Bolton NHS Foundation Trust Board Meeting 29th September 2016 · Mrs A Bennett Deputy DoF (for...

1

Bolton NHS Foundation Trust – Board Meeting 29th September 2016

Location: Boardroom Time: 0900 – 1230 hrs

Time Topic Lead Process Expected Outcome

Patient Story

Verbal Patient story and learning points noted

09:20 1. Welcome and Introductions Chairman verbal

2. Apologies for Absence Trust Sec. Verbal Apologies noted

3. Declarations of Interest Chairman Verbal To note any declarations of interest in relation to items on the agenda

09:25 4. Minutes of meeting held 28th July 2016 Chairman Minutes To approve the previous minutes

4.1 Minutes of the Extraordinary Board Meeting held on 17th August 2016

Chairman Minutes To approve

5. Action sheet Chairman Action log To note progress on agreed actions

6. Matters arising Chairman Verbal To address any matters arising not covered on the agenda

09:35 7. Chairman’s Report Chairman Verbal To receive a report on current issues

09:45 8. CEO Report including reportable issues CEO Report To receive a report on any reportable issues including but not limited to SUIs, never events, coroner reports and serious complaints

Safety Quality and Effectiveness

09:55 9. Quality Assurance Committee – Chair Report 17th August 2016 and 21st September 2016

QA Chair Report QA Chair to escalate any items of concern to the Board

10:00 9.1 QA Committee Annual Report QA Chair Report

10:05 10. Finance and Investment Committee – Chair Report

FC – Chair Report FC Chair to escalate any items of concern to the Board

10:35 11. Integrated Performance Report Exec team Report To receive for information

2

Time Topic Lead Process Expected Outcome

10:45 12. Complaints Annual Report DoN Report To receive the annual complaints report

10:55 Coffee break

11:10 13. Medical Revalidation Medical Director

Report To receive assurance with regard to processes in place for revalidation of medical staff

11:20 14. Nursing revalidation DoN Report To receive assurance with regard to processes in place for revalidation of nursing staff

Governance

11:30 15. Sickness Absence Director of Strategic & OD

Report To note

11:40 15. Equality and Diversity Update Director of Strategic & OD

Report To note

Strategy

11:45 17. Approval of Standing Orders Trust Secretary Report To approve

Reports from Sub-Committees (for information)

11:50 18. Charitable Funds Committee

19. Audit Committee

20. Any other business

Questions from Members of the Public

21. To respond to any questions from members of the public that had been received in writing 24 hours in advance of the meeting.

Resolution to Exclude the Press and Public

12.00 To consider a resolution to exclude the press and public from the remainder of the meeting because publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted

Next meeting: Thursday 27th October 2016

Board of Directors minutes –28th July 2016 Page 1 of 9

Meeting Board of Directors Meeting

Time 09.00

Date 30th June 2016

Venue Board Room Bolton NHS FT

Present:-

Mr D Wakefield Chair DW

Dr J Bene Chief Executive JB

Mrs P Armstrong Child Director of Nursing TAC

Mr N Chamberlain Non-Executive Director NC

Mrs C Davies Non-Executive Director CD

Mr Allan Duckworth Non-Executive Director AD

Mr A Ennis Chief Operating Officer AE

Ms A Gavin Daley Non-Executive Director AGD

Mr S Hodgson Medical Director SH

Mr A Thornton Non-Executive Director AT

Mr M Wilkinson Director of Strategic and Organisational Development MW

In attendance:-

Mrs E Steel Trust Secretary ES

Mrs A Bennett Deputy DoF (for Simon Worthington) AB

Apologies

Mr S Worthington Director of Finance SCW

Dr M Harrison Vice Chair MH

The Chairman welcomed all Board members and observers to the meeting.

1 Patient Story

Michelle Barber, a member of the Estates Department staff attended to share her

son’s patient story with the Board. Her son N, a healthy 30 year old had

collapsed and been taken to A&E by car, on arrival at the A&E department, the

swift action of staff and of one doctor in particular resulted in the speedy

diagnosis of a subarachnoid haemorrhage. After diagnosis, he was transferred

to Salford for treatment; Mrs Barber and her family attribute her son’s recovery to

the immediate diagnosis and fast action. After his discharge, N wanted to say a

personal thank you to the doctor whose fast actions had saved his life,

unfortunately the doctor concerned had been acting as a locum and the

department had not been able to arrange a meeting.

Board members thanked Michelle for sharing her story which highlighted the key


role of early decision making in A&E. Concern was expressed that it had not

been possible to enable N to personally thank the doctor concerned and it was

agreed that an action would be taken to identify this doctor and pass on N’s

thanks.

FT/16/60 Identify the doctor involved and pass on the thanks of N and his family SH

3. Declarations of Interest

No interests declared in relation to agenda items

4. Minutes of The Board Of Directors Meeting Held 30th June 2016

The minutes of the meeting held on 30th June 2016 were approved as an

accurate record

5. Action Sheet

For updates to individual actions please refer to the action tracker

FT/16/47 The CCG are developing a network solution for tier 4 CAMHS services and are exploring opportunities to work with a mental health trust to provide more support for CAMHS

FT/16/48 The Chief Operating Officer confirmed that the provision of public Wi-Fi will be funded from the charitable fund

The Action sheet has been updated to reflect updates to actions.

6. Matters Arising

No matters arising

7 Chairman’s Report

The Chairman reminded Board members that the meeting would be Carol

Davies’s last as a Non-Executive Director of the Trust. On behalf of the Board

and of the Trust he thanked Carol for her contribution to the Trust, particularly

through her work as Chair of the Audit Committee.

Board members joined the Chairman in thanking Carol who was presented with a

gift from Board colleagues in recognition of her service.

Mrs Davies responded, thanking the Chairman and the Board for their words and

gift and thanking the governors for giving her the opportunity to sit on the Board.

Mrs Davies expressed her gratitude for the best wishes and gift and her pride at

having been part of a strong collective team that had worked tirelessly to achieve

a position of strength with no outstanding audit recommendations.


NHS Improvement – A recent publication “Strengthening financial performance

and accountability” sets out the stark reality of the current financial performance

of the NHS. Figures within the report indicate that delivery of the financial plan

will place Bolton’s financial performance in the top 5% of the country.

Greater Manchester Health and Social Care Partnership – Jon Rouse has

been appointed as Chief Officer for Greater Manchester, early key messages are

that the central focus will be on transformation. A Greater Manchester

dashboard is to be introduced and Trusts will be required to deliver in line with

agreed trajectories, all Manchester trusts are facing challenges with regard to the

A&E four hour target with all but two currently failing to meet this target.

Board changes – interviews for a new Non-Executive Director have been

conducted with a recommendation agreed for approval at an extraordinary

governor meeting on August 1st 2016.

FT/16/52 forward Monitor publication "Strengthening financial performance and

accountability" to NEDs

7.1 CEO report

The Chief Executive presented the key points of her written report:

Awards and recognition - The Trust performed very well in the latest cancer

patient experience study – the full report will be shared with the Quality

Assurance Committee.

CQC – The draft report has been received for factual accuracy check ahead of

final review by the CQC on August 4th and publication on August 15th 2016. The

Trust received positive feedback in a recent SEND inspection conducted jointly

by CQC and Ofsted.

NHSI – A Greater Manchester response was submitted in response to the letter

from NHSI regarding consolidation of back office services.

A&E improvement plan – a pragmatic approach has been taken with all trusts

cohorted into segments to share learning. The Chief Operating Officer recently

visited Luton and Dunstable, one of only a very small number where the four

hour target has been achieved consistently.

Board Assurance Framework – for discussion during the afternoon

development session.

Resolved: The Board noted the CEO report

8 Quality and Assurance Committee Chair Report

The Chair of the Quality Assurance Committee presented his report from the

meeting held on Wednesday 20th July 2016.

The Families division presented a good, clear transparent report which gave

assurance to the committee in most areas. Further assurance was

requested with regard to compliance with technical appraisal 102, this

requires multiagency services to be commissioned (report due to next


meeting)

A paper on the new Bolton Standard of Care Accreditation Scheme was

presented; Committee members requested further detail on this scheme

which has replaced the ESSA accreditation scheme for wards and

departments.

Positive assurance was received for critical care and bowel screening.

Progress has been made within Ophthalmology; although the backlog of

patients has now been addressed there is still a capacity/demand gap. A

workshop was scheduled to define future plans for the service.

Issues raised in the rheumatology action plan stimulated a discussion

regarding the challenge of small services that are reliant on a single

member of staff. The Executive team were asked to report back with

recommendations to address this challenge.

The CCG have committed to funding for health trainers

The Chief Operating Officer highlighted an emerging risk with regard to the

NHS email system, and a potential cost implication for the cost of new

licences.

Resolved: the Board noted the report of the QA committee Chair.

9 Finance Committee Chair Report

The Chair of the Finance Committee presented his summary of the Finance

Committee meeting held on 19th July 2016. The major concerns of the

committee are:

Divisional performance and ICIP delivery

The delivery of critical cap ex schemes which are vital for the longer term

performance of the trust – the Committee were delighted that additional

resource has been allocated to address capacity and capability concerns

but remained nervous with regard to the ability to deliver the project within

the agreed timescale.

In response to a question regarding Lord Carter recommendations, the Deputy

Director of Finance confirmed that PMO support and exec leads have been

allocated and actions are in hand. There are some specific actions for the Board

which will be presented to the October Board meeting.

Resolved: the Board noted the report of the Finance Committee Chair.

10. Integrated Performance Report

Board members discussed key metrics in the performance report by objective;

this discussion included requests for assurance and clarification with regard to

metrics and performance against targets:

Quality Safety and Patient Experience

96% of complaints were responded to within the target timescale


Further analysis is underway to understand the anecdotal comments

relating to falls in the community.

Urgent care pressures have resulted in an increased number of on the

day cancellations. Board members were reassured that urgent

procedures for example for cancer patients are not cancelled. The CCG

have requested a recovery plan, this will be linked to the urgent care plan.

Valued Provider

Accident & Emergency – Board members discussed the continued challenge with

regard to the pressures in the A&E department. Concern was expressed that the

improvement plan did not appear to be having the desired impact; the Chief

Operating Officer was asked when performance would improve.

The Chief Operating Officer advised that there has been some impact from the

plan however there was an unusual pattern of activity in July with some high

attendances and high admissions. The A&E improvement plan is being run by

the Programme Management Office with oversight through the system resilience

meeting and weekly reports to the Executive Directors meeting.

The CCG are supportive of the actions and are actively working with the Trust to

deflect inappropriate activity from the A&E department. A pilot will take place for

two weeks from 1st August with GPs in A&E working to divert patients and

actively turn away patients whose attendance is deemed inappropriate.

Board members expressed concern regarding the challenge in the winter if the

pressure has not eased during the summer months; the Chief Operating Officer

advised that the winter plan includes additional beds and capacity and

acknowledged the pressure on the system and on the staff was a concern.

Great place to work

Board members noted the improvement in the number of agency shifts filled and

requested assurance that this provides a meaningful indicator of safe staffing

levels. The Director of Nursing advised that the Lord Carter Model Hospital

programme includes an indicator for the number of care hours per unit or activity

– further detail is included in the nurse staffing paper.

Sickness absence – An observation was made that sickness absence figures

appear to have plateaued raising the question if further interventions should be

considered to bring about a further reduction. The Director of Strategic and

Organisational Development advised that having addressed policies, the focus

had now moved to staff health and wellbeing, some of the highest absence levels

are in the acute adult divisions possibly relating to the high pressures of work in

these areas. The Director of Strategic and Organisational Development was

asked to report back on proposed actions to further improve sickness absence

levels.

FT/16/53 report back on absence management to include consideration of innovative

actions

Well Governed – no questions

Financially viable – no questions


Fit for the Future

Concern was expressed that the report referred to a single service model for

General Surgery as opposed to Emergency Surgery; the Director of Strategic

and Organisational Development confirmed that the sector plan is for high risk

surgery to transfer to Salford however General Surgery is linked to high risk

surgery and will be discussed within NW sector plans.

Referring to section 8.3 of the report a suggestion was made that this area of the

report should also include “workforce for the future”

FT/16/54 next report to include more on workforce for the future

Data Pack

Board members noted the detailed data pack provided as an appendix to the

Integrated Performance Report

Resolved: The Board noted the performance report.

11 Royal College of Surgeons Report - update

The Medical Director presented a report to provide assurance that the

recommendations in the Royal College of Surgeons Report (2015) are being

addressed. Progress made since the report includes improved incident

reporting, improved WHO checklist compliance and strengthened governance

arrangements. The team recognise that continued vigilance is required to avoid

never events and incidents.

Board members noted the report and agreed the importance of an open and

honest culture with high levels of reporting and robust responses and lessons

learned when incidents occurred.

The Director of Nursing as Exec buddy for theatres confirmed that theatre staff

were aware of the report and actions and took great pride in promoting a safe

theatre culture.

The Medical Director confirmed that good progress has been made with regard

to addressing the perception that the Board were not focused on patient safety.

Board members requested assurance that the actions would continue long term;

the Medical director confirmed that the team see this as a continuous piece of

work supported by a suite of indicators, a multidisciplinary governance team,

monthly reviews and incident reporting. Any issues would be flagged through the

governance reports to the QA Committee.

Resolved: Board members noted the update on the RCS report

FT/16/55 update on theatre action plan/culture change in six months SH


12 Mazars Report

The Medical Director presented a summary of a recent review into the deaths of

people in contact with Southern Health NHS Foundation Trust. NHS England

has asked all NHS organisations to consider the report and relevant learning. A

response has been provided through NHS Bolton as included in the report.

Board members discussed the implications of the report and the Trust response

and agreed in light of the following that they were partially assured with regard to

the processes in place:

The Trust has a robust process to share and learn from incidents

The Trust has an active Mortality Review Group, this is attended by the

CCG

The Trust has a small but proactive learning disability team.

Good systems are in place to review maternal and child deaths. A

process is being established to review all deaths – the Board agreed that

establishment of this review would provide the assurance they required.

Resolved: board members noted the report and approved the recommendations

within the report. An update to the QA Committee on the establishment of

mortality reviews was requested.

FT/16/56 update to QA Committee Dec 2016 SH

13. Staffing Report

The Director of Nursing presented the six monthly staffing report, in line with the

recommendation in a recent NHS publication (Safe sustainable and productive

staffing July 2016) a comprehensive staffing review will be presented to the

Board every 12 months. The next comprehensive staffing review will be in

January 2017.

The Carter report highlighted variation in the management of staffing

levels and recommended a new metric of care hours per patient day.

An acuity tool is used on acute wards with day to day flexing of staff to

ensure cover for the areas with the highest acuity.

In addition to the July 2016 report the Trust has received a report from Birth Rate

Plus in relation to maternity staffing, an overview of this report and summary of

the findings was also provided to Board members.

The Director of Nursing advised that a three month audit of acuity shows a higher

number of women with higher acuity deliveries. The Board previously endorsed

midwifery staffing levels 0f 1:28, this compares favourably with many units where

average levels are 1:30 – 1:32 however Birth Rate plus are proposing a change

to a ratio of 1:26.

Further debate will be required with regard to the 1:26 ratio, achieving a ratio of

1:26 would have significant financial implications and indications are that the

service has maintained quality and access at 1:28. There is however a need to


be mindful with regard to any reputational impact of not picking up the 1:26

recommendation.

Resolved: Board members noted the report and agreed that for midwifery

staffing, further analysis and discussion would be required including GM

discussion

FT/16/57 update on midwifery staffing to October Board TAC

14. Monitor Q1 submission

The Board considered the Q1 governance declaration for submission to NHSI

and approved the following:

For finance – unable to confirm a financial risk rating of at least three over the

next 12 months

For capital expenditure – confirmed that the expenditure for the remainder of the

financial year would not materially differ from the forecast.

For targets – in light of the continued challenges for A&E, unable to confirm

satisfaction with plans in place to ensure ongoing compliance with targets.

Otherwise able to confirm that there are no matters arising in the quarter which

have not already been reported.

15. Operational Plan Refresh

The Director of Strategic and Organisational Development presented the revised

Operational Plan for approval of amendments.

Board members agreed that the Operational Plan should be a dynamic document

with a robust process for continually evolving.

Board members considered the proposed amendments.

With regard to the proposed changed to the time to recruit target, Board

members discussed the elements of the process and challenged the length of

time allocated for pre-employment checks querying if the activities could be done

concurrently. After some discussion, Board members accepted the proposed

timescales whilst emphasising the need to recruit staff into post in an expedient

manner. A six month update on the time to recruitment was requested.

FT/16/58 update on recruitment times MW



The Chairman thanked the Director of Nursing and the Trust Secretary for their

ongoing work to review and respond to the draft CQC report.

20. Questions From Members of the Public

No questions raised

Date And Time Of Next Meeting

29th September 2016

Resolved: to exclude the press and public from the remainder of the meeting

because publicity would be prejudicial to the public interest by reason of the

confidential nature of the business to be transacted.

Board of Directors minutes –17th August 2016 Page 1 of 2

Meeting Board of Directors Meeting

Time 11.00

Date 17th August 2016

Venue Board Room Bolton NHS FT

Present:-

Mr D Wakefield Chair DW

Dr J Bene Chief Executive JB

Mrs P Armstrong Child Director of Nursing TAC

Mr N Chamberlain Non-Executive Director NC

Mrs C Davies Non-Executive Director CD

Ms A Gavin Daley Non-Executive Director AGD

Mr S Hodgson Medical Director SH

Mr A Thornton Non-Executive Director AT

In attendance:-

Mrs E Steel Trust Secretary ES

1. Apologies

Mr A Ennis Chief Operating Officer AE

Mr M Wilkinson Director of Strategic and Organisational Development MW

Mr Allan Duckworth Non-Executive Director AD

Dr M Harrison Vice Chair MH

2. Declarations of Interest

No interests declared in relation to agenda items

3. Establishment of a subsidiary company

The Director of Finance reminded Board members that they had previously

discussed the formation of a subsidiary company with a verbal update at the

June Board meeting and a paper presented to the July meeting.

Board members acknowledged that they recognised the significant potential

benefits and had supported progressing with the project.

The Director of Finance advised that an extraordinary meeting had been called in

order for Board members to formally approve the establishment of a company

and to approve a submission to Company’s House to establish integrated

Facilities Management Bolton (iFM Bolton) as a subsidiary company of Bolton

NHS FT.

In order to establish the company, the Director of Finance proposed that he

Board of Directors minutes –17th August 2016 Page 2 of 2

should be named as Director of the subsidiary with the Trust Secretary acting as

Company Secretary. It was stressed that these appointments were as a

temporary measure to expedite the application, consideration would be given to

the appointment of substantive officers of the company in due course.

The Director of Finance assured the Board that there was no risk to establishing

an entity and with nothing in the Trust SFIs to cover the governance of a

subsidiary all decisions would be brought to the Board until such time as formal

articles had been approved and adopted by the company. In due course it was

anticipated that the Deputy Director of Finance would be named as the Finance

Director of the Company and the DDO for Estates and Facilities would be the

Managing Director.

The Chairman asked if the Board of the subsidiary would also include members

from the Trust Board of Directors, it was agreed that this would be considered at

a future meeting.

Board members discussed the proposal, in discussion the following points were

made:

Conflicts of interest in relation to the subsidiary company would need to

be formally declared.

Although there are no risks full due diligence will be undertaken to

understand and mitigate against any unintended consequences.

There is a risk that the project could be misconstrued as privatisation, the

message will require careful communication.

The first act of the new company will be the transfer in of services

currently provided by ISS, the unions are aware of this intent and view it

as a positive move

The practicalities of a separate pension scheme and retention of pension

rights will require significant work to protect individuals and the Trust.

The CCG have given their support to the initiative.

Resolved: Board members approved the formal establishment of Integrated

Facilities Management Bolton as a wholly owned subsidiary of Bolton NHS

Foundation Trust.

The Director of Finance advised that in order to progress at pace direct awards

for legal and VAT advice would need to be made, awarding contracts in this way

would be outside the Standing Financial Instructions and would require a formal

waiver.

Resolved: The Board approved the appointment of advisors at the discretion by

the use of a waiver at the discretion of the Director of Finance.


No other business

Date And Time Of Next Meeting

29th September 2016

July Board actionsCode Date Context Action Who Due CommentsFT/16/52 28/07/2016 Chairman's update forward Monitor publication "Strengthening financial

performance and accountability" to NEDs

ES Aug-16 complete

FT/16/58 28/07/2016 shared surgical services paper to be redrafted to reflect Board discussion MW Aug-16 verbal updateFT/16/21 31/03/2016 Equality and Diversity report on actions to improve our equality and diversity

performance for employees and patients

MW Sep-16 agenda item

FT/16/35 26/05/2016 IT strategy EPR business case to June Board AE Sep-16 agenda item part twoFT/15/65 29/10/2015 Board development future development session for Board and clinical leads/QA

members

JB/ES Sep-16 verbal update

FT/16/54 28/07/2016 Performance update next report to include more on workforce for the future MW Sep-16 verbal updateFT/16/59 28/07/2016 Branding brand guidelines including format for slides MW Sep-16FT/16/53 28/07/2016 Performamance update report back on absence management to include consideration

of innovative actions

MW Oct-16

FT/16/39 30/06/2015 violence against staff update to be provided in October 2016 MW Oct-16FT/16/50 30/06/2015 QA strategy develop new strategy with consultation SH Oct-16FT/16/57 28/07/2016 staffing report update on midwifery staffing TAC Oct-16FT/16/20 31/03/2016 Actions report back on impact of the dementia friendly environment,

including staff experience and feedback from LM (carer from

previous patient story)

TAC Nov-16 part two discussion item to include dementia friend

training and input from dementia nurse

FT/16/46 30/06/2015 Hip Fracture report through Clinical Governance Committee on actions and

other metrics, report back to Board in 6 months

SH Dec-16

FT/16/56 28/07/2016 Mazzar's report update to QA Committee Dec 2016 SH Dec-16FT/16/49 30/06/2015 Pharmacy presentation update to Jan 2017 Board SS Jan-17FT/16/55 28/07/2016 RCS action plan update on theatre action plan/culture change in six months SH Jan-17

FT/16/38 26/05/2016 Premises Assurance Model update in March 2017 ST Mar-17

Key

complete agenda item due overdue not due

All information provided in this written report was correct at the close of play 20/06/2016 a verbal update will be provided during the meeting if required

Agenda Item No: 8

Meeting Board of Directors

Date 29th September 2016

Title Chief Executive Update

Executive Summary

The Chief Executive update includes a summary of key issues since the previous Board meeting, including but not limited to:

NHS Improvement update

Stakeholder update

Reportable issues log

o Coroner communications

o Never events

o SUIs

o Red complaints

Board Assurance Framework summary

Next steps/future actions Clearly identify what will follow i.e. future KPI’s, assurance requirements

The Board are asked to note this update

Discuss Receive

Approve Note

This Report Covers (please tick relevant boxes)

Strategy Financial Implications

Performance Legal Implications

Quality Regulatory

Workforce Stakeholder implications

NHS constitution rights and pledges Equality Impact Assessed

For Information Confidential

Prepared by Esther Steel Trust Secretary

Presented by Dr J Bene Chief Executive


Chief Executive Update

1. Awards and recognition

National

The Trust has been shortlisted in in the finance category of the Guardian Public Sector

Awards, up against projects from Angus Council and Sevenoaks District Council. Although

this is in the finance category, the nomination recognizes the efforts of the whole trust to

turnaround financial and quality performance.

Tracey Garde Acting Deputy DND for the Acute Adult Division received national recognition

from St John Ambulance receiving the “Community Hero Award” in appreciation of her work

raising funds and awareness for community defibrillators.

Vishika Rabadia, a pharmacist based at Breightmet Health Centre in Bolton was shortlisted

as a Regional Finalist for Northern England for the I Love My Pharmacist Award. Vishika

works as part of an Integrated Health and Social Team including pharmacists,

physiotherapists, occupational therapists as well as social workers. As a team they take

referrals from GPs whose patients are at high risk of ending up in hospital (in the top 2%),

and they work together to reduce hospital admissions.

At the British Medical Association 2016 Patient Information Awards ceremony Dr Veronica

Kennedy, Consultant Audiovestibular Physician and the team from Halliwell Children’s

Centre were awarded Highly Commended and Commended for a series of leaflets they

have developed for children with tinnits

2. Stakeholders

2.1 CQC

Our CQC report was published on 17th August 2016 giving us an overall rating of good.

The Trust Quality Summit with the CQC was held on Tuesday September 20th 2016 with

the CQC, NHSI, the CCG and HealthWatch in attendance. Feedback continues to be very

positive with wide recognition of the work done and acknowledgement from all parties with

regards to the next steps. The action plan will be reviewed by the QA Committee and

submitted to the CQC by the 30th September.

2.2 NHS Improvement

Following consultation, the NHSI have published their new “Single Oversight Framework”

(information provided with July CEO report and July Q1 declaration)

The new framework will consider performance in five areas and will segment providers from

1 (best) to 4 depending on the support required.

Segments 3 and 4 will be considered to be in breach of the provider licence. Trusts will

only be in segment 1 if not triggering concerns in any of the five areas.

2.3 Greater Manchester Devolution/Healthier together

Discussions with partners in the North West Sector and the wider Greater Manchester

Health and Social Care Partnership continue. Board members spent a recent development


session discussing the implications of local and regional developments on the Trust and on

the public of Bolton.

2.4 Hospital Chain

No further developments

3. Reportable Issues Log

Issues occurring between 28th July 2016 and 20th September 2016

3.1 Serious Incidents and Never events

We have reported one serious incident relating to a C Difficile infection.

3.2 Red Complaints

No red complaints received

3.3 Coroner report

Nothing to report

3.4 Reputational Issues

Nothing to report

3.5 Whistleblowing

.

4 Board Assurance Framework

The risk of achieving each of the 34 objectives has been assessed by the executive lead

and calibrated through challenge at the exec team meeting. The risk of achieving the key

objectives will be incorporated into the performance report; scores will be reviewed monthly

with significant changes highlighted through this report.

Risks scored at 15 or higher have been included on the full BAF – this is scheduled for

discussion at the Audit Committee meeting on 27th September 2016.

The monthly performance report includes an update on the achievement of each of these

objectives and performance against the relevant metrics. The score is a function of the

impact and the likelihood of failing to achieve the objective.


Trust Wide Objective Lead I L Key Risks/issues Actions required Oversight

1.1 Respond to the deteriorating patient MD 4 5 20 NEWS compliance Escalation of ill patients

Divisional action plans Mortality reduction

1.4 To develop a systematic process to ensure safe staffing levels both within the hospital and the community

DON 4 5 20 L:imited pool of staff International recruitment IPM workforce

1.5 For our patients to receive harm free care DON 5 4 20 Falls, Pressure Ulcers and Medication incidents

Implementation of policies and training QA Comm

2.1 To deliver the NHS constitution, achieve Monitor standards and contractual targets

COO 5 4 20 A&E flow and staffing Urgent Care programme plan Urgent care prog board

2.3 To improve system resilience to enable timely and appropriate flow through the hospital.

COO 5 4 20 Intermediate care delays Late bed availability

Application of SAFER Urgent Care action plan

Urgent care prog board

3.6 Compliance with NHS improvement agency rules

DSOD 5 4 20 Gaps in medical rota Industrial action

Ongoing recruitment National recruitment plan

IPM Workforce comm

5.1 Service and Financial Sustainability DOF 5 4 20 Sustainability fund

Capital to revenue transfer

finance plan and A&E improvement

Agreement with NHSI

IPM F&I comm

6.6 Progress delivery of the Bolton Locality Plan DSOD 5 4 20 Estates and IT infrastructure Access to transformation fund

Explore sources of finance EPR OBC to Sept Board

F&I comm

3.4 Teams are appropriately staffed and flexible DSOD 4 4 16 Sickness absence e-rostering and workforce planning

Full e-rostering roll out by March 2017 Workforce comm

6.3 Work alongside the CCG to Support continued provision of a sustainable and quality primary care service

DSOD 4 4 16 GP co-location GP Federation

Engagement with CCG and GP Federation Health and Wellbeing Board

2.2 Clear strategy for our services considering the challenges of system resilience and the provision of 7 day and out of hour services.

