DerbyshireCommunityHealthServices BoardPublicSession ...2020/03/26 · 46 PSED Annual Report.docx...

Derbyshire Community Health ServicesBoard Public Session - 26 March 2020

Telephone Conference Call - for details of how to access the call please contact [email protected] [email protected] or telephone 07584 475972

26 March 2020 13:00 - 26 March 2020 14:00

AGENDA

# Description Owner Time

33 Part 2 - Public Session 13:00

34 INTRODUCTORY ITEMS

35 Introductions and WelcomeVerbal

Prem Singh

36 Apologies for Absence: Kay Fawcett, James Reilly, Jim Austin

Verbal

Prem Singh

37 Declarations of InterestVerbal

Prem Singh

38 Questions from the PublicVerbal

Prem Singh

39 Draft Minutes of the meeting held on 30 January 2020Paper for Decision

39 Minutes 30 January 2020.docx 7

Prem Singh

40 Matters ArisingVerbal

Prem Singh

41 Actions MatrixPaper for Information

41 Actions Matrix.docx 21

Prem Singh

42 Chairman’s ReportVerbal

Prem Singh 13:05

43 STRATEGY, VALUES AND VISION

44 Chief Executive’s ReportPaper for Information and Assurance

44 CE Report.docx 23

Tracy Allen


45 QUALITY, PERFORMANCE AND GOVERNANCE

46 Quality People Committee Summary Report including Staff Survey; Public Sector Equality Duty and Statutory Gender Pay Gap report

Paper for Assurance

Kaye Burnett

46.1 Staff SurveyPaper for Information, Decision and Assurance

46 2019 NHS Staff Survey.docx 27

Paul Renshaw

46.2 Public Sector Equality DutyPaper for Information, Decision and Assurance

46 PSED Annual Report.docx 41

Paul Renshaw

46.3 Statutory Gender Pay Gap reportPaper for Information, Decision and Assurance

46 GPG Summary 2019.20.pdf 45

Paul Renshaw

47 Quality Report including Update on CoronavirusPaper for Information and Assurance

47 Quality Report.docx 55

Michelle Bateman

48 Staffing for Quality ReportPaper for Information and Assurance

48 Staffing for Quality.pdf 59

Michelle Bateman

49 Performance ReportPaper for Information and Assurance

49 Performance Report.pdf 75

Cath Benfield

50 Financial Performance ReportPaper for Information and Assurance

50 Financial Performance Report.pdf 99

Cath Benfield


51 Quality Service Committee Summary Report inc IPC Q3 Report

Paper for Assurance

51 QSC Summary Report.docx 111

51 IPC Quarter 3 Report.docx 115

Ben Pearson

52 Quality Business Committee Summary ReportPaper for Assurance

Ian Lichfield

53 Council of Governors Summary ReportPaper for Assurance to follow

Prem Singh

54 Charitable Funds Committee Summary ReportPaper for Assurance to follow

Prem Singh

55 CONCLUDING ITEMS

56 Any Other BusinessVerbal

Prem Singh

57 Self-Certification/Risk/Board Assurance FrameworkVerbal

All

58 Questions from the public relating to today's board business

Verbal

Prem Singh

59 Review of the Meeting and OutcomesVerbal

Prem Singh

60 Date of Next Meeting: 4 June 2020 at Oakland Village, HallFarm Rd, Swadlincote DE11 8ND

Members of the public and staff are invited to join the Board for an informal discussion over tea and coffee from 12.30pm; this will include a presentation on developing services provided in that area. The Public Board meeting will commence at 1.30pm

INDEX

39 Minutes 30 January 2020.docx..................................................................................................7

41 Actions Matrix.docx....................................................................................................................21

44 CE Report.docx.........................................................................................................................23

46 2019 NHS Staff Survey.docx.....................................................................................................27

46 PSED Annual Report.docx........................................................................................................41

46 GPG Summary 2019.20.pdf......................................................................................................45

47 Quality Report.docx...................................................................................................................55

48 Staffing for Quality.pdf...............................................................................................................59

49 Performance Report.pdf............................................................................................................75

50 Financial Performance Report.pdf.............................................................................................99

51 QSC Summary Report.docx......................................................................................................111

51 IPC Quarter 3 Report.docx........................................................................................................115

PUBLIC BOARD MEETING

Minutes of the Meeting held on Thursday 30 January 2020At The Riverside Centre, Riverside Court, Derby DE24 8HY

Name Initials Job titlePrem Singh PS Chair Tracy Allen TA Chief Executive Jim Austin JA Senior Information and Transformation OfficerMichelle Bateman MB Director of Quality/Chief NurseTim Broadley TB Director of StrategyKaye Burnett KB Non-Executive DirectorMelanie Curd MC Associate Director of Corporate Governance/

Trust SecretaryKay Fawcett KF Non-Executive DirectorRichard Harcourt RH Associate Non-Executive DirectorJoy Hollister JHol Non-Executive DirectorJulie Houlder JH Non-Executive DirectorBen Pearson BP Medical DirectorJames Reilly JR Non-Executive Director Chris Sands CS Director of Finance and Strategy/Deputy Chief

Executive Amanda Rawlings AR Director of People Services and Organisational

Effectiveness William Jones WJ Chief Operating Officer

Present

Ian Lichfield IL Non-Executive Director

Apologies

Cath Benfield CB Deputy Director of Finance Attendees Andrea Graham AG Acting Deputy Trust Secretary

Item Description ActionDeveloping Services in this Area

1/20 PART 2 – Public Session

2/20 INTRODUCTORY ITEMS3/20 Introductions and Welcome

4/20 Apologies for Absence

None

Page 1 of 1339 Minutes 30 January 2020.docx

Item Description Action5/20 Declarations of Interest

There were no declarations of interest.

6/20 Questions from the Public

There were no questions received from the public.

7/20 Patient Story

MB presented Mr and Mrs Draper’s story which highlights the valuable learning that the Trust takes from patient feedback including complaints and how that feedback can be used to improve services for other families. The Story shows the importance of listening to concerns and understanding what matters to each Patient and their Carer.

Mrs Draper has Parkinson’s Disease and following a period at Derby Hospital was discharged to Ilkeston Hospital for Rehabilitation. Mr and Mrs Draper were informed that the hospital policy did not allow for Self-Medication either by Mrs Draper herself or by Mr Draper. As Parkinson’s medication is time sensitive Mr Draper noticed a decline in Mrs Drapers condition and concluded that it was because she was not receiving her medication at the correct time. Despite raising his concerns Mr Draper was not listened to and was not allowed to administer her medication. Eventually Mr Draper raised his concerns with the Physiotherapist and Mrs Draper was discharged home. Since discharge Mrs Draper has made a good recovery.

Mr Draper explained to the Board that he complained as he wanted to make sure that the experience was not repeated for other patients with Parkinson’s as often medication needs to be given 6 or 7 times a day at very prescribed times which did not fit with the wards timed medication rounds.

Jenny Harrison met with Mr and Mrs Draper to discuss their complaint and following an investigation it was found that it would have been possible for Mr Draper to administer Mrs Drapers medication if it was safe to do so.

All staff have since been made aware of the policy and a refresher session on Parkinson’s disease was provided for all staff on the ward. In addition the learning was highlighted at the Matrons and Community Integrated Managers meeting to highlight the policy for self-administration of medication.

PS thanked Mr Draper for sharing his story so publically and apologised to Mrs and Mrs Draper on behalf of the Board for the experience they had. PS explained it was important to the Trust that staff formed good relationships with carers and actively listened to their concerns.

JH asked what assurance there was that learning has been embedded. MH advised that it is not known how well it has been embedded however there


Item Description Actionhave not been any similar experiences since. MH explained the Trust works across the system in terms of Carer support.

PS asked whether the Trust can consider creating a Carers forum at a local level to provide a forum for people to come together but also for the Trust to listen and learn. Jenny Harrison advised that there was previously a forum but they have not met recently. She advised that the team had already considered attending some support groups. PS also suggested there was an opportunity for Governors to be involved to help create a link with their constituents which is something which can be explored with the Governor Engagement Group.

KB thanked Mr Draper for telling his story and for his determination and perseverance. KB stated as a system it is important that staff recognise that people are experts in themselves and not to disempower people. Mr Draper agreed stating that he could see his wife was deteriorating and he knew why which was frustrating.

TA highlighted that there is a broader issue in respect of personalised care and there is more to do to ensure patients are considered experts in their own condition.

JA asked whether the staff have the flexibility to administer the drugs 6 or 7 times a day. Jenny Harrison confirmed that as long as it is prescribed it can be administered as often as needed. She explained the teams are now using alarm clocks to alert staff and also make a point of asking the patients and relatives what time they normally take their medication at the point of admission.

KB asked how the good practice was being spread across the Trust. MB advised that Jenny is meeting with Matrons to discuss the learning and there is an intention to spread the learning to as many staff as possible.

PS summarised that there has been lots of work done to learn from Mr Drapers experience and share the lessons. The story has shown there is a need to be flexible and to ask what matters to the patient and their carer and there is work to do in respect of ensuring the Trust really does offer personalised care which will require a mind-set shift. PS concluded by apologising to Mr and Mrs Draper again and for thanking Mr Draper for sharing his experience with the Board.

The Board received the story for information

MC

8/20 Draft Minutes of the meeting held on 29 November 2019

The minutes were approved as a true and accurate record of the meeting subject to the following amendments:

197/19 – panned care should be corrected to planned care. Ben Pearson’s initials should be corrected in the attendance table.


Item Description Action9/20 Matters Arising

None.

10/20 Actions Matrix

The Board noted the actions matrix.

11/20 Chairman’s Report

PS wished everyone a “Happy New Year” and with a new government, there is a lot going on. The Chief Execs report captures the national and local context brilliantly, in a nutshell all the messages reinforce the need to integrate care at a system level. On the agenda, today will also be the draft JUCD 5 year strategy plan. It is clear that the momentum to build system working with the development of ICS, ICPs, PCNs and Place is going to be critical in the next year or two. There is a significant piece of work going on in DCHS to help prepare for these changes and to help with the improvement journey, refreshing and building on the DCHS way.The strategic theme of the meeting is therefore, the need to harness collective leadership across the system, to build on the successes e.g. £100m saving, whilst supporting colleagues through change and uncertainty, to really connect with our joint purpose, energy, processes, governance and effectiveness to deliver on the ambitions of joined up care in Derbyshire.

Continuing to build strategic partnerships TA and PS met with Gavin Boyle and Kathy Maclean, of University

Hospitals of Derby and Burton (UHDB) in early January for a catch up and strategic discussion.

In keeping with our strategic theme, PS has been continuing discussions with John MacDonald (Chair of JUCD) and his team about STP Board development. Key developments in the next couple of months will provide some clarity on how we build a coherent OD/Effectiveness plan to support our work going forward.

TA and PS attended the January meeting of the first meeting in public of Joined Up Care Derbyshire Board, details in the Chief Execs report.

MC and PS met with the Chair and Trust Secretary of Worcestershire Health and Care NHS Trust to share our experiences and learning from the Trusts Well led review and improvement journey.

Keeping in touch with colleagues and services PS joined CS in carrying out an Insight visit to the Jubilee Day Centre in

New Mills. This was a valuable opportunity to visit our services in the High Peak and the centre has mainly elderly clients with mental Health, Physical Health and learning Disabilities needs.

IL and PS joined the very “festive” Quality Always Gold Accreditation panel just before Christmas. Congratulations to the teams in Ripley MIU and Babington Day Unit for their very well deserved accreditation.

In January the Trust held a celebratory tea party to honour and thank


Item Description Actionvolunteers for all the hard work and commitment they give to DCHS. JHol and MC joined PS to host some 23 volunteers out of a total of 250 volunteers in DCHS. The NHS and DCHS would be much the poorer were it not for the immense contributions of volunteers. A huge thank you to all of them.

Key Governance & Accountability activities have included: The full board met for a half day development session in December

giving us an opportunity to review and discuss the Board Assurance Framework (BAF) aligned to our strategic priorities.

TA and PS attended the quarterly Board Equalities Forum in December which was a very productive discussion on progressing priorities, reverse mentoring and augmenting the work of our networks.

The Board and Council of Governors came together for the biannual joint development session looking at the context and system working and our improvement journey.

The DCHS Systems strategy meeting continues to spend time sense making, thinking about aligning our response to the changing environment. More on this at our board time out in Feb

PS attended the Quality People Committee on 20th January as part of a rolling programme to attend the board quality committees – a very busy committee chaired really well by KB.

The annual appraisal process for board members will begin in the coming months and PS has met with KB, the SID, who will be undertaking PS’s appraisal once the round of NED appraisals has been completed. The Trust is looking at the new framework from NHSI/E regarding Chairs’ performance reporting to ensure our processes comply.

Regional and National Agenda At the beginning of December PS attended the NHS Confederation

Board of Trustees meeting, and also met with the incoming chair of the Confederation Lord Victor Adebowale. Victor starts in April but is getting tuned in and involved.

PS reported back in September on plans to set up a joint chairs event for NHS chairs, Independent STP/ICS chairs, Health and Wellbeing board chairs along with NEDs and lay members, which PS has agreed to co-sponsor. These arrangements are being coordinated by the NHS Confederation Regional Lead for the East Midlands and the LGA. The inaugural meeting will take place on 5th February and PS has been involved closely with the planning process.

Some other news highlights: (lots going on but of specific note…)

December Our major news story was the announcement of the nearly £10m Belper

health plans. http://www.dchs.nhs.uk/home/news/updated-plans-unveiled-for-the-multi-million-pound-development-of-belper-health-service.


http://www.dchs.nhs.uk/home/news/updated-plans-unveiled-for-the-multi-million-pound-development-of-belper-health-service



Item Description ActionJanuary The new physiotherapy unit at Ripley Hospital was opened officially on

17 January – this was a chance for the Trust to thank the hospital’s League of Friends for funding the entire project, costing more than £163,000, and celebrate the new facilities.http://www.dchs.nhs.uk/home/news/celebrations-to-mark-the-opening-of-a-new-physiotherapy-unit-at-ripley-hospital/.

The short waiting times and wide scope of services provided by the four minor injury units/urgent care centres was top story on BBC Radio Derby’s morning news bulletins on 10 January, with a four-minute piece also recorded in Ilkeston Hospital with two of the Trusts senior nursing team, broadcast during the breakfast show. This was in counterpoint to long Accident and Emergency waits receiving negative publicity.

The Board received the Chairman’s Report.

12/20 STRATEGY, VALUES AND VISION

13/20 Chief Executive’s Report

TA presented the Chief Execs Report and highlighted:

NHS Providers recently published some interesting case studies of how NHS Trusts have worked with Partners across the wider system to develop joined up workforce solutions. Examples included how system working can help address workforce challenges but it will require a shift in how the NHS operates, making cross boundary relationships part of the day to day business of frontline staff, and getting leaders from across the system together to engage in joint strategic planning.

Communication on learning from complaints – Healthwatch England has published a report looking at how NHS Trusts learn from complaints and communicate this with the public. MB is reviewing the report to inform our ongoing work on improving our complaints processes.

Joined Up Care Derbyshire Board – the key messages are available for information.

Primary Care Networks – The Board re-iterated its approach to support colleagues in Primary Care in the way they are implementing Primary Care Networks.

Winter Pressures – The Health and Care system has experienced significant pressure during recent weeks and the Winter plan has allowed the system to work supportively and effectively to manage the pressure as well as possible.

Flu – more than 80% of frontline colleagues have received the flu vaccine to help protect patients and staff as well as supporting Children across the world via UNICEF.

Redeveloping Health Facilities in Belper – Belper is set to benefit from a new £10m Health Facility on the existing Belper Clinic Site. The Trust will continue to engage with local people over the next couple of months.


http://www.dchs.nhs.uk/home/news/celebrations-to-mark-the-opening-of-a-new-physiotherapy-unit-at-ripley-hospital/

http://www.dchs.nhs.uk/home/news/celebrations-to-mark-the-opening-of-a-new-physiotherapy-unit-at-ripley-hospital/

Item Description Action The Trust will be hosting a visit from Professor Briggs and the “getting it

right first time” team with a focus on community flow on 21st February 2020.

JR asked whether, on the basis there are a number of new MPs in the region, there was a plan to meet with them to explain the trust strategy and vision. TA agreed it was a good point and it would be useful to do that as a system. TA agreed to follow up with Vicki Taylor and John MacDonald.

IL highlighted that there are some red and amber areas within the big 9 and queried whether the plans are robust enough. After discussion the Board agreed the objectives were right but there needs to be smarter measures in respect of targets and plans.

PS concluded that the Board will back ambitious targets if they are in the right areas and asked that the Big 9 for 2020/21 includes work around the deteriorating patient. TA agreed and explained there is work to do in ensuring staff are empowered to use their clinical judgement rather than adopting a blanket approach.

PS thanked TA for a useful and informative report in keeping with the Strategic theme

The Board received the Chief Executive’s Report and the Significant Assurance it provided.

TA

14/20 Sustainability and Transformation Plan

TB presented the draft Joined up Care Derbyshire 5 year strategy delivery plan to the Board for 2019/20 to 2023/24.

TB explained the plan is a draft and is presented for information however the Trust should be able to recognise itself within the plan.

KB thanked TB for the plan and asked how the Trust plans to engage the public with the plan. TB advised the plan reflects the engagement and discussions which have happened to date and there will be engagement at a system level. TB advised that there will be opportunities for the public to engage. JA advised that JUCD had created a link to 1600 citizens in Derbyshire to encourage representation across the region. KB asserted that the Trust needs to challenge itself to open up the conversation with the public as often as it can. PS agreed and stated that the Trust and system needs to build momentum to create a two way dialogue around the needs of the public and co create solutions. RH explained that it is not enough just to publish documents and the Trust needs to help the public understand and simplify the message.

PS summarised that it was positive to see that comments were about making the plan a reality and relevant and it provides useful feedback to pass to the next JUCD meeting. There is also some important work to ensure there is traction and that the trajectory against the plan can be


Item Description Actionmeasured.

The Board received the Report and the Significant Assurance it provided

15/20 QUALITY, PERFORMANCE AND GOVERNANCE

16/20 Quality Report

MB presented the Quality Report to the Board and highlighted:

Information has been provided to organisations about the Corona Virus and what to do if a patient is suspected to have the Corona virus.

CQUIN guidance has been published for 2020/21 and work is underway to understand and implement the CQUINS.

Two DCHS staff members have been successful in securing places on the NHS England and Improvement “personalisation collaborative”.

2020 is the “Year of the Nurse and the Midwife” There will be a range of local, regional and national events throughout the year. DCHS is planning its second Celebrating Nursing and Midwifery Conference in October 2020.

Work is underway to refresh the Quality Improvement and Assurance Framework building on the work undertaken to date.

KB asked if the Trust could use the publicity surrounding the year of the Nurse and Midwife to assist with recruitment. MB advised there had been a discussion at the Staff Forum and it was agreed that some targeted videos placed on the website would be helpful.

PS added that there was an opportunity to use DCHS Community week to assist with recruitment and to start to knit all of the work together.

The Board received the Quality Report and the Significant Assurance it provided.

17/20 Staffing for Quality

MB presented the Staffing for Quality Report to the Board.

MB explained that Inpatient Establishment Reviews for all inpatient wards including Older Peoples Mental Health have been completed and have been scheduled to continue on a six month basis. The reviews showed there was a lack of consistent use of e-rostering, an inconsistent approach to using bank and agency and a lack of consistency in defining acuity and dependency.

MB also explained that both QPC and QSC had received and reviewed the Staffing for Quality Report.


Item Description Action

TA stated that the inconsistency is concerning and asked if there was monitoring in place and whether there was assurance that the use of agency is justified in some areas. MB explained that she is starting to see some evidence in respect of patient acuity which would support the request for agency staff but that evidence base is still building.

The Board agreed there is assurance that the Trust has enough staff but there is a need to ensure the resources are used optimally.

PS agreed that the report shows that staffing levels are safe and the key issue is ensuring that staffing is kept under scrutiny and that momentum continues with the reviews.

The Board received the Report and the Significant Assurance it provided.

18/20 Performance Report

MB presented the Quality Service Section of the report and highlighted that there are no red areas on the CQUIN indicators schedule.

AR presented the Quality People Section of the report and highlighted that the Appraisals rate for December was 91.5% against a target of 96% and work was ongoing to remind leaders that appraisals are due. In addition RIDDORS are 16 for the year against a target of 13. AR also highlighted that there are ongoing difficulties in providing a consistent resuscitation training offer and attempts are being made to pool resources and find a system solution.

CB presented the Quality Business Section of the report and highlighted that the Delayed Transfers of Care (DToC) score for December was 1.6% against an NHS England/Improvement target of 3.5%.

TA highlighted that as the Trust approaches year end there are a few indicators, like inpatient length of stay and length of wait in Urgent Treatment Centres, which are consistently achieving targets yet they are still described as aspirational. TA stated that the narrative needs to change if the Trust is going to use SPC charts successfully. CB agreed to look at the reporting. RH agreed the reports are confusing and there needs to be some thought as to how the charts will be used to support the conversation.

IL stated that for those measures that are being consistently achieved there should be some thought as to whether the targets are rebased.

PS concluded that the reports should not be about presenting raw data but the ability to analyse the data and provide a narrative to help draw attention to the key issues.

The Board received the Report and the Significant Assurance it

CB


Item Description Actionprovided.

19/20 Financial Performance Report

CB presented the Financial Performance of the Trust as at 31st December 2019 and highlighted:

The Trust is continuing to forecast achieving the control total set by NHS Improvement.

The 2019/20 SQIP programme is forecast to be achieved in full. The Trusts Agency expenditure at month 9 is 63% and the situation

is being monitored closely. Year to date activity data is indicating under performance against

the cost and volume plans set.

PS thanked the team for a good solid performance.

The Board Received the Finance Report and the Significant Assurance it provided.

20/20 Quality Service Committee Summary Report including the Learning from Deaths Report

KF presented the Summary Report to the Board and highlighted:

The Committee received an inspiring Patient Story about the great work of the Chaplaincy service and how it could be used to support staff.

Learning from deaths report – of the 29 deaths three were classified as Category one deaths. The report is continuing to be developed.

PS acknowledged and encouraged the drive to improve reporting and the use of Summary Reports which provide important assurances to the Board.

The Board received the Learning from Deaths Report.

The Board took Significant Assurance from the work of the Committee.

21/20 Quality People Committee Summary Report

KB presented the Summary Report to the Board and highlighted:

The Committee had received an inspiring staff story. The Committee had discussed and are highlighting the potential risk

associated with both the Director of Organisational Effectiveness and Peoples Services and the Deputy Director leaving at the same time.

The Board took Significant Assurance from the work of the


Item Description ActionCommittee.

22/20 Quality Business Committee Summary Report

IL presented the Summary report to the Board and highlighted that the impact of working as a system played a significant part of the meeting and the data produced need to change to show both a DCHS position and a system position.


23/20 Audit and Assurance Committee Summary Report including Board Assurance Framework Q3

JH presented the Summary Report to the Board and highlighted:

There was a strong theme of reviewing readiness for year-end as well as the actions being taken in respect of system governance.

The BAF arrangements were discussed and some amendments made.

A comprehensive report was received in respect of changes in accounting for operational leases in 2020/21.

TA stated that the summary report was a good example to follow for others.

The Board: Approved the quarter 3 BAF.Approved the QBC Annual Report and Terms of Reference.


24/20 Council of Governors Summary Report

PS presented the Summary Report to the Board and highlighted that the Council had received the Annual Report of the Quality Business Committee for review.


25/20 Mental Health Act Committee Summary Report

JR presented the Summary Report to the Committee and highlighted:

The staffing Challenges within Learning Disability Services had caused some issues with MHA Compliance.

The guidance in respect of Liberty Protection Safeguards is still awaited.


Item Description Action

TA highlighted the Anti-ligature review which seemed to be taking a long time to complete. MB explained it was a National Alert which had been received by the Estates Team and all areas which patients could access had been reviewed which was over and above the alert. MB advised that risk assessments had been completed and any urgent work was undertaken as a priority.

PS concluded that there should have been some narrative in the summary report to explain the delay of the anti-ligature work and risk to the Board.

The Board took significant assurance from the work of the Committee

26/20 Charitable Funds Committee Summary Report

PS presented the Summary Report to the Board and highlighted that the meeting had taken place to review the Annual Report and accounts of the Charity. PS highlighted the drive to continually reduce the Charities running costs and also to replenish funds where possible.

The Board took Significant Assurance from the work of the Committee

27/20 CONCLUDING ITEMS28/20 Any Other Business

Amanda Rawlings leavingPS informed the Board that this was ARs last Board meeting in public before she takes up her post at UHDB. PS thanked AR for her passion, commitment, hard work and service to the Trust. AR has been instrumental in establishing the trust, developing the DCHS Way and culture and a key player in our success. AR has been a fantastic colleague and will be very much missed. PS wished her well in her new role.

The Board noted the item of any other business.

29/20 Self-Certification/Risk/Board Assurance Framework

None

30/20 Questions from the public relating to today's board business

Bernard Thorpe, Lead Governor noted the increasing emphasis on working as a system as asked if Non-Executive Directors are involved in the decision making processes. PS explained that the ICS Board and other mechanisms are not decision making bodies, the Board is the decision making body. PS advised that there are efforts to create opportunities for the Non-Executive Directors to align together within the system, such as the Finance and Workforce groups.

A question was received from a member of staff who asked how the Board


Item Description Actioncan be assured that the quality of care of patients is not compromised by the pressure of productivity. TA explained it is an issue that is discussed frequently and the focus should be on productivity within the right framework. The work should focus on patient outcomes and the Trust needs to think about how it can work differently and how it can demonstrate the value of the work staff do. PS concluded that it was about reducing waste and working smarter not doing more.

31/20 Review of the Meeting and Outcomes

The Board agreed it was a productive meeting with lots of focus on system working and the challenges that brings.

32/20 Date of Next Meeting: 26 March 2020 – Bakewell Agricultural Centre, Agricultural Way, Bakewell, Derbyshire DE45 1AH


DCHS BOARD – ACTIONS MATRIX DATE: March 2020 – Public Session

Date/Item No:

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

Progress: Responsible Person:

Deadline: Outcome:

Jan 2020 Performance Report To look at reporting targets and indicators to ensure that the Trust is using the SPC charts successfully

Chris Sands March 2020 Agenda item March 2020

Nov 2019191/19

Operational Plan Delivery Report 19/20

A Patient Story to be presented to Board to cover the work of Quality conversations.

Michelle Bateman

June 2020

Jan 20207/20

Patient Story Carer’s support to be discussed at the Governor Engagement Group

This item was on the agenda but the Engagement Group was cancelled. It has been added to the next meeting.

Melanie Curd June 2020

Jan 202013/20

Chief Executive’s Report

To explore within the system, meeting with new MPs in the region to explain strategy and vision.

Tracy Allen June 2020

Page 1 of 241 Actions Matrix.docx

Date/Item No:

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

Progress: Responsible Person:

Deadline: Outcome:

Nov 2019195/19

Raising Concerns Report

Future reports to contain more prominent themes and should also contain information about the “so what” detail of the themes. Also future reports to set out what the themes are and what the Trust is going to do in response to those themes in the next 6 months.

March 2020 Following the agreement for a bi annual Raising Concerns board report these actions will form part of the next report due August 2020

Michelle Bateman

August 2020

Agenda item August 2020

Page 2 of 241 Actions Matrix.docx

TRUST BOARDDocument Title: Chief Executive’s Report

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

Author/Title: Elzabet Lombard, Business ManagerContact Email and Telephone Number:

Elzabet Lombard, Business [email protected] 07814 793488

Date of Meeting: 26 March 2020 AgendaItem No: 44/20

No of pagesinc. this one: 4

Has an Equality Impact Assessment been undertaken Yes No x

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

Purpose of Paper

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

The national context and perspectiveo Coronavirus COVID-19

System transformationo Joined Up Care Derbyshire

Key Trust Issues and updateso Planning and contracting

Headline organisational performance – the Big 9

Recommendations

The Board is recommended to note the report.

Board Assurance Framework Risk Reference

Coronavirus COVID-19: 3.5/19

Financial Impact

The COVID-19 pandemic will have significant financial implications for the NHS and the economy as a whole. The Treasury have indicated that the NHS will be supported as required.

Page 1 of 444 CE Report.docx

mailto:[email protected]

Further Information and Appendices

Chief Executive's Report March 2020

1. Purpose of the paper

This paper is to provide the Board with information about key national and local strategic issues affecting the Trust. Whilst there has been many positives and business as usual to report on since the previous report to Board, we are now focused on looking forward in the context of the rapidly developing response to COVID-19.

2. National Issues

2.1 Coronavirus COVID-19

Clearly the anticipated community spread of the COVID-19 infection is going to pose some very significant challenges to the NHS and wider society over the coming weeks and months and we have an incredibly important role to play in supporting the response. We will be relied on by our local communities and partners to be able to maintain services, do everything we can to protect the vulnerable people and be trusted sources of accurate information for service users, family and friends.

