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BOARD OF DIRECTORS Thursday 25 April 2019 at 9.00am

Voluntary Action, The Spectrum, Coke Hill, Rotherham, S60 2HX

No Time Item Request to Lead Enc

1 9:00 Welcome

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2 Apologies for Absence:

Note

3 Quoracy (One third of the Board; inc at least one NED and one ED)

4 Declarations of Interest A

PATIENT STORY

5 9:05 Adult ADHD Service in Rotherham DS

STANDING ITEMS

6 9:40 Minutes of the last meeting held on the 28 March 2019 Decision

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B

7 Matters Arising and Follow up Action List Decision C

8 Chairman’s Report and Council of Governors update Information D

9 Chief Executive’s Report Information KSi E

STRATEGY

10 Integrated Care System (ICS) Update Assurance KSi F

COMMITTEE REPORTS AND SUPPORTING PAPERS

11 10:05 Report from the Finance, Performance and Informatics Committee

Assurance TS/SH G

12 Report from the Quality Committee Assurance DL/AM H

12a Freedom To Speak Up (FTSU) Guardian 6 month update Assurance RJ I

12b Staff Survey Results Information RJ J

12c Mortality Quarterly Update Assurance /

Decision NA K

GOVERNANCE

13 Extreme Operational Risks Assurance PG L

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14 Board Assurance Framework Decision PG M

15 Any Other Business (to be notified in advance to the Chair)

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-

16 Public questions * -

17 11:30

Chair to resolve ‘that because publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted, the public and press be excluded from the meeting.’

* PUBLIC QUESTIONS:

The Board of Directors meetings are held in public, but they are not ‘public meetings’ and as such the meetings will be conducted strictly in line with the above agenda. For those members of the public in attendance, the agenda provides the opportunity for questions to be received at an appointed time. In respect of this agenda item, the following guidance is provided:

Questions at the meeting must relate to papers being presented on the day.

There is no need for questions to be submitted in advance, although this may mean that it is not always possible to provide an answer at the meeting. In that case, the questioner’s contact details will be requested for response.

Questions will be taken in rotation, to ensure those wishing to raise questions have equal opportunity, within the limited time available

Members of the public and Governors are very much welcome to raise questions at any other time, on any other matter, through the office of the Chair and Chief Executive or other contact points

The next meeting of the Board of Directors will take place on

Date / Time: Thursday 30 May 2019 at 9 am

Venue: Almond Tree Court, Woodfield Park, Tickhill Road, Tickhill Road, Balby, Doncaster,

DN4 8QN

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ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST

Committee Name

Board of Directors

Agenda Item Paper A Date 25 April 2019

Title of Paper Declarations of Interest

Decision The Register is presented as attached and Directors are asked to confirm at the meeting that this register is accurate and that no further amendments are necessary. The Board of Directors to confirm whether any declaration results in a conflict that requires a Director to be excluded from the discussions or decisions being made.

Assurance

Information The Board of Directors to receive and note the Register of Interests

Prepared by Philip Gowland, Board Secretary/Director of Corporate Assurance

Presented by Lawson Pater, Chairman

Delivery against

Strategic Goal(s) 1. To provide safe, effective, compassionate care

2. To attract, retain, support and develop the finest workforce

3. To maintain financial stability

4. To work with partners to offer and deliver market-leading services

5. To be an outstanding, well-led organisation Receipt of the declarations ensures robust governance is in place

and accountabilities and responsibilities are not compromised and that Constitutional and policy requirements are adhered to.

Strategic Risk(s) Number Level of Assurance Number Level of Assurance

CQC Domain Safe Effective Caring Responsive Well-Led

Impact The requirement to declare interests is applicable to all Directors. The impact of the declarations will be considered by the Board of Directors and if any interest results in a conflict, the Chairman will decide on what action to take, which could include the exclusion of the Director for part of the meeting.

Previously Presented to

Presented on a monthly basis to the Board of Directors meetings.

Appendices to Paper

n/a

ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST BOARD OF DIRECTORS – REGISTER OF INTERESTS

Executive Summary The Trust and the people who work with and for it, collaborate closely with other organisations, delivering high quality care for our patients. These partnerships have many benefits and should help ensure that public money is spent efficiently and wisely. But there is a risk that conflicts of interest may arise. Providing best value for taxpayers and ensuring that decisions are taken transparently and clearly, are both key principles in the NHS Constitution. The Trust is committed to maximising its resources for the benefit of the whole community. As a Trust and as individuals, there is a duty to ensure that all dealings are conducted to the highest standards of integrity and that NHS monies are used wisely so that the Trust uses the finite resources in the best interests of patients. For this reason each Director makes a continual declaration of any interests they have. Declarations are made to the Board Secretary as they arise, recorded on the public register and formally reported to the Board of Directors at the next meeting. To ensure openness and transparency during Trust business, the Register is included in the papers that are considered by the Board of Directors each month. This month there are updates in respect of Kathryn Singh and Nigel Smith – as per the table below.

Name / Position Interests Declared Lawson Pater Chairman • Trustee of Doncaster Community Arts, a registered charity

• Senior Trust Associate Manager at RDaSH Dr Nav Ahluwalia Executive Medical Director • Chair Y&H RO/Appraisal Leads network

• Research Lead for the South Yorkshire Specialist Higher Trainees in Psychiatry • Member of the Y&H National Clinical Excellence Awards Committee • RCPsych Trent Division Regional Representative in Addictions • RCPsych Trent Division Regional Representative for Workforce

RCPsych Membership CASC (Clinical Examination): member of Examination panel, run examination circuits, train new examiners

Richard Banks Director of Health Informatics • Nil

Philip Gowland Board Secretary/Director of Corporate Assurance

• Partner is employed by RDaSH as a Patient and Public Engagement and Experience Lead (working in Nursing & Quality Directorate) and is from 1 March 2019 undertaking a 12 month, part-time secondment as Integrated Neighbourhood Project Coordinator –

East Neighbourhood, with Primary Care Doncaster

Steve Hackett Executive Director of Finance and Performance

• Director of Flourish Enterprises Community Interest Company • Son has commenced working with the Trust via the Admin Bank

Rosie Johnson Executive Director Workforce and Organisational Development

• Director of 1825 Residence Ltd – Residents Property Management Company

Dawn Leese Non-Executive Director • Working with Birmingham and Solihull CCG during the period from July to September 2018 (work now complete)

• Worked with Extracare UK Charitable Trust (West Midlands) during May and June 2018 (work now complete)

Andrew MacCallum, Interim Executive Director of Nursing

• Nil

Alison Pearson Non-Executive Director • Chair of Stillingfleet Village Institute • Trustee for the Two Ridings Community Foundation • Independent Member of the Parole Board • Senior Trust Associate Manager at RDaSH

Justin Shannahan Non-Executive Director • Head of Finance Strategy and Processes, Derbyshire County Cricket Club • Ad hoc consulting work for GLG (Gerson Lehrman Group, Inc.)

Tim Shaw Non-Executive Director • Senior Trust Associate Manager at RDaSH • Chair of Doncaster Business for the Community

Kathryn Singh Chief Executive • Executive Reviewer for the Care Quality Commission (CQC) • Husband is Chair of Derbyshire Community Health Services NHS FT • Husband is Chair of George Elliot Hospital NHS Trust in Warwickshire • Husband is MD of PMS Consulting Ltd (provides consultancy support to NHS

organisations and individuals) Deborah Smith Chief Operating Officer • Director of Flourish Enterprises Community Interest Company

Nigel Smith Non-Executive Director • Non- Executive Director, Derbyshire Community Health Services NHS Foundation Trust

• Trustee, Age UK Sheffield • Associate Mental Health Act Manager at Derbyshire Community Health Services

NHS Foundation Trust • Trustee at Citizens Advice Derbyshire Dales.

ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST

Committee Name

Board of Directors

Agenda Item Paper B Date 25 April 2019

Title of Paper Minutes from the public Board of Directors meeting held on 28 March 2019

Decision The Board of Directors to approve the minutes of the Board of Directors meeting held in public on 28 March 2019

Assurance

Information

Prepared by Louise Wood, Personal Assistant, Children’s Care Group

Presented by Lawson Pater, Chairman

Delivery against

Strategic Goal(s) 1. To provide safe, effective, compassionate care

2. To attract, retain, support and develop the finest workforce

3. To maintain financial stability

4. To work with partners to offer and deliver market-leading services

5. To be an outstanding, well-led organisation The receipt and agreement of the minutes strengthens the

governance processes in place within the Trust.

Strategic Risk(s) Number Level of Assurance Number Level of Assurance

CQC Domain Safe Effective Caring Responsive Well-Led

Impact The impact of the discussion and actions are referenced within the minutes.

Previously Presented to

n/a

Appendices to Paper

n/a

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PRESENT Lawson Pater Chairman Kathryn Singh Chief Executive Tim Shaw Non-Executive Director Justin Shannahan Non-Executive Director Dawn Leese Non-Executive Director Rosie Johnson Executive Director of Workforce & Organisational

Development Deborah Smith Chief Operating Officer Steve Hackett Executive Director of Finance & Performance Dr Nav Ahluwalia Executive Medical Director Andrew MacCallum Interim Executive Director of Nursing and AHPs APOLOGIES Alison Pearson Non-Executive Director Nigel Smith Non-Executive Director IN ATTENDANCE Philip Gowland Director of Corporate Assurance/BoardSecretary Richard Banks Director of Health Informatics Cheryl Watkinson Patient & Public Engagement Lead Natasha Collinson Patient & Public Engagement Naomi Turgoose CPN (for patient story item) Christina Patient (for patient story item) Leanda Sowerby CPN (for patient story item) Louise Wood Personal Assistant to the Children’s Care Group

Triumvirate (Note Taker) Two members of the public attended the meeting.

Minute Ref

ACTION

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WELCOME AND APOLOGIES Mr Shaw welcomed everyone to the meeting (Mr Pater was caught in traffic).

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APOLOGIES Mr Nigel Smith and Mrs Alison Pearson.

MINUTES OF THE BOARD OF DIRECTORS MEETING – HELD IN PUBLIC ON THURSDAY 28 MARCH 2019

AT ALMOND TREE COURT, WOODFIELD PARK, TICKHILL ROAD, BALBY, DONCASTER

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QUORACY Mr Shaw declared that the meeting was quorate (Mr Pater arrived).

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DECLARATIONS OF INTEREST There were no declarations of interest received.

PATIENT STORY

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DONCASTER CARE GROUP : COMMUNITY MENTAL HEALTH SERVICES Ms Smith introduced the patient, Christina, who was attending to talk about her experiences in the NHS throughout the years in relation to her eating disorder. She was supported in the meeting by a number of staff from the eating disorders community team. Mr Pater expressed his gratitude to Christina for taking the time to attend the meeting and to talk about her story. Christina spoke about her struggle with her illness and the support she had received over the last few years from the NHS – from services in Leeds to those provided more recently by the Trust. She highlighted that at times it was difficult to navigate the system and find the necessary support and she expressed her wish that more specialist services were located closer to families, and were able to support patients and their families. It was noted that the level of support for eating disorders in CAMHS had been classed as “outstanding”, but the service was only provided to people of up to 19 years of age. She expressed her wish for the service to be mirrored in adult services. Mr Pater thanked Christina for being courageous enough to talk about her experiences. He commented that Christina’s story had had an impact on the Board and had given the Board a clear perspective of what was taking place in the Trust and the wider health service. There were a number of issues discussed:

In response to Mrs Singh’s question, Ms Sowerby and Ms Turgoose (community team) described and presented an overview of their service and team. They described the way in which the team have to respond to an array of different health issues, for example personality disorders, depression, anxiety, transgender and eating disorders. They highlighted that the number of referrals to their service was increasing – which with limited resources in the team, was proving a challenge; and they also described how between them they work to ensure a consistent provision is in place. Ms Turgoose highlighted that conversations were currently taking place about improvements to the service and that there was work underway on a business case to secure additional resources for the

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team. Ms Smith commented that she would ask the Business Support Manager to assist with the business case.

Mrs Leese asked Board members if there was any knowledge about commissioning intentions around the adult eating disorders service. The Board commented that it was not clear at this point on the commissioning intentions. Mr Hackett questioned whether, having listened to Christina’s story, the eating disorders service would be classed as a specialised commissioning service, and therefore the commissioners would be NHS England. He commented that Trusts have to follow a specific prescribed way to buy specialist services.

Mrs Singh noted that from a recent survey of mental health Chief Executives, only 15% of Trusts said they were able to manage demand and could plan for some unmet need; 48% were struggling to meet current demand, and 36% were unable to meet demand. There was funding going into some specialist services, but not all services were receiving funding from the five year plan.

Mr Pater commented that, if Christina felt able, it may be helpful, when the Trust was having conversations with commissioners, for Christina to attend the meeting to tell her story. Christina indicated that she would be happy to do so.

Mr Pater, on behalf of the Board, again offered his thanks to Christina and the team for attending the meeting and sharing her story with the Board of Directors.

DS

STANDING ITEMS

Bpu 19/03/06

MINUTES OF THE LAST MEETING HELD ON 28 FEBRUARY 2019 The minutes of the meeting held on 28 February 2019 were agreed as a true record, subject to the following amendments: Bpu 19/02/14 -

The figures in the first bullet point were £ thousands i.e. £2,757k and £2,857k.

The second bullet should not reference a recommendation from Investec and should now read : Investec, the investment company for the funds, had attended the Committee meeting to discuss the Reserve Policy and, following this discussion, the Committee concluded that a maximum of 90% of the funds could be committed, leaving a reserve of 10%.

The third bullet point should not reference high risk investments, but should now read: The Investec charts provided with today’s briefing show greater detail and the split of investments, and that the

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company are managing the investments well.

The fourth bullet point needed the word ‘should’ inserting as per - At the meeting Investec asked the Committee to complete a questionnaire and the results matched their assumptions that the fund should operate on a medium to low risk.

In the final paragraph in this section, the response from Mr Shannahan should read - Mr Shannahan informed that the investment policy that Investec works to prohibits investment in companies having links to smoking and alcohol.

Bpu 19/02/12 The final paragraph on page 7 to be replaced with the following: The Board discussed the limitations and safe staffing assessment. Mrs Leese discussed the comprehensive assessment of risk to patient safety when staffing deficits are identified. Bpu 19/02/12b The last paragraph of page 8 of the minutes should read Mr Shaw referred to the table that presented the sickness rates and asked that future reports included detail of the ward staff numbers to provide context to the figures presented. Bpu19/02/12b A final paragraph to be inserted before the last Bold paragraph. Mrs Leese made specific reference to the need to make explicit reference to previous staffing declarations to the Board. This included risks identified, actions to be taken and transparency around implementation. Bpu19/02/11 The last bullet point on page 5. The paragraph should read

The Committee received a report on Data Security and protection which identified a risk associated with achieving 95% coverage of data security awareness training.

Bpu 19/03/07

MATTERS ARISING AND FOLLOW UP ACTION LIST The paper informed the Board of the completed actions and progress updates. 19/01/09 – the Board Development sessions were being discussed in the private session. It was agreed to close the action. 19/01/10 – NHS long term plan – the action was agreed as closed.

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19/01/14 - Board assurance framework – it was agreed that this action would be carried forward to the April Board meeting. 19/02/11 – ADHD/ASD presentation to the Quality Committee in April 2019 - It was agreed that this action would be carried forward to the April Board meeting. 19/02/12a – Guardian of Safe Working Hours - Dr Ahluwalia noted that the current guardian had tended his resignation from the role and the Trust. Dr Ahluwalia was in the process of securing a new guardian. He commented that he was unable to provide assurance to the Board that junior doctors were having their compensatory rest periods, but he would provide more details at the April Board meeting. There were no further matters raised. The Board noted the matters arising report.

NA

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CHAIRMAN’S REPORT AND COUNCIL OF GOVERNORS UPDATE Mr Pater presented his report (Paper D) to the Board. The report included commitments from the Non-Executive Directors, and the Council of Governors meeting, which he and his colleagues were involved in the previous month. Mr Pater noted that the NHS Providers Governwell training session got Governors had reportedly been an interesting and valuable exercise and was aimed as assisting Governors to carry out their responsibilities which include holding Non-Executives to account for the performance of the Board. He also highlighted the Governors ‘Raising the Profile’ working group, and it was noted that further work would be taking place in April. Mr Gowland reported on the progress for the recruitment of Mr Pater’s successor. The Board noted the Chairman’s report.

Bpu 19/03/09

CHIEF EXECUTIVE’S REPORT Mrs Singh presented her report to the Board (Paper E). The following was highlighted.

Mrs Singh noted that the Trust would be moving away from the ‘Listening into Action’ (LiA) programme, and would, going forward, have a Trust programme entitled ‘The RDaSH Way’ addressing the continuous improvement of quality. This would begin to be rolled out from April. At the same time, Mrs Singh commented that the Trust had also been asked to become designated ‘Brand Ambassadors’ for the LiA programme.

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Mrs Singh highlighted the culture and cultural improvement work that Dr Jude Graham and Paula Rylatt would be progressing for the Trust. She commented that there were two significant leadership development programmes taking place with NHS Improvement, that will upskill and enable staff to increase their everyday service improvement approach.

Mrs Singh reported that the five year strategy view document for RDaSH would be published the following week, which included the 6 strategic ambitions for the Trust.

The Board were informed that Tracey Wrench would be joining the Trust as Executive Director of Nursing and AHPS from 1 July 2019. Mr MacCallum had agreed to stay as interim until 30 June 2019.

Mrs Singh commented on the Grounded Research work and the recent visit by Professor Chris Whitty (Chief Scientific Adviser for the Department of Health and Social Care). She wanted to give credit to Dr Ahluwalia and team for the huge growth in research activities. The Trust is in respect of success in recruiting patients to NHS research studies, the leading mental health Trust in the Yorkshire and ranked sixth in the country. She expressed her thanks for the work of this team.

Mrs Singh reported that the staff survey results were scheduled to be discussed at the Quality Committee and the Trust Board in April.

Mrs Singh advised that the CQC report ‘Monitoring the Mental Health Act 2017/18’, would be brought to and reviewed by the Mental Health Legislation Committee. Mrs Leese had requested that it was put on the agenda for May 2019.

Comments from the Board were as follows:

Mr Shannahan commented on ‘The RDaSH Way’ and the potential for having some type of mark to show that a document e.g. a policy had been was completed in ‘The RDaSH Way’. He suggested a kite mark, with someone in the Trust qualified to “stamp” the document to ensure it completed all the necessary standards. The Board felt that the standards should include sustainability. Mrs Singh noted that the discussions had not got to this part of the process yet, but a kite mark would be a very helpful tool for the Trust. She noted that the PMO team were currently completing the QI training, and that the next step could be a QI “kitemark” approach. More work would be required on this.

Mr Shaw commented on NHS England’s ‘Proposal for possible changes to legislation’, currently in consultation, and the effect and impact it may have on foundation Trusts. Mrs Singh noted that NHS providers were coordinating the work, and had sought views

RJ

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from individual organisations. At the recent Chair and Chief Executives meeting, they had discussed it at length. Mrs Singh agreed to circulate available information from NHS Providers to board members.

Mr Shaw stated that with the merger of the central regulators (NHSI and NHSE) and the potential reconfiguration of the existing NHS system. The Trust Board would need to have assessed the implications of the developments for the Trust. It was agreed to have an agenda item at a private board meeting.

Mr Banks reported on NHS X - the Secretary of State decision about a central digital function within the Department of Health, and how this would link with NHS Digital, both nationally and regionally. He noted he would provide a report to the April Board meeting.

Mrs Singh reported that the three main commissioners had signed their service contracts with the Trust for 2019/20. She also commented that a contractual value with the specialised services commissioner (NHS England) was progressing, however, contract documentation was currently delayed, and had yet to be signed. This was a national issue. She expected that the contract would be agreed and signed the following week. It was noted that, after a few delays, the commissioners had also signed the contracts with Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust. Mrs Singh expressed her thanks to the teams involved behind the scenes to achieve this. In response to Mrs Leese’s question regarding the outcomes, Mr Hackett confirmed he was content that there had been a reasonable settlement reached with commissioners collectively. Further work was progressing with North Lincolnshire colleagues on the details of the contract.

The Board noted the Chief Executive’s report.

KS

LP/KS/ PG

STRATEGY

Bpu 19/03/10

INTEGRATED CARE SYSTEM (ICS) UPDATE Mrs Singh presented her update report to the Board (Paper F). The following items were highlighted.

Interim governance arrangements from 1 April 2019 – key meetings and key groups had been identified.;

System Health Oversight Board and System Health Executive

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Group (Chief Executives).

Work is continuing with Local Authorities regarding system health and care partnership arrangements. Rotherham MBC were leading on the ICS involvement.

Place discussions were continuing. Mr Shaw commented that new legislation would probably be needed regarding the governance approach. Mr Banks highlighted to the Board on Point 5 (page 42) of the report regarding NHS into the digital age. There had been a large amount of emphasis on the NHS App introduction and it was now compulsory for GP practices to register for the App by July 2019 – a large number of practices were already implementing the App. He noted that there may be implications for secondary care regarding patients viewing records going forward. The Board received and noted the ICS update.

COMMITTEE REPORTS

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Report from Finance, Performance and Informatics Committee Mr Hackett presented the paper to the Board (Paper G). The following was highlighted:

The report showed the Trust was in a good financial state, with key indicators showing the NHSI Single Oversight Framework rating remaining at one.

Expenditure was above plan due to additional staffing costs to meet activity demands and non-recurrent spend on non-pay.

Cash remained consistent to previous months and Mr Hackett reported this would be reviewed as part of the cash utilisation discussion to be held at Board. At year end, the Trust was forecasting a cash balance of £34.5million.

Capital expenditure was finishing lower than planned. Capital schemes were progressing. The revised forecast for NHS Improvement would be between £3million and £3.2million.

QIPP was showing as an Amber rating, with approximately 77% being achieved (as of the date of the meeting). Mr Hackett commented that the Trust was in a similar position that had previously been reported regarding under delivery on non recurrent monies in this financial year. It was noted that they would be added

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to the QIPP requirements for next year, and would be part of the operating plan for 2019/2020.

Mr Hackett noted that, although the Trust was receiving an incentive payment, it would be restricted under the NHS finance rules on what the monies could be used for. Of the £8.3million forecast surplus £2.7million has been generated by the Trust with the balance of £5.4million coming from Performance Incentive Scheme allocations.

The Committee had noted four internal audit reports on core financial systems in 2018/19 – three had significant assurance and one had full assurance regarding operating systems and how well the systems were working.

Single oversight framework – all achievements were being met against national indicators.

Performance hot spots were highlighted: - ADHD/ASD waiting list (due to staffing difficulties and recruitment) – a deep dive report would be presented to the Quality Committee. A revised date for delivery would be agreed with each service; - Doncaster CAMHS – 8 week referral to treatment target – this had been delivered and was now being monitored; - IAPT access rates.

Health informatics report on information quality work programme had been received at the meeting.

Data Security and Protection toolkit report gave significant assurance to the Committee. However, not all standards had been fully met. A plan had been agreed to achieve full assurance. Mr Banks noted that the training achievement may not reach its 95% target, but all other indicators were in place.

FPIC terms of reference were being reviewed and this would be brought to the Board for ratification.

Standing Orders/Standing Financial instructions had been reviewed and approved.

Mr Hackett reported that the Finance team were working diligently to deliver the draft set of accounts by 24 April 2019. Mr Banks and Mr Shaw noted the information quality update regarding kite marking of SOP indicators, and how it could be extended out to other areas of the Trust. Plans were in place for the next six months

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regarding a combined team approach for IT trainers and some senior clinical operational leads on data quality issues. Mr Banks expected that data quality would improve in the next year. The Board thanked the Finance team, operational teams, Mr Banks and his team and the FPIC committee for all their work. The Board received and noted the FPIC report.

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REPORT FROM THE QUALITY COMMITTEE Mrs Leese presented the paper to the Board (Paper H), and highlighted the following.

Workforce report – discussions had taken place regarding aligning MAST to CQC standards. Compliance was currently at 90.40%,with Slips, Trips and Falls, Safeguarding Level 3 and Management of Violence and Aggression being identified as being less than 75%. The team had a recovery plan for these MAST areas. The Board noted that the CQC paper hadn’t given the assurance required. Ms Smith and Mr MacCallum were working with Care Group Directors and Associate Nurse Directors with regards to the action plan and identifying evidence (which was almost complete). A further report would be taken to the EMT meeting and Quality Committee in April. Ms Smith commented that there would be a Quality week conducted in May, with a mock CQC inspection. Mr MacCallum reported that discussions were taking place with staff to contextualise the CQC action plan and make them aware of personal responsibility and accountability. Mr Shannahan noted the legal proceedings that FPIC were sighted on regarding Slips, Trips and Falls, and he noted the opportunity to establish whether the people concerned had compliance with the relevant MAST course.

Cross Government suicide prevention workplan – more details would be received at the April meeting. Work was progressing to identify the present position and any gaps in organisational plans and future plans.

Mrs Leese reported that there were a number of areas that the

Quality Committee required further assurance:

- ADHD services – a risk assessment would be presented at the April meeting;

- Physical health and wellbeing quarterly report had been delayed, but would be presented at the April meeting;

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- CQC Must Do and Should Do action plans – further work had been requested in terms of the position with the plans, and would be discussed at the next Quality Committee.

Detailed discussions had taken place regarding extreme operational risks, including the mortality risk.

Staffing on inpatient wards – the Quality Committee had reviewed the risk with the associated mitigating actions. Further work was being conducted in the assessment of staffing levels and the ongoing quality and safety issues. Ms Smith reported that the Trust had experienced many staffing issues during March, particularly in the Rotherham and Doncaster services. She stated that there were extraordinary OMM meetings being held to review staffing issues, along with monthly staffing meetings. It had been agreed that additional staffing would be authorised with an additional qualified member of staff on inpatient areas being employed to be a “floating” colleague to use during this difficult period. A full assessment of the impact would be completed during the first quarter of the financial year, and the annual review of safe staffing would be completed at the same time. Mr MacCallum discussed with the Board the tools that the Trust would be using regarding staffing levels and workloads. The QUEST trigger tool would be used to risk to quality and patient safety. The Quality Committee would be receiving an outline plan in the next two months. Mrs Leese noted it had been agreed that gaps would be identified where areas were not achieving the standard 90% and plans were being made to help achieve the standard.

Mr Hackett noted his concerns with regards to the performance of a supplier of agency staff and that he had met with the company and expressed these concerns. He had agreed that regular block bookings would continue, but adhoc bookings would cease. Further discussions with other suppliers were ongoing.

Mr Shannahan asked about the formalisation of the short term, medium term and long term workforce plans. Ms Johnson clarified that the Trust had to follow some nationally prescribed processes linked to the current workforce and the education and training system. As an organisation, coordination was required for the future vision of skills and knowledge and for contracting processes, including the national long term plans and other national initiatives that were required. The HR team work closely with operational services and finance colleagues on the workforce model, and adapt the model when negotiating with commissioners. Workforce plans for operational and corporate services were signed off on an annual basis. A Workforce Planner had been employed to work alongside

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managers to support them in articulating and improving the workforce plans and also to link with external organisations, for example the universities.

Mr Pater thanked Mrs Leese and the Committee for the report. Mr Pater proposed that the topic be discussed in more detail at a future Board Development session. The Board noted that workforce and staffing would continue to be on the Quality Committee agenda. The Board received and noted the Quality Committee report.

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MORTALITY Dr Ahluwalia presented the paper on “Learning from Deaths” policy (Paper I), and the Board noted the following:

In 2017, the national framework for learning from deaths had been launched.

The Trust policy was ratified in September 2018 in line with the national framework, which had a one year shelf life and had been extended by a further six months in order to ensure that revisions took account of an Internal Audit Report.

The revised policy had been brought to the Board describing a new

system for Learning from Deaths which has also been developed

following staff consultation

The pre-populated updated 360 Assurance report action plan would be presented to EMT for comments after the Board confirmed its decision regarding ratifying the policy.

The Board commented on the following:

The paper received did not yet read as a policy according to one member although it read well. It was felt that it may be useful to have the flow chart to support staff with following the process adhere to international flowchart standards.

The Board indicated that it would be helpful to have new policies with implementation dates, dates when the policy was issued or ratified, and to for policies to have a consistent look. It was felt this would be simple to implement. Mr Gowland and Mrs Singh agreed to discuss and return to a future Board meeting with a proposed way forward.

Mr Shaw asked about the relevance of section 8.2 Mental Capacity Act in the policy. Dr Ahluwalia confirmed that the section was appropriate as all individuals, even in death, have the right to confidentiality depending upon their capacity to make certain

PG/KS

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decisions in life. He noted patient capacity issues would have a bearing on the decision making process of professionals that might occur afterwards. The Board suggested that the wording of this section be reviewed.

The Board commented on Appendix A and the Purple Box “Structured Judgement Review (SJR) and the reference to “should include a doctor or senior nurse” - Dr Ahluwalia stated that this was ‘should’ not ‘must’ as not all teams have a senior nurse or doctor. The seniority level needed to be appropriate and would be determined by the judgement of the reviewer. The document had been received by EMT, and the risks would be reviewed at the EMT meeting the following week. The Board agreed to ratify the policy subject to agreed changes.

