Council of Governors Meeting

9.30am to 12.35 pm on Thursday 21 January 2016

Denham Room, Conference Centre, Worthing College, 1 Sanditon Way, Worthing BN14 9FD

AGENDA

1 9.30 Welcome and Apologies for Absence Mike Viggers

2 9.30 Declarations of Interests Verbal Mike

Viggers

3 9.30 Minutes of Meeting of the Council of Governors held on 13 October 2015 To approve

Enclosure Mike Viggers

4 9.35 Matters Arising from the Minutes

To note Enclosure Mike

Viggers LISTENING AND REPRESENTING

5 9.40 Lead Governor’s Report To receive and agree any necessary action

Enclosure Vicki King

6 9.55 Staff Governors Report To receive and agree any necessary action

Verbal Staff Governors

ACCOUNTABILITY

7 10.05 Board Report to Council including CQC Inspection and Patient First Update To receive and agree any actions

Enclosure Marianne Griffiths

8 10.55 Quality Priorities 2016/17

To receive and agree any necessary action Presentation Rob Haigh

and Vivienne Colleran

9 11.15 Charitable Funds Committee Feedback

To receive and agree any necessary action Presentation Lizzie

Peers GOVERNANCE

10 11.35 Update from Appointment of Auditor Working Group To receive and agree any necessary action

Enclosure John Thompson/ Paul Benson/ Andrew Harvey

11 11.45 Holding Non-Executive Directors to Account

To discuss and agree any actions Enclosure Lead

Governor

12 12.00 Trust Board Redacted Minutes To discuss and agree any actions

Enclosure Lead Governor

13 12.15 Governors Annual Plan

To discuss and agree any actions Enclosure Lead

Governor

OTHER ITEMS

14 12.25 Other Business Chair

15 12.35 Questions from the Members of the Public

Andy Gray Company Secretary Tel: 01903 285288 / Mobile: 07785332416

Minutes

Minutes of the Council of Governors Meeting held in Public from 09.30am on

Tuesday 13 October 2015 at the Mickerson Hall, Chichetser Medical Education

Centre, St Richards Hospital, Chicheseter, West Sussex PO19 6SE

Present: Mike Viggers Chairman Barbara Porter Public Governor – Adur John Todd Public Governor – Adur Margaret Bamford Public Governor – Arun Brian Hughes Public Governor – Arun Jill Long Public Governor – Arun John Thompson Public Governor – Arun Margaret Burgess

Vicki King Abigail Rowe John Bull Beda Oliver Paul Benson Jennifer Edgell Richard Farmer

Public Governor – Chichester Public Governor – Chichester Public Governor – Chichester Public Governor – Worthing Public Governor – Worthing Patient Governor Patient Governor Patient Governor

Greg Daliling Staff Governor - Additional Clinical Services Helen Dobbin Staff Governor - Scientific, Technical and

Professional Andrew Harvey Staff Governor – Administration and Clerical David Walsh Staff Governor – Nursing and Midwifery Gillian Keegan Appointed Governor, Chichester District

Council Andrew Lloyd Appointed Governor, University of Brighton Jane Ramage Appointed Governor, Friends of WSHFT

Hospital and WRVS Val Turner Appointed Governor, Worthing Borough

Council In Attendance:

Bill Brown Non-Executive Director Joanna Crane

Jon Furmston Lizzie Peers Mike Rymer

Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director

Maggie Davies Karen Geoghegan Marianne Griffiths Denise Farmer

Deputy Director of Nursing (To end of item 9) Director of Finance Chief Executive Director of Organisational Development and Leadership

Andy Gray Company Secretary Mike Jennings Commercial Director Barbara Mathieson Assistant to Company Secretary (Minutes) Nicky Sullivan

Head of Therapies (For item 10)

Item No Item Title Action COG/10/15/1

1.1

Welcome and Apologies for Absence The Chairman opened the meeting by recognising the tremendous contribution that David Langley had made to the Council of Governors.

Minutes page 2

1.2

1.3

Everyone had been very sad to learn of his recent death and thoughts were with his wife and family. The Chairman welcomed everyone to the meeting of the Council of Governors and particularly the new Governors: John Bull, Margaret Burgess, Andrew Harvey, Andrew Lloyd, Jill Long and John Thompson. Apologies for Absence were noted from : Executives – Jane Farrell, George Findlay, Mike Jennings and Amanda Parker Governors – Shirley Hawkridge, Nigel Peters, Peter Pimblett-Dennis Barbara Porter and Val Turner

COG/10/15/2 Declarations of Interest

2.1 There were no declarations of interest.

COG/10/15/3 Minutes of the Council of Governors Meeting held in Public on 16

July 2015

3.1

3.2

3.3

The Council of Governors received the minutes of the meeting held on 16 July 2015. Present : Remove Karen Geoghegan from list of those present. The minutes of the meeting of the Council of Governors held on the 16 July 2015 were approved, subject to the amendments above and it was agreed that they should be signed by the Chairman.

COG/10/15/4 Matters Arising from the Minutes

4.1

4.2

4.3

4.4

The Matters Arising from the meeting held on the 16 July 2015 were noted by the Council of Governors. Items not covered elsewhere on the Agenda :- COG/7/15/5.21 – Seminar on Bed reconfiguration It was confirmed that this would be led by Rob Haigh and held on the 24th November 2015. Richard Farmer asked about the draft Minutes of the Council of Governors meeting held in Private on the 16 July 2015. It was agreed that these would be circulated immediately after the meeting.

AG

COG/10 /15/5 Lead Governor’s Report

5.1

5.2

Margaret Bamford, Lead Governor, proposed that the report should be taken as read. However she said that as she completed her two years as Lead Governor she wished to reflect on items that really stood out in her mind as being important, not only for the lead governor, but for all governors.

Margaret said that she was really proud to be associated with the Trust. It was managed by a group of people all of whom were extraordinarily able and hard working. She said that she admired their grasp of the enormous, numerous complex issues which were dealt with on a day to day basis, but that always, at the heart of everything they did, was to try to make things better for patients. When mistakes were made, the Board

Minutes page 3

5.3

5.4

5.5

5.6

always acknowledged them, was concerned about them, and took action to put them right. Similarly Margaret said that there were an excellent group of Non- Executive Director’s (NED’s) who always challenged constructively and appropriately. They were closely involved with patients concerns and worked well over and beyond their contractual obligations. The Leadership within the Trust was always positive and encouraging, no matter what the blows and Margaret reflected on these skills while speaking about Marianne Griffiths the Chief Executive of the Trust.

Evidence of what a great Trust Western Sussex Hospitals NHS Foundation Trust is, had been clear to all who had attended the recent staff conference or anyone who was at the Star Awards Ceremony. Margaret said that she believed that truly wonderful staff work at Western Sussex Hospitals and how could anyone not be inspired and proud of what they achieve. Margaret thanked all the Council of Governors for their support and contributions to the work of the Trust. Margaret also wished Vicki and Richard all the best as they took over as Lead and Deputy Lead Governor at the beginning of November. Mike Viggers said that the Trust was indebted to Margaret for all the work she had undertaken in her role of Lead Governor and her overall contribution to the work of the Council of Governors since its inception.

COG/10/15/6 Membership and Public Engagement

6.1

6.2

6.3

Vicki King presented the report from the Membership and Engagement Committee and confirmed that they had met twice since the last Council of Governors meeting. Vicki reminded the Committee that the Trust had developed a Membership Strategy and Action Plan. She confirmed that the Committee had decided to priortise recruiting to the membership to ensure that it was representative. Work at the recent meetings had included developing metrics for increasing membership in the various categories and a dashboard to check that progress was being made. Several recruitment activities had been carried out by members of the Committee and these had included :-

An event at Penguin Corner at Worthing Hospital

Visiting local Women and Children Centres

Distributing leaflets via the local Medical Schools

Distributing information at Car Boot Sales

Sending letters to all County and District Councilors both within the County and in neighboring areas such as East Hampshire.

6.4

6.5

It was noted that often at recruitment events and at other opportunities feedback on the Trusts services was received. This was noted and collated to be sent via the PALS Team to the Patient Engagement and Experience Committee. To conclude the item Vicki encouraged all Governors to think about how they could contribute to growing the Trust Membership.

