A - Front cover · Governing Body To be held on Thursday 15 September 2016 Commencing at 12.30pm...

Governing Body

To be held on Thursday 15 September 2016

from 12.30pm until 3.30pm

in the Boardroom, Sovereign House, Heavens Walk, Doncaster DN4 5HZ

Governing Body

To be held on Thursday 15 September 2016 Commencing at 12.30pm – 3:30pm

In the Boardroom, Sovereign House, Heavens Walk, Doncaster, DN4 5HZ

PUBLIC AGENDA

Presenter Enc

1. Welcome and Introductions

Chair

2. Apologies

Chair

3. Declarations of Interest

Chair

4. Patient Stories / Questions from Members of the Public (Please see our website for guidance on how to submit question/story requests)

Chair

5. Minutes of the previous meeting held on 18th August 2016

Chair Enc A

6. Matters Arising

Chair

Strategy

7. Working Together Joint Committee Proposal Mrs Sherburn Enc B

Assurance

8. Finance Report

Mrs Tingle Enc C

9. Emergency Preparedness, Resilience & Response Standards Self-Assessment

Mrs Atkins Whatley Enc D

Standing Items

10. Chair & Chief Officer Report

Dr Crichton & Mrs Pederson

Enc E

Items to Note / Receipt of Minutes

11. Items to Note

• Quality & Performance Report o Safeguarding Adults Annual Report

Mr Russell & Mr Fitzgerald

Enc F

12. Receipt of Minutes from Committees

• Audit Committee – Minutes of the meeting held on 14th July

2016. • Quality & Safety Committee – minutes of the meeting held

on 7th July 2016.

• Engagement & Experience Committee – Minutes of the meeting held on 7

th July 2016

• Executive Committee – Minutes of the meeting held on 3rd

August 2016 will be received in October.

• Primary Care Commissioning Committee – Minutes of

the meeting held on 11th August 2016 will be received in October

2016.

Chair Enc G

13. Any Other Business

Chair

14. Date and Time of Next Meeting Thursday 20th October 2016 at 12.30pm

Chair

15. To resolve that representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest Section 1(2) Public Bodies (Admission to Meetings) Act 1960.

Chair

Enc A

Minutes of the previous meeting

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Minutes of the Governing Body Held on Thursday 18th August 2016 commencing at 12.30pm

In the Boardroom, Sovereign House Members Present:

Dr David Crichton – NHS Doncaster CCG Chairman (Chair) Miss Anthea Morris – Lay Member and Vice Chair of the Governing Body Mrs Jackie Pederson – Chief Officer Mrs Linda Tully – Lay Member Dr Emyr Wyn Jones – Secondary Care Doctor Member Dr Sam Feeney – Locality Lead, Central Locality Dr Jeremy Bradley – Locality Lead, North East Locality Dr Andy Oakford – Locality Lead, North East Locality Dr Marco Pieri – Locality Lead, North West Locality Dr Niki Seddon – Locality Lead, North West Locality Dr Pat Barbour – Locality Lead, South East Locality Mrs Hayley Tingle – Chief Finance Officer Mrs Mary Shepherd – Chief Nurse

Formal Attendees present

Dr Rupert Suckling – Director of Public Health Mrs Sarah Atkins Whatley – Chief of Corporate Services Mrs Laura Sherburn – Chief of Partnerships Commissioning and Primary Care Mr Anthony Fitzgerald – Chief of Strategy & Delivery

In attendance:

Miss Lindsay Moore – Senior Corporate Services Support Officer (Taking Minutes) Mr Ian Carpenter, Head of Communications & Engagement

ACTION

1. Welcome and Introductions Dr Crichton welcomed everyone to the Governing Body meeting. There was 1 member of the public in attendance at the meeting and 3 members of DCCG Staff observing the meeting.

2. Apologies Apologies were received from:

• Dr Khaimraj Singh – Locality Lead, South East Locality

• Dr Lindsey Britten – Locality Lead, South West Locality

• Dr Karen Wagstaff – Locality Lead, South West Locality

• Mrs Kim Curry – DMBC Representative

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• Mrs Deborah Hilditch – Healthwatch Doncaster Representative

3. Declarations of Interest There were no new or additional declarations of interest made.

4. Questions from Members of the Public/ Patient Stories It was noted that there was no patient story or questions from members of the public received for this meeting.

5. Minutes of the Previous Meeting held on 21 July 2016 The minutes of the meeting held on 21 July 2016 were agreed as an accurate record.

6. Matters Arising There were no matters arising and all actions noted within the minutes have been completed.

7. Strengthening Financial Performance and Accountability Mrs Pederson and Mrs Tingle gave a presentation regarding Strengthening Financial Performance and Accountability to the Governing Body and the following points were noted:

• The guidance published in July 2016 highlights and pulls together the work done around finances within the NHS and sets out actions to stabilise NHS finances in 2016/17 alongside providing further detail on access to the Sustainability and Transformation Fund (STF) and outlining the proposed basis for assessing the financial performance of providers.

• The plans already in place put forward a current predicted provider shortfall of £580m in 2016/17.

• Providers have been asked to provide action plans to cut this by £250m (taking into account the Carter Review, back office functions and pay bill growth).

• The Improvement and Assessment Framework will be changing for CCGs which will include four domains - Better Health, Better Care, Sustainability, Leadership, and six clinical priorities - Mental Health, Dementia, Learning Disabilities, Cancer, Diabetes and Maternity.

• NHS Improvement (NHSI) is introducing financial special measures for providers and regimes of special measures for commissioners both of which will be used when there is failure to meet the financial discipline expected of the NHS. This will include an agreed recovery plan being put in place within a month and evidence of immediate

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improvement will be required.

Mrs Pederson informed the Governing Body that the first 5 providers and 7 CCGs to be put in Special Measures have been identified. Mrs Pederson agreed to keep the Governing Body informed of developments and progress.

Mrs Tingle advised the Governing Body that the Sustainability and Transformational Fund (STF) is designed to support providers in reaching financial balance and improving performance and highlighted the following points:

• £1.8bn is available in 2016/17 (already taken account of in the £580m deficit forecast).

• £1.6bn allocated to providers of acute care.

• £200m allocated to maximising efficiency (half already allocated Mental Health /Community and Ambulance providers).

Access to the £1.6bn is subject to a number of conditions:

• Achievement of a financial control total each quarter.

• Performance measured against set trajectories.

• Mandatory A&E improvement initiatives implemented. The Governing Body noted that NHS England will be establishing Referral to Treatment Time (RTT) and A&E Improvement Boards and there is a view that CCG System Resilience groups will be re-configured to become local A&E Delivery Boards. Mrs Tingle advised that following the 2016/17 financial reset, there will be a rapid move to agree operating plans that deliver on the visions of the STP which will include:

• Guidance published around 14th September 2016.

