to demonstrate a balance between oversight of divisions and their autonomy (hover not helicopter).

The Trust conducted an evaluation of the CMT meeting which is the interface between Clinical Directorates and Executives. As part of this the Trust surveyed CDs, AMDs and ADs on the extent to which the clinical directorates are empowered to make decisions 50% agreed, with 50% responding neutrally or negatively.

During our interviews with a sample of directorate leadership teams and the Executive it appeared the balance was more towards central oversight rather than autonomy of the directorates. Given the structure is still relatively new this may be appropriate. As the structure continues to embed, the Trust may want to consider the merits of moving towards a framework of earned autonomy where a directorate is performing well.

Develop the appraisal process for clinical directors to support the changes made and to ensure that clear objectives are set.

CDs are jointly appraised by the MD and COO. The target date for appraisals as per the Trust’s action plan was October 2015, however as of our site work in November not all CDs had yet had their appraisal. The delay was due to clinical commitments. Subsequently we understand that all CD appraisals were completed by the 2nd of December.

Appendix 1.3 Structures and Processes



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3B. Are there clearly defined, well understood proc esses for escalating and resolving issues and manag ing performance?

Demonstrate that the Board / Executive Team is empowering Clinical Directorates whilst also maintaining an appropriate level of oversight.

The Trust implemented a compulsory leadership training programme for CDs and ADs known as the PULSE programme. As part of this CDs and ADs had the opportunity to work with an external coach. See section 2C within this report for a more detailed discussion of the PULSE programme.

Continue to focus on impact and outcomes for example by focussing on improving performance metrics e.g. A&E, cancer, 18 week RTT, and also ensuring that there is a focus on the ‘when’ i.e. when will things change/be delivered.

The Board meeting minutes demonstrate the Board have a high focus on performance metrics and continuously review the IPR.

Analysis of the Board minutes demonstrated the Board have limited discussions into when changes will be implemented. However, there were a few examples of discussions of projected target dates and information on how this will be achieved, for example, in relation to RTT.

Our review of a sample of directorate performance review papers showed variability across directorates in committing to timescales in many instances, directorates described actions as ongoing rather than providing a target date.

3C. Does the Board actively engage patients, staff, governors and other key stakeholders on quality, o perational and financial performance?

Hold Board to Board meetings with key stakeholders. N/A

Given the current climate within the local health economy, the Board has discussed the appropriateness of a stakeholder Board-to-Board meetings and agreed that this is not something to pursue for the time being. The Board should review this decision in 6 months.

Continue to develop oversight of feedback from staff in order to ensure that key issues are being addressed and actions communicated to staff.

It was agreed by CMT in March that each clinical directorate would be responsible for analysing their staff survey results and identifying 2 key areas of concern to develop an action plan for and 2 positive areas to celebrate success.

It was decided that progress against the staff survey action plan would be monitored at Directorate performance review meetings, however from our review of a sample of directorate performance management meetings this is not consistently on the agenda.

The Trust communicated action plans to staff through Core Brief, local newsletters and the Friday Round-up bulletin. A You said we did format was used to communicate changes as a result of the staff survey.




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Headline Comments on Progress

3C. Does the Board actively engage patients, staff, governors and other key stakeholders on quality, o perational and financial performance?

Revise education provided to governors. The Governors’ Education and Training group completed a training needs analysis in April 2015 and reviewed the induction process in July 2015. This revised induction process has been used for Governors appointed in August 2015. The Trust sought feedback from the new Governors who attended this induction. At the time of this review the Trust were still waiting on some responses however some constructive criticism had been provided. The Trust should take these forward and refine the induction process further ahead of the next round of appointments.




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Headline Comments on Progress

4A. Is appropriate information on organisational an d operational performance being analysed and challe nged?

Executives to continue to work on presenting complex issues and data in a simpler manner.

During the Board development session in July the Board reviewed the IPBR. The Executive team now meet to review Board papers as a collective before taking to the Board. Both NEDs and EDs commented during our interviews on the positive impact this exercise has had.

Further development of the IPBR as the new Clinical Directorates become embedded and performance management arrangements are refined.

The Board have further developed the IPR since the last review. The IPBR submitted to the Board on a monthly basis now has an SI section. The Board discussed and agreed that the SI report should be moved to the public meetings, as it no longer holds any patient identifiable information.

We note that the quality and level of analysis has increased for example the executive summary now has a breakdown of each section with a high level summary of performance.

The IPBR does not currently show performance at directorate level. It is considered best practice for the Board or one of its sub-committees to review performance at directorate level, as overall results can mask areas of poor performance.

The IPBR would benefit from an upfront dashboard which shows a snapshot of overall performance across the domains on one page.