Minutes page 4

6.6

6.7

6.8

Brian Hughes asked where the comments collected at the Membership Recruitment event held in August at Worthing would be shared. Margaret Bamford confirmed that they would have been taken to the Patient Engagement and Experience Committee. It was noted that Bill Brown also attended this meeting and that the minutes of this meeting were received at the Trust’s Patient Experience and Feedback Committee. Jill Long suggested that the letter regarding membership which Nigel Peters had sent to County and District Councilors should also be sent to both Town and Parish Councils as they also had direct access to members of the Public. David Walsh asked how many staff chose not to be members of the Trust and Denise Farmer confirmed that it was less than 5.

VK/NP

COG/10/15/7 Staff Governors Report

7.1

7.2

7.3

7.4

7.5

7.6

7.7

David Walsh introduced the Staff Governors report and confirmed that a series of meetings had now been established with the Chair and Company Secretary for this group of Governors. David outlined the concerns which staff were currently expressing. These included:-

Continued high levels of activity

Delays in Transfers of Care

Being able to provide safe levels of staffing

Car Parking

David said that he knew that staff were able to have an exit interview on leaving the Trust but wondered what was being done with that information. Mike Viggers acknowledged that car parking was a big issue for staff and confirmed that the Director of Estates and Facilities would be undertaking a review of this area of concern. Richard Farmer talked about recent reports published by CQC on a variety of Trusts and noted that several had been considered inadequate due to a lack of alignment between the views of staff throughout the Trust. He therefore asked how embedded the Patient First Programme was amongst the wider Trust staff. David confirmed that he regularly taught in the Annual Clinical Updates and that at these meetings both NHS Quest and Patient First were discussed. Awareness of NHS Quest had only increased slightly but he said that currently he felt that over 50% of Trust Staff attending these events had a good level of awareness of the Patient First Improvement Programme. Also patient safety, patient care and doing a good job were the three areas which staff regularly talked about. Helen Dobbin echoed David Walsh’s view and said that the focus on Patient First was improving the quality of care delivered to patients across the Trust. However, there had always been a strong emphasis on Patient Safety and Care within the Trust. Greg Daliling spoke about the value of the daily Safety Huddles and the importance of trying to replicate something similar for staff who regularly worked late or night shifts. It was important that information for these

Minutes page 5

7.8

7.9

7.10

staff was circulated in a similar proactive way and that they were able to contribute to initiatives. Marianne Griffiths confirmed that regular 1 hour Patient First Taster Events were being held on all sites and that all staff were able to attend. Also Patient First information would be displayed on Ward Screens and would be introduced into Outpatient areas. Patient First priorities including quality and safety were the focus of team meetings. It was however acknowledged that it would take time to embed the Patient First principles around all of an organisation with over 6000 staff. Vicki King asked how Nurses could express concerns or raise issues when it may not be appropriate to bring them up within a Safety Huddle. She gave examples of concerns about new recruits, where English may not be their first language and therefore there may be perceived areas of concern from differences in the way that care may be given. It was confirmed that in the first instance any concerns should be raised on a one to one basis with the Ward Sister or if necessary should be escalated to the relevant Matron. Andrew Harvey stated that he felt that Administration and Clerical staff were also embracing the Patient First Improvement Programme.

COG/10/15/8 Board Report to Council

8.1

8.2

8.3

8.4

Marianne Griffiths, Chief Executive gave an update on the Operational context and Strategic Priorities for the Trust from Quarter 2 2015/16. She confirmed that the hospitals were once again extremely busy with an increase in emergency activity and that delayed discharges had increased from 3.17 % to over 4% in September. This was creating a real challenge across the Trust. Marianne also confirmed that Sussex Community NHS Trust had recently reduced its number of available beds by 54 due to continued staffing issues. It was also noted that there continued to be issues within the wider local health economy and with sufficient provision of Social Care places. Western Sussex Hospitals NHS Foundation Trust was confirmed to also be continuing to be having problems with recruitment into several roles but especially nurses. Following the recent visit to the Philippines; 141 nursing places had been offered at the Trust and it was expected that they would be able to start in role in January 2016. A further 20 nurses had recently been recruited from Portugal and would be due to start work in the Trust in November 2015. ‘One-Stop’ recruitment days for UK nursing candidates were also continuing to work well. Marianne confirmed that a review of the type of beds across the Trust had recently taken place. As a result, and to reflect the acuity of the patients seen within the hospitals, a number of good quality high profile beds had been purchased. This would help provide the best possible nursing care. Other initiatives across the Trust which were currently in progress included providing more clerical support on the wards so that time could be released to provide greater nursing. Band 4 Nursing roles were also being piloted across the Trust. However there were still concerns across the Trust that it would be very difficult to cope with the same level of activity and acuity of patients which had occurred during December 2014 and January 2015. Emergency Care continued to run at a high level representing 85 to 90%

Minutes page 6

8.5

8.6

8.7

8.8

8.9

8.10

8.11

of all cases. It was however recognised that a lot of surgical work was now being dealt with as day cases. Also the overall increase in emergency admissions and delayed transfers of care was having an effect on the Referral to Treatment Time (RTT) and the Trusts ability to achieve meet the 18 week rule as previously reported to the Council. Despite the continued demand on the Trust, Marianne confirmed that there continued to be a strong shared ambition to provide the best possible care for patients and it was acknowledged that the Trusts performance was testament to this and the dedication of staff. With regard to the varied performance metrics it was confirmed that the Trust standard for A&E arrival to treatment times of under 4 hours was 97.28% for August and 97.4% for Quarter 2 making the Trust within the top 10 in the country. However it was acknowledged that achieving that level of compliance continued to be a challenge. The provisional position for August was that the Trust was compliant against all 7 cancer metrics in month but that there continued to be significant and sustained challenges to deliver against the 2 week referral rules. For RTT targets it was confirmed that the Trust was now 2.5% ahead of recovery plan commitments for the year to date. In terms of patient safety there had been zero cases of Methicillin-resistant Staphylococcus Aureus (MRSA) bacteraemia in August and three cases of Clostridium difficile (C Diff). The Annual Infection Control Report had been presented to the last Trust Board and it had been confirmed that the Trust was the 3rd best in England for lack of occurrence of MRSA and was in the bottom quarter for the cases of C Diff. It was however confirmed that the Trust had reported two “Never Event’s” which are currently under investigation. With regard to the Trusts Finances it was confirmed that in August the Trust reported a deficit of £892K bringing the year to date position to £1.53m deficit. However the Trust was continuing to forecast the delivery of a surplus of £992k and a continuity of service rating of ‘3’ as per the 2015/16 plan submitted to Monitor. The Efficiency Programme had delivered cumulative savings of £6.3m against a plan of £6.5m (97.7%). Marianne then spoke about the major strategic projects which were taking place across the Trust. It was confirmed that a Sussex wide review of Stroke Services was underway which was considering if there should be a reduction in the number of Hyper Acute Stroke Units (HASUs) within the area. The SNAPP data for both Trust sites had shown great improvement over the past eighteen months and it was confirmed that Worthing was now showing the 7th best score in England and St Richard’s the 34th. It was confirmed that the Trust had the view that it could run an integrated Stroke Care Service but from two sites. As such the Trust would be aiming to work with local Commissioners to promote this proposal. It was also confirmed that work was progressing well on the Trust becoming prime provider for Musculoskeletal Services for the local area. This involved working in partnership with Sussex Community Trust and the Patient Representative Service. Currently there were some issue with developing an integrated IT service with Sussex Community Trust but these were being worked through. Marianne confirmed that work was continuing to develop a partnership

Minutes page 7

8.12

8.13

8.14

with the Trusts from Guildford and Brighton to build three Linear Accelerators which are used for the treatment of cancer on the St Richard’s site. It was expected that the contracts for this would be signed within the next few weeks. Planning permission would need to be granted for the build but from this point it was expected that the centre would open within 14 to 16 months. The development of the new Ophthalmology Centre at Southlands was progressing well and it was confirmed that this was an opportunity to review and improve patient pathways. Marianne confirmed that the Care Quality Commission would be carrying out a routine inspection of the Trust from the 8th to 11th December 2015. It would be followed up by a “surprise” visit within 2 weeks and would be an opportunity for the Trust us to demonstrate the excellent care that its staff provide. To conclude her presentation Marianne summarised the key risks to on-going improvement and sustainability with the Trust:

Continuing workforce challenges – in the “here and now” & longer term

Balancing capacity & demand / ensuring all activity and income assumptions are met.

