Board of Directors Meeting
29 May 2014
Room A, RED Centre, Tickhill Road Hospital, Doncaster, DN4 8QN
No
Time
Item
1
2
3
4
5
6
7
9.00
Welcome
Apologies for Absence – Debbie Smith
Declarations of Interest
Minutes of Board of Directors meeting held in public on 24 April 2014
Matters Arising and Follow Up Action List
Chairman’s Report and Council of Governors update
Chief Executive’s Report
Lead
Enc
LP
LP
PG
LP
LP
LP
CB
A
B
C
D
E
PG
F
HD
HD
HD
MS
G
H
I
J
PW
JM
K
L
KS
RB
Verbal
M
RB
N(i)
N(ii)
DW
O
Strategy
8
Annual Plan Review – Declarations
Safety, Clinical Effectiveness and Patient Experience
9
10
11
12
9.45
Report by the Deputy Chief Executive / Director of Nursing & Partnerships
Quality Report 2013/14 and Forward Strategy 2014/15 – final
Inpatient Staffing Declaration
Report by the Chair of the Mental Health Legislation Committee
Finance Infrastructure and Business Development
13
14
Report by the Director of Finance
Report by the Chair of the Charitable Funds Committee
15
Public questions
11.00
BREAK
Performance / Assurance
16
17
18
19
Report by the Chair of the Audit Committee
Report by the Director of Business Assurance
Board Assurance Framework (BAF)
• Strategic Work Programmes Quarter 4 update
• BAF close down summary report
Performance Dashboard
Rotherham Doncaster & South Humber NHS Foundation Trust
Woodfield House, Tickhill Road, Doncaster DN4 8QN
www.rdash.nhs.uk
No
Time
Item
Lead
Enc
RJ
NA
P
Q
Human Resources and Organisational Development
20
21
Report by the Director of Workforce and OD
Organisational Revalidation Self-Assessment
22
23
Any Other Business
Public questions
12.45
Chair to resolve that because publicity would be prejudicial to the public
interest by reason of the confidential nature of the business to be
transacted, the public and press be excluded from the meeting.
Verbal
LP
Date, time and venue of next meeting:
Thursday 26 June at 9am at the RED Centre, Tickhill Road Hospital, Doncaster DN4 8QN
PAPER A
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Group/Committee
Name
Board of Directors – Public meeting
Meeting Date
29 May 2014
Title of Paper
Author
Declarations of Interest
Philip Gowland, Board Secretary
Paper For
Decision
Strategic Work
Programme:
- Relevance
- Progress
Key Points to Note
(including any
identified risks )
Debate
Assurance
Information

Reference
What Strategic Work Programmes is the paper
relevant to?
Does the paper provide assurance against
delivery of the identified Strategic Work
Programme?
None
Yes / No
No
The Trust’s Constitution states, ‘If a Director has a pecuniary, personal or
family interest or any other interest which is relevant and material to the
Trust, whether that interest is actual or potential and whether that interest is
direct or indirect in any proposed contract or other matter which is under
consideration, or is to be or is likely to be considered, by the Board of
Directors, the Director shall disclose that interest to the Members of the
Board of Directors as soon as he becomes aware of it.’
Declarations are made to the Board Secretary as they arise, recorded on
the public register and formally reported to the Board of Directors at the next
meeting.
To ensure openness and transparency during Trust business, the Register
has, from September 2012, been included in the papers that are considered
by the Board of Directors each month. Updates are shown in bold.
Board Assurance
Framework
If the paper also provides assurance against
the effectiveness of a Key Control what is the
reference and what level of assurance do you
think it provides?
CQC
If the paper provides assurance against
Essential Standards of Quality and Safety
(ESQS) specify the outcome number.
Financial/Budget
Equality &
Diversity/Human
Rights
Action proposed
following the
Group meeting
BAF Key
Control Ref.
Effectiveness
F/S/P/V/N
ESQS outcome number
NA
N/A
Directors to continue to declare any interest to the Board Secretary
for recording on the public register and reporting to the Board of
Directors
1
PAPER A
Person
Responsible
Directors
Philip Gowland, Board Secretary
Date for
completion
Outcome required
from the Group
On-going
The Board of Directors to note the Register of Interests and to
consider any conflicts of interest arising from the agenda items.
2
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
BOARD OF DIRECTORS – REGISTER OF INTERESTS
Name / Position
PAPER A
Interests Declared
Lawson Pater Chairman
• Volunteer at South West Yorkshire Partnership NHS Foundation Trust (Cardio Rehab
Services)
James Marr Non-Executive Director
•
•
•
•
Andrew Law Non-Executive Director
•
•
•
•
Michael Smith Non-Executive Director
•
•
•
•
•
•
Kathryn Smart Non-Executive Director
• Voluntary Trustee / Director at Doncaster Rape Crisis and Sexual Abuse Counselling
Service (DRASACS) [from 20 January 2014 providing interim management & consultancy
on a temporary basis]
• Member of the Friends of Town Fields Fundraising Committee
Tim Shaw Non-Executive Director
• Wife employed as a Health Visitor with RDaSH and based at Thorne, Doncaster
• Equity Partner with Nabarro LLP, a commercial law firm.
Trustee of the Methodist Relief and Development Fund
Managing Trustee of the Barton and Brigg Methodist Circuit
Trustee of Lincolnshire Chaplaincy Services (resigned)
Daughter is working through her Pharmacy pre-registration placement at a community
pharmacy in Hull, also works on a zero hour contract with Boots in Scunthorpe.
• Volunteer Manager at Brigg Job Club
Freelance Interviewer at NatCen
Director of Sharks Ski Club CIC
Director of Sheffield Ski Ventures CIC
Trustee of a charity called "Optimism Is", which supports disadvantaged children and
young adults in the Doncaster area through sport
Trustee, Magna Science Adventure Centre
Director of Magna Enterprises Ltd
Trustee, Jeremy Beadle Memorial Trust
Director MJS Business Consultancy Ltd
Lieutenancy officer for South Yorkshire
Director (employee not Company Director) Chamber Skills Solutions – August 2012 an
associate company of Chamber Skills Solutions purchased training resource from
RDaSH
• Director of Flourish Enterprises Community Interest Company
3
Petar Vjestica Non-Executive Director
•
•
•
•
Christine Bain Chief Executive
• Husband is retired Manager who previously worked at Doncaster and Bassetlaw
Hospitals NHS Foundation Trust
• Member of the Governing Body (The Corporation Board) of Rotherham College of Arts
and Technology
Helen Dabbs Deputy Chief Executive / Executive Director of
Nursing and Partnerships
• Son is registered on the Trust’s staff bank as a Health Care Assistant
• Professional and Clinical Advisor to the Care Quality Commission (CQC)
Dr Nav Ahluwalia Executive Medical Director
• Director and majority shareholder of “Navjot Ahluwalia Partnership Limited”
Paul Wilkin Executive Director of Finance
• Director of Flourish Enterprises Community Interest Company
• Nominated Director of the RDaSH Social Enterprise Company – currently not
trading
• Wife is the lead volunteer of Friends of Woodfield Park (public) group
Richard Banks Executive Director of Business Assurance
• Nil
Rosie Johnson Executive Director Workforce and
Organisational Development
Deborah Smith Service Director, Mental Health Services
• Nil
Sharon Schofield, Service Director, Children & Community
Services
Deborah Wildgoose, Interim Service Director, Children &
Community Services
• Nil
Director of Trojan Horse Ltd
Company Secretary of Marks Natural Foods
Secretary of ‘Starlights’ Drama Group
Member of Winterton 2022 Committee
• Nil
• Nil
4
Paper B
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Group/Committee
Board of Directors – Public Meeting
Name
Meeting Date
29 May 2014
Title of Paper
Minutes of the Public Board of Directors – 24 April 2014
Author
Melanie Gregson
Paper For
Decision
Debate
Assurance
Information
Strategic Work
Programme:
- Relevance
- Progress

Reference
What Strategic Work Programmes is the paper
relevant to?
None
Yes / No
Does the paper provide assurance against
delivery of the identified Strategic Work
Programme?
No
Key Points to Note
(including any
identified risks )
Board Assurance
Framework
If the paper also provides assurance against
the effectiveness of a Key Control what is the
reference and what level of assurance do you
think it provides?
CQC
If the paper provides assurance against
Essential Standards of Quality and Safety
(ESQS) specify the outcome number.
Financial/Budget
BAF Key
Control Ref.
Effectiveness
F/S/P/V/N
ESQS outcome number
N/A
Equality &
Diversity/Human
Rights
N/A
Action proposed
following the
Group meeting
The Chairman to sign a copy of the ratified minutes
Person
Responsible
Lawson Pater, Chairman
Date for
completion
Outcome required
from the Group
29 May 2014
The Board of Directors is asked to consider whether the attached
minutes are a true record of the Board of Directors meeting on 24
April 2014.
1
Paper B
ROTHERHAM DONCASTER AND SOUTH HUMBER
NHS FOUNDATION TRUST
MINUTES OF THE PUBLIC BOARD OF DIRECTORS MEETING
HELD ON THURSDAY 24 APRIL 2014
AT GLANFORD PARK, SCUNTHORPE
PRESENT
Lawson Pater
Jim Marr
Andrew Law
Kathryn Smart
Mike Smith
Petar Vjestica
Tim Shaw
Christine Bain
Helen Dabbs
Dr Navjot Ahluwalia
Richard Banks
Rosie Johnson
Paul Wilkin
Chairman
Non Executive Director (Vice Chair)
Non-Executive Director (Senior Independent Director)
Non-Executive Director
Non-Executive Director
Non-Executive Director
Non-Executive Director
Chief Executive
Deputy Chief Executive / Director of Nursing and Partnerships
Executive Medical Director
Director of Business Assurance
Director of Workforce and Organisational Development
Director of Finance, IT and Estates
IN ATTENDANCE
Philip Gowland
Deborah Smith
Dr Deborah Wildgoose
Melanie Gregson
Board Secretary
Service Director, Mental Health Services
Interim Service Director, Children and Community Services
PA to the Chairman and Board Secretary (Minute taker)
Members of the public:
Alex Sangster
Christine O’Sullivan
Graham Bailey
Public Governor, Rotherham
Public Governor, North Lincolnshire
Mental Health Carer Governor
APOLOGIES
Sharon Schofield
Service Director, Children and Community Services
Mr Pater opened the meeting, welcomed all and explained the format of the meeting.
The members of the public were welcomed.
58A/14
ACTION
APOLOGIES FOR ABSENCE
Apologies were recorded for Mrs Schofield.
59A/14
DECLARATIONS OF INTEREST
The Register of Interests of the Board of Directors was noted. Following Mr Smith’s
comment, Mr Gowland agreed to remove the sentence relating to the purchase of
training resource from RDaSH in August 2012.
60A/14
PG
MINUTES OF PUBLIC BOARD OF DIRECTORS MEETING 27 MARCH 2014
The minutes were accepted as an accurate record of the meeting, subject to the
following change:-
2
Paper B
45A/14 Chairman’s Report
“Mr David Nicholson” to be changed to “Sir David Nicholson”.
61A/14
MATTERS ARISING AND FOLLOW UP ACTION LIST
The previously circulated paper informed the Board of Directors of the completed
actions and progress updates.
53A/14 – Children and Communities performance dashboard
Mrs Smart commented on the waiting list data for Rotherham CAMHS and asked
whether the Trust was confident with regards to the “clock start” and “clock stop” in
terms of treatment for the patient. Dr Wildgoose reported on the complex work that
was currently underway to understand the true patient waits and the reasons. She
assured the Board that immediate work had been completed and there were no
vulnerable patients on the waiting list and all patients had been assessed and triaged
within 24 hours. The work had not yet considered the potential periods of
suspension from waiting lists.
47A/14 – Draft Operational Annual Plan
Mr Shaw asked if there had been any feedback from commissioners following the
sharing of the draft operational plan. Ms Dabbs commented that the document had
been well received with feedback that the Trust annual plan reflected the
commissioning plans.
62A/14
CHAIRMAN’S REPORT AND COUNCIL OF GOVERNORS UPDATE
Mr Pater presented the paper containing the meetings and service visits he attended
during the month with details contained in the paper. Mr Pater commented on the
positive report by the independent observer of the Clinical Excellence Awards
process.
He also reported on the Governor and Non Executive Director’s involvement in a
variety of activities that were detailed in the paper.
Mr Smith commented that he had also been involved with the Trust Associate
Managers (TAMs) Forum and individual TAM reviews.
The Board of Directors noted the Chairman’s Report.
63A/14
CHIEF EXECUTIVE REPORT
Mrs Bain highlighted some of the key points contained within her previously
circulated paper:The recent Leading the Way with Quality (LWQ) sessions had been completed which
followed on from the Fit For the Future (FFF) sessions held for Band 7’s and above.
The LWQ sessions were well attended in terms of numbers and cross sections of
staff. The Trust values discussions held at the LWQ and FFF sessions had been
distilled and Mrs Bain had posted a blog on the intranet about the resetting of the
Trust values.
Kendal Stokes had won the 2014 Advancing Healthcare Award for her improvement
ideas in Rotherham and this was recognised by the Board as a great achievement.
Mrs Bain commented on the appointment of Mr David Hill as the new Chief
3
Paper B
Executive of Humber FT.
Mrs Bain reported on the discussions held at the Mental Health Chief Executive’s
meetings she attended with regards to the overall rise in the number of FOI requests
to organisations. There had been debate about capacity and ability to respond to the
number of more complex and detailed requests being made and this seemed to be
replicated across Yorkshire and the Humber region.
Mr Smith suggested that perhaps all requests for information should not
automatically be treated as Freedom of Information requests. Mr Banks commented
that the specific FOI requests are handled by the Information Governance team but
the organisation also needed to ensure governance around all requests for
information.
Mrs Smith commented on a suicide in Doncaster and reported that the person
involved was not in receipt of Trust services and therefore the incident had been delogged from the system.
Mrs Smart noted the ‘Putting Patients First – NHS England’s Business Plan 2014/15
– 2016/17’ publication and asked how the Trust would engage. Mrs Bain replied that
some of the elements would be linked in to discussions with commissioners and their
plans for the future.
(Mr Sangster arrived at the meeting)
Mr Vjestica commented on an event he had recently attended. He reported that
commissioners seemed to look at provider collaborative ventures in a progressive
way but had some frustration that this was not happening very quickly. Mrs Bain
noted this and highlighted the work the Trust had done with One Team Working in
Doncaster Community Services in partnership with Doncaster Metropolitan Borough
Council and she commented that there will be more expectation of this type of
collaborative work in the future.
Mr Shaw noted the information contained in the report regarding a review of nurse
training by Health Education England and the Nursing and Midwifery Council. He
asked whether there was any indication that the proposals would have an effect on
the Trust. Ms Dabbs commented that there was no guidance as yet but would it
would likely effect placements at the Trust. Mrs Bain commented that this was a
topical debate at the Local Education Training Board of which she was a member.
The Board of Directors noted the paper.
SAFETY, CLINICAL EFFECTIVENESS AND PATIENT EXPERIENCE
64A/14
REPORT BY THE DEPUTY CHIEF EXECUTIVE / EXECUTIVE DIRECTOR OF
NURSING AND PARTNERSHIPS
Ms Dabbs highlighted the key issues contained within her report.
Quality Governance
The Clinical Governance Group met in April and the Clinical Audit internal audit
report was presented which provided ‘significant assurance’ on the work conducted.
There were some areas to improve on but overall a very good outcome with areas of
good practice highlighted. A follow up exercise by internal audit will be undertaken in
September 2014.
The Group continued its deep dive focused on serious incidents and complaints for
4
Paper B
Doncaster Community Integrated Services (DCIS) and Adult Mental Health. A
review of SI category and locality with a view to benchmarking by locality population
was taking place as well as a historical analysis of SIs to ensure there was
consistent monitoring and reporting as well as learning lessons.
The Organisational Learning Forum are reviewing adult mental health suicide SIs for
the past 6 months to focus on any systemic learning points to be shared across all
the divisions. The Group was also reviewing the pressure ulcer action plan in place
in DCIS and the lessons that had been learned. The Patient Safety team in
Business Assurance is reviewing the recording of suicide and coroners outcomes
and how this is reported by the organisation.
Quality Improvement
The Trust had been invited to participate in the pilot of the revised Care Quality
Commission (CQC) Adult Social Care inspection approach. Two pilot sites within the
Learning Disability business division had been identified and details were contained
within the paper.
Nursing and Partnership update
The Trust had been successful in becoming a pilot site for the ‘certificate in
fundamental care’ which was being developed by Health Education England. Ms
Dabbs commented that this was an opportunity to look at setting benchmarks for
Nursing Assistants.
Following the issue of NICE public health guidance ‘smoking cessation in secondary
care: acute, maternity and mental health services’, the Trust needed to further
consider its implementation and specifically smoke free grounds with the removal of
shelters and designated areas. The implications for service users were detailed in
the report and Ms Dabbs commented that this guidance had significant implications
for the Trust. It was noted that an interim statement had been issued by the Trust
including e-cigarettes in the policy. The Senior Leadership Team (SLT) would
consider all the factors around smoke cessation at the Trust.
The paper contained details of the work undertaken by the Trust in 5 action areas as
a response to a letter to Trusts by NHS England. This was a significant piece of work
which has to be complete by the end of June 2014. The 5 actions were in response
to the second government response to the Francis Report ‘Hard Truths: the Journey
of Putting Patients First’ and the National Quality Board publication ‘How to ensure
the right people, with the right skills, are in the right place at the right time’.
The Nursing Network and the Listen to Learn Steering Group had both met in April
and details of the topics discussed were contained in the paper.
Mrs Smart commented on the recent focus in the media on diabetes and end of life
care and asked how these were fed into the Trust’s clinical governance process to
understand if there were any issues for the Trust. Ms Dabbs responded with details
of the Medicines Management Committee, POMH UK audits, on-going awareness of
NICE guidance with the Clinical Effectiveness Committee reporting to the Clinical
Governance Group.
The Board of Directors noted the information contained within the paper.
65A/14
QUARTERLY QUALITY IMPROVEMENT REPORT QUARTER 4 (2013/14) –
EXECUTIVE SUMMARY
Ms Dabbs highlighted the key issues contained with the report.
5
Paper B
Good News
The Trust would receive £238k from NHS England’s Nursing Technology Fund,
details of which were contained in the paper.
Patient Safety
There had been 23 Serious Incidents in Quarter 4 and details of the total number of
Serious Incidents by quarter since 2011/12 was contained in the paper. Analysis of
the SIs for 2013/14 was also detailed.
The largest number of SIs were attributable to the Adult Mental Health and DCIS
Business Divisions but it was noted that both divisions were twice the size of others
in terms of staffing levels in the Trust.
Patient Experience
There had been 34 complaints in Quarter 4 and details of the total number of
complaints by quarter since 2011/12 were contained in the paper. The outcomes
and analysis of complaints for 2013/14 were also detailed. Mr Shaw asked if there
was a comparative analysis available for the two previous years and Mr Banks
agreed to make these available to Mr Shaw. Mr Banks highlighted the difficulty of a
standard response time to complaints as some were very complex.
RB
Clinical Effectiveness
Ms Dabbs commented on NICE guidance requiring implementation by the Trust.
There had been 52 clinical audits completed showing areas of good practice and
some areas requiring improvement. The information was contained in the report.
Ms Dabbs agreed to share with Mr Banks the breadth of the clinical audit relating to
the management of people with a learning disability and mental illness for the
Monitor Declaration.
HD
External Reviews
Details regarding CQC inspections, CQC Mental Health Act monitoring visits and
Commissioner quality visits were contained in the report.
Ms Dabbs highlighted the focus of the Trusts quality improvement work during
2014/15.
Mr Law commented that missing from the report was the linkage between complaints
and serious incidents by location and using that as one of the Trust’s ‘smoke
detectors’ for early recognition of any potential problems. Ms Dabbs commented that
this had been in previously and taken out in Quarter 3 by agreement at the Clinical
Governance Group. Ms Dabbs confirmed that it would be re-instated in Quarter 1
2014/15.
HD
Ms Dabbs commented on the visits by Non-Executive Directors which could be
included in the report and noted that reference was made in the next paper to them
and a cross-reference would be useful.
Mrs Smith suggested that a communication is sent from the Board to the staff
expressing their thanks for the hard work in delivering quality. Mrs Bain and Mr
Pater agreed to do this on behalf of the Board of Directors.
CB/LP
The Board of Directors noted the Executive Summary of the Quality
Improvement Report for Quarter 4, 2014/15.
66A/14
QUALITY GOVERNANCE FRAMEWORK
6
Paper B
Ms Dabbs reported that the Nursing and Partnerships Directorate, the Business
Assurance Directorate and the Board Secretary had completed the Quality
Governance Framework (QGF) report for the Quarter 4 self-assessment. Ms Dabbs
and Mr Gowland provided an overview of the supporting evidence and conclusions
for each of the four sections of the Framework that had previously been presented
and discussed at the Clinical Governance Group.
Area 4 remained at a rating of ‘Amber/Green’ based on the continuing work to
improve the robustness of quality information. Areas 1, 2 and 3 remained at ‘Green’
as in Quarter 3. The overall rating of ‘Green’ against the framework at the end of
Quarter 4 had been recommended and this was agreed by the Board.
Ms Dabbs reminded the Board of the change in the guidance from Monitor which
meant that the QGF was no longer subject to quarterly declaration under the new
Risk Assessment Framework. However, there remained a clear need for the Board
of Directors to assure itself on quality governance and to conduct periodic
governance reviews, as these support the Annual Governance Statement.
The Board of Directors agreed the overall rating of ‘Green’ for Quarter 4.
67A/14
DRAFT QUALITY REPORT 2013/14 AND FORWARD STRATEGY 2014/15
The draft quality report had been presented and discussed at two recent Clinical
Governance Group meetings and the paper presented to the Board of Directors was
a working draft.
Mrs Smart commented that the Quality report reflected previous discussions at
Board and the Policy and Planning groups of which she was a member of.
Ms Dabbs highlighted that the next step was to circulate to the Clinical
Commissioning Groups and other Partner organisations, who would be requested to
provide a statement in response.
It was noted that the final version of the report would be presented to the Board of
Directors in May 2014.
HD
The Board of Directors noted the draft Quality Report 2013/14 and Forward
Strategy 2014/15.
68A/14
FINAL CQC INSPECTION REPORT – TRUST HEADQUARTERS
Following the CQC inspection report in October 2013, an action plan was developed
and presented to the Board in January 2014.
Ms Dabbs referred to the previously circulated action plan which had been
completed in all areas with the exception of the refurbishment of Brodsworth Ward.
This would be completed as part of the 2014/15 capital expenditure programme.
The Board noted and agreed sign off of the CQC Inspection of Trust Services
action plan.
FINANCE INFRASTRUCTURE AND BUSINESS DEVELOPMENT
69A/14
REPORT BY THE DIRECTOR OF FINANCE
Financial Position Quarter 4 2013/14
7
Paper B
Mr Wilkin highlighted the key information detailed in his report in terms of the
financial position of the Trust. The audited financial accounts for the 2013/14
financial year would be submitted to Monitor by 30 May 2014, following formal
adoption at the Audit Committee meeting on 27 May. Some reconciliation of
accounts would be reported to the next Board of Directors meeting.
PW
Mr Law commented on the management of the message to staff to highlight that the
main purpose of the surplus was to help with QIPP plans and the financial position of
the Trust in the future.
Mr Wilkin commented that there would be significant financial challenges for
2014/15.
Better Care Fund
The paper contained details of the launch of the Better Care Fund and it was noted
that this was not additional funding but from existing funds and would go live in
2015/16. The paper highlighted the financial position in relation to Doncaster and
Rotherham Clinical Commissioning Group and the position for North Lincolnshire will
be reported to the May Board of Directors. The work will be co-ordinated by the
Health and Wellbeing Boards in each area and the Trust were members of all of
these Boards.
PW
Service Line Reporting (SLR) plan
Service line reporting will be further developed in 2014/15 and split into 4 areas
highlighted in the report. Mr Wilkin highlighted that one of the projects would be a full
analysis of local authority contracts to understand the risks involved.
It was noted that there was no ‘go live’ date for Payment by Results and a local
commissioner debate would probably be the way forward for the Trust.
The Board of Directors noted the Finance Director’s report.
70A/14
PUBLIC QUESTIONS
Mr Bailey referred to the Matters Arising paper (Paper C) and the referral time for the
memory clinic in Rotherham. He asked why the Trust or GP’s could not provide the
ECG prior to the patient starting the pathway. Mrs Smith commented that the Trust
was reviewing the ability for Trust staff to conduct ECGs for patients but the problem
would be ensuring appropriate training for the detailed diagnostic area and the
governance implications for the Trust.
Following a comment by Mr Bailey, Mrs Bain stated that the Trust’s current data for
the memory clinic was showing no patients waiting in Rotherham and North
Lincolnshire beyond the commissioned 18 week target and 90% of its patients were
seen within 8 weeks. Mrs Smith commented that the Trust was working within the
resources provided by commissioners.
Mrs O’Sullivan asked whether there had been any feedback from North Lincolnshire
following the sharing of the Trust’s Operational Annual Plan. Ms Dabbs would
confirm, but she thought not.
HD
Mrs O’Sullivan asked about the ‘certificate in fundamental care’ detailed in Paper F.
She asked what level of education the certificate would be and would it be on-the-job
training or elements of e-learning. Ms Dabbs replied that the Trust was taking part in
the pilot to assess how different approaches worked in practice. All the
8
Paper B
organisations involved in the pilot would take a different approach and these would
be reviewed at the end of the pilot programme.
Mr Sangster asked about the criteria applied for allocation of funding in connection
with the ‘Better Care Fund’ (Paper K) and it was noted that this was per head of
population and deprivation.
Mr Sangster noted that in Paper G, all the categories were clinical and asked
whether other criteria such as day of discharge, time of day and socio-economics
were considered in the ‘deep dive’ of serious incidents. Ms Dabbs responded that
various demographic factors were considered and Mr Sangster commented that
deprivation may be an issue which possibly needed to be considered.
PERFORMANCE / ASSURANCE
71A/14
REPORT BY THE DIRECTOR OF BUSINESS ASSURANCE
Mr Banks highlighted the detail contained in the report relating to the year-end
CQUIN position. The areas where money had been withheld were detailed and the
finalised figure may change and will be presented through the Performance and
Assurance Group (PAG) in May 2014.
PAG had considered the Trust’s position against Monitor targets and indicators for
Quarter 4 and had recommended a governance self-assessment of ‘Green’.
It had been agreed that all staff would receive Fire Marshall training during the 3 in 1
training to fulfil the statutory obligation to have a Fire Marshall on every shift and to
provide flexibility for staff rotas.
Premises inspection update details were contained in the paper.
The PAG meeting received the summary close down Board Assurance Framework
2013/14 and there were no issues to be highlighted in the Annual Governance
Statement.
The Board of Directors noted the report.
72A/14
BOARD ASSURANCE FRAMEWORK 2014/15
Mr Banks commented that the document had been agreed at the April meeting of the
Performance and Assurance Group and was being presented to the Board of
Directors for final sign off.
There had been some changes to the document from last year following work with
internal audit. A risk score mechanism had been introduced to evidence the
effectiveness of key controls in the delivery of work programmes.
Mrs Bain highlighted the gap in control identified for 1.2 (page 4) relating to the
research strategy. Dr Ahluwalia commented that research would report through the
Clinical Governance Group.
Mr Pater asked about the accessibility of policies for staff on the intranet including
perhaps an ‘easy read’ document. Mr Banks reported that a new Trust website was
due to go live on 2 June 2014 and part of the development work was to ensure ease
of searching for policies on the website. Discussion took place regarding the rewriting of policies to put them in an easier to read format. The capacity of staff was
discussed and it was recognised that the time to do that would be when the policy
9
Paper B
was due to be reviewed. Dr Wildgoose commented that there was a balance as
some policies needed to be more complex. Ms Dabbs suggested a discussion at the
Clinical Effectiveness Committee with a definition of the top 5 or 10 in each business
division. The Standard Operating Procedure for each could be defined by a flow
chart.
The Board of Directors approved the Board Assurance Framework for 2014/15.
73A/14
CORPORATE RISK REGISTER
There were currently 11 extreme risks on the Corporate Risk Register and
movement of risks was detailed in the report. The risks continued to be moderated
at the Senior Leadership Team meetings.
Mr Vjestica commented that there seemed to be a strong financial emphasis on the
corporate risk register and patient risks did not seem to feature. Mrs Bain
commented that the Business Divisions were managing the risks to patient safety
and the financial position of the Trust helped in the mitigation of these risks. Mrs
Bain agreed to take further and discuss with the services.
CB
The Board of Directors noted the content of the Corporate Risk Register.
74A/14
RISK REGISTERS – SUMMARY OF ALL RISKS
The summary of all current risks was detailed in the paper, giving the Board the
opportunity to see all of the risks. Mr Banks commented on the 3 highlighted risks in
the paper that had escalated since January 2014.
Mr Vjestica commented on the Pharmacy and Medical risks, with them all rated with
a risk rate score of 12. Mrs Bain commented that these were linked to the initiatives
currently underway for pharmacy including electronic prescribing and training. Mrs
Bain suggested a discussion at SLT regarding an action plan against these risks.
RB/SLT
Mrs Bain commented on the pie charts in the report which emphasised the
assurance process and financial risks more than service quality risks. It was noted
that relative to its size, the Learning Disabilities division had registered higher
numbers of risks.
Mr Shaw commented on OP4/13 in relation to the Older People’s Mental Health
Service experiencing a significant reduction in medical capacity as a result of
vacancies. He asked if the organisation was having difficulty in recruiting to posts
within the national market or if the posts were not being filled because of the financial
position. Dr Ahluwalia commented that there had only been one post the
organisation had difficulty recruiting to and Mrs Smith reported on the lengthy
process involved. There was a financial risk involved in the process as usually
agency staff were used to cover the role prior to completion of the recruitment
process.
Mr Pater commented on the risk DCIS 10/13 which had escalated since January
2014. This related to the meals provided in the DCIS inpatient areas and he asked
for assurance that this had been attended to. Dr Wildgoose commented that the
immediate issue had been resolved but was also linked to a wider piece of work with
the catering department across all the business divisions to look at how the mealtime
experiences can be enhanced for patients. Mr Law noted that this linked into the
PLACE visits regarding nutrition and hydration on Wards.
The Board of Directors noted the summary of all current risks.
10
Paper B
75A/14
PERFORMANCE DASHBOARD
The Performance Exception Report had been presented to the March Performance
and Assurance Group meeting which had agreed on the issues which needed to be
highlighted to the Board. Details of these were contained within the paper.
Mental Health and Forensics performance dashboard
Following a question by Mr Vjestica about the Section 117 6 month reviews, Mrs
Smith commented that the reported figures included people who were not in receipt
of Trust services and this would be changed for the report to the next Board of
Directors in May 2014.
Children and Communities performance dashboard
Dr Wildgoose commented on the actions put in place to improve the level of
reporting data in Rotherham CAMHS. This will give greater clarity to the numbers
who are waiting. Work will now continue to focus on performance and achievement
against commissioner targets.
Work had been undertaken in the Learning Disabilities service to understand the
level of new referrals and activity within the psychology service in Doncaster and
North Lincolnshire. All referrals are triaged to ensure urgent needs are met but
significant waits were being experienced by non urgent cases. Dr Wildgoose
confirmed that patients are receiving other services at the same time. Work is
currently underway to review the level of funding and resource allocated from
commissioners.
The Board of Directors noted the report.
76A/14
REPORT FROM THE CHAIR OF THE AUDIT COMMITTEE
Mrs Smart referred to the previously circulated paper and highlighted the final reports
that had been received with assurance given by internal audit.
An Audit Committee planning session was scheduled to take place on 9 May to
discuss compliance against the Audit Committee Handbook and also to consider the
Audit Committee Chair survey presented by the external auditors at the last meeting
in March 2014.
The Board of Directors noted the Report from the Chair of the Audit
Committee.
HUMAN RESOURCES AND ORGANISATIONAL DEVELOPMENT
77A/14
REPORT BY THE DIRECTOR OF WORKFORCE AND OD
Ms Johnson highlighted some of the key issues, details of which were contained
within her paper.
Sickness absence had decreased to 5.8% in February. Agency expenditure had
increased mainly due to medical staffing issues. Overtime expenditure decreased in
February.
Mop up sessions of the Fit For the Future (FFF) programme were currently taking
place and an event would be held in July regarding maintaining momentum /
celebration.
11
Paper B
The Mutually Agreed Resignation Scheme (MARS) continued to progress and staff
whose applications had been accepted were currently in the process of leaving the
organisation. The majority of staff would leave at the end of April and June 2014
The e-rostering and e-expenses tendering process had been completed and an
action plan for the roll out has been developed.
Total Reward Statements (TRS) have been developed to give staff a clear picture of
their NHS total reward package. Mr Law commented that this seemed to be a useful
management information tool and he would be interested in more details.
Mrs Bain commented that with regards to the Pay Award detailed in the paper, her
understanding was that UNISON was consulting with its members.
The Board of Directors noted the content of the paper.
78A/14
EQUALITY AND DIVERSITY MONITORING
Ms Johnson referred to the previously circulated paper which contained detailed
workforce information which had been reviewed to ensure no discrimination was
occurring at the Trust.
It was noted that the age profile of staff has showed no change reflecting the
recruitment of younger people. Ms Johnson commented on the work in this area
including apprenticeships and work with the Princes Trust. Mr Vjestica asked if an
update regarding progress with apprenticeships could be included in a future report
to the Board of Directors.
RJ
The Board of Directors noted the paper.
79A/14
MENTAL HEALTH ACT – SECTION 12 APPROVAL PANEL
The Trust had successfully tendered for the Section 12 Approval Panel contract.
This would commence in transitional form on 1 April 2014 and would come into effect
fully on 1 May 2014.
Due to the timing, the proposal in terms of governance arrangements and Terms of
Reference of the Approval Panel was presented to the HR&OD policy and planning
group meeting and was approved. Mr Mike Smith, Chair of the Mental Health
Legislation Committee had been kept informed throughout the process.
The Board of Directors approved the proposed governance arrangements and
Terms of Reference document.
GOVERNANCE
80A/14
MONITOR QUARTERLY RETURN
Mr Wilkin referred to the previous finance update paper and the detailed breakdown
that informed a Continuity of Services risk rating of 4 for Quarter 4 2013/14.
Mr Banks highlighted the situation regarding the Delays in Transfer of Care indicator
figures. The process was changed in Quarter 4 resulting in an increased number of
delay days for that Quarter. The external auditors are currently reviewing the
indicator and details were contained within the report. It was agreed to include the
same narrative in the Quality Report to ensure clarity.
12
Paper B
The report recommended a declaration to Monitor of “Green” for Quarter 4.
The Board of Directors agreed with the declaration to Monitor of a Continuity
of Services risk rating of 4 and Governance Rating of ‘Green’ for Quarter 4
2013/14.
81A/14
ANY OTHER BUSINESS
Ms Dabbs commented that the Quality Report will be updated with the PLACE
assessments.
82A/14
HD
PUBLIC QUESTIONS
Mr Sangster asked if the Trust had a vacancy management system in operation and
Ms Johnson commented that there was an Establishment Control Group which
considered vacancies but there was not a process to hold vacancies because of
financial constraints.
83A/14
Mr Pater thanked the members of the public for their attendance and read the
following statement as the Board of Directors meeting moved to private session. “To
resolve that because publicity would be prejudicial to the public interest by
reason of the confidential nature of the business to be transacted, the public
and press be excluded from the meeting.”
DATE, TIME AND VENUE OF NEXT MEETING
Thursday 29 May 2014 at 9am in the RED Centre, Tickhill Road Hospital, Doncaster.
13
Paper C
Follow up actions from the Public Board of Directors meeting on 24 April 2014
The statements below provide assurance that the actions have been completed and / or provide an update on the progress to date.
Minute
59A/14
Progress
DECLARATIONS OF INTEREST
The Register of Interests of the Board of Directors was noted.
Following Mr Smith’s comment, Mr Gowland agreed to remove
the sentence relating to the purchase of training resource from
RDaSH in August 2012.
65A/14
The Register of Interests document has been updated.

2011/12
12 (10.4%)
47 (40.9%)
46 (40%)
9 (7.8%)
1 (0.9%)

QUARTERLY QUALITY IMPROVEMENT REPORT QUARTER
4 (2013/14) – EXECUTIVE SUMMARY
Patient Experience
There had been 34 complaints in Quarter 4 and details of the
total number of complaints by quarter since 2011/12 were
contained in the paper. The outcomes and analysis of
complaints for 2013/14 were also detailed. Mr Shaw asked if
there was a comparative analysis available for the two previous
years and Mr Banks agreed to make these available to Mr
Shaw.
Clinical Effectiveness
Ms Dabbs agreed to share with Mr Banks the breadth of the
clinical audit relating to the management of people with a
learning disability and mental illness for the Monitor Declaration.
Upheld
Partially upheld
Not upheld
Withdrawn
Unable to
conclude
2012/13
15 (10%)
62 (41%)
49 (33%)
21 (14%)
3 (2%)
Completed. The clinical audit was a Commissioner
requirement to re-audit to check if the recommendations from
the previous care pathway audit in 2011 (CQUIN requirement)
had been implemented and improvements made to practice.
The re-audit results identified improvements in relation to
implementation of our policy and pathway which specifies clear
standards to ensure that for those people coming into service,
arrangements to meet their needs have been put in place and
met.

External Reviews
Mr Law commented that missing from the report was the linkage
between complaints and serious incidents by location and using
that as one of the Trust’s ‘smoke detectors’ for early recognition
of any potential problems. Ms Dabbs commented that this had
been in previously and taken out in Quarter 3 by agreement at
the Clinical Governance Group. Ms Dabbs confirmed that it
would be re-instated in Quarter 1 2014/15.
Mrs Smith suggested that a communication is sent from the
Board to the staff expressing their thanks for the hard work in
delivering quality. Mrs Bain and Mr Pater agreed to do this on
behalf of the Board of Directors.
69A/14
Better Care Fund
The paper highlighted the financial position in relation to
Doncaster and Rotherham Clinical Commissioning Group and
the position for North Lincolnshire will be reported to the May
Board of Directors.

This is included in the Finance Directors report to the May
Board meeting.
This is included in the Finance Directors report to the May
Board meeting.


PUBLIC QUESTIONS
Mrs O’Sullivan asked whether there had been any feedback
from North Lincolnshire following the sharing of the Trust’s
Operational Annual Plan. Ms Dabbs would confirm, but she
thought not.
73A/14
The Board of Director’s comments were shared with the
Clinical Governance Group on 19 May 2014 and all Assistant
Directors asked to cascade to relevant staff in Business
Divisions.

REPORT BY THE DIRECTOR OF FINANCE
The audited financial accounts for the 2013/14 financial year
would be submitted to Monitor by 30 May 2014, following formal
adoption at the Audit Committee meeting on 27 May. Some
reconciliation of accounts would be reported to the next Board of
Directors meeting.
70A/14
This information will be included in future editions of the Quality
Improvement Report, Executive Summary presented to the
Board of Directors.
No feedback was received from North Lincolnshire on the
Operational Plan prior to submission.
CORPORATE RISK REGISTER
Mr Vjestica commented that there seemed to be a strong
Discussion on the wording of clinical risks and their relevant

financial emphasis on the corporate risk register and patient
risks did not seem to feature. Mrs Bain commented that the
Business Divisions were managing the risks to patient safety
and the financial position of the Trust helped in the mitigation of
these risks. Mrs Bain agreed to take further and discuss with
the services.
74A/14
scoring for inclusion in the Corporate Risk Register is still
under discussion.
RISK REGISTERS – SUMMARY OF ALL RISKS
Mr Vjestica commented on the Pharmacy and Medical risks, with Mr Banks confirmed that a discussion was due to take place at
them all rated with a risk rate score of 12. Mrs Bain commented the Senior Leadership meeting on 2 June 2014.
that these were linked to the initiatives currently underway for
pharmacy including electronic prescribing and training. Mrs Bain
suggested a discussion at SLT regarding an action plan against
these risks.
78A/14

EQUALITY AND DIVERSITY MONITORING
It was noted that the age profile of staff has showed no change
reflecting the recruitment of younger people. Ms Johnson
commented on the work in this area including apprenticeships
and work with the Princes Trust. Mr Vjestica asked if an update
regarding progress with apprenticeships could be included in a
future report to the Board of Directors.
81A/14

A report regarding the work we are doing in the area of
apprenticeships and the Princes Trust is due to go to the July
HR and OD policy and planning group meeting. This report will
then go forward to the Board of Directors meeting at the end of
July.

Section 38: PLACE Assessments in the “Quality Report
2013/14 and Forward Strategy 2014/15” has been updated to
reflect the work that has been undertaken across the Trust on
the ‘Ward Hostess’ project.

ANY OTHER BUSINESS
Ms Dabbs commented that the Quality Report will be updated
with the PLACE assessments.
Paper D
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Group/Committee
Name
Board of Directors public meeting
Meeting Date
29 May 2014
Title of Paper
Author
Chairman’s Report
Lawson Pater, Chairman
Paper For
Decision
Strategic Work
Programme:
- Relevance
- Progress
Debate
Assurance
Information

Reference
What Strategic Work Programmes is the paper
relevant to?
Does the paper provide assurance against
delivery of the identified Strategic Work
Programme?
None
Yes / No
No
Since the last Board of Director’s meeting report, in addition to my weekly
meetings with the Chief Executive, I have met with / attended / visited:Corporate
• Corporate Induction
• Audit Committee meeting (observing)
• Mental Health Legislation Committee
• Council of Governors (chairing)
Business Divisions
• Meeting with Director of Business Assurance and Deputy Director of
Business Assurance re: management information
• Meeting Chief Pharmacist re: 10 point plan and POMH
Key Points to Note
(including any
identified risks )
External
• Rotherham Partnership Governance Board
• Yorkshire and Humber Regional NHS FT Chairs meeting
• Chairman and Chief Operating Officer, Doncaster Clinical
Commissioning Group (CCG)
• Rotherham CCG Board to Board meeting
Non-Executive Director activities
Non-Executives have ensured representation at all four Policy and Planning
groups during the month.
In addition this month Non-Executives attended:
• Audit Committee meeting
• Mental Health Legislation Committee
• Charitable Funds Committee
• Visit to Coral Lodge (Mrs Smart)
• Visit to Rotherham ICT (Mr Law)
Also, a number of Mental Health Act Hearings have been chaired by NonExecutives, which are held across the Trust.
Paper D
Council of Governors
The Council of Governors met earlier this month at the RPC Welcome
Centre in Rotherham. The meeting started with the ‘Patient’s Story’ and
Governors and those in attendance from the Board and members of the
public heard from Jason Tune who provided a valuable insight into the
challenges and difficulties he has faced and the way in which he has tackled
them including his engagement with Trust’s services. Jason’s presentation
was very well received and appreciated by Governors.
Governors received the current quality, finance and performance updates
and agreed its final statement to be included in the Trust’s Quality Report
2014. An update on the Trust’s Annual Plan was provided and Governors
notified of an opportunity for their involvement in the next stages of the
development of the five year plan. The views of Governors were also sought
as part of the Trust’s consultation on a revised set of Trust Values.
Governor Elections commenced on 20 May 2014, with the nominations
process now open for the following seats:
• Community Services Patient - 2 seats
• Community Services Carer - 2 seats
• Mental Health Service User - 1 seat
• North East Lincolnshire Public - 1 seat
• Learning Disability Service User - 1 seat
• Allied Health Professional / Psychology Staff - 1 seat
• Nursing Staff - 1 seat
• Community Nursing Staff - 1 seat
Nominations must be received by 6 June 2014. More information is
available from the FT Office (0800 015 0370) or
[email protected]
Board Assurance
Framework
If the paper also provides assurance against
the effectiveness of a Key Control what is the
reference and what level of assurance do you
think it provides?
CQC
If the paper provides assurance against
Essential Standards of Quality and Safety
(ESQS) specify the outcome number.
BAF Key
Control Ref.
Effectiveness
F/S/P/V/N
ESQS outcome number
N/A
Financial/Budget
Equality &
Diversity/Human
Rights
Action proposed
following the
Group meeting
N/A
Person
Responsible
Date for
completion
Outcome required
from the Group
Lawson Pater, Chairman
None
29 May 2014
The Board of Directors is asked to receive and note the Chairman’s Report
and the Council of Governor’s update.
Paper E
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Group/Committee
Name
Board of Directors – Public Meeting
Meeting Date
29 May 2014
Title of Paper
Author
Chief Executive’s Report
Christine Bain, Chief Executive
Paper For
Decision
Strategic Work
Programme:
- Relevance
Debate
Assurance
Information