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REPORT FROM THE AUDIT COMMITTEE Mr Shannahan presented the report from the Audit Committee (Paper J) and the following was highlighted to the Board.

The Audit Committee discussed the process by which assurance was provided to the Audit Committee as well as the actual level of assurance provided by individual activities and intended distinguishing between the two from now on.

The Audit Committee received significant assurance that proactive and reactive counter fraud activities took place in the quarter under review.

Significant assurance was received by the Audit Committee that an effectively planned and executed internal audit programme existed which supports the Board Assurance requirements, the Trust Board and EMT.

Deloitte reported to the Audit Committee that the work plan to meet the year-end timetable was on course and there had been no significant issues to date.

The Audit Committee received significant assurance that there is a robust risk management framework in place and that risk registers were reviewed regularly.

Significant assurance was received by the Audit Committee that the core financial systems reviewed by Internal Audit were working effectively with one system gaining full assurance.

Mr Shannahan raised two areas of concern:

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There were eleven internal audit actions that were overdue for implementation and therefore limited assurance had been received that audit actions are implemented in a timely manner. Further work is required to implement the actions by the committed date and Mr Shannahan requested that Trust to ensure implementation timetables were realistic and matched against the levels of risk.

The Head of Internal Audit's overall opinion for year has not yet been finalised but the Audit Committee felt that there could be ‘moderate’ assurance for this, reflecting the number of core audits where only limited assurance was provided.

The Board asked the following:

Mr Pater referred to whether there was capacity to adhere to the deadlines for quality related audits. In response to Mr Pater’s question about the actions from the quality related audits, Mrs Singh confirmed that there was sufficient capacity within the team to deliver against them within the timescales agreed.

The Board discussed the likely outcome in terms of the Head of Internal Audit Opinion, noting that the ‘moderate’ opinion – which was not as yet confirmed – would be the first time that such an opinion had been received by RDaSH. Mr Hackett indicated that he did not expect any resulting concerns to be raised from External Audit as a result but he confirmed that the Executive team were sighted on this and that throughout 2019/20 they would be striving to ensure that an improved opinion was received. The HoIA Opinion would be referenced in the Annual Report.

The Board noted that they were assured that an effective Internal Audit function was in place and that the implementation of the new RDaSHWay represents an opportunity to promote compliance with effective processes and systems.

GOVERNANCE

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EXTREME OPERATIONAL RISKS Mr Gowland presented the extreme risk report (Paper K) to the Board, and the following was discussed:

There were three extreme risks identified in the report. The report provided more information and mitigating actions.

Two of the risks had already been discussed in the Quality Committee report and the Learning from Deaths paper.

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Medical staffing at Doncaster was highlighted. A meeting had taken place the previous week to discuss immediate actions to take. Some actions were in place and additional actions were being identified. Ms Smith reported that a recruitment and retention premium had been proposed for Consultants in Doncaster and potentially junior doctors. The team were reviewing the number of PAs across Doncaster, and work was progressing with the doctors on other options. The Board noted that there were a number of issues that had been concerning over a number of years, including the on-call rota, and how difficult it was to manage. Dr Ahluwalia highlighted the impact of the on-call work on their emotional and motivational resilience and that the on-call requirements also impact on the Trust’s ability to recruit. Dr Ahluwalia explained that the Trust’s requirements in this regard were different o those at other similar Trusts.

The Board made the following comments:

Mrs Singh noted that dialogue was ongoing with commissioners about inpatient workload acuity, attendance and occupancy, the increase demand, the impact of 136 and the high volume of necessary police engagement. She hoped that additional funding would be received from commissioners to invest in the critical services.

Mrs Leese requested that the Quality Committee was sighted on the specific gaps and the impact, and the understanding of the mitigations.

The Board acknowledged that, although recruitment and retention was part of the issue, there were other factors that were involved, including morale, the environment and health and wellbeing of staff. Tools such as the Barometer of Culture of Care would provide the Trust with further information and reflection on the issue and what needed to be put in place.

The Board agreed that the paper would be taken forward through EMT and reported through the Quality Committee.

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RISK MANAGEMENT FRAMEWORK Mr Gowland the risk management framework report (Paper L) to the Board, and the following was discussed:

The report was the annual refresh of the risk management framework for 2018-2021 and responded to recommendations made in a recent internal audit report – relating to the expected work of Committees and the availability of training.

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There was one minor change under the Executive Summary – the document stated “EMT reviewed the Risk Management Framework on the 18 March 2018”, this should read “18 March 2019”.

The Board comments were as follows:

Appendix D – expectations of Committees – Mr Gowland to review further and include greater detail on the effective monitoring of mitigation.

Appendix C – the six ambitions to include an overarching quality methodology (enabler).

Framework to include the strategic risks, linked to the ambitions.

Quality system – the quality methodology to be a circle around the quality triangle.

The Board asked that the terms of references for the committees are included.

The Board requested that the document was revisited and brought to the April meeting for further review.

PG

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ANY OTHER BUSINESS No further business was discussed.

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PUBLIC QUESTIONS (Mrs Singh left the meeting.) The public were asked for questions.

A question was raised regarding Paper F (ICS update) Item 2.13 - the expected reduction of administration costs by 20% in CCGs. Mr Hackett confirmed the £320million was a national figure from other organisations and that the Trust would not receive a share of these monies.

Paper L - Roles and Responsibilities (section 3). There was no note of Governors responsibilities. Mr Gowland commented that in terms of direct management of risk in organisation, there would not be a specific responsibility for Governors for managing risk. Their role was to hold Non Executives to account, and hold them to account for the performance of the Board.

DATE, TIME AND VENUE OF NEXT MEETING Thursday 25 April 2019, 9 am, Voluntary Action, The Spectrum, Coke Hill, Rotherham, S60 2HX.

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PAPER C - MATTERS ARISING

BOARD OF DIRECTORS – HELD IN PUBLIC ALMOND TREE COURT, WOODFIELD PARK, TICKHILL ROAD, BALBY, DONCASTER

THURSDAY 25 April 2019

Follow up actions from the Board of Directors meeting held in public on 31 January 2019

REF AGREED ACTION OWNER PROGRESS OPEN

/ CLOSED

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BOARD ASSURANCE FRAMEWORK Refresh of the BAF to reflect the Trust’s 5 Year Strategy to be discussed at a Board Development session

PG 28 February update - The first draft of the 2019/20 BAF will be discussed at the Board Development Session and include the links to the Ambitions (from within the new Five Year Strategy) 28 March update – the Board discussed the overarching principles behind the development of the 2019/20 Board Assurance Framework at its Board Development session in February; also discussing the way in which it would be an integral part of a broader planning and monitoring process that will ensure the alignment of all key pieces of work and projects towards the delivery of the Trust’s Strategic Ambitions, the supporting Operational Plan, Quality priorities and organisational delivery objectives as well as national priorities linked for example to NHS Long Term Plan. The 2019/20 draft Board Assurance Framework will be further developed then presented to the Board of Directors in April 2019.

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25 April update – The Board of Directors will discuss in private session the Board Assurance Framework prior to it being presented for final approval in the public session in May 2019.

Follow up actions from the Board of Directors meeting held in public on 28 February 2019

REF AGREED ACTION OWNER PROGRESS OPEN

/ CLOSED

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REPORT FROM THE FINANCE, PERFORMANCE AND INFORMATICS COMMITTEE The ADHD/ASD target to be discussed further through the Quality Committee and for mitigation of the risk to be considered.

DS

28 March update: A paper is being prepared on this topic and will be presented to the Quality Committee in April 2019. 25 April update: Paper completed and presented to Quality Committee on 16 April 2019

Closed

Follow up actions from the Board of Directors meeting held in public on 28 March 2019

REF AGREED ACTION OWNER PROGRESS OPEN

/ CLOSED Bpu 19/03/07

MATTERS ARISING Dr Ahluwalia noted that the current guardian had tended his resignation from the role and the Trust. Dr Ahluwalia was in the process of securing a new guardian. He commented that he was unable to provide assurance to the Board that

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25 April update: The Medical Director will present the latest position regarding the Guardian role and the assurances linked to compensatory rest periods in the meeting.

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junior doctors were having their compensatory rest periods, but he would provide more details at the April Board meeting.

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CHIEF EXECUTIVE’S REPORT Mrs Singh noted the Monitoring Mental Health Act 2017/18, and that the mental health led committee would be reviewing it. Themes and issues regarding mental health visits and issues for RDaSH would be returned to the Executive. Action from 28 March Board meeting Mr Banks reported on NHS X - the Secretary of State decision about a central digital function within the Department of Health, and how this would link with NHS Digital, both nationally and regionally. He noted he would provide a report to the April Board meeting.

AM

RB

25 April update: Scheduled for discussion at the MHLC meeting in May 2019. 25 April update: This has been included in the Chief Executive’s report for today’s meeting

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Closed

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DONCASTER CARE GROUP – COMMUNITY MENTAL HEALTH SERVICES Improvements to the service - Ms Smith to ask the Business Support Manager to assist with the business case.

DS 25 April update: Doncaster Care Group Business manager requested to support business case.

Closed

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CHIEF EXECUTIVE’S REPORT Staff survey results to be presented to the April board meeting.

RJ 25 April update: This is an agenda item at today’s meeting

Closed

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19/03/09 Mrs Singh to circulate available information from NHS Providers regarding NHS England’s proposals for possible changes to legislation

the Board of Directors by email on 17 April 2019 – consideration to be given to further discussion of the matter.

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CHIEF EXECUTIVES’ REPORT Implications of the merger of the central regulators NHSI and NHSE to be discussed at a private board meeting.

LP/KS/ PG

25 April update: Related information was circulated to the Board of Directors by email on 17 April 2019 – consideration to be given to further discussion of the matter.

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MORTALITY The Board indicated that it would be helpful to have new policies with implementation dates, dates when the policy was issued or ratified, and to for policies to have a consistent look. It was felt this would be simple to implement. Mr Gowland and Mrs Singh agreed to discuss and return to a future Board meeting with a proposed way forward.

PG/KS 25 April update – further consideration to be given to the issues raised regarding policies (and many related aspects such as their format, content, accessibility); this will inform the Trust’s approach towards the ‘policy on policies’ which will be presented to the Board of Directors for approval.

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RISK MANAGEMENT FRAMEWORK RMF to be re-presented for approval with amendments actioned as outlined.

PG

25 April update - The suggested revisions to the RMF and the desire to incorporate the terms of reference for the Board’s Committees are inter-related – and require the completion of the work underway at present to update the terms of reference with due regard for the Board Assurance Framework. To ensure all documents are consistent the RMF will be re-presented in May to the Board of Directors along with the other relevant documentation.

Open

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ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST

Committee Name Board of Directors

Agenda Item Paper D Date 25 April 2019

Title of Paper Chairman’s Report

Decision

Assurance

Information The Board of Directors to receive and note the Chairman’s report

Prepared by Lawson Pater, Chairman Philip Gowland, Board Secretary/Director of Corporate Assurance Diane Jeavons, Personal Assistant

Presented by Lawson Pater, Chairman

Delivery against Strategic Goal(s) 1. To provide safe, effective, compassionate care

Engagement with the Council of Governors provides opportunities to seek feedback particularly from the service user and carer governors.

2. To attract, retain, support and develop the finest workforce

As per 1. above but with specific reference to staff governors. 3. To maintain financial stability

4. To work with partners to offer and deliver market-leading services

Engagement with external organisations to promote partnership working, to learn from service users and their representatives, to act as an ambassador for the Trust to assist in building strong relationships.

5. To be an outstanding, well-led organisation

Engagement with and accountability to the Council of Governors. NED chairmanship and involvement in the governance structures supporting the Board of Directors and engagement with the Council of Governors.

Strategic Risk(s)

Number Level of Assurance Number Level of Assurance

CQC Domain

Safe Effective Caring Responsive Well-Led

2

Impact

There are occasional costs associated with attendance at some of the events recorded in the report (for example conference fees).

Previously Presented to

N/A

Appendices to Paper

N/A

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CHAIRMAN’S REPORT

The Chairman’s report provides details of the internal and external meetings, events and engagements that he has undertaken in the last month. In addition, the report also captures the work in the month of the Non-Executive Directors and provides an update on issues relating to and attendance by, the Council of Governors at the Trust. Chair Activity report This includes background notes indicating the rationale for the various activities undertaken by the Chair since the last meeting, which include the following attendances and engagements, in addition to regular meetings with the Chief Executive and other Trust staff: Internal

Trust Corporate Induction

GEM awards ceremony

Non-Executive Director (NED) meeting

Meeting with Mr Ed Ryder, Governor

Service visit to the Perinatal Service Team, Doncaster External

Rotherham Together Partnership meeting I attend board committees and other meetings to observe their operation and contribution to the effectiveness of Trust Governance systems. I take the opportunity to visit services and internal events to engage with and learn from patients, staff and other stakeholders. External events provide the opportunity to both formally represent the Trust and to also engage and learn from other organisations and stakeholders. Non-Executive Director Update Non-Executives chair (C) / are members (X) of the six Board Committees as per the table below. The Committees that have met in the month are shaded and their respective reports are included on the agenda today. Apologies are noted with ‘a’ and details of attendance are recorded and included for the full year in the Trust’s Annual Report.

COMMITTEE LP NS TS AP JS DL

Remuneration X X X X X C

Quality C X

Finance, Performance and Informatics X C X

Audit X X X C

Mental Health Legislation C

Charitable Funds C X

Lawson Pater (LP)

Tim Shaw (TS)

Alison Pearson (AP)

Nigel Smith (NS) Justin Shannahan (JS) Dawn Leese (DL)

In addition to their roles in, and preparation for Board Committees, over the last month the Non-Executive Directors were engaged in a wide range of activities in support of the Trust, its staff and the executive team as listed below:

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Mrs Leese Telephone call with Gatenby Sanderson (external recruitment agency) regarding Chair and NED recruitment Telephone call with Lawson Pater and meetings with Phil Gowland, Director of Corporate Assurance and Andrew MacCallum, Interim Executive Director of Nursing and AHPs regarding an investigation (complaint review) Mental Health Legislation training One to One with Debbie Smith, Chief Operating Officer Non-Executive Director meeting Mr Shannahan Effective Audit Committees (Training and Development) with 360 Assurance Meeting with Gatenby Sanderson (external recruitment agency) regarding Chair and NED recruitment Non-Executive Director meeting Mrs Pearson Telephone call with Gatenby Sanderson (external recruitment agency) regarding Chair and NED recruitment Telephone call with Andrew MacCallum, Interim Executive Director of Nursing and AHPs, re: Quality Committee Freedom To Speak Up (FTSU) meeting One to One meeting with Debbie Smith, Chief Operating Officer Non-Executive Director meeting Mr Shaw Meeting with Steve Hackett, Executive Director of Finance and Performance Meeting with Richard Banks, Director of Health Informatics Non-Executive Director meeting Mr Smith Effective Audit Committees (Training and Development) with 360 Assurance Non-Executive Director meeting Council of Governors The Council of Governors has been ‘out and about’ during the last month supporting the Trust’s Membership Week. Along with the Trust’s Patient and Public Engagement and Experience (PPEE) Team, Governors took the Health Bus out to Rotherham Parkgate, Scunthorpe Shopping Centre (Tesco) and to Doncaster Lakeside. Governors and the team engaged with members of the public discussing their role, the Trust and its services and the many ways that people can get involved – Over 50 new members were recruited and a number of other people took away information about the Trust (including the new 5 year strategy) and how they could be a governor or volunteer at the Trust. Thanks to Richard Rimmington, John Carter, Helen Ward, Kathleen Green, Sally French, Stuart Wilson and Brendan Fox who gave up their time to support the Trust. We will be evaluating the success of the initiative through the ‘Raising the Profile’ Governor Working Group. Additional activities:

NHS Providers Regional Governor event (Leeds)

Members Drop In (Rotherham) Lawson Pater Chairman 18 April 2019

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Addendum to the Report of the Chair to the Board of Directors by the Trust’s Board Secretary Appointment of a Chair and Non-Executive Director to the Board of Directors. As reported at previous Board of Directors meetings, the appointment of the Chair and Non-Executive Directors to the Board of Directors rests with the Council of Governors. Support to the Nominations Committee – which is undertaking the initial work on behalf of the Council of Governors, before making a formal recommendation to them – continues to be provided by the Board Secretary and Alison Pearson, NED / Vice Chair and Senior Independent Director. The work with Governors and with Gatenby Sanderson, external recruitment organisation, has continued in the last month with keen interest in respect of both the Chair and Non-Executive roles. The search and engagement work being undertaken by Gatenby Sanderson will continue up to the planned ‘closing date’ of 29 April 2019. There will then be a review process undertaken before a shortlist of applications is agreed. The interview and assessment of the Chair applicants will take place on 31 May. Subject to the proceedings of the day a recommendation from the Nominations Committee will be presented to the Council of Governors in early June and a formal announcement will then follow. Whilst the two recruitment processes are at present being run concurrently, the final stage of the NED appointment will be concluded once the outcome of the Chair process is known. Philip Gowland Board Secretary 18 April 2019

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ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST

Committee Name Board of Directors

Agenda Item Paper E Date 25 April 2019

Title of Paper Chief Executive’s Report

Decision

Assurance

Information The Board of Directors to receive and note the Chief Executive’s Report

Prepared by Philip Gowland, Director of Corporate Assurance

Diane, Jeavons, Personal Assistant Rosie Johnson, Director of Workforce and OD/Deputy Chief Executive

Presented by Kathryn Singh, Chief Executive

Delivery against Strategic Goal(s)

1. To provide safe, effective, compassionate care

2. To attract, retain, support and develop the finest workforce

3. To maintain financial stability

4. To work with partners to offer and deliver market-leading services

Attendance at meetings during the month with local, regional and national partners as detailed in the report.

5. To be an outstanding, well-led organisation

The Trust has a statutory responsibility to respond to Freedom of Information requests which are presented in the report. National publications – ensuring that the Trust is receiving and responding to national guidance (instruction)

Strategic Risk(s)

Number Level of Assurance Number Level of Assurance

CQC Domain Safe Effective Caring Responsive Well-Led

Impact Any impact on each individual item is included in the paper.

1

Previously Presented to

N/A

Appendices to Paper

N/A

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CHIEF EXECUTIVE’S REPORT

The Chief Executive’s Report provides the Board with information about policy, legislative and developmental issues and changes that affect the Trust and local initiatives across the Trust in the last month. Further information can be gained from the relevant lead director. This month’s report contains the following:

• RDaSH News • National / Regional Update • RDaSH Summary Information • Media coverage • Freedom of Information (FOI) Requests

RDaSH Leading the way with care ‘Our Five Year Strategy 2019-2024 On Monday 1 April 2019 we launched our Leading the Way with Care – Five Year Strategy. The new strategy focusses on 6 Ambitions allowing us to take the next steps for our patients, staff, members and our communities. We are delighted to be supporting the development of The RDaSHWay (see next item) which will help us to deliver the Trust’s ambitions by working together to improve the quality of our services and the culture we work within. The Trust’s Strategy Team have been across the Trust distributing and sharing the strategy and raising awareness of the ambitions. To read the document in full please click here: https://www.rdash.nhs.uk/54697/rdash-five-year-strategy-launch/ Hard copies of the Strategy are available via the Trust’s Communications Team.

The new Ambitions are: Ambition one – Be a leading provider of co-ordinated mental and physical healthcare services for people of all ages. Ambition two – Develop and deliver services which have a focus on prevention and early intervention, building resilience and promoting recovery. Ambition three– Take the lead with our partners to drive the development of accessible patient centred care services closer to people’s homes. Ambition four – Develop a healthcare workforce who are equipped to provide the highest level of clinical care. Ambition five – Embrace technology to innovate and continually improve clinical services. Ambition six – Maximise benefits to patients through ensuring a strong and sustained financial position to underpin the delivery of high quality clinical services. The Strategy Team are working with the Care Groups and Corporate Services to develop more detailed plans that will help ensure we deliver against the ambitions and to make it clear how every member of staff at the Trust can play their part, how their hard work and dedication will make a contribution and to understand the opportunities for individuals and the Trust that will arise.

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The RDaSHWay Linked to the previous item – the Trust’s Five Year Strategy – I am also delighted to report that we have also launched The RDaSHWay . This is our approach to improving quality and culture which will support us to deliver our strategic ambitions. The RDaSHWay is underpinned by some key principles which include a recognition that change is complex, that support and governance must be proportional to risk, cost and complexity and that one size generally fits no one. To make changes that improve the quality of services we must also focus on culture and the way we do things around here. Our quality improvement, project management and organisation development teams are working together to support people at the right time, and in the right way. We are supporting cultural developments around safety, equality, diversity and inclusion, spiritual care and freedom to speak up. We are pleased to launch the iMPROVEMENT HUB and the Public, Patient, Experience and Engagement (PPEE) engagement Hub which will support increased staff and service user engagement and enable people to work together to make positive changes.

I am delighted to launch ICAN; our Improvement and Culture Ambassadors Network made up of staff and patient representatives who will both champion and take improvements forward.

We are committed to building our capability for change, and I am pleased to be working with NHS Improvement to become an accredited QSIR college provider (Quality, Service Improvement and Review) and embed this model across the organisation.

We are also delighted to be working with the Leadership and Culture programme with NHS Improvement. This will help us to assess our culture and respond accordingly.

I am looking forward to our annual conference in May - Leading the Way with Care -The RDaSHWay, where we will celebrate the achievements of staff and hear more about the significance of culture in building quality services for all. Culture of Care Barometer In previous years you have completed the LiA pulse check which helps gain feedback about staff experience. We have explored feedback concerning this tool and analysed other tools that are available to use when developing The RDASHWay to help us gain more information to better improve our workplace and care for patients. For these reasons April will see the launch of the ‘Culture of Care Barometer’ in replacement of the Pulse Check. This is still a one page questionnaire which is quick to complete however it will provide more localised and targeted cultural insights enabling our improvement journey. What is the Culture of care barometer The barometer is a validated tool to measure culture and workplace experience rated by staff. It has been developed at Kings College London and is supported for use by NHS England. It is developed to be applicable for use by front line care staff and also support staff, with questions which all staff groups should find applicable to them no matter what their role. It compliments existing regulation and inspection frameworks and provides meaningful feedback, with minimal bureaucracy. Why does this matter – when completing the LIA pulse check some staff stated that some of the questions seemed not to be appropriate for them in their job role, this effected how people completed the questionnaire and number of responses. We hope that changing to the barometer all people of RDASH will feel able to complete this and provide feedback on Trust culture. Who will take part: All staff in the organisation will be invited to take part. Forms will be made available on the intranet, in work areas and also via our managers and clinical leads. Why does this matter – great workplace

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culture is affected by all staff who work in it. It is therefore really important that all voices are heard, therefore please complete your feedback and encourage other colleagues to do the same.

What will happen to the results: As the ‘Culture of Care Barometer’ is more comprehensive than the previous LIA pulse check results will better inform our cultural and quality improvement as we progress with ‘The RDASHWay’. The Barometer provides results that can be explored in the following domains: Engagement; Empowerment; Management and Leadership; Trust Values and access to resource in the Trust. Results can also be used to explore experience for different roles in the trust/teams in the trust.

After people have completed their questionnaire results will be analysed and provided to all teams in the trust. This will help teams focus upon what is working well but also upon areas in which improvements are needed in order to provide the best care for patients and support for one another in the workplace. Additional to this, feedback provided specifically from inpatient and community clinical teams will be used by the Clinical Leads, led by the Associate Nurse Directors, to inform the review of safe staffing in the organisation. The results gained will be discussed within clinical forums and also with clinical teams in order to strengthen clinical care and care pathways. Why does this matter – what we have learned from both internal reviews and also understanding care successes and failures in other NHS Trusts is that culture matters. What we know is that areas of really positive culture can exist alongside of teams that have less positive culture – and this lack of consistency can hinder the spread of good practice across our organisation. The use of the ‘culture of care barometer’ aims to improve our organisational insights and allow us to internally understand and use this measurement tool to target support and improvements supporting the development of compassionate leadership and culture. Chief Executive highlights

• Service visit to the Doncaster School Nursing Team • GEM awards

National / Regional / Local Announcements Sheffield Rotherham and Doncaster Perinatal Mental Health Service The Sheffield Rotherham and Doncaster Perinatal Mental Health Service is a new service providing specialist assessment and treatment to mums and their families living in Sheffield, Rotherham and Doncaster. The service being run in partnership between ourselves , Sheffield Health and Social Care NHS Foundation Trust, and Light, a local perinatal peer support charity offer confidential non-judgemental care and treatment to mums who experience more serious of complex mental health issues. Next month I will be attending the official opening in Rotherham. NHSX: New joint organisation for digital, data and technology X standing for “User Experience” also known as UX in tech industry as a process of creating products that provide meaningful and relevant experiences to users. NHSX is aiming to create advanced health and care services utilising latest technology and methods to:

• Increase opportunities for earlier diagnosis, intervention and treatment o Business Intelligence, advanced analytics, AI, population health

• Release staff time, increase automation and improve decision support o AI, wearables, dashboards, demand, capacity & flow management

• Empower patients to take control and interact with their own healthcare. o Patient portals, Internet screening, Wearables / IoT, guided care

• Align technology delivery to post internet & latest digital standards o Open standards, NHSapp, interchangeable, plug and play, shared value

• Promote culture, openness, productivity and speed of iteration to delivery o Agile, value focused, minimal viable product (MVP), feedback, coproduction

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Part of the NHS “Future of Healthcare Vision” and “Long Term Plan for NHS”, NHSX brings together modern benefits of technology to every patient and clinician, combining skills, talent and knowledge from government, NHS and tech industry. NHSX will bridge the gap between healthcare and technology, guiding leadership and thinking towards a shared view and approach on digital transformation and effective enablement using open standards and shared value based solutions. The CEO of NHSX will have strategic responsibility, setting the national direction on technology across organisations, accountable to the Health Secretary and chief executives of NHS England and NHS Improvement. NHSX’s responsibilities will include:-

• National policy and developing best practice and standards • Agreeing and mandating clear and safe use of technology • Ensuring that NHS systems can talk to each other across the health and care system • Improving clinical care by delivering agile, user-focused products • Use of new & advanced technologies by the NHS • Common technologies and shared services, e.g NHS App • Ensure source code is open by default supporting wider collaboration • New procurement frameworks that support new standards • National strategy and mandating cyber security standards • Championing and developing digital training, supporting digital ready staff • Efficient process for technology purchasing, management and security.