Delivery of the Efficiency Programme (circa £19m (4.75%)

Seasonal Resilience

Preparing for the CQC Inspection – December 2015

8.15

8.16

8.17

8.18

Finally Marianne gave details of the recent Trust STARs Awards event and confirmed that it had been humbling to attend. The Housekeeping Team who were awarded the Governor’s Award received a standing ovation. Overall the event confirmed what amazing, kind and compassionate staff worked for the Trust. Jane Ramage asked for clarification on the increase in number of emergency patients and whether any additional space was needed within the Trust. Marianne confirmed that the Trust currently runs between 800 and 1000 beds depending on the time of year and needs of the patients. Usually 85% were used for emergency admissions and 15% of planned surgery cases. In times of escalation there tended to be a move to more medical patients occupying surgical beds which tended to give rise to issues with skill mix. It was confirmed that the Trust had put in place an increase of one ward on each site to accommodate medical outliers. Jane also asked about the impact of the Emergency Floor at Worthing and what was planned to expand the existing Acute Medical Unit facilities at St Richard’s, Marianne confirmed that there would be a “One Year Review” of the Emergency Floor. It had already been confirmed that the new facility had reduced the average of stay for emergency surgery patients by 22%. Paul Benson acknowledged the achievement of the Trusts Efficiency Programme but related it to the finance issues that were apparent across all of the wider Health and Social Care System and that nationally £22 billion in savings needed to be made. Paul therefore asked if sufficient was being done amongst local Health Economy Partners in terms of transformation work. Marianne confirmed that local partners within West

Minutes page 8

8.19

8.20

8.21

8.22

8.23

8.24

Sussex were beginning to work in a more integrated way and acknowledged the importance of more transformation plans being developed. Abigail Rowe spoke about the Sussex Review of Stroke Services and confirmed her support for two full HASU’s and that it would not be the right thing to do to withdraw the services of one of the best units in the country. Andrew Harvey asked how the development of Band 4 Nurses would affect the ratios of patients to staff. Maggie Davies confirmed that Monitor had been informed of the pilot which would last for three months. At the end of this possible changes to staffing levels/ratios may be considered. Jennifer Edgell asked for further clarification of the increase in Bank Rate of pay for nurses and asked why the base rate of pay could not be increased instead. It was confirmed that all NHS Staff are subject to national contracts and that there had been minimal or no increase in pay for the last three years. Richard Farmer acknowledged the impressive list of achievements that had been described during the presentation and related them to the forthcoming CQC Inspection. Richard asked what opportunity there would be to collect information from members of the public on how they view the Trust. It was confirmed that the CQC Team, itself would issue notices via the local press for people to attend public meetings. Marianne encouraged Governors and all members to attend these meetings. Vicki King spoke about the Friends and Family Test (FFT) results and particularly noted that the inpatient responses were better than the national average. She further commented that it was disappointing that the results for the Maternity Services had reduced. Maggie Davies reminded the meeting that the FFT score was the aggregate of the four occasions when these patients were asked to rate the services. Unfortunately on occasions these were less than ideal for some of the community services provided. Gillian Keegan asked about the number of patients being treated within the Stroke Services on the two sites and the fact that currently it was below the numbers for a Hyper Acute Stroke Unit (HASU). She asked if the modelling had been based on future demographics within the local area. It was confirmed that demand management had been considered but it was also recognised that prevention work was also important.

COG /10/15 /9 Update on Trust Workforce Issues

9.1

9.2

Denise Farmer, Director of Organisational Development and Leadership gave a presentation on the current workforce issues within the Trust. To begin the presentation Denise outlined the profile of the Trust’s workforce and gave details of some of the current metrics :

The Trust employs 6500 staff. Only 50% of female staff work full time whereas 82% of men employed within the Trust work full time.

32% of the current workforce were over the age of 50 and it

Minutes page 9

was recognised that many staff choose to retire at 55.

There was a diverse workforce from over 70 nations

There is an average staff turnover of 9.2% with a national comparison of 9.6% and 11.2% for the South East of England

The sickness rate averages at 4.1%. The highest rate of sickness had traditionally been within the Estates and Facilities Division but it was recognised that there had been a real reduction in that rate.

The vacancy rate averages at 12%

The current temporary staffing figure was 10.7%

Results from the Staff Friends and Family Test were that 71.4% of staff would recommend working at the Trust and 86.7% would recommend the Care and Treatment provided by the Trust.

9.3

9.4

9.5

9.6

9.7

9.8

9.9

Denise then outlined the main workforce issues within the Trust and the actions being taken to support resolving them.

Recruitment and retention It was recognised that there were long standing national supply difficulties in several professions within the NHS including nurses, radiographers and middle grade doctors. Denise confirmed that 140 nurses had been recruited in the Philippines and it was hoped that they would be able to start work in the Trust early in the New Year. A further 20 nurses had been recruited in Europe and the domestic recruitment campaign had led to a good number of newly qualified nurses committing to roles within the Trust. Denise also confirmed that the HR Team had done a good deal of research on staff retention within the Trust and this has been considered both staff by groups and length of employment. It was noted that currently 40% of staff were leaving the Trust within their first or second year of employment. It was also noted that younger staff now tended to change jobs more often than in the past as their expectations changed. ‘Stay Interviews’ for staff who had been in the Trust for less than six months had been initiated. Temporary Staffing Denise reminded the meeting that for financial reasons it was very important to reduce the reliance on temporary staffing across the Trust. She confirmed that for Nursing Staff the decision had been made to increase the bank rate as it was recognised that many of the Trust’s staff choose to do additional shifts via the bank. Work was also continuing to move away from the use of non-framework agencies. Rostering It was confirmed that rostering on the wards was being reviewed especially to ensure hard to fill shifts were adequately resourced. Health and Wellbeing Denise confirmed that sickness absence was being extensively managed across the Trust and wellbeing initiatives included the provision of staff physiotherapy support and counselling services alongside an extensive health and wellbeing programme. Staff Engagement - listening to staff concerns and ideas. These included the Patient First Programme, workshops, open forums, newsletters, events, security improvements, Safety Huddles and Staff 6

Minutes page 10

9.10

9.11

9.12

9.13

9.14

months in meetings. National Terms and Conditions versus local flexibility Denise confirmed that the Trust was part of the national system for NHS Terms and Conditions and rates of Pay (Agenda for Change). There were many benefits of being part of this but it did mean reduced flexibility to deal with local issues. Largely there had been a pay freeze for most NHS staff over the past three years. Other work which was being undertaken included trying to reduce the average length of time from vacancy request to start date which was currently running at 13 weeks. Brian Hughes commented on the outcomes of the Staff Friends and Family Test results and that 29% of staff would not recommend the Trust as a place to work. He asked if the Trust knew what the reasons were and Denise confirmed that primarily it was due to the level of pressure staff were feeling. Richard Farmer asked about the National Staff Survey whether the Trust was in the bottom 20% for any of the areas. Denise confirmed there were four main areas for improvement but that the Trust is not in the bottom 20% :

• Staff Security and Safety • Receiving feedback on the learning from incidents • Listening to ideas from staff • Communication with staff

Helen Dobbin asked whether it was possible to give any local incentives outside the parameters of Agenda for Change. Denise confirmed that it was possible to make the case to award a “Hard to recruit premium.” Helen also asked whether there were plans to launch a scheme similar to ward accreditation within Outpatients and it was confirmed that there was.

COG /7/15/10 Outpatients Improvement Programme

10.1

Marianne Griffiths introduced Nicky Sullivan, Head of Therapies for the Trust who was taking the lead on the Outpatient Services Project. She began the meeting by stating that the Trust’s Patient First Programme had identified outpatient services as a priority for improvement. This was because :

It was the area of highest volume of patient activity for the Trust - the 61st busiest Outpatient Service in England

There were on going challenges around matching capacity and demand

That there are a number of process inefficiencies that result in patient complaints

10.2

Nicky confirmed that KPMG had be retained by the Trust to undertake an Outpatient Diagnostic Project with the aim of where best practice could be share between divisions and services more effectively and to asses areas of concern. It was also particularly noted that the project set out to prioritise the opportunities so that the Trust would be able to focus on delivering those which have the biggest impact. The diagnostic project aimed to carry out:

A capacity and demand analysis

Minutes page 11

A process analysis of the Trust’s processing and booking of referrals and follow ups

A benchmarking of current services

An evaluation of the current services from the perspective of patients and staff

And the approach used was to ensure that the analysis would align to the emerging Patient First Improvement Programme.