• Tariff consultation will run for a month.

• CQUIN guidance 30th September 2016.

• Contract documentation consultation through October 2016.

• 2 year Contracts signed 23rd December 2016.

• STP Finance submission - end of August 2016.

• STP final submission - 21st October 2016.

Mrs Pederson

8. Children’s Services (Surgery and Anaesthesia) The Governing Body acknowledged that this work has been extensively discussed at other meetings and that there is awareness of the work completed to date and planned for the future. Mrs Sherburn informed the Governing Body that the review and work completed to date has highlighted variations in provision which could then lead to variations in the quality of provision available. This may have an impact on clinical outcomes and a variation in care provided dependant on location of services. It has been highlighted that the current configuration requires change and this was agreed by the Governing Body in the Autumn of 2015.

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Mrs Sherburn highlighted the following points to the Governing Body:

• The specification for provision has been agreed clinically and a designation toolkit has been developed to designate providers as part of a network across CCGs

• A proposed model on future configuration has been drafted and considered by the clinical Task and Finish Group. The basis of the model was clinically supported and now forms part of the options appraisal.

• An options appraisal around a model has been drafted and appraised and is being discussed more widely.

• A service model is emerging and requires consideration as this will change pathways of care.

• A managed clinical network has been funded for 2016/17, as part of the Provider Working Together vanguard to enable the mobilisation and implementation of change in line with the proposed service model.

• Pre consultation is now complete and all CCGs and providers are engaged in the consultation and engagement plan for the next phases.

• A full business case for mobilising change is being drafted, which will include proposals for contracting and commissioning intentions for 2017/18 for CCGs.

This programme of work is currently within Phase 2 of the plan which was in place from October 2015 to September 2016 and includes:

• Implementation of communication and engagement strategy enacting procurement advice.

• Development of a service specification and gap analysis against existing provision.

• Development of options on a service model and assessment of options.

• Development of full business case including activity and financial impact.

• Formal consultation starts (ends December 2016).

• Consideration of options to implement change. Phase 3 is expected to commence in October 2016 and run to March 2017 to enable consultation, implementation planning and mobilisation of the preferred option to take place. Mrs Sherburn advised that in line with the tiered approach South Yorkshire and Bassetlaw Hospitals will provide tiers 1 and 3 but we will need to consider where Tier 2 services are sited. The recommended option is that Doncaster and Bassetlaw Hospital Foundation Trust (DBHFT) retains and increases services, alongside Sheffield and Pinderfields. The impact on services and wait times for this option will form part of an impact assessment. The Governing Body was informed that the consultation process will be centralised as this approach covers a wider area than just Doncaster. There is a central website set up and a survey system will be launched. There is also a central steering group in operation.

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Dr Suckling advised that Doncaster Metropolitan Borough Council (DMBC) Overview and Scrutiny Panel is supportive of this work but would like sight of the consultation documents and plan before they are published. The Governing Body noted the work to date and approved the options appraisal and emerging model subject to it being viewed before going out to consultation. The Governing Body requested to see the consultation plan prior to it going live and also requested to see validated figures from the consultation prior to receiving the business case for approval.

9. Future Hosting Model for Previously Un-assessed Periods of Care (PUPoC) Mrs Shepherd informed the Governing Body that in 2015 the Yorkshire & Humber Commissioning Support Unit was unsuccessful in gaining approval to enable them to be accepted onto the Lead Provider Framework (LPF) for all services except Continuing Health Care. This led to the demise of the Yorkshire & Humber Commissioning Support Unit which initiated the implementation of a transition board with various work streams of which NHS Doncaster CCG looked at options for the future of Continuity Healthcare (CHC) / Previously Un-assessed Periods of Care (PUPoC) / Personal Health Budgets (PHB). A business case was then created which resulted in the following allocations:

• CHC – each CCG ‘in-housing’ their teams.

• PHB – NHS Doncaster CCG to host on behalf of the following 6 CCGs: o Doncaster o Rotherham o Wakefield o Calderdale o North Kirklees / Greater Huddersfield o York Partnerships

• PUPOC – NHS Doncaster CCG to host on behalf of the following 12 CCGs: o Doncaster o Rotherham o Bassetlaw o Barnsley o Sheffield o North Kirklees / Greater Huddersfield o Wakefield o 3 Leicester CCGs o North Lincolnshire

This meant that a small number of staff were not aligned to any of the services outlined and if staff redundancies occurred, the approximate

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cost would be £162,743 taking into account lengths of service. Based on this, this cohort of staff were combined together to form a shared support service for CHC which is hosted by Doncaster on behalf of 5 CCGs. This team consists of 9 staff members. The services and staff transferred over to the respective CCGs on the 1st December 2015. This enabled a safe transfer of all staff and also aided business continuity. The PUPoC function remains the most complex hosted service as this is a large team of 47 staff based at Sheffield and includes both clinical and administrative staff. The team is currently working on the PUPoC period 2004-2012. The total cost of making the whole team redundant is approximately £566,000. If the clinical staff were removed from that, the calculation for admin only is £41,068. The collaborative have outsourced in the region of 600 cases to support the performance against September 2016 trajectories which will now bring the completion date to January 2017. Further outsourcing is being considered to bring completion in line with NHS England expectations of September 2016 however the original business case was developed against a service delivery of March 2017. The collaborative is currently considering what the future arrangements may be, based on the possibility of a further PUPoC period being announced in early 2017 with uncertain parameters. The options being considered are the current 12 CCGs, none at all, or a different Yorkshire and Humber collaborative. Discussions within the current collaborative with NHS England and Chief Officers have identified the preferred recommendation to be a move to a Yorkshire and Humber collaborative which will include:

• Doncaster

• Rotherham

• Sheffield

• Barnsley

• Bassetlaw

• North Links

• Wakefield

• Greater Huddersfield / North Kirklees

The three Leicester CCGs are exploring their future arrangements within their NHS England region. The Governing Body was informed that resources and capacity planning are being reviewed to accommodate Leicester potentially leaving the collaborative. Remodelling will need to be carried out if this takes place however there will always be a need and requirement for this workforce. The Governing Body noted the report and approved the continued hosting of the PUPoC service on behalf of 9 CCGs within the Yorkshire and Humber region.

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10. Quality & Performance Report Mrs Shepherd and Mr Fitzgerald presented the report to the Governing Body for noting and highlighted the following key points; Doncaster & Bassetlaw Hospitals NHS Foundation Trust (DBHFT)

• A case of MRSA was identified during May 2016. This was unavoidable however still breaches the zero tolerance standards.