DSOD 4 4 16 Estates and IT challenges Healthier Together/GM devolution

Ongoing engagement with partners Development of service strategy

Board F&I

1.2 Reduce healthcare acquired infections DON as DIPC

5 3 15 Lack of assurance relating to ANTT competence

New ANTT policy and training IPC committee

Committee/Group Chair’s Report

Version 4 – 10/08/16

Name of Committee/Group: Quality Assurance Committee Report to: Board of Directors

Date of Meeting: 17th August 2016 Date of next meeting: 21st September 2016

Chair: Andrew Thornton, Non-Executive Director Parent Committee: Board of Directors

Apologies: Chrisella Morgan, Mike Robinson, Simon Worthington, Steve Simpson, Marie Forshaw, Mark Wilkinson, Harni Bharaj and Janet Roberts

Quorate (Yes/No): Yes

Key Agenda Items: Assurance

Yes/No Lead Key Points Action/decision

Acute Adult Division Quarterly Report yes B Bradley Comprehensive report prompted discussion regarding observations and incidents

No actions required

Integrated Care Division Quarterly Report yes J Pinington

Division commended for improvements to the report and for positive feedback from CQC. Darley Court refurbishment now underway

BOSCA yes L Denman Presentation on the new programme for ward assessments. Committee commended the process

Annual Complaints Report yes R Sachs Report approved for submission to the Board Report submitted for Board approval

Report on Compliant Response Breaches Yes R Sachs Explanation of actions taken to address complaints response time breaches

For continued oversight through Clinical Governance Committee

LSA Audit (Midwifery supervision Yes S Anderton

Positive report although below the recommended ratio – all standards met

SEND Inspection Report yes L Barnes Positive assurance with regard to Special Education needs

Cancer Patient Experience yes COO Positive report, overall very good performance


Version 4 – 10/08/16

Name of Committee/Group: Quality Assurance Committee Report to: Board of Directors

Date of Meeting: 21st September 2016 Date of next meeting: 19th October 2016

Chair: Andrew Thornton, Non-Executive Director Parent Committee: Board of Directors

Apologies: S Hodgson, A Ennis, S Worthington, H Bharaj, J Pinnington, R Wheatcroft, M Robinson, C Morgan

Quorate (Yes/No): Not quorate after 10am

Key Agenda Items: Assurance


Patient Story Yes G Riley District nurses can now certify and expected death which improves the family experience

Elective Division Quarterly Report yes J Wood Comprehensive an open report

Update on Quality Account Priorities Partial C McPeake

Report on progress with regard to Stroke objective within the quality account

Request for further information

CQC Action Plan and Quality Summit Yes DoN Positive outcome noted. Committee approved the response to the CQC recommendations

CQC action plan to be monitored through the Clinical Gov Committee

Quarterly Patient Experience Update yes DoN Committee assured with regard to progress in line with the aims of the Patient Experience Strategy

RCS Case Closure Yes J Wood Received letter noting case closure

Duty of Candour Training-e-learning update yes R Sachs Assured that arrangements are effective and the duty is not initiating any additional complaints

Quality Assurance Committee Annual Report yes E Steel Approved for submission to the board

Was the Agenda of the meeting in line with the objectives and goals of the Committee?

Yes/No Action(s) required

yes

Meeting

Date

Title

Executive Summary

Previously considered by Name of Committee/working group and any recommendation relating to the report

Next steps/future actions

For discussion and approval prior to presentation to the Board

Discuss Receive

Approve Note

For Information Confidential y/n

This Report Covers the following objectives(please tick relevant boxes)

Quality, Safety and Patient Experience To be well governed

Valued Provider To be financially viable and sustainable

Great place to work To be fit for the future


Presented by Esther Steel Trust Secretary

Agenda Item No: 9.1

Board of Directors

29th September 2016

QA Committee Annual Report

The attached report was approved by Quality Assurance Committee on its meeting 21st September it is to provide a summary of the work of the committee during the year 2015/16

Quality Assurance Committee Annual Report

1st April 2015 – 31st March 2016

Report approved by the Quality Assurance Committee date to be inserted

1. Introduction

1.1 Purpose of the Report

This annual report has been prepared for the attention of the Board of Directors and reviews

the work and performance of the Quality Assurance Committee in satisfying its terms of

reference.

The report covers the period 1st April 2015 – 31st March 2016 (the reporting period).

1.2 Context

The Quality Assurance Committee was established to provide assurance to the Board with regard to the quality of care, safety and experience of patients, staff and visitors to the Trust and to provide oversight of the systems of governance and risk management to ensure they are appropriately and effectively deployed.

2. Committee Membership

The Quality Assurance Committee membership and attendance in2015/16 is shown on the table below

Ap

ril 15

Ma

y 1

5

Ju

ne

15

Ju

ly 1

5

Au

g 1

5

Se

pt 1

5

Oct 1

5

No

v 1

5

De

c 1

5

Ja

n 1

5

Feb

15

Ma

r 15

David Wakefield (chair) A 11/12

Andrew Thornton (NED) A 12/12

Carol Davies (NED) A A A A A 7/12

Neal Chamberlain (NED) A A A 9/12

Ann Gavin Daley (NED) - - - - 8/8

Jackie Bene A 11/12

Steve Hodgson A A 12/12

Trish Armstrong-Child A A A A 8/12

Simon Worthington - - A A A A A 5/10

Mark Wilkinson A A A A 8/12

Andy Ennis A 11/12

Regular attendance is also required as below:

Representation from each clinical division

Trust Secretary

Head of Governance

Chief Pharmacist

3. Compliance with the Terms of Reference

The Terms of Reference of the Quality Assurance (QA) Committee are reviewed annually and were last reviewed in April 2016. (appendix A)

The QA Committee met 12 times during the reporting period.

All meetings were quorate (quorum is defined in the terms of reference as two Non-

Executive Directors, three Executive Directors and representation from each clinical division).

A Chair report from the Quality Assurance Committee is submitted to the next meeting of the

Board of Directors.

4 Activities and Accomplishments

The QA Committee agenda is constructed in order to provide assurance to the Board

of Directors.

The following table shows the main duties of the Committee and the key activities undertaken by the committee to fulfil them: -

Duties and responsibilities Committee activities/actions

To promote systems which provide assurance and improve the quality of care, safety and experience of patients, carers, staff and visitors to the Trust

Cycle of reports from each clinical division in line with CQC key lines of enquiry (KLOE)

Regular reports on key aspects of patient care including:

o Dementia care

o Staffing levels

o Complaints

o Weekend mortality

o Patient experience

o Pharmacy

Regular Chair reports from each of the reporting committees:

o Clinical Governance and Assurance Committee

o Patient Experience, Inclusion and Partnership Committee

o Risk Management Committee

o Workforce Committee

o Mortality Reduction Group

o Safeguarding Committee

o Informatics Committee

Oversight of the systems of governance and risk management

Report on case note tracking

Regular reports from the Risk Management Committee

Annual complaints report

Patient Experience Strategy update

Assurance with regard to compliance with Trust policies and with all relevant external regulations and standards of governance and risk management.

Reports requested and received by the committee including but not limited to:

Breast screening services

Ophthalmology

Organ donation

Compliance with NICE technology appraisals

Rheumatoid Arthritis

Diabetic Eye screening

Appraisals

Approval of the Annual Quality Account.

Review of relevant external reports and oversight of action plan delivery

Regular reports on the implementation of actions to address the findings in the RCS report.

Reports to ensure learning from national reports including the Kirkup review

Overview of the process to investigate and learn from serious incidents

Reports to provide assurance of actions following surgical never events

Regular reports on pressure ulcers and falls

Agreement of the process to appoint a Freedom to Speak up Guardian

Approval of the Duty of Candour policy

5 Issues and Concerns

At the end of each meeting, Committee members reflect on the meeting and agree issues for

escalation to the Board either for positive assurance or to highlight concerns. The QA

Committee Chair report is received each Board meeting prior at the start of the agenda section

focusing on quality. The Board may also choose to devolve an issue for further discussion and

assurance at the QA Committee.

During 2015/16, issues escalated to the Board included but were not limited to concerns with

regard to capacity within the Ophthalmology department, the action plan for the Care of the

Deteriorating Patient and the requirement for an environmental upgrade to Darley Court

6 Priorities for 2016/7

The workplan for 2016 is attached (appendix B)

Following reflections on the 2015/16 Quality Account, it was agreed to strengthen the oversight

of actions to achieve the agreed priorities with a quarterly report on each of the three priorities

added to the workplan from September onwards

7 Effectiveness of the QA Committee

In 2016, the internal auditors PwC undertook a formal review of the effectiveness of the QA

Committee including observation of a meeting and a review of compliance with the Terms of

Reference. The report concluded that the Committee operated in line with its approved terms

of reference with good practice noted for action tracking, escalation to the Board, themed

agenda and effective chairing with sufficient time allocated for each item.

The internal audit report expressed the view that the large number of attendees at the

Committee could hinder effective decision making and recommended a review of meeting

attendance. The QA Committee discussed this recommendation and felt the current

membership and attendance was appropriate for inclusivity of leaders from each of the clinical

divisions.

8 Conclusion

The Board are asked to note the work of the QA Committee and to approve the workplan and

terms of reference.

Quality Assurance Committee

1. Authority

The Quality assurance Committee (The Committee) is authorised by the Board to investigate

any activity within its terms of reference. It is authorised to seek any information it requires

from any employee and all employees are directed to co-operate with any request made by

the Committee.

The Committee is authorised by the Board to obtain outside legal or other independent

professional advice and to secure the attendance of outsiders with relevant experience and

expertise if it considers this necessary.

2. Reporting Arrangements

The Quality Assurance Committee will be accountable to the Board of Directors.

The minutes of Committee meetings shall be formally recorded and approved by the

subsequent meeting. The Chair of the Committee shall through the Chair’s report draw to

the attention of the Board any issues that require disclosure to the full Board, or require

executive action.

The Committee will refer to the other two Board governance Committees (the Audit

Committee and the Finance and Investment Committee) matters considered by the

Committee deemed relevant for their attention. The Committee will consider matters

referred to it by those two governance Committees.

The annual work plan of the Committee may be reviewed by the Audit Committee at any

given time.

3. Main Duties and Responsibilities

To promote systems which provide assurance and improve the quality of care,

safety and experience of patients, carers, staff and visitors to the Trust

The Committee will exercise oversight of the systems of governance and risk

management and seek assurance that they are fit-for-purpose, adequately

resourced and effectively deployed to concentrate on matters of concern.

To oversee the effective management of risks as appropriate to the purpose of the

committee

The Committee will seek assurances that the Trust complies with its own policies

and all relevant external regulations and standards of governance and risk

management.

Review quality governance and require action to address any non-compliance

with Monitor’s Quality Governance Framework

Review any relevant external reports including those from the CQC and ensure

that action plans are devised and performance managed to address any identified

deficiencies in clinical governance.

To have an overview of the process to investigate and learn from serious

incidents.

Satisfy itself and the Board that the structures, processes and responsibilities for

identifying and managing key risks to patients, staff and the organisation are

adequate.

To ensure that standards and procedures relating to risk are embedded

throughout the Trust, with mechanisms through the Committee for detailed

scrutiny of high and significant areas, including consultation with appropriate Trust

staff.

Such other relevant matters which the Board may delegate to the Committee

Such other relevant matters which are referred to the Committee by its sub-

committees or the other committees of the Board

Such other relevant matters as the Committee takes upon itself.

4. Membership

The Committee shall be appointed by the Board to ensure representation by non-executive

and executive directors.

Three Non-Executive Directors (one of whom will Chair the Committee)

Medical Director

Chief Operating Officer

Director of Nursing

Director of Strategic and Organisational Development

There is an open invitation to the Chair and CEO of the Trust

Each member will have one vote with the Chair having the casting vote, if required. Should

a vote be necessary, a decision will be determined by a simple majority.

In attendance

Trust Secretary

Head of Governance

Divisional Representation

Head of Pharmacy

Bolton CCG

From time to time the committee may wish to invite individuals to attend the meeting to aid in

the understanding of particular items. The Secretary will issue such invitations on behalf of

the Chair of the Committee

5. Chair

One of the Non-Executive Directors will be appointed as Chair of this committee. In the

absence of the Chair, a decision will be taken in advance of the meeting with regard to who

will chair that particular meeting.

6. Frequency of meetings

Meetings shall normally be monthly and there should be no less than ten meetings per year.

Additional meetings may be arranged from time to time, if required to support the effective

functioning of the Trust.

7. Quorum

At least two non-executive directors and three executive directors plus representation from

each clinical division

8. Attendance

It is highly important that members attend the Quality Assurance Committee on a regular

basis. No more than two meetings should be missed in any one year unless due to

extenuating circumstances. Executive members are expected to nominate a deputy to

attend in their absence.

If a committee member is unable to attend the meeting or send a deputy then a formal

summary report of progress made against their areas of responsibility should be given, in

advance of the meeting, identifying the key issues that should be raised.

If a member fails to attend two consecutive meetings the Chair of the Committee will speak

to the individual. The Chair of the Committee will also be required to bring to the attention of

the Chairman of the Trust if they feel that lack of attendance has not enabled adequate

discussion or decision making

9. Decisions

The Quality Assurance Committee is a decision-making committee. Decisions by the

Committee must accord with the requirements of the Standing Orders and the Scheme of

Delegation – General Principles and be reported to the next available Board of Directors

meeting via the Chair report of the Quality Assurance Committee

10. Agenda & Papers

An agenda for each meeting, together with relevant papers, will be forwarded to committee

members no later than 5 working days before the meeting.

11. Standard Agenda Items

Quality Dashboard and ward to Board heat map

The Committee will receive reports from the following committees:

o Clinical Governance and Assurance Committee

o Safeguarding Committee

o PEIP Committee

o Informatics Committee



Quarterly quality reports from the three clinical divisions

12. Organisation

The Committee will be supported by the Trust Secretary and the secretariat whose duties in

this respect will include:

Agreement of the agenda with Chairman and attendees and collation of papers

Taking the minutes and keeping an action log of matters arising and issues to be

carried forwards

Advising the committee on pertinent areas

Minutes of the meeting will be approved by the committee members.

13. Monitoring Effectiveness

The Committee will undertake an annual review of its performance against its annual work

plan, in order to evaluate the achievement of its duties this will inform the production of a

review by the Audit Committee each year.

14 Review of Terms of Reference

These Terms of Reference will be reviewed at least annually. Changes to these Terms of

Reference must be approved by the Board of Directors

April 2016

Quality Assurance Committee – Workplan 2016/17

September 2016

The Quality Assurance will meet on a monthly basis

The following will be standing agenda items at all formal meetings of the Quality Assurance Committee:

Minutes of the previous meeting

Actions and matters arising

Declarations of Interest

Chairman’s update including horizon scanning and items delegated by the Board

Performance report

Ward to Board heat map

Assurance from reporting committees:

o Patient Experience Committee


o Mortality committee


o IT and Information Committee

The following reports will be received on a quarterly basis:

Divisional Quality Reports

Quarterly update on patient experience

Reports on Quality Account objectives

The following reports will be received twice a year

Quality Strategy update

Safeguarding report

Patient Safety report – a collated report on outcomes of BOSCA assessments and walk


September 2016

Quarterly reports Bi-annual reports Annual and one off reports Additional items

September

Division report – Elective care

Quality Account objective - Stroke

Patient Safety report Committee Annual Report Patient story – integrated Care Division

Draft CQC action plan

October

Division report - families

Quality Account objective – deteriorating patient

Pressure ulcers

Falls

Patient story – Acute Division

November

Division report – Acute Adult

Division Report – Integrated Care

Quality Account objective – end of life care

Patient story – Elective Care Division CQC actions update

December


Quality Account objective - Stroke

Quality Strategy update I Patient story – Families Division

January


Quality Account objective – deteriorating patient

Review terms of reference

Agree workplan

Nine month quality account

Patient story – integrated Care Division

CQC actions update

February



Quality Account objective – end of life care

Committee review of effectiveness



September 2016

Quarterly reports Bi-annual reports Annual and one off reports Additional items

March


Quality Account objectives Patient story – Elective Care Division

April


Pressure ulcers

Falls

Draft Quality Account Patient story – Families Division

May



Final Quality Account Patient story – integrated Care Division

June


Quality Account objective tbc

Nurse staffing report Auditor report on the quality account


July



Quality Strategy update Annual Complaints report Patient story – Elective Care Division

August




Patient story – Families Division


Name of Committee/Group: Finance & Investment Committee

Date of Meeting: 23rd August 2016

Chair: Allan Duckworth

Apologies: Andy Ennis, Mark Wilkinson


Parent Committee: Board of Directors

Other Committees that the report should be shared with:

Key Agenda Items:

Decision/Action

Finance & Activity Report for July 2016 (Month 4) and Integrated Performance Management Framework – Finance

The Committee received and noted the Month 4 Finance Report. Discussions focused, in particular, on the significant risks relating to Divisional performance/ICIP delivery, agency spend, capital project delivery and a potential risk relating to litigation. Actions are being taken under the performance management framework to address the issues underpinning the negative movements in Divisions.

The fundamental review of the Trust’s financial forecast will be brought forward and undertaken based on the Month 5 results, due to the scale of the risks noted in the reports and the likely changes in the national planning timetable.

Report from Capital, Revenue & Investment Group

The Committee noted the report from the Capital, Revenue and Investment Group meeting held on 12th July.

Report from Estates & IT Capital Programme Board

The Committee received an update from the Divisional Director of Operations for Estates & Facilities (DDO) in relation to progress being made against all the schemes. The Committee commended the DDO on the much improved narrative format now included as an integral part of the report.

Model Hospital The Committee received and noted a report on the implementation and roll out of the Bolton Model Hospital process. The process has encouraged significant clinical engagement and the identification of £2.3m savings which are now being implemented as a result of the work to date.

Integrated Facilities Management Service

The Trust has developed an innovative model for the integration of facilities management staff support to the operations of the Trust. Similar schemes have been implemented successfully at other Foundation Trusts. Under the model, Estates and facilities management services are to be provided by a wholly owned subsidiary company.

Procurement KPI Report The monthly KPI Report was received and noted. The increased spend through waivers would be monitored the Committee.

Results of the Finance & Investment Committee self-assessment review

The Committee reviewed the results of the self-assessment survey. With regard to ongoing professional development, it was agreed that this would be best achieved as part of the overall Board Development programme. Through its work plan, the Committee will provide recommendations to the Board as to the priority areas for potential finance training. With regard to improved input on Healthier Together/Devolution Manchester, it was noted that these issues were now more formally recognised in the Committee work plan. To date these matters had often been discussed at Board but it is anticipated that Committee input is likely as matters progress and related “Business Cases” require more formal appraisal. It was anticipated that September's Board development session would cover governance and financial implications of collaboration/single services.

Decisions/Approvals:

Risks to be escalated

The Committee highlights a number of significant risks that should be noted by the Board:

Divisional Performance/ICIP – significant delivery risks

A&E performance and project delivery

Cash

Delivery of the Estates & IT Capital Expenditure Plan

A potential risk relating to litigation

Date of next meeting: Thursday 22nd September 2016


Name of Committee/Group: Finance & Investment Committee

Date of Meeting: 22nd September 2016

Chair: Allan Duckworth

Apologies: None


Parent Committee: Board of Directors


Key Agenda Items:

Decision/Action

Finance & Activity Report for August 2016 (Month 5)

The Committee received and noted the Month 5 Finance Report. Discussions focused, in particular, on the significant risks relating to Divisional performance and cash.

2016/17 Financial Position – Fundamental Review

The fundamental review was presented and a strategy in terms of how this should be reported and what areas of negotiation needed to be entered into with NHS Improvement was agreed in principle.

Report from Estates & IT Capital Programme Board

The Committee received the report from the Estates & IT Capital Programme Board and noted good progress overall. A late objection had been received from the Mining Authority in relation to the A&E scheme but it was anticipated that construction would not be held up by this.

Report from Capital, Revenue & Investment Group

The Committee noted the report from the Capital, Revenue and Investment Group meeting held on 9th August.

Reference Costs The Committee received the results of the National Reference Costs audit and indicative Reference Cost results for 2015/16. The report was well received however paragraphs 12 to 14 would be reviewed to ensure the overall result, taking account of the market forces factor, was accurate.

Costing Transformation The Committee noted that the Trust has agreed to be an early adopter for the Costing Transformation Programme, placing it at the forefront of this new way of costing and enabling it to influence policy developments as well as being recognised nationally as a hospital with good costing practice.

North West Sector Governance The Committee received and noted a report which set out the present governance arrangements within the North West sector and the proposed arrangements under development for the establishment of a Single Shared Service Board between Bolton, Wrightington, Wigan and Leigh, and Salford Royal NHS Foundation Trusts.

Procurement KPI Report The monthly KPI Report was received and noted.

Integrated Facilities Management Bolton

The Committee received an update on progress in relation to the setting up of Integrated Facilities Management Bolton together with a report relating to the scoping exercise currently being undertaken. The Committee discussed the options available and agreed that as a matter of policy independent tax advice must be obtained.



The Committee highlights a number of significant risks that should be noted by the Board:

Divisional Performance/ICIP – significant delivery risks

The fundamental review of the financial position is in hand

A&E performance and project delivery

Cash

Delivery of the Estates & IT Capital Expenditure Plan

A potential risk relating to litigation (options for mitigation under consideration)

Date of next meeting: Tuesday 18th October 2016

1 Concerns and Complaints Annual Report 2015/16 Final

Annual Complaints & Patient Advice and

Liaison Service (PALS) Report

April 2015-March 2016


Page

2. Contents

3. Purpose of report

Introduction

4. Key successes

Improvements required

5. Number of complaints and pals concerns

received

6. Response times for complaints

7. Outcome of complaints received

8. Parliamentary Health Service Ombudsman

(PHSO)

9. Re-opened cases

10. Analysis of themes

11. Analysis of themes cont…

12. Learning from complaints

Pals concerns

13. Benchmarking complaints data

14. Other methods of Patient feedback

NHS Choices and Patient Opinion Feedback

Friends and Family Test

15. Overview of learning from Divisions

16. Recommendations and Next Steps


Purpose of report In accordance with the NHS Complaints regulations (2009) this report sets out a detailed analysis of the nature and number of complaints and concerns received by Bolton NHS Foundation Trust from April 2015 to March 2016. It provides information on our performance in responding to these complaints and concerns; what learning has been identified as a result of investigations undertaken and how practice has changed in response to the issues being raised through the complaints process.

Introduction

Bolton NHS Foundation Trust is an integrated organisation including acute hospital services; specialist and general out patients; maternity and Women’s Health; Emergency Department; Community services, which are continuing to be developed many as shared services across health and social care (Local Authority). This year we have agreed a new 3 year Patient and Carer Experience Strategy which will provide a focus for delivering the best experience for all our patients over the next 3 years, building on our current achievements. From time to time the report talks in terms of ‘upheld’ and ‘not upheld’ – this is terminology that the NHS is required to use. However, whether upheld or not, the Trust will always seek to learn from complaints as we value greatly the time that patients and relatives spend feeding back to us about the services we provide to them.

Key Successes Since the introduction of a revised Management of Concerns and Complaints policy in April 2015 we have worked with the staff to embed key changes, which have delivered the following;

To respond to all complaints within 35 working days, unless the

complainant wanted a later date for example to meet up at

their convenience. Overall achieved 92.65% against a target of

95% compliance. This was an improvement on 2014/15 which

met 89.49%

Each complaint response is accompanied by a learning

log/action plan prior to submission for final sign off by the

Chief Executive. This was introduced in October 2015 and we

have been able to achieve 100% compliance in this element of

the management process.

To monitor action plans/learning from complaints- Patient

Experience Manager attends Weekly Incident, Inquests, Claims,

Complaints, Action Monitoring (WIICCAM) meeting and

completed actions updated onto Safeguard System.

Training delivered to approximately 60% of ward managers

and matrons on complaint investigation and response writing.

To be repeated throughout the year to include remainder.


Key Successes continued...

Training on awareness of dealing with concerns delivered

as part of HCA development programme. (4x per year)

Following collaboration of the PHSO, Local Government

Ombudsman and Health Watch England, and the resulting

publication ’My Expectations for raising concerns and

complaints’, we have amended our complaints

management evaluation questionnaire which will be

introduced for all complaints responded to from 1st April

2016. (Appendix 1.)This may in time allow us to benchmark

nationally on our performance in the management of

complaints.

Improvements required;

To ensure more robust measures in place to support consistent the provision of a timely quality response to all complainants within 95% target.

A reduction in the number of re-opened cases by 5%. This year did not see the desired drop in cases being re-opened (see details on page 9). Many of the re-opened cases were resolved by the complainant agreeing to a local resolution meeting.

To provide a more user friendly environment within the PALS office to ensure improved privacy and dignity. Work has started to address this and will be completed by 31st August 2016.


0

10

20

30

40

50

60

Q1 Q2 Q3 Q4

All complaints received quarterly by Division 15-16

Acute Adult Care Elective Care

Family Care Integrated Community Care

Other

Total Number of Complaints

Total

14/15 15/16

Total No of complaints and PALS concerns

1321 (486

complaints 835 PALS

concerns)

1340 (398

Complaints 942 PALS concerns)

Total number of episodes of care

1,316,104

1,232,422

Ratio of complaints and PALS concerns to episodes of care

1:996 1:919

There has been a decrease in complaints and an increase in PALS concerns, demonstrating that the Trust is being responsive and able to find a swift resolution to concerns raised

Whilst there has been no significant difference in total number of complaints and PALS concerns between 2014/15 and 2015/16 there have been 83,682 less episodes of care in 2015/16. This does mean that there has been a slight increase in the ratio of complaints and PALS concerns to number of episodes of care over the 12 month period.

There has been a downward trend for all divisions over the 12 month period in number of complaints; however Acute Adult Care and Elective Care Divisions have both seen a more significant decrease in Q3, although the Trust did see an increase in activity in Q3 and Q4.

176 136 65 14 7

292 453

106

28 63 0

100

200

300

400

500

600

700

Acute AdultCare

Elective Care Family Care IntegratedCommunity

care

Other

Complaints and PALS concerns by Division 2015-16

Complaints PALS


Response times to complaints

The Trust policy stipulates that all complaints should be responded to within 35 working days unless at the complainants request and then an extension must be authorised by the Director of Nursing.

The trust breached on 34 responses in the 12 month period out of 396 due a response in this period.

Complainants were kept informed as much as possible. Most breaches occurred a result of insufficient responses

provided late and the requirement of further amendments which could not be delivered by due date.

Other responses which exceeded the 35 days were all agreed to be extended in line with policy and then provided by agreed date.

No complaints exceeded the 6 month timescale recommended within the NHS complaints regulations.

60%

65%

70%

75%

80%

85%

90%

95%

100%

Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar

Monthly percentage of complaints responded to in agreed timescale 14-15 and 15-16

2014/15 2015/16 Response Target

0

50

100

150

200

250

300 No of days taken to respond

No of responses


Outcome of complaints

There have been 398 complaints received during the year 2015-16.