We’ve established an incident management team under the leadership of Will Jones, who is our Accountable Emergency Officer and there’s a huge amount of energy and effort going into planning, guided by national guidance.

This is understandably an anxious time for all of us, both personally and professionally. We have stepped up communications with our staff and we will keep our Board informed on an ongoing basis. This is going to be a very tough few months, a marathon rather than a sprint, and we need to maintain our brilliant DCHS focus on looking after each other. I want to extend my heartfelt thanks for everybody’s contribution and commitment.

3. System Transformation

3.1 Joined Up Care Derbyshire (JUCD)

The national planning work has been paused until 31st July 2020, to allow system partners to focus on managing the COVID-19 situation.

4. Key Trust issues and updates

4.1 Planning and contracting

Chris Sands, director of finance, will provide a verbal update on local planning and contracting as we are expecting further guidance at the time of writing.


4.2 Interim appointments - People Services and Organisational Effectiveness leadership team

Paul Renshaw has joined DCHS on 9 March as the interim director of People Services and Organisational Effectiveness, replacing Amanda Rawlings. Paul has worked within the NHS as an executive director of HR and OD since 2013 at a number of trusts, most notably at Salford Royal and most recently for the South East Coast Ambulance Service.

I would also like to welcome Helen Cooper who will be joining us on a one year secondment from Sheffield Hallam University as deputy director of People Services and Organisational Effectiveness, replacing Jen Guiver. Helen has worked at Sheffield Hallam University for the last six years, most recently leading on an organisation-wide transformation programme.

Paul and Helen have been working with Amanda and Jen to ensure a smooth transition prior to their departure at the end of February. I am sure you will join me in welcoming them to DCHS, particularly at this challenging time.

5. Headline organisational performance – the Big 9

The Trust’s performance against our 2019/20 ‘Big 9’ for February is attached for information at Appendix A.

Appendix A: Big 9 – February 2020

Monitoring Information Brief Summary

What are the Governor Involvement implications?

Governors will be regularly briefed on our management of the COVID-19 situation.

What are the Equality, Diversity and Inclusion implications?

Prioritisation of NHS services as part of the COVID-19 response will have equality, diversity and inclusion implications that will be assessed and managed as the situation unfolds.

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

Engagement of the whole workforce and affected members of the public will be required as the COVID-19 response continues.

Risk Register

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

Number? N/A

Does this update recommend a change in the current risk score? N/A


Appendix A: Big 9 – February 2020

Objective Priorities 2019/20 Target

Patient Safety: Improving the Identif ication of Sepsis and Recognition of the Deteriorating Patient

TPP Baseline Observations To Be 80% , starting October 2019 70% 27.64% (RED) 40% (RED)

Clinical Effectiveness: Increasing participation in National Institute for Health Research across DCHS

Services

Recruitment of 500 Participants by March 2020

455 (91%) 642 (128%) (GREEN) 642 (128%) (GREEN)

Patient Experience: Improving the Dementia Friendly Environment and Culture - All services linked to a

Dementia Champions, Improvement Actions & Dementia Friendly Actions.

(i) April-August-97 Service Champions Identif ied (ii) August-Nov-97 Service

Improvement Actions Agreed (iii) Jan-Mar-97 Service Actions Complete

60 Actions Complete 52Actions

Complete (RED) 75Actions

Complete (RED)


Inclusive Employer:Increase Number of Staff w ho are Under 25 to 5% of Workforce 214 204 (4.76%) 108 (2.52%) (RED) 110 (2.6%) (RED)

Staff Safety: Reduction in Violence Incidents resulting in Staff injury by 10% to an annual 157

incidents157 144 196 (RED) 210 -(30.3%) (RED)

Staff Wellbeing:Improve 12 month rolling average attendance across the Trust to 95.5% 95.50% 95.46% 95.15% (AMBER) 95.0% (AMBER)


Demonstration of eff iciency: Delivery of the Sustainable Quality Improvement Plan (SQIP) Delivery of £5.582m SQIP Plan £5.064m (90.7%) £5.079m (71,1%) (GREEN) £5.558m (100.0%) (GREEN)

Delivery of effective services w ithin the Community85% of records updated w ithin 30 mins of

Intervention 84.09% 81.60% (AMBER) 82% (AMBER)

Delivery of safe information systems w ithin the Community

Machines patched w ith 97.50% of cyber security patches w ithin last 30 days

97.27% 91.60% (RED) 92.5% (AMBER)

Big 9 - February 2020

Quality Service

Plan to end of February

Achieved to end of February Forecast

To deliver high quality and sustainable services that

echo the values and aspirations of the community

w e serve

Quality Business



To ensure an effective, eff icient and economical

organisation w hich promotes productive w orking and

w hich offers good value to its community and commissioners

Quality People



To build a high performance w ork environment that engages, involves and

supports staff to reach their full potential


TRUST BOARDDocument Title: 2019 NHS Staff Survey – next steps for DCHS

Presenter/Title: Paul Renshaw, Interim Director of People Services and Organisational Effectiveness

Contents of Paper were previously discussed by:

Some elements discussed at Trust Board on the 27 February and fully reviewed by Quality People Committee on the 16 March.

Author/Title: Clair Sanders, Engagement and OD LeadContact Email and Telephone Number: [email protected] | 07827 983897



Has an Equality Impact Assessment been undertaken Yes No X

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

Purpose of Paper

The purpose of this paper sets out further analysis on the 2019 NHS Staff Survey results for DCHS, including looking at the free text comments we received during the survey, benchmarking against all Trusts in our group and the headline plan for the proposed focus areas for the year ahead and summarises the scrutiny given to the results by the Quality People Committee as follows:

Quality People Committee review

This paper has been fully reviewed by the Quality People Committee and this committee provided support for the priority areas as identified within the paper.These priority areas are :

1. Health and Wellbeing2. Quality of Appraisals3. Safe Environment – Violence and Aggression4. Team Working

The committee also supported the proposal to look at the variation of results within specific areas of the Trust to ensure specific focus was given to lower performing teams.

The committee also requested a deep dive on Violence and Aggression (V&A) and it was advised that a task and finish group had been established to look at this.It was also suggested in the area of team working that we obtained staff views so that we can improve in the areas of showing initiative and staff being involved in making improvements.

It was agreed at the committee that a more detailed action plan would be presented to QPC in May 2020.The Committee took Limited Assurance from the report as the actions are in the early stage of development.

Page 1 of 1446 2019 NHS Staff Survey.docx


Recommendations

Trust Board are requested to:

receive and review the additional analysis on the 2019 NHS Staff Survey results discuss and input into the recommendations for proposed focus areas from the 2019

results approve the priorities for 2020

agree to these actions being paused until the Trust has fully recovered from the affect of Coronavirus pandemic outbreak and that QPC members will be fully involved in decisions about when to commence these plans


2.4/19 - There is a risk to our staff’s health and wellbeing due to the challenging and uncertain environment DCHS is operating within, resulting in reduced engagement, attendance and poor morale.

Financial Impact

It is now well-researched that when staff are engaged in their work, they are less likely to have time off sick and deliver better patient outcomes. This makes staff engagement critical to business success.

The health and wellbeing CQUIN is linked to relevant NHS Staff Survey results.


See report following this cover sheet.




Information on our NHS Staff Survey results are reported to our governors.


All colleagues have a right to expect that feedback they provide during our regular staff surveys is responded to fairly and equally.

The NHS Staff Survey results will be analysed by the protected characteristics to highlight any areas of concern so we can act upon these.


All staff are encouraged to participate in DCHS staff surveys, so all of our staff are impacted by our focus on achieving high levels of staff engagement.

The level of staff engagement directly impacts the quality and safety of care that we deliver to patients, and for this reason maintaining a focus on achieving high levels of staff engagement is critical.

Risk Register

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

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


2019 NHS Staff Survey – next steps for DCHS

Introduction

The purpose of this paper sets out further analysis on the 2019 NHS Staff Survey results for DCHS, including looking at the free text comments we received during the survey, benchmarking against all Trusts in our group and the headline plan for the proposed focus areas for the year ahead.

All results were previously shared in the Trust Board paper on 27 February, where each theme was broken down in detail (including the individual questions which make up each theme), looking at how we scored against 2018 and against the other 15 Trusts in our benchmarking group. As a reminder the headlines are below:

NHS England Reporting Themes

Compared to the other 15 organisations we are benchmarked against, we are: Best in 0 Above average in 7 (equality, diversity & inclusion) (health & wellbeing) (morale) (quality of

care) (safe environment – bullying & harassment) (safety culture) (staff engagement) Average in 2 (immediate managers) (quality of appraisals) Below average in 1 (team working) Worst in 1 (safe environment – violence)

Compared to last year, we are:

Better than 2018 in 9 themes (equality, diversity & inclusion) (health & wellbeing) (immediate managers) (morale) (quality of appraisals) (quality of care) (safe environment – bullying & harassment) (safety culture) (staff engagement)

The same as 2018 in 2 themes (safe environment – violence) (team working) Worse than 2018 in 0 themes

Figure 1: Overview of all 11 themes for Community Trusts


Comments Received During the NHS Staff Survey

All 439 free text comments were circulated to Executives/Deputies and ADs via email on 27 February 2020, to be shared with their senior teams following the usual cascade process. Each locality is to work with their Divisional People Lead to act on their comments in an appropriate way.

A thorough and detailed analysis of all 439 free text comments was undertaken – including further detail and themes split down to directorate level found in appendix 1 – however the main organisational themes that came out are listed below:

DCHS is a well-run, forward thinking and supportive organisation Staff feel valued, respected and appreciated Colleagues are proud to work for our outstanding Trust Staff enjoy the ability to work autonomously We have proactive, compassionate management Working under pressure with extending caseloads, increased complexity and staffing issues We could improve how we handle change in the organisation Ongoing vacancies are not sustainable Lack of feedback given when issues/concerns are raised Culture of working above and beyond hours.

NHS Benchmarking

A benchmarking exercise against all other 15 Community Trusts can be found in appendix 2. This shows the scores for all 11 themes for each Trust in our benchmarking group so we can see where we are in relation to other named Trusts. See the next steps section for further work planned to learn from Trusts which are above average/scoring better than us.

In addition to the Trusts in our benchmarking group, we have researched the ‘most engaged’ Trusts in the whole of the NHS (minus CCGs). The following Trusts came top in the Staff Engagement theme (we scored 7.3 out of 10 in this area) this year, so our aspiration to be the ‘most engaged Trust in the NHS’ is very much in reach.

Figure 2: Most engaged Trusts in the wider NHS

Benchmarking Group Best Trust 2019 Staff Engagement Score

Acute The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust 7.5

Combined Acute & Community Northumbria Healthcare NHS Foundation Trust 7.6Acute Specialist The Royal Marsden NHS Foundation Trust 7.7Mental Health & Learning Disability

Dudley and Walsall Mental Health Partnership NHS Trust 7.5

Combined Mental Health, Learning Disability & Community Northamptonshire Healthcare NHS Foundation Trust 7.5

Community Cambridgeshire Community Services NHS Trust 7.5Ambulance Yorkshire Ambulance Service NHS Trust 6.6

2020 Areas of Focus

It was suggested that, rather than trying to focus on improving all 11 themes, picking 2-3 and working hard to improve the staff experience behind those themes was determined the best way forward for the year ahead.


In addition to analysis of the results and triangulation of our free text comments, we have been consulting with colleagues in our Staff Forum and all the Staff Network Groups over the past few weeks via a Survey Monkey on the 11 themes. We asked for their opinion on what they feel would make the most difference for us to focus on as Trust over the next 6 – 12 months. Whilst this survey has still not ‘closed’ the consensus of responses are mainly in line with the suggestions below.

The proposed focus areas for 2020 are as follows (more detail under these themes can also be found below):

5. Health and Wellbeing6. Quality of Appraisals7. Safe Environment – Violence and Aggression8. Team Working

1. Health and Wellbeing

What the data tell us?Whilst our theme score is classed as above average compared to the other 15 Community Trusts, we saw an improvement on the overall theme score compared to last year and all individual questions to make up this theme scored both better than average and better than last year; the reason for selection of this theme isn’t because we are ‘doing badly’ but for us to aspire to be the best in this area next year.

What else do we know?Following Masters level research conducted across DCHS we know that the major factors impacting staff engagement and wellbeing are job demands, level of perceived organisational support and staff self-compassion. These findings help us ground any conversation about staff wellbeing into the day to day reality of life for our staff and mean that any attempts to become best in class across the wellbeing survey questions will require engagement across our frontline services too.

Headline proposal… Increase visibility of the staff wellbeing offer: Our staff wellbeing services are gold

standard, however awareness and subsequent access for them can be patchy across our services. We will launch pathways for MSK and mental health that will help us tackle the most common causes of sickness absence, ensure staff know what is available and when they might require it, whilst also increasing a sense of organisational support for staff.

Continue to focus on ‘cause of the cause’ factors: We will continue to implement the staff wellbeing 2020 planner which places a specific focus on the causes of staff wellbeing issues such as finances, relationships & caring responsibilities, utilising training, resources and support services to increase awareness and reduce stigma around these topics whilst linking staff with support they may require.

Implement the women’s health project: Following staff feedback we have recruited to a full time projects role focusing on several aspects of women’s health, including menopause, fertility & maternity – with the aim of making DCHS a best in class employer for women. This project is currently gathering data from staff before trialling interventions.

Embed staff wellbeing within DCHS ways of working: given the clear message from research and staff feedback we need to find multiple ways of embedding staff wellbeing thinking within the regular practices and decision making of DCHS. This could take the form of a wellbeing section within Quality Always reviews, a staff wellbeing checklist to be applied at decision making committees or specific sections within appraisals or 1-1s focused on wellbeing.


Implement the stress policy: The new DCHS stress policy was recently approved which provides clear guidance that all staff should have a wellness action plan completed with their manager and that all managers should complete the HSE stress risk assessment for their teams. This will highlight specific issues which can then be tackled at ground level before larger issues can occur.

Develop a ‘comfortable with conflict’ culture and increase use of mediation: Having now increased our pool of accredited mediators to over 16, we can start offering more mediation across the trust. We can also now leverage the expertise of these mediators to provide coaching for managers about how to manage conflict as it arises. This will link with our courageous conversations training offer.

Link to delivery of wider Leadership Development offer: Both the research and staff surveys show that staff wellbeing is impacted by the quality of the line manager relationship. Prioritising the development of our leaders and managers, ensuring appraisals are effective and promoting a compassionate application of our people policies will all have a large impact on our staff wellbeing performance.

2. Quality of Appraisals

What the data tells us?Whilst we saw an improvement in the overall theme score from last year (5.6 to 5.8) this theme score remains average when compared to the other 15 Community Trusts. The 2 questions which were worse than average and pulled the theme down were:

Q19c: It helped me agree clear objectives for my work Q19e: The values of my organisation were discussed as part of the appraisal process.

What else do we know?Feedback from training and discussions with leaders has identified the following issues:

Volume – some line managers have very high numbers of staff to appraise Structure – some appraisers are holding reviews with staff they do not directly work with or

line manage Development opportunities – support for secondments and movement between services is

area/manager dependent Language – terminology ‘Leader’ and ‘Non-Leader’ appraisal does not support the idea of

leadership at all levels Data – understanding compliance levels locally

Headline proposal… Appraisal Paperwork: Whilst the new simplified paperwork was launched April 2019 the

terminology of Leader and Non-Leader is impacting on the view of role and leadership with lower banded staff. Tweaking the language to ‘People Manager’ and ‘Non People Manager’ supports the NHS view of leadership at all levels and the Trusts view that leadership is an approach not a job title.

Communication & Promotion: The new policy and simplified paperwork was launched April 2019. Further promotion of this using line manager and staff stories on the positives and focus of appraisal will help embed the new approach.

Business Intelligence/HR Reporting: Work with BI team on reporting and use the BI functionality to triangulate HR data & training data. Thus giving the ability to drill down information i.e. where compliance/training levels low the HR Team & Leadership Team can work together with leaders to understand what’s getting in the way and what action needs to be taken.

Training: Continue to deliver the monthly face to face masterclasses for appraisers, review content and monitor attendance levels. Introduce new bitesize sessions which could be


offered to experience appraisers on the new paperwork and refresh. Look at alternative ways of delivery through Webinars/Skype/eLearning etc. to get the most out of appraisal.

3. Safe Environment – Violence and Aggression

What the data tells us?Whilst we maintained our overall theme score from last year (9.6) this theme score is benchmarked as the worst Trust in our group. The question which scored worse than average and worse than 2018 was:

Q12a: In the last 12 months how many times have you personally experienced physical violence at work from patients / service users, their relatives or other members of the public?

What else do we know? Violence, aggression, or other abusive behaviour is not part of the job and DCHS is

committed to addressing it. A working group has already been set up to build on our existing work and identify how we can continue to improve.

Supporting colleagues around violence/aggression requires different approaches for different settings/services.

We see higher levels of physical assault in our Learning Disabilities and Older People’s Mental Health inpatients settings, where we are supporting patients with challenging behaviour. As we increasingly care for patients with cognitive impairment, we have seen an increase in the number of physical assaults on our rehabilitation wards.

Headline proposal… Reporting: The key message is that colleagues should report all incidents (via Datix), so

that managers can appropriately support/follow up, and to help us understand the full scale of the issue, and provide additional support where it’s needed.

Policy: Where the individual has capacity, managers should address their unacceptable behaviour with them in line with the ‘Aggressive and Violent Behaviour Towards Staff’ policy. We have recently reviewed the policy and are now producing supporting guidance for colleagues. We are re-reviewing to incorporate the recently published Joint Agreement on offences against emergency workers.

Communication & Promotion: A leaflet has been produced to support community colleagues to have conversations with patients around appropriate behaviour, as well as other ways of ensuring a safe environment for us to work in. It’s important that we continue to send the message that we will challenge unacceptable behaviour towards our staff.

Specifics in LD/OPMH: As mentioned above, in our inpatient settings we see higher levels of physical violence as we care for patients with challenging behaviours and our work focuses both on how we can reduce the likelihood of incidents, and how we support colleagues and learn lessons after an incident. Work with LD/OPMH and our other inpatient wards will be a large part of our work over the next few months. Work will be at both a local level (for example improving the quality of post-incident debriefs, staffing levels, and the support available to staff) and also working with system partners.

4. Team Working

What the data tells us?Team Working was a new theme introduced this year, but we were given comparable data for previous years. Whilst we maintained our overall theme score from last year (6.9) this theme score is benchmarked below average compared to other Community Trusts in our group. The questions used to measure the score of this theme, which both scored worse than average, are as below:

Q4h: The team I work in has a set of shared objectives Q4i: The team I work in often meets to discuss the team's effectiveness


What else do we know?Feedback from discussions with colleagues has identified the following issues:

The move to a more agile way of working has made some teams feel a lot more isolated Some colleagues confirmed a lack of team meetings in their areas due to capacity and the

priority on patient care.

Headline proposal… OE Offer: Introduction of the team support referral form has so far been successful.

However we will develop a more specific offer around what the Organisational Effectiveness team can support teams with – whether than be team development/away days, additional wellbeing support or bespoke training sessions etc.

Team Support Packs: Launch of an electronic team support pack filled with helpful ideas and resources to support leaders engaging with their teams.

Divisional People Leads: Closer working with the services, DPLs and wider People Services Team to identify key hotspots early and work together to develop bespoke targeted OD interventions.

Leadership Development: Prioritising the development of our leaders and managers, ensuring our programmes and masterclasses are fit for purpose, appraisals are effective and promoting a compassionate application of our people policies will all have a large impact on our wider performance.

It is worth noting that, for the purpose of the action plan, whilst we will be focussing hard on health and wellbeing, appraisals, reducing violence and aggression and team working, in theory these efforts will link to other themes such as Morale and Staff Engagement etc., so we would envisage seeing an improvement in more than the 4 specific themes.

Next steps

Please note: Our proposed actions are subject to the impact of the current Coronavirus outbreak and no actions will now be progressed until further notice.

Following approval of the 2020 focus areas at March Trust Board (this meeting), the final focus areas and detailed action plan(s) will be finalised. Communications will then be sent to all staff to share the focus areas and the actions we will be taking as a result of what the survey has told us.

We will continue to work with our Staff Forum and all the Staff Network Groups to ask for their support within our confirmed areas of focus. Their ideas on what we can change to improve these 4 themes will be progressed as part of the detailed action plan(s).

In line with our open and transparent culture, all results, reports, focus areas and action plans will be available for all staff to access on the dedicated NHS Staff Survey Resource Centre: https://my.dchs.nhs.uk/guidance/nhsss18.

Communication of updates to the action plan relating to the key focus areas as we progress will be labelled under the following:

We said, we are doing… We said, we did… We said, we can’t do because… (to feedback and show we have still taken on board and

listened and explained why we cannot change if applicable)

This year we are planning to engage with other Community Trusts in our benchmarking group, particularly those that are scoring higher than us in certain themes, and also certain Trusts (from


https://my.dchs.nhs.uk/guidance/nhsss18

all benchmarking groups) who have score the ‘best’ in certain areas. This will ensure we are able to share best practice and see what/where we can learn from each other. Further actions will be added into the final action plan(s), linked to themes, based on networking findings.

As was the case for the past few years, there will be no mandatory organisational requirement for each service to submit an action plan to address the areas of focus. Instead, People Services and the Divisional People Leads will engage with service leaders to ensure they understand the areas of focus and have local plans in place to address them. We believe that ‘one size does not fit all’ so localised planning is the best way to make improvements.

The Organisational Effectiveness Team and Divisional People Leads will work closely with services over the next 6 months and monitor progress at set touch points throughout the year using the Pulse Check and Staff FFT surveys.

It is proposed that progress on the action areas is reported bi-monthly to the Staff Health, Wellbeing, Safety and Engagement Group; then fed through the summary reports to Quality People Committee and Trust Board.


Comments and Free Text Analysis produced by Pippa Short, Staff Wellbeing Officer

Appendix 1: DCHS 2019 NHS Staff Survey – Comments & Free Text Analysis

LocalityTotal

number of comments

Positive Negative Neutral

Health Wellbeing & Inclusion Service Forward thinking, supportive organisation Valued and appreciated Staffing issues Changes implemented without consultation and required infrastructure Lack of career progression Bullying and harassment not managed effectively Lack of job security Culture of working above and beyond hours Poor communication Sickness policy is abused

66 9 51 6

Integrated Community Services DCHS is well run and supportive Good initiatives such as leadership and development, staff wellbeing and bullying and

harassment Outstanding place to work Supportive and available leaders Staff feel valued and respected No recognition Working under pressure with extending caseloads, increased complexity and staffing issues Disparity in pay banding Lack of development opportunities Reactionary approach to service change Team conflict Audits and numbers come first Unfair rotas Equipment not provided in a timely manner Technology is a barrier to patient care Problems with accessing eLearning training Culture of working above and beyond hours Too much documentation

203 27 158 18



Managers listen to concerns, but do not take appropriate action Standard of care compromised due to unsafe staffing levels Name and shame culture Not confident in raising concerns - no support Low staff morale Bullying behaviour Communication between frontline staff and management not good enough

People Services Divisional Group Staff feel valued and cared for by DCHS Staff enjoy the ability to work autonomously Unrealistic demands of joint venture Lack of capacity and resource Decommissioning of services in an unsupportive manner Inconsistent management and induction Quality of work affected by workload

19 3 12 4

Planned Care and Specialist Services Proud to work at DCHS Proactive, compassionate management Staff feel appreciated, respected and supported Culture of health and wellbeing Positive team spirit Cramped working environment Restrictive policies and procedures No career paths Limited communication and untimely action from management Ongoing vacancies not sustainable Datix reporting is time consuming Numbers/stats more important than their workers Poor management of investigations Admin requirements are overwhelming Conflicting message between productivity and quality IT problems Isolation feels a problem for agile workers Banding not appropriate for job(s)

110 30 68 12



Quality Directorate Proud to work at DCHS Supportive management Patient and staff wellbeing always at the centre of departmental goals Staff feel valued and respected Lack of progression opportunities Low morale No funding for training Vacancies on hold Unfairness over Tupe and non-Tupe staff No feedback and negative treatment received from managers when issues raised Change and transformation managed ineffectively Undervalued

25 11 8 6

COMBINED* Chief Exec Div Group & Exec Services Group Estates Service Finance And Strategy Divisional Group Service Transform and IMT Divisional Group

*Please note where there have been less than 11 comments in the following localities – these comments have been combined by Picker to ensure anonymity is protected.

Proud to work for DCHS Caring supportive environment Staff are at the heart of the organisation Leaders not trained to manage staff Criteria for pay banding not adhered to No time to attend training Concern that the new freedom to speak up guardian has conflicted roles

16 7 7 2

Total 439 87 303 49


Appendix 2: DCHS 2019 NHS Staff Survey Theme Score Comparison with all Community Trusts

Response Rate

Percentage that

responded from total recipients

Equality, diversity & inclusion

Health & wellbeing

Immediate managers Morale Quality of

appraisalsQuality of

care

Safe environme

nt – bullying & harassmen

t

Safe environme

nt – violence

Safety culture

Staff engageme

ntTeam

Working

COMMUNITY TRUSTS (A-Z) % out of 10 out of 10 out of 10 out of 10 out of 10 out of 10 out of 10 out of 10 out of 10 out of 10 out of 10

Birmingham Community Healthcare NHS Foundation

Trust40.9 8.9 5.9 6.9 6 5.3 7.5 8.1 9.6 6.8 7 6.7

Bridgewater Community Healthcare NHS Foundation

Trust42.5 9.4 6 7.1 6.1 5.2 7.4 8.4 9.8 6.8 7 7.2

Cambridgeshire Community Services NHS Trust 59.7 9.5 6.7 7.6 6.7 5.9 7.5 8.7 9.9 7.4 7.5 7.5

Central London Community Healthcare NHS Trust 45.1 8.8 5.8 7 5.9 5.8 7.7 7.9 9.8 6.9 7 6.8

Derbyshire Community Health Services NHS Foundation Trust 62.4 9.5 6.3 7.2 6.5 5.8 7.7 8.6 9.6 7.2 7.3 6.9

Gloucestershire Care Services NHS Trust 35.9 9.3 6 7.2 6.2 5.5 7.4 8.3 9.7 7 7.1 6.6

Hertfordshire Community NHS Trust 69.7 9.4 5.9 7.2 6.2 6.2 7.3 8.6 9.7 7.2 7.1 7

Hounslow And Richmond Community Healthcare NHS

Trust67.1 9.1 6.4 7.3 6.5 6.3 8 8.6 9.8 7.3 7.5 7.3

Isle of White NHS Trust (Community Sector) 48.5 9.2 5.4 7 6.2 5.7 7.1 7.6 9.8 6.5 6.6 7

Kent Community Health NHS Foundation Trust 58.8 9.5 6.4 7.6 6.6 6.1 7.6 8.6 9.8 7.3 7.4 7.5

Leeds Community Healthcare NHS Trust 54.7 9.3 6.1 7.2 6.4 5.7 7.3 8.5 9.7 7.3 7.2 7.1

Lincolnshire Community Health Services NHS Trust 70.7 9.5 6.5 7.1 6.3 6 7.5 8.4 9.6 7.1 7.3 7

Norfolk Community Health And Care NHS Trust 57.3 9.4 6 7 6.4 5.6 7.4 8.2 9.7 7 7.2 6.9

Shropshire Community Health NHS Trust 57.7 9.6 6.2 7.3 6.4 5.8 7.4 8.5 9.7 7 7.4 7

Sussex Community NHS Foundation Trust 65.8 9.4 6.2 7.3 6.4 6 7.5 8.3 9.7 7.1 7.3 7.1

Wirral Community NHS Foundation Trust 52.2 9.5 5.8 7.4 6.2 5.6 7.2 8.6 9.9 7 7.1 7


TRUST BOARD Document Title: Public Sector Equality Duty Annual Report 2020

Presenter/Title: Paul Renshaw- Director of People Services and Organisational Effectiveness


EDILF 31st January 2020QPC 16th March, 2020

Author/Title: Harinder Dhaliwal - Head of Equality, Diversity and InclusionMarian Ogunkoya, Senior Equality, Diversity and Inclusion Advisor

Contact Email and Telephone Number:

[email protected] Mobile : 07827 552863




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

Purpose of Paper

To present our Public Sector Equality Duty Annual Report 2020 to the Board following review by the Quality People Committee.

Recommendations

The Board is asked to note, scrutinise and approve the report, prior to it being published on DCHS’ external website on 5th April 2020 in accordance with our duties under the Equality Act 2010. The Board is also asked to take assurance from this.


Quality People

2.7/19 There is a risk to the Trust due to our inability to continue to establish an open and transparent organisational culture that demonstrates inclusion, diversity and fairness resulting in staff unable to achieve their potential and legal / financial sanctions

Quality Governance

4.2/19 There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions.

4.5/19 There is a risk to the organisation due to lack of comprehensive data quality systems resulting in poor decisions that could affect outcomes and financial loss.