• Complaints and concerns have risen slightly again in June 2016 however this rise is mainly due to concerns being raised, rather than formal complaints.

• The NHS England Quality Surveillance Team completed an external Peer Review of the Cancer of Unknown Primary (CUP) service. All of the concerns raised had already been identified by DBHFT and plans are in place to address them. The Lead Cancer Nurse has produced an action plan which will be used to provide assurance to the Trust Board, NHS England and Commissioners.

• Cancer 62 day measures – all measures were met by the Trust again in May 2016 which is the fourth month running.

• Diagnostics met target in June 2016 for 3 months running, which is the first time since 2013.

• A&E – Performance was 92.8% in July 2016 against the NHS Improvement trajectory of 94%

Rotherham, Doncaster & South Humber NHS Foundation Trust (RDASH)

• Improved Access to Psychological Treatment (IAPT) Recovery Rate failed to meet target at 44.4% The CCG is arranging a meeting with RDASH to review the current service provision, as patients with different levels of complexity are accessing the service which impacts on reported performance.

The Governing Body was informed that work around access to IAPT services is currently being looked at alongside waiting times and stroke services and this will be discussed at a future Clinical Reference Group meeting. The Governing Body noted the report and its content and agreed that the report was useful and well received.

11. Corporate Assurance Report - Quarter 1 Mrs Atkins Whatley presented the report to the Governing Body and highlighted the following points; Risk:

• The Risk Register now holds 47 risks, which is an increase from 33 at the end of the last Quarter. This reflects a more proactive use of the Risk Register to capture emerging risks and also includes the Primary Care Commissioning risks since we received delegated responsibility for Primary Care commissioning in April 2016.

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External Assessments:

• Positive assurance has been received through the final Head of Internal Audit Opinion. A report will be presented at the Annual General Meeting in September 2016

Committee activity:

• The Engagement Committee held a development session during the last quarter to develop a shared understanding of the role of the Committee, its future priorities, and to consider how to increase Committee effectiveness. A report will be presented to Governing Body on a quarterly basis.

Governance Structure:

• The revised meeting governance structure was implemented from 1 June 2016.

Business Continuity:

• The results from the Business Continuity exercise that took place have highlighted a need for more work on embedding business continuity within the CCG. Work around this will take place in the next 2 quarters.

Information Governance:

• A new General Data Protection Regulation (GDPR) was adopted across the EU on 27 April 2016 and must be implemented across the EU by 25 May 2018. There will be significant changes to the regulation which will have an impact on Doncaster CCG, a significant programme of work will be initiated to prepare for this.

Organisational Development:

• Work is starting on the review of the CCG Organisational Development Strategy in 2016/17 to make sure it is fit for purpose with the changing commissioning landscape.

Mrs Atkins Whatley informed the Governing Body that succession planning for the Caldicott Guardian is in progress and training will be given. There are currently 2 Deputy Guardians in place however a new deputy will need to be appointed and approved as one of the current deputies. Mr Russell will be taking on the role of Caldicott Guardian as part of his new role as Chief Nurse.

The Governing Body noted the report.

12. Chair and Chief Officer Report The Governing Body noted the report and Mrs Pederson highlighted the following:

• Work on the Doncaster Place Plan (DPP) is progressing well with energy, enthusiasm and excitement from all partners. Meetings

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have been held with partners to look at future ambitions and discuss the development of a Neighbourhood Model from a Health & Care perspective. It has been agreed that the first test of the model will be the roll out of Intermediate Care.

The Governing Body noted that the number of neighbourhoods and their geographic boundaries have not yet been agreed and also recognised the need to identify which parts of the plan will sit in which areas and ensure finances are current and correct. The partnership ambition is to have a draft DPP available by mid-September 2016 which will then connect to the STP and progress through the formal meeting structure to discuss and progress the pathways.

13. Standards of Business Conduct & Conflicts of Interest Policy Mrs Atkins Whatley advised Governing Body that revised statutory guidance from NHS England was issued in late June 2016 to provide support to CCGs in the management of Conflicts of Interest. The Standards of Business Conduct & Conflicts of Interest Policy has been revised in line with this guidance, and Mrs Atkins Whatley highlighted the main changes in the policy to the Governing Body. The planned next steps to roll out the approved policy are:

• Policy approval by Governing Body (August 2016).

• Highlights of policy changes cascaded to staff in month-end organisational e-briefing (August) and Staff Brief (September).

• Launch of new Declarations of Interest Form to staff and member practices, requiring returns within the month (September 2016).

• Corporate Governance Manager to populate new declarations of interest and gifts/hospitality/sponsorship register templates and publish on NHS Doncaster CCG website (September 2016).

• Development of training sessions for admin staff responsible for minuting meetings (September 2016).

• Briefing session at Strategy & Delivery Directorate Management Team meeting for commissioning managers on changes to business case and procurement conflicts of interest management (October 2016).

• Development of “Lunchtime Learning” sessions for all staff to further raise awareness of the policy (October 2016).

• Rollout of the mandatory online training to all staff when it is launched by NHS England (expected during Autumn 2016 with compliance required by 31 January 2017).

Mrs Pederson informed Governing Body that online training is not yet available and felt that a separate training session for Governing Body members may be useful. Mrs Atkins Whatley agreed to look at suitable times and dates for this.

Mrs Atkins Whatley

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The Governing Body noted the changes to the policy in line with the statutory guidance, gave their support to the planned next steps and approved the revised policy.

14. Finance Report The Governing Body noted the Finance Report.

15. Receipt of Minutes from Committees The following minutes were received and noted by the Governing Body:

• Audit Committee – Minutes from the meeting held on 14th July 2016 will be received in September 2016

• Quality & Patient Safety Committee – Minutes from the meeting held on 7th July 2016 will be received in September 2016

• Engagement & Experience Committee – The Minutes of the meeting held on 7th July 2016 will be received in September 2016

• Primary Care Commissioning Committee- The minutes of the meeting held on 16th June and 14th July 2016

• Executive Committee - The minutes of the meeting held on 6th July 2016.

16. Any Other Business Dr Crichton informed Governing Body that this is Mrs Shepherd and Dr Feeney’s final Governing Body meeting and thanked them both for their valuable contribution to the Governing Body meetings and to the CCG as a whole and extended his best wishes to them both for the future.

17. Date and Time of Next Meeting Thursday 15 September 2016 at 12:30pm.

18. It was resolved that representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest Section 1(2) Public Bodies (Admission to Meetings) Act 1960.