“This is just the beginning of the tech revolution, building on our Long Term Plan to create a predictive, preventative and unrivalled NHS.” Health Secretary Matt Hancock https://www.gov.uk/government/news/nhsx-new-joint-organisation-for-digital-data-and-technology https://www.gov.uk/government/publications/the-future-of-healthcare-our-vision-for-digital-data-and-technology-in-health-and-care https://digital.nhs.uk/about-nhs-digital/our-work/nhs-digital-data-and-technology-standards https://www.england.nhs.uk/long-term-plan/ Rotherham Council Rotherham Council’s period of government intervention formally came to an end at the end of March 2019. The Secretary of State, in their report published on 27 March 2019, stated that the former Commissioners endorsed the ending of the intervention, saying “the pace of improvement across the Council has increased beyond [their] expectations, which bodes well for future prospects”, adding that “the political and managerial leadership of the Council have re-established the Council’s moral compass. There is clarity on the Council’s values and ethos and a whole council commitment to safeguarding young people. This gives confidence that the council will be vigilant in protecting the vulnerable, will avoid back-sliding or failure to address adverse issues as they arise.” https://www.gov.uk/government/publications/rotherham-intervention-conclusion National Publications and Guidance Listed below are the key publications and guidance issued in the last month which are received within the Executive Management Team and incorporated / referred to in the ongoing relevant pieces of work at the Trust. A Lead Director has been identified against each item to take forward the work on understanding implications for our organisation. 1. Learning From Deaths – A review of the first year of NHS trusts implementing the national

guidance

This report follows the first year of the implementation of national guidance to support improved investigations and better family engagement when patients die. The report identifies that good progress is being made by some NHS hospital trusts but failure to fully embrace an open, learning culture may be holding organisations back. It also indicates that progress made varies between trusts suggesting that

6

some organisations have found it harder than others to make the changes needed. https://www.cqc.org.uk/sites/default/files/20190315-LfD-Driving-Improvement-report-FINAL.pdf Lead: Dr N Ahluwalia, Executive Medical Director 2. Closing the gap: Key areas for action on the health and care workforce Staffing is the make-or-break issue for the NHS in England. Workforce shortages are already having a direct impact on patient care and staff experience. Urgent action is now required to avoid a vicious cycle of growing shortages and declining quality. The workforce implementation plan to be published later this year presents a pivotal opportunity to do this. The Closing the gap report sets out a series of policy actions that, evidence suggests, should be at the heart of the workforce implementation plan. They focus on nursing and general practice, where the workforce problems are particularly severe. https://www.kingsfund.org.uk/sites/default/files/2019-03/closing-the-gap-health-care-workforce-overview_0.pdf Lead: Rosie Johnson, Executive Director of Workforce and OD, Deputy CEO 3. Mental Health Services – addressing the care deficit NHS Providers published a new report on the current operating environment for mental health services and its impact on the sector, based on their survey of chair and chief executives of mental health trusts. https://nhsproviders.org/mental-health-services-addressing-the-care-deficit?utm_medium=email&utm_campaign=Mental%20health%20services%20addressing%20the%20care%20deficit%20members&utm_content=Mental%20health%20services%20addressing%20the%20care%20deficit%20members+CID_b2ab82cdf12575cf324a9b199659f06c&utm_source=campaign%20monitor&utm_term=Mental%20health%20services%20Addressing%20the%20care%20deficit Lead: Debbie Smith, Chief Operating Officer 4. NHS financial sustainability : progress review This report finds that, while the NHS did balance its overall budget in 2017/18, there is a disparity in financial health and patient experience at a local level. It concludes that the top-level picture hides warning signs that the NHS's financial health is getting worse: increasing loans to support trusts in difficulty; raids on capital budgets to cover revenue shortfalls; and the growth in waiting lists and slippage in waiting times do not indicate a sustainable position. https://publications.parliament.uk/pa/cm201719/cmselect/cmpubacc/1743/1743.pdf?utm_source=The%20King%27s%20Fund%20newsletters%20%28main%20account%29&utm_medium=email&utm_campaign=10444965_NEWL_HMP%202019-04-05_v1&dm_i=21A8,67VDX,R1KOZ6,OHWN6,1 Lead: Steve Hackett, Executive Finance and Performance Director 5. Early access to mental health support This report illustrates the findings of a data collection exercise to understand spending on low-level children's mental health services across England. While the total reported spend on low-level mental health services across all areas in England increased by 22 per cent between 2016/17 and 2018/19 in cash terms, and by 17 per cent in real terms, over a third of areas around the country still saw a real-terms fall in spending – with nearly 60 per cent of local authorities seeing a real-terms fall. https://www.childrenscommissioner.gov.uk/wp-content/uploads/2019/04/Early-access-to-mental-health-support-April-2019.pdf?utm_source=The%20King%27s%20Fund%20newsletters%20%28main%20account%29&utm_medium=email&utm_campaign=10458413_NEWSL_HMP%202019-04-12&dm_i=21A8,685RH,PGMKDX,OJF1T,1 Lead: Debbie Smith, Chief Operating Officer

7

6. Health and Wellbeing at work This is the nineteenth annual CIPD survey exploring trends and practices in health, wellbeing and absence management in UK workplaces. Overall, the findings reflect employers' growing recognition of their critical role in improving the health of the workforce. But the survey highlights some cause for concern, including an increase in stress-related absence and a lack of support for managers, who are increasingly expected to take responsibility for their team's wellbeing. https://www.cipd.co.uk/Images/health-and-well-being-at-work-2019_tcm18-55881.pdf?utm_source=The%20King%27s%20Fund%20newsletters%20%28main%20account%29&utm_medium=email&utm_campaign=10458413_NEWSL_HMP%202019-04-12&dm_i=21A8,685RH,PGMKDX,OJU1A,1 Lead: Rosie Johnson, Executive Director of Workforce and OD, Deputy CEO 7. Community Services – Our Time

This report explores the opportunities and risks for the community services sector following the publication of the NHS long term plan and whether the sector will now receive the greater national focus it needs. The report features 10 interviews from NHS trust leaders in the hospital, community, ambulance and mental health sectors, as well as representatives from social care, primary care, integrated care systems and the joint NHS Providers and NHS Confederation supported Community Network. https://nhsproviders.org/provider-voices-community-services?utm_medium=email&utm_campaign=Community%20Network%20-%20Provider%20Voices%20Community%20Services%20members&utm_content=Community%20Network%20-%20Provider%20Voices%20Community%20Services%20members+CID_7f16a72864aa657177f92168b355baa7&utm_source=campaign%20monitor&utm_term=Community%20Services%20Our%20time Lead: Debbie Smith, Chief Operating Officer RDaSH Summary Information Media Coverage – March 2019 12 press releases 2 partner press releases 1 statement 78 Facebook posts/Tweets 6 positive media hits 0 negative media hits 0 media factual 237 Twitter likes 283 Twitter shares 51,839 Twitter impressions 453 Facebook likes 145 Facebook shares 45,935 Facebook reach Statement – CAMHS Press release – New clinic room for Doncaster hostel Press release – Shoppers donate eggs to hospice Press release – More training opportunities on the way Partner press release – Doncaster’s Rapid Response service shortlisted in national awards Press Release – Victorian Tea Rooms closing Partner Press release – Work continues to improve mental health services for new and expectant mums

8

Press release – Child exploitation workers shortlisted for award Press release – Big boost for hospice - Skelton family Press release – Flying the recovery flag at United Nations in Vienna Press release – Students urged to visit health trust staff Press release – Pensioner bowling green challenge Press release – Stress Awareness month in Doncaster Press release – Stress Awareness month in Rotherham Press release – Stress Awareness month in Scunthorpe

Freedom of Information (FoI) Requests – 16 March 2019 to 15 April 2019 Date Received FOI Reference Number Subject of Request 22.03.19 2237 Use of Mechanical Restraint 26.03.19 2238 Agency SLAs for Medical Locums 26.03.19 2239 Agency spend of Medical Locums/AHPs 26.03.19 2240 Homes Sold Under Right to Buy Scheme 27.03.19 2241 Violence and Abuse of NHS Staff 27.03.19 2242 HIV Prevalence Rates 27.03.19 2243 NHS Staff Assaults 28.03.19 2244 Finance and Procurement Structure 28.03.19 2245 Hearings Convened Under S.23 01.04.19 2246 Interpretation Services 01.04.19 2247 Obesity Discrimination 03.04.19 2248 Estates/Infrastructure Failures 03.04.19 2249 Use of Surgical Robots 03.04.19 2250 Pest Control 04.04.19 2251 Hand Drying Systems 04.04.19 2252 Use of Pets in Treatment 04.04.19 2253 LAN Information 04.04.19 2254 Use of Translators 10.04.19 2255 Infections 10.04.19 2256 Referrals to CAMHS and specialists employed 11.04.19 2257 Mental Health Services and Polish People 12.04.19 2258 Telephone Maintenance 15.04.19 2259 Potential Transition to Hydrogen as an alternative to

natural gas Kathryn Singh Chief Executive 18 April 2019

9

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ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST

Committee Name

Board of Directors

Agenda Item Paper F Date 25 April 2019

Title of Paper Integrated Care System (ICS) – Chief Executive Update

Decision

Assurance

Information The Board is asked to receive and note the monthly update from the ICS CEO

Prepared by Philip Gowland, Director of Corporate Assurance

Presented by Kathryn Singh, Chief Executive

Delivery against

Strategic Goal(s)

1. To provide safe, effective, compassionate care

2. To attract, retain, support and develop the finest workforce

3. To maintain financial stability

4. To work with partners to offer and deliver market-leading services

The Trust continues to develop system wide relationships and encourage partnership working to maintain financial viability.

5. To be an outstanding, well-led organisation

Strategic Risk(s)

Number Level of Assurance Number Level of Assurance

8 Partial

CQC Domain

Safe Effective Caring Responsive Well-Led

Impact There are no specific matters in the report that are linked to the Trusts services – the revised new governance arrangements outlined in section 2.1 will require the involvement of the Trust.

Previously Presented to

Previous reports from the SY&B ICS have been presented to the Board of Directors – most recently in March 2019

Appendices to Paper

ICS Scorecards

Executive Summary The latest report from the SYB ICS Chief Executive provides update in relation to the ICS leadership meetings and their discussions. The latest performance metrics were reported and are presented in the attached appendices - including an additional chart linked to the performance of the local acute provider trusts and CCGs (Rotherham and Doncaster CCG performance in respect of Early Intervention in Psychosis and IAPT access and recovery rates are all ‘green’ and are linked to the performance of the Trust in these areas). Of note in the report are the following areas: o Interim Governance Arrangements effective from 1 April 2019 (2.1 below) o The ICS financial position is expected to be favourable for 2018/19 (2.3 below) o Involvement with stakeholders, staff and the public to inform the response to the

NHS Long Term Plan (2.5 below) o Digital Update (2.7 below and linked to the NHS X update within the RDaSH Chief

Executive Report – Paper E) ================================================================ South Yorkshire and Bassetlaw Integrated Care System CEO Report April 2019 1. Purpose This paper from the South Yorkshire and Bassetlaw Integrated Care System Chief Executive provides an update on the work of the South Yorkshire and Bassetlaw Integrated Care System over the last month. 2. Report – April 2019 2.1 This Report From April 1, the South Yorkshire and Bassetlaw Integrated Care System (SYB ICS) will adopt the interim governance that has been agreed across partners covering the 2019/2020 financial year. The new ways of working are for a twelve month period and include the Collaborative Partnership Board (CPB), System Health Oversight Board (HOB), System Health Executive Group (HEG) and Integrated Assurance Committee (IAC). The CEO Report, which will go to the monthly HEG, will be available for all partner boards, governing bodies and committees. The HEG will also receive an integrated assurance report highlighting the performance across the system which will also be made available for partners following the meeting. The performance report, which has been a section of my report and remains so this month, will therefore be picked up by the integrated assurance report from May 2019. 2.2 Priority areas for system working We continue to work with our Local Authority partners to inform and shape how our system health and care partnership arrangements might be organised, including a revised Collaborative Partnership Board as set out in the NHS Long Term Plan. At a workshop in March, led by the Local Authority Chief Executives, three areas of focus and priority for system working were agreed:

Comple x live s , including a s ys te m wide a pproa ch, he a lth a nd s ocia l ca re The impa ct of loneliness, including mental, physical and wider services Activity a nd he a lth, including e xe rcis e , a ctive tra ve l, pla nning a nd tra ns port The areas are supported by the South Yorkshire and Bassetlaw Health and Wellbeing Board Leads and arrangements for taking them forward will be discussed and agreed at the Collaborative Partnership Board. 2.3 Performance Scorecard The attached scorecards show our collective position at March 2019 (using predominantly January 2019 data) as compared with other areas in the North of England and also with the other nine advanced ICSs in the country. The data shows that across the system, our overall performance is comparatively good. We do, however, need to focus our efforts to secure sustainable improvement in Cancer Waiting times. While we remain red for A&E performance (which has dropped from 89.5 to 88.1) and referral to (RTT), where our performance is marginally below the constitutional standard at 91.6%, we are now making good progress towards achievement of the March 2019 waiting list objective. I would like to record my thanks to the Chief Executives and their teams in our system for their sustained efforts in helping turn our collective position around. The ICS financial position is reporting a year to date favourable variance against plan of £17.3m excluding PSF; and is currently forecasting a £12.2m favourable variance which is expected to improve further at Month 12 to £16.7m. This is due to phasing of plans and the continued hard work by Trusts and CCGs to deliver their financial positions. 2.4.1 Hospital Services Update The Hospital Services Review Programme continues to focus on two main areas. These are Hosted Networks and the development of clinical models on maternity, paediatrics and gastroenterology. At the March Joint Committee of Clinical Commissioning Groups, it was agreed that commissioners will play a role in supporting the Networks, shaping the strategic priorities and working with them to ensure that proposals are deliverable as they are being developed. A workshop with Trust Medical Directors, Networks Leads and commissioner representatives will shortly take place to agree the structure and high level work programme for the Networks. These will be reviewed by the Health Executive Group before they are signed off. Accountable Officers and Chief Executives met on 21st March and 1st April to discuss the way forward on changes around paediatrics and maternity. A recommendation will be submitted to Governing Bodies over the coming weeks. 2.5 The NHS Long Term Plan Involvement with stakeholders, staff and the public to inform our response to the NHS Long Term Plan will start to get underway in April. A three-month conversation with people across South Yorkshire and Bassetlaw will build on what we learned from the engagement that took place in 2016 on our Sustainability and Transformation Plan. The engagement will be co-ordinated by the ICS and supported by ICS partners and Healthwatches and the findings will inform our local Plan.

As part of the programme of work, SYB ICS Chief Executives and Accountable Officers will meet in April to start to discuss the refresh of the ICS priorities in view of the NHS Long Term Plan. The discussion will form part of the development session at the launch of the Health Executive Group. The System Operational Plan, which is in development and focuses on the year ahead, will shortly be published and also help to inform the ongoing strategic discussions. 2.6 Workforce update Following the publication of the NHS Long Term Plan, the Chair of NHS Improvement, Baroness Dido Harding and Chief Executive of Leeds Teaching Hospitals NHS Trust, Julian Hartley are leading work on a national Workforce Implementation Plan (WIP). We have responded as SYB ICS and also as part of a collective response from the six ICSs in the North of England following a request for our initial thoughts on the development of the WIP. The letters are supportive of the WIP and outline how ICSs will be a key driver in ensuring that the ambitions are realised. At the same time, work to support the agreement of the workforce priorities in SYB ICS has concluded with the development of a Maturity Matrix. It has been developed with engagement of colleagues across the system and seeks to confirm priorities and the level of role played by SYB ICS. 2.7 Digital update As part of the Yorkshire and Humber Care Record (YHCR) work, SYB ICS continues to work with partners to deliver the milestones set within the NHS England’s funding agreement which has resulted in a further release of over £2m in capital across Yorkshire and the Humber (Y&H). Work in SYB includes a pilot across Y&H to test patient information sharing. The Government has committed £37.5m to develop Digital Innovation Hubs (DIHs) as a first step towards a national approach to enable the safe and responsible use of health-related data at scale for research and innovation. We are supporting a joint application across Yorkshire and the Humber to become a Digital Innovation Hub (DiH). 2.8 Joint Health Overview and Scrutiny Committee Colleagues from the ICS were called before the South Yorkshire, Derbyshire, Nottinghamshire and Wakefield Joint Health Overview and Scrutiny Committee (JHOSC) in March to discuss the implications for the populations of the area on the NHS Long Term Plan, SYB ICS governance and updates on the SYB ICS workstreams. The JHOSC was formed in 2015 to oversee and scrutinise proposals to change hyper acute stroke services and some out of hours children’s surgery and anaesthesia services across South Yorkshire and Bassetlaw and North Derbyshire. It continues to meet to review and scrutinise matters relating to the planning, provision and operation of health services covering the geographical footprint. Andrew Cash Chief Executive, South Yorkshire and Bassetlaw Integrated Care System 2 April 2019

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ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST

Committee Name

Board of Directors

Agenda Item

Paper G Date 25 April 2019

Title of Paper

Report from the Finance, Performance and Informatics Committee (FPIC)

Decision

x The Board of Directors are asked:

To note the updates and assurances provided in section 1 of the report, including the Month 12 Single Oversight Framework declaration.

To note the risks and mitigations detailed in section 2 of the report.

To note the additional information in section 3 of the report.

Assurance

x The Board of Directors is asked to receive the FPIC report which provides assurance against delivery of the Financial Plan and against delivery of the Single Oversight Framework.

Information

Prepared by Steve Hackett – Director of Finance and Performance

Tim Shaw - Non-Executive Director, Chair of FPIC

Presented by Steve Hackett – Director of Finance and Performance

Tim Shaw - Non-Executive Director, Chair of FPIC

Delivery against

Strategic Goal(s)

1. To provide safe, effective, compassionate care

2. To attract, retain, support and develop the finest workforce

3. To maintain financial stability

Financial performance as at Month 12 included in the report.

4. To work with partners to offer and deliver market-leading services

5. To be an outstanding, well-led organisation

Compliance with Regulatory requirements – Single Oversight Framework (SOF) / Agency Spend

Strategic Risk(s)

Number Level of Assurance Number Level of Assurance

3.1 Substantial 5.3 Substantial

CQC Domain

Safe x Effective x Caring x Responsive x Well-Led x

Impact

The report from FPIC identifies the financial impact on the Trust through the presentation of the latest Trust-wide financial position. The delivery of the financial plan (strategic risk 3.1) is therefore being mitigated.

The requirements of the Single Oversight Framework are being met helping to ensure that the strategic risk 5.3 is being mitigated.

Previously Presented to

Finance, Performance and Informatics Committee (FPIC) – 18 April 2019.

Appendices to Paper

N/A

Page 1 of 6

REPORT FROM THE FINANCE, PERFORMANCE AND INFORMATICS COMMITTEE (FPIC) HELD ON 18 APRIL 2019 Executive Summary The assurances provided via the Committee in Section 1 of this report in relation to: The achievement of financial targets as at Month 12 of the Financial Year 2018/19. The achievement of the Single Oversight Framework performance requirements. The key risks discussed at the Committee as highlighted in Section 2 of this report as follows: The actions in relation to the performance hotspots for CAMHS in Doncaster and Trust wide ADHD/ASD services. The update on the Trust’s Continuous Service Improvement plan. Achievement of the Month 12 - 2018/19 Agency Cap. The updates on other issues in section 3: 1. Assurances

1.1 The Financial position as at Month 12 for the Financial Year 2018/19

The summary below describes the Month 12 financial position as discussed at the Committee. The key messages are as follows:

Page 2 of 6

31 March 2019

No. Performance Indicator

Full Year

Annual Plan

Year to Date

Actual

Agreed

Forecast Narrative Trend

1NHS Improvement Risk

Rating1 1 1 The NHS Improvement financial risk rating is 1 for the year to date.

2 Control Total Surplus £8.357m £8.548m £8.357m

The year to date financial performance is a surplus of £8.548m, which is

£191k above the revised plan for 2018-19, £1k of which relates to Flourish.

The Trust also received £129k from SY&Bassetlaw ICS to support

transformation.

2a Income £158.257m £162.378m £160.857m

Income is above plan due to greater than expected activity in Cost per

Case contracts, additional Non Contract Community Activity and contract

variations in year from main commissioners regarding the development

of services.

2b Expenditure £149.900m £153.831m £152.500m

The main reason the expenditure is above plan is due a combination of

additional staffing costs to meet activity demands and non recurrent

spend on non pay.

3 Agency Cap £5.124m £4.661m £4.8m

The Trust ended the year 8.6% below the Agency Cap set for 2018-19. All

Agency appointments continue to be reviewed for 2019-20. The forecast

was expected to be £4.8m.

4 Cash £34.5m £34.082m £34.5mThe Trust ended the year £0.418m below its revised plan. Of this £282k

related to Flourish.

5 Capital £5.092m £3.085m £3.2m

Capital expenditure ended £2m below the origonal plan for the year to

date. Against a revised plan it is £100k under. Total forecast spend on

capital by the end of the year was £3.2m.

6 Delivery of QIPP £5.146m £4.739m £5.146m

To date £1.925m or 37.4% of QIPP Plans have been delivered recurrently

and £3.23m remains outstanding. Once non recurrent plans and those at

QSIA stage have been factored in then £4.739m or 92% has been

achieved.

7 Better Payments 95% 96.5% 95%

The better payments policy for March for NHS payments is 100% and for

Non-NHS payments it is 98.3% (by value paid). The combined position for

both NHS and other for March is 98.6% and the Cumualtive position for

the year is 96.5%.

Red Adverse Variance from Plan greater than 15% Plan

Amber Adverse Variance from Plan ranging from 0% to 15% Actual

Green In line, or Greater than Plan Forecast

Executive Summary / Key Performance Indicators

0.0

500.0

1,000.0

1,500.0

2,000.0

2,500.0

Val

ue (£

'000

)

Trust Monthly I&E Profile

Original Planned Surplus / (Deficit) Actual Position before impairment

Forecast

0.0

1,000.0

2,000.0

3,000.0

4,000.0

5,000.0

6,000.0

7,000.0

8,000.0

9,000.0

Val

ue (£

'000

)

Trust Cumulative I&E Profile

Original Planned Surplus / (Deficit) Actual Position before impairment Forecast

0

0.5

1

1.5

1 3 5 7 9 11

0

5,000

10,000

1 3 5 7 9 11

0

100,000

200,000

1 3 5 7 9 11

-200,000

-100,000

0

1 3 5 7 9 11

0

2,000

4,000

6,000

1 3 5 7 9 11

0

20,000

40,000

1 3 5 7 9 11

0

2,000

4,000

6,000

1 3 5 7 9 11

0

5,000

10,000

1 3 5 7 9 11

85.0%

90.0%

95.0%

100.0%

1 3 5 7 9 11

Page 3 of 6

In October, the Trust has submitted a revised plan to NHSI detailing a revised surplus of

£2.1m above the agreed £2.057m Control Surplus for 2018-19. NHSI have confirmed that

the Trust will receive a 2:1 incentive payment relating to this increase and that this will be

paid in line with existing PSF payments. The Trust therefore has a revised Control Surplus of

£8.357m and the revised phasing of the plan is detailed below;

Although the sum is sizeable there are restrictions under NHS finance rules on what this can

be used for. Almost all the figures would need to be used for capital purposes only and

cannot be used for revenue purposes.

The Committee also reviewed a paper on Restructuring Provisions and noted the position

reported in the final Month 12 position.

1.2 NHS Improvement Single Oversight Framework (SOF) performance targets

The Committee received a report detailing the current position in relation to the Single

Oversight Framework performance targets. The report gave assurance that the Trust was

achieving all the current requirements. The following areas were discussed in more detail

and a risk around delivery of the following targets were raised:

OP10 (Out of Area Placements) assurance was received that year end performance was below the target of 1320 at 1043.

OP9 (Improving access to Psychological Adult Mental Health Services ) Quarter 4 targets were achieved at 4.75% or above

The Trust declared compliance with all measures where there is a target in place for

2018/19.

2. Risks

The Committee discussed the following areas:

2.1 Performance Hotspots

The Committee noted the following performance hotspots:

Service and KPI Date Escalated Forecast Recovery

Doncaster CAMHS – 8 week referral to treatment target

April 2016 Delivered - Data Quality Issues to be Monitored to

ensure resolution

Trust wide ADHD / ASD – significant waiting list

March 2017 Report produced and reported to

Quality Committee which highlights

next steps

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Origonal Planned Surplus 130 130 127 148 156 148 197 197 192 218 219 196 2,057

Revised Plan

Additional Surplus 1225 175 175 175 175 175 2,100

PSF 910 910 910 490 490 490 4,200

Revised Surplus 130 130 127 148 156 148 2332 1282 1277 883 884 861 8,357

Cumulative Phasing 130 260 387 535 691 839 3,170 4,453 5,730 6,613 7,497 8,357

Page 4 of 6

including a capacity and

demand appraisal. Report will go to EMT in May for

agreement of a full action plan.

Trust wide IAPT access rates – 19% by year end / 4.75% in Quarter 4

October 2018 March 2019 FPIC

congratulated all Care Groups for achieving at least 4.75% in quarter 4

The hotspot associated with ADHD/ASD was noted in association with long waiting times and concerns around the capacity of commissioned pathways.

Low risk performance hotspots continue to be reported to Care Group Performance and Finance meetings and OMM.

2.2 Performance against the Agency Cap

Overall the Trust has spent £4,661k on agency which is 3.8% of the pay bill, last month it was 3.7%.

The NHS Improvement ceiling has been undershot by 8.6% or £463k, last month it was 11.6% and £543k.

The overall spend in Medical Staff is 7.0% of the total Trust pay bill and Medical agency makes up 46% of all agency spend. Should the Trust still have the NHSI cap to reduce medical agency spend by £391.2k, it would currently be 9% or £203k under this target, last month it was 9% under.

2.3 Continuous Service Improvement - Project Management Office Report (PMO)

The Committee received an update report on the Continuous Service Improvement plan for

2018-19 following recent considerations by the Executive Management Team. The main

highlights from the report were as follows:

2018/19 QIPP

Delivery of the 2018-19 QIPP plans.

The total recurrent QIPP challenge for 2018-19 is £5.146m. This target relates to £1.686m carried forward from 2017/18 (of which at the year-end there were plans in place for £1.4m of this), and the 2018/19 QIPP target is an additional £3.460m.

Below is a breakdown of delivery in year highlighting risk that may be carried forward into 2019/20 ( Non recurrent £648k plus No plans £211k ).

Page 5 of 6

Updates on the individual schemes, detailed below, were provided :-

Clinical Service Improvement;

Unity;

E-roster;

Agile; and

Voice Recognition

The Committee were advised of the new work stream on Recruitment and Retention.

3. Other information

The Committee received reports on the following matters:-

3.1 Health Informatics

The Committee noted a year end update on performance regarding IG training this was reported as 93.4% against a target of 95%. Plans to address this were in place.

3.2 Extreme Operational Risks / BAF

The Committee received the monthly report on the Trust’s Extreme Operational Risks and

were advised at the present time there are no Extreme Operational Risks that are under the

remit of the Committee.

The Committee also considered the three risks outlined for monitoring and control within the

remit of the Committee. FPIC reviewed the risks as stated for 18/19 and confirmed that :

o Appropriate controls were identified and in place

o Assurance and reports to the Committee had been received throughout the year,

including Internal Audit and External Audit.

o Gaps in either controls or assurance are not significant.

3.3 Other Papers

The Committee received the following general items for consideration

Full Year

Effect

FYE %

Achieved

Recurrent Plans Delivered £1,924,565 37.4%

Ferns Ward (Non-Recurrent Delivery) £1,050,535 20.4%

Dietetics and DMBC Reserve (Non-

Recurrent Delivery) £648,000 12.6%

Plans at QSIA Stage £1,116,164 21.7%

Total YTD Delivered at Month 12 £4,739,264 92.0%

Plans £195,608 3.8%

Total No Plans in 2018/19 £210,727 4.1%

Total NHS Improvement Plan £5,145,600 99.9%

In Year Overhead Losses £6,627 0.1%

Total QIPP Target 2018/19 £5,152,227 100.0%

Page 6 of 6

o The Committee received a paper outlining the capital spend for 2018/19 and the

planned spend by scheme for 2019/20

o The Committee received the Going Concern statement for 2018/19 and endorsed the

conclusions reached in the report that the Trust is able to prepare its accounts on

going concern basis. This will be recommended to the Audit Committee and Board

accordingly.

4 Recommendation The Board of Directors are asked:

4.1 To note the updates and assurances provided in section 1 of the report, including the Month 12

4.2 Single Oversight Framework declaration. 4.3 To note the risks and mitigations detailed in section 2 of the report. 4.4 To note the additional information and assurances in section 3 of the report.

ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST

Committee Name

Board of Directors

Agenda Item

Paper H Date 25 April 2019

Title of Paper

Report from the Quality Committee – 16 April 2019

Decision

Assurance

X The Board of Directors is asked to receive the update report from the Quality Committee.

Information

Prepared by

Alison Pearson, Non-Executive Director, Chair of the Quality Committee Andrew MacCallum, Interim Director of Nursing and Allied Health Professions

Presented by

Alison Pearson, Non-Executive Director, Chair of the Quality Committee

Delivery against

Strategic Goal(s)

1. To provide safe, effective, compassionate care X

This report provides a summary report on the quality of services and care delivery.

2. To attract, retain, support and develop the finest workforce X

The work of the Quality Committee and this report details how the Trust is working to recruit and retain a skilled workforce.

3. To maintain financial stability

4. To work with partners to offer and deliver market-leading services

5. To be an outstanding, well-led organisation X

The Quality Committee is a key Assurance Committee of the Board of Directors and provides a key strand of governance to the Board of Directors and supports the effective and safe running of the organisation.

Strategic Risk(s)

Number Level of Assurance Number Level of Assurance

1 Partial 11 Partial

2 Partial 12 Substantial

3 Partial 13 Substantial

4 Partial 14 Substantial

5 Partial

CQC Domain

Safe X Effective X Caring X Responsive X Well-Led X

Impact

Financial – Through the review of safe staffing levels there may be a financial impact. This is being addressed as part of the work plan within each care group.

Equality & Diversity – No additional impact.

Quality – The impact on the provision of quality services and care delivery is covered throughout the report.

Workforce – There are issues with regard to the workforce and this is detailed through the specific items regarding workforce.

IT – Issues regarding IT and the impact this has is detailed in the update regarding risk assessments.

Statutory legislative requirements – No additional impact identified

Previously Presented to

None

Appendices to Paper

None

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Board of Directors – 25 April 2019

REPORT FROM QUALITY COMMITTEE – 16 APRIL 2019 1. Introduction The last meeting of the Quality Committee (QC) was held on 16 April 2019. The meeting was chaired by Alison Pearson (Non-Executive Director (NED) and was quorate. This paper provides a summary report that captures key messages and levels of assurance from this meeting, it is framed around:

Highlights and Opportunities

Assurance

Gaps

Risks 2. Highlights and Opportunities

Annual Trust Quality Accounts 2018/19 (Quality Governance) – report received for comment. Mandatory requirements, together with local achievements and challenges were outlined across the key domains of Patient Safety, Clinical Effectiveness and Patient Experience. Key achievements highlighted and included:-

- CQC Well Led inspection of core services published in June 2018 with an overall rating of GOOD.

- Expansion of the single point of access to services. - Rollout of agile working completed in Rotherham. - Launch of Carer’s Charter.

The QC discussed the learning taken from this year (the need to improve controls/governance, the clarity on the achievement of objectives, other audit feedback) and requested this be included in the final report.

Quality Committee Annual Assurance Statement (Quality Governance) – the QC discussed the production of the report prior to the Quarter 4 2018/19 results being issued but felt that there is unlikely to be a material change. Some additional items were suggested.