Financial Impact

None identified for the purpose of providing this summary paper.

Page 1 of 346 PSED Annual Report.docx



The Public Sector Equality Duty Annual Report 2020 (Appendix 1) meets our statutory obligations under the Equality Act, which requires public sector organisations such as ours, and private or voluntary organisations undertaking work on behalf of a public sector organisation, to undertake the Public Sector Equality Duty. It also enables us to fulfil our specific equality duty under the Equality Act to publish our equality data, disaggregated by the protected characteristics, about the people who access/use our services as well as our workforce. It highlights our equality activity as well as our equality journey over the past year as a service provider and an employer; including the progress made to mainstream Equality, Diversity and Inclusion (EDI) Trust-wide and across organisational boundaries in Derby, Derbyshire and beyond.

Section 149 of the Equality Act requires public bodies like DCHS to have ‘due regard’ to the three aims of the General Equality Duty which are to:

1. Eliminate unlawful discrimination, harassment, victimisation and other conduct prohibited by the Act.

2. Advance equality of opportunity between people who share any of the nine protected characteristics and those who do not.

3. Foster good relations between people who share a protected characteristic and those who do not.

Under the Equality Act, public bodies must also meet the Specific Equality Duty to:

Publicly publish sufficient equality information annually to comply with the General Equality Duty from 31st January 2012. The information must relate to people such as our employees who share or do not share a protected characteristic or people affected by our Trust’s policies and practices.

Prepare and publish Equality Objectives to achieve any of the aims of the General Equality Duty at no more than four year intervals from 5th April 2012.

The report entails: An overview of patients’ versus local population demographics 2018/19. Patients’ experience data 2018/19, including charts disaggregated by the protected groups. Workforce profiles as of 31st March 2019. Members as of January 2020.

The Quality People Committee reviewed the report and confirmed that it gained Assurance from it.

Important aspects for the Board to note in terms of our activities are;

Effective sub groups reporting into the QPC ( EDILF and PEEG)Effective staff networks High mandatory training compliance – c98%Successful reverse mentoring programmeThe start of an Under 2’s recruitment programme which needs revised focus for 2020/21



What are there Governor Involvement implications?

Governors are engaged in the activities to enable the Trust to achieve its inclusion aspirations.


Since the Equality Act 2010 (Specific Duties) Regulations 2011 came into force on 10 September 2011, there has been a duty for public bodies with 150 or more employees to publish information on the diversity of their workforce and services.


Forum members include public governor, public members and service users.

Risk Register

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

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


TRUST BOARD Document Title: Gender Pay Gap Review Summary 2019/2020

Presenter/Title: Paul Renshaw - Director of People Services and Organisational Effectiveness


EDILF 31st January 2020. QPC 16th March, 2020

Author/Title:

Harinder Dhaliwal - Head of Equality, Diversity and Inclusion Liam Carrier - Assistant Head of Systems & Information/Project Manager Samantha Pepper - Equality, Diversity and Inclusion Advisor Data Source: Systems & Information Team


[email protected] Mobile : 07468749602

Date of Meeting: 26 March 2020 Agenda Item No: 46/20

No of pages inc. this one: 10


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

Purpose of Paper

To present to the Trust Board a summary of the Trust’s position in the latest Gender Pay Gap report prior to it being forwarded to the Government Office by the end of March 2020 and being published on our external website. To also receive a summary of discussions and actions following the Quality People committee review.

Quality People Committee summary

At the QPC the paper was presented and it was noted that gender pay gap had reduced and was slightly better than the national average.

The action plan was approved in principle by the committee and requested more detailed actions be presented to a future Committee. It was also agreed that QPC receive a quarterly update on the pay gap going forward.

Planned actions are : − Publishing our results nationally – by 30th March 2020 including explaining the steps we

intend to take to close the gaps.− Publish results on our external website – by 30th March 2020 as above.

The following actions have been approved in principle however the following will be on hold until the current Covid-19 situation has been resolved.

− Diversity Recruitment Group championed by Director of People & OrganisationalEffectiveness to check job descriptions and person specifications to ensure they are clearand challenge of what is needed e.g. specific qualifications.

− Continue to promote opportunities for flexible working, shared parental leave, careerprogression, promotion and leadership development opportunities.

− Gap analysis 'what works - good practice and evidenced based actions' – carry out a gapanalysis against the actions recommended by the Government Equalities Office to ensure

X

Page 1 of 1046 GPG Summary 2019.20.pdf

we are implementing what works: https://gender-pay-gap.service.gov.uk/ The Committee took Significant Assurance from the report

Recommendations

The Board is asked to note the contents of this report and take assurance from it. Members are invited to comment upon and approve prior to both forwarding to the Government Office, and publishing on our external website.


Quality People 2.7/19 There is a risk to the Trust due to our inability to continue to establish an open and transparent organisational culture that demonstrates inclusion, diversity and fairness resulting in staff unable to achieve their potential and legal / financial sanctions Quality Governance 4.2/19 There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions. 4.5/19 There is a risk to the organisation due to lack of comprehensive data quality systems resulting in poor decisions that could affect outcomes and financial loss. Financial Impact None identified for the purpose of providing this summary paper. There is no immediate financial impact; however, following further analysis it may be possible that DCHS decide to take steps to address the Gender Pay Gap and any under/over representation by gender that comes out of such analysis.


Please refer to Appendix 1 Gender Pay Gap Report 2019/20 (data extract as at 31 March 2019) for detailed analysis. Note: the ‘snapshot’ for Gender Pay Gap reporting required nationally for public sector organisations is data as of 31st March 2019. As a summary, Graph 1 below shows that as of 31st March 2019, DCHS has decreased the ‘Average Hourly Rate’ gender pay gap difference by 1.1% since 2018. However, the ‘Median Hourly Rate’ gender pay gap difference has increased by 1.68% since 2018.


https://gender-pay-gap.service.gov.uk/

It is worth noting that at DCHS 89% of the workforce is female, therefore small changes to the male numbers (11%) through turnover or new starters could disproportionately change the figures above. There is limited information about the NHS as a whole, but insight suggests that the difference in average hourly rate is approximately 23%. Graph two below demonstrates that DCHS has smallest ‘Average Hourly Rate’ and ‘Median Hourly Rate’ compared to neighbouring Trusts such as Derbyshire Healthcare NHS Foundation Trust, Derby Teaching Hospitals NHS Foundation Trust and Chesterfield Royal NHS Foundation Trust. However, this is only an indicative comparison due to this being historical data.

(Note: that benchmarking data is only available when a Trust formally publishes the results. Currently the above Trusts have not submitted the 31st March 2019 results to the Government reporting service and still have until the 30th March 2020 to do so).


Planned actions include:

− Publishing our results nationally – by 30th March 2020 including explaining the steps we intend to take to close the gaps.

− Publish results on our external website – by 30th March 2020 as above. − The following actions have been scrutinized and assurance taken by the Quality People

Committee and have been agreed in principle. These actions will be acted upon once the current Covid-19 situation has been resolved.

− Diversity Recruitment Group championed by Director of People & Organisational Effectiveness. To check job descriptions and person specifications to ensure they are clear and challenge of what is needed e.g. specific qualifications.

− Continue to promote opportunities for flexible working, shared parental leave, career progression, promotion and leadership development opportunities.

− Gap analysis 'what works - good practice and evidenced based actions' – carry out a gap analysis against the actions recommended by the Government Equalities Office to ensure we are implementing what works: https://gender-pay-gap.service.gov.uk/

Appendix 1 : Gender Pay Gap Report 2019/20 (data extract as at 31 March 2019)


What are there Governor Involvement implications?

Governors are engaged in the activities to enable the Trust to achieve its inclusion aspirations.


Since the Equality Act 2010 (Specific Duties) Regulations 2011 (SDR) came into force on 10 September 2011, there has been a duty for public bodies with 150 or more employees to publish information on the diversity of their workforce. The GPG data provides a basic understanding of what the gender pay gap balance looks like within DCHS. It shows the proportion of women and men at different pay levels. It can be used to target resources/interventions effectively and address gender balance and workforce strategies.


Forum members include public governor, public members and service users.

Risk Register




https://gender-pay-gap.service.gov.uk/

Gender Pay Gap Report 2019/20 (data extract as at 31 March 2019)

Prepared by: Systems and Information Team People Services Department Tel no: 01332 564 856 (Option 3, Option 4) Email: [email protected]


Background

Since the Equality Act 2010 (Specific Duties) Regulations 2011 (SDR) came into force on 10 September 2011, there has been a duty for public bodies with 150 or more employees to publish information on the diversity of their workforce. Although the SDR did not require mandatory GPG reporting, the Government Equalities Office (GEO) and the Equality and Human Rights Commission (EHRC) provided guidance that made it clear that employers should consider including GPG information in the data they already publish. It was evident that not all employers did this, so the government made GPG reporting mandatory by amending the SDR so that all public sector employers with more than 250 employees have to measure and publish their gender pay gaps.

Employers with 250 employees and over need to publish the following information annually for all employees who are employed under a contract of employment, a contract of apprenticeship or a contract personally to do work. This will include those under Agenda for Change terms and conditions, medical staff and very senior managers. All calculations are made relating to the pay period in which the snapshot day falls. For this third year of publication, it will be the pay period including 31 March 2019.

Employers will need to:

• calculate the hourly rate of ordinary pay relating to the pay period in which the snapshot day falls

• calculate the difference between the mean hourly rate of ordinary pay of male and female employees, and the difference between the median hourly rate of ordinary pay of male and female employees

• calculate the difference between the mean (and median) bonus pay paid to male and female employees

• calculate the proportions of male and female employees who were paid bonus pay

• calculate the proportions of male and female employees in the lower, lower middle, upper middle and upper quartile pay bands by number of employees rather than rate of pay.

Ordinary pay includes:

• basic pay

• paid leave, including annual, sick, maternity, paternity, adoption or parental leave (except where an employee is paid less than usual or nothing because of being on leave)

• arrears and other allowances

• shift premium pay, defined as the difference between basic pay and any higher rate paid for work during different times of the day or night

• pay for piecework.

It does not include:

• remuneration referable to overtime.

• remuneration referable to redundancy or termination of employment

• remuneration in lieu of leave

• remuneration provided otherwise than in money.


The relevant pay period means the pay period within which the snapshot date falls, which for monthly-paid staff would be the month in which the date is included.

Bonus pay relates to performance, productivity, incentive, commission or profit-sharing, but excludes:

• remuneration referable to overtime

• remuneration referable to redundancy

• remuneration referable to termination of employment.

Doctors' clinical distinction/excellence awards will be regarded as bonus pay, as well as any other payments above the level of ordinary for performance or expertise such as performance related pay for very senior managers, long service awards and others. When looking at the gender pay gap for bonus pay it highlighted that the only payments deemed to be “bonus pay” that DCHS make are those made for Long Service Awards. As these payments are typically in the form of vouchers and therefore not through the payroll then we cannot utilise the ESR report and have had to make a manual calculation.

Calculating the quartiles

Determine the hourly rate of pay and then rank the relevant employees in rank order from the lowest to the highest.

Divide those employees into four sections, each comprising an equal number of employees to determine the lower, lower middle, upper middle and upper quartile pay bands.

Show the proportion of male and female employees in each band as a percentage of the total employees in each band.

What employers need to publish

The information outlined above will need to be published within one year of the date for the 2019 snapshot (publishing deadline of 30 March 2020 for data as at 31 March 2019)

The information must be published on a website that is accessible to employees and the public free of charge. The information should remain on the website for a period of at least three years beginning with the date of publication.

In addition employers have the option to provide narrative that will help people to understand why a gender pay gap is present and what the organisation intends to do to close it.

During the first publication employers will have already registered with the Government online reporting service to submit their GPG results.

Colleagues from the Electronic Staff Record (ESR) continue to refine the tool that helps organisations nationally to calculate their GPG data.


The 2019 Gender Pay Gap (GPG) results for Derbyshire Community Health Services NHSFT are detailed below:

GPG results as at 31 March 2019:

Q1 = Lowest, Q4 = Highest

GPG Bonus results as at 31 March 2019:

A comparison of 2018 v 2019 Gender Pay Gap result is detailed below:

GPG comparison 31 March 2018 v 31 March 2019:

Gender Avg. Hourly Rate Median Hourly RateMale 17.32 15.08Female 14.52 12.82Difference 2.80 2.26Pay Gap % 16.17% 15.01%

Quartile Female Male Female % Male %1 953 80 92.26% 7.74%2 912 104 89.76% 10.24%3 914 109 89.35% 10.65%4 877 152 85.23% 14.77%

Gender Avg. Bonus Pay Median Bonus PayMale 292.35 230Female 298.46 230Difference -6.11 0Pay Gap % -2.09% 0.00%

31st March 2018Gender Avg. Hourly Rate Median Hourly Rate

Male 17.05 14.70Female 14.10 12.74Difference 2.95 1.96Pay Gap % 17.27% 13.33%

31st March 2019Gender Avg. Hourly Rate Median Hourly Rate

Male 17.32 15.08Female 14.52 12.82Difference 2.80 2.26Pay Gap % 16.17% 15.01%

VariationGender Avg. Median

Male 0.27 0.38Female 0.42 0.08Difference -0.15 0.30Pay Gap % -1.10% 1.68%


GPG Bonus comparison 31 March 2018 v 31 March 2019:

31st March 2018Quartile Female Male Female % Male %

1 948 82 92.04% 7.96%2 988 114 89.66% 10.34%3 937 116 88.98% 11.02%4 929 159 85.39% 14.61%

Total 4273

31st March 2019Quartile Female Male Female % Male %

1 953 80 92.26% 7.74%2 912 104 89.76% 10.24%3 914 109 89.35% 10.65%4 877 152 85.23% 14.77%

Total 4101

VariationQuartile Female Male Female % Male %

1 5 -2 0.22% -0.22%2 -76 -10 0.10% -0.10%3 -23 -7 0.37% -0.37%4 -52 -7 -0.16% 0.16%

Total -172

31st March 2018Gender Avg. Bonus Pay Median Bonus Pay

Male 303.75 350Female 300.92 290Difference 2.83 60Pay Gap % 0.93% 17.14%

31st March 2019Gender Avg. Bonus Pay Median Bonus Pay

Male 292.35 230.00Female 298.46 230.00Difference -6.11 0.00Pay Gap % -2.09% 0.00%

VariationGender Avg. Bonus Pay Median Bonus Pay

Male -11.40 -120.00Female -2.46 -60.00Difference -8.94 -60.00Pay Gap % -3.02% -17.14%


Further GPG Hourly Rate analysis as at 31 March 2019 by Staff Group and Service Area

By Staff Group

By Service Area

Latest benchmarking data available (31 March 2018):

Note that benchmarking data is only available when a Trust formally publishes the results. Currently the above Trusts have not submitted the 31st March 2019 results to the Government reporting service and still have until the 30th March 2020 to do so.

Average of Hourly Rate GenderStaff Group Male Female Diff Gap %Add Prof Scientific and Technic 16.74 18.97 -2.23 -13.30%Additional Clinical Services 11.22 11.15 0.07 0.64%Administrative and Clerical 19.28 12.45 6.83 35.45%Allied Health Professionals 20.50 17.80 2.70 13.17%Estates and Ancillary 12.81 10.24 2.57 20.07%Medical and Dental 45.74 37.11 8.63 18.87%Nursing and Midwifery Registered 17.94 17.30 0.64 3.58%Students 0.00 14.40 -14.40 0.00%

Average of Hourly Rate GenderService Area Male Female Diff Gap %Chief Executives 0.00 15.59 -15.59 0.00%Estates 16.33 12.59 3.73 22.87%Executive Group 63.86 36.15 27.70 43.38%Finance and Strategy 20.72 18.14 2.58 12.45%Health Wellbeing & Inclusion 22.91 15.52 7.39 32.24%Integrated Community Services 14.81 14.43 0.38 2.56%Ops. Management 47.44 37.30 10.14 21.38%People Services 17.14 16.35 0.79 4.59%Planned Care & Specialists 17.85 13.59 4.26 23.87%Quality Directorate 16.06 17.49 -1.43 -8.91%Service Transform and IMT 19.14 15.53 3.61 18.85%

Trust Average MedianDerbyshire Community Health Services NHS Foundation Trust 17.27% 13.33%Derby Teaching Hospitals NHS Foundation Trust 30.60% 17.10%Chesterfield Royal NHS Foundation Trust 33.20% 18.70%Derbyshire Healthcare NHS Foundation Trust 18.73% 13.52%


TRUST BOARDDocument Title: Quality Report

Presenter/Title: Michelle Bateman, Chief Nurse/ Executive Director of Quality/ William Jones, Accountable Emergency Officer

Contents of Paper were previously discussed by:Author/Title: Jo Hunter, Deputy Chief NurseContact Email and Telephone Number:

[email protected]




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

Purpose of Paper

This report is brought to Board to provide an update on key issues across the national and local Quality agenda. The majority of this report will focus on the current Covid19 position however there needs to be recognition that the national picture has been rapidly changing on a daily basis and the detail in this report may need an additional verbal update.

Recommendations

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

The Board is asked to note the temporary changes made to the Quality Always processes outlined on Page 5 section 2.5.


1.1/19 There is a risk to patient care due to stretched management capacity and overall service continuity from the processes related to significant service change (including bidding for and acquiring new services the requirement to retender for existing services and transformation of existing services e.g. BCCTH) resulting in a reduced quality of service1.2/19 There is a risk to patient care due to a failure to optimise use of current information systems resulting in reduced time to care and inaccurate management information1.3/19 There is a risk to patient care due to a lack of consistent deployment of the Trust’s patient quality improvement and assurance framework resulting in care that is less safe and effective1.4/19 There is a risk to patient care due to a failure to apply evidenced based practice, learn from clinical governance processes and implement change resulting from audit and feedback resulting in the provision of less effective care1.5/19 There is an overarching risk to patient care due to periods of major system change and employment of new governance systems and processes related to place based care resulting in a reduced quality of service 1.6/19 There is a risk to population health through the failure to fully embed public health

Page 1 of 447 Quality Report.docx


principles within DCHS service delivery resulting in an inability to reduce inequalities for our resident communities1.7/19 There is a risk to patients due to DCHS not consistently considering principles of equality, diversity and inclusion resulting in the way we plan and deliver our services being at odds with what matters to individuals/ service users/ carers2.1/19 There is a risk to patient care due national and local workforce supply shortages resulting in our staff not being able to provide high quality, safe and effective care.

Financial Impact

The majority of the items covered in this paper have no or very limited direct financial impact on DCHS. The use of Bank and /or agency nurses will have additional financial implications for operational services and increased agency use could cause a breach of agreed spending limits.


1.0 Covid19Coronavirus is a type of virus. As a group of viruses, coronaviruses are common across the world. Typical symptoms of coronavirus include fever, shortness of breath and a cough that may progress to severe pneumonia causing shortness of breath and breathing difficulties. COVID19 is a new coronavirus that was identified in Wuhan City, China in December 2019, following investigation of a cluster of cases. The transmission of COVID19 is thought to occur mainly through respiratory droplets generated by coughing and sneezing and through contact with contaminated surfaces. However initial research has identified the presence of live COVID19 virus in the stools and conjunctival secretions of confirmed cases. Therefore all secretions (except sweat) and excretions including diarrhoeal stools from patients with known or suspected COVID19 should be regarded as potentially infectious and appropriate precautions taken.

COVID19 infection caused by a Corona virus is a high consequence infectious disease for the population due to its rapid spread and the lack of population immunity in the absence of effective drugs or a vaccine, the control of the disease will rely upon effective infection prevention and control measures, including transmission-based precautions (airborne, droplet and contact precaution) and isolation of potential infected patients. Appropriate cleaning and decontamination of the environment is also essential in preventing the spread of the virus. It is essential for all staff to practice good hand hygiene as per DCHS advice.

The Trust has issued a third Standard Operating Procedure (V3. 20/03/2020) which has the following objectives:

To ensure that the Trust develops a local response that is in keeping with the latest guidance from Public Health England (PHE) and NHS England (NHSE)

To ensure that staff understand their role in the management of suspected and confirmed COVID19 cases

To ensure that staff understand the key Infection, Prevention and Control (IP&C) principles, including personal protective equipment (PPE) requirements

To outline the current process for swabbing suspected cases

The Trust has established incident control and planning arrangements:


Incident Control Centre (Gold/ICC) led by William Jones (Accountable Emergency Officer) supported by an extended Executive Team, based at Ashgreen

Operational control room (Silver/Ops) led by Assistant Directors and Deputies based at Babington

Developing detailed plans in anticipation of absence rates being high, increasing bed capacity and redeploying colleagues to appropriate front line duties. Training and appraisal timescales have been extended by 4 months

Guidance was anticipated at the time of writing, that will provide a Service Prioritisation Matrix – some community health services will cease or be reduced significantly

Guidance is also anticipated to support maximizing discharges from hospitals (Acute and Community) with a relaxation of certain requirements to speed up flow

We are encouraging as many colleagues as possible to work from home and support patients remotely where possible

Maximum priority is being given to hand-washing and increased cleaning frequency and use of hand sanitiser

The IP&C Team continue to triage enquiries and provide advice and support to all services across DCHS, based on good practice guidance and best evidence from previous pandemic and inter-pandemic periods that is provided through guidance issued by PHE and NHSE. The communications team has provided a page on ‘My DCHS’ where staff can access all current guidance and advice.

2.0 Local Update

2.1 Allied Health Professionals (AHPs): A secondment to support the work of the Assistant Director AHPs for 6 months was advertised. Trudie Marlow has been appointed from the Transformation Team (1 day a week until September 2020). She is undertaking a piece of work to address AHP recruitment challenges, with a specific focus on Band 5 Physiotherapy posts. Working with the Derbyshire AHP Council, we are exploring a shared approach to recruitment, with an attractive rotation offer for newly registered Physios. There is aggressive competition from the private sector in the Muscular Skeletal (MSK) labour market, and we need to be able to secure a workforce not just for MSK but also for community posts.

Podiatry is a shortage profession and the Assistant Director AHPs and the Podiatry service lead have been working with University of Derby to establish a local pre-registration training programme (currently we recruit from Salford, Huddersfield and Coventry). Our CEO has supported a bid for funding to Health Education England Strategic Support Fund.

2.2 Nursing Update: Nationally work is underway with the Nursing and Midwifery Council (NMC) to allow retired nurses and 3rd year students to be admitted to an emergency NMC register to allow their deployment to support existing staff to manage the Covid19 pandemic across Great Britain. This will be entirely voluntary for both groups, will be paid and will require emergency legislation which is moving through Parliament in the next 3 weeks. It is entirely possible that Revalidation requirements will be pushed back for each nurse by 4 months. There is no further detail available at the time of writing this report.


2.5 Quality Assurance: Currently the QA process is suspended to allow the team to consider their redeployment opportunities to support colleagues in Operational Services and the wider system.

The Amber Valley SPA team has achieved Gold since the last report; and Erewash 0-19 and Chesterfield Central ICT have been put forward to the next panel, when it is convened.



The Chief Nurse presents a paper covering the Quality Agenda reflected in this report to the Council of Governors


Individual items within this report will have implications for Equality, Diversity and Inclusion. When managing Registered Professionals in distress individual needs and required reasonable adjustments are taken into account It is always possible to present the information in more accessible formats should this be required.


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

Risk Register

Is the issue on the current Risk Register?

No If yes, what is the Risk Number? N/A



TRUST BOARD Document Title: Staffing for Quality Report

Presenter/Title: Michelle Bateman - Chief Nurse/Executive Director of Quality Contents of Paper were previously discussed by: QPC March 2020

Author/Title: Michelle Bateman - Chief Nurse/Executive Director of Quality Julie Wheeldon - Head of Operational Quality Melanie Moss – Business Lead for Operational Quality Nikki Myronko – Head of People Resourcing


[email protected] [email protected] [email protected]



Has an Equality Impact Assessment been undertaken Yes No x

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

Purpose of Paper

This paper provides information on: 1. Assurance on legislative reporting including Care Hours Per Patient Day and Safe Staffing on

inpatient staffing levels which are reported retrospectively to NHS England and availablepublicly on the DCHS website

2. Update on ongoing work to inpatient establishment reviews - nursing only3. The overall workforce challenges for operational services and actions taken to address

Recommendations

The Trust Board is asked to RECEIVE the report for INFORMATION and ASSURANCE


1.1/19 There is a risk to patient care due to stretched management capacity and overall service continuity from the processes related to significant service change (including bidding for and acquiring new services the requirement to retender for existing services and transformation of existing services e.g. BCCTH) resulting in a reduced quality of service

2.1/19 There is a risk to patient care due national and local workforce supply shortages resulting in our staff not being able to provide high quality, safe and effective care.

Page 1 of 1648 Staffing for Quality.pdf


Financial Impact

• Utilising bank/agency shifts adds additional financial pressures on the services


NHS England Safe Staffing Reporting (Nursing) – Inpatient Areas The DCHS Staffing for Quality report provides the Board with an overview of the Nursing Workforce up to the end of February 2020 and is set out in line with the National Quality Board (NQB) Standards and Expectations for Safe Staffing published in 2016. (See Appendix 1). The full graphs showing inpatient staffing are uploaded to the NHS England website and DCHS website for the inpatient areas within DCHS. The National Quality Board recommended use of a metric, Care Hours per Patient Day (CHPPD); this is collected monthly and submitted to NHSE/I UNIFY database as required. Feedback has been given to the National Board in regard to this standalone data as there is not any acknowledgement to the patient’s acuity nor dependency to put context to the National benchmarking, which is shared with DCHS approximately every 6 months and will be shared within this report upon receipt. The Safe Care model within e-roster however does demonstrate the CHPPD available, taking into account the patient’s acuity and dependency which are collated three times daily and identifies any shortfall or excess staffing hours. Work is ongoing with the Head of Systems and Information and Head of Operational Quality to revise and refresh this data and presentation going forward. In order to meet the standard of safe staffing and provide assurance around having the right number of staff with the right skills in the right place at the right time DCHS have a flexible model that utilises

- additional hours - a responsive workforce including a centralised team as well as a newly recruited Band 3

responsive workforce - bank staff - agency staff

DCHS Current Position with Safe Staffing Integrated Community Services 1. Inpatient Establishment Reviews The next review for in-patient areas are planned for May 2020; however the Head of Operational Quality has held additional meetings during February and March 2020 with all of the Hospital Matrons to review the current position particularly the use of agency including off framework agency.


Significant work continues in regard to e-roster compliance with rosters now being completed every 10 weeks. There has been some challenge identified with this in terms of sufficient support to the ward and team areas to ensure the roster is fit for purpose, with a risk being raised identifying the shortfall. Feedback in regard to the newly launched acuity and dependency tool within the Pathway 3 wards is very positive, its application being more reflective of the type of patients now being cared for. Work is ongoing in regard ensuring its consistent application which in turn supports the allocation of the new Band 3 Responsive team as well as additional staffing such as bank and agency. The Inpatient Band 3 Responsive Team have 3 staff currently in post, a further 3 on induction and all staff (10 WTE) due to be in post by April 2020. The allocation and responsiveness of the staff is being managed within ICS operational services and the Clinical Navigation Team The staff will be allocated to shifts which have escalated to agency and remain unfilled 24 hours before the shift is due to commence. Careful monitoring is in place to demonstrate a positive in terms of a reduced requirement to escalate to both agency but particularly off framework agencies. The introduction of this team is also being monitored in terms of the financial impact. Community Services Work remains ongoing in order to review capacity and demand in relation to safely staffing numbers for the community teams. A meeting took place with the Assistant Director ICS and Head of Operational Quality to review the findings of internal capacity and demand reviews and discuss the assumptions. There remain some challenges in terms of staffing recruitment resulting in an inability to fully implement the new Rapid and Core team models; hot spots remain in North East, Chesterfield, Derby City and a focused area in Derbyshire Dales. Operational services have confirmed they will able to identify hierarchies for core and rapid community teams as of April 2020. A number of actions are taking place to better understand the concept of ‘safe staffing’ within the community setting: • A daily demand and capacity tool is under development, intended to be in place by end March

2020. • The Community Nursing external review is underway with an anticipated report date for end

of March 2020 and finally, • DCHS has been successful in being selected for taking part in data collection for the QNI

funded acuity and dependency study.