Enc B

Working Together Joint Committee Proposal

Meeting name Governing Body

Meeting date 15 September 2016

Title of paper

Working Together – Joint Committee of CCGs

Executive / Clinical Lead(s)

Jackie Pederson, Chief Officer Dr David Crichton, Chair

Author(s) Will Cleary-Gray, Programme Director Commissioners Working Together

Purpose of Paper - Executive Summary NHS Doncaster CCG has a history of collaboration with its partners in Commissioners Working Together, a collaborative between 8 CCGs covering South Yorkshire & Bassetlaw, Mid Yorkshire and North Derbyshire. In September 2015 our collaborative approach was formalised in a non-binding Memorandum of Understanding between the CCGs. This set out the key objectives of the collaboration, the principles governing this approach, the governance structures and the respective roles and responsibilities of the CCGs. The CCGs, through their respective Clinical Chairs and Accountable Officers, agreed to move towards formalising joint decision-making structures in readiness for a number of major programmes that will need to be developed and implemented. At the moment this includes hyper acute stroke services, and children’s surgery & anaesthesia services. CCG Governing Bodies considered the collective proposal to establish a Joint Committee of Clinical Commissioning Groups (JC CCG) as the natural next step for Commissioners Working Together. Our Governing Body considered and approved this at the Governing Body meeting held in June 2016 and gave support for its establishment, agreeing:

• There is a need to formalise joint decision-making arrangements around the Working Together Programme.

• There is precedent set for this in previous NHS structures, such as the historic Yorkshire & Humber Specialised Commissioning Group.

• Legal advice has been sought on the proposed approach; it is accepted that a Joint Committee is the most appropriate structure to explore further.

Draft Terms of Reference for the Joint Committee of Clinical Commissioning Groups (JC CCG) were approved by Governing Body subject to the following points being clarified:

• The delegated functions have not yet been defined, and still need to be inserted into the Terms of Reference. It was suggested that these needed to be agreed by the parties and re-presented to Governing Body at a later date, for sign-off separately. As a minimum, decisions regarding financial affordability need to be reserved to the CCG.

• The voting mechanism needs more clarity; the Terms of Reference state each CCG has 12.5% of the vote, but there is a Director of Finance and 2 Lay Members who are also in the list of voting members - so that doesn't add up to 12.5% of the vote each. This needs clarifying.

• The notice period is 6 months enacted from the start of the next financial year. Technically therefore if a member CCG gave notice in November, a 17 month notice would apply (i.e. 6 months notice and then another 11 months to the start of the next financial year). This needs clarification – it was felt 12 months maximum was appropriate.

• If responsibility is delegated to the Joint Committee of CCGs, Governing Body will want excellent communication at each stage of the process for each area. It was felt the Hyper Acute Stroke Unit (HASU) process had gone well and we had felt involved, so replicating this process would be advantageous.

• The suggested Joint Commissioning agreement to support and supplement the Terms of Reference may be helpful in providing further assurance and clarity.

The revised Terms of Reference and Manual Agreement (appended to this paper) have now been updated to fully incorporate feedback from Governing Body members reflected above. The only functions delegated at this stage are Hyper Acute Stroke Unit (HASU) services, and Children's Surgery & Anaesthesia services. Other functions beyond these areas continue to be reserved to CCGs. Proposals to delegate further functions beyond HASU and Children's Surgery & Anaesthesia will be agreed with CCGs through a clear and transparent process As future plans are agreed through the South Yorkshire and Bassetlaw Sustainability and Transformation Plan, there will likely be further need to take joint decisions, at which point the Terms of Reference and Manual Agreement would need to be revised. NHS Doncaster CCG’s Constitution will to be updated to include reference to the Joint Committee of CCGs and submitted to NHS England, and our Schemes of Delegation will need to be reviewed to set a common level of authority and to define the decisions within the remit of the Joint Committee as detailed in the manual Agreement and Terms of Reference. It is intended that the Joint Committee of CCGs will hold its inaugural meeting on 4th October 2016, which is timely for the South Yorkshire and Bassetlaw Sustainability and Transformation collaborative partnership board and formal consultation period for the two major change programmes – HASU and Children’s Surgery & Anaesthesia.

Recommendation(s) The Governing Body is asked to:

• Commence the necessary governance steps to establish a joint committee, specifically updating the CCG Constitution and Scheme of Delegation.

• Formally support the establishment of the JC CCG and its inaugural meeting in October.

• Confirm the timeline for updating the Constitution to enable the above.

• Delegate to CCG Chief Officers and Clinical Chairs the action of taking forward the development of and the approach to any process for scheme of delegation for the JC CCG beyond the current JC CCG Terms of Reference and Manual Agreement.

Impact analysis

Quality impact The aim is to improve the quality of services by working together where

services are better commissioned / provided at scale.

Equality impact

Neutral – all programmes which fall within the programme will be assessed individually for equality impact

Sustainability impact

Positive – greater sustainability of services commissioned / provided at scale

Financial implications

Nil – all programmes which fall within the programme will be assessed individually for financial impact

Legal implications

NHS Doncaster CCG will be creating an additional Committee of the Governing Body. Legal advice has been sought.

Management of Conflicts of

Interest

None identified. Management of conflicts of interest are clearly specified within the Joint Committee documentation.

Consultation / Engagement

(internal departments,

clinical, stakeholder & public/patient)

[Identify any prior consultation/engagement] [include engagement with internal departments (e.g. finance, medicines management, contracting,

quality), clinical engagement, stakeholder engagement and public/patient engagement]

Report previously

presented at

Strategy & Organisational Development Forum – June 2016 Governing Body – June 2016

Risk analysis

Management of risk is identified in the documentation.

Assurance Framework

1.2, 4.2, 4.3

Manual/Agreement for JC CCG

1

Manual Agreement:

Joint Committee of Clinical Commissioning Groups

Commissioners Working Together

September 2016


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Chapter Content Detail Page

1. Introduction and Overview Short Introduction setting out:-

Background to creating JC CCG.

Context for decision making and purpose.

Overview of role in local health system.

Purpose of this agreement/manual.

2. Commissioning intentions

and statutory duties

Set out:-

Regional/Local commissioning intentions.

Application of existing arrangements.

Complying with the Statutory Duties of CCGs (should include those relating to procurement and competition as well).

Governance, including provision of assurance to members, for JC CCG.

3. Delegation

Delegation pursuant to section 14Z3:-

State purpose of delegation, what it means and the CCGs who have made it.

Set out minute and resolution [separately drafted] of delegation.

Explain terms of delegation in context of joint commissioning approach.