Reference
What Strategic Work Programmes is the paper
relevant to?
All
Yes / No
- Progress
Does the paper provide assurance against
delivery of the identified Strategic Work
Programme?
Key Points to Note
(including any
identified risks )
The Chief Executive’s Report contains a briefing on issues of a national and RDASH
perspective. Further information can be gained from speaking to the relevant lead
director. This month’s report contains the following:
• RDaSH News
• National / Regional Update
• RDaSH Summary Information
o Media coverage
o Freedom of Information (FOI) Requests
o Complaints
o Serious Incidents
Board Assurance
Framework
If the paper also provides assurance against
the effectiveness of a Key Control what is the
reference and what level of assurance do you
think it provides?
CQC
If the paper provides assurance against
Essential Standards of Quality and Safety
(ESQS) specify the outcome number.
No
BAF Key
Control Ref.
Effectiveness
F/S/P/V/N
ESQS outcome number
Indicate in the paper where appropriate
Financial/Budget
Equality &
Diversity/Human
Rights
Action proposed
following the Group
meeting
Indicate in the paper where appropriate
Person Responsible
Christine Bain, Chief Executive
Date for completion
29 May 2014
Outcome required
from the Group
The Board of Directors to received and note the Chief Executive’s Report
None
1
Paper E
ROTHERHAM DONCASTER AND SOUTH HUMBER
NHS FOUNDATION TRUST
CHIEF EXECUTIVE REPORT
29 May 2014
RDaSH
Service Visits
During April and May 2014 visits by members of the Senior Leadership Team included the following
services. The visits gave an opportunity to meet staff and discuss current issues.
•
•
•
•
RDaSH support services (including sewing room, laundry, transport, switchboard, print room
and estates)
CAMHS, IAPT Service, North Lincolnshire
Older People’s Community Mental Health Team, Doncaster
Older People’s Community Services, North Lincolnshire
Lead: Christine Bain, Chief Executive
Visit to the Trust by Ed Miliband MP
Labour leader and Doncaster North MP Ed Miliband along with Richard Desmond have joined forces
to champion a Doncaster health project. The pair visited the Conservation Volunteers Green Gym
one of 49 TCV projects which are funded through the Health Lottery which is owned by Mr Desmond
who is also the boss of channel 5 and Express newspapers. The project supports people with
anxiety, loneliness and depression to work together and reclaim green spaces in local communities,
benefitting themselves and the communities they live in.
The pair met TCV volunteers at Woodfield Park and aided in the construction of a local woodland
path. The visited marked the People’s Health Trust awarding TCV projects around Doncaster
£87,932 using money raised by Health Lottery players.
Lead: Paul Wilkin, Director of Finance
Royal Garden Parties - 2014
Sheila Barnes, lead Governor is heading to Buckingham Palace in London on 21 May after receiving
an invite to one of the Queen’s famous Royal Garden Parties. Madeleine Keyworth former Chairman
of the Trust will also be joining the Queen on 10 June. Approximately 8,000 guests attend each
garden party and people from all walks of life are invited. Both Sheila and Madeline were nominated
by the Trust to these prestigious events.
Lead: Christine Bain, Chief Executive
2
Paper E
National / Regional / Local News
Care Act 2014
The Care Bill has been approved by Parliament and is now the Care Act 2014. The Act has been
developed over the past four years and is designed to simplify the care system for people who need care
and carers. The Act aims to consolidate the current range of Acts, guidance and regulation and to make
things clearer.
The Act requires a consistent approach to be adopted by all local authorities with standard minimum
eligibility thresholds, so that local authorities will no longer be able to select their own criteria to determine
whether an individual requires care. However, once it has been established that a person qualifies for
care, there is an emphasis on providing care to meet the individual's needs through Personal Budgets.
This is designed to give more power to those receiving care and aims to deliver a more efficient approach
to the provision of care.
The Act places greater responsibility on local authorities to provide the public with information and advice
relating to care. The Act provides an obligation upon local authorities to consider the physical, mental and
emotional wellbeing of individuals, as well as implementing requirements to take preventative action to
reduce the need for care and maintain people's health and wellbeing for longer.
The Act introduces a financial cap on the amount individuals will pay towards their care. The cap of
£72,000 will apply to all individuals when it comes into force in April 2016. Once the cap is reached, the
State will meet the costs.
The Act is also designed to address some of the key issues arising from the Francis Inquiry into Mid
Staffordshire hospital. In order to increase transparency and openness, the Government aims to improve
care standards in all areas of the country by making it easier for the public to identify good care. In
addition to the information provided by local authorities, the Act has established provider profiles on the
NHS Choices website. This will provide the public with an opportunity to share experiences and to identify
providers who fail to meet expectations. The Act provides greater regulatory powers to address bad care,
with poor providers having to account to the Chief Inspector of Social Care for failures to meet the
expected standard, which may ultimately lead to prosecutions.
The Government has highlighted the importance of cohesion between health and social care provisions in
order to improve overall standards provided by the NHS and local authorities. It is hoped that the
provisions of the Act will take the Government a step closer to achieving its goal of creating a unified
health and care system by 2018.
The Department of Health intends to launch a consultation in respect of the draft regulations and
guidance for Part 1 of the Care Act, the dates of which are still to be confirmed. The Trust will receive and
respond to the regulations as they become operational.
Lead: Christine Bain, Chief Executive
Chief Executive - Doncaster Children’s Services
Interviews for the post of Chief Executive for Doncaster Children’s Service have recently been held
and Paul Moffat, former Director of Children’s Services for Northumberland, has been appointed to
the role. Paul has worked in local government for over 20 years and had also worked for the
National Society for the Protection of Cruelty to Children. He will take up his role in June
and the Trust is expected to become operational 1 October 2014.
Lead: Christine Bain, Chief Executive
3
Paper E
Director of Adults, Health and Well-being - Doncaster MBC
It has been announced that David Hamilton has been appointed to the post of Director of Adults,
Health and Wellbeing for Doncaster MBC. David currently works at Nottinghamshire County Council
and has previously worked at Rotherham MBC.
Lead: Christine Bain, Chief Executive
Yorkshire & Humber Academic Health Science Network appointments
Yorkshire & Humber Academic Health Science Network have recently announced the appointment of
Andrew Riley as managing director, Dr Dawn Lawson as chief operating officer and Richard Stubbs
as commercial director.
•
Andrew Riley is an experienced Executive Director in the NHS and commercial sector, with over
15 years’ experience as Chief Executive Officer in three large NHS hospitals.
•
Dr Dawn Lawson has significant experience of working with a wide range of stakeholders
delivering complex strategic agendas in a multi-sector environment at senior management and
Chief Executive level. Dawn also holds a PhD in health psychology and a masters in public
administration.
•
Richard Stubbs brings to the role ten years’ management experience in the NHS, and has an
excellent track record in leading on commercial and international innovation through major
transformation projects, including at national level.
Lead: Christine Bain, Chief Executive
Commissioning Support Unit Merger Announcement
The North Yorkshire and Humber CSU and West and South Yorkshire and Bassetlaw CSU recently
announced a strategic partnership in order to bid to secure a place on the Lead Provider Framework.
As this work progressed it has become clear that both organisations have much in common and a
decision has now been taken by both boards of directors that it is in the best interests of staff and
customers for the organisations to work more closely together with the aim of merging into one
organisation by 1 October 2014.
Lead: Christine Bain, Chief Executive
4
Paper E
Support to the 2015 Challenge
The NHS Confederation is running a major campaign called the 2015 challenge which seeks to
create the most positive conditions for change possible after the general election next year. As part
of this they have been working with partners to publish a declaration that sets out the challenges
facing health that they would like the political parties to address in the run up to the election and
between 2015-2020. They will continue to work with partners, colleges and patient organisations to
set out a set of policy and a future vision for the NHS.
On behalf of the Trust I have signed up to the declaration in support of this challenge.
Further information can be found at the following:http://www.nhsconfed.org/PRIORITIES/2015CHALLENGE/Pages/2015challenge.aspx
Lead: Christine Bain, Chief Executive
Choice of mental health provider update
NHS England intends shortly to launch the guidance on choice of mental health provider at first
outpatient to help implement the new legal right. They will then commence further consultation and
engagement with commissioners, providers, GPs, charities and other stakeholders to obtain any
additional feedback on how the guidance could be strengthened, before publishing a final
version later in the summer. During this time they plan to work with the FTN on the wider programme
of work needed to ensure the legal right operates effectively and benefits patients.
Further information can be found at the following:http://www.england.nhs.uk/ourwork/qual-clin-lead/pe/bp/guidance/
Lead: Debbie Smith, Service Director, Mental Health
Well-Led Organisations
Three national NHS partners have agreed to work together to provide trusts with a single view of
what good leadership looks like for NHS providers. Monitor has, at the same time, launched its
contribution to this work.
Monitor, Care Quality Commission (CQC) and NHS Trust Development Authority (NHS TDA) have
committed to developing an aligned framework for making judgements about how well-led NHS
providers are. The framework will ensure a consistent view which will form the basis of regulatory
judgements. This initiative will help organisations to improve as it provides clarity of expectation of
what good looks like, and will allow them to benchmark themselves against that expectation. A
joined-up approach will also remove unnecessary duplication and burden on NHS providers.
The partners intend to put these plans into action by October 2014. Monitor’s contribution has been
captured in separate guidance to NHS foundation trust boards on how to assess the quality of their
leadership in its 'Well-led framework for Governance Reviews' document.
The Trust will review the guidance and framework and respond accordingly.
Leads: Lawson Pater, Chairman and Christine Bain, Chief Executive
5
Paper E
RDaSH Summary Information
Media coverage 14 April – 16 May 2014
37 releases, statements, interviews, Tweets and columns
37 taken up
262 positive hits
8 neutral/factual hits
0 negative hits
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Press release – Top award for saving water (Corporate)
Tweet – Want a stall at St Catherine’s food festival (Flourish)
Press release – Want a stall at our food festival? (Flourish)
Tweet only – Easter event on Friday (Flourish)
Press release – Kendal is a winner (AMH)
Press release – Wheely good support for hospice appeal (DCIS – adults)
Press release – Condom drop in clinic launched (DCIS – CYP)
Tweet – Easter event tomorrow (Flourish)
Column – Mel’s weekly Star column for hospice (DCIS adults)
Press release – Doncaster nan heads to Palace garden party
Press release – Fun at St Catherine’s – Easter Bonanza (flourish)
Press release – New breast feeding support group to launch in Bentley (DCIS -CYP)
Press release – Teenager comes to the rescue of the hospice (DCIS – adults)
Press release – Can you help walkers raise cash for hospice? (DCIS – adults)
Press release – Get on board the Health Bus during Mental Health Awareness Week (AMH –
PT)
Radio Sheffield – Mel Hewitt, hospice– My Life Feature (DCIS – adults)
Press release - Keeping people more agile for longer (DCIS – adults)
Column – Mel Hewitt’s weekly Star column (DCIS adults)
Press release – Optima choose hospice as charity of the year (DCIS – adults)
AW inquest coverage – Statement issued after inquest
Story – Ed Milliband pays tribute to volunteers RDaSH not mentioned (only St Catherine’s
Hospital) due to Purdah focus is TCV (Corporate)
Column – Mel Hewitt’s weekly Star column (DCIS adults)
Press release – Dragonfly lollies for hospice appeal (Corporate/DCIS –adults)
Inquest coverage – LF (Substance Misuse)
Press release – Fun run for hospice appeal
Press release – Help us rename our information centre (DCIS – adults)
Press release – Rose Brothers (footballers) support hospice appeal (DCIS – adults)
Press release – History exhibition at St Catherine’s House (Flourish)
Column – Mel Hewitt’s weekly Star column
Press release – Event to raise awareness about epilepsy, dementia and Parkinsons (DCIS –
adults)
Statement – Re: former Roma drugs service in Rotherham (Substance Misuse)
Solar Centre – Call for CCTV (LD) not asked to comment
Press release – Patients hand over vests to Soroptimists for babies in Ethiopia (DCIS –
adults)
Press release – Want to help shape our services (Corporate)
Press release – Donny’s Got Talent, raising money for Hospice (DCIS – adults)Two versions
– one for Roth; second for Doncaster
Press release – Dementia Awareness Week event (OPMHS and Corporate)
Press release – Next Board meeting (Corporate)
Press release – Event to mark Carers’ Week in Scunthorpe (OPMH)
Press release – James is a role model for young people with LD (CYPMHS)
6
Paper E
•
•
•
•
•
•
Column – Star (hospice) DCIS adults
Comment – Re how the Star and Free Press are helping support our hospice appeal for local
newspaper week (DCIS – adults)
Press release – Toy box raffle for hospice (LD)
Twitter – Council of Governor’s Meeting (Corporate)
Twitter – Tweet re history event on Sunday at St Catherine’s (Flourish)
Filming – For Neighbourhood Blues – BBC TV
Freedom of Information Requests - 17 April – 16 May 2014
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
How much did the Trust spend on temporary/permanent estates professionals in the financial
year 2012 to date
Copy of the winning bid for manned security services and evaluation notes of the same manned
security services tender method statements
For each hospital within the Trust a list of clinical software and management systems in operation
including software title, vendor name and year of installation
Details of breaches of the data protection act, in particular the number of medical personnel and
non-medical personnel breaches
What is the total spend on agency nurses and breakdown by individual supplier
Dates that my grandmother was in Tickhill hospice
Has the organisation used the company Danwood at any point in the last 5 financial years for
printing or administrative services
Amount spent on Children and Adolescent Mental Health Services (CAMHS) for the financial
years 2010/2011, 2011/12, 2012/13, 2013/14 and 2014/15
Does the Trust have a policy regarding the diagnosis of pathological demand avoidance by
clinicians
Structure, names and contact numbers of the senior management team
Information regarding the use of uterine systems and heavy menstrual bleeding for patients
under the Trust’s care between 1 January 2013 and 31 December 2013
How many members of staff in the organisation have been placed on pay protection in the years
2011/12, 2012/13 and 2013/14
Contract and maintenance information for the telephone systems
Information regarding number of wheelchair and cushions issued by the Trust
If the Trust has a ADHD service for Adults and Childrens supply the number of people diagnosed
in the CCG area, total cost of diagnosis per person in the last year and number on medication for
one year or more
Number of locum staff within biomedical science currently in the Trust and total spend for the last
financial tax year
Total budget for 2014/15 for the provisions of the organisations mental health services excluding
CAMHs and Forensic services
Request from a service user regarding information on themselves
Number of non-clinical members of staff in RDaSH whose salaries fall within NHS pay bands 8
and 9
Details of the lease car scheme
Information regarding to the management of annual consultant job planning process, whether
there is a software application and if it is owned by the NHS or a third party
Request from MP regarding a wide range of mental health information
Number of complaints, compliments and feedback that are handled by the Trust, is there a
central place where the data is captured
Professional qualifications for the Chief Executive, Chair of the Board of Governors and Director
of Operations
7
Paper E
Serious Incidents – 11 April – 15 May 2014
Ten Serious Incidents (SIs), as defined by National Patient Safety Agency guidance, were reported
by the Trust to NHS England during the reporting period from 11 April to 15 May 2014. The twelve
SIs relate to:
Doncaster
• DCIS
o
7 x Pressure Ulcers (Grade 3)
North Lincs
•
Older People Mental Health
o
1 x Slips/Trips/Falls
North East Lincs
•
Substance Misuse
o
1 x Unexpected Death
Barnsley (patient under Rotherham Service but has a Barnsley GP – currently in discussion with
Barnsley CCG regarding process)
•
Rotherham Substance Misuse
o
1 x Unexpected Death
8
Paper E
Complaints – April 2014
Date Received
Locality
Business Division
Specialty
Ward /Team
Category Type
Category
02/04/2014
Doncaster
DCIS
Community Nursing
DN - North
Clinical treatment
Nursing care - unsatisfactory
08/04/2014
North
Lincolnshire
Adult Mental
Health
Community Services (MH)
Community Therapies Intensive
Attitude of staff
Inappropriate behaviour
07/04/2014
Doncaster
Adult Mental
Health
Inpatients
Brodsworth Ward
Attitude of staff
Inappropriate behaviour
08/04/2014
Doncaster
Adult Mental
Health
Inpatients
Cusworth Ward
Clinical treatment
Medical care - unsatisfactory
11/04/2014
Doncaster
DCIS
Intermediate Care
Community Intermediate
Care Team
Attitude of staff
Inappropriate behaviour
16/04/2014
Doncaster
DCIS
Health Visiting/School
Nursing
CYP & F
Attitude of staff
Inappropriate behaviour
24/04/2014
Doncaster
DCIS
Community Nursing
Hazel Ward
Medication
Adhering to trust policy
28/04/2014
Doncaster
Adult Mental
Health
Inpatients
Brodsworth Ward
Attitude of staff
Inappropriate behaviour
Doncaster
Adult Mental
Health
Social Inclusion Team
Comm/info to or about a
patient
Information provided inadequate
29/04/2014
Community Services (MH)
Christine Bain
Chief Executive
May 2014
9
Paper F
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Group/Committee
Name
Meeting Date
Title of Paper
Author
Paper For
Strategic Work
Programme:
- Relevance
- Progress
Board of Directors
29 May 2014
Annual Plan Review Declarations
Philip Gowland, Board Secretary
Decision
X Debate
X
Assurance
X
Information
Reference
What Strategic Work Programmes is the
paper relevant to?
3
Does the paper provide assurance against
delivery of the identified Strategic Work
Programme?
As part of the Trust’s Annual Planning Review (Annual Plan
submission) a number of declarations need to be considered, approved
and submitted.
1&2
3
Key Points to Note
(including any
identified risks )
4
5
6
Systems for compliance with licence conditions - in
accordance with General condition 6 of the NHS provider
licence
Availability of resources and accompanying statement - in
accordance with Continuity of Services condition 7 of the
NHS provider licence
Corporate Governance Statement - in accordance with the
Risk Assessment Framework
Certification on AHSCs and governance - in accordance with
Appendix E of the Risk Assessment Framework
Certification on training of Governors - in accordance with
s151(5) of the Health and Social Care Act
Declarations 1, 2 and 3 must be approved and submitted to Monitor
by 30 May 2014. Further details regarding these are attached.
Declarations 4, 5 and 6 must be approved and submitted to Monitor
by 30 June 2014 – and will therefore be presented to the Board of
Directors in June 2014.
Board Assurance
Framework
If the paper also provides assurance against
the effectiveness of a Key Control what is
the reference and what level of assurance
do you think it provides?
CQC
If the paper provides assurance against
Essential Standards of Quality and Safety
(ESQS) specify the outcome number.
Financial/Budget
None
Equality &
Diversity/Human
Rights
None
BAF Key
Control
Ref.
Effectivenes
s
F/S/L/N
ESQS outcome number
N/A
Paper F
Action proposed
following the Group
meeting
The submission will be made to Monitor by 30 May 2014 regarding declarations
1, 2 and 3.
A paper setting out the supporting information in respect of declarations 4, 5
and 6 will be prepared and submitted to the Board of Directors in June 2014.
Person
Responsible
Philip Gowland, Board Secretary
Date for completion
First declarations to be made by 30 May 2014; second set of declarations by 30
June 2014.
Paper F
1&2
Systems for compliance with licence conditions - in accordance with General condition 6 of
the NHS provider licence
The declaration refers to paragraph 2b of licence condition G6. Paragraphs 1 and 2 of licence
condition G6 are presented below:
1. The Licensee shall take all reasonable precautions against the risk of failure to comply
with:
(a) the Conditions of this Licence,
(b) any requirements imposed on it under the NHS Acts, and
(c) the requirement to have regard to the NHS Constitution in providing health care services
for the purposes of the NHS.
2. Without prejudice to the generality of paragraph 1, the steps that the Licensee must take
pursuant to that paragraph shall include:
(a) the establishment and implementation of processes and systems to identify risks and
guard against their occurrence; and
(b) regular review of whether those processes and systems have been implemented and of
their effectiveness.
Declarations 1 and 2 were presented to the Performance and Assurance Group in May 2013.
PAG supported the recommendation to the Board of Directors that statements 1 and 2 could
be signed as ‘confirmed’.
3
Availability of resources and accompanying statement - in accordance with Continuity of
Services condition 7 of the NHS provider licence
Declaration 3 was presented to FIBD in May 2014.
It is very much linked to the Going Concern accounting principle and hence a supporting
paper – which was also presented to the Audit Committee at its meeting on 27 May 2014 for
when it considered and adopted the accounts - is attached.
FIBD Group supported the recommendation to the Board of Directors that statement 3a could
be signed ‘confirmed’, having also confirmed to the Audit Committee its view (for use when
adopting the accounts and annual report) that the Trust remains a going concern.
Paper F
Declarations 1 and 2 (as required by General Condition 6)
The board are required to respond "Confirmed" or "Not confirmed" to the following statements (please select 'not confirmed' if confirming another
option). Explanatory information should be provided where required.
1&
2
1
General condition 6 - Systems for compliance with license conditions
Following a review for the purpose of paragraph 2(b) of licence condition G6, the Directors of the Licensee are
satisfied, as the case may be that, in the Financial Year most recently ended, the Licensee took all such
precautions as were necessary in order to comply with the conditions of the licence, any requirements imposed on
it under the NHS Acts and have had regard to the NHS Constitution.
CONFIRMED
AND
2
The board declares that the Licensee continues to meet the criteria for holding a licence.
CONFIRMED
Paper F
Declarations required by Continuity of services condition 7 of the NHS provider licence
The board are required to respond "Confirmed" or "Not confirmed" to the following statements (please select 'not confirmed' if confirming another
option). Explanatory information should be provided where required.
3
3a
3b
3c
Continuity of services condition 7 - Availability of Resources
EITHER:
After making enquiries the Directors of the Licensee have a reasonable expectation that the Licensee will have the
Required Resources available to it after taking account distributions which might reasonably be expected to be
declared or paid for the period of 12 months referred to in this certificate.
CONFIRMED
OR
After making enquiries the Directors of the Licensee have a reasonable expectation, subject to what is explained
below, that the Licensee will have the Required Resources available to it after taking into account in particular (but
without limitation) any distribution which might reasonably be expected to be declared or paid for the period of 12
months referred to in this certificate. However, they would like to draw attention to the following factors which may
cast doubt on the ability of the Licensee to provide Commissioner Requested Services.
OR
In the opinion of the Directors of the Licensee, the Licensee will not have the Required Resources available to it
for the period of 12 months referred to in this certificate.
Statement of main factors taken into account in making the above declaration
In making the above declaration, the main factors which have been taken into account by the Board of Directors
are as follows:
Operational Plan including financial plan and related financial risk and quality impact assessments.
Confirmation of the Trust being a ‘going concern’ as per the annual report and accounts.
Signed on behalf of the board of directors, and having regard to the views of the governors
“Required Resources” means such as Management resources, financial resources and financial facilities, personnel, physical and other assets, working capital as would be regarded as
sufficient to enable the Licensee at all times to provide the Commissioner Requested Services.
Paper F
GOING CONCERN STATEMENT TO SUPPORT THE DECLARATION
– presented to the Audit Committee on 27 May 2014
There is no presumption of going concern status for NHS Foundation Trusts. Directors must decide each year
whether or not it is appropriate for the NHS foundation trust to prepare its accounts on the going concern basis,
taking into account best estimates of future activity and cash flows. The NHS foundation trust should include a
statement on whether or not the financial statements have been prepared on a going concern basis and the
reasons for this decision, with supporting assumptions or qualifications as necessary (NHS Foundation Trust Code of
Governance F.1.2).
After consideration of the evidence presented below the following statement is suggested for inclusion within the
Annual Report
It is the responsibility of the Board of Directors to prepare the accounts and after making enquiries, it has a
reasonable expectation that the NHS Foundation Trust has adequate resources to continue in operational existence
for the foreseeable future. For this reason, it continues to adopt the going concern basis in preparing the accounts.
ISA (UK&I) 570 requires those charged with governance (TCWG) - at RDaSH this is the Audit Committee - to carry
out an assessment of the going concern assumption.
The External Auditors are required to review and discuss with TCWG the assessment, and whether they have
identified any events which may cast significant doubt on the Trust’s ability to continue as a going concern.
Assurance must be obtained regarding the appropriateness of the going concern basis of preparation of the
financial statements.
In support of the statement made by the Board and in order for the Audit Committee to make its assessment, the
following points are made for consideration / in support of the statement:
•
The Trust has recorded a surplus (before impairment) for the year of £1.47m (£1.79m 12/13). This is
before net impairment charges of £3.155m (£1.03m in 12/13) which are effectively 'non-cash'. This details
the Trust position, excluding Charitable Funds.
This reconciles to the Published Accounts as follows: Monitor Surplus (before impairment)
Less Impairment
Plus Charitable Funds
Operating surplus on face of Accounts
Operating surplus per accounts (Before impairment)
2013/14
1.47
3.16
0.49
(1.19)
1.96
Depreciation is excluded from both the Monitor surplus and face of accounts operating surplus
•
At 31/3/14 the Trust has cash of £22.04m (£19.76m in 12/13) which equates to 14.2% of its 13/14
operating expenditure.
•
Cash flow statement shows that the Trust increased its level of cash by £2.28m during 13/14.
•
Cash balance alone provides 275% coverage of trade and other creditors due within 1 year and 100%
coverage of all current liabilities.
•
Although the Trust has £19.6m of long term borrowing, £12.1m relates to obligations under the PFI/leases
over the next 20 years and £7.5m to a long term loan from the Foundation Trust Financing facility over the
next 25 years. The Trust is within its Prudential borrowing limits which, themselves, are based on key
financial ratios and the ability to repay/service potential debt.
•
Also the Trust has cancelled the working capital facility of £9m with NATWEST bank.
Paper F
•
We are not aware of any significant threats to major contracts or any loss in income sources in 2014/15.
Other than the reductions associated with the change in commissioning responsibilities to Local
Authorities for some services.
•
Compared to some public sector organisations (in particular councils) the impact of the Governments
spending cuts on NHS trusts in less severe. In addition, FTs are seen as the future and are not earmarked
for abolition.
•
The 2014/15 budget and cash flow both show a positive outlook. The I & E shows a forecast EBITDA
of £7.324m and 'surplus' on a retained earnings basis. The cash flow forecast shows an average monthly
cash balance in a range of £18m - £20m and is forecast to be at a similar level to the previous year.
•
The Trust is holding a revenue contingency of £1.5m.
•
The Trust is planning on the basis of a Continuity of Services Risk Rating of 4 for the next two years. This
measure used by Monitor also measures the Trusts ability to pay its debts and its liquidity position. The
Trust repaid £3m of its loan in 2013/14 thus reducing the interest and capital repayment charges in the
future.
Paper G
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Group/Committee
Name
Board of Directors
Meeting Date
29 May 2014
Title of Paper
Report by the Deputy Chief Executive / Director of Nursing and Partnerships
Author
Helen Dabbs, Deputy Chief Executive / Director of Nursing and Partnerships
Paper For
Decision
Strategic Work
Programme:
- Relevance
- Progress
Key Points to Note
(including any
identified risks )
Debate
Assurance
What Strategic Work Programmes is the paper
relevant to?
Does the paper provide assurance against
delivery of the identified Strategic Work
Programme?

Information

Reference
1.1, 4.1c, 5.3
Yes / No
Yes
Key points to note as follows:
o Quality Governance
o Clinical Governance Group
o Quality Improvement:
o CQC Inspections
o Participation in wave 1 inspections of Adult Social Care
o CQC Mental Health Act Inspections
o Safeguarding
o Serious Case Reviews
o Nursing and Partnerships Update
o Community Nurses and Allied Health Professions Event – June 2014
o Nick Arkle, Patient Engagement Lead – Retirement
Board Assurance
Framework
If the paper also provides assurance against
the effectiveness of a Key Control what is the
reference and what level of assurance do you
think it provides?
CQC
If the paper provides assurance against
Essential Standards of Quality and Safety
(ESQS) specify the outcome number.
BAF Key
Control Ref.
1.1
4.1c
5.3
Effectiveness
F/S/P/V/N
S
S
S
ESQS outcome number
7, 16
Managed within overall budgets
Financial/Budget
Equality &
Diversity/Human
Rights
These were considered under each theme. Improvement in patient experience as
part of the overall approach to quality improvement should be noted.
Action proposed
following the
Group meeting
Note the key points in relation to:
o Quality Governance
o Quality Improvement
o
o
Safeguarding
Nursing and Partnerships Update
Person
Responsible
Helen Dabbs, Deputy Chief Executive / Director of Nursing and Partnerships
Date for
completion
Outcome required
from the Group
29 May 2014
The Board is asked to:
o Receive and note the Report by the Deputy Chief Executive / Director of
Nursing and Partnerships
2
REPORT BY THE DEPUTY CHIEF EXECUTIVE / DIRECTOR OF NURSING AND
PARTNERSHIPS
SECTION ONE
Quality Governance
SECTION TWO
Quality Improvement
SECTION THREE
Safeguarding
SECTION FOUR
Nursing and Partnerships Update
3
SECTION ONE
QUALTY GOVERNANCE
Clinical Governance Group
The Clinical Governance Group (CGG) held on Monday 19 May 2014 discussed the
following items:
Presentations on:
o CQUIN 2013/14 – quality outcomes from the CQUIN schemes across the
Trust were shared with the Group
o Open and Honest Care – the initiative, which aims to support organisations to
become more transparent and consistent in publishing safety, experience and
improvement data; with the overall aim of improving care, practice and
culture, was presented to the Group. It was agreed that members would
consider how ‘Open and Honest Care’ could link in to current work being
undertaken across the Trust and to have a further discussion in June 2014.
o Quality Improvement Approach – the peer review approach was presented to
the Group as the model that is being used to embed the quality improvement
approach into the Trust. The Quality Improvement Team is working to
embed the model over 2014/15 prior to handing over to the Service
Directorates.
National reports were discussed on:
o ‘Mental Health Crisis Care Concordat: Improving outcomes for people’, which
sets out the principles and statutory requirements that all services involved in
responding to mental health crises should follow. The Trust is working with
our local health communities to self-assess against the principles to develop
local declarations.
o ‘National Confidential Inquiry into Suicide in Primary Care 2002-2011’, which
highlights the need to work jointly with primary care to improve the
identification of mental illness in primary care.
A new report was presented to the Group to track suicides and unexpected
deaths throughout the year. The report was approved and will be included in the
Quality Improvement Report in quarter 1 2014/15.
The deep dive presentation on patient safety in the Adult mental health and
DCIS business divisions focussed on quarter 4 2013/14, which showed a
reducing trend in serious incidents and complaints. The Group agreed that
going forward the deep dive will be presented quarterly to the Clinical
Governance Group.
A further draft version of the ‘Quality Report 2013/14 and Forward Strategy
2014/15’ was presented to the CGG for comment. The report will be presented
to the Audit Committee on 27 May 2014 and the final version of the report is
presented to the Board of Directors at Paper H.
The Business Division Clinical Governance internal audit report was presented.
The Audit Opinion provides ‘Significant Assurance’ with a number of areas of
good practice identified, including good connections between the Trust Clinical
Governance Group and the Business Division Clinical Governance Groups. Six
low risk issues have been identified with recommendations for improvement.
The actions are due for completion by June 2014 and reported through the
quarterly Quality Improvement Report. Internal audit will undertake a follow-up
exercise in September 2014 to evaluate progress.
Minutes and updates from other relevant Groups and Clinical Governance SubGroups included:
4
o
o
o
o
o
o
o
Clinical Effectiveness Group
Research Group
Organisational Learning Forum
Safeguarding Forum
Infection Prevention and Control Committee
Resuscitation Committee Annual Report
Listen to Learn Steering Group
SECTION TWO
QUALITY IMPROVEMENT
Care Quality Commission (CQC) Inspections
The Trust has not been subject to any CQC inspections since the last meeting of the Board.
Participation in wave 1 CQC inspections of Adult Social Care
The Trust was invited to participate in the pilot of the revised CQC Adult Social Care
inspection approach. This is a key element of the CQC development work towards
implementing the new approach from 1 October 2014. The Trust participated in the pilot at
Danescourt and Station Road within the Learning Disability Business Division, with both
community homes receiving a pilot inspection in early April 2014. Verbal feedback was
positive and the reports are still awaited, as is a test rating (good, outstanding, requires
improvement or inadequate), which will be shared with the Trust.
Care Quality Commission (CQC) Mental Health Act Monitoring Visits
The Trust has been subject to two CQC Mental Health Act monitoring visit since the last
meeting of the Board:
Adult Mental Health Services
Emerald Lodge, Doncaster – 15 April 2014
The visit focussed on Domain 2 – Detention in Hospital. Positive comments were received
from both patients and staff. Actions identified from the visit are in the area of:
Purpose, respect, participation and least restriction
Older Peoples Mental Health Services
The Ferns, Rotherham – 16 May 2014
Initial positive verbal feedback has been received and the report from the CQC is awaited.
Forensic Services
Amber Lodge, Doncaster – 27 February 2014
A verbal update on the visit was given by the Deputy Chief Executive / Director of Nursing
and Partnerships to the Board of Directors in March 2014. The Trust has now received the
CQC Mental Health Act inspection report.
The visit focussed on Domain 2 – Detention in Hospital. Positive comments were received
from both patients and staff. Actions identified from the visit are in the areas of:
Purpose, respect, participation and least restriction
Admission to the ward
5
‘Quality Matters’
The revised format ‘Quality Matters’ Bulletin can be found at Appendix 1. This version of
‘Quality Matters’ has been circulated to the Clinical Governance Group for comments /
suggestions.
SECTION THREE
SAFEGUARDING
Serious Case Reviews (SCR) – Children services
There are no new Serious Case Reviews in Manchester, Rotherham, Doncaster, North
Lincolnshire or North East Lincolnshire.
Serious Case Reviews (SCR) – Adult services
There are no new Serious Case Reviews in Manchester, Rotherham, Doncaster, North
Lincolnshire or North East Lincolnshire.
SECTION FOUR
NURSING AND PARTNERSHIPS UPDATE
Community Nurses and Allied Health Professions Event – June 2014
Members of the DCIS business division are attending a community nurses and allied health
professions event in Manchester in June 2014 to showcase their multidisciplinary 6Cs work.
The objectives of the event are:
Conversations with nurses and allied health professionals to help shape the future
Active engagement with patients and the public to ensure meaningful production
Share and celebrate innovative practice.
Nick Arkle, Patient Engagement Lead – Retirement
Nick
Arkle,
the
Trust
Patient
Engagement Lead based in Nursing
and Partnerships, has retired from the
Trust after nearly 40 years service with
the NHS.
Friends and colleagues gathered to
wish Nick the best in his retirement on
21 May 2014.
Helen Dabbs
Deputy Chief Executive / Director of Nursing and Partnerships
April 2014
6
Appendix 1
7
Paper G
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Group/Committee
Name
Board of Directors
Meeting Date
29 May 2014
Title of Paper
Author
Quality Report 2013/14 and Forward Strategy 2014/15
Karen Cvijetic, Head of Quality Governance and Pathways
Paper For
Decision
Strategic Work
Programme:
- Relevance
- Progress
Debate

Assurance
What Strategic Work Programmes is the paper
relevant to?
Does the paper provide assurance against
delivery of the identified Strategic Work
Programme?

Information

Reference
5
Yes / No
Yes
The Draft ‘Quality Report 2013/14 and Forward Strategy 2014/15’ has been
developed based on the guidance in the recently published Monitor document ‘NHS Foundation Trust Annual Reporting Manual 2013/14’.
The ‘Quality Report 2013/14 and Forward Strategy 2014/15’ will be adopted by the
Audit Committee on 27 May 2014, and is presented to the Board of Directors for
information.
The ‘Quality Report 2013/14 and Forward Strategy 2014/15’ attached builds on the
previous versions presented to the CGG in March, April and May 2014 and to the
Board of Directors on 24 April 2014.
Key Points to Note
(including any
identified risks )
The ‘Quality Report 2013/14 and Forward Strategy 2014/15’ has been circulated to
stakeholders, including Commissioners, Overview and Scrutiny Committees and
Healthwatch for consultation to get stakeholder comments for inclusion in the final
version to be submitted to Monitor and will be tabled at the meeting on 29 May 2014.
The ‘Improving data quality’ and ‘Data quality indicators’ sections will be tabled at
the meeting on 29 May 2014, as the finalised external audit results for CPA 7 day
follow up and the recommendations from the data quality testing will be approved at
the Audit Committee on 27 May 2014.
An easy read version of the ‘Quality Report 2013/14 and Forward Strategy 2014/15’
will also be produced.
The deadline for submission of the ‘Quality Report 2013/14 and Forward Strategy
2014/15’ to Monitor is 30 May 2014.
Board Assurance
Framework
If the paper also provides assurance against
the effectiveness of a Key Control what is the
reference and what level of assurance do you
think it provides?
CQC
If the paper provides assurance against
Essential Standards of Quality and Safety
(ESQS) specify the outcome number.
Financial/Budget
Equality &
Diversity/Human
Rights
To be identified within the Quality Report
To be identified within the Quality Report
BAF Key
Control Ref.
5.3
Effectiveness
F/S/L/N
S
ESQS outcome number
16
Paper G
• To submit ‘Quality Report 2013/14 and Forward Strategy 2014/15’ to Monitor as
part of the Trust’s Annual Report by 30 May 2014.
Action proposed
following the Group
meeting
Person Responsible
Helen Dabbs, Deputy Chief Executive / Director of Nursing and Partnerships
Date for completion
Outcome required
from the Group
30 May 2014
The Board is asked to note the ‘Quality Report 2013/14 and Forward Strategy
2014/15’.
Paper H
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Group/Committee
Name
Board of Directors
Meeting Date
29 May 2014
Title of Paper
Author
Quality Report 2013/14 and Forward Strategy 2014/15
Karen Cvijetic, Head of Quality Governance and Pathways
Paper For
Decision
Strategic Work
Programme:
- Relevance
- Progress
Debate

Assurance
What Strategic Work Programmes is the paper
relevant to?
Does the paper provide assurance against
delivery of the identified Strategic Work
Programme?

Information

Reference
5
Yes / No
Yes
The Draft ‘Quality Report 2013/14 and Forward Strategy 2014/15’ has been
developed based on the guidance in the recently published Monitor document ‘NHS Foundation Trust Annual Reporting Manual 2013/14’.
The ‘Quality Report 2013/14 and Forward Strategy 2014/15’ will be adopted by the
Audit Committee on 27 May 2014, and is presented to the Board of Directors for
information.
The ‘Quality Report 2013/14 and Forward Strategy 2014/15’ attached builds on the
previous versions presented to the CGG in March, April and May 2014 and to the
Board of Directors on 24 April 2014.
Key Points to Note
(including any
identified risks )
The ‘Quality Report 2013/14 and Forward Strategy 2014/15’ has been circulated to
stakeholders, including Commissioners, Overview and Scrutiny Committees and
Healthwatch for consultation to get stakeholder comments for inclusion in the final
version to be submitted to Monitor and will be tabled at the meeting on 29 May
2014.
The ‘Improving data quality’ and ‘Data quality indicators’ sections will be tabled at
the meeting on 29 May 2014, as the finalised external audit results for CPA 7 day
follow up and the recommendations from the data quality testing will be approved at
the Audit Committee on 27 May 2014.
An easy read version of the ‘Quality Report 2013/14 and Forward Strategy 2014/15’
will also be produced.
The deadline for submission of the ‘Quality Report 2013/14 and Forward Strategy
2014/15’ to Monitor is 30 May 2014.
Board Assurance
Framework
If the paper also provides assurance against
the effectiveness of a Key Control what is the
reference and what level of assurance do you
think it provides?
CQC
If the paper provides assurance against
Essential Standards of Quality and Safety
(ESQS) specify the outcome number.
1
BAF Key
Control Ref.
5.3
Effectiveness
F/S/L/N
S
ESQS outcome number
16
Financial/Budget
Equality &
Diversity/Human
Rights
To be identified within the Quality Report
To be identified within the Quality Report
Action proposed
following the Group
meeting
Person Responsible
• To submit ‘Quality Report 2013/14 and Forward Strategy 2014/15’ to Monitor as
part of the Trust’s Annual Report by 30 May 2014.
Helen Dabbs, Deputy Chief Executive / Director of Nursing and Partnerships
Date for completion
Outcome required
from the Group
30 May 2014
The Board is asked to note the ‘Quality Report 2013/14 and Forward Strategy
2014/15’.
2
Paper H
Quality Report 2013/14 and
Forward Strategy 2014/15
3
CONTENTS
Section Title
Page
PART 1 - QUALITY REPORT 2013/14 – CHIEF EXECUTIVE’S WELCOME
1.
Our Vision, our Mission Statement, our Strategic Goals
PART 2A – PRIORITIES FOR IMPROVEMENT 2013/14
2.
A Look Back at the Year 2013/14 - performance against quality
improvement priorities
3.
Personalised care
4.
Record keeping
5.
Clinical leadership
6.
Annual Awards Ceremony
7.
Local Commissioning Priorities
8.
Progress with business division quality markers 2013/14
9.
Progress with User Carer Partnership Council (UCPC) quality markers
2013/14
10.
Trust Business Division Governance framework 2013/14
11.
The Trust’s response to Francis, Berwick and Keogh
PART 2B - PRIORITIES FOR IMPROVEMENT 2014/15
12.
Strategic context
13.
Priorities for quality improvement 2014/15
14.
Trust business divisions’ quality markers
15.
Patient, carer and public engagement and feedback
16.
Collaborative working with commissioners
17.
Monitor’s risk assessment framework
18.
Commissioning for Quality and Innovation (CQUIN) payment framework
19.
Clinical audit
20.
Monitoring and measuring progress and reporting on quality
PART 2C – STATEMENTS OF ASSURANCE FROM THE BOARD 2013/14
21.
Review of services
4
22.
Participation in clinical audits
23.
Participation in clinical research
24.
Commissioning for Quality and Innovation (CQUIN) scheme 2013/14
25.
Care Quality Commission (CQC)
26.
Data quality
27.
Information governance
28.
Clinical coding error rate
29.
Improving data quality
30.
Data quality indicators
PART 3 – OTHER INFORMATION
PATIENT SAFETY
31.
32.
33.
Learning from patient safety incidents
31.1
Never events
31.2
Serious incidents
31.3
Patient safety incidents
31.4
Key areas for improvements identified from incidents
31.5
Organisational learning
Safeguarding
32.1
Safeguarding Children and Vulnerable Adults
32.2
Looked After Children (LAC) Doncaster
32.3
Domestic abuse
Infection prevention and control
CLINICAL EFFECTIVENESS
34.
National Institute for Health and Clinical Excellence (NICE)
34.1
NICE quality standards
34.2
NICE consultations
PATIENT EXPERIENCE
35.
Listen to Learn
5
36.
National Mental Health Community Survey 2013 results
37.
Listening to service users, patients and carers
37.1
Complaints and compliments
37.2
Your Opinion Counts / Patient Advice and Liaison Service
38.
Eliminating mixed sex accommodation (EMSA)
39.
Patient-Led Assessments of the Care Environment (PLACE)
OUR PEOPLE / STAFF
40.
41.
Staff views of quality
40.1
Staff survey
40.2
Staff sickness absence (Mandatory for Annual Report)
Leading the Way with Quality
PERFORMANCE AGAINST KEY NATIONAL PRIORITIES
42.
Monitor Compliance Framework 2013/14
43.
Monitor Risk Ratings 2013/14
ANNEXES
A1
Statements from our stakeholders
A2
Statement of directors’ responsibilities in respect of the Quality Report
A3
Independent auditor’s report to Council of Governors (Mandatory for Annual
Report)
A4
How to contact us
A5
Glossary of terms
6
PART 1 – QUALITY REPORT 2013/14 – CHIEF EXECUTIVE’S WELCOME
1.
Chief Executive’s Welcome
I am delighted to welcome you to the Rotherham Doncaster and South Humber NHS
Foundation Trust Quality Report for 2013/14, which focusses on how the Trust is working to
meet our quality ambitions and reflects on our achievements and areas for improvement.
We aim to deliver our vision of ‘Leading the Way with Care’ by ‘promoting health and quality
of life for the people and communities we serve’ and through the implementation of our five
strategic objectives:
•
•
•
•
•
Continuously improve service quality (safety, effectiveness and patient experience)
for our service users and carers
Nurture the talent, commitment and ideas of our staff in order to deliver excellent
services
Ensure value for money and increased organisational efficiency whilst maintaining
quality
Adapt and deliver services to meet agreed commissioned needs through enhanced
multi-agency partnerships
Maintain excellent performance and governance and a strong market position; and
improve further our reputation for quality
The economic circumstances in the public sector continue to have an impact and the market
for healthcare is increasingly becoming more competitive. We can no longer assume that
NHS provided care is the first or most optimal solution for commissioners to meet the needs
of their populations. We must be able to compete and demonstrate that we can operate
efficiently, to high standards of customer care and in line with commissioner expectations.
The way in which we position ourselves by ensuring we keep ahead of our competitors in
terms of quality and service user/patient feedback, working flexibly and imaginatively with
what we know are reducing resources and delivering care in a way that is innovative and
developmental will stand us in good stead for the future and must be beneficial for our
patients/service users.
To be able to meet these challenges we have continued to deliver our programme of quality
improvement work, focussing on the three Trust quality priorities:
•
•
•
Personalised care
Record keeping
Clinical leadership
In September 2013, the Trust held its Annual Members’ Meeting and Awards Ceremony at
the New York Stadium in Rotherham. The event gave us an opportunity to celebrate all that
is great about RDaSH care, services and staff, with a fantastic response of over 200
nominations across the 10 categories received from services across the Trust’s footprint.
The awards include categories for each of the three Trust quality priorities and commends
staff that have made an exceptional contribution, along with a Quality Care Award that is
exclusively nominated by patients, services users and carers. Further details on the winners
and runners up of these awards can be seen in Section 2a.
If we are to face the challenges that are heading our way, both following the Francis Report
and its focus on NHS Quality and in the light of the financial position the Trust will find itself
working within, we need staff who feel they are part of an organisation that values them,
supports them and provides the environment in which they can do their best. Change is
probably the only certainty in our future and the creation of an organisation and a staff team
7
that can respond to those changes cannot be achieved from a top down approach alone. To
support these challenges the Trust launched our ‘Fit 4 the Future’ (F4F) Leadership
Development Programme, engaging over 300 leaders in the organisation in debate and
development to support our roles moving forward.
To build on F4F a wider series of ‘Leading the Way with Quality’ workshops for all staff
groups has focussed on culture and what makes RDaSH ‘tick’. Culture is a complex product
of many things – communication, values, rewards, involvement, attitude, fun, the modelling of
behaviours that show respect, and positive engagement. Over 400 staff have joined me at
these workshops to review the role that culture plays in the organisation and to discuss how
we can make it productive and positive.
We have implemented our plans for 2013/14, along with the service redesigns and reviews
that accompany them. Commissioners are holding us to account for the delivery of our
services in a more robust way than before. The Francis report and the Berwick report into
Patient Safety require us to review the way we handle quality issues in the Trust and our
Quality, Innovation, Productivity and Prevention (QIPP) plans for 2014/15 have been
formulated. In December 2013, we published our response to the Francis Declaration on our
website, which details work already completed and our future action plan of work to
implement the recommendations from the Francis Report. It was jointly signed off by our
Board of Directors and Council of Governors.
In October 2013, we were visited by inspectors from the Care Quality Commission (CQC)
who conducted thorough inspections of both our services and our governance processes. If
you had the opportunity to talk with the inspectors then my thanks for providing them with the
opportunity to meet you, answer their questions and provide a view as to how our services,
systems and processes work in practice. We received a very positive report from the CQC,
showing that we meet all the standards expected of us in relation to the quality outcomes
they investigated during their visit. Its contents will be an important source of information and
feedback for us to continue to improve our offer to patients and service users and to review
how we deliver our services and support.
The CQC inspectors asked some very challenging questions. One of the areas they probed
was how do we as Board members assure ourselves what is happening day to day on the
front line of our services? I talked to them about all the ways we do that, the arrangements
we have in place for quality governance and assurance and the visits and involvement we
have with services on a regular basis. The inspectors also asked how confident I was, that
staff knew how to raise concerns and felt able to do so. I discussed all the work that we have
done with teams about the Trusts quality strategy, our quality objectives, our vision ‘Leading
the Way with Care’, F4F and our approaches to raising concerns and whistleblowing. I know
that when the CQC asked staff on our wards and in services, many staff also confirmed this
view.
During the year we have also had a number of quality challenges to deal with, which have
led to improvement plans and actions being agreed with our Commissioners.
In Rotherham, the Clinical Commissioning Group identified a number of performance
and quality shortfalls in our Childrens and Young Peoples Services, which resulted in
a lack of confidence being expressed by General Practitioner colleagues in our
services. A detailed action plan has been implemented and improvements have been
made, however there is still more work to be done to embed these changes;
In Doncaster, a number of quality concerns were highlighted through our own
governance processes relating to Adult Mental Health Services. A detailed plan of
action focussing on care planning, communication and risk management, particularly
in ward areas and at the interface of inpatient and community services has been
8
implemented. A fundamental review of services has also been undertaken by our
Commissioner and a joint approach to service redesign and improvement is
underway;
In North Lincolnshire, work has been completed on reviewing and implementing a
new management and senior leadership structure across adult mental health services
and strengthening our approach to risk management and care planning. Work is
underway with North Lincolnshire service users and the local Healthwatch to embed
these improvements.
Overall, our approach to quality governance has been shown to be robust and has enabled
us to respond to issues promptly.
On the governance front, we have appointed a new Chairman, Lawson Pater, who took up
post in December 2013 when Madeleine Keyworth retired, we also appointed two new NonExecutive Directors to our Board.
So, overall…how are we doing? Well, my summary is that we are on the right track, and
although our path looks somewhat steeper in the future we are as well placed as any Trust to
tackle what lies ahead. The important thing is that we keep our lines of communication open,
continue to open our minds to learning from our challenges and remember that ‘Leading the
Way with Care’ is what we do around here.
As the Chief Executive of Rotherham Doncaster and South Humber NHS Foundation Trust, I
can confirm that, to the best of my knowledge, the information contained within this
document is accurate.
Our annual report 2013/14 contains further information about our performance over the past
year, as well as a summary of our financial accounts. For more details please contact the
Communications
Team
on
telephone
01302
796204
or
email
[email protected]
CB pic & electronic signature
9
PART 2A – PRIORITIES FOR IMPROVEMENT 2013/14
2.
A look back at the year 2013/14 - performance against quality improvement
priorities
The three quality improvement priorities for 2013/14, identified within the 2012/13 Quality Report,
were as follows:
•
•
•
Personalised care
Record keeping
Clinical leadership
The quality improvement priorities were set by the Board of Directors and the Council of
Governors. The priorities were first identified in the 2011/12 Quality Report and progress has
been reported on an annual basis. The programmes of work associated with each of the priorities
have principally been delivered through quality markers agreed with each of the Trust’s business
divisions and have been supported by the Quality Improvement Team (QIT) and the records
manager.
The progress and outcomes of the work on the quality priorities for 2013/14 is summarised below:
3.
Personalised care
Each business division identified a quality marker for 2013/14 for improving personalised care,
specific to the identified improvement needs of their services. A selection of service specific
examples of improvement are provided below:
•
•
•
•
All inpatient staff within the Adult Mental Health business division have undertaken
personalised care planning (PCP) training and have worked with patients and carers to
raise awareness. Audit has shown that there is increased patient and carer input into care
plans.
A new care plan format has been introduced in the Forensic business division and has
received positive feedback following a recent CQC Mental Health Act monitoring visit.
The Learning Disabilities business division has improved the quality and availability of
accessible information. The business division was highly commended in a national award
for easy-read information and a group has been established to continue reviewing the
quality of communications to service users.
The Substance Misuse business division care plan audits, evidence that there is an
increase in patient involvement in their care plans and that there has been an increase in
the delivery of recovery focussed interventions.
Our services that have been subject to CQC inspection since July 2012 have been assessed as
‘compliant’ with the CQC standards for care planning and record keeping, when reviewed. In
2012/13, two CQC inspections identified ‘minor’ compliance actions for ‘records’, and one
inspection identified a ‘minor’ compliance action for ‘respecting and involving people who use
services’. Action plans were completed and the services were reinspected and assessed as
‘compliant’ with both standards.
4.
Record Keeping
Personalised care is evidenced through good record keeping. Since the post was established in
July 2012, the records manager has worked with individual staff and teams and made
improvements in the following priority areas:
10
•
•
•
•
•
5.
Production and implementation of Safe Haven Policy, Retention and Disposal Policy and a
Moving Premises Package.
A revised Records Management Induction
A refresher records management session for existing staff has been developed to support
staff in their clinical roles.
A Corporate Templates Repository has been initiated to provide consistency in the
standard of records used throughout the Trust.
Records Management Co-ordinators have been identified to implement the records
management work streams in their service areas.
Clinical Leadership
The Trust has commissioned an organisational development programme ‘Fit 4 the Future’ (F4F),
which includes modules dedicated to quality, innovation, culture and leadership:





Module 1 – Engaging Your Team for Success
Module 2 – Engaging Your Team in Quality Services
Module 3 – Leading your team through change
Module 4 – Leading in partnership
Module 5 – Inspiring your team and promoting your service
A final half day ‘celebration and where next’ event is being planned for quarter 1, 2014/15.
The Chief Executive relaunched the ‘Leading the Way with Quality’ workshops in February and
March 2014. The workshops cascaded some of the thinking and activities from F4F and enabled
other staff to engage in the programme. Positive feedback has been received, with staff finding
that the sessions gave plenty of opportunity for interaction through the activities, they were
listened to and staff felt that they are valued.
In addition, a range of short workshops have been made available covering topics such as:
• Change management
• Personal effectiveness
6.
Annual Awards Ceremony
The Annual Members Meeting and Award Ceremony was held on 25 September 2013 and once
again showcased the excellent work that is happening across the Trust. The awards include
categories for each of the three Trust priorities and commend staff that have made an exceptional
contribution to the Trust’s vision statement of ‘Leading the Way with Care’ as well as a Quality
Care Award that is exclusively nominated by patients, services users and carers. Winners and
runners up for this year’s awards were as follows:
•
Leadership
o
Vikki Sullivan, Occupational Therapist, Manchester Early Intervention in Psychosis (EIP) Winner
“Vikki has collaborated with clinicians to develop an accessible care pathway for first episode
psychosis clients. She has made links with safeguarding adults and children’s services, promoting
supervision, offering guidance and navigating IT systems.
She set up a working group to write and design pages for the Manchester EIP pages of the
RDaSH website, involving clients in a photography group to gather images. Vikki delivers her role
in a dignified, thoughtful, sensitive and intelligent manner.”
11
o
Les Monks, East Dene, Doncaster – Runner Up
“Les Monks was seconded to East Dene in Doncaster to manage the Community Therapies
Team.
Les has been in post for only a few months, during which time he has adopted an inclusive and
shared leadership style. His maturity and ’solid’ personality reflect the strengths needed to
manage a team in the midst of change.
The team have transformed themselves under his leadership into an effective, dynamic and
innovative clinical team. His leadership and management style are an inspiration to his staff and
he has won their confidence and respect.”
•
Personalised Care
o
Wheelchair and Special Seating Service, Doncaster - Winner
“The Wheelchair and Special Seating service supports approximately 9,000 children and adults in
Doncaster with their mobility and postural needs.
Patient and carers have commented that staff actively listen to concerns and make every effort to
ensure that the chair is appropriate for the person. They feel involved and valued by being given
time to ask questions and gain confidence in the use of the chair.”
o
Vicki Brown, Rotherham and Holly Newton, Scunthorpe, Occupational Therapy Service –
Runners Up
“Occupational Therapists Vicki, who is based in Rotherham and Holly, who is based in
Scunthorpe participated in the first phase of Valuing Active Life in Dementia (VALID).
This is an important international occupational therapy research project for people with dementia
and their family and carers. Vicki and Holly have shown great enthusiasm, resourcefulness and
resilience in the training and tasks required for the project - and have done this alongside their
busy clinical roles.”
•
Record Keeping
o
Community Assessment and Intensive Support (CAIS) Team and Sapphire Lodge
Learning Disabilities Service, Doncaster - Winners
“These clinical teams developed the accessible Proactive Risk Management Plans that are
person centred plans specifically designed to support the proactive management of risks
associated with challenging behaviour.
The plans were developed by professionals in collaboration with service users, their families and
advocates feedback has been very positive”.
o
Wendy Batchelor and Lorraine Preston, Substance Misuse Services, Scunthorpe –
Runners Up
“Wendy and Lorraine work as administrative staff across two sites at The Junction and the
Community Alcohol Service in Scunthorpe.
During the last year the service has implemented a new case management system, the
changeover period has involved a lot of extra work for administrative staff and has led to dramatic
12
changes to processes and procedures. Administrators in the service are now up to date and more
accurate due to the hard work and dedication of these staff members”
•
Quality Care Award
o
Community Memory Therapy Service, Doncaster - Winner
“The service was nominated by the wife of a service user. The service user went to cognitive
therapy units which helped to keep him motivated and happy. The therapy ranged from trips to
the seaside to visits from school children. He mixed with similar patients and met other carers
who also gave support.
The clinic also ran six useful lectures about finance, power of attorney, making a will, how to deal
with service users in stressful situations and when to go for help.”
o
Rachel Matharoo, Peer Support Worker, Children and Young People’s Mental Health
Services, Doncaster – Runner Up
“The parent who made this nomination said that without Rachel and CAMHS their son would not
be where he is today. CAMHS have been very supportive of both parent and child, understanding,
very patient and non-judgmental, making numerous appointments with various people to help with
his difficulties. Because of this the child has now started studying at the Deaf College.”
7.
Local Commissioning Priorities
During 2013/14 we have had a number of quality challenges to deal with, which have led to
improvement plans and actions being agreed with our commissioners and monitored through the
locality Contract Monitoring meetings:
Rotherham
The Clinical Commissioning Group identified a number of performance and quality shortfalls in
our Children’s and Young People’s Mental Health services, which resulted in reduced confidence
being expressed by General Practitioner colleagues in our services. A detailed action plan has
been implemented and improvements have been made. Initial indications are that significant
progress has been made by working in partnership with commissioners in delivering the
improvements to this service. Feedback from the GP survey as part of the action plan has been
positive and the action plan has been signed off. However, it is acknowledged that there is still
more work to be done to fully embed these changes and work will continue in 2014/15.
Doncaster
A number of quality concerns were highlighted through our own governance processes relating to
Adult Mental Health services.
A detailed plan of action focussing on care planning,
communication and risk management, particularly in ward areas and at the interface of inpatient
and community services has been implemented. A fundamental review of services has also been
undertaken by the Clinical Commissioning Group and a joint approach to service redesign and
improvement is underway.
North Lincolnshire
Work has been completed on reviewing and implementing a new management and senior
leadership structure across Adult Mental Health services and strengthening our approach to risk
management and care planning. Work is underway with North Lincolnshire service users and the
local Healthwatch to embed these improvements.
8.
Progress with business division quality markers 2013/14
13
The Trust business divisions have identified quality markers linked to the Trust quality priorities for
2013/14. Some examples of progress against the business division quality markers for 2013/14 is
summarised in table 1:
Table 1 Business division quality markers 2013/14
QUALITY MARKER
OUTCOME
Personalised care planning
Personalised Care
All inpatient staff within the Adult Mental Health business
Planning (PCP)
division have undertaken PCP training and have worked with
patients and carers to raise awareness. Audit has shown that
there is increased patient and carer input into care plans.
Collaborative work with
patients to improve care
plans
A new care plan format has been introduced in the Forensic
business division and has received the following positive
feedback following a recent CQC Mental Health Act monitoring
visit; “patients were involved in their care planning process in a
way that enabled them to talk to us about it.”
Improve service pathways
The Doncaster Community Integrated Service (DCIS) business
division has recruited two telehealth nurses for the long term
conditions pathway and funding has been secured for
telehealth equipment from the NHS England Nursing
Technology Fund to allow patients to access telemonitoring
seven days a week.
Copying care plans to
patients
The Older People’s Mental Health business division patient
experience survey shows improved results with 86.3% of
patients reporting that they were copied into their personalised
care plan, and 100% of respondents reported that they were
offered therapeutic activities indicating that patient activities are
embedded as core in inpatient services.
Improve experience of
transitions to other
services
Leaflets on transitions have been produced and the Peer
Support Workers (PSWs) in the Child and Adolescent Mental
Health Services (CAMHS) business division are improving the
transition experience. Service user evaluation of the benefits of
the PSW role has been positive.
Record keeping
Improve record keeping
Improve record keeping
Clinical leadership
Develop high quality
clinical supervisions
Staff responsibility to raise
concerns
An Integrated Record System is now in place in the Forensic
business division and positive feedback has been received
following the 90 day Quality Improvement Team (QIT) check.
The record keeping audit shows that there have been
improvements in the Adult Mental Health business division.
The Forensic business division has commenced Reflective
Practice Groups, and the quality of supervision is monitored by
the Modern Matron and the Ward Manager.
All senior staff have undertaken Personal Responsibility training
in the Learning Disabilities business division and this is now
being cascaded to more staff. Random snapshot telephone
14
survey conducted to assess staff awareness of how to raise
concerns, 95% of answers were correct and clear. All staff
completed survey to follow up. 99% of staff aware of procedure.
Leaders embed a ‘Quality
Culture’
The Substance Misuse business division has held a third
reflective practice event regarding the Francis Report. Leaders
have identified ways to make cultural changes, increased
ownership of quality reporting for all leaders across Division.
Improve the quality and
availability of clinical
supervision
The DCIS business division has set up dedicated clinical
supervision groups for each service and increased the number
of trained supervisors across Division.
9.
Progress with User Carer Partnership Council (UCPC) quality markers 2013/14
The User Carer Partnership Council (UCPC) quality markers were signed off for 2013/14 at the
final meeting of the UCPC in November 2013. The UCPC service users and carers will be able to
engage with the Adult Mental Health business division through the locality collaborative meetings.
10.
Trust Business Division Governance Framework 2013/14
The Business Division Performance Reviews are informed by risks highlighted based on a
dashboard of Key Performance Indicators (KPIs) in each of the four areas of the Business
Division Governance Framework. These four areas are
• ‘Finance Efficiency and Business Strategy’,
• ‘Quality and Standards’,
• ‘Our People/ Our Staff’ and
• ‘Service Performance and Risk’.
RAG ratings are applied based on the review period data and, in addition, any significant
information available for the review referenced.
Each of the Trust’s seven business divisions took part in a mid-year performance review meeting
between 12 November and 16 December 2013. The reviews focused on performance during
Quarters 1 and 2, 2013/14. Outlined in table 2 are the ratings given in the domain of ‘Quality and
Standards’ since the Mid-Year Reviews in 2012/13 to allow comparison, in line with the scope of
this report. A further set of reviews are scheduled for June 2014 to review performance
throughout 2013/14.
Table 2: Business Division ‘Quality and Standards’ Performance Reviews
A robust improvement plan was put in place to address a number of areas spanning quality,
finance, performance and human resources in the Forensic business division and has been
supported by the Quality Improvement Team. The plan is monitored through the Trust and the
15
Forensic business division Clinical Governance Group, and as shown in the mid-year some
improvements have been made.
11.
The Trust’s response to Francis, Berwick and Keogh
The Trust produced a response to the Francis Inquiry and to the two Government responses,
which details the changes that have taken place within the Trust to address the issues raised, and
also highlights areas where further improvement is still required.
The Trust’s Francis Declaration was developed jointly by the Board of Directors and the Council
of Governors representatives and jointly signed off by the Board of Directors and the Council of
Governors at a public Board of Directors meeting, prior to publication on the Trust website at
http://www.rdash.nhs.uk/corporate-information/public-declarations/francis-report/.
The Francis Declaration focusses on:
• Our Quality Journey
• Trust Response to ‘Hard Truths: The Journey to Putting Patients First’
• Francis Priorities for 2014/15
• Board of Director and Council of Governor Statement
In developing the Trust’s quality improvement approach and the Francis Declaration, RDaSH has
also taken the following national independent reports into consideration through its governance
processes:
• Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England,
led by Professor Sir Bruce Keogh, the NHS Medical Director in NHS England
• The Cavendish Review: An Independent Review into Healthcare Assistants and Support
Workers in the NHS and Social Care Settings, by Camilla Cavendish.
• A Promise to Learn – A Commitment to Act: Improving the Safety of Patients in England,
by Professor Don Berwick
• A Review of the NHS Hospitals Complaints System: Putting Patients Back in the Picture
by Rt Hon Ann Clwyd MP and Professor Tricia Hart
• Challenging Bureaucracy, led by the NHS Confederation.
• The report by the Children and Young People’s Health Outcomes Forum, co-chaired by
Professor Ian Lewis and Christine Lenehan.
Based on the recommendations from the Francis Inquiry the Board of Directors has identified four
Francis priorities for further development and consideration over the next 12 months:
• Culture - the organisational development programme “Fit for the Future” includes a
module dedicated to culture and analysis of the results of the annual staff survey.
• Engagement – the “Leading the Way with Quality” workshops in Spring 2014 cascaded
the thinking from the Fit 4 the Future programme and completed some work together on
refreshing the Trusts values. The professional networks are contributing to the refreshed
professional strategy in the light of the recommendations from the Francis Report.
• Non-professionally qualified staff – the Trust is taking part in the pilot programme for a
certificate on fundamental care and apprenticeships for non-qualified staff and contributing
to the national agenda.
• Supporting whistleblowing- refreshed policy and ongoing promotion campaign.
The Board of Directors and Council of Governors endorsed the Trust Francis Declaration by
stating:
‘The Board, Governors and staff pursue the ongoing development of a culture that:
• Puts the patient at the heart of everything we do
• Supports and develops our staff to deliver positive care
16
•
Delivers continuous improvement’
A mid-year review of progress will be considered by the Board of Directors and Council of
Governors during 2014.
17
PART 2B – PRIORITIES FOR IMPROVEMENT 2014/15
12.
Strategic context
The Trust’s Strategic Objectives define the approach we are taking to deliver our Vision of
‘Leading the Way with Care’. Our Strategic Objectives and the associated workstreams have
been refreshed for 2014/15, taking into account national guidance and recommendations, such
as the Francis Report, the Berwick and Keogh Reports and the revised CQC inspection regime.
The Strategic Objectives have stood us in good stead, remain valid and also take into
consideration the challenging financial and competitive environment in which the Trust is
working. Therefore in 2014/15 the Trust’s Strategic Objectives will be:
•
•
•
•
•
13.
Continuously improve service quality (safety, effectiveness and patient experience) for
our patients and carers
Nurture the talent, commitment and ideas of our staff in order to deliver excellent
services
Ensure value for money and increased organisational efficiency whilst maintaining
quality
Adapt and deliver services to meet agreed commissioned needs through enhanced
multi-agency partnerships
Maintain excellent performance and governance and a strong market position; and
improve further our reputation for quality
Priorities for quality improvement 2014/15
The Trust commenced its quality journey in July 2011. This followed the lessons learned from
the investigations into a number of incidents and from inspections, which included CQC
inspections identifying further quality concerns relating principally to personalised care and
record keeping. Subsequent internal actions revealed concerns about clinical leadership,
which led to the Trust identifying its top three quality improvement priorities within its quality
strategy for 2011/12 and 2012/13 as:
•
•
•
Personalised care
Record keeping
Clinical leadership
Following approval by the Board of Directors in January 2012, the Quality Improvement Team
(QIT) was established as a two year project to support the sustainable implementation of the
three quality priorities and the delivery of the quality improvement programme identified in the
Quality Marker schemes.
Building on the improvements we have achieved in 2012/13 and 2013/14 and our assessment
of quality performance during 2013/14 the Trust has been able to refocus its quality priorities
from three to one for 2014/15; Clinical Leadership.
This is based on a fully compliant CQC inspection of Trust services in October 2013 and being
fully compliant with the Essential Standards of Quality and Safety inspected by the CQC since
July 2012, including care planning and record keeping. In addition, assurance has been taken
from other external and internal inspections, including outcomes from the Clinical
Commissioning Group quality visits, Health and Safety Executive, Clinical Audit and the Quality
Improvement Team.
To support the quality priority, the Trust has commissioned an organisational development
programme ‘Fit 4 the Future’, which includes modules dedicated to quality, innovation, culture
and leadership. This quality priority is aligned to the Strategic Goal of ‘Continuously improving
18
service quality (safety, effectiveness and patient experience) for our patients and carers’.
A clinical staffing review group has been formed, to respond to the national recommendation
that NHS trusts have the right staff, with the right skills, in the right place. The Trust will be
reporting staffing levels from June 2014. There is key representation from each business
division to develop and implement the staffing review for both inpatient and community services
where relevant. An inpatient escalation process focusses on acuity and dependency levels,
aligning the staffing review with the quality impact assessment process and benchmarking
against best practice, nationally.
The views of patients and carers, our staff and the wider public have been taken into account in
agreeing our priorities in some of the following ways:
• Council of Governors whose membership comprises patients, carers, public and partner
governors
• Discussions at locality patient and carer groups such as the mental health collaboratives
• Feedback provided by patients and carers through the national and local experience
surveys
• Feedback provided by patients and carers through CQC inspections and CQC Mental
Health Act monitoring visits
• Feedback provided by GPs through local surveys
• Discussions with local HealthWatch
• Attendance at local health economy groups such as the Health and Wellbeing Boards
• ‘Leading the Way with Quality’ workshops for staff
• Discussions at the Trust professional network groups
• External and internal visits to discuss and review quality issues with teams/staff
We will keep this priority for quality improvement under review throughout the year to ensure it
remains current and responsive, based on the outcomes of the work of the Quality
Improvement Team and any other emergent priorities.
Measurement of the quality improvement priority will be achieved through the quality markers
for 2014/15, set within the quality domains of patient experience, patient safety and clinical
effectiveness that have been agreed with each of the Trust’s business divisions. Progress
against the quality markers will be monitored through the Clinical Effectiveness Committee and
reported in the quarterly Quality Improvement Report.
14.
Trust Business Divisions’ Quality Markers
For 2014/15 the business divisions have agreed quality markers set within the domains of
quality:
• Patient experience
• Patient safety
• Clinical effectiveness.
The quality markers are also linked, where required, to the business divisions’ self-assessment
against the CQC essential standards of quality and safety. The quality markers have clear
outcomes and measurements and are discussed regularly at business division and team
meetings. An example of a business divisions quality markers for 2014/15 is shown in table 3:
Table 3: Business division quality markers 2013/14
Business Division
• Adult Mental Health
Patient Experience
•
The Adult Mental Health business division meets the six key standards of the carer’s
‘Triangle of Care’
19
Patient Safety
• Service users will access clinical pathways relevant to their needs and waiting times
will be within commissioned thresholds
Clinical Effectiveness
• The Adult Mental Health business division will have clearly defined roles and
responsibilities for its clinical and managerial staff
15.
Patient, carer and public engagement and feedback
During 2013/14, the refreshed Patient Carer and Public Engagement and Experience (PPEE)
Strategy - ‘Listen to Learn’ was launched. The Listen to Learn Steering Group was also
established to implement the strategy and to further develop engagement with patients, carers
and the public. Patients, carers and Governors are members of the Listen to Learn Steering
Group and are working with business divisions to develop plans to further improve engagement
and feedback, which will be measured using the “ladder of participation”.
‘Listen to Learn’ is a key component of our overall quality strategy, and we will ensure that we
act on feedback as effectively as we can and that it informs all the work that we do. Feedback
from patient and carer surveys, complaints and PALs etc. will continue to be reported and
shared through our Quality Improvement Report.
16.
Collaborative working with commissioners
Collaborative working with commissioners will continue to be an important priority for the Trust
during 2014/15, for all services.
The national and local commissioning priorities have become increasingly competitive and
quality orientated. It can no longer be assumed that NHS provided care is the first or most
optimal solution for commissioners to meet the needs of their populations. The Trust must be
able to compete and demonstrate that it can operate efficiently, to high standards of care and in
line with commissioner expectations.
National commissioning priorities that the Trust will be involved with include:
• CAMHS Inpatient Services (Tier 4) – the Trust is submitting information to the Health
Select Committee Review of the provision of Tier 4 CAMHS. The Trust will work with
commissioners to implement the recommendations following the completion of the
review.
• 7 Day Working – the Trust currently provides some 7 Day Working services and is
working with commissioners to develop further services over the next three years, taking
into account the 10 national clinical standards.
• Better Care Fund – engaged in local health economy plans for development of the fund.
• Closing the Gap – the Trust is working with Commissioners over the next two years to
bridge the gap between long-term ambitions for mental health and shorter-term actions.
The Trust will work with each local health economy to demonstrate changes in the 25
areas where the most immediate change and improvement is expected, and to deliver
outcomes aligned to the Parity of Esteem principle of providing equitable access to
mental health and physical health services for people with both mental health and
physical health needs. Recent commissioner led reviews of the mental health services
have resulted in an expressed intention from commissioners to support the Trust to
work more closely with General Practices to build capacity and capability to meet the
mental health needs of the community, on a whole system basis.
20
Public health commissioning priorities that the Trust will be involved with include:
• Provision of Substance Misuse services and possible retendering of services
• Provision of Contraception and Sexual Health Services
• Provision of School Nursing
Local commissioning priorities that the Trust will be working on include:
Doncaster
The development of:
• The mental health crisis pathway
• A case management approach for community nursing
• Local specialist pathways
• The new memory service pathway
• Care pathways and packages (Mental Health Payment and Pricing Systems)
A review of the:
• Unplanned care system
• Children’s community nursing service
And also include:
• Joint commissioning of Learning Disabilities Assessment and Treatment Unit
• Utilising capacity within Older People’s Mental Health inpatient services to meet more
complex needs
Rotherham
Consideration of investment in priority areas following the outcomes of the reviews, as detailed
below:
• Mental health and learning disability services
• Learning Disabilities Assessment and Treatment Unit and community services
• A comprehensive CAMHS strategy
• Development of care pathways and packages (Mental Health Payment and Pricing
Systems)
North Lincolnshire
The development of:
• A potential specialist Learning Disabilities service
• Care pathways and packages
The Trust aims to keep ahead of its competitors in terms of quality and patient experience, by
working flexibly and imaginatively to deliver care in ways that are innovative and
transformational.
17.
Monitor’s risk assessment framework
Monitor is the external regulator of NHS Foundation Trusts. The key governance targets set by
Monitor’s risk assessment framework for 2014/15, which support the Trust’s quality
improvement plans, are shown in Tables 4 and 5:
Table 4: Monitor’s Mental Health and Learning Disability risk assessment framework
targets for 2014/15
Targets
Threshold
Care programme approach:
Follow-up contact within 7 days of discharge
95%
Care programme approach:
Having formal review within 12 months
95%
Admissions to inpatients services has access to crisis
95%
21
resolution/home treatment teams
Meeting commitment to service new psychosis cases by early
intervention
Minimising delayed transfers of care
Data completeness identifiers
Data completeness: outcomes for patients on CPA
Certification against compliance with requirements regarding
access to health care for people with a learning disability
95%
<= 7.5%
97%
50%
n/a
Table 5: Monitor’s Community Services risk assessment framework targets for 2014/15
Targets
Threshold
Referral to treatment information
Referral information
Treatment activity information
50%
50%
50%
18.
Commissioning for Quality and Innovation (CQUIN) payment framework
In 2014/15, 2.5% of the Trust's income will be conditional on achieving quality improvement and
innovation goals agreed with our commissioners, through the CQUIN payment framework.
Tables 6-8 show the 2014/15 CQUIN schemes for Community, Mental Health and Learning
Disability and Forensic services.
Table 6: Community Services CQUIN indicator framework for 2014/15
•
•
•
•
•
•
•
•
National Safety Thermometer – Community (national indicator)
Friends and family test (national indicator)
Patient and Carer Experience
Dementia Community
Community Nursing and OTW
Safeguarding
Supporting Breastfeeding
Building Community Capacity
Table 7: Mental Health and Learning Disability Services CQUIN indicator framework for
2014/15
•
•
•
•
•
•
•
•
•
Friends and family test (national indicator)
National Safety Thermometer - Mental Health (national indicator)
Improving physical healthcare to reduce premature mortality in people with severe
mental illness (SMI) (national indicator)
Patient and Carer Experience including CAMHS and Dementia and Stakeholder
views
Recovery Mental Health
Carer education and training support
Safeguarding
Learning Disabilities Dementia - Case Finding (Find, Assess, Investigate and Refer)
Care planning
Table 8: Forensic Services CQUIN indicator framework for 2014/15
•
•
Friends and family test (national indicator)
Improving physical healthcare to reduce premature mortality in people with severe
22
•
•
•
•
•
19.
mental illness (SMI) (national indicator)
Safeguarding
Collaborative Risk Assessments
Supporting Carer Involvement
Service User formulation of need at transition
Quality Dashboard
Clinical audit
We will continue to develop the use of clinical audit during 2014/15 to improve patient care and
to make sure that improvements are implemented and sustained. Our clinical audit strategy and
annual clinical audit programme are shaped by our strategic priorities, national and local
expectations and prioritises local concerns. As such, clinical audit is a crucial component of our
quality strategy.
During 2013/14 Internal Audit conducted a review of clinical audit to provide assurance over
the effectiveness of planning and organisational learning. The review found that ‘significant
assurance’ can be provided from the clinical audit process. There were two minor
recommendations that will be implemented during 2014/15 and the increasingly systematic use
of clinical audit during 2014/15 will enable us to measure and improve the quality of care
patients receive against evidence based standards and to further quantify the improvements
made. It will also provide us with a measure of how well we are implementing our key risk
management policies and identifies where policies can be improved to provide clearer
procedural guidance for staff.
Used in conjunction with a number of related processes such as significant event enquiries,
patient surveys, internal audit and measurable quality markers, clinical audit will provide a
framework for measurement of quality improvement.
This work will be supported and driven forward by the Quality Improvement Team, working
collaboratively with the business divisions.
20.
Monitoring and measuring progress and reporting on quality
The committees and groups within the Trust’s governance structure meet on a regular basis to
review plans for quality improvement, challenge areas of concern and manage in-year issues.
Performance against key quality measures is reported to and monitored by the:
• Council of Governors (CoG)
• Board of Directors (BoD)
• Clinical Governance Group (CGG)
• Performance and Assurance Group (PAG)
• Organisational Learning Forum (OLF)
• Business Division Clinical Governance meetings
• Audit Committee
and externally to our commissioners via the Quality Review Group and the contract monitoring
meetings.
Quality priorities and issues are raised with staff through:
• Monthly Quality Matters bulletin
• Chief Executive Blog
• Trust Matters
• Professional Forums such as Nursing Network and the Allied Health Professionals
Forum
• Leading the Way with Quality workshops
23
•
Team meetings
In addition, the Trust works collaboratively with a number of patient and carer groups in each of
the localities in which the Trust provides services, who play a key role in providing us with
feedback and challenge and in monitoring quality improvement. The Trust has reviewed its
patient engagement approach and produced a new Listen to Learn Strategy. The
implementation of this strategy is overseen by a steering group comprised of:
• Governors
• Trust members
• Representatives from patient and carer groups
• Representatives from each Healthwatch for the Trust’s localities
• Representatives from each business division
The quarterly Quality Improvement Report is produced to analyse quality and report on
performance against the key priorities, quality markers, CQUINs and the three domains of
quality. The information from each of the sections of the Quality Improvement Report is
triangulated in the Conclusion section, and using the early warning indicators implemented by
the Trust, services that have hit the early warning trigger points are highlighted. Actions to be
taken are agreed by the CGG and followed up at the next meeting. Examples of the early
warning system being triggered are the rising trend in the number of suicides in Adult Mental
Health services and the rise in the number of pressure ulcers in Doncaster Community
Integrated Services, and the approach taken to conduct monthly thematic and quantitative deep
dives and to monitor progress against the quality improvements actions to address these areas
and the lessons learned.
The quarterly Quality Improvement Report supports the delivery of the Trust’s Strategic
Objectives, annual Quality Report, the Trust’s quarterly self-assessment against Monitor’s
Quality Governance Framework and the forthcoming three-yearly Governance Reviews, and
the embedding of the CQC Essential Standards (to be replaced by the CQC Fundamental
Standards in 2014/15). In addition, the business divisions’ performance, including quality
improvement work, is reviewed by the Senior Leadership Team and outcomes reported to the
Board. Where progress is not sufficient, improvement actions are agreed and progress towards
achievement is monitored. In addition, a bespoke Quality Improvement Report is presented to
every Council of Governors meeting.
In November 2013 a revised approach to presenting performance information to the Board of
Directors was agreed. The two Service Directorates produce a one page performance
dashboard for each of their business divisions. The dashboard is presented to the Performance
and Assurance Group on a monthly basis for analysis and discussion. The dashboards are
then presented to the Board of Directors with the focus on performance exceptions highlighted
by the Performance and Assurance Group.
Key risks to quality are also identified and monitored through other internal quality monitoring
processes including:
• Quality Impact Assessment (QIA) - supports the quality innovation productivity and
prevention (QIPP) process. All QIPP plans are assessed on their quality impact, with
the more complex schemes assessed using the Birmingham QIA tool and are signed off
by the Director of Nursing and the Medical Director.
• Quality Risk Profile – in 2013/14 the Trust has piloted a Quality Risk Profile (QRP). The
QRP is business division specific and includes quality risks in the areas of patient
safety, clinical effectiveness, patient experience and other areas for consideration,
including regulatory and stakeholder concerns. The Trust continues to develop this
process and in 2014/15 the quarterly QRP will include monitoring of the QIPP schemes.
RDaSH has performed well in achieving its quality priorities and indicators for patients in
24
2013/14 and the Trust is aspiring to continue achieving the quality priorities and indicators for
patients in 2014/15.
25
PART 2C – STATEMENTS OF ASSURANCE FROM THE BOARD 2013/14
21.
Review of services
During 2013/14 Rotherham Doncaster and South Humber NHS Foundation Trust provided
and/or sub-contracted 106 relevant health services.
Rotherham Doncaster and South Humber NHS Foundation Trust has reviewed all the data
available to them on the quality of care across all of the business divisions and all 106 of
these relevant health services.
The income generated by the relevant health services reviewed in 2013/14 represents 100
per cent of the total income generated from the provision of relevant health services by
Rotherham Doncaster and South Humber NHS Foundation Trust for 2013/14.
Further details of the services provided/sub-contracted by RDaSH are provided on the trust’s
website at: http://www.rdash.nhs.uk/information-for-the-public/services/service-directory/
All business divisions review information on a monthly basis relating to the performance of
their services, the quality of care provided including clinical effectiveness, patient safety and
patient experience. The review measures progress against quality improvement priorities
and actions are taken, as required. Business divisions also work with corporate services to
validate information relating to services and quality and where planned or appropriate, data
quality is tested. Examples of data quality are included in the performance indicators
included in the three domains of quality in part 3.
22.
Participation in clinical audits
During 2013/14 seven national clinical audits and one national confidential inquiry covered
relevant health services that Rotherham Doncaster and South Humber NHS Foundation Trust
provides.
During 2013/14 Rotherham Doncaster and South Humber NHS Foundation Trust participated in
100% clinical audits and 100% national confidential enquiries of the national clinical audits and
national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Rotherham Doncaster and
South Humber NHS Foundation Trust was eligible to participate in during 2013/14 are as
follows:
National Clinical Audits
• National Audit of Schizophrenia
• National Audit of Psychological Therapies for Anxiety and Depression
• National Audit of Intermediate Care
• Prescribing Observatory for Mental Health UK (POMH-UK) (3 clinical audits)
National Confidential Inquiry
• National Confidential Inquiry into Suicide and Homicide by People with Mental Illness
The national clinical audits and national confidential enquiries that Rotherham Doncaster and
South Humber NHS Foundation Trust participated in during 2013/14 are as follows:
National Clinical Audits
• National Audit of Schizophrenia
26
• National Audit of Psychological Therapies for Anxiety and Depression
• National Audit of Intermediate Care
POMH-UK Audits
• Prescribing for ADHD
• Monitoring of Patients prescribed Lithium
• Prescribing Anti-Dementia Drugs
National Confidential Inquiry
• National Confidential Inquiry into Suicide and Homicide by People with Mental Illness
The national clinical audits and national confidential enquiries that Rotherham Doncaster and
South Humber NHS Foundation Trust participated in, and for which data collection was
completed during 2013/14, are listed in table 9 alongside the number of cases submitted to each
audit or enquiry as a percentage of the number of registered cases required by the terms of that
audit or enquiry.
Table 9: Participation in national clinical audits
Audit
Participation
National Audits
• National Audit of
Schizophrenia
•
National Audit of
Psychological Therapies for
Anxiety and Depression
•
National Audit of
Intermediate Care
POMH-UK
• Prescribing for ADHD
Yes
Yes
Yes
Cases submitted
% Cases
required
100/100 audit of
practice
100%
38/50 service user
questionnaires
17/25 carer
questionnaires
98 therapist
questionnaires
2039/6 (guideline)
case note audits
397 service user
questionnaires
3/3 (100%) clinical
areas
76%
Yes
284
•
Monitoring of Patients
prescribed Lithium
Yes
20
•
Prescribing Anti-Dementia
Drugs
Yes
400
68%
N/A
N/A
N/A
100%
100% of
caseload or
representative
100% of
caseload or
representative
100% of
caseload or
representative
The reports of three national clinical audits were reviewed by the provider in 2013/14. The
results of the National Audit of Schizophrenia, Prescribing for ADHD and Prescribing AntiDementia Drugs are expected in quarter 1 2014/15. Rotherham Doncaster and South Humber
NHS Foundation Trust intends to take the following actions to improve the quality of healthcare
provided:
National Audit of Psychological Therapies for Anxiety and Depression:
• Improve data recording
• Improve training and identify future training needs
27
• Improve accessibility for patients who are 65+
• Ensure staff have access to appropriate supervision
National Audit of Intermediate Care:
• Patients are being engaged in service change i.e. Enhancing the Healing Environment
bid for Hawthorn
• The Trust is fully engaged in the Intermediate Care Review Plan, working closely with
commissioners
• Service specific training is being undertaken
• All staff now record on a single electronic patient system and a single multi-professional
assessment tool is being developed.
Monitoring of Patients prescribed Lithium
• Business division action plans are being presented to the Medicines Management
Committee and progress will be monitored by the Clinical Audit Department.
Over 2013/14, 52 Clinical Audits have been completed. The audits conducted across the year
have identified the following areas of good practice and areas for improvement:
•
Good practice:
 Management of people with a learning disability and mental illness
 Physical Assessments on admission
 Care Programme Approach
 Recovery and Discharge
 Monitoring of Patients on Lithium
 Review of Health Assessments for Looked After Children
 Clinical Supervision
•
Areas for improvement:
Record Keeping
Pressure Ulcer management
Supervision Training
23.
Participation in clinical research
The number of patients receiving relevant health services provided or sub-contracted by
Rotherham Doncaster and South Humber NHS Foundation Trust in 2013/14 that were
recruited during that period to participate in research approved by a research ethics
committee was 271 at the end of March 2014, against a target of 132. The Trust undertook a
significant amount of work to improve the Trust's standing with research, which is now
beginning to come to fruition.
24.
Commissioning for Quality and Innovation (CQUIN) Scheme 2013/14
A proportion, 2.5% of the annual income equivalent to £3,258,592, of Rotherham Doncaster
and South Humber NHS Foundation Trust income in 2013/14 was conditional upon achieving
quality improvement and innovation goals agreed between Rotherham Doncaster and South
Humber NHS Foundation Trust and any person or body they entered into a contract,
agreement or arrangement with for the provision of relevant health services, through the
Commissioning for Quality and Innovation payment framework. The proportion and amount
of the Trusts annual income remains the same as 2012/13. Further details of the agreed
goals for 2013/14 are available online at: http://www.england.nhs.uk/wpcontent/uploads/2013/02/cquin-guidance.pdf
28
The Trust achieved 97.9% of the CQUIN indicators and received income of £3,189,570 for
2013/14.
Tables 10-14 show the outcomes of the 2013/14 CQUIN schemes for Community, Mental
Health and Learning Disability and Forensic services.
Table 10: National CQUIN indicator framework for 2013/14
• NHS Safety Thermometer
Partially achieved
During 2013/14 the Trust gathered monthly patient safety
information from inpatient and community areas. The
information included the percentage of:
• Patients who had a pressure ulcer
• Patients who had recently fallen
• Patients who had been treated for a urinary tract
infection who had a catheter
• Patients who had harm free care
The indicator concentrated on collecting data in 2013/14.
In 2014/15 the indicators focusses on making
improvements in each of the four areas above.
Table 11:Trustwide CQUIN indicator framework for 2013/14
• Patient
Experience
– Partially achieved
including
family
and • The Trust undertook two surveys of patients and on
friends test
an agreed date in 2013/14.
• The carer survey was available throughout the year.
• A total of 3318 patient surveys were received,
compared to 3241 in 2012/13
• A total of 1155 carer surveys were received,
compared to 627 in 2012/13.
• Overall the satisfaction levels of patients and carers
were high.
• Examples of where satisfaction levels need
improvement for patients include:
o Ward activities
o Meals and refreshments
o Care planning and involvement
• Examples of where satisfaction levels need
improvement for carers include:
o Availability and quality of information
o Being able to give feedback
Examples of changes made following feedback from
patients and carers includes:
• Business divisions quality marker schemes have
focussed on improving the quality of information
provided to patients and carers, and current leaflets
are being revised and going through the ‘Get it Write’
panel.
• The new Trust website to be launched in June 2014
29
will include an electronic version of the ‘Your Opinion
Counts’ form for stakeholders to submit comments.
• All business divisions have had a ‘Ward hostess’ on
inpatient wards, with facilities staff supporting patients
in their choice of meals and working with nursing staff
to ensure that special diets and portion control
requirements are met.
Table 12: Community Services CQUIN indicator framework for 2013/14
• Community
and Data
Information Achieved
During 2013/14 the DCIS business division has focussed
on improving the collection of community information and
data. Examples of data items collected include:
• Referral source
• Discharge destination
• Diagnosis
• Use of technology i.e. Telehealth
Using the improved information and data, the Trust will
work with commissioners on improving care pathways.
• One Team Working
Achieved
The evaluation framework developed as part of the
CQUIN in 2012/13 has been used in 2013/14.
Feedback collected during the evaluation on One Team
Working includes:
• “Certainly we are doing a lot more joined-up visits
which I feel is most definitely a benefit for the
patients.”
• “When we have the MDT we arrange any joint visits
that need doing after that and it’s the same thing.”
• “The administration part has perhaps proved a bit
more difficult […] we still aren’t quite up to them being
able to operate each other’s systems.”
Table 13: Mental Health and Learning Disability Services CQUIN indicator framework
for 2013/14
• Transition Planning
Achieved
In 2012/13 the CQUIN indicator focussed on transitions
between the CAMHS and Adult Mental Health services.
In 2013/14 the CQUIN indicator was extended to focus
on:
• Transitions between CAMHS to Adult Mental Health
services and Learning Disability
• Patients being jointly worked between Learning
Disability and another business division
• Older Peoples Mental Health S117 discharges to
external provision
Each transition under the categories above was audited
30
twice during 2013/14, against a set of standards agreed
with commissioners. All standards were fully achieved at
the second audit. Examples of the areas audited
include:
• Patients having an identified care coordinator/named
worker
• Patients having a care plan that outlines the transition
arrangements
• Evidence of joint meetings taking place
• Evidence of information about the services being
shared with the patient
A further area focussed on as part of the CQUIN
indicator is:
• Transitions between IAPT to Adult Mental Health
services
This element of the CQUIN indicator continues as a
piece of work with commissioners in 2014/15 to improve
the transition protocol and the patient experience of
transition to Adult Mental Health services.
• Recovery (Discharge and Achieved
Each of the business divisions has identified a recovery
Planning)
outcomes tool for use with their patients. Examples of
the tools identified are:
• Four Factor Model – Adult Mental Health and Older
Peoples Mental Health
• Recovery STAR – Adult Mental Health
• Health Equalities Framework – Learning Disability
In 2013/14 the CQUIN indicator has focussed on
business divisions implementing the recovery outcome
tools and collecting data. In 2014/15 the focus of the
CQUIN indicator is being extended to show the
outcomes being experienced by patients.
Table 14: Forensic Services CQUIN indicator framework for 2013/14 (Outcomes of
the CQUIN indicators has not yet been confirmed by commissioner)
• Optimising Pathways
The Forensic service has been measured on a number
of key areas that indicate whether the pathways are
being optimised. Areas include:
• Referral to acceptance
• Acceptance to admission
• Estimated treatment length
• Average length of stay
The majority of areas have shown improvement over
2013/14.
• Provision
of
literacy, During quarter 2 2013/14 feedback was gathered from
numeracy,
IT
and the patients on Amber Lodge, which suggested that the
majority would like to improve their knowledge and skills.
vocational skills training
31
Taking into account known cognitive and learning
difficulties, a non-standardised, learning disability
friendly, assessment tool of basic computer skills was
devised by the lead occupational therapist. 75% of the
patients on Amber Lodge have undertaken 1:1
assessments of their basic computer skills.
• Improving
the
Care An audit of CPA meetings during 2013/14 showed that:
Programme
Approach • The attendance of care coordinators at the CPA
(CPA) process
meeting had increased to 71%
• The attendance of psychology representatives had
increased to 88%
• Nursing staff were in attendance 79% of the time
• Increase
in
use
communications
technology
25.
of Amber Lodge has introduced the use of e-meetings. Emeetings will initially be used for:
• CPA meetings
• MDT meetings
The introduction of e-meetings allows family / carers to
be involved in the patients meeting.
Care Quality Commission (CQC)
Rotherham Doncaster and South Humber NHS Foundation Trust is required to register with
the Care Quality Commission and its current registration status is registered with no
conditions.
The Care Quality Commission has not taken enforcement action against Rotherham
Doncaster and South Humber NHS Foundation Trust during 2013/14.
Rotherham Doncaster and South Humber NHS Foundation Trust has not participated in any
special reviews or investigations by the Care Quality Commission during the reporting period.
Over 2013/14, the Trust has had a total of 12 inspections to the following Business Divisions:
Business Division
DCIS
Learning Disabilities
Trust Inspection
Number of Visits
1
10
1
The CQC inspections have taken place in:
Trust wide
 Trust Headquarters (reviewing child and adolescent, adult and older people’s
inpatient and community mental health services, learning disability inpatient and
community services and forensic services)
Learning Disabilities Business Division
 10a/b Station Road, Doncaster
 88 Travis Gardens, Doncaster
 Danescourt, Doncaster
 Rhymers Court, Rotherham
32
Doncaster Community Integrated Services (DCIS)
 St John’s Hospice, Doncaster
Learning Disabilities Business Division (provided by South Yorkshire Housing
Association Limited)
 Howbeck Close, Doncaster
 263 Sandringham Road, Doncaster
 Gardens Lane, Doncaster
 Larch Avenue, Doncaster
 John Street, Rotherham
 Cranworth Close, Rotherham
The Trust has been assessed as compliant with the essential standards of quality and
safety reviewed by the CQC in the inspections above.
Over 2013/14, the Trust has had a total of 21 CQC Mental Health Act Monitoring Visits to the
following Business Divisions and services:
Business Division
Adult Mental Health
Learning Disabilities
Forensic
Older Peoples Mental Health
Assessment and Application for Detention
and Admission
Seclusion Facilities
Number of Visits
8
2
3
6
1
1
The CQC Mental Health Act monitoring visits, which have all focussed on ‘Domain 2 –
Detention in Hospital’, have taken place in:
Forensic Business Division
 Jubilee Close, Doncaster
 Amber Lodge, Doncaster
Adult Mental Health Business Division
 Skelbrooke Ward, Doncaster
 Brodsworth Ward, Doncaster
 Osprey Ward, Rotherham
 Sandpiper Ward, Rotherham
 Cusworth Ward, Doncaster
 Emerald Lodge, Doncaster
 Goldcrest Ward, Rotherham
 Kingfisher Ward, Rotherham
 Coral Lodge, Doncaster
Older People’s Mental Health Business Division
 Coniston Lodge, Doncaster
 Windermere Lodge, Doncaster
 The Glade, Rotherham
 Laurel Ward, North Lincolnshire
 The Brambles, Rotherham
Learning Disabilities Business Division
 Rhymer’s Court, Rotherham
33