Staff Survey Results 2018 (People) – 45% of Trust staff completed the survey which is 6% higher than 2017. Results shown by theme versus. comparators with RDaSH being above the national average in 6 of the 10 themes. Analysis of Trust results indicates improvement for 63% of questions, and 17% stayed the same. Corporate priorities have been identified around Line management/Quality of Appraisals/Safety Culture. Care Groups have been asked to identify 2 key areas to focus on. The QC asked for clarification on the triangulation with other results, and whether hot spots could be identified for potential follow up.

Health and Wellbeing Service Development Plan – to be developed based on the recommendations of “2017 Thriving at Work”, an independent national report, with a number of standards be deployed. A report on implementation will be reviewed in Quarter 4 2019/20.

Sickness absence (People) - in February 2019 this was 5.9% (Jan 6.3%, Dec 6%, Nov 5.9%, Oct 5.2%, Sep 5.1%, Aug 4.9%, Jul 4.8%, Jun 4.6%, May 4.8%, Apr 4.7%, Mar 5.1%, Feb 6.3%, Jan 6.3%), cumulative 5.3% versus Trust target 5.3%. Year on year comparison is a -0.4% in the month.

3. Assurance

Substantial Assurance – Freedom to Speak Up (FTSU) Guardian 6 month update (People) – Use of FTSU tools was demonstrated. Action taken to improve FTSU culture has included combining Advocate and B&H roles, targeting induction sessions, attending Diversity networks and joining the Big Conversations using the Health Bus roadshows. The QC noted the Guardian’s concerns that some of the staff survey engagement responses are lower than

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comparators but it was sufficiently assured about the use of the FTSU processes to take substantial assurance from the paper.

Substantial Assurance – Quality & Safety Impact Assessment Quarter 4 2018/19 update (Quality Governance) - process has been reviewed to ensure focus remains on cost improvement projects. 11 QSIAs submitted, 3 approved first time, 1 resubmitted and approved, 3 not approved, 4 carried forward to Quarter 4. Substantial assurance relates to initial implementation decision.

Substantial Assurance - Clinical Audit Assurance Statement 2018-19 (Clinical Effectiveness) – 56 audits were supported with 8 being National, 7 POMH topics, 8 CQUIN, 9 Local Trust-wide, and 24 Care Group specific audits. As of end March 2019, 41 of the 56 projects were complete with 20 Good outcomes and 14 Requires Improvement. Action plans for RI outcomes are monitored. 15 topics were carried forward to the 2019/20 programme.

Substantial Assurance – Patient Led Assessment of the Care Environment (PLACE) 2018 action plan update received. All actions reported as complete, or redecoration work underway. The QC requested that a RAG system be adopted for future reports.

Substantial Assurance – Emergency Preparedness, Resilience and Response Quarter 3 2018/2019 quarterly report (Patient Safety) – self-assessment report received. On Call decision making training has been well received. The QC requested that a RAG system be adopted for future reports.

Partial Assurance - CQC inspection action plan (Quality Governance) – A much improved action plan was received which outlined the action agreed/lead director/timescales and progress update by each of the 11 Must Do and 40 Should Do actions. 8 of the 11 Must Do actions have been completed; remainder due for completion by end June 2019 leading to the partial assurance. The QC sought clarity on the ward specific actions versus the Trust-wide ones in the report, so that we are clear about the gaps.

Partial Assurance – Safeguarding Training (Quality Governance) – current compliance noted by Care Group with partial assurance noted due to variation in this compliance. The training and core competency framework approach is under development.

Partial Assurance – Safeguarding Children Supervision (Quality Governance) – current compliance noted by Care Group with partial assurance noted due to varied compliance. The QC noted that a more consistent approach is to be taken forward as LIA work. The QC queried whether we are clear about the supervision requirement (management/group/clinical/peer). The revised policy/plan will be presented to QC in August 2019.

Partial Assurance – February 2019 Inpatient staffing (People) – Rotherham Care Group has reported fill rates of below 90% for staffing across adults and older people’s services. This is linked to registered nurses. There were 53 RED rated shifts reported (using local reporting v. occupancy & acuity criteria) across the Trust (45 in Doncaster and 8 in Rotherham). Skelbrooke (25), Amber Lodge(10), Jubilee(10), Brambles(1), Osprey(1), Sandpiper(6). Doncaster Care Group reported 14 IR1s and Rotherham reported 18 IR1s related to staffing. No correlations noted with SI and complaints have been identified at this stage. The Chief Operating Officer (COO) updated on the discussions that have taken place to improve Agency coverage. The QC requested more assurance to be provided in this report with mitigating actions to be strengthened in future reports.

Partial Assurance - Serious Incident report for February 2019 (Patient Safety). There were 15 IR1s of moderate or above level, and 5 of these were pressure ulcers (subject to RCA process). Of the 10 remaining incidents 3 were deaths subject to mortality review, 5 were subject to structured review, and 3 are being investigated through SI framework. A total of 3 Serious Incidents were reported on STEIS in February 2019. Overall 3 serious incidents were concluded in February. Of the 48 actions in place 2 are currently overdue and no immediate risks have been identified as a result of overdue actions. Annual SI data (year to date) shows 54 reported versus 75 reported in 2017/18. Two RIDDOR incidents were reported due to +7 day employee absence. Partial assurance due to the ongoing Internal Audit actions.

Partial Assurance - Mortality Quarterly Report (Patient Safety) – Training on the updated Learning from Deaths Policy is due for completion by end May 2019. Quarter 3 2018/19 data review has taken place. A review of North Lincolnshire unexpected deaths between November

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2017 and October 2018 has taken place with areas for improvement noted and taken forward in the Care Group. Quoracy at the Mortality Surveillance Group remains a challenge with 2 out of 3 meetings non-compliant. Partial assurance due to the ongoing Internal Audit actions.

Partial assurance – ADHD/ASD Service Performance (Clinical Effectiveness) – excellent report received to ensure the QC remains sighted on the risk that current performance creates for patients. Across both adults and children’s there is a significant proportion of patients waiting over 18 weeks, with a theme that capacity in teams does not meet demand. Next steps have been identified. The QC requested an action to cover what happens to people whist awaiting a support intervention. An update to be provided to QC in November 2019.

Partial Assurance – Mandatory and Statutory Training (MAST) (People) - compliance in February 2019 90.7%. There are 3 subjects below 75% compliance; Slips, Trips and Falls Level 3; Prevention and Management of Violence and Aggression; Manual Handling. Further work undertaken on areas of DNA rates should enable the Chief Operating Officer to follow up with Care Groups. Details were provided of action being taken to drive compliance.

4. Gaps

Personal Development Reviews (PDRs) (People) - level of completion in February 2019 78.02% (Jan 80%, Dec 79.9%, Nov76.62%, Oct 78.59%, Sep 79.51%, Aug 80.32%). Continued focus confirmed as underway with the names of those people requiring a PDR now provided to Care Group leads each month to drive activity.

Community Pharmacy Review Outcome (Patient Safety) – report to be presented in May 2019.

Physical Health and Wellbeing (Clinical Effectiveness) – to be presented following the review of EMT portfolios May 2019.

5. Risks (Governance)

An extract of the Board Assurance Framework (BAF) was reviewed regarding progress made on the three 2018/19 QC aligned strategic risks. The QC noted that all 3 remained above the target risk level identified at the start of the year. The QC agreed that appropriate controls have been identified, and noted that the outstanding gaps would continue into 2019/20 BAF.

The “Extreme” risks aligned to QC are:

o MED/1/16 – If the Trust does not reliably and robustly ensure that all relevant deaths are

logged, screened and, if necessary, investigated, with key lessons distilled, analysed and any lessons learnt incorporated into wider organizational learning, there is a risk that there will be sub-optimal learning from deaths. As a consequence we may miss opportunities both to prevent future avoidable harm/death and to promote positive examples of high quality care. The new mortality reporting module in Ulysses will be live from the first week in June 2019. Verbal update received from Medical Director that training on the updated policy and use of the reporting module will be completed by end May 2019. Until that time, existing processes for the logging of deaths will continue.

o O1/19 - If the Trust does not have in place and implement an appropriate recruitment and

retention of staff strategy then Safety and Quality of clinical services may be compromised. Update covered a review undertaken by COO on daily basis. A Recruitment and Retention Steering Group has been established, and a 20 day review is being led by the Director of Nursing (scheduled for May 2019). An additional Recruitment Agency has been identified for future use. The COO confirmed that the risk applies to wider staffing than inpatient nursing. The QC sought clarity on the locality of the risk and the root cause for each so that we can be sure the strategy for resolution is clearly identified. It was felt the current wording of the risk is more reflective of an action and doesn’t accurately reflects the fact the risk relates to insufficient availability of appropriate front line staff in specific clinical settings. In view of this a request was made for EMT to review the wording of this risk.

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o DCG5/17 – if gaps in the medical staffing in Doncaster services are not appropriately and expeditiously filled, then there is a risk to the delivery of care for patients. The COO, Medical Director and Care Group Director met with the Medical staff to understand the concerns. Terms and conditions of employment, including on-call arrangements, are under review and 2 additional roles are under development. In the meantime

6. Recommendation The Board of Directors is asked to note the update from the Quality Committee held on 16 April 2019. Alison Pearson Non-Executive Director April 2019

ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST

Committee Name Board of Directors

Agenda Item Paper I Date April 2019

Title of Paper Freedom To Speak Up (FTSU) Guardian - Six Month Update

Decision No decision required

Assurance Assurance provided that FTSU processes are in place and are being utilised in the Trust.

Information This paper is ultimately intended for presenting at Board of Directors and has been written with that in mind. Information is provided concerning the governance and reporting of FTSU concerns since the previous FTSU Report in Dec 2018. Information is also provided concerning National Developments concerning FTSU.

Prepared by Dr Judith Graham – Freedom To Speak Up Guardian, Deputy Director for Organisational Learning & Development.

Presented by Dr Judith Graham – Freedom To Speak Up Guardian, Deputy Director for Organisational Learning & Development.

Delivery against

Strategic Goal(s) 1. To provide safe, effective, compassionate care x Ensure delivery of high standard of care for patients, enabling concerns to

be raised at any level at the earliest point. This enables a focus upon early risk detection and risk prevention.

2. To attract, retain, support and develop the finest workforce x Workforces who are empowered and supported to raise concerns are

evidenced as not only safer but improved in their levels of engagement. 3. To maintain financial stability x FTSU principles concern safety and improved worker satisfaction. This

leads to improved retention and has an impact upon sustainable services. 4. To work with partners to offer and deliver market-leading services x We follow FTSU principles to monitor internal performance and processes

as well as being able to assess the influence of partner agency working to ensure that clinically lead services are safe.

5. To be an outstanding, well-led organisation x Our responses to concerns that have been raised combined with our individual, team and organisation learning connected with FTSU concerns raised contributes to improved performance.

Strategic Risk(s) Number Level of Assurance Number Level of Assurance

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2.3 Substantial – in using FTSU principles we are engaging with our workforce and acting on feedback contributing to a culture that supports high performance.

5.1 Substantial – The rating of substantial is provided when considering all FTSU processes. A partial rating is considered within this connected with the staff survey results which rate how staff feel they are able to ‘speak up’ in the trust. This rating has been discussed and agreed at the Quality Committee.

CQC Domain Safe X Effective X Caring X Responsive X Well-Led X

Impact Financial – There are no financial implications within this paper.

Contractual – The adherence to FTSU principles is within the NHS contract and aspects covered within this paper demonstrate how we are adhering to these at RDaSH.

Equality & Diversity – The FTSU approach concerns supporting people to “raise concerns” and provides them with protection to do anonymously if required.

There is substantial evidence published in reports such as the Mid Staffordshire inquiry that recognises that people may feel unable or unsupported to “speak up safely”. This can be associated with: power relationships between professionals, cultures and subcultures within teams and organisations. This has been researched to occur at a higher frequency in some organisations for people from minority backgrounds.

Quality – Care quality is analysed within all FTSU concerns raised.

Workforce – Within all concerns raised contact is made with the relevant level of management and any workforce issues will be raised within the appropriate Care Group or Directorate team.

Previously Presented to

April 2019 - Peoples Committee, OMM, EMT and Quality Committee

* Please note that biannual reporting for FTSU through BoD will now be April and October rather than April and December.

Appendices to Paper

Appendix 1: FTSG Guardian Board Reporting Recommendations Summary (National Guardians Office and NHS Improvement 2018).

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Freedom to Speak Up (FTSU) Guardian Executive Summary This paper is ultimately intended for presentation at Board of Directors and has been written with that in mind. This paper provides an update regarding RDaSH activity since the last Board paper in December 2018. Within the paper the results of the National Guardian’s Office data collection, Staff Survey data and National Guardians Office conference are presented alongside RDaSH information to provide national and regional comparison and context. The information is a summary of more detailed information analysed via the Peoples Preparation meeting, Operational Management Team Meeting monitored on a monthly basis. The paper is presented in a structured format to ensure compliance with the – “Guidance for Boards on Freedom to Speak Up in NHS trusts and NHS foundation trusts” published by the National Freedom to Speak Up Guardians Office and NHS Improvement in May 2018. The presentation of this information is structured in such a way that enables the FTSU office to describe arrangements by which Trust staff may raise any issues, in confidence, concerning a range of different matters and to enable the Board to be assured that arrangements are in place for the proportionate and independent investigation of such matters and that appropriate follow-up action is taken.

Introduction Freedom to Speak Up (FTSU) concepts are embraced at RDaSH. This biannual report is provided to the Board of Directors (BoD) meeting, to provide assurance that FTSU processes are in place in RDaSH and are being utilised. The format is structured to comply with the 2018 publication by the National Guardians Office and NHS Improvement published guidance concerning FTSU Guardians Board Reporting (see appendix 1). To ensure ‘best practice’ and the guidance is adhered to, the following report has been structured to provide information concerning the following, presented by the FTSU Guardian:

• Section 1 - The assessment of issues • Section 2 - Potential patient safety or workers experience issues • Section 3 - Action taken to improve FTSU culture • Section 4 - Learning and improvement • Section 5 - Recommendations

Strategic context FTSU principles are contained within the NHS contract. Research connects good ‘speak up’ cultures with: improved patient safety, higher staff wellbeing and retention, lower levels of dissatisfaction and higher care quality. The FTSU concepts embrace the following RDaSH strategic goals:

• To provide safe, effective and compassionate care. • To attract, retain, support and develop the finest workforce. • To be an outstanding, well-led organisation.

Section 1 - The Assessment of FTSU Issues Summary of FTSU concerns to date: All concerns raised at RDaSH since the commencement of FTSU are provided in the tables below. The previous year’s concerns are highlighted to enable year on year comparisons in the sections below:

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Table1: RDASH Concerns Table 2: RDASH % comparators

Date Period Quarter No. of Concerns

Concerns per area

Number & %

Number of Staff in Locality (FTE)

Staff allocation %

April – June 2016 1 5 Don Care Group 33 (42%) 1587 44%

July – Sept 2016 2 2 Roth Care Group 14 (18%) 617 17%

Oct – Dec 2016 3 7 NL Care Group 10 (13%) 242 7%

Jan – March 2017 4 6 CYP Care Group 8 (10%) 528 15%

Apr – June 2017 1 2 Corporate 14 (17%) 599 17%

July – Sept 2017 2 8 Total 79 (100%) 3573 100%

Oct – Dec 2017 3 12 Jan – Mar 2018 4 3 Apr – June 2018 1 10 July – Sept 2018 2 11

Oct – Dec 2018 3 10 Jan – Apr 2019 (*data collected until 27/3/19) 4 3

The number of concerns raised within RDaSH is within the comparable range of neighbouring Trusts. Discussion concerning comparisons using the national data collection is summarised in sections below, drawing from the National Guardians Office (NGO) data report published in September 2018.

Comparative data The NGO asked FTSU Guardians in all Trusts for information on FTSU cases; the latest results were published in September 2018, and were detailed in the previous Quality Committee and Board of Directors Report in December 2018. This information will therefore not be repeated here, however contextual data is provided in regards to the concerns that have been raised since the last Board report, with additional information in regards to ‘zones of tolerance’ as discussed in the previous Quality Committee. Concern Rates: Trust concern rates are monitored on an individual basis. Month by month concern levels fluctuate, however they are monitored in regards to both trends and number. With the full year comparison data presented by the NGO in 2018, this makes it easier to monitor whether concerns raised lie within an expected ‘zone of tolerance’. What this means is that concern rates are comparable with ranges from other Trusts. What this means at RDaSH - The data presented in September 2018 by the National Guardians office shows two things which are important for RDaSH – firstly it provided control averages for comparison, and secondly it showed an overall increase in the number of concerns that are raised through FTSU processes within Trusts. Overall increase in reporting - In terms of overall increase in reporting through FTSU – the NGO showed that the 2017/18 reporting had an increase in concern raising by 51% over all organisations monitored. This is a significant increase, which is due to a number of factors – some factors included the fact that some Trusts had only recently adopted guardians and were therefore collecting data, or the fact that

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some Trusts began promoting the use of FTSU routes, whereas previously they had not had such communication. Within RDaSH we saw a 25% rise in the use of FTSU in the 2017/18 comparison period. This is a lower rate than overall rate shown by the NGO; however this is likely due to the fact that RDASH has been an early adopter of FTSU ways of working and has been actively promoting FTSU principles since early 2016. Although the data for the 2018/19 period has not been published by the NGO, and is not expected until September 2019, it is anticipated that there will be a further increase in terms of rate of concerns, which has been discussed in both regional leads meetings with the NGO and at the recent national conference. There has been an increase in the rate of concerns reported through FTSU in RDaSH in the 2018/19 period the total number of concerns raised has increased from 25 to 34 which is a 36% Control averages and ‘zones of tolerance’ – The September 2018 NGO data provided two control averages which are important for reporting at RDaSH. This data showed that the average FTSU reporting for Mental Health, LD and Community Trusts was 34 concerns, and it showed that for Trusts described as small (under 5000 staff) the average reporting was 25 concerns in the year. The comparative 2017/18 year in RDaSH had a total report of 25 concerns – which fell at the lower end of these control averages. However in 2018/19 is 34 which is at the upper range of these control averages, with an expected overall increase in the control averages when the NGO 2018/19 data is published. Section 2 - Potential patient safety or workers experience issues

FTSU processes are in place to proactively support patient safety and improve worker experience. Within national reporting, the NGO have demonstrated that more issues are raised through FTSU concerning staff experience than patient safety; this is consistent with RDaSH experience:

Table 7 – National Comparisons concerning ‘speak up’ theme and experience Theme or experience 2017/18 –

% reported Nationally RDASH 2017/18 comparisons

RDaSH 2018/19 Comparisons

% of Patient Safety Concerns 2266 (32%) 8 (32%) 15 (44%) % of Bullying / Harassment Concerns 3206 (45%) 10 (40%) 16 (47%) % reported anonymously 1254 (18%) 2 (8%) 2 (6%) % who reported perceived detriment 361 (5%) 2 (8%) 0 (0%)

What this means at RDaSH – Each of the concerns raised in the Trust have been discussed and progressed at a team level, with learning then explored at an organisational level, triangulating learning and data through Care Group, directorate and OMM meetings, identifying opportunities to learn and improve. Any case of detriment reported is explored within the case analysis and with the senior FTSU team, including the Non-Executive Director for FTSU.

As a final point, at RDaSH we encourage where possible for people to raise concerns directly, protecting anonymity where appropriate. However, acknowledging that we have reported a lower rate of anonymous concerns in RDaSH than other Trusts.

Section 3 - Action taken to improve FTSU culture

Specific work has been conducted over the past year to improve FTSU culture, specifically concerning visible leadership. The information presented in this next section builds upon the significant work described within the December 2018 paper: - Merger of Freedom to Speak up Advocates Role and Bullying and Harassment Officer Role -

Work has been conducted between the FTSU advocates and Bullying and Harassment Officers. It has been agreed that the roles will combine, to increase FTSU visibility and also decrease any confusion between the roles. In order to merge these teams, there is specific training being commissioned to

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upskill the FTSU advocates and also to enable the Bullying and Harassment Officers to expand their remit in regards to receiving patient safety concerns. The training is being planned for completion by Q2 2019/20.

- Targeted FTSU communication at induction – Within the previous paper it was detailed how FTSU

communication has increased at Trust induction, this means that not only are FTSU concepts detailed in the CEO presentation to inductees, but also within the induction ‘market place’ in the morning and at lunch time, there is a specific FTSU stall which is staffed by either the Deputy FTSU Guardian or a FTSU advocate. Additional to this, the FTSU Deputy Guardian attends all new Doctor Inductions. From feedback at induction, additional material has been developed to assist people speaking up including: business cards and pens with the Trust FTSU contact details.

- Strategy Publication – Following coproduction of the FTSU strategy this has now been designed in an easy read format and publicised on the Trust website – link – https://www.rdash.nhs.uk/wp-content/uploads/2019/03/FTSU-Vision-strategy-2018-21.pdf This publication adheres with the NHSi timeline for strategy production, however we remain one of a small number of trusts who have published their strategy at this time.

- Discussions concerning ‘Speaking Up’ in Diversity Networks – December 2018 saw the launch of

the RDaSH BAME Network, and March the RDaSH virtual LGBT+ Ally network. These networks are now starting to take shape. Discussions have been held in terms of FTSU, and it is intended for members of the FTSU Guardian team to meet with the networks and explore ways in which ‘speaking up’ can be improved.

- Site Visits - The Deputy FTSU Guardian joined the cultural improvement team in their travelling ‘Big

Conversations’ using the RDaSH Health Bus in January and February 2019, along with the health and wellbeing, PPEE and communications team. The Health Bus visited sites in North Lincolnshire, Rotherham and Doncaster. Less visited sites were accessed by the bus, and over 150 staff attended and gained information in regards to FTSU processes at RDaSH.

Has the cultural work been effective at RDaSH?

The focus upon FTSU cultural work appears to have been effective in both supporting the development of a Trust wide ‘speak up’ culture and also increasing the number of concerns raised as evidenced in section 1 of this paper. The discussions concerning FTSU are also widening in terms of the Trust and introduction of ‘just culture’ approaches, ‘human factors’ approaches through work conducted by the patient safety team, cultural improvement team and operational teams.

The number of concerns is only one metric that can help explore whether FTSU approaches are effective. Another specific monitor is the NHS National Staff Survey. Within the staff survey there are specific questions that relate to FTSU, below is a table that presents the staff survey results and comparator results for these questions considering the 2017 results and also national comparators:

Area and related Staff Survey Question

2017 result

2018 results

Comparator Result 2018

Variation

1) Do staff know how to report concerns? (Q13a – now 18a)

96% 97% 96% Positive Result: - 1% higher from 2017 score, equal to 2016 score. 1% higher than comparator trusts.

2) Do staff feel secure in reporting concerns? (Q13b – now 18b)

70% 69% 74% Result requiring attention: - 1% reduction from 2017 score, 2% lower than 2016 score. 5 % lower than comparator trusts

3) Did staff actually report concerns? (Q11c – now

97% 93% 96% Result requiring attention:- 4% reduction from 2017, 3% reduction than 2017– 3%

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16c) lower than comparator trusts 4) Are staff encouraged to report concerns? (Q12b – now 17b)

87% 87% 89% Result requiring attention:- Same score as 2016/2017 – 2% lower than comparator trusts

5) Do staff feel that they are treated fairly after reporting concerns? (Q12a – now )

51% 54% 58% Result requiring attention: - 3% increase from 2017 score, and 2% from 2017. But still 4% lower than comparator trusts

The staff survey questions do not pertain directly to FTSU Guardian activity but are good indicators in terms of FTSU culture and recommended by NHS England as requiring focus in terms of developing FTSU cultures. The questions that are highlighted above were rated by RDaSH staff in Autumn 2017 and therefore may have changed due to the work that has been conducted, however focus has been provided via the Trust People’s Committee and the Operational Management Meeting concerning how to better support staff in terms of these ratings.

Widening Cultures via Communities of FTSU practice The efficacy and impact of the FTSU approach is not solely about internal Trust processes, but also relates to across Trust relationships and supporting transient members of the workforce who may be bank workers, volunteers, students or other types of learners. Within our RDaSH FTSU approach we ensure that we are fully linked into a number of networks to benefit from a collective approach to ‘speaking up’. The RDaSH FTSU Guardian is also the regional lead Guardian for Yorkshire and the Humber, holding the chair role for bimonthly meetings and also participating in bimonthly regional leads meetings facilitated by the NGO. Since the previous work detailed in the December 2018 FSU report, additional work has been conducted regionally and nationally that the RDASH guardian processes are linked in with. This work includes:

Improved focus upon Bullying and Harassment – In March 2019, RDaSH hosted the regional FTSU network, at each network meeting a regional or national speaker is asked to join. On this occasion the meeting was joined by Anthony Fishenden who is the Complaints and Whistleblowing Manager at NHS Improvement (pictured below). At the meeting Regional Guardians discussed the relationship between Guardians NHSi and CQC, guidance provided by NHSI in terms of FTSU and also supportive data and resources that could be provided by NHS Improvement to improve the way that Guardian can support organisations.

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Additional to this, the Trust FTSU Guardian and HR Employee Relations Manager have attended the National Conference concerning ‘Collective Leadership to Address Bullying and Harassment in the NHS Workplace’, on 28th March 2019. This conference was hosted by Caroline Corrigan – Director for People Strategy, NHS Improvement, and provided focus concerning the cost of bullying in NHS organisations – providing a Toolkit for Trusts to test on calculating the cost of bullying in their own organisations. This toolkit is being explored in terms of how it can be used as part of a culture measure at RDaSH to support FTSU processes.

Section 4 - Learning and improvement At the point of this paper being presented seven FTSU cases are actively open at RDaSH, all other cases have been closed. Below is a list concerning high level detail of learning points related to the concerns raised within the 2018/19 period since the last paper presented to the Board of Directors in December 2018:

• To review policies and practices concerning support provided to staff who may experience domestic abuse.

• To ensure that any ‘deep dive’ meetings involve corporate service representatives as well as front line services.

• To ensure that any learner in practice who experiences difficulties has triangulated support from the learning and development teams and operational mentors or supervisors.

• To ensure that clinical leads link in with operational managers if there are any changes to staff rotation or student placement planning.

• To develop a supportive leaflet for staff who experience verbal abuse from patients in the workplace.

• To provide more targeted support in regards to autism training in specific areas of the Trust. • To look at how Bank Admin Staff are managed when moving from assignment to assignment. • To review training and potential skills gaps within teams. • To understand the problems that could come from dual line management.

All of the concerns raised have been discussed in detail either via the specific Care Group or Directorate teams, then analysed for across Care Group learning in the operational management meeting and in relevant directorate meetings where required. Each case is also subject to analysis via a senior leadership team meeting consisting of the Chief Executive, Non-Executive Director for FTSU, Director for Workforce & OD and the FTSU Guardian.

RDaSH Feedback

Feedback is obtained from all who speak up, except for those who speak up anonymously. The feedback that has been provided by staff and learners who have spoken up has been predominantly positive summarised with national comparators. Within the national data collection 34% of all cases reported in the year provided feedback, to the single question “Given your experience, would you speak up again?”. At RDaSH all people who spoke up confidentially or declared their name provided feedback – feedback was not able to be gained from those who raised concerns anonymously as no contact details have been provided, therefore these are exclude from the comparison reports below: National Comparisons- question:-“Given your experience, would you speak up again?” Answer 2017/18 - % reported Nationally 2018/19

RDaSH Comparisons (excluding 3 anonymous concerns

where feedback could not be gained) % stated ‘Yes’ 2077 (87%) 34 (100%) % stated ‘No’ 84 (4%) 0% % stated ‘maybe’ 108 (5%) 0% % stated ‘don’t know’ 114 (5%) 0%

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Alongside of the question above, a specific questionnaire is provided to people who ‘speak up’ which is optional to return. Within the feedback received, the following are extracts of qualitative feedback that has been received: - “I wish I would have done this sooner to address my concern they had such an impact on my role and my

health”

- Speaking to someone in confidence, someone who listened to my concerns, someone who didn’t judge me, someone who was kind and caring, having someone who was willing to speak up for ME has made the world of difference. I had a voice and I felt that my voice has been heard.

- Having had this help has made it much easier for me to focus on what is important to me, being the best person

I can be, I feel much less stressed, less anxious, I feel that my confidence has improved. In short I feel more like me again.

- It’s easy to walk away or turn a blind eye, but I can honestly say, it is much easier to make a difference than you

think by speaking to a Freedom to Speak up Guardian.