Recruitment to support a further 10 Band 6 community nurses to undertake the Specialist Practitioner Course (District Nursing) has commenced with continued part funding from HEEM. 2. Health, Wellbeing and Inclusion (HWBI) There continues to be significant transformation initiatives and tender processes for services across this division that impacts on staff morale and planning. Children and Young People Services The impact of the Section 75 agreement continues to be monitored and the impact is being negotiated with partnership organsiations, particularly for School Nursing, less so for Health


Visiting. Due to the decrease in resources within School Nursing, the service has specified that referrals needs to go through SPA on standard referral forms. The service is currently awaiting confirmation from HEEM in regard to the model for 2020-21 i.e. via the apprenticeship route or backfill funding for the Specialist Practitioner Course. If funding through HEEM is made available, the service will support 4 Health Visitors; however if the apprenticeship route is confirmed, the service will also support an additional 2 School Nurse posts. GP Practices The People Resource team continues to actively seek solutions for gaps by working closely with agencies, regional recruitment groups and framework providers. Integrated Sexual Health Services (ISHS) Due to an increase in their patient caseloads and the subsequent impact on protected time for staff, staff training and competencies remain an area of focus. Health Psychology New roles are being developing within the Health Psychology service with support and oversight being provided by the Clinical Quality Reference Group (CQRG). 3. Planned Care and Specialist Services Learning Disability Services There continues to be challenges with staffing within the Learning Disability inpatient area with some very complex patients to manage. The daily situation report is in place, and further exploration of the recommendations from Keith Hurst in relation to the staffing requirements has commenced. The senior leadership team are now attending the e-roster “confirm and challenge meetings”. Discussion took place in regards to the challenges in completing the roster with further discussion taking place at QPC. There is a plan to move to completing rosters 10 weekly but considerable support and actions are required in order to enact this. Agency use, including off-framework agency, remains high in this area, and this includes Medical staffing. Recruitment and sustainability remains a key risk as identified on the risk register. Alternative approaches/models have been explored with OPMH providing a supportive approach in terms of staffing as and when available. Older People Mental Health Service Following the 6 month Quality Dashboard review it was agreed by the Executive Director of Quality not to formally undertake the Keith Hurst Mental Health Optimum Staffing tool due to the unit transitioning to SystmOne currently. However, contact has been made with Imperial College London in relation to the tool to prepare for when the review is undertaken. There continues to be difficulties in recruiting to Registered Mental Health Nurses but the leadership team are able to also recruit to Registered Nurses to compliment the establishment. This is proving of some benefit due to the patients having complex physical support requirements as well as mental health needs.


Urgent Treatment Centres Some work has commenced with the Operational Quality Analyst and the senior leadership team initially within two of the units to review the activity and staffing complement as there appear to be some inconsistencies with the data in terms of skill mix, competency and activity and to support a more equitable model going forwards. There has been some increased activity with regards to the COVID-19 virus, particularly within Buxton, in relation to general queries and queries from 111.



This could provide information to Governors in relation to the inpatient staffing levels and our performance against agency target.


Shifts are allocated irrespective of any protected characteristic and in line with service need. When changes are made to rotas, an equality impact assessment must be undertaken


There is a correlation between staffing numbers, skill mix and use of agency to patient safety

Risk Register

Is the issue on the current Risk Register?

Yes If yes, what is the Risk Number? 3062 , 3263, 3276 and 3311

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


1

March 2020

Data as at 29th February 2020

Prepared by: People Services - Systems and Information Team Tel no: 01332 564856 (Option 3, Option 4) Email: [email protected]

DCHS Safer Staffing Report


1

Ash Green - Hillside …………………………………………………………………………………………………………………..3

Babington Hospital - Baron …………………………………………………………………………………………………………………..4

Cavendish - Fenton …………………………………………………………………………………………………………………..5

Clay Cross - Alton …………………………………………………………………………………………………………………..6

Ilkeston - Hopewell …………………………………………………………………………………………………………………..7

Ripley - Butterley …………………………………………………………………………………………………………………..8

St Oswald's - Okeover …………………………………………………………………………………………………………………..9

Walton Unit …………………………………………………………………………………………………………………..10

Whitworth - Oker …………………………………………………………………………………………………………………..11

Contents


1

RN 4 4 1

HCA 5 5 3

Ash Green - Hillside Ward Safer Staffing as at February 2020

Early Late Night

Safe Staffing Minimum Numbers (based on funded establishment)

69% 62%

111%

146% 149%

208%

112% 110%

184%

0%

20%

40%

60%

80%

100%

120%

140%

160%

180%

200%

220%

E L N

Hillside Ward - 1st to 29th February 2020 % staffing against agreed staffing levels Registered Staff % Non-registered % Overall %

6

4

0

1

2

3

4

5

6

7

Hillside

Hillside Ward Bed Occupancy February 2020 - 68%

RN Early HCA Early RN Late HCA Late RN Night HCA Night

Agency 0% 40% 0% 49% 0% 26%

Bank 0% 8% 0% 5% 0% 19%

Substantive 100% 52% 100% 46% 100% 55%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hillside Ward - Bank and Agency Use February 2020

Substantive Bank Agency

0

60

0

229

0

50

100

150

200

250

RN HCA RN HCA

Shifts Filled by Bank Shifts filled by Agency

Hillside Bank and Agency use

It is important to note that the staffing levels for the Learning Disability inpatient area are not yet finalised against a national benchmark. The National Learning Disability Optimum Staffing tool LDDOS is

now available and work is taking place to review this for DCHS. Currently on the ward there is a small amount of unavailability due to sickness as well as high patient acuity on the ward that is requiring increased staffing requirements for observation As a result a significant amount of shifts were sent to bank and agency.


1


2 2 2

Babington Baron Ward Safer Staffing as at February 2020

Early Late Night

HCA 3 3 2

RN

10 9

0

2

4

6

8

10

12

Available Max Avg. Bed No. for Month

Baron Ward Bed Occupancy February 2020 - 91%

33

46

0

4

0

5

10

15

20

25

30

35

40

45

50

RN HCA RN HCA


Baron Bank and Agency use

104% 105% 104%

80% 82%

104%

89% 91%

104%

0%

20%

40%

60%

80%

100%

120%

E L N

Baron Ward - 1st to 29th February 2020 % staffing against agreed staffing levels Registered Staff % Non-registered % Overall %


Agency 0% 3% 0% 3% 0% 0%

Bank 10% 22% 15% 30% 31% 17%

Substantive 90% 75% 85% 67% 69% 83%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baron Ward - Bank and Agency Use February 2020


Baron ward are part of the transformation plan to reduce beds, recruitment and retention to this ward has been challenging. In addition, there have been serval admissions of high acuity with patients who have required increased staffing for observation, currently responsive workforce support is in place to gaps but there has been additional support of bank and agency. There has been some sickness and some new HCA starters who have required induction and supernumary support. There are further vacancies going through the recruitment process.


1

RN 2 2 2

HCA 3 3 2

Cavendish Hospital - Fenton Ward Safer Staffing as at February 2020

Early Late Night


104% 104% 104% 106% 106%

104% 105% 105% 104%

0%

20%

40%

60%

80%

100%

120%

E L N

Fenton Ward - 1st to 29th February 2020 % staffing against agreed staffing levels Registered Staff % Non-registered % Overall %

11

9

0

2

4

6

8

10

12

Fenton

Fenton Ward Bed Occupancy February 2020 - 82%

37

31

0 0

0

5

10

15

20

25

30

35

40

RN HCA RN HCA


Fenton Bank and Agency use


Agency 0% 0% 0% 0% 0% 0%

Bank 14% 9% 16% 17% 34% 14%

Substantive 86% 91% 84% 83% 66% 86%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Fenton Ward - Bank and Agency Use February 2020


There has been some bank use in this area but no agency to cover some unavailability due to sickness and vacancy which is in the recruitment process.


1

Safe Staffing Min Numbers (based on funded est)

Early NightLate

Clay Cross Hospital - Alton Ward Safer Staffing as at February 2020

2

2

3

2

HCA

RN

3

2

104% 102% 104% 105% 102%

145%

104% 102%

124%

0%

20%

40%

60%

80%

100%

120%

140%

160%

E L N

Alton Ward - 1st to 29th February 2020 % staffing against agreed staffing levels

Registered Staff % Non-registered % Overall %

14 13

0

2

4

6

8

10

12

14

16


Alton Ward Bed Occupancy February 2020 - 95%

31 34

19 14

0

5

10

15

20

25

30

35

40

RN HCA RN HCA


Alton Bank and Agency use


Agency 12% 1% 11% 0% 10% 16%

Bank 14% 2% 16% 22% 24% 16%

Substantive 74% 97% 74% 78% 66% 68%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Alton Ward - Bank and Agency Use February 2020


Currently there is a vacancy for a registered nurse which is in the recruitment process. This has resulted in some bank and agency use. There is also vacancy of 2 HCA which are appointed to and awaiting start date.


1Ilkeston Hospital - Hopewell Ward Safer Staffing as at February 2020

Early Late Night


RN 2 2 2

HCA 4 4 2

138%

114%

104% 97%

103%

157%

111% 107%

130%

0%

20%

40%

60%

80%

100%

120%

140%

160%

180%

E L N

Hopewell Ward - 1st to 29th February 2020 % staffing against agreed staffing levels Registered Staff % Non-registered % Overall %

18 17

0

5

10

15

20


Hopewell Ward Bed Occupancy July 2019 - 91%

0

5

1

2

0

1

2

3

4

5

6

RN HCA RN HCA


Hopewell Bank and Agency use


Agency 0% 1% 0% 1% 2% 0%

Bank 0% 2% 0% 2% 0% 1%

Substantive 100% 97% 100% 97% 98% 99%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hopewell Ward - Bank and Agency Use February 2020


• Previously Ilkeston had 2 wards which have now merged as 1 ward, due to this staffing levels are adjusted and utilised accordingly on this ward and others within the locality. Bank/agency use is very

low and a result of late notice unavailability.


1

RN 2 2 2

HCA 4 4 2

Ripley Hospital - Butterley Ward Safer Staffing as at February 2020

Early Late Night


111% 105% 104%

115% 120%

184%

114% 115%

144%

0%

20%

40%

60%

80%

100%

120%

140%

160%

180%

200%

E L N

Butterley Ward - 1st to 29th February 2020 % staffing against agreed staffing levels

Registered Staff % Non-registered % Overall %

18

16

0

2

4

6

8

10

12

14

16

18

20

Butterley

Butterley Ward Bed Occupancy February 2020 - 88%

4

101

9

47

0

20

40

60

80

100

120

RN HCA RN HCA


Butterley Bank and Agency use


Agency 3% 11% 5% 13% 7% 15%

Bank 0% 17% 0% 31% 7% 37%

Substantive 97% 72% 95% 56% 86% 49%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Butterley Ward - Bank and Agency Use February 2020


Patient acuity has been high on occassions alongside unavailability due to sickness, maternity leave and vacancy which is in the recruitment process, this has resulted in some bank and agency use.


1


St Oswald's Hospital - Okeover Ward Safer Staffing as at February 2020

HCA 4 4 2

RN 2 2 2

Early late Night

109% 105% 104%

133% 131%

173%

125% 123%

138%

0%

20%

40%

60%

80%

100%

120%

140%

160%

180%

200%

E L N

Okeover Ward - 1st to 29th February 2020 % staffing against agreed staffing levels Registered Staff % Non-registered % Overall %

18

16

0

5

10

15

20

Okeover

Okeover Ward Bed Occupancy February 2020 - 89%

5

118

2

31

0

20

40

60

80

100

120

140

RN HCA RN HCA


Okeover Bank and Agency use


Agency 0% 4% 0% 5% 3% 18%

Bank 0% 31% 5% 29% 3% 30%

Substantive 100% 65% 95% 65% 93% 53%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Okeover Ward - Bank and Agency Use February 2020


Increased acuity on the ward with increased staffing requirements for observation. There has also been vacancies with new starters coming into post and requiring an induction/supernumary period, this has resulted in a small amount of registered nurse bank/agency and some HCA bank and agency use.


1

HCA 8 8 6

RN 4 4 3

Walton Unit Safer Staffing as at February 2020

Early Late Night


90% 92%

104%

133% 135%

127%

119% 121% 119%

0%

20%

40%

60%

80%

100%

120%

140%

160%

E L N

Walton Unit - 1st to 29th February 2020 % staffing against agreed staffing levels Registered Staff % Non-registered % Overall %

30

18

0

5

10

15

20

25

30

35

Walton Unit

Walton Unit Bed Occupancy February 2020 - 61%

26

87

0

13

0

10

20

30

40

50

60

70

80

90

100

RN HCA RN HCA


Walton Unit Bank and Agency use

1 2 3 4 5 6

Agency 0% 1% 0% 2% 0% 3%

Bank 8% 13% 9% 10% 10% 8%

Substantive 92% 86% 91% 88% 90% 89%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Walton Unit - Bank and Agency Use February 2020


It is important to note that the staffing levels for the older peoples mental health inpatient area are not yet finalised against a national benchmark. The National mental health Staffing tool MHOST is now available and work is taking place to review this for DCHS.

There are ongoing RMN band 5 vacancies, which are nationally classed as hard to fill posts. These posts are currently out to advert as rolling recruitment to keep activity for recruitment live and active. There is a small amount of over establishment of band 3 HCA to offset the RMN recruitment issues and to support the changed acuity on the unit, but even with the over establishment on the HCA line we still need to use bank/agency from time to time depending on bed numbers and acuity.


1


Whitworth Hospital - Oker Ward Safer Staffing as at February 2020

Early Late

HCA 3 3 2

RN 2 2 2

Night

109% 104% 102%

108%

117%

104% 109%

111%

103%

0%

20%

40%

60%

80%

100%

120%

140%

E L N

Oker Ward - 1st to 29th February 2020 % staffing against agreed staffing levels Registered Staff % Non-registered % Overall %

14 13

0

2

4

6

8

10

12

14

16

Oker

Oker Ward Bed Occupancy February 2020 - 92%

8

66

2 2

0

10

20

30

40

50

60

70

RN HCA RN HCA


Oker Bank and Agency use


Agency 0% 1% 3% 0% 0% 2%

Bank 5% 27% 0% 37% 9% 9%

Substantive 95% 71% 97% 63% 91% 90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oker Ward - Bank and Agency Use February 2020


There has been some high patient acuity requiring increased support and enhanced supervision. In addittion, there has been s ome sickness and vacancies. The vacancies are appointed to but the new starters are not yet in post. This has resulted in a small amount of RN bank and agency use and some HCA bank and agency use.


TRUST BOARD Document Title: Performance Report

Presenter/Title: Cath Benfield - Deputy Director of Finance Contents of Paper were previously discussed by:

Author/Title: David Caddy, Senior Management Accountant - Performance and Costing

Contact Email and Telephone Number: [email protected] 07834 234966



Has an Equality Impact Assessment been undertaken Yes No

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

Purpose of Paper

The purpose of this paper is to present the Board Performance Report.

Recommendations

The Board are asked to note the contents of this report in particular the current performance exceptions :- - The Big 9 measure for Sepsis Baseline observations is 27.6% ytd against a target of 70% - The Big 9 figure for Violence and Aggression is 196 ytd against a target of 144 - Agency costs continue to track significantly ahead of plan ,year to date spend of £1.77m

against a plan of £1.21m. However, this is an improving position at M11 and this has had the impact of reverting the Trust’s overall UoR score to a 1.


References 1.1/19 , 1.2/19 , 1.3/19 , 2.1/19 , 2.2/19 , 2.3/19 , 2.4/19 , 2.5/19 , 3.1/19 , 3.2/19 , 3.3/19 , 3.4/19 , 3.5/19 , 3.7/19 , 3.8/19 , 4.1/19 , 4.2/19 , 4.3/19 , 4.5/19 , 4.6/19

Financial Impact

The report contains a number of issues and risks that have a financial impact on the organisation.


The Performance Report sets out a summary of Derbyshire Community Health Services (DCHS) performance against the three DCHS Way focus areas of Quality People, Quality Service and Quality Business.

Page 1 of 2349 Performance Report.pdf

The key issues for the Board to discuss are:

• The Big 9 measure for Sepsis Baseline Observations is red rated. 27.6% of baseline observations have been recorded against target of 70%. The year end target is 80%. • The Big 9 figure for Violence and Aggression Incidences was 196, against our year to date target of no more than 144. • Agency Costs as percentage of Paybill (£m) are £1.77 million for the year to date against a target of £1.21 million.

There are 18 green, 7 amber, 4 red, and 3 unrated indicators this month.


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


Equality and Diversity measurements are recorded in the report


The report includes measurements of service experienced by patients

Risk Register




Board Performance Report – February 2020

Background The Board Performance Report sets out a summary of Derbyshire Community Health (DCHS) performance against the three DCHS Way focus areas of Quality People, Quality Service and Quality Business.

Section Index

Document Page Number 1.1 - Executive Summary 2-52.1 – Performance Dashboard 62.2 – Statistical Process Control Charts 7-113.1 - Exception Reports 12-194.1 - Appendix 1 – CQUIN Dashboard Appendix 15.1 - Appendix 2 – NHSI Quality Dashboard Appendix 2

1 of 19 Page 3 of 2349 Performance Report.pdf

1.1 - EXECUTIVE SUMMARY Key Issues The key issues for the Board to discuss are:

• The Big 9 measure for Sepsis Baseline Observations is red rated. 27.6% of baseline observations have been recorded against target of 70%. The year end target is 80%. An exception report is presented at page 12.

• The Big 9 figure for Violence and Aggression Incidences was 196, against our

year to date target of no more than 144. An exception report is presented at page 15.

• Agency Costs as percentage of Paybill (£m) are £1.77 million for the year to

date against a target of £1.21 million. An exception report is presented at page 17.

Quality Service

• The Big 9 measure for Sepsis Baseline Observations is red rated. 27.6% of

baseline observations have been recorded against target of 55%. The year end target is 70%. An exception report is presented at page 12.

• The Big 9 measure for Dementia Friendly Environment is red rated. 52 actions completed against a target of 60. An exception report is presented at page 13.

Quality People

• The Resuscitation measure for February, against a target of 96%, was

88.55% (89%). This has been red rated. An exception report for Resuscitation is enclosed at page 14.


• By the end of February there were 196 incidents of violence and aggression

for the year to date against a year to date target of 144. The monthly figures, including a breakdown of incidents in Learning and Development are:

This has been red rated. An exception report is included at page 15.

• February’s year to date Big 9 figure of 108 for staff who are under 25 has

been red rated against our year to date target of 204. The monthly figures to are:

Month All LD Other

Apr-19 14 9 5May-19 36 24 12Jun-19 16 11 5Jul-19 18 13 5Aug-19 20 10 10Sep-19 15 5 10Oct-19 17 9 8Nov-19 11 1 10Dec-19 13 4 9Jan-20 19 14 5Feb-20 17 8 9

Big 9 - Violence & Aggression Incidences


An exception report is included at page 16.

• Agency costs were at £1.77m for the year to date. The NHS England year to

date cumulative target is 1.21m and £1.36m for the year. This has been red rated. An exception report is included at page 17.

Quality Business

• The Big 9 for Machines Patched With Security Patches in last 30 Days was

91.6% (92%) in February against a target of 97.27%. The year-end target is 97.5%. This has been red rated. The roll out of Windows 10 machines has had an effect on the patching process. 8.4% of devices were without a patch. An exception report is presented at page 18.

• The Data Quality Maturity Index score was 87.9 against a target of 95. This has been red rated. An exception report is presented at page 19.

Month All 16-18 19-21 22-24

Apr-19 108 2 18 88May-19 108 2 19 87Jun-19 103 1 19 83Jul-19 103 1 16 86Aug-19 95 1 12 82Sep-19 89 1 11 77Oct-19 99 1 13 85Nov-19 100 1 12 87Dec-19 95 1 10 84Jan-20 100 1 11 88Feb-20 108 0 15 93

Big 9 - Staff who Are Under 25 (no)


Quality Governance

• Appendix 2, attached separately, sets out benchmarking from NHS Improvement (NHSI) of the Trust’s performance against a number of metrics used against the CQC Well Led Framework. The metrics have been updated against the NHSI website for February. The Board will note that the Trust benchmarks well across most of these metrics.


DCHS Board Performance Report 2019/20 SPCKitemark

ScoreMonth

Month Feb-20 Current Current Trend Plan for Month

Outturn Plan

Outturn Forecast

Benchmark Notes

QUALITY SERVICE

Friends and Family Score 12 98.2% 98.2% 98% 98% 98% 96%

Length of Stay 10 22.7 20.5 20 20 20 Inpatients

Occupancy 10 83.7% 82.6% 85% 85% 83% 75%-85% Inpatients

Information Sharing - 93.25% 93.25% 90% 90% 93% EDSM

RTT Completed Pathways Non Admitted (1b)

14 Not now collected

Not now collected

- - - - Services transferred Nov 19

RTT Incomplete Pathways (2) 14 Not now collected

Not now collected


RTT Incomplete Pathways - Decision to Admit (2a)

14 Not now collected

Not now collected


A&E 4 Hr Wait 19 99.9% 99.90% >95% >95% 100% >95% National target

Pressure Ulcers 12 1 22 43 47 24

% of Total Shifts Covered 18 84.7% 84.7% 80% 80% 80%

Falls Resulting in Severe Injury 12 0 7 8 9 8

Never Events 12 0 2 0 0 2

QUALITY PEOPLE

RIDDOR Reported Injuries 12 0 18 16 17 20

Appraisal Rate 18 91.46% 91.46% 96% 96% 91.5% 90% Year to date is 12 month figure

Attendance Rate 18 95.02% 95.15% 95.5% 95.5% 95.5%

Engagement Index - 79 78 75 75 78

Mandatory Training Compliance 18 98.0% 98.0% 96% 96% 98% 90%

Agency Costs as percentage of Paybill (£m)

15 1.77 1.77 1.21 1.36 1.90 Original 3% calculation - £1.36m

QUALITY BUSINESS

I&E Surplus 15 -3,740 -3,740 -3,639 -3,878 -3,878

Cash 15 37,000 37,000 30,204 29,591 33,830

Sustainable Quality Improvement Plan 15 5,079 5,079 5,064 5,582 5,583

Delayed Transfer of Care 10 5.0% 4.6% 3.5% 3.5% 4.6% 6.0% NHS 3.9%. Social 1.1%. Both 0.0%.

NHSI Single Oversight Framework (SOF) - Amber Amber Green Green Green 16 green 2 amber 2 red 4 unrated

Information Sharing - 93.25% 93.25% 90% 90% 93%

Data Quality Maturity Index - 87.9 87.9 95.0 95.0 87.9

Electronic Records Across DCHS - 93.7% 93.7% 70% 70% >77% TPP used

Electronic Point of Care Recording - 82.1% 82.1% 84.1% 85% >66% TPP used

Estate Utilisation 17 5.2% 5.2% 3.0% 3.0% 5.2% 3% Proportion of space unoccupied (%). Plan = Model Hospital Community

QUALITY GOVERNANCE

NHS England Quality Surveillance Rating - Green Green Green Green Green

Governance Rating - Green Green Green Green Green

AMHAM Audits - 0 2 2 4 4 Associate Mental Health Act Manager

AMHAM Audit Results - Significant Assurance

- 100% 100% 100% 100% -

SAFE

Year to Date Outturn

CARING

EFFECTIVE

RESPONSIVE


Feb-20 BOARD MEASURES - STATISTICAL PROCESS CONTROL (SPC) CHARTS

QUALITY SERVICE

Friends and Family Score

Length of Stay

Occupancy

96.8%

97.3%

97.8%

98.3%

98.8%

Apr-1

7

Jun-

17

Aug-

17

Oct

-17

Dec

-17

Feb-

18

Apr-1

8

Jun-

18

Aug-

18

Oct

-18

Dec

-18

Feb-

19

Apr-1

9

Jun-

19

Aug-

19

Oct

-19

Dec

-19

Feb-

20

Apr-2

0

Jun-

20

Aug-

20

Actual Percent

Control Mean (x̅) Percent

UCL (3σ) Percent

LCL (3σ) Percent

Improvement Percent

Concern Percent

Forecast Percent

Target Percent

14

15

16

17

18

19

20

21

22

23

24

Apr-1

7

Jun-

17

Aug-

17

Oct

-17

Dec

-17

Feb-

18

Apr-1

8

Jun-

18

Aug-

18

Oct

-18

Dec

-18

Feb-

19

Apr-1

9

Jun-

19

Aug-

19

Oct

-19

Dec

-19

Feb-

20

Apr-2

0

Jun-

20

Aug-

20Actual Average

Control Mean (x̅) Average

UCL (3σ) Average

LCL (3σ) Average

Improvement Average

Concern Average

Forecast Average

Target Average

72%

77%

82%

87%

92%

97%

Apr-1

7

Jun-

17

Aug-

17

Oct

-17

Dec

-17

Feb-

18

Apr-1

8

Jun-

18

Aug-

18

Oct

-18

Dec

-18

Feb-

19

Apr-1

9

Jun-

19

Aug-

19

Oct

-19

Dec

-19

Feb-

20

Apr-2

0

Jun-

20

Aug-

20

Actual Percent


UCL (3σ) Percent

LCL (3σ) Percent

Improvement Percent

Concern Percent

Forecast Percent

Target Percent



A&E 4 Hr Wait

Pressure Ulcers

Total Shifts Covered

99.00%

99.20%

99.40%

99.60%

99.80%

100.00%

100.20%

100.40%

100.60%

100.80%

Apr-1

7

Jun-

17

Aug-

17

Oct

-17

Dec

-17

Feb-

18

Apr-1

8

Jun-

18

Aug-

18

Oct

-18

Dec

-18

Feb-

19

Apr-1

9

Jun-

19

Aug-

19

Oct

-19

Dec

-19

Feb-

20

Apr-2

0

Jun-

20

Aug-

20

Actual Percent


UCL (3σ) Percent

LCL (3σ) Percent

Improvement Percent

Concern Percent

Forecast Percent

Target Percent

-8

-3

2

7

12

Apr-1

7

Jun-

17

Aug-

17

Oct

-17

Dec

-17

Feb-

18

Apr-1

8

Jun-

18

Aug-

18

Oct

-18

Dec

-18

Feb-

19

Apr-1

9

Jun-

19

Aug-

19

Oct

-19

Dec

-19

Feb-

20

Apr-2

0

Jun-

20

Aug-

20Actual Number Sum

Control Mean (x̅) Number Sum

UCL (3σ) Number Sum

LCL (3σ) Number Sum

Improvement Number Sum

Concern Number Sum

Forecast Number Sum

Target Number Sum

72%

74%

76%

78%

80%

82%

84%

86%

88%

Apr-1

8M

ay-1

8Ju

n-18

Jul-1

8Au

g-18

Sep-

18O

ct-1

8N

ov-1

8D

ec-1

8Ja

n-19

Feb-

19M

ar-1

9Ap

r-19

May

-19

Jun-

19Ju

l-19

Aug-

19Se

p-19

Oct

-19

Nov

-19

Dec

-19

Jan-

20Fe

b-20

Mar

-20

Apr-2

0M

ay-2

0Ju

n-20

Jul-2

0Au

g-20

Actual Percent


UCL (3σ) Percent

LCL (3σ) Percent

Improvement Percent

Concern Percent

Forecast Percent

Target Percent



Falls Resulting in Severe Injury

QUALITY PEOPLE

RIDDOR

Appraisals

0.00

1.00

2.00

Apr-1

7

Jun-

17

Aug-

17

Oct

-17

Dec

-17

Feb-

18

Apr-1

8

Jun-

18

Aug-

18

Oct

-18

Dec

-18

Feb-

19

Apr-1

9

Jun-

19

Aug-

19

Oct

-19

Dec

-19

Feb-

20

Apr-2

0

Jun-

20

Aug-

20

Actual Number Sum





Concern Number Sum

Forecast Number Sum

Target Number Sum

(4.00)

(2.00)

0.00

2.00

4.00

6.00

8.00

Apr-1

7

Jun-

17

Aug-

17

Oct

-17

Dec

-17

Feb-

18

Apr-1

8

Jun-

18

Aug-

18

Oct

-18

Dec

-18

Feb-

19

Apr-1

9

Jun-

19

Aug-

19

Oct

-19

Dec

-19

Feb-

20

Apr-2

0

Jun-

20

Aug-

20

Actual Currency

Control Mean (x̅) Currency

UCL (3σ) Currency

LCL (3σ) Currency

Improvement Currency

Concern Currency

Forecast Currency

Target Currency

91%

92%

93%

94%

95%

Apr-1

7

Jun-

17

Aug-

17

Oct

-17

Dec

-17

Feb-

18

Apr-1

8

Jun-

18

Aug-

18

Oct

-18

Dec

-18

Feb-

19

Apr-1

9

Jun-

19

Aug-

19

Oct

-19

Dec

-19

Feb-

20

Apr-2

0

Jun-

20

Aug-

20

Actual Percent


UCL (3σ) Percent

LCL (3σ) Percent

Improvement Percent

Concern Percent

Forecast Percent

Target Percent



Attendance Rate

Mandatory Training

(Essential Learning)

93.60%

94.10%

94.60%

95.10%

95.60%

96.10%

Apr-1

7

Jun-

17

Aug-

17

Oct

-17

Dec

-17

Feb-

18

Apr-1

8

Jun-

18

Aug-

18

Oct

-18

Dec

-18

Feb-

19

Apr-1

9

Jun-

19

Aug-

19

Oct

-19

Dec

-19

Feb-

20

Apr-2

0

Jun-

20

Aug-

20

Actual Percent


UCL (3σ) Percent

LCL (3σ) Percent

Improvement Percent

Concern Percent

Forecast Percent

Target Percent

96%

96%

97%

97%

98%

98%

99%

Apr-1

7

Jun-

17

Aug-

17

Oct

-17

Dec

-17

Feb-

18

Apr-1

8

Jun-

18

Aug-

18

Oct

-18

Dec

-18

Feb-

19

Apr-1

9

Jun-

19

Aug-

19

Oct

-19

Dec

-19

Feb-

20

Apr-2

0

Jun-

20

Aug-

20

Actual Percent


UCL (3σ) Percent

LCL (3σ) Percent

Improvement Percent

Concern Percent

Forecast Percent

Target Percent



QUALITY BUSINESS

Delayed Transfer of Care

Information Sharing

Data Quality Maturity Index

90%

92%

94%

96%

98%

100%

Jan-

18Fe

b-18

Mar

-18

Apr-1

8M

ay-1

8Ju

n-18

Jul-1

8Au

g-18

Sep-

18O

ct-1

8N

ov-1

8D

ec-1

8Ja

n-19

Feb-

19M

ar-1

9Ap

r-19

May

-19

Jun-

19Ju

l-19

Aug-

19Se

p-19

Oct

-19

Nov

-19

Dec

-19

Jan-

20Fe

b-20

Mar

-20

Apr-2

0M

ay-2

0Ju

n-20

Jul-2

0Au

g-20

Actual Percent


UCL (3σ) Percent

LCL (3σ) Percent

Improvement Percent

Concern Percent

Forecast Percent

Target Percent

84

86

88

90

92

94

96

98

Apr-1

9

May

-19

Jun-

19

Jul-1

9

Aug-

19

Sep-

19

Oct

-19

Nov

-19

Dec

-19

Jan-

20

Feb-

20

Mar

-20

Apr-2

0

May

-20

Jun-

20

Jul-2

0

Aug-

20

Actual Number Sum





Concern Number Sum

Forecast Number Sum

Target Number Sum

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Apr-1

7

Jun-

17

Aug-

17

Oct

-17

Dec

-17

Feb-

18

Apr-1

8

Jun-

18

Aug-

18

Oct

-18

Dec

-18

Feb-

19

Apr-1

9

Jun-

19

Aug-

19

Oct

-19

Dec

-19

Feb-

20

Apr-2

0

Jun-

20

Aug-

20

Actual Percent


UCL (3σ) Percent

LCL (3σ) Percent

Improvement Percent

Concern Percent

Forecast Percent

Target Percent


Measure2019/20

Full Year Target

YTD Target Q2 Dec-19 Jan-20 Feb-20 YTD

TPP Sepsis Baseline Observations (%) (Big 9) 80% 70% 0% 20.7% 23.1% 27.6% 27.6%

Exception Report Analysis

The results are due by the end of March and inevitably there will be improvement actions required. It is proposed that this audit is undertaken quarterly in 2020/21 to ensure that there is clinical recognition of our patients at risk of sepsis and improved outcomes. The results will reported to QSC via the Quality Performance Report to provide assurance on this workstream.