Sapphire Lodge, Doncaster
Seclusion Facilities
 Adult Mental Health, Forensic and Learning Disability, Doncaster
The feedback following both the CQC and CQC Mental Health Act inspections has been
positive, with no compliance actions after the CQC inspections, and shows a continuing
improving picture across the Trust. However there are some themes in the areas of
improvement:
 Personalised care
 Record keeping
26.
Data quality
Rotherham Doncaster and South Humber NHS Foundation Trust did not submit records
during 2013/14 to the Secondary Uses service for inclusion in the Hospital Episode Statistics
which are included in the latest published data.
27.
Information governance
Rotherham Doncaster and South Humber NHS Foundation Trust Information Governance
Assessment Report overall score for 2013/14 was 68% overall for the 45 standards, which
attained a level 2 in 2013/14 and was graded ‘Satisfactory’.
28.
Clinical coding error rate
Rotherham Doncaster and South Humber NHS Foundation Trust was not subject to the
Payment by Results clinical coding audit during the reporting period by the Audit Commission
(it is only appropriate for Acute Secondary Care services).
29.
Improving data quality
Rotherham Doncaster and South Humber NHS Foundation Trust will be taking the following
actions to improve data quality:
Data quality audit being undertaken by PwC in April 2014 and feedback provided in May
2014.
In April / May 2014, External Audit tested the accuracy of the data and the systems used to
monitor the following indicators:
•
•
•
100% enhanced Care Programme Approach patients receiving follow-up contact with
seven days of discharge from hospital (mandatory indicator)
Admissions to inpatient services had access to crisis resolution home treatment
teams (mandatory indicator)
Minimising delayed transfers of care (local indicator selected by Council of
Governors)
34
•
30.
[insert actions – to be inserted in May 2014 following receipt of External Audit report].
Data quality indicators
From 2012/13 all trusts are required to report against a core set of indicators, for at least the last
two reporting periods, using a standardised statement set out in the NHS (Quality Accounts)
Amendment Regulations 2012. Trusts are only required to include indicators that are relevant to
the services that they provide. The indicators relevant to RDaSH are included in tables 15-20.
Table 15: % of patients on CPA who were followed up within 7 days after discharge
from psychiatric in-patient care during the reporting period
Indicator
Q1
Q2
Q3
Q4
2013/14 All England Average
97.4%
97.5%
96.7%
97.4%
2013/14 RDaSH
94.2%
97.9%
97.5%
99.3%
2012/13 RDaSH
100%
98.1%
100%
100%
Source: Information Centre Portal
2013/14 RDaSH adjusted+
+This indicator was subject to data testing by PwC, the external auditor, who have
recalculated the results. The PwC audited results are reported in the final row of the table.
These differences are not material and do not result in a breach of the indicator target.
However the Trust has chosen to adjust for the results reported following audit.
Rotherham Doncaster and South Humber NHS Foundation Trust considers that this data
is as described for the following reasons.
• During 2013/14, the Trust monitored all CPA discharges to identify those patients
whose follow-up was due within seven days of discharge. During the year the
trust was not able to follow-up 12 patients on CPA within seven days. All of
these cases were investigated by the trust and reported to the Performance and
Assurance Group.
Rotherham Doncaster and South Humber NHS Foundation Trust continues to take the
following actions to improve this performance and so the quality of its services, by continuing
to alert staff that the seven day follow-up is due and providing refresher training for staff as
required. The data quality of this indicator has been audited by our external auditors and the
outcomes included in section 28.
The indicator is expressed as the proportion of those patients on Care Programme Approach
(CPA) discharged from inpatient care who are followed up within 7 days:
• ‘Patients discharged’ includes patients discharged to their place of residence, care
home, residential accommodation, or to non psychiatric care, or to prison;
• The indicator excludes patients who die within seven days of discharge;
• The indicator excludes patients removed from the country as a result of legal
precedence within seven days of discharge;
• The indicator excludes patients transferred to NHS psychiatric inpatient ward when
35
•
•
•
discharged from inpatient care;
The indicator excludes CAMHS (children and adolescent mental health services), i.e.
patients aged under 18;
Those that are recorded as followed up receive face to face contact or a telephone
conversation (not text or phone messages); and
The seven day period should be measured in days not hours and should start on the
day after discharge.
Table 16: % of admissions to acute wards for which the Crisis Resolution Home
Treatment Team acted as a gatekeeper during the reporting period
Indicator
Q1
Q2
Q3
Q4
2013/14 All England Average
97.7%
98.7%
98.6%
98.3%
2013/14 RDaSH
99.30%
100%
99.20%
100%
2012/13 RDaSH
100%
100%
100%
100%
98.9%
99.6%
98.8%
100%
Source: Information Centre Portal
2013/14 RDaSH adjusted+
+This indicator was subject to data testing by PwC, the external auditor, who have
recalculated the results. The PwC audited results are reported in the final row of the table.
These differences are not material and do not result in a breach of the indicator target.
However the Trust has chosen to adjust for the results reported following audit.
Rotherham Doncaster and South Humber NHS Foundation Trust considers that this data
is as described for the following reasons:
• During 2013/14, the trust monitored all admission to acute wards to ensure that the
Crisis Resolution Home Treatment Team acted as gatekeeper for all appropriate
patients. The threshold set by Monitor is 95%, which the Trust has achieved.
Rotherham Doncaster and South Humber NHS Foundation Trust has taken the following
actions to improve this percentage, and so the quality of its services, by implementing an
electronic tool in all Access Teams, which is being used consistently and has resulted in a
significant improvement in the accuracy of data. The data quality of this indicator has been
audited by our external auditors and the outcomes included in section 28.
The indicator is expressed as proportion of inpatient admissions gatekept by the crisis
resolution home treatment teams in the year ended 31 March 2014;
•
•
•
•
The indicator should be expressed as a percentage of all admissions to psychiatric
inpatient wards;
Patients recalled on Community Treatment Order should be excluded from the
indicator;
Patients transferred from another NHS hospital for psychiatric treatment should be
excluded from the indicator;
Internal transfers of service users between wards in the trust for psychiatry treatment
should be excluded from the indicator;
36
•
•
•
•
Patients on leave under Section 17 of the Mental Health Act should be excluded from
the indicator;
Planned admission for psychiatric care from specialist units such as eating disorder
unit are excluded;
An admission should be reported as gatekept by a crisis resolution team where they
have assessed* the service user before admission and if the crisis resolution team
were involved in the decision-making process which resulted in an admission ;
*An assessment should be recorded if there is direct contact between a member of the
team and the referred patient, irrespective of the setting, and an assessment made.
The assessment may be made via a phone conversation or by any face-to-face
contact with the patient;
Where the admission is from out of the trust area and where the patient was seen by
the local crisis team (out of area) and only admitted to this trust because they had no
available beds in the local areas, the admission should only be recorded as gatekept if
the CR team assure themselves that gatekeeping was carried out.
Table 17: % patients re-admitted to hospital within 28 days of being discharged.
Indicator
RDaSH
All England
RDaSH
Average
2011/12
2011/12
2010/11
% patients re-admitted to hospital
within 28 days of being discharged
aged 0-14
No data available
No data
available
No data available
% patients re-admitted to hospital
within 28 days of being discharged
aged 15 or over
13.51%
11.45%
No data available
Source: Information Centre Portal
Rotherham Doncaster and South Humber NHS Foundation Trust considers that this data
is as described for the following reasons:
•
The Trust does monitor the % of patients who are re-admitted to any of its acute
mental health wards within 30 days as a locally commissioned target. All readmissions are investigated and reported within the Trust and to commissioners.
RDaSH has taken the following action to improve this performance, and so the quality of its
services, by analysing and taking action from the common themes from investigating the
reasons for re-admission with the aim of reducing re-admissions in future.
Table 18: % Staff Employed by, or under contract to, the Trust during the reporting
period who would recommend the Trust as a provider of care to their family of friends
Staff Survey Questions
2012 RDaSH
2013 RDaSH
2013
average for
other mental
% strongly
% strongly
agree or agree agree or agree health trusts
% strongly
agree or
agree
37
If a friend or relative needed treatment, I
would be happy with the standard of care
provided by this Trust
63%
63%
59%
Source: Information Centre Portal
Rotherham Doncaster and South Humber NHS Foundation Trust considers that this data
is as described for the following reasons:
•
As part of the CQC Staff Survey, mental health, learning disability and community staff
are asked the question ‘If a friend or relative needed treatment, I would be happy with
the standard of care provided by this Trust’. The Trust has performed above the
national average in this area.
RDaSH has taken the following action to improve this performance and so the quality of its
services, by all services developing and implementing action plans following the publication of
the results of the CQC Staff Survey. These action plans are monitored and reported to the
Human Resources and Organisational Development Group, one of the four policy and
planning groups reporting to the Board of Directors.
Table 19: Patient experience of community mental health services – patient experience
of contact with a health or social care worker
Trust 2013 Score
England 2013 Score
Trust 2012 Score
Trust 2011Score
88.5
85.8
88.0
88.8
Source:
Information
Centre Portal
Rotherham Doncaster and South Humber NHS Foundation Trust considers that this data is
as described for the following reasons:
• the RDaSH score against the indicator has remained consistent over the past three
years and above the England score in all three years.
RDaSH has taken the following action to improve this score, and so the quality of its
services, by the Adult Mental Health and Older Peoples Mental Health business divisions
developing and implementing an action plan to improve scores. Progress against the
action plan is reported to the Clinical Effectiveness Committee.
Table 20: Number and rate of Patient Safety Incidents reported within the Trust
Patient Safety Incidents (PSI)
1 April – 30
1 April – 30
1 April – 30
September
September 2013 All
September
2013 RDaSH
MH Trusts NRLS
2012 RDaSH
NRLS Data
Data
NRLS Data
Total number of deaths
24
1106
30
Total number of severe patient
11
442
14
safety incidents
38
% of PSI resulting in death
% of PSI resulting in severe harm
Source: Information Centre Portal
0.9%
0.4%
0.9%
0.4%
1.0%
0.5%
Rotherham Doncaster and South Humber NHS Foundation Trust considers that this data
is as described for the following reasons:
•
the total number of deaths and severe patient safety incidents has reduced in
comparison to the 2012 data. The number of PSI resulting in death and severe harm
remains consistent with the national average for mental health trusts.
Rotherham Doncaster and South Humber NHS Foundation Trust has taken the following
actions to improve this rate/number, and so the quality of its services, by undertaking
additional reporting via the Organisational Learning Forum, of analysing the Monitor
categories of ‘Severe Harm’ and ‘Death’ of patient safety incidents. All serious incidents
continue to be investigated with reports and action plans agreed and followed up with
commissioners.
39
PART 3 – OTHER INFORMATION
RDaSH reports its quality improvement work to stakeholders through the three nationally
recognised domains of quality:
•
•
•
Patient safety
Clinical effectiveness
Patient experience
In addition the Trust also reports in the domain of:
•
Our people/staff
The indicators reported in each of the four domains are key indicators reported nationally and
are included within our contracts with commissioners.
PATIENT SAFETY
31.
Learning from patient safety incidents
31.1
Never events
During 2013/14, RDaSH has had:
0 never events (never events are serious, largely preventable patient safety incidents that
should not occur if the available preventative measures have been implemented)
31.2
Serious incidents
In 2013/14, RDaSH reported 99 serious incidents. Table 21 shows the number of serious
incidents in comparison to the past three years.
Table 21: Number of serious incidents reported
2013/14
2012/13
Number
99*
83
2011/12
84
2010/11
51
*Reporting of Grade 3 Pressure Ulcers as an SI began on 21 October 2013. The Trust reported 86 SIs in
2013/14 if Grade 3 Pressure Ulcers are excluded from the total.
Source: Strategic Executive Reporting System (STEIS)
NB. The size of the Trust’s portfolio of services increased significantly in 2010/11 under the
Transforming Community Services initiative.
The main categories of serious incidents reported in 2013/14 were:
• Suicide
• Unexpected Death
• Pressure Ulcers
• Slips/trips/falls
31.3
Patient safety incidents
The Trust reports patient safety incidents to the NHS Commissioning Board National
Reporting and Learning Service (NRLS). The NRLS provides six monthly reports to the Trust
which contains comparative information on our reporting rate per 1,000 bed days, types of
40
incidents reported and incidents reported by degree of harm, compared with 56 similar
organisations
The majority of patient safety incidents reported by the Trust fall into the following categories:
•
•
•
Violence, Abuse or Harassment
Adverse Healthcare Event
Patient Accident/Incident
Table 22 shows the number and rate of PSI against the categories of Severe and Death.
Table 22: Number and rate of Patient Safety Incidents reported within the Trust
Patient Safety Incidents (PSI)
1 April – 30
1 April – 30
1 April – 30
September
September 2013 All
September
2013 RDaSH
MH Trusts NRLS
2012 RDaSH
NRLS Data
Data
NRLS Data
Total number of deaths
24
1106
30
Total number of severe patient
11
442
14
safety incidents
% of PSI resulting in death
0.9%
0.9%
1.0%
% of PSI resulting in severe harm
0.4%
0.4%
0.5%
Source: Information Centre Portal
31.4
Key areas for improvement identified from incidents
Care planning, records and communication remain some of the most frequently occurring
themes. Over 50% of serious incidents take place within the Adult Mental Health business
division and the majority of the remainder are spread between Doncaster Community
Integrated Services (DCIS), Older People’s and Substance Misuse business divisions.
Our analysis has identified the following key areas for improvement:
• Joint communication and care planning by teams
• Involvement of, and communication with carers
• Service information to patients’ carers, prior to admission
• Timely implementation and evaluation of care
• Clinical risk management
• Safe transport of patients and service users
• Leave and discharge planning
• Care transfer between in-patient and community services
• Record keeping
31.5
Organisational learning
The Trust’s Organisational Learning Forum (OLF) brings clinical staff together from each of
the Trust’s business divisions to share themes and learning from incidents, complaints and
claims. It provides an opportunity for challenge and robust discussion regarding incident
reporting, actions taken and learning. Members of OLF are responsible for the further
dissemination and discussion of this information within their services.
Examples of Trust wide improvements made during 2013/14 as a result of shared learning
from incidents include:
•
Trust Patient Safety Lead has worked with business divisions to look at ligature points
and other environmental issues and considered options available in conjunction with
Estates Department and Head of Health, Safety and Security.
41
•
•
•
32.
A Standard Operating Procedure (SOP) for managing communication from the
Coroner’s office has been written.
The Board Secretary has sourced and provided to services a list of telephone
numbers from the Trust’s solicitors for out of hours legal advice on the Mental
Capacity Act 2005.
A Practice Development Day was held in the Adult Mental Health business division for
both inpatient and community services, looking at carers’ needs and information
governance in relation to carers.
Safeguarding
NHS Trusts are required to make a self-declaration identifying compliance against their
arrangements with regard to Safeguarding Children and Safeguarding Vulnerable Adults.
RDaSH continues to be compliant against all of the standards relating to provider trusts.
Details of the full declaration submitted by RDaSH are available on the Trust website
(http://www.rdash.nhs.uk/information-for-the-public/safeguarding/).
The Trust has published Safeguarding Children and Safeguarding Vulnerable Adults annual
reports, which are available on the Trust website. The Trust is currently producing the
Safeguarding Vulnerable Adults, Safeguarding Children and Looked After Children Annual
Report which will provide detail on the progress made in these areas over 2013/14.
32.1
Safeguarding Children and Vulnerable Adults
As a trust we are committed to ensuring that all our staff across all the business divisions
remain vigilant and are aware of the issues relating to Safeguarding Children and Vulnerable
Adults.
RDaSH works very closely with the five Local Safeguarding Children and Vulnerable Adults
Boards (LSCBs/LSAPBs) across the geographical areas it covers, and has representatives
on the Boards in the three main Trust service localities of Doncaster, Rotherham and North
Lincolnshire.
•
Section 11 Audit
Throughout 2013/14 the RDaSH Safeguarding Children Team has continued to make
progress against the new Section 11 documentation. Doncaster’s Section 11 documentation
has been updated and discussions have taken place as to how best to obtain the views and
experiences of children, young people and families around safeguarding issues. The same
process is now being undertaken in North Lincolnshire and Rotherham.
•
Training
RDaSH has an up to date safeguarding children and safeguarding vulnerable adults training
strategy and training programme available to all staff, and multi-disciplinary training continues
to be delivered across the Trust at all levels. Training compliance is shown in table 23:
Table 23: Safeguarding Training Compliance
2013/14
Safeguarding Children
82%
Safeguarding Adults
80%
Source: Oracle Learning Management System
42
2012/13
70%
77%
32.2
Looked After Children (LAC) Doncaster
We are continuing to work in close partnership with our health and social care colleagues to
develop a pathway of care for all looked after children and young people in Doncaster from
the time they enter the care system, until they leave care.
Each LAC/Young Person receives an Initial and Review Health Assessment (6 monthly for
the 0 - 4 age group and yearly for the 5-18 age group) resulting in a personal health plan that
is monitored and reviewed according to each child’s needs.
The co-ordination and monitoring of the pathway will continue to be provided by the Trust
LAC Health Team.
33.
Infection prevention and control
Infection prevention and control (IPC) is the term used to ensure that the Trust’s services
have the lowest number of infections possible; this is very important to the Trust. Infection
rates are very low and have been since information was collected. This has continued in
2013/14 as shown in table 24. RDaSH is very proud of its infection control rates and
continues to review and monitor how its infection control services have performed.
Table 24: Health care acquired infections*
Indicator
2013/14
2012/13
2011/12
2010/11
E.Coli Bacteraemia
1
1
0
0
MRSA
1
0
0
0
C-Diff
1
0
3
1
Source: Local Reporting System, cases as defined by Health Protection Agency Guidelines
CLINICAL EFFECTIVENESS
The Trust has reviewed its performance on clinical effectiveness using a number of key
measures and indicators. Staff training and clinical supervision are key to helping deliver
effective clinical practice and table 25 demonstrates how many staff believe that the training
they have received has helped them to keep up to date with professional requirement.
Table 25: Staff survey – ‘My training, learning and development has helped me to stay
up to date with professional requirements’
Indicator
2013 (%)
2012 (%)
2011 (%)
2010 (%)
All Trusts
Strongly disagree
7
6
4
5
6
Disagree
3
4
5
5
4
Neither agree or disagree
17
16
23
23
14
Agree
53
53
53
54
53
Strongly agree
21
22
14
12
22
Source: Staff Survey, National Survey
Other indicators of clinical effectiveness are reported through the Monitor risk assessment
framework and include:
• Care programme approach: Follow-up contact within 7 days of discharge
• Care programme approach: Having formal review within 12 months
• Minimising delayed transfers of care
• Admissions to inpatients services has access to Crisis Resolution/Home Treatment
teams
• Meeting commitment to service new psychosis cases by early intervention
43
Performance against these indicators is reported in table 32 in comparison to the previous
two years.
34.
National Institute for Health and Clinical Excellence (NICE)
NICE guidance supports healthcare professionals and others to make sure that the care they
provide is of the best possible quality and offers the best value for money.
NICE issues guidance monthly and this is circulated widely throughout the Trust and to
members of the Clinical Effectiveness Committee. We then decide if the guidance is relevant
and at what level, then undertake a gap analysis where required, to identify if our services
meet the guidance, to identify any risks and to develop an improvement action plan.
Over 2013/14 NICE has published 129 pieces of guidance, of which 26 have been
determined to be relevant to the Trust in some way. The Trust has initiated implementation of
21 pieces of NICE Guidance with plans in place for the remaining 5 which have only recently
been issued. Guidance published in 2013/14 includes the following:
• Smoking cessation in acute, maternity and mental health services – applicable Trustwide and therefore the impact of this guidance is significant. Discussions have been
held at the Senior Leadership Team, Clinical Governance Group and Clinical
Effectiveness about the next steps with regard to implementation.
34.1
NICE quality standards
NICE quality standards set out what a quality service should achieve.
RDaSH uses NICE quality standards to develop services for our patients and make sure they
deliver the best care possible.
We have developed a system to ensure that as NICE quality standards are published, we
ensure that our services are delivered in this way. Following a successful pilot, a template of
this system is now available for all business divisions to use when reporting on quality
standards.
Examples of quality standards published in 2013/14 with some relevance to the Trust are:
• Supporting people to live well with dementia
• Health and wellbeing of looked-after children and young people
• Lower urinary tract symptoms
34.2
NICE consultations
The Trust has continued to register as a stakeholder with NICE throughout the year, so that
we can proactively contribute to consultations on the development of guidance and quality
standards.
In 2013/14 the Trust has contributed as a stakeholder with NICE to the following
consultations and has agreed to be identified as consultation contributors:
•
•
•
•
•
•
•
Constipation in children and young people
Conduct Disorders
Infection Control
Mental wellbeing of older people in residential care.
Delirium
Challenging Behaviour Learning Disability
Autism in Children and Young People
44
PATIENT EXPERIENCE
The Trust uses different methods to obtain feedback and information from patients, service
users and carers within the overall framework of its ‘Patient, Carer and Public Engagement
and Experience Strategy’. Tables 26-29 show performance against key measures and
indicators over the previous three years. Methods of obtaining patient experience feedback
include:
•
•
•
•
•
•
•
•
35.
Patient / carer groups;
Consultation events;
Complaints;
Compliments;
Patient Advice and Liaison Service;
‘Your Opinion Counts’;
Surveys – national / local;
Workshops.
Listen to Learn
‘Listen to Learn’, the Trust Patient, Carer and Public Engagement and Experience Strategy
was ratified by the BoD in August 2013.
The first two meetings of the Listen to Learn Steering Group were held in November 2013
and January 2014 with over 40 people from a range of backgrounds attending each of the
meetings. Representatives attended from patient and carer groups, local Healthwatch,
Doncaster CVS, the Council of Governors and each of the seven business divisions,
providing a voice for the full range of Trust services.
The ‘Ladder of Participation’ has been introduced to all stakeholders, a method of measuring
the level of patient and carer participation in services. The Listen to Learn Steering Groups
have focussed on patients and carers ‘getting to know’ services and members participating in
interactive exercises, highlighting where each business division currently sits on the Ladder
and plans to be taken forward during 2014/15, linking to the business division patient
experience quality markers, to increase patient/carer participation in services.
36.
National Mental Health Community Survey 2013 results
The Trust participated in this annual survey which reflects the experiences of more than
17,000 people who have used community mental health services in England in the last 12
months.
This was the tenth annual survey (undertaken 2004 to 2013) and provides the Trust with an
opportunity to monitor progress over time based on feedback from people about the services
they received.
The survey is undertaken, by an independent contractor – Picker Institute Europe, through a
postal questionnaire, sent to a random sample of 850 Trust services users, who were seen in
the period 1 July 2012 to 30 September 2012.
The Trust response rate was 33% compared to a national average of 29%, showing an
increase from last year, when our response rate was 28%.
Table 26 shows that there has been a slight increase in the number of service users rating
the care they received from RDaSH in the last 12 months as ‘excellent,’ ‘very good’ or ‘good’
45
and also a slight increase in the overall satisfaction with the level of involvement of members
of family/persons closest to the patient.
Table 26: Patient Survey*
Indicator
2013/14
Overall rating of quality of care received
7.2
as ‘excellent’, ‘very good’ or ‘good’
Overall satisfaction with the level of
6.9
involvement of member of family/ person
close to patient
Source: Mental Health Community Surveys, national survey.
37.
2012/13
6.9
2011/12
7.2
6.4
6.7
Listening to service users, patients and carers
In addition to the National Community Mental Health Survey, the Trust listens to service
users, patients and carers through:
•
•
•
•
37.1
Complaints;
Your Opinion Counts;
Patient Advice Liaison Service (PALS);
Patient Opinion.
Complaints and compliments
Most care and treatment goes well, but things occasionally do go wrong, and RDaSH has a
complaints policy to provide a framework to:
• Provide fair and equitable access for patients and service users to make complaints
and to provide an honest and open response to these complaints.
• Provide patients and service users and those acting on their behalf with support to
bring a complaint or to make a comment, where such assistance is necessary
• Have mechanisms in place to learn from complaints and to share this learning across
the Trust where appropriate.
Lessons learned from complaints are shared through the Organisational Learning Forum and
outcomes are acted upon within the quality improvement work.
The main categories of complaints received within the Trust relate to:
• Communication/ information to patients/ about patients to relatives
• Attitude of staff
• Concern about aspects of clinical care
• Care plans not being made available to patients
Table 27 shows the number of complaints across the Trust in comparison to the previous
three years. There has been an increase in the number of complaints, which will be subject
to further analysis and improvement actions during 2014/15. The main themes identified
within complaints include staff attitude and communication.
Table 27: Complaints and compliments across the Trust
Indicator
2013/14
2012/13
2011/12
Complaints
158
135
115
Compliments
3794
2855
2100
Source: Safeguard Incident Reporting System
2010/11
88
1166
NB. The size of the Trust’s portfolio of services increased significantly in 2010/11under the
Transforming Community Services initiative.
46
Patients and service users may also want to contribute positive comments on the care and
services that they have received. These comments are just as important because they tell us
which factors are contributing to a good experience for patients. Table 27 also shows the
number of compliments that have been received in 2013/14. The majority of both complaints
and compliments have been received by the Adult Mental Health and DCIS business
divisions.
Feedback received through the Trust’s patient experience office is shared with the relevant
business divisions, to both disseminate the positive comments that have been received and
to develop action plans to address areas of concern.
A number of ‘You Said, We Did’ posters have been displayed in the public areas of the Trust
to demonstrate how services have acted on service user/patient feedback and to encourage
further feedback.
37.2
Your Opinion Counts / Patient Advice Liaison Service
`Your Opinion Counts' (YOCs) and the Patient Advice Liaison Service (PALS) provide
patients, service users and carers with alternative methods of providing feedback to the
Trust. Table 28 shows the number of PALS and YOC received in 2013/14.
Table 28: Patient feedback received via PALS and local Your Opinion Counts
Indicator
2013/14
2012/13
2011/12
2010/11
Patient Advice Liaison Service
392
267
370
422
Your Opinion Counts
3740
2668
2776
355
Source: Safeguard, Trust reporting system and local reporting system
The feedback received through YOCs continues to be predominantly positive. The types of
enquiries received through PALS are:
• General concern
• Information request
• Signposting
• Request for advice
38.
Eliminating mixed sex accommodation (EMSA)
Providers of NHS funded care are asked to confirm whether they are compliant with the
national definition “to eliminate mixed sex accommodation except where it is the overall best
interests of the patient, or reflects their patient choice”. The Trust’s EMSA declaration
2013/14 can be found on (http://www.rdash.nhs.uk/wp-content/uploads/2010/03/EMSADeclaration.pdf). The Trust has an excellent record in eliminating mixed sex accommodation,
with the majority of inpatient care being provided on wards that have single en-suite
bedrooms. For those wards that do not have en-suite facilities clear guidance is provided for
the care of patients to ensure that no breach occurs and also to maintain all patients privacy
and dignity. All mental health and learning disability wards also have female only lounges.
Eliminating mixed sex accommodation is only part of the patients experience with regard to
maintaining their privacy and dignity and therefore there is an ongoing work programme in
place with all inpatient modern matrons. This work continually updates approaches and
ensures the Trust maintains the high profile that dignity within care should have. This work is
reported into the Trust’s Clinical Effectiveness Committee.
Breaches in providing same sex accommodation
There has been 1 reported breach in EMSA during Quarter 4, 2013/14 in the Learning
47
Disabilities business division; Rhymer’s Court, Rotherham where there was a short period
with no access to a female only lounge.
Remedial action was taken immediately and a subsequent Quality Visit undertaken.
Rotherham Clinical Commissioning Group has been informed of this breach.
39.
Patient-Led Assessments of the Care Environment (PLACE)
For 2013/14, Patient-Led Assessments of the Care Environment (PLACE) have replaced the
previous Patient Environment Action Team (PEAT) assessments conducted at healthcare
organisations across the country.
The primary change to the assessment process is the increased presence of patients as part
of the visiting team, which now make up a minimum of 50% of the team. The PLACE
assessments were undertaken in January 2013. PLACE covers broadly the same areas that
were covered by PEAT assessments; namely:
• Privacy, dignity and wellbeing;
• Cleanliness;
• Condition, appearance and maintenance and
• Food and hydration.
Following the assessments within each service, every participating organisation is given a
score, expressed as a percentage of the maximum score, for each of the four domains in the
assessment. The results for all 274 participating organisations were published on 18
September 2013 and provide a position for the Trust in relation to each of the four domains
as well as overall, as follows:
Table 29: Trust-wide PLACE Results 2013
Domain
Overall
Privacy, dignity and wellbeing
Cleanliness
Condition, appearance and maintenance
Food and hydration
Trust
Rank
Trust
Average
National
Average
National
Range
123 of 274
65 of 274
91 of 274
25 of 274
241 of 274
90.98%
93.12%
98.30%
99.35%
77.17%
89.87%
88.87%
95.74%
88.75%
84.98%
76.54% - 98.24%
73.35% to 100.00%
75.94% - 100.00%
71.39% - 99.35%
61.24% - 100.00%
Key
Red:
> 5% below national average
Amber: < 5% below national average
Green: above national average
The results show that as an organisation, the Trust has performed best in the domain of
‘condition, appearance and maintenance’ with a score significantly higher than the
national average and ranked in the top 10% of participating organisations.
However, the Trust has scored poorly in the domain of ‘food and hydration’ with a score
significantly lower than the national average and ranked in the bottom 15% of participating
organisations. The RDaSH catering team is currently working on an amended menu book,
individually weighing out all menu items to more accurately determine portions. The ‘Ward
Hostess’ pilot has been undertaken, with facilities staff supporting patients in their choice of
meals and working with nursing staff to ensure that special diets and portion control
requirements are met.
The Trust has scored better than average and in the top third of organisations for both
‘cleanliness’ and ‘privacy, dignity and wellbeing’.
48
OUR PEOPLE / STAFF
40.
Staff views of quality
Staff are vital to the delivery of high quality, safe and clinically effective care. The views of
our staff on their ability to deliver high quality care are important in helping us shape our
plans for quality improvement. Tables 30 and 31 show performance against key measures
and indicators over previous years.
The Trust uses different methods to engage with staff and to secure their views, including:
•
•
•
•
•
•
Surveys
Leading the Way with Quality workshops
Chief Executive blog
Professional networks
Trust matters
Board member visits to services
40.1 Staff survey
Table 30: Staff survey results relating to quality
Staff Survey Questions
2012
RDaSH
2013
RDaSH
% strongly
agree or
agree
%
strongly
agree or
agree
59%
Senior managers where I work are committed to patient
care
If a friend or relative needed treatment, I would be
happy with the standard of care provided by this Trust
I am satisfied with the quality of care I give to
patients/service users
I feel that my role makes a difference to patients/service
users
I am able to deliver the patient care I aspire to
54%
I am able to make improvements happen in my area of
work
2013
average for
other trusts
% strongly
agree or
agree
52%
63%
63%
59%
72%
66%
70%
78%
78%
81%
58%
51%
52%
57%
55%
60%
Source: Information Centre Portal
We have received detailed feedback on the 2013 staff survey. Headlines from the Care
Quality Commission (CQC) Staff Survey summary report are:
•
•
•
•
•
A total of 59% of the Trust’s staff surveyed completed their 2013 questionnaire,
compared to 56% in 2012.
The Trust has seen an improvement in all of the CQC pledge areas compared to 2012
with the exception of two areas. Namely, a 1% reduction in team members stating
they have shared objectives (from 78% in 2012 to 77% in 2013) and the % of staff
having an appraisal in the last 12 months has decreased from 81% (2012) to 79%
(2013) and we are also below the national average in this area (87%).
‘Communication between senior management and staff is effective’ has improved by
6% from 40% in 2012 to 46% in 2013 and exceeds the national average (37%).
The Trust had improved at 57% (on the 2012 result 54%) relating to ‘my manager
asks for my opinion before making decisions which affect me’.
The Trust had improved in the percentage of staff who ‘believe care of
49
•
40.2
patients/service users was the Trust's top priority’ with the Trust result being 66% and
the national average 64% (the 2012 Trust result was 60%).
59% of staff would recommend the Trust as a place to work compared to the national
average at 55% (54% in RDaSH 2012 results).
Staff sickness absence
The Trust’s staff sickness absence rate has decreased in the calendar year in comparison to
2012.
Table 31: Sickness absence rates
Year
2013
2012
2011
2010
Data Source: NHS iview
Rate
5.4%
5.5%
5.3%
5.7%
The main reason for sickness absence remains as stress and anxiety, but this is a
combination of both work and personal stress and anxiety. The Trust has implemented a
number of support programmes for employees (Employee Assistance Programme,
Counselling and Stress and Anxiety Classes).
41.
Leading the Way with Quality
The focus of the Leading the Way with Quality sessions held in February and March 2014
was 'Fit for the Future' and provided an opportunity for staff member in Bands 1-6 and those
in bands 7 to 8 who were not on F4F because they do not lead a team to discuss a number of
issues building on the F4F leadership programme. There was a chance to discuss the
organisation’s strategy and values post Francis, our approach to future staff development and
support and how we can develop a nourishing and engaging staff culture within the
organisation. Feedback from the LWQ sessions was complimentary, with staff stating that
the sessions were informative, enjoyable and interesting.
50
PERFORMANCE AGAINST KEY NATIONAL PRIORITIES
42.
Monitor Compliance Framework 2013/14
Monitor also set targets for Foundation Trusts as part of its ‘Risk Assessment Framework –
2013/14’. Table 32 shows our progress against the Mental Health and Learning Disability
governance indicators for 2013/14 and where applicable includes comparative information for the
two previous years.
Table 32: Performance against Monitor’s mental health governance Indicators
Targets
Threshold
2013/14
2012/13
2011/12
Care programme
approach:
95%
99.3%
99%
98.5%
Follow-up contact within 7
days of discharge
Care programme
approach:
95%
98.28%
97.17%
95.76%
Having formal review
within 12 months
Minimising delayed
<= 7.5%
1.8%*
0.9%
2.2%
transfers of care
Admissions to inpatients
services has access to
95%
100%
100%
99.5%
Crisis Resolution/Home
Treatment teams
Meeting commitment to
service new psychosis
95%
100%
>100%
>100%
cases by early
intervention
Data completeness
identifiers
- NHS Number
99.7%
99.64%
- Date of Birth
100%
99.98%
- Postcode (normal
99.59%
99.77%
residence)
97%
99%
- Current gender
100%
99.99%
- Registered General
99.07%
99.21%
Medical Practice
organisation code
- Commissioner
100%
100%
organisation code
Data completeness:
outcomes for patients on
CPA
- settled
accommodation;
50%
94.88%
94.67%
64.95%
- employment.
50%
94.84%
94.58%
64.91%
- Having a HoNOS
assessment in the
last 12 months*
50%
93.65%
95.70%
Access to healthcare for
people with a learning
n/a
Compliant
51
Compliant
Compliant
disability
*Following a recommendation from 360 Assurance, the Trust’s Internal Auditors, from quarter 3,
2013/14 the 28 day grace period for reporting delays was removed from Older People’s Mental
Health Services. This has resulted in an increase in the numbers of delay days reported in Q4 and
impacted on the overall 2013/14 performance.
Monitor introduced Community Care governance indicators as part of the ‘Compliance Framework
– 2011/12’. Table 33 shows our progress against these indicators.
Table 33: Performance against Monitor’s community care governance indicators
Targets
Threshold
2013/14
2012/13
Referral to treatment information
50%
97.97%
98.64%
Referral information
50%
100%
99.91%
Treatment activity information
50%
96.61%
97.01%
43.
Monitor Risk Ratings 2013/14
The Trust submits quarterly declarations to Monitor in relation to continuity of services and
governance. Monitor reviews the declaration and issues a quarterly risk rating for each element:
•
•
continuity of services rating (rated 1-4, where 1 represents the highest risk and 4 the
lowest)
governance rating (trusts are rated green if no issues are identified and red where we are
taking enforcement action)
Tables 34 and 35 show the ratings for the four quarters of 2013/14 and 2012/13 compared with the
Trust’s expectations at the beginning of the year, as stated in the Annual Plan.
Table 34: 2013/14 risk rating compared to Annual Plan
Annual Plan
Quarter 1
Quarter 2
2013/14
2013/14
2013/14
Continuity of
3
4
4
services
rating
Governance
G
G
G
risk rating
Quarter 3
2013/14
4
Quarter 4
2013/14
4
G
G
Table 35: 2012/13 risk rating compared to Annual Plan
Financial
risk rating
Governance
risk rating
Annual Plan
2012/13
3
Quarter 1
2012/13
4
Quarter 2
2012/13
4
Quarter 3
2012/13
4
Quarter 4
2012/13
3
G
G
G
G
G
52
Annexes
Annex 1:
Statements Clinical Commissioning Boards, Local Healthwatch organisation
and Overview and Scrutiny Committees
NHS Doncaster Clinical Commissioning Group
NHS Rotherham Clinical Commissioning Group
NHS North Lincolnshire Clinical Commissioning Group
Doncaster Healthwatch
Rotherham Healthwatch
North Lincolnshire Healthwatch
Doncaster OSC
Rotherham OSC
North Lincolnshire OSC
RDaSH Council of Governors
The Council of Governors is pleased to have been fully engaged in the development of the
Quality Report for 2013 - 2014.
Throughout the year Governors have taken opportunities to be closely involved with
initiatives to promote and assure quality services within the Trust:
• Governors have been involved in visits to service delivery areas and have been
impressed with the quality of accommodation and care delivered to service users;
• There are Governor representatives on the team that completes the Patient Led
Assessment of the Care Environment visits;
• Governors were fully engaged in the development of the Francis Declaration for the
Trust;
• A group of Governors have attended the Listen to Learn workshops which are
focused on ways to involve service users, carers and stakeholders in how we deliver
our services;
• Governors have attended service specific user groups to directly engage with users
and carers about services e.g. local collaborative meetings;
• Governors regularly attend the Leading the Way with Quality workshops where they
engage with staff members to listen to their experiences and opinions.
Governors regularly attend the Board of Directors meeting where they are actively
encouraged to engage by asking questions and providing appropriate challenge.
Governors have been involved in the development of the Annual Plan and the Forward
Strategy has been discussed at the Council of Governors in February 2014 where
participation was encouraged through table top exercises.
The Council of Governors selected the local indicator this year as Delays in Transfer of Care
with emphasis on ensuring that the diversity of services offered should be reflected in the
53
audit.
Staff governors have represented the Council of Governors and attended regular meetings
with the Trust Quality Report Working Group to develop the Quality Report and take
responsibility for informing the Governors of the content and progress. The Staff governors
presented a draft of this statement to all Governors at their meeting on 16 May 2014.
The Governors support the content of the report as an open and honest reflection of the
Trust’s position. The Council of Governors is looking forward to working with the Board of
Directors, staff, service users, carers and public over the coming year to achieve the Quality
Priority contained within the Quality Forward Strategy 2014/15.
54
Annex 2:
Statement of directors’ responsibilities in respect of the quality report
The statement is in the following form:
[FT’s only – NHS Trusts will be similar but, at the preparation of this checklist, had not been
made available. Check to the correct NHS Trust proforma]
“The directors are required under the Health Act 2009 and the National Health Service Quality
Accounts Regulations to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality
reports (which incorporate the above legal requirements) and on the arrangements that foundation
trust boards should put in place to support the data quality for the preparation of the quality report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves that:
the content of the Quality Report meets the requirements set out in the NHS Foundation Trust
Annual Reporting Manual 2013/14;
the content of the Quality Report is not inconsistent with internal and external sources of information
including:
o Board minutes and papers for the period April 2013 to May 2014
o Papers relating to Quality reported to the Board over the period April 2013 to May 2014
o Feedback from the commissioners dated XX/XX/20XX
o Feedback from governors dated XX/XX/20XX
o Feedback from Local Healthwatch organisations dated XX/XX/20XX
o The trust’s complaints report published under regulation 18 of the Local Authority Social Services
and NHS Complaints Regulations 2009, dated XX/XX/20XX;
o The [latest] national patient survey XX/XX/20XX
o The [latest] national staff survey XX/XX/20XX
o The Head of Internal Audit’s annual opinion over the trust’s control environment dated XX/XX/20XX
o CQC quality and risk profiles dated XX/XX/20XX
the Quality Report presents a balanced picture of the NHS foundation trust’s performance over the
period covered;
the performance information reported in the Quality Report is reliable and accurate;
there are proper internal controls over the collection and reporting of the measures of performance
included in the Quality Report, and these controls are subject to review to confirm that they are
working effectively in practice;
the data underpinning the measures of performance reported in the Quality Report is robust and
reliable, conforms to specified data quality standards and prescribed definitions, is subject to
appropriate scrutiny and review; and the Quality Report has been prepared in accordance with
Monitor’s annual reporting guidance (which incorporates the Quality Accounts regulations) (published
at www.monitor-nhsft.gov.uk/annualreportingmanual) as well as the standards to support data quality
for the preparation of the Quality Report (available at www.monitornhsft.gov.uk/annualreportingmanual)).
The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Report.
By order of the Board
NB: sign and date in any colour ink except black
..............................Date.............................................................Chairman
55
..............................Date............................................................Chief Executive
56
Annex 3:
Independent Auditor’s Report to the Council of Governors
57
Annex 4 - How to contact us
Let us know what you think
Hopefully, our quality account has been informative and interesting to you and we welcome your
feedback, along with any suggestions you may have for next year’s publication.
Please contact our communications team at:
Woodfield House
Tickhill Road
Balby
Doncaster
DN4 8QN
Email: [email protected]
Telephone: 01302 796204/796282/798134
Join us as a member and have a say in our future plans
A representative and meaningful membership is important to the success of the Trust and provides
members of our local communities the opportunity to be involved in how the Trust and its services
are developed and improved. Membership is free and the extent to which our members are
involved is entirely up to them. Some are happy to receive a newsletter twice a year while others
are keen to be involved in consultations and come along to meetings. Some have even become
members of our Council of Governors. For further information please contact our Foundation Trust
Office on:
Freephone 0800 015 0370
Email: [email protected]
Check out our website
The RDaSH website provides comprehensive details of the Trust’s services and where they are
provided, information about mental health and learning disabilities, what to do in a crisis situation,
updates on Trust initiatives and links to other useful websites.
There is also a section about Foundation Trust membership under the ‘Information for the Public’
heading, where there is an opportunity to sign up online.
Visit www.rdash.nhs.uk to find out more.
This Quality Report can be found on the NHS Choices website at www.nhs.uk . By publishing the
report with NHS Choices, RDaSH complies with the Quality Reports Regulations.
This report can be made available in a variety of formats, available on request.
58
Annex 5 - Glossary of Terms
This section aims to explain some of the terms used in the Quality Account. It is not an exhaustive
list but hopefully will help to clarify the meaning of the NHS jargon used in these pages.
Annual Plan: this document sets out the Trust’s annual financial forecasts, strategic plans, key
risks and priorities
BME: Black and Minority Ethnic
CAMHS: Child and Adolescent Mental Health Service
CCG: Clinical Commissioning Group
CDiff: clostridium difficile
CDW: Community Development Worker
CGAS: Children’s Global Assessment Scale
CPA: Care Programme Approach – the framework for good practice in delivering mental health
services. CPA aims to ensure that services work closely together to meet service users’ identified
needs and support them in their recovery.
Cluster: a group of service users with similar diagnoses and needs.
COG: Council of Governors
CQC: Care Quality Commission
CQUIN: Commissioning for Quality and Innovation
Dashboard: summary overview of key areas of performance
DCIS: Doncaster Community Integrated Services
DRE: Delivering Race Equality
DSSA: Delivering Same Sex Accommodation
FT: Foundation Trust
KPIs: Key Performance Indicators
LD: Learning Disability
LINks: Local involvement networks
LWQ: Leading the Way with Quality
Maracis: A computerised system used to keep service user profiles and records.
MHMDS: Mental Health Minimum Data Set
Monitor: Independent regulator for foundation trusts
MRSA: Methicillin-resistant staphylococcus aureus
MWRV: Managing work related violence and aggression
NAPT: National Audit of Psychological Therapies
NIHR: National Institute for Health Research
NHS: National Health Service
NHS England/NHS Commissioning Board: Formally established as the NHS Commissioning
Board on 1 October 2012, NHS England is an independent body at arm’s length to the
Government.
NHSLA: National Health Service Litigation Authority
NICE: National Institute for Health and Clinical Excellence
NRLS: National Reporting and Learning Service
NSF: National Service Framework
OPMHS: Older People’s Mental Health Service
OSC: Overview and Scrutiny Committee/Panel – a local authority body which scrutinises and
makes recommendations regarding public services provided by the Trust.
PEAT: Patient Environment Action Team
PbR: Payment by Results
PCT: Primary Care Trust
POMH: Prescribing Observatory for Mental Health UK
Productive Mental Health Ward
Programme: a programme of positive changes to ward processes such as handovers and
mealtimes, incorporating service user feedback and participation which have been sustained and
embedded into practice.
QIPP: Quality, innovation, productivity and prevention
59
QOF: Quality Outcome Framework
QRP: Quality and Risk Profile
Quarter 1: April, May, June.
Quarter 2: July, August, September.
Quarter 3: October, November, December.
Quarter 4: January, February, March.
RDaSH: Rotherham Doncaster and South Humber NHS Foundation Trust
RAP: Referrals, Assessments and Packages of Care
SARN: Summary Assessment of Risk and Needs
SHA: Strategic Health Authority
SI: Serious incident – an unexpected occurrence requiring investigation
Service engagement scale: an assessment to help improve the level of service user engagement
with services e.g. attending appointments.
TBD: Trust Business division
Tool/Toolkit: A package of information and written guidance
UCPC: User Carer Partnership Council
UCRG: User Carer Research Group
Validate: prove valid, declare, provide evidence for
60
Paper I
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Group/Committee
Name
Board of Directors
Meeting Date
29 May 2014
Title of Paper
Author
Inpatient Staffing Declaration
Helen Dabbs, Deputy Chief Executive / Director of Nursing and Partnerships
Chris Prewett, Interim Deputy Director of Nursing and Standards
Paper For
Decision
Strategic Work
Programme:
- Relevance
- Progress
Key Points to Note
(including any
identified risks )
th
Debate
Assurance
√
Information
√
Reference
What Strategic Work Programmes is the paper
relevant to?
2.1
Yes / No
Does the paper provide assurance against
delivery of the identified Strategic Work
Programme?
Yes
In November 2013 the National Quality Board (NQB) issued guidance to assist
provider organisations to fulfil their commitments as outlined in “ Hard Truths: The
Journey to Putting Patients First” DH 2013
The guidance sets out clear expectations in relation to getting the numbers of
nursing and care staffing right so that high quality care and the best possible
outcomes can be achieved for our patients.
The updates on progress against the NQB requirements are detailed below:
• Inpatient Staffing Acuity and Dependency profiles have been completed
(appendix 2 of this paper).
• The design of inpatient staff information boards has been completed and
the boards are undergoing manufacture, followed by a planned installation
th
programme to be completed by 30 June 2014.
• Display boards for each patient featuring the names and photographs of the
patients Named Nurse, Named Therapist and Consultant will be installed by
the end May 2014.
• Clinical Staffing Review Governance arrangements have been put in place
and a monthly oversight report will be provided to the Board of Directors
from June 2014. This monthly information will be utilised to provide a
biannual review and declaration.
• From June 2014, following the launch of the Trust’s new public website, the
Inpatient Staffing Declaration will be published monthly, on a dedicated page
and linked to the Trust’s NHS Choices profile.
Therefore this report outlines the progress made by the Trust in achieving the NQB
requirements and provides the Board of Directors with the assurance that it can
make the declaration.
Board Assurance
Framework
If the paper also provides assurance against
the effectiveness of a Key Control what is the
reference and what level of assurance do you
think it provides?
CQC
If the paper provides assurance against
Essential Standards of Quality and Safety
(ESQS) specify the outcome number.
BAF Key
Control Ref.
2.1 c
Effectiveness
F/S/P/V/N
S
ESQS outcome number
12, 14
Paper I
Financial/Budget
Equality &
Diversity/Human
Rights
The budgetary elements of this work have been taken into consideration and have
been achieved within existing allocated funding. Any further financial implications will
be highlighted as appropriate
All Trust equality and diversity policies and procedures are being considered
throughout the course of this review
Action proposed
following the
Group meeting
The clinical staffing review process will continue as detailed
Person
Responsible
Helen Dabbs, Deputy Chief Executive/ Director of Nursing and Partnerships
Chris Prewett, Interim Deputy Director of Nursing and Standards
Date for
completion
Outcome required
from the Group
May 2014
The Board is asked to note:
• progress to date on the clinical staffing review
• Trust inpatient Staffing Declaration
Inpatient Staffing
Declaration
Nursing and Partnerships Directorate
Service Directorates
May 2014
CONTENTS
1.
Introduction .............................................................................................
3
2.
Background .............................................................................................
3
3.
Board of Directors Responsibility .........................................................
3
4.
Update on Progress against the National Quality Board (NQB)
Requirements and Milestones ...............................................................
3-6
5.
Conclusion ..............................................................................................
6-7
Appendices:
Appendix 1
Inpatient Staffing Figures as at April 2014
Appendix 2
Inpatient Staffing Acuity and Dependency Profiles
___________________________________________________________________________________________________
Staffing Declaration – May 2014 (v.1.0)
2|Page
1.
Introduction
In November 2013 the National Quality Board (NQB) issued guidance to assist provider
organisations to fulfil their commitments as outlined in “Hard truths: The Journey to Putting
Patients First” DH 2013.
The guidance sets out a number of clear expectations in relation to getting the numbers of
nursing, and care staffing right so that high quality care and the best possible outcomes can
be achieved for our patients. At the end of March 2014, NHS England wrote to all NHS
Chief Executives of Foundation Trusts with inpatient areas, detailing a timetable of five
actions to be undertaken by Trusts by June 2014.
2.
Background
In April 2014, an update was presented to the Board of Directors (BoD) on progress made
against each of the following requirements contained in ‘Hard Truths Commitments
Regarding the Publishing of Staffing Data – Timetable of Actions’:
•
•
•
•
•
3.
The Board receives a report every six months on staffing capacity and capability
The Trust clearly displays information about the nurses, midwives and care staff
present and planned in each clinical setting on each shift.
The Board receives a monthly update containing details and summary of planned
and actual staffing on a shift-by-shift basis
The Trust will ensure that the published monthly update report is available to the
public via not only the Trust’s website but also the relevant hospital(s) profiles on
NHS Choices.
The Trust reviews the actual versus planned staffing on a shift by shift basis,
responds to address gaps or shortages and uses systems and processes such as erostering and escalation and contingency plans to make the most of resources and
optimise care
Board of Directors Responsibility
It is the responsibility of the BoD, at any point in time to be able to demonstrate to their
commissioners that robust systems and processes are in place to assure themselves that
the nursing and care staffing capacity and capability in the Trust is sufficient to provide safe
care.
This report will outline the progress made in achieving the NQB requirements and will
recommend to the BoD that a declaration is made to record and publish progress against
the requirements and milestones.
To support this process, a Clinical Staffing Review Group has been established with key
representation from each relevant Business Division. The group meets monthly and has
developed a robust approach to ensuring that appropriate staffing levels are in place for
each ward.
4.
Update on Progress against the NQB Requirements and Milestones
The updates on progress against the NQB requirements and milestones are detailed below:
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3|Page
4.1
The Board receives a report every six months on staffing capacity and capability
The inpatient staffing figures of qualified and unqualified staff per ward, on a shift by
shift basis were detailed in the ‘Inpatient Staffing Declaration: Clinical Staffing
Review’ Paper G, submitted to the BoD in November 2013. This format, with
current minimum figures is presented at (Appendix 1).
The Trust has established a Clinical Staffing Review Group which has the
responsibility for reviewing minimum staffing levels on an on-going basis, to ensure
that these remain current. The group has produced Inpatient Staffing Acuity and
Dependency Profiles for every ward in the Trust, detailing the minimum staffing
levels for each. These profiles were presented to the Human Resources and
Organisational Development (HR&OD) Group in April 2014.
There are currently limited national recommendations on safe staffing to patient
ratios for a Trust as diverse as RDaSH. The Trust is aware of and engaged in the
national work to develop a tool for use within mental health and learning disability
services. In the interim, the Trusts minimum staffing levels have been developed by
senior clinicians from the relevant Business Divisions. This has resulted in the
development of the Inpatient Staffing Acuity and Dependency Profiles for
inpatient services (Appendix 2). The profiles identify the following:
•
•
•
•
The minimum staffing levels required for each ward, qualified and unqualified.
The measures to be taken should numbers fall below minimum standards
The roles and responsibility of the staff to maintain safe staffing levels based
on patient need.
The escalation process to authorise safe staffing levels.
The Inpatient Staffing Acuity and Dependency Profiles form the basis on which
the BoD’s biannual declaration on minimum inpatient staffing will be made,
commencing from June 2014 and every six months thereafter (December 2014).
Exceptions in minimum staffing levels will be presented monthly by the Service
Directors to BoD and supported by the biannual staffing capacity and capability
review. The Director of Nursing and Partnerships has a rolling oversight of each
month during the declaration period and will update the BoD every six months.
4.2
The Trust clearly displays information about the nurses and care staff present and
planned, in each clinical setting on each shift.
The design of inpatient information boards has been undertaken in consultation with
each of the inpatient areas and the Listen to Learn Steering Group. The
manufacture of the boards commenced in April 2014 and will be completed by 31
May 2014, which will be followed with installation by 30 June 2014. A sample picture
of the board can be seen in Figure 1.
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Figure 1: Staff Information Boards
To complement this, situated by every patient’s bed area there will be a display
board featuring the names and photographs of the patient’s Named Nurse, Named
Therapist and Named Consultant. These boards will be installed by the end of May
2014.
Figure 2: Named Clinician Board
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4.3
The Board receives a monthly update containing details and summary of planned
and actual staffing on a shift-by-shift basis
The 25 inpatient wards will be responsible for completing a monthly safe staffing
levels dashboard to be submitted to the Business Support Units for collation into an
oversight report. This report will then be reviewed by the Service Directors and
signed off accordingly. This oversight report will be presented to HR&OD for
discussion and assurance, with the BoD receiving a monthly exception report. It is
likely that the format and reporting arrangements will be refined during quarter 1 and
2, 2014/15 and potentially subject to further national guidance.
The Clinical Governance Group will receive, on a quarterly basis, a synopsis of the
monthly reports in order to triangulate against serious incidents and complaints,
taking into account bed occupied days.
4.4
The Trust will ensure that the published monthly update report is available to the
public via not only the Trust’s website but also the relevant hospital(s) profiles on
NHS Choices.
In June 2014, following the launch of the Trusts new public website, the Inpatient
Staffing Declaration will be published on a dedicated page on the website and and
linked to the Trust’s NHS Choices profile, updated monthly. The Trusts NHS
Choices web editor has been fully engaged in the planning of this process and will
ensure that the link to NHS Choices is in place at the point of publishing the data on
the Trust’s public website.
The information will be in an accessible and understandable format for the public.
This will be tested by the Trust’s Listen to Learn Steering Group and the BoD.
4.5
The Trust reviews the actual versus planned staffing on a shift by shift basis,
responds to address gaps or shortages and uses systems and processes such as erostering and escalation and contingency plans to make the most of resources and
optimise care.
•
•
•
•
•
5.
Modern Matrons and Ward Managers are responsible for reviewing the actual
versus planned staffing on a shift by shift basis and subsequently taking action
to address gaps or shortages.
The Trust is currently progressing plans to proceed with e-rostering.
Clear escalation processes in place, detailed within the Inpatient Staffing
Acuity and Dependency Profiles.
All wards have a Business Continuity Plan in place.
In addition, the Trust has an out of hours ‘on-call’ system in place, with an ‘oncall’ manager and an ‘on-call’ Director on duty at all times.
Conclusion
In order to manage the monthly and biannual requirements and incorporate potential new
national guidance, the proposed governance arrangements are represented in Figure 3:
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Figure 3:
Clinical Staffing Review Governance Arrangements
The Trust will also utilise information from:
• Incident Reports relating to Staffing Numbers
• On Call staffing level alerts
• Any whistle blowing alerts
The Service Directors will review and sign off the report on a monthly basis providing a full
report to HR&OD and an exception report to the BoD.
The Director of Nursing and Partnerships will have monthly oversight of the monthly report and
utilise the information to provide a biannual review report.
The approach described within the paper will provide the BoD with the assurance it requires to
make the Trust’s six monthly declaration on safe staffing levels.
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Appendix 1
Rotherham Doncaster and South Humber NHS Foundation Trust
Minimum Inpatient Staffing Figures as at April 2014
Business
Division
AMH
AMH
AMH
AMH
AMH
AMH
AMH
AMH
AMH
AMH
Ward
Beds
Brodsworth
Cusworth
Mulberry
Emerald
Osprey
Sandpiper
Goldcrest
Coral Lodge
Kingfisher
Skelbrooke
LD
Early
Late
Nights
Qualified
Unqualified
Qualified
Unqualified
Qualified
Unqualified
20
20
19
16
18
18
19
16
5
5
2
2
2
1
2
2
2
2
2 (1)
2 (1)
2
2
2 (3)
2
2
2
2
2
2
2
2
2
2
1
2
2
1
2
1
2 (1)
2
2
2 (3)
2
2
2
2
2
2
2
1
1
2 (1)
1
1
1
1
1
1
1
2
2
2 (3)
2
2
2
2
2
2
2
Rhymers Court
3(5)
1
2(4)
1
2(4)
1
1(3)
LD
Sapphire
5
1
3
1
3
1
2
Forensic
5
1
2
1
2
1
2
18
1
4(3)
1
4(3)
1
2
Forensic
Amber ISU
Amber Lodge
Rehab
& Recovery
Jubilee Close
10
1
2
1
2
1
2
OPMH
OPMH
OPMH
OPMH
OPMH
OPMH
Bramble
Coniston
Fern
Glade
Laurel
Windermere
15
20
12
15
13
20
2
2
2
2
1
2
2
2
3
3
3
2
1(2)
2
1(2)
1(2)
1
2
3(2)
2
3(2)
3(2)
3(2)
2(3)
1
1
1
1
1
1
2
2
2
2
2
2
DCIS
Hawthorn
18
2
3
2
2
2
1
DCIS
Hazel
20
2
4
2
3
1
2
DCIS
Hospice, IPU
10
2
2
2
2
2
1
DCIS
Magnolia
14
2
3
2
2(1)
1
2
Forensic
The numbers highlighted in brackets are those levels identified in September 2013 and have
subsequently been amended following the development of the Inpatient Staffing Acuity and
Dependency Profiles.
___________________________________________________________________________________________________
Staffing Declaration – May 2014 (v.1.0)
Appendix 2
Inpatient Staffing Acuity and
Dependency Profiles
Clinical Staffing Review Group
Nursing and Partnerships Directorate
Dianne Graham
Assistant Director, Adult Mental Health
Louisa Endersby
Assistant Director, Forensic
Chris Williams
Assistant Director, Learning Disabilities
Jan Smith
Assistant Director, Older People’s Mental Health
Jill Cowley
Assistant Director, Doncaster Community Integrated Services
March 2014
CONTENTS
Page
1. Introduction ............................................................................................ 2
2. Adult Mental Health ............................................................................... 4
3. Doncaster Community Integrated Services (DCIS) ............................. 15
4. Forensic .................................................................................................. 20
5. Learning Disability Services ................................................................. 24
6. Older People’s Mental Health Services ................................................ 27
7. Conclusion ............................................................................................ 34
Appendix 1: Protocol for Inpatient Staff Levels
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1.
INTRODUCTION
The negative impact of inadequate staffing levels on patient care has been a consistent
theme identified in the recent reviews undertaken on patient care within NHS provider
organisations. The full findings and outcomes of these reviews can be referenced within the
following reports:
•
Francis Inquiry 2013 – Report of the Mid Staffordshire NHS Foundation Trust Public
Inquiry;
•
Keogh Overview Report 2013 – Review into the Quality of Care and Treatment
Provided by 14 Hospital Trusts in England;
•
Berwick Report 2013 - A promise to Learn – A Commitment to Act: Improving the
Safety of Patients in England;
•
Cavendish Review 2013 – An Independent Review into Healthcare Assistants and
Support Workers in the NHS and Social Care settings.
In response to the above reports, Rotherham Doncaster and South Humber NHS
Foundation Trust (RDaSH) is committed to ensuring the safety of patients, staff and the
public by ensuring that:
“The right people with the right skills are in the right place
at the right time”
(National Quality Board 2013 – A Guide to Nursing and Midwifery and Care Staffing
Capacity and Capability)
The Trust Board is ultimately accountable for the quality of patient care and has the
responsibility for staffing capacity and capability. Therefore it must ensure that the
organisation is operating with safe, appropriate quality staffing levels based on robust
systems and procedures that regularly measure nursing and care staffing levels.
There are currently no national recommendations on what is considered to be a safe staff to
patient ratio within inpatient services for a Trust such as RDaSH. However this document
clearly outlines how each inpatient area across the Trust will deliver appropriate quality care
through having the required staffing levels on a shift by shift basis.
This review of appropriate staffing levels has taken into consideration the following
components that constitute good quality care:
•
•
•
•
The complexity of patients mental and physical health needs
Clinical Risk Assessment
Activity levels within the specific services
The design of the environment in which care is being provided
There is also an accepted expectation that there will be occasions due to unplanned
sickness or absence of staff, which may result in the staffing levels falling below the agreed
minimum level. In order to manage this in a consistent and effective manner, there is a
staffing escalation process in place (appendix 1) which provides the Nurse in Charge of the
ward to take the necessary steps to arrange for additional staffing
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This document therefore provides the Board with the assurance that it requires by means of
the following evidence:
•
•
•
•
The minimum staffing levels for each ward
The measures to be taken should numbers fall below minimum standards
The responsibility and accountability of the Ward Manager, Modern Matron and
Nurse in Charge to review the staffing level based on the needs of the patients
The escalation process to authorise increased staffing levels
The following chapters outline each of the inpatient area’s minimum staffing levels and the
process for increasing staff number’s should the need arise.
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2.
2.1
ADULT MENTAL HEALTH SERVICES
Providing for safe and appropriate staffing levels within the adult mental health
services is a dynamic decision making process which reflects the unplanned and
responsive nature of the services we provide. Any decision around safe staffing
levels will include full consideration of the patients:
•
•
•
•
•
•
•
mental health needs
clinical risk
presenting behaviour
physical healthcare needs
vulnerability
level of required supportive observation
personal relationships and interactions with each other
It is recognised that the needs of the patient group can change quickly and that
staffing levels and skill mix may need to be adjusted to adapt to these changes in the
ward and patient cohort.
In each of our inpatient areas we have consulted with staff and managers to
determine a minimum level of staffing required for each clinical area and identified
some of the clinical and environmental factors we will consider when determining if
changes are required on an unplanned basis. For unplanned changes to the
minimum staffing levels the Nurse in Charge has a central role in determining the
needs and risks presented by the patient population and agreeing and implementing
appropriate actions to meet these needs.
Changes on a planned basis will be made by the Ward Manager and/or Matron
responsible for the clinical area.
This document outlines the minimum staffing levels for the inpatient wards within the
Adult Mental Health services, and defines some of the conditions the Nurse in
Charge may need to consider when requesting/making changes to the minimum
staffing levels and practical steps the Nurse in Charge can take to resolve concerns
regarding staffing levels should they occur.
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2.2
Emerald Lodge (Rehabilitation Unit)
Name of Ward
Emerald Lodge
Minimum Staffing Levels
Qualified Nursing Staff
Early
1
Late (or late/twilight) 1
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and special observations.
Number of patients requiring support to
attend appointments away from the ward
(including ECT).
Number of patients/levels of challenging
behaviour in evidence.
Additional 1:1 required for patients in the
care of the Recovery services.
The collective and individual activity and
needs of the patient population.
The additional non-clinical demands to be
managed (ward round, tribunal out of area
assessment etc.)
Beds
16
Unqualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover the
required shifts.
2. Cancel any off site activities such as training
or out of area assessments and bring the staff
onto shift.
3. Flexible use of Ward Manager and nonnursing grade staff (Occupational Therapist)
to support with supervision and activity on the
ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff
(authorisation required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on
call arrangements for your area
Specific
1. Request to other adult inpatient wards within
the Doncaster locality for support.
2. Request to other adult inpatient wards in the
Rotherham or North Lincolnshire locality.
Authority and authorisation
Emerald Lodge is a 16 bed unit, providing care to adults over the age of 18 years with a range
of mental disorders and are now as part of their recovery pathway are now ready to reestablish their life in the community. As such the staffing levels and safety of patients will be
under constant review by the Nurse in Charge. This is a responsibility and accountability which
cannot be delegated or transferred as the Nurse in Charge is in the best place to make
decisions regarding the needs of the resident population. Where actions defined above require
additional authorisation this is to support the Nurse in Charge to make decisions which are
reasonable and robust, and also to ensure that all options and alternatives have been
considered as appropriate. The authorisation process will also take responsibility for enacting
the escalation procedures defined at Appendix 1 if required.
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2.3
Coral Lodge (Rehabilitation Unit)
Name of Ward
Coral Lodge
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
1
Consideration for additional staffing
Escalating clinical risk.
Patients requiring 1:1 interventions,
including special observations
Patients requiring support to attend
appointments off the ward
Indirect clinical demands e.g. MDT
reviews, MHA tribunals, CPA reviews, etc.
Patients requiring 1:1 interventions on
transfer to other clinical areas e.g.
seclusion, MAU, etc.
Patients requiring higher levels of physical
care
Beds
16
Unqualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover the
required shifts.
2. Cancel any off site activities such as training
or out of area assessments and bring the staff
onto shift.
3. Flexible use of staff who are not routinely
counted in the numbers (Ward Manager,
Occupational Therapist,) to support with
supervision and activity on the ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff
(authorisation required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on
call arrangements for your area
Specific
10. Request to other adult inpatient wards within
the Doncaster locality for support.
11. Request to other adult inpatient wards in the
Rotherham or North Lincolnshire locality.
Authority and authorisation
Coral Lodge is a 16 bed locked rehabilitation unit providing care and support to adult males
coping with severe and enduring mental health needs, who are detained under the Mental
Health Act. As such, the safety of our staff and patients is under constant review by the Shift
Co-ordinator. It is the responsibility of the shift co-ordinator to make informed decisions (in
consultation with colleagues, on-call managers, etc.), regarding the needs of our patient
population, along with managing clinical risk. See Appendix 1 (decision-making tree) to help
with and inform this process.
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2.4
Brodsworth Ward (Acute Ward)
Name of Ward
Brodsworth Ward
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight) 2
Night
1
Consideration for additional staffing
Number of patients requiring 1:1
support and special observations.
Number of patients requiring support to
attend appointments away from the
ward (including ECT).
Number
of
patients/levels
of
challenging behaviour in evidence.
Additional 1:1 required for patients in
the care of the acute services.
The collective and individual acuity and
needs of the patient population.
The additional non-clinical demands to
be managed (ward round, tribunal etc.)
Beds
20
Unqualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can be
changed from later in the week to cover the
required shifts.
2. Cancel any off site activities such as training or
out of area assessments and bring the staff onto
shift.
3. Flexible use of staff who are not routinely
counted in the numbers (Ward Manager,
Occupational Therapist, Physiotherapist) to
support with supervision and activity on the ward.
4. Flexible use of Ward Manager and non-nursing
grade staff (Occupational Therapist,) to support
with supervision and activity on the ward.
5. Cancellation of routine non-essential activity.
6. Use of bank staff (authorisation not required).
7. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
8. Use of overtime for existing staff (authorisation
required).
9. Use of agency (authorisation required).
10. Refer to the Business Continuity Plan and on call
arrangements for your area
Specific
1. Check with the other wards on the Adult Acute
Mental Health unit if they have any spare staff.
2. Request to other adult inpatient wards within the
Doncaster locality for support.
3. Request to other adult inpatient wards in the
Rotherham or North Lincolnshire locality.
Authority and authorisation
Brodsworth Ward is a 20 bed unit, providing care to adults over the age of 18 years with a
range of mental health disorders. As such the staffing levels and safety of patients will be under
constant review by the Nurse in Charge. This is a responsibility and accountability which
cannot be delegated or transferred as the Nurse in Charge is in the best place to make
decisions regarding the needs of the resident population. Where actions defined above require
additional authorisation this is to support the Nurse in Charge to make decisions which are
reasonable and robust, and also to ensure that all options and alternatives have been
considered as appropriate. The authorisation process will also take responsibility for enacting
the escalation procedures defined at Appendix 1 if required.
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2.5
Cusworth Ward (Acute Ward)
Name of Ward
Cusworth Ward
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and special observations.
Number of patients requiring support to
attend appointments away from the ward
(including ECT).
Number of patients/levels of challenging
behaviour in evidence.
Additional 1:1 required for patients in the
care of the acute services.
The collective and individual acuity and
needs of the patient population.
The additional non-clinical demands to
be managed (ward round, tribunal etc.)
Beds
20
Unqualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can be
changed from later in the week to cover the
required shifts.
2. Cancel any off site activities such as training or
out of area assessments and bring the staff
onto shift.
3. Flexible use of staff who are not routinely
counted in the numbers (Ward Manager,
Occupational Therapist) to support with
supervision and activity on the ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff (authorisation
required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on
call arrangements for your area
Specific
10. Check with the other wards on the Adult Acute
Mental Health unit if they have any spare staff.
11. Request to other adult inpatient wards within
the Doncaster locality for support.
12. Request to other adult inpatient wards in the
Rotherham or North Lincolnshire locality.
Authority and authorisation
Cusworth Ward is a 20 bed unit, providing care to adults over the age of 18 years with a range
of mental health disorders. As such the staffing levels and safety of patients will be under
constant review by the Nurse in Charge. This is a responsibility and accountability which
cannot be delegated or transferred as the Nurse in Charge is in the best place to make
decisions regarding the needs of the resident population. Where actions defined above require
additional authorisation this is to support the Nurse in Charge to make decisions which are
reasonable and robust, and also to ensure that all options and alternatives have been
considered as appropriate. The authorisation process will also take responsibility for enacting
the escalation procedures defined at Appendix 1 if required.
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2.6
Skelbrooke Ward (Psychiatric Intensive Care Unit)
Name of Ward
Skelbrooke Ward
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and special observations.
Number of patients requiring support to
attend appointments away from the ward
(including ECT).
Number of patients/levels of challenging
behaviour in evidence.
Additional 1:1 required for patients in the
care of the acute services.
Safe management of a patient in
seclusion.
The collective and individual acuity and
needs of the patient population.
The additional non-clinical demands to be
managed (ward round, tribunal etc.)
Beds
5
Unqualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can be
changed from later in the week to cover the
required shifts.
2. Cancel any off site activities such as training or
out of area assessments and bring the staff
onto shift.
3. Flexible use of staff who are not routinely
counted in the numbers (Ward Manager,
Occupational Therapist) to support with
supervision and activity on the ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff (authorisation
required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on
call arrangements for your area
Specific
10. Check with the other wards on the Adult Acute
Mental Health unit if they have any spare staff.
11. Request to other adult inpatient wards within
the Doncaster locality for support.
12. Request to other adult inpatient wards in the
Rotherham or North Lincolnshire locality.
13. Close the 136 suite to assessments
(authorisation required).
14.
Authority and authorisation
Skelbrooke Ward is a 5 bed psychiatric intensive care unit, providing care to adults over the age
of 18 years with a range of mental health disorders. As such the staffing levels and safety of
patients will be under constant review by the Nurse in Charge. This is a responsibility and
accountability which cannot be delegated or transferred as the Nurse in Charge is in the best
place to make decisions regarding the needs of the resident population. Where actions defined
above require additional authorisation this is to support the Nurse in Charge to make decisions
which are reasonable and robust, and also to ensure that all options and alternatives have been
considered as appropriate. The authorisation process will also take responsibility for enacting
the escalation procedures defined at Appendix 1 if required.
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2.7
Mulberry Ward (Acute Ward)
Name of Ward
Mulberry Ward
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
2
Consideration for additional staffing
Number of patients requiring 1:1
support and special observations.
Number of patients requiring support to
attend appointments away from the
ward (including ECT).
Number
of
patients/levels
of
challenging behaviour in evidence.
Additional 1:1 required for patients in
the care of the acute services.
Safe management of a patient in the
seclusion facility.
The collective and individual acuity and
needs of the patient population.
The additional non-clinical demands to
be managed (ward round, tribunal etc.)
Beds
19
Unqualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can be
changed from later in the week to cover the
required shifts.
2. Cancel any off site activities such as training or out
of area assessments and bring the staff onto shift.
3. Flexible use of staff who are not routinely counted
in the numbers (Ward Manager, Occupational
Therapist) to support with supervision and activity
on the ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not required).
6. Use of additional hours for part time staff of lowest
required grade (authorisation not required).
7. Use of overtime for existing staff (authorisation
required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on call
arrangements for your area
Specific
10. Check with the Adult Acute Mental Health wards in
Doncaster and Rotherham to see if they have any
spare staff.
11. Request to access team to see if their staff can
base themselves on the ward to provide an
additional presence.
12. Request to the Older People’s Ward at Great
Oaks for support.
13. Closure of the section 136 suite to assessments
(authorisation required).
Authority and authorisation
Mulberry Ward is a 19 bed unit, providing care to adults over the age of 18 years with a range of
mental health disorders. As such the staffing levels and safety of patients will be under constant
review by the Nurse in Charge. This is a responsibility and accountability which cannot be
delegated or transferred as the Nurse in Charge is in the best place to make decisions regarding
the needs of the resident population. Where actions defined above require additional
authorisation this is to support the Nurse in Charge to make decisions which are reasonable and
robust, and also to ensure that all options and alternatives have been considered as appropriate.
The authorisation process will also take responsibility for enacting the escalation procedures
defined at Appendix 1 if required.
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2.8
Osprey Ward (Acute Ward)
Name of Ward
Osprey
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and special observations.
Number of patients who require personal
care requiring more than 2 staff in
attendance.
Number of patients requiring support to
attend appointments away from the ward
(including ECT).
Number of patients/levels of challenging
behaviour in evidence.
Additional 1:1 required for patients in the
care of the Acute Trust.
The collective and individual acuity and
needs of the patient population.
The additional non-clinical demands to
be managed (ward round, tribunal etc.)
Beds
18
Unqualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover the
required shifts.
2. Cancel any off site activities such as training
or out of area assessments and bring the staff
onto shift.
3. Flexible use of Ward Manager and nonnursing grade staff (Occupational Therapist,
who is shared across the wards) to support
with supervision and activity on the ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff
(authorisation required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on
call arrangements for your area
Specific
10. Request to Sandpiper for support.
11. Request to the inpatient services in Doncaster
and North Lincolnshire for support.
Authority and authorisation
Osprey Ward is an 18 bed acute mental health ward providing care to adults with a range of
mental health disorders. As such the staffing levels and safety of patients will be under
constant review by the Nurse in Charge. This is a responsibility and accountability which
cannot be delegated or transferred as the Nurse in Charge is in the best place to make
decisions regarding the needs of the resident population. Where actions defined above
require additional authorisation this is to support the Nurse in Charge to make decisions
which are reasonable and robust, and also to ensure that all options and alternatives have
been considered as appropriate. The authorisation process will also take responsibility for
enacting the escalation procedures defined at Appendix 1 if required.
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2.9
Sandpiper Ward (Acute Ward)
Name of Ward
Sandpiper
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and special observations.
Number of patients who require personal
care requiring more than 2 staff in
attendance.
Number of patients requiring support to
attend appointments away from the ward
(including ECT).
Number of patients/levels of challenging
behaviour in evidence.
Additional 1:1 required for patients in the
care of the Acute Trust.
The collective and individual acuity and
needs of the patient population.
The additional non-clinical demands to be
managed (ward round, tribunal etc.)
Beds
18
Unqualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover
the required shifts.
2. Cancel any off site activities such as training
or out of area assessments and bring the
staff onto shift.
3. Flexible use of Ward Manager and nonnursing grade staff (Occupational Therapist,
who is shared across the wards) to support
with supervision and activity on the ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not
required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff
(authorisation required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on
call arrangements for your area
Specific
10. Request to Osprey Ward for support.
11. Request to Doncaster and North
Lincolnshire inpatient services for support.
Authority and authorisation
Sandpiper is an 18 bed acute mental health ward providing care to adults with a range of
mental health disorders. As such the staffing levels and safety of patients will be under
constant review by the Nurse in Charge. This is a responsibility and accountability which
cannot be delegated or transferred as the Nurse in Charge is in the best place to make
decisions regarding the needs of the resident population. Where actions defined above
require additional authorisation this is to support the Nurse in Charge to make decisions
which are reasonable and robust, and also to ensure that all options and alternatives have
been considered as appropriate. The authorisation process will also take responsibility for
enacting the escalation procedures defined at Appendix 1 if required.
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2.10
Goldcrest Ward (Rehabilitation Unit)
Name of Ward
Goldcrest
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight)
1
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and special observations.
Number of patients who require personal
care requiring more than 2 staff in
attendance.
Number of patients requiring support to
attend appointments away from the ward
(including ECT).
Number of patients/levels of challenging
behaviour in evidence.
Additional 1:1 required for patients in the
care of the Acute Trust.
The collective and individual acuity and
needs of the patient population.
The additional non-clinical demands to be
managed (ward round, tribunal etc.)
Beds
19
Unqualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover
the required shifts.
2. Cancel any off site activities such as training
or out of area assessments and bring the
staff onto shift.
3. Flexible use of Ward manager and nonnursing grade staff, to support with
supervision and activity on the ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not
required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff
(authorisation required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on
call arrangements for your area
Specific
10. Request to Osprey/Sandpiper for support.
11. Request to the inpatient wards in Doncaster
and North Lincolnshire for support.
Authority and authorisation
Goldcrest is a 19 bed rehabilitation mental health ward providing care to adults with a range
of mental health disorders. As such the staffing levels and safety of patients will be under
constant review by the Nurse in Charge. This is a responsibility and accountability which
cannot be delegated or transferred as the Nurse in Charge is in the best place to make
decisions regarding the needs of the resident population. Where actions defined above
require additional authorisation this is to support the Nurse in Charge to make decisions
which are reasonable and robust, and also to ensure that all options and alternatives have
been considered as appropriate. The authorisation process will also take responsibility for
enacting the escalation procedures defined at Appendix 1 if required.
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2.11
Kingfisher Ward (Psychiatric Intensive Care Unit)
Name of Ward
Kingfisher
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight)
1
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and special observations.
Patient being cared for in seclusion.
Number of patients who require personal
care requiring more than 2 staff in
attendance.
Number of patients requiring support to
attend appointments away from the ward
(including ECT).
Number of patients/levels of challenging
behaviour in evidence.
Additional 1:1 required for patients in the
care of the Acute Trust.
The collective and individual acuity and
needs of the patient population.
The additional non-clinical demands to be
managed (ward round, tribunal etc.)
Beds
5
Unqualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover
the required shifts.
2. Cancel any off site activities such as training
or out of area assessments and bring the
staff onto shift.
3. Flexible use of Ward Manager and nonnursing grade staff (Occupational Therapist,
who is shared across the wards) to support
with supervision and activity on the ward
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not
required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff
(authorisation required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on
call arrangements for your area.
Specific
10. Request to Osprey/Sandpiper for support.
11. Request to the inpatient wards in Doncaster
and North Lincolnshire for support.
Authority and authorisation
Kingfisher is a 5 bed acute intensive psychiatric mental health ward providing care to adults
with a range of mental health disorders. As such the staffing levels and safety of patients will
be under constant review by the Nurse in Charge. This is a responsibility and accountability
which cannot be delegated or transferred as the Nurse in Charge is in the best place to make
decisions regarding the needs of the resident population. Where actions defined above
require additional authorisation this is to support the Nurse in Charge to make decisions
which are reasonable and robust, and also to ensure that all options and alternatives have
been considered as appropriate. The authorisation process will also take responsibility for
enacting the escalation procedures defined at Appendix 1 if required.
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3.
3.1
DONCASTER COMMUNITY INTEGRATED SERVICES (DCIS)
Providing for safe and appropriate staffing levels in the hospice, intermediate care
and neurorehabilitation ward is a dynamic decision making process which reflects the
unplanned, planned and responsive nature of the services we provide. In DCIS this
decision making process will include the physical health care needs, risk, mental
health and cognitive needs of the defined patient group which can change quickly
and staffing may need to be adjusted to adapt to the changes in the ward and patient
cohort.
In each of our inpatient areas we have consulted with staff and managers to
determine a minimum level of staffing required for each clinical area and identified
some of the clinical and environmental factors we consider when determining if
changes are required on an unplanned basis. For unplanned changes to the
minimum staffing levels the Nurse in Charge has a central role in determining the
needs and risks presented by the patient population and agreeing and implementing
appropriate actions to meet these needs.
Changes on a planned basis will be made by the Ward Manager and/or Modern
Matron responsible for the clinical area.
This document outlines the minimum staffing levels for each of the DCIS inpatient
services, defines some of the conditions the Nurse in Charge may need to consider
when requesting/making changes to the minimum staffing levels and practical steps
the Nurse in Charge can take to resolve concerns regarding staffing levels should
they occur.
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3.2
Magnolia Ward (Neurorehabilitation Ward)
Name of Ward
Magnolia Ward
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and a level of observations.
Number of patients who require personal
care requiring more than 2 staff in
attendance.
Number of patients requiring support to
attend appointments away from the ward.
Number of patients/levels of challenging
behaviour in evidence.
Number
of
patients
with
nursing
rehabilitation programmes, e.g. Orientation
Log (O-log).
The collective and individual acuity and
needs
of
the
patient
population
(Rehabilitation Complexity Scale (RCS)).
The additional non-clinical demands to be
managed (ward round, case reviews, etc).
Number of admissions and discharges.
Beds
14
Unqualified Nursing Staff
Early
3
Late (or late/twilight)
2
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover
the required shifts.
2. Cancel any off site activities such as training
or out of area assessments and bring the
staff onto shift.
3. Flexible use of Ward Manager and nonnursing grade staff to support with
supervision and activity on the ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff
(authorisation required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on
call arrangements for your area.
Specific
10. Request to Hazel, Hawthorn, Day Hospital,
Hospice, Stroke Outreach and CICT for
support.
Authority and authorisation
Magnolia Ward is a 14 bed sub-acute level 2b neurorehabilitation ward providing care to
people with a range of neurological disorders. As such the staffing levels and safety of patients
will be under constant review by the Nurse in Charge. This is a responsibility and accountability
which cannot be delegated or transferred as the Nurse in Charge is in the best place to make
decisions regarding the needs of the resident population. Where actions defined above require
additional authorisation this is to support the Nurse in Charge to make decisions which are
reasonable and robust, and also to ensure that all options and alternatives have been
considered as appropriate. The authorisation process will also take responsibility for enacting
the escalation procedures defined at Appendix 1 if required.
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3.3
Hazel Ward (Intermediate Care Ward)
Name of Ward
Hazel Ward
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support or
a level of observations.
Number of patients who require personal
care requiring more than 2 staff in
attendance.
Number of patients requiring support to
attend appointments away from the ward.
Number of patients/levels of challenging
behaviour in evidence.
Number of admissions and discharges.
Beds
20
Unqualified Nursing Staff
Early
4
Late (or late/twilight)
3
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover
the required shifts.
2. Cancel any off site activities such as training
or out of area assessments and bring the
staff onto shift.
3. Flexible use of Ward Manager and nonnursing grade staff to support with
supervision and activity on the ward.
4. Cancellation of routine non-essential activity.
The collective and individual acuity and 5. Use of bank staff (authorisation not required).
needs of the patient population.
6. Use of additional hours for part time staff of
The additional non-clinical demands to be
lowest required grade (authorisation not
managed (ward round, case reviews, etc).
required).
Number of unwell patients with an Early 7. Use of overtime for existing staff
Warning Score (EWS) of 3 or more.
(authorisation required).
8. Use of agency (authorisation required).
Number of high risk falls patients.
9. Refer to the Business Continuity Plan and on
call arrangements for your area.
Specific
10. Request to Hawthorn, Magnolia, Day
Hospital, Hospice, Stroke Outreach and CICT
for support.
Authority and authorisation
Hazel Ward is a 20 bed step down intermediate care ward providing care to older people with a
range of sub-acute physical health needs and long term conditions. As such the staffing levels
and safety of patients will be under constant review by the Nurse in Charge. This is a
responsibility and accountability which cannot be delegated or transferred as the Nurse in
Charge is in the best place to make decisions regarding the needs of the resident population.
Where actions defined above require additional authorisation this is to support the Nurse in
Charge to make decisions which are reasonable and robust, and also to ensure that all options
and alternatives have been considered as appropriate. The authorisation process will also take
responsibility for enacting the escalation procedures defined at Appendix 1 if required.
_________________________________________________________________________________
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3.4
Hawthorn Ward (Intermediate Care Ward)
Name of Ward
Hawthorn Ward
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
2
Consideration for additional staffing
Number of patients requiring 1:1 support or
a level of observations.
Number of patients who require personal
care requiring more than 2 staff in
attendance.
Number of patients requiring support to
attend appointments away from the ward.
Number of patients/levels of challenging
behaviour in evidence.
Number of admissions and discharges.
Beds
18
Unqualified Nursing Staff
Early
3
Late (or late/twilight)
2
Night
1
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover
the required shifts.
2. Cancel any off site activities such as training
or out of area assessments and bring the
staff onto shift.
3. Flexible use of Ward Manager and nonnursing grade staff to support with
supervision and activity on the ward.
4. Cancellation of routine non-essential activity.
The collective and individual acuity and 5. Use of bank staff (authorisation not required).
needs of the patient population.
6. Use of additional hours for part time staff of
The additional non-clinical demands to be
lowest required grade (authorisation not
managed (ward round, case reviews, etc).
required).
7. Use of overtime for existing staff
Number of unwell patients with an Early
(authorisation required).
Warning Score (EWS) of 3 or more.
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on
Number of high risk falls patients.
call arrangements for your area.
Specific
10. Request to Hawthorn, Magnolia, Day
Hospital, Hospice, Stroke Outreach and CICT
for support.
Authority and authorisation
Hawthorn Ward is an 18 bed step up intermediate care ward providing care to older people with
a range of sub-acute physical health needs & long term conditions. As such the staffing levels
and safety of patients will be under constant review by the Nurse in Charge. This is a
responsibility and accountability which cannot be delegated or transferred as the Nurse in
Charge is in the best place to make decisions regarding the needs of the resident population.
Where actions defined above require additional authorisation this is to support the Nurse in
Charge to make decisions which are reasonable and robust, and also to ensure that all options
and alternatives have been considered as appropriate. The authorisation process will also take
responsibility for enacting the escalation procedures defined at Appendix 1 if required.
_________________________________________________________________________________
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3.5
St John’s Hospice
Name of Ward
Hospice
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
2
Consideration for additional staffing
Number of patients requiring 1:1
support and special observations.
Number of patients who require
personal care requiring more than 2
staff in attendance.
Number of patients requiring support to
attend appointments away from the
ward.
Number
of
patients/levels
of
challenging behaviour in evidence.
Additional staff may be required for
Bariatric patients following Moving and
Handling Assessment.
Additional staff to cover Pregnant staff
or staff on phased return
Patient complexity e.g. symptom
management, blood transfusions, end
of life care.
The additional non-clinical demands to
be managed (ward round, tribunal etc.)
All patients admitted have an Early
Warning Score (EWS) of 3 or more.
Number of high risk falls patients.
Twice weekly ward rounds.
Weekly Multi-Disciplinary Team (MDT).
Beds
10
Unqualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
1
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can be
changed from later in the week to cover the
required shifts.
2. Cancel any off site activities such as training or out
of area assessments and bring the staff onto shift.
3. Flexible use of Ward Manager and non-nursing
grade staff to support with supervision and activity
on the ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not required).
6. Use of additional hours for part time staff of lowest
required grade (authorisation not required).
7. Use of overtime for existing staff (authorisation
required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on call
arrangements for your area.
Specific
10. Liaise with other Hospice services for availability
of staff.
11. Request to Hazel, Magnolia, Hawthorn, Day
Hospital, Stroke Outreach and CICT for support.
12. Review ward round attendance.
13. Review Hospice Day Care attendance.
Authority and authorisation
The hospice is a 10 bed unit providing care to patients with long term conditions including cancer
who require complex symptom management and end of life care. Support is also required for
their families and significant others. As such the staffing levels and safety of patients will be
under constant review by the Nurse in Charge. This is a responsibility and accountability which
cannot be delegated or transferred as the Nurse in Charge is in the best place to make decisions
regarding the needs of the resident population. Where actions defined above require additional
authorisation this is to support the Nurse in Charge to make decisions which are reasonable and
robust, and also to ensure that all options and alternatives have been considered as appropriate.
The authorisation process will also take responsibility for enacting the escalation procedures
defined at Appendix 1 if required.
Other Notes: Other wards in DCIS are relying on sufficient staffing at the Hospice to support
them.
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4.
4.1
FORENSIC SERVICES
Providing for safe and appropriate staffing levels in forensic services is a
dynamic decision. In Forensic Services, this decision making process will
include the mental health, risk, physical health and care needs of the defined
patient group which can change quickly and staffing may need to be adjusted
to adapt to the changes in the ward and patient cohort.
In each of our inpatient areas we have a minimum level of staffing required for
each clinical area. For unplanned changes to the minimum staffing levels the
Shift Co-ordinator and bleep holder have a central role in determining the
needs and risks presented by the patient population and agreeing and
implementing appropriate actions to meet these needs.
Changes on a planned basis will be made by the Ward Manager and/or
Modern Matron responsible for the clinical area.
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4.2
Amber Lodge (Rehabilitation and Recovery)
Name of Ward
Amber Lodge
Rehabilitation and
Recovery
Minimum Staffing Levels
Qualified Nursing Staff
Early
1
Late (or late/twilight)
1
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and special observations.
Beds
18
Unqualified Nursing Staff
Early
4
Late (or late/twilight)
4
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover
the required shifts.
Number of patients requiring support to
2. Cancel any off site activities such as training
attend appointments away from the ward
or out of area assessments and bring the
staff onto shift.
Number of patients/levels of challenging
3. Flexible use of Ward Manager and nonbehaviour in evidence.
nursing grade staff (Occupational Therapist,
who is shared between the wards) to
The additional non clinical demands to be
support with supervision and activity on the
managed (MDT’s CPA’s Tribunals)
ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not
required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff
(authorisation required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and
on call arrangements for your area.
Specific
10. Request to Amber Lodge Intensive Support
Unit and Jubilee Close for support.
11. Use of Forensic bank staff (authorisation not
required).
Authority and authorisation
Amber Lodge Rehabilitation and Recovery Unit is an 18 bed low secure unit providing care to
restricted patients under the Mental Health Act. There is access to the ISU Seclusion Suite if
required. In order to provide as much assistance to the day to day running of the Forensic
Division, a bleep holder and shift co-ordinator is identified on each shift.
The role and responsibility of the bleep holder is to have an awareness and understanding of
all three clinical areas within the Forensic Business Division.
The Shift Coordinator is responsible for continually reviewing and managing their individual
Units staffing levels, taking into consideration patient and staff safety, as well as informing the
Bleep holder of significant changes.
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4.3
Amber Lodge (Intensive Support Unit)
Name of Ward
Amber Lodge
Intensive Support
Unit (ISU)
Minimum Staffing Levels
Qualified Nursing Staff
Early
1
Late (or late/twilight)
1
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and special observations.
Number of patients requiring support to
attend appointments away from the ward
Number of patients/levels of challenging
behaviour in evidence.
Beds
5
Unqualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover the
required shifts.
2. Cancel any off site activities such as training
or out of area assessments and bring the staff
onto shift.
The additional non clinical demands to 3. Flexible use of Ward Manager and nonbe managed (MDT’s CPA’s Tribunals)
nursing grade staff (Occupational Therapist,
who is shared between the wards) to support
with supervision and activity on the ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff
(authorisation required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on
call arrangements for your area.
Specific
10. Request to Amber Lodge ISU and Jubilee
Close for support.
11. Use of Forensic bank staff (authorisation not
required).
Authority and authorisation
Intensive Support Unit is a 5 bed ward within Amber Lodge providing care to restricted
patients under the Mental Health Act. It has a seclusion room which ISU and Rehabilitation
and Recovery have access to when required. Patients placed here may be extremely
challenging and complex in their presentation.
In order to provide as much assistance to the day to day running of the Forensic Division, a
bleep holder and shift co-ordinator is identified on each shift.
The role and responsibility of the bleep holder is to have an awareness and understanding of
all three clinical areas within the Forensic Business Division.
The Shift Coordinator is responsible for continually reviewing and managing their individual
Units staffing levels, taking into consideration patient and staff safety, as well as informing the
Bleep holder of significant changes.
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4.4
Jubilee Close (Step Down Facility)
Name of Ward
Jubilee Close
Minimum Staffing Levels
Qualified Nursing Staff
Early
1
Late (or late/twilight)
1
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and special observations.
Number of patients requiring support to
attend appointments away from the ward
Number of patients/levels of challenging
behaviour in evidence.
Beds
10
Unqualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover the
required shifts.
2. Cancel any off site activities such as training
or out of area assessments and bring the staff
onto shift.
The additional non clinical demands to
3. Flexible use of Ward Manager and nonbe managed (MDT’s CPA’s Tribunals)
nursing grade staff (Occupational Therapist,
who is shared between the wards) to support
with supervision and activity on the ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff
(authorisation required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on
call arrangements for your area.
Specific
10. Request to Amber Lodge Rehabilitation and
Recovery Unit for support.
11. Use of Forensic bank staff (authorisation not
required).
Authority and authorisation
Jubilee Close is a 10 bed step down service for restricted patients who have previously been
placed at Amber Lodge Rehabilitation and Recovery Service or similar units elsewhere.
In order to provide as much assistance to the day to day running of the Forensic Division, a
bleep holder and shift co-ordinator is identified on each shift.
The role and responsibility of the bleep holder is to have an awareness and understanding of
all three clinical areas within the Forensic Business Division.
The Shift Coordinator is responsible for continually reviewing and managing their individual
Units staffing levels, taking into consideration patient and staff safety, as well as informing the
Bleep holder of significant changes.
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5.
LEARNING DISABILITY SERVICES
5.1
Providing for safe and appropriate staffing levels in Assessment and
Treatment Services is a dynamic decision making process which reflects the
unplanned and responsive nature of the services we provide. In Learning
Disabilities this decision making process will include the mental health, risk,
behavioural, physical health and care needs of the defined patient group
which can change quickly and staffing may need to be adjusted to adapt to
the changes in the ward and patient cohort.
In each of our inpatient areas we have consulted with staff and managers to
determine a minimum level of staffing required for each clinical area and
identified some of the clinical and environmental factors we will consider when
determining if changes are required on an unplanned basis. For unplanned
changes to the minimum staffing levels the Nurse in Charge has a central role
in determining the needs and risks presented by the patient population and
agreeing and implementing appropriate actions to meet these needs.
Changes on a planned basis will be made by the Ward Manager and/or
Matron responsible for the clinical area.
This document outlines the minimum staffing levels for each of the Learning
Disability Inpatient Services, defines some of the conditions the Nurse in
Charge may need to consider when requesting/making changes to the
minimum staffing levels and practical steps the Nurse in Charge can take to
resolve concerns regarding staffing levels should they occur.
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5.2
Acute Treatment Unit (ATU) - Sapphire Lodge
Name of Ward
Acute Treatment
Unit (ATU) Sapphire Lodge
Minimum Staffing Levels
Qualified Nursing Staff
1 WTE BAND 7 8.30 – 16.30
Early
1
Late
1
Night
1
Consideration for additional staffing
Number of patients requiring 1:1
support and special observations.
Number of patients who require
personal care requiring more than 2
staff in attendance.
Number of patients requiring support to
attend appointments away from the
ward.
Number
of
patients/levels
of
challenging behaviour in evidence.
Additional 1:1 required for patients in
the care of the Acute Trust.
The collective and individual acuity and
needs of the patient population.
The additional non-clinical demands to
be managed (ward round, tribunal etc).
Beds
5
Unqualified Nursing Staff
Early
3
Late
3
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can be
changed from later in the week to cover the
required shifts.
2. Cancel any off site activities such as training or out
of area assessments and bring the staff onto shift.
3. Flexible use of Ward Manager and non-nursing
grade staff to support with supervision and activity
on the ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not required).
6. Use of additional hours for part time staff of lowest
required grade (authorisation not required).
7. Use of overtime for existing staff (authorisation
required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on call
arrangements for your area.
Specific
10. Request to sister ATU/Community Homes for
support.
Authority and authorisation
Sapphire Lodge is staffed accordingly to the needs and risks presented by the patients in situ.
There is a core staff skill mix that would need to be provided even if the unit is occupied by just 1
patient. Patient numbers are variable up to 5 beds. The skill mix required and staffing levels
required is very much based upon professional and clinical judgement taking into account,
needs, dependency, levels of cooperation and aggression and activities planned and anticipated.
We operate a core and flex staffing model at Sapphire Lodge as we have beds available to
market to other commissioners. This enables us to manage and control the cost of staff
regardless of occupancy.
As such the staffing levels and safety of patients will be under constant review by the Nurse In
Charge. This is a responsibility and accountability which cannot be delegated or transferred as
the Nurse In Charge is in the best place to make decisions regarding the needs of the resident
population. Where actions defined above require additional authorisation this is to support the
Nurse In Charge to make decisions which are reasonable and robust and also to ensure that all
options and alternatives have been considered as appropriate. The authorisation process will
also take responsibility for enacting the escalation procedures defined at Appendix 1 if required.
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5.3
Acute Treatment Unit (ATU) - Rhymers Court
Name of Ward
Acute Treatment Unit
(ATU) - Rhymers Court
Minimum Staffing Levels
Qualified Nursing Staff
Early
1
Late
1
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and special observations.
Number of patients who require personal
care requiring more than 2 staff in
attendance.
Number of patients requiring support to
attend appointments away from the ward.
Number of patients/levels of challenging
behaviour in evidence.
Additional 1:1 required for patients in the
care of the Acute Trust.
The collective and individual acuity and
needs of the patient population.
The additional non-clinical demands to be
managed (ward round, tribunal etc).
Beds
5
Unqualified Nursing Staff
Early
2
Late
2
Night
1
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can be
changed from later in the week to cover the
required shifts.
2. Cancel any off site activities such as training or
out of area assessments and bring the staff
onto shift.
3. Flexible use of Ward Manager and non-nursing
grade staff to support with supervision and
activity on the ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff (authorisation
required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on
call arrangements for your area.
Specific
10. Request to sister ATU/Community Homes for
support.
Authority and authorisation
Rhymers Court is staffed accordingly to the needs and risks presented by the patients in situ.
There is a core staff skill mix that would need to be provided even if the unit is occupied by just 1
patient. Patient numbers are variable up to 5 beds. The skill mix required and staffing levels
required is very much based upon professional and clinical judgement taking into account,
needs, dependency, levels of cooperation and aggression and activities planned and anticipated.
As such the staffing levels and safety of patients will be under constant review by the Nurse In
Charge. This is a responsibility and accountability which cannot be delegated or transferred as
the Nurse In Charge is in the best place to make decisions regarding the needs of the resident
population. Where actions defined above require additional authorisation this is to support the
Nurse In Charge to make decisions which are reasonable and robust and also to ensure that all
options and alternatives have been considered as appropriate. The authorisation process will
also take responsibility for enacting the escalation procedures defined at Appendix 1 if required.
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6.
OLDER PEOPLE’S MENTAL HEALTH SERVICES
6.1
Providing for safe and appropriate staffing levels in acute mental health care
is a dynamic decision making process which reflects the unplanned and
responsive nature of the services we provide. In Older People’s Mental Health
Service this decision making process will include the mental health, risk,
physical health and care needs of the defined patient group which can change
quickly and staffing may need to be adjusted to adapt to the changes in the
ward and patient cohort.
In each of our inpatient areas we have consulted with staff and managers to
determine a minimum level of staffing required for each clinical area and
identified some of the clinical and environmental factors we will consider when
determining if changes are required on an unplanned basis. For unplanned
changes to the minimum staffing levels the Nurse in Charge has a central role
in determining the needs and risks presented by the patient population and
agreeing and implementing appropriate actions to meet these needs.
Changes on a planned basis will be made by the Ward Manager and/or
Matron responsible for the clinical area.
This document outlines the minimum staffing levels for each of the Older
People’s Mental Health Inpatient Services, defines some of the conditions the
Nurse in Charge may need to consider when requesting/making changes to
the minimum staffing levels and practical steps the Nurse in Charge can take
to resolve concerns regarding staffing levels should they occur.
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6.1
Laurel Ward (Acute Ward)
Name of Ward
Laurel Ward
Minimum Staffing Levels
Qualified Nursing Staff
Early
1
Late (or late/twilight)
1
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and special observations.
Number of patients who require personal
care requiring more than 2 staff in
attendance.
Number of patients requiring support to
attend appointments away from the ward
(including Electro Convulsive Therapy
(ECT)).
Number of patients/levels of challenging
behaviour in evidence.
Additional 1:1 required for patients in the
care of the Acute Trust.
The collective and individual acuity and
needs of the patient population.
The additional non-clinical demands to be
managed (ward round, tribunal, etc).
Beds
13
Unqualified Nursing Staff
Early
3
Late (or late/twilight)
3
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover
the required shifts.
2. Cancel any off site activities such as
training or out of area assessments and
bring the staff onto shift.
3. Flexible use of Ward Manager and nonnursing grade staff (Occupational Therapist,
Physiotherapist) to support with supervision
and activity on the ward.
4. Cancellation of routine non-essential
activity.
5. Use of bank staff (authorisation not
required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff
(authorisation required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and
on call arrangements for your area.
Specific
10. Request to Mulberry House for support.
Authority and authorisation
Laurel Ward is a 13 bed acute mental health ward providing care to older people with a range
of mental disorders. As such the staffing levels and safety of patients will be under constant
review by the Nurse in Charge. This is a responsibility and accountability which cannot be
delegated or transferred as the Nurse in Charge is in the best place to make decisions
regarding the needs of the resident population. Where actions defined above require
additional authorisation this is to support the Nurse in Charge to make decisions which are
reasonable and robust, and also to ensure that all options and alternatives have been
considered as appropriate. The authorisation process will also take responsibility for enacting
the escalation procedures defined at Appendix 1 if required.
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6.2
Coniston Lodge (Acute Ward)
Name of Ward
Coniston Lodge
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and special observations.
Number of patients who require personal
care requiring more than 2 staff in
attendance.
Number of patients requiring support to
attend appointments away from the ward
(including Electro Convulsive Therapy
(ECT)).
Number of patients/levels of challenging
behaviour in evidence.
Additional 1:1 required for patients in the
care of the Acute Trust.
The collective and individual acuity and
needs of the patient population.
The additional non-clinical demands to be
managed (ward round, tribunal, etc).
Beds
20
Unqualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover
the required shifts.
2. Cancel any off site activities such as training
or out of area assessments and bring the
staff onto shift.
3. Flexible use of Ward Manager and nonnursing grade staff (Occupational Therapist,
Physiotherapist who are shared between
the wards) to support with supervision and
activity on the ward.
4. Cancellation of routine non-essential
activity.
5. Use of bank staff (authorisation not
required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff
(authorisation required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and
on call arrangements for your area
Specific
10. Request to Windermere Lodge for support.
Authority and authorisation
Coniston Lodge is a 20 bed acute mental health ward providing care to older people with a
range of functional mental disorders. As such the staffing levels and safety of patients will be
under constant review by the Nurse in Charge. This is a responsibility and accountability
which cannot be delegated or transferred as the Nurse in Charge is in the best place to make
decisions regarding the needs of the resident population. Where actions defined above
require additional authorisation this is to support the Nurse in Charge to make decisions
which are reasonable and robust, and also to ensure that all options and alternatives have
been considered as appropriate. The authorisation process will also take responsibility for
enacting the escalation procedures defined at Appendix 1 if required.
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6.3
Windermere Lodge (Acute Ward)
Name of Ward
Windermere Lodge
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and special observations.
Number of patients who require personal
care requiring more than 2 staff in
attendance.
Number of patients requiring support to
attend appointments away from the ward
(including Electro Convulsive Therapy
(ECT)).
Number of patients/levels of challenging
behaviour in evidence.
Additional 1:1 required for patients in the
care of the Acute Trust.
The collective and individual acuity and
needs of the patient population.
The additional non-clinical demands to be
managed (ward round, tribunal, etc).
Beds
20
Unqualified Nursing Staff
Early
2
Late (or late/twilight)
2
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover
the required shifts.
2. Cancel any off site activities such as training
or out of area assessments and bring the
staff onto shift.
3. Flexible use of Ward Manager and nonnursing grade staff (Occupational Therapist,
Physiotherapist who are shared between the
wards) to support with supervision and
activity on the ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not
required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff
(authorisation required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on
call arrangements for your area
Specific
10. Request to Coniston Lodge for support.
Authority and authorisation
Windermere Lodge is a 20 bed acute mental health ward providing care to older people with a
range of organic mental disorders. As such the staffing levels and safety of patients will be
under constant review by the Nurse in Charge. This is a responsibility and accountability
which cannot be delegated or transferred as the Nurse in Charge is in the best place to make
decisions regarding the needs of the resident population. Where actions defined above
require additional authorisation this is to support the Nurse in Charge to make decisions
which are reasonable and robust, and also to ensure that all options and alternatives have
been considered as appropriate. The authorisation process will also take responsibility for
enacting the escalation procedures defined at Appendix 1 if required.
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6.4
The Brambles (Acute Ward)
Name of Ward
The Brambles
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight)
1
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and special observations.
Number of patients who require personal
care requiring more than 2 staff in
attendance.
Number of patients requiring support to
attend appointments away from the ward
(including Electro Convulsive Therapy
(ECT)).
Number of patients/levels of challenging
behaviour in evidence.
Additional 1:1 required for patients in the
care of the Acute Trust.
The collective and individual acuity and
needs of the patient population.
The additional non-clinical demands to be
managed (ward round, tribunal, etc).
Beds
15
Unqualified Nursing Staff
Early
2
Late (or late/twilight)
3
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover
the required shifts.
2. Cancel any off site activities such as training
or out of area assessments and bring the
staff onto shift.
3. Flexible use of Ward Manager and nonnursing grade staff (Occupational Therapist,
Physiotherapist who are shared between the
wards) to support with supervision and
activity on the ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not
required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff
(authorisation required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on
call arrangements for your area
Specific
10. Request to The Glade or Ferns for support.
Authority and authorisation
The Brambles is a 15 bed acute mental health ward providing care to older people with a
range of functional mental disorders. As such the staffing levels and safety of patients will be
under constant review by the Nurse in Charge. This is a responsibility and accountability
which cannot be delegated or transferred as the Nurse in Charge is in the best place to make
decisions regarding the needs of the resident population. Where actions defined above
require additional authorisation this is to support the Nurse in Charge to make decisions
which are reasonable and robust, and also to ensure that all options and alternatives have
been considered as appropriate. The authorisation process will also take responsibility for
enacting the escalation procedures defined at Appendix 1 if required.
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6.5
The Glade (Acute Ward)
Name of Ward
The Glade
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight)
1
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and special observations.
Number of patients who require personal
care requiring more than 2 staff in
attendance.
Number of patients requiring support to
attend appointments away from the ward
(including Electro Convulsive Therapy
(ECT)).
Number of patients/levels of challenging
behaviour in evidence.
Additional 1:1 required for patients in the
care of the Acute Trust.
The collective and individual acuity and
needs of the patient population.
The additional non-clinical demands to be
managed (ward round, tribunal, etc).
Beds
15
Unqualified Nursing Staff
Early
3
Late (or late/twilight)
3
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover
the required shifts.
2. Cancel any off site activities such as training
or out of area assessments and bring the
staff onto shift.
3. Flexible use of Ward Manager and nonnursing grade staff (Occupational Therapist,
Physiotherapist who are shared between the
wards) to support with supervision and
activity on the ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not
required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff
(authorisation required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on
call arrangements for your area
Specific
10. Request to Brambles and Ferns for support.
Authority and authorisation
The Glade is a 15 bed acute mental health ward providing care to older people with a range
of organic mental disorders. As such the staffing levels and safety of patients will be under
constant review by the Nurse in Charge. This is a responsibility and accountability which
cannot be delegated or transferred as the Nurse in Charge is in the best place to make
decisions regarding the needs of the resident population. Where actions defined above
require additional authorisation this is to support the Nurse in Charge to make decisions
which are reasonable and robust, and also to ensure that all options and alternatives have
been considered as appropriate. The authorisation process will also take responsibility for
enacting the escalation procedures defined at Appendix 1 if required.
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6.6
The Ferns (Complex Care Ward)
Name of Ward
The Ferns
Minimum Staffing Levels
Qualified Nursing Staff
Early
2
Late (or late/twilight)
1
Night
1
Consideration for additional staffing
Number of patients requiring 1:1 support
and special observations.
Number of patients who require personal
care requiring more than 2 staff in
attendance.
Number of patients requiring support to
attend appointments away from the ward
(including Electro Convulsive Therapy
(ECT)).
Number of patients/levels of challenging
behaviour in evidence.
Additional 1:1 required for patients in the
care of the Acute Trust.
The collective and individual acuity and
needs of the patient population.
The additional non-clinical demands to be
managed (ward round, tribunal, etc).
Beds
12
Unqualified Nursing Staff
Early
3
Late (or late/twilight)
3
Night
2
Actions to be taken (this is a progression list)
Core
1. Review the duty rota to see if any shifts can
be changed from later in the week to cover
the required shifts.
2. Cancel any off site activities such as training
or out of area assessments and bring the
staff onto shift.
3. Flexible use of Ward Manager and nonnursing grade staff (Occupational Therapist,
Physiotherapist who are shared between the
wards) to support with supervision and
activity on the ward.
4. Cancellation of routine non-essential activity.
5. Use of bank staff (authorisation not
required).
6. Use of additional hours for part time staff of
lowest required grade (authorisation not
required).
7. Use of overtime for existing staff
(authorisation required).
8. Use of agency (authorisation required).
9. Refer to the Business Continuity Plan and on
call arrangements for your area
Specific
10. Request to Glade or Brambles for support.
Authority and authorisation
The Ferns is a 12 bed complex care ward providing care to older people with a range of
organic mental disorders. As such the staffing levels and safety of patients will be under
constant review by the Nurse in Charge. This is a responsibility and accountability which
cannot be delegated or transferred as the Nurse in Charge is in the best place to make
decisions regarding the needs of the resident population. Where actions defined above
require additional authorisation this is to support the Nurse in Charge to make decisions
which are reasonable and robust, and also to ensure that all options and alternatives have
been considered as appropriate. The authorisation process will also take responsibility for
enacting the escalation procedures defined at Appendix 1 if required.
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7.
CONCLUSION
This document identifies the minimum staffing levels required for each inpatient area within
the Trust and will provide the Board with the assurance that safe effective care can be
delivered by having the right people with the right skills in the right place at the right time.
The governance and assurance framework in relation to safe staffing levels will be
monitored through the Human Resources and Organisational Development Group
(HR&OD). A Clinical Staffing Review Group has been established which includes
membership of senior clinical staff from each inpatient area. The group meets regularly and
its remit includes the following:
•
To review national guidance regarding safe staffing levels;
• Review and monitor the implementation of the agreed Protocol for Inpatient Staffing
Levels;
•
Support the development of the twice yearly inpatient staffing declaration.
HD/March 2014
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Protocol for Inpatient Staff Levels
CORE INPATIENT SERVICES
Each of the inpatient wards have a core level of staff allocated to provide the fundamental level of care to patients admitted up to maximum occupancy.
The core staffing structure is funded in all services allowing for and adjusted to provide cover at anticipated absence rates.
ASSESSMENT OF PATIENT NEED
Will the core services provide the appropriate level of support to the current patient population?
NO, UNDERSTAFFED
YES
CONTINUAL
REVIEW AND
ASSESSMENT
OF PATIENT
NEED, STAFF
TRAINING NEED
AND ANNUAL
LEAVE
COMMITMENTS
Continue to
function using
core services.
Complex Patient Needs
Arising Staffing Issues
The need for additional
capacity will arise in the event
that patients admitted to the
ward have more complex
needs than the core services
are designed to care for, in
which case, additionally
capacity will be acquired
through ‘flexing up’.
In the event that the capacity
of the core services is affected
such as through unplanned
staff absence or the need to
provide support to other
services, additional capacity
will be acquired through
‘flexing up’.
NO, OVERSTAFFED
Consider the possibility to:
• Book staff onto Mandatory and
Statutory training
• Book staff in to take annual
leave
• Deploying staff to support
community services.
ESCALATION PROCESS
The number and type of staff required based on the specific needs of the patient population is decided by the Nurse in Charge in consultation with appropriate
and available line management support as defined in the inpatient staffing profiles. Where the allocation of staff has exhausted all opportunities and the
service remains at risk the Modern Matron or On-call Service Manager will agree with the Nurse in Charge a safe contingency arrangement. This may include:
• Mandating attendance at work for staff not rostered.
Moving staff from community or day services to attend on the ward
• Providing cover from available managers on-call
• Blending/merging two or more wards to provide safe cover
All contingencies must be notified to the Assistant Director/on-call Assistant Director
•
___________________________________________________________________________________________________
Staffing Declaration – May 2014 (v.1.0)
PAPER J
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Group/Committee
Name
Board of Directors – Public Meeting
Meeting Date
29 May 2014
Title of Paper
Author
Report of the Chair of the Mental Health Legislation Committee
Michael Smith, Non-Executive Director and Chair of the Mental Health
Legislation Committee
Paper For
Decision
Strategic Work
Programme:
- Relevance
- Progress
Debate
Assurance
What Strategic Work Programmes is the paper
relevant to?
Does the paper provide assurance against
delivery of the identified Strategic Work
Programme?