Appendix 1.4 Measurement


Conclusion• We found that, whilst the Trust has completed the majority of actions within its action plan to address our previous recommendations, further

work is required to fully implement a number of the original recommendations. The Trust should continue to progress their work and we have provided further examples of how the Trust can do so.

R19: The Trust should continue to make progress aga inst the previous recommendations from January 2015 .



Appendix 2: Summary of New Recommendations



Appendix 2: Summary of New RecommendationsRec Ref Recommendation

Priority/risk rating

Timescale

J F M A M J J A S O N D

1 1B Provide risk assessment and risk management refresh er training to all staff, with the content varied according to levels of responsib ility.

Medium

2 1B The Board should aim to review the CRR and BAF at l east four times a year. Further to this at each Board meeting the Board sho uld consider whether discussions have influenced BAF scores.

Medium

3 1B The Trust should standardise how often sub-committe es review the individual BAF risks in the year. The Trust should allocate al l BAF risks to a sub-committee for a detailed review or should ensure there is a d etailed separate review of these BAF risks at Board in addition to the full review o f the BAF.

Medium

4 1B The Trust should:

• Review the Datix references on the BAF and ensure t hese map correctly across to the CRR.

• Consider whether all high level risks on the CRR ar e captured on the BAF.

• Align the risks to the Trust’s new strategic object ives.

• Link assurances to the relevant control.

• Include a target risk scoring on the trend graph an d provide data over a 12 month period.

• Include milestone dates for actions.

• Provide details of real assurances obtained.

High

5 1B At least annually the QAC should receive assurance that the QIA process is effective. This should include details of percentag e of schemes that have a QIA in place, details of schemes which have been rejected and assurance that schemes are being monitored on an ongoing basis.

Medium

6 1B QIAs should have SMART quality KPIs identified to e nable the monitoring of impact. The QAC should monitor the ongoing impact o n quality of transformation schemes.

Medium

7 2B The Trust should develop a structured communication plan to inform staff of their visits to service areas and insights gained through these.

Low

8 2C The Trust should consider how it can incorporate re gular internal and external benchmarking in order to drive improvement and prov ide assurance to the Board.

Low



Appendix 2: Summary of New RecommendationsRec Ref Recommendation

Priority/risk rating

Timescale

J F M A M J J A S O N D

9 2C The integrated dashboard with results at directorate level should be presented to one of the Board’s sub-committees in order to scrut inise performance.

High

10 2C Evaluation of the effectiveness of sub-committee me etings should be a standing item on the agenda of all sub-committees.

Medium

11 2C The governance team should track the efficacy of le arning from harm events and bulletins by tracking the level of similar incident s post a learning campaign.

Medium

12 2C Develop a communication plan to highlight the devel opmental opportunities available to staff.

Low

13 2C The Governance team should consider and formalise a plan for how they can capture and disseminate learning both from other pr oviders in the local health economy and national NHS learning.

Medium

14 3A Consider realigning the Board sub-committee portfol ios to ensure each has an equitable and manageable workload and appropriate f ocus given to key issues.

High

15 3A Increase the frequency of meetings of both the Fina nce and InvestmentCommittee and the Quality Assurance Committee to re flect good practice.

Medium

16 3A Consider the findings of the recent Internal Audit report, views of the Chief Nurse, and the findings of this review to action changes t o address the areas for improvement of the Quality Assurance Committee.

High

17 3A Ensure that, if appointed, the NED with a clinical b ackground becomes a member of the Quality Assurance Committee.

Medium

18 3A Review the level of, and need for, governance suppor t across the clinical directorates to address any inconsistencies.

Medium

19 App 1 The Trust should continue to make progress against t he previous recommendations from January 2015.

High



Appendix 3: Survey Results


Appendix 3: Survey ResultsWe have surveyed the Board against the relevant areas of the framework and have compared results to summer 2014.

In order to make this information meaningful we have indicated the range of overall responses (in grey). Where this range is extraordinary (i.e. of significant variance) we have indicated this with an amber alert. The overall range is pivoted at blue which indicates where the majority of responses were placed. All of the statements are positively proposed which means that higher scores indicate a more positive response. The ideal scenario for a unitary Board with a positive synchronicity is a short range (1 or 2) combined with a blue indicator of 4 or 5. If there is a short range but a low score this too can be observed as a positive outcome because this still indicates the ‘known knowns’ i.e. The unitary Board are all aware that they have issues with a certain domain.

We have indicated hotspot areas as being areas where there may be a large variance but also a low score, or simply a low variance and low score. The scoring method and key are found on this page. For the purpose of this exercise we have focussed on the range and most common response.

Number of responses:Board Survey 2015: 14Board Survey 2014: 13

Key Criteria

The whole range of overall responses

The most common response given

Beware of potential hotspots

Beware of significant variance

Each box contains the number of responses, apart from the Staff survey which contains the percentage of responses.