National Guardians Conference and Developments The National FTSU conference was hosted at City Hall in London on Monday 18th March 2019. Dr Henrietta Hugues opened the conference covering the work of the office and the Guardians over the past year, giving some specific focus too:- the impact of: the #MeToo movement, NGO Case Reviews, the Gosport Inquiry, Kark & The NHS 10 year plan. Within the conference there was a presentation by Professor Megan Reitz concerning “Speaking Truth to Power”. This session focussed upon relational aspects of culture, and how power imbalance really affect FTSU. A supportive video concerning subject matter has been shared with the trust FTSU Guardian and advocate team ‘How your power silenced Truth’ - https://m.youtube.com/watch?feature=youtu.be&v=Sq475Us1KXg The Yorkshire and Humber region was well represented in the main stage presentations - John Walsh from Leeds, presented upon the first vanguard session which concerned the introduction of FTSU in primary care in Leeds. The second vanguard presented was Col. Phil Carter, his focus was on FTSU the armed forces. The RDASH Guardian led a focussed session concerning FTSU integration in the newly formed ‘North East and Yorkshire region’. The new FTSU regions mirror the new NHSE & NHSI footprints, and the discussions focussed upon the requirement for expansion of FTSU in primary care and private providers, and also ways in which organisations can better integrate to proactively identify and address concerns as well as share learning. The ‘North East and Yorkshire region’ is one of the geographically largest regions and therefore has challenges in terms of diversity of providers and also diversity of populations. One of the main concerns raised by attendees of the session was about individual and organisational concern in losing regional identity and current well-developed networks and supervision groups, whilst also wishing to have better integration with the North larger patch. Recommendation made by attendees was the potential for 3-4 sub-regions inside of this region. It was suggested that these sub-regions could grow to include Primary and Private providers who need support establishing their systems and processes. These sub-regions could have a joint leadership (potential triumvirate) with chairs and vice chairs from secondary/ specialist provider, primary care and private provider. The triumvirate for each of the 3-4 sub-regions would then meet on a quarterly or biannual basis and then feedback into the sub-regions. There was also a suggestion of an annual large regional conference in the North which could be attended by all – focussed on integration. The latter part of the conference hosted the following sessions:

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- Dr Chris Turner, from ‘civility saves lives’ this session concerned values and behaviours, and specifically how incivility and poor behaviours effects patient safety, staff wellbeing and also speaking up. The link to this movements website is:- https://www.civilitysaveslives.com/

- Caroline Dinenage MP - Minister of State for Care, whose constituency also covers Gosport. Caroline focussed upon her support for efficacy and support for FTSU and ‘Just Culture’ approach across system.

- A Guardian and Trust Presentation from East Lancashire Hospitals – (Guardian - Jane Butcher) – they are the HSJ Award FTSU Awards winner and have completed substantial work concerning staff engagement, staff reward and FTSU. As a Trust we have plans to link in with this Trust to visit and share policies and practices to help our development.

- Dr Jo Sauvage – provided a focussed session discussing FTSU from a Commissioner perspective. - Dr Navina Evans - CEO at ELFT - talking about how important speaking up is from the perspective

of a Chief Executive. National FTSU Case Reviews - There have been 2 FTSU case reviews published by the National Guardians office (NGO), since the presentation of last Board Report. These case reviews have been at the Nottinghamshire Healthcare NHS Foundation Trust (published November 2018) and the Royal Cornwall Hospital (published December 2018). The NGO review make specific recommendations for how both Trusts can improve the support they provide to their staff, they are available upon the NGO website hosted by the CQC – accessible via this weblink: https://www.cqc.org.uk/national-guardians-office/content/case-reviews - Nottingham Case Review - A number of the report themes are unique to the Trust; however analysis

and exploration has been conducted by the RDaSH FTSU team in order to see any recommendations which could be considered for RDaSH in order to improve practice. From the recommendations made, improvements are being considered in terms of supporting staff who are suspended and also staff who have periods of long term sickness absence and flexible return. Discussions in regards to strengthening support have been held with the Human Resources Team and Staff Side Representatives.

- Royal Cornwall Case Review – Again a number of the recommendations made in this review are

unique to the Trust and issue explored. However through analysis there are learning points that will help shape development of RDaSH process, these particularly relate to: (1) the support for all staff to speak up through the range of different routes in RDaSH (not solely the FTSU team); (2) the use of and phrasing of non-disclosure / settlement agreements, (3) the approach all RDaSH managers and leads take when providing feedback after concerns have been raised to them and (4) exploration of the recommendations concerning ‘conflicts of interests’ that have been commented upon in the case review by the NGO.

National Advisory Working Group – The RDaSH Guardian has been approached by Dr Henrietta Hughes to for part of a small (20 person) Advisory Working Group. Membership has been agreed after Trust discussion. The group is formed of professionals from a range of diverse backgrounds and interests, and the group is designed to provide advice to the National Guardian, meeting on a quarterly basis in London starting from May 2019.

Section 5 - Recommendations

Within this paper details have been provided in terms of FTSU approaches, developments and concerns raised within RDaSH since the previous Board of Directors paper in December 2018. Internal and external data collection is summarised and presented in a way to Board of Directors to review Freedom to Speak Up arrangements, in terms of the actions taken regarding case management and monitoring as well as activities to promote leadership visibility and an encouragement for systemic approaches to concern raising. Within the next 6 months recommendations are made that the following work will be conducted in order to

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enhance FTSU approaches at RDaSH:- - FTSU team are focused upon working with leads in the organisation to focus upon the results of the

staff survey specifically focused upon the FTSU questions. The aim of this work is to support staff to feel more able to speak up and feel that they are responded to in a more compassionate way. The effectiveness of this work will be monitored via FTSU feedback and also the staff survey results that will come from the survey planned for Q3 2019.

- Further work within the Workforce and Organisational Development team to progress the integration of the FTSU Advocate Role and the Bullying and Harassment Officer role in the Trust. Policy changes will be made concerning this alignment of roles.

- Active links are being made with the FTSU team in Lancashire who presented at the National FTSU

Conference, in order to learn more about their approach to staff engagement and FTSU to see whether their work and policy changes could be replicated at RDaSH.

- Patient safety team work concerning ‘just cultures’ and ‘human factors’ is being progressed jointly

between the Nursing and AHP directorate, the cultural improvement team and the FTSU team.

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Appendix 1: “Guidance for boards on Freedom to Speak Up in NHS trusts and NHS foundation trusts” – Page 11&12 – Guardian Board Reports Reports are submitted frequently enough to enable the board to maintain a good oversight of FTSU matters and issues, and no less than every six months. Reports are presented by the FTSU Guardian or a member of the Trust’s local Guardian network in person. Reports include both quantitative and qualitative information and case studies or other information that will enable the board to fully engage with FTSU in their organisation and to understand the issues being identified, areas for improvement, and take informed decisions about action. Data and other intelligence are presented in a way that maintains the confidentiality of individuals who speak up. Board reports on FTSU could include: Assessment of issues

• information on what the trust has learnt and what improvements have been made as a result of Trust workers speaking up

• information on the number and types of cases being dealt with by the FTSU Guardian and their local network

• an analysis of trends, including whether the number of cases is increasing or decreasing; any themes in the issues being raised (such as types of concern, particular groups of workers who speak up, areas in the organisation where issues are being raised more or less frequently than might be expected); and information on the characteristics of people speaking up (professional background, protected characteristics)

Potential patient safety or workers experience issues • information on how FTSU matters relate to patient safety and the experience of workers,

triangulating data as appropriate, so that a broader picture of FTSU culture, barriers to speaking up, potential patient safety risks, and opportunities to learn and improve can be built

Action taken to improve FTSU culture

• details of actions taken to increase the visibility of the FTSU Guardian and promote the speaking up processes

• details of action taken to identify and support any workers who are unaware of the speaking up process or who find it difficult to speak up

• details of any assessment of the effectiveness of the speaking up process and the handling of individual cases

• information on any instances where people who have spoken up may have suffered detriment and recommendations for improvement

• information on actions taken to improve the skills, knowledge and capability of workers to speak up and to support others to speak up and respond to the issues they raise effectively

Learning and improvement

• feedback received by FTSU Guardians from people speaking up and action that will be taken in response

• updates on any broader developments in FTSU, learning from case reviews, guidance and best practice

Recommendations - suggestions of any priority action needed.

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ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST

Committee Name

Board of Directors

Agenda Item Paper J Date April 2019

Title of Paper CQC Staff Survey Results 2018

Decision

Assurance

Information X Board of Directors is asked to receive the CQC Staff Survey Results for 2018. Following feedback at the Quality Committee the following additions have been made to the paper - review to triangulate any trust held information/data in relation to the key themes which have seen a significant change or are being targeted for action in 2019/20 - the areas of focus have been mapped against the strategic ambitions - the highest and lowest performing teams have been identified. We will celebrate and review what the best performing teams/managers are doing and consider supporting the lowest performing teams with some external independent facilitated support.

Prepared by Carlene Holden, Head of Employee Relations

Presented by Rosie Johnson, Director of Workforce and Organisational Development

Delivery against

Strategic Goal(s) 1. To provide safe, effective, compassionate care X The NHS Staff Survey aims to gather information that will help the

Trust improve the working lives of our employees and in turn to provide better care for our patients. The NHS Staff survey also provides the Staff Family and Friends data for Quarter 3.

2. To attract, retain, support and develop the finest workforce X The NHS Staff Survey will help the Trust understand the views of our

workforce to develop the provision of training, supervision and PDR’s to maintain high performance. By responding to the feedback which our employees provide via the NHS Staff Survey this should have a position impact on both recruitment and retention.

3. To maintain financial stability

4. To work with partners to offer and deliver market-leading

services

5. To be an outstanding, well-led organisation X The NHS Staff Survey will help the Trust assess how we are

delivering the staff elements of the NHS Constitution as well as providing an opportunity for our employees to provide their views on working in the Trust and the areas which they would like to see improved. This contributes to the achievement of being a well-led Trust and ensuring statutory regulations are maintained.

Strategic Risk(s) Number Level of Assurance Number Level of Assurance

CQC Domain Safe X Effective X Caring X Responsive X Well-Led X

Impact Financial – There are no financial implications within this paper. Contractual – It is a contractual requirement to facilitate the NHS Staff Survey on an annual basis. Equality & Diversity – The NHS Staff Survey provides equality and diversity monitoring data, which facilitates the Trust reviewing the equality and diversity objectives/priorities for the forthcoming year. Quality – The Trust is benchmarked on the NHS Staff Survey both by the Care Quality Commission and also the LiA Scatter Map. The NHS staff Survey also highlights quality feedback for the Trust to consider. Workforce – Alongside the LiA Pulse check the NHS Staff Survey provides the workforce with the opportunity to share their views on their employment, managers and the care which we provide in an anonymous manner. The Trust chooses to survey the full eligible workforce rather than the core sample to provide all eligible employees with the opportunity to respond. IT – There are no IT implications identified within this paper. Statutory legislative requirements – There are no statutory legislative requirements identified within this paper

Previously Presented to

People Prep Meeting – 5 March 2019

Care Group Meetings – March 2019

Executive Management Team – 8 April 2019

Quality Committee – 16 April 2019. Following feedback from Quality Committee the paper has been updated to include the following information linkages to IR1s’ Trust Strategic Objectives and the top and worst performing teams

Appendices to Paper

Appendix One – LiA Scatter Map

Appendix Two – Trust results – RAG rated

Appendix Three - Corporate Workplan

Appendix Four – Areas of Focus – Detailed Analysis

CQC Staff Survey Results 2018 1.0 Purpose The purpose of this paper is to provide the Board of Directors with a summary of the 2018 CQC Staff Survey Results and to update on the proposed next steps. 2.0 Overview of 2018 Results The NHS staff survey is carried out on an annual basis between September and December. The decision was made to survey all applicable employees via a paper questionnaire. The Trusts comparator (benchmarking) group is Mental Health/Learning Disability and Community Trusts. A total of 45% of the Trust staff surveyed completed their 2018 questionnaire. This is comparable with the Trust’s benchmarking group which was also 45%.Trust response rate has increased by 6% compared to the 39% response rate which the Trust achieved in 2017. The staff survey for 2018 has been measured against 10 key themes as opposed to previous years where the measurement was against 32 key findings. All of the 10 themes are scored on a 0-10 scale where a higher score is more positive than a lower score. The theme scores are created by scoring question results and grouping the results together. The graph (1) below provides an overview of the 2018 Trust results (across the 10 key themes) against the national average from our comparator group and is further broken down in table 1 below which shows the Trust performance compared to the best and worst performing organisations under each of the key themes. Graph 1 - Overview of Trust CQC results 2018

0123456789

10

RDaSH

Average

Table 1 - Detailed breakdown of Trust results against comparators

The results demonstrate that the Trust is performing the same as or above the national average in 6 of the key themes which are as follows; Equality, Diversity and Inclusion – above national average Health and Wellbeing – above national average Morale - above national average Quality of Care - above national average Safe environment – bullying and harassment - above national average Staff engagement – same as the national average There are 4 areas for improvement which are detailed below however it is important to note that these are only marginally below the national average; Immediate Managers – same as our 2017 results Quality of Appraisals – positive increase compared to our 2017 results Safe environment – violence – negative decrease compared to our 2017 results Safety Culture – positive increase compared to our 2017 results The LiA Scatter map (which details how staff have rated the Trusts leadership and culture) for the 2018 staff survey results has been released and it is included at Appendix One. In relation to the national position, RDaSH are rated 110th/222 NHS providers which is an improvement of 16 places when compared to the 2017/18 results. When reviewed against our comparator group, RDaSH are ranked 12th/29 Trusts, which is an improvement of 3 places compared to the previous year. The areas of focus from the LiA Scatter map are safety culture and staff engagement, with safety culture being addressed in the latter sections of this report. In relation to staff engagement it should be noted that our rating for this year has improved (6.8 to 7.0) which is comparable to the average score (7.0) therefore we need to continue the good work on this area and strive to improve the rating to that which is currently categorised as best (7.5). The detailed analysis (question by question based on the Quality Health data) is contained in Appendix Two. The Trust results compared to the previous three years are detailed and then the Trust results compared to our comparator group. The results are then RAG rated to facilitate a visual comparison.

When comparing the 2018 Quality Health results against the Trust 2017 results

• 63% of the results improved • 19.6% of the results declined • 17.4% of the results stayed the same

The Trust results can be compared and analysed against the Trust values (detailed below) and the communication plan for 2019 will align the staff survey results with the Trust values

Equality, Diversity & Inclusion

Health & Wellbeing

Immediate Managers Morale

Quality of Appraisals

Quality of Care

Safe environment- Bullying & Harassment

Safe environment - Violence

Safety Culture

Staff engagement

Best 9.4 6.6 7.4 6.7 6.0 7.7 8.6 9.7 7.4 7.5

RDaSH 9.3 6.3 7.1 6.3 5.3 7.6 8.5 9.4 6.7 7.0

Average 9.2 6.1 7.2 6.2 5.5 7.4 8.2 9.5 6.8 7.0

Worst 8.5 5.6 6.9 6.0 4.8 7.0 7.6 9.2 6.4 6.7

3.0 Local Analysis It is not possible to directly compare the 32 key findings like for like from the 2017 results to the 10 theme scores however the results from 2017 have been grouped and themed in order to allow some comparisons to be made. The graph (2) below demonstrates the 2018 Trust results against the results from 2017. This is further broken down into the individual themes within table 2. Graph 2 - Trust results for 2017 compared to 2018

Table 2 – Detailed breakdown of Trust results between 2017 and 2018

*There is no comparator for morale in 2017 as this was a new set of questions for 2018. In summary the results are positive in that 5 of the 10 key themes have increased in comparison to 2017 and 1 remained the same. There is however 1 key theme which has changed to represent a significant negative change, which is Safe Environment – violence. Within this theme, three questions were asked with regard to physical violence at work. The response rate for Q12a – ‘in the last 12 months, how many times have you personally experienced physical violence at work from patients/ service users their relatives or other members of the public’, has increased the percentage for this theme from 11.6% in 2017 to 15.7% in 2018. This has resulted in the overall comparator score reducing from 9.5% in 2017 to 9.4% in 2018. For the remaining 2 questions in this theme, one remained the same (in the last 12 months how many times have you personally experienced physical violence at work from managers – remained at 0.5% which is the same as the national average) and the other is a positive decrease (In the last 12 months how many times have you personally experienced physical violence at work from colleagues – 1.6% to 1.2%).

Equality, Diversity & Inclusion

Health & Wellbeing

Immediate Managers *Morale

Quality of Appraisals

Quality of Care

Safe environment- Bullying & Harassment

Safe environment - Violence

Safety Culture

Staff engagement

2017 9.4 6.1 7.1 0 5.1 7.4 8.6 9.5 6.6 6.82018 9.3 6.3 7.1 6.3 5.3 7.6 8.5 9.4 6.7 7.0

0

2

4

6

8

10

Equality,Diversity &Inclusion

Health &Wellbeing

ImmediateManagers

Morale Quality ofAppraisals

Quality ofCare

Safeenvironment-

Bullying &Harassment

Safeenvironment -

Violence

Safety Culture Staffengagement

2017

2018

The remainder of the changes in the remaining 9 key themes were deemed ‘not significant’ changes (both positive and negative) and are as follows; Not statistically significant positive change:-

• Health and Wellbeing • Quality of Appraisals • Quality of Care • Safety Culture • Staff engagement • Immediate managers (remained the same)

Not statistically significant negative change:- • Equality, Diversity and Inclusion • Safe environment, Bullying and Harassment

In respect of the theme Equality, Diversity and Inclusion, the overall score was 9.4% for 2017 compared to 9.3% in 2018. This theme was made up of 4 questions, 2 of which contributed to the reduction in the overall percentage which were:- ‘In the last 12 months have you personally experienced discrimination at work from patients / service users, their relatives and other members of the public’ which has negatively increased from 3.0% in 2017 to 5.1% in 2018 and ‘Has your employer made adequate adjustments to enable you to carry out your work’ which has negatively reduced from 79% in 2017 to 74.6% in 2018. For the theme, Safe Environment – Bullying and Harassment, the overall theme score has reduced from 8.6% in 2017 to 8.5% in 2018. In comparison to 2017, out of the 3 questions asked, the percentages for all questions have negatively increased as follows; ‘In the last 12 months how many times have you personally experienced harassment, bullying or abuse at work from patients, service users their relatives or other members of the public’ the response has increased from 21.9% in 2017 to 25.2% in 2018. ‘In the last 12 months how many times have you personally experienced harassment, bullying or abuse at work from managers’ the response has increased from 8.3% in 2017 to 9.0% in 2018. ‘In the last 12 months how many times have you personally experienced harassment, bullying or abuse at work from other colleagues’ the response has increased from 11.8% in 2017 to 12% in 2018. It is not possible to compare the response for the theme Morale against the 2017 results as this theme compromises of a new set of questions which were added to the 2018 questionnaire. 4.0 Next Steps, Future Priorities and Targets Overall, the results have improved in comparison to 2017 in that 5 themes have seen a positive increase and one has remained the same. As such, a communication plan needs to be agreed in order to promote and celebrate this across the Trust. There will need to be detailed focus on the areas where the Trust’s score has decreased since 2017 which are Equality, Diversity and Inclusion, Safe environment – bullying and harassment and Safe environment – Violence (as highlighted in section 3.0) as well the

areas where the Trust was rated below the national average against the 2018 results (section 2.0) which are Immediate Managers, Quality of Appraisals and Safety Culture. The corporate workplan (which is still in development) is detailed in appendix three which summarises the work which is planned for 2019 to address the feedback and issues which our staff have highlighted via the staff survey. The primary focus of the corporate workplan is to support a communication strategy with the workforce to highlight the areas of focus from the staff survey(without all of the associated detail) to then update on a monthly basis on progress, to facilitate feedback on the actions and increase the engagement for the 2019 staff survey The detailed results for all questions and themes have been broken down by Care Group and have been RAG rated and have been shared with the Care Groups in order for them to explore these areas further. Each Care Group will also be asked to identify 2 key areas to focus on for improvement in 2019 and these key areas will be from the following key themes Immediate Managers Quality of Appraisals Safe environment – violence Safety Culture A review of other data held by the Trust has been explored in relation to the feedback from staff in the staff survey of an increase in staff reporting that they have experienced violence or bullying harassment from patients, relatives or members of the public. This has revealed that there has not been the same increase in the number of associated Human Resource or Serious Incident investigations related to this subject area however, there has been an increase in the number of incident reporting -IR1’s which has increased by 11% compared to 2017/18 (which is a higher increase than the increase reported via the staff survey results). From reviewing the CQC staff survey results which are available at both a Trust and Corporate/Care Group level suggested areas of focus are detailed below as the Care Group/Corporate results are below the Trust results

Areas of Focus Corporate Directorates

Children’s Care

Group

Doncaster Care Group

North Lincolnshire Care Group

Rotherham Care Group

Immediate Managers

✓ ✓

Quality of Appraisals

✓ ✓

Safe Environment - violence

✓ ✓ ✓

Safety Culture ✓ ✓ As part of the analysis work the highest performing and lowest performing teams have been identified within the Trust, to recognise, celebrate and share the good work which has been undertaken (for the highest performing teams) and to focus efforts on the teams where the results indicate there is significant room for improvement. This measurement has been undertaken by identifying the teams with the fewest number of red rated questions (best teams) and those with the highest number of red rated questions (worst teams). Highest Performing Teams Lowest Performing Teams Doncaster Care Group – Central Locality Team

Corporate – Estates

Children’s Care Group – Doncaster 0-5

Corporate - Logistics

Doncaster Care Group – Specialist Palliative Care and LTC

Joint 3rd Doncaster Care Group – Acute All Age Doncaster Care Group – North Locality Team

The highest performing teams will be celebrated across the Trust and consideration will be given to an independent team supporting the four teams which have been recognised as the lowest performing within the Trust, to address these areas of concern which employees have clearly highlighted to us. Within the key themes there are specific questions which require focus and these are summarised alongside the scores in Appendix Four. Should the Care Groups have any areas of concern which are outside of the above key themes they will also be asked to consider further action to address any specific concerns. The areas of focus can be mapped against the Trust’s six Strategic Ambitions, specifically Ambition One and Four which are highlighted below. By demonstrating the links to the wider trust agenda it is hoped that this will improve staff engagement and encourage employees to respond to the 2019 staff survey as they can easily identify the organisational linkages.

Equality, Diversion and Inclusion

Safety Culture Immediate Managers

Safe Environment Bullying & Harassment Violence

Quality of Appraisals

Appendix One

LiA Scatter Map

RDaSH

How to interpret the Scatter Map – the higher up you are, the better the Trust is performing against our peers, in the eyes of our employees. The further to the right the Trust is the more positive the Trend, year on year.

Question Number

Question 2016

Response 2017

Response 2018 Results

Comparator 2017*

Comparator 2018*

1Do you have face to face contact with patients/service users as part of your job? 85% 83% 86% 84% 84%

2a I look forward to going to work 58% 56% 56% 58% 59%2b I am enthusiastic about my job 72% 71% 73% 73% 75%2c Time passes quickly when I am working 76% 76% 75% 78% 78%

3aI always know what my work responsibilities are 84% 84% 84% 84% 85%

3b I am trusted to do my job 91% 90% 91% 91% 91%

3cI am able to do my job to a standard I am personally pleased with 82% 79% 83% 77% 78%

4aThere are frequent opportunities for me to show initiative in my role 73% 72% 73% 74% 74%

4bI am able to make suggestions to improve the work of my team/department 76% 75% 75% 78% 78%

4c

I am involved in deciding on changes introduced that affect my work area/team/department 51% 51% 52% 53% 54%

4dI am able to make improvements happen in my area of work 56% 54% 54% 58% 59%

4eI am able to meet all the conflicting demands on my time at work 46% 45% 48% 44% 46%

4fI have adequate materials, supplies and equipment to do my work 62% 61% 65% 58% 59%

4gThere are enough staff at this organisation for me to do my job properly 37% 33% 35% 32% 33%

4hThe team I work in has a set of shared objectives 74% 70% 71% 75% 75%

4iThe team I work in often meets to discuss the teams effectiveness 69% 67% 68% 69% 69%

4jI receive the respect I deserve from colleagues at work NA NA 75% NA 76%

5a The recognition I get for good work 58% 56% 61% 57% 62%

5b The support I get from my immediate manager 73% 72% 75% 73% 75%5c The support I get from my work colleagues 85% 82% 83% 85% 85%

5d The amount of responsibility which I am given 76% 73% 75% 75% 76%5e The opportunities I have to use my skills 73% 69% 73% 71% 72%

5fThe extent to which my organisation values my work 44% 44% 49% 43% 47%

5g My level of pay 42% 37% 42% 32% 38%

5h The opportunities for flexible working patterns 59% 57% 60% 58% 61%6a I have unrealistic time pressures NA NA 29% NA 25%

6b I have a choice in deciding how to do my work NA NA 62% NA 63%6c Relationships at work are strained NA NA 48% NA 51%

7aI am satisfied with the quality of care I give to patients/service users 84% 81% 84% 81% 81%

7bI feel that my role makes a difference to patients/service users 89% 86% 87% 89% 88%

7c I am able to deliver the care I aspire to 70% 68% 71% 65% 66%

8aMy immediate manager encourages me at work NA NA 75% NA 76%

8bMy immediate manager can be counted on to help with a difficult task at work 76% 73% 74% 76% 75%

8cMy immediate manager gives me clear feedback on my work 69% 66% 69% 68% 68%

8dMy immediate manager asks for my opinion before making decision that affect my work 58% 57% 58% 61% 61%

8eMy immediate manger is supportive in a personal crisis 77% 78% 79% 80% 80%

8fMy immediate manager takes a positive interest in my health and well-being 72% 73% 72% 74% 75%

8g My immediate manager values my work 74% 74% 74% 76% 77%

9a I know who the senior managers are here 87% 85% 89% 85% 86%

9bCommunication between senior management and staff is effective 43% 40% 41% 41% 43%

9cSenior managers here try to involve staff in important decisions 35% 36% 36%

9d Senior managers act on staff feedback 35% 33% 35% 32% 35%

10aHow many hours are you contracted to work - up to 29 hours? 24% 22% 23% 23% 22%

10b

On average, how many additional paid hours do you work per week for this organisation, over and above your contracted hours? 25% 24% 27% 22% 23%

10c

On average, how many additional unpaid hours do you work per week for this organisation, over and above your contracted hours? % working additional unpaid hours 57% 57% 56% 61% 59%

11aDoes your organisation take positive action on health and well-being? 92% 90% 91% 91% 91%

11b

In the last 12 months have you experienced musculoskeletal (MSK) problems as a result of work activities? 18% 19% 19% 22% 23%

Trust Results

11cDuring the last 12 months have you felt unwell as a result of work related stress? 37% 39% 38% 39% 40%

11d

In the last three months have you ever come to work despite not feeling well enough to perform your duties? 55% 58% 57% 56% 56%

11eHave you felt pressure from your manager to come to work? 19% 21% 20% 20% 20%

11fHave you felt pressure from colleagues to come to work? 15% 15% 14% 16% 16%

11gHave you put yourself under pressures to come to work? 92% 93% 92% 93% 93%

12a

In the last 12 months how many times have you personally experienced physical violence at work from patients/service users, their relatives or other members of the public 14% 12% 16% 14% 14%

12b

In the last 12 months how many times have you personally experienced physical violence at work from managers 1% 1% 0% 1% 0%

12c

In the last 12 months how many times have you personally experienced physical violence at work from other colleagues 2% 2% 1% 2% 1%

12d

The last time you experienced physical violence at work, did you or a colleague report it? 89% 90% 91% 88% 86%

13a

In the last 12 months how many times have you personally experienced harassment, bullying or abuse at work from patients/service users, their relatives or other members of the public 23% 22% 25% 26% 26%

13b

In the last 12 months how many times have you personally experienced harassment, bullying or abuse at work from managers 8% 8% 9% 10% 10%

13c

In the last 12 months how many times have you personally experienced harassment, bullying or abuse at work from other colleagues 13% 12% 12% 15% 15%

13d

The last time you experienced harassment, bullying or abuse at work, did you or a colleague report it? 63% 61% 66% 57% 58%

14

Does your organisation act fairly with regard to career progression/promotion, regardless of ethnic background, gender, religion, sexual orientation, disability or age? 90% 88% 91% 87% 87%

15a

In the last 12 months have you personally experienced discrimination at work from any of the following - patients/service users, their relatives or other members of the public 3% 3% 5% 6% 6%

15b

In the last 12 months have you personally experienced discrimination at work from any of the following - manager/team leader or other colleagues 4% 5% 5% 6% 6%

15cOn what grounds have you experienced discrimination - ethnic background 15% 9% 16% 35% 30%On what grounds have you experienced discrimination - gender 28% 20% 24% 20% 19%On what grounds have you experienced discrimination - religion 3% 4% 4% 5% 5%On what grounds have you experienced discrimination - sexual orientation 7% 7% 5% 5% 5%On what grounds have you experienced discrimination - disability 14% 13% 14% 9% 9%On what grounds have you experienced discrimination - age 28% 27% 28% 20% 20%On what grounds have you experienced discrimination - other 39% 37% 36% 28% 28%

16a

In the last month have you seen any errors, near misses, or incidents that could have hurt staff? 14% 12% 17% 15% 15%

16b

In the last month have you seen any errors, near misses, or incidents that could have hurt patients/service users? 14% 16% 19% 18% 20%

16c

The last time you saw an error, near miss or incident that could have hurt staff or patients/service users, did you or a colleague report it? 96% 97% 93% 96% 96%

17aMy organisation treats staff who are involved in an error, near miss or incident fairly 52% 51% 54% 53% 58%

17bMy organisation encourages us to report errors, near misses or incidents 87% 87% 87% 89% 89%

17c

When errors, near misses or incidents are reported, my organisation takes action to ensure that they do not happen again 71% 67% 69% 69% 71%

17d

We are given feedback about changes made in response to reported errors, near misses and incidents 61% 54% 55% 59% 62%

18aIf you were concerned about unsafe clinical practice, would you know how to report it? 97% 96% 97% 96% 96%

18bI would feel secure about raising concerns about unsafe clinical practice 72% 70% 69% 72% 73%

18cI am confident that my organisation would address my concern 61% 60% 59% 59% 61%

19a

In the last 12 months, have you had an appraisal, annual review, development review or knowledge and Skills Framework (KSF) development review? 89% 88% 93% 92% 93%

19bDid it help you to improve how you do your job? 74% 72% 72% 73% 72%

19cDid it help you agree clear objectives for your work? 85% 83% 83% 85% 85%

19dDid it leave you feeling that your work is valued by your organisation? 77% 75% 77% 75% 77%

19eWere the values of your organisation discussed as part of the appraisal process? 71% 70% 73% 82% 83%

19fWere any training, learning or development needs identified? 66% 64% 67% 68% 70%

19gDid your manager support you to receive this training, learning or development? 95% 95% 95% 92% 93%

20Have you had any training, learning or development in the last 12 months? 75% 73% 77% 75% 72%

21aCare of patients/service users is my organisations top priority. 73% 71% 74% 73% 75%

21bMy organisation acts on concerns raised by patients/service users 77% 74% 74% 74% 75%

21cI would recommend my organisation as a place to work 57% 54% 61% 56% 60%

21d

If a friend or relative needed treatment I would be happy with the standard of care provided by the organisation 65% 62% 67% 65% 67%

22aIs patient/service user experience feedback collected within your directorate/department? 96% 95% 95% 94% 94%

22b

I receive regular updates on patient/service user experience feedback in my directorate/department 62% 61% 60%

22c

Feedback from patients/service users is used to make informed decisions within my directorate/department 57% 56% 56% 54% 54%

23a I often think about leaving this organisation NA NA 28% NA 29%

23bI will probably look for a job at a new organisation in the next 12 months NA NA 22% NA 22%

23cAs soon as I can find another job, I will leave this organisation NA NA 14% NA 15%

23d

If you are considering leaving your current job, what would be your most likely destination NA NA NA NA NA

I am not considering leaving my current job NA NA 50% NA 49%I would want to move to another job within this organisation NA NA 13% NA 13%I would want to move to a job in a different NHS Trust/organisations NA NA 18% NA 17%I would want to move to a job in healthcare, but outside the NHS NA NA 3% NA 4%I would want to move to a job outside healthcare NA NA 7% NA 7%I would retire or take a career break NA NA 10% NA 10%

28a

Do you have any physical or mental health conditions, disabilities or illnesses that have lasted or are expected to last for 12 months or more? - Yes NA 20% 22% 18% 22%

28b

Has your employer made adequate adjustment(s) to enable you to carry out your work? NA 79% 75% 78% 76%

The Trust response rate for 2017 was 39%The Trust response rate for 2018 was 45%

The response in 2018 for out comparator group was 45.5%

N.B. These results are not the official CQC results, they are the Quality Health results which represent our additional sample.