Information

Reference
1 4 5
Yes / No
No
The business of the Committee centres on its key responsibilities:
• That there are systems, structures and processes in place that
ensure compliance with legislation, associated codes of practice and
recognised best practice.
• That appropriate policies and procedures are in place
• That hospital managers and staff receive guidance education and
training
Key Points to Note
(including any
identified risks )
To this end, the key issues discussed at the meeting on 7 May 2014 were:
• Mental Health Legislation Sub Group Update
• CQC MHA Visits Update
• Mental Health Act Approvals Functions [Section 12(2) & Section
145(1)] annual report and terms of reference
• Implications of the recent Supreme Court decision in Cheshire West
and the P & Q case
• Compliance audits
• Hospital Manager update report Quarter 4 2013/14
• MCA update report
Board Assurance
Framework
If the paper also provides assurance against
the effectiveness of a Key Control what is the
reference and what level of assurance do you
think it provides?
CQC
If the paper provides assurance against
Essential Standards of Quality and Safety
(ESQS) specify the outcome number.
BAF Key
Control Ref.
Effectiveness
F/S/L/N
ESQS outcome number
None
Financial/Budget
Equality &
Diversity/Human
Rights
The relevant MH legislation and the Trust's compliance with such is a key
objective of the work of the MHLC
PAPER J
Action proposed
following the
meeting
The minutes and actions will be included in the minutes to be presented for
ratification at the next meeting on 6 August 2014.
Person
Responsible
Michael Smith, NED and Chair of the Mental Health Legislation Committee
Date for
completion
At the next meeting of the MHLC on 6 August 2014
Outcome required
from the Board of
Directors
The Board of Directors to note and receive the update in respect of the
Mental Health Legislation Committee.
Paper K
ROTHERHAM DONCASTER AND SOUTH HUMBER
NHS FOUNDATION TRUST
BOARD OF DIRECTORS MEETING
Group/Committee
Name
Board of Directors
Meeting Date
29th May 2014
Title of Paper
Author
Finance Directors Report
Paul Wilkin, Director of Finance
Paper For
Decision
Strategic Work
Programme:
- Relevance
- Progress
Key Points to Note
(including any
identified risks )
Debate
Assurance
Information
x
Reference
What Strategic Work Programmes is the paper
relevant to?
3.2a. b and c
Yes / No
Does the paper provide assurance against
delivery of the identified Strategic Work
Programme?
•
•
•
•
Yes
Month 01 position 2014/15
Update on North Lincolnshire better care fund
Update on Woodfield Park and Flourish Enterprises
Consolidated accounts 2013/14
Board Assurance
Framework
If the paper also provides assurance against
the effectiveness of a Key Control what is the
reference and what level of assurance do you
think it provides?
CQC
If the paper provides assurance against
Essential Standards of Quality and Safety
(ESQS) specify the outcome number.
Financial/Budget
Overall budgets
Equality &
Diversity/Human
Rights
None
Action proposed
following the
Group meeting
To note the finance update
Person
Responsible
Date for
completion
Outcome required
from the Group
Paul Wilkin, Director of Finance
BAF Key
Control Ref.
Effectiveness
F/S/L/N
N/A
N/A
ESQS outcome number
29th May 2014
The Board of Directors to receive and note the Financer Director’s Report
1
ROTHERHAM DONCASTER AND SOUTH HUMBER
NHS FOUNDATION TRUST
FINANCE DIRECTORS REPORT
1) The Financial results for month 01 of the Financial year 1/4/2014 to 31/3/2015
Appendix 1 attached to this paper is the month 01 Financial position for the financial year 1/4/14 to
31/3/15. This is the first month of the new financial year and therefore gives an early indication of the
financial performance but month 02 will give a much clearer position of the trend for the year. The
key messages at month 01 are:
•
A surplus before impairments of £0.082m (0.6%) against a month end target of £0.053m
(0.4%)
•
An EBITDA margin of 5.02% against a target of 4.74%.
•
A continuity of services rating of 4 (the highest rating)
•
Capital expenditure of £120k against a target of £228k.
•
A month end cash balance of £19.9m against a plan target of £19.3m.
•
All divisions and Directorates are achieving a break-even or surplus position at month 01 with
the exception of the Adult Mental Health division. This division has a deficit position of £62k
in April due to slippage in the delivery of QIPP and agency staffing pressures. The division
will produce a trajectory for the year at month 02 and will be monitored on delivery of this
trajectory. As part of the financial plan for 2014/15 a non recurrent deficit of up to £500k has
been underwritten for this division recognising their challenging QIPP position.
•
Within this position the Trust reserves for CQUIN, Divisional risk and capacity issues are
intact.
2) Update on North Lincolnshire better care fund
At the last board meeting an update was provided on the better care fund development for
Doncaster and Rotherham. The detail of the North Lincolnshire fund is now available and the key
messages are:
• The value of the fund in 2015/16 will be £12.4m.
• £7m of the fund will come from the decommissioning of Acute sector spend.
• The fund will be mainly re-invested in community services, GP services and social care
services. Most of these services are not provided by RDaSH.
3) Update on Woodfield park and Flourish Enterprises
As part of the estates strategy on the Balby site, the area surrounding St Catherines house has been
re-named Woodfield Park. The park is now a public open space and is been developed in 2 areas as
follows:
•
Commercial lease of the buildings in the park surrounding St Catherines house and office
space in the house.
•
Development of St Catherines House, the walled garden and the Victorian tea room as
Flourish Community Interest Company (CIC).
2
Commercial lease update
The table below shows the current position in relation to the commercial leases agreed on Woodfield
park:
Start
Building
Tennant
Lease Period
Date
EIEW Ltd (Construction
recruitment)
10 Years
with break
clauses
April
2014
Lonson Engineering
10 Years
with break
clauses
Feb 2014
1 Year
April
2014
3 Years
August
2014
Better 4 Communities CIC
6 Months
June
2014
Room 201
Bodyfix Wellbeing
9 Months
Room 202
Room 203
Room 204
Room 205
Ceri Goode
Vacant
Safe House Solutions
Vacant
3 Months
Jan 2014
April
2014
6 Months
Jan 2014
Room 206
Room 207
Zenza Ltd
Vacant
1 Year
March
2014
Room 208
Time for You
3 Months
Room 209
Elsium Solutions Ltd
1 Year
Room 210
Elsium Solutions Ltd
1 Year
Room 211
Room 212
Beauty Therapy by Paula Warren
Bellisima Hair Studio
1 Year
1 Year
Kale Lodge (old
Health Ed building)
Sorrel Lodge (Part of
old wheel chair
building)
Bergmont Centre
(Part of old wheel
chair building)
Andrew Lyons Photography
Hyssop - Ground
Floor (Old estates
building)
Tall Trees Yoga & Pilates
Almond tree Court
(old red centre)
Vacant but used as a larger
training facility
Woodbury Court (old
IT training room)
St Catherines House
April
2014
April
2014
April
2014
April
2014
May 2014
3
These leases will bring in an additional £96k per year to the Trust.
Flourish CIC Update
The following developments of Flourish have occurred since the last update:
•
4 Directors of Flourish have been appointed (1 Executive and 1 non-executive member of the
RDaSH Board and 2 independent Directors selected from the council of governors). (Paul
Wilkin, Mike Smith, Stuart Hall and Alex Sangster).
•
Confirmation was received from companies house on the 9th May that Flourish has been
registered as a community interest company from the 2nd May.
•
A new business manager and operations manager have been appointed to take the
company forward and they will take up post officially on the 2nd June.
4) Consolidated Accounts 2013/14
For the first time in 2013/14 the Trust is required to consolidate the charitable fund accounts with the
RDaSH activities in the final accounts. The table below shows the consolidated reported final
accounts Income and expenditure and the split between RDaSH activities and charitable funds.
RDaSH Activities
£000
Income from
patient activities
Other operating
income
Total Income
Operating
Expenses
Charitable fund
expenditure
Finance Liabilities
Finance income
Public Dividends
payable
Surplus / (Deficit)
before impairments
Impairment
Surplus/Deficit
after impairment
Charitable funds
£000
156790
Group position
£000
156790
9348
166138
1137
1137
10485
167275
-161026
-27
-161053
-639
-639
-2041
122
-2041
101
21
-1700
-1700
1472
-3155
492
1964
-3155
-1683
492
-1191
Paul Wilkin
Director of Finance
4
MAY 14 BoD Paper K Finance Report 2014-15 Appendix
APPENDIX 1
Corporate Overview
Financial Performance - 1st April 2014 to
30th April 2014
30th April 2014
Actual
£m
Plan
£m
Variance
£m
Plan
£m
31st March 2015
Forecast
Variance
£m
£m
Trading Position
Income
Expenditure
Interest, Depreciation and Dividends Paid
Retained Surplus / (Deficit) before impairment
12.9
-12.3
-0.6
0.1
12.7
-12.0
-0.6
0.1
-0.2
0.2
0.0
0.0
154.6
-147.3
-6.7
0.6
154.6
-147.3
-6.7
0.6
0.0
0.0
0.0
0.0
Impairment
0.0
0.0
0.0
0.0
0.0
0.0
Retained Surplus / (Deficit) after impairment
0.1
0.1
0.0
0.6
0.6
0.0
87.7
4.3
-19.8
89.7
3.4
-19.4
2.0
-0.9
0.3
88.2
3.7
-19.2
88.2
3.7
-19.2
0.0
0.0
0.0
72.2
73.7
1.5
72.6
72.6
0.0
19.3
19.9
0.6
18.6
18.6
0.0
Depreciation and PDC funded Schemes
-0.3
-0.1
0.2
3.9
3.9
0.0
Total Capital Investment
-0.3
-0.1
0.2
3.9
3.9
0.0
Key Exceptions:
Balance Sheet
Long Term Assets (non-current)
Net Current Assets / Liabilities
Long Term Liabilities (non-current)
Total Assets Employed
Key Exceptions:
Nothing to Report
Liquidity
Cash at Bank and in Hand
Key Exceptions:
Capital investment
Key Exceptions:
Key Performance Against Terms of Authorisation
EBITDA Margin
Continuity of Services Risk Rating (CoSRR)
30th April 2014
Plan
Actual
31st March 2015
Plan
Forecast
4.74%
5.02%
4.74%
4.74%
4
4
4
4
Notes
Green
Red
= Compliant
= Not Compliant
1
23/05/2014 11:09
Paper L
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Group/Committee
Name
Board of Directors – Public Meeting
Meeting Date
29 May 2014
Title of Paper
Author
Report of the Chair of the Charitable Funds Committee
Jim Marr, Chair of the Charitable Funds Committee
Paper For
Decision
Strategic Work
Programme:
- Relevance
- Progress
Debate
Assurance
What Strategic Work Programmes is the paper
relevant to?
Does the paper provide assurance against
delivery of the identified Strategic Work
Programme?

Information
Reference
1
3
Yes / No
No
1) Committee Meeting
The business of the Committee at its meetings is to oversee the
administration of the Charitable Funds held by the Trust, acting as
Corporate Trustee. To this end, the key issues discussed at the meeting on
1 May 2014 were:
The business of the Committee at its meetings is to oversee the
administration of the Charitable Funds held by the Trust, acting as
Corporate Trustee. To this end, the key issues discussed at the meeting on
1 May 2014 were:
•
Key Points to Note
(including any
identified risks )
•
•
•
•
•
•
Presentation of this year's Charitable Funds Audit Plan by
Pricewaterhouse Cooper
St John’s Hospice plans / refurbishment and update on fundraising
Charity Commission Guidelines for NHS Charitable Funds
Charitable Fund Finance Report Quarter 3, 2013/14
Unaudited Annual Accounts for 2013/14
Investment policy for portfolio
One external application for charitable funds was considered
2) The total funds at the end of March 2014 stood at £1.227Million with
£0.992Million associated with the Hospice and Hospice Development. Of
this total £593,497 (value at 31.03.14) is invested by Investec Wealth and
Investment Ltd on the Trusts behalf. The committee reviewed the
performance of the investments against the FTSE WMA Balanced Portfolio
benchmark.
3) As the total income for the last financial year will be above £1million, the
Trust is required to show a consolidated set of accounts including the
activity of the Charitable Funds. As a result a full audit is required this year.
Our expectation is that next year’s income will fall below £1Million and will
not therefore require consolidation or a full audit.
4) The committee welcomed Governors Ian Fairbank and Helen Ward as
non voting members of the group. The chair outlined the role of the meeting
and advised all members to read the NHS Charitable Trusts Guidelines to
remind themselves of the duties of the committee. The Governors support
Paper L
and advice regarding applications to the fund would be most welcome.
5) The draft Annual Accounts for 2013/14 were reviewed, further work was
required before approval by the Board, prior to sending to the Charities
Commission.
Board Assurance
Framework
If the paper also provides assurance against
the effectiveness of a Key Control what is the
reference and what level of assurance do you
think it provides?
CQC
If the paper provides assurance against
Essential Standards of Quality and Safety
(ESQS) specify the outcome number.
BAF Key
Control Ref.
Effectiveness
F/S/L/N
ESQS outcome number
Financial/Budget
Equality &
Diversity/Human
Rights
Action proposed
following the
meeting
Person
Responsible
Date for
completion
Outcome required
from the Board of
Directors
The financial implications of the Committee’s actions are reported and
monitored at each meeting. The operational management of the funds is
under the control of designated fund managers.
None
Actions agreed at the meeting will be completed to agreed timescales. The
minutes will be ratified at the next meeting of the CFC on 7 August 2014.
Jim Marr, NED and Chair of the Charitable Funds Committee
The Charitable Funds Committee meeting on 7 August 2014
The Board of Directors to note and receive the update in respect of the
Charitable Funds Committee.
Paper M
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Group/Committee
Name
Board of Directors
Meeting Date
29th May 2014
Title of Paper
Author
Report by Director of Business Assurance
Richard Banks, Executive Director Business Assurance
Paper For
Decision
Strategic Work
Programme:
- Relevance
- Progress
Debate
Assurance
What Strategic Work Programmes is the paper
relevant to?
Does the paper provide assurance against
delivery of the identified Strategic Work
Programme?
x
Information
x
Reference
Goal 5
Yes / No
Commissioning for Quality and Innovation (CQUIN) Quarter 4 2013/14
PAG and CGG
A year-end summary report relating to the 2013/14 CQUIN scheme was
received by the Performance and Assurance Group, and a presentation on
the clinical impact of the schemes was given to the Clinical Governance
Group in May.
The report confirmed the level of achievement and payments received to
date. The Group agreed that a paper highlighting any early risks for
2014/15 would usefully be discussed at the June meeting.
Key Points to Note
(including any
identified risks )
At 22 May 2014, Doncaster, Rotherham and Manchester CCGs had
reviewed and confirmed the Q4 payment to be made. Doncaster CCG
removed £53,252 from the CQUIN contract value in Q2 for the DCIS Safety
Thermometer where Q3 and Q4 payment was not accessible due to not
meeting the minimum data collection in Q1 and Q2. However the value was
processed as a CV and £22,188 was paid for partial achievement of
improvement trajectories set against the Pressure Care Audit in Q4.
The CQUIN loss for 2013/14 so far is £69,022 (97.9% achieved), which
includes the full £53,252 described above as it must be declared as a
CQUIN loss; however the actual loss to the Trust to date is £46,834 (98.6%
achieved).
Decisions from North Lincolnshire CCG and NHS England Specialist
Commissioners are expected during May. Some risk exists for payment by
North Lincolnshire CCG in relation to the Older People’s Mental Health
Recovery STAR CQUIN if the CCG do not accept the reported exceptions
as sufficient.
CQUIN Pre-qualification criteria
The Performance and Assurance Group received a report showing the
submissions that were made in Q4 to the CCGs in relation to progress
against the CQUIN Pre-Qualification Criteria in 2013/14.
These reports provided a progress update against the initial plans made to
the CCGs in February 2013. As these programmes developed through the
year, some timescales and aims changed to reflect the fast moving nature
of these technologies and the services’ demands. While the development of
these plans were directly linked to access into the 2013/14 CQUIN scheme,
the achievement of the plans were not linked to CQUIN. The plans
throughout 2013/14 formed part of on-going contract monitoring with the
CCGs.
The report for Doncaster CCG was discussed at their April Finance,
Performance and Information Group (FPIG), and received good feedback.
The CCG acknowledged that these are on-going pieces of work and asked
to see 6 monthly reports in 2014/15 in the same format (August and
January). These programmes of work will be referred to as High Impact
Innovations (HII) from 2014/15.
To date no feedback has been received from Rotherham CCG or North
Lincolnshire CCG.
Although the PQC schemes are not mandated in 2014/15 there is an
opportunity to build on the progress and momentum achieved and there are
many strands of the PQC schemes which are being fed into the refresh of
the Information and Technology Strategy, including:
Appointment Booking Online
Mobile Working in the Community
Appointment Reminders
Remote Follow-up in Secondary Care
Remote delivery of test results
Quality Report (Account) – Performance Indicators
During April and May the Trust’s external auditor, PWC, has undertaken
testing against the following Monitor Indicators which are included in the
Monitor requirements of the Quality Report:
Crisis resolution home treatment
Care programme approach 7 day follow up
Delayed transfers of care.
At 22 May a number of initial findings had been reported back to the Trust in
anticipation of the report from PWC under Monitor’s Audit Code and
‘Detailed Guidance for External Assurance on the Quality Reports 2013/14’.
These findings would be presented to the Audit Committee 27th May and a
verbal report provided to the Board.
Business Intelligence software
At its meeting 22nd May the FIBD group approved a business case to
procure Qlikview business intelligence software. The issues this investment
are envisaged to address include:
• The lack of visibility of our data to frontline staff responsible for data
capture hinders data quality.
• Reliance on a mix of Excel and Access files and Microsoft Reporting
Services solution. This is inflexible and involves lots of manual processes
with copying and pasting of data with a high likelihood of differing numbers
reported internally and to commissioners leading to reputational damage to
the Trust.
• There is very little if any triangulation of data from differing systems.
Risk management:
Risk Management Strategy
An interim review of the Risk Management Strategy has been undertaken
and the suggested amendments agreed at the Performance and Assurance
Group in May. These changes were primarily to update changes in
Directors’ portfolios and also to incorporate changes to external agencies
e.g. NHSLA. The Board of Directors will be asked to review the Strategy in
full in 2016.
Premises Inspection Updates
A summary of the April analysis of the premises risk assessment is included
below:
TOTAL PREMISES
TOTAL COMPLETED
NUMBER NEEDING
COMPLETION
PERCENTAGE
COMPLETED
Fire
173
H&S
173
Security
173
159
172
156
14
1
17
91.90%
99.42%
90.17%
Where premises are owned by third parties, the Trust obtains assurance
that appropriate risk assessments have been undertaken by landlords.
Where such assurances have not been forthcoming the Health & Safety
Team have commenced direct inspections of the premises.
Board Assurance
Framework
If the paper also provides assurance against
the effectiveness of a Key Control what is the
reference and what level of assurance do you
think it provides?
CQC
If the paper provides assurance against
Essential Standards of Quality and Safety
(ESQS) specify the outcome number.
BAF Key
Control Ref.
ESQS outcome number
CQUIN recovery noted.
Financial/Budget
Equality &
Diversity/Human
Rights
None identified.
Action proposed
following the
Group meeting
N/A
Person
Responsible
Richard Banks, Executive Director Business Assurance
Date for
completion
Outcome required
from the Group
On-going
1.
Effectiveness
F/S/L/N
Board of Directors to note issues highlighted in the report
Paper N
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Group/Committee
Name
Board of Directors
Meeting Date
Thursday 29th May 2014
Title of Paper
Author
Board Assurance Framework Report 2013/14
Risk and Assurance Officer
Paper For
Decision
Strategic Work
Programme:
- Relevance
What Strategic Work Programmes is the paper
relevant to?
- Progress
Does the paper provide assurance against
delivery of the identified Strategic Work
Programme?
 Debate