Strongly Agree

AgreeSlightly Agree

SlightlyDisagree

DisagreeStrongly Disagree

Cannot Say

6 5 4 3 2 1 0

Papworth Hospital NHS Foundation Trust – Independent Review of Governance Arrangements - FINAL

43Southend University Hospital NHS FT – Independent Review of Governance – FINAL REPORT © 2015 Deloitte LLP. All rights reserved.© 2016 Deloitte LLP. All rights reserved.


Appendix 3: Survey Results - 2015 Board Survey

44

6 5 4 3 2 1 0 Key

I can articulate the strategic priorities that have been agreed by the Board to deliver the vision.

4 10 0 0 0 0 0

I can explain how the strategic priorities will be progressed this year. 3 11 0 0 0 0 0

Our strategy is based upon clear consultation with key internal and external stakeholders.

7 7 0 0 0 0 0

There are clear mechanisms in place to disseminate lessons learned throughout the Trust.

2 6 6 0 0 0 0

When corrective action is taken, changes made are embedded. It is rare for our Trust to have issues which reoccur.

0 3 7 4 0 0 0

When organisational performance slips it is clear how the Board will monitor the progress of the corrective actions taken.

2 10 2 0 0 0 0

After a decision has been made by the Board it is clear who is responsible for implementing it and by when.

7 6 1 0 0 0 0

I am assured that the organisation has the right culture to deliver its core business and vision and can provide evidence of that assurance if required.

3 6 4 1 0 0 0

The Board ensures that staff receive appropriate and timely responses to issues raised.

3 10 1 0 0 0 0

Members of staff and other key stakeholders are routinely invited to present at the Board.

5 7 1 0 1 0 0

The Board has a strong external focus, proactively influencing and responding to key external partners (e.g. the Local Authority, the voluntary sector, universities and other healthcare organisations).

6 4 4 0 0 0 0


© 2015 Deloitte LLP. All rights reserved.© 2015 Deloitte LLP. All rights reserved.45

6 5 4 3 2 1 0 Key

The Board is open to learning from elsewhere. 4 9 1 0 0 0 0

The Board’s committees provide the Board with assurance and do not stray into managing the business.

6 4 2 1 1 0 0

There is minimal duplication between the work of the various Board-level committees.

5 5 2 2 0 0 0

Each committee is adequately supported by sub-groups to enable effective delegation to occur.

3 6 4 1 0 0 0

The process by which committees highlight key issues and escalate decisions to be made to the Board is effective.

4 7 2 1 0 0 0

The information I receive as a Board member enables me to effectively hold management to account.

4 9 0 1 0 0 0

As a Board we regularly review the key performance indicators we use and can explain why they are relevant to our strategic objectives.

6 7 1 0 0 0 0

The Board regularly receives information that meaningfully benchmarks the performance of the organisation against other similar organisations.

0 8 5 1 0 0 0

There are clear mechanisms in place to monitor the impact of CIPs on quality throughout the life of a scheme.

1 8 3 2 0 0 0

The Board has a consistent view of the top 5 risks within the organisation’s internal and external environment.

7 6 1 0 0 0 0

The Board routinely reviews the BAF and actively uses this document to oversee strategic risks.

5 9 0 0 0 0 0





6 5 4 3 2 1 0 Key

I am assured that risks are appropriately identified and controlled and can provide evidence of that assurance if required.

0 12 2 0 0 0 0

All proposed changes in service delivery, workforce and/or organisational policies, systems and processes are risk assessed.

4 8 0 2 0 0 0

I am clear on the role of the Board and its committees in relation to risk management.

6 6 1 1 0 0 0

As a Board member I feel able to say what I am thinking and can openly express my doubts, uncertainties or lack of understanding of an issue.

11 3 0 0 0 0 0

The Board is open to feedback on its own performance and acts swiftly upon this.

10 4 0 0 0 0 0

I am able to access training which is relevant to my role as a Board Member.

5 5 4 0 0 0 0

I have objectives that clearly focus on my role as a Board Member. 4 8 1 1 0 0 0

I am confident that the Board will oversee the successful implementation of the actions arising from this review.

12 2 0 0 0 0 0






47

6 5 4 3 2 1 0 Key

I can articulate the strategic priorities that have been agreed by the Board to deliver the vision.

3 8 1 0 1 0 0

I can explain how the strategic priorities will be progressed this year. 3 6 2 1 1 0 0

Our strategy is based upon clear consultation with key internal and external stakeholders.

1 4 6 0 0 2 0

There are clear mechanisms in place to disseminate lessons learned throughout the Trust.