The main reason for introducing this Big 9 indicator was to support the introduction into DCHS of NEWS2 as a means of recognising the deteriorating patient particularly those with Sepsis. The final part of this Big 9 is an audit in quarter 4 to ensure that where the NEWS2 score is greater than 5 appropriate escalation action has been taken.

Since this was agreed as a Big 9 item last March (2019) the Community Teams in ICS have gone through significant reconfiguration to work as much more integrated community teams. The evidence (both from the data and clinical observation) suggest that baseline observations are taken by Nursing staff on first visit but if they ask other team members (e.g. Physio or OT) to visit as part of the care plan then quite reasonably baseline observations are not done. It is clear from the data that where there is a single visiting clinician (e.g. Community Matron) observations are undertaken as a baseline and this would support the view above. It is not possible to report on this clinical decision making electronically and any further work would require a lengthy and detailed manual trawl of the records. It is proposed that the focus of this Big 9 item moves onto NEWS2 escalation and outcomes as part of a mainstreaming of this work.

A forecast is shown on the graph.

1-Summary of Issues:

2-Action Plan: (actions taken, including assignment of responsibility for this plan)

3-Timescales

4-Effect of this Exception on the Forecast Plan (how we get to our final forecast position from here)

15.8% 15.8% 20.7% 23.1% 27.6%

13%

26%

40%

55%

70%

80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

obse

rvat

ions

(%)

Month

Actual %

Target %

Forecast %

TPP Sepsis Observations - February


Measure2019/20

Full Year Target


Services Linked to Dementia Friendly Actions (no) (Big 9) 97 60 40 93 16 52 52


We expect to receive a few more completed returns confirming actions undertaken. The current pressure on operational services may make reaching the full 97 returns unlikely by end of March. We have adjusted our forecast to 75 by year end.

We consider that the actions already in place are sufficient.

The actual return confirming completed actions was a little later than forecasted. February's target was exceeded by mid March (62 by 13th March). Some very good examples of small local changes which will make a difference to people with dementia across services have been collected and are already being shared on the Quality and Safe Care Champions Facebook pages.

We will need a longer period to achieve forecast position, in view of the exceptual pressures on operational services.



3-Timescales


84 90 93 16 52

65

97

0

15

60

97

0

20

40

60

80

100

120


obse

rvat

ions

(%)

Month

Actual %

Target %

Forecast %

Dementia Friendly Environment - February


Measure2019/20 Full Year Target

YTD Target Dec-19 Jan-20 Feb-20 YTD

Training - Resuscitation (% compliance) 96% 96% 88.7% 88.7% 88.6% 88.6%


Positively, as in the last two exception there has been a stabilisation of the compliance and there has been no further decrease in compliance. The team continue to see the return to work of all of the educators and this means that capacity will be increasing. The team are aware of those who require the courses and are contacting them to book on the courses that are available. The team have also increased the number of places available. The resuscitation compliance is comprised of several courses which staff attend to obtain their competence. The two courses of concern are ILS and pILS. The Trust should be assured that whilst this compliance remains low for DCHS, across the health population the compliance is above average.

Over the upcoming months the Trust should continue to see a sustained maintenance and improvement within the compliance. However, it is highly unlikely that the year end target will be met

Moving forward the trust can see that all of the level 2 resuscitation courses are on ESR for staff to book on. For the MIU staff who require pILS, People Development Team have booked all of the relevant staff on the course through to March 31st 2021. There has been agreement that all OPMH and LD (inpatient staff) will complete the RC(UK) ILS course. This will lead to reduced confused and more streamlined reporting.


2. Action Plan

3-Timescales


91.4% 92.1%

90.6%

89.0% 89.7%

91.9%

90.7%

89.5% 88.7% 88.7% 88.6%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%


%ag

e Co

mpl

ianc

e

Month

Resuscitation(%)

Forecast (%)

Target Profile(%)

Resuscitation (% compliance) - February


Measure2019/20

Full Year Target


Physical Violence and Aggression Incidents Towards Staff (no) (Big 9) 157 144 51 160 179 196 196


1) COO/Chief Nurse overseeing calls to monitor progress with action plan, which is progressing well. Training needs analysis complete with training planned to commence April 2020. 2) Report from NHSE/I mirrored their verbal feedback – i) Agree bed based model going forward, ii) Prioritise discharge of the two people we had at the time of the visit, which is now a system issue that all parties are being held to account to. (These patients are still with DCHS and two additional patients are now being supported at Hillside which has placed additional pressure on the ward team). iii) Any change of services require co–production, iv) Review of crisis offer across system. 3) Programme of work now complete. 4) Training ongoing and is being monitored through the staffing for quality paper. 5) Funding request resubmitted to HEE to support this work. 6) Chief Nurse and Head of Operational Quality to commence 6 monthly staffing reviews with each Pathway 3 site with the Matron and ward manager from April 2020 and then rolling Programme. Monthly meeting with Matrons and Ward Managers with Head of Operational Quality to review rosters and application of consistent dependency tool - commenced October 2019 and rolling programme monthly. 7) This has been completed and the policy approved at QPC in November. Staff and managers' guides are being drafted with communications to promote the importance of early reporting and challenge of unacceptable behaviour. 8) Adjustments to alarm system completed, recruitment underway. 9) Initial meeting scheduled April 2020.

1) There is significant focus to support inpatient wards. This includes a project group (sponsored by COO and Chief Nurse) reviewing the current provision of LD Inpatient Assessment and Treatment which has been reported to CCG. A risk is on the register (3221) to monitor further actions. This includes a training needs analysis for staff to mitigate the risk. 2) NHSE/I have visited inpatient wards to provide advice and guidance. 3) Capital expenditure has been agreed for work on inpatient ward to mitigate risks. 4) Colleagues on rehabilitation wards and in community teams will be supported by ongoing work to roll out new learning pathways (tiered approach) by the Workforce Development team following a review of the existing framework by the Specialist Lead Trainer for End of Life and Dementia. 5) As patients with an increasing acuity and complexity of conditions such as dementia are being cared for on rehab wards, project work is ongoing to develop a holistic approach including the environment, training, liaison team, and support from Derbyshire Healthcare FT. A risk is on the register (3271) to monitor further actions. 6) The Chief Nurse is undertaking a review of establishments on all of our wards to ensure we have the right staff on shift to care for our patients' needs and complexities. 7) Aggressive and Violent Behaviour Towards Staff Policy has been reviewed to support colleagues to challenge unacceptable behaviour. 8) Review of arrangements in LD inpatients has identified short and medium term improvements (eg adjustments to alarm system, staff recruitment to reduce reliance on agency). 9) Review of Joint Agreement on Offences against Emergency Workers (published January 2020) carried out to determine how to implement in DCHS. Task and Finish Group on Violence and Aggression set up led by Chief Nurse.

We do not want any staff to suffer injury whilst at work, and therefore set ourselves a Big 9 target for 2019/20 to decrease the number of 'Violence and Aggression' incidents resulting in injury occurring across the Trust. Sadly, we have seen an increase this year; between April 2019 and February 2020 there have been 179 incidents of physical violence against staff resulting in injury. The locations with the highest numbers of incidents have been LD inpatients (109 incidents) and OPMH inpatients (50 incidents). There have been 24 incidents across other inpatient wards.

The most significant impact will come through reducing violence in our inpatient services. The forecast has been adjusted to reflect that the current incident numbers have exceeded the year end target. Although November and December saw a reduction in incident numbers, we have seen an increase during January and February which is attributable to new admissions to LD inpatients, and have adjusted the forecast to reflect this.



3-Timescales


13

50 66

84 104

119 136

147 160

179 196

13 26

39 52

65 79

92 105

118 131

144 157

0

50

100

150

200

250


Assa

ults

(no

)

Month

CumulativeActivity (no)

CumulativeTarget (no)

Forecast(no)

Violence & Aggression - Cumulative Assaults - February


Measure2019/20

Full Year Target


Increase Number of Staff who are Under 25 to 5% of Workforce (no) (Big 9) 214 204 108 95 100 108 108


It has been acknowledged that this needs to operate as a long term project. We anticipate that the work so far will come to fruition during the next financial year.

Progress on the Under 25s workstream includes: The Prince's Trust Programme begins this month and we have 10 people signed up to undertake work experience here at DCHS. We hope to convert some of these placements into permanent employment. Our apprenticeship programme continues to gain momentum with a number of entry-level apprenticeships being advertised since September, which have attracted some under 25s. External promotion events for DCHS and NHS as a employer have been led by the people development team at schools/colleges and career events.

The number of under 25s employees at DCHS rose by eight in February 2020; which was an improvement on the revised forecast. We remain significantly below our trajectory for the year.

Revised forecast included.



3-Timescales


108 108 103 103 95 89 99 100 95 100 108

105 115

125 135

145 155

164 174

184 194

204 214

0

50

100

150

200

250


Staf

f (no

)

Month

Activity (no)

Target (no)

Forecast(no)

Staff Under 25 - February


Measure2019/20

Full Year Target


Agency Costs as percentage of Paybill (£m) 1.36 1.21 0.21 1.50 1.67 1.77 1.77


The current year-end forecast is for a total spend of £1.9m. Based on this forecast there is remaining headroom of £0.1m before the total spend for the year would exceed £2.0m and therefore limit the Trust’s overall UoR to a 3.

Progress on the ongoing actions (which Board are already sighted on) to mitigate Agency spend is as follows: 1. Recruitment to a Responsive Workforce Team of 10 wte Ward HCAs is now complete with remaining start dates in February and March. 2. Recruitment to the vacant posts within the central Responsive Workforce Team has been successful and this team are supporting a range of community teams. 3. Recruitment to a pilot of a 'local' Responsive Workforce Team in the NED/Chesterfield community team has been very successful with appointment of 4.4 wte band 6s. We will evaluate the impact on patient care and agency spend of this trial. 4. The incentive 'bonus payment' programme for Bank Workers to work more shifts was very successful during February , with fill rate of 84.7%. 5. In our Learning Disabilities Service we continue to secure ways to contain agency spend (such as block bookings and use of less expensive agencies) but this is extremely challenging. We have now secured a Speciality Doctor on our internal Bank which will mitigate some medical spend, however the service does legally require consultant cover for the Mental Health Act and therefore this does not offer a full solution.

The Trust has a £1.36 million annual agency spend ceiling set by NHSI and agreed a planned monthly spend profile as part of the financial plan for 2019/20. By the end of month 11 of 2019/20; total expenditure incurred on agency staff was £1.77m, so as Board are already aware, we have already breached our target. Agency spend in February remains consistent to the previous few months mostly driven by continued pressures in our Learning Disability Service. This is due to additional nursing staff needed to safely care for a 4th patient on the Hillside Inpatient Unit, as well as Locum Medical cover. Both are ongoing pressures . Due to the performance framework under which the Trust’s NHSI Use of Resources (UoR) rating is determined, in order to maintain the UoR rating of a 1, the Trust needs to contain total agency for the year to £2.04m (i.e. less than 150% of the overall ceiling). Spend in excess of 150% of the annual ceiling would trigger a 4 against this metric, limiting the Trust’s overall UoR score to a 3.

We are forecasting a total year-end spend of £1.9m



3-Timescales


0.21 0.40

0.61

0.87

1.06 1.18

1.26 1.34

1.50 1.67

1.77

0.13 0.23

0.33 0.42

0.52 0.64

0.75 0.83

0.92 1.07

1.21 1.36

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00


£ (m

)

Month

Activity(£m)

Target (£m)

ActivityForecast (£m)

Agency Costs (£m) Cumulative - February


Measure2019/20 Full Year Target


Machines Patched With Security Patches In Last 30 Days (%) (Big 9) 97.5% 97.3% 89.9% 89.8% 91.6% 91.6%


The underlying cause of the drop in compliance has not been identified to a single factor. While the ongoing investigation continues, changes in operating systems, large scale machine swap-outs and changes to patching mechanisms provide for a temporary, unstable environment.

The original end of year forecast is unlikely to be met.

As above

• The regular patching cycle will continue with new patches being released 21st March.• Forced patching to non-compliant devices will continue throughout the month• Deployment of patching via Ivanti End Point Manager is now in pilot. • Full deployment of Ivanti End Point Manager planned for end of March 2020 subject to successful pilot.


2. Action Plan

3-Timescales


93.4% 93.4%

89.5%

91.8%

96.6% 97.0%

91.3%

85.0%

89.9% 89.8%

91.6% 92.5%

78.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%


%ag

e

Month

Actual(%)

Forecast(%)

TargetProfile(%)

Patched in last 30 days (%) - February


Measure2019/20

Full Year Target


Data Quality Maturity Index Compliance - Overall (no) 95 95 85.7 86.8 87.9 87.9


3-6 months

DCHS has concluded that to submit an accurate reflection of DCHS provision a local version of the Community Services Data Set is to be built. This is scheduled to be done by April 2020. Prior to that DCHS have identified certain fields that can be coded prior to submission from within the database and this work is now being actioned. this should reflect an increase in DQMI performance in March but the significant improvements will be realised in 2020/21.

Data extract/definition issues with the system supplier delivered extract have caused ongoing DQMI issues for DCHS. These have been escalated to TPP directly and to national bodies (NHSE&I/NHSD) on separate occasions. Many issues are 'quick fixes' in that a field has been misinterpreted or misrepresented in the extract causing a data quality trigger.

Increase in DQMI score towards the national target of 95% by the end of Q1 2020/21.



3-Timescales


89.7 89.2 89.5 89.3

85.7 86.8

87.9

80.0

82.0

84.0

86.0

88.0

90.0

92.0

94.0

96.0


Scor

e

Month

Actual

Target

Forecast

Data Quality Maturity Index - February


MeasureFrequency of

Reporting2019/20 Full Year Target Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Forecast Outturn

Narrative

Staff Flu vaccinations

Quarter 480% uptake of flu vaccination by frontline

clinical staff in Q4

A comprehensive work plan has been delivered by the Staff Wellbeing Team in support of the 80% target for 2019-20. Flu campaign now complete. Uptake in frontline staff has now met 80% target at the end of Q3.

Quarterly80% of patients to be screened for tobacco

and alcohol use within rehab inpatient services

Processes already embedded following introduction of alcohol and tobacco pathways in 2017 for CQUIN. Close monitoring remains in place to support clinical staff in the provision of screening and advice. All targets met for Q3.

Quarterly90% of relevant patients offered brief advice

where identified as smokers within rehab inpatient services


Quarterly

90% of relevant patients offered brief advice and specialist referral for where identified as

above low risk level drinkers within rehab inpatient services


Quarterly80% of relevant patients have lying and

standing blood pressure recorded at least once

Standard recording of lying and standing blood pressure now in place as part of admission procedure, following launch with ward managers on 22.05.19. Supporting paperwork amended to enable data capture. SystmOne developments now complete and live within ANP unit to enable automated data reporting for rehab wards. Manual process agreed for Older People's Mental Health Wards and baseline manual audit undertaken. Manual audit has confirmed that the Q3 target has been met (81% achievement).

Quarterly80% of relevant patients have no hypnotics, antipsychotics or anxiolytics prescribed or

rationale documented if given

Further changes to SystmOne launched on 22nd October 2019. New development supports data capture regarding rationale, utilising clinical indication functionality within the S1 e-prescribing module. Completion of rationale within SystmOne is a mandatory field which ensures compliance. Manual audit has confirmed that the Q3 target has been met (81% achievement).

Quarterly

80% of relevant patients have mobility assessment documented, and mobility aid

provided where required, within 24 hours of admission

SystmOne template changes have been completed to enable capture of relevant data elements - clinical pathways already in place. Training now delivered following go-live in June 2019. Targets not met for Q1 as a result of data collection processes being established during June. Manual audit has confirmed that the Q3 target has been met (81% achievement).

Personalised Goals for Venous

Leg Ulcer Wounds

Quarterly Progress against locally agreed milestones.

Use of an enhanced wound assessment template to record and review personalised patient goals now being rolled out following review of SystmOne use by wound clinic staff. CQUIN launch event undertaken with clinic leads on 9th July 2019. Audit sample size agreed at 50% based on patient numbers attending established clinics. All targets met for Q1. All targets met for Q2 - 100% of appropriate patients had a goal documented within their record. All targets met for Q3 - 100% of appropriate patients had a goal documented within their record.Q3 deep dive audit on a sample of records has now been completed to establish links between goal setting and clinical outcomes for patients.

CQUIN INDICATORS 2019-20

Preventing Risky Behaviour -

Tobacco and Alcohol

Three High Impact Actions

to Prevent Hospital Falls

NHS DERBYSHIRE COUNTY CCGs AND ASSOCIATES CONTRACT


TrustPeer Group

Domain Indicator Relevance ValuePeer

group average

Rank Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 - Notes

Referral To Treatment (RTT) waiting time compliance (%):

Incomplete Trust Level 96.17 95.23 95.9% 95.8% 95.3% 95.2% 94.8% 94.1% Not now collected

Not now collected

Not now collected

Not now collected

Not now collected

Services transferred

Accident and Emergency (% discharged, admitted or transferred within 2 hours of arrival at MIU/walk-in centre) (%)

A&E Depts 92.72 - 95.2% 94.2% 92.8% 90.9% 95.0% 94.7% 94.0% 94.9% 94.2% 96.3% 99.5%

Outpatients (% DNA):

Adults (%)Clinics in

community5.97 - 4.9% 5.6% 5.3% 5.0% 5.4% 5.1% 5.1% 5.4% 5.7% 5.7% 5.1%

Children (%)Clinics in

community- - 10.5% 9.1% 9.6% 9.4% 8.7% 6.9% 8.8% 6.6% 7.3% 6.51.% 5.5%

Average Length of Stay (days):

EmergencyCommunity

beds14.12 - 15.8 17.7 16.2 15.2 15.9 11.8 28.2 13.9 14.5 11.9 21.2

Urgent Care

OtherCommunity

beds17.96 - 21.4 20.7 20.1 20.7 22.2 21.3 19.9 21.4 18.6 23.7 22.9

Rehab

Return to usual place of residence after discharge (%)Community

beds63.39 - 60.4% 63.5% 64.3% 62.2% 58.2% 60.9% 58.5% 55.6% 55.8% 53.9% 52.5%

Minor Injuries Unit Friends and Family (from Apr 2015):Response Rate (%) MIU depts - - 7.4% 10.7% 8.6% 7.6% 10.7% 9.4% 3.5% 11.0% 4.2% 8.2% 10.7%

Recommended (%) MIU depts - - 99.8% 99.3% 100.0% 99.0% 99.6% 99.2% 100.0% 99.2% 98.4% 99.6% 99.2%

Community Friends and Family (from Jan 2015)

Response Rate (%)Community

services4.15 4.66 3.1% 3.4% 3.4% 3.3% 4.2% 3.7% 3.0% 4.0% 2.9% 3.0% 3.1%

Recommended (%)Community

services98.59 96.04 98.5% 98.2% 98.5% 98.2% 98.2% 98.0% 98.3% 98.4% 97.3% 98.4% 98.2%

Staff Friends and Family:

Response Rate (%) Trust Level 38.94 17.13 42% 42% 42% 42% 42% 42% 42% 42% 42% 42% 42%

Recommend as Place to Work (%) Trust Level 72.00 62.32 69% 69% 69% 72% 72% 72% 72% 72% 72% 72% 72%

Recommend as Caring Place (%) Trust Level 90.41 83.48 90% 90% 90% 91% 91% 91% 91% 91% 91% 91% 91%

Not Recommend as Place to Work (%) Trust Level 13.32 18.85 12.6% 12.6% 12.6% 12.4% 12.4% 12.4% 12.4% 12.4% 12.4% 12.4% 12.4%

Not Recommend as Caring Place (%) Trust Level 2.43 4.44 2.3% 2.3% 2.3% 1.7% 1.7% 1.7% 1.7% 1.7% 1.7% 1.7% 1.7%

Safe Staffing

Percentage of staff turnover (Monthly) Trust Level 0.64 1.03 0.82% 0.77% 0.76% 0.77% 0.76% 0.73% 0.70% 0.68% 0.78% 0.77% 0.77%

Percentage of staff turnover (Rolling 12 Months) Trust Level 12.87 17.79 8.98% 8.99% 9.04% 9.29% 9.15% 9.15% 9.09% 9.00% 9.01% 8.99% 8.99%

Percentage of unplanned sickness absence (%) Trust Level 5.43 - 4.41% 4.31% 4.69% 4.78% 4.53% 4.74% 5.27% 5.22% 5.34% 5.40% 4.98%

Well Led

Averages as at July 2018, against peer if available

Appendix 2 -NHS Improvement Community Indicators Scorecard 2019-20

Community

Effective

DERBYSHIRE COMMUNITY HEALTH SERVICES NHS TRUST

Responsive

Caring


TRUST BOARD Document Title: Financial Performance Report

Presenter/Title: Cath Benfield, Deputy Director of Finance Contents of Paper were previously discussed by: n/a

Author/Title: David Gray Head of Financial Management Contact Email and Telephone Number: [email protected] 07768646362




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

Purpose of Paper

The paper sets out the financial performance of the Trust as at 29th February 2020. The report details performance against statutory and internal targets.

Recommendations

Board Members are asked to receive the report and note the following key points from the report

- The Trust is reporting a surplus position of £3.74m at month 11, which represents a £0.1m surplus variance against the planned surplus of £3.64m. A year end surplus of £3.88m is forecast in line with the control total set by NHS Improvement.

- The Trust’s agency expenditure at month 11 is approximately 46% above the planned

year to date level. This means that the Trust is now reporting a UoR score of 1.

- As the situation regarding COVID-19 continues to escalate the national guidance is to spend what is required but to ensure financial control is maintained. The Trust is actively monitoring and recording costs incurred in managing the impact of the pandemic.

- Due to the uncertainty around the COVID-19 pandemic and to enable organisations to

respond some changes are being implemented to the NHS Finance regime for the period 1ST April to 31st July 2020 that will have implications for operational and financial planning for 2020/21. As a result an interim financial plan will be presented to the Board in April which will need to be revised once the situation regarding the pandemic has abated.


3.3/19 There is a risk to the financial stability of the organisation due to not meeting the future Sustainable Quality Improvement Programme over the next two years (2018/19 and 2019/20) and the loss of service contracts, decommissioning of services and / or unfavourable contract negotiations resulting in unfunded stranded costs

Page 1 of 1250 Financial Performance Report.pdf


Financial Impact The Trust is reporting a surplus position of £3.74m at month 11, which represents a £0.1m surplus variance against the planned surplus of £3.64m. A year end surplus of £3.88m is forecast in line with the control total set by NHS Improvement. The 2019/20 SQIP programme is forecast to be achieved in full by the end of the financial year. The Trust’s agency expenditure at month 11 is approximately 46% above the planned year to date level. This means that the Trust is now reporting a UoR score of 1. The month 11 cash position is £6.8m ahead of plan and the cash position is forecast to be £33.8m at the end of March 2020. As the situation regarding COVID-19 continues to escalate the national guidance is to spend what is required but to ensure financial control is maintained. The Trust is actively monitoring and recording costs incurred in managing the impact of the pandemic to enable reimbursement. The report contains a number of issues and risks that may have a financial impact on the organisation however the Trust is continuing to forecast that it will meet all its statutory financial duties for the year.


Report attached



Governors will hold the Board to account around its financial position

What are the Equality, Diversity and Inclusion implications? None


None

Risk Register




WORKING CAPITAL37.00 G 33.83 G8.07 G 4.90 G

£m % £m % % £m % £m % £m % (3.72) G (2.95) GEBITDA (8.87) (5.10) (8.73) (5.04) (1.58) (9.54) (5.04) (9.29) (4.92) 0.26 (2.68)

Net (surplus)/deficit (3.64) (2.09) (3.74) (2.16) 2.78 (3.88) (2.05) (3.88) (2.05) 0.00 0.00 SINGLE OVERSIGHT FRAMEWORKSingle oversight framework capital service capacity (x) 4.34 G 4.33 G

I&E SURPLUS (excl. IMPAIRMENT) I&E SUMMARY AS AT 29 FEBRUARY 2020 Single oversight framework capital service capacity 1 G 1 GSingle oversight framework liquidity (days) 57.97 G 53.27 G

FEB 2020

YTD

FOTYTD

VAR

ACTU

AL

PLAN

Current Liabilities Variance (£m)£m

VAR

FOT

PLAN

FULL YEAR

(0.10)

0.14

DERBYSHIRE COMMUNITY HEALTH SERVICES NHS FOUNDATION TRUST FINANCIAL PERFORMANCE REPORT

PLAN ACTUAL VARIANCE PLAN FOT VARIANCE

FEBRUARY 2020 KEY FINANCIAL INDICATORS

EBITDA AND SURPLUS AS AT 29 FEBRUARY 2020YTD 2019/20 FULL YEAR

FEBRUARY 2020

FOTYTD

Current Assets Variance (£m)Cash at bank as per the ledger (£m)

Single oversight framework liquidity 1 G 1 GSingle oversight framework I&E margin (%) 2.16 G 2.05 GSingle oversight framework I&E margin 1 G 1 G

£m £m £m £m £m £m Single oversight framework distance from plan (%) 0.07 G 0.01 G(173.96) (173.26) 0.70 (189.26) (188.73) 0.53 Single oversight framework distance from plan 1 G 1 G

PAY 119.67 119.04 (0.64) 130.68 129.89 (0.79) Single oversight framework agency spend - Dist. from Cap (%) 46.12 R 40.10 RNON-PAY 45.42 45.50 0.08 49.03 49.55 0.52 Single oversight framework agency spend - Dist. from Cap 3 R 3 ROTHER 5.23 4.99 (0.24) 5.66 5.41 (0.26) Overall rating 1 G 1 G

(3.64) (3.74) (0.10) (3.88) (3.88) (0.00)

PERFORMANCE AND SQIP YTD FOTSQIP MONITORING MONTH END CASH BALANCE Contract over/(under) performance (£m) (0.88) R (0.71) R

Over/(under)achievement of SQIP target (£m) 0.02 G 0.00 G(Over)/underspend against investments (£m) 0.00 G 0.00 GNet impact Performance and SQIP (£m) (0.86) R (0.71) R

ADDITIONAL TRIGGERS YTD FOTReceivables aged over 90 days (%) 5.0 6.3 R 5.0 GPayables aged over 90 days (%) * 5.0 36.9 R 25.0 RChange in Finance Director in last year 2 0 G 0 GInterim Finance Director in place over QE 2 0 G 0 GDays expenditure covered by QE cash 10 68.8 G 68.8 GCapital Expenditure % of plan (%) 85.0 49.5 R 87.0 A

*The additional trigger of Payables aged over 90 days is showing as red due to the Trust being in dispute with NHS Property services (NHSPS) over invoices raised in 2019/20 that relate to historic financial periods. Escalation meetings are in place with NHSPS to resolve the outstanding debt.