Three of these were on-going at the time of this report being finalised,

however of those for which the investigation has been completed 235 were considered upheld or partially upheld and 160 not upheld

0

20

40

60

80

100

120

140

160

180

200

Acute AdultCare

Elective Care Family Care Integratedcommunity

Care

Estates andFacilities

Distribution by Division of Upheld/Partially Upheld and Not Upheld

UpheldPartially Upheld

0 20 40 60 80 100 120 140 160

Admission, Discharge And Transfer

All Aspects Of Clinical Treatment

Aids And Applicances, Equipment

Appointments -

Attitude Of Staff

Communication

Various others

Not upheld Upheld/partially Upheld Complaints


Parliamentary Health Service Ombudsman (PHSO) Start

Date Division Details End Date Outcome

1 12/05/2015 Acute Adult Care

04/06/2015 Not Upheld


Communication Delayed

Diagnosis


3 02/07/2015 Elective Care

Communication 24/03/2016 Partially Upheld


Clinical treatment



End of life care 07/03/2016 Not Upheld


Pain service referral

N/A On-going

7 23/03/16 Family Care and Estates

Security concerns and

discharge planning

N/A On-going


Medication and Equipment

check

N/A On-going

9 10/04/2015 Int Community care and /Salford

NHS

End of life priorities

07/03/2016 Not upheld

10 14/08/2015 Family care

Birth experience

31/03/2016 Not upheld

There have been 10 cases accepted by the PHSO for investigation in 15/16 as opposed to 5 the previous year. The increase in numbers investigated by the PHSO was anticipated as a result of them increasing the number of investigators available, following the outcome of a public consultation. There were 17 enquiries from Q1 to Q3 (the number is not published for enquiries in Q4). This was a reduction in enquiries to the PHSO from 47 (full year) in 2014/15 and the lowest number against other local trusts. PHSO data report Q1-Q3 2015/16 provides a benchmark for the ombudsman’s enquiries in comparison to similar sized organisations.(Q4 data not available)

Trust Enquiries Accepted for investigation

Upheld/or partially upheld

Not Upheld

Bolton 17 8 2 3

Salford 33 10 0 1

WWL 33 12 5 4

Tameside 20 7 1 2

Stockport 33 10 4 1


Re-opened cases During the 12 month period 60 complaints were re-opened compared with 59 the previous year. The re-opened cases are not necessarily all from the complaints investigated in the current year but also from the complaints closed in 14/15.

Of the 60 cases that were re-opened 30 were not upheld and 30 either partially or fully upheld. 4 where subsequently agreed to be investigated by the PHSO and of these 3 were not upheld and one is on-going. Of the 60 re-opened cases, 30 resulted in a local resolution meeting. Often complainants prefer to decline a meeting in the first instance until they have received a written response. Acute Adult Care Division saw a decrease in re-opened cases to the previous year from 34 to 25, whilst Elective care division increased from 16 to 25 and family remained stable with 9 and 8 respectively. The reasons for cases being re-opened are outlined below;

Disputes Information

Requests local

resolution meeting

Unresolved issues

Not all issues

addressed

New Questions

32 7 8 7 6

Acute Adult Care,

25

Elective Care, 25

Family Care, 8

Int Comm Care, 2

Re-opened cases by Division


All Complaints

Acute Adult

Elective Care

Family Care

all aspects of clinical treatment

66% 59% 76% 68%

attitude of staff

9% 9% 6% 17%

communication

9% 14% 4% 6%

admission, discharge and transfer

6% 12% 1% 0%

appointments

4% 1% 9% 4%

aids and equipment provision

2% 1% 1% 0%

privacy and dignity

1% 2% 1% 0%

personal records

1% 1% 1% 5%

Other various

2% 1% 1% 0%

Total

100% 100% 100% 100%

Analysis of themes

Overall although the top 5 themes remain the same, there has been a positive shift in complaints relating to attitude of staff by 4%, and 1% in complaints relating to Admission and discharge arrangements; similarly there has been a negative shift in complaints relating to communication from 6% to 9% in 2015/16

Themes of Complaints by Division

Acute Adult Care Division received 176 complaints a reduction of 43 from 14/15.

The breakdown in themes was very much the same as last year however 2 of the top 5 themes have seen significant changes with a 7% reduction in percentage of complaints relating to ‘Attitude of staff’ as the main theme for some complaints and an increase in percentage of complaints around ‘Communication’ and ‘All aspects of Clinical Treatment’ by 5%. ‘Admission and Discharge’ arrangements related complaints remained the same.

99 complaints (56%) related to care provided within Emergency Department i.e. A&E, D1 and D2 and CDU

Admission and Discharge arrangements 15 of 22 related to the Emergency Department and Complex care areas. 10 out of 22 raised concerns regarding the patients not being fit for discharge.

All aspects of Clinical Treatment- 50% related to Decisions about clinical treatment were upheld or partly upheld.

Wrong diagnosis all were patients seen within the A&E Department

Nursing care for various areas-16 out of 20 were upheld or partly upheld.


Elective care Themes mirror last year, however there has been an

increase in percentage of complaints relating to ‘All Aspects of clinical care’ from 68% 14/15 to 76% in 15/16 and is greatest number compared to other Divisions as was also reported in 15/16.. (The breakdown of sub-categories in this group can be seen in chart 12 below)

‘Attitude of staff’ related complaints have greatly reduced from 10% to 6% in this division.

Complaints regarding ‘Appointment issues’ has reduced from 11% to 9%. However in PALS concerns appointment issues were at 28% and it is likely that the doctor’s strikes may have had an impact on this type of concern as well as the increase in capacity issues across the Trust in Q3and Q4.

‘Admission and Discharge Arrangements’ related complaints and ‘Communication’ have both increased from 1% to 4% and from 3% to 4% respectively.

Family care Family care Division received 65 complaints a reduction on

previous year when received 74. All Aspects of Clinical treatment accounts for 68% of total

complaints-decrease of 5%

Attitude of staff 17% and significant increase on previous year when accounted for 11% of complaints

Integrated Community care

this division received 14 complaints in the 12 month period and therefore difficult to identify themes from, however the in the main did relate to nursing care.


Learning from Complaints Every complaint response regardless of whether considered to be upheld or not upheld will have an learning log completed to signify any actions or incidental learning if not directly related to the concerns expressed by the complainant. The learning and actions are uploaded onto the Safeguard system and are able to be monitored for regularly and updates obtained from the areas concerned. At the weekly WICCAM (Weekly Incident, Complaint, Claims Action Monitoring) complaints are discussed alongside incidents and claims to ensure governance arrangements are robustly embedded to improve patient safety. Monthly reports on outstanding actions from complaints are monitored in this way. Monthly slides are produced and circulated across the organisation with examples of any learning from complaints, along with other learning through incidents etc so that this learning is shared widely.

PALS Concerns

The Trust received 942 Pals concerns over the 12 month period 2015/16. This is an increase of 107 from previous year. The Divisional breakdown can be seen on page 5. These concerns will usually be dealt with quickly by telephone or by senior staff visiting the patient or relative on a ward. However if resolving the concern is not possible in this way, then the concern will be upgraded to a complaint with a thorough investigation then taking place.

Although the themes do mirror those of complaints the percentage of each themes does differ from that of complaints as can be seen below.

31% All Aspects of Clinical Care- this category includes many subcategories including, decisions about clinical treatment; delay in diagnosis; nursing care and complications from surgery or procedure.

11%- Attitude of staff- this category includes all staff either clinical or non-clinical.

5%- Admission, Discharge and Transfer Arrangements- this includes such as patient not being fit for discharge or family not being involved.

8% Communication - ranging from ineffective communication with patient/family to lack of information.

28% Appointment Delays/Cancellations Appointment issues feature heavily in all PALs concerns, with Elective Care Division receiving the highest number as it holds the majority of the out-patient services.


Benchmarking complaints data PALS/Complaints ratio to episodes of care from 2014-2016

The KO41 data collection is the statutory based mechanism for collating written complaints data about NHS care and treatment, across all NHS organisations in England. There are some exceptions to the criteria; such as if a complaint investigation is led by another trust and therefore the numbers do not assimilate to the total number. The table below provides some level of benchmarking in relation to other North West Trusts.

Year Bolton WWL Salford Central M/C

Pennine Stockport

2012/2013 428 486 351 1081 795 621

2013/2014 562 391 383 1192 813 708

2014/2015 467 377 418 1035 756 775

2015/16

Q1-Q3 available

307

Q4

259 207 857 374 552

2013/14 2014/15 2015/16 Ratio of

PALS/Complaints to episodes of care

1:910

1:996

1:919

Ratio of PALS concerns to episodes of care

1:1643 1:1576 1:1308

Ratio of Complaints to episodes of care

1:2040 1:2708 1:3096

NHS Choices

The Trust responds to all postings on both NHS Choices and Patient Opinion websites and the content of these are fed back to the appropriate service areas for their attention and learning. Within our new Patient and Carer Experience Strategy 2016-18 one of our missions is to listen to our patients and act on their feedback. In order to do this we aim to develop a more robust approach to collecting, sharing and using feedback from websites such as NHS Choices and patient opinion. Of the 130 postings, 23 were complaints about our services. There were no key areas identified.

Star ratings

Total number

1 2 3 4 5

Comment 1 - - - 1 -

Compliment 103 2 - - 6 95

Complaint 23 14 6 3 - -

Mixed 3 - - 2 - -

Total 130 16 6 5 7 95


Friends and Family Test

The FFT is a feedback tool has been expanded this year to

include Day Cases, Community and Out - Patients. Our

challenge this year has been to improve our ability to analyse

the feedback and make comparisons with other information

such as received through complaints data. Also introduced in

15/16 has been the Staff FFT which is also helping to improve

the quality of our feedback on our services and to identify

improvements as necessary.

The table below demonstrates our response rates in relation to

each service.

Response Rates

Area 2014 2015 2016

In-patients 36.8% 44.6% 41%

Emergency Care

16% 21% 19%

Maternity Services

5.9% 7.1% 11%

Day Cases N/A N/A 26.3%

Community N/A N/A TBC

Out -patients N/A N/A 15%

The table below demonstrates the Ratings received from FFT feedback

Extremely Likely

Extremely Unlikely

Total responses

Eligible patients

In-patients 4766 22 6258 15084

Emergency Care

8672 709 13205 67760

Maternity Services

1932 73 2453 21903

Day Cases 5581 83 6660 25320

Community TBC TBC TBC TBC

Out -patients 28328 856 39325 266290


Overview of Learning from Divisions Many of the themes highlighted from complaint investigations and from other patient feedback, such as the National In-Patient Survey have been incorporated into the new ward accreditation programme, The Bolton System of Care Accreditation (BoSCA). This programme grades wards on categories including, noise at night, availability of specific patient information leaflets, timeliness of answering buzzers, etc. Below are examples of learning and actions taken as a direct result of complaint investigations. All Aspects of Clinical Treatment Complications of Surgery You Said Patient said he was unaware that he would have a digital rectal examination prior to a colonoscopy - not referred to in colonoscopy leaflet We did Patient Information Leaflet content discussed at Endoscopy Governance and amended as appropriate. You said Patient developed post -operative infection following tooth extraction - required further emergency surgery and admittance to ICU. We did Guidelines for pre-operative antibiotics for oral surgery patients having tooth removal reviewed and discussed at speciality Governance meeting.

Decisions about Clinical Treatment You said Staff did not refer on from A&E to Gynaecology in line with pathway. We did Pathway for Obstetrics and Gynaecology reviewed to ensure appropriate referrals are made in the future. You said Patient had sustained a fracture, and this was not noted on review of the X – ray We did Patient's' imaging shared with the department as a learning opportunity, and to highlight the diagnosis error. Also shared at missed X-ray meeting in A&E Nursing Care You said Incomplete food charts in the notes. Patient was unable to reach his food and was not assisted sufficiently. Hearing aid missing /not working. We did Business Unit Manager discussed this with Matron and Ward Manager who will ensure documentation is complete and accurate. Standard of documentation to be monitored Use of boards by the bed to inform staff of patients' needs. HCA staff in available each bay as appropriate


Nursing care continued You said Thickener and water left on bedside when patient was unable to have these himself. Food not thickened to the correct consistency. We did Thickener is no longer left on bedsides due to risk to patient. Protocol for use of thickener changed. Staff spoken to at the time re preparation of thickener SALT team on ward daily to offer advice Nutrition Champion on ward to assess SALT recommendations are followed. Provision of Aids/Equipment You said Patient admitted to A&E when PEG tube became dislodged Delay in replacing a PEG tube when attended A&E as not in stock We did Introduction of ACE stopper in event of tube becoming dislodged. Tubes now ordered once patients home so always a spare one. New specialist stock of equipment now available in A&E so can replace tubes as needed

Appointment concerns Appointment Booking/Communication You said Patient thought he was coming in for vasectomy procedure but it was only an Out-Patient Consultation. We did Information on directory of services changed to note clearly 'APPOINTMENT FOR CONSULTATION ONLY - NOT SURGERY'. You said Appointment cancelled Nickle implants not available for patient's surgery. Staff failed to inform patient who consequently turned up for procedure We did All staff made aware of importance of making OBM aware of any failure to obtain implant in a timely manner. OBM to ensure that this is communicated to patient to prevent cancellation on the day Attitude of Staff You said Lack of caring attitude shown by some of the Nursing Staff We did Copy of NMC Code of Conduct 2015 - Professional Standards of Practice and Behaviour for Nurses and Midwives given out to all members of nursing staff on Ward. Staff attitude and behaviour highlighted at daily Safety Huddles. Staff attitude discussed at Ward Meeting May 2015


Admission and Discharge arrangements/Transfers You said Therapist failed to try the equipment in the patient’s home. Family raised concerns relating to safety of the patient. The therapist did not listen to them, and failed to document that the family had concerns. We did Business Manager spoke to the Therapy team and advised that she would expect that when families of patients raise concerns that they are listened to, with any concerns raised being documented. In addition, as part of an assessment of a patients home and needs, equipment such as Zimmer frames should be tested in the home environment. Communication You said DNACRP not completed properly and family were not informed when patient did not have capacity even though they had POA We did Discussed at Governance Meetings, Ward Meetings and End of Life Steering Group to ensure staff are aware of their responsibility and the importance of discussing with families Regular audits being undertaken.


Equality Diversity and Inclusion Complaints are currently analysed against Age, Ethnicity and Gender and Source Complaints/PALS by Sex

Female Male

Complaints 224 174

PALS 535 407

Complaints/PALS by age group

Complaints/PALS by Ethnicity

Complaints PALS

British White 119 171

Other White 3 3

Black Caribbean 1 1

Indian/Asian 1 6

Irish white 1 0

Other Asian 1 2

Other mixed 1 1

Chinese 0 1

Not recorded 271 755

0102030405060708090

100

Age range of patients in refernce to complaints and PALS concerns

Complaints PALS


Complaints/PALS by Source

It is clear from the available data that Equality and Diversity information in relation to complainants is not consistently available. Improvements in this data will be monitored within the Equality, Diversity & Inclusion work plan.

0

100

200

300

400

500

600Source of PALS concerns

0

20

40

60

80

100

120

140

160

180Source of complaints


Recommendation Proposed Action By Whom/When

Well Led

To consistently achieve 95%

monthly compliance in responding to

complaints within 35 working days.

(monthly average)

Continuous training planned to address statements and response letters for matrons and

ward managers. Quarterly

Further Investigation training planned March/May/Sept/Nov 2016

Weekly meeting held with divisional teams to

discuss status of complaints and maintain internal target dates in line with policy

Patient Experience Manager

Clinical Risk Manager-quarterly

Patient Experience and Complaints Coordinators -weekly

Safe

To build on ability to share learning from complaints across

the integrated organisation.

To continue to monitor at regular WICCAM meeting on a monthly basis

PET to audit 15 action plans

Monthly feedback Tree/Branch slides

demonstrating learning from complaints

Divisional Governance leads/Patient Experience Team

PET by 31st March 2017

PE Manager/Head of Governance/Monthly

Effective

To reduce number of re-opened cases by

5%

Implement use of revised Evaluation Questionnaire

Report in quarterly reports(PEIP Committee/QA

meetings)

Patient Exp Manager/31st March 2017


Responsive

To respond to all re-opened cases and PALS concerns in a timely manner and in line with Policy.

Delivery of training as above

To monitor timescales for responding to re-opened cases/PALS concerns

Patient Experience Manager/Divisional Governance Leads Quarterly

Caring

To address PALS Office environment

and ensure conducive to

promote e.g. privacy and dignity/suitable for bereaved families

To identify requirements and make changes within resources available

Patient Experience Manager 30th September 2016


Appendix 1

Customer Care Complaints Survey

Please tell us how satisfied you are with the handling of your recent complaint about our services

Please mark the appropriate answer

How did you first make contact?

Telephone

Face to Face

Letter

Email

When considering a complaint

Making a complaint

Did you feel you were able to communicate your concerns in the way you wanted?

Yes No

Did you feel your concerns were taken seriously?

Yes No

Did you feel the staff dealing with your complaint were helpful and understood your complaint?

Yes No

If you had a meeting with staff during your complaint did you feel comfortable discussing your concerns?

Yes No

Did you use the PALS service?

Yes No

Staying informed

Did you feel you were kept informed of how your complaint was being processed?

Yes No

Did you feel any correspondence or responses were personal to you and to the nature of your complaint?

Yes No

Did you feel that the staff who were handing your complaint had the power to resolve it?

Yes No

Were you offered the choice to keep your details anonymous and confidential?

Yes No

Did you know you had the right to complain?

Yes No

Were you aware you would be supported if you made a complaint?

Yes No


Receiving outcomes

Reflecting on the experience

Would you complain again if you needed to? Yes No Has your complaint been handled fairly? Yes No

Would you encourage others to complain if they felt they need to? Yes No Do you feel you know how the complaints help to improve service? Yes No

Exceeded Met Fell Below

Respect and Courtesy shown by staff

Extent which you feel listened to

Level of quality of advice

Length of time taken to address your complaint

Overall Experience

Do you have any other comments or suggestions you would like to

make about the complaints service?

http://www.ombudsman.org.uk/__data/assets/pdf_file/0010/28774/Vision_report.pdf

Did you feel you received the outcome of your complaint in a timely manner?

Yes No

Were you told of the outcome in an appropriate place by an appropriate person in the appropriate manner?

Yes No

Did you feel the outcome directly addressed your initial complaint? Yes No

Do you feel that the response to your complaint and the action from this will be used to prevent the same thing happening again?

Yes No

http://www.ombudsman.org.uk/__data/assets/pdf_file/0010/28774/Vision_report.pdf



Title Annual Board Report – Medical Staff

Executive Summary

Why is this paper going to the Board

To summarise the main points and key issues that the Board should focus on including risk, compliance priorities, cost and penalty implications, KPI’s, Trends and Projections, conclusions and proposals

Performance in 2015/16 demonstrates our Appraisal and Revalidation system is fit for purpose. Appraisal rates have continued to improve which supported by strong corporate and divisional governance and robust employment checks has resulted in a low number of medical staff requiring formal remediation. Trust Board is asked to support completion of our annual statement of compliance (Annex E) for submission to NHS North.

Next steps/future actions Clearly identify what will follow a Board decision i.e. future KPI’s, assurance requirements

To note.

Discuss Receive

Approve Note

Assurance to be provided by:

Board of Directors




Quality Regulatory

Workforce Stakeholder implications



Prepared by Steve Hodgson Medical Director

Presented by Steve Hodgson Medical Director

Agenda Item No: 13

OFFICIAL

1

A Framework of Quality Assurance for Responsible Officers and Revalidation

Annex D - Annual Board Report Template

1/4/15 – 31/3/16 Version 5, June 2014

OFFICIAL

2

NHS England INFORMATION READER BOX

Directorate

Medical Commissioning Operations Patients and Information

Nursing Trans. & Corp. Ops. Commissioning Strategy

Finance

Publications Gateway Reference: 03551

Document Purpose

Document Name

Author

Publication Date

Target Audience

Additional Circulation

List

Description

Cross Reference

Action Required

Timing / Deadlines

(if applicable)

Guidance

[email protected]

http://www.england.nhs.uk/revalidation/

0

A template board report for use by designated bodies to monitor their

organisation’s progress in implementing the Responsible Officer

Regulations.

From June 2015

Gary Cooper, Project Manager Quality and Assurance, Professional

Standards Team

16 June 2015

All Responsible Officers in England

Foundation Trust CEs , NHS Trust Board Chairs, Medical Appraisal

Leads, CEs of Designated Bodies in England, NHS England Regional

Directors, NHS England Directors of Commissioning Operations, All NHS

England Employees, Directors of HR, NHS Trust CEs

The Medical Profession (Responsible Officers) Regulations, 2010 (as

amended 2013) and the GMC (Licence to Practise and Revalidation)

Regulations 2012

A Framework of Quality Assurance for Responsible Officers and

Revalidation, Annex D - Annual Board Report Template, version 4 April

2014.

Designated Bodies to receive annual board reports on the

implementation of revalidation and submit an annual statement of

compliance to their higher level responsible officers.

A Framework of Quality Assurance for Responsible Officers and

Revalidation, Annex D - Annual Board Report Template

Superseded Docs

(if applicable)

Contact Details for

further information

Document StatusThis is a controlled document. Whilst this document may be printed, the electronic version posted on

the intranet is the controlled copy. Any printed copies of this document are not controlled. As a

controlled document, this document should not be saved onto local or network drives but should

always be accessed from the intranet. NB: The National Health Service Commissioning Board was

established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the

National Health Service Commissioning Board has used the name NHS England for operational

purposes.

OFFICIAL

3

Annual Board Report Template Version number: 2.0 First published: 4 April 2014 Updated: 16 June 2015 Prepared by: Gary Cooper, Project Manager for Quality Assurance, NHS England Classification: OFFICIAL

OFFICIAL

4

Contents

Contents ...................................................................................................................... 4

1. Executive summary .............................................................................................. 5

2. Purpose of the Paper ............................................................................................ 5

3. Background .......................................................................................................... 5

4. Governance Arrangements ................................................................................... 6

5. Medical Appraisal ................................................................................................. 6

d. Access, Security and Confidentiality ..................................................................... 7

6. Revalidation Recommendations ........................................................................... 8

7. Recruitment and engagement background checks ............................................... 8

8. Monitoring Performance ....................................................................................... 8

9. Responding to Concerns and Remediation .......................................................... 8

10. Risks and Issues ............................................................................................... 9

11. Board / Executive Team Reflections ................................................................. 9

12. Corrective Actions, Improvement Plan and Next Steps ..................................... 9

13. Recommendations ............................................................................................ 9

14. Reporting with small numbers ........................... Error! Bookmark not defined.

15. Annual Report Template Appendix A – Audit of all missed or incomplete

appraisals .................................................................................................................. 10

16. Annual Report Template Appendix B – Quality assurance of appraisal inputs

and outputs ............................................................................................................... 11

17. Annual Report Template Appendix C – Audit of concerns about a doctor’s

practice ...................................................................................................................... 12

18. Annual Report Template Appendix D – Audit of revalidation recommendations14

19. Annual Report Template Appendix E – Audit of recruitment and engagement

background checks ................................................................................................... 16

OFFICIAL

5

1. Executive summary

Performance in 2015/16 demonstrates our Appraisal and Revalidation system is fit for purpose. Appraisal rates have continued to improve supported by strong corporate and divisional governance and robust employment checks has resulted in a low number of medical staff requiring formal remediation.

2. Purpose of the Paper

The purpose of this report is to inform Trust Board of the status of our processes for management and performance against requirements as a designated body employing doctors. This covers the domains of appraisal, revalidation recommendations, identifying and responding to concerns and recruitment and engagement background checks. The Board is required to receive this report on an annual basis. If the Board are satisfied, the statement of compliance with the regulations (Annex E) needs to be signed off by the Chairman or Chief Executive and submitted to the Responsible Officer for NHS North.

3. Background

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

Provider organisations have a statutory duty to support their Responsible Officers in discharging their duties under the Responsible Officer Regulations1 and it is expected that provider boards / executive teams [delete as applicable] will oversee compliance by:

monitoring the frequency and quality of medical appraisals in their organisations;

checking there are effective systems in place for monitoring the conduct and performance of their doctors;

confirming that feedback from patients and colleagues is sought periodically so that their views can inform the appraisal and revalidation process for their doctors; and

Ensuring that appropriate pre-employment background checks (including pre-engagement for locums) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the work performed.

1 The Medical Profession (Responsible Officers) Regulations, 2010 as amended in 2013’ and ‘The

General Medical Council (Licence to Practise and Revalidation) Regulations Order of Council 2012’

OFFICIAL

6

4. Governance Arrangements

The governance of the appraisal and revalidation system is provided by Steve Hodgson (Responsible Officer), Priya Bhatt (Trust Clinical Lead for Appraisal and Revalidation) and Lorraine Bowman (Interim Appraisal and Revalidation Administrator). Support for responding to concerns and employment checks is provided from the Human Resources Department. Our electronic appraisal system allows real time monitoring of the rates and timeliness of medical staff appraisals. Our electronic system, Premier IT, is complaint with national requirements. There is close communication between our Employee Service Centre and the appraisal and revalidation team to ensure that newly appointed medical staff are connected to Bolton FT as their designated body. There is a clear escalation plan in place to ensure appraisals are performed in a timely fashion. Appraisal rates are shared with the individual departments on a monthly basis.

5. Medical Appraisal

a. Appraisal and Revalidation Performance Data

Our 2015/16 Bolton NHS Foundation Trust Annual Comparator Report (Appendix 1) for the appraisal year 2015/16 shows how we compare with other organisations. We have made very good progress in appraisal rates for consultant medical staff. Having achieved this we will now focus on appraisal rates for other grades of medical staff. As a result of our latest annual organisation audit information and a desktop assessment by the NHS North Regional Revalidation and Appraisal Clinical Lead everything has been found to be satisfactory (Appendix 2).

During 2015/16 I agreed to be the Responsible Officer for ABL Health Limited (a small private origination that delivers services on this site). This is a commercial arrangement whereby their two employed doctors have me as their Responsible Officer and use our appraisers and appraisal systems. The attached comparator report shows 100% compliance (Appendix 3).

b. Appraisers

During 2015/16 we have reduced our number of appraisers from 70 to 50. They have all received face-to-face training. Their performance is monitored by inspection of the appraisal output forms by our Appraisal and Revalidation Clinical Lead. Our electronic appraisal system provides the opportunity for appraisee feedback. Our Appraisal and Revalidation Clinical Lead chairs quarterly appraiser meetings aimed at continuous improvement in the quality and consistency of appraiser performance. We still have rather more appraisers than we need. This gives us the opportunity to stop using appraisers whose performance falls below the required standard. The aim will be for all of our appraisers to do between 3 and 10 appraisals per year.

OFFICIAL

7

c. Quality Assurance

Appendix B of this report contains the summary of the Quality Assurance of appraisal inputs and outputs performed by our Appraisal and Revalidation Lead. All appraisals are reviewed by our Appraisal and Revalidation Lead and Responsible Officer looking for evidence listed below.

Appraisal portfolios:

Review of appraisal folders to provide assurance that the appraisal inputs: the pre-appraisal declarations and supporting information provided is appropriate and available.

Review of appraisal folders to provide assurance that the appraisal outputs: personal development plan, summary and sign offs are complete and to an appropriate standard.

Review of appraisal outputs to provide assurance that any key items identified pre-appraisal as needing discussion during the appraisal are included in the appraisal outputs - by whom and sign offs.