4. Terms of reference of joint

committee : setting out the

role and operation of the

committee

Provisions setting out:-

Role

Delegated decisions [defined list as set out in terms]

Reserved decisions [All other than defined list]

Meetings and frequency

Agenda and Minutes

Voting


3

Electronic meetings

Resolutions [form]

Quorum

Ability to create sub-committees and further delegate (as set out in terms)

5. Additional terms

supplementing the terms of

reference

Matters to be addressed:-

Guiding Principles for JC CCG.

Definitions and interpretation [especially delegated decisions and reserved decisions] and how to deal with disputes on definitions.

Approach to Conflicts of Interest.

Liability and indemnities.

Disputes and process to be followed to resolve. [This section may also go on to consider ability for members to revoke the delegation.

Information Sharing and Data Protection protocols

Approach to FOIA requests.

Compliance with procurement and competition law obligations (to extent not dealt with in statutory duties section)

List of any other relevant protocols

Clarification and/or additional commercial terms

Process to make variations to Delegation, ToR and/or agreement/manual

Explanation of how ratification works an process to apply.

JC CCGs reporting obligations to members and form of such reports.

Set out how finance for the programme will be dealt with, including issues such as pooled funding.

Process and form for issuing Notices by JC CCG.


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What happens if a member leave the JC CCGs

Supporting the JC CCG and how the PMO will operate.

Implementing change through NHS Standard Contract and variations to it.

Workforce and Staffing considerations within decision making.

6. Appendices Include a copy of the Delegation, ToR, statutory

duties checklist and all protocols which

the JC CCG need to follow.


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Chapter 1 - Introduction and Overview

1. Background

The purpose of the Handbook/Agreement is to set out in practical terms how the local health

system will work together in both commissioning and providing health services to the public,

as well as how it will interact with the delivery of social care.

As a first step, the local health commissioners have decided to create a joint committee,

through which they can both consider and undertake regional wide commissioning decisions.

The CCGs who are members of the joint committee (‘the JC CCG’) are:

NHS Barnsley Clinical Commissioning Group;

NHS Bassetlaw Clinical Commissioning Group;

NHS Doncaster Clinical Commissioning Group;

NHS Rotherham Clinical Commissioning Group;

NHS Sheffield Clinical Commissioning Group;

NHS North Derbyshire Clinical Commissioning Group;

NHS Hardwick Clinical Commissioning Group; and

NHS Wakefield Clinical Commissioning Group.


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The eight member CCGs have a history of working together on a number of common

strategic issues and change programmes under an informal memorandum of understanding

between parties. Member CCGs now wish to formalise those arrangements to show the

strength of their commitment to working together.

In terms of the legal basis on which the CCGs have agreed to jointly exercise a group of

their functions through delegating them to the JC CCG, this has been done using their

powers under section 14Z3 of the NHS Act 2006 (as amended) (‘the Act’), which provides:

“(1) Any two or more clinical commissioning groups may make arrangements under this

section.

(2) The arrangements may provide for—

(a) one of the clinical commissioning groups to exercise any of the commissioning

functions of another on its behalf, or

(b) all the clinical commissioning groups to exercise any of their commissioning

functions jointly.

(2A) Where any functions are, by virtue of subsection (2)(b), exercisable jointly by two or

more clinical commissioning groups, they may be exercised by a joint committee of the

groups….

(7) In this section, “commissioning functions” means the functions of clinical

commissioning groups in arranging for the provision of services as part of the health

service (including the function of making a request to the Board for the purposes of

section 14Z9).”

As a result, the JC CCG has been created to exercise both commissioning functions and

those related to commissioning, as has been set out in each CCGs delegation to it. The

actual Delegations from each CCG are set out in Appendix 1 and the Terms of Reference

are in Appendix 2. This should enable and support a more integrated regional approach to

support the work of the STP as well.

2. Purpose of the JC CCG

2.1 The JC CCG has the primary purpose of enabling the CCG members to work

effectively together, to collaborate and take joint decisions in the areas of work that

they agree, by exercising the Joint Functions.

2.2 The Joint Functions are those set out in the Delegation, appended in Appendix 1

(Delegation) and summarised in Clause [add] below.

2.3 In agreement with CCG Governing Bodies the purpose of the JC CCG may expand to

support implementation of Sustainability and Transformation plans.

2.4 The role of the JC CCG, as set out in Clause 3.1 of the Terms of Reference is:


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2.4.1 Development of collective strategy and commissioning intentions;

2.4.2 Development of co-commissioning arrangements with NHS England;

2.4.3 Joint contracting with Foundation Trusts and other service providers;

2.4.4 System transformation, including the development and adoption of service

redesign and best clinical practice across the area – which may include

the continuation or establishment of clinical networks in addition to those

nationally established;

2.4.5 Representation and contribution to Alliances and Networks including

clinical networks nationally prescribed;

2.4.6 Work with NHS England on the outcome and implication of national or

regional service reviews;

2.4.7 Work with the NHS England Area on system management and resilience;

2.4.8 Collaboration and sharing best practice on Quality Innovation Productivity

and Prevention initiatives; and

2.4.9 Mutual support and aid in organisational development.

2.5 Generally, it is envisaged that the JC CCG will work across the region to develop a

strategic approach to commissioning sustainable services that are patient centred.

Further, it will enable the development of integrated working with social services so

that the patients receive a more seamless service.

3. Role in local health system

3.1 As indicated above, it is envisaged that the JC CCG will support the development of a

clear regional sustainable and transformation plan for across the footprint. In bringing

commissioning leaders together, it will support strategic planning and provide an

interface with both providers of health services and social care. The work which it can

do with local authorities on creating better integrated health and social care services

will support meeting the quality and financial challenges in the coming years.

3.2 In terms of looking at strategic issues across the STP footprint then the JC CCG will

feed in to the work on such as:

Leadership and governance and the best ways to set up joint working, taking

account of the ability of providers and commissioners to set up shared governance

structures. Some key issues to work through are conflicts and procurement, as

well as good governance using the Handbook approach and assurance.

Working out how best to play in your ongoing integrated care programmes and

vanguards, especially in looking to implement change to benefit patients.

Engagement and consultation strategies, both overall and when changes are

needed to improve services.


8

Productivity strategies, especially around joint and integrated working proposals.

4. Status of this Manual and Interpretation

This Manual sets out the arrangements that apply in relation to the exercise of the Joint

Functions of the JC CCG.

If there is any conflict between the provisions of this Manual and the provisions of the Terms

of Reference, the provisions of the Terms of Reference will prevail.

This Manual is to be interpreted in accordance with Schedule 1 (Definitions and

Interpretation).