*Comparator = Combined Mental Health/Learning Disability

Better than 2017 result

Better than comparator result

Worse than 2017 result

Worse than comparator result

Same as 2017 result

Same as comparator result

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2018 Staff Survey Results – Corporate Workplan

Key Theme

Target for 2019

Developments for 2019/20

Equality, Diversity and Inclusion

Improve results to the Best category – currently 9.3 to 9.4

• Dedicated workstream to review the zero tolerance approach across the Trust

• Relaunch of the national zero tolerance campaign • Managerial guidance/workshops on disabilities and reasonable

adjustments • Launch of the new Sickness Absence Policy which includes guidance

on reasonable adjustments and the inclusion of disability leave

Safe environment – bullying and harassment/Safe environment – Violence

Improve results to the Best category – currently 8.5 to 8.6

• Dedicated workstream to review the zero tolerance approach across the Trust

• Relaunch of the national zero tolerance campaign • Relaunch and expansion of the Personal Harassment Contact

Officers • Launch of the Trust mediation service to address issues timely

before they escalate • Managers training ‘handling difficult conversations’ • Managers training and guidance documents for resolving issues

timely and to prevent escalation

Immediate Managers

To improve results to the national average 7.1 to 7.2

Quality of Appraisals

To improve results to the national average 5.3 to 5.5

2018 Staff Survey Results – Corporate Workplan (2)

Key Theme

Target for 2019

Developments for 2019/20

Immediate Managers

To improve results to the national average 7.1 to 7.2

• Implementation of the RDaSH way. • Staff consultation events • Introduction of Cultural Ambassadors • Launch of a digital platform to suggest ideas/improvements • Revised PMO approach for low risk/quick implementation ideas • Comprehensive Health and Wellbeing programme • Recognition for good work

Quality of Appraisals

To improve results to the national average 5.3 to 5.5

• The area which requires improvement is the discussion of the Trust values as part of the appraisal process.

• Revised PDR policy to be launched which includes as reminder on the PDR form for the Trust values to be discussed.

• PDR training to be updated. • Quarterly reminder emails to be sent to managers to remind them of this

requirement

2018 Staff Survey Results – Corporate Workplan (3)

Key Theme

Target for 2019

Developments for 2019/20

Safety Culture To improve results to the national average 6.7 to 6.8

• Relaunch and expansion of the FTSU and Personal Harassment Contact Officers. • Board development session focussing on FTSU and the staff survey feedback

associated with the 6 FTSU questions. • Introduction of a work stream to understand the significant increase in staff

reporting experience of harassment, bullying or abuse from patient, service users or their relatives to identify further work which can be undertaken to manage this client group and to equip employees with the skills to further manage situations to prevent them from escalating and also to manage situations where they are experiencing this unacceptable behaviour.

• Review of the national material which is available to support this work stream, zero tolerance.

• Communication campaign re IR1 reporting – automated feedback now provided (previously when an IR1 was submitted feedback wasn't automatically provided)

• Quarterly safety publication which details lessons learnt from investigations, SI’s, complaints and IR1’s

• Launch of the RDaSH way – cultural improvement

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Areas of Focus – Detailed Analysis Equality, Diversion and Inclusion The following questions are the Trust’s area on focus within the Equality, Diversion and Inclusion theme.

Areas of Focus – Detailed Analysis Safe Environment - Bullying & Harassment - Violence The following questions are the Trust’s area on focus within the themes, Safe Environment – Bullying and Harassment and Safe Environment – Violence. theme.

Areas of Focus – Detailed Analysis Immediate Managers The following questions are the Trust’s area on focus within the Immediate Managers theme.

Areas of Focus – Detailed Analysis Quality of Appraisals The following question is the Trust’s area on focus within the Quality of Appraisal theme.

Areas of Focus – Detailed Analysis Safety Culture The following questions are the Trust’s area on focus within the Safety Culture theme.

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ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST

Committee Name

Board of Directors-PUBLIC

Agenda Item

Paper K Date 16 April 2019

Title of Paper

Mortality Quarterly Report - Quarter 4 2018/2019 (with focus on data Quarter 3 : October - December 2018)

Decision

Assurance

X In relation to mortality surveillance and management in RDaSH

Information

Prepared by

Dr Navjot Ahluwalia, Executive Medical Director

Presented by

Dr Navjot Ahluwalia, Executive Medical Director

Delivery against

Strategic Goal(s)

1. To provide safe, effective, compassionate care X

2. To attract, retain, support and develop the finest workforce

3. To maintain financial stability

4. To work with partners to offer and deliver market-leading services

5. To be an outstanding, well-led organisation X

Strategic Risk(s)

Number Level of Assurance Number Level of Assurance

1.1 5.1

5.2

CQC Domain

Safe X Effective Caring Responsive Well-Led X

Impact

Previously Presented to

Quality Committee 16 April 2019 Points noted by the Quality Committee

1. Roll out of training to staff in Care Groups on the new mortality module and the revised Learning from Deaths process to be completed before end May 2019. New mortality module would not be switched on until staff trained. Planned switchover to the new system on 3 June 2019. Up to that point the existing system for managing deaths will continue which staff are familiar with.

2. Updated 360 Assurance Internal Audit action plan has been updated and discussed at Executive Management Team on 15 April 2019. It has been sent to Internal Audit. This will be presented to the Quality Committee once Internal Audit has responded.

3. The Quarter 2 2019-2020 Mortality Report to the Board will focus on

data in Quarter 1 and will start to provide data as outlined within the revised Learning from Deaths policy.

Appendices to Paper

MORTALITY QUARTERLY REPORT – QUALITY COMMITTEE APRIL 2019

QUARTER 4 2018/2019

(DATA FOCUS QUARTER 3 2018/2019)

Introduction The Medical Director chairs the monthly Mortality Surveillance Group (MSG). On a quarterly basis he provides a report to the Quality Committee (QC). After his report has been considered by the QC it is then forms the basis of the Medical Director’s Quarterly Report to the Board of Directors (Public). This report provides the Quality Committee with salient features and issues in relation to mortality surveillance management with a focus on data Quarter 3 (October -December) 2018-2019 and other significant additional matters since then that the Medical Director wishes to highlight. In terms of quoracy at the Mortality Surveillance Group:

October 2018: quorate

November 2018: not quorate as no representative from the Childrens Care Group

December 2018: not quorate as no representative from the Doncaster care Group This will continue to be monitored and reported in the Quarterly Report to the Quality Committee. Quarter 3 2018/2019 Data and Issues 1. Review of unexpected deaths in North Lincolnshire November 2017 - October 2018 This review was actioned by the North Lincolnshire Care Group following a concern raised by a general practitioner surgery in terms of the referral of two patients who had died in circumstances suggestive of suicide. In addition the Care Group identified a number of serious incidents involving the psychiatric Access and Hospital Liaison team where suicide was suspected. The review was conducted jointly by Sharon Greensill, Trust Mortality Lead and Wendy Fisher, Associate Nurse Director in the North Lincolnshire Care Group. A total of 8 deaths were identified as suspected suicides. At the time of the review in November 2018, 6 serious incident investigations had completed and 2 were ongoing. The 2 ongoing investigations involved a review of demographic data. The following is a summary of the review’s findings:

5 patients were under the care of the Access Team/Hospital Liaison Team; 1 patient was an inpatient; 1 patient under the care of the Early Intervention Psychosis service; 1patient in the Recovery Team. National data highlights an increasing number of suicides in patients under crisis resolution/home treatment teams. Since 2007 there have been more patient suicides in

these teams than inpatient services reflecting the fact that home treatment should be seen as an alternative to inpatient care in line with National guidance

5 patients were male and 3 females. National data reveals that approximately ¾ of suicides occur in males.

4 patients did not have a diagnosis; 2 were related to substance misuse; 1 depression; 1 cognitive impairment

The fact that patients did not have a diagnosis is not unusual in access and hospital liaison services as their private primary role is to assess before arriving at the diagnosis (if this is possible).

Based on the data available 2 deaths occurred by hanging; 2 by jumping from a height; one overdose and one cutting the wrists Nationally the most common method of suicide is hanging/strangulation followed by self-poisoning.

Relationship breakdown had occurred in 4 patients with difficulties accessing children in 2 of these cases (both males) A previous deep dive into substance misuse service deaths in RDaSH highlighted that recent life events (which will include relationship breakdowns) have been linked to the eventual suicide. The Royal College of Psychiatrists have stated that relationship breakdown is the single most likely because of depression in males. In addition men have significant social upheaval after breakdown involving children because they often have to move home, there is a significant financial burden incurred and may lose touch with their children.

Good practice identified

Four of the SI reports identified high quality assessments. In one case a previous access practitioner with knowledge of a patient was invited to play a part during the assessment.

In one case the robust a carefully considered reintegration plan following prolonged inpatient stay

Key areas for improvement

Referral pathways: 3 SI reports identified a need to improve the pathway from the Access Team to the Early Intervention Psychosis service in terms of communication and joint working

Triage documentation: 3 SI reports identified that documents required more robust completion

Carer engagement: a need to consistently record next of kin details to ensure timely engagement families. The families need to be consistently involved where patient has given consent for this involvement.

Key actions from learning

The North Lincolnshire Care Group has developed service improvement plan to address all of the key areas for improvement

Skill mix in the Access Team is been reviewed to ensure staff with older adults experience/ expertise is included

The Team Manager of the Access Team reviews Triage outcomes

The North Lincolnshire Care Group has compared processes and systems with the Doncaster Access Team Service Manager

2. Northern Alliance Involvement

The Trust Mortality Lead attends the Northern Alliance meetings to compare policies, processes and emerging themes. The Executive Medical Director has agreed that mortality data should be shared with this group to enhance learning. The Northern Alliance will undertake focused work over the next 12 months on deaths related to clozapine and choking, both of which have been issues flagged up at RDaSH Mortality meetings. 3. Monthly review of all mortality reviews and structured judgement reviews by Trust

Mortality Lead and Executive Medical Director

This was initiated to address one of the concerns raised in the 360 Assurance Internal Audit report on learning from deaths produced in 2018 pending the implementation of systems and process described within the Learning from Deaths policy ratified 28 March 2019.

This review process started in October 2018 to provide assurance regarding review quality of the currently used tools and will continue until the new processes take over.

4. Support for a young person

In December 2018 the Committee received assurance that a friend of a person who had taken their own life had received appropriate support. This highlights the proactive good practice of CAMHS services in RDaSH. National guidance expects robust and compassionate family or carer involvement after the death of a loved one.

5. Data relating to RDaSH deaths in Quarter 3 2018-2019 Deaths in scope are identified on page 31 of the 2017-2019 Learning from Deaths Trust policy (which was the guidance document in place at that time): (https://www.rdash.nhs.uk/46897/learning-from-deaths-policy-the-right-thing-to-do/

0

1

2

3

4

5

6

7

8

9

AMH

LD

OPMH

D&A

Total number of deaths reported by Specialty

0

2

4

6

8

10

12

14

Doncaster

Rotherham

North Lincs

Children's

Total number of deaths reported by Care Group

0

2

4

6

8

10

12

Total number of deaths reported by age range

Age group <18

Age group 18-24

Age 25-34

Age group 35-44

Age group 45-64

Age group >65

Month Total number of deaths reported

Total Number of deaths by Care Group

Su

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on

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Gender Age Group

No

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No

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Ch

ild

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’s

M F <18

18-24

25-34

35-44

45-64

>65

Dec 2018 9 7 2 0 0 1 0 3 6 5 4 0 0 1 2 2 4 9 4 6 1 0 1 4

Nov 2018 12 7 3 2 0 0 0 1 11 8 4 0 1 0 2 5 4 12 8 3 2 1 5 8

Oct 2018 11 6 4 1 0 0 0 3 8 5 6 0 0 1 2 5 3 11 6 6 2 0 4 6

Sept 2018 15 9 2 3 1 0 0 2 13 9 6 1 0 0 2 3 9 15 9 8 1 1 6 8

Aug 2018 6 4 1 1 0 0 0 3 3 3 3 0 0 0 0 2 4 6 3 5 1 2 0 2

July 2018 12 7 2 2 1 0 0 2 10 4 8 1 0 2 2 7 0 12 9 9 3 0 2 5

Jun 2018 12 10 2 0 0 1 0 2 10 9 3 0 0 3 1 6 2 12 9 5 7 0 2 8

May 2018 9 4 3 2 0 0 0 0 9 4 5 0 0 1 2 4 2 9 6 2 7 0 2 8

Apr 2018 10* 5 3 2 0 2 0 1 9 3 7 0 1 3 0 3 3 11* 11 2 8 1 5 9

Mar 2018 8 6 2 0 0 1 0 0 8 5 3 0 1 2 2 2 1 8 0 8 0 4 8

Feb 2018 5 4 1 0 0 0 0 0 5 3 2 0 0 0 1 3 1 5 3 2 0 1 3

Jan 2018 18 12 5 1 0 2 16 11 7 0 0 0 3 11 4 18 3 5 12

Dec 2017 14 11 2 1 0 2 12 8 5 0 0 1 2 6 5 14 2 5 5**

Nov 2017 8 3 3 2 0 1 7 6 6 0 2 2 4 0 8 0 4 6

Oct 2017 6 3 2 1 0 1 5 3 3 0 1 1 1 3 6 0 2 3

6. Current Position (as of April 2019) in the Progress of Mortality Reviews reported in Quarter 1 – Quarter 2 2018-2019

The table below lists all deaths reported by IR1s Quarter 1 2018/19

IR1 number

Incident date

Care Group

Service Level of Investigation required

Date SI due Status

106632 01/04/2018

Rotherham IAPT Serious Incident – 2018/10342

19/07/2018 Completed

100501 01/04/2018 Rotherham The Glade Structured Review

N/A Completed

100566 03/04/2018 North Lincs

Community Mental Health

Serious Incident 04/07/2018 Completed

100754 11/04/2018 North Lincs

Early Intervention Team

Serious Incident 10/07/2018 Completed

100774 11/04/2018 Doncaster Drug & Alcohol Structured Review

N/A Completed

100792 12/04/2018 Rotherham Community Access Team

Serious Incident 10/07/2018 Completed

100962 18/04/2018 Rotherham Community Therapies - Intensive

Serious Incident 16/07/2018 Completed

101132 24/04/2018 Doncaster Recovery Team Structured Review

N/A Completed

101183 26/04/2018 Doncaster DN – East Incident Appraisal

N/A Completed

101174 26/04/2018 Doncaster 32/34 Gardens Lane

Incident Appraisal

N/A Completed

101269 27/04/2018 Doncaster Drug & Alcohol Serious Incident 27/07/2018 Completed

101524 09/05/2018 Doncaster Drug & Alcohol Structured Review

N/A Completed

101582 10/05/2018 North Lincs

Mulberry House Serious Incident 06/08/2018 Completed

101965 11/05/2018 Rotherham Social Inclusion Team

Structured Review

N/A Completed

101729 15/05/2018 Doncaster Drug & Alcohol Structured Review

N/A Completed

101797 18/05/2018 Doncaster Social Inclusion Team

Serious Incident Investigation

19/09/2018 Completed

101861 21/05/2018 Rotherham Community Therapies - Intensive

Serious Incident 20/08/2018 Completed

102658 26/05/2018 North Lincs

Care Group Management Team

Structured review

N/A Completed

102110 30/05/2018 Rotherham Community Therapies

Incident Appraisal

N/A Completed

102152 31/05/2018 Doncaster DN - North Incident Appraisal

N/A Completed

102268 01/06/2018 Doncaster Social Inclusion Team

Incident Appraisal

N/A Completed

102305 06/06/2018 Doncaster Assertive Outreach

Structured review

N/A Completed

IR1 number

Incident date

Care Group

Service Level of Investigation required

Date SI due Status

102368 08/06/2018 Doncaster DN - South Incident Appraisal

N/A Completed

102357 08/06/2018 Doncaster Social Inclusion Team

Incident Appraisal

N/A Completed

102422 & 102419

10/06/2018 Rotherham Goldcrest Ward Serious Incident 05/09/2018 Structured Review & SI Completed

102593 18/06/2018 Doncaster Drug & Alcohol Structured Review

N/A Completed

102826 20/06/2018 Doncaster Drug & Alcohol Structured Review

N/A Completed

102721 22/06/2018 Doncaster DN – North

Incident Appraisal

N/A Completed

102790 23/06/2018 Doncaster Drug & Alcohol Structured Review

N/A Completed

102798 25/06/2018 Rotherham The Brambles Serious Incident - 2018/17866

15/10/2018 Structured review and SI completed.

102866 27/06/2018 Doncaster Drug & Alcohol Structured Review

N/A Completed

102926 29/06/2018 Doncaster DN - North Incident Appraisal

N/A Completed

The table below lists all deaths reported by IR1s during Quarter 2 2018/19.

IR1 number

Incident date

Care Group

Service Level of Investigation required

Date SI due (if applicable)

Status

103267 03/07/2018 Doncaster DN - Central Incident Appraisal

N/A Completed

103095 04/07/2018 Doncaster DN - South Incident Appraisal

N/A Completed

103084 05/07/2018 Doncaster Drug & Alcohol Incident Appraisal

N/A Completed

103117 05/07/2018 Doncaster Drug & Alcohol Incident Appraisal

N/A Completed

103181 06/07/2018 Children's CAMHS Structured review

N/A Structured review completed Ongoing Coroners investigation

103178 09/07/2018 Doncaster Drug & Alcohol Incident Appraisal

N/A Completed

103237 11/07/2018 North Lincs

Recovery Team Incident Appraisal

N/A Completed

103268 11/07/2018 Doncaster Drug & Alcohol Structured review

N/A Completed

105776 14/07/2018 North Lincs

Recovery Team Structured review

(Reported Oct 18)

Ongoing

103382 17/07/2018 North Lincs

Recovery Team Incident Appraisal

N/A Completed

IR1 number

Incident date

Care Group

Service Level of Investigation required

Date SI due (if applicable)

Status

103447 18/07/2018 Rotherham Community Access Team

Structured Review

N/A Completed

104017 21/07/2018 Rotherham Community Therapies - Intensive

Incident Appraisal

N/A Completed

103600 23/07/2018 Doncaster Recovery Team Incident Appraisal

N/A Completed

104349 25/07/2018 Rotherham Recovery Team Incident Appraisal

N/A Ongoing

103881 27/07/2018 Doncaster Recovery Team Incident Appraisal

N/A Completed

104324 30/07/2018 North Lincs

Community Access Team

Serious Incident reported 2018/20246

13/11/2018 Completed

103754 30/07/2018 Rotherham Assertive Outreach

Incident Appraisal

N/A Completed

104599 07/08/2018 Doncaster CTLD LeDeR N/A To be completed by DBHFT

104047 10/08/2018 North Lincs

Recovery Team Incident Appraisal

N/A Completed

104138 13/08/2018 Rotherham Liaison And Diversion

Structured review

N/A Structured review completed Ongoing Coroners investigation

104230 17/08/2018 Doncaster Community Intermediate Care Team

Incident Appraisal

N/A Completed

104339 21/08/2018 Doncaster DN - East Incident Appraisal

N/A Completed

104437 23/08/2018 Doncaster 32/34 Gardens Lane

Incident Appraisal

N/A Completed

104915 23/08/2018 North Lincs

Community Access Team

Structured review

N/A Ongoing

104681 03/09/2018 Doncaster DN - North Incident Appraisal

N/A Completed

104806 05/09/2018 Doncaster Drug & Alcohol Incident Appraisal

N/A Completed

104765 07/09/2018 Rotherham CMHT - Elderly Incident Appraisal

N/A Completed

105145 12/09/2018 Doncaster Social Inclusion Team

Incident Appraisal

N/A Completed

104854 12/09/2018 Rotherham Community Therapies

Incident Appraisal

N/A Ongoing

105264 14/09/2018 North Lincs

OPMHS Liaison Team

Serious Incident 28/12/2018 Completed

104991 14/09/2018 Doncaster Drug & Alcohol Structured review

N/A Completed

104947 16/09/2018 Doncaster 1/2 Howbeck Close

Serious Incident 11/12/2018 Ongoing – extension agreed.

IR1 number

Incident date

Care Group

Service Level of Investigation required

Date SI due (if applicable)

Status

105002 17/09/2018 Doncaster Recovery Team Serious Incident

14/12/2018 Completed

105006 17/09/2018 North Lincs

Community Access Team

Serious Incident 12/12/2018 Completed

104969 17/09/2018 Doncaster DN - East Incident Appraisal

N/A Completed

105147 19/09/2018 Doncaster Social Inclusion Team

Incident Appraisal

N/A Completed

105110

22/09/2018 Children's CAMHS Serious Incident 17/12/2018 Completed

105157 23/09/2018 North Lincs

OPMHS Liaison Team

Serious Incident 19/12/2018 Completed

105439 29/09/2018 Doncaster Social Inclusion Team

Incident Appraisal

N/A Completed

The table below lists all deaths reported by IR1s during Quarter 3 2018/19.

IR1 number

Incident date

Care Group

Service Level of Investigation required

Date SI due (if applicable)

Status

105409 03/10/2018 Doncaster Assertive Outreach team

Structured Review escalated to SI - 2018/28130

21/02/2018 Structured review Completed SI Ongoing

105408 08/10/2018 Rotherham Recovery Team

Incident Appraisal

N/A Ongoing

105468 10/10/2018 Doncaster Drug & Alcohol

Incident Appraisal

N/A Completed

105582 13/10/2018 Doncaster Community Intermediate Care Team

Incident Appraisal

N/A Completed

105618 15/10/2018 Doncaster Drug & Alcohol Structured Review

N/A Completed

105660 18/10/2018 Doncaster Drug & Alcohol

Incident Appraisal

N/A Completed

105742 21/10/2018 Rotherham Hospital Liaison Team

Serious Incident – 2018/25542

21/01/2018 Ongoing – extension agreed

105833 24/10/2018 North Lincs

Community Mental Health

Incident Appraisal

N/A Ongoing

105813 24/10/2018 Doncaster Drug & Alcohol

Incident Appraisal

N/A Completed

105949 28/10/2018 Rotherham Community Access Team

Serious Incident - 2018/26078

28/01/2018 Completed

106006 31/10/2018 Rotherham Goldcrest Ward Serious Incident - 2018/26655

04/02/2018 Ongoing – extension agreed

106110 02/11/2018 Rotherham Early Intervention Team

Serious Incident - 2018/26951

07/02/2019 Completed

106351 05/11/2018 North Lincs

POIESIS No investigation required

N/A N/A

106107 06/11/2018 Rotherham Community Access Team

Serious Incident – 2018/26630

04/02/2019 Completed

IR1 number

Incident date

Care Group

Service Level of Investigation required

Date SI due (if applicable)

Status

106144 07/11/2018 Rotherham Hospital Liaison Team

Serious Incident - 2018/26955

07/02/2019 Completed

106266 12/11/2018 Doncaster Cherry Tree Court

Serious Incident - 2018/27049

07/02/2019 Completed

106381

16/11/2018 Doncaster DN - South Incident Appraisal

N/A Completed

106866

16/11/2018 Doncaster Drug & Alcohol No investigation required

N/A N/A

106503

21/11/2018 Doncaster Recovery Team Structured Review escalated to Serious Incident 2019/524

03/04/2019 Ongoing

106489

21/11/2018 Doncaster DN - South Incident Appraisal

N/A Completed

107283

24/11/2018 Doncaster Drug & Alcohol Incident Appraisal

N/A Completed

106624 26/11/2018 Doncaster Community Access Team

Serious Incident – 2018/28218

22/02/2018 Ongoing

106727 30/11/2018 North Lincs

CTLD Not an RDASH investigation

N/A RDASH timeline completed

106759 02/12/2018 Doncaster Community Intermediate Care Team

Incident Appraisal

N/A Completed

106806 04/12/2018 Doncaster DN - South DRI Investigation N/A N/A

106995 09/12/2018 Doncaster Community Therapies - Intensive

Incident Appraisal

N/A Completed

107031 11/12/2018 Rotherham Recovery Team Structured Review requested

N/A Ongoing

107201 17/12/2018 Doncaster Coniston Lodge Incident Appraisal

N/A Completed

107412 26/12/2018 Doncaster Community Therapies - Intensive

Serious Incident - 2019 377

01/04/2019 Ongoing

107414 27/12/2018 Doncaster Drug & Alcohol Incident Appraisal

N/A Completed

107419 27/12/2018 Rotherham Community Therapies - Intensive

Incident Appraisal

N/A Ongoing

107503 28/12/2018 Doncaster DN - East Incident Appraisal

N/A Completed

Issues for the Quality Committee to note in Quarter 4 2018-2019 7. Learning from Deaths Policy (Version 2)

Considerable work has been undertaken over the last 6 months on developing new Learning from Deaths policy. This was required not only because of a 6 month extension to the previous policy after September 2018 (the final month for the shelf life of the previous policy) but also to deal with assurance gaps highlighted in a 2018 360 Assurance Internal Audit report. The new policy was ratified by the Board of Directors on 28 March 2019. Staff training and engagement to implement the new policy successfully will be rolled out to be completed by end of May 2019. This will involve demonstration of the system to team leaders, Care Group Directors Associate Nurse Directors and Associate Medical Directors to ensure that they are aware of the new system. Structured Judgement Reviewers will be trained in the new methodology which will be a ‘Train the Trainers’ system. The Ulysses incident recording system will now be finally reconfigured taking into account the mortality module that has been developed in advance of the new policy being ratified. The key performance indicators within the Learning from Deaths policy will be monitored on a monthly basis by the Mortality Surveillance Group. In the period up to end May 2019 staff will continue to use the existing system which they are familiar with. There will not be double running of two systems. It is planned that the new system will go live 3 June 2019. The Executive Medical Director will start to provide data on the revised Learning from Deaths processes in his Quarter 2 2019-2020 report which focuses on Quarter 1 data.

8. Internal Audit 360 Assurance

The Executive Medical Director has updated the action plan. The vast majority of the action points are addressed through the new Learning from Deaths policy ratified at the Board of Directors 28 March 2019. This updated action plan has been presented to the Executive Management Team for assurance and comment on 15 April 2019. Subsequently it has been submitted to 360 Assurance Internal Audit. It will be presented to the Quality Committee for assurance once Internal Audit has considered it. Dr Navjot Ahluwalia Executive Medical Director April 2019

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ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST

Committee Name Board of Directors

Agenda Item L Date 25 April 2019

Title of Paper Extreme Risk Report

Decision

Assurance The Risk Register Update provides assurance that operational risks

(including the extreme risks) are being managed. The Board of Directors is asked to:

note the content;

raise query where required;

raise any risks identified through busines discussed at the meeting.