For the individual appraiser:

An annual record of the appraiser’s reflection on his or her appropriate continuing professional development.

An annual record of the appraiser’s participation in Trust appraisal meetings.

360° feedback from doctors for each appraiser.

For the organisation:

Audit of timelines of process of appraisal by department,

System user feedback,

Review of lessons learned from any complaints,

Review of lessons learned from any significant events.

d. Access, Security and Confidentiality

All appraisal and revalidation information is now stored electronically on our appraisal system. This is compliant with national IT security standards. An individuals appraisal folder is accessible to the individual, the appraiser, Trust Revalidation and Appraisal Lead and Responsible Officer only. The only patient specific data contained within appraisal portfolios relate to complaints which do not contain any patient identifiable data. There have been no information governance breaches reported relating to appraisal documentation.

e. Clinical governance

The annual consultant level performance data is provided by CHKS, our data analysts, and is available to Consultant/Senior medical staff to upload into their appraisal folder.

OFFICIAL

8

Our Complaints and Litigation Team send complaints relating to senior medical staff to our Appraisal and Revalidation Team to be uploaded into the input folder to ensure discussion at the appraisal meeting. Consultants are expected to use individual and departmental performance in national audits in their appraisal portfolios.

6. Revalidation Recommendations

Annex D of this report shows that during 2015/16 167 Bolton FT medical staff were scheduled for revalidation recommendations. All were completed on time, these comprised 160 positive recommendations for revalidation and 7 deferral requests. Deferral was for periods of between 6 and 12 months after agreement with the doctor. This is a neutral act designed to be used when there is not sufficient evidence to make a positive recommendation for revalidation. Reasons included; the doctor being new to the organisation and lack of sufficient evidence. The mechanism for reporting non-engagement with the appraisal process to the General Medical Council was used on one occasion. This stimulated good engagement resulting in a positive recommendation for revalidation and no further action by the General Medical Council.

7. Recruitment and engagement background checks

Appendix E of this report demonstrates that we have recruited a large number of medical staff in 2015/16. The vast majority of these were in short term posts both Trust employed and particularly agency locums. For temporary Trust employed doctors two satisfactory references including one from the most recent employer are regarded as sufficient assurance rather than requiring routine Responsible Officer to Responsible Officer communication. Annex E shows the numbers, areas and grades where locums are commonly employed in the Trust.

8. Monitoring Performance

Annual satisfactory appraisal is a key component of monitoring individual doctors performance. Engagement with the process and portfolio content including clinical outcomes, colleague/ patient feedback and engagement in quality improvement activity are an indicator of satisfactory performance. Medical staff performance is also monitored by our systems of clinical governance including clinical incidents and complaints which are all seen by the Responsible Officer. An individual doctors performance is closely linked to that of their department. Benchmarked departmental performance is monitored by our CHKS data, outcomes of National Audits and via our own internal governance systems.

9. Responding to Concerns and Remediation

Appendix C of this report contains data on the small number of doctors subject to formal intervention due to concerns regarding performance. Dealing with these concerns have involved consulting with and using the resource of the National Clinical Advisory Service. The importance of robust high quality annual appraisal helps ensure that medical staff performance remains at a level that does not constitute a concern.

OFFICIAL

9

10. Risks and Issues

The number of temporary employed and locum doctors used is a risk mitigated by robust employment checks. Reducing this usage by recruitment to substantive posts will reduce the risk and also deliver value for money. This is a corporate and divisional priority being addressed by the model hospital work.

11. Board / Executive Team Reflections

This report demonstrates that our appraisal and revalidation processes are fit for purpose and benchmark favourably with other organisations. This has been supported by the strong systems of clinical governance in place in the organisation. These systems are a key component of delivering high quality patient care.

12. Corrective Actions, Improvement Plan and Next Steps

Objectives for 2016/17 include:

Completion of a peer review process of our appraisal and revalidation systems. The plan is for a three way process involving Salford Royal Foundation Trust and Wrightington Wigan and Leigh Foundation Trust.

Ensure appraisal rates for staff and associate specialist doctors reach those of consultants.

Reduce usage of temporary employed and locum doctors.

13. Recommendations

The Trust Board is asked to accept the report which will be shared along with the Annual Audit with the higher level Responsible Officer at NHS North. The Trust Board is requested to approve the statement of compliance confirming that the organisation as a designated body is in compliance with the regulations.

OFFICIAL

10

14. Annual Report Template Appendix A – Audit of all

missed or incomplete appraisals

Doctor factors (total) Number

Maternity leave during the majority of the ‘appraisal due window’ 3

Sickness absence during the majority of the ‘appraisal due window’ 2

Prolonged leave during the majority of the ‘appraisal due window’ 0

Suspension during the majority of the ‘appraisal due window’ 0

New starter within 3 month of appraisal due date 0

New starter more than 3 months from appraisal due date 0

Postponed due to incomplete portfolio/insufficient supporting

information

1

Appraisal outputs not signed off by doctor within 28 days 6

Lack of time of doctor Number

Lack of engagement of doctor Number

Other doctor factors Number

(describe)

Appraiser factors Number

Unplanned absence of appraiser Number

Appraisal outputs not signed off by appraiser within 28 days Number

Lack of time of appraiser Number

Other appraiser factors (describe) Number

(describe)

Organisational factors Number

Administration or management factors N/A

Failure of electronic information systems N/A

Insufficient numbers of trained appraisers N/A

Other organisational factors (describe) N/A

OFFICIAL

11

15. Annual Report Template Appendix B – Quality

assurance of appraisal inputs and outputs

Total number of appraisals completed 193

Number of

appraisal

portfolios

sampled (to

demonstrate

adequate

sample size)

Number of the

sampled appraisal

portfolios deemed

to be acceptable

against standards

Appraisal inputs Number

audited 50

Number acceptable

49

Scope of work: Has a full scope of practice been

described?

50 50

Continuing Professional Development (CPD): Is CPD

compliant with GMC requirements?

50 49

Quality improvement activity: Is quality improvement

activity compliant with GMC requirements?

50 49

Patient feedback exercise: Has a patient feedback

exercise been completed?

Yes/No 50

Colleague feedback exercise: Has a colleague feedback

exercise been completed?

50 50

Review of complaints: Have all complaints been included? 50 50

Review of significant events/clinical incidents/SUIs: Have

all significant events/clinical incidents/SUIs been

included?

50 50

Is there sufficient supporting information from all the

doctor’s roles and places of work?

50 50

Is the portfolio sufficiently complete for the stage of the

revalidation cycle (year 1 to year 4)?

Explanatory note:

For example

Has a patient and colleague feedback exercise

been completed by year 3?

Is the portfolio complete after the appraisal which

precedes the revalidation recommendation (year

5)?

Have all types of supporting information been

included?

50 50

Appraisal Outputs

Appraisal Summary 50 50

Appraiser Statements 50 50

Personal Development Plan (PDP) 50 50

OFFICIAL

12

16. Annual Report Template Appendix C – Audit of

concerns about a doctor’s practice

Concerns about a doctor’s practice High

level2

Medium

level2 Low

level2 Total

Number of doctors with concerns about their practice

in the last 12 months

Explanatory note: Enter the total number of doctors

with concerns in the last 12 months. It is recognised

that there may be several types of concern but

please record the primary concern

2 1 3

Capability concerns (as the primary category) in the

last 12 months

1 1 2

Conduct concerns (as the primary category) in the

last 12 months

1 1

Health concerns (as the primary category) in the last

12 months

0

Remediation/Reskilling/Retraining/Rehabilitation

Numbers of doctors with whom the designated body has a prescribed connection as

at 31 March 2016 who have undergone formal remediation between 1 April 2015 and

31 March 2016.

Formal remediation is a planned and managed programme of interventions or a

single intervention e.g. coaching, retraining which is implemented as a consequence

of a concern about a doctor’s practice

A doctor should be included here if they were undergoing remediation at any point

during the year

1

Consultants (permanent employed staff including honorary contract holders, NHS

and other government /public body staff)

1

Staff grade, associate specialist, specialty doctor (permanent employed staff

including hospital practitioners, clinical assistants who do not have a prescribed

connection elsewhere, NHS and other government /public body staff)

0

General practitioner (for NHS England only; doctors on a medical performers list,

Armed Forces)

0

Trainee: doctor on national postgraduate training scheme (for local education and

training boards only; doctors on national training programmes)

0

Doctors with practising privileges (this is usually for independent healthcare

providers, however practising privileges may also rarely be awarded by NHS

organisations. All doctors with practising privileges who have a prescribed

connection should be included in this section, irrespective of their grade)

0

2 http://www.england.nhs.uk/revalidation/wp-

content/uploads/sites/10/2014/03/rst_gauging_concern_level_2013.pdf

http://www.england.nhs.uk/revalidation/wp-content/uploads/sites/10/2014/03/rst_gauging_concern_level_2013.pdf

http://www.england.nhs.uk/revalidation/wp-content/uploads/sites/10/2014/03/rst_gauging_concern_level_2013.pdf

OFFICIAL

13

Temporary or short-term contract holders (temporary employed staff including

locums who are directly employed, trust doctors, locums for service, clinical

research fellows, trainees not on national training schemes, doctors with fixed-

term employment contracts, etc) All Designated Bodies

0

Other (including all responsible officers, and doctors registered with a locum

agency, members of faculties/professional bodies, some management/leadership

roles, research, civil service, other employed or contracted doctors, doctors in

wholly independent practice, etc) All Designated Bodies

0

TOTALS 1

Other Actions/Interventions

Local Actions:

Number of doctors who were suspended/excluded from practice between 1 April

and 31 March:

Explanatory note: All suspensions which have been commenced or completed

between 1 April and 31 March should be included

0

Duration of suspension:

Explanatory note: All suspensions which have been commenced or completed

between 1 April and 31 March should be included

Less than 1 week

1 week to 1 month

1 – 3 months

3 - 6 months

6 - 12 months

N/A

Number of doctors who have had local restrictions placed on their practice in the

last 12 months?

2

GMC Actions:

Number of doctors who:

Were referred by the designated body to the GMC between 1 April and 31

March

0

Underwent or are currently undergoing GMC Fitness to Practice

procedures between 1 April and 31 March

1

Had conditions placed on their practice by the GMC or undertakings

agreed with the GMC between 1 April and 31 March

1

Had their registration/licence suspended by the GMC between 1 April and

31 March

0

Were erased from the GMC register between 1 April and 31 March 0

National Clinical Assessment Service actions:

Number of doctors about whom the National Clinical Advisory Service (NCAS) has

been contacted between 1 April and 31 March for advice or for assessment

Number of NCAS assessments performed 1

OFFICIAL

14

17. Annual Report Template Appendix D – Audit of

revalidation recommendations

Revalidation recommendations between 1 April 2015 to 31 March 2016

Recommendations completed on time (within the GMC recommendation

window) 167

Late recommendations (completed, but after the GMC recommendation

window closed) 0

Missed recommendations (not completed) 0

TOTAL 167

Primary reason for all late/missed recommendations

For any late or missed recommendations only one primary reason must be

identified

N/A

No responsible officer in post N/A

New starter/new prescribed connection established within 2 weeks

of revalidation due date

N/A

New starter/new prescribed connection established more than 2

weeks from revalidation due date

N/A

Unaware the doctor had a prescribed connection N/A

Unaware of the doctor’s revalidation due date N/A

Administrative error N/A

Responsible officer error N/A

Inadequate resources or support for the responsible officer

role

N/A

Other N/A

Describe other

TOTAL [sum of (late) + (missed)] 167

OFFICIAL

15

OFFICIAL

16

18. Annual Report Template Appendix E – Audit of recruitment and engagement

background checks

Number of new doctors (including all new prescribed connections) who have commenced in last 12 months (including where appropriate

locum doctors)

Permanent employed doctors 12

Temporary employed doctors 65

Locums brought in to the designated body through a locum agency 481

Locums brought in to the designated body through ‘Staff Bank’ arrangements 48

Doctors on Performers Lists

Other

Explanatory note: This includes independent contractors, doctors with practising privileges, etc. For membership organisations this

includes new members, for locum agencies this includes doctors who have registered with the agency, etc

TOTAL 606

For how many of these doctors was the following information available within 1 month of the doctor’s starting date (numbers)

Tota

l

Identity

check

Past G

MC

issues

GM

C c

onditio

ns

or

undert

akin

gs

On-g

oin

g

GM

C/N

CA

S

investigations

Dis

clo

sure

and

Barr

ing S

erv

ice

(DB

S)

2 r

ecent

refe

rences

Nam

e o

f la

st

responsib

le

off

icer

Refe

rence f

rom

last

responsib

le

off

icer

Language

com

pete

ncy

Local conditio

ns

or

undert

akin

gs

Qualif

ication

check

Revalid

ation d

ue

date

Appra

isal due

date

Appra

isal

outp

uts

Unre

solv

ed

perf

orm

ance

concern

s

Permanent employed

doctors

12 12 12 12 12 12 12 - 12 12 12 12

Temporary employed

doctors

65 65 65 65 26 26 65 65 65 65 26

Locums brought in to the

designated body through

481 481 481 481 481 481 481 481 481 481 481

OFFICIAL

17

a locum agency

Locums brought in to the

designated body through

‘Staff Bank’ arrangements

48 48 48 48 48 48 48 48 48 48 48

Doctors on Performers

Lists

Other

(independent contractors,

practising privileges,

members, registrants,

etc)

Total 606 606 606 606 567 567 606 606 606 606 606

For Providers of healthcare i.e. hospital trusts – use of locum doctors:

Explanatory note: Number of locum sessions used (days) as a proportion of total medical establishment (days)

The total WTE headcount is included to show the proportion of the posts in each specialty that are covered by locum doctors

Locum use by specialty:

Total establishment in

specialty (current

approved WTE

headcount)

Consultant:

Overall number

of locum days

used

SAS doctors:

Overall

number of

locum days

used

Trainees (all

grades): Overall

number of locum

days used

Total Overall

number of locum

days used

Surgery 124.13 WTE

(258900.42

hours)

219.5 2806.00

Medicine 106.13 WTE

(221357.46

hours)

266 1041.27

OFFICIAL

18

Psychiatry

Obstetrics/Gynaecology 45.70 WTE

(95317.40 hours)

379.32

Accident and Emergency 38.40 WTE

(80091.65 hours)

36.75 2175.85

Anaesthetics 66.48 WTE

(138658.66

hours)

220 1.56

Radiology 21.58 WTE

(45009.84 hours))

477.44

Pathology 15.00 WTE

(31285.80 hours)

269.00

Other

Total in designated body (This includes all

doctors not just those with a prescribed

connection)

Number of individual locum attachments by

duration of attachment (each contract is a

separate ‘attachment’ even if the same doctor

fills more than one contract)

Total

Pre-

employment

checks

completed

(number)

Induction or

orientation

completed

(number)

Exit reports

completed (number)

Concerns reported

to agency or

responsible officer

(number)

2 days or less

3 days to one week

1 week to 1 month

1-3 months

3-6 months

OFFICIAL

19

6-12 months

More than 12 months

Total

Annual Organisational Audit (AOA) End of year questionnaire 2015-16

YGurney

Typewritten text

Appendix 1

0114

OFFICIAL

Please do not use this version of the form to submit your response. 2

NHS England INFORMATION READER BOX

Directorate

Medical

Nursing

Commissioning Operations

Trans. & Corp. Ops.

Patients and Information

Commissioning Strategy

Finance


Document Purpose

Document Name

Author

Publication Date

Target Audience

Additional Circulation

List

Description

Cross Reference

Action Required

Timing / Deadlines

(if applicable)

Annual Organisational Audit Annex C (end of year questionnaire)

Superseded Docs

(if applicable)

Contact Details for

further information

Document StatusThis is a controlled document. Whilst this document may be printed, the electronic version posted on

the intranet is the controlled copy. Any printed copies of this document are not controlled. As a

controlled document, this document should not be saved onto local or network drives but should

always be accessed from the intranet.

Resources

Gary Cooper

Professional Standards Team

Quarry house

Leeds

LS2 7UE

0

0

By 00 January 1900

Gary Cooper

18 March 2016

Medical Directors, NHS England Regional Directors, GPs

#VALUE!

A Framework for Quality Assurance for Responsible Officers &

Revalidation April 2014 Gateway ref 01142

2014/15 AOA cleared with Publications Gateway Reference 02945

0

OFFICIAL

Annual Organisational Audit (AOA)

End of year questionnaire 2015-16

Version number: 3.0

First published: 4 April 2014

Updated: 24 March 2015 & 18 March 2016

Prepared by: Gary Cooper, Project Manager for Quality Assurance, NHS England

Classification: OFFICIAL

“The National Health Service Commissioning Board was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the National Health Service Commissioning Board has used the name NHS England for operational purposes.”

Promoting equality and addressing health inequalities are at the heart of NHS England’s values. Throughout the development of the policies and processes cited in this document, we have:

Given due regard to the need to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited under the Equality Act 2010) and those who do not share it; and

Given regard to the need to reduce inequalities between patients in access to, and outcomes from healthcare services and to ensure services are provided in an integrated way where this might reduce health inequalities.


OFFICIAL

Contents

Contents ..................................................................................................................... 4

1 Introduction.......................................................................................................... 5

2 Guidance for submission ..................................................................................... 7

3 Section 1 – The Designated Body and the Responsible Officer .......................... 8

4 Section 2 – Appraisal......................................................................................... 15

5 Section 3 – Monitoring Performance and Responding to Concerns .................. 24

6 Section 4 – Recruitment and Engagement ........................................................ 28

7 Section 5 – Comments ...................................................................................... 30

8 Reference.......................................................................................................... 31


OFFICIAL

1 Introduction

The Framework of Quality Assurance (FQA) and the monitoring processes within it are designed to support all responsible officers in fulfilling their statutory duty, providing a means by which they can demonstrate the effectiveness of the systems they oversee. It has been carefully crafted to ensure that administrative burden is minimised, whilst still driving learning and sharing of best practice. Each element of the FQA process will feed in to a comprehensive report from the national-level responsible officer to Ministers and the public, capturing the state of play in implementing medical revalidation across the country.

The reporting processes are intended to be streamlined, coherent and integrated, ensuring that information is captured to contribute to local processes, whilst simultaneously providing the required assurance. The process will be reviewed and revised on a regular basis.

The AOA (Annex C) is a standardised template for all responsible officers to complete and return to their higher-level responsible officer. AOAs from all designated bodies will be collated to provide an overarching status report of implementation across England. Where small designated bodies are concerned, or where types of organisation are small in number, these will be appropriately grouped to ensure that data is not identifiable to the level of the individual.

The AOA has been simplified and shortened considerably from its predecessor, (ORSA), with a focus on what is happening, with what outcome, along with an assessment of the designated body’s organisational capacity to ensure a robust consistent system of revalidation. Learning from the experience of ORSA, the AOA has been designed to reduce the administrative burden upon organisations and to be of maximum help to responsible officers in fulfilling their obligations.

The aims of the annual organisational audit exercise are to:

• gain an understanding of the progress that organisations have made during 2015/16;

• provide a tool that helps responsible officers assure themselves and theirboards/management bodies that the systems underpinning the recommendations theymake to the General Medical Council (GMC) on doctors’ fitness to practise, thearrangements for medical appraisal and responding to concerns, are in place;

• provide a mechanism for assuring NHS England (as the Senior Responsible Ownerfor medical revalidation in England), the England Revalidation Implementation Board(ERIB) and the GMC that systems for evaluating doctors’ fitness to practice are inplace, functioning, effective and consistent.


OFFICIAL

This AOA exercise is divided into five sections:

Section 1: The Designated Body and the Responsible Officer

Section 2: Appraisal

Section 3: Monitoring Performance and Responding to Concerns

Section 4: Recruitment and Engagement

Section 5: Additional Comments

The questionnaire should be completed by the responsible officer on behalf of the designated body, though the input of information to the questionnaire may be appropriately delegated. The questionnaire should be completed during April and May 2016 for the year ending 31 March 2016. The deadline for submission will be detailed in an email containing the link to the electronic version of the form, which will be sent after 31 March 2016.

Whilst NHS England is a single designated body, for the purpose of this audit, the national and regional offices of NHS England should answer as a ‘designated body’ in their own right.

Following completion of this AOA exercise, designated bodies should:

• consider using the information gathered to produce a status report and to conduct areview of their organisations’ developmental needs.

• complete a statement of compliance and submit it to NHS England by the 30th

September 2016.

The audit process will also enable designated bodies to provide assurance that they are fulfilling their statutory obligations and their systems are sufficiently effective to support the responsible officer’s recommendations.

For further information, references and resources see pages 30-31 and www.england.nhs.uk/revalidation


www.england.nhs.uk/revalidation

OFFICIAL

2 Guidance for submission

Guidance for submission: • Several questions require a ‘Yes’ or ‘No’ answer. In order to answer ‘Yes’, you must

be able to answer ‘Yes’ to all of the statements listed under ‘to answer ‘Yes’’• Please do not use this version of the questionnaire to submit your designated body’s

response.• You will receive an email with an electronic link to a unique version of this form for

your designated body.• You should only use the link received from NHS England by email, as it is unique to

your organisation.• Once the link is opened, you will be presented with two buttons; one to download a

blank copy of the AOA for reference, the second button will take you to the electronicform for submission.

• Submissions can only be received electronically via the link. Please do not completehardcopies or email copies of the document.

• The form must be completed in its entirety prior to submission; it cannot be part-completed and saved for later submission.

• Once the ‘submit’ button has been pressed, the information will be sent to a centraldatabase, collated by NHS England.

• A copy of the completed submission will be automatically sent to the responsibleofficer.

• Please be advised that Questions 1.1-1.3 may have been automatically populatedwith information previously held on record by NHS England. The submitter has aresponsibility to check that the information is correct and should update theinformation if required, before submitting the form.


OFFICIAL

3 Section 1 – The Designated Body and the Responsible Officer

SSection 1 The Designated Body and the Responsible Officer

1.1 Name of designated body: Address line 1 Address line 2 Address line 3 Address line 4 City County Postcode

GMC registered last name Phone

Responsible officer: Title GMC registered first name GMC reference number Email


Medical Director: Title GMC registered first name GMC reference number Email


Clinical Appraisal Lead: Title GMC registered first name GMC reference number Email Chief executive (or equivalent): Title First name Last name GMC reference number (if applicable) Phone Email


No Medical Director

No Clinical Appraisal Lead

*****

*****

Bolton

*****

*****

*****

*****

*****

*****

*****

**********

*****

*****

*****

Bolton NHS Foundation Trust

BL4 0JR

*****

*****

*****

*****

*****

*****

*****

*****

*****

Trust Headquarters

Minerva Road

Farnworth

OFFICIAL

1.2 Type/sector of designated body:

(tick one) NHS

Acute hospital/secondary care foundation trust

Acute hospital/secondary care non-foundation trust

Mental health foundation trust

Mental health non-foundation trust

Other NHS foundation trust (care trust, ambulance trust, etc)

Other NHS non-foundation trust (care trust, ambulance trust, etc) Special health authorities (NHS Litigation Authority, NHS Trust Development Authority, NHS Blood and Transplant, etc)

NHS England

NHS England (local office)

NHS England (regional office)

NHS England (national office)

Independent / non-NHS sector

(tick one)

Independent healthcare provider

Locum agency

Faculty/professional body (FPH, FOM, FPM, IDF, etc)

Academic or research organisation

Government department, non-departmental public body or executive agency

Armed Forces

Hospice

Charity/voluntary sector organisation

Other non-NHS (please enter type)


✔

OFFICIAL

1.3 The responsible officer’s higher level NHS England North responsible officer is based at: [tick one] NHS England Midlands and East

NHS England London

NHS England South

NHS England (National)

Department of Health NHS

Faculty of Medical Leadership and Management - for NHS England (national office) only

Other (Is a suitable person)

1.4 A responsible officer has been nominated/appointed in compliance with the regulations.

To answer ‘Yes’: • The responsible officer has been a medical practitioner fully registered under the Medical Act 1983

throughout the previous five years and continues to be fully registered whilst undertaking the role ofresponsible officer.

• There is evidence of formal nomination/appointment by board or executive of each organisation for whichthe responsible officer undertakes the role.

Yes

No


✔

✔

OFFICIAL

1.5 Where a Conflict of Interest or Appearance of Bias has been identified and agreed with the higher levelresponsible officer; has an alternative responsible officer been appointed?

(Please note that in The Medical Profession (Responsible Officers) Regulations 2010 (Her Majesty’s Stationery Office, 2013), an alternative responsible officer is referred to as a second responsible officer)

To answer ‘Yes’: The designated body has nominated an alternative responsible officer in all cases where there is a conflict of interest or appearance of bias between the responsible officer and a doctor with whom the designated body has a prescribed connection.

To answer 'No’: A potential conflict of interest or appearance of bias has been identified, but an alternative responsible

officer has not been appointed. To answer 'N/a’:

No cases of conflict of interest or appearance of bias have been identified.

Additional guidance

Each designated body will have one responsible officer but the regulations allow for an alternative responsible officer to be nominated or appointed where a conflict of interest or appearance of bias exists between the responsible officer and a doctor with whom the designated body has a prescribed connection. This will cover the uncommon situations where close family or business relationships exist, or where there has been longstanding interpersonal animosity.

In order to ensure consistent thresholds and a common approach to this, potential conflict of interest or appearance of bias should be agreed with the higher level responsible officer. An alternative responsible officer should then be nominated or appointed by the designated body and will require training and support in the same way as the first responsible officer. To ensure there is no conflict of interest or appearance of bias, the alternative responsible officer should be an external appointment and will usually be a current experienced responsible officer from the same region. Further guidance is available in Responsible Officer Conflict of Interest or Appearance of Bias: Request to Appoint and Alternative Responsible Officer (NHS Revalidation Support Team, 2014).

Yes

No

N/A


✔

OFFICIAL

1.6 In the opinion of the responsible officer, sufficient funds, capacity and other resources have been provided by the designated body to enable them to carry out the responsibilities of the role.

Each designated body must provide the responsible officer with sufficient funding and other resources necessary to fulfil their statutory responsibilities. This may include sufficient time to perform the role, administrative and management support, information management and training. The responsible officer may wish to delegate some of the duties of the role to an associate or deputy responsible officer. It is important that those people acting on behalf of the responsible officer only act within the scope of their authority. Where some or all of the functions are commissioned externally, the designated body must be satisfied that all statutory responsibilities are fulfilled.

Yes

No

1.7 The responsible officer is appropriately trained and remains up to date and fit to practise in the role of responsible officer.

To answer ‘Yes’:

• Appropriate recognised introductory training has been undertaken.• Appropriate ongoing training and development is undertaken in agreement with the responsible

officer’s appraiser.• The responsible officer has made themselves known to the higher level responsible officer.• The responsible officer is engaged in the regional responsible officer network.• The responsible officer is actively involved in peer review for the purposes of calibrating their decision-

making processes and organisational systems.• The responsible officer includes relevant supporting information relating to their responsible officer role

in their appraisal and revalidation portfolio including the results of the Annual Organisational Audit andthe resulting action plan.

Yes

No


✔

✔

OFFICIAL

1.8 The responsible officer ensures that accurate records are kept of all relevant information, actions and decisions relating to the responsible officer role.

The responsible officer records should include appraisal records, fitness to practise evaluations, investigation and management of concerns, processes relating to ‘new starters’, etc.

Yes

No

1.9 The responsible officer ensures that the designated body's medical revalidation policies and procedures are in accordance with equality and diversity legislation.

To answer ‘Yes’: • An evaluation of the fairness of the organisation’s policies has been performed (for example, anequality impact assessment).