5. Term

The Manual has effect from the date of the Terms of Reference and will remain in force

unless terminated in accordance with Clause 0 (Termination of the Manual).

Individual Member CCG(s) may terminate their membership of the JC CCG and so no longer

be obliged to work in accordance with this Manual under Clause 0 (Leaving the Joint

Committee) below.


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Chapter 2- Commissioning Intentions and Statutory Duties

6. Regional/ local commissioning intentions

6.1 Commissioning intentions relating to Hyper Acute Stroke services and Childrens

Surgery and Anaethesia

7. Any existing arrangements

8. Complying with the Statutory Duties of CCGs

The JC CCG will need to be clear that is exercising functions it meets the statutory

obligations of the CCGs which are its members. A failure to do so could lead to challenge to

decisions made and an inability to assure the CCG Governing Bodies that their delegated

functions are being properly exercised. Such an inability would impact on a CCG’s ability to

assure NHS England that it was operating in accordance with the CCG Improvement and

Assessment Framework.

The statutory duties which need to be taken into account are summarised in the Checklist in

Appendix 3.

Further, each CCG should note that under s.14Z3(6) of the Act “any delegation of functions

to a joint committee of CCGs do not affect the liability of a clinical commissioning group for

the exercise of any of its functions.”

The result of this is that:

a) the Member CCGs need to ensure that the JC CCG is complying with the CCGs’

statutory duties, as the Member CCGs continue to be responsible if there are any

failings in decision making; and

b) the Member CCGs need to ensure that an appropriate reporting mechanism from

the JC CCG to them is in place. This will allow the Member CCGs to maintain

effective oversight of the JC CCG’s processes and decision making.

In effect, the JC CCG will stand in the place of the multiple CCGs who are its members for

decision making, but those individual CCGs will continue to have liability for those decisions.

It is therefore essential that the JC CCG understand the statutory framework within which it

will make decisions.

9. Governance

It is important that CCGs maintain effective oversight of the activities of the JC CCG.

The JC CCG will make a quarterly written report to the Member CCG governing bodies.

This will cover, as a minimum summary of key decisions.


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The JC CCG will also hold at least annual engagement events to review aims, objectives,

strategy and progress and will publish an annual report on progress made against

objectives.

As to conducting business the JC CCG will operate in accordance with the Terms of

Reference approved by each CCG member when delegating functions to it. It shall also

adopt the SFO and SIs of Sheffield CCG in respect to the operation of committees, with all

CCG members assuring themselves that will enable their own constitution, SFIs and SOs to

be met.

Regular reporting will take place with all member CCGs to include formal decisions and

minutes.

Decisions and minutes will be made public and will be posted onto the Commissioners

Working Together website.

Reports will be prepared by Commissioners Working Together secretariat.

Reports from any JC CCG sub-committee will be shared with CCGs by agreement or

request of the JC CCG.


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Chapter 3 – Delegation

10. Purpose of delegation

The Member CCGs have agreed to delegate functions to the JC CCG in order to enable the

Member CCGs to work effectively together, to collaborate and to take joint decisions in those

areas of work delegated.

The Member CCGs also consider that the delegation of functions will help the CCGs more

easily collaborate and take integrated decisions with NHS England in respect of those

services which are directly commissioned by NHS England for example specialised

services.

This will also link in to the work that each STP needs to undertake to support the delivery of

the Five Year Forward View under the South Yorkshire and Bassetlaw Sustainability and

Transformation Plan.

The JC CCG forms a critical element of the interim governance arrangements agreed by the

SYB STP executive and the mechanism by which future collective commissioning decisions

can be made.

11. The delegation

The delegation of functions from each CCG to the JC CCG is set out in the delegation

document at Appendix A (Delegation). A summary of what that means is:-

Under s.14Z3 of the NHS Act 2006 each CCG delegates a range of its commissioning

functions to a joint committee, in particular to allow the joint committee to take decisions on

current and future transformation programmes which involve all, or a sub-set, of the CCGs.

The delegated functions are referred to in this Manual as the “Joint Functions”.

As is noted above, the JC CCG needs to also comply with statutory duties which the CCGs

have. As a result, the Delegation also delegates the requirement to comply with statutory

requirements relevant to the delegated functions.

12. Terms of delegation in context of joint commissioning

12.1 The JC CCG will work with NHS England on ensuring commissioning is joined up and

collaborative across such as primary and specialist care under existing agreements.


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Chapter 4 - Terms of reference of joint committee

[setting out the role and operation of the committee]

13. Terms of Reference of the JC CCG

The CCGs have established the JC CCG in accordance with the Terms of Reference, see

Appendix 2. The JC CCG and each member will act at all times in accordance with the

Terms of Reference and that means the decisions of the JC CCG will be binding on the

Member CCGs.

In determining those matters on which they want to share decision making, the CCGs have

also agreed a number of areas in which they are not planning to make joint decisions. The

following are functions which have not been delegated to the JC CCG:

Reserved Functions

All functions are reserved for statutory organisations that are not specifically stated in the

scheme of delegation.

It will be important for the JC CCG to be cognisant of the above Reserved Functions and to

engage with member CCGs if any of those arise in the context of the functions which the JC

CCG are to exercise.

14. Exercise of the Joint Functions

The JC CCG must exercise the Joint Functions in accordance with:

the Terms of Reference;

the terms of this Manual;

all applicable law, see framework in Appendix 3;

all applicable Guidance issued by health system regulators; and

good Practice.


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Chapter 5- Additional terms supplementing the Terms of Reference

15. Key Objectives and Guiding Principles for JC CCG

15.1 The JC CCG shall work towards achieving the Key Objectives of the JC CCG and all

members of the JC CCG shall act in good faith to support achievement of the Key

Objectives.

15.2 The Key Objectives of the JC CCG are:

15.2.1 To achieve better patient experience, better outcomes and more efficient

service delivery through the Member CCGs collaborating in the

commissioning of services, by:

15.2.1.1 working together on contractual and service issues with

providers several or all of the Member CCGs use, due to

patient flows;

15.2.1.2 sharing clinical expertise, best practice and management

resource in service redesign, enabling more focussed

commissioning capacity and leadership;

15.2.1.3 leading transformation change where working together is

necessary to ovate change;

15.2.1.4 achieving economies of scale through shared representation

and input to clinical networks, specialised commissioning and

primary care commissioning (where CCGs will wish to influence

primary and tertiary commissioned pathways, and specialised

and primary care commissioners will wish to influence

secondary care and enhanced care pathways);

15.2.1.5 coordinate work with NHS England, particularly on specialised

and primary care, where this improves experience for patients,

giving consistency along pathway interfaces and avoiding

duplication;

15.2.1.6 resolving cross boundary issues, where the action of one

Member CCG could have an impact on a neighbour Member

CCG;

15.2.1.7 providing leadership to the health system in the area covered

by the Member CCGs; and

15.2.1.8 ensuring equity of access to services collaboratively

commissioned; and

15.2.2 To support ongoing effective working of the Member CCGs.


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15.3 The JC CCG shall adopt and follow the JC CCG Guiding Principles and all members of

the JC CCG shall act in good faith to follow the Guiding Principles.