Information

Prepared by Jane Charlesworth, Risk and Assurance Officer Executive Leads

Presented by Phil Gowland, Board Secretary/Director of Corporate Assurance

Delivery against

Strategic Goal(s) 1. To provide safe, effective, compassionate care

2. To attract, retain, support and develop the finest workforce

3. To maintain financial stability

4. To work with partners to offer and deliver market-leading services

5. To be an outstanding, well-led organisation

The review and presentation of the report ensures the requirements of the Risk Management Framework are being achieved.

Strategic Risk(s)

Number Level of Assurance Number Level of Assurance

5.2 Substantial

CQC Domain

Safe Effective Caring Responsive Well-Led x

Impact

All implications are noted within the individual risks.

Previously Presented to

Quality Committee 16 April 2019, FPIC 18 April 2019

Appendices to the report

N/A

1. INTRODUCTION The Board of Directors is responsible for the implementation of the Risk Management Framework and for overseeing the effectiveness of processes for the identification, assessment, management and mitigation of risk.

To assist the Board of Directors in its duties the Committees are responsible for providing assurance in relation operational risks under the remit of their Terms of Reference. The Committees are scheduled to:

Review all extreme operational risks on a monthly basis

Review all operational risks on a quarterly basis

This update report provides assurance that reviews have been undertaken as laid out in the Risk Management Framework.

2. EXTREME OPERATIONAL RISKS There are currently three extreme risks, all of which fall under the remit of the Quality Committee for oversight and support. The three risks are summarised below:

Risk Score Days as extreme

Latest position update

ME

D 1

/16

If the Trust does not reliably and robustly ensure that all relevant deaths are logged, screened and if necessary investigated, with key lessons distilled, analysed, and any lessons learnt incorporated into wider organisational learning, there is a risk that there will be a suboptimal learning from deaths. As a consequence we may miss opportunities both to prevent future avoidable harm/ death and to promote positive examples of high quality care.

Risk Lead – Medical Director

I x 4 L X 4 RS = 16

197 Detailed discussion held at Mortality Surveillance Group on 12 March 2019 where edits were made to the draft revised policy produced by the Medical Director. Submission of the policy was made to the Quality Committee on the 19 March 2019 for assurance/opinion and then went the Board of Directors and was ratified on 28 March 2019. The Action plan for 360 Assurance has been updated, provided to internal Audit and was presented on 15 April 2019 to the Executive Management Team. 360 Assurance to be requested to provide assurance on systems and processes in relation to version 2 of the policy in quarter 3, 2019/20. The new mortality module, screening and structured/judgement review process will be rolled out April-May 2016 for a go live date of 3 June 2019. In the interim the Medical Director and mortality lead are reviewing every mortality review and structured judgement review for assurance to the Mortality Surveillance Group.

Risk Score Days as extreme

Latest position update O

1/1

9

If the Trust does maintain safe staffing levels within a number of areas, Inpatients, Community Nursing, Crisis services and Intensive Community Therapy Teams there will be risk that the quality and safety of clinical services may be compromised.

Risk Lead - Chief Operating Officer

I x 5 L x 4 RS = 20

58 Safe Staffing Levels remain a concern and an extreme risk. The Chief Operating Officer is monitoring the situation on a daily basis. A Recrtuitment and Retention Steering Group supported by the PMO and led by the Director of Workforce and OD has been established. This group meets monthly to provide additional focus to the progress with mitigating actions. The Director of Nursing and AHP is leading on a 20 day assessment exercise, ahead of and to inform the next round of safe staffing reviews on each ward. The Director of Finance and Performance has met with the Trust’s main agency supplier and reinforced expectations and requirements. An additional agency has also been identified as a future source of staff.

Additional actions being taken include the implementation of an Annual Leave policy regarding buying and selling leave days, development of workforce plans for each Care Group, the implementation and review recruitment and retention premium and a review of sickness absence to identify additional support that may be required.

DC

G 5

/17

If gaps in medical staffing in Doncaster junior doctor and consultant posts are not filled then there is a risk to the delivery of care for patients.

Risk Lead – Chief Operating Officer

I x 4 L x 4 RS = 16

30 The situation with Doncaster Medics remains a concern and an extreme risk and the Chief Operating Officer / Medical Director are monitoring the situation regularly. The COO and MD together with the Care Group Director met with the Doncaster based Medical Staff to better understand the concerns and position and as a result one course of action is the development of a recruitment and retention package – this will be presented for consideration by EMT. Additional posts (one in-patient / one Community) are to be recruited to and the review and reparation of the necessary paperwork is underway with adverts planned to be placed in early May 2019. Recruitment to these two additional posts will impact on the workloads of current medical staff including the on-call requirements. On-Call is also being reviewed to identify opportunities for a more efficient and effective use of Consultants (i.e. to ensure all ‘calls’ are necessary and appropriate and to identify where other staff can manage situations / make decisions / undertake assessments).

The above risks have been presented to and discussed at the Quality in their April 2019 meeting. The Report from the Quality Committee to the Board of Directors – agenda item 12 (Paper H) includes reference to the discussions that was held at the meeting.

3. OTHER OPERATIONAL RISKS As at 18 April 2019 there are currently 86 Operational risks (including the extreme rated risks). Each risk has a designated lead responsible for managing the risk and oversight – in terms of ensuring updates are undertaken. To date in 2019/20 the committee have received and reviewed:

Quality Committee and the Finance, Performance and Informatics Committee o extreme operational risks on a monthly basis – April 2019, o all operational risks on a quarterly basis – scheduled for May 2019

Mental Health Legislation Committee has received and reviewed: o all operational risks on a quarterly basis – scheduled for May 2019.

4. MODERATION BY EXECUTIVE MANAGEMENT TEAM (EMT) EMT is responsible for the implementation of risk management and is scheduled to:

Review all risks to provide a confirm and challenge function and moderate all risk: o The risk registers will be received every month on an annual rolling cycle and

will include a summary of the movement of risks, any longstanding risks and percentage of reviews (April and May due to bank holidays).

o The themes will be received on a rolling cycle of 1 theme per month.

Moderation all risks score 15 or above onto and off the Extreme Operational Risk Register

Moderate the tolerated risk scored 8 or above where the likelihood is 3 or above.

EMT Review of Risks The reviews undertaken to date for 2019/20 are:

Operational Change Theme held on the 15 April 2019;

Children’s Care Group Risk Register held on the 15 April 2019;

Extreme risks held on the 15 April 2019. EMT Moderation of Extreme Risks There have been no risks presented for moderation to date during 2019/20. 5. Board of Directors Action The Board of Directors is asked to:

note the content;

raise query where required; identify any risks not captured.

OTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST

Committee Name

Board of Directors

Agenda Item Paper M Date 25 April 2019

Title of Paper Board Assurance Framework position statement

Decision The Board of Directors is asked to • Review each strategic risk and consider whether:• Appropriate Controls have been identified and are in place,• Sufficient Assurance both internal and external have been

received,• The gaps in either control or assurance are significant• Note that the outstanding (planned and unplanned) gaps have

continued into 2019/20• and to consider the overall position in respect

o the effectiveness of its Board Assurance Framework; ando in the preparation of the Annual Governance Statement.

Assurance The Board Assurance Framework extract for the Quality Committee provides assurance that strategic risks are being managed.

Information

Prepared by Jane Charlesworth, Risk and Assurance Officer

Phil Gowland, Board Secretary/Director of Corporate Assurance

Presented by Phil Gowland, Board Secretary/Director of Corporate Assurance

Delivery against

Strategic Goal(s) 1. To provide safe, effective, compassionate care

2. To attract, retain, support and develop the finest workforce

3. To maintain financial stability

4. To work with partners to offer and deliver market-leadingservices

5. To be an outstanding, well-led organisation

Requirements of the Risk Management Framework are being achieved.

Strategic Risk(s) Number Level of Assurance Number Level of Assurance 13 Substantial

CQC Domain Safe Effective Caring Responsive Well-Led

Impact As identified within the individual strategic risks

Previously Presented to

Extracts of the Board Assurance Framework are reported on a quarterly basis with the last report being received by the Quality Committee and Finance Performance and Informatics Committee in April 2019.

Appendices to Paper

Appendix A – Board of Directors BAF extract as at 17 April 2019

Appendix B - Quality Committee and FPIC BAF Extract as at 17 April 2019

Executive Summary This report provides an update on the progress made on the 2018/19 Board Assurance Framework and the position of the strategic risks. The remaining gaps in planned assurance (to be received by year end) mainly relating to the internal audit plan for which the final reports are due to be received by the Trust and reported to the Audit Committee in May 2018. In addition there are a number of gaps in control/assurance identified in the year which have not been addressed within 2018/19. The majority of these gaps and their associated actions will continue to be monitored within the 2019/20 Board Assurance Framework. In respect of the risks, there are other control and sources of assurance therefore the current gaps are not considered to be significant. The BAF is in the process of being refreshed for 2019/20 and to ensure it appropriately reflects the new Strategic Ambitions, a review of the risks has been completed. 1. Background The Board Assurance Framework (BAF) provides the Board of Directors with a high level management assessment process and record of the strategic risks relating to the delivery of its key objective and strategic goals; and the internal controls to prevent these risks from occurring. The five Strategic Goals for 2018/19 were:

• To provide safe, effective compassionate care; • To attract, retain, support and develop the finest workforce; • To maintain financial stability; • To work with partners to offer and deliver market-leading services; • To be an outstanding, well-led organisation.

In respect of each Strategic Goal, the Board of Directors identified a number of strategic risks – there were fourteen in total identified. 2. Monitoring during 2018/19

2.1 Board of Directors Of the fourteen strategic risks within the BAF, eight were assigned to the Board of Directors (remainder assigned to the Quality Committee or to the Finance, Performance and Informatics Committee). The eight risks assigned to the Board of Directors were:

• If there is not a clear vision and strategy in place then there is a risk to Trust being a credible and sustainable organisation.

• If we do not provide care around effective clinical pathways then there is a risk to the delivery of safe and effective care.

• If we do not foster positive relationships with partners and participate in environmental changes then we may fail to provide integrated and co-ordinated care to our service users.

• If we do not have sufficient management capacity and resource then there may be an impact on delivery of services.

• If we do not adequately interpret, analyse and report clinical and management information then there may be an impact on the Trust's ability to manage service delivery.

• If we do not hold and work in line with the Trusts values and principles then there may be a risk to the delivery of the Trust's mission.

• If we do not have a robust governance process in place then this may lead to the Trust being ineffective and a poor performer.

• If we do not comply with Trust systems, processes and statutory legislative requirements then this may lead to compliance notices, breach of FT license, sanctions and/or financial penalties and reputational damage.

Throughout the year the BAF has been populated with the assurances (and levels) received at the Board of Director and its Committees. During the year the Board of Directors has reviewed the above risks in July, October 2018 and January 2019 (and again here in April 2019) to consider the assurances that have been received regarding the controls put in place to mitigate the strategic risks. 2.2 Quality Committee Of the fourteen strategic risks within the BAF, three were assigned to the Quality Committee:

• If we do not deliver care in line with quality and safety standards then this may lead to avoidable harm

• If we do not identify learning when harm or potential harm does occur then there is a risk that we will not to provide safe, innovative care.

• If we do not have the right people, with the right skills, in the right place at the right time then there is a risk to the delivery of safe and effective care.

During the year the Quality Committee has reviewed the above risks in July, October 2018 and January 2019 to consider the assurances that have been received regarding the controls put in place to mitigate the strategic risks. The Quality Committee considered the year-end position at its meeting in April and this is reflected in Section 3.2 below and in Appendix C. 2.3 Finance, Performance and Informatics Committee Of the fourteen strategic risks within the BAF, three were assigned to FPIC:

• If service income is not sufficient to cover the cost of operational delivery and an appropriate overhead cost then there is a risk that the Trust may not be financially viable.

• If the existing or future workforce is not affordable then there is a risk to financial viability of service provision.

• If we do not use our resources efficiently, both internally and collaboratively, then public money may not be used effectively.

During the year FPIC has reviewed the above risks in July, October 2018 and January 2019 to consider the assurances that have been received regarding the controls put in place to mitigate the strategic risks. FPIC considered the year-end position at its meeting in April and this is reflected in Section 3.3 below and in Appendix C. 3. Year-end status

3.1 Board of Directors For the eight strategic risks under the remit of the board of Directors, the majority of the assurance sources, identified when the BAF was developed for 2018/19, have been received during the year. In developing the BAF for 2018/19 there were (additional) actions or controls that were to be taken or implemented (before the yearend) that would contribute to the mitigation of the identified risks. Where these have not progress through to full completion / implementation, they are presented in the table below.

Ref Exception 2 Implementation of agreed clinical pathways 2 LIA: CAMHS / LIA: CMHT Capacity & Demand / LIA: MH Rehabilitation Pathways

2 Implementation of all recommendations relating to the ‘safe’ domain of the CQC inspection (see April 2019 report from Quality Committee)

12 PDR process to be reviewed to be more ‘values’ based Additionally, other actions / controls to be taken / implemented in a longer period (i.e. beyond the year-end) are listed below and work in respect of each remains ongoing:

Ref Exception

1 Develop method of measuring progress and implement progress and begin reporting against 5 year strategy – by June 2019

1 Review and Refresh where appropriate other supporting strategy documents – by March 2020

1 Contribute to ‘System’ 5 Year Plan – by summer 2019 2 Undertake a review of clinical pathways implementation – by September 2019 10 Capacity and Demand (development and roll-out) – by April 2019

11 Work associated with quality improvement through LiA BI work stream (launched 24/9/2018) -– by April 2019

11 Implement information quality work plan for 2018/19 – by April 2019 11 Implement project for developing analytic software pilot – by April 2019 12 Agree & implement Governance process of Cultural Team Output - by April 2019

Ref Exception

13 Implementation of agreed actions to address the recommendation made in the Quality Governance audit – by April 2019

14 Health & Safety reporting requirements to be established and implemented – by Appendix A provides the full details from the BAF in respect of the eight strategic risks that were assigned to the Board of Directors. Appendix B presents the details from the BAF in respect of the six strategic risks that were assigned to the Quality Committee and the Finance, Performance and Informatics Committee. 3.2 Quality Committee For the three strategic risks detailed in this report, the majority of the assurance sources, identified when the BAF was developed for 2018/19, have been received by the Committee during the year. The exceptions are recorded in the table below:

Ref Exception Comment

5 Internal Audit Plan – Workforce Strategy (including Organisational Development / Recruitment and Retention Strategies)

Report in draft – receipt of finalised report expected April 2019

In developing the BAF for 2018/19 there were (additional) actions or controls that were to be taken or implemented (before the yearend) that would contribute to the mitigation of the identified risks. Where these have not progress through to full completion / implementation, they are presented in the table below.

Ref Exception

3 Implementation of all recommendations relating to the ‘safe’ domain of the CQC inspection

3 Identification of the skills and knowledge to deliver data analysis

4 Efficiency of investigative approach and learning (Learning Matters Forum / Evaluate Patient Safety Model)

4 Robust triangulation processes (Patient safety strategy / LiA Patient Safety) 4 Implementation of recommendations from the Mortality Internal Audit Report. 5 LiA Leadership/ LiA Psychiatry 5 Capacity and Demand – planning, development and roll-out.

Additionally, other actions / controls to be taken / implemented in a longer period (i.e. beyond the year-end) are listed below and work in respect of each remains ongoing:

Ref Exception

5 Completion of yearlong Board and Executive Development Programme – by December 2019

5 NHS I Recruitment and Retention Action Plan Year 2 – by August 2019 5 Longer term actions relating to safer staffing review – by 2020.

The Quality Committee has considered the gaps as presented above and acknowledged that there remain actions to be completed which have been transferred to 2019/20. It was agreed that none of these outstanding actions are considered to represent a significant gap in control/assurance as other controls/assurances are in place to mitigate the stated risks. The Quality Committee has recommended that the three strategic risks within it remit are appropriately and correctly represented in the year end position and that where appropriate and relevant, gaps in control and assurance will remain in the BAF during 2019/20. 3.3 Finance, Performance and Informatics Committee

For the three strategic risks detailed in this report, the majority of the assurance sources, identified when the BAF was developed for 2018/19, have been received. The exceptions are recorded in the table below:

Ref Exception Comment

9 Internal Audit Plan – Agile Working

Report in Final draft – receipt of finalised report expected April 2019

9 Internal Audit Plan – Unity Report in draft – receipt of finalised report expected April 2019

Relevant assurances will also be received via the work of External Audit as part of the 2018/19 Annual Report and Accounts audit. In developing the BAF for 2018/19 there were (additional) actions or controls that were to be taken or implemented (before the yearend) that would contribute to the mitigation of the identified risks. Where these have not progress through to full completion / implementation, they are presented in the table below.

Ref Exception

7 Service Line Reporting – activity reports for non-MH services (by year end) Additionally, other actions / controls to be taken / implemented in a longer period (i.e. beyond the year-end) are listed below and work in respect of each remains ongoing:

Ref Exception 7 Routine production of service line reports – during 2019/20

7 Implementation of the longer term actions linked to safe staffing reviews – by 2020

FPIC has considered the gaps as presented above and that they will further strengthen existing controls. It was acknowledged that there remain actions to be completed which have been transferred to 2019/20. It was agreed that none of these outstanding actions are considered to represent a significant gap in control/assurance as other controls/assurances are in place to mitigate the stated risks. The three risks under the remit of FPIC have all been managed in year and the ‘target’ risk’ score achieved through the controls and actions and receipt of assurances. FPIC has recommended that the three strategic risks within it remit are appropriately and correctly represented in the year end position with some minor updates and that where appropriate and relevant, gaps in control and assurance will remain in the BAF during 2019/20. 4. Annual Refresh

The annual review of the Board Assurance Framework is underway to ensure it outlines the Trust’s current strategic risks. The review also took into account the change from Strategic Goals to Strategic Ambitions and the Trust’s new 5 Year Strategy. The Board of Directors and its committees are progressing this and will present for approval in May 2019 the refreshed BAF. 5. Board of Directors Action The Board of Directors is asked to:

• Review each strategic risk taking the above findings into account and consider whether:

o Appropriate Controls have been identified and are in place, o Sufficient Assurance both internal and external have been received, o The gaps in either control or assurance are significant

• Note that the outstanding (planned and unplanned) gaps have continued into 2019/20

• Accept the recommendations from the Quality Committee and the Finance, Performance and Informatics Committee regarding the strategic risks within their remit.

• Consider the overall position in respect of the strategic risks, providing its concluding assessment of this position for consideration by the Chief Executive in the preparation of the Annual Governance Statement.

Philip Gowland, Director of Corporate Assurance Jane Charlesworth, Risk and Assurance Officer 18 April 2018

APPENDIX A

BOARD OF DIRECTORS – BOARD ASSURANCE FRAMEWORK EXTRACT

Ref: Risk Description: Link to Strategic Goals: Lead Assurance Committee: Lead Director: Risk Appetite:

1. If there is not a clear vision and strategy in place then there is a risk to Trust being a credible and sustainable organisation.

1, 2, 3, 4, 5 Board of Directors Director of Finance and Performance Cautious

Risk Rating: First Line of Defence:

Initial Risk Score Current Risk Score Target Risk Score

4 x 2 = 8 4 x 2 = 8 4 x 2 = 8 Associate Director of Finance, Strategy, Contracts and Programmes / Senior Strategy Lead in place since July 2018 Business Development Forum (informal meeting) Board of Directors Development Session (October 2018)

Controls (the systems and processes in place that mitigate the risk): Second Line of Defence:

Assurance Received /Due Level

• Mission, Vision and Values • 2 year operational plan (2017/19) • 5 Year Strategic Plan • Estates Strategy • Strategic Lead • Place Based Plans

Annual Plan 2018/19 To FPIC & BoD (Apr 2018) Substantial Annual Accounts 2017/18 To AC & BoD (May 2018) Substantial Quality Report 2017/18 (inc Quality priorities) To QC (May 2018) Substantial Strategy and Commercial Development Updates To FPIC (Aug, Oct & Nov 2018 & Jan – Mar 2019) Partial Workforce Strategy – bi-annual update on progress To QC (Jun 2018 and Jan 2019) Partial Estates Strategy Update Annual update to FPIC (Jun 2018) Substantial

Links to Operational Risks : Third Line of Defence: Assurance Received /Due Level

NHSI Improvement Rating As at 31/03/2019 Segment 1 External Audit review of Quality Report May 2018 Substantial Annual accounts and financial statements May 2018 Substantial CQC Inspection (Well-led) June 2018 Good

Gaps in control(s)/Assurance(s): Actions to address gaps: Due Date:

1. Measurement of Progress on implementation 1a. Develop method of measuring progress and implement progress and begin reporting against June 2019 2. Overarching Commercial Strategy and long term plan to be developed and agreed that links to all supporting strategies in place and to the Trust’s operational plans (to be submitted to NHS Improvement)

2a. Develop Five Year Strategy Board Development Session Board of Directors Approval

Complete Complete

2b. Review and Refresh where appropriate other supporting strategy documents March 2020 2c. Develop 19/20 Operational Plan Draft Operational Plan Final Operational Plan

Complete Complete

2d. Contribute to ‘System’ 5 Year Plan Summer 2019

Ref:

Risk Description: Link to Strategic Goals: Lead Assurance Committee: Lead Director: Risk Appetite:

2 If we do not provide care around effective clinical pathways then there is a risk to the delivery of safe and effective care.

1, 2, 4 Board of Directors Chief Operating Officer Supported by Medical Director and Director of Nursing and Allied Health Profession

Seek

Risk Rating: First Line of Defence: Initial Risk Score Current Risk Score Target Risk Score

4 x 3 = 12 4 x 3 = 12 4 x 1 = 4 Feedback from local meetings relating to Continuous Service Improvement

Controls (the systems and processes in place that mitigate the risk): Second Line of Defence: Assurance Received /Due Level

• Operational Plan • Clinically-Led Services Review Project Plan • Programme Management Officer to oversee project • Agreed Clinical Pathways • Friends Relatives and Carers Charter

PMO reporting (Clinically-Led service review) Monthly to FPIC (Apr – Nov 2018 & Jan – Mar 2019) Partial

QSIA reporting Quarterly to QC (May, Aug, Nov 2018 & Feb 2019) Full Annual Report to QC (May 2018) Partial

Quality Report (inc Quality priorities) Annual to QC (May 2018) Partial Physical Health & Wellbeing Reporting Biannually to QC (Jul 2018 & Feb 2019) Substantial Clinical Pathways update reporting To QC (Sep 2018) Partial Community MH Survey Annual to QC (Oct 2018) Partial

Links to Operational Risks: Third Line of Defence: Assurance Received /Due Level

NLCG 8/17 O 5/18 O 6/18

O 1/19 CCG 15/18 DCG 9/18

DCG 11/17 NLCG 13/17 NLCG 3/18

FP 10/19

DCG 4/19 NLCG 1/18 O 6/18 O7/18

RCG 3/19

CQC Inspection (Safe) June 2018 Requires Improvement CQC Inspection (Effective) & (Responsive) June 2018 Good & Good

Gaps in control(s)/Assurance(s): Actions to address gaps: Due Date:

1. Agreed clinical pathways not yet implemented 1a. Implementation of agreed clinical pathways March 2019 1b. LIA: Community Mental Health Teams (Capacity and Demand) March 2019 1c. LIA: Child and Adolescent Community Mental Health Teams (CAMHS) March 2019

2. Review of the clinical pathways implementation 2a. Undertake a review of clinical pathways implementation September 2019 3. CQC Inspection rated the domain ‘Safe’ as requiring improvement 3a. Identify actions to address the areas of concerns raised Complete

3b. Implement the identified actions July 2019 3c. LIA: Mental Health Rehabilitation Pathways March 2019

Ref: Risk Description: Link to Strategic Goals: Lead Assurance Committee: Lead Director: Risk Appetite:

8

If we do not foster positive relationships with partners and participate in environmental changes then we may fail to provide integrated and co-ordinated care to our service users.

1, 3, 4, 5 Board of Directors Chief Executive Seek

Risk Rating: First Line of Defence: Initial Risk Score Current Risk Score Target Risk Score

4 x 3 = 12 4 x 3 = 12 4 x 2 = 8 Commissioner Contract & Performance meetings Board to Boards meetings Team Doncaster/Rotherham Better together

Place Based Plans Provider Alliance meetings South Yorkshire and Bassetlaw MH & LD Work Stream Health & Wellbeing Boards

Trust Staff Council

Controls (the systems and processes in place that mitigate the risk): Second Line of Defence: Assurance Received /Due Level

• Staff Engagement Strategy • PPEE Strategy • Being Open Policy • Communications Plan • Single Oversight Framework • Contracts with Commissioner/other Trusts • Patient Sign Up for Research • MOU with SYB ICS • Friends Relatives and Carers Charter

Staff Survey Reporting to QC (Apr 2018 & Jan 2019 Partial Staff Engagement Strategy Update Biannual to QC (Sep 2018 & Mar 2019) Partial LiA/Pulse Checks Monthly to BoD (Apr - Sep & Nov 2018 & Jan 2019) Partial Friends and Family Test Quarterly to QC (Apr 2018) Partial Community MH Survey Annual to QC (Oct 2018) Partial PPEE Annual Report Annual to QC (Jun 2018) Partial PPEE Strategy Update Biannual to QC (Oct 2018) Partial Patient Stories Monthly at BoD (Apr – Nov 2018 & Jan – Mar 2019) Partial Contract and Performance reporting Monthly to FPIC (Apr – Nov 2018 & Jan – Mar 2019) Substantial CEO reporting Monthly to BoD (Apr - Dec 2018 & Jan – Mar 2019) Partial ICS Chief Executive Report To BoD (Nov 2018 & Feb 2019) Partial Freedom to Speak Up Biannual to QC (Apr & Oct 2018) Substantial Research Briefing Annual to QC (Sep 2018) Partial

Links to Operational Risk Third Line of Defence: Assurance Received /Due Level

NLCG 2/17

DCG 3/19 DCG 3/18

CQC Inspection (Effective), (Caring) & (Responsive)

June 2018 Good, Good & Good

Gaps in control(s)/Assurance(s): Actions to address gaps: Due Date:

1. Integrated Governance/Systems not in place for Place based Plans 1a. Development of MOU with SYB ICS Complete 2. Assurance from established ACP, Exec Boards and Working Groups 2a. Confirm receipt and pathway within the Trust to the Board and Committees, Care Groups and Business

Development. Complete

3. Formal shared work programmes with independent user group 3a. Scoping approach to engage with independent groups to engage in work programmes Complete 3b. Implement and embed formal shared work programmes as part of year 2 of the PPEE Strategy. Complete

Ref: Risk Description: Link to Strategic Goals: Lead Assurance Committee: Lead Director: Risk Appetite:

10

If we do not have sufficient management capacity and resource then there may be an impact on delivery of services.

1, 2, 3, 4, 5 Board of Directors Chief Executive Supported by the Executive Management Team

Open

Risk Rating: First Line of Defence:

Initial Risk Score Current Risk Score Target Risk Score

3 x 3 = 9 3 x 3 = 9 3 x 1 = 3 EMT ‘heat map’ of management capacity and workloads Leadership Development Forum Clinical / Professional Leadership

Controls (the systems and processes in place that mitigate the risk): Second Line of Defence: Assurance Received /Due Level

• PDR/Supervision Process • Place Based Plans • Capacity Heat Map Process

Workforce reporting Monthly to QC (Apr - Nov 2018 & Jan – Mar 2019) Partial

Links to Operational Risks: Third Line of Defence:

Assurance Received /Due Level NLCG 9/17 RCG 10/17 CCG 10/17 CA 1/18

RCG 2/19

Gaps in control(s)/Assurance(s): Actions to address gaps: Due Date:

1. Capacity and demand planning 1a. Definition of priority areas Complete 1b. Undertake pilot May 2019 1c. Roll out by Care Group Pending 1b.

Ref: Risk Description: Link to Strategic Goals: Lead Assurance Committee: Lead Director: Risk Appetite:

11

If we do not adequately interpret, analyse and report clinical and management information then there may be an impact on the Trust’s ability to manage service delivery.