Yes

No

1.10 The responsible officer makes timely recommendations to the GMC about the fitness to practise of all doctors with a prescribed connection to the designated body, in accordance with the GMC requirements and the GMC Responsible Officer Protocol.

To answer ‘Yes’: • The designated body’s board report contains explanations for all missed and late recommendations,and reasons for deferral submissions.

Yes

No

1.11 The governance systems (including clinical governance where appropriate) are subject to external or independent review.

Most designated bodies will be subject to external or independent review by a regulator. Designated bodies which are healthcare providers are subject to review by the national healthcare regulators (the Care Quality Commission or Monitor). Where designated bodies will not be regulated or overseen by an external regulator (for example locum agencies and organisations which are not healthcare providers), an alternative external or independent review process should be agreed with the higher level responsible officer.

Yes

No


✔

✔

✔

✔

OFFICIAL

1.12 The designated body has commissioned or undertaken an independent review* of its processes relating to appraisal and revalidation. (*including peer review, internal audit or an externally commissioned assessment)

Yes

No


✔

4

OFFICIAL

Section 2 – Appraisal Section 2 Appraisal

2.1 IMPORTANT: Only doctors with whom the designated body has a prescribed connection at 31 March 2016 should be included. Where the answer is ‘nil’ please enter ‘0’.

1a 1b 2 3

Num

ber of Prescribed

Connections

Com

pleted A

ppraisal (1a)

Com

pleted A

ppraisal (1b)

Approved

incomplete or

missed appraisal

(2)

Unapproved

incomplete or

missed appraisal

(3)

Total See guidance notes on pages 16-18 for assistance completing this table

2.1.1 Consultants (permanent employed consultant medical staff including honorary contract holders, NHS, hospices, and government /other public body staff. Academics with honorary clinical contracts will usually have their responsible officer in the NHS trust where they perform their clinical work).

2.1.2 Staff grade, associate specialist, specialty doctor (permanent employed staff including hospital practitioners, clinical assistants who do not have a prescribed connection elsewhere, NHS, hospices, and government/other public body staff).

2.1.3 Doctors on Performers Lists (for NHS England and the Armed Forces only; doctors on a medical or ophthalmic performers list. This includes all general practitioners (GPs) including principals, salaried and locum GPs).

2.1.4 Doctors with practising privileges (this is usually for independent healthcare providers, however practising privileges may also rarely be awarded by NHS organisations. All doctors with practising privileges who have a prescribed connection should be included in this section, irrespective of their grade).

2.1.5 Temporary or short-term contract holders (temporary employed staff including locums who are directly employed, trust doctors, locums for service, clinical research fellows, trainees not on national training schemes, doctors with fixed-term employment contracts, etc).

2.1.6 Other doctors with a prescribed connection to this designated body (depending on the type of designated body, this category may include responsible officers, locum doctors, and members of the faculties/professional bodies. It may also include some non-clinical management/leadership roles, research, civil service, doctors in wholly independent practice, other employed or contracted doctors not falling into the above categories, etc).

2.1.7 TOTAL (this cell will sum automatically 2.1.1 – 2.1.6).

15 Please do not use this version of the form to submit your response.

0

11

1961

0

153

0

82

1

22 17

5

259

50

58

1

0

0

0

0

1

1 6

500

7

0

23

0

0 0

0

0

196

12

130

0

10

0

259

12

OFFICIAL


Did the doctor have an appraisal meeting

between 1st April 2015 and 31st March 2016, for

which the appraisal outputs have been

signed off? (include if appraisal

undertaken with previous organisation)

No Was the reason for missing the

appraisal agreed by the RO in advance?

No

Yes

Yes

Was this in the 3 months preceding the appraisal due

date*,

AND

was the appraisal summary signed off

within 28 days of the appraisal date,

AND

did the entire process occur

between 1 April and 31 March?

Approved incomplete or missed appraisal

(2)

Completed Appraisal (1a)

Completed Appraisal (1b)

Unapproved incomplete or missed appraisal

(3)

2.1

OFFICIAL

Column - Number of Prescribed Connections: Number of doctors with whom the designated body has a prescribed connection as at 31 March 2016The responsible officer should keep an accurate record of all doctors with whom the designated body has a prescribed connection and must be satisfied that the doctors have correctly identified their prescribed connection. Detailed advice on prescribed connections is contained in the responsible officer regulations and guidance and further advice can be obtained from the GMC and the higher level responsible officer. The categories of doctor relate to current roles and job titles rather than qualifications or previous roles. The number of individual doctors in each category should be entered in this column. Where a doctor has more than one role in the same designated body a decision should be made about which category they belong to, based on the amount of work they do in each role. Each doctor should be included in only one category. For a doctor who has recently completed training, if they have attained CCT, then they should be counted as a prescribed connection. If CCT has not yet been awarded, they should be counted as a prescribed connection within the LETB AOA return.

Column - Measure 1a Completed medical appraisal: A Category 1a completed annual medical appraisal is one where the appraisal meeting has taken place in the three months preceding the agreed appraisal due date*, the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor within 28 days of the appraisal meeting, and the entire process occurred between 1 April and 31 March. For doctors who have recently completed training, it should be noted that their final ACRP equates to an appraisal in this context.

Column - Measure 1b Completed medical appraisal: A Category 1b completed annual medical appraisal is one in which the appraisal meeting took place in the appraisalyear between 1 April and 31 March, and the outputs of appraisal have been agreed and signed-off by the appraiserand the doctor, but one or more of the following apply:- the appraisal did not take place in the window of three months preceding the appraisal due date;- the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor between 1 April and 28April of the following appraisal year;- the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor more than 28 days afterthe appraisal meeting.However, in the judgement of the responsible officer the appraisal has been satisfactorily completed to the standardrequired to support an effective revalidation recommendation.


OFFICIAL

Where the organisational information systems of the designated body do not permit the parameters of a Category 1a completed annual medical appraisal to be confirmed with confidence, the appraisal should be counted as a Category 1b completed annual medical appraisal.

Column - Measure 2: Approved incomplete or missed appraisal: An approved incomplete or missed annual medical appraisal is one where the appraisal has not been completed according to the parameters of either a Category 1a or 1b completed annual medical appraisal, but the responsible officer has given approval to the postponement or cancellation of the appraisal. The designated body must be able to produce documentation in support of the decision to approve the postponement or cancellation of the appraisal in order for it to be counted as an Approved incomplete or missed annual medical appraisal.

Column - Measure 3: Unapproved incomplete or missed appraisal: An Unapproved incomplete or missed annual medical appraisal is one where the appraisal has not been completed according to the parameters of either a Category 1a or 1b completed annual medical appraisal, and the responsible officer has not given approval to the postponement or cancellation of the appraisal. Where the organisational information systems of the designated body do not retain documentation in support of a decision to approve the postponement or cancellation of an appraisal, the appraisal should be counted as an Unapproved incomplete or missed annual medical appraisal.

Column Total: Total of columns 1a+1b+2+3. The total should be equal to that in the first column (Number of Prescribed Connections), the number of doctors with a prescribed connection to the designated body at 31 March 2016.

* Appraisal due date:A doctor should have a set date by which their appraisal should normally take place every year (the ‘appraisal duedate’). The appraisal due date should remain the same each year unless changed by agreement with the doctor’sresponsible officer. Where a doctor does not have a clearly established appraisal due date, the next appraisal shouldtake place by the last day of the twelfth month after the preceding appraisal. This should then by default become theirappraisal due date from that point on. For a designated body which uses an ‘appraisal month’ for appraisal scheduling,a doctor’s appraisal due date is the last day of their appraisal month.For more detail on setting a doctor’s appraisal due date see the Medical Appraisal Logistics Handbook (NHS England,2015)


OFFICIAL

2.2 Every doctor with a prescribed connection to the designated body with a missed or incomplete medical appraisal has an explanation recorded

If all appraisals are in Categories 1a and/or 1b, please answer N/A.

To answer Yes:

• The responsible officer ensures accurate records are kept of all relevant actions and decisions relating to theresponsible officer role.

• The designated body’s annual report contains an audit of all missed or incomplete appraisals (approved andunapproved) for the appraisal year 2015/16 including the explanations and agreed postponements.

• Recommendations and improvements from the audit are enacted.Additional guidance: A missed or incomplete appraisal, whether approved or unapproved, is an important occurrence which could indicate a problem with the designated body’s appraisal system or non-engagement with appraisal by an individual doctor which will need to be followed up.

Measure 2: Approved incomplete or missed appraisal: An approved incomplete or missed annual medical appraisal is one where the appraisal has not been completed according to the parameters of either a Category 1a or 1b completed annual medical appraisal, but the responsible officer has given approval to the postponement or cancellation of the appraisal. The designated body must be able to produce documentation in support of the decision to approve the postponement or cancellation of the appraisal in order for it to be counted as an Approved incomplete or missed annual medical appraisal.

Measure 3: Unapproved incomplete or missed appraisal: An Unapproved incomplete or missed annual medical appraisal is one where the appraisal has not been completed according to the parameters of either a Category 1a or 1b completed annual medical appraisal, and the responsible officer has not given approval to the postponement or cancellation of the appraisal. Where the organisational information systems of the designated body do not retain documentation in support of a decision to approve the postponement or cancellation of an appraisal, the appraisal should be counted as an Unapproved incomplete or missed annual medical appraisal.

Yes

No

N/A


✔

OFFICIAL

2.3 There is a medical appraisal policy, with core content which is compliant with national guidance, that has been ratified by the designated body's board (or an equivalent governance or executive group) To answer ‘Yes’: • The policy is compliant with national guidance, such as Good Medical Practice Framework for Appraisal and

Revalidation (GMC, 2013), Supporting Information for Appraisal and Revalidation (GMC, 2012), MedicalAppraisal Guide (NHS Revalidation Support Team, 2014), The Role of the Responsible Officer: Closing theGap in Medical Regulation, Responsible Officer Guidance (Department of Health, 2010), Quality Assurance ofMedical Appraisers (NHS Revalidation Support Team, 2014).

• The policy has been ratified by the designated body’s board or an equivalent governance or executive group.

Yes

No

2.4 There is a mechanism for quality assuring an appropriate sample of the inputs and outputs of the medical appraisal process to ensure that they comply with GMC requirements and other national guidance, and the outcomes are recorded in the annual report template. To answer ‘Yes’: • The appraisal inputs comply with the requirements in Supporting Information for Appraisal and Revalidation

(GMC, 2012) and Good Medical Practice Framework for Appraisal and Revalidation (GMC, 2013), which are:o Personal information.o Scope and nature of work.o Supporting information:

1. Continuing professional development,2. Quality improvement activity,3. Significant events,4. Feedback from colleagues,5. Feedback from patients,6. Review of complaints and compliments.

o Review of last year’s PDP.o Achievements, challenges and aspirations.

• The appraisal outputs comply with the requirements in the Medical Appraisal Guide (NHS Revalidation SupportTeam, 2014) which are:

o Summary of appraisal,o Appraiser’s statement,o Post-appraisal sign-off by doctor and appraiser.

Yes

No


✔

✔

OFFICIAL

Additional guidance: Quality assurance is an integral part of the role of the responsible officer. The standards for the inputs and outputs of appraisal are detailed in Supporting Information for Appraisal and Revalidation (GMC, 2012), Good Medical Practice Framework for Appraisal and Revalidation (GMC, 2013) and the Medical Appraisal Guide (NHS Revalidation Support Team, 2014) and the responsible officer must be assured that these standards are being met consistently. The methodology for quality assurance should be outlined in the designated body’s appraisal policy and include a sampling process. Quality assurance activities can be undertaken by those acting on behalf of the responsible officer with appropriate delegated authority.

2.5 There is a process in place for the responsible officer to ensure that key items of information (such as specific complaints, significant events and outlying clinical outcomes) are included in the appraisal portfolio and discussed at the appraisal meeting, so that development needs are identified. To answer ‘Yes’: • There is a written description within the appraisal policy of the process for ensuring that key items of supporting

information are included in the doctor’s portfolio and discussed at appraisal.• There is a process in place to ensure that where a request has been made by the responsible officer to include

a key item of supporting information in the appraisal portfolio, the appraisal portfolio and summary are checkedafter completion to ensure this has happened.

Additional guidance:

It is important that issues and concerns about performance or conduct are addressed at the time they arise. The appraisal meeting is not usually the most appropriate setting for dealing with concerns and in most cases these are dealt with outside the appraisal process in a clinical governance setting. Learning by individuals from such events is an important part of resolving concerns and the appraisal meeting is usually the most appropriate setting to ensure this is planned and prioritised. In a small proportion of cases, the responsible officer may therefore wish to ensure certain key items of supporting information are included in the doctor’s portfolio and discussed at appraisal so that development needs are identified and addressed. In these circumstances the responsible officer may require the doctor to include certain key items of supporting information in the portfolio for discussion at appraisal and may need to check in the appraisal summary that the discussion has taken place. The method of sharing key items of supporting information should be described in the appraisal policy. It is important that information is shared in compliance with principles of information governance and security. For further detail, see Information Management for Revalidation in England (NHS Revalidation Support Team, 2014).

Yes

No


✔

OFFICIAL

2.6 The responsible officer ensures that the designated body has access to sufficient numbers of trained appraisers to carry out annual medical appraisals for all doctors with whom it has a prescribed connection To answer ‘Yes’: The responsible officer ensures that: • Medical appraisers are recruited and selected in accordance with national guidance.• In the opinion of the responsible officer, the number of appropriately trained medical appraisers to doctors

being appraised is between 1:5 and 1:20.• In the opinion of the responsible officer, the number of trained appraisers is sufficient for the needs of the

designated body.Additional guidance: It is important that the designated body’s appraiser workforce is sufficient to provide the number of appraisals needed each year. This assessment may depend on total number of doctors who have a prescribed connection, geographical spread, speciality spread, conflicts of interest and other factors. Depending on the needs of the designated body, doctors from a variety of backgrounds should be considered for the role of appraiser. This includes locums and salaried general practitioners in primary care settings and staff and associate specialist doctors in secondary care settings. An appropriate specialty mix is important though it is not possible for every doctor to have an appraiser from the same specialty. Appraisers should participate in an initial training programme before starting to perform appraisals. The training for medical appraisers should include: • Core appraisal skills and skills required to promote quality improvement and the professional development of

the doctor• Skills relating to medical appraisal for revalidation and a clear understanding of how to apply professional

judgement in appraisal• Skills that enable the doctor to be an effective appraiser in the setting within which they work, including both

local context and any specialty specific elements.Further guidance on the recruitment and training of medical appraisers is available; see Quality Assurance of Medical Appraisers (NHS Revalidation Support Team, 2014).

Yes

No


✔

OFFICIAL

2.7 Medical appraisers are supported in their role to calibrate and quality assure their appraisal practice. To answer ‘Yes’:

The responsible officer ensures that: • Medical appraisers have completed a suitable training programme, with core content compliant with

national guidance (Quality Assurance of Medical Appraisers), including equality and diversity andinformation governance, before starting to perform appraisals.

• All appraisers have access to medical leadership and support.• There is a system in place to obtain feedback on the appraisal process from doctors being appraised.• Medical appraisers participate in ongoing performance review and training/development activities, to

include peer review and calibration of professional judgements (Quality Assurance of MedicalAppraisers).

Additional guidance: Further guidance on the support for medical appraisers is available in Quality Assurance of Medical Appraisers (NHS Revalidation Support Team, 2014).

Yes

No


✔

OFFICIAL

5 Section 3 – Monitoring Performance and Responding to Concerns

Section 3 Monitoring Performance and Responding to Concerns

3.1 There is a system for monitoring the fitness to practise of doctors with whom the designated body has a prescribed connection. To answer ‘Yes’: • Relevant information (including clinical outcomes, reports of external reviews of service for example Royal

College reviews, governance reviews, Care Quality Commission reports, etc.) is collected to monitor thedoctor’s fitness to practise and is shared with the doctor for their portfolio.

• Relevant information is shared with other organisations in which a doctor works, where necessary.• There is a system for linking complaints, significant events/clinical incidents/SUIs to individual doctors.• Where a doctor is subject to conditions imposed by, or undertakings agreed with the GMC, the responsible

officer monitors compliance with those conditions or undertakings.• The responsible officer identifies any issues arising from this information, such as variations in individual

performance, and ensures that the designated body takes steps to address such issues.• The quality of the data used to monitor individuals and teams is reviewed.• Advice is taken from GMC employer liaison advisers, National Clinical Assessment Service, local expert

resources, specialty and Royal College advisers where appropriate.

Additional guidance:

Where detailed information can be collected which relates to the practice of an individual doctor, it is important to include it in the annual appraisal process. In many situations, due to the nature of the doctor’s work, the collection of detailed information which relates directly to the practice of an individual doctor may not be possible. In these situations, team-based or service-level information should be monitored. The types of information available will be dependent on the setting and the role of the doctor and will include clinical outcome data, audit, complaints, significant events and patient safety issues. An explanation should be sought where an indication of outlying

Yes

No


✔

OFFICIAL

quality or practice is discovered. The information/data used for this purpose should be kept under review so that the most appropriate information is collected and the quality of the data (for example, coding accuracy) is improved. In primary care settings this type of information is not always routinely collected from general practitioners or practices and new arrangements may need to be put in place to ensure the responsible officer receives relevant fitness to practise information. In order to monitor the conduct and fitness to practise of trainees, arrangements will need to be agreed between the local education and training board and the trainee’s clinical attachments to ensure relevant information is available in both settings.

3.2 The responsible officer ensures that a responding to concerns policy is in place (which includes arrangements for investigation and intervention for capability, conduct, health, and fitness to practise concerns) which is ratified by the designated body’s board (or an equivalent governance or executive group). To answer ‘Yes’:

• A policy for responding to concerns, which complies with the responsible officer regulations, has beenratified by the designated body's board (or an equivalent governance or executive group).

Additional guidance: It is the responsibility of the responsible officer to respond appropriately when unacceptable variation in individual practice is identified or when concerns exist about the fitness to practise of doctors with whom the designated body has a prescribed connection. The designated body should establish a procedure for initiating and managing investigations. National guidance is available in the following key documents: • Supporting Doctors to Provide Safer Healthcare: Responding to Concerns about a Doctor’s Practice (NHS

Revalidation Support Team, 2013).• Maintaining High Professional Standards in the Modern NHS (Department of Health, 2003).• The National Health Service (Performers Lists) (England) Regulations 2013.• How to Conduct a Local Performance Investigation (National Clinical Assessment Service, 2010).

The responsible officer regulations outline the following responsibilities: • Ensuring that there are formal procedures in place for colleagues to raise concerns.• Ensuring there is a process established for initiating and managing investigations of capability, conduct,

Yes

No


✔

OFFICIAL

health and fitness to practise concerns which complies with national guidance, such as How to conduct a local performance investigation (National Clinical Assessment Service, 2010).

• Ensuring investigators are appropriately qualified.• Ensuring that there is an agreed mechanism for assessing the level of concern that takes into account the

risk to patients.• Ensuring all relevant information is taken into account and that factors relating to capability, conduct,

health and fitness to practise are considered.• Ensuring that there is a mechanism to seek advice from expert resources, including: GMC employer liaison

advisers, the National Clinical Assessment Service, specialty and royal college advisers, regionalnetworks, legal advisers, human resources staff and occupational health.

• Taking any steps necessary to protect patients.• Where appropriate, referring a doctor to the GMC.• Where necessary, making a recommendation to the designated body that the doctor should be suspended

or have conditions or restrictions placed on their practice.• Sharing relevant information relating to a doctor’s fitness to practise with other parties, in particular the new

responsible officer should the doctor change their prescribed connection.• Ensuring that a doctor who is subject to these procedures is kept informed about progress and that the

doctor’s comments are taken into account where appropriate.• Appropriate records are maintained by the responsible officer of all fitness to practise information• Ensuring that appropriate measures are taken to address concerns, including but not limited to:

• Requiring the doctor to undergo training or retraining,• Offering rehabilitation services,• Providing opportunities to increase the doctor’s work experience,• Addressing any systemic issues within the designated body which may contribute to the concerns

identified.• Ensuring that any necessary further monitoring of the doctor’s conduct, performance or fitness to practise

is carried out.

3.3 The board (or an equivalent governance or executive group) receives an annual report detailing the number and type of concerns and their outcome.

Yes

No


✔

OFFICIAL

3.4 The designated body has arrangements in place to access sufficient trained case investigators and case managers.

To answer ‘Yes’: The responsible officer ensures that: • Case investigators and case managers are recruited and selected in accordance with national guidance

Supporting Doctors to Provide Safer Healthcare, Responding to concerns about a Doctor’s Practice (NHSRevalidation Support Team, 2013).

• Case investigators and case managers have completed a suitable training programme, with essential corecontent (see guidance documents above).

• Personnel involved in responding to concerns have sufficient time to undertake their responsibilities• Individuals (such as case investigators, case managers) and teams involved in responding to concerns

participate in ongoing performance review and training/development activities, to include peer review andcalibration (see guidance documents above).

Additional guidance

The standards for training for case investigators and case managers are contained in Guidance for Recruiting for the Delivery of Case Investigator Training (NHS Revalidation Support Team, 2014) and Guidance for Recruiting for the Delivery of Case Manager Training (NHS Revalidation Support Team, 2014). Case investigators or case managers may be within the designated body or commissioned externally.

Yes

No


✔

OFFICIAL

6 Section 4 – Recruitment and Engagement

Section 4 Recruitment and Engagement

4.1 There is a process in place for obtaining relevant information when the designated body enters into a contract of employment or for the provision of services with doctors (including locums).

In situations where the doctor has moved to a new designated body without a contract of employment, or for the provision of services (for example, through membership of a faculty) the information needs to be available to the new responsible officer as soon as possible after the prescribed connection commences. This will usually involve a formal request for information from the previous responsible officer.

Additional guidance

The regulations give explicit responsibilities to the responsible officer when a designated body enters into a contract of employment or for the provision of services with a doctor. These responsibilities are to ensure the doctor is sufficiently qualified and experienced to carry out the role. All new doctors are covered under this duty even if the doctor’s prescribed connection remains with another designated body. This applies to locum agency contracts and also to the granting of practising privileges by independent health providers. The prospective responsible officer must: • Ensure doctors have qualifications and experience appropriate to the work to be performed,• Ensure that appropriate references are obtained and checked,• Take any steps necessary to verify the identity of doctors,• Ensure that doctors have sufficient knowledge of the English language for the work to be performed, and• For NHS England regional teams, manage admission to the medical performers list in accordance with the

regulations.It is also important that the following information is available: • GMC information: fitness to practise investigations, conditions or restrictions, revalidation due date,• Disclosure and Barring Service check (although delays may prevent these being available to the responsible

officer before the starting date in every case), and

Yes

No


✔

OFFICIAL

• Gender and ethnicity data (to monitor fairness and equality; providing this information is not mandatory).It may be helpful to obtain a structured reference from the current responsible officer which complies with GMC guidance on writing references and includes relevant factual information relating to: • The doctor’s competence, performance or conduct,• Appraisal dates in the current revalidation cycle, and,• Local fitness to practise investigations, local conditions or restrictions on the doctor’s practice, unresolved

fitness to practise concerns.See Good Medical Practice: Supplementary Guidance: Writing References (GMC, 2007) and paragraph 19 of Good Medical Practice (GMC, 2013) for further details.


7 Section 5 – Comments

Section 5 Comments

5.1


OFFICIAL

Submitted by Janet Bell on 31.05.16 as the information had been submitted in error on the ABL Health link. Requested correctinformation for ABL Health.

OFFICIAL

8 Reference Sources used in preparing this document

1. The Medical Profession (Responsible Officers) Regulations 2010 (Her Majesty’sStationery Office, 2013)

2. The Medical Profession (Responsible Officers) (Amendment) Regulations 2013 (HerMajesty’s Stationery Office, 2013)

3. The Medical Act 1983 (Her Majesty’s Stationery Office, 1983)4. Maintaining High Professional Standards in the Modern NHS (Department of Health,

2003)5. The National Health Service (Performers Lists) (England) Regulations 20136. The Role of the Responsible Officer: Closing the Gap in Medical Regulation,

Responsible Officer Guidance (Department of Health, 2010)7. Appraisal Guidance for Consultants (Department of Health, 2001)8. Appraisal Guidance for General Practitioners (Department of Health, 2004)9. Revalidation: A Statement of Intent (GMC and others, 2010)10. Good Medical Practice (GMC, 2013)11. Good Medical Practice Framework for Appraisal and Revalidation (GMC, 2013)12. Good Medical Practice: Supplementary Guidance - Writing References (GMC, 2012)13. Guidance on Colleague and Patient Questionnaires (GMC, 2012)14. Supporting Information for Appraisal and Revalidation (GMC, 2012)15. Effective Governance to Support Medical Revalidation: A Handbook for Boards and

Governing Bodies (GMC, 2013)16. Making Revalidation Recommendations: The GMC Responsible Officer Protocol –

Guide for Responsible Officers (GMC, 2012)17. The Medical Appraisal Guide (NHS Revalidation Support Team, 2014)18. Quality Assurance of Medical Appraisers (NHS Revalidation Support Team, 2014)19. Providing a Professional Appraisal (NHS Revalidation Support Team, 2012)20. Information Management for Medical Revalidation in England (NHS Revalidation

Support Team, 2014)21. Supporting Doctors to Provide Safer Healthcare: Responding to Concerns about a

Doctor’s Practice (NHS Revalidation Support Team, 2013)22. Guidance for Recruiting for the Delivery of Case Investigator Training (NHS

Revalidation Support Team, 2014)23. Guidance for Recruiting for the Delivery of Case Manager Training (NHS Revalidation

Support Team, 2014).24. Responsible Officer Conflict of Interest or Appearance of Bias: Request to Appoint and

Alternative Responsible Officer (NHS Revalidation Support Team, 2014).25. Guide to Independent Sector Appraisal for Doctors Employed by the NHS and Who

Have Practising Privileges at Independent Hospitals: Whole Practice Appraisal (BritishMedical Association and Independent Healthcare Forum, 2004)

26. Joint University and NHS Appraisal Scheme for Clinical Academic Staff (Universitiesand Colleges Employers Association, 2002)

27. Preparing for the Introduction of Medical Revalidation: a Guide for Independent SectorLeaders in England (GMC and Independent Healthcare Advisory Services, 2011)


OFFICIAL

28. How to Conduct a Local Performance Investigation (National Clinical AssessmentService, 2010)

29. Use of NHS Exclusion and Suspension from Work amongst Doctors and Dentists2011/12 (National Clinical Assessment Service, 2011)

30. Return to Practice Guidance (Academy of Medical Royal Colleges, 2012)31. Medical Appraisal Logistics Handbook (NHS England, 2015)


From: revalidation-north england (NHS ENGLAND)To: Hodgson StephenSubject: Higher Level Responsible Officer Quality Review (HLROQR) - desktop review - ABL HealthDate: 01 August 2016 09:59:30

Dear Dr Hodgson, Thank you for submitting the latest Annual Organisational Audit (AOA) information. In accordance with the Framework of Quality Assurance (FQA) and in acknowledgement of theHLROQR process we can confirm that we have concluded a desktop review of your designatedbody. As we found everything to be satisfactory there is no action to be taken by us. Wewould like to take this opportunity to congratulate you on achieving a good appraisal uptakerate. We look forward to seeing you at the networks in September. Kind regards Paul TwomeyRegional Revalidation & Appraisal Clinical Lead

mailto:[email protected]

mailto:[email protected]

YGurney

Typewritten text

Appendix 2

Simon BennettSenior Responsible Owner

Director - Clinical Policy and Professional Standards NHS EnglandQuarry House

Quarry HillLeeds

LS2 7UE

PA Contact Details: [email protected]

Tel: 0113 824 9428

Responsible Officer

Medical Revalidation Annual Organisational Audit (AOA) Comparator Report for:

Thank you for submitting a response to the NHS England Annual Organisational Audit (AOA) exercise in April/May 2016. The AOA is one element of the Framework of Quality Assurance.