1 6 4 1 1 0 0

When corrective action is taken, changes made are embedded. It is rare for our Trust to have issues which reoccur.

0 0 5 2 4 2 0

When organisational performance slips it is clear how the Board will monitor the progress of the corrective actions taken.

0 7 3 0 0 3 0

After a decision has been made by the Board it is clear who is responsible for implementing it and by when.

3 5 3 1 1 0 0

I am assured that the organisation has the right culture to deliver its core business and vision and can provide evidence of that assurance if required.

0 4 5 2 1 1 0

The Board ensures that staff receive appropriate and timely responses to issues raised.

1 6 4 0 2 0 0

Members of staff and other key stakeholders are routinely invited to present at the Board.

4 4 5 0 0 0 0

The Board has a strong external focus, proactively influencing and responding to key external partners (e.g. the Local Authority, the voluntary sector, universities and other healthcare organisations).

1 4 4 1 2 1 0



6 5 4 3 2 1 0 Key

The Board is open to learning from elsewhere. 1 6 4 2 0 0 0

The Board’s committees provide the Board with assurance and do not stray into managing the business.

2 7 2 0 2 0 0

There is minimal duplication between the work of the various Board-level committees.

1 7 3 2 0 0 0

Each committee is adequately supported by sub-groups to enable effective delegation to occur.

1 8 2 1 1 0 0

The process by which committees highlight key issues and escalate decisions to be made to the Board is effective.

3 7 1 1 1 0 0

The information I receive as a Board member enables me to effectively hold management to account.

1 8 1 1 1 0 1

As a Board we regularly review the key performance indicators we use and can explain why they are relevant to our strategic objectives.

3 8 2 0 0 0 0

The Board regularly receives information that meaningfully benchmarks the performance of the organisation against other similar organisations.

0 7 4 1 1 0 0

There are clear mechanisms in place to monitor the impact of CIPs on quality throughout the life of a scheme.

2 7 2 2 0 0 0

The Board has a consistent view of the top 5 risks within the organisation’s internal and external environment.

1 6 5 1 0 0 0

The Board routinely reviews the BAF and actively uses this document to oversee strategic risks.

0 8 4 1 0 0 0





6 5 4 3 2 1 0 Key

I am assured that risks are appropriately identified and controlled and can provide evidence of that assurance if required.

0 5 6 2 0 0 0

All proposed changes in service delivery, workforce and/or organisational policies, systems and processes are risk assessed.

2 8 1 1 1 0 0

I am clear on the role of the Board and its committees in relation to risk management.

4 4 4 1 0 0 0

As a Board member I feel able to say what I am thinking and can openly express my doubts, uncertainties or lack of understanding of an issue.

6 2 3 0 2 0 0

The Board is open to feedback on its own performance and acts swiftly upon this.

0 10 2 0 1 0 0

I am able to access training which is relevant to my role as a Board Member.

3 5 5 0 0 0 0

I have objectives that clearly focus on my role as a Board Member. 1 8 1 0 2 1 0

I am confident that the Board will oversee the successful implementation of the actions arising from this review.

4 5 1 0 3 0 0





Appendix 4: Glossary


Glossary of terms used throughout this report

AC = Audit Committee

AD = Associate Director

BAF = Board Assurance Framework

BM = Board Member

Board = The Board of Directors at Southend University Hospital NHS Foundation Trust

CAC = Clinical Assurance Committee

CCG = Clinical Commissioning Group

CD = Clinical Director

CEO = Chief Executive Officer

CFO = Chief Finance Officer

CIP = Cost Improvement Plan

CMT = Corporate Management Team

CRR = Corporate Risk Register

FIC = Finance and Investment Committee

CN = Chief Nurse

CoG = Council of Governors

COO = Chief Operating Officer

CRR = Corporate Risk Register

ED = Executive Director

ET = Executive Team

FT/ Trust = Southend University Hospital NHS Foundation Trust

GM = General Manager

51

HoN = Head of Nursing

HR = Human Resources

IA = Internal Audit

IM&T = Information Management and Technology

IPBR = Integrated Performance Board Report

IT = Information Technology

KPI = Key performance indicator

Monitor = Independent Regulator of NHS Foundation Trusts

MD = Medical Director

MRSA = Methicillin-resistant Staphylococcus aureus

NED = Non-Executive Director

NHS = National Health Service

OD = Organisational Development

QAC = Quality Assurance Committee

QIA = Quality Impact Assessment

PALS = Patient Advice Liaison Service

RAG = Red, Amber, Green

RR = Risk Register

RTT = Referral to treatment time

SI = Serious Incidents

SMART = Specific, measurable, attainable, realistic and time-sensitive

SUHFT = Southend University Hospital NHS Foundation Trust

ToR = Terms of Reference

Appendix 4: Glossary

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