1, 4, 5 Board of Directors Director of Health Informatics Supported by the Executive Management Team

Open

Risk Rating: First Line of Defence: Initial Risk Score Current Risk Score Target Risk Score

3 x 3 = 9 3 x 3 = 9 3 x 2 = 6 System Reporting

Real-time reporting workshop 29 January 2019

Controls (the systems and processes in place that mitigate the risk): Second Line of Defence:

Assurance Received /Due Level

• Single Oversight Framework • IM Strategy supported by IM Team • Information management Change Control Board • Contract for Clinical System • Performance Management Framework supported by Performance

Team • Reportal

Information Quality reporting Quarterly to FPIC (May, Sep, Nov 2018 & Mar 2019) Partial

Integrated Performance Dashboard Monthly to FPIC (Apr – Aug 2018 & Jan – Mar 2019 Partial

Dashboard – exception reporting Monthly to FPIC (Apr – Nov 2018 & Jan – Mar 2019) Substantial

IM Strategy Update Annual to FPIC (May 2018) Substantial

Links to Operational Risks: Third Line of Defence: Assurance Received /Due Level

HI 12/17 O 1/18

O 2/18

HI 3/18

External Audit review of Quality Report May 2018 Substantial Regulatory Framework – Out of Area Placements (Performance Standards) Audit (IA)

April 2019 Limited

Gaps in control(s)/Assurance(s): Actions to address gaps: Due Date:

1. Inconsistent Data capture 1a. Work associated with quality improvement through LiA BI work stream (to be launched 24/9/2018) April 2019 2. Inconsistent Data Quality 2a. Implement information quality work plan for 2018/19 April 2019

2b. Work associated with quality improvement through LiA BI work stream (to be launched 24/9/2018) April 2019 3. Lack of Data Analysis 3a. Create and approve business plan for project for the development of analytic software Complete

3b. Implement project for developing analytic software pilot April 2019

Ref: Risk Description: Link to Strategic Goals: Lead Assurance Committee: Lead Director: Risk Appetite:

12

If we do not hold and work in line with the Trusts values and principles then there may be a risk to the delivery of the Trust's mission.

1, 2, 4, 5 Board of Directors Chief Executive Supported by the Executive Management Team

Cautious

Risk Rating: First Line of Defence: Initial Risk Score Current Risk Score Target Risk Score

4 x 2 = 8 4 x 2 = 8 4 x 2 =8 Managers

Controls (the system and processes in place that mitigate the risk): Second Line of Defence: Assurance Received /Due Level

• Mission, Vision and Values • PDR/Appraisal Process • Clinical Supervision • Value based recruitment • Friends Relatives and Carers Charter • Trust Induction • Culture Improvement Team

Workforce reporting (PDR) Monthly to QC (Apr - Nov 2018 & Jan – Mar 2019 Partial

Dashboard Reporting (Complaints/Compliment) Quarterly to QC (May, Aug, Nov 2018 & Feb 2019) Partial

Conflicts of interest reporting Biannual to AC (Sep 2018 & Mar 2019) Partial

Freedom to Speak Up Guardian reporting Biannual to QC (Apr & Oct 2018) Substantial

LiA/Pulse Checks Monthly to BoD (Apr - Sep & Nov 2018 & Jan 2019) Partial

Links to operational risks: Third Line of Defence:

Assurance Received /Due Level

CQC Inspection (Caring) June 2018 Good

Gaps in control(s)/Assurance(s): Actions to address gaps: Due Date:

1. Enhance awareness and application 1a. PDR process to be reviewed to be more ‘values’ based March 2019 2. Output from Cultural Improvement 2a. Governance process to be agreed and implemented April 2019

Ref: Risk Description: Link to Strategic Goals: Lead Assurance Committee: Lead Director: Risk Appetite:

13

If we do not have a robust governance process in place then this may lead to the Trust being ineffective and a poor performer.

1, 5 Board of Directors Director of Corporate Assurance Cautious

Risk Rating: First Line of Defence: Initial Risk Score Current Risk Score Target Risk Score

5 x 2 = 10 5 x 2 = 10 5 x 2 =10

Controls (the systems and processes in place that mitigate the risk): Second Line of Defence: Assurance Received /Due Level

• Code of Governance • Scheme of Delegation • Governance and Reporting Structure • Board Assurance Framework (BAF) • Clinical, Internal and External Audit agreed work plans

Committee Review of Terms of reference and Work plans

Annual to BoD (May 2018) Substantial

Annual Governance Statement Annual to AC (May 2018) Substantial Assurance Statements from Committees Annual to BoD, AC (Jun 2018), FPIC (Aug 2018)

Mid-Year to FPIC (Oct 2018), QC & MHLC (Nov 2018) Substantial Substantial

BAF reporting Quarterly to QC/FPIC//BOD (Jul & Oct 2018 & Jan 2019) Quarterly to MHLC (Aug & Nov 2018 & Feb 2019)

Substantial Substantial

Risk Reporting Monthly to QC/FPIC (May - Nov 2018 & Jan – Mar 2019), Monthly to BoD (May – Dec 2018 & Jan – Mar 2019) Quarterly to MHLC (Aug & Nov 2018 & Feb 2019)

Substantial Substantial Substantial

Risk Management Framework Report Annual to AC (May 2018) Substantial IG Toolkit submission Annual to FPIC (Mar 2019) Partial Conflicts of interest reporting Biannual to AC (Sep 2018 & Mar 2019) Partial Internal Audit Follow Up reporting Quarterly to AC (May, Sep & 2018 & Mar 2019)

Quarterly to QC/FPIC (May, Aug, Nov 2018 & Feb 2019) Substantial Partial

Clinical Audit reporting Quarterly to QC (May, Aug - Oct 2018) Partial

Links to operational risks: Third Line of Defence: Assurance Received /Due Level

HI 7/18

HOIA Opinion Stage 1 May 2018, Stage 2 December 2018 Significant Quality Governance (IA) January 2019 Limited Care Group Governance Audit (IA) December 2018 Limited Risk Management Audit (IA) December 2018 Significant MHA/MCA Governance (IA) August 2018 Significant CQC Rating (Well-Led) June 2018 Good

Gaps in control(s)/Assurance(s): Actions to address gaps: Due Date:

1. Limited assurance assigned – Policy Management 1a. Implementation of audit action plan (Policy Management) Completed 2. Accountability Framework not in place 2a. Operations Governance Process to be developed Completed 3. Limited assurance assigned to Care Group Governance Audit 3a. Implementation of agreed audit action plan (Care Group Governance) Completed 4. Quality Governance Audit received Limited assurance opinion 4a. Implementation of agreed actions to address the recommendation made in the audit April 2019

Ref: Risk Description: Link to Strategic Goals: Lead Assurance Committee:

Lead Director: Risk Appetite:

14

If we do not comply with Trust systems, processes and statutory legislative requirements then this may lead to compliance notices, breach of FT license, sanctions and/or financial penalties, reputational damage and harm.

1, 2, 3, 5 Board of Directors Director of Corporate Assurance Supported by Executive Management Team

Avoid

Risk Rating: First Line of Defence: Initial Risk Score Current Risk Score Target Risk Score

5 x 2 = 10 5 x 2 = 10 5 x 2 = 10 • Quarterly Review Meetings – NHS Improvement • Engagement Team Meetings – Care Quality Commission

• NHS Improvement License • CQC Fundamental Standards • Legislation e.g. H & S, Safeguarding, IG, PSED, MHA, MCA etc • Internal Audit Programme • Clinical Audit Programme • Clinical Supervision Process • Single Oversight Framework (SOF)

Second Line of Defence: Assurance Received /Due Level Provider License Reporting Biannual to BoD (Aug 2018 & Feb 2019)) Substantial CQC registration reporting Biannual to BOD (May & Aug 2018 and Feb 2019) Substantial Review of Trust’s Annual Report Annual to AC & BoD (May 2018) Substantial Quality and Patient Reporting Quarterly to QC (May, Aug, Nov 2018 & Feb 2019) Partial Quality Report Quarterly to QC (May 2018) Substantial Accountable Officer for controlled drugs Annual to QC/BoD (Aug 2018) Partial NICE compliance reporting Quarterly to QC (May, Aug, Nov 2018 & Feb 2019) Partial MHA/MCA reporting Quarterly to MHLC (Jun, Aug, Nov 2018 & Feb 2019) Partial CQC MHA Visits Quarterly to MHLC (Jun, Aug, Nov 2018 & Feb 2019) Partial MHA/MCA Training Quarterly to MHLC (Jun, Aug, Nov 2018 & Feb 2019 Partial H & S Annual report Annual to QC (Nov 2018) Substantial IG Toolkit submission Annual to FPIC (Mar 2019) Partial Internal Audit reporting Quarterly to AC (May, Sep & Dec 2018 & Mar 2019) Substantial Clinical Audit reporting Quarterly to QC (May, Aug –Nov 2018) Partial SOF reporting Monthly to FPIC (May - Nov 2018 & Jan – Mar 2019) Substantial Information Quality reporting Quarterly to FPIC (May, Sep, Nov 2018 & Mar 2019) Partial Equality & Diversity Reporting Biannual to QC (Nov 2018 & Jan 2019) Partial EPRR Core Standards Statement of Compliance

Annual to BoD (September 2018) Quarterly to QC (Jan 2019)

Substantial Substantial

Procedural Documents Updates Quarterly to QC/FPIC (Jul & Nov 2018 & Feb 2019) Partial

Links to Operational Risks: Third Line of Defence: Assurance Received /Due Level

O 4/18

NQ 3/19

FP 9/19 CA 1/17 NQ 2/19

HI 3/17 HI 10/18

External Audit review of Quality Report May 2018 Substantial Health & Safety Audit (IA) March 2019 Significant/Limited General Data Protection Regulations (IA) August 2018 Limited PLACE September 2018 Substantial Procedural Documents Audit (IA 17/18) March 2018 Limited MHA/MCA Governance (IA 17/18) August 2018 Significant CQC Inspection (Effective) & (Responsive) June 2018 Good & Good

Gaps in control(s)/Assurance(s): Actions to address gaps: Due Date:

1. Limited assurance assigned – Policy Management 1a. Implementation of audit action plan (Policy Management) Completed 2. Limited assurance assigned - Health and Safety 2a. Implementation of audit action plan (Health & Safety) September 2019

3. Limited assurance assigned to GDPR Audit 3a. Implementation of agreed audit action plan (GDPR) Completed

APPENDIX B

QUALITY COMMITTEE AND FPIC – BOARD ASSURANCE FRAMEWORK EXTRACT

Ref: Risk Description: Link to Strategic Goals: Lead Assurance Committee: Lead Director: Risk Appetite:

3 If we do not deliver care in line with quality and safety standards then this may lead to avoidable harm

1, 5 Quality Committee Director of Nursing and Allied Health Profession

Cautious

Risk rating: First Line of Defence: Initial Risk Score Current Risk Score Target Risk score

5 x 2 = 10 5 x 3 = 15 5 x 2 = 10 • Care Group Reporting • Nursing and Quality oversight of patient safety • Regular Care Group meetings

• Operational oversight

Controls (the systems and processes in place that mitigate the risk): Second Line of Defence:

Assurance Received /Due Level

• Quality Priorities (Safe and Effective) • CQC Fundamental Standards (Safe and Caring) • Mental Health Act • Mental Capacity • Legislation • CQUIN targets • Commissioning Contracts • Nurse Revalidation Process • Medical Revalidation Process • MAST/CPD Training & PDR Process

Quality Report Annual to QC (May 2018) Partial Quality/Patient Safety Reporting Quarterly to QC (May, Aug, Nov 2018 & Feb 2019) Partial IPC Annual Report Annual to QC (Jun 2018) Partial Safeguarding Annual Reports Annual Report to QC (Jul 2018) Partial Nurse Revalidation Reporting Quarterly to QC (May & Nov 2018 & Feb 2019) Substantial Medical Revalidation Reporting Annual to QC & BoD (Sep 2018) Substantial Medical Workforce Reporting Monthly to BoD (Apr – Dec 2018 & Jan – Mar 2019) Substantial MHA/MCA reporting Quarterly to MHLC (Jun, Aug, Nov 2018 & Feb 2019) Partial Medicines Management reporting Quarterly to QC (May, Aug, Nov 2018 & Feb 2019) Partial Health, Safety and Security Reporting Annual to QC (Nov 2018) Substantial CQC MHA Visits and outcomes Quarterly to MHLC (Jun, Aug, Nov 2018 & Feb 2019) Substantial Workforce Reporting Monthly to QC BoD (Apr - Nov 2018 & Jan –Mar 2019) Partial Safer Staffing Reporting Monthly to QC (Apr – Nov 2018 & Jan – Mar 2019) Partial

Links to Operational Risks: Third Line of Defence:

Assurance Received /Due Level

A 2/16D FP 4/19

FOR 3/12 FP 1/19

NQ 1/19 NLCG 4/18

A 11/14

DCG 2/19

FP 5/19 RCG 12/18 RCG 13/18

CCG 14/18 HI 2/19 NQ 5/19

HI 6/18

RCG 5/18

CQC Inspection (Safe) June 2018 Requires Improvement CQC Inspection (Effective) & (Caring) June 2018 Good & Good

External Audit review of Quality Report May 2018 Limited MHA/MCA Governance (IA) August 2018 Significant PLACE Rating September 2018 Substantial Incident Investigation Audit (IA) March 2019 Limited Health & Safety Audit (IA) April 2019 Significant/Limited Quality Governance Audit (IA) January 2019 Limited

Gaps in control(s)/Assurance(s): Actions to address gaps: Due Date:

1. CQC Inspection rated the domain ‘Safe’ as requiring improvement 1b. Implement the identified actions March 2019

2. Availability of timely and relevant quality monitoring data 2a. Review quality monitoring data at care group and corporate levels April 2019

3. Explicit quality improvement objectives. 3a. Process to agree objectives for 2019/20 April 2019

4. Quality Governance Audit received Limited assurance opinion 4a. Implementation of agreed actions to address the recommendation made in the audit April 2019

5. Incident Investigation Audit received Limited Assurance opinion 5a. Implementation of agreed actions to address the recommendation made in the audit August 2019

Ref: Risk Description: Link to Strategic Goals: Lead Assurance Committee: Lead Director: Risk Appetite:

4

If we do not identify learning when harm or potential harm does occur then there is a risk that we will not to provide safe, innovative care.

1, 5 Quality Committee Director of Nursing and Allied Health Profession Supported by the Medical Director

Open

Risk Rating: First Line of Defence: Initial Risk Score: Current Risk Score Target Risk Score

5 x 2 = 10 4 x 4 = 16 4 x 1 = 4 • Care Group Reporting • Nursing and Quality oversight of patient safety • Nursing and Quality reporting to OMM • Operational oversight – including daily report

Controls (the systems and processes in place to mitigate the risk): Second Line of Defence: Assurance Received /Due Level

• Incident Reporting Policy • NQB/NHS – Mortality Standards • Structured Review Methodology • Weekly Patient Safety Bulletin

Quality Report Quarterly to QC (May 2018) Partial Quality Dashboard Reporting Quarterly to QC (May, Aug, Nov 2018 & Feb 2019) Partial Integrated Performance Dashboard Monthly to FPIC (Apr - Aug 2018 & Jan – Mar 2019) Partial Outcomes from investigations Monthly to QC (Apr - Nov 2018 & Jan – Mar 2019) Partial Freedom to Speak up Guardian reporting Biannual to QC (Apr & Oct 2018)

Biannual To AC (Sep 2018) Substantial Substantial

Mortality Reporting Quarterly to QC & BoD (Jun & Sep 2018 & Jan 2019) Partial Outcomes from Clinical Audit Programme Quarterly to QC (May, Aug, Oct 2018 & Feb 2019) Partial Pressure Ulcer Harm Reduction To QC (Sep 2018) Partial Medicines Management (Insulin) To QC (Sep 2018) Partial Research Briefing Annual to QC (Sep 2018) Partial

Links to Operational Risks: Third Line of Defence: Assurance Received /Due Level

MED 1/16 NQ 4/19

FP 7/19

Incident Investigation Audit (IA) March 2019 Limited Mortality Audit (IA) September 2018 Limited CQC Inspection (Safe) June 2018 Requires Improvement CQC Inspection (Caring) & (Responsive) June 2018 Good & Good

Gaps in control(s)/Assurance(s): Actions to address gaps: Due Date:

1. Efficiency of investigative approach and learning 1a. Evaluation of the implementation of the patient safety model March 2019 2.Lack of a robust system for triangulating information 2a. Development of a Patient Safety Strategy March 2019

2b. Triangulation process to be established March 2019 2c. LIA: Patient Safety: improving processes relating to Reporting, Human Factors & Analysing System March 2019

3. CQC Inspection rated the domain ‘Safe’ as requiring improvement 3a. Identify actions to address the areas of concerns raised Complete 3b. Implement the identified actions March 2019

4. Mortality Audit received Limited Assurance Opinion 4a. Implementation of agreed actions to address the recommendation made in the audit March 2019 5. Process to share learning across the Trust that leads to change 5a. Agree process by which learning across the trust is in place April 2019 6. Incident Investigation Audit received Limited Assurance opinion 6a. Implementation of agreed actions to address the recommendation made in the audit August 2019

Ref: Risk Description: Link to Strategic Goals:

Lead Assurance Committee:

Lead Director: Risk Appetite:

5 If we do not have the right people, with the right skills, in the right place at the right time then there is a risk to the delivery of safe and effective care.

1, 2, 4, 5 Quality Committee Director of Workforce and OD Supported by Chief Operating Officer & Director of Nursing and Allied Health Profession

Open

Risk Rating: First Line of Defence: Initial Risk Score Current Risk Score Target Risk Score

4 x 3 = 12 4 x 3 = 12 4 x 2 = 8 Staff working within and adherence to policy and procedures.

Controls (the systems and processes in place that mitigate the risk): Second Line of Defence: Assurance Received /Due Level

• Workforce Strategy and Plan • Recruitment and Selection process • National Quality Board Standards • CQC Fundamental Standards (Safe & Effective) • Professional Strategy • Nursing Strategy • Induction process • Education programme • Freedom to Speak Up process • Nurse Revalidation Process • Medical Revalidation Process • MAST/CPD Training & PDR Process

Workforce Dashboard including: • Sickness • Turnover • Training & PDR • Use of Agency staffing

Monthly to QC (Apr – Nov 2018 & Jan - Mar 2019) Partial

Workforce Vacancy Position Quarterly to QC (May, Aug, Nov 2018 & Feb 2019) Partial Workforce Strategy Update Biannual to QC (Jun 2018 & Jan 2019) Partial Workforce Planning Reporting To QC (Jul 2018) Partial Staff Engagement Strategy Update Biannual to QC (Sep 2018 & Mar 2019) Partial Safer Staffing reporting Monthly to QC (Apr - Nov 2018 & Jan - Mar 2019 Partial Safer Staffing Declaration Biannual to BoD (Aug 2018 & Feb 2019) Partial Quality Dashboard (Professional Leadership) Quarterly to QC (May, Aug, Nov 2018 & Feb 2019) Partial

Medical Workforce Reporting Monthly to BoD (Apr - Dec 2018 & Jan – Mar 2019) Substantial Medical Revalidation Reporting Annual to QC & BoD (Sep 2018) Substantial

Guardian of Safe Working Hours Quarterly to QC (Jun & Nov 2018 & Feb 2019) Substantial Freedom to Speak up Guardian reporting Biannual to QC (Apr & Oct 2018)

Biannual to AC (Sep 2018) Substantial Substantial

Integrated Performance Dashboard Monthly to FPIC (Apr - Aug 2018 & Jan – Mar 2019) Partial

Links to Operational Risks: Third Line of Defence: Assurance Received /Due Level

O 1/19 DCG 10/18

DCG 11/18 A 5/15

DCG 5/17 DCG 8/18 O 3/18 RCG 6/18 RCG 13/17

FP 8/19 BA 3/14 FP 2/19 FP 3/19

MP 2/17 HI 12/18 RCG 1/19

HI 11/18

Workforce Strategy (including Recruitment and Retention Strategies) Audit (IA)

Scheduled for Qtr. 4

Safer Staffing Policy Audit (IA) December 2018 Limited

Absence Management Audit (IA) December 2018 Significant

Pre-employment checks (IA) December 2018 Advisory

CQC Inspection (Effective) June 2018 Good

Gaps in control(s)/Assurance(s): Actions to address gaps: Due Date:

1. PDR compliance target is not being met

1a. Review supervision/PDR practices (phase 1) Complete 1b. Design an integrated management support package (phase 2) March 2020

1b. LIA: Leadership – Growing & developing our staff / PDR / Supervision March 2019 2. Recruitment & Retention within Psychiatry 2a.LIA: Psychiatry (improve morale, engagement, resilience and retention) March 2019

3. Vacancies in acute wards and Doncaster community services (general) e.g. District Nursing 3a. Implementation of NHSI Recruitment & Retention action plan (initial 12 month plan) Complete

3b. Implementation of NHSI Recruitment & Retention action plan (year two) August 2019

4. Safer staffing

4a. Undertake a staffing establishment review of all bed based services Complete

4b.Implement via roster and budgets the revised staffing establishments Complete

4c. Review implementation of new NHSI resource, safe, sustainable staffing guidance Complete

5. Limited assurance assigned to Safer Staffing Audit 5a. Implementation of agreed audit action plan (Safer Staffing) 2020

6. Capacity and demand planning 6a. Definition of priority areas Complete

6b. Undertake pilot May 2019

6c. Roll out by Care Group Pending 6b.

7. Board of Directors/Executive Team Development 7a. Roll out of Deloitte Board and Executive Programme Dec 2019

Ref: Risk Description: Link to Strategic Goals: Lead Assurance Committee:

Lead Director: Risk Appetite:

6

If service income is not sufficient to cover the cost of operational delivery and an appropriate overhead cost then there is a risk that the Trust may not be financially viable.

3, 4, 5 Finance, Performance and Informatics Committee

Director of Finance and Performance Cautious

Risk Rating: First Line of Defence: Initial Risk Score Current Risk Score Target Risk Score

5 x 2 = 10 5 x 1 = 5 5 x 1 = 5 • Monthly management accountant meeting with Care Group Directors • Detailed monthly budget report to budget holders including income and expenditure

Controls (the systems and processes in place to mitigate the risk): Second Line of Defence: Assurance Received /Due Level

• Operational Plan 2017/19 • NHS Improvement SOP • Signed Contracts • Standing Financial Instructions • Established budgets

Finance reporting (Income & QIPP) Monthly to FPIC (Apr –Nov 2018 & Jan – Mar 2019) Substantial

CQUIN reporting (finance) Monthly to FPIC (Apr –Nov 2018 & Jan – Mar 2019 Partial

Contract reporting(signed & unsigned) Monthly to FPIC (Apr – Nov 2018 & Jan – Mar 2019) Substantial Performance reporting Monthly to FPIC (Apr – Nov 2018 & Jan – Mar 2019) Partial

Risk analysis reporting Monthly to FPIC (Apr – Nov 2018 & Jan – Mar 2019) Substantial

Costing and Activity reporting To FPIC (Jun & Jul 2018) Partial

PMO reporting (Indirect Costs Review) Monthly to FPIC (Jun & Sep – Nov 2018 & Jan – Mar 2019)

Partial

Links to Operational risks: Third Line of Defence: Assurance Received /Due Level

FP 2/18 RCG 10/18

FP 11/19

FIN 4/16 FP 1/18

RCG 2/18

FP 6/19

Budgetary Control (IA) February 2019 Significant Integrity of GL & Financial reporting audit (IA) February 2019 Significant Asset Register (IA) February 2019 Full Fixed Pay Expenditure (IA) February 2019 Significant External Audit Reporting Due May 2019

Gaps in control(s)/Assurance(s): Actions to address gaps: Due Date:

1. QIPP plans not yet fully established (reserve in place) 1a. Establish QIPP plans for 2018/19 target Complete 2. Limited assurance has been assigned to Internal Audit on Procurement (Key Financial Systems)

2a. Implementation of the Procurement Internal Audit agreed action plan Complete

3. Contract require re-negotiation 3a. Agree additional income/agree reduction in specification to match funding available Complete 4. Exploration of options to increase income /decrease costs as part of the review of the Commercial Strategy and the five year strategy development

4a. Further income generation to be explored as part of the strategic direction Complete 4b. Explore whether noticed should be served on commissioners for loss making services as part of managing the overall business and is actioned in line with agreed contract notice.

Complete

4c. Explore whether to undertaken service re-design to deliver contract obligations in a reduced cost envelope, specifically where services have been tendered, recent examples being school nursing and health visiting.

Complete

Ref: Risk Description: Link to Strategic Goals:

Lead Assurance Committee: Lead Director: Risk Appetite:

7

If the existing or future workforce is not affordable then there is a risk to financial viability of service provision.

2, 3 Finance, Performance and Informatics Committee

Director of Finance and Performance Supported by Director of Workforce and OD

Open

Risk Rating: First Line of Defence: Initial Risk Score Current Risk Score Target Risk Score

4 x 2 = 8 4 x 2 = 8 4 x 2 = 8 • Monthly management accountant meeting with Care Group Directors • Detailed monthly budget report to budget holders including income and expenditure • QSIA process

Controls (the systems and processes in place that mitigate the risk): Second Line of Defence: Assurance Received /Due Level

• Operational Plan 2017/19 • Workforce Strategy and Plan • Establishment Control Group • Care Group Accountabilities (SFI) • Service Specifications

Safer Staffing reporting Monthly to QC (Apr – Nov 2018 & Jan – Mar 2019) Partial Safer Staffing declaration Biannual to BoD (Aug 2018 & Feb 2019) Substantial Finance reporting Monthly to FPIC (Apr – Nov 2018 & Jan – Mar 2019) Substantial Restructuring provision reporting Quarterly to FPIC (Jul & Oct 2018 & Feb 2019)

BoD (Sep 2018) Substantial

Agency Spend Monthly to FPIC (Apr - Nov 2018 & Jan – Mar 2019) Substantial Workforce Strategy Update Biannual to QC (Jun 2018 & Jan 2019) Partial Workforce Planning Reporting Annual to QC (Jul 2018) Partial

Links to Operational Risks: Third Line of Defence: Assurance Received /Due Level

Safer Staffing Policy Audit (IA) December 2018 Limited

Gaps in control(s)/Assurance(s): Actions to address gaps: Due Date:

2. Limited service line reporting 2a. Prepare proposal on resource required to populate system Complete

2b. Activity reports for Mental health services to be programmed and tested Complete

2c. Activity reports for Non - Mental health services to be programmed and tested March 2019

2d. Produce service line reports on a routine basis 2019/20 3. Safer staffing 3a. Undertake a staffing establishment review of all bed based services Complete

3b. Implement via roster and budgets the revised staffing establishments November 2019

3c. Review implementation of new NHSI resource, safe, sustainable staffing guidance Compete

3d. Additional resources to recruit to regarding bed management Complete

4. Limited assurance assigned to Safer Staffing Audit 3a. Implementation of agreed audit action plan (Safer Staffing) 2020

Ref: Risk Description: Link to Strategic Goals: Lead Assurance Committee: Lead Director: Risk Appetite:

9

If we do not use our resources efficiently, both internally and collaboratively, then public money may not be used effectively.

1, 2, 3, 4, 5 Finance, Performance and Informatics Committee

Director of Finance and Performance

Open

Risk Rating: First Line of Defence: Initial Risk Score Current Risk Score Target Risk Score

3 x 3 = 9 3 x 1 = 3 3 x 1 = 3 • Procurement • Code of conduct for public life

Controls (the systems and processes in place that mitigate the risk): Second Line of Defence: Assurance Received /Due Level

• SFI’s and Scheme of Delegation • Programme Management Office approach (benefits realisation) • Quality and Safety Impact Assessment Process • Workforce Strategy • Procurement Strategy • Estates Strategy • IC & T Strategy • Business Continuity suite of policies • IM Strategy • Operations Governance Process

QSIA reporting Quarterly to QC (May, Aug, Nov 2018 & Feb 2019) Full Annual Report to QC (May 2018) Partial

PMO reporting (all work streams) Monthly to FPIC (Apr – Nov 2018 & Jan – Mar 2019) Partial Finance reporting Monthly to FPIC (Apr - Nov 2018 & Jan – Mar 2019) Substantial QIPP reporting Monthly to FPIC (Apr – Nov 2018 & Jan – Mar 2019) Substantial Benchmarking reporting Adhoc to FPIC (Jul 2018) Partial Capital Programme updates Monthly to FPIC (May, Sep 2018 & Jan – Mar 2019) Substantial NHSI/SoF Feedback Monthly to FPIC (May - Nov 2018 & Jan - Mar2019) Substantial Integrated Performance Dashboard Monthly to FPIC (Apr - Aug 2018 & Jan – Mar 2019) Partial Workforce Strategy Update Biannual to QC (Jun 2018 & Jan 2109) Partial ICT Strategy Updates Annual to FPIC (May 2018) Substantial IM Strategy Updates Annual to FPIC (May 2018) Substantial Procurement Strategy updates Annual to FPIC (Oct 2018) Substantial Estates Strategy Update Annual to FPIC (Jun 2018) Substantial EPRR Reporting Annual to BoD (September 2018)

Quarterly to QC (Jan 2019) Substantial Substantial

Links to Operational Risks: Third Line of Defence: Assurance Received /Due Level

HI 5/17 NLCG 11/17

CCG 13/18

Agile Working Audit (IA) Scheduled for Qtr. 4 Unity Audit (IA) Scheduled for Qtr. 4 External Audit Reporting Due May 2019

Gaps in control(s)/Assurance(s): Actions to address gaps: Due Date:

1. Accountability Framework not in place 1a. Operations Governance Process to be developed Complete 2. NHSI Use of Resource (required by Acute Trust only currently. Proposed

doing baseline before relevant to MH Trusts) 2a. Undertake baseline assessment and identify areas for action Complete 2b. Develop action plan and trajectory for areas that require improvement Complete