I enclose a report, which sets out your response to the AOA, as per your submission, in terms of the systems that your organisation has in place for implementing the Responsible Officer Regulations. It compares your organisation’s submission with that of other designated bodies across England, both in a similar sector and nationwide. A more detailed Senior Responsible Owners annual report will be published in the autumn.

The AOA exercise is designed to help designated bodies assure themselves and their boards (or equivalent management bodies) that the systems underpinning the recommendations they make to the General Medical Council (GMC) on doctors’ fitness to practise, and the arrangements for medical appraisal and responding to concerns, are in place and functioning effectively. Similarly, it provides a mechanism for assuring NHS England, as the Senior Responsible Owner for implementation of the Responsible Officer Regulations in England, that systems are functioning, effective and consistent.

1

Official

Publications Gateway Reference 05236

ABL Health Ltd

29 July 2016

Dear Mr Hodgson

Mr Stephen Hodgson

1086 - ABL Health Ltd

Our Ref: 1086

YGurney

Typewritten text

Appendix 3

Board-level accountability for the quality and effectiveness of these systems is important and this report, along with the resulting action plan, should be presented to the board, or an equivalent management body. Including the report in an NHS organisation’s Quality Account is also good practice.

This letter has been sent to the responsible officer recorded in the AOA return at 31 March 2016. If you are no longer the responsible officer, please pass this report on to the new responsible officer immediately, or to the Chief Executive of the organisation. If there are any changes to notify, or you have any queries, please contact your local revalidation team.

Please note that for transparency and openness, your submitted AOA return will be shared with your higher level responsible officer and some elements of the return will be shared with the appropriate regulatory bodies. A full report including the anonymised results of all organisations involved in this AOA exercise will be published in the autumn. Thank you for providing assurance to your higher level RO, and the Senior Responsible Owner for revalidation, of your processes.

Further information on revalidation can be found at www.england.nhs.uk/revalidation

Yours sincerely

Simon BennettSenior Responsible OwnerDirector - Clinical Policy and Professional Standards

cc: Your higher level responsible officer

cc: Your local revalidation team’s lead contact

2

In this the third year of the AOA, and the seventh consecutive year of monitoring preparedness for, and the implementation of, medical revalidation, I am pleased to report a continuing upward trend, not only in the overall appraisal rate, but also the improvement of the system in general. I would like to thank you once again for your continued work to ensure that rigorous revalidation and clinical governance processes are in place across the healthcare system.

On reviewing the results presented below, designated bodies should produce an action plan to address any development needs that are identified. Should you need support in improving any element of your system in relation to revalidation, your local revalidation team (contact details below) can provide assistance.

Your higher level responsible officer Your local revalidationteam’s lead contact

Your local revalidation team’s contact details

Dr Mike Prentice

Kerry Gardner

[email protected]

Name of designated body: Name of responsible officer:

Sector:

Prescribed connection to:

Please note:

a) In some instances, data was not suitable for comparative reporting. In these cases your own response may be reported, but comparative data is not. Anexplanation is given for this within the report. If you require further information on these areas, please contact your local revalidation lead:

b) Only the questions asked are presented below. Please refer to AOA 2015/16 for the full indicator definitions if required.

YOUR ANNUAL ORGANISATIONAL AUDIT

The following information is presented as per your own AOA submission.

3

Official

NHS England (Regional Team - North)

Kerry Gardner at [email protected].

Independent/non-NHS, Independent healthcare provider

Analysis is based on the total of 769 returns from designated bodies (DBs) to the 2015/16 Annual Organisational Audit (AOA) exercise for the year ending 31March 2016 which had been received by NHS England by 29 July 2016

Mr Stephen Hodgson

ABL Health Ltd

2015/16 AOA indicator

SECTION 1: The Designated Body and the Responsible Officer

Your organisation’s

response

No. of DBs in all sectors and (%) that

said ‘Yes’

1.4

1.5 This question is not applicable to many DBs

1.6

1.7

1.8

1.9

4


response

Same sector: All sectors:

Official

No. of DBs in same sector and (%) that said ‘Yes’

A responsible officer has been nominated/appointed in compliance with the regulations.

Where a conflict of interest or appearance of bias has been identified and agreed with the higher level responsible officer; has an alternative responsible officer been appointed?

In the opinion of the responsible officer, sufficient funds, capacity and other resources have been provided by the designated body to enable them to carry out the responsibilities of the role.

The responsible officer is appropriately trained and remains up to date and fit to practice in the role of responsible officer.

The responsible officer ensures that accurate records are kept of all relevant information, actions and decisions relating to the responsible officer role.

The responsible officer ensures that the designated body's medical revalidation policies and procedures are in accordance with equality and diversity legislation.

769 (100.0%)

Total DBs: 769

Yes

N/A

Yes

Yes

Yes

Yes

758 (98.6%)

755 (98.2%)

DBs in sector: 272

755 (98.2%)264 (97.1%)

271 (99.6%) 764 (99.3%)

266 (97.8%)

268 (98.5%)

272 (100.0%)


SECTION 1 (cont.): The Designated Body and the Responsible Officer

No. of DBs in all sectors and (%) that

said ‘Yes’

1.10

1.11

1.12

5


response


Official



response

The responsible officer makes timely recommendations to the GMC about the fitness to practise of all doctors with a prescribed connection to the designated body, in accordance with the GMC requirements and the GMC Responsible Officer Protocol.

The governance systems (including clinical governance where appropriate) are subject to external or independent review.

The designated body has commissioned or undertaken an independent review* of its processes relating to appraisal and revalidation. (*including peer review, internal audit or an externally commissioned assessment)

Total DBs: 769

184 (67.6%)

269 (98.9%)

744 (96.7%)

762 (99.1%)

569 (74.0%)

DBs in sector: 272

Yes

No

Yes

262 (96.3%)


SECTION 2: Appraisal

2.1 Number of doctors with whom the designated body has a prescribed connection as at 31 March 2016

No. of doctors (in organisation)

Total no. of doctors (in SAME sector)

Total no. of doctors (across ALL sectors)

2.1.1 Consultants

2.1.2 Staff grade, associate specialist, specialty doctor

2.1.3 Doctors on Performers Lists

2.1.4 Doctors with practising privileges

2.1.5 Temporary or short-term contract holders

2.1.6 Other doctors with a prescribed connection to this designated body

2.1.7 Total number of doctors with a prescribed connection

6


response


Official

Total DBs: 769

2

0

2

6640

45540

0 11593

0

0

1246

9

455

109

1573

4106

714

DBs in sector: 272

16544

1703

0

49289

131309


SECTION 2 (cont): Appraisal

Completed appraisals (1a & 1b)

2.1 Number of doctors with whom the designated body has a prescribed connection on 31 March 2016 who had a completed annual appraisal between 1 April 2015 – 31 March 2016

Yourorganisation’s

response and (%) calculated

appraisal rate

Same sector appraisal rate

ALL sectors appraisal rate

2.1.1 Consultants






2.1.7 Total number of doctors who had a completed annual appraisal

7


response


Official

89.2%

88.1%

N/A

86.8%

Total DBs: 769

2 (100%)

86.4%

93.0%

81.1%

88.6%

83.8%

88.9%

85.4%

75.7%86.2%

89.7%

87.6%

DBs in sector: 272

N/A

N/A

2 (100%)

N/A

N/A



Approved incomplete or missed appraisal (2)

2.1

Yourorganisation’s

response and (%) calculated

appraisal rate



2.1.1 Consultants






2.1.7 Total number of doctors who had an approved incomplete or missed appraisal

8


response


Official

Number of doctors with whom the designated body has a prescribed connection on 31 March 2016 who had an Approved incomplete or missed appraisal between 1 April 2015 – 31 March 2016

5.5%N/A

Total DBs: 769

N/A

7.8%

7.8%0 (0%)

9.1%N/A

N/A

13.7%

12.6%

9.2%

N/A

0 (0%)

9.2%

DBs in sector: 272

5.5%7.6%

7.2%

11.1% 5.4%

11.9%



Unapproved incomplete or missed appraisal (3)

2.1

Number of doctors with whom the designated body has a prescribed connection on 31 March 2016 who had an Unapproved incomplete or missed annual appraisal between 1 April 2015 – 31 March 2016

Your organisation’s response and (%)

calculated appraisal rate



2.1.1 Consultants






2.1.7 Total number of doctors who had an unapproved incomplete or missed annual appraisal

9


response


Official

4.8%

N/A

Total DBs: 769

N/A

4.6%

1.6%

5.4%

5.1%

0 (0%)

4.5%N/A

7.0%

N/A

0 (0%)

DBs in sector: 272

3.8%

11.7%

5.3%

0.0%

5.3%

4.8%

N/A

1.8%


SECTION 2 (cont.): Appraisal


2.2

2.3

2.4

2.5

2.6

2.7

10


response


Official

No. of DBs in all sectors and (%) that said ‘Yes’

Your organisation’s response

Every doctor with a prescribed connection to the designated body with a missed or incomplete medical appraisal has an explanation recorded.

There is a medical appraisal policy, with core content which is compliant with national guidance, that has been ratified by the designated body’s board (or an equivalent governance or executive group).

There is a mechanism for quality assuring an appropriate sample of the inputs and outputs of the medical appraisal process to ensure that they comply with GMC requirements and other national guidance, and the outcomes are recorded in the annual report template.

There is a process in place for the responsible officer to ensure that key items of information (such as specific complaints, significant events and outlying clinical outcomes) are included in the appraisal portfolio and discussed at the appraisal meeting, so that development needs are identified.

The responsible officer ensures that the designated body has access to sufficient numbers of trained appraisers to carry out annual medical appraisals for all doctors with whom it has a prescribed connection.

Medical appraisers are supported in their role to calibrate and quality assure their appraisal practice.

This question is not applicable to many DBs

262 (96.3%)

Total DBs: 769

734 (95.4%)

Yes

742 (96.5%)

753 (97.9%)

Yes

Yes

Yes

Yes

DBs in sector: 272

258 (94.9%)

259 (95.2%)

260 (95.6%)

256 (94.1%)

Yes

745 (96.9%)

739 (96.1%)


SECTION 3: Monitoring Performance and responding to concerns

SECTION 4: Recruitment and Engagement


response


3.1

3.2

3.3

3.4

4.1

11

Official

Your organisation’s response

No. of DBs in all sectors and (%) that said ‘Yes’


There is a process in place for obtaining relevant information when the designated body enters into a contract of employment or for the provision of services with doctors (including locums).

The designated body has arrangements in place to access suffici ent trained case investigators and case managers.

The board (or an equivalent governance or executive group) receives an annual report detailing the number and type of concerns and their outcome.

The responsible officer ensures that a responding to concerns policy is in place (which includes arrangements for investigation and intervention for capability, conduct, health and fitness to practice concerns) which is ratified by the designated body’s board (or an equivalent governance or executive group).

There is a system for monitoring the fitness to practice of doctors with whom the designated body has a prescribed connection. 264 (97.1%)

Total DBs: 769

Yes

Yes

266 (97.8%)

749 (97.4%)

Yes

710 (92.3%)

741 (96.4%)

DBs in sector: 272

Yes

Yes

262 (96.3%)

256 (94.1%)

244 (89.7%)

752 (97.8%)

753 (97.9%)

2015/16 AOA indicator SECTION 5: Comments Your organisation’s response

5.1

12

Official

Amended and submitted on 02.06.16 by Janet Bell on the instructions of Priya Bhatt due to the previous submissioncontaining information relating to Bolton NHS FT10.06.16: Amended by Janet Bell on instructions of Priya Bhatt as 1 doctor has had a measure 1a appraisal.13.06.16 Amended by JBell on instructions of Priya Bhatt

OFFICIAL

A Framework of Quality Assurance for Responsible Officers and Revalidation

Annex E - Statement of Compliance

YGurney

Typewritten text

Annex E

OFFICIAL

2

Statement of Compliance Version number: 2.0 First published: 4 April 2014 Updated: 22 June 2015 Prepared by: Gary Cooper, Project Manager for Quality Assurance, NHS England Classification: OFFICIAL


NB: The National Health Service Commissioning Board was established on 1

October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes.

OFFICIAL

3

Designated Body Statement of Compliance

The board / executive management team – [delete as applicable] of [insert official name of DB] can confirm that

an AOA has been submitted,

the organisation is compliant with The Medical Profession (Responsible Officers) Regulations 2010 (as amended in 2013)

and can confirm that:

1. A licensed medical practitioner with appropriate training and suitable capacity has been nominated or appointed as a responsible officer;

Yes/No [delete as applicable]

2. An accurate record of all licensed medical practitioners with a prescribed connection to the designated body is maintained;

Comments:

3. There are sufficient numbers of trained appraisers to carry out annual medical appraisals for all licensed medical practitioners;

Comments:

4. Medical appraisers participate in ongoing performance review and training / development activities, to include peer review and calibration of professional judgements (Quality Assurance of Medical Appraisers1 or equivalent);

Comments:

5. All licensed medical practitioners2 either have an annual appraisal in keeping with GMC requirements (MAG or equivalent) or, where this does not occur, there is full understanding of the reasons why and suitable action taken;

Comments:

6. There are effective systems in place for monitoring the conduct and performance of all licensed medical practitioners1 (which includes, but is not limited to, monitoring: in-house training, clinical outcomes data, significant events, complaints, and feedback from patients and colleagues) and ensuring that information about these matters is provided for doctors to include at their appraisal;

Comments:

7. There is a process established for responding to concerns about any licensed medical practitioners1 fitness to practise;

Comments:

1 http://www.england.nhs.uk/revalidation/ro/app-syst/

2 Doctors with a prescribed connection to the designated body on the date of reporting.

http://www.england.nhs.uk/revalidation/ro/app-syst/

OFFICIAL

4

8. There is a process for obtaining and sharing information of note about any licensed medical practitioner’s fitness to practise between this organisation’s responsible officer and other responsible officers (or persons with appropriate governance responsibility) in other places where the licensed medical practitioner works;3

Comments:

9. The appropriate pre-employment background checks (including pre-engagement for locums) are carried out to ensure that all licenced medical practitioners4 have qualifications and experience appropriate to the work performed;

Comments:

10. A development plan is in place that ensures continual improvement and addresses any identified weaknesses or gaps in compliance.

Comments:

Signed on behalf of the designated body

[(Chief executive or chairman (or executive if no board exists)]

Official name of designated body: _ _ _ _ _ _ _ _ _ _ _

Name: _ _ _ _ _ _ _ _ _ _ _ Signed: _ _ _ _ _ _ _ _ _ _

Role: _ _ _ _ _ _ _ _ _ _ _

Date: _ _ _ _ _ _ _ _ _ _

3 The Medical Profession (Responsible Officers) Regulations 2011, regulation 11: http://www.legislation.gov.uk/ukdsi/2010/9780111500286/contents

1

Agenda Item No: 14



Title Revalidation – Nurses & Midwives

Executive Summary

Why is this paper going to the Board

To summarise the main points and key issues that the Board should focus on including risk, compliance priorities, cost and penalty implications, KPI’s, Trends and Projections, conclusions and proposals

To update Board Members on Revalidation for nurses and midwives. It will provide an overview of the Revalidation process as determined / directed by the Nursing and Midwifery Council (NMC); key requirements and trust compliance to date.

Next steps/future actions Clearly identify what will follow a Board decision i.e. future KPI’s, assurance requirements

Discuss * Receive *

Approve Note

Assurance to be provided by:

Carol Le Blanc. Head of Clinical and Professional Development




Quality Regulatory *

Workforce * Stakeholder implications



Prepared by Carol Le Blanc, Head of Clinical & Professional Development

Presented by Trish Armstrong-Child, Director of Nursing

2

Revalidation – Nurses and Midwives 1. PURPOSE

To provide an update for Board Members on Revalidation for nurses and midwives. It will

provide an overview of the Revalidation process as determined / directed by the Nursing

and Midwifery Council (NMC); key requirements and trust compliance to date.

2. BACKGROUND

The Nursing and Midwifery Council (NMC) changed the requirements which nurses and

midwives must meet when they revalidate their registration every three years.

In September 2013, The Nursing and Midwifery Council committed to introducing a

proportionate and effective system of revalidation by the end of 2015, in order to enhance

public protection. A new process for Nurse Revalidation went ‘live’ in April 2016 and should

be fully implemented by December 2018.

Nurses and midwives need to stay up-to-date in their professional practice, develop new

skills, keep up-to-date on standards and understand the changing needs of the public they

serve, and fellow healthcare professionals with whom they work.

The aim is that revalidation will give greater confidence to the public, employers and fellow

professionals that nurses and midwives are up-to-date with their practice.

Revalidation Requirements

All registrants’ need to revalidate in order to renew their registration. Every three years all

registrants will be required to declare that they have:

1. Practiced for at least 450 hours during the last three years (900 hours if dual

qualified).

2. Undertaken at least 35 hours of Continued Professional Development (CPD) with a

minimum of 20 hours of these being participatory learning (face to face and not

mandatory training).

3. Collected practice-related feedback from at least five sources over the 3 years.

4. Record a minimum of five written reflections on the Code, their CPD and their

practice-related feedback, over the 3 years, which must be discussed with another

NMC registered nurse or midwife.

5. Have an appropriate professional indemnity arrangement in place.

3

6. Obtained confirmation from a third party about their compliance with the revalidation

requirements and the absence of unaddressed concerns about their practice.

All nurses and midwives need an online NMC account to revalidate.

In preparation, the trust invested in a Band 6 Revalidation Facilitator for 6 months from

October 2015-March 2016 to support the implementation. The role focused on raising

awareness of Revalidation amongst nurses and midwives, offered support, guidance and

training relating to Portfolio development, developed guidance and templates on the trust

intranet, has written a Policy which has been through Workforce Committee and liaised with

the NMC regarding any queries/ questions.

3. CURRENT TRUST POSITION

One member of staff is on a career break in Australia and has chosen not to revalidated and

two member of staff is on long term sick and unable to revalidate at present thus been given

an extension/ deferment by the NMC, whilst another has just returned from long term

sickness and is requesting a deferment from the NMC.

It should be noted that the figures above are a snapshot in time as nurses and midwives

come and go within the trust and they may have already revalidated in another trust. ESR

automatically updates an individuals’ record once they have completed the Revalidation

process (there is an interface with the NMC Register) and managers are emailed on a

monthly basis data on their staff relating to registration compliance.

4. CONCLUSION

The Trust has an effective system in place for supporting and ensuring appropriate

monitoring of nurses and midwives through the revalidation process.

5. RECOMMENDATIONS

The board is asked to note progress.

Number of staff due to revalidate between April

– September 2016

Number of deferrals/ non

revalidated

Number of extensions/ deferments

Number of requests from NMC to review

evidence

196 1 3 1

Page 1 of 8

Agenda Item No


Date 29 September 2016

Title Reducing Sickness Absence

Executive Summary

The Trust has made steady progress over the last year to reduce

its staff sickness absence. However it is noted that sickness has

remained at around 4.6% for the last few months and has not

reached the target of 4.2%.

One of the aims of the People Strategy 2016-2021 is to reduce

sickness absence; and therefore identifies sickness absence and

the management of as an ongoing risk to Trust operational

delivery.

This report focusses on the key future proposed actions to help

prevent and manage sickness absence as effectively as

possible.


Discuss X Receive

Approve X Note

For Information Confidential y/n N


Strategy X Legal Implications

Performance and Quality X Regulatory

Financial Implications X Stakeholder implications X

Workforce X Risk X

Prepared by Carol Sheard, Head of Workforce

Presented by Mark Wilkinson, Director of Strategic and Organisational Development

Page 2 of 8

REDUCING SICKNESS ABSENCE

1. PURPOSE

The purpose of this paper is to seek the Board’s approval for the recommended actions in this report to help prevent and manage sickness absence as effectively as possible. 2. BACKGROUND

At the July Board it was noted that the Trust sickness absence level had not reached the target of 4.2% and following steady progress over the last year has remained fairly static. This paper briefly sets out the Trust’s position in comparison to other similar providers; the current actions in place to manage absence and then focusses on the proposed actions to be considered, to reduce sickness absence levels further to meet, or exceed the target.

One of the key operational objectives for the Trust is to reduce Bank and Agency spend which is at least partly related to sickness absence. We know that of the reasons for temporary staffing requests 15% relate to sickness whilst 53% relate to vacancies, 19% relate to “specialing”, and 11% relate to increased activity. 3. WHAT ARE THE CAUSES OF ABSENCE?

It is becoming more common to shift away from the more punitive approach of ‘absence control’ in favour of ‘attendance management’ strategies which aim to provide a working environment which maximises and motivates employee attendance.

However, if such a shift is to be encouraged and successful strategies found, we need a clear understanding of the causes of absence in order to formulate policies that address the true causes of non- attendance. The main causes of absence can be viewed as four distinct clusters1:

Health & lifestyle factors

genuine illness/poor health

smoking

excessive use of alcohol

lack of exercise

body weight

Workplace factors

working patterns

breaks between and during shifts

health & safety concerns

travel times

excessive hours

1 Attendance Management - a Review of Good Practice Bevan S, Hayday S Report

353, Institute for Employment Studies, December 1998

Page 3 of 8

Attitudinal & stress factors

job satisfaction

career satisfaction

intention to leave

organisational commitment

stress

absence ‘culture’

Domestic & kinship factors

gender

no. of children under 16

lack of flexible working

arrangements

4. COMPARISON DATA The data below places the Trust 29th out of 34 Trusts within the comparison sample in relation to average % sickness absence from May 2015-April 2016.

This comparative data reflects our Trust sickness absence % performance against similar organisations, including “integrated” Acute and Community NHS Trusts, although it should be noted that some of the organisations listed are from the Mental Health and Community sectors. It shows our overall performance to be in the bottom quartile, justifying the continuation of a performance target of 4.2% which brings us into mid-levels of sickness performance. The current cost of sickness absence i.e. the amount of money spent on sick pay with no return on productivity, was £551k in July 2016. Factoring in temporary cover, of the 15% usage of temporary staffing requests for sickness, 15% is for agency and 16% is for bank. Therefore at a total annual temporary staffing cost to July 2016 of £12.8m, this equates to a total temporary staffing sickness backfill cost of £2m in the last year. Combining these figures, this information suggests the true cost of sickness absence to the Trust over the last year was £8.8m. Achieving our target of 4.2% would save directly and indirectly £850k on this basis. Our top two reasons for staff absence in terms of episodes over the last 12 months have been Gastrointestinal (number one) and Colds, cough, flu and influenza (number two);

0.00%1.00%2.00%3.00%4.00%5.00%6.00%

Gre

at W

este

rn…

Luto

n &

Du

nst

able

…

No

rth

De

von

Wes

t H

ertf

ord

shir

e…

Bu

ckin

gham

shir

e…

Surr

ey

& S

uss

ex

Pe

terb

oro

ugh

&…

Co

lch

este

r U

ni F

St H

ele

n's

&…

Be

rksh

ire

He

alth

F

Bas

ildo

n &

…

Ro

yal B

ou

rne

mo

uth

…

Med

way

F

Co

un

tess

Ch

est

er F

Wri

ghti

ngt

on

Wig

&…

No

rth

amp

ton

Ge

n

Shre

wsb

ury

&…

Salf

ord

Ro

yal F

Ro

yal U

nit

ed B

ath

Sou

th W

est

Lo

nd

on

…

Bla

ckp

oo

l Te

ach

ing

F

Sher

wo

od

Fo

rest

F

War

rin

gto

n &

…

Sto

ckp

ort

F

No

rth

Te

es &

…

Her

tfo

rdsh

ire…

Wo

rce

ster

shir

e…

Bar

ne

t En

fie

ld &

…

Bo

lto

n F

T

Wir

ral C

om

mu

nit

y F

Du

dle

y &

W's

all M

H…

Mo

reca

mb

e B

ay…

Co

rnw

all P

artn

ers

F

Lin

coln

shir

e…

Page 4 of 8

although in terms of long term absence (which usually contribute the highest to cost and lost productivity) the top two are anxiety / stress and musculo-skeletal problems respectively. The majority of sickness is attributed to long term cases, which has the tightest ‘grip’ in terms of case management.

5. CURRENT ACTION TO MANAGE ABSENCE

Broadly, current activity to manage absence focusses on the following areas:

Monitoring of absence metrics by local area, Division and Trust level (via IPM) and reported to Workforce Committee and the Board of Directors.

Proactive implementation of the sickness absence policy including return to work interviews, trigger points implementation and informal and formal review meetings.

Audits of the application of the sickness absence policy are conducted regularly for each division. The outcomes are reported, via the Divisional HR Business Manager, to the Divisional DDO and DND and any areas where the policy hasn’t been complied with are addressed.

Training on the attendance management policy is carried out on a quarterly basis. On the last two courses 23 managers have attended with 16 people booked on the course in November 2016.

Advisory services from Well Being Partners (Occupational Health Provider) in relation to self and management referrals as well as a range of other services including emotional wellbeing drop in service, counselling services, early intervention case conferences, aromatherapy and reflexology, staff health clinics on a monthly basis, the provision of self-help guides, and staff training on stress management skills, healthy lifestyle and completing stress risk assessment forms.

Staff Health and Wellbeing Plan in place and managed through the H&WB Steering Group. Staff Health and Wellbeing launch event held in July 2016 attended by 113 staff.

Part time Mindfulness Practitioner in post for 12 months to provide direct support to staff through drop in sessions, targeted work in identified ward and other areas and training for staff to develop improved resilience and coping strategies through mindfulness skills. The work is underpinned by a clinically evidence-based research project carried out a controlled trial to assess the efficacy of mindfulness for NHS staff in targeted teams across the Trust.

Annual staff flu vaccination programme which this year, in accordance with the NHS England CQUIN, aims to reach a target of 75% of frontline staff.

Staff Physiotherapy provided at the RBH site with staff having access to fast track referrals via Occupational Health.

Pilot of an emotional wellbeing tool implemented in Acute Adult Division.

Page 5 of 8

Developing resilience for staff through the ‘Good Day at Work’ programme run by Organisational Development and Learning.

Sports and social club activities including Gym, fitness classes and social activities.

6. RECOMMENDED FUTURE ACTIONS

There are a number of recommended further actions the Trust should consider to further reduce staff sickness absence: 6.1 Extend audit of compliance against policy requirements for Q3 Regular sickness management audits are conducted however due to the scale of services provided by the Trust, the scope for these audits is relatively limited. Audits often reveal different practices and quality of policy application which is perhaps to be expected and remedial action is taken to address this. By extending the scope of audits the impact will be much wider. One of the most effective techniques to reduce sickness absence is the return to work interview, the timescales for which are picked up as part of the audits. Where the audits pick up particularly good areas of best practice these should be shared with other departments and replicated. 6.2 Explore further opportunities for proactive early intervention services through Well

Being Partners Early intervention case conferences with Wellbeing Partners (Occupational Health) are relatively common in helping the management of complex staff sickness cases. They involve meeting the OH Physician either with or without the member of staff, as appropriate, and discussing strategies for resolving the case. Further close working with Wellbeing Partners to agree appropriate cases and ensure sufficient resource is available to facilitate case conferences at short notice should be discussed between the Workforce Team and Wellbeing Partners. It is also recommended that the Trust discuss with Wellbeing Partners the opportunity to promote NHS Health checks for NHS staff. 6.3 Identify absence related consequences of Dignity at Work cases The Workforce Team and Staff Side representatives attended mediation training in September 2016 as part of a renewed focus to resolve dignity at work (bullying and harassment) issues as locally and informally as possible which is shown to be more successful than formal investigations into interpersonal conflict. All dignity at work cases will be assessed at the outset to ensure that informal interventions are considered and implemented where appropriate. It is anticipated that this will reduce associated staff absence and direct costs related to often protracted, formal investigations. The Workforce Team will monitor the impact of the implementation of informal conflict resolution via Workforce Committee. 6.4 Employee Assistance Programme Employee Assistance Programmes (EAP) are employee benefit programmes offered by many large employers. EAP are intended to help employees deal with personal problems that might adversely impact their work performance, health and well-being. EAP generally include assessment, options for short-term counselling and referral services for employees and their immediate family.