15.4 The Guiding Principles of the JC CCG are set out in the Terms of Reference and are:

15.4.1 To collaborate and co-operate. Do it once rather than repeating or duplicating

actions and increasing cost across the CCGs. Establish and adhere to the

governance structure set out in the Terms of Reference and in this Manual, to

ensure that activities are delivered and actions taken as required;

15.4.2 To be accountable. Take on, manage and account to each other for

performance of the respective roles and responsibilities set out in the Terms

of Reference and in this Manual;

15.4.3 To be open. Communicate openly about major concerns, issues or

opportunities relating to the functions delegated to the JC CCG, as set out in

Appendix 1 (Delegation);

15.4.4 To learn, develop and seek to achieve full potential. Share information,

experience, materials and skills to learn from each other and develop effective

working practices, work collaboratively to identify solutions, eliminate

duplication of effort, mitigate risk and reduce cost whilst ensuring quality is

maintained or improved across all the Member CCGs;

15.4.5 To adopt a positive outlook. Behave in a positive, proactive manner;

15.4.6 To adhere to statutory requirements and best practice. Comply with applicable

laws and standards including EU procurement rules, data protection and

freedom of information legislation.

15.4.7 To act in a timely manner. Recognise the time-critical nature of the functions

delegated to the JC CCG as set out in Appendix 1 (Delegation), and respond

accordingly to requests for support;

15.4.8 To manage stakeholders effectively;

15.4.9 To deploy appropriate resources. Ensure sufficient and appropriately qualified

resources are available and authorised to fulfil the responsibilities set out in

the Terms of Reference and in this Manual; and

15.4.10 To act in good faith to support achievement of the Key Objectives and

compliance with these Principles.

16. Sub committees of the JC CCG

16.1 The JC CCG shall be able to appoint sub-committees, which shall include:

16.1.1 Finance group

16.1.2 Contracting group


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17. Finances/ Pooled Funding

17.1 The Member CCGs may, for the purposes of exercising the Joint Functions under this

Manual, establish and maintain a pooled fund in accordance with section 14Z3 of the

NHS Act 2006.

17.2 Specifically, member CCGs may want to look at how to support the implementation of

the decisions they make from service reconfiguration processes through to enabling

strategic system change across the region. Pooling funds for use across the region for

the overall benefit of all patients would ensure that best use of limited resources is

achieved. It will also mean that implementation of decisions is less likely to stall due to

financial challenges in that a pooled fund provides greater regional support options

than CCGs seeking to implement change individually.

17.3 In some instances, consideration can also be given to getting better value for money

by consolidating purchasing/commissioning power in a pooled fund.

18. Secretariat

18.1 Commissioners Working Together will provide the secretariat to the JC CCG

18.2 Commissioners Working Together and associated staffing resource are hosted by

Sheffield CCG on Behalf of the JC CCG

18.3 Funding of Commissioners Working Together is Funded by all member CCGs of the

JC CCG.

19. Staffing

19.1 See 18 above

20. Conflicts of Interest.

20.1 The Member CCGs must comply with their statutory duties set out in Chapter A2 of the

NHS Act 2006, including those relating to the management of conflicts of interest as

set out in section 14O of the Act.

20.2 Each member of the JC CCG must abide by NHS England’s guidance Managing

conflicts of interest – statutory guidance for CCGs as updated from time to time

(https://www.england.nhs.uk/commissioning/pc-co-comms/coi/) and all relevant

Guidance and policies of their appointing body in relation to conflicts of interest.

20.3 In addition, the JC CCG shall operate a register of interests and has a Conflicts of

Interest Policy. Members of the JC CCG shall comply with the JC CCG’s conflicts of

interest policy and shall disclose any potential conflict; where there is any doubt or

where there is a divergence between the terms of the conflicts of interest policy of a

member’s appointing CCG and that of the JC CCG, the member should always err on

the side of disclosure of any potential conflict.

https://www.england.nhs.uk/commissioning/pc-co-comms/coi/


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20.4 Where any member of the JC CCG has an actual or potential conflict of interest in

relation to any matter under consideration by the JC CCG, that member must not

participate in meetings (or parts of meetings) in which the relevant matter is discussed,

or make a recommendation in relation to the relevant matter. The relevant appointing

body may send an alternative representative to take the place of the conflicted

member in relation to that matter.

20.5 Any breaches of the JC CCG’s conflicts of interest policy or NHS England guidance on

managing conflicts of interest shall be reported to the Member CCGs promptly and in

any event within 5 business days of the breach having come to light.

21. Information Sharing and Data Protection protocols

21.1 The Member CCGs shall all comply with the DPA.

21.2 The Member CCGs have entered into a Data Sharing Agreement that governs the

processing of Personal Data pursuant to this Manual. A copy of this template Data

Sharing Agreement is set out in Schedule 2 (Further Information Sharing Provisions).

21.3 The Data Sharing Agreement:

21.3.1 sets out the relevant Information Law and best practice;

21.3.2 sets out how that law and best practice will be implemented, including

responsibilities of the Member CCGs to co-operate properly and fully with

each other;

21.3.3 identifies the information that may be processed, including what may be

shared, under this Agreement;

21.3.4 identifies the purposes for which the information may be so processed and

states the legal basis for the processing in each case;

21.3.5 states who is/are the Data Controller/s and, if appropriate, the Data

Processor/s of Personal Data;

21.3.6 sets out what will happen to the Personal Data on the termination of this

Agreement (with due regard to clause 0 (Leaving the JC CCG) of the

Agreement);

21.3.7 explains how Member CCGs shall deal with subject access requests and

other requests made under the DPA; and

21.3.8 sets out such other provisions as are necessary for the sharing of information

to be fair, lawful and meet best practice.

21.4 The Member CCGs will share all non-Personal Data in accordance with Information

Law and their statutory powers as set out in section 14Z23 of the Act.