INCOME

TOTAL

FEB 2020

VAR

ACTU

AL

PLAN

VAR

FOT

PLAN

0.00.51.01.52.02.53.03.54.04.5

Cum

ulat

ive

surp

lus

(£m

)

Plan Actual Forecast

0.05.0

10.015.020.025.030.035.040.045.0

Cas

h at

mon

th e

nd (£

m)

Plan Actual Forecast

0.0

0.1

0.2

0.3

0.4

0.5

0.6

SQIP

(£m

)

Plan (£m) Actual (£m) Forecast (£m)


DERBYSHIRE COMMUNITY HEALTH SERVICES NHS FOUNDATION TRUST

MONTHLY FINANCIAL PERFORMANCE REPORT FOR TRUST BOARD AS AT 29TH FEBRUARY 2020

1. Introduction The purpose of this report is to update and inform the Board on performance against key financial criteria for month 11 of the current financial year, 2019/20. The Trust is reporting a surplus position of £3.74m at month 11, which represents a £0.1m surplus variance against the planned surplus of £3.64m. The cash position is £6.8m ahead of plan (see Appendix 4). The Trust is forecasting a year end surplus of £3.88m, which is consistent with our control total set by NHS Improvement. 2. Summary Financial Position The Single Oversight Framework used by NHS Improvement assesses the financial sustainability of providers. The framework uses five metrics, each with an equal weighting, to derive an overall rating score for the organisation. A rating of a 1 represents the lowest financial risk, with a score of a 4 being the highest risk. Table One – Finance Metrics The Trust’s Performance against the new Finance Metrics ratings is detailed in the table below. The Trust achieved a rating of 1 at year-end. This reflects the strong balance sheet of the Trust.

Area Metric Weight Year to Date Year End Outturn

Value Score Wtd Score

Value Score Wtd Score

Financial Sustainability

Capital Service Capacity

20% 4.34 1 0.2 4.33

1 0.2

Financial Sustainability

Liquidity (Days)

20% 57.97

1 0.2 53.27 1 0.2

Financial Efficiency

I&E Margin 20% 2.16% 1 0.2 2.05% 1 0.2

Financial Controls

Distance from Control Total

20% 0.07% 1 0.2 0.01% 1 0.2

Financial Controls

Agency Spend 20% 46.12% 3 0.6 40.10% 3 0.6

Overall Rating 1 1.4 1 1.4


The Trust’s performance against the Agency Spend metric has slightly improved in month 11 resulting in the Trust being 46% over the cap as opposed to 57% in month 10. This improvement means that the Trust’s overall UoR score at Month 11 is now a 1 as the financial control on agency is only scored as a 3. Due to the performance framework under which the Trust’s Use of Resources (UoR) rating is determined, in order to maintain the UoR rating of a 1 at the end of the Financial Year, the Trust needs to contain total agency for the year to £2.04m or less than 150% of the overall ceiling. Spend in excess of 150% of the annual ceiling would trigger a 4 against this metric, limiting the Trust’s overall UoR score to a 3. This means that agency spend cannot exceed £0.27m during March, if the overall rating of a 1 is to be maintained. The current agency forecast indicates a year end-spend of £1.90m, which would mean that the Trust’s overall UoR score would remain at a 1. However, the situation continues to be monitored closely, particularly with the potential impact of COVID-19 on staffing levels being unknown at present. Bi-weekly meetings continue to take place to review the agency expenditure across the Trust and to ensure there is a robust forecast in place. 3. Income & Expenditure Appendix 1 details the Income and Expenditure Statement as at Month 10. More detail on the income and expenditure position is provided below.

3.1 Clinical Income The month 11 Clinical Income position is £883k behind plan, and we are forecasting to under-perform at year end by £713k. The main driver behind this is the under-achievement seen on the cost and volume activity plans and is a reflection of the Trust activity monitoring. This equates to £823k of the current year to date under performance and represents £725k of the year-end forecast. As part of planning for the financial year-end, the Trust has agreed a fixed out-turn position on the main multi-lateral contract with Derby and Derbyshire CCG. This position takes into account contract variations, and forecast cost and volume and CQUIN performance, and is reflected within the reported year to date and forecast out-turn figures.

3.2 Non-Clinical and Other Income Overall Non-Clinical Other Income is slightly ahead of plan, however there are a number of services underachieving against plan these being Estates (IFM) through reduction in maintenance works for external organisations and the POE Joint Venture with Derbyshire Healthcare where income has reduced against plan due to corresponding expenditure underspends.

3.3 Expenditure Overall, the Trust is reporting an underspend position against the expenditure plan at month 10 of £0.56m.


Pay costs are underspent compared to plan by £0.64m. This is being driven by a mixture of slippage on SQIP schemes, unachieved Vacancy Factors, and use of Flexible Workforce and Agency. The pressures highlighted above are however largely mitigated with underspends due to vacancies in other areas. Agency Spend is significantly higher than plan at the end of January (£0.56m) due to ongoing use of medical locums within both the Learning Disability and Primary Care Divisions covering vacancies and maternity cover alongside the significant use of registered and unregistered nursing attending to Learning Disability patients admitted to Ash Green whom require intensive support. Agency and Flexible Workforce represent 3.6% of the Total Pay Spend to date. Non-pay Costs are slightly over-spent against plan by £0.08m As the situation regarding COVID-19 continues to escalate the national guidance is to spend what is required but to ensure financial control is maintained. The Trust is actively monitoring and recording costs incurred in managing the impact of the pandemic. In order to facilitate an initial reimbursement a template has been submitted to NHS England and Improvement on the 23rd March 2020 outlining actual costs up to the 15th March 2020 with an estimate of costs up to 31st March 2020. A final return will be collected after the 31st March 2020 and a final payment will be made mid-April. A monthly collection for 2020/21 is being developed and the Trust awaits further information on how this will be collected going forward. 3.4 Sustainable Quality Improvement Plan (SQIP) The Trust has a SQIP target of £5.582m for 2019/20. At the end of Month 11 the Trust is over achieving by £0.015m against the target against the planned schemes of £5.079m. The Trust is forecasting to fully deliver against the SQIP target of £5.582m by year end. Further detail of the SQIP position can be found in Appendix 2. 4. Statement of Financial Position Appendix 3 sets out the Statement of Financial Position. 4.1 Cash At the end of February, the cash balance was £6.8m ahead of plan (actual £37.0m against a plan of £30.2m). The factors driving the cash position are:

- A £4.9m year to date under spend on the capital programme - Working capital variations

The Trust continues to actively manage working capital in line with the Working Capital Framework. In particular, the Treasury team continues to chase outstanding debt and promote prompt invoicing of income.


Further detail can be found in Appendix 4. 5. Capital Plans and Expenditure

The month 11 position for capital is an under spend of £4.9m. There is significant expenditure planned for the last month of the year including on key strategic capital developments and continued investment in the Trust’s IM&T infrastructure. The forecast out-turn position has been undertaken at the end of month 11 is showing a £1,1m under spend at year end. Further detail can be found in Appendix 5 attached. 6. Risks Due to the uncertainty around the COVID-19 pandemic and to enable organisations to respond some changes are being implemented to the NHS Finance regime for the period 1ST April to 31st July 2020 that will have implications for operational and financial planning for 2020/21. As part of this, income levels covering the four month period are being calculated for each provider nationally and will be shared with organisations on the 23rd March. As a result an interim financial plan will be presented to the Board in April that will need to be revised once the situation regarding the pandemic has abated. Given the agreement reached on the contractual out-turn position, the residual risks to the 2019/20 financial position are:-

- Delivery of the Trust’s SQIP programme both in-year and on a recurrent basis. - Delivery of the service line positions in line with the forecast - Winter pressures

7. Summary

Board Members are asked to note the month 11 position against the financial targets. Cath Benfield Deputy Director of Finance


Appendix 1

1 2 3 4 5 6 7 8 9 10 11 12

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

Actual Plan Variance Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Forecast Outturn Plan

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

OPERATINGIncome

INC1 Income from Patient Care - Contracted -158,170 -159,053 883 -14,570 -14,963 -13,934 -14,349 -14,926 -14,847 -14,701 -14,420 -13,481 -14,068 -13,911 -14,129 -172,299 -173,012

INC5 Income from Patient Care - Other -613 -574 -39 -48 -46 -65 -57 -52 -47 -61 -63 -57 -59 -58 -57 -670 -626

INC2 Other NHS Income -11,768 -11,633 -135 -1,015 -1,040 -972 -1,190 -1,010 -1,058 -952 -1,082 -1,216 -1,054 -1,179 -1,018 -12,786 -12,667

INC3 Education and Training -1,086 -1,077 -9 -88 -91 -160 -91 -23 -103 -104 -95 -100 -124 -107 -85 -1,171 -1,175

INC4 Other Income -1,626 -1,623 -3 -196 -113 -141 -155 -134 -148 -212 -140 -109 -144 -134 -176 -1,802 -1,776

INCOME TOTAL -173,263 -173,960 697 -15,917 -16,253 -15,272 -15,842 -16,145 -16,203 -16,030 -15,800 -14,963 -15,449 -15,389 -15,465 -188,728 -189,256

Operating ExpensesEXP Employee Benefit Expenses 119,037 119,673 -636 11,364 10,869 10,954 10,889 10,757 10,827 10,746 10,538 10,573 10,575 10,945 10,856 129,893 130,681

EXP Drugs 1,891 2,012 -121 163 128 247 197 168 209 170 176 127 141 165 150 2,041 2,175

EXP Clinical Supplies and Services 8,957 9,227 -270 825 828 741 830 861 836 844 785 859 843 705 774 9,731 9,997

EXP Other Costs 34,648 34,178 470 2,998 2,880 2,579 2,853 2,877 4,199 3,253 3,454 3,456 3,209 2,890 3,130 37,778 36,862

OPERATING EXPENSES TOTAL 164,533 165,090 -557 15,350 14,705 14,521 14,769 14,663 16,071 15,013 14,953 15,015 14,768 14,705 14,910 179,443 179,715

OPERATING (PROFIT) / LOSS EBITDA -8,730 -8,870 140 -567 -1,548 -751 -1,073 -1,482 -132 -1,017 -847 52 -681 -684 -555 -9,285 -9,541

NON OPERATINGNON Loss / (Profit) on Asset Disposal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Impairment of non-current assets 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NON Depreciation / Amortisation 3,241 3,272 -31 308 332 320 209 290 291 291 305 295 291 309 308 3,549 3,588

NON Interest (Receivable) / Payable -263 -266 3 -20 -28 -15 -29 -22 -25 -25 -24 -25 -27 -23 -25 -288 -290

NON Public Dividend Capital 2,012 2,225 -213 176 228 201 184 185 238 126 176 160 160 178 134 2,146 2,365

NON OPERATING TOTAL 4,990 5,231 -241 464 532 506 364 453 504 392 457 430 424 464 417 5,407 5,663

RETAINED (SURPLUS) / DEFICIT -3,740 -3,639 -101 -103 -1,016 -245 -709 -1,029 372 -625 -390 482 -257 -220 -138 -3,878 -3,878

ADJUSTMENTS TO RETAINED SURPLUSDonated Asset Income -332 0 -332 0 0 -18 0 0 -95 -17 64 -256 4 -14 0 -332 0

Donated Asset Depreciation 111 144 -33 10 10 10 8 10 10 9 14 10 10 10 10 121 158

Impairment of non-current assets 16 0 16 0 16 0 0 0 0 0 0 0 0 0 0 16 0

TOTAL ADJUSTMENTS -205 144 -349 10 26 -8 8 10 -86 -8 78 -246 14 -4 10 -195 158

ADJUSTED RETAINED (SURPLUS) / DEFICIT -3,945 -3,495 -450 -93 -990 -253 -701 -1,020 287 -633 -312 236 -243 -224 -128 -4,073 -3,720

ADJUSTMENTS TO NORMALISE POSITIONAdjustments Retained Surplus 205 -144 349 -10 -26 8 -8 -10 86 8 -78 246 -14 4 -10 195 -158

STF Funding 1,808 1,808 0 102 102 103 136 136 137 205 205 204 239 239 238 2,046 2,160

TOTAL NORMALISING POSITION ADJUSTMENTS 2,013 1,664 349 92 76 111 128 127 223 213 127 450 225 243 228 2,241 2,002

NORMALISED POSITION (SURPLUS) / DEFICIT -1,932 -1,831 -101 -1 -914 -142 -573 -893 509 -420 -185 686 -18 19 100 -1,832 -1,718

STATEMENT OF INCOME & EXPENDITUREFEBRUARY 2020

Category

Year to Date Monthly Actual / Forecast

As at 28 February 2020


Appendix 2

SQIP Monitoring 2019/20 - Feb 2020

Summary of Overall SQIP Monitoring 2019/20

R/NR Plan Plan % of Annual

Actual Actual % of Annual

Variance Risk Rating Plan Out-turn Actual Variance Risk Rating

FYE Forecast

£'s % £'s %

Total SQIP 19/20 £5,063,645 90.7% £5,078,966 91.0% £15,321 0.3% £5,582,000 £5,582,610 £610 0.0% £4,182,810Recurrent SQIP R £4,713,645 90.1% £3,718,383 -£995,262 -21.1% £5,232,000 £4,170,610 -£1,061,390 -20.3% £4,182,810Non Recurrent SQIP NR £350,000 100.0% £1,360,583 £1,010,583 288.7% £350,000 £1,412,000 £1,062,000 303.4% £0

SQIP Schemes 2019/20

Scheme R/NR Plan Plan % of Annual

Actual Actual % of Annual

Variance Risk Rating Plan Out-turn Actual Variance Risk Rating

FYE Forecast

£'s % £'s %

Integrated Community Services Skill Mix Review R £263,767 90.8% £262,179 90.2% -£1,588 -1% £290,600 £290,600 £0 0% £322,000Additional Schemes to 1.5% target R £202,992 93.3% £198,841 91.4% -£4,151 -2% £217,510 £217,510 £0 0% £217,510Ilkeston Inpatient review R £79,400 83.4% £79,400 83.4% £0 0% £95,250 £95,250 £0 0% £190,500Non Pay Review R £98,600 91.6% £98,600 91.6% £0 0% £107,600 £107,600 £0 0% £107,600Medical Cover Review R £41,900 83.4% £18,583 37.0% -£23,317 -56% £50,250 £22,300 -£27,950 -56% £22,300Medical Cover Review R £7,500 83.3% £0 0.0% -£7,500 -100% £9,000 £0 -£9,000 -100% £0OT rotational posts R £24,700 83.4% £0 0.0% -£24,700 -100% £29,600 £0 -£29,600 -100% £0FYE 18/19 schemes R £38,900 91.7% £38,900 91.7% £0 0% £42,400 £42,400 £0 0% £42,400Planned Care Podiatry On-Call R £14,220 90.0% £4,920 31.1% -£9,300 -65% £15,800 £5,600 -£10,200 -65% £19,000Therapy Consolidation R £62,500 83.3% £37,150 49.5% -£25,350 -41% £75,000 £41,800 -£33,200 -44% £150,000Buxton Theatre Recharges R £9,200 92.0% £7,150 71.5% -£2,050 -22% £10,000 £7,800 -£2,200 -22% £10,000Consultant Led Transformation R £320,800 91.7% £47,014 13.4% -£273,786 -85% £350,000 £49,100 -£300,900 -86% £0Review of Management Structure R £45,800 91.6% £45,800 91.6% £0 0% £50,000 £50,000 £0 0% £50,000Additional Schemes to 1.5% target R £147,800 91.7% £84,583 52.5% -£63,217 -43% £161,187 £94,300 -£66,887 -41% £161,200Specialist ServicesAdmin efficiencies R £13,800 92.0% £13,800 92.0% £0 0% £15,000 £15,000 £0 0% £15,000Review of RTA income target R £36,700 91.8% £36,700 91.8% £0 0% £40,000 £40,000 £0 0% £40,000Specialist Services Non Pay Review R £4,466 66.7% £4,466 66.7% £0 0% £6,700 £6,700 £0 0% £10,000Inflationary rise on sale of Continence Products R £9,200 92.0% £9,200 92.0% £0 0% £10,000 £10,000 £0 0% £10,000Additional Schemes to 1.5% target R £220,100 91.7% £111,456 46.4% -£108,644 -49% £240,099 £121,700 -£118,399 -49% £240,100Integrated Facilities ManagementReview of Management Structure R £55,000 91.7% £53,263 88.8% -£1,737 -3% £60,000 £58,500 -£1,500 -3% £60,000Review of SLAs R £75,000 83.3% £0 0.0% -£75,000 -100% £90,000 £0 -£90,000 -100% £0Manor Stores R £42,200 91.7% £0 0.0% -£42,200 -100% £46,000 £0 -£46,000 -100% £46,000Catering Review R £194,500 90.9% £195,336 91.3% £836 0% £214,000 £214,000 £0 0% £40,000Health, Wellbeing and InclusionManagement Savings R £14,700 91.9% £14,700 91.9% £0 0% £16,000 £16,000 £0 0% £16,000Children's 0-19 M7-M12 R £416,700 83.3% £416,700 83.3% £0 0% £500,000 £500,000 £0 0% £500,000Children's 0-19 M1-M6 NR £350,000 100.0% £620,000 177.1% £270,000 77% £350,000 £620,000 £270,000 77% £0SAIS R £30,300 91.8% £30,300 91.8% £0 0% £33,000 £33,000 £0 0% £33,000DISH Non Pay Review R £91,700 91.7% £0 0.0% -£91,700 -100% £100,000 £0 -£100,000 -100% £0CorporateNon Pay Inflation Reserve - Zero Inflation Purchases R £275,000 91.7% £275,000 91.7% £0 0% £300,000 £300,000 £0 0% £300,000Estate Efficiencies R £320,800 91.7% £320,800 91.7% £0 0% £350,000 £396,000 £46,000 13% £350,000Procurement Efficiencies R £183,300 91.7% £74,000 37.0% -£109,300 -60% £200,000 £76,000 -£124,000 -62% £0MARS R £409,100 90.9% £303,900 67.5% -£105,200 -26% £450,000 £334,300 -£115,700 -26% £346,400Revenue to Capital ( Major Capital schemes) R £55,000 91.7% £55,000 91.7% £0 0% £60,000 £60,000 £0 0% £60,000Walton site demolition R £91,700 91.7% £19,000 19.0% -£72,700 -79% £100,000 £19,000 -£81,000 -81% £0Cash Reserves / Interest Receivable R £45,800 91.6% £110,600 221.2% £64,800 141% £50,000 £120,700 £70,700 141% £50,000LED lighting R £39,200 83.4% £0 0.0% -£39,200 -100% £47,000 £0 -£47,000 -100% £0Asset Lives R £220,000 91.7% £242,000 100.8% £22,000 10% £240,000 £264,000 £24,000 10% £240,000NHS Supply Chain - margin reduction R £183,300 91.7% £57,042 28.5% -£126,258 -69% £200,000 £68,450 -£131,550 -66% £136,900Business Rates R £32,100 91.7% £32,100 91.7% £0 0% £35,000 £35,000 £0 0% £35,000NHSPS Rent Reduction - Riverside R £66,700 88.9% £169,600 226.1% £102,900 154% £75,000 £185,000 £110,000 147% £0Additional Schemes to 1.5% target R £229,200 91.7% £250,300 100.1% £21,100 9% £250,004 £273,000 £22,996 9% £361,900

£0Total £5,063,645 £4,338,383 -£725,262 £5,582,000 £4,790,610 -£791,390 £4,182,810

MITIGATIONSScheme R/NR Review of Non Pay NR £0 - £302,500 £302,500 £0 £330,000 £330,000 £0Non recurrent service underspend NR £0 £175,000 £175,000 £0 £175,000 £175,000 £0GP Pension reimbursement NR £0 - £263,083 - £263,083 0% £0 £287,000 £287,000 £0

Total £0 £740,583 £740,583 £0 £792,000 £792,000 £0

£5,063,645 £5,078,966 £15,321 £5,582,000 £5,582,610 £610 £4,182,810

Year to Date

Year to Date

Annual

Annual


Appendix 3

1 2 3 4 5 6 7 8 9 10 11 122018-19 Annual Annual

Year Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Outturn PlanEnd Actual Plan Variance Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Forecast Outturn

£'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s

ASSETSNon Current

Tangible Assets 76,162 76,635 80,470 (3,835) 75,991 75,769 75,600 75,602 75,625 75,841 75,548 75,821 75,885 76,092 76,635 80,350 88,718

Intangible Assets 1,918 1,526 1,648 (122) 1,859 1,811 1,763 1,715 1,667 1,620 1,572 1,524 1,476 1,517 1,526 2,127 1,766

Total Non Current Assets 78,080 78,161 82,118 (3,957) 77,850 77,580 77,363 77,317 77,292 77,461 77,120 77,345 77,361 77,609 78,161 82,477 90,484

CurrentInventories 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NHS Trade Receivabes 3,676 2,258 1,370 888 3,558 4,692 2,431 2,216 2,223 2,182 2,206 2,119 2,031 2,731 2,258 2,231 1,631

Non NHS Trade Receivabes 2,208 2,930 1,879 1,051 2,244 870 1,044 2,184 2,241 1,074 2,529 4,077 902 2,416 2,930 1,232 1,032

PDC Dividend Receivable 127 0 0 0 127 127 127 127 127 0 0 0 0 0 0 0 0

Bad Debt Provision (189) (188) (234) 46 (177) (185) (179) (174) (176) (181) (184) (181) (182) (198) (188) (195) (215)

Capital Receivables 109 265 133 132 109 109 109 109 109 204 98 0 256 252 265 0 0

Accrued Income 4,015 2,621 2,625 (4) 4,711 5,844 4,598 1,956 2,045 1,896 2,228 2,550 2,052 1,802 2,621 2,875 2,475

Prepayments 1,742 1,108 1,811 (703) 1,540 1,665 1,782 2,018 1,738 1,557 1,770 1,394 1,093 1,398 1,108 1,408 1,908

Other Receivables 506 587 725 (138) 505 560 611 883 684 694 826 780 610 602 587 667 725

Asset Held For Sale 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Cash and Cash Equivalents 30,799 37,000 30,204 6,796 28,555 28,779 33,189 34,100 36,387 37,587 36,199 34,640 39,989 37,827 37,000 33,830 29,591

Total Current Assets 42,993 46,581 38,513 8,068 41,172 42,461 43,712 43,419 45,378 45,013 45,672 45,379 46,751 46,830 46,581 42,048 37,147

TOTAL ASSETS 121,073 124,742 120,631 4,111 119,022 120,041 121,075 120,736 122,670 122,474 122,792 122,724 124,112 124,439 124,742 124,525 127,631

LIABILITIESCurrent

Trade Payables (6,171) (4,220) (1,958) (2,262) (3,380) (3,851) (6,212) (4,922) (4,171) (4,844) (4,655) (3,469) (3,728) (4,834) (4,220) (2,508) (2,408)

Other Payables (4,038) (4,206) (4,000) (206) (4,272) (4,042) (4,112) (4,191) (4,108) (4,161) (4,198) (4,130) (4,116) (4,095) (4,206) (4,148) (4,000)

PDC Dividend Payable 0 (800) (880) 80 (176) (404) (605) (789) (974) 0 (126) (302) (462) (622) (800) 0 0

Capital Payables (1,306) (556) (791) 235 (525) (541) (506) (514) (512) (467) (523) (510) (590) (457) (556) (1,919) (1,119)

Accrued Expenditure (4,467) (6,146) (5,188) (958) (5,925) (5,433) (3,642) (3,588) (4,287) (4,887) (4,479) (5,363) (6,653) (5,661) (6,146) (5,338) (4,788)

Annual Leave Accrual (634) (634) (495) (139) (634) (634) (634) (634) (634) (634) (634) (634) (634) (634) (634) (784) (495)

Deferred Income, Current (155) (491) (937) 446 (179) (202) (176) (232) (1,101) (882) (1,016) (854) (703) (677) (491) (211) 0

Provisions, Current (1,518) (1,020) (103) (917) (1,053) (1,127) (1,129) (1,106) (1,104) (1,106) (1,036) (1,026) (1,026) (1,016) (1,020) (950) (103)

Other Liabilities 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Total Current Liabilities (18,289) (18,073) (14,352) (3,721) (16,144) (16,234) (17,016) (15,976) (16,891) (16,981) (16,667) (16,288) (17,912) (17,996) (18,073) (15,858) (12,913)

Non CurrentDeferred Income, Non Current 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Provisions, Non Current (30) (30) (30) 0 (30) (30) (30) (30) (30) (30) (30) (30) (30) (30) (30) (30) (30)

Total Non Current Liabilities (30) (30) (30) 0 (30) (30) (30) (30) (30) (30) (30) (30) (30) (30) (30) (30) (30)

TOTAL LIABILITIES (18,319) (18,103) (14,382) (3,721) (16,174) (16,264) (17,046) (16,006) (16,921) (17,011) (16,697) (16,318) (17,942) (18,026) (18,103) (15,888) (12,943)

TOTAL ASSET EMPLOYED 102,754 106,639 106,249 390 102,848 103,777 104,029 104,730 105,749 105,463 106,095 106,406 106,170 106,413 106,639 108,637 114,688

TAXPAYERS' EQUITYPublic Dividend Capital 1,377 1,377 1,377 0 1,377 1,377 1,377 1,377 1,377 1,377 1,377 1,377 1,377 1,377 1,377 2,447 7,417

Retained Earnings 73,314 77,260 76,809 451 73,408 74,398 74,650 75,351 76,370 76,084 76,716 77,027 76,791 77,034 77,260 77,388 72,700

Revaluation Reserve 28,063 28,002 28,063 (61) 28,063 28,002 28,002 28,002 28,002 28,002 28,002 28,002 28,002 28,002 28,002 28,802 34,571

TOTAL TAXPAYERS EQUITY 102,754 106,639 106,249 390 102,848 103,777 104,029 104,730 105,749 105,463 106,095 106,406 106,170 106,413 106,639 108,637 114,688

Year to DateAs at 29 February 2020

Monthly Actual / Forecast

STATEMENT OF FINANCIAL POSITION 2019-2029 FEBRUARY 2020


Appendix 41 2 3 4 5 6 7 8 9 10 11 12

Annual Annual Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Outturn Plan

Actual Plan Variance Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Forecast Forecast Outturn£'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s

ADJUSTED RETAINED SURPLUS / (DEFICIT) 3,944 3,495 449 93 990 253 701 1,020 (287) 633 312 (236) 243 224 128 4,072 3,721

Less Non Operating Income / ExpenditureFinance Income / Charges (262) (266) 4 (20) (28) (15) (29) (22) (24) (25) (24) (25) (27) (23) (25) (287) (290)

Depreciation and Amortisation 3,351 3,416 (65) 318 342 330 217 300 301 300 319 305 301 318 318 3,669 3,746

Donated Asset Income 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

PDC Dividend Expense 2,012 2,225 (213) 176 228 201 184 185 238 126 176 160 160 178 134 2,146 2,365

Other non-cash adjustments 0 0 0 0 16 (18) 0 0 0 0 (1) 3 (16) (16) 0

OPERATING CASHFLOWS BEFORE MOVEMENTS IN WORKING CAPITAL 9,046 8,870 176 567 1,548 751 1,073 1,483 228 1,034 782 204 677 700 539 9,585 9,542

OPERATING ACTIVITIESInventories 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NHS Trade Receivabes 1,378 2,304 (926) 119 (1,134) 2,220 215 (7) 41 (24) 87 88 (700) 473 27 1,405 2,045

Non NHS Trade Receivabes (726) 374 (1,100) (48) 1,382 (180) (1,145) (55) 1,172 (1,455) (1,551) 3,176 (1,498) (524) 1,705 979 1,202

Accrued Income 1,394 1,390 4 (696) (1,133) 1,246 2,642 (89) 149 (332) (322) 498 250 (819) (254) 1,140 1,540

Prepayments 634 (69) 703 202 (125) (117) (236) 280 181 (213) 376 301 (305) 290 (300) 334 (166)

Other Receivables (81) (219) 138 1 (55) (51) (272) 199 (10) (132) 46 170 8 15 (80) (161) (219)

Trade Payables (1,951) (4,213) 2,262 (2,791) 471 2,361 (1,290) (751) 673 (189) (1,186) 259 1,106 (614) (1,712) (3,663) (3,763)