10.3

10.4

10.5

Nicky confirmed that over 70 people were involved in the review through a number of clinical, managerial and administrative forums. As a result the full complexity of the Outpatient Pathway was drawn together and shown in the form of a diagram. At the current time it was confirmed that KPMG support for the project was coming to an end and they were producing a diagnostic report which would include a detailed analysis of the Outpatient booking process, using existing data and performance to triangulate and confirm key findings and solutions. During the work the patient pathway was simplified into three key steps and key themes:- Referral and Grading

GP Expectations

Patient Communication

Referral tracking and “paper” management

Grading/ triage of referrals Booking

Capacity not matching demand

Multiple booking processes with limited “standard work”

Capacity of central and specialty teams Attendance and Follow Up / Discharge

Information before and during clinic limited

Variable patient satisfaction with clinical consultation

Variation in recording of outcomes

10.6

From this nine solutions were developed in a “project on a page” approach (An A3 ‘thinking template’). These were :

Acknowledgement letter compliance

Grading Protocols

Electronic Referral Management

Optimising Hub and Call Centre

Template review – including the capacity and demand of clinics

In-Clinic Waiting Time - keeping patient informed

Clinical Consultation – Improve the quality and consistence of the clinical consultation

Way finding – around the hospitals

Housekeeping – ensuing all clinicians have access to full patient files – physical or electronic

10.7

Brian Hughes confirmed that the outcomes of the analysis reflected the experiences that patients were sharing with members of the Membership Committee and he described a visit of a diabetic patient who had recently attended a clinic at the Trust which had over-run. Brian asked how the

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10.8

projects would be supported when KPMG had finished their work within the Trust. Marianne Griffiths confirmed that the Outpatients work would form one of the six major Patient First Programmes and would receive support through that Board. Paul Benson commented on the recent press coverage on the use of Management Consultants within the NHS. However through its work on Outpatients he was sure that KPMG had certainly added value to the work especially through the use of Lean Tools which had previously been tested in hospitals.

COG /10/15/11 Audit Committee Feedback

11.1

11.2

Jon Furmston, Non-Executive Director gave a presentation to the Council of Governors on the work of the Trust’s Audit Committee and in particular the activity undertaken over the last year. It was confirmed that the Audit Committee used four main tools to review and report on the robustness of the Trust’s governance and assurance processed. These were :-

External Audit Ernst and Young audit the Trusts Financial Accounts, Annual Report and Quality Report. Within these they are looking for Economy, Efficiency, Effectiveness (“Value for money”). They present a report to Council of Governors on an annual basis.

Internal Audit The responsibility of the Internal Audit team, BDO, included ensuring that the Trust had the correct controls in place and that they were being followed by staff. As the result of an audit, if necessary, an action plan for improvement would be drawn up.

Local Counter Fraud Service Baker Tilly support the Trust with Counter Fraud services. They had also advised on a Fraud Risk Ranking which included Recruitment, Working whilst sick and emerging risks such as cyber fraud.

Reports and Executive Challenge Clinical Coding – which is critical to a wide range of Trust processes including securing the correct level of income and that mortality metrics are correct. Updates had been received by the Committee on the use of Encoder software which was helping the process.

“Policy on Policies” - monitoring the review of the Trust Policies Board Assurance Framework: - This work included the

development of the tracker, defining the risk appetite (target) and the development of the quarterly risk trend chart.

Reference Costs – the Committee is required to confirm that it is satisfied with the submission of the Reference cost.

11.3

Jon confirmed that the challenges and key areas of work for the Committee over the next year included :-

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The continuing challenging financial environment

Increased regulation and scrutiny

With the Council of Governors the External Audit Tender to be completed by end of March 2017

Learning from best practice from other Audit Committees

COG/10/15/12 Autumn 2015 Governor Election

12.1

12.2

Andy Gray outlined the proposal to hold an election to fill the current vacancies on the Council of Governors during the autumn of 2015. Currently the proposed date of appointment for these new Governors would be 1 January 2016 which would mean that they would only be able to serve a period of six months before having to stand for re-election. The proposal was to therefore to extend the term of office of these Governors until the 30 June 2019, thereby serving an initial term of office of three years and six months. The Council of Governors APPROVED the proposal to extend the term of office of these Governors until 30 June 2019, thereby serving an initial term of office of three years and six months.

COG /10/15/13 Other Business

13 .1

13.2

13.3

13.4

13.5

13.6

Brian Hughes asked for clarification of how a Governor could request that an item be included within the Agenda for the Council of Governors meeting either in Public or Private. Mike Viggers confirmed that the preferred route would be for an item to be discussed at the Pre-Council of Governors or with the Lead Governor so that ideally a collective view could be taken to the Council meeting to which the Trust could respond. Mike Viggers suggested that himself and Andy Gray met initially with Vicky and then a cross section of governors including staff representatives review any outstanding issues. David Walsh reminded the meeting that the Pre-Council of Governors meeting was an informal gathering and as such had no formal standing within the Governance of the Trust. Beda Oliver asked why the sign off for new equipment was taking a long time when funding had been agreed. It was agreed that Beda would share the specific example with Karen Geoghegan who would investigate further. Beda also said that she had recently taken part in a PLACE inspection on the Private Ward at Worthing and commented on its less than ideal facilities. She also asked why the profit made from the unit was not being reinvested to make it more “Patient Friendly”. Marianne Griffiths confirmed that the Business Case for the development of the Worthing Private Patient Facilities was due to come to the Trust Board later in the year. Richard Farmer asked if the Trust would be willing to fund any training courses provided by organisations such as NHS Providers to aid the development of Governors. It was noted that some which may be suitable were due to take place in November 2015.

MV/AG/VK BO/KG AG/VK

Minutes page 14

13.7

13.8

Richard Farmer asked about the Code of Conduct of Governors and the process of dealing with any areas of concern which had been approved at the previous Council of Governors meeting. It was confirmed that these had been incorporated into the new Governor Induction Pack copies of which would be circulated to all Governors. Margaret Bamford spoke about the recent Trust STAR Awards and explained that there had been a decision to introduce a Governor Award this year in addition to the Chairman’s Award. The Governor’s Award had been given to the Domestic Teams across the Trust. This had been a very popular choice and had recognised the tremendous work that all the domestic teams undertake across the Trust to keep all areas clean and therefore promote positive patient safety.

AG

COG /10/15/14 Questions from the Members of the Public

14.1

Roger Hammond, member of the Public commented that he had recently agreed to become a Trust Volunteer at Worthing and one of the areas where he had expressed an interest in working was Outpatients. He asked whether volunteers were contributing to the Outpatient work taking place throughout the Trust. Marianne Griffiths said that this was an excellent suggestion that she would take forward.

MG

COG /10/15/15 Date of Next Meeting

15.1 The next meeting of the Council of Governors would take place at 09.30 am on Thursday 21 January 2016 at in the Denham Room, Conference Centre, Worthing College, 1 Sanditon Way Worthing BN14 9FD

Barbara Mathieson

Assistant to Company Secretary Signed as an accurate record of the meeting

October 2015

………………………………………………….

Chair

…………………………………………………

Date

MATTERS ARISING FROM COUNCIL OF GOVERNORS MEETINGS

MATTERS ARISING FROM THE MEETING HELD ON 13 October 2015

Minute Ref Description of Action Responsible Person

Deadline Report

COG/10/15/4.4 Circulate Minutes Private COG Meeting held on 16 July 2015

AG January

2016 Completed 27 October 2015

COG/10/15/6.7 Circulate Membership Recruitment Letter to District and Parish Councillors

VK/NP January

2016 Verbal update to be given at meeting

COG/10/15/13.1 Chairman and Company Secretary to meet with Lead Governor

MV/AG/VK November

2015 Completed November 2015

COG/10/15/13.2 Discuss delays in sign off for equipment BO/KG January

2016 Discussed post meeting and concerns addressed

COG/10/15/13.6 Consider options for Governors Training ( Via NHS Providers)

AG/VK November

2015

Two Governors will be attending the Induction Course in January 2016. Full dates for 2016 now available proposal for attendance including costing to be drawn up

COG/10/15/13.7

Circulate copies of new Induction Pack with updated Code of Conduct of Governors and process of dealing with concerns to all Governors

AG November

2015 Completed 29 October 2015

COG/10/15/14.1 Consider the involvement of Trust Volunteers in the ongoing Outpatient Development work

MG January

2016 This is being considered a part of the overall outpatients engagement programme

To: Council of Governors

21st January 2016

From: Vicki King, Lead Governor

Agenda Item: 5

TO RECEIVE

REPORT FROM THE LEAD GOVERNOR

Introduction

1. This is my first report as Lead Governor since taking on the role from Margaret

Bamford. I would like to pay tribute to Margaret who worked so tirelessly with

Governors and the Trust over the last two years and achieved so much. To say she

is a hard act to follow is an understatement but I will do my best.