Page 6 of 8

As a rule of thumb, employee uptake on EAP is relatively low (typically less than 10% of the workforce accessing services), although the cost per head across the organization is also relatively low. It is recommended the Trust determines a cost/benefit analysis to the provision of a 24/7 Employee Assistance Programme. A business case would be required for this recommendation. 6.5 Emotional wellbeing tool To date the emotional wellbeing tool, (which helps bridge the gap in understanding staff emotional wellbeing and enables teams to talk openly and regularly about emotional health) has been rolled out as a pilot in the Acute Adult Division and is being led by the senior management team. Support for implementation is being provided by the Staff Engagement Lead and the HR Team. It is recommended that Divisional feedback is obtained on the impact of the emotional wellbeing tool and the Trust considers roll out across all Divisions. 6.6 Staff engagement focus groups Since August 2015 the Staff Engagement Lead has facilitated a number of staff focus groups both with open agendas and with specific topics for discussion. The feedback has been positive and it is therefore proposed that a series of focus groups, attended by a cross section of staff from different roles and departments, be held, focusing on attendance and the factors influencing attendance from a staff and leaders perspective. The focus groups will require the support of Divisional senior management teams in facilitating, clarifying the findings and incorporating these at Divisional and Trust level to form monitored action plans. The outcomes and recommendations for action should be reported via the Staff Engagement Steering Group and Workforce Committee. As part of the engagement work, the Trusts with the lower percentage reported absence will be contacted to ascertain their approach and whether there is any learning that can be successfully applied at Bolton. 6.7 Implementation of an absence management system It is recommended that we further explore the potential benefits and costs of an absence management system such as First Care or Absence Manager. Both systems benefit from much better oversight of absence management at the early stages, absence data available much earlier (virtually “live”), the ability to “manage the managers” and hold them to account for low return to work completion following staff sickness and the mandatory recording of each employee “expected return to work date” for every episode of sickness. First Care would cost £201K per year and Absence Manager approximately £100k per year. First Care predict that a modest reduction in absence by 10% (to our target of 4.2%) would provide a net saving of £494k. Following exploration of how these systems have been used in other Trusts and to what effect, a business case would be required for this recommendation. 6.8 Real time sickness data from E-roster It is recommended, in line with the agreement to roll out E-rostering across all areas and staff groups, that we explore the extraction and use of real time sickness data from E-rostering to help managers manage sickness much more proactively. Further to an

Page 7 of 8

assessment of how the data would be extracted and used, consideration would need to be given to the resource required to maximize the use of real time sickness data. 6.9 Further development of Health and Wellbeing services It is clear that an equally important factor in tackling sickness, compared to robust policy based management, is developing and promoting proactive preventative measures that help staff self-care and therefore be less likely to become unwell in the first place. The Health and Wellbeing Steering Group is established and well attended, and within its workplan is focused on:

Health Promotion

National, regional and local wellbeing campaigns

Increasing staff uptake on initiatives designed to support with stress

To identify and support the provision of early interventions to help staff avoid absence or return to work earlier

To promote Trust health and wellbeing offerings and signpost to external options

To monitor the progress of the health and wellbeing CQUIN’s This group is limited in the amount of progress it can realistically make due to the lack of focused resource, either within the divisions, within Workforce or within Occupational Health, to drive these initiatives, increase their profile, uptake and establishment within the organisational culture. It is therefore proposed that a business case be developed to appoint a Health and Wellbeing Project Lead to ensure these initiatives are delivered within the organisation. 6.10 Link sickness and ICIP performance It is recommended that we identify at Divisional level the potential for cost savings if the target of 4.2% is achieved and the consequential reduction in bank and agency which is a target for Divisions. 6.11 Staff fast track Physiotherapy service We know that the quality of outcomes, waiting times and staff feedback on the in-house staff Physiotherapy service is very good. However we also know that the number of referrals is continuing to grow and that demand is highly likely to exceed capacity in the near future. It is therefore recommended that a review of the service provision is conducted to identify the potential impact on sickness absence. The outcome of this may be that a business case is required. 6.12 Further development of leadership and management within the organisation We know that high quality leadership is crucial to ensure staff want to work for the Trust and be an important part of their team. This is built into leadership and HR training which is continually reviewed to ensure the right development is being provided. One specific area of support the Trust needs to address is how leaders support managers and colleagues who are covering absent colleagues and therefore take on extra work or responsibilities. This can create significantly higher levels of pressure on services and individuals and needs to be carefully managed. Another important factor for leaders is creating “headspace” for their managers and teams to address staff health and wellbeing. 16 managers are booked onto the Attendance Management programme in

Page 8 of 8

November 2016 and Divisional feedback will be sought regarding future demand for places. 7. RECOMMENDATION

The Board of Directors are asked to review and support the recommendations proposed to reduce staff sickness and meet or exceed the 4.2% target.


Date Thursday 29th September 2016

Title 2016 Equality, Diversity and Inclusion Report Update

Executive Summary

The purpose of this report is to present key information around the current workforce in relation to protected characteristics. It follows the discussion in March 2016 after the presentation of the Trust’s annual report on the Public Sector Equality Duty. Our current understanding is limited - a key step is to increase awareness among existing employees of the importance of updating their details. Unconscious bias training has been incorporated within the recruitment and selection training available to managers. The Board is asked to receive a further update in a development session. The CQC reported a positive and inclusive approach to equality and diversity

Previously considered

by

This has previously been discussed at Equality Diversity and

Inclusion Steering group.

Next steps/future

actions

Discuss Receive

Approve Note

For Information Confidential y/n y





Prepared by

Mark Wilkinson Director of

Strategic and

Organisational

Development

Presented by

Mark Wilkinson Director of

Strategic and Organisational

Development

Agenda Item No: 16

2

2016 Equality, Diversion and Inclusion Report Update

Introduction

The purpose of this report is to present key information around the current workforce of Bolton Foundation Trust that relates to the 9 protected characteristics, outlining the Trust’s current position and where appropriate identifying any changes.

The report is directly looking at the following protected characteristics;

Age Disability Race Religion or Belief Sex Sexual Orientation

The reporting period covers April 2015 – March 2016, and is based on data held in the Trust’s Electronic Staff Record. Conclusions drawn from this data should be interpreted cautiously as around 40% choose not to answer questions on, for example, their sexual orientation or disability status.

The report goes on to present a recruitment analysis to identify the likelihood of shortlisted candidates being appointed under the identified protected characteristics. The level of data completeness is much higher however it only covers people who have participated in a recruitment process over the last year.

Findings

Age

The age profile of Bolton Foundation Trust is significant when identifying future workforce gaps, the data suggests 20% of the workforce are already within retirement age with only 13% of the workforce in the younger age brackets following completion of education.

3

By pay band data shows decreases in band 5-7 and increases in band 8+ within age ranges 31-60 in comparison to 2015 data suggesting there is transitional movement within career progression.

The age profile since 2014 (2014 & 2015 in brackets) is split as follows;

14.79% (15.5% in 2014, 16.2% in 2015) of the workforce are aged 30 or under

50.81% (54.9% in 2014, 53.4% in 2015) of the workforce are aged between 31-50

34.4% (29.6% in 2014, 30.2% in 2015) of the workforce are aged 51 or over

Disability

In 2015 data it was recorded 157 employees considered themselves to have a disability, current data shows that figure has decreased to just 149 employees with a further 2004 employees who chose not to declare.

By pay band data shows employees in bands 5 – 6 are the highest groups of employees declaring themselves to have a disability with only 10% of the total declared being in a higher banded role.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<21 21-30 31-40 41-50 51-60 >60

Other

Bands 8+

Bands 5-7

Bands 1-4

3%

60%

37%

Yes

No

Not Declared

4

Race

In 2011 the office for national statistics reported 18.1% of the Bolton population was from a BME background with 15.5% reported at working age (over 16), 10.58% of Bolton Foundation Trust’s workforce are from Black or Minority Ethnic (BME) groups, which is a growth of 0.88% from 2015’s reported figure.

The chart below also shows an increase of 1.44% compared to 2015’s reported figure, of employees who chose not to state their ethnicity.

By pay band data shows BME employees are under-represented with only 7.47% of employees within bands 1-4, 10.87% of employees within bands 5-7 and 3.27% of employees above band 8+ which in comparison to 2015 recorded data has not increased or decreased significantly. BME employees are over represented among medical staff.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Band 1 Band 2 Band 3 Band 4 Band 5 Band 6 Band 7 Band 8+ Other (incMedical)

Yes

Not Declared

No

82.68%

10.58%

6.74%

White

BME

Not stated

5

Religion or Belief

The most common religion is Christianity (46.57%), which remains consistent with the figure reported in 2015 (46.7%). Those wishing not to disclose their religion (38.24%) have not shown any significant improvement on the figure reported in 2015 (38.9%). The data does however show an increase on 2015’s reported data to 3.20% of those reporting Islam as their religion.

Sex

Bolton Foundation Trust is strongly led by a female workforce (84.84%), which is consistent with 2015 data. Estates and Facilities and Medical and Dental remain the two staffing groups that are predominantly male dominated professions.

0%

20%

40%

60%

80%

100%

Bands 1-4 Bands 5-7 Bands 8+ Other (Incmedical)

BME

White

Christianity, 46.57%

I do not wish to disclose, 38.24%

Atheism, 5.30%

Other, 4.47%

Islam, 3.20%

Hinduism, 1.68%

Judaism, 0.28%

Buddhism, 0.11%

Sikhism, 0.09%

Jainism, 0.04%

Other, 0.52%

6

By banding the data shows an increase of male employees within band 8d in comparison to 2015 data that identified the higher bandings becoming increasingly male populated. Within bands 1-7 the data does not suggest any significant changes.

Sexual Orientation

Sexual orientation is under-represented in the non-heterosexual categories but that may be due to the large volume of employees choosing to not disclose their sexual orientation at the application stage. Band 8+ however shows a slight decrease compared to 2015 data of those wishing not to disclose.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Band 1 Band 2 Band 3 Band 4 Band 5 Band 6 Band 7 Band 8+ Other (incMedical)

Male

Female

7

Key findings for applicants and recruits

*The table is live recruitment data available through Trac (September 2015 onwards).

Characteristic Metric Number Data Declaration

Sex 1.29 times more likely for female candidates to be appointed (from shortlisting) than male candidates

1.29 100%

Age 1.51 times more likely to be appointed (from shortlisting) if you are under the age of 50 1.51 100%

Disability 0.97 times more likely for non-disabled candidates to be appointed (from shortlisting) than disabled candidates

0.97 97.2%

(only 2% selected yes)

Race 1.49 times more likely for white candidates to be appointed (from shortlisting) when compared to BME candidates

1.49 97.6%

Religion or Belief 0.89 times more likely to appoint (from shortlisting) Christian candidates than non-Christian candidates

0.89 90.8%

Sexual Orientation

1.09 more likely to appoint (from shortlisting) heterosexual candidates than non-heterosexual candidates

1.09 93.9%

*Data declaration confirms the % of applicants who disclosed the selected protected characteristic and does not include ‘Not stated or I do not wish to disclose’*

Trac is a credible source that allows us to track a candidate’s journey from application to start date and with the exception of disability the data suggests more candidates are now making full declarations of their protected characteristics.

This data presents a different and more ‘optimistic’ position to that reported in March 2016 based on ESR data describing our current workforce.

Protected Characteristics in priority order based on perceived misalignment

Conclusions drawn from ESR 2014/15 data

Recruitment data 2015/16

Disability 2.71 0.97 (small sample)

Sexual orientation 1.35 1.09

Age 1.17 1.51

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Bands 1-4 Bands 5-7 Bands 8+ Other

Lesbian

I do not wish to disclose mysexual orientation

Heterosexual

Gay

Bisexual

8

Current Position

The Trust now has an Equality and Diversity Lead, Lenny St Jean, who has led significant progress since joining the Trust.

The CQC reported on a positive and inclusive approach to equality and diversity, with good progress being made against the EDS2 standards. Data from the NHS staff survey showed positive results in most areas. The exception was an increase in all staff experiencing harassment bullying or abuse from staff in the last 12 months, with a notable increase in BME staff reporting bullying. We have acted upon these findings as part of actions in place to support staff engagement.

We have increased communication to existing employees of the importance of updating their details within ESR Self-Service on a regular basis, and have introduced Unconscious bias training incorporated within the recruitment and selection training available to managers

Recommendations

The Board is asked to note the report and receive a further presentation on this subject at a future board development session.



Title Standing Orders

Executive Summary

It is considered good practice to undertake an annual review of

the Standing Orders.

The following changes are proposed:

The addition of a change log

A correction to the title of the Finance and Investment

Committee

Previously considered by

Last approved September 2016


Discuss Receive

Approve Note

For Information Confidential y/n






Presented by Esther Steel Trust Secretary

Agenda Item No : 17

STANDING ORDERS

September 2016

FOREWORD

NHS Foundation Trusts need to agree Standing Orders (SOs) for the regulation of

their proceedings and business. The Board of Directors are also required to adopt

schedules of reservation of powers and delegation of powers.

The documents, together with Standing Financial Instructions, provide a regulatory

framework for the business conduct of the Trust. They fulfil the dual role of

protecting the Trust's interests and protecting staff from any possible accusation that

they have acted less than properly.

The Standing Orders, Delegated Powers and Standing Financial Instructions provide

a comprehensive business framework. All executive and non-executive directors,

and all members of staff, should be aware of the existence of these documents and,

where necessary, be familiar with the detailed provisions.

It is acknowledged within these Standing Orders and the Standing Financial

Instructions of the Trust that the Chief Executive and Director of Finance will have

ultimate responsibility for ensuring that the Trust Board meets its obligation to

perform its functions within the financial resources available.

All references to the masculine gender shall be read as equally applicable to the

female gender.

Provisions within the Standing Orders which are not subject to suspension under SO

3.32 are indicated in italics.

CONTENTS

FOREWORD

INTRODUCTION

Statutory Framework 1

NHS Framework 1

Delegation of Powers 2

1. INTERPRETATION 3

2. THE BOARD OF DIRECTORS 5

Composition of the Board of Directors 5

Appointment of the Chairman and Directors 5

Terms of Office of the Chairman and Directors 5

Appointment of Deputy-chairman 6

Powers of Deputy-chairman 6

Joint Directors 6

3. MEETINGS OF THE BOARD OF DIRECTORS 7

Admission of the Public and Press 7

Calling Meetings 7

Notice of Meetings 7

Setting the Agenda 8

Chairman of Meeting 8

Annual Public Meeting 8

Notices of Motion 8

Withdrawal of Motion or Amendments 8

Motion to Rescind a Resolution 8

Motions - right of reply 9

Chairman's Ruling 9

Voting 9

Non-Voting Directors 10

Minutes 10

Joint Directors 10

Suspension of Standing Orders 11

Variation and Amendment of Standing Orders 11

Record of Attendance 11

Quorum 11

4. ARRANGEMENTS FOR THE EXERCISE OF FUNCTIONS BY DELEGATION 13

Emergency Powers 13

Delegation to Committee 13

Delegation to Officers 13

5. COMMITTEES 14

Appointment of Committees 14

Confidentiality 15

6. DECLARATIONS OF INTEREST AND REGISTER OF INTEREST 16

Declaration of Interest 16

Register of Interests 17

7. DISABILITY OF DIRECTORS IN PROCEEDINGS ON ACCOUNT OF

PECUNIARY INTEREST 18

8. STANDARDS OF BUSINESS CONDUCT POLICY 20

Interest of Officers in Contracts 20

Canvassing of, and Recommendations by, Directors in Relation to Appointments 20

Relatives of Directors or Officers 20

9. CUSTODY OF SEAL AND SEALING OF DOCUMENTS 22

Custody of Seal 22

Sealing of Documents 22

Register of Sealing 22

10. SIGNATURE OF DOCUMENTS 23

11. MISCELLANEOUS 24

Standing Orders to be given to Directors and Officers 24

Documents having the Standing of Standing Orders 24

Review of Standing Orders 24

- 1 -

INTRODUCTION

Statutory Framework

Bolton NHS Foundation Trust (the Trust) is a Public Benefit Corporation which was

established under the granting of Authority by the Independent Regulator for NHS

Foundation Trusts. The principal place of business of the Trust is:

Royal Bolton Hospital, Minerva Road, Bolton, BL4 0JR

NHS Foundation Trusts are governed by statute, mainly the Health and Social Care

(Community Health and Standards) Act 2006 and the National Health Service Act 1977

(NHS Act 1977). The statutory functions conferred on the Trust are set out in the Health

and Social Care (Community Health and Standards) Act 2006 and in the Trust's terms of

authorisation issued by the Independent Regulator.

As a public benefit corporation the Trust has specific powers to contract in its own name

and to act as a corporate trustee. In the latter role it is accountable to the Charity

Commission for those funds deemed to be charitable as well as to the Independent

Regulator. The Trust also has a common law duty as a bailee for patients' property held

by the Trust on behalf of patients.

The Health and Social Care (Community Health and Standards) Act 2006 requires the

Trust to adopt Standing Orders (SOs) for the regulation of its proceedings and business.

The Independent Regulator requires NHS Foundation Trusts to adopt Standing Financial

Instructions (SFIs) setting out the responsibilities of individuals.

NHS Framework

In addition to the statutory requirements further guidance has been issued, many of these

are contained within the NHS Finance Manual. The manual also contains a list of the main

statutes and legislation relevant to NHS Foundation Trusts.

Included in the Manual are the Codes of Conduct and Accountability for NHS Boards. The

Code of Accountability requires that, inter alia, boards draw up a schedule of decisions

reserved to the Board, and ensure that management arrangements are in place to enable

responsibility to be clearly delegated to senior executives (a scheme of delegation). The

code also requires the establishment of audit and remuneration committees with formally

agreed terms of reference. The Code of Conduct makes various requirements concerning

possible conflicts of interest of board directors.

Also included in the Corporate Governance Framework Manual (Finance) is the Code of

Practice on Openness in the NHS, which sets out the requirements for public access to

information on the NHS and is considered good practice by the Trust.

- 2 -

Delegation of Powers

Under the Standing Orders relating to the Arrangements for the Exercise of Functions (SO

4) the Board of Directors exercises its powers to make arrangements for the exercise, on

behalf of the Trust, of any of its functions by a committee or sub-committee appointed by

virtue of SO 5 or by an officer of the Trust, in each case subject to such restrictions and

conditions as the Board of Directors thinks fit or as the Independent Regulator may direct.

Delegated Powers are covered in a separate document (Reservation of Powers to the

Board and Delegation of Powers). That document has effect as if incorporated into the

Standing Orders.

- 3 -

1 INTERPRETATION

1.1 Save as permitted by law, at any meeting the Chairman of the Trust shall be the

final authority on the interpretation of Standing Orders (on which the Chief

Executive should advise him).

1.2 Any expression to which a meaning is given in the Health Service Acts or in the

Regulations or Orders made under the Acts shall have the same meaning in this

interpretation and in addition:

"ACCOUNTABLE OFFICER" shall be the Officer responsible and accountable for

funds entrusted to the Trust. He shall be responsible for ensuring the proper

stewardship of public funds and assets. For this Trust it shall be the Chief

Executive.

"TRUST" means Bolton NHS Foundation Trust.

"BOARD OF DIRECTORS" shall mean the Chairman and non-executive directors,

appointed by the Governing Body, and the executive directors appointed by the

relevant committee of the Trust.

"BUDGET" shall mean a resource, expressed in financial terms, proposed by the

Board of Directors for the purpose of carrying out, for a specific period, any or all of

the functions of the Trust;

"CHAIRMAN" is the person appointed by the Governing Body to lead the Board of

Directors and to ensure that it successfully discharges its overall responsibility for

the Trust as a whole. The expression “the Chairman of the Trust” shall be deemed

to include the Senior Independent Director of the Trust if the Chairman is absent

from the meeting or is otherwise unavailable.

"CHIEF EXECUTIVE" shall mean the chief officer and accounting officer of the

Trust.

"COMMITTEE" shall mean a committee appointed by the Board of Directors.

"COMMITTEE MEMBERS" shall be persons formally appointed by the Board of

Directors to sit on or to chair specific committees.

“CONSTITUTION” shall be the Constitution of Bolton NHS Foundation Trust.

“DEPUTY CHAIRMAN” shall be the Senior Independent Director of the Trust.

"DIRECTOR" shall mean a person appointed as a director in accordance with the

Constitution section 20.1 for the appointment of the Chairman, section. 20.1 for the

appointment of non-executive directors, section 23.1 for the appointment of the

- 4 -

Chief Executive and section 23.4 for the appointment of all other directors.

Directors for the purpose of SO/SFI and Scheme of Delegation are those reporting

directly to the Chief Executive, including executive board members.

"DIRECTOR OF FINANCE" shall mean the chief finance officer of the Trust.

"FUNDS HELD ON TRUST" shall mean those funds which the Trust holds at its

date of incorporation.

"MOTION" means a formal proposition to be discussed and voted on during the

course of a meeting.

"NOMINATED OFFICER" means an officer charged with the responsibility for

discharging specific tasks within SOs and SFIs.

"OFFICER" means an employee of the Trust.

"SECRETARY" means the Trust Secretary or any other person appointed to

perform the duties of the secretary to the Board, including a joint, assistant or

deputy secretary, hereinafter to be referred to as the Secretary to the Board.

"SFIs" means Standing Financial Instructions.

"SOs" means Standing Orders.

- 5 -

2. THE BOARD OF DIRECTORS

2.1 All business shall be conducted in the name of the Trust.

2.2 All funds received in trust shall be in the name of the Trust as corporate trustee. In

relation to funds held on trust, powers exercised by the Trust as corporate trustee

shall be exercised separately and distinctly from those powers exercised as a

Trust.

2.3 The Trust has the functions conferred on it by the Health and Social Care

(Community Health and Standards) Act 2006 and its terms of authorisation issued

by the Independent Regulator.

2.4 Directors acting on behalf of the Trust as a corporate trustee are acting as quasi-

trustees. Accountability for charitable funds held on trust is to the Charity

Commission and to the Independent Regulator. Accountability for non-charitable

funds held on trust is only to the Independent Regulator.

2.5 The Trust has resolved that certain powers and decisions may only be exercised or

made by the Board of Directors in formal session. These powers and decisions are

set out in "Reservation of Powers to the Board" and have effect as if incorporated

into the Standing Orders.

2.6 Composition of the Board of Directors - In accordance with the Health and

Social Care (Community Health and Standards) Act 2006 and the constitution

section 18 composition of the Board of Directors of the Trust shall be:

The Chairman of the Trust

At least 5 non-executive directors

At least 5 executive directors including:

• the Chief Executive (the Chief Officer and Accounting Officer)

• the Director of Finance (the Chief Finance Officer)

• the Medical Director

• the Director of Nursing

The number of Executive Directors must not be greater than the number of Non

Executive Directors

2.7 Appointment of the Chairman and Directors - The Chairman and non-executive

directors are appointed by the Governing Body and the appointments will be in

accordance with section 20.1 of the constitution.

- 6 -

2.8 Terms of Office of the Chairman and Directors - The regulations governing the

period of tenure of office of the Chairman and directors will be in accordance with

section 9.5 of the constitution.

2.9 Appointment of Senior Independent Director – the appointment of a Senior

Independent Director (Deputy Chairman) of the Trust is as prescribed in section 22

of the constitution.

2.10 Powers of Senior Independent Director - Where the Chairman of an NHS

Foundation Trust has died or has otherwise ceased to hold office or where he has

been unable to perform his duties as Chairman owing to illness, absence from

England and Wales or any other cause, references to the chairman in the Schedule

to these Regulations shall, so long as there is no Chairman able to perform his

duties, be taken to include references to the Senior Independent Director

.

2.11 Joint Directors - Where more than one person is appointed jointly to a post in the

Trust which qualifies the holder for executive directorship or in relation to which an

executive director is to be appointed, those persons shall become appointed as an

executive director jointly, and shall count for the purpose of Standing Order 2.6 as

one person.

- 7 -

3. MEETINGS OF THE BOARD OF DIRECTORS

3.1 Admission of the Public and Press – The public shall be admitted to all formal

meetings of the Board, but shall be required to withdraw upon the Board of

Directors resolving as follows: “That representatives of the press and other

members of the public be excluded from the remainder of this meeting having

regard to the confidential nature of the business to be transacted, publicity on

which would be prejudicial to the public interest”.

3.2 Without prejudice to the generality of the right of the Board to exclude the public in

accordance with Standing Order 3.1 above, the Board may treat the need to

receive or consider recommendations or advice from sources other than Directors,

Committees or Sub-Committees of the Board as a special reason why publicity

would be prejudicial to the public interest, without regard to the subject or purpose

of the recommendation or advice and may treat as a special reason for excluding

the public any matter arising as to the appointment, promotion, dismissal, salary or

conditions of service or as to the conduct of any person employed by the Board..

3.3 Nothing in these Standing Orders shall require the Board of Directors to allow

members of the public or representatives of the press to record proceedings in any

manner

3.4 Calling Meetings - Ordinary meetings of the Board of Directors shall be held at

such times and places as the Board of Directors may determine.

3.5 The Chairman may call a meeting of the Board of Directors at any time. If the

Chairman refuses to call a meeting after a requisition for that purpose, signed by at

least one-third of the whole number of directors, has been presented to him, or if,

without so refusing, the Chairman does not call a meeting within seven days after

such requisition has been presented to him, at the Trust’s Headquarters, such one

third or more directors may forthwith call a meeting.

3.6 Notice of Meetings - Before each meeting of the Board of Directors, a notice of

the meeting, specifying the business proposed to be transacted at it, and signed by

the Chairman or by an officer of the Trust authorised by the Chairman to sign on

his behalf shall be delivered to every director, or sent by post to the usual place of

residence of such director, so as to be available to him at least three clear days

before the meeting.

3.8 In the case of a meeting called by directors in default of the Chairman, the notice

shall be signed by those directors and no business shall be transacted at the

meeting other than that specified in the notice.

3.9 Public notice of the time and place of any meeting of the Board (open to the public)

shall be given by posting such notice at the Offices of the Board three clear days at

least before the meeting or, if the meeting is convened at shorter notice, then at the

- 8 -

time it is convened. Such notice, together with a copy of the agenda, shall be

supplied, on request to the press.

3.10 Setting the Agenda - The Board of Directors may determine that certain matters

shall appear on every agenda for a meeting of the Board of Directors and shall be

addressed prior to any other business being conducted.

3.11 A director desiring a matter to be included on an agenda shall make his request in

writing to the Chairman at least ten clear days before the meeting. Requests made

less than ten days before a meeting may be included on the agenda at the

discretion of the Chairman.