Other Payables 168 (38) 206 234 (230) 70 79 (83) 53 37 (68) (14) (21) 111 (58) 110 (38)

Accrued Expenditure 1,259 721 538 1,038 (492) (1,791) (54) 699 600 (408) 884 1,290 (992) 485 (808) 451 321

Annual Leave Accrual 0 (139) 139 0 0 0 0 0 0 0 0 0 0 0 150 150 (139)

Deferred Income, Current & Non Current 376 782 (406) 24 23 14 56 869 (219) 134 (162) (151) (26) (186) (280) 96 (155)

Provisions, Current & Non Current (72) (1,415) 1,343 (45) 74 2 (23) (2) 2 (64) (10) 0 (10) 4 (70) (142) (1,415)

Increase / (Decrease) in working capital 2,379 (522) 2,901 (1,962) (1,219) 3,774 (28) 1,060 2,642 (2,646) (1,906) 5,617 (2,188) (765) (1,680) 699 (787)

NET CASHFLOW FROM OPERATIONS 11,425 8,348 3,077 (1,395) 329 4,525 1,045 2,543 2,870 (1,613) (1,124) 5,821 (1,511) (65) (1,141) 10,284 8,755

INVESTING ACTIVITESProperty, Plant & Equipment Expenditure (3,533) (7,139) 3,606 (88) (172) (113) (171) (276) (469) 41 (544) (321) (549) (871) (3,818) (7,351) (8,451)

Proceeds on Disposal of Property, Plant & Equipment 23 0 23 0 23 0 0 0 0 0 0 0 0 0 0 23 0

Donated Asset Income 130 0 130 0 0 18 0 0 0 112 0 0 0 0 130 0

(Increase) / Decrease in Capital Receivables (251) (24) (227) 0 0 0 0 0 (95) 11 98 (256) 4 (13) 265 14 109

Increase / (Decrease) in Capital Payables (770) (515) (255) (781) 16 (35) 8 (2) (45) 36 (13) 80 (133) 99 1,363 593 (187)

NET CASHFLOW FROM INVESTING ACTIVITIES (4,401) (7,678) 3,277 (869) (133) (130) (163) (278) (609) 200 (459) (497) (678) (785) (2,190) (6,591) (8,529)

FINANCING ACTIVITESPDC Dividends Paid (1,212) (929) (283) 0 0 0 0 0 (1,212) 0 0 0 0 0 (934) (2,146) (2,238)

PDC Received 127 0 127 0 0 0 0 0 127 0 0 0 0 0 1,070 1,197 2,020

Interest Received on Cash and Cash Equivalents 262 266 (4) 20 28 15 29 22 24 25 24 25 27 23 25 287 290

NET CASHFLOW FROM FINANCING ACTIVITIES (823) (663) (160) 20 28 15 29 22 (1,061) 25 24 25 27 23 161 (662) 72

NET CASH INFLOW / (OUTFLOW) 6,201 7 6,194 (2,244) 224 4,410 911 2,287 1,200 (1,388) (1,559) 5,349 (2,162) (827) (3,170) 3,031 298

Opening Cash Balance 30,799 30,197 602 30,799 28,555 28,779 33,189 34,100 36,387 37,587 36,199 34,640 39,989 37,827 37,000 30,799 29,293

Net Cash Inflow / (Outflow) 6,201 7 6,194 (2,244) 224 4,410 911 2,287 1,200 (1,388) (1,559) 5,349 (2,162) (827) (3,170) 3,031 298

CLOSING CASH BALANCE 37,000 30,204 6,796 28,555 28,779 33,189 34,100 36,387 37,587 36,199 34,640 39,989 37,827 37,000 33,830 33,830 29,591

CASHFLOW STATEMENT 2019-2028 FEBRUARY 2020

As at 28 February 2020Monthly Actual / ForecastYear to Date


APPENDIX 5

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

Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

SAFETY AND STATUTORYA5155 Boilers - Hillside Ash Green Backlog 45.0 0.8 (0.9) 0.1 0.0 45.0A5051 New Windows - Hillside Ash Green Backlog 120.0 8.9 40.9 (1.6) 1.8 25.9 33.9 109.8 10.2A5076 Fire Doors - Hillside Ash Green Backlog 13.7 (2.2) 11.5 (11.5)A5156 Fire Stopping Ash Green Backlog 16.2 16.2 (16.2)A5092 Circles - 3 Access Roof Doors Ash Green Backlog 6.2 6.2 (6.2)A5052 Windows and Radiators - Alton Ward Clay Cross Hosp Backlog 35.0 1.0 (0.2) 23.4 (3.9) 32.3 52.6 (17.6)A5183 Alton Ward Roofing Clay Cross Hosp Backlog 9.2 9.2 (9.2)A5081 Conversion of Office to Treatment Room Clay Cross Hosp Estates 9.6 14.4 (0.8) 23.2 (23.2)A5054 Tank and Pipework Ilkeston Hospital Backlog 6.0 13.8 4.0 17.8 (11.8)A5058 Data / VOIP Ilkeston Hospital Backlog 25.0 25.0 25.0A5059 Gas Solenoid Protection and Gas Sensing for Flange Pipes Ilkeston Hospital Backlog 20.0 20.0 20.0A5060 Hot Water Upgrade - 4 Plant Rooms Ilkeston Hospital Backlog 20.0 20.0A5061 Replacement Mixer Valves Ilkeston Hospital Backlog 14.4 19.5 19.5 (5.1)A5062 Nurse Call System - Shipley Ward Renal Ilkeston Hospital Backlog 18.0 15.1 15.1 2.9A5063 Upgrade Physiotherapy Ilkeston Hospital Backlog 200.0 1.0 38.1 268.0 307.1 (107.1)A5185 Upgrade Premises Ripley MC Backlog 200.0 15.9 (4.3) (0.1) 0.8 1.1 (0.3) 13.1 186.9A5065 Communications / VOIP Walton Hospital Backlog 40.0 20.0 20.0 20.0A5066 Ancilliary Pipework / Suspended Ceilings Walton Hospital Backlog 250.0 1.0 4.0 (0.4) 4.6 2.1 88.7 100.0 150.0A5067 Hot and Cold Water Services Walton Hospital Backlog 45.0 1.0 (0.8) (0.2) 2.1 0.6 (0.1) 1.1 62.6 1.4 67.7 (22.7)A5068 Drains - The Lodge Walton Hospital Backlog 25.0 25.0 25.0A5069 Emergency Lights Walton Hospital Backlog 140.0 25.1 31.9 22.8 11.4 14.1 105.3 34.7A5082 Conversion of Office to Treatment Room Walton Hospital Estates 7.2 18.2 (1.1) 1.1 25.4 (25.4)A5070 Generator House Asbestos Removal Whitworth Hosp Backlog 10.0 5.9 0.6 (0.1) 6.4 3.6A5071 Roof Access Works Whitworth Hosp Backlog 33.0 16.6 8.9 25.5 7.5A5049 Wound Clinic Cavendish Hosp Backlog 20.0 8.8 (1.5) 0.9 1.0 9.2 10.8A5053 Wound Clinic Ilkeston Hospital Backlog 35.0 15.0 10.7 10.0 51.6 (9.4) (0.9) 77.0 (42.0)A5072 CCTV Systems Trustwide IM&T 25.6 5.0 (5.0) 4.7 20.9 25.6A5073 LED Lighting (NHSI) Trustwide Backlog 220.0 184.4 35.6 220.0A5073 LED Lighting (Trust) Trustwide Backlog 30.0 28.6 28.6 1.4

Temperature Monitoring System Trustwide IM&T 30.0 30.0A5091 Upgrade Roofing to Spencer Ward, Physio and Patients Patio Garden Cavendish Hosp Backlog 8.4 2.8 11.2 (11.2)A5180 Asbestos Enabling Work Cavendish Hosp Backlog 78.9 (6.8) (0.2) 0.5 0.1 72.5 (72.5)A5179 New Boiler / BMS Eckingdton HC Backlog 5.2 6.1 11.3 (11.3)A5163 Replacement Windows Staveley Backlog 5.8 5.8 (5.8)A5158 Fire Stopping Ilkeston Hospital Backlog 26.9 26.9 (26.9)A5096 Upgrade Skylight Buxton HC BacklogA5109 Replacing Roof Brimington Backlog 10.0 10.0 (10.0)A5110 Conversion of Office to Treatment Room (MSK) Clay Cross Hosp Backlog 30.0 30.0 (30.0)A5111 Conversion of Office to Treatment Room (MSK) Dronfield BacklogA5227 New Flood Defence Orchard Cottage Backlog 10.0 10.0 (10.0)A5112 Supply and Instal New Theatre Light Buxton Hospital Backlog 16.6 (2.7) 13.9 (13.9)A5113 New Fuel Tank and Boiler Orchard Cottage Backlog 20.1 20.1 (20.1)A5119 New Boiler Chapel HC Backlog 5.0 5.0 (5.0)A5125 Upgrade Meeting Room - Compton Ward Cavendish Hosp Estates 6.8 6.8 (6.8)

STAY IN BUSINESSA5432 Desktop Renewal Trustwide IM&T 1,600.0 7.5 40.1 36.0 122.2 100.0 107.3 (174.0) 429.6 110.0 262.5 85.8 571.1 1,698.1 (98.1)A5046 End User Licensing Trustwide IM&T 300.0 4.9 195.1 200.0 100.0A5434 LAN / WAN Infrastructure Trustwide IM&T 250.0 10.7 0.8 2.7 40.8 96.7 148.3 300.0 (50.0)A5170 Intranet Upgrade Trustwide IM&T 43.0 (2.1) 38.4 (11.4) 2.2 23.8 50.9 (7.9)

TBC Portable Ultrasound Machine Ilkeston DTC EquipmentA5166 Diathermy Machines Ilkeston DTC Equipment 20.0 23.7 23.7 (3.7)A5135 Defibrillators Trustwide Equipment 21.1 25.8 1.7 27.5 (6.4)A5136 Theatre Monitoring Equipment Ilkeston DC Equipment 69.5 (57.9) 11.6 (11.6)A5195 Decon Equipment Trustwide Equipment 85.0 (0.1) (6.5) 7.1 154.5 155.0 (70.0)A5190 Snow Ploughs Trustwide Equipment 14.4 7.8 7.8 6.6A5189 Podiatry Power Sets ? Equipment 29.0 29.0 29.0A5080 Bladder Scanner Equipment 8.6 8.6 (8.6)A5087 Bladder Scanner ICS Dist. Nurses Equipment 7.7 7.2 14.9 (14.9)A5088 Bladder Scanner Continence Team Equipment 71.8 71.8 (71.8)A5181 Pharmacy Fridge Walton Equipment (1.4) 4.7 0.9 (0.1) 4.1 (4.1)A5084 Telerphone System eswell, Langwith & Cas IM&T 8.5 8.5 (8.5)A5089 Fire Suppression System Ilkeston Hospital Equipment 10.7 (1.7) 9.0 (9.0)A5104 ISDHS Edge ii Scanner Wheatbridge Equipment 21.6 21.6 (21.6)A5095 Trollies x 12 ICH DTC Equipment 65.6 65.6 (65.6)A5097 Nurse Call System ICH OPD Equipment 20.0 20.0 (20.0)A5101 Upgrade Security Ash Green Equipment 20.0 20.0 (20.0)A5108 Medical Testing Kits Medical Device Equipment 24.3 24.3 (24.3)A5098 Treatment Couches Various Equipment 37.3 37.3 (37.3)A5102 Wound Care Kit erby city & Amber Valle Equipment 5.6 7.6 13.2 (13.2)A5122 Replacement Ovens Various Equipment 40.5 40.5 (40.5)A5124 Community Nursing Bladder Various Equipment 14.3 22.1 36.4 (36.4)

TBC Plinth/Specialist Chair South Derbys Equipment 6.5 6.5 (6.5)

Other Equipment Trustwide Equipment 383.0 383.0Estates Staff Costs Trustwide Estates 210.0 34.6 30.5 29.8 30.7 30.9 30.4 30.0 30.0 30.0 30.0 29.0 31.0 366.9 (156.9)

SYSTEM TRANSFORMATIONA5077 IP EPR Trustwide IM&T 30.0 8.4 (8.4) 30.0 30.0A5078 OP EPR Trustwide IM&T 30.0 30.0 30.0A5079 OPMH EPR Trustwide IM&T 100.0 100.0 100.0A5100 Upgrade SQL and Micro Strattegy Environment Trustwide IM&T 122.4 122.4 (122.4)A5057 Site Development Belper STP 1,000.0 46.2 (7.5) 2.0 0.7 9.6 2.4 5.4 0.9 14.7 18.2 11.0 646.4 750.0 250.0A5105 Site Development Buxton Estates 500.0 31.6 1.9 9.4 2.7 (37.3) (3.2) 1.2 0.9 192.8 200.0 300.0A5074 Site Development - Road, Delivery, G&G Walton Estates 500.0 0.7 69.8 (5.3) 54.0 31.0 6.2 24.1 70.3 330.2 581.0 (81.0)A5075 Site Development - Leahurst Walton Estates 500.0 7.7 0.1 (0.2) 2.5 42.1 (1.8) 50.4 449.6A5090 Conversion opf Catering Department to Staff Training Room Walton Estates 0.1 120.8 59.2 180.1 (180.1)A5157 Site Development Bakewell STP 400.0 (2.0) (0.5) 4.9 3.9 11.5 8.4 (0.2) 13.9 (2.1) 1.0 12.0 24.2 75.0 325.0A5083 Site Development Manor Stotes Estates 100.0 20.0 20.0 80.0

TBC Land Creswell Estates 400.0 400.0TBC Car Park (Rhoslan) Ripley Hospital Estates 2.7 73.3 76.0 (76.0)

OTHERContingency Contingency 35.5 35.5Prior year schemes (17.4) 13.5 (14.3) 5.4 11.5 22.7 3.9 (54.2) (0.5) 12.2 (17.2) 17.2

Capital Programme Expenditure 8,158.0 86.4 125.1 89.7 169.4 275.0 436.1 (67.4) 494.6 237.6 553.9 867.2 3,808.4 7,076.0 1,082.0

DONATEDA5064 Upgrade Physiotherapy Ripley Hospital LOF 168.5 0.9 (0.1) 0.4 23.4 50.2 84.6 (4.5) 3.9 9.7 168.5

A5167 * Additional Car Parking Spaces Whitworth Hosp LOF 124.5 1.2 46.8 22.5 2.5 (0.5) 33.1 2.6 (1.0) 107.2 17.3

Capital Programme Expenditure 293.0 1.2 46.8 23.4 2.4 (0.1) 33.1 26.0 49.2 84.6 (4.5) 3.9 9.7 275.7 17.3

CAPITAL PROGRAMME 2019-2029 FEBRUARY 2020

Scheme Number

Scheme Description Location Category2019-20 Plan

Full Year Forecast

Plan v Forecast


Summary Report from Quality Service CommitteeReport To: Public Board Date: 26th March 2020Name of Reporting Committee / Group: Quality Service Committee Date of Meeting: 17th March 2020Presenter: Kay Fawcett, Non-Executive Director Author: Andrea Graham, Deputy Trust Secretary This paper is for Assurance

Key Issues discussed at meeting: Board Assurance Framework Reference and Level of Assurance Agreed by the relevant Committee/group

47/20 DCHS Fall Strategy – Deep Dive

The Committee discussed:

Current position within DCHS. The NHS long Term Plan and ageing well. 2020-2021 aims. Inpatient falls prevention journey. Challenges to delivery. There is a need to tell the story of continuous improvement

and system working in a more succinct way The falls agenda falling into the frailty strategy has been a

powerful enabler and has allowed conversation with Divisional Assistant Directors to include the work within the operational plan.

Significant Assurance1.3/19 to 1.7/19

49/20 Learning Disability Service - Hillside Assessment & Treatment Unit Review

Highlights included:

Background to the review. DCHS Action plan. Learning Disability and Autistic Spectrum Disorder Delivery

Board action plan. Integration with Derbyshire Healthcare Foundation Trust. The main challenge is the medical workforce and the Trust still

requires a whole time equivalent Consultant and at present the service is using Locum Consultants.

Good progress is being made but progress is slow, however the Trust is confident that the care provided is of high quality.

The Committee took Significant Assurance on the Process and Limited Assurance on the outcomes. The Committee note that staffing is still an issue and that leads to a potentially fragile service.1.1/19,2.3/19, 3.2/19, 3.8/19

Page 1 of 351 QSC Summary Report.docx

54/20 Divisional Governance Report Significant Assurance1.4/19, 4.1/19

50/20 Patient Safety Incident Response Framework

Background. DCHS requirements to become an early adopter. Early adopter readiness assessment. Patient Safety Incident Response plan. DCHS is well placed to become an early adopter as it has

been developing a “Just Culture”. The readiness checklist will be reviewed by the Clinical Safety

Group in April 2020 and will be presented to QSC in May 2020.

The Committee endorsed DCHS being an Early Adopter.

Significant Assurance4.1/19, 4.2/19, 4.3/19

55/20 Staffing for Quality and Agency Spend Report Significant Assurance1.1/19, 2.1/19

56/20 Corporate Risk Management Report (QSC) Significant Assurance4.3/19

57/20 Board Assurance Framework

The Committee approved the Quarter 4 BAF. The Committee approved the 2020/21 BAF subject to amendments.

Significant Assurance4.1/19

52/20 Compliance and Assurance

Developments in relation to the development of the Quality Improvement and Assurance framework

CQC engagement events and preparations for the annual CQC well-led inspections

CQC updates More work is required on the Quality Improvement Assurance

Framework to make it much more accessible and consistent and the Board will be involved in shaping the QIAF.

The Committee did not approve the QIAF.

Significant Assurance1.3/19, 1.4/19, 4.1/19, 4.2,19, 4.6/19

53/20 Quality Performance Report

Staff flu vaccination – final position was 80.8% Development of the Quality Performance Dashboard for

2020/21. Exception Reports. The proposed Quality Big 9 including; reducing needlestick

incidents, response times to complaints, and flagging of records with people with Learning Disabilities, Autism or both

Significant Assurance1.1/19 to 1.7/19


59/20 Summary Report from Information Governance & Records Management Group

Significant Assurance4.2/19

60/20 Summary Report from Equality, Diversity and Inclusion Leadership Forum

Significant Assurance1.7/19, 2.7/19

61/20 Summary Report from Quality Impact Assessment Panel Significant Assurance

62/20 Summary Report from Clinical Effectiveness Group Significant Assurance1.3 -1.7/19, 2.7/19

63/20 Summary Report from Patient Experience and Engagement Group

The Committee received the Health Watch England Chair Shifting the Mind-set DCHS self-assessment.

Significant Assurance1.3/19, 1.4/19, 1.6,19, 1.7/19, 2.7/19, 3.6/19, 4.1/19, 4.2/19, 4.6/19

64/20 Summary Report from Infection Prevention and Control Group including Infection, Prevention and Control Quarterly Report

Significant Assurance1.1/19, 1.3/19, 1.4/19, 1.7/19, 2.6/19, 2.7/19, 4.1/19, 4.2/19, 4.3/19, 4.6/19

65/20 Summary Report from Mortality Review Group

The Committee approved the Terms of Reference

Significant Assurance1.3/19, 1.4/19, 2.7/19, 3.6/19, 4.2/19

66/20 Summary Report from Clinical Safety Group Significant Assurance1.3/19, 1.4/19, 1.7/19, 4.1/19, 4.2/19, 4.3/19

67/20 Summary Report from Safeguarding Governance Group Significant Assurance1.1/19 – 1.5/19, 1.7/19, 2.1/19, 2.4/19, 2.5/19, 3.2/19, 3.6/19, 4.2/19, 4.3/19

69/20 Advance Decisions Policy

The Committee approved the Policy

Policies Approved

Issues to be escalated to Board or a Committee


IP&C 2019-20 Quarter 3 Report Page 1 of 33

Infection Prevention & Control Report

2019-2020 Annual Strategy

Quarter 3(October - December)

Page 1 of 3351 IPC Quarter 3 Report.docx


Executive Summary:

This report outlines DCHS’s continued commitment to promoting best practice in Infection Prevention and Control and reducing the number of healthcare associated infections. DCHS continues to have very low infection rates and training compliance remains in excess of 95%. The following report provides an overview of the work undertaken in 2018/19 and the outlines the priorities and future developments for 2019-20.

Table of Contents:

1 Introduction

2 Annual Infection Prevention & Control Strategy for 2019 to 2020

3 IP&C PERFORMANCE REPORT – April 2019 to March 2020

4 Key achievements Q3

5 Compliance with the Health And Social Care Act 2008: Code of Practice on the Prevention and Control of Healthcare Associated Infections and Related Guidance.

Criterion 1 Systems to manage and monitor the prevention and control of infection

Criterion 2 Provide and maintain a clean environment

Criterion 3 Antimicrobial stewardship

Criterion 4 Information for service users and providers

Criterion 5 Ensure that people who have an infection are identified promptly and receive the appropriate treatment and care

Criterion 6 All staff to be involved in preventing and controlling infection

Criterion 7 Adequate isolation facilities

Criterion 8 Access to laboratory support as appropriate

Criterion 9 Policies

Criterion 10 Protection of healthcare workers

Appendices



Annual Infection Prevention & Control Annual Strategy for 2019 to 2020Criterion 1 Systems to manage and monitor the prevention and control of infection.

These systems use risk assessments and consider how susceptible service users are and any risks that their environment and other users may pose to

them.

Evidence Progress

1.1 IP&C root cause analysis reports for community hospital wards: Are in draft format within 10 working days. Include clinical teams within the development/review. Include patient or carer feedback.

Not to exceed: 10 Clostridioides difficile infections 0 MRSA Bacteraemia

All cases presented for assessment at CCG lapse in care meeting: Follow agreed process. Are assessed within 10 weeks of the sample date (100% of reported

incidents)

RCA reports Monthly Dashboard ReportQuarterly Report

Three Clostridioides infections reported for Quarter 3.

One RCA has been completed and following a Post Incident Review (PIR) meeting with the Commissioners, no lapse in care was identified. Please refer to Criterion 5 of the report for a full update.

Criterion 2 Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections.

Evidence Progress

2.1 The credits for cleaning (technical audit) process is: Monitored to ensure all areas are audited as per recommended

frequency. Any shortfalls in standards are addressed in line with the agreed

framework.

Credits for cleaning reports PLACE audit results

The PLACE audits were undertaken throughout September 2019 – November 2019. The outcome will be disseminated in the Qtr 4 report.

2.2 DCHS gains assurance: From organisations monitoring the premises where DCHS services are

located and providing evidence that the premises are compliant with the national guidance for Legionella and water quality.

Quarterly reportWater Safety meeting minutes

The Health and Safety and Estates Departments have drafted a checklist for health & safety risks and requests for information have been sent to the sites. Responses received from sites to the Health & Safety checklist enquiry are generally acceptable Stuart Pilkington (H&S Manager) and Tony Gent (Deputy Director of Estates) to meet again and decide on the action required on areas of concern and for those sites who have



not responded. (NB From the Estates Risk Management Group Meeting (22-01-20).

2.3 DCHS gains assurance that (where applicable): Premises where DCHS services are located are compliant with the

national guidance for ventilation, where ventilation, plant and equipment is installed.

Quarterly reportVentilation meetingSafety Group

Wound care services remain on-going with either risk assessment or capital investment to meet treatment room/clinical room standards. A risk has been placed on the risk register which is updated monthly – 3274.

2.4 Wound care clinics AuditsQuarterly report

An audit of the wound care clinics has been completed and a review of the initial risk assessments completed and updated.

Criterion 3 Ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance.

Evidence Progress

3.1

Review podiatry antibiotic audit practice through antimicrobial audit programme

Develop system/process for the capture of Non Medical Prescribing Practices in relation to E.coli bacteraemia e.g. Prescribing rates of Trimethoprim v Nitrofurantoin

Quarterly reportMOSTIP&C Committee minutes

Producing a quarterly report of nitrofurantoin and trimethoprim using EPACT data for DCHS non- medical prescribers using FP10 prescriptions in the community setting. Prescribing in the community hospitals of DCHS is included in the quarterly audit of antibiotic prescribing.

Criterion 4 Provide suitable accurate information on infections to service users, their visitors and any person concerned with providing further support or nursing/ medical care in a timely fashion.

Evidence Progress

4.1 Report to commissioner within 1 working day all: Infection outbreaks. Ward closures due to infection outbreaks.

Datix reportsMonthly Dashboard ReportQuarterly reports

No infection outbreaks reported during Q3.

4.2 Review patient information leaflets. IP&C committee meeting.Leaflets Group.CSG meeting.

Patient leaflets have been uploaded to the My DCHS page.

Criterion 5 Ensure prompt identification of people who have or are at risk of developing an infection so that they receive timely and appropriate treatment to reduce the risk of transmitting infection to other people.

Evidence Progress



5.2 Raise awareness of sepsis through training and contributing to campaigns.

Task and Finish Group.Changes in practice.Quarterly reports.

Campaign was initiated across DCHS by Sepsis task and finish group in Qtr 2/3 and NEWS2 is now being utilised within the integrated community teams. Recognition of Patient Deterioration (Adults) Policy has been approved by the Clinical Effectiveness Group and is available on MyDCHS.

Criterion 6 Systems to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the process of preventing and controlling infection.

Evidence Progress

6.1 IP&C Specialist Nurses and Quality Always Team provide support: Through the QA assessment process To the IP&C Quality Always Champions including the delivery of annual

face to face updates. To managers with regard to compliance with IP&C Standards.

Quarterly reportsQA report

Two further training sessions were delivered to the IP&C Quality Always Champions in December. The IP&C team have now delivered 6 sessions and all evaluations of the sessions have been positive. The schedule has now been completed for this year.

6.2 To provide IP&C support related to any themes and trends identified through, for e.g. the QA assessment process/DATIX/infection rates.

IP&C committeeQuarterly reports

IP&C bespoke sessions delivered to teams as required or requested.

6.4 Raise awareness of the role of clinicians in the prevention of E.coli bacteraemia through training and the launch of ‘Don’t be a Dipstick’ campaign to ensure that best practice is followed with regard to diagnosis of UT.I

Quarterly reportsIP&C committee minutes

'Don't be a dipstick' initiative on hold. (See criterion 8.2)

6.5 Infection Prevention & Control training is included within: The induction training programme. The essential training programme (e-learning).


IP&C training is included on induction and essential training.

Criterion 7 Provide or secure adequate isolation facilities. Evidence Progress

7.1 Provide advice to in-patient teams on a ‘case by case’ basis relating to patients requiring source isolation.

TPP activity. Ongoing as required.

Criterion 8 Secure adequate access to laboratory support as appropriate. Evidence Progress



8.1 IP&C team, IP&C Pharmacist and Continence team:: Have 24 hour access to a qualified infection control doctor or consultant in

health protection/communicable diseases. Receive supervision on a bi-monthly basis. Provided to IP&C/continence

and IP&C pharmacist.

Contract arrangements with UHDB.

On-going. Dates are arranged throughout the year.

8.2 Urine sampling. It was identified that there was inconsistency across North and South Derbyshire with regards to the containers used to collect urine samples. North Derbyshire Microbiology changed to a red top container with boric acid that preserves a urine sample for upto 96 hours. South Derbyshire microbiology use a white top sample bottle with no preservatives as the microscopy equipment is unable to process samples containing boric acid. These samples would require refrigeration and transportation to the lab within 4 hours of collection. If this process is not followed, microorganisms could multiply and antimicrobials could be prescribed when they are not needed.

‘Don’t be a dipstick’ initiative remains on hold. Currently UHDB is unable to process Boric Acid urine sample bottles therefore awaiting consistency of equipment for processing urine analysis across Derbyshire before commencing the initiative. UHDB has purchased the equipment to process the Boric Acid urine sample bottles however the equipment is awaiting validation tests to ensure the quality of the results remains high when changing processes.

Criterion 9 Have and adhere to policies, designed for the individual’s care and provider organisations that will help to prevent and control infections.

Evidence Progress

9.1 Review of the IP&C policy. Policy approved at CSG.

Completed.

9.2 Review of the Decontamination of Medical Devices Policy. Policy approved at CSG.

Review due in 2020.

Criterion 10

Providers have a system in place to manage the occupational health needs and obligations of staff in relation to infection.

Evidence Progress

10.1 Flu vaccination service offered for staff across DCHS. 80% of staff vaccinated. Quarterly reportsIP&C committee

Flu campaign in progress. Current data indicates:76.2% of staff vaccinated.

10.2 Review the data relating to sharps injuries to ensure reporting processes are robust i.e. Datix incident data reflects referrals to occupational health.


10 sharps injuries reported – mainly related to sharp disposal.