2. Since the last Council, our newly appointed Governors have engaged enthusiastically

and are now involved in various committees and hospital activities.

3. Elections will take place this spring as the three year term of office expires for nine

Public Governors, one Staff Governor and three Appointed Governors. The election

will also be taking place for an existing vacancy for a Public Governor for Horsham

and for a Staff Governor representing Estates and Ancillary Staff.

Membership and Engagement Committee

4. I am pleased to report that Jill Long, Public Governor for Arun is now chairing the

Membership and Engagement Committee. Since the last Council there have been

two committee meetings one in November and the other in early January.

Dashboard of Membership Data and Objective/Target Revision

5. This data is now routinely monitored by the Committee and the original Membership

Target of increasing public membership by 5% year on year has been revised. The

Committee discussed trends in data on new members “joiners” and on “leavers” and

it became clear that recruiting needs to backfill the leavers before any increase in

public membership is achieved. For this reason the Membership Target is now

To increase the number of public members by 1% year on year, and to maintain staff

and out of area patient numbers, taking the end of March 2014 as the baseline.

6. The other objectives/targets in the Membership and Engagement Strategy and Action

Plan, that cover levels of engagement of members and achieving a representative

membership in terms of age, gender, ethnicity and disability, remain unaltered.

7. The committee also discussed the population in the Horsham constituency area.

Currently the recruitment target is 0.5% of the whole population. After an assessment

of how many in the north of the constituency would use Surrey and Sussex Hospitals

(SASH) rather than WSHFT, it was decided that using a recruitment target of 0.5% of

a proportion of the population was more realistic.

2

Recruitment and Engagement Initiatives

Two Governors attended a meeting of the Adur and Worthing Youth Council and

gave a presentation about the Trust, the role of Governors, and the advantages of

membership to them. This resulted in recruitment of a small number of enthusiastic

young members. Those under 16 years were disappointed that they could not join!

Trust volunteers in the future will receive a membership leaflet as part of their

induction pack and encouraged to join.

Littlehampton Town Council has agreed to include Membership leaflets in the

Welcome Packs that are delivered to residents in new housing developments.

The committee has asked West Sussex County Council Public Health for ethnicity

data by locality (ward) in order to identify were recruitment initiatives for ethnic

minorities should be focussed.

“Pop-up recruitment shops” are being planned for Chichester and for Worthing

Supermarkets, as are visits to Family and Children’s Centres in the Chichester area.

Posters are currently being drafted to be placed in GP surgeries to introduce Public

Governors from the area and to promote active membership and feedback of views.

A survey is being sent out with the Trust Newsletter to all Members to find out if the

Membership feels as though they are receiving the information they need, as often

as they would like and asking if Members are as involved as much in Trust activities

as they would wish to be.

Nomination and Remuneration Committee

8. This committee met on 3 November 2015. The process for investigation of non-compliance had been amended to include, if applicable, the involvement of an independent assessor in accordance with Monitor’s Code of Governance. This was now included in the Governors’ Induction Booklet.

9. The Non-Executive Director appraisal process was reviewed and potential areas for improvement identified. With regard to Board composition and succession, it was confirmed that there would be two vacancies in 2017 as both Joanna Crane and Jon Furmston would be reaching the end of their second term. It was agreed that succession planning and any associated recruitment needs would be discussed further at subsequent GN&RC meetings, having regard to any CQC feedback and the upcoming external review of Board effectiveness.

10. It was also confirmed that an annual review of the effectiveness of the committee would be undertaken.

Patient Engagement and Experience Committee (PEEC)

11. The PEEC met on 30th November with a full agenda covering;

Complaints/PALS quarter 2 Report, Action Plan and Review of Complaints Policy;

Patient experience reports and action plan including Privacy and Dignity;

Stakeholder feedback, from Governors, CCG and Local Healthwatch in particular

their Discharge Report and the Trust response; and

The Cancer Survey and Paediatric patient survey plus their action plans.

3

12. PEEC is now a Trust committee whereas it was originally set up as a Governor’s

committee.

Strategy Group/Workshops

13. A discussion paper about the role of Governors in Strategy planning and

development was considered at the Pre-Council meeting. The paper re-iterated

Guidance from Monitor and set out possible options. The sixteen Governors that

attended that meeting recommended replacing the current small Governors Strategy

Group with three workshops throughout the year to fit in with the Trust’s Annual

Business Planning Cycle. The workshops will be open to all Governors thereby

allowing a greater input of views from members and the public. As a precursor to the

workshops Mike Jennings is holding a seminar for Governors on the Strategy

Planning Cycle on Thursday 4th February.

Issues for Future Governor Seminars

14. Governors are grateful for staff time spent on providing information seminars to help

them understand complex issues facing the Trust and recently had an excellent

seminar on Bed Reconfiguration. Another seminar is planned in the next month or so

on Finance and they have expressed the view that they would like seminars on the

Research and Innovation Strategy, Estates Strategy, Assurance Framework and Risk

Register, Incident Investigation and Root Cause Analysis, Private Patients Strategy,

Exit Interviews, Seven Day Working and the impact of the Comprehensive Spending

Review on WSHFT.

Patient First Improvement Programme Board

15. The latest Board meeting was on 9th December and consisted mainly of two

presentations and associated discussions. The KPMG management consultant’s

presentation was on Standard Work (consistent operation of work) and Leader

Standard Work (processes in place to ensure continuous improvement).

16. This was followed by a presentation from Katrina O’Shea, ward accreditation matron,

about the Lavant Ward Improvement Programme. This is introducing a host of

measures designed to improve the discharge process, for patients and their families.

One of these is a pharmacist/patient discussion about medication before discharge,

so that patients are better informed and have the opportunity to ask questions.

Another measure to improve information for patients and their families is a clear

colourful poster on the ward that states Lavant is a specialised unit consisting of 26

beds dedicated to the care of stroke patients. The poster then lists with an

explanation all the different roles of staff on the ward from the medical team to the

housekeeper. Recognition has also been given to the need for patients to know their

Estimated Date of Discharge as soon as possible, even though it might change, and

this is being implemented.

4

CQC Visit

17. Governor interaction with CQC inspectors was possibly via the public CQC listening

events and via the CQC Governor Focus Group session on 8th December. Topics

discussed included staffing issues, the challenge presented by the revision of MSK

services, the review of Outpatients, and Ophthalmology services. There were

plaudits for A&E and cleanliness at both hospitals.

18. The overwhelming view from Governors at the Focus group was that the Trust was a

high performing one with a caring environment, very dedicated staff and was

committed to the constant improvement of services for patients as witnessed by the

implementation of the Patient First Programme.

Conclusion

19. Governors remain committed to performing their functions as set out by Monitor

guidance and to working with the Non-Executive Directors, the Executive team and

hospital staff to constantly improve services for patients.

VK 10/01/16

This report can be made available in other formats and in other languages. To discuss your requirements please contact the Company Secretary on 01903 285288.

To: Council of Governors

Date of Meeting : 21 January 2016 Agenda Item: 7

Title

Chief Executive’s Performance Report

Responsible Executive Director

Marianne Griffiths, Chief Executive Officer

Prepared by

Andy Gray, Company Secretary

Status

Disclosable

Summary of Proposal

The Chief Executive will update the Council of Governors on the performance of the Trust over the past quarter in its strategic context, to enable a discussion by Governors on overall performance against targets and strategic objectives, and the performance of the board in leading the Trust’s achievements. The update will cover patient safety, patient feedback, activity, finance and workforce. The board has received detailed monthly reports on each of these areas, and these are available for governors on the Trust’s public website and via the Governors website page. At the time of writing the latest available performance data is to the end of November 2015.