3.12 Chairman of Meeting - At any meeting of the Board of Directors, the Chairman, if

present, shall preside. If the Chairman is absent from the meeting the Deputy-

Chairman, if there is one and he is present, shall preside. If the Chairman and

Deputy-Chairman are absent such non-executive director as the directors present

shall choose shall preside.

3.13 If the Chairman is absent from a meeting temporarily on the grounds of a declared

conflict of interest the Deputy-Chairman, if present, shall preside. If the Chairman

and Deputy-Chairman are absent, or are disqualified from participating, such non-

executive director as the directors present shall choose shall preside.

3.14 Annual Public Meeting - The Trust will publicise and hold an annual public

meeting in accordance with the constitution and the Health and Social Care

(Community Health and Standards) Act 2006.

3.15 Notices of Motion - A director of the Trust desiring to move or amend a motion

shall send a written notice thereof at least ten clear days before the meeting to the

Chairman, who shall insert in the agenda for the meeting all notices so received

subject to the notice being permissible under the appropriate regulations. This

paragraph shall not prevent any motion being moved during the meeting, without

notice on any business mentioned on the agenda subject to SO 3.8.

3.16 Withdrawal of Motion or Amendments - A motion or amendment once moved

and seconded may be withdrawn by the proposer with the concurrence of the

seconder and the consent of the Chairman.

3.17 Motion to Rescind a Resolution - Notice of motion to amend or rescind any

resolution (or the general substance of any resolution) which has been passed

within the preceding six calendar months shall bear the signature of the director

who gives it and also the signatures of four other directors. When any such motion

has been disposed of by the Board of Directors, it shall not be competent for any

director other than the Chairman to propose a motion to the same effect within six

months, however the Chairman may do so if he considers it appropriate.

- 9 -

3.18 Motions - The mover of a motion shall have a right of reply at the close of any

discussion on the motion or any amendment thereto.

3.19 When a motion is under discussion or immediately prior to discussion it shall be

open to a director to move:

An amendment to the motion.

The adjournment of the discussion or the meeting.

That the meeting proceed to the next business. (*)

The appointment of an ad hoc committee to deal with a specific item of business.

That the motion be now put. (*)

* In the case of sub-paragraphs denoted by (*) above to ensure objectivity motions

may only be put by a director who has not previously taken part in the debate. No

amendment to the motion shall be admitted if, in the opinion of the Chairman of the

meeting, the amendment negates the substance of the motion.

3.20 Chairman’s Ruling - The decision of the chairman of the meeting on questions of

order, relevancy and regularity (including procedure on handling motions) and his

interpretation of the Standing Orders, shall be final.

3.21 Voting - Every question at a meeting shall be determined by a majority of the votes

of the directors present and voting on the question and, in the case of any equality

of votes, the person presiding shall have a second or casting vote.

3.22 All questions put to the vote shall, at the discretion of the Chairman of the meeting,

be determined by oral expression or by a show of hands. A paper ballot may also

be used if a majority of the directors present so request.

3.23 If at least one-third of the directors present so request, the voting (other than by

paper ballot) on any question may be recorded to show how each director present

voted or abstained.

3.24 If a director so requests, his vote shall be recorded by name upon any vote (other

than by paper ballot).

3.25 In no circumstances may an absent director vote by proxy. Absence is defined as

being absent at the time of the vote.

3.26 An officer who has been appointed formally by the Board of Directors to act up for

an executive director during a period of incapacity or temporarily to fill an executive

director vacancy, shall be entitled to exercise the voting rights of the executive

director. An officer attending the Board of Directors to represent an executive

director during a period of incapacity or temporary absence without formal acting

up status may not exercise the voting rights of the executive director. An officer’s

status when attending a meeting shall be recorded in the minutes.

- 10 -

3.27 Non – Voting Directors - Non Voting Directors are ones who Board members

have determined should attend the Board in order to provide it with particular

expertise on a continuing basis. They are expected to attend all Board meeting

whether held in public or private.

They will receive all board papers for agenda items against which their

contributions are required. They will have the opportunity to participate in all board

discussions but may not take part in any voting and may be excluded from any part

of a Board meeting at the request of the Chairman.

All matters discussed or witnessed by attendees shall be regarded as confidential

to the board save for those where actions are agreed otherwise.

In order that they do not become liable for decisions made, the chairman will make

clear that they are being invited to comment upon items for debate but not take part

in any vote should one occur

3.28 Minutes - The Minutes of the proceedings of a meeting shall be drawn up and

submitted for agreement at the next ensuing meeting.

3.29 No discussion shall take place upon the minutes except upon their accuracy or

where the Chairman considers discussion appropriate. Any amendment to the

minutes shall be agreed and recorded at the next meeting.

3.30 Minutes shall be circulated in accordance with directors' wishes. Where providing

a record of a public meeting the minutes shall be made available to the public.

3.31 Joint Directors - Where a post of executive director is shared by more than one

person:

(a) both persons shall be entitled to attend meetings of the Trust:

(b) either of those persons shall be eligible to vote in the case of agreement

between them:

(c) in the case of disagreement between them no vote should be cast;

(d) the presence of either or both of those persons shall count as one person

for the purposes of SO 3.38 (Quorum).

3.32 Suspension of Standing Orders - Except where this would contravene any

statutory provision or any direction made by the Independent Regulator, any one or

more of the Standing Orders may be suspended at any meeting, provided that at

least half (normally six) of the Board of Directors are present, including one

executive director and one non-executive director, and that a majority of those

present vote in favour of suspension.

- 11 -

3.33 A decision to suspend SOs shall be recorded in the minutes of the meeting.

3.34 A separate record of matters discussed during the suspension of SOs shall be

made and shall be available to the directors.

3.35 No formal business may be transacted while SOs are suspended.

3.36 The Audit Committee shall review every decision to suspend SOs.

3.37 Variation and Amendment of Standing Orders - These Standing Orders shall

not be revoked, varied or amended except upon:

a) A report to the Board by the Chief Executive or.

b) A notice of motion under Standing Order 3.15, such revocation, variation or

amendment having to be approved by a number of Directors equal to at

least two-thirds (normally eight including the Chairman) of the whole

number of Directors of the Board, and provided that any revocation,

variation or amendment does not contravene a statutory provision or

direction made by the Secretary of State.

3.38 Record of Attendance - The names of the directors present at the meeting shall

be recorded in the minutes.

3.39 Quorum - No business shall be transacted at a meeting of the Board of Directors

unless at least one-third (normally four) of the whole number of the directors are

present including at least one executive director and one non-executive director.

3.40 An officer in attendance for an executive director but without formal acting up

status may not count towards the quorum.

3.41 If a director has been disqualified from participating in the discussion on any matter

and/or from voting on any resolution by reason of the declaration of a conflict of

interest (see SO 6 or 7) he shall no longer count towards the quorum. If a quorum

is then not available for the discussion and/or the passing of a resolution on any

matter, that matter may not be discussed further or voted upon at that meeting.

Such a position shall be recorded in the minutes of the meeting. The meeting must

then proceed to the next business. The above requirement for at least one

executive director to form part of the quorum shall not apply where the executive

directors are excluded from a meeting (for example when the Board of Directors

considers the recommendations of the Remuneration Committee).

- 12 -

4. ARRANGEMENTS FOR THE EXERCISE OF FUNCTIONS BY DELEGATION

4.1 Subject to SO 2.7 and such directions as may be given by the Independent

Regulator, the Board of Directors may make arrangements for the exercise, on

behalf of the Trust, of any of its functions by a committee or sub-committee,

appointed by virtue of SO 5.1 or 5.2 below or by a director or an officer of the Trust

in each case subject to such restrictions and conditions as the Board of Directors

thinks fit.

4.2 Emergency Powers - The powers which the Board of Directors has retained to

itself within these Standing Orders (SO 2.5) may in emergency be exercised by the

Chief Executive and the Chairman after having consulted at least two non-

executive directors. The exercise of such powers by the Chief Executive and the

Chairman shall be reported to the next formal meeting of the Board of Directors for

ratification.

4.3 Delegation to Committees - The Board of Directors shall agree from time to time

to the delegation of executive powers to be exercised by committees or sub-

committees, which it has formally constituted. The constitution and terms of

reference of these committees, or sub-committees, and their specific executive

powers shall be approved by the Board of Directors.

4.4 Delegation to Officers - Those functions of the Trust which have not been

retained as reserved by the Board of Directors or delegated to an executive

committee or subcommittee shall be exercised on behalf of the Board of Directors

by the Chief Executive. The Chief Executive shall determine which functions he

will perform personally and shall nominate officers to undertake the remaining

functions for which he will still retain an accountability to the Board of Directors.

4.5 The Chief Executive shall prepare a Scheme of Delegation identifying his

proposals, which shall be considered and approved by the Board of Directors,

subject to any amendment, agreed during the discussion. The Chief Executive

may periodically propose amendment to the Scheme of Delegation, which shall be

considered and approved by the Board of Directors as indicated above.

4.6 Nothing in the Scheme of Delegation shall impair the discharge of the direct

accountability to the Board of Directors of the Director of Finance and

Commissioning or other executive director to provide information and advise the

Board of Directors in accordance with any statutory requirements.

4.7 The arrangements made by the Board of Directors as set out in the "Reservation of

Powers to the Board and Delegation of Powers" shall have effect as if incorporated

in these Standing Orders.

- 13 -

5. COMMITTEES

5.1 Appointment of Committees - Subject to SO 2.7 and such directions as may be

given by the Independent Regulator, the Board of Directors may and, if directed by

him, shall appoint committees of the Board of Directors, consisting wholly or partly

of directors of the Trust or wholly of persons who are not directors of the Trust.

5.2 A committee appointed under SO 5.1 may, subject to such directions as may be

given by the Independent Regulator or the Board of Directors appoint sub-

committees consisting wholly or partly of members of the committee (whether or

not they include directors of the Trust or wholly of persons who are not members of

the Trust committee (whether or not they include directors of the Trust).

5.3 The Standing Orders of the Trust, as far as they are applicable, shall apply with

appropriate alteration to meetings of any committees or sub-committee established

by the Board of Directors.

5.4 Each such committee or sub-committee shall have such terms of reference and

powers and be subject to such conditions (as to reporting back to the Board of

Directors), as the Board of Directors shall decide. Such terms of reference shall

have effect as if incorporated into the Standing Orders.

5.5 Committees may not delegate their executive powers to a sub-committee unless

expressly authorised by the Board of Directors.

5.6 The Board of Directors shall approve the appointments to each of the committees,

which it has formally constituted. Where the Board of Directors determines that

persons, who are neither directors nor officers, shall be appointed to a committee,

the terms of such appointment shall be determined by the Board of Directors

subject to the payment of travelling and other allowances being in accordance with

such sum as may be determined.

5.7 Where the Board of Directors is required to appoint persons to a committee and/or

to undertake statutory functions as required by the Independent Regulator, and

where such appointments are to operate independently of the Board of Directors

such appointment shall be made in accordance with the regulations laid down by

the Independent Regulator.

- 14 -

5.8 The committees and sub-committees formally established by the Board of Directors

are:

Audit

Quality Assurance

Finance and Investment

Remuneration

Charitable Funds

5.9 Confidentiality - A member of a committee shall not disclose a matter dealt with

by, or brought before, the committee without its permission until the committee

shall have reported to the Board of Directors or shall otherwise have concluded on

that matter.

5.10 A Director of the Trust or a member of a committee shall not disclose any matter

reported to the Board of Directors or otherwise dealt with by the committee,

notwithstanding that the matter has been reported or action has been concluded, if

the Board of Directors or committee shall resolve that it is confidential.

- 15 -

6. DECLARATIONS OF INTERESTS AND REGISTER OF INTERESTS

Pursuant to Section 20 of Schedule 1 of the Health and Social Care (Community

Health and Standards Act 2006), a register of Director’s and Governor’s interests

must be kept by the Trust

6.1 Declaration of Interests - The Code of Accountability requires board directors

(including for the purposes of this document Non-executive Directors) and

Governors to declare interests, which are relevant and material. All existing board

directors should declare relevant and material interests. Any board directors or

governors appointed subsequently should do so on appointment or election.

6.2 All employees of the Trust who have a direct financial interest in a private company

of any description which may be engaged in the provision of goods or services to

the NHS, must declare that interest in writing to the Chief Executive at the time of

appointment or commencement of any such interest.

6.3 Interests which should be regarded as "relevant and material" and which, for the

avoidance of doubt, should include in the register are:

a) Directorships, including non-executive directorships held in private companies

or PLCs (with the exception of those of dormant companies).

b) Ownership or part-ownership of private companies, businesses or

consultancies likely or possibly seeking to do business with the NHS.

c) Majority or controlling share holdings in organisations likely or possibly seeking

to do business with the NHS.

d) [A position of authority] in a charity or voluntary organisation in the field of

health and social care.

e) Any connection with a voluntary or other organisation contracting for NHS

services.

f) Any connection with an organisation, entity or company considering entering

into or having entered into a financial arrangement with the NHS Foundation

Trust, including but not limited to, lenders or banks.

6.4 If board directors or governors have any doubt about the relevance of an interest,

this should be discussed with the Chairman.

6.5 At the time the interests are declared, they should be recorded in the Board of

Directors minutes or Governing Body minutes as appropriate. Any changes in

interests should be declared at the next Board of Directors meeting or Governing

Body meeting as appropriate following the change occurring. It is the obligation of

the Director or Governor to inform the Secretary to the Board in writing within 7

days of becoming aware of the existence of a relevant or material interest. The

Secretary to the Board will amend the Register upon receipt within 3 working days.

- 16 -

6.6 Directors directorships of companies in 6.3(a) above or in companies likely or

possibly seeking to do business with the NHS (6.3(b) above) should be published

in the board's annual report. The information should be kept up to date for

inclusion in succeeding annual reports.

6.7 During the course of a Board of Directors meeting or Governing Body meetings, if a

conflict of interest is established, the director or governor concerned should

withdraw from the meeting and play no part in the relevant discussion or decision.

For the avoidance of doubt, this includes voting on such an issue where a conflict

is established. If there is a dispute as to whether a conflict of interest does exist,

majority will resolve the issue with the Chairman having the casting vote.

6.8 Register of Interests - The details of directors and governors interests recorded in

the Register will be kept up to date by means of a quarterly review of the Register

by the Secretary to the Board, during which any changes of interests declared

during the preceding quarter will be incorporated.

6.9 Subject to contrary regulations being passed, the Register will be available for

inspection by the public free of charge. The Chairman will take reasonable steps to

bring the existence of the Register to the attention of the local population and to

publicise arrangements for viewing it. Copies or extracts of the Register must be

provided to members of the Trust free of charge and within a reasonable time

period of the request. A reasonable charge may be imposed on non-members for

copies or extracts of the Register.

- 17 -

7. DISABILITY OF DIRECTORS IN PROCEEDINGS ON ACCOUNT OF

PECUNIARY INTEREST

7.1 Subject to the following provisions of this Standing Order, if a director of the Trust

has any pecuniary interest, direct or indirect, in any contract, proposed contract or

other matter and is present at a meeting of the Board of Directors at which the

contract or other matter is the subject of consideration, he shall at the meeting and

as soon as practicable after its commencement disclose the fact and shall not take

part in the consideration or discussion of the contract or other matter or vote on any

question with respect to it.

7.2 The Independent Regulator may, subject to such conditions as he may think fit to

impose ,remove any disability imposed by this Standing Order in any case in which

it appears to him in the interests of the National Health Service that the disability

shall be removed.

7.3 The Trust shall exclude a director from a meeting of the Board of Directors while

any contract, proposed contract or other matter in which he has a pecuniary

interest, is under consideration.

7.4 Any remuneration, compensation or allowances payable to a director by virtue of

paragraph 9 of Schedule 2 to the NHS & CC Act 1990 shall not be treated as a

pecuniary interest for the purpose of this Standing Order.

7.5 For the purpose of this Standing Order the Chairman or a director shall be treated,

subject to SO 7.2 and SO 7.6, as having indirectly a pecuniary interest in a

contract, proposed contract or other matter, if:

a) he, or a nominee of his, is a director of a company or other body, not being

public body, with which the contract was made or is proposed to be made or

which has a direct pecuniary interest in the other matter under consideration;

or

b) he is a business partner of, or is in the employment of a person with whom the

contract was made or is proposed to be made or who has a direct pecuniary

interest in the other matter under consideration; and in the case of married

persons or cohabiters the interest of one shall, if known to the other, be

deemed for the purposes of this Standing Order to be also an interest of the

other.

7.6 A director shall not be treated as having a pecuniary interest in any contract,

proposed contract or other matter by reason only:

a) of his membership of a company or other body, if he has no beneficial interest

in any securities of that company or other body;

- 18 -

b) of an interest in any company, body or person with which he is connected as

mentioned in SO 7.5 above which is so remote or insignificant that it cannot

reasonably be regarded as likely to influence a director in the consideration or

discussion of or in voting on, any question with respect to that contract or

matter.

7.7 Where a director:

a) has an indirect pecuniary interest in a contract, proposed contract or other

matter by reason only of a beneficial interest in securities of a company or

other body, and

b) the total nominal value of those securities does not exceed £5,000 or one

hundredth of the total nominal value of the issued share capital of the company

or body, whichever is the less, and

c) if the share capital is of more than one class, the total nominal value of shares

of any one class in which he has a beneficial interest does not exceed one

hundredth of the total issued share capital of that class, this Standing Order

shall not prohibit him from taking part in the consideration or discussion of the

contract or other matter or from voting on any question with respect to it

without prejudice however to his duty to disclose his interest.

7.8 Standing Order 7 applies to a committee or sub-committee of the Board of

Directors as it applies to the Board of Directors and applies to any member of any

such committee or sub-committee (whether or not he is also a director of the Trust)

as it applies to a director of the Trust.

- 19 -

8. STANDARDS OF BUSINESS CONDUCT

8.1 Policy – The Trust has adopted a Standards of Business Policy and staff must

comply with this guidance and guidance in the 2010 Bribery Act. The following

provisions should be read in conjunction with these documents.

8.2 Interest of Officers in Contracts - If it comes to the knowledge of a director or an

officer of the Trust that a contract in which he has any pecuniary interest not being

a contract to which he is himself a party, has been, or is proposed to be, entered

into by the Trust he shall, at once, give notice in writing to the Chief Executive of

the fact that he is interested therein. In the case of married persons [or persons]

living together as partners, the interest of one partner shall, if known to the other,

be deemed to be also the interest of that partner.

8.3 An officer must also declare to the Chief Executive any other employment or

business or other relationship of his, or of a spouse or cohabiting partner, that

conflicts, or might reasonably be predicted could conflict with the interests of the

Trust. The Trust shall require interests, employment or relationships so declared

by staff to be entered in a register of interests of staff.

8.4 Canvassing of and Recommendations by, Directors in Relation to

Appointments -Canvassing of directors of the Trust or members of any committee

of the Trust directly or indirectly for any appointment under the Trust shall disqualify

the candidate for such appointment. The contents of this paragraph of the

Standing Order shall be included in application forms or otherwise brought to the

attention of candidates.

8.5 A director of the Trust shall not solicit for any person any appointment under the

Trust or recommend any person for such appointment: but this paragraph of this

Standing Order shall not preclude a director from giving written testimonial of a

candidate's ability, experience or character for submission to the Trust.

8.6 Informal discussions outside appointments panels or committees, whether solicited

or unsolicited, should be declared to the panel or committee.

8.7 Relatives of Directors or Officers - Candidates for any staff appointment shall

when making application disclose in writing whether they are related to any director

or the holder of any office under the Trust. Failure to disclose such a relationship

shall disqualify a candidate and, if appointed, render him liable to instant dismissal.

8.8 The directors and every officer of the Trust shall disclose to the Chief Executive

any relationship with a candidate of whose candidature that director or officer is

aware. It shall be the duty of the Chief Executive to report to the Board of Directors

any such disclosure made.

- 20 -

8.9 On appointment, directors (and prior to acceptance of an appointment in the case

of executive directors) should disclose to the Trust whether they are related to any

other director or holder of any office under the Trust.

8.10 Where the relationship of an officer or another director to a director of the Trust is

disclosed, the Standing Order headed `Disability of directors in proceedings on

account of pecuniary interest' (SO 7) shall apply.

8.11 Any Board member or member of staff who receives or is offered and declines

hospitality in excess of £25.00 is required to enter the details of the hospitality in

the Trust's Hospitality Register.

8.12 The Board recognise the 2010 Bribery act which introduces new bribery offences:

to give, promise or offer a bribe,

to request, agree to receive or accept a bribe either in the UK or overseas

A corporate offence of failure to prevent bribery by persons working on

behalf of a commercial organisation.

- 21 -

9. CUSTODY OF SEAL AND SEALING OF DOCUMENTS

9.1 Custody of Seal - The Common Seal of the Trust shall be kept by the Chairman in

a secure place in accordance with arrangements approved by the Board.

9.2 Sealing of Documents - The Seal of the Trust shall not be fixed to any documents

unless the sealing has been authorised by a resolution of the Board of Directors or

of a committee, thereof or where the Board of Directors has delegated its powers.

9.3 On approval by the Board, or by the Chairman or the Chief Executive under

delegated powers, to a transaction in pursuance of which the Common Seal of the

Board is required to be affixed to appropriate documents, shall be deemed also to

convey authority for the use of the Common Seal.

9.4 Where approval to the sealing of a document has been given specifically in

pursuance of a resolution of the Board or in accordance with Standing Order

No.9.3 above, the Seal shall be affixed in the presence of the Chairman, or other

Officer duly authorised by him and an Executive Director of the Trust, and shall be

attested by them.

9.5 Register of Sealing - An entry of every sealing shall be made and numbered

consecutively in a book provided for that purpose, and shall be signed by the

persons who shall have approved and authorised the document and those who

attested the seal. A report of all sealing shall be made to the Audit Committee at

least quarterly. (The report shall contain details of the seal number, the description

of the document and date of sealing).

- 22 -

10. SIGNATURE AND INSPECTION OF DOCUMENTS

10.1 Where the signature of any document will be a necessary step in legal proceedings

involving the Trust, it shall be signed by the Chief Executive, unless any enactment

otherwise requires or authorises, or the Board of Directors shall have given the

necessary authority to some other person for the purpose of such proceedings.

10.2 The Chief Executive or nominated officers shall be authorised, by resolution of the

Board of Directors, to sign on behalf of the Trust any agreement or other document

(not required to be executed as a deed) the subject matter of which has been

approved by the Board of Directors or committee or sub-committee to which the

Board of Directors has delegated appropriate authority.

10.3 A Director of the Board may for purposes of his duty such as a Director, but not

otherwise, inspect any document which has been considered by the Chairman or

Chief Executive or senior officers under the terms of their delegated powers, or by

the Board, and if a copy is available shall, on request, be supplied for the like

purpose which a copy of such document provided that the Director shall not

knowingly inspect and shall not call for a document relating to a matter in which he

is professionally interested or in which he has directly or indirectly any pecuniary

interest, and that this Standing Order shall not preclude the Chief Executive to the

Board from declining to allow inspection of any document which is, or in the event

of legal proceedings would be, protected by privilege.

10.4 Nothing in the above paragraphs of this Standing Order 10 shall be interpreted as

giving the right to Directors to have access to personal medical information relating

to patients or to the examination of confidential patient records.

- 23 -

11. MISCELLANEOUS

11.1 Standing Orders to be given to Directors and Officers - It is the duty of the

Chief Executive to ensure that existing directors and officers and all new

appointees are notified of and understand their responsibilities within Standing

Orders and SFIs. Updated copies shall be issued to staff designated by the Chief

Executive. New designated officers shall be informed in writing and shall receive

copies where appropriate of SOs.

11.2 Documents having the standing of Standing Orders - Standing Financial

Instructions and Reservation of Powers to the Board and Delegation of Powers

shall have the effect as if incorporated into SOs.

11.3 Review of Standing Orders - Standing Orders shall be reviewed annually by the

Board of Directors. The requirement for review extends to all documents having

the effect as if incorporated in SOs.

- 24 -

Change Log

Change Page

Addition of a change log

24

Change of Committee name from Finance Committee to Finance and

Investment Committee

14

Level for declaration of hospitality changed to £25 in line with new

guidance to be issued by NHS England

20


Version 2 – 22/6/15

Name of Committee/Group:

Charitable Fund Committee

Date of Meeting:

21st September 2016

Chair:

Neal Chamberlain

Apologies:

Allan Duckworth,

Quorate (Yes/No):

No

Parent Committee:

Board of Directors


Key Agenda Items:

Decision/Action

Investment Presentation

Tilney Bestinvest Group previously selected as preferred suppliers: input recommending ‘Cautious Income’ fund; agreed, precise sum to be invested to be confirmed. Safeguards about release of funds confirmed.

Funding requests

Agreed to fund: Two flagpoles from front of building for national events (£1.9k) Security system for Orthopaedic Outpatients area (£3.7k) Reminiscence materials & clocks (time/day/date/month) for dementia-friendly focus (£3.3k & £23k) Oral Surgery Lowerable Trolleys (£11k) – query: should come from Elective Care Division? Breastfeeding Chairs(£1k) Breast milk Warmers (£270) ECG machine for Children’s Outpatients, Bolton One (£5.7k) Hoist for Acute Paediatric (£5.7k) – query: should come from Division? All to come from General Purposes Fund, apart from queries to be tested.

Vision Statement and Key Goals Broadly on track, to be reviewed at December meeting.

Fundraising Report

Good progress from Fundraiser – Raise £1 for Dementia Blackpool – Bolton Staff Walk - £4k raised so far (expected £7k in total). Continued progress with third party sponsors.

Independent Examination External audit currently underway.


Investment recommendation.


Investment decision noted above.

Date of next meeting: 21st December 2016


Version 4 – 10/08/16

Name of Committee/Group: Audit Committee Report to: Board of Directors

Date of Meeting: 27th September 2016 Date of next meeting: 29th November 2016

Chair: Jackie Njoroge Parent Committee: Board of Directors

Apologies: Mark Harrison Quorate (Yes/No): yes

Key Agenda Items: Assured


Internal Audit Plan y Internal audit

Plan provided for information, discussed frequency of IT reviews in light of developments and agreed the risk should be reflected with an annual report on IT

Revision to workplan

Progress report Y Internal audit

Plan on track, two final reports presented to the Committee and progress made with regard to follow up actions

Noted

A&E waiting times internal audit report

Y Internal audit

Medium risk report following a targeted review of the recording of A&E waiting times (previously overstated the number of patients with a 12 hour wait)

Noted – auditors confirmed that recommendations have been addressed

Non-financial data quality Y Internal audit

Medium risk report – the review of four community service indicators found that good progress had been made with some evidence of self audit

Report noted

PAS convergence Y Deputy CIO The Deputy CIO attended to provide assurance that recommendations in the PAS convergence report had been addressed

Report noted

Technical update To note External Audit

The external auditor provided a very useful summary of issues around the sector for information.

Report noted

Counter Fraud Y LCFS Comprehensive report on counter fraud activity Report noted

Board Assurance Framework Y Trust Secretary

New BAF noted, committee and auditors commended the new format and inclusion of a scale for risk appetite. The cycle of deep dives into elements of the BAF will commence with effect from the November meeting

BAF noted

Learning from Doncaster Y Deputy DoF Assurance provided that the Finance team have reflected on any applicable learning s from a recent significant financial breach at Doncaster NHSFT

Report and actions noted

Regular reports Y The Committee noted the regular reports on the Finance Improvement Plan, Losses and Waivers and the Use of the Trust Seal

Reports noted.

Date post:	05-Aug-2020
Category:	Documents
Upload:	others
View:	4 times
Download:	0 times