IP&C PERFORMANCE REPORT – April 2019 to March 2020

2019-20Ref Indicator Type

Definition Target Type

Full Year Target Q1 Q2 Q3 Q4

2018-19

Trend Actual to Date

Lead Officer

1 Health & Social Care Act 2012

Compliance with each Criterion Min100% 80% 70% 70% 80% 73.3%

Julie Mills

% RCA reports for Clostridioides difficile infections submitted to CCG within 10 weeks of sample date

Min100% 100% 100% 100% 100% 100%

Julie Mills2 RCA/SI

% Serious Incident review completed within 20 days

Min 100% N/A N/A N/A 100% 100% Julie Mills

Technical audits of clinical areas - average % score

Min 95% 100% 100% 100% 99% 100% Alan Woolven

4 Cleanliness

PLACE Community Hospitals - average % score

Min 95% N/A N/A N/A N/A N/A N/A Julie Mills

MRSA Infections Incidence 0 0 0 2 0MRSA Infections Lapse in Care

Monitor0

0 0 0 0 0Julie Mills

ESBL/AMP C Infections Incidence 1 0 2 1 3ESBL/AMP C Infections Lapse in care

Monitor0

0 0 0 0 0

Julie Mills

Norovirus – Management of outbreaks

Monitor 0 0 0 0 3 0 Julie Mills

MRSA Bacteraemia Incidence 0 0 0 0 0MRSA Bacteraemia Lapse in care

Monitor 0 0 0 0 0 0Julie Mills

E-coli Bacteraemia Monitor N/A 0 0 0 0 0 Julie MillsClostridioides Difficile Incidence 10 1 2 3 1 6

6 HCAI Rates

Clostridioides Difficile Significant Lapse in Care

Monitor

<10 0 11

1 RCA outstand

ing

0 2

Julie Mills

% of DCHS patients who have developed phlebitis related to peripheral intravenous cannula

Min0% 0% 0% 0% 0% 0%

Jane Stacey7 Safe Care

% of surgical site infections with no lapse in care

Min 100% 100% 100% 100% 100% 100% Julie Mills



8 Antibiotic Stewardship

Staff prescribing antibiotics meet the DCHS antibiotic stewardship requirements

Min100% 98% 98% 96% 98% 97.3%

Jayne Booth

9 Training Core Mandatory Training Attendance

Min 95% No data received 98% No data

received 93% No data received

Donna Wright

10 Blood & Body Fluid exposure incidents, including sharps

Number of needle stick injuries reported

Monitor

≤20 7 8 10 No Data 25

Nina Woolhouse

KEYPerformance Improved / is above target Performance Stable and on target to be delivered Performance Declined / is below target Quality Indicator is being delivered – in line with or above target

Quality Indicator has control action in place to deliver target

Quality Indicator requires immediate rectification action in order to deliver target / or target not met

TARGET TYPEMin Minimum required to be achieved (number or

percentage)Max The maximum number allowed under the quality

indicatorMonitor Put systems in place to monitor the number (and

monitor)



CRITERION 1 – Criterion 1: Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider the susceptibility of service users and risks that their environment and other

users may pose to them.KEY MESSAGES

Compliance position FULL

1.1 Key progress areas / successes Quarter 3

SurveillanceThere are no MRSA bacteraemias to report for Quarter 3.3 Clostridioides difficile infections, 1 ESBL infection and 1 AMP C infection have been reported during Quarter 3.

Infection rates continue to remain low.

1.2 High risk areas for Quarter 4

None identified.

1.3 Key challenge areas for action in Quarter 4

IP&C provision to Local Authority premises with DCHS beds

To continue to liaise with Local Authority in order to ensure that any IP&C issues that impact both services are dealt with promptly (e.g. Pathway 2 beds)

1.4 Compliance outcome measures

Health and Social Care Act

xx



CRITERION 2 – Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections.

KEY MESSAGESCompliance Position PARTIAL


Monitoring of Cleanliness against National Standards

Technical Audits: The overall aggregate score for Quarter 3 is 100% against the DCHS standard of 95%. The detailed data can be obtained from [email protected]. We have an average of 95.63% completion of required technical audits in Quarter 3 and the level of scores <95% is becoming less and less with no exceptions. Exceptions for AMBER & RED would be included in the report when applicable with actions.

Summary of Deep Clean Activity The Team have had a full schedule of work for the period October to December 2019 (Quarter 3) as detailed below:

Month ActivityOctober 2019 St Oswalds Hospital – Okeover Ward – Deep Clean

Ripley Hospital – Deep Clean – Paediatric Office Cavendish Hospital – Maintenance Cleaning Ilkeston Hospital – Maintenance Cleaning Annual Health & Safety Chairs checks Transportation of Items – DCHS Wide Staff Training

November 2019 St Oswalds Hospital – Maintenance Cleaning Ash Green –Spa Pool - Maintenance Cleaning Alfreton PCC – Dental Dept. – Maintenance

Cleaning Hartington Unit – Maintenance Cleaning Babington Hospital – Baron Ward – Deep Clean Ripley Hospital – Butterley Ward – Deep Clean Transportation of Items – DCHS Wide Staff Training

December 2019 Ripley Hospital – Butterley Ward – Deep Clean Ash Green –Spa Pool - Maintenance Cleaning Ripley Hospital – Physiotherapy – Post Refurb’

Clean Ilkeston Hospital/DTC – Deep Clean Transportation of Items – DCHS Wide

Pest Control Arrangements & Activity The Pest Activity for Quarter 3 has shown no particular areas or issues of concern and reassurance is given that there is no risk to any patient and non-patient activity within the organisation.



The actual pest activity has recorded x3 incidents and overall this is deemed to be at an acceptable and manageable level for the time of year.

For Graphical representation of activity for this period please see Appendix 2

Kitchen Hygiene Inspections The Kitchen Hygiene Audit Programme continues to be undertaken across DCHS Hospital and satellite sites.

Year to date including Quarter 3, DCHS Hospitals continue to be awarded the full ‘5’ Star status in line with the Food Standards Agency (FSA) and this further confirms the high standards being achieved and maintained throughout. This is shown in the Year-to-Date Summary in Appendix 3.

Decontamination agenda

Dental decontamination process – A quote has been received from the laboratory in respect of the testing of dental hand pieces.

The quote is for the supply: of a recovery diluent fluid, sterile sample bottles, a temp controlled box with ice packs for sample return

And the testing of: Bioburden Total Viable Count (TVC)

The quantity will be suitable to test 4 handpieces in duplicate. Results will be provided by PDF certificate. Currently awaiting the addition of the laboratory on to Oracle by procurement.

Water Safety: Pool Safety Group: next meeting 16-01-20.Water Safety Group: next meeting 16-01-20

Ilkeston Community Hospital, Shipley Ward Renal UnitPseudomonas Sampling: Not detected 22nd July 2019.Legionella Sampling: Not detected 22nd July 2019.Next sampling: due January 2020.

LIFT Co Derbyshire: Re-assurance and Water Management Issues:Darren Woods is now a member of the LIFT Co Derbyshire Water Safety Group Meetings (Quarterly), last meeting 27-11-19, from the Water Risk Assessments remedial action plan on-going, FES to bring to the next meeting 01-04-19.All sites have very good control schemes in place in compliance with HSG 274 Part 2.

NHS Property Services Derbyshire: Re-assurance and Water Management Issues:Quarterly Audits in place, all sites have good control schemes in place, next audit meeting 15-01-20.



Ilkeston Hospital DTC Theatre ventilation upgrade

Following ventilation systems refurbishment, some installation issues are outstanding that the Estates design team are addressing under warranty which is currently taking place:

Ductwork replacement complete and Dale Moreton to arrange duct cleaning to be done mid-October 2019. Complete apart from Recovery room system, DM currently arranging.

Two new extract-air motors bypass-inverters were to commence in October. Inverter changes complete but awaiting motor installation following manufacturer delivering incorrect parts.

Excessive noise levels raised by theatre staff. Anesthetic 1 proposal is to install an in-line sound attenuator before final validation. Also highlighted in other areas which will be addressed once theatre validation complete and findings reviewed.

Independent validation will follow on completion of these works which will identify any performance and issues and ensure correct air dilution and extraction are achieved.

A review by the Trust independent Authorising Engineer for specialist advice will be undertaken once all works are completed.

Estimated completion date for these works is early February 2020.

Buxton Hospital TheatreAnnual duct cleaning and verification of the ventilation system performance for the theatre suite is being arranged for February 2020 by specialist contractors CVS.

Ventilation Compliance Annual AuditThe Trust-appointed Authorising Engineer (Ventilation) from TAD FM, will undertake the independent annual audit of ventilation compliance on the 11th March 2020. Improvements items following the previous 2019 audit are in place which should be reflected in TAD FM audit report and will be reported at the April committee meeting.

2.2 High risk areas for action in Quarter 4

None identified


Clinical procedures requiring Treatment Room standards It is acknowledged that services across DCHS may be provided from rooms which are not to national IP&C or Ventilation standards due to the age of the building, fabric of the building, change of usage or not owned by DCHS. A risk is on the risk register – 3274. The IP&C team will continue to audit the clinics on a 6 monthly basis.




HTM 04-01: The control of Legionella, Hygiene. “safe” hot water, cold water and drinking water systems

HSE Legionnaires’ disease HSG 274 Addendum.

HTM 03-01: Specialised ventilation for healthcare premises.

Health & Social Care Act

xx



CRITERION 3 - Ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial

resistance.KEY MESSAGES



Antimicrobial stewardship

The audit of antibiotics prescribed in the community hospitals of DCHS for Q3 was carried out in December 2019 to ensure on going compliance with good Antimicrobial Stewardship practice guidance.

For the current audit 11 courses of antibiotics were prescribed in the community hospitals of DCHS. The results of the audit show excellent compliance with the requirements of the “Start Smart then Focus” antimicrobial stewardship guidance.

The stop/review, the allergy status and the indication were recorded on the treatment card for all of the courses prescribed.

The indication was recorded in the medical notes for all courses antibiotics prescribed as well as all other requirements of the “Start Smart then Focus” guidance for recording of antimicrobial prescribing details in the medical notes except for 2 courses of antibiotics prescribed on the Walton Unit where the indication was not recorded on the treatment card and a course prescribed on the Walton unit did not have the antibiotic dose details and course length recorded in the medical notes. The audit will be shared with the prescribers of the Walton Unit to raise awareness of including all antibiotic prescribing information in the medical notes and writing the indication on the treatment card as recommended in the “Start Smart then Focus” guidelines.The results are summarized in the table below:

Overall antibiotic use:

December 2019

September 2019

Total number of wards audited: 9 9Total number of currently prescribed antibiotic courses audited

11 10

Overall results for standard of antibiotic prescribing for 8 courses of antibiotics prescribed:

December 2019

% September 2019

%

Stop date/review date recorded on the

8 (3 x NA long term

100% 8 (2 x NA long term

100%



treatment card prophylaxis) prophylaxis)

Allergy status recorded on the treatment card

11 100% 10 100%

Indication recorded on the treatment card

9 82% 10 100%

Indication recorded in the medical record

11 100% 10 100%

Antibiotic prescribed recorded in the medical record

11 100% 10 100%

Dose / Frequency recorded in the medical record

10 91% 9 90%

Course duration recorded in the medical record

7 (2 x NA long term prophylaxis)

87.5% 8 (2 x NA long term prophylaxis)

100%

Overall results for standard of antibiotic prescribing with regard to 4 courses of antibiotics prescribed which followed the JAPC Derbyshire Antimicrobial Treatment Guidelines:

Choice of antibiotic follows the JAPC Derbyshire Medicines Management Antimicrobial Treatment Guidelines:

%

Follows the recommended dose 4 100%Follows the recommended frequency 4 100%Follows the recommended course length 4 100%


None identified


None identified

3.4 Compliance outcome measuresHealth & Social Care Act

xx



CRITERION 4 – Provide suitable, accurate information on infections to service users, their visitors and any person concerned with providing further support

or nursing/ medical care in a timely fashion. KEY MESSAGES



The IP&C team continue to be involved in the wider healthcare meetings relating to the management of infection control and reduction of E coli bacteraemia infections across Derbyshire.


None identified


None identified



xx



CRITERION 5 – Ensure prompt identification of people who have or are at risk of developing an infection so that they receive timely and appropriate treatment to reduce the risk of transmitting infection to other people.

KEY MESSAGESCompliance position FULL


Community Hospital HCAI Rate There were 3 cases of Clostridioides difficile infection reported during Quarter 3

1. Sample date: 02/10/2019Ward: Alton Ward, Clay Cross Hospital

The patient was transferred from Chesterfield Royal Hospital to Alton ward on the evening of 30/09/2019. During her admission in the acute sector the patient had been treated with a course of IV Co-amoxiclav for a respiratory tract infection. The patient commenced with loose stools 01/10/2019 and a stool sample was obtained which tested positive for Clostridioides infection. All relevant IP&C measures were in place and the patient was successfully treated with a course of oral Vancomycin. A Root Cause Analysis Report (RCA) was completed and no lapse in care was identified at the PIR meeting with DDCCG.

2. Sample date: 03/12/2019Ward: Oker Ward, Whitworth Hospital

The patient was transferred to Oker Ward on 27/11/19 from UHRD&B where he had been treated with various antibiotics due to aspiration pneumonia. The patient developed loose stools and a stool sample was obtained which tested positive for Clostridioides difficile infection. The ANP prescribed a course of Vancomycin. All IP&C precautions are in place but the patient’s clinical status deteriorated and he was transferred to the acute sector with a query of sepsis. The RCA report has commenced and the outcome will be disseminated in the Quarter 4 report following the PIR meeting with the commissioners.

3. Sample date: 11/12/2019Ward: Oker Ward, Whitworth Hospital

The patient admitted from home by the GP due to continued loose stools and generally feeling unwell. She was transferred straight into a side room under barrier precautions until further cause of the diarrhoea was established. Patient had previously been treated for C. diff on 05/11/19 while an in-patient at CRHFT. A stool sample was obtained and tested positive for Clostridioides infection, following which the patient was prescribed a course of Vancomycin. However, the following morning the patient was transferred to the acute sector due an increased EWS and abdominal pain. As all relevant IP&C measures were in place and the patient was under DCHS care for less than 24 hours the RCA will be undertaken by CRHFT – with DCHS input shared if required.



Outstanding Post Incident Review meetings with the DDCCG – 27/11/2019

There were 2 outstanding RCA’s from Quarter 2 for which a PIR has now taken place:


A lapse in care was identified due to a delay in sending a Type 5 stool sample. However, it was also agreed that no significant harm had occurred to the patient as he remained clinically well throughout.


No lapse in care was identified.

MRSAThere have been no MRSA infections reported for Quarter 3

MRSA/MSSA bacteraemiasThere have been no MRSA/MSSA bacteraemia infections reported for

ESBL/AMP C1 AMP C and 1 ESBL infection were reported for Quarter 3

1. Sample: 03/12/2019Ward: Butterley Ward, Ripley Hospital

The patient was admitted to Butterley Ward from home via SPA on 14/11/19 for rehabilitation due to reduced mobility and treatment of recurrent urinary tract infections. A urine sample was sent due to clinical symptoms which included increased urinary frequency, malodour, a raised temperature and changes in renal function. The sample tested positive for an AMP C infection and the patient was successfully treated with a course of appropriate antibiotics after discussion with the Microbiologist and Pharmacist. All necessary IP & C precautions were in place. The patient has since been discharged home.

2. Sample: 09/12/2019Ward: Heanor Ward, Ilkeston Hospital

The patient was admitted to Heanor Ward from UHD&B for rehabilitation on 14/11/19. A urine sample was sent due to haematuria (blood) and history of urinary tract infections. The sample tested positive for an ESBL infection and the patient was successfully treated with a course of appropriate antibiotics. All necessary IP & C precautions were in place. The patient has since been discharged to a care home



Norovirus outbreaksNo outbreaks have been reported for Quarter 3

Surgical Site InfectionsThere were no surgical site infections identified with lapses reported for Quarter 3

Reduction in Gram Negative Blood Stream InfectionsWork continues within this area via the Health Economy Infection Control Group and the action plan will continue to be a standing agenda item for review by the IP&C Committee.

Access to national HCAI databaseThere are no changes with this issue. There are no plans at a national level to enable DCHS data to be separated from the CCG data regarding healthcare associated infections. Due to the low numbers of infections within the organisation, verification of the infection incidence against the national database continues to be managed via the CCG IP&C leads.


No issues identified


No issues identified.


Health & Social Care ActClinical Audit Framework

xx



CRITERION 6 – Systems to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the

process of preventing and controlling infection.KEY MESSAGES

Compliance position PARTIAL


Quality AlwaysThe Quality Always team have continued to roll out the Quality Always process across clinical teams and services in all DCHS divisions and localities. The Quality Always dashboard tool enables the Clinical Lead to analyse themes and trends across the assessments to highlight good practice to be shared and poor compliance with quality standards that need to be addressed. The Quality Always team and the IP&C team continue to work together to address areas where teams are rated either red or amber.

Champion ProgrammeThe IP&C team have delivered 6 sessions on the required elements of the Safe Care Champion programme during Q1, 2 and 3. The feedback evaluation has been positive.

Catheter Associated Urinary Tract InfectionsThe continence service continues to work in partnership with Peoples Services. The Foundations In Care (FIC) has been reviewed and the continence team has been facilitating two days per month. The Continence Appliance Prescribing Guidelines and the NHS catheter passport have been approved by the Joint Area Prescribing Committee. Continued effort is to be deployed in improving communication and collaboration with the UHDB.The prescribing guidelines will be launched across multiple sites.

Joined Up Care Derbyshire STP Urology Improvement PlanA pathway for the management of recurrent urinary tract infections and management with prophylactic antibiotics has made progress and includes patient information.

The DCHS catheter prevalence audit has been returned by the community teams and the findings and recommendations / action plan has been developed to present to the IP& C committee meeting.

CAUTI RATES

Total number of DATIX incident reports received for CAUTI in Quarter 1 2019/2020 = 14

The incident reports were all verified as unavoidable.



April 19 May 19 June 190

1

2

3

4

5

6

Finally Approved CAUTI Incidents



July 19 August 19 Sept 190

2

4

6

8

10

12






Oct 19 Nov 19 Dec 190

1

2

3

4

5

6

7

8



Quality AlwaysThe Quality Improvement Leads (QILs) will continue to work with the IP&C team to support the Quality and Safe Care Champions with training, updates and support with best practice with regards to hand hygiene processes and Aseptic Non Touch Technique.


QA trends are identifying that hand hygiene is consistently emerging as one of the 5 lowest rated standards. A campaign to raise awareness of hand hygiene is currently in progress and will remain so through the year.

Although six IP&C sessions were delivered during the year two of them had attendance rates of seven and below. The QA team is looking at various strategies to get across the key messages.


Health & Social Care Act, 3. Hand Hygiene.

xx



CRITERION 7 – Provide or secure adequate isolation facilities. KEY MESSAGES










xx



CRITERION 8 - Secure adequate access to laboratory support as appropriate. KEY MESSAGES



All microbiology laboratories used by DCHS services have clinical pathology accreditation.Previous work to implement ‘Don’t be a dipstick’ initiative highlighted that the pathology department at the Royal Derby Hospital did not have the correct equipment to undertake a microscopy on urine samples received in a red top bottle. There have been discussions with the pathology manager and GP pathology lead and there are new urine analysers live in the lab at both sites which means Derby will be able to accept boric acid samples in the future. The department are currently validating use with the analyser to ensure the quality of the results remains high with a plan to roll out the changes.


No issues identified.


Continue to await confirmation from UHDB that they are able to accept boric acid samples. This continues to delay the commencement of the ‘Don’t be a Dipstick Campaign’.


Health & Social Care Act.

xx



CRITERION 9 – Have and adhere to policies, designed for the individual’s care and provider organisations that will help to prevent and control infections.

KEY MESSAGESCompliance position FULL


Decontamination Audits

The IP&C Team completed the Dental and Podiatry decontamination audits during October – December 2019. Overall, standards continued to remain high. Staff were knowledgeable and aware of their role within the IP&C and decontamination agenda. Any areas of concern were discussed with staff at the time of the visit or, if required, escalated to the Estates Team/relevant managers to ensure continued monitoring and improvement.

Rapid Response IV Therapy ServiceThere have been no incidents reported within the service or notification of infections relating to IV therapy reported to the IP&C team.


No areas identified


Review is on-going as to how evidence can best be captured for hand hygiene compliance/practice as this has been identified as an area of concern through the Quality Always CAAS and also during wound clinic audits. The IP&C team will be attending an Audit for Improvement Group meeting with representation from a variety of trusts during Qtr 4. Currently awaiting a confirmation date.



xx



CRITERION 10 - Providers have a system in place to manage the occupational health needs and obligations of staff in relation to infection.

KEY MESSAGESCompliance position PARTIAL


Influenza vaccine:The flu vaccine campaign has continued throughout Qtr3 and current data indicates that 76.2% of staff have received the vaccine, which has been a great improvement over previous years.

Occupational Health and wellbeing Accidental Exposure Incidents for DCHS Staff

From October 2019 – December 2019

ICS North Community NSI -used lancet found in a patients bedding -non retractable needle x1

NED Chesterfield planned care and specialist services (podiatry) sharps injury during disposal x1

Belper ICT after use of insulin pen sustained NSI on disposal of sharp x1

Central ICT - NSI during multistep procedure after giving injection on disposal of sharp /Chesterfield Core services Central ICT - during disposal of sharp post injection x2

Amber valley place management -Sexual health - on disposal of a sharp - sustained NSI from a used needle due to being full sharps container x1

Ilkeston Community HWB & Inclusion - Dental between steps of a multi step procedure x1

Ilkeston Community -splash incident whilst assisting with catherisation procedure x1

Chesterfield core planned care -caught safety needle during disposal of sharp post injection x1

Derbyshire Dales core based services -ICT - after disposal of Sharp x1






To explore strategies in how we can reduce accidental exposure incidents across the Trust with a view to promoting zero tolerance.


Health & Social Care ActHealth & Safety at Work Act

xx



Cleanliness and Environment Audit Report – ‘Quarter 3’ 2019/20 Appendix 1:

Year to date - Quarter 3 – 2019/20

Category 1A – DCHS Services – DCHS Cleaning – DCHS Owned Property – Hospitals2019/20 Current PerformancePremise

Hospitals2018-19Average Q1 Q2 Q3 Q4 Red Ambe

rYello

wGreen Movement

Ash Green 99 99 99 98 Buxton Hospital 100 99 99 99 Cavendish Hospital 99 100 99 99 Clay Cross Hospital 99 99 99 98 Ilkeston Hospital 100 100 100 100 Ripley Hospital 100 100 100 100 Walton Hospital 100 100 100 100 Whitworth Hospital 99 99 100 99 Average Score 100 100 100 99

Category 1B – DCHS Services – DCHS Cleaning – DCHS Owned Property – Community2019/20 Current PerformancePremise

Hospitals2018-19Average Q1 Q2 Q3 Q4 Red Ambe

rYello

wGreen Movement

Brimington Clinic 100 100 100 100 Chapel HC 100 100 100 98 Eckington HC 100 100 100 100 Heanor HC 100 100 100 100 New Mills Clinic 99 99 99 98 Orchard Cottage 100 100 100 100 Repton HC 100 100 100 100 Robertson Road 100 100 100 100 Rockley Core Unit 99 100 100 99 Shirebrook HC 100 100 100 100 Staveley Clinic 100 100 100 100 Manor Stores 100 100 100 100 Buxton HC 98 100 98 98 Castle St HC 97 100 100 Average Score 100 100 100 100

Category 2 – DCHS Services – DCHS Cleaning – DCHS Leased Property – Community2019/20 Current PerformancePremise

Community2018-19Average Q1 Q2 Q3 Q4 Red Ambe

rYello

wGreen Movement

Key

Performance Movement Exclusion RationalesAchieved > 95% Performance Improved Not available at time of

reportingN/A

Action Required 87-94% Performance Stable Not included N/IUrgent Action Required

75-86% Performance Declined Done in Quarter 1Due in Quarter 2Due in Quarter 3Due in Quarter 4

D1D2D3D4

Trust Priority < 74 % No previous baseline Cancelled CCurrent Performance score not available / measured



Category 2 – DCHS Services – DCHS Cleaning – DCHS Leased Property – CommunityPremiseCommunity

2018-19Average

2019/20 Current PerformanceQ1 Q2 Q3 Q4 Red Ambe

rYello

wGreen Movement

Dronfield H/C 100 100 100 100 Hannage Brook 100 100 100 100 Killamarsh Clinic 100 100 100 100 Springs HC Clowne 100 100 100 100 Stubley Medical Centre 100 100 100 100

The Hub (Sth Normanton) 100 100 100

100

Welbeck Rd HC 100 100 100 100 Wheatbridge HC 100 100 100 100 Average Score 100 100 100 100

Category 3A – DCHS Services – DCHS Cleaning – NHS Property Services – Hospitals2019/20 Current PerformancePremise 2018-19

Average Q1 Q2 Q3 Q4 Red Amber

Yellow

Green

Movement

Babington Hospital 100 100 100 99 Newholme Hospital 99 99 100 99

Average Score 100 100 100 99

Category 3B – DCHS Services – DCHS Cleaning – NHS Property Services – Community2019/20 Current PerformancePremise 2018-19


Yellow

Green

Movement

Belper Clinic 100 100 100 100 Mill Hill Dental 99 97 97 100


Category 4A – DCHS Services – DCHS Cleaning –The Community Partnership Property (LIFT) –Hospital2019/20 Current PerformancePremise 2018-19


Yellow

Green Movement

St Oswald’s Hospital 99 100

99 99


Category 4B – DCHS Services – DCHS Cleaning –The Community Partnership Property (LIFT) – Community Premise

2019/20 Current PerformancePremise 2018-19Average Q1 Q2 Q3 Q4 Red Ambe

rYello

wGree

nMovement

Alfreton PCC 100 100 100 100 Long Eaton HC 99 98 99 99 Swadlincote HC 100 99 99 100 Average Score 100 99 99 100

Category 5 – DCHS Services – Non DCHS Cleaning – Non DCHS Property2019/20 Current PerformancePremise 2018-19


Yellow

Green

Movement

Sure Start Fairfield 100 100 98 99 Scarsdale 100 100 100 100



Village Medical Centre 98

98 100 99

Coleman Street, Derby 97

100 98 99

Revive HC Derby 100 100 99 100

Peartree HC Derby 97 99 100 99

Sinfin HC Derby 98 100 100 99

London Road CH 100 100 99 100 Holmewood Surgery 100 100 100 100

Queens Court 98 100 100 100 Average Scores 99 100 100 100



Overall Trend of where DCHS Provide Patient Care

2019/202018-19Average Q1 Q2 Q3 Q4

Movement from previous year

Overall Average 99% 100%

100%

100%

Service/Cleaning/Building AverageScore

1A1B

DCHS Services – DCHS Cleaning –DCHS Owned Property (Hospitals)DCHS Services – DCHS Cleaning –DCHS Owned Property (Community Premises)

99%100%

2 DCHS Services – DCHS Cleaning –DCHS Leased Property (Community Premises)

100%

3A3B

DCHS Services – DCHS Cleaning – NHS Property Services (Hospitals)DCHS Services – DCHS Cleaning – NHS Property Services (Community Premises)

99%100%

4A4B

DCHS Services – DCHS Cleaning –The Community Partnership Property (Hospitals)DCHS Services – DCHS Cleaning –The Community Partnership Property (Community Premises)

99%100%

5 DCHS Services – DCHS Cleaning – Non DCHS Property 100%



Appendix 2: Pest Activity Activity and specific pest groups are categorised by the following graphical representations:- Total Calls by Locality – Quarter ‘3’ 2019/20

0

1

2

3 3

0Amber Valley

& ErewashChesterfield High Peak &

DalesLearning Disability Service

North East South Dales0

1

1

2

2

3

3

4

Total Calls by Pest Group – Quarter ‘3’ 2019/20

6

1

2

Ants Rodent Activity Wasps0

1

2

3

4

5

6

7



Appendix 3: Kitchen Hygiene Inspections

Local Authority – Environmental Health Inspection Status DCHS Kitchen Hygiene Inspection Programme

Local Authority – Environmental Health Status DCHS Kitchen Hygiene Inspections Quarter 3 – 2019/20

DCHS In-house InspectionsPREMISES

Local Authority – Current Status

(Rating 1 – 5) and date of last

Inspection

Previous Year

2018/2019

Current Year

2019/2020

Movement

Trust Priorit

y

UrgentAction

Required

Action Require

d

Achieved

Ash Green

Hospital

09/02/2018

No food production

- food service

only

No food production - food service

only

Babington

Hospital

10/09/2019

98% 98%

Cavendish

Hospital

03/07/2018

98% 96%

Clay Cross

Hospital

12/04/2018

95% 98%

Ilkeston Hospital

08/08/2019

99% 97%

Newholme

Hospital

10/05/2018

95% 98%

Ripley Hospital

19/08/2019

95% 100%

St Oswald’s Hospital

09/10/2018

96% 97%

Walton Hospital

03/12/2018

97% 98%

Whitworth

Hospital

11/10/2017

95% 97%

Key

Performance MovementAchieved > 95% Performance Improved

Action Required 87-94% Performance Stable Urgent

Action Required75-86% Performance Declined


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