Implications for Quality of Care

Patient Safety and Quality of Care are covered in the presentation

Link to Strategic Objectives/Board Assurance Framework

The quarterly report demonstrates progress against all the strategic objectives

Financial Implications

The financial position is covered in the presentation

Human Resource Implications

Workforce is covered in the presentation

Recommendation

The Council is asked to: NOTE the report and ask any questions of the Executive Directors.

Communication and Consultation

The information included is publicly available and has been discussed by the board.

Appendices

None

2

To: Council of Governors

Date: 21 January 2016

From: Marianne Griffiths, Chief Executive

Agenda Item: 7

FOR INFORMATION

1. INTRODUCTION

This paper sets out how the Trust has performed and gives an overview of the quality metrics since the last Council meeting, setting that in the context of the local and national picture. It also gives an update on the Patient First Programme.

Performance and Quality is reviewed monthly by the Trust Board in public, and these papers are available on the Trust website for Governors wishing for further background information. In addition Governors and members of the public can make use of the information provided at the Governors Assurance page, on the Trust website. 2. OVERVIEW AND SETTING THE CONTEXT

The Council of Governors has previously been updated on the high level of activity within the Hospitals, the issues we have had regarding compliance with Referral to Treatment Targets (RTT), the challenging financial position and particular concerns regarding recruitment. Within this report we shall update on all of these key items. Further information with the most recently available performance, quality and financial metrics will be given at the Council of Governors meeting. 3. PERFORMANCE SUMMARY

Based on provisional Month 8 positions, the Monitor Risk Assessment Framework performance was notionally two penalty points. This related to continued ‘managed failed’ in Referral to Treatment (RTT) as part of an agreed recovery planning process, and provisional under-performance for cancer 62 day referral to treatment patients.

Key indicators of operational pressure during November included:

10,880 A&E attendances compared to 10,781 in November 2014 (+0.9%).

4,477 emergency admissions compared to 4,057 in November 2014 (+10.4%).

Formally reportable delayed transfers of care totalled 3.49% for November 2015. 3.1. A&E Compliance The Trust was fully compliant in November with 96.14% of patients waiting less than four hours from arrival at A&E to admission, transfer, or discharge, against a national target of 95%. The Trust also achieved compliance for the overall Quarter 3 achieving 95.1% for the period.

3

3.2. Cancer Metrics Compliance The provisional position for November showed the Trust to be compliant against 6 out of 7 Cancer metrics as projected in the Month 6 Board report.

The Trust was provisionally below target for 62 day referral to treatment patients in October, with 84.7% of patients seen within 62 days against a target of 85%. Compliance is set within the context of an 11% increase in treatment activity, and a 20.5% increase in 2 week urgent referrals April – November 2015 compared to the same period 2014.

For context, latest nationally published data relating to October 2015/16 showed national aggregate compliance for cancer attendance to be 94.73% for 2 week rule (target 93%), 94.44% for symptomatic breast (target 93%), and treatment within 62 days to be 81.82% (target 85%). Although further validation is required initial figures indicate full compliance against all metrics for December 2015. 3.3 Referral to Treatment (RTT/18 Weeks) The Trust completed 12,273 RTT patient pathways in November and is 3,013 (3.4%) cases ahead of planned recovery volumes. However, cumulative referrals exceed recovery plan levels by 4,077 cases (3.3%). The subset of referrals that are suspected as having cancer or are urgent has increased by 16.3% on the same period of the previous year. In conjunction with the over-performance of pathway completion at WSHFT, redeployment of Independent Sector capacity through the WSHFT hosted RTT Programme Management Office (PMO) has increased backlog completion to drive compliance and offset in year referrals above plan.

4. QUALITY REPORT

The full Trust Quality report, together with its dashboard of indicators, is presented in public each month at the Trust Board meetings. The dashboard is based on national and regional benchmarks where available. In the absence of established benchmarks, locally agreed targets or levels have been defined.

The highlights from the Quality Report taken to the November Trust Board reporting data are as follows; 4.1. Mortality The Council have previously been advised of the improvements made in crude mortality rates which have fallen year on year. Crude non-elective mortality increased to 3.56% in November 2015. The 12 month mortality fell to 3.01%. The Trusts Hospital Standardised Mortality rates continue to improve and we are awaiting validation of the December value but this is anticipated to show the best performance the Trust has made to date.

4

4.2 Patient Safety Report There have been zero cases of Methicillin-Resistant Staphylococcus Aureus (MRSA) bacteraemia during the current year. There were two cases of hospital attributable Clostridium Difficle during November 2015 one of which was deemed avoidable. There were four Serious Incidents Requiring Investigation during November 2015. Also there were three falls across the Trust which resulted in moderate harm to patients and four Grade 3/4 pressure ulcers. 4.3 Exception Reports Relating to Safety: Never Events: Unfortunately the Trust reported a Never Event in October 2015. This was in relation to a retained pin during knee replacement surgery. A full investigation has been completed and will be presented to the Trust Board. 4.4 Friends and Family Test (FFT) In line with national guidance the Friend and Family test is now reported as a ‘percentage recommending’ score National performance is published on the NHS England website: http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/ The table below shows the latest available local scores against national benchmarks:

Percentage recommending

WSHFT in August (year to

date in brackets)

National median (April

2014 to March 2015)*

Inpatient care 94.6% (94.8%) 94.1%

A&E 90.6% (91.5%) 86.8%

Maternity: Delivery care 91.4% (95.3%) 95.4%

Outpatient care 87.9% (88.0%) No benchmark

National benchmark for response rates: National data comes out a few months in arrears, but to give an idea of where we stand the following response rates are the national averages for July 2015. • Inpatients: 26.7% • A&E: 15.2% • Maternity: 22.4% It is worth noting that in November the Trust achieved 100% positive scores across each of the Maternity Friends and Family domains of Antenatal Care, Delivery Care, Postnatal ward and Postnatal Community Care.

http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/

5

5 ORGANISATIONAL DEVELOPMENT AND LEADERSHIP

The headlines for Organisational Development and Leadership as at the end of December 2015 were: 5.1 Recruitment activity Recruitment continues to be a priority in the organisation. During November 19 registered nurses joined the Trust including 8 from Europe, a further 11 started in December with another 21 starting in January 2016. Alongside this 30 Certificates of Sponsorship for nurses from the Philippines have recently been issued by the Home Office and it is anticipated that the first cohort will be arriving at the Trust in mid-January. Recruitment (International/Domestic) and Temporary Staffing working groups have been brought together with revised aligned objectives to ensure visibility and tracking. Also weekly recruitment huddles have been established to ensure focus on process delays/withdrawn candidates and actions for Ward Managers are followed up. 5.2 Workforce Efficiency Sickness absence during October increased marginally to 3.8%, with the rolling 12 month position falling to 4.0%. The proportion of staff on long term sickness reduced again in month with a notable reduction in the Facilities and Estates Division which had been a particular area of concern. 5.3 NHS Staff Survey 2015 The NHS Staff Survey for 2015 was completed during the quarter and initial findings are now available. The Trust’s final response rate of 54% was above the average of 42%. Full results by Division will be available by the end of January 2016 with the publication of the results and comparator against the national position towards the end of February 2016. A full report will be given at the next Council of Governors meeting. 5.4 Junior Doctors Strike Appropriate planning is underway to mitigate the impact of the proposed Junior Doctors Strikes. 6 FINANCE REPORT Up to November our year to date position as reported is £2.6m deficit. As a consequence, our FSR rating drops from 3 to 2. The underlying causes are consistent with those previously discussed;

Significant levels of agency spend caused by workforce shortages across nursing and medical posts.

Workforce capacity constraints are having a knock-on effect on our ability to provide elective activity in the way we had planned to do so

The number of patients fit for discharge but unable to transfer into a community or alternative care setting has increased significantly.

6

These issues combined have exerted significant pressure on our overall financial performance and the position is not improving. Workforce costs are still very high.

We will obviously be doing everything we can to mitigate but the year- end situation is not positive.

6.1 Efficiency and Transformation Programme

At the end of November, the Efficiency Programme delivered cumulative savings of £10.2m against a plan of £11.5m (88.6%). The forecast out-turn is currently less than plan following and comprehensive review of risk and mitigating schemes are currently being developed to offset the shortfall.

6.2 Key Financial Risks are;

6.3.1. Ability to exit premium rate workforce arrangements. Vacancies and long-term sickness in key staff groups are driving significant increases in agency expenditure. The Workforce Transformation Group is overseeing action plans to increase recruitment, redesign workforce roles and manage sickness, rostering and retention issues. Opportunities to move to framework agency and reduce rates paid per shift are also being explored.