Assurance

Information

Reference
5.5
Yes
Board Assurance Framework Report 2013/14
i. Strategic Work Programmes Quarter 4 update
The attached report is an extract from the 2013/14 Board Assurance
Framework that details the narrative update, identified in purple, regarding
progress with all Strategic Work Programmes.
Key Points to Note
(including any
identified risks )
ii. BAF 2013/14 close down summary report
The work to include all appropriate assurances in the 2013/14 BAF has now
been completed. The summary provides the:
• background to the BAF,
• monitoring undertaken during the year,
• year-end findings,
• outstanding assurances
• summary table identifying totals for levels of assurance populated.
The BAF Aide Memoire and monitoring arrangements are listed below.
Board Assurance
Framework
If the paper also provides assurance against
the effectiveness of a Key Control what is the
reference and what level of assurance do you
think it provides?
CQC
If the paper provides assurance against
Essential Standards of Quality and Safety
(ESQS) specify the outcome number.
BAF Key
Control Ref.
Effectiveness
F/S/L/N
5.5a
S
ESQS outcome number
16
No financial costs identified
Financial/Budget
Equality &
Diversity/Human
Rights
None
Action proposed
following the
Group meeting
The Board of Directors is asked to approve the report.
Paper N
Person
Responsible
Richard Banks, Executive Director Business Assurance
Date for
completion
Outcome required
from the Group
29th May 2014
To approve the report
BOARD ASSURANCE FRAMEWORK (BAF) AIDE MEMOIRE:
The BAF is a tool for the Board of Directors to corporately assure itself (gain confidence, based on
evidence) about successful delivery of the organisation’s principal objectives. The framework is designed to
focus the Board of Directors on controlling principal risks threatening the delivery of those objectives. The
BAF aligns principal risks, key controls and assurances on controls alongside each objective.
The Board of Directors needs to be confident that the systems, policies and people they have put in place
are operating in a way that is effective in driving the delivery of the key objectives by focusing on managing
risk.
MAIN COMPONENTS OF THE ASSURANCE FRAMEWORK
Principle Objectives
(Work Programmes)
The first step in preparing a BAF is to identify the Trusts objectives. These
objectives are identified in the BAF and reflect the current year and are linked to
other key plans so that they are consistent with strategic objectives
Quarterly Strategic
Goal Update
Principal Risk
Quarterly narrative performance updates against the work programmes
Key Controls
Existing Controls to assist in securing delivery of objectives examples are:
• Operational plans;
• Statutory frameworks, for instance standing orders, standing financial
instructions and associated scheme of delegation;
• Actions in response to audits, assessments and reviews;
• Workforce training and education;
• Clinical governance processes;
• Incident reporting and risk management processes;
• Complaints and other patient and public feedback procedures;
• Performance management systems
The organisation’s main risks against the delivery of work programmes
The key controls should be mapped to the principal risks. When assessments
are made about controls, consideration must be given not only to the control but
also the likelihood of them being effective e.g. even the best controls can fail if
staff are not adequately trained
Assurance on Controls
Where can the Board of Directors gain evidence that the controls / systems are
effective, i.e. sources of assurance, e.g. Management checks, Budgets, Training
assessments, Internal Audit, Clinical Audit, CQC, External Audit, Local Counter
Fraud Services, NHS Litigation Authority, Complaints & Compliments and
Incident monitoring
Assurance Position
Confidence, based on sufficient evidence, that internal controls are in place,
operating effectively and objectives are being achieved
Further Control
Required (GAPS)
Failure to put in place policies, procedures, practices or organisational structures
to manage risks
Further assurances
required and gaps in
source of assurance on
control
Assurances are not yet received for whole year.
Failure to gain sufficient evidence that policy, procedures, practices or
organisational structures on which reliance is placed are operating effectively.
Paper N
Action being taken to
address gaps
What the organisation is doing (and by when) to address identified gaps.
BOARD ASSURANCE FRAMEWORK (BAF) MONITORING ARRANGEMENTS
The reporting history for the BAF from April 2013 to March 2014
Month
Group
Report content
April 2014
Performance and
Assurance Group
Risk Management Sub
Group
Board of Directors
Performance and
Assurance Group
Risk Management Sub
Group
Audit Committee
Performance and
Assurance Group
Risk Management Sub
Group
Performance and
Assurance Group
Risk Management Sub
Group
Board of Directors
Performance and
Assurance Group
Risk Management Sub
Group
Performance and
Assurance Group
Risk Management Sub
Group
Audit Committee
•
Full 2013/14 Board Assurance Framework
Date
received
11/04/2013
•
Full 2013/14 Board Assurance Framework
23/04/2013
•
•
Full 2013/14 Board Assurance Framework
Full 2013/14 Board Assurance Framework
25/04/2013
17/05/2012
•
All work programmes under Strategic Goals 1 to 3
21/05/2013
•
•
28/05/2012
13/06/2013
•
Full 2013/14 Board Assurance Framework
Board Assurance Framework 2013/14 Exception
Report
All work programmes under Strategic Goals 4 and
5
Full Report including Strategic Goals update
•
All work programmes under Strategic Goal 1
17/07/2013
•
•
Full Report including Strategic Goals update
Board Assurance Framework 2013/14 Exception
Report
All work programmes under Strategic Goal 2 & 3
25/07/2013
15/08/2013
Board Assurance Framework 2013/14 - Exception
Report
All work programmes under Strategic Goals 4 & 5
12/09/2013
Board Assurance Framework 2013/14 - Exception
Report
Q1 NED Monitoring of Assurances
Board Assurance Framework 2013/14 - Exception
Report
All work programmes under Strategic Goal 1
Full Report including Strategic Goals update
06/09/2013
Board Assurance Framework 2013/14 – Mid-Year
Review of Strategic Goal 2
Update on Board Assurance 2013/14
Mid-Year Review
Board Assurance Framework 2013/14
Mid-year Review Update
Board Assurance Framework 2013/14
Mid-Year Review of Strategic Goals 1, 3, 4 & 5
BAF 2013/14 Mid-Year Review
BAF 2014/15 Update via BA Report
Board Assurance Framework 2014/15 – Strategic
Goals and draft Work Programmes
14/11/2013
May 2013
June 2013
July 2013
August
2013
September
2013
October
2013
Performance and
Assurance Group
Board of Directors
November
2013
December
2013
•
•
•
•
•
•
•
•
•
Performance &
Assurance Group
Board of Directors
•
Audit Committee
•
Performance &
Assurance Group
Board of Directors
Senior Leadership Team
•
•
•
•
18/06/2013
11/07/2013
27/08/2013
25/09/2013
17/10/2013
31/10/2013
28/11/2013
06/12/2013
12/12/2013
19/12/2013
23/12/2013
Paper N
January
2014
Non-Executive Directors
•
Performance &
Assurance Group
Board of Directors
•
•
•
February
2014
Council of Governors
•
Performance &
Assurance Group
•
Board of Directors
March
2014
Audit Committee
•
•
•
•
•
Performance &
Assurance Group
Board of Directors
•
•
Board Assurance Framework 2014/15 –
consultation on Strategic Goals and work
programmes
Board Assurance Framework 2013/14 - Exception
Report
Board Assurance Framework 2013/14 - Exception
Report
Board Assurance Framework 2014/15 – Draft
Strategic Goals & Work Programmes
Board Assurance Framework 2014/15 – Strategic
Goals and work programmes
Board Assurance Framework 2013/14 - Exception
Report
Board Assurance Framework 2014/15 - update
Board Assurance Framework 2013/14 - Update
st
Board Assurance Framework 2014/15 – 1 Draft
Board Assurance Framework 2013/14 – Exception
Report
Board Assurance Framework 2013/14 - NED
Monitoring Report
Board Assurance Framework 2013/14 – SG 4/5
Exception Report
st
Board Assurance Framework 2014/15 – 1 Draft
submission
02/01/2014
16/01/2014
30/01/2014
12/02/2014
13/02/2014
27/02/2014
11/03/2014
13/03/2014
27/03/2014
Strategic Goal Quarter 4 Update
Board Assurance Framework
Report 2013/14
Risk & Assurance Officer
Business Assurance Directorate
22/05/2014
Page 3 of 19
ON/OFF
ON/OFF
The Transformation Director and the Director
of Workforce and Organisational Development
incorporated developing a culture in which
innovation thrives within Module 1 of the Fit for
the Future programme.
Project proposals for the staff development
programme have been received from both Hull
and Sheffield Hallam Universities and
evaluated. The proposal from Sheffield Hallam
University has been agreed to commence in
the new financial year.
ON
ON
ON
Progress with Quality Markers and QIT as
above. CQC Inspections and Mental Health
Act Monitoring visits have provided evidence
of continued progress with fewer areas
identified for improvement. Those that have
been identified have been included within
Quality Markers for 2014/15 for relevant
Business Divisions. Our self assessment of
compliance against Essential Standard 4 has
improved as reported in the Q4, 2013/14
Quality Improvement Report .
A number of inspections have taken place in
Learning Disability Services and compliance
confirmed. The Trust has no compliance
actions from inspections. Monitoring and
reporting arrangements are as described in the
Q2 update. The Q4 Business Division
Essential Standards Review process was
completed and reported in the Q4 Quality
Improvement Report, identifying a smaller
number of areas requiring quality improvement
action planning. We are participating in the
CQC Phase 1 pilot for Adult Social Care in two
of our Doncaster Learning Disability
Community Homes and the outcomes will be
shared to inform our quality monitoring
processes.
Following the completion of the Fit for the
Future organisational development
programme, plans are being progressed to
launch the Innovation Strategy across the
Trust. The Change and Innovation Staff
Development Programme commences on 9
May 2014 and nominations are currently being
sought from the business divisions. The
programme has been co-produced by the
Trust and Sheffield Hallam University. The
Medical Director will present a case for the
continuation of the Research Assistant
Director post on the basis of research income
that has been accrued by the Trust.
Version 5
ON
ON
Progress with Quality Markers and QIT as
above. The clinical record audit is being
completed and will provide an end of year
position against this Trust quality priority.
ON
The Innovation Strategy was presented to SLT
on 30 September 2013 and agreed for
implementation. The strategy launch will be
aligned with the Fit for the Future organisational
development programme. A staff development
programme to support service improvement
and project management is being co-produced
with Sheffield Hallam University.
A large inspection of the Trust Headquarters
location took place in Q3 and compliance
confirmed with each of the Essential Standards
inspected. A number of other inspections have
also taken place and compliance confirmed.
Monitoring and reporting arrangements are as
described in the Q2 update. The Q2 Business
Division Essential Standards Review process
was completed and reported in the Q2 Quality
Improvement Report, identifying a smaller
number of areas requiring quality improvement
action planning. Each Business Division has
now developed their Essential Standards self
assessment process to a locality level, the
outcomes of which have informed the Trust
Francis declaration.
ON
A workshop session has been held within the
Professional Development Forum. The Forum
constructed a summary documents based on
feedback from staff, including an action plan to
progress strategy. The Trust has appointed a
Research Lead.
One core inspection has taken place in Q2 of St
John's Hospice. Verbal feedback very positive
on the day and report awaited from CQC. CQC,
MHA, Monitoring visits have now been
undertaken on all wards except Coral Lodge
which is expected. Some reports have been
received and some are awaited. They show an
improving picture with much positive feedback
and some areas for improvement. The themes
are reported and triangulated within the Quality
Improvement Report to the Clinical Governance
Group and action plans are monitored to
completion via the Clinical Effectiveness
Committee. The Q2 Business Division
Essential Standards Review process is
underway and the compliance position will be
reported in the Q2 Quality Improvement Report.
The meetings have included a wider discussion
about the emergent (5 key questions) focus for
the revised CQC inspection regime and will be
used to inform the Francis declaration to be
made by the BoD.
Each Business Division provided assurance to
the Clinical Effectiveness Committee (CEC)
that Q4 scheduled progress with Quality
Markers was achieved. The QIT Phase 1 work
is being drawn to a close and Phase 2 initiated
which will seek to utilise the Fit for the Future
outcomes to establish a quality Peer Review
model for the Service Directorates. Some
focussed activities around Clinical Leadership
of 'compassion in practice' are being
undertaken by Business Divisions in order to
embed the core values.
ON
Develop and
implement a Research
and Innovation
Strategy
Progress with Quality Markers and QIT as
above. The next clinical record audit has been
designed based on the areas identified for
improvement in each Business Division and
will be carried out in Q4. This re-audit will
provide an end of year position against this
Trust quality priority.
Progress with Quality Markers and QIT as
above. Findings from CQC, MHA, Monitoring
visits, complaints, incidents, clinical audit
results and QIT findings are being used to
design the next clinical record audit.
ON
No core inspections have been undertaken by
the CQC in Quarter 1 and all action plans have
been completed from 2012/13 inspections.
Four CQC Mental Health Act Visits have been
undertaken which have necessitated the
submission of Action Statements to CQC, the
completion of which will be monitored by the
Clinical Effectiveness Committee. The Quarter
4, 2012/13 Business Division reviews of
compliance with Essential Standards-discussed
at the April 2013 Clinical Governance Group
as part of the quarterly Quality Improvement
report - show an improving compliance
position.
Progress with Quality Markers and QIT as
above. CQC Inspections and Mental Health
Act visits have provided evidence of continued
progress with fewer areas identified for
improvement. A comprehensive review of care
plan templates for all Business Divisions has
been undertaken and the final templates
issued.
Quarter 4:
ON
d) To maintain full
compliance with the
CQC essential
standards of Quality
and Safety
ON
The implementation and monitoring of the
Quality Markers continue to progress in each
Business Division. Record keeping continues
to be a central theme for the QIT. The QIT
report some on-going improvements. A
summary report of the Trust wide record
keeping audit will be completed within Quarter
2. This summary report will outline key themes
and trends, which will inform the next stage of
work.
Each Business Division provided assurance to
the Clinical Effectiveness Committee (CEC)
that Q2 scheduled progress with Quality
Markers was achieved, with Q3 to be reported
to CEC in January 2014. The QIT work plan
continues to be delivered and reported via the
quarterly Quality Improvement Report to the
Clinical Governance Group. Clinical
Leadership around 'compassion in practice' is
being discussed and debated at the
Professional Leadership Group and Nursing
and Allied Health Professions Networks in
order to embed core values in multidisciplinary
thinking, narrative and practice.
ON
c) Record keeping
Progress with Quality Markers and QIT as
above. CQC Mental Health Act visits have
provided evidence of continued progress with
some areas also identified for improvement. A
comprehensive review of care plan templates
for all Business Divisions has been undertaken.
This work is nearing completion and the final
templates will be completed within Q3.
Quarter 3:
ON
The implementation and monitoring of the
Quality Markers continue to progress in each
Business Division. Care planning remains a
key focus of the QIT in each locality, with
additional support to individual services areas
and teams, as required. Work is underway to
develop corporate care plan templates for each
Business Division.
ON
b) Personalised Care
Each Business Division provided assurance to
the Clinical Effectiveness Committee (CEC)
that Q1 scheduled progress with Quality
Markers was achieved, with Q2 to be reported
to CEC in October 2013. The QIT work plan
continues to be delivered and reported via the
quarterly Quality Improvement Report to the
Clinical Governance Group. Clinical
Leadership around 'compassion in practice' is
being discussed at the Professional Leadership
Group and Nursing and Allied Health
Professions Networks.
ON
The implementation and monitoring of the
Quality Markers continue to progress in each
Business Division. The Quality Improvement
Team (QIT) continue to make good progress.
A timetabled plan for the QIT for 2013/14 has
been developed, allowing for key areas of
focus and flexibility to be responsive to
services, as required. The roles and
responsibilities for community services
document was successfully launched at the
Professional Leadership Group on 12 April
2013.
ON
a) Clinical leadership
ON
Quarter 1:
Quarter 2:
Focus on achieving demonstrable progress in relation to the quality improvement priorities that have been identified of:
ON
1.2
ON/OFF
ON/OFF
Quarterly Strategic Goal Update
ON
1.1
Principal Objectives
(Work Programmes)
ON
Ref No
Strategic Goal 1
Continuously improve service quality (safety, effectiveness and patient experience) for our patients and carers
A draft of 'Listen to Learn', the Trusts Patient
Public and Carer Engagement and Experience
Strategy, was presented to the Clinical
Governance Group on 20 May 2013. 'Listen to
Learn' will be presented to the User Carer
Partnership Council on 23 July 2013. A
2013/14 Implementation Plan has been
included in 'Listen to Learn'. A new 'Listen to
Learn' Steering Group is proposed and initial
discussions will take place on 8 July 2013.
1.5 Provide both those who
are cared for and those
who work for the Trust
a safe and secure
environment
Weapons in the Community Policy has been
drafted and circulated for comment and an Anti
Social Behaviour Policy is to be developed. A
self assessment against NHS Protect security
Standards has been completed and a forward
plan has been drawn up and will be approved
by the Director of Business Assurance.
The Trust Safeguarding Annual Reports for
Children and Vulnerable adults have been
completed. Each includes a work plan for
2013/14. Progress against the work plans will
be monitored by the Trust Safeguarding Forum.
The Trust has completed Safeguarding
Declarations for all main providers. Each
declare compliance, however will be monitored
throughout the year to ensure on-going
compliance and improvements in key areas.
The Trust has submitted Section 11 audits for
each main provider.
The Trust Infection
Prevention and Control annual report has been
completed and includes the work plan for
2013/14. This is on target and is being
monitored through the IP&C committee.
22/05/2014
The Weapons in the Community Policy was
approved and circulated to the Trust in
September 2013. The NHS Project Self
Assessment Tool and Forward Work Plan were
approved and forwarded to NHS Project. The
premises assessment process position
statement is reported to the RMSG monthly. All
security related incident reports are monitored
by a Local Security Management Specialist and
escalated if required to a relevant manager.
The poor compliance with fire procedures, fire
manual updating and carrying of fire/security
keys in secure units have entries within the
Directorate Risk Register. Each has a robust
series of actions which include inspections,
training and exception reporting to either the
Health, Safety & Security Forum or RMSG. The
Safety Team continue to provide Health &
Safety, security and fire training (3in1 training)
and include pertinent topics within this session.
The Trust achieved the Contractors health &
Safety Assessment (CHAS) standard again.
This is a robust accreditation of the Trust's
health and safety processes.
Page 4 of 19
ON/OFF
ON/OFF
ON
The Trust Quality Report for 2013/14 is being
developed and draft versions, which include
updates on the Quality Priorities, have been
discussed at the Clinical Governance Group
and with the Quality Report Co-ordinating
Group. The Quality Report will be submitted to
Monitor on 30 May 2014.
To encourage feedback from patients and
carers, a poster has been designed to be
placed in ward areas and community team
reception areas. The Trust Complaints and
PALS leaflets have been updated to reflect
changes with Healthwatch and the Patient
Experience Team change of address. Work
has been ongoing to create a 'Have your Say'
page on the revised Trust website, this will
offer patients and carers the ability to view
comments made about the Trust and for us to
publish responses (you said - we did).
ON
ON/OFF
Bespoke Complaints training has been offered
to Business Divisions (BDs) and as a result
BDs are effectively catching feedback and
strengthening reporting to Patient Experience
Team. The service User/Carer Surveys for Q2
included the Family & Friends Test (FFT)
question and the revised YOC form also has
the FFT question included. The Organisational
Learning Forum had Patient Experience as a
key topic for discussion at the September
meeting where alternative methods of gaining
feedback were discussed.
The Council of Governor Quality Markers are
the three Trust quality priorities. Governors are
involved in the Quality Report Co-ordinating
Group, which began meeting monthly in
October 2013. Progress on the three Trust
quality priorities for 2013/14 will be reported in
the annual Quality Report, which has to be
finalised and ratified by the Board of Directors
and the Audit Committee by 30 May 2014.
Quarter 4:
Progress on the three Trust Quality Priorities is
reported in 1.1a, b and c.
The second 'Listen to Learn' Steering Group
was held in January 2014 and was attended by
over 30
patients/carers/governors/stakeholders. The
meeting included:
- group work on the ladder of participation
- an update on the consultation work being
undertaken to increase service user / carer
engagement with the Trust
- an opportunity for attendees to 'have their
say'
The mid year report on the NHS Protect Self
Assessment tool and work plan was delivered
the Risk Management Sub-Group,
demonstrating that the Trust has moved
forward from the Q1 position.
The premises assessment process position
statement is reported to the RMSG monthly.
All reported incidents are read by a relevant
subject matter expert and any necessary
escalation notified to the manager.
A Quarterly trend report on incidents is
prepared for the Quarterly Quality Improvement
Report and discussed at the Organisational
Learning Forum.
Compliance with Fire Procedures has
improved, as has emergency Key use, but both
will remain on the Risk Register.
The Incident Reporting Policy, Prevent Policy,
COSHH Policy, PPE Policy, Pregnant &
Nursing Mothers Workers Policy, Work
Equipment Policy, CCTV Policy, were all
updated during the Quarter.
Reports on the position on Managers
Outcomes on Incidents, and the Compliance
with Fire Procedures were presented to the
Trust during the Quarter.
ON
Re-established the patient forum on the Adults
inpatient wards in Doncaster and they are ongoing in North Lincs and Rotherham. A new
YOC form has been launched following
feedback from service users which is self
sealing. Formally collecting form Business
Division where they have changed practice or
service as a result of feedback from patient and
carers.
Quarter 3:
The User Carer Partnership Council (UCPC)
quality markers were signed off for 2013/14 at
the final meeting of the UCPC in November
2013. The UCPC service users and carers will
be able to engage with the Adult Mental Health
Business Division through the locality
collaborative meetings.
ON
Encourage feedback
from patients and
carers and listen, act
and publicise what the
Trust has done (you
said - we did)
ON
1.4
Quarter 2:
An update on the four User Carer Partnership
Council (UCPC) Quality Markers was given at
the UCPC meeting in September 2013.
Leaflets for the Older People and Adult Mental
Health Services are going through the "Get it
Right" process prior to publication. A training
date for service users and carers is taking place
in October 2013 for involvement in staff
recruitment. A WRAP leaflet will be piloted in
October 2013 and the WRAP/Self-Management
questions will remain on the CPA Audit in
2013/14. An increase in meaningful activities
on wards has been reported through the locality
Collaborative meetings and is also reported
through the 2013 Community Mental Health
Survey. Further updates on the UCPC Quality
Markers will be presented at the final UCPC
meeting in November 2013.
ON
Quarter 1:
The User Carer Partnership Council has set
four Quality Markers for 2013/14 on Patient
Information, Service User Involvement in
Recruitment, WRAP and Ward Activities. Clear
links between the CQC Essential Standards of
Quality and Safety and the Trust's quality
priorities have been made. The Quarter 1
2013/14 update on the UCPC Quality Markers
will be made at the UCPC meeting on 23 July
2013.
ON
Implement, monitor
and manage the
Quality Markers
identified by the User
Carer Partnership
Council and the
Council of Governors.
ON/OFF
1.3
Quarterly Strategic Goal Update
ON
Ref No
Principal Objectives
(Work Programmes)
Each year the Trust is required to submit an
annual Safeguarding declaration to our NHS
Commissioners to assure compliance against
national standards.The declaration has been
submitted and the trust is compliant against all
the actions with the exception of the MCA
Policy which has been reviewed and updated
and is due for ratification in May 2014. Staff
compliance against mandatory level 1
safeguarding adult and children training is at
100%.
Version 5
ON/OFF
ON/OFF
Quarter 4:
ON
Quarter 3:
Training in Health & Safety, Fire and Security
(3 in 1) continued, as did the Conflict
Resolution Training.
The safeguarding team are responding
appropriately to case reviews across the Trust
localities. This includes submitting IMR’s and
appropriate action plans. Safeguarding level 1
training has been agreed and will be
implemented throughout the Trust during
Quarter 4. Trust systems and processes and
new national guidance have been tested out in
response to an MRSA bacteraemia. Swift and
effective action has resulted in positive
engagement with clinical teams. Positive
feedback on the Trust approach has been
received from partner agencies, including the
Doncaster CCG. Collectively this has resulted
in whole system improvement in the quality of
patient care.
In April 2013 the Trust Policy Review Panel
was established to monitor compliance with the
Trust Policy for the Development, Management
of Procedural Documents, an evaluation of the
group will be undertaken during January 2014.
ON
Quarter 2:
The safeguarding teams continue to progress
work against the work plan. This includes the
review of relevant clinical policies, ongoing
safeguarding supervision monitoring, work
against lesson learned action plans and
ongoing work with partner agencies with regard
to key national priorities including Child Sexual
Exploitation (CSE) and neglect/early help.
Focus on safeguarding training compliance
continues. The Infection Prevention & Control
work plan is on target. The delivery of training
has been reviewed and through a whole Trust
approach level 1 training and been reaffirmed.
ON
ON
Quarter 1:
ON/OFF
Quarterly Strategic Goal Update
ON/OFF
Ref No
Principal Objectives
(Work Programmes)
Audits - data collection for POMH 7d (Lithium)
data compiled and submitted. Data collection
for medicines audit against 'PRN prescribing',
'safe and secure handling of medicines' policy,
and the SOP for Management of Controlled
Drugs, took place through September (to report
in October). Reporting process of actions plans
against POMH audits revised.
22/05/2014
Training - Medicines Management Training
sessions provided for Junior Doctors (2) and
nursing staff (12). Pharmacist 10 point plan
completed for 615 patients.
Page 5 of 19
• POMH audit results for 13a & 7d presented
Quality meetings. Action plan reporting is still
patchy but improving. Process of running the
audits revised with the audit team.
• Medicines management training session
continued to run across the Trust for nursing
staff - 5 sessions/month. Each session
included policy update and medicines related
IR1 issues.
• Reviewed or established four PGDs
• Ratified SOP for medicines administration by
syringe drive, including support training and
review/redraft of ‘Instruction to administer’
paperwork between primary care and Trust
clinicians
• Reviewed/redrafted Dressings Formulary
• Reviewed guidance for monitoring for
antipsychotics – redraft in new ‘At a Glance’
(single side of A4) format
ON
• 590 ten point plans undertaken. Previous
areas of concern continue to decline in
frequency.
• POMH 1f audit received by MMC. Direction
given to re-audit some wards due to delay in
report getting to committee.
• In-patient antipsychotic audit received. Junior
doctors training amended in response
• Insulin administration chart developed and
undergoing trial.
• Clozapine clinic protocol reviewed and
agreed.
• Three PGD’s updated
• Two new PGDs developed
• Lithium monitoring policy has been updated
in line with national renal standards
• Antibiotic guidance agreed for use in
Rotherham and Doncaster
Version 5
ON
POMH outcomes – there has been none
returned to the Trust within this quarter. Data
submission for POMH 13a [ADHD] took place
in April 2013. Data collection for POMH 7d
[lithium] is underway in June 2013.
The CQUIN loss for 2013/14 so far is £69,022
(97.9% achieved), which includes the full
£53,252 described above as it must be
declared as a CQUIN loss; however the actual
loss to the Trust to date is £46,834 (98.6%
achieved).
ON
Continually review
medicines
management systems,
approach and safety
The first meeting of the Information
Performance & Digital Health Group met in
November. Regular meetings with
Commissioners are in place and mechanisms
remain effective
ON
1.7
Processes for managing the delivery of
CQUINs remain in place and updates are
provided to PAG. Working groups continue
where required. A Trust wide group to oversee
CQUIN and Pre-qualification Criteria
Performance is being established for Q3. Q2s
submission is due to Commissioners by end of
October.
ON
Processes for managing the delivery of
CQUINS continue in 2013/14 via reporting to
BIG and the Performance and Assurance
Group. In addition, working groups have been
established for some of the bigger CQUINs e.g.
OTW, Community Nursing Information,
Transition and Recovery. All CQUINs are on
track for delivery against Q1 requirements and
submissions will be made to commissioners by
the end of July.
ON
Maintain an effective
mechanism to support
the delivery of CQUIN
targets and as a result
demonstrate
improvements in
quality
ON
1.6
ON
The Risk Management Sub Group receives
quarterly reports on the management of Trust
procedural documents that details compliance
with agreed policy review dates.
ON/OFF
ON
The system continues to work
well.
In last quarter almost all
appraisals conducted (that
needed to be conducted as part
of the annual cycle), signed off
by appraisers and appraisees,
then final forms seen by
Medical Director. Where this
has not occurred it was in order
for final supporting information
to be supplied.
ON
TBC
There are no changes therefore
the position remains the same
as for Q2
ON
The system is working fine. We
are still in the first 12 months of
a major national overhaul,
hence the reason for constantly
needing to respond to the
Revalidation people at the GMC
and Dept of Health, as to
whether anything else is
required.
Update at Q2
b) further develop
and enhance medical
appraisal processes
and the use and
provision of
supporting
information to support
the effective
implementation of
revalidation for
doctors
ON
ON
Quarter 1:
Quarter 2:
Quarter 3
Quarter 4:
2.1 Continually improve leadership capacity and capability, specifically regarding clinical engagement, innovation and succession planning and
implementation of 360 degree feedback systems.
a) to include
2 cohorts have just completed
Each Business Division
Both advanced nurse
Each Business Division
Advanced Practice
the internal leadership
provided assurance to the
practitioners remain on
provided assurance to the
and Professional
programme in Q1. A
Clinical Effectiveness
schedule with their academic
Clinical Effectiveness
Standards
management and leadership
Committee (CEC) that Q1
work, clinical placements and
Committee (CEC) that Q4
scheduled progress with Quality
scheduled progress with Quality
programme has been scoped
overall achievements. The
Markers was achieved, with Q2
Markers was achieved. The
and discussed at the Senior
Trust is undertaking work with
to be reported to CEC in
QIT Phase 1 work is being
Leadership Team meeting on 1
HEEYH to establish a further 2
October 2013. The QIT work
drawn to a close and Phase 2
July to support the Fit For
advanced nurse practitioner
plan continues to be delivered
initiated which will seek to
Future programme.
posts. It is anticipated
and reported via the quarterly
utilise the Fit for the Future
recruitment will begin early in
Quality Improvement Report to
outcomes to establish a quality
The two Trust Advanced
the new calendar year.
the Clinical Governance Group.
Peer Review model for the
Practitioners are both on target
The second Government
Clinical Leadership around
Service Directorates. Some
to complete their first year of
response to Francis ‘Hard
'compassion in practice' is
focussed activities around
training. Plans are in place to
Truths: The Journey to Putting
being discussed at the
Clinical Leadership of
evaluate the initiative at year 1
Patients First’ published on 19
Professional Leadership Group
'compassion in practice' are
(end of Q2). Developments
November 2013 (DH 2013) has
and Nursing and Allied Health
being undertaken by Business
have been shared at a regional
been shared at professional
conference aimed at supporting
Professions Networks.
Divisions in order to embed the
forums and key sections
the development of advanced
core values.
discussed in detail, for example
practice roles. The Trust
the ‘Nursing’ section at the
professional leadership group is
Trust Nursing network.
active and is currently reviewing
national implications for
professional practice, The
Francis Report and
Winterbourne View SCR.
ON
ON/OFF
ON/OFF
Principal Objectives Quarterly Strategic Goal Update
(Work Programmes)
ON/OFF
Ref No
Strategic Goal 2
Nurture the talent, commitment and ideas of our staff in order to deliver excellent services
All doctors who required a
Revalidation recommendation
from the Medical Director to the
GMC in the quarter have had
positive recommendation.
System for collecting
supporting information in place
with dedicated admin support
for this.
22/05/2014
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Version 5
22/05/2014
7 of 19
ON/OFF
The Trust's compliance with the
Public Sector Equality Duty
(PSED) 2013/14 has been
completed and will be
published following Board
approval, this includes the
workforce data information
relating to the protected
characteristics. The Equality
and Diversity webpage is being
updated as part of the 'New
Look' Trust website. The E&D
Lead and E&D Assistant are
attending the National
Conference of the new EDS2 in
Manchester in April 2014.
Work is ongoing on the Equality
Analysis process for all policies,
services, events and strategies
throughout the Trust.
ON
ON/OFF
The EDS has been
independently evaluated and a
refreshed EDS known as EDS2
was published in November
2013. This has a core set of
outcomes and a more
streamlined grading system,
organisations are encouraged
to use the tool more flexibly and
to enforce key local health
inequalities. The EDS 2 will be
applied to people with protected
characteristics and those from
disadvantaged groups. NHS
England starting in 2014 will
identify one EDS2 outcome per
year where it believes
concerted national effort is
required in order for the NHS to
improve on its Equality
performance an easy read
version of EDS2 is to be made
available. A presentation on
the EDS2 will be delivered to
the HR&OD Policy Planning
Group on the 9th January
2014.
ON
ON/OFF
Work is ongoing to integrate the
EDS with the work being
undertaken on the Essential
Standards through the Essential
Standards Working Group.
Equality Act Awareness training
continues to be part of the Trust
Induction Programme and the
'update' week. Training
sessions are continuing to be
delivered to teams and
locations within Business
Divisions. Work on Equality
Impact Assessments continues
and a Policy Review Panel
meets monthly to review both
policy and EIA before being
submitted to the relevant
committee for approval.
Quarter 4:
The Fit for the Future
programme is drawing to a
conclusion with most of the
Managers having completed all
5 modules. Additional sessions
are currently taking place to
ensure all participants have the
opportunity to complete the
programme.
The latest sickness audit was
reported at HROD in April and
sickness continues to be
reported through the HROD
dashboard.
The staff survey results (core
results compated with sample
survey) were reported at the
February HROD and
subsequently repoted to the
TSC. An increase in response
rate was noted.
The Personal Responsibility
Framework is being used
significantly and an associated
reduction in disciplinary
hearings is evident.
ON
Work is ongoing to integrate
the EDS with the work being
undertaken on the Essential
Standards through the
Essential Standards Working
Group. Equality Act Awareness
training continues to be part of
the Trust Induction programme
and the 'update' week. Training
sessions are continuing to be
delivered to teams and
locations within Business
Divisions. Work on Equality
Impact Assessments continues.
Quarter 3
The Fit for the Future
programme has commenced
and the Trust is currently
inviting attendance at the spring
series of Leading the Way with
Quality events for those staff
members not involved in the
FFF workshops to engage a
wider audience with the themes
from the programme. The
sickness absence audit has
been undertaken and the
results passed to the BSU's for
action. The results of the staff
survey for 2013 have been
received and the information is
currently under review. The
Policy Forum have been
working through the Personal
Responsibility Framework draft
policy and a meeting has been
arranged for January for staff
side to discuss the final
practicalities with the Director of
W & OD.
ON
Ensure that the Trust
exercises its
functions with due
regards to the
General Duty as
stated in the Equality
Act 2012 and that it
can demonstrate
compliance with the
Public Sector Equality
Duty.
ON
2.3
Quarter 2:
Review of staff survey action
plans planned for October
2013. Fit for the Future
development programme
includes cultural issues to be
considered within the
programme. Personal
Responsibility Framework
Policy drafted and due for
discussion at Policy Forum in
October. Staff side are
exploring the practical
implications of operating within
the PRF. Sickness absence
monitoring and review of the
management processes
continues to be reported
through the Dashboard to
HR&OD.
ON
ON/OFF
Audit the culture of
the organisation to
continuously improve
service quality, safety
and effectiveness for
our service users and
carers.
ON
2.2
Quarter 1:
Culture Audit Trust document
/evaluation discussed at
HR&OD meeting in June 2013,
and main theme of current
Leading the Way with Quality
Workshops. Personal
Responsibility Framework
rollout planned training
throughout 2014, Director of
Workforce has received a draft
proposal from staff side in
relation to progressing further
integration of the Framework
within the Trust. Sickness
Policy under revision and
planning commenced for
2013/14 Sickness Absence
Audit.
ON
Ref No
Principal Objectives Quarterly Strategic Goal Update
(Work Programmes)
Version 5
ON/OFF
ON/OFF
Quarter 3
As the service needs develop
and evolve the Education
service continue to review the
mandatory training based on
service need and organisational
requirements. A new model is
currently being developed for
implementation in April 2014
making better use of resources
through blended learning and
offering more bespoke
sessions within clinical areas.
Prior learning will be taken into
consideration with
competencies assessed before
training is undertaken.
Compliance continues to be
reported monthly to HR/OD and
national competencies are
currently being applied to
individual staff training records
on OLM/ESR to improve
compliance reporting
Quarter 4:
Working with SME's and
service managers alternative
methods of delivery have been
reviewed with a new
programme ready for
implementation April 2014.
Quality assurance within
training programmes is secured
through piloting and
assessment evaluation and
audit. Quality measures are
already in place for external
training and guidance
documentation for trainers.
Compliance reporting
information is taken from the
National Oracle Learning
Management System. The
system is being constantly
refined to ensure accurate
figures are recorded.
A large piece of work has been
identified this year and, new
NHS Competencies have being
agreed with local managers for
all staff and then applied to all
staff electronic records.
ON
ON
Quarter 2:
Learning and Development
Forum. New dates to be
arranged for the coming year
taking into consideration other
strategic meetings to ensure full
attendance where possible.
Mandatory training report
occurs monthly. Continue to
update all staff attending
Induction to Dashboard and
HR/OD on a monthly basis.
Compliance is reported through
HR/OD and we have improved
the reporting mechanism.
Through OLM and the NHS
Competencies, we are able to
monitor the resources available
to meet the demands of the
service.
ON
ON/OFF
ON/OFF
Quarter 1:
Improve compliance From April 2013 a revised
on the uptake of
format for the mandatory
Statutory/Mandatory training report on compliance
training with
has been introduced. This
consideration given to report provides: number of
existing and future
places available, uptake
national legislation
including number of staff
including NHSLA and attended and compliance and
training specific
number of places lost due to
role/discipline and
DNA’s. The report will enable
service requirements. the individual Assistant
Directors/Heads of Service to
monitor compliance and uptake
of training on a month by month
basis to ensure that sufficient
numbers of staff are accessing
training. It will also enable the
Learning and Development
Service to monitor the courses
delivered and uptake so that
there are sufficient numbers of
places available across the
year. A comprehensive
benchmark of mandatory
training has taken place to
reduce the number of training
days overall and introduce
different modes of delivery
ON
Ref No
2.4
Principal Objectives Quarterly Strategic Goal Update
(Work Programmes)
This will assist in the accurate
reporting of all training. It will
also ensure all staff are aware
of what training they should be
completing via an online visual
individualised training matrix
prior to self- service being
rolled out in April 2014.
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22/05/2014
9 of 19
ON
ON
The draft 2014/15 QIPP plans
have been agreed with the
divisions. These will be followed
up with a detailed meeting with
each division on the 7th Jan
and a board presentation by the
divisional leads at the board
timeout on the 27th January
The QIA analysis will be
completed by 11th October and
the plans presented to Find in
November.
ON/OFF
ON/OFF
ON/OFF
ON
Draft QIPP plans for 2014/15
have been developed and
meetings have been held with
the divisions to review the
plans.
Quarter 4:
The outturn position reported to
the board in April acheives the
plan target set out in the original
plan and maintains the Trust
COSR at 4. This is subject to
external audit
The Quality Impact
Assessments (QIAs) position
for the 2014/15 QIPP schemes
was included in the QIPP paper
presented to the Board of
Directors in February 2014.
The completed QIAs have been
submitted to each of the Clinical
Commissioning Groups and
monitoring arrangements
agreed.
The QIPP plans were signed off
by the Board of Directors in
March when a paper was
submitted that show the RAG
rating for each initiative. The
red RAG rated initiatives are
subject to an action plan until
they deliver on a recurrent
basis.
Version 5
ON
A time line for the development
and sign off of the QIPP plans
has been agreed by the board
and initial ideas will be reviewed
at the end of July.
Quarter 3:
The Trust financial position at
the end of November as
reported to the BoD in
December is on target to
achieve the financial plan.
ON
To develop the
financial plan for
2014/15 during
2013/14 and in
particular the
development of the
2014/15 QIPP plans
ensuring that:
• attendance at key
meetings to ensure
intelligence is
gathered and
reported back to the
Board
• Financial plans are
RAG rated for
delivery and reviewed
by the Board
• QIAs are RAG rated
for delivery and
reviewed by the
Board
Quarter 2:
As at the end of August (Month
5) the Trust is overachieving on
it's financial plan and targets
ON
3.2
Quarter 1:
Month 02 Financial position has
been reported to FIBDG and the
Trust Board and is currently on
target to deliver the annual plan
targets.
In addition a call conference has
been held with Monitor to discuss
the annual plan which was
positive.
ON
3.1 To ensure the
2013/14 Financial
plan is signed off by
the Trust Board and
Monitor and that
appropriate
monitoring is put in
place for delivery
including:
• monthly monitoring
and reporting of the
revenue, cash and
working capital and
CAPEX position
• quality impact
assessment
processes of financial
decisions.
ON/OFF
Principal Objectives Quarterly Strategic Goal
(Work Programmes)
ON
Ref No
Strategic Goal 3
Ensure value for money and increased organisational efficiency whilst maintaining quality
The moves from St Catherine's
house to Woodfield House are
complete. With the final moves
of the business division to park
lodge annex to be completed by
the end of July. An update on the
strategy for the red zone will be
presented to June board - private
session.
22/05/2014
The Care Pathways and
Currency Development Group
continues to meet on a monthly
basis, with the December 2013
meeting focussing on the
development of the 2014/15
Memorandum of
Understanding, which will be
finalised in quarter 4 2013/14.
An event will beheld on 17th
October to develop the Friends
of Woodfield Park. The park
will be officially launched on the
1st December.
10 of 19
Woodfield park has now been
officially launched and the
business plan for the
establishment of Flourish
Enterprises will go to the Trust
board in January. With effect
from the 6th January there will
be 6 tenants in St Catherine's
house and a tenant in the old
health promotion building.
Further discussions are
progressing re the other
buildings on the site.
The funding for the PBR team
has been secured for 2014/15
and the MOU has been agreed
with each commissioner as part
of the contract negotiations.
Work is continuing to share the
prices with commisioners and
understand the potential impact
of a move to a PBR regime.
The Flourish business case has
been signed off by the board,
the Directors have been
identified and the application for
Flourish to be a community
interest company has been
submitted to company's house.
The drive to lease out buildings
no longer needed for NHS use
has been a success in that a
number of business have
signed up to leases on the site.
Interviews were held at the end
of April for the business
manager and operations
manager and appointments will
be announces early in May.
Version 5
ON
The local CQUIN for 2014/15
for care pathways and
packages has been agreed,
and will for adult and older
peoples mental health services
will focus on the continued
development and
implementation of the 'Four
Factor Model'.
ON
The Trust continues to be a
member of the National Care
Pathways and Packages
Project (CPPP) Consortium,
and is actively involved in all
workstreams, including the
development of the costing
guidance and the development
of the national outcome
measures.
ON/OFF
ON/OFF
ON/OFF
The final mental health pricing
system guidance was published
on 15 December 2013. This
guidance will be considered at
the 2014/15 contract meetings
with each of the
Commissioners, which begin in
January 2014.
ON
3.4 Ensure delivery of the
key milestones in
relation to the signed
of Balby Estates
Strategy
The development of the Care
Pathways and Packages
continue to be discussed,
reviewed and understood in
locality clinical-to-clinical
meetings. The Memorandum
of Understanding (MoU) has
been reviewed in Q2 2013/14
by the Care Pathway and
Currency Development Group
and comments will be
considered in the development
of the 2014/15 MoU. The joint
Care Pathway and Currency
Development Group continues
to meet on a monthly basis and
monitors the implementation of
the jointly developed Project
Plan. Members of the Trust
and Commissioners attend
national and regional groups to
contribute to the development
of Care Pathways and
Packages, ie Quality and
Outcomes Group. The Finance
Director and members of the
Trust have contributed to the
development o the National
Guidance 2014/15 which is
expected to be published for
consultation in October 2013.
Quarter 4:
The Care Pathways and
Currency Development Group
continues to meet on a monthly
basis. Discussions during
quarter 4 2013/14 have
focussed on the 2014/15
contract. The Group has
developed and agreed the
Memorandum of Understanding
and local prices for inclusion in
the 2014/15 contract. The draft
project plan for 2014/15 has
been discussed and will
continue to be monitored by the
Group.
ON
The Group is responsible for
monitoring the jointly agreed
2013/14 Project Plan and
considers and responds to
national documents and
guidance on care pathways and
PbR. The Trust continues to be
a member of the Care Pathways
and Packages Project
Consortium and members of the
Trust regularly attend and
contribute to work stream
groups, the Central Project Team
and the Programme Board. The
Finance Director continues to
attend the National Costing
Group and contributes to the
debate to develop future national
PbR guidance.
Quarter 3:
Contract negotiations will be
held in January to discuss the
scope of PBR for 2014/15 and
to agree the MOU with
commissioners.
ON
ON
The Trust and the three main
Commissioners have an agreed
Memorandum of Understanding
in place for 2013/14 for the
development of Care Pathways
and Packages and PbR. Care
Pathway and Packages
development continues with
Commissioners, and sessions
have taken place during quarter
1 2013/14 in each locality. The
Care Pathways and Contract
Currency Development Group, a
joint Trust and Commissioner
group, continues to meet on a
monthly basis.
Quarter 2:
The draft Guidance for 2014/15
has now been received and a
paper will be presented to
FIBDG in October, updating on
this and progress todate.
ON
Quarter 1:
The Finance Director attended a
further meeting of the national
costing / MH PBR group in June
where draft guidance for 2014/15
was discussed. A paper setting
out the current thinking was
presented to June FIBDG and an
action plan will be presented
later in the financial year.
ON
3.3 Continue the
implementation and
development of the
Care Pathways and
Packages Project
with support of PbR
in partnership with
Health and Social
Care commissioning
partners.
ON/OFF
Ref No
Principal Objectives Quarterly Strategic Goal
(Work Programmes)
22/05/2014
11 of 19
ON/OFF
ON/OFF
Quarter 3:
A further meeting is scheduled
with the Deputy Director of
public health in the 3rd week in
January to discuss the value of
contracts for 2014/15 and in
particular the re-design of the
substance misuse service.
Contract meetings with the
other key commissioners have
been set up throughout January
and February.
Quarter 4:
The DMBC contract has been
signed and agreed and regular
commissioning meetings will be
scheduled for the year. Regular
1:1 meetings and attendance at
Health and Wellbieng boards
are ensuring an understanding
of the better care fund and an
initial paper on the impact was
submitted to FIBDG in April.
Version 5
ON
Quarter 2:
A meeting is to be held in
October with the Deputy
Director of Public Health to
discuss the financial
assumptions for 2014/15.
ON
ON/OFF
ON/OFF
Quarter 1:
RDaSH staff attended the soft
market event on the 7th June. A
further meeting will be held with
senior staff at DMBC to discuss
the way forward.
ON
Continual liaison with
the Trust's
commissioners to
ensure that the
financial risk of health
and social care
changes are
managed
ON
Ref No
3.5
Principal Objectives Quarterly Strategic Goal
(Work Programmes)
ON/OFF
Commissioner Relationship
Management remains a
standing agenda items at the
Business Development Forum
and is reported in the quarterly
Commercial Development
Update to the Board of
Directors (January 2014).
There continues to be a focus
in respect of our local authority
commissioners. In addition, the
Trust's CAMHS in Doncaster
and Rotherham have received
some attention in the report as
a result of contracting and
funding matters. The 2014/15
contract negotiations were
concluded and contracts with
all of our main commissioners
were signed.
Rotherham DCCG has
commenced discussions in
September 2013 with the Trust
in relation to developing a
liaison service within the
Rotherham Foundation Trust.
22/05/2014
Page 12 of 19
Version 5
ON
Quarter 4:
The quarterly Commercial
Development Update to the
Board of Directors in January
2014 presented an update on
the implementation of the
Business Strategy 2012-15.
The main focus on risk
continued to be in relation to
public health commissioning,
particularly the tendering of the
Doncaster and Rotherham
smoke free services and the
plans of North East Lincolnshire
Council in respect of the future
procurement of drug and
alcohol services.
Opportunities reported included
East Midlands Male Mental
Health Locked Rehabilitation
and Rotherham Mental Health
Liaison developments.
ON
ON/OFF
Commissioner Relationship
Management remains a
standing agenda items at the
Business Development Forum
and is reported in the quarterly
Commercial Development
Update to the Board of
Directors. Commissioner
relationship considerations
within the October 2013 report
continued to focus primarily on
Local Authority commissioners.
Towards the end of the quarter,
Rotherham CCG and
Doncaster CCG commenced
engagement with the Trust in
relation to developing their
future commissioning
intentions. Negotiations with
Rotherham CCG continue in
relation to developing a liaison
service within the Rotherham
Foundation Trust A & E service.
ON
ON/OFF
Commissioner Relationship
Management remains a
standing agenda items at the
Business Development Forum
an dis reported in the quarterly
Commercial Development
Update. Commissioner
relationship considerations
within the July 2013 report
particularly focussed on our
approach with Local Authority
commissioners.
Commissioners are well
engaged with the Care
Pathways and Packages
Project with cluster specific
care pathway development
progressing well in Doncaster
and Rotherham. Doncaster
CCG invited the Trust to attend
an event in September 2013 to
inform their commissioning
intentions for 2014/15.
Quarter 3:
The quarterly Commercial
Development Update to the
Board of Directors in October
2013 presented an update on
the implementation of the
Business Strategy 2012-15.
The main focus on risk within
the update was a further update
on public health commissioning
intentions and procurement
timescales in Doncaster.
Potential opportunities were
highlighted for the Adult Mental
Health and CAMHS Business
Divisions. The CAMHS Tier 4
Business Case presentation to
FIBDG and resultant decision
was also identified.
ON
Commissioner Relationship
Management remains a
standing agenda item at the
Business Development Forum
and is reported in the quarterly
Commercial Development
Update. Commissioner
relationship considerations are
included within each of the
relevant business risk and
opportunity quarterly updates.
Commissioners are well
engaged with the Care
Pathways and Packages
Project with cluster specific
care pathway development
having now commenced in all
three localities.
ON
b) Continue the
implementation and
development of the
Commissioner
Relationship
Management
approach, to support
clinical engagement
in service
performance and
improvement
planning.
Quarter 2:
The quarterly Commercial
Development Update to the
Board of Directors in July 2013
presented an update on the
implementation of the Business
Strategy 2012-15. The main
focus on risk within the update
was in relation to the current
assessment o of the public
health commissioning intentions
in each locality, including the
financial implications. Other
risks discussed included the
transfer of the supported living
service to Care UK and the
commissioning position o of the
Manchester Early Intervention
in Psychosis Service. Potential
opportunities were highlighted
for the ADULT Mental Health
and DCIS Business Divisions.
The role of the Trust Staff
Council in this agenda was also
recognised.
ON
Quarter 1:
The quarterly Commercial
Development Update was
presented to the Board of
Directors in April 2013. The
matters addressed included
strategic development and
updates on the relevant
business risks and
opportunities. Information was
also provided on the
development of Flourish
Enterprises and the progress of
the Care Pathways and
Packages Project.
ON
4.1 a) Manage any risk
arising from
implementing the
Business Strategy
2012-2015.
ON
Principal Objectives Quarterly Strategic Goal
(Work Programmes)
ON/OFF
Ref No
Strategic Goal 4
Adapt and deliver services to meet agreed commissioned needs through enhanced multi-agency partnerships
ON
ON/OFF
ON/OFF
The Joint Governance Board
met for the final meeting in
September 2013. Adults have
rolled out in all areas although
the accommodation remains an
issue for the North area, and
timelines have been exceeded.
There still remain issues
around the progress in
Children's due to Central
Government intervention into
the Local Authority. The
Government imposed financial
savings within the Local
Authority is also having an
impact on the accommodation
requirements and further rollout
within Children's. RDaSH is
working closely with DMBC and
partners and are included as
part of the Early Help Strategic
group to shape the future. The
One Team Working approach
has the capacity to flex and
adapt.
ON
ON
Quarter 4:
A marketing approach
continues to be adopted in the
implementation of the ICT
Strategy, the Listen to Learn
Strategy, the Fit for the Future
Programme, The Woodfield
Park development and the
Hospice Fundraising campaign.
The evaluation continues for
the adult pathway and OTW is
well embedded into Trust
community services.
There is some variation on how
MDTs are running but a
framework is being developed.
Many GPs are well engaged
but further work is required to
support them in risk stratifying
their patients.
The SPA is up and running
successfully and is currently
based at the Mary Woollett
centre.
The CYP&F pathway for OTW
continues with some colocation
and much improved
relationships and joint working.
The CYP&F teams are working
closely with partners with the
formation of the new
collaboratives and are building
on the ethos of integrated
working.
In Adults, North has now gone
live with the Single Point of
Access, this will be rolled out
across the area to all One
Team Working areas following
the pilot in the North.
22/05/2014
Page 13 of 19
Version 5
ON
The project will finish at the end
of September 2013. The Joint
Governance Board will meet for
a final time on the 15th
September 2013 to signoff the
transition arrangements. There
remain issues around the
progress in Children's due to
Central Government
intervention into the Local
Authority. As more information
becomes available, the One
Team Working approach has
the capacity to flex and adapt.
Quarter 3:
In October 2013, the Business
Development Forum undertook
a review of the current
marketing activity in relation to
strategies that is taking place.
This was reported to the Board
of Directors in the quarterly
Commercial Development
Update. A marketing approach
is currently being applied to the
Listen to Learn Strategy, the Fit
for the Future programme, the
Hospice fundraising campaign,
the flu fighter campaign and it is
anticipated will be required to
the workforce strategies that
are under development.
ON
ON/OFF
ON/OFF
An update on the progress of
the One Team Working Project
was considered at the June
2013 Board of Directors
meeting. The project is
progressing in line with the plan
and continues to role out. Adult
model is on target to deliver.
However co location is delayed.
Children's one team working is
progressing slowly and
accommodation issues are
actively being worked on.
Quarter 2:
In addition to the Q1 update, a
marketing approach has been
adopted for - The Woodfield
Park development; - the Fit for
the Future programme; - and to
support the selling of beds at
Coral Lodge. Development
work commenced in the quarter
in relation to developing
marketing materials to support
the Stop Smoking service, in
preparation for tender, also the
Flu Campaign and the Hospice
fundraising project.
ON
4.2 Implement the
arrangements
associated with One
Team Working in
Doncaster for Adults
and Children’s
services
Quarter 1:
The implementation of the ICT
Strategy, continues to adopt a
marketing approach. The initial
draft of the Recovery Strategy
has been produced and a
marketing approach will be
adopted to its implementation.
Flourish Enterprises continues
to utilise marketing approaches
to promote its products e.g.
Sunday opening.
ON
c) Adopt a marketing
approach to the
development of Trust
strategies.
ON
Ref No
Principal Objectives Quarterly Strategic Goal
(Work Programmes)
ON/OFF
ON
ON
ON
Quarter 1:
Quarter 2:
Quarter 3:
Quarter 4:
4.3 Support the workforce aspects of service redesign/integration initiatives aimed at more efficient and effective service provision,
a) including review of Rotherham LD revised structure
LDSL Doncaster Service in
Consultation re move from
The BSU's comntinue to work
waking nights to sleep-ins in
and re-modelling
actioned following consultation
Doncaster successfully
well and are developing
Rotherham suspended pending
Learning Disability
process. Only one individual
transferred to Care UK on 1st
positively. We are now
further review of the needs of
Services
remains at risk. All other staff
September 2013. Work on the
beginning to review wider
individuals and contract
have been redeployed with
first immediate phase of
corporate services to assess if
negotiations with RMBC for
appropriate protection where
workforce redesign in LD
any further functions need to
new care packages in line with
applicable. LD Supported Living
complete. Continues to work
become part of the BSU.
the modernisation plans for
service in Doncaster transfer
on the development of the
Following further negotiations
Oak Close and John Street, for
arrangements are currently in
Community Interest Company
and agreement with RMBC a
Supported Living from
the consultation process phase
revised plan to move from
Feb/March 2014.
and actioned in accordance
Consultation concerning the
waking nights to sleep-ins in
with the project plan. Terms
move from Waking Nights to
Rotherham has been consulted
Consultation to reduce the
and conditions /competitive
"sleep-ins" has commenced.
upon and achieved. The night
substantive medical workforce
market issues discussed with
Proposals to review "sleep-in"
service in Rotherham is
in Rotherham has now ended
staff side
payments in Doncaster has
bespoke to each service area
and a workforce plan and
been raised at the TSC.
and is being appropriately
clinical review has commenced.
Progress is continuing in
Consultation arrangements
provided in line with the needs
developing the organisation
have concluded in relation to
of the individuals being
Final management restructure
vehicle to support the review
the GP Out-of-Hours Service
supported
consultation following loss of
and remodelling of LD services.
(Rotherham)
SL Services ends on 31/12/13.
This was agreed at SLT on
10.6.2013
The final management
ATU beds in Rotherham
restructure consultation
reduced to 5 (from 10) and
following loss of SL Services
Commissioners requesting
has now concluded and has
independent clinical review
been achieved. Final
before progressing any further
management structure was
reductions. Workforce plan in
operational from March 2014
place to mitigate any
redeployment risks.
ON
ON/OFF
ON/OFF
ON/OFF
Ref No
Principal Objectives Quarterly Strategic Goal
(Work Programmes)
The substantive consultant
workforce has been reduced by
1 WTE and an established LD
locum has been arranged for a
period of 6 months in order to
ensure clinical safety during the
on-going commissioner led
review and change to the
service model Independent
clinical review of ATU has
concluded and a decision on
the chosen recommendation is
expected be to be confirmed at
the LD Partnership Board on
16th May 2014. The Division
has plans to mitigate and
manage any option.
22/05/2014
Page 14 of 19
All actions linked to Phase 1 for
Intermediate Care from a
workforce perspective have
been successfully concluded.
The staffing rotas and Job
descriptions have all been
updated. The current focus is
on the maintenance of a flexible
workforce.
Version 5
ON
All actions linked to Phase 1 for
Intermediate Care from a
workforce perspective have
been successfully concluded.
ON
New intermediate care facility
on Hazel ward opened 4th
June. Further discussions to be
had regarding phase 2 of
intermediate care provision.
Work commencing on Phase 2
of the Intermediate Care facility.
Draft rotas have been prepared
for sharing with the staff, and
the accommodation moves
have been actioned. Final
phase is to review the job
descriptions which is planned
for Sep/Oct 2013.
ON
Consultation document
discussed at TSC in May 2013
ON
b) including the
remodelling of
intermediate care
provision in
Doncaster
Page 15 of 19
(b) The workshop facilitated by
PwC and Capsticks' s was
held in October 2013 to inform
and
enable
further
consideration by the relevant
Business Divisions as to their
future organisational form.
ON/OFF
ON/OFF
ON
ON
ON
ON
(a) A Recovery College has
been established in the North
Lincolnshire
Adult
Mental
Health service, which became
operational during this quarter.
Forms have been submitted to
companies house to register
Flourish as a community
interest company. A 4 year
business plan supported by the
RDaSH board has been agreed
and appointments to the key
posts will be announced in May.
(a) The development of the
North Lincolnshire Recovery
College has continued. A
provider collaborative is being
planned for wellbeing support
providers (including RDaSH)
within the Doncaster locality,
based on the model proposed
within the Wellbeing Strategy
(b) A teleconference has taken
place with another trust that
has established a social care
arm and a visit is planned to
this trust. A proposal for the
establishment of a social care
arm in RDaSH will be prepared
during Q1 of 2014/15
Version 5
ON
(b) A report has been
submitted to the Trust's
advisors (PWC/Capsticks) in
advance of the workshop to be
held on 25 October 2013, to
consider the applicability of
various organisational models
to meet the needs of those
services under the threat of
competition.
Quarter 4:
The BSUs continue to work well
and are developing positively.
We are now beginning to
review wider corporate services
to assess if any further
functions need to become part
of the BSU.
ON
ON/OFF
ON/OFF
A business case is currently
been prepared to recommend
the establishment of Flourish
Enterprises as a stand alone
social enterprise. The aim is to
present this to the January
FIBDG and Board.
(a) A Wellness & Recovery
Strategy has been completed
and approved by SLT.
Business Divisions are in the
process of developing their
specific plans aligned to the
strategy.
N/A
22/05/2014
Quarter 3:
The BSU’s continue to develop
looking at ways to support the
business divisions with a new
meeting structure in place
which replaces the old
Business Intelligence Groups,
further development work with
the Business divisions is
planned for the new year.
ON
b) Establish a whollyowned arms- length
subsidiary body to
provide a suitable
competitive vehicle
through which the
Trust may compete
for services
competitively
tendered across all
localities.
The draft Business Plan has
been completed. A meeting will
beheld in October with PWC
and Capstick to discuss the
social enterprises model. Once
this is clear, the business case
will be presented to FIBDG.
ON
4.4 Develop and implement a Recovery Strategy to:
a) To develop
Flourish Enterprises
as a stand- alone
trading social
enterprise to provide
work and vocational
N/A
opportunities to
service users / ex
service users.
Quarter 2:
The new arrangements
commenced in July 2013. The
Business Support Units are now
in place and fully functioning.
All Business Divisions have
participated in a workshop with
the BSU to look at how they can
work together effectively - this
was positively received by all.
The new meeting structure is
now in place and working
effectively.
ON
Progress is continuing in setting
up the business Support unit.
Colocation will begin in middle
of July 2013. Business Support
unit will go live from beginning
July 2013.
ON
Quarter 1:
Following the consultation
process Operational roles have
been appointed to and the
Corporate staff highlighted as
moving to the BSU's have now
been allocated to the BSU's
Update at Q3
c) including the
reorganisation of
operational and
corporate services
Update at Q2
Ref No
Principal Objectives Quarterly Strategic Goal
(Work Programmes)
CQC registration requirements
continue to be met and
monitored via the Business
Assurance Directorate. Monitor
requirements are monitored via
PAG and FIBDG. The Trust
responded to Monitor's recent
consultation on the new Risk
Assessment Framework which
will be introduced later in
2013/14.
There have been no new
Ofsted inspections. Work is
ongoing with Partner
organisations in each of the
Trusts main localities to prepare
for the new Ofsted inspection
regime due to commence in
late 2013.
22/05/2014
Marketing and support to
tenders has impacted on the
redesign work for the Trust
website. Prioritisation
discussions scheduled for SLT
in early New Year
The new OFSTED inspection
regime has not yet
commenced. Therefore work
with all partner agencies in
each of the Trust main localities
is continuing. The approach
differs in each locality, however,
all focus is on reviewing the key
anticipated areas of injury.
Page 16 of 19
The CQC has announced that it
will be undertaking inspections
of Safeguarding and Looked
After Children services within
health providers. The CQC has
indicated that it will initially
focus on the 20 local authorities
in England that have been
inspected by Ofsted and found
to be ‘Inadequate’ which
includes Doncaster. It is
therefore expected that the
CQC could commence their
inspection in Doncaster at any
time. The Trust has ley
representatives working with
each CCG to ensure all
activities and processes are in
place for any future inspection.
This includes briefing key staff.
Actions continue to be
implemented in relation to the
Communications Strategy
including the production of
press releases, media
management, Trust newsletters
such as Connect and GP
newsletters. The completion
and Launch of teh new Trust
website has been highest
priority during the quarter and
extra temporary staffing
employed to secure this.
ON/OFF Trajectory
ON/OFF Trajectory
ON
ON
AMM supported with materials,
preparation, photography and
refreshed "market street"
approach. Woodfield Park and
St Catherine's House initiatives
supported.
ON
ON
Actions continue to be
implemented in relation to the
Communications Strategy
including the production of
press releases, media
management, Trust newsletters
such as Connect and GP
newsletters.
Quarter 4:
Arrangements have been put in
place to review the Information
and Technology Strategy, in
line with the requirements of
the Monitor 5 year planning
guidance. All Business
Dividsions and corporate
services will be involved in the
review, which will comprise a
minimum of 3 scoping
meetings and individual
sessions for business divisions.
Marketing and support to
tenders has impacted on the
redesign work for the Trust
website. Prioritisation
discussions scheduled for SLT
in early New Year
The Safeguarding Children and
Looked After Children teams
continue to work in partnership
with the Doncaster, Rotherham,
North and North Lincs CCG's to
prepare for a potential CQC
inspection. Each of the areas
have completed a CQC key line
of enquiry assessment and are
currently collating the relevant
evidence and undertaking multidisciplinary case file audits
accross all services.
Version 5
ON
Ensure appropriate
arrangements are in
place in respect of
regulatory
requirements of the
CQC, Monitor
(including new
licensing
arrangements) and
OFSTED
Actions continue to be
implemented in relation to the
Communications Strategy
including the production of
press releases, media
management, Trust newsletters
such as Connect and GP
newsletters.
ON
5.3
Internal updates on
developments, initiatives and
opportunities for engagement
are communicated through the
Connect briefing. A refresh of
the strategy will be initiated
during the second half of Q4.
ON
Actions continue to be
implemented in relation to the
Communications Strategy
including the production of
press releases, media
management, Trust newsletters
such as Connect and GP
newsletters.
ON
Deliver the action
plans agreed within
the Communications
Strategy to enhance
the Trust's reputation,
relationships and
market position
ON
5.2
Quarter 3:
The IT and Information Strategy
continues to be progressed
through the ICT Board and the
new Information, Performance
& Digital Health Group. These
report into FIBD Group and the
Performance & Assurance
Group, respectively.
ON
Quarter 2:
Strategy implementation
continues. "Connect" bulletin
produced and distributed Trust
wide. E-prescribing
procurement process initiated.
Strategy refresh planned for
Q4. Licensing risks identified
and mitigated for Oracle and
Microsoft systems.
ON/OFF Trajectory
Quarter 1:
A paper has been presented to
P&A and the board updating on
the progress and investment to
date in relation to the strategy.
A recent CEO blog has
received positive feedback in
general.
ON
5.1 Implement the IT and
Information Strategy
improving the
accessibility of data to
support clinicians and
provide clear
reporting.
ON
Principal Objectives Quarterly Strategic Goal
(Work Programmes)
ON/OFF Trajectory
Ref No
Strategic Goal 5
Maintain excellent performance and governance and a strong market position; and improve further our reputation
for quality
Quarter 3:
The CQC carried out an
unannounced inspection over
seven days in October 2013,
visiting a number of wards
across the Trust. The Trust met
all of the standards inspected
and the CQC reported that
people who they had talked
with told them they were asked
for their consent and their care
and treatment was explained to
them. The report also stated
that they found that care and
treatment was planned and
delivered in a way that ensured
people’s safety and welfare and
that people who used the
service were protected from the
risk of abuse. The inspections
found there were enough
qualified, skilled and
experienced staff to meet
people’s needs.
ON/OFF Trajectory
Quarter 2:
ON/OFF Trajectory
ON/OFF Trajectory
Quarter 1:
ON/OFF Trajectory
Ref No
Principal Objectives Quarterly Strategic Goal
(Work Programmes)
Quarter 4:
The CQC recently published a
new approach making greater
use of people’s views and
experiences of care and using
inspectors who have specialist
knowledge of mental health
services, including experts by
experience, and these
elements were used as part of
the inspection in October. A
proposed timeline for
developing the assessment
framework is included in the
document and it is proposed
that the new model is rolled out
to all providers by October
2014.The CQC recently
published a new approach
making greater use of people’s
views and experiences of care
and using inspectors who have
specialist knowledge of mental
health services, including
experts by experience, and
these elements were used as
part of the inspection in
October.
A proposed timeline for
developing the assessment
framework is included in the
document and it is proposed
that the new model is rolled out
to all providers by October
2014.
22/05/2014
Page 17 of 19
Version 5
An annual report against the
Risk Management Strategy has
been prepared and reported to
RMG. The BAF for 2013/14
has been prepared and
evidence for quarter 1
assessed and recorded. An