6.3.2. Management of patient flow to ensure that activity is able to be delivered within funded capacity and that numbers of patients medically fit for discharge are minimised. The Trust is working closely with health economy partners to ensure that the levels of fit for discharge patients and community bed capacity is managed.

6.3.3 Delivery of savings within the efficiency programme. As in 2014/15 the Trust has a significant efficiency requirement in order to deliver its planned surplus. The savings profile increases in Q3 in order to deliver the total programme. The Programme Management Office is now fully established and governance around the programme has been strengthened. Pipeline schemes are continuing to be developed to provide head-room within the programme.

6.3.4. The affordability for commissioners to pay in full for over-performance above contracted activity levels. Activity levels in year and being closely monitored and escalation triggers for significant variances to plan have been agreed with commissioners.

7 PATIENT FIRST PROGRAMME Introduced in November 2014, Patient First is the Trust’s approach to ensuring patients receive safe, high quality care, now and in the future. The philosophy behind the programme is centred on: • The patient being at the heart of every decision • Empowering staff to build on existing high standards • Continuous improvement of services through small steps of change • Standardising practices to ensure consistency of service The Patient First Programme Board oversees and assures delivery of all improvement and transformation work in the Trust.

7

Patient First Themes

7.1 Sustainability

The principal focus of the Programme is the development of a sustainable workforce that

reduces our reliance on temporary staffing and enables access to services that are safe

for patients.

Detailed work is underway to more accurately forecast the arrival of new overseas

nurses and to align this with the Trust’s activity plan and aim to eliminate non-framework

agency usage. This recruitment, alongside a focus on improving retention is the key to

creating a sustainable nursing workforce.

The Nurse Resource Management Programme is now being rolled out to all wards,

beginning with the Surgical wards. It is expected that temporary staffing usage will be

reduced by maximising the use of nursing establishments. Improvements will be realised

through more planned staff attendance that will result from allocation of unallocated

hours, proportionate annual leave throughout the year, proactive sickness management

and fair allocation of work hours.

7.2 Our People

The Trust is making good progress to establish a Kaizen Office. A Director of

Continuous Improvement has been appointed and the Kaizen Office is fully established.

The first wave of training in the Patient First Improvement System (PFIS) began in

October. Four wards are included in the first wave and will be used to tailor the

improvement method to Western Sussex to support subsequent waves. The first four

PFIS units are Botolphs, Fishbourne, Clapham and Wittering wards. Subsequent training

modules will be run monthly until completion of the first wave of training in February

2016. The training has been well attended by the ward leadership teams and there is

very high participation and enthusiasm for the training and application of the method in

their ward areas.

In December, attention focused on developing a lean training plan identification of the six

improvement projects, selection of units to participate in the next PFIS waves and

implementation of the Strategy Deployment Room.

7.3 Quality Improvement

A review of the improvement projects and alignment with the Quality Board objectives is

currently underway to ensure focus on the right quality improvement objectives.

7.4 Systems and Partnerships

The Non-Elective and Elective Transformation Programmes are now well into the delivery phase. The scope and timeline for these programmes and critical dependence on the Workforce Transformation projects makes delivery highly complex and challenging. Nonetheless, good progress is being made in a number of patient flow improvement projects, including elimination of the pre-assessment backlog, implementation of senior daily review, implementation of bed reconfiguration proposals and agreement of a new theatre schedule.

8

8 CARE QUALITY COMMISSION STANDARD INSPECTION 8 – 11 DECEMBER 2015

The Care Quality Commission Standard Inspection took place from the 8 – 11 December when Inspectors all three of the Trust Sites. Initial feedback which was shared with the executive team was that they were extremely impressed by the positive attitude and caring approach of staff they met across the Trust. They said they were struck throughout their visit by the passion you showed in all aspects of delivering patient care, by the way in which our caring values shine from everything you do and by the support colleagues provide for each other in all circumstances. Activities which took place during the inspection included the inspectors being tours of the hospitals and held focus group meetings with a wide range and all bands of staff. They discussed end-of-life care with the family of a patient during the tour, visited areas across medicine, surgery, outpatients, diagnostics, critical care and women & children, attended a breast MDT meeting and held discussions around IT and finance. At Worthing the tour areas included the Emergency Floor, Endoscopy, the Breast Care Unit and Medical Records.

As part of the inspection process the CQC inspectors also made an unannounced visit to Worthing Hospital on the 21 December and visited two wards. This additional visit was a standard part of the inspection process, which always includes unannounced visits within 14 days of the end of the main inspection. Six areas were raised for action and these can all be addressed prior to the draft report being received. Alongside this, aspects from the preparation for the CQC Inspection process will be maintained and these will include:-

Mock Inspections to become an Annual Event

Topic of the week to be retained and developed

Estates work plan – to be maintained as part of business as usual

Trust Innovation booklet to be updated annually

Ward information folders to be retained and updated regularly

The formal report from CQC is expected in approximately three months and will be shared

with the Council of Governors when received.

9 CONCLUSION AND RECOMMENDATIONS

The Council is asked to NOTE the report and ask any questions.

1

To: Council of Governors Agenda Item: 10

Date of Meeting: 21st January 2016

Title

External Auditor Appointment Process

Responsible Non-Executive Director/Governor

Jon Furmston, Chair of Audit Committee; John Thompson, Governor

Prepared by

David Lowe, Assistant Director of Finance

Status

Confidential

Summary of Proposal

Implications for Quality of Care

External audit provide a limited assurance opinion on the Quality Accounts

Support for/integration with Corporate Objectives and Strategies

Supports corporate governance

Financial Implications

External auditor fees assessment

Human Resource Implications

Not applicable

Recommendation

The Council of Governors is asked to NOTE the report and APPROVE the appointment process of the Trust’s external auditors for 2017/18

Consultation

Audit Committee

Appendices

N/A

2

FOR INFORMATION

EXTERNAL AUDITOR APPOINTMENT PROCESS

1. INTRODUCTION 1.1 The National Health Service Act 2006 states that every NHS foundation trust must have an

auditor that is appointed by the council of governors. The law states that it is for the council of governors to appoint or remove the auditor at a general meeting of the council.

1.2 The auditor has statutory duties to ensure that:

the accounts of the NHS foundation trust are prepared in accordance with all relevant directions set by Monitor and any other statutory provisions;

proper practices are observed in compiling the accounts; and

the NHS foundation trust is using its resources economically, efficiently and effectively. 1.3 While the Council as a whole is responsible for the appointment, the work associated with this

process would normally be discharged through a smaller working group.

1.4 This working group will include Governors (one more in number than the number of independent Non-Executive Director members of the Audit Committee), independent Non-Executive Director members of the Audit Committee, the Finance Director/Deputy Director of Finance, Company Secretary and support from other finance and procurement staff. The purpose of the group will be to oversee the entire appointment process, right up to the recommendation to the Council for appointment.

1.5 Once established the Audit Committee Chair (who will be the Chair of the Working Group) will convene its first meeting and schedule thereafter to ensure effective management of the procurement process.

1.6 The current schedule for the Working Group meetings and decision points are set out in Appendix 1.

2.0 APPOINTING THE AUDITOR 2.1 A diagram of the key stages for appointing the auditor is shown below – Chapter 7 of the

Monitor publication “Your statutory duties – a reference guide for NHS foundation trust governors”

2.1.1 Trigger for action - The impending end of the existing auditor’s contract term will trigger a

new appointment process, whether or not the existing auditor is seeking reappointment. 2.1.2 Agree process and establish criteria - The council of governors should take the lead in

agreeing with the audit committee the criteria for appointing, reappointing or removing auditors. As with all appointments or reappointments, the procedure must be formal, rigorous and transparent. The audit committee will run the process but the final decision on any

3

appointment rests with the council of governors. Having established objective criteria, the audit committee should:

agree with the council of governors a clear process for nominating a new auditor or reappointing the existing one, including a timetable showing the deadline by which a new appointment should be made; and

prepare a specification defining the role and capabilities required, including the necessary qualifications, skills and experience, and agree the specification with any governors’ audit working group or similar.

2.1.4 Procurement process - the audit committee should run a formal procurement process to

obtain the best candidate as fairly and transparently as possible. The process may vary depending on the NHS foundation trust’s particular procurement rules but it must be within procurement law. The Trust is proposing using the ConsultancyOne RM1502 framework for shortlisting the auditors; this procurement framework is fully compliant with the Public Sector Procurement Regulations, including EU law. A list of the organisations on the framework is found in Appendix 1.