internal audit of the BAF has
provided significant assurance.
During quarter 3 the scrutiny of
the Board Assurance
Framework was transferred to
PAG.
Learning Opportunities have
been taken up with 360
Assurance, focussing on best
practice across the region.
An in depth mid year review of
the BAF was undertaken and
presented to PAG.
ON
At the April PAG meeting it was
noted tha there were no gaps
identified. Work continues to
populate the BAF with
assurances/evidence for the
remainder of the financial year
and a closedown report for the
2013/14 BAF will be presented
to the PAG at the meeting in
May 2014. Any gaps identified
will be transferred to the
2014/15 BAF to ensure that the
Trust monitors any outstanding
actions.
Refreshing the 2013/14 BAF
was completed during Q4 . The
final 2013/14 BAF is to be
presented to the Board of
Directors at the May meeting
for approval to close down.
22/05/2014
Page 18 of 19
ON/OFF Trajectory
ON
Scrutiny of the BAF has
continued at PAG.
Refresh of the 2014-15 BAF
has started in consultation with
360 Assurance.
Planning initiated for 2014/15
BAF
ON
ON/OFF Trajectory
ON/OFF Trajectory
Scrutiny of the BAF has
continued at Risk Management
Sub Group and will transfer to
PAG from October (Q3).
ON
As a result of a previous
Internal Audit Report an action
was completed which
recommended long standing
high/extreme risks are reported
to the Performance &
Assurance Group (PAG). The
report identified all the high and
extreme risks added to the risk
registers over 12 months ago
(pre December 2012). The
report shows the original risk
and target scores alongside the
current risk and target scores.
The report was also presented
to the Risk Management Sub
Group for their information and
assurance.
Quarter 4:
Corporate and Divisional risk
registers continue to be
reviewed and updated on a
monthly basis.
In addition to the monthly
reviews, the risk leads are
required to present their risk
registers to the Risk
Management Sub Group for
review, on an annual basis. All
the risk registers were
presented at the RMSG during
the year.
All the risk registers were
moderated by SLT during the
biannual reviews in 2013/14.
The Corporate Risk Register is
reported to PAG, AC and the
Board of Directors on a regular
basis, and incorporated into the
Board Assurance Framework
Report where applicable.
All extreme risks are reviewed
by SLT before being added or
removed from the Corporate
Risk Register.
Version 5
ON
Provide the Board of
Directors with a
framework which
provides robust
assurance against
risks identified in the
achievement of
organisational
strategic goals
Quarter 3:
Corporate and Divisional Risk
Registers continue to be
reviewed and updated. The
Corporate Risk Register is
reported to PAG and the Board
of Directors on a regular basis
and moderated by SLT.
ON
5.5
ON
Quarter 2:
Corporate and Divisional Risk
Registers continue to be
reviewed and updated. The
Corporate Risk Register is
reported to PAG and the Board
of Directors on a regular basis
and moderated by SLT.
Further work undertaken to
ensure clear action plans are in
place to delivery mitigation
strategies.
ON
Quarter 1:
Ensure a sound
The annual Report of the
Trust's Risk Management
system of risk
Strategy was produced and
management is in
reported to RMG in quarter 1.
place to identify,
Corporate and Divisional risk
assess, evaluate,
record and review all registers continue to be
significant risks to the reviewed and updated. The
Corporate Risk Register is
organisation
reported to PAG and the Board
of Directors on a regular basis
and moderated by SLT.
ON/OFF Trajectory
Ref No
5.4
Principal Objectives Quarterly Strategic Goal
(Work Programmes)
22/05/2014
Page 19 of 19
ON
Agreed exceptions are then
reported to the Board
Version 5
ON/OFF Trajectory
Quarter 4:
The performance dashboards
are updated monthly and
presented at the Performance
and Assurrance Group,
following discussion areas for
escalation are agreed and
these are highlighted to the
Board. Individually Business
Divisions attend the
Performance and Assurrance
group to undertake a 'deep
dive' into the individual division
KPIs
ON
Quarter 3:
Business Support Units have
developed new dashboards
which are presented to the
Performance & Assurance
Group monthly.
ON/OFF Trajectory
ON/OFF Trajectory
Quarter 2:
Performance against KPIs is
monitored on a monthly basis
by the performance team and
reported to Business Division's
performance meetings, BIG,
the Performance and
Assurance Group and the
Board of Directors.
ON
ON/OFF Trajectory
Quarter 1:
Ensure that robust
Performance against KPIs is
monitored on a monthly basis
governance
arrangements are in by the performance team and
reported to Business Divisions
place around the
delivery of all contract performance meetings, BIG,
Key Performance
the Performance and
Indicators (KPI's)
Assurance Group and the
Board of Directors. In addition,
more detailed papers and
action plans about areas of
under performance are
prepared and shared with PAG
e.g. breastfeeding and IAPT
recovery rates.
ON
Ref No
5.6
Principal Objectives Quarterly Strategic Goal
(Work Programmes)
Paper N
Board Assurance
Framework Closedown
Summary 2013/14
Risk and Assurance Officer
May 2015
Business Assurance Directorate
Paper N
Board Assurance Framework 2013 / 2014
Closedown Report
1.
1.1
Purpose
The purpose of this report is to provide the Performance and Assurance Group with the
2013 / 2014 Board Assurance Framework (BAF) end of year position statement and
highlight any gaps in control or assurance for discussion and debate in order to
recommend close down of the 2013 / 2014 BAF.
2.
2.1
Background
The BAF provides the Board of Directors with assurance that appropriate arrangements
are established about the effectiveness of risk controls in the Trust. These are the controls
that have been put in place to mitigate the Trust’s exposure to risk in the achievement of its
strategic objectives.
2.2
The BAF for 2013/14 comprised 35 work programmes split under the headings of the
Strategic Goals:
1
Continuously improve service quality (safety, effectiveness and patient experience) for
our patients and carers
2
Nurture the talent, commitment and ideas of our staff in order to deliver excellent
services
3
Ensure value for money and increased organisational efficiency whilst maintaining
quality
4
Adapt and deliver services to meet agreed commissioned needs through enhanced
multi-agency partnerships
5
Maintain excellent performance and governance and a strong market position; and
improve further our reputation for quality
3.
3.1
Monitoring during 2013/14
The BAF has been reviewed in a number of meetings as follows:
• Risk Management Sub Group – all the work programmes within each Strategic Goal
were reviewed over each three month period. In September 2013 it was agreed the
monitoring of the BAF would transfer to the Performance and Assurance Group on a
monthly basis.
• Performance and Assurance Group – a monthly exception report was provided
based on the gaps in control and/or assurance and the work programme off trajectory
(quarter one only). At the end of each quarter the BAF was presented in full and
included an update of the Strategic Goals.
• Audit Committee - a quarterly exception report was provided based on the gaps in
control and/or assurance and a copy of the full BAF for information. A further
assurance was provided through the sampling of evidence by a Non-Executive Director
who provided an opinion on the level of assurance assigned on the coversheet against
the evidence selected by the Corporate Governance Team.
• Board of Directors - a quarterly exception report was provided based on the gaps in
control and/or assurance, the work programme off trajectory (quarter one only) and a
copy of the full BAF for information.
3.2
During 2013 / 2014 the Corporate Governance Team has continued to develop and
strengthen the assurances within the BAF. An example of this work is during quarter 3 for
the mid-year review classification of the partial assurances was broken down to enable
easier analysis of the level of assurance had been provided against the key controls. The
classifications were defined as Green/Amber and Amber/Red – to provide a judgement
about the level of assurance. Also two further levels of assurance classification were
Paper N
added for Verbal (verbal report submitted therefore no documentary evidence available)
and None (written report submitted but provides no evidence that offers assurance).
4.
4.1
Year-end Findings
Following receipt of quarter 4’s evidence the majority of work programmes within the 2013
/ 2014 BAF have received the identified assurances
4.2
Of the 35 work programmes within the BAF 32 have been assessed as having significant
assurance and no concerns.
4.3
The remaining 3 work programmes have been assessed as having a high number of
amber / red assurances:
• 1.5 Provide both those who are cared for and those who work for the Trust a safe and
secure environment.
• 2.4 Improve compliance on the uptake of statutory / mandatory training with
consideration given to existing and future national legislation including NHSLA and
training specific role / discipline and service requirements.
• 5.6 Ensure that roust governance arrangements are in place around the delivery of all
contract key performance indicators.
The nature of the evidence received for these work programmes was discussed at the
Performance and Assurance Group in April and the Group concluded that it had sufficient
assurance regarding these work programmes.
4.4
Please refer to Appendix I – Board Assurance Framework Report Closedown Summary for
further information about the above work programmes.
4.5
In addition to the above there are audits or opinions from the 2013/14 Internal Audit Plan
that are outstanding:
• Health & Safety – due Q4
• Investigations, Analysis & Improvement – due Q4
• Mental Health PbR – due Q1 2014/15 (was Q2)
• HolA – due Q4
4.7
Going forward for the 2014 /2015 BAF, assurances will continue to be reported from the
internal audit reports received.
Business Assurance Directorate
Explanation of Selected Headings
Principle Risk - The organisation’s main risks against the delivery of work programme
Minute
Reference -
The reference is a hyperlink to the section of the minutes of the applicable group where the evidence of assurance has been received
Assurances
Provided:
a) Internal Assurance (I) - Reports / Minutes from within the Trust (including those compiled by external providers)
b) External Assurance (E) - Reports from outside the organisation, e.g. Care Quality Commission / Health and Safety Executive
Level of
Assurance:
This is the level of assurance against the control that has been assigned to the evidence and is categorised as :
Full
Full Assurance is assigned where the evidence demonstrates that the controls in place fully mitigate the
identified risk.
Significant Assurance is assigned where the evidence demonstrates that generally controls are operating
satisfactorily and risks are mitigated.
Minor improvements may be required.
Significant
Partial
Full
Significant
Partial Assurance is assigned when the evidence is unable to Fully or Significantly demonstrate that existing
controls are effective in risk mitigation.
Partial assurance is assigned for a number of reasons:
Content (C) - where the content of the evidence advises that more work is required to provide Significant/Full
assurance;
Green Amber
Accumulative (A) - where the evidence indicates an in year position which is expected to change to Significant
/Full as the year progresses
OR
Quality (Q) - where a lack of detail provided in the evidence means that Significant/Full assurance is not
identifiable;
Process (P) - where the evidence presented is primarily about process, rather than implementation
Amber Red
GreenAmber or AmberRed is assigned to provide a judgement about the level of assurance.
Verbal
Verbal report submitted therefore no documentary evidence available
None
Written report submitted but provides no evidence that offers assurance
Not Yet Due
The timeframe column will reflect proposed dates/quarters of when assurance will be due
None
Not Due
Ref No
Strategic Goal 1
Continuously improve service quality (safety, effectiveness and patient
experience) for our patients and carers
Principal Objectives (Work
Programmes)
1.1
Focus on achieving demonstrable
progress in relation to the quality
improvement priorities that have
been identified of:
Full Significant Green Amber Amber Red
a) Clinical leadership
b) Personalised Care
c) Record keeping
d) To maintain full compliance with
the CQC essential standards of
Quality and Safety
1.2
1.3
1.4
1.5
1.6
1.7
Number of assurances received during 2013-14
Develop and implement a Research
and Innovation Strategy
Implement, monitor and manage the
Quality Markers identified by the
User Carer Partnership Council and
the Council of Governors.
Encourage feedback from patients
and carers and listen, act and
publicise what the Trust has done
(you said - we did)
Verbal
Close down
summary
None Not Due
-
17
16
12
21
17
22
5
1
3
3
6
-
-
-
16
9
3
5
-
-
-
9
4
-
-
-
-
7
8
1
1
-
-
-
20
7
4
1
-
-
Provide both those who are cared
for and those who work for the Trust
a safe and secure environment
Maintain an effective mechanism to
support the delivery of CQUIN
targets and as a result demonstrate
improvements in quality
Continually review medicines
management systems, approach
and safety
-
69
30
16
-
2
5
-
19
4
7
-
2*
1
-
-
1
-
-
2x referred to internal
audits and maintaining
evidence and
inconsistencies in
application of controls;
8x Si Reporting
identifying high number
of red actions/expired
timeframes;
3x concerns with
safeguarding database
training and reporting;
and
3x reporting clarification/comparativ
e analysis required, low
figures, key issues
* Health & Safety Internal Audit - due Q4 (in progress
Investigation, Analysis & Improvement - due Q4
19/05/2014
Page 4 of 8
Version 1
Ref No
Strategic Goal 2
Nurture the talent, commitment and ideas of our staff in order to deliver excellent
services
Principal Objectives (Work
Programmes)
2.1
Continually improve leadership
capacity and capability, specifically
regarding clinical engagement,
innovation and succession planning
and implementation of 360 degree
feedback systems.
Full
a) to include Advanced Practice and
Professional Standards
b) further develop and enhance medical
appraisal processes and the use and
provision of supporting information to
support the effective implementation of
revalidation for doctors
2.2
2.3
2.4
Number of assurances received during 2013-14
Audit the culture of the organisation to
continuously improve service quality,
safety and effectiveness for our service
users and carers.
Ensure that the Trust exercises its
functions with due regards to the
General Duty as stated in the Equality
Act 2012 and that it can demonstrate
compliance with the Public Sector
Equality Duty.
Improve compliance on the uptake of
Statutory/Mandatory training with
consideration given to existing and
future national legislation including
NHSLA and training specific
role/discipline and service requirements.
19/05/2014
Significant
Green
Amber
Amber
Red
Verbal
None
Not Due
-
12
15
1
2
-
-
-
8
-
-
-
-
-
-
-
18
1
-
-
-
1
1
13
-
-
-
-
-
9
11
5 of 8
11
-
-
-
Close down
summary
9x training non
attendance/low
induction rates:
2x poor meeting
attendance
Version 1
Ref No
Strategic Goal 3
Ensure value for money and increased organisational efficiency whilst maintaining
quality
Principal Objectives (Work
Programmes)
3.1
To ensure the 2013/14 Financial
plan is signed off by the Trust
Board and Monitor and that
appropriate monitoring is put in
place for delivery including:
• monthly monitoring and
reporting of the revenue, cash
and working capital and CAPEX
position
• quality impact assessment
processes of financial decisions.
3.2
3.3
3.4
3.5
*
To develop the financial plan for
2014/15 during 2013/14 and in
particular the development of the
2014/15 QIPP plans ensuring
that:
• attendance at key meetings to
ensure intelligence is gathered
and reported back to the Board
• Financial plans are RAG rated
for delivery and reviewed by the
Board
• QIAs are RAG rated for delivery
and reviewed by the Board
Continue the implementation and
development of the Care
Pathways and Packages Project
with support of PbR in partnership
with Health and Social Care
commissioning partners.
Ensure delivery of the key
milestones in relation to the
signed of Balby Estates Strategy
Number of assurances received during 2013-14
Full
Significant
Green
Amber
Amber
Red
Close down summary
Verbal
None
Not Due
1
58
20
2
-
-
-
-
19
14
3
1
-
-
-
3
4
-
11
-
1*
-
16
1
1
-
-
-
-
-
-
-
3
-
-
Continual liaison with the Trust's
commissioners to ensure that the
financial risk of health and social
care changes are managed
MH PbR - due Q1 2014/15 (was Q2 2013/14)
19/05/2014
6 of 8
Version 1
Ref No
Strategic Goal 4
Adapt and deliver services to meet agreed commissioned needs through enhanced
multi-agency partnerships
Principal Objectives (Work
Programmes)
4.1
a) Manage any risk arising from
implementing the Business Strategy
2012-2015.
b) Continue the implementation and
development of the Commissioner
Relationship Management
approach, to support clinical
engagement in service performance
and improvement planning.
c) Adopt a marketing approach to
the development of Trust strategies.
4.2
4.3
Implement the arrangements
associated with One Team Working
in Doncaster for Adults and
Children’s services
Full
Significant
Green
Amber
Amber
Red
Close down summary
Verbal
None
Not Due
-
7
6
-
10
-
-
-
4
4
-
18
-
-
-
1
1
-
-
-
-
-
6
3
1
-
-
-
Support the workforce aspects of service redesign/integration initiatives aimed at more efficient and effective service provision,
a) including review of and remodelling Learning Disability
Services
-
6
5
-
1
-
-
b) including the remodelling of
intermediate care provision in
Doncaster
-
3
4
2
-
-
-
-
6
9
1
-
-
-
-
4
2
-
-
-
-
-
2
4
-
6
-
-
c) including the reorganisation of
operational and corporate services
4.4
Number of assurances received during 2013-14
Develop and implement a Recovery Strategy to:
a) To develop Flourish Enterprises
as a stand- alone trading social
enterprise to provide work and
vocational opportunities to service
users / ex service users.
b) Establish a wholly-owned armslength subsidiary body to provide a
suitable competitive vehicle through
which the Trust may compete for
services competitively tendered
across all localities.
19/05/2014
Page 7 of 8
Version 1
Ref No
Strategic Goal 5
Maintain excellent performance and governance and a strong market position;
and improve further our reputation for quality
Principal Objectives
(Work Programmes)
5.1
Implement the IT and
Information Strategy
improving the accessibility
of data to support
clinicians and provide clear
reporting.
5.2
5.3
5.4
5.5
5.6
Number of assurances received during 2013-14
Full
Deliver the action plans
agreed within the
Communications Strategy
to enhance the Trust's
reputation, relationships
and market position
Ensure appropriate
arrangements are in place
in respect of regulatory
requirements of the CQC,
Monitor (including new
licensing arrangements)
and OFSTED
Ensure a sound system of
risk management is in
place to identify, assess,
evaluate, record and
review all significant risks
to the organisation
Provide the Board of
Directors with a framework
which provides robust
assurance against risks
identified in the
achievement of
organisational strategic
goals
Ensure that robust
governance arrangements
are in place around the
delivery of all contract Key
Performance Indicators
(KPI's)
Significant
Green
Amber
Amber
Red
Close down summary
Verbal
None
Not Due
-
25
49
4
1
-
1*
-
1
-
-
-
-
1*
-
29
2
1
-
-
-
-
45
2
-
5
-
-
-
13
22
-
-
-
1*
-
18
26
7
1
-
-
4x exception reporting target performance;
3x performance
dashboards - reporting
inconsistencies, gaps clarification sought
* IG Toolkit Submission to PAG/BoD - due May 2014
HolA Internal Audit - Due Q4
Communications Strategy - Year End Report - Due May 2014
19/05/2014
Page 8 of 8
Version 1
Paper O
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Group/Committee
Name
Board of Directors
Meeting Date
29 May 2014
Title of Paper
Author
Performance Dashboards & Exception Escalation Update
Deb Wildgoose, Service Director Children and Communities (Interim)
Debbie Smith, Service Director Mental Health
Paper For
Decision
Strategic Work
Programme:
- Relevance
- Progress
Debate
x
Assurance
Information
x
Reference
What Strategic Work Programmes is the paper
relevant to?
Does the paper provide assurance against
delivery of the identified Strategic Work
Programme?
5.1, 5.6
Yes / No
Yes
The performance exception report was presented at the May 2014,
Performance and Assurance Group (PAG) which highlighted issues to be
raised at the Board of Directors:
MENTAL HEALTH
The PAG group have identified that there have been lower occupancy rates
in both the Doncaster and Rotherham older people's wards. This has been
noted by both CCG's therefore work is on-going with the Older Peoples
Business Division to look at how these beds could be used more effectively
particularly in developing specialist services for older people with
challenging behaviour to prevent them being placed out of area.
Key Points to Note
(including any
identified risks )
Additionally the group noted that Emerald ward the Adult Business Division
Rehabilitation ward in Doncaster has also had a lower occupancy rate in
recent months, therefore the division have agreed to review this area as
part of the recovery review which will commence over the summer.
CAMHS
Following the recent focus on the CAMHS action plan identified at the last
Board meeting in April 2014 and again at the PAG group in May 2014, an
increased emphasis remains on the performance and achievements in the
Rotherham services.
LD
Following the deep dive into performance and activity within the psychology
services in the LD Business Division, further detailed work has been
completed. This includes a review of current provision and the development
of an action plan to reduce waiting times. The report also provides
information to support discussions with the Trust commissioners for
Psychology services.
The performance dashboards for both Service Directorates are attached.
Reviewed May 2014
Paper O
Board Assurance
Framework
If the paper also provides assurance against
the effectiveness of a Key Control what is the
reference and what level of assurance do you
think it provides?
CQC
If the paper provides assurance against
Essential Standards of Quality and Safety
(ESQS) specify the outcome number.
BAF Key
Control Ref.
Effectiveness
F/S/P/V/N
5.1d, 5.6a
S
ESQS outcome number
n/a
None
Financial/Budget
Equality &
Diversity/Human
Rights
None
Action proposed
following the
Group meeting
The Board of Directors is asked to note the performance
Person
Responsible
Deb Wildgoose, Service Director Children and Communities (Interim)
Debbie Smith, Service Director Mental Health
Date for
completion
Outcome required
from the Group
On-going
To note the updates provided against performance issues.
Reviewed May 2014
Performance Dashboards
Board of Directors
29 May 2014 2014
Author: Business Support Units
Children & Communities
Key Performance Indicators
As part of the on-going development of performance dashboards with the Business Divisions, it has been essential to identify a ‘top 5’ KPI list to
be monitored on a monthly basis.
Key:
Improved on last month - Still meeting target
Red
Not meeting target
Stayed the same - Still meeting target
Green
Meeting Target
Deteriorated since last month - Still meeting target
Improved on last month - Not meeting target
Stayed the same - Not meeting target
Deteriorated since last month - Not meeting target
Contents:
Children's and Communities Business Support Unit:
Doncaster Community Integrated Services
Substance Misuse
Children Young People and Families
Learning Disabilities
DCIS Performance Dashboard - March 2014
Service Area
Podiatry New Patient Wait
Podiatry Nail Assessment
Podiatry Nail Surgery
Podiatry Biomechanics
Podiatry Rheumatology Access
Podiatry Routine Diabetes Access
Podiatry Emergency Acc(T<1wk)
CICP Consultant
CICP AHP
Occupational Therapy
Physio Therapy
Dietician
Speech & Language Therapy
Still Waiting for Treatment
(92% <18 weeks)
Pts
Longest
Waiting **
Wait
100% 271/271
12wks
88/88
6wks
7wks
12wks
n/a
108/108
12wks
100%
31/31
6wks
Not available
100%
77/77
12wks
100%
2/2
3wks
100% 146/146
10wks
100%
100%
100%
n/a
100%
n/a
96%
89%
100%
100%
100%
100%
86/86
44/44
n/a
n/a
47/49
n/a
n/a
34wks
24wks
16wks
11wks
18wks
15wks
17/19
143/143
116/116
74/74
50/50
Breastfeeding Prevalence at 6-8 Weeks
Current Performance
31.20%
Target
Referral to Treatment
(95% within 18 weeks)
Pts
Longest
Seen *
Wait
12wks
100% 224/224
100%
99%
100%
100%
100%
100%
n/a
n/a
71/71
17wks
18wks
17wks
13wks
16wks
17wks
122/123
157/157
84/84
93/93
129/129
Target
Current Performance
80% (Oct14 - Mar14)
89.3% (459/514)
Status
Percentage of Safety Thermometer surveys completed
100.0%
90.0%
% ST surveys
completed
80.0%
70.0%
60.0%
50.0%
Target
40.0%
30.0%
20.0%
10.0%
0.0%
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
District Nursing Service - Face to Face Activity
31.1% (96 / 309)
Status
22000
30
20000
17141
Status
DCIS District Nursing Face to Face Activity
24000
35
Current Performance
16380 p/mth
Target
Breastfeeding prevalence at 6-8 weeks
40
CQUIN - Safety Thermometer
(District Nursing, Community Matrons, CICT, NROT, Cardiac)
18000
25
16000
20
14000
15
12000
10
10000
Apr-12
Jun-12
Aug-12
Oct-12
Dec-12
Feb-13
Apr-13
Prevalence
Jun-13
Aug-13
Oct-13
Dec-13
Feb-14
Apr-11
Jul-11
Oct-11
Jan-12
Apr-12
Jul-12
Oct-12
Face to Face Activity
Target
Jan-13
Apr-13
Jul-13
Oct-13
Jan-14
Target
DCIS Inpatient Delays in Transfer of Care (no target)
Number of Days
250
200
Hawthorn
150
Hazel
100
Magnolia
50
Hospice
0
Apr-13
May-13
Jun-13
Jul-13
Alerts
KPI 97 - Average Length of Stay less than 7 days
KPI 93 - Neurology - Patients seen within 6 weeks
RTT - * number (total seen within 18 weeks)/number (total number seen)
Key
Monitor/Assess Situation. No Further Action Req'd.
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Status
Length of stay - consistently under target. KPI's to be reviewed as part of Intermediate Care spec
High number of admin errors effecting data / action plan in place with staff to address issues
RTT ** number(total waiting under 18 weeks)/number (total waiting)
Action Plan required with trajectory dates for compliance against the target.
Doncaster Community Integrated Services - RTT Waiting Times / completed & incomplete pathway / non-admitted patients
Target - 95% Seen within 18 weeks
MARCH 14
< 4 wks
5-8 wks
9-12 wks
13-18 wks
Total ≤ 18
wks
Target-92% waiting <18wks
>18-19 wks >19-20 wks >20-21 wks >21-22 wks >22-28 wks
>28 wks
% pts seen
Total > 18
Total seen
wks
≤18 wks
Number
Waiting
<18 wks
Number
Waiting
>18 wks
% pts
waiting <18
wks
Podiatry / Community Caseload
91
125
8
0
224
0
0
0
0
0
0
0
224
100.00%
271
0
100.00%
Podiatry / Nail Assessment
79
7
0
0
86
0
0
0
0
0
0
0
86
100.00%
31
0
100.00%
Podiatry / Nail Surgery
41
3
0
0
44
0
0
0
0
0
0
0
44
100.00%
Podiatry / Biomechanics
24
59
5
0
88
0
0
0
0
0
0
0
88
100.00%
77
0
100.00%
Podiatry / Rheumatology
0
0
0
0
0
0
0
0
0
0
0
0
0
n/a
2
0
100.00%
Podiatry / Routine Diabetes
34
69
5
0
108
0
0
0
0
0
0
0
108
100.00%
146
0
100.00%
CICP / Consultant Pathway
17
24
4
2
47
1
0
0
0
0
1
2
49
95.92%
71
0
100.00%
CICP / AHP Pathway
3
7
7
0
17
1
0
0
0
1
0
2
19
89.47%
122
1
99.19%
15
5
0
0
0
0
0
0
143
100.00%
100.00%
AHP / Occupational Therapy
99
24
143
0
157
0
AHP / Physiotherapy
98
14
4
0
116
0
0
0
0
0
0
0
116
100.00%
84
0
100.00%
AHP / Dietician
59
12
1
2
74
0
0
0
0
0
0
0
74
100.00%
93
0
100.00%
9
AHP / Speech & Language
31
Podiatry Emergency Access - 100% within 1 week
5
5
50
0
0
0
0
0
0
0
50
100.00%
129
0
100.00%
Podiatry / Emergency Access
>0-2 days
>2-4 days
>4-6 days
7 days
Total ≤ 1
week
>1-2 wks
>3-4 wks
>5-6 wks
>7-8 wks
>9-14 wks
>15 wks
Total > 1
weeks
Total seen
% pts seen
<1 wk
0
0
0
0
0
0
0
0
0
0
0
0
0
n/a
DCIS Waiting Times
waiting <18 waiting >18 waiting <18
wks
wks
wks
0
0
n/a
Page 4
Substance Misuse Performance Dashboard - March 2014
*Successful completions & TOPS is based on February 14 data as NDTMS not yet released for March
Treatment Outcomes Profile (TOPs)
Doncaster
Start (100%)
Review (100%)
Exit (98%)
Apr-13
100%
100%
100%
May-13
100%
100%
Jun-13
100%
Aug-13
Sep-13
North Lincs
Start (80%)
Review (80%)
Exit (80%)
Start (80%)
Review (80%)
Exit (80%)
Apr-13
84%
100%
100%
Rotherham
Apr-13
99%
95%
97%
N.E. Lincs
Apr-13
Start (100%)
73%
Review (100%)
88%
Exit (98%)
100%
May-13
90%
100%
100%
May-13
100%
100%
97%
May-13
90%
100%
100%
100%
100%
Jun-13
88%
100%
100%
Jun-13
100%
100%
100%
Jun-13
75%
100%
100%
100%
100%
100%
Aug-13
100%
100%
100%
Aug-13
96%
100%
97%
Aug-13
83%
86%
83%
100%
100%
100%
Sep-13
100%
100%
100%
Sep-13
98%
100%
100%
Sep-13
78%
100%
100%
100%
Oct-13
100%
100%
100%
Oct-13
100%
100%
100%
Oct-13
98%
100%
100%
Oct-13
69%
100%
80%
Nov-13
100%
100%
100%
Nov-13
92%
100%
100%
Nov-13
98%
98%
100%
Nov-13
76%
89%
100%
Dec-13
79/79 (100%)
382/382 (100%)
24/24 (100%)
Dec-13
19/20 (95%)
13/13 (100%)
9/9 (100%)
Dec-13 117/122 (95.9%)
42/43 (97.7%)
35/35 (100%)
Dec-13
17/21 (81%)
8/8 (100%)
4/4 (100%)
Jan-14
80/80 (100%)
418/418 (100%)
16/16 (100%)
Jan-14
21/23 (91.3%)
6/60 (100%)
5/5 (100%)
Jan-14
88/90 (97.8%)
40/41 (97.6%)
26/27 (96.3%)
Jan-14
Feb-14
26/26 (100%)
342/342 (100%)
32/32 (100%)
Feb-14
15/15 (100%)
9/9 (100%)
5/5 (100%)
Feb-14
75/77 (97.4%)
39/40 (97.5%)
21/22 (95.5%)
Feb-14
14/16 (88%)
6/8 (75%)
3/4 (75%)
3/3 (100%)
5/5 (100%)
5/5 (100%)
Successful Completions / Opiates Only
Successful Completions / All Drugs
224 / 2102
Doncaster
26 / 342
North Lincs
The Junction
11.0%
125 / 1263
Rotherham
8.0%
31 / 414
Nth East Lincs
9.9%
7.0%
123 / 1870
Doncaster
North Lincs
The Junction
7.0%
RDASH Successful completions as a proportion of all in treatment - 12 month rolling
20 / 314
56 / 1096
Rotherham
6.0%
5.1%
Nth East Lincs
28 / 393
7.0%
Opiates - Successful completions as a proportion of all in treatment - 12 months rolling
14.0%
8.5%
12.0%
8.0%
10.0%
7.5%
8.0%
7.0%
6.0%
6.5%
4.0%
6.0%
2.0%
5.5%
5.0%
0.0%
Apr-13
May-13
Jun-13
Doncaster (15%)
Jul-13
Aug-13
Rotherham (16%)
Sep-13
Oct-13
Nov-13
Dec-13
North Lincs (target n/a)
Jan-14
Apr-13
Feb-14
May-13
North East Lincs (target n/a)
Jun-13
Jul-13
Doncaster (target n/a)
Waiting Times / First Intervention
73 / 75
97.3%
Doncaster
North Lincs
The Junction
7/7
100.0%
Sep-13
Oct-13
Nov-13
North Lincs (7.5%)
Dec-13
Jan-14
Feb-14
North East Lincs (n/a)
Service Users Offered Hep B
35 / 35
100.0%
Rotherham
Aug-13
Rotherham (10%)
Nth East Lincs
7/7
100.0%
72 / 72
100.0%
Doncaster
North Lincs
The Junction
7/7
100.0%
35 / 35
100.0%
Rotherham
Nth East Lincs
5/5
100.0%
Proportion of Service Users offered Hep B Vaccination
Waiting Times: Referral to first treatment intervention, <3weeks
100%
100%
98%
90%
96%
80%
94%
70%
92%
60%
90%
50%
88%
40%
86%
30%
Apr-13
Apr-13
May-13
Doncaster (100%)
Jun-13
Jul-13
Aug-13
Rotherham (target n/a)
Sep-13
Oct-13
Nov-13
Dec-13
North Lincs (90% The Junction)
Alerts
Jan-14
Feb-14
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
North East Lincs (100%)
Doncaster (100%)
Rotherham (100%)
North Lincs (Target n/a)
Status
Rotherham - KPI 1.3 Offered and accepted HBV (Partnership Target 90%)
Seasonal trend; achievement has shown an increase and is expected to rise in Qtr 4
Rotherham - KPI 1.4 Receiving HCV (Partnership Target 95%)
Seasonal trend; achievement has shown an increase and is expected to rise in Qtr 4
Rotherham - KPI 5.4 Drinking pop'n in treatment (Partnership target 869pa)
Qtr3 419 against 651 YTD target; KPI reviewed in 2014 / 15
North Lincs / The Junction - KPI 5 Offered and accepted HBV (target 80%)
Service has implemented new process nurse / doctor lead which is expected to increase take-up
North Lincs / The Junction - KPI 3 Non Opiate Growth in clients in effective treatment
Change in client group; service discussing with commissioners
Key
Monitor/Assess Situation. No Further Action Req'd.
Dec-13
Jan-14
Feb-14
Mar-14
Action Plan required with trajectory dates for compliance against the target.
North East Lincs (100%)
Mar-14
Learning Disabilities Performance Dashboard - March 2014
Seen <18
weeks
RTT
New Patient Count
DONCASTER
Behavioural Outreach
Community Nurses
CAIS (New November)
Health Action Team
Occupational Therapy
Physiotherapy
Longest
No.
No.
Waiting <18
No Waits
Wait seen
Waiting<
Seen
weeks
>18wks
above 18
18 wks
Longest
Wait
0
0
0
2
0
0
5
8
2
11wks4d
6wks0d
12wks1d
23wks6d
0wks0d
7wks2d
26wks 6d
33wks4d
21wks3d
100%
100%
2
21
100%
0
3
1
20
Psychology Treatment & Assessment
100%
71%
Consultant Psychiatrist
80%
0
4
Speech & Language
50%
75%
2
21wks2d
3
Rotherham - Consultant DNA Rate - % of Appointment DNAs
Appointments/DNA's
5/63
Current/Target
10.00%
0
0
8
1
1
18wks0d
4wks1d
46wks0d
26wks 3d
19wks0d
Qtr1 13/14
Qtr2 13/14
Qtr3 13/14
Qtr4 13/14
Rotherham - All Clinical Information Input into SystmOne within 24 hours
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
Assessment & Treatment
Unit (Target 100%)
Health Support Team
(Target 95%)
Intensive Community
Support (Target 95%)
Integrated Community
Team (Target 95%)
Mar 14
3
4
23
20
0
4
40
16
23
Feb 14
100%
100%
100%
91%
100%
100%
89%
67%
92%
Jan 14
19wks6d
21wks5d
46wks1d
-
Target
Dec 13
4
3
14
4
11
7
26
4
5
ROTHERHAM
Art Therapy
Clinical Psychologist
Community Nurse
Consultant Psychiatrist
Consultant Psychologist
Assistant Psychologist
Occupational Therapy
Physiotherapy
Speech & Language
NORTH LINCS
Community Nurses
Physiotherapy
% screened
Nov 13
75%
100%
100%
100%
82%
100%
69%
100%
100%
Psychiatry
Psychology (Treatment & Assessment)
Speech & Language
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Oct 13
3-4wks
5wks 4d
0wks 3d
6wks 4d
10wks 1d
6wks 1d
16wks 5d
30wks 1d
10wks 5d
Sep 13
0
0
0
0
0
0
0
6
0
Aug 13
2
5
0
8
6
8
6
29
6
Jul 13
100%
100%
100%
100%
100%
100%
100%
83%
100%
Jun 13
31wks0d
-
May 13
3
11
1
21
12
2
2
13
8
Apr 13
100%
100%
100%
100%
100%
100%
100%
85%
100%
Rotherham - % of Patients Receiving a Full Health Screening within 24 hours of Admission
Required/Screened
2/2
Current
100.0%
Status
Doncaster - Percentage on a CPA requiring and receiving a Comprehensive CPA review within 12 mths
Required/Received
10/10
Current
100%
Status
Status
12.0%
10.0%
100%
Target
8.0%
6.0%
% DNA Rate
4.0%
Target
95%
No on a CPA requiring a
Comprehensive CPA review
90%
2.0%
No receiving a Comprehensive
CPA review at no more than
<12 mths
0.0%
Mar 14
Feb 14
Jan 14
Dec 13
Nov 13
Oct 13
Sep 13
Aug 13
Jul 13
Jun 13
May 13
Doncaster/Rotherham - Commissioned Beds: Delays in Transfer of Care
Delay days/Patient No
Target
0
0/0
38/1
Delay days/Patient No
Target
0
85%
Percentage receiving a
Comprehensive CPA review
80%
Status
Status
Jan-14
Feb-14
Mar-14
Doncaster - Percentage of patients requiring and receiving a 6 month Section 117 review
Required/Received
6/6
Current
100%
Status
45
40
100%
35
30
Donc' Total Delay days
25
Target
95%
Donc' Total No Patients
20
Roth' Total Delay days
15
90%
Percentage of patients
receiving a 6 month
Section 117 review
Roth' Total No Patients
10
85%
5
0
Percentage receiving a Comprehensive CPA review
Apr
80%
May
June
Jul
Aug
Sep
Oct
Nov
Dec
Feb
Jan-14
Mar
Feb-14
Mar-14
Status
Alerts
Key
Jan
Monitor/Assess Situation. No Further Action Req'd.
Action Plan required with trajectory dates for complaince against the target.
RMBC6 - All clinical activity input onto SystmOne within 24 hours
Monitoring and putting action plans into place for all clinicians so that target can be met. Investigation regarding
agile working underway. Part of Rationale for KPI change paper to amend KPI target. Tough books sourced which
should help reach targets as records can be input straight after most appointments if appropriate.
Rotherham RTT Waiting Times - Physio' and OT
Action Plan required with trajectory dates for complaince against the target for OT; Work Group set up for Physio'
to improve performance
LD Services: Waiting Times - March 2014
-
Completed / Incomplete pathway within 18 Wks
18.1wks - 19.0wks
19.1wks - 20.0wks
20.1wks - 21.0wks
21.1wks - 22.0wks
22.1wks -28.0wks
28.1+wks
0
0
0
0
0
0
0
0
0
3
0
0
0
0
0
0
0
3
100%
2
0
100%
0
0
0
0
0
0
0
0
0
0
11
0
0
0
0
0
0
0
11
100%
5
0
100%
Community Assessment & Intensive Support Team
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
1
100%
0
0
Occupational Therapy
1
3
1
3
0
0
0
1
1
0
0
0
1
0
1
0
0
0
12
0
0
0
0
0
0
0
12
100%
6
0
100%
Physiotherapy
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
2
100%
8
0
100%
Psychiatry
1
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
2
100%
6
0
100%
Psychology Referral to Treatment/Assessment*
3
0
2
0
0
0
0
1
0
0
0
0
0
0
4
0
1
0
11
0
0
0
0
1
1
2
13
85%
29
6
83%
Speech & Language
0
2
4
0
0
0
0
0
0
0
0
0
0
0
0
1
0
1
8
0
0
0
0
0
0
0
8
100%
6
0
100%
Total
17.1wks - 18.0wks
0
0
16.1wks - 17.0wks
0
1
15.1wks - 16.0wks
0
1
14.1wks - 15.0wks
0
1
13.1wks - 14.0wks
0
3
12.1wks - 13.0wks
0
0
11.1wks - 12.0wks
2
10.1wks - 11.0wks
6.1wks - 7.0wks
0
4
9.1wks - 10.0wks
5.1wks - 6.0wks
1
1
8.1wks - 9.0wks
4.1wks - 5.0wks
BOT
Community Nurses
7.1wks - 8.0wks
3.1wks - 4.0wks
Total
Above 18
Wks
Doncaster LD / Weeks
0-7days
2.1wks - 3.0wks
Incomplete Pathway
1.1wks - 2.0wks
New Patient Wait
Total
Equal to or
Below 18
Wks
Total
% of
Total Waiting % of Patients
Patients Total Waiting
for
Waiting for
for Treatment
seen
Treatment Treatment <18
within 18
<18 Wks
>18 Wks
Wks
Wks
North Lincs LD / Weeks
0-7days
1.1wks - 2.0wks
2.1wks - 3.0wks
3.1wks - 4.0wks
4.1wks - 5.0wks
5.1wks - 6.0wks
6.1wks - 7.0wks
7.1wks - 8.0wks
8.1wks - 9.0wks
9.1wks - 10.0wks
10.1wks - 11.0wks
11.1wks - 12.0wks
12.1wks - 13.0wks
13.1wks - 14.0wks
14.1wks - 15.0wks
15.1wks - 16.0wks
16.1wks - 17.0wks
17.1wks - 18.0wks
Total
Equal to or
Below 18
Wks
18.1wks - 19.0wks
19.1wks - 20.0wks
20.1wks - 21.0wks
21.1wks - 22.0wks
22.1wks -28.0wks
28.1+wks
*Due to service changes Psychology Assesment and treatment waits have been combined into the same waiting lists. DISCO waits to be removed.
Total
Above 18
Wks
Community Nurses
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
2
Physiotherapy
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Psychology (Assessment & Treatment)*
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
1
Consultant Psychiatrist
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Speech & Language*
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
1
0
0
1
2
Total
% of
Total Waiting % of Patients
Patients Total Waiting
for
Waiting for
for Treatment
seen
Treatment Treatment <18
within 18
<18 Wks
>18 Wks
Wks
Wks
100%
100%
50%
21
0
100%
3
0
100%
20
8
71%
4
1
80%
3
1
75%
10.1wks - 11.0wks
11.1wks - 12.0wks
12.1wks - 13.0wks
13.1wks - 14.0wks
14.1wks - 15.0wks
15.1wks - 16.0wks
16.1wks - 17.0wks
17.1wks - 18.0wks
18.1wks - 19.0wks
19.1wks - 20.0wks
20.1wks - 21.0wks
21.1wks - 22.0wks
22.1wks -28.0wks
28.1+wks
0
0
0
0
0
1
1
0
1
0
0
0
0
3
0
1
0
0
0
0
1
4
75%
3
0
100%
0
1
0
0
0
0
1
0
0
0
0
0
0
0
3
0
0
0
0
0
0
0
3
100%
4
0
100%
Community Nurse
2
2
0
2
2
2
1
1
0
1
0
0
0
0
0
0
0
1
14
0
0
0
0
0
0
0
14
100%
23
0
100%
Consultant Psychiatrist
0
1
0
0
0
0
0
0
0
0
0
0
1
1
1
0
0
0
4
0
0
0
0
0
0
0
4
100%
20
2
91%
Consultant Psychologist
0
0
2
0
0
0
1
2
1
2
0
0
0
0
0
1
0
0
9
0
0
0
2
0
0
2
11
82%
0*
0
100%
Assistant Psychologist
3
0
1
1
1
0
1
0
0
0
0
0
0
0
0
0
0
0
7
0
0
0
0
0
0
0
7
100%
4
0
100%
Occupational Therapy
8
1
1
0
0
1
2
1
0
0
0
0
1
2
0
0
0
1
18
3
0
0
1
1
3
8
26
69%
40
5
89%
Physiotherapy
1
1
0
0
0
0
0
1
0
0
0
0
0
0
1
0
0
0
4
0
0
0
0
0
0
0
4
100%
16
8
67%
Speech & Language
0
0
1
1
3
0
0
0
0
0
0
0
0
0
0
0
0
0
5
0
0
0
0
0
0
0
5
100%
23
2
92%
8.1wks - 9.0wks
0
0
7.1wks - 8.0wks
0
0
6.1wks - 7.0wks
0
1
5.1wks - 6.0wks
0
0
4.1wks - 5.0wks
0
3.1wks - 4.0wks
Art Therapy
Clinical Psychologist
2.1wks - 3.0wks
Total
Above 18
Wks
1.1wks - 2.0wks
Total
Equal to or
Below 18
Wks
Rotherham LD / Weeks
0-7days
9.1wks - 10.0wks
*Due to service changes Psychology Assesment and treatment waits have been combined into the same waiting lists. DISCO waits to be removed.
Children and Community PAG Exception Working Document
% of
Total Waiting % of Patients
Patients Total Waiting
for
Waiting for
seen
for Treatment
Treatment Treatment <18
within 18
<18 Wks
>18 Wks
Wks
Wks
Page 7
CAMHS Performance Dashboard - March 2014
Target
%
Num/Den
DONCASTER
Doncaster - % of Patients with an Agreed Care Pathway & Treatment Plan
Paitients/Careplans
% referrals starting treatment plan within 8 wks
95.0%
100.0%
22/22
% triaged referrals assessed within 4 weeks
95.0%
82.8%
48/58
% booked appointment/DNA Compliance
<10%
7.9%
100/1266
% urgent referrals assessed within 24 hrs
98.0%
-
0/0
<10% (TBC)
7.0%
43/602
% of Urgent referrals seen within 24hrs/next working day
95.0%
100.0%
2/2
Referral to Treatment - Completed pathway < 12 weeks
ROTHERHAM
95.0%
56%
19/34
Number of referrals assessed within 24 hours in A&E
100.0%
100.0%
3/3
% referrals triaged for urgency within 24 working hrs
100.0%
99.5%
206/207
% of re-referrals within 30 days of discharge
Waiting Times Completed Pathway 18 wk wait
≤15%
3%
1/33
95.0%
73.0%
30/41
Appointments/DNA's
58/704
Current Performance
100.0%
Status
101.0%
100.0%
98.0%
% With
Agreed
careplan
97.0%
Target
99.0%
NORTH LINC'S
% booked appointments DNAs
976/976
96.0%
95.0%
Rotherham - Percentage of DNA's
Current Performance
8.20%
94.0%
North Linc's - % time spent on face to face client contact
Contact Hrs/F2F contact hrs
421/652 Current Performance
65.0%
Status
12.0%
Status
90%
80%
10.0%
% DNA's
70%
% Spent Face
to face
60%
8.0%
50%
Target
<10%
6.0%
40%
Target
30%
4.0%
20%
10%
2.0%
0%
0.0%
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Alerts
Status
RTT - Waits showing due to intial transfer of service user referrals from TPP without contact information
Key
Investigation required. Monitor Situation.
Service working with Informatics to remove referrals that have had contacts as per RTT
internal rules
Action Plan required to remedy situation.
March
3.1wks - 4.0wks
4.1wks - 5.0wks
5.1wks - 6.0wks
6.1wks - 7.0wks
7.1wks - 8.0wks
Total
Equal
to or
Below
8 Wks
35
24
32
30
19
16
11
6
173
4
2
2
4
10
3
4
1
30
New Patient Wait - Completed pathway within 8 Wks - referral to treatment)
0
28.1+wks
1
22.1wks -28.0wks
1
1
1
1
2
1
19
0
1
0
0
0
0
0
0
0
1
1
3
0
1
2
3
2
0
2
0
4
2
2
2
0
1
0
0
1
1
4
1
1
3
16
39
212
82%
173
39
2
0
1
2
0
1
0
0
0
0
0
0
0
5
11
41
73%
30
11
0
78.1 - 104 wks
0
52.1 - 78 wks
0
28.1- 52 Wks
0
22.1wks -28.0wks
0
21.1wks - 22.0wks
28.1+wks
1
22.1wks -28.0wks
3
21.1wks - 22.0wks
1
20.1wks - 21.0wks
4
0
20.1wks - 21.0wks
0
19.1wks - 20.0wks
3
0
19.1wks - 20.0wks
March
18.1wks - 19.0wks
New Patient Completed Wait
0
18.1wks - 19.0wks
Total
Equal to
or
Below
12 Wks
18.1wks 19.0wks
19.1wks 20.0wks
20.1wks 21.0wks
21.1wks 22.0wks
North Linc's KPI 32 - CAHMS Waiting List - 100% ≤ 12weeks
Completed / Incomplete pathway within 12 Wks
0
17.1wks - 18.0wks
0
17.1wks 18.0wks
0
17.1wks - 18.0wks
0
16.1wks - 17.0wks
0
16.1wks - 17.0wks
1
15.1wks - 16.0wks
0
15.1wks - 16.0wks
0
Total
Above
18 Wks
14.1wks - 15.0wks
0
14.1wks - 15.0wks
11.1wks - 12.0wks
0
Total
Equal
to or
Below
18 Wks
13.1wks - 14.0wks
10.1wks - 11.0wks
March
9.1wks - 10.0wks
Total
Equal to
or
Below
10 Wks
10.1wks - 11.0wks
11.1wks - 12.0wks
12.1wks - 13.0wks
13.1wks - 14.0wks
14.1wks - 15.0wks
15.1wks - 16.0wks
16.1wks - 17.0wks
17.1wks - 18.0wks
18.1wks - 19.0wks
19.1wks - 20.0wks
20.1wks - 21.0wks
21.1wks - 22.0wks
22.1wks -28.0wks
28.1+wks
8.1wks - 9.0wks
0
13.1wks - 14.0wks
9.1wks - 10.0wks
8.1wks - 9.0wks
7.1wks - 8.0wks
0
12.1wks - 13.0wks
8.1wks - 9.0wks
7.1wks - 8.0wks
6.1wks - 7.0wks
0
12.1wks 13.0wks
13.1wks 14.0wks
14.1wks 15.0wks
15.1wks 16.0wks
16.1wks 17.0wks
7.1wks - 8.0wks
6.1wks - 7.0wks
5.1wks - 6.0wks
0
12.1wks - 13.0wks
6.1wks - 7.0wks
5.1wks - 6.0wks
4.1wks - 5.0wks
0
11.1wks 12.0wks
5.1wks - 6.0wks
4.1wks - 5.0wks
3.1wks - 4.0wks
0
11.1wks - 12.0wks
4.1wks - 5.0wks
3.1wks - 4.0wks
2.1wks - 3.0wks
0
10.1wks 11.0wks
3.1wks - 4.0wks
2.1wks - 3.0wks
1.1wks - 2.0wks
0
10.1wks - 11.0wks
2.1wks - 3.0wks
1.1wks - 2.0wks
0-7days
1
9.1wks - 10.0wks
1.1wks - 2.0wks
Doncaster
CAMHS /
Weeks
0-7days
March
9.1wks - 10.0wks
North
Linc's
CAMHS /
Weeks
0-7days
Doncaster
CAMHS /
Weeks
8.1wks - 9.0wks
2.1wks - 3.0wks
March
1.1wks - 2.0wks
Rotherham
CAMHS /
Weeks
0-7days
CAMHS Services: Waiting Times - March 2014
New Patient Wait
Doncaster - ADHD Waiting times (Referral to Connors) KPI 18 - New Service User Waits - Completed pathway within 10 Wks
Total
Above
10 Wks
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
% of
Total
Total
Patients
Patients Patients
Total
seen
Seen <10 Seen
within
Wks
>10 Wks
10 Wks
1
100%
Total
Above
12 Wks
1
0
1
0
0
15
1
Total
Patients
Total <12
seen
Above 8 Total
Wks
within 8
Wks
100%
New Patient Wait
ADHD Waiting times (Connors to intervention, therapy or medication) KPI 18 - New Service User Waits - Completed pathway within 18 Wks
Total
Total
% of
Patients
Patients Patients
Total Seen
Seen
Seen
<18
>18 Wks <18 Wks
Wks
0
100%
Total
% of
Patients
seen
within 12
Wks
34
56%
New Patient Wait - Incomplete pathway within 8 Wks
Rotherham Waiting List - All service users 100% ≤ 12weeks - Referral to treatment
% of
Total >8
Wks
Wks
Performance Dashboards
Board of Directors
29 May 2014
Author: Business Support Units
Mental Health and Forensics
Performance Dashboards: Priorities Report
Key:
Red
Not meeting target
Amber
Within 5% of target
Green
Meeting Target
↑
Improved on last month
→
Stayed the same
↓
Deteriorated since last month
No comparator available yet
Contents:
Mental Health and Forensics Business Support Unit:
Adult Mental Health Services
Older Peoples Mental Health Services
Forensic Services
Contents
Page 2
95%
94%
Apr May Jun Jul
Target
Aug Sep
Don
Oct Nov Dec Jan
Roth
N.Lincs
Feb Mar
Rotherham Doncaster
Acute Inpatient Occupancy Rates
2.
% Occupancy Including Leave
160%
140%
120%
100%
80%
60%
20%
0%
Apr
May Jun Jul
Total Donc
Aug
Sep Oct
Total Roth
KPI Area:
Nov
Dec Jan Feb
Total N.Lincs
Mar
N.Lincs
40%
n/a
2387
2117
89%
n/a
1860
1882
101%
n/a
589
737
125%
→
↑
↑
↓
Donc
Roth
Rotherham Doncaster
Target
Available BDs
OBDs
Actual
Target
Available BDs
OBDs
Actual
Target
Available BDs
OBDs
Actual
→
95%
90%
85%
80%
75%
Apr
May Jun
Jul
Target
Aug Sep
Oct
Don
Nov Dec
Roth
Jan
Feb
Mar
N.Lincs
% of Patients seen within 18 weeks
4.
% 18 Week Waits
105%
100%
95%
90%
Apr
Weeks
May
Jun Jul
Target
<=4
Aug
>4 <=8
Sep
Don
Oct Nov
Roth
>8 <=12
Dec Jan Feb
N.Lincs
>12 <=18
Mar
>18 <=26
Average
Donc
61
7
7
0
0
<=4
Roth
39
16
4
4
1
<=4
N.Lincs
37
5
6
2
1
<=4
CPA 12 month review
5.
N.Lincs
CPA 12 Month Reviews
% in employment
IAPT recovery rate
IAPT waiting times
30 day readmissions
No new cases Psychosis
No home treatment episodes
AOT Caseload
Delays in Transfer of Care - Delay Days
Delays in Transfer of Care - Number of Patients
100%
100%
100%
49/49
32/32
11/11
→
→
→
(Rotherham Quarterly Figures only)
102%
100%
98%
5%
5%
8%
96%
39/717
48/997
31/410
94%
↓
→
→
92%
53%
63%
57%
90%
132/247
128/204
63/110
88%
→
↑
↑
590
1132
431
↑
↑
↑
5
0
0
↑
→
→
49
50
42
Apr
May
Jun
Jul
Target
Aug
Sep
Don
Oct
Nov
Roth
Dec
Jan
Feb
Mar
N.Lincs
Rotherham Doncaster All
Gatekeeping
Section 117 6 month Reviews
6.
Section 117
100%
↑
↑
↑
80%
591
547
239
60%
↑
↑
↑
26
111
57
↓
→
→
37
75
174
↑
↑
↓
2
3
8
↑
↑
↑
40%
20%
0%
Apr
May
Jun
Jul
Target
AMHS
Aug
Sep
Don
Oct
Roth
Nov
Dec
N.Lincs
96%
100%
Rotherham Doncaster
97%
7 Day Follow Up
105%
N.Lincs
98%
↓
7 Day Follow Up
3.
Rotherham Doncaster
99%
100%
66
65
98%
100%
71
71
100%
n/a
35
35
100%
Jan
N.Lincs
N.Lincs
100%
Target
Required
Seen in 4 Hours
Actual
Target
Required
Seen in 4 Hours
Actual
Target
Required
Seen in 4 Hours
Actual
Feb
Mar
N.Lincs
% 4 Hour Waits
101%
N.Lincs
% emergency referrals seen Face to Face in 4 Hours
1.
Rotherham Doncaster
Adult Mental Health Services Performance Dashboard
Target
Discharged
Followed Up
Actual
Target
Discharged
Followed Up
Actual
Target
Discharged
Followed Up
Actual
→
→
↑
95%
23
23
100%
95%
20
20
100%
95%
7
7
100%
Target
All Waits
Waits < 18 weeks
Actual
Target
All Waits
Waits < 18 weeks
Actual
Target
All Waits
Waits < 18 weeks
Actual
95%
75
75
100%
95%
63
62
98%
95%
50
49
98%
Target
Due
Received
Actual
Target
Due
Received
Actual
Target
Due
Received
Actual
↓
95%
800
782
98%
95%
1020
1001
98%
95%
578
562
97%
Trajectory Target
Open S117s
95%
498
Reviews completed
in 6 months
409
→
↓
↓
Actual
Open S117s
↑
→
↑
Reviews completed
in 6 months
Actual
Open S117s
↑
Reviews completed
in 6 months
Actual
↑
82%
415
311
75%
150
77
51%
Page 3
Older Peoples Mental Health Services Performance Dashboard
>12 <=18
>18 <=26
Average
Donc
6
7
5
4
1
>4 <=8
Roth
4
3
2
4
1
<=4
14
2
1
0
<=4
18
N.Lincs
2.
Waiting Times 85% Target within 14 days
85% Target within 14 days
150%
100%
50%
0%
May Jun
Don
Jul
Aug Sep
Roth
Oct Nov Dec
N.Lincs
Jan Feb
Target
Donc
4
Roth
7
N.Lincs
3.
Mar
N.Lincs
Average
Wait
(Days)
Apr
4
Waiting Times 85% Target within 8 weeks
85% Target within 8 weeks
200%
100%
0%
May Jun
Don
Jul
Aug
Roth
Sep
Oct Nov
N.Lincs
Dec
Jan Feb
Target
Mar
<=4
>4 <=8
Average
Donc
49
12
<=4
Roth
11
6
<=4
N.Lincs
7
4
<=4
Weeks
4.
N.Lincs
Apr
Waiting Times 95% Target within 18 weeks
95% Target within 18 weeks
105%
100%
95%
90%
Apr
Weeks
May Jun
Don
Jul Aug
Roth
Sep Oct Nov
N.Lincs
Dec Jan
Target
Feb
Mar
<=4
>4 <=8
>8 <=12
>12 <=18
>18 <=22
Average
Donc
49
12
2
1
0
<=4
Roth
11
6
1
2
0
<=4
N.Lincs
7
4
4
0
0
<=4
↑
85%
149
140
94%
85%
40
34
85%
85%
25
25
100%
Target
All Waits
Waits < 8 weeks
Actual
Target
All Waits
Waits < 8 weeks
Actual
Target
All Waits
Waits < 8 weeks
Actual
95%
64
61
95%
95%
20
17
85%
95%
15
11
73%
Target
All Waits
Waits < 18 weeks
Actual
Target
All Waits
Waits < 18 weeks
Actual
Target
All Waits
Waits < 18 weeks
Actual
95%
64
64
100%
95%
20
20
100%
95%
15
15
100%
→
↓
↑
↓
↓
↑
→
→
→
Rotherham Doncaster
Target
Referrals
1st Contact (on time)
Actual
Target
Referrals
1st Contact (on time)
Actual
Target
Referrals
1st Contact (on time)
Actual
↓
40%
20%
0%
Apr
May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Total Donc
Total Roth
Total N.Lincs
6.
N.Lincs
>8 <=12
60%
ALOS
300
250
200
150
100
50
0
Apr
May
Jun
Jul
Aug
Coniston
Glade
Sep
Oct
Nov
Dec
Windermere
Ferns
7.
Jan
Feb
Mar
Brambles
Laurel
Delays in Transfer of Care
DTOC - Delayed Days
80
60
40
20
0
Apr May
D - NHS
R - Both
OPMHS
Jun
Jul Aug
D - SC
NL - NHS
8.
Sep Oct
D - Both
NL - SC
Nov
Dec Jan
R - NHS
NL - Both
Feb Mar
R - SC
30 Day Readmissions
30 Day Readmissions
3
2
2
1
1
0
Apr May Jun
Don
Jul
Aug Sep Oct Nov Dec Jan Feb Mar
Roth
Target
Available BDs
OBDs
Actual
Target
Available BDs
OBDs
Actual
Target
Available BDs
OBDs
Actual
↓
↓
↓
Target
Average Length of Stay
All
>4 <=8
80%
D
<=4
100%
N.Lincs
R
Feb
Mar
Target
Inpatient Occupancy
120%
N
L
Dec
Jan
N.Lincs
Inpatient Occupancy
Rotherham Doncaster
Nov
↑
5.
N.Lincs
Oct
Roth
95%
22
21
95%
95%
13
12
92%
95%
35
35
100%
Rotherham Doncaster
Sep
Rotherham Doncaster
Weeks
Aug
Don
Rotherham Doncaster
Jul
Target
All Waits
Waits < 18 weeks
Actual
Target
All Waits
Waits < 18 weeks
Actual
Target
All Waits
Waits < 18 weeks
Actual
N.Lincs
0%
Rotherham Doncaster
% Memory Clinic Waits
200%
N.Lincs
Rotherham Doncaster
Memory Clinic Waiting Times (from July)
N.Lincs
1.
n/a
1240
723
58%
n/a
1302
871
67%
n/a
403
253
63%
n/a
*ALOS is based on number
discharged and LOS, divided
by occupied bed days in
month. This creates the vast
fluctuations in data.
Coniston
Windermere
Brambles
Glade
Ferns
Laurel
46.2
61.4
34.4
57.3
52.8
63.3
Target
NHS<30 Both<15
NHS
0
Social Care
0
Both
74
Target
n/a
NHS
16
Social Care
0
Both
0
Target
0
NHS
0
Social Care
17
Both
0
0
Target
Actual
→
0
Target
Actual
→
0
0
Target
Actual
0
→
0
Page 4
Forensic Services Performance Dashboard
Amber Lodge Summary:
Jubilee Close Summary:
The Trust has reported against a new suite of KPIs from July 2013 and therefore previous information is not
available for comparison. The following priorities are part of Amber Lodge’s NHS England’s Key Performance
Indicators. There is one KPI exception reported for March 2014.
Doncaster CCG signed off a suite of KPIs and Activity for Jubilee Close during January 2014. The service and
performance teams have collated information retrospectively from July 2013. All 10 Jubilee KPIs are achieving
DCCG targets for March 2014.
Target
% of all new admissions offered a dental service within
12 weeks of admission.
% New Admissions offered Dental Service in 12 weeks
120%
100%
80%
60%
40%
20%
0%
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
Target
2
Offered
2
→
23
Patients with
completed plan
20
↓
Number required
MOJ conditions
23
Conditions met
23
% of Patients receiving 25 hours of Meaningful Activity weekly
Target
3.
→
4.
Feb-14
36
0
3.90%
Mar-14
65
0
3.00%
120%
100%
80%
60%
40%
20%
0%
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
Target
% of Patients
→
100%
100%
Patients (DCCG
Beds 1-3)
3
Patients Receiving
3
→
100%
100%
Patients (DCCG
Beds 1-3)
3
Patients Engaged
3
Doncaster
Actual
% of Patients engaging in Community Education
% of Patients engaging in Community Education
3
Target
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
Target
% of Patients
100%
Other Key Priorities:
% of Patients engaging in Community Work
% of Patients engaging in Community Work
Patients Engaged
Actual
% of Patients
120%
100%
80%
60%
40%
20%
0%
3
Target
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
100%
Actual
% of Patients receiving 25 hours of Meaningful Activity
weekly
100%
Patients (DCCG
Beds 1-3)
Actual
% of Patients
120%
100%
80%
60%
40%
20%
0%
87%
% of MoJ conditions that have been met
Incidents
Complaints
Sickness Absence
2.
100%
Target
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
Target
Percentage of patients
Target
100%
All patients
Target
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
100%
Percentage of MoJ conditions that have been met
120%
100%
80%
60%
40%
20%
0%
% of Patients engaged in the Whole Dining Experience
120%
100%
80%
60%
40%
20%
0%
100%
Patients admitted
in last 12 weeks
Actual
% completed Outcomes Plans
Doncaster
4.
→
Target
Doncaster
% of completed Outcomes Plan
14
Actual
All patients have completed Outcomes Plan based on
outcome areas in specification
105%
100%
95%
90%
85%
80%
75%
Received
Target
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
Target
% Offered
3.
14
Actual
% of Patients
Doncaster
2.
Patients with LOS
>9 months
% of Patients engaged in the Whole Dining Experience
program
Doncaster
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
1.
100%
Doncaster
% HCR 20 & HONOS
120%
100%
80%
60%
40%
20%
0%
Target
→
Target
Doncaster
% patients with LOS >9 months who had HCR 20 &
HONOS in previous 6 months
Doncaster
1.
100%
100%
Patients (DCCG
Beds 1-3)
3
Patients Engaged
3
Actual
→
100%
Feb-14
16
0
3.70%
Mar-14
13
0
0.00%
↓
→
↓
Other Key Priorities:
↑
→
↓
Incidents
Complaints
Sickness Absence
Forensics
Page 5
Paper P
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Group/Committee
Name
Board of Directors Meeting
Meeting Date
29 May 2014
Title of Paper
Author
Report of the Director of Workforce and Organisational Development
Rosie Johnson
Paper For
Decision
Strategic Work
Programme:
- Relevance
- Progress
Debate
Assurance
What Strategic Work Programmes is the paper
relevant to?
Information
X
Reference
2.2, 2.3, 2.4, 3.1, 3.2
Does the paper provide assurance
against delivery of the identified Strategic
Work Programme?
Yes
1.0
INTRODUCTION
1.1
This report sets out the key workforce and organisational
development areas of work within Rotherham Doncaster and South
Humber NHS Foundation Trust as at 22 May 2014.
2.0
KEY OPERATIONAL ACTIVITY
2.1
Key highlights from the HR & OD Dashboard
Sickness absence was at 5.2% as at March 2014, which was noted
to be the same as March 2013. Cumulative sickness absence for the
Trust was noted to be 5.3% for the year which was a 0.3% reduction
from the previous year.
Agency spend increased from £524,677 in March 2013 to £852,541
in March 2014 (+62.5%). This was linked to medical agency usage
to manage HR issues including sickness absence, retirements and
leavers.
Key Points to Note
(including any
identified risks )
Overtime spend decreased from £79,748 as at March 2013 to
£57,879 in March 2014 (-27.4%).
2.2
Fit For the Future Programme
The “maintaining the momentum” event is currently being planned. A
series of “mop up” sessions for any members of staff who missed
any of the earlier modules have been undertaken.
Overall the evaluation forms and the verbal feedback from
participants relating to all the modules has been extremely positive
with staff stating it has been very relevant, contributed to their
personal development and the practical tools and techniques shared
during the workshops are being taken and applied back in the
workplace.
1
Paper P
2.3
Mutually Agreed Resignation Scheme (MARS)
All approved and accepted applications for the MAR scheme have
been processed.
Dates for release of staff are between mid-April and the end of June
2014 for the majority with a couple of exceptions.
2.4
Workforce QIPP Workstream
Highlights from the 10 April 2014 meeting included:
-
-
-
-
2.5
E-rostering. Allocate Software have been identified as the preferred
provider and work is continuing through the Workforce QIPP
Workstream in relation the implementation plan and next steps.
Junior doctors North Lincolnshire property. Refurbishment has taken
place and the property is ready for use. A review of the rent and the
property usage would be undertaken in approximately 6–9 months
time.
Medical staffing. Work continues in relation to the monitoring of
medical staffing issues within Adult Services, Older Adult Services,
Learning Disability Services, CAMHS and DCIS. It was agreed that
dedicated work would be undertaken with regards to the increasing
medical agency costs within the affected Business Division.
The launch of the pooled cars scheme was discussed at the meeting
and it was noted that “co wheels” would be delivering the cars on 2
May 2014.
Lengthy discussion took place with regards to apprenticeships and
how to move forward with this initiative.
E-rostering and E-expenses update
Allocate Software have been awarded the contract. Work is currently
underway on a project plan which will be shared at the June 2014
HR and OD Policy and Planning Group meeting. A project board
group would be set up to include members of the Workforce QIPP
Workstream with additional representation from the operations
directorate.
2.6
HR and OD Policy and Planning Group terms of reference
The draft terms of reference was presented and discussed at the
meeting. The HR and OD Policy and Planning Group approved the
draft terms of reference in the current format on the understanding
that some suggested amendments would be made in relation to
membership.
2.7
Equality and Diversity Monitoring Analysis Report
An analysis of the information that was provided as part of the Public
Sector Equality Duty (PSED) was noted and discussed by the group.
The analysis period used was April to September as the information
was published in January.
2.8
Learning and Development Annual Report 2013/14
The Learning and Development Annual Report 2013/14 was noted
and discussed by the group. The report contained a list of all training
2
Paper P
which is supported within the Trust.
2.9
Update on Oracle Learning Management (OLM) competencies
Work has been undertaken to cleanse the system and update the
national competencies and certifications. Each member of staff can
now view their own Electronic Staff Record (ESR) and see clearly
what training they should be completing and when the training is due
and when they are nearing compliance expiry. The training matrix is
also available on the intranet as an aide memoir.
2.10
Certificate in Fundamental Care
It was reported that the Trust had been successful in being a pilot
site for the Certificate in Fundamental Care.
2.11
Memorandum of Understanding
The Trust has adopted and will apply the Memorandum of
Understanding with regard to redeployment of staff at risk of
redundancy within the region. Participation should not necessarily
increase the amount of time taken in the recruitment process, but
does try to retain people with the right skills within the NHS and to
prevent redundancies. RDaSH staff will also be able to access this.
2.12
Revised Policy and Planning group cover sheet
The revised cover sheet for use by the policy and planning groups
was noted to be used from May 2014 onwards.
3.0
RECOMMENDATIONS
3.1
The Board is asked to:
3.1.1 Note the progress made on the Workforce and
Organisational Development agenda highlighted in this report.
Board Assurance
Framework
If the paper also provides assurance against
the effectiveness of a Key Control what is the
reference and what level of assurance do you
think it provides?
BAF Key
Control Ref.
2.2, 2.3, 2.4,
3.1, 3.2
Effectiveness
F/S/P/V/N
ESQS outcome number
CQC
Financial/Budget
Equality &
Diversity/Human
Rights
If the paper provides assurance against
Essential Standards of Quality and Safety
(ESQS) specify the outcome number.
13 Staffing
14 Supporting Workers
Significant savings continue to be released via the systems and processes
put in place for securing the services of temporary staff via an agency.
As noted within the Equality and Diversity Monitoring Analysis Report.
3
Paper P
Action proposed
following the
Group meeting
To note the issues raised in the Workforce and Organisational Development
report.
Person
Responsible
Rosie Johnson, Director of Workforce & Organisational Development
Date for
completion
Outcome required
from the Group
22 May 2014
To note the content of this paper.
4
Paper Q
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Group/Committee
Name
Board of Directors – Public meeting
Meeting Date
29 May 2014
Title of Paper
Author
Organisational Revalidation Self-Assessment
Dr Ahluwalia, Executive Medical Director
Paper For
Decision
Strategic Work
Programme:
- Relevance
- Progress
Key Points to Note
(including any
identified risks )
Debate
Assurance
Information
Reference
What Strategic Work Programmes is the paper
relevant to?
Does the paper provide assurance against
delivery of the identified Strategic Work
Programme?
Yes / No
Revalidation started on 3 December 2012 and the GMC expects to
revalidate the majority of licensed doctors in the UK for the first time
by March 2016.
Revalidation is the process by which licensed doctors are required to
demonstrate on a regular basis that they are up to date and fit to
practice. Revalidation aims to give extra confidence to patients that
their doctor is being regularly checked by their employer and the
GMC.
Licensed doctors have to revalidate, usually every five years, by
having regular appraisals with their employer. Only doctors who have
a license to practice will need to revalidate.
The attached paper is a self-assessment statement on current
progress with revalidation at the Trust for the year ending March
2014.
BAF Key
Control Ref.
Effectiveness
F/S/P/V/N
Board Assurance
Framework
If the paper also provides assurance against
the effectiveness of a Key Control what is the
reference and what level of assurance do you
think it provides?
CQC
If the paper provides assurance against
Essential Standards of Quality and Safety
(ESQS) specify the outcome number.
Financial/Budget
Budgetary requirements are considered alongside the medical
appraisal and revalidation agenda.
Equality &
Diversity/Human
Rights
ESQS outcome number
The processes and policies to be implemented and conducted in a
fair and equitable manner.
Paper Q
Action proposed
following the
Group meeting
Person
Responsible
Date for
completion
Outcome required
from the Group
To proceed with any identified action points
Once the report has been approved at the Board of Directors the
Executive Medical Director will write a statement of assurance to
Doncaster CCG in line with an existing agreement.
Dr Ahluwalia, Executive Medical Directors
The Board of Directors to note the self-assessment.
Processed: 21-May-2014 15:36:01
Annex C
Annual Organisational Audit
(AOA)
End of year questionnaire 2013-14
This questionnaire has been approved by the Return of Central Returns
Steering Committee (ROCR) Licence number ROCR-OR-2127-005 MAND
For Admin Use Only
A
B
C
electronic forms solution by www.evenlogic.co.uk/forms
Form EI017
1
March 2014
www.england.nhs.uk/revalidation
Annual Organisational Audit (AOA): End of year questionnaire 2013 - 2014
Revalidation is the process by which doctors in the UK will have their licence to practise renewed. The purpose of revalidation is to assure
patients and the public, employers and other healthcare professionals that licensed doctors are up to date and fit to practise.
The annual organisational audit exercise is designed to help designated bodies in England provide assurance to responsible officers, boards,
regulators, commissioners, higher level responsible officers1 and other interested bodies that each designated body has effective systems in
place which comply with the requirements of the responsible officer regulations.
The aims of the annual organisational audit exercise are to:
•
gain an understanding of the progress that organisations have made during 2013/14
•
provide a tool that helps responsible officers assure themselves and their boards/management bodies that the systems underpinning the
recommendations they make to the General Medical Council (GMC) on doctors’ fitness to practise, the arrangements for medical
appraisal and responding to concerns, are in place;
•
provide a mechanism for assuring NHS England (as the Senior Responsible Owner for medical revalidation in England), the England
Revalidation Implementation Board (ERIB) and the GMC that systems for evaluating doctors’ fitness to practice are in place, functioning,
effective and consistent.
For the purpose of this document the ‘higher level responsible officer’ is the responsible officer’s own responsible officer who may be based at
the regional or national office of the NHS England, Health Education England, the Department of Health or the Faculty of Medical Leadership
and Management.
1
2
March 2014
www.england.nhs.uk/revalidation
This AOA exercise is divided into four sections:
Section 1: The Designated Body and the Responsible Officer
Section 2: Appraisal
Section 3: Monitoring Performance and Responding to Concerns
Section 4: Recruitment and Engagement
The questionnaire should be completed by the responsible officer on behalf of the designated body, though this duty may be appropriately
delegated. The questionnaire should be completed during April and May 2014 for the year ending 31 March 2014. The deadline for
submission is detailed in the accompanying email.
Whilst NHS England is a single designated body, for the purposes of this audit, the national and regional offices and each area team of NHS
England should answer as a ‘designated body’ in their own right.
Following completion of this AOA exercise, designated bodies should produce an action plan to address the identified development needs.
Board-level accountability for the quality and effectiveness of these systems is important and this report, along with the resulting action plan,
should be presented to the board, or an equivalent governance or executive group, and should be included in an NHS organisation’s quality
account.
The audit process will also enable designated bodies to provide assurance that they are fulfilling their statutory obligations and their systems
are sufficiently effective to support the responsible officer’s recommendations.
For further information, references and resources see pages 4 and 5 below and www.england.nhs.uk/revalidation.
3
March 2014
www.england.nhs.uk/revalidation
Sources used in preparing this document
1. The Medical Profession (Responsible Officers) Regulations 2010 (Her Majesty’s Stationery Office, 2013)
2. The Medical Profession (Responsible Officers) (Amendment) Regulations 2013 (Her Majesty’s Stationery Office, 2013)
3. The Medical Act 1983 (Her Majesty’s Stationery Office, 1983)
4. Maintaining High Professional Standards in the Modern NHS (Department of Health, 2003)
5. The National Health Service (Performers Lists) (England) Regulations 2013
6. The Role of the Responsible Officer: Closing the Gap in Medical Regulation, Responsible Officer Guidance (Department of Health,
2010)
7. Appraisal Guidance for Consultants (Department of Health, 2001)
8. Appraisal Guidance for General Practitioners (Department of Health, 2004)
9. Revalidation: A Statement of Intent (GMC and others, 2010)
10. Good Medical Practice (GMC, 2013)
11. Good Medical Practice Framework for Appraisal and Revalidation (GMC, 2012)
12. Good Medical Practice: Supplementary Guidance - Writing References (GMC, 2007)
13. Guidance on Colleague and Patient Questionnaires (GMC, 2012)
14. Supporting Information for Appraisal and Revalidation (GMC, 2012)
15. Effective Governance to Support Medical Revalidation: A Handbook for Boards and Governing Bodies (GMC, 2013)
16. Making Revalidation Recommendations: The GMC Responsible Officer Protocol – Guide for Responsible Officers (GMC, 2012)
17. The Medical Appraisal Guide (NHS Revalidation Support Team, 2013)
18. Quality Assurance of Medical Appraisers (NHS Revalidation Support Team, 2013)
19. Providing a Professional Appraisal (NHS Revalidation Support Team, 2012)
20. Information Management for Medical Appraisal and Revalidation in England (NHS Revalidation Support Team, 2013)
21. Supporting Doctors to Provide Safer Healthcare: Responding to Concerns about a Doctor’s Practice (NHS Revalidation Support Team,
2013)
22. Guidance for Recruiting for the Delivery of Case Investigator Training (NHS Revalidation Support Team, 2014)
23. Guidance for Recruiting for the Delivery of Case Manager Training (NHS Revalidation Support Team, 2014).
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24. Responsible Officer Conflict of Interest or Appearance of Bias: Request to Appoint and Alternative Responsible Officer (NHS
Revalidation Support Team, 2014).
25. Guide to Independent Sector Appraisal for Doctors Employed by the NHS and Who Have Practising Privileges at Independent
Hospitals: Whole Practice Appraisal (British Medical Association and Independent Healthcare Forum, 2004)
26. Joint University and NHS Appraisal Scheme for Clinical Academic Staff (Universities and Colleges Employers Association, 2002)
27. Preparing for the Introduction of Medical Revalidation: a Guide for Independent Sector Leaders in England (GMC and Independent
Healthcare Advisory Services, 2011)
28. How to Conduct a Local Performance Investigation (National Clinical Assessment Service, 2010)
29. Use of NHS Exclusion and Suspension from Work amongst Doctors and Dentists 2011/12 (National Clinical Assessment Service, 2011)
30. Return to Practice Guidance (Academy of Medical Royal Colleges, 2012)
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1
The Designated Body and the Responsible Officer
Designated Body
1.1
Name of designated body: Rotherham Doncaster & South Humber NHS FT
Address line 1 Woodfield House
Address line 2 Tickhill Road Hospital
Address line 3 Tickhill Road
Address line 4
City
Doncaster
County
South Yorkshire
Postcode DN4 8QN
Responsible officer:
Title
*****
GMC registered first name *****
GMC registered last name *****
GMC reference number
Phone *****
*****
Email *****
Chief executive (or equivalent):
Title
*****
First name *****
Last name *****
First name *****
Last name *****
Email *****
Medical Appraisal Lead:
Title
*****
Email *****
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1.2
Type/sector of
designated body:
(tick one)
NHS England (national office)
NHS England (regional office)
NHS England (area team)
Acute hospital/secondary care foundation trust
Acute hospital/secondary care non-foundation trust
Mental health foundation trust
✔
Mental health non-foundation trust
Other NHS foundation trust (care trust, ambulance trust, etc)
Other NHS non-foundation trust (care trust, ambulance trust, etc)
Special health authorities (Health Education England, NHS Litigation Authority, NHS Trust
Development Authority, NHS Blood and Transplant, etc)
Local education and training board/deanery
Independent/non-NHS
sector
(tick one)
Independent healthcare provider
Locum agency
Faculty/professional body (FPH, FOM, FPM, IDF, etc)
Academic or research organisation
Government department, non-departmental public body or
executive agency
Armed forces
Hospice, charity/voluntary sector organisation
Other non-NHS (please enter type)
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1.3
The responsible officer’s (higher level)
responsible officer is based at:
[tick one]
Each responsible officer has a responsible officer
based at one of these organisations.
NHS England (North) region
✔
NHS England (Midlands and East) region
NHS England (London) region
NHS England (South) region
Department of Health
NHS England (national office)
Health Education England – for local education and training
boards only
Faculty of Medical Leadership and Management – for NHS
England (national office) only
1.4
Number of doctors with whom the designated body has a prescribed connection as at 31 March 2014
The responsible officer should keep an accurate record of all doctors with whom the designated body has a prescribed
connection and must be satisfied that the doctors have correctly identified their prescribed connection. Detailed advice
on prescribed connections is contained in the responsible officer regulations and guidance and further advice can be
obtained from the GMC and the higher level responsible officer. The categories below relate to current roles and job
titles rather than qualifications or previous roles. The number of individual doctors in each category should be entered.
Where a doctor has more than one role in the same designated body a decision should be made about which category
they belong to based on the amount of work they do in each role. Each doctor should be included in only one
category.
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IMPORTANT: ONLY DOCTORS WITH WHOM THE DESIGNATED BODY HAS A PRESCRIBED CONNECTION AS
AT 31 MARCH 2014 SHOULD BE INCLUDED IN THIS SECTION.
Please note that fields 1.4.1 – 1.4.7 are mandatory. Where the answer is nil, please enter “0”.
1.4.1
Consultants (permanent employed consultant medical staff including honorary contract holders, NHS, hospices, and
government /other public body staff. Academics with honorary clinical contracts will usually have their responsible
officer in the NHS trust where they perform their clinical work)
42
Staff grade, associate specialist, specialty doctor (permanent employed staff including hospital practitioners,
clinical assistants who do not have a prescribed connection elsewhere, NHS, hospices, and government/other public
body staff)
17
1.4.3
Doctors on Performers Lists (for NHS England area teams and the Armed Forces only; doctors on a medical or
ophthalmic performers list. This includes all general practitioners (GPs) including principals, salaried and locum GPs)
0
1.4.4
Doctors in training (for local education and training boards/deaneries only; this includes doctors on national
postgraduate training schemes. Doctors on independent schemes will usually have a prescribed connection to the
employing trust and should not be counted under this heading)
1.4.5
Doctors with practising privileges (this is usually for independent healthcare providers, however practising
privileges may also rarely be awarded by NHS organisations. All doctors with practising privileges who have a
prescribed connection should be included in this section, irrespective of their grade)
0
Temporary or short-term contract holders (temporary employed staff including locums who are directly employed,
trust doctors, locums for service, clinical research fellows, trainees not on national training schemes, doctors with
fixed-term employment contracts, etc)
0
Other doctors with a prescribed connection to this designated body (depending on the type of designated body,
this category may include responsible officers, locum doctors, and members of faculties/professional bodies. It may
also include some non-clinical management/leadership roles, research, civil service, doctors in wholly independent
practice, other employed or contracted doctors not falling into the above categories, etc)
0
1.4.2
1.4.6
1.4.7
1.4.8
TOTAL (this cell will sum automatically 1.4.1 - 1.4.7)
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Responsible Officer
1.5
A responsible officer has been nominated/appointed in compliance with the regulations
To answer ‘Yes’:
•
•
1.6
The responsible officer has been a medical practitioner fully registered under the Medical Act 1983 throughout
the previous five years and continues to be fully registered whilst undertaking the role of responsible officer
There is evidence of formal nomination/appointment by board or executive of each organisation for which the
responsible officer undertakes the role
An alternative responsible officer has been nominated/appointed where a conflict of interest or appearance of
bias has been agreed with the higher level responsible officer
Each designated body will have one responsible officer but the regulations allow for an alternative responsible officer
to be nominated or appointed where a conflict of interest or appearance of bias exists between the responsible officer
and a doctor with whom the designated body has a prescribed connection. This will cover the uncommon situations
where close family or business relationships exist, or where there has been longstanding interpersonal animosity.
✔ Yes

 No
 Yes
 No
✔ N/A

In order to ensure consistent thresholds and a common approach to this, potential conflict of interest or appearance of
bias should be agreed with the higher level responsible officer. An alternative responsible officer should then be
nominated or appointed by the designated body and will require training and support in the same way as the first
responsible officer. To ensure there is no conflict of interest or appearance of bias, the alternative responsible officer
should be an external appointment and will usually be a current experienced responsible officer from the same region.
Further guidance is available in Responsible Officer Conflict of Interest or Appearance of Bias: Request to Appoint and
Alternative Responsible Officer (NHS Revalidation Support Team, 2014).
To answer ‘Yes’:
•
•
Where potential conflict of interest or appearance of bias has been identified, advice has been sought from the
higher level responsible officer
An alternative responsible officer is nominated or appointed in all situations where a conflict of interest or
appearance of bias has been agreed with the higher level responsible officer
To answer ‘No’:
•
A potential conflict of interest or appearance of bias has been identified, but an alternative responsible officer
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has not been nominated/appointed
To answer ‘N/A’:
•
1.7
No cases of conflict of interest or appearance of bias have been identified
The designated body provides the responsible officer with sufficient funds, capacity and other resources to
enable the responsible officer to carry out the responsibilities of the role.
Each designated body must provide the responsible officer with sufficient funding and other resources necessary to
fulfil their statutory responsibilities. This may include sufficient time to perform the role, administrative and
management support, information management and training. The responsible officer may wish to delegate some of the
duties of the role to an associate or deputy responsible officer. It is important that those people acting on behalf of the
responsible officer only act within the scope of their authority. Where some or all of the functions are commissioned
externally, the designated body must be satisfied that all statutory responsibilities are fulfilled.
✔ Yes

 No
To answer ‘Yes’:
•
In the opinion of the responsible officer, sufficient funds, capacity and other resources have been provided to
enable them to carry out the responsibilities of the role
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1.8
The responsible officer is appropriately trained and remains up to date and fit to practise in the role of
responsible officer
To answer ‘Yes’:
1.9
•
Appropriate recognised introductory training has been undertaken
•
Appropriate ongoing training and development is undertaken in agreement with the responsible officer’s
appraiser
•
The responsible officer has made themselves known to the higher level responsible officer
•
The responsible officer is engaged in the regional responsible officer network
•
The responsible officer is actively involved in peer review for the purposes of calibrating their decision-making
processes and organisational systems
•
The responsible officer has access to appropriate regional and national support
•
The responsible officer includes relevant supporting information relating to their responsible officer role in their
appraisal and revalidation portfolio including the results of the Annual Organisational Audit and the resulting
action plan
The responsible officer ensures that accurate records are kept of all relevant information, actions and
decisions relating to the responsible officer role.
The responsible officer records should include appraisal records, fitness to practise evaluations, investigation and
management of concerns, processes relating to ‘new starters’, etc.
1.10
The responsible officer ensures that the designated body's medical revalidation policies and procedures are
in accordance with equality and diversity legislation.
To answer ‘Yes’:
•
✔ Yes

 No
✔ Yes

 No
✔ Yes

 No
An evaluation of the fairness of the organisation’s policies has been performed (for example, an equality impact
assessment).
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1.11
The responsible officer makes timely recommendations to the GMC about the fitness to practise of all doctors
with a prescribed connection to the designated body, in accordance with the GMC requirements and the GMC
Responsible Officer Protocol
✔ Yes

 No
To answer ‘Yes’:
•
1.12
The designated body’s annual report contains explanations for all missed and late recommendations, and
reasons for deferral submissions
The governance systems (including clinical governance where appropriate) are subject to external or
independent review.
Most designated bodies will be subject to external or independent review by a regulator. Designated bodies which are
healthcare providers are subject to review by the national healthcare regulators (the Care Quality Commission or
Monitor). Local education and training boards/deaneries are externally approved for training by the GMC. Where
designated bodies will not be regulated or overseen by an external regulator (for example locum agencies and
organisations which are not healthcare providers), an alternative external or independent review process should be
agreed with the higher level responsible officer.
13
✔ Yes

 No
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1.13
The designated body has areas of practice that are considered to be good or excellent in relation to the
elements of revalidation.
If you answer yes to any of the elements below, one of NHS England’s regional leads may make contact to find out
more detail:
•
The designated body and the responsible officer
•
Appraisal
•
Monitoring performance and responding to concerns
•
Recruitment and engagement
•
Has the designated body commissioned an external QA review?
14
✔ Yes

 No
✔ Yes

 No
✔ Yes

 No
✔ Yes

 No
 Yes
✔ No
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March 2014
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2
Appraisal
For doctors in training it has been agreed that revalidation recommendations will be based on the process of annual
review of competence progression (ARCP). Therefore local education and training boards/deaneries should only
complete section 2 for those doctors with whom they have a prescribed connection who are NOT doctors in training.
Policy, Leadership and Governance
2.1
There is a medical appraisal policy, with core content which is compliant with national guidance, that has
been ratified by the designated body's board (or an equivalent governance or executive group)
To answer ‘Yes’:
•
•
•
✔ Yes

 No
The policy is compliant with national guidance, such as Good Medical Practice Framework for Appraisal and
Revalidation (GMC, 2013), Supporting Information for Appraisal and Revalidation (GMC, 2013), Medical
Appraisal Guide (NHS Revalidation Support Team, 2013), The Role of the Responsible Officer: Closing the
Gap in Medical Regulation, Responsible Officer Guidance (Department of Health, 2010), Quality Assurance of
Medical Appraisers (NHS Revalidation Support Team, 2013).
The policy has been ratified by the designated body’s board or an equivalent governance or executive group
The responsible officer ensures that:
o There is a written protocol for the handling of information for appraisal and revalidation which complies
with information governance, confidentiality and data protection requirements
o There is a process for the allocation of appraisers and the scheduling of appraisals
o No appraisals are carried out by an appraiser who is not trained to undertake the role
o Steps are taken to ensure the objectivity of the appraisal
o The appraiser submits the completed appraisal outputs within 28 days of the appraisal meeting
o There is a process for quality assuring the inputs and outputs of appraisal to ensure that they comply
with GMC requirements and other national guidance
o Feedback is received from doctors on the appraisal process
o Appraisals will be undertaken according to professional standards as laid out in Providing a
Professional Appraisal (NHS Revalidation Support Team, 2012)
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Appraisal Rates
2.2
Number of doctors with whom the designated body has a prescribed connection on 31 March
2014 who had a completed annual appraisal between 1 April 2013 and 31 March 2014
A completed annual appraisal is one where the appraisal meeting has taken place between 9 and 15
months of the date of the last appraisal and the outputs of appraisal have been agreed and signed off
by the appraiser and the doctor within 28 days of the appraisal meeting.
The number of completed appraisals refers only to those doctors who have a prescribed connection
with the designated body on 31 March 2014. Doctors who have had a completed appraisal but have left
the designated body before 31 March 2014 should not be included in this number. The number of
doctors in each category has been brought forward from those reported in question 1.4. The number of
completed appraisals will therefore be less than or equal to the number of doctors in each category.
For doctors in training it has been agreed that revalidation recommendations will be based on the
process of annual review of competence progression (ARCP). Please therefore note that question 2.2.4
has been greyed out as this section is not applicable to doctors in training.
IMPORTANT: ONLY DOCTORS WITH WHOM THE DESIGNATED BODY HAS A PRESCRIBED
CONNECTION AS AT 31 MARCH 2014 SHOULD BE INCLUDED IN THIS SECTION.
Number of
Doctors
Completed
Appraisals
Please note that fields 2.2.1 – 2.2.7 are mandatory. Where the answer is nil, please enter “0”.
2.2.1
2.2.2
2.2.3
Consultants (permanent employed consultant medical staff including honorary contract holders, NHS,
hospices, and government /other public body staff. Academics with honorary clinical contracts will
usually have their responsible officer in the NHS trust where they perform their clinical work)
42
37
Staff grade, associate specialist, specialty doctor (permanent employed staff including hospital
practitioners, clinical assistants who do not have a prescribed connection elsewhere, NHS, hospices,
and government/other public body staff)
17
13
0
0
Doctors on Performers Lists (for NHS England area teams and the Armed Forces only; doctors on a
medical or ophthalmic performers list. This includes all general practitioners (GPs) including principals,
salaried and locum GPs)
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2.2.4
Doctors in training (not applicable)
2.2.5
Doctors with practising privileges (this is usually for independent healthcare providers, however
practising privileges may also rarely be awarded by NHS organisations. All doctors with practising
privileges who have a prescribed connection should be included in this section, irrespective of their
grade)
0
0
Temporary or short-term contract holders (temporary employed staff including locums who are
directly employed, trust doctors, locums for service, clinical research fellows, trainees not on national
training schemes, doctors with fixed-term employment contracts, etc)
0
0
Other doctors with a prescribed connection to this designated body (depending on the type of
designated body, this category may include responsible officers, locum doctors, and members of
faculties/professional bodies. It may also include some non-clinical management/leadership roles,
research, civil service, doctors in wholly independent practice, other employed or contracted doctors not
falling into the above categories, etc)
0
0
59
50
2.2.6
2.2.7
2.2.8
N/A
N/A
TOTAL (this cell will sum automatically 2.2.1 – 2.2.7)
The difference between the number of doctors and the number of completed appraisals is the number of
missed or incomplete appraisals
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2.3
Every doctor with a prescribed connection to the designated body with a missed or incomplete medical
appraisal has an explanation recorded
A missed or incomplete appraisal is an important occurrence which could indicate a problem with the designated
body’s appraisal system or non-engagement with appraisal by an individual doctor which will need to be followed up.
✔ Yes

 No
Missed appraisals are those which were not performed or which were performed outside the 9 to 15 month window for
‘annual appraisal’. In most cases where an appraisal is missed, there is a good explanation (for example, maternity
leave, long term sickness absence, etc) and in these cases postponement of the annual appraisal can be approved by
the responsible officer in advance.
Incomplete appraisals are those where, for example, the appraisal discussion was not completed or where the
personal development plan or appraisal summary have not been signed off within 28 days of the appraisal meeting.
To answer ‘Yes’:
•
•
2.3.1
The designated body’s annual report contains an audit of all missed or incomplete appraisals for the appraisal
year 2013/14 including the explanations and agreed postponements
Recommendations and improvements from the audit are enacted
Number of doctors with a missed or incomplete appraisal for whom a postponement of appraisal was not approved in
advance by the responsible officer
18
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2.4
There is a mechanism for quality assuring an appropriate sample of the inputs and outputs of the medical
appraisal process to ensure that they comply with GMC requirements and other national guidance, and the
outcomes are recorded in the annual report template.
✔ Yes

 No
Quality assurance is an integral part of the role of the responsible officer. The standards for the inputs and outputs of
appraisal are detailed in Supporting Information for Appraisal and Revalidation (GMC, 2012), Good Medical Practice
Framework for Appraisal and Revalidation (GMC, 2012) and the Medical Appraisal Guide (NHS Revalidation Support
Team, 2013) and the responsible officer must be assured that these standards are being met consistently. The
methodology for quality assurance should be outlined in the designated body’s appraisal policy and include a sampling
process. Quality assurance activities can be undertaken by those acting on behalf of the responsible officer with
appropriate delegated authority.
To answer ‘Yes’:
•
The appraisal inputs comply with the requirements in Supporting Information for Appraisal and Revalidation
(GMC, 2012) and Good Medical Practice Framework for Appraisal and Revalidation (GMC, 2012), which are:
o Personal information
o Scope and nature of work
o Supporting information:
1. Continuing professional development
2. Quality improvement activity
3. Significant events
4. Feedback from colleagues
5. Feedback from patients
6. Review of complaints and compliments.
•
o Review of last year’s PDP;
o Achievements, challenges and aspirations
The appraisal outputs comply with the requirements in the Medical Appraisal Guide (NHS Revalidation Support
Team, 2013) which are:
o Summary of appraisal
o Appraiser’s statement
o Post-appraisal sign-off by doctor and appraiser
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2.5
There is a process in place for the responsible officer to ensure that key items of information (such as specific
complaints, significant events and outlying clinical outcomes) are included in the appraisal portfolio and
discussed at the appraisal meeting, so that development needs are identified
✔ Yes

 No
It is important that issues and concerns about performance or conduct are addressed at the time they arise. The
appraisal meeting is not usually the most appropriate setting for dealing with concerns and in most cases these are
dealt with outside the appraisal process in a clinical governance setting. Learning by individuals from such events is an
important part of resolving concerns and the appraisal meeting is usually the most appropriate setting to ensure this is
planned and prioritised.
In a small proportion of cases, the responsible officer may therefore wish to ensure certain key items of supporting
information are included in the doctor’s portfolio and discussed at appraisal so that development needs are identified
and addressed. In these circumstances the responsible officer may require the doctor to include certain key items of
supporting information in the portfolio for discussion at appraisal and may need to check in the appraisal summary that
the discussion has taken place. The method of sharing key items of supporting information should be described in the
appraisal policy. It is important that information is shared in compliance with principles of information governance and
security. For further detail, see Information Governance for Medical Appraisal and Revalidation in England (NHS
Revalidation Support Team, 2013).
To answer ‘Yes’:
•
•
There is a written description within the appraisal policy of the process for ensuring that key items of supporting
information are included in the doctor’s portfolio and discussed at appraisal
There is a process in place to ensure that where a request has been made by the responsible officer to include
a key item of supporting information in the appraisal portfolio, the appraisal portfolio and summary are checked
after completion to ensure this has happened
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Capacity and Capability
2.6
The number of trained medical appraisers is sufficient for the needs of the designated body
It is important that the designated body’s appraiser workforce is sufficient to provide the number of appraisals needed
each year. This assessment may depend on total number of doctors who have a prescribed connection, geographical
spread, speciality spread, conflicts of interest and other factors. Depending on the needs of the designated body,
doctors from a variety of backgrounds should be considered for the role of appraiser. This includes locums and
salaried general practitioners in primary care settings and staff and associate specialist doctors in secondary care
settings. An appropriate specialty mix is important though it is not possible for every doctor to have an appraiser from
the same specialty.
✔ Yes

 No
Appraisers should participate in an initial training programme before starting to perform appraisals. The training for
medical appraisers should include:
•
•
•
Core appraisal skills and skills required to promote quality improvement and the professional development of
the doctor
Skills relating to medical appraisal for revalidation and a clear understanding of how to apply professional
judgement in appraisal
Skills that enable the doctor to be an effective appraiser in the setting within which they work, including both
local context and any specialty specific elements.
Further guidance on the recruitment and training of medical appraisers is available; see Quality Assurance of Medical
Appraisers (NHS Revalidation Support Team, 2013).
To answer ‘Yes’:
2
•
Appraisers are recruited and selected in accordance with national guidance
•
In the opinion of the responsible officer, the number of appropriately trained medical appraisers to doctors
being appraised is between 1:5 and 1:20.2
•
In the opinion of the responsible officer, the number of trained appraisers is sufficient for the needs of the
designated body
This point may be disregarded for doctors in training.
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2.7
Medical appraisers are supported in their role to calibrate and quality assure their appraisal practice
Further guidance on the support for medical appraisers is available in Quality Assurance of Medical Appraisers (NHS
Revalidation Support Team, 2013).
✔ Yes

 No
To answer ‘Yes’:
•
As a minimum, support arrangements for appraisers should include access to:
o
Leadership and advice on all aspects of the appraisal process from a named individual (for example,
the appraisal lead)
o
Training and professional development activities to improve appraiser skills
o
Regular assurance groups / peer support networks with calibration of professional judgements and
opportunity to discuss handling the difficult areas of appraisal in an anonymised and confidential
environment
o
Annual review of performance in the role of appraiser, including feedback from appraisees and
suggestions for inclusion in their personal development plan to address their development needs
o
Specialty-specific support, where necessary
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3
Monitoring Performance and Responding to Concerns
Policy, Leadership and Governance
3.1
There is a system for monitoring the fitness to practise of doctors with whom the designated body has a
prescribed connection
Where detailed information can be collected which relates to the practice of an individual doctor, it is important to
include it in the annual appraisal process. In many situations, due to the nature of the doctor’s work, the collection of
detailed information which relates directly to the practice of an individual doctor may not be possible. In these
situations, team-based or service-level information should be monitored. The types of information available will be
dependent on the setting and the role of the doctor and will include clinical outcome data, audit, complaints, significant
events and patient safety issues. An explanation should be sought where an indication of outlying quality or practice is
discovered. The information/data used for this purpose should be kept under review so that the most appropriate
information is collected and the quality of the data (for example, coding accuracy) is improved.
✔ Yes

 No
In primary care settings this type of information is not always routinely collected from general practitioners or practices
and new arrangements may need to be put in place to ensure the responsible officer receives relevant fitness to
practise information. In order to monitor the conduct and fitness to practise of trainees, arrangements will need to be
agreed between the local education and training board/deanery and the trainee’s clinical attachments to ensure
relevant information is available in both settings.
To answer ‘Yes’:
•
Relevant information (including clinical outcomes, reports of external reviews of service for example Royal
College reviews, governance reviews, Care Quality Commission reports, etc) is collected to monitor the
doctor’s fitness to practise and is shared with the doctor for their portfolio
•
Relevant information is shared with other organisations in which a doctor works where necessary
•
There is a system for linking complaints, significant events/clinical incidents/SUIs to individual doctors
•
Where a doctor is subject to conditions imposed by, or undertakings agreed with the GMC, the responsible
officer monitors compliance with those conditions or undertakings
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3.2
•
The responsible officer identifies any issues arising from this information, such as variations in individual
performance, and ensures that the designated body takes steps to address such issues
•
The quality of the data used to monitor individuals and teams is reviewed
•
Advice is taken from GMC employer liaison advisers, National Clinical Assessment Service, local expert
resources, specialty and Royal College advisers where appropriate
There is a responding to concerns policy in place, with core content which is compliant with national
guidance, which is ratified by the designated body's board (or an equivalent governance or executive group)
It is the responsibility of the responsible officer to respond appropriately when unacceptable variation in individual
practice is identified or when concerns exist about the fitness to practise of doctors with whom the designated body
has a prescribed connection. The designated body should establish a procedure for initiating and managing
investigations.
✔ Yes

 No
National guidance is available in the following key documents:
•
•
•
•
Supporting Doctors to Provide Safer Healthcare: Responding to Concerns about a Doctor’s Practice (NHS
Revalidation Support Team, 2013)
Maintaining High Professional Standards in the Modern NHS (Department of Health, 2003)
The National Health Service (Performers Lists) (England) Regulations 2013
How to Conduct a Local Performance Investigation (National Clinical Assessment Service, 2010)
The responsible officer regulations outline the following responsibilities:
•
Ensuring that there are formal procedures in place for colleagues to raise concerns
•
Ensuring there is a process established for initiating and managing investigations of capability, conduct, health
and fitness to practise concerns which complies with national guidance, such as How to conduct a local
performance investigation (National Clinical Assessment Service, 2010)
•
Ensuring investigators are appropriately qualified
•
Ensuring that there is an agreed mechanism for assessing the level of concern that takes into account the risk
to patients
•
Ensuring all relevant information is taken into account and that factors relating to capability, conduct, health
and fitness to practise are considered
•
Ensuring that there is a mechanism to seek advice from expert resources, including: GMC employer liaison
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advisers, the National Clinical Assessment Service, specialty and royal college advisers, regional networks,
legal advisers, human resources staff and occupational health
•
Taking any steps necessary to protect patients
•
Where appropriate, referring a doctor to the GMC
•
Where necessary, making a recommendation to the designated body that the doctor should be suspended or
have conditions or restrictions placed on their practice
•
Sharing relevant information relating to a doctor’s fitness to practise with other parties, in particular the new
responsible officer should the doctor change their prescribed connection
•
Ensuring that a doctor who is subject to these procedures is kept informed about progress and that the doctor’s
comments are taken into account where appropriate
•
Appropriate records are maintained by the responsible officer of all fitness to practise information
•
Ensuring that appropriate measures are taken to address concerns, including but not limited to:
•
o
Requiring the doctor to undergo training or retraining
o
Offering rehabilitation services
o
Providing opportunities to increase the doctor’s work experience
o
Addressing any systemic issues within the designated body which may contribute to the concerns
identified
Ensuring that any necessary further monitoring of the doctor’s conduct, performance or fitness to practise is
carried out.
To answer ‘Yes’:
•
3.3
A policy for responding to concerns, which complies with the responsible officer regulations, has been ratified
by the designated body's board (or an equivalent governance or executive group)
The board (or an equivalent governance or executive group) receives an annual report detailing the number
and type of concerns and their outcome.
25
✔ Yes

 No
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Capacity and Capability
3.4
The designated body has arrangements in place to access sufficient trained case investigators and case
managers
The standards for training for case investigators and case managers are contained in Guidance for Recruiting for the
Delivery of Case Investigator Training (NHS Revalidation Support Team, 2014) and Guidance for Recruiting for the
Delivery of Case Manager Training (NHS Revalidation Support Team, 2014). Case investigators or case managers
may be within the designated body or commissioned externally.
✔ Yes

 No
To answer ‘Yes’:
•
•
•
•
Case investigators and case managers are recruited and selected in accordance with national guidance
Supporting Doctors to Provide Safer Healthcare, Responding to concerns about a Doctor’s Practice (NHS
Revalidation Support Team, 2013)
Case investigators and case managers have completed a suitable training programme, with essential core
content (see guidance documents above)
Personnel involved in responding to concerns have sufficient time to undertake their responsibilities
Individuals (such as case investigators, case managers) and teams involved in responding to concerns
participate in ongoing performance review and training/development activities, to include peer review and
calibration (see guidance documents above)
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4
Recruitment and Engagement
4.1
There is a process in place for obtaining relevant information when the designated body enters into a contract
of employment or for the provision of services with doctors
The regulations give explicit responsibilities to the responsible officer when a designated body enters into a contract of
employment or for the provision of services with a doctor. These responsibilities are to ensure the doctor is sufficiently
qualified and experienced to carry out the role. All new doctors are covered under this duty even if the doctor’s
prescribed connection remains with another designated body. This applies to locum agency contracts and also to the
granting of practising privileges by independent health providers.
✔ Yes

 No
The prospective responsible officer must:
•
Ensure doctors have qualifications and experience appropriate to the work to be performed
•
Ensure that appropriate references are obtained and checked
•
Take any steps necessary to verify the identity of doctors
•
Ensure that doctors have sufficient knowledge of the English language for the work to be performed
•
For NHS England area teams, manage admission to the medical performers list in accordance with the
regulations.
It is also important that the following information is available:
•
GMC information: fitness to practise investigations, conditions or restrictions, revalidation due date;
•
Disclosure and Barring Service check (although delays may prevent these being available to the responsible
officer before the starting date in every case), and
•
Gender and ethnicity data (to monitor fairness and equality; providing this information is not mandatory).
It may be helpful to obtain a structured reference from the current responsible officer which complies with GMC
guidance on writing references and includes relevant factual information relating to:
•
The doctor’s competence, performance or conduct
•
Appraisal dates in the current revalidation cycle, and
•
Local fitness to practise investigations, local conditions or restrictions on the doctor’s practice, unresolved
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fitness to practise concerns
See Good Medical Practice: Supplementary Guidance: Writing References (GMC, 2007) and paragraph 19 of Good
Medical Practice (GMC, 2013) for further details.
In situations where the doctor has moved to a new designated body without a contract of employment, or for the
provision of services (for example, through membership of a faculty) the information needs to be available to the new
responsible officer as soon as possible after the prescribed connection commences. This will usually involve a formal
request for information from the previous responsible officer.
Please now return to page 1 of the form to submit your return.
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March 2014
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