According to best practice the audit committee should draw up a shortlist of at least two appointable candidates in conjunction with the governors’ audit working group.

2.1.5 Presentation by the audit committee - The audit committee and any governors’ audit

working group should present to the council of governors:

• the procurement process they have followed; • the results of the procurement process; and • recommendations

The recommendations should describe in full the shortlisted candidates and assess their relative strengths and weaknesses. The appointment must be based on merit and objective criteria. The committee should also recommend the preferred candidate and set terms of engagement for the external auditor. A suggested evaluation criteria outline can be found in Appendix 2, which will be discussed at subsequent meetings of the working group and the agreed template will then be used as a basis for appointing the auditors.

2.1.6 Approval of terms of engagement - the council of governors should then make a final

decision in line with its statutory obligations. If the council of governors chooses to make an appointment, the audit committee will need to approve the auditor’s terms of engagement. The council of governors and the audit committee should consider in particular how long the appointment should last. Best practice is to appoint an auditor for a period which allows it to develop a strong understanding of the NHS foundation trust, normally three to five years.

3.0 WORKING GROUP MEETING 1 3.1 The first meeting of the working group was held on the 23rd November 2015. The members

are as follows:

Jon Furmston – Chair of Audit Committee

Paul Benson – Patient Governor

John Thompson – Public Governor

Andrew Harvey – Staff Governor

David Lowe – Assistant Director of Finance Non-Voting

Andrew Gray – Company Secretary Non-Voting

John Giffford – Deputy Head of Procurement Non-Voting 3.2 The meeting agreed that the process as defined by Chapter 7 of the governors’ guide

published by Monitor should be recommended to the Council of Governors for approval. It also

4

agreed the proposal from the Trust’s management to follow the ConsultancyOne RM1502 framework for shortlisting the auditors was agreed by the Working Group. This was due to the process already being fully compliant with the Public Sector Procurement Regulations, including EU law.

3.3 The working group noted that best practice should be to draw up a shortlist of at least two

appointable candidates, the group agreed that it would recommend that the shortlist consist of a minimum of three and a maximum of four candidates, using the suggested criteria as a basis for the shortlisting with a final criteria being agreed at the next working group meeting scheduled for the 14th January 2016.

3.4 The timeline for the process, in Appendix 3, which takes into account the procurement timeline and aligns with the regular governance meetings, was also agreed to be recommended to the Council of Governors for approval.

4.0 Recommendations

4.1 The Council of Governors to NOTE:-

4.1.1 The External Auditor appointment process as set out in Chapter 7 of the Monitor publication “Your statutory duties – a reference guide for NHS foundation trust governors”;

4.1.2 The procurement process to follow the ConsultancyOne RM1502 framework for shortlisting auditors;

4.1.3 A minimum of three and a maximum of four appointable candidates on the shortlist, using the suggested criteria (once agreed);

4.1.4 The timeline for the process and the next update will be received by the governors at the Council of Governors Meeting due to take place on the 12 April 2016.

5

Appendix 1

6

Appendix 1 continued

7

Appendix 1 continued

8

Appendix 2

High level criteria

Detailed criteria Weighting Factors

Commercial (25%)

Fees 20% • Total cost

Value for money 5% • Minimum number of days support • Added value e.g. evidence that the auditor has given

Trusts advice and guidance outside of the normal audit remit including technical guidance and sector specific advice

Professional Capability (55%)

Experience and skills of key personnel

25% • Skills Character • Knowledge • Professional and technical competence of the audit team • Ability to challenge and scrutinise • Public interest motivation • Independence from management • Ability to provide the full range of services required • Recent experience in the field • Track record working with NHS Foundation Trusts • Qualifications and awards • Communication skills • Project management skills

Service quality and approach

30% • Mindset & Culture • Judgement • Quality Control • Suitability of the audit approach, standards and methods • Innovation in practice • Support to be provided outside of audit cycle (e.g.

assistance in the application of new accounting treatments and standards)

• Attendance and contribution to Audit Committee meetings • Internal quality assurance processes and the findings of

any external quality reviews • Approach to continuity of service delivery over the

Contract (e.g. policy on rotation)

Quality - Non-technical (20%)

Quality of submission

5% • Transparency of fee structure and service level (e.g. how many days provided to each activity)

• Clarity on proposed approach, standards and methods • Provision of robust and relevant evidence • Presentation of information (e.g. structure, style,

language, jargon)

Stakeholder engagement

15% • Understanding of the provision of mental health services • Understanding of the Trust’s vision and values • Suitability of approach to liaison with Governors, Audit

Committee, Finance, and Internal Audit • Appreciation of the distinct roles of the Council of

Governors, Audit Committee and Board of Directors • Attendance and contribution to Council of Governors

meetings • Information, advice and guidance provided to Council of

Governors

9

Appendix 3

Draft Timeline for External Audit Tender

Date Governance

Procurement - via

Framework RM1502 Lot

5.4 External audit & Advice

Finance

13-Oct-15Council of Governors - forms

working group

19-Nov-15

Briefing paper setting out

process and timeline etc "to

set the scene", including

procurement timeline

23-Nov-15

Appointment of new auditors

working group - Meeting 1 -

approve appointment process

15-Dec-15

Send out paper containing

suggested evaluation criteria,

weightings etc for discussion

at next working group

meeting

14-Jan-16

Appointment of new auditors

working group - Meeting 2 -

review specification,

evaluation criteria, weightings

etc

15-Jan-16

Send out update paper for

CoG meeting - containing

progress to date

21-Jan-16Council of Governors

Meeting

25-Feb-16

Appointment of new auditors

working group - Meeting 3 -

approve specification,

evaluation criteria, weightings

etc

12-Apr-16Council of Governors

Meeting - tbc

26-Apr-16

Procurement finalise

invitation to offer doc and

send out to all suppliers on

the Lot 5.4 framework27-Apr-1628-Apr-1629-Apr-16

02-May-1603-May-1604-May-1605-May-1606-May-1609-May-1610-May-1611-May-1612-May-1613-May-1616-May-1617-May-1618-May-1619-May-1620-May-16

23-May-16

03-Jun-16

Evaluation team - have

completed reading and

scoring bids, agree shortlist

for presentations

13-Jun-16

Notify shortlisted

suppliers/carry out any

clarifications required

27-Jun-16

01-Jul-16

14-Jul-16 Audit Committee - tbc

20-Jul-16 Council of Governors tbc

28-Jul-16 Trust Board for Approval

01-Aug-16 Contract Award Notification

01-Sep-16 Debriefing Session

Ye

ar

En

d

Presentations and final scoring and award recopmmendation

Award recommendation paper drawn up for internal approval process

Closing date for receipt of offers, official tender opening,

details of bids circulated to evaluation team

December 2015 VK/BH/RF Page 1 of 2

Council of Governors 21

st January 2016

Agenda Item: 11

Council of Governors

Holding the Non-Executive Directors to account for the performance of the Foundation Trust Board

Governors have an important role in making an NHS foundation trust publicly accountable for the services it provides. They bring valuable perspectives and contributions to its activities. Importantly, Governors are expected to hold Non-Executive Directors to account for the performance of the Trust Board of Directors. This line of accountability is a key role in their Job Description and forms an important part of the NED training. The following sets out the process by which the Governors will discharge their responsibility to hold Non Executive Directors to account. In agreeing this document the following principles have been applied:

To ensure that the process of holding to account is transparent and fulfils the

statutory duties of the Council of Governors

To make the most effective and efficient use of time and resources, and to avoid

duplication

To work with the Non-Executive Directors to ensure there are effective strategies,

policies and processes in place via the NEDs to ensure good governance of the Trust.

To be proportionate, recognising that Governors are volunteers and that Non

Executives are contracted for two and a half days per month only.

The following sets out the mechanism through which Governors enact their responsibility:

The Non-Executive Chair of each Board Committee presents updates from their Committee in public to Governors at a Council of Governors meeting based on Council of Governors Annual Programme agreed each year*.

Non-Executive Directors meet with Governors twice a year for a private discussion on

Trust activity, performance and developments.

Executive Directors will be invited to attend the full Council of Governors meeting and provide updates in line with the Annual Programme of the Council.*

The Chair a