21.5 The Member CCGs agree that, in relation to information sharing and the processing of

information for the purposes of the Joint Functions, they must comply with:


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21.5.1 all relevant Information Law requirements including the common law duty of

confidence and other legal obligations in relation to information sharing

including those set out in the NHS Act 2006 and the Human Rights Act 1998;

21.5.2 Good Practice; and

21.5.3 relevant Guidance (including guidance given by the Information

Commissioner).

22. IT inter-operability

22.1 The Member CCGs will work together to ensure that, where necessary for the exercise

of the Joint Functions, all relevant IT systems operated by the Member CCGs in

respect of the Joint Functions will be inter-operable and that data may be transferred

between systems securely, easily and efficiently.

22.2 The parties will use their respective reasonable endeavours to help develop initiatives

to further this aim.

23. Confidentiality

23.1 Where information is shared with the JC CCG of a confidential or commercially

sensitive nature information will be treated under the confidential policy of the host

CCG

24. Freedom of Information

24.1 Each Member CCG acknowledges that the other Member CCGs are a public authority

for the purposes of the Freedom of Information Act 2000 (“FOIA”) and the

Environmental Information Regulations 2004 (“EIR”).

24.2 Each Member CCG may be statutorily required to disclose information about the

Agreement and the information shared or generated by the Member CCGs pursuant to

this Agreement and the Terms of Reference, in response to a specific request under

FOIA or EIR, in which case:

24.2.1 each Member CCG shall provide the others with all reasonable assistance

and co-operation to enable them to comply with their obligations under FOIA

or EIR;

24.2.2 each Member CCG shall consult the others regarding the possible application

of exemptions in relation to the information requested, giving them at least 5

working days within which to provide comments. Such consultation shall be

effected by contacting [the CCG Representative named in Column 2 of

Schedule 2 (Member CCGs)]; and

24.2.3 each Member CCG acknowledges that the final decision as to the form or

content of the response to any request is a matter for the Member CCG to

whom the request is addressed.


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25. Procurement

Commissioners are required to ensure that their decisions to procure services, which

actually relates to most commissioning decisions you make, comply with the National Health

Service (Procurement, Patient Choice and Competition) (No. 2) Regulations 2013. Key

questions are set out under each heading below to assist you when considering whether you

are meeting these requirements. Commissioners are also required to comply with EU/UK

general procurement law but this is not covered in the list below.

25.1 The real procurement objective is to -

‘To secure the needs of patients and improve quality and efficiency of services’

Therefore, part of considering how robust your decision is in terms of meeting procurement

obligations is to look at:

• What have you done to assess patient need and do you have evidence to support

your findings?

• How are you assessing the quality of services and the performance of the current

providers? How have you assessed whether the service is offering value for money?

• Have you reviewed the current service specification to ensure it is working well and

whether there is scope for further improvement? In particular, it would be helpful to

have a schedule of all existing contracts and relationships, including performance

monitoring on contracts.

• What steps have you taken to assess equitable access to services by all patient

groups?

25.2 In achieving the main objective, the regulations contain three general requirements,

which are:

25.2.1 To act transparently and proportionately and in a non-discriminatory way.

• What steps have you taken to make providers and stakeholders aware of your

plans? Have you provided reasons to support your decisions?

• Are you publishing details in a timely manner and have you kept records of

decision making, e.g. board minutes and briefing papers?

• Do providers understand the selection criteria you are using and are they able to

express an interest in providing the services? Can you show that you have not

favoured one provider over the other?

• Is your approach proportionate to the nature of the services in relation to the

value, complexity and clinical risk associated with the provision of the services in

question?

25.2.2 To contract with providers who are most capable of meeting the objectives

and provide best value for money


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• How have you identified existing and potential providers and objectively evaluated

their relative ability to deliver the service specification, improve quality and meet

the needs of patients?

• Are you satisfied providers are capable and robust enough to deliver a safe and

efficient service and provide the best value for money in doing so?

25.2.3 Consider ways of improving services through integration, competition and

patient choice

• What evidence do you have to show the steps you taken to determine whether it

might be better for patients if the services are integrated with other health care

services?

• Have you asked providers, patients, and other stakeholders for their views?

• Does your specification or performance monitoring process incentivise delivery of

care in a more integrated manner?

• Have you considered whether competition or choice would better incentivise

providers to improve quality and efficiency? Do you have evidence to support your

findings?

25.3 Advertisements and expressions of interest

To ensure providers are able to express an interest in in providing any services which

includes the requirement to publish opportunities and awards on a website

• How have you gathered evidence about the existing and potential providers

on the market?

• Have you published your intentions to the market by way of commissioning

intentions or publication on a website?

25.4 Award of a new contract without a competition

A new contract may be awarded without publishing a contract notice where the

commissioner is satisfied that the services in question are capable of being provided

only by that provider, e.g. A&E services in a particular area or where it is not viable

for providers to provide one service without also providing another service.

• What steps have you taken and what evidence are you relying on to satisfy

yourself that there is only one capable provider?

25.5 Conflict of Interests

Commissioners are prohibited from awarding a contract where conflicts, or potential

conflicts, between the interests of Commissioners in commissioning services and the

interests involved in providing the services affect, or appear to affect, the integrity of

the award of the contract.

• Have you recorded how you have managed any conflict or potential conflict?


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This will be an issue over which the STP needs to be sensitive given the

collaborative working between commissioners and providers. Further information and

guidance is available in section 20 above.

25.6 Anti-competitive behaviour

Not to engage in anti-competitive behaviour unless to do so would be in the interests

of people who use NHS services

• Are you acting in an anticompetitive manner – for instance have you

prevented new providers from entering the market or caused a provider to exit

the market?

• If so, is it objectively justifiable as being in the interests of users and

stakeholders? What evidence do you have to support this?

26 Competition Issues

26.1 Requirement to Notify the Competition and Markets Authority (CMA)

The obligation to notify the CMA sits with the provider and guidance is set out below

on when that duty bites. It should also be noted that if a provider has given any

undertakings to the CMA or its predecessor, the Competition Commission, then they

may prohibit a statutory transaction and should be checked. A brief overview of the

merger regime is set out below:

26.2 Merger control rules

The merger control regime may apply to NHS service reconfigurations where two or

more services are merged and the transaction meets the jurisdictional tests.

26.3 Jurisdictional Tests

The CMA has jurisdiction to examine a merger where:

26.3.1 Two or more enterprises cease to be distinct (change of control)

26.3.2 and either

• the UK turnover of the acquired enterprise exceeds £70 million; or

• the enterprises which cease to be distinct together supply or acquire at least

25% of all those particular services of that kind supplied in the UK or in a

substantial part of it. The merger must also result in an increment to the share

of supply, i.e. the merging providers must supply or acquire the same

category of services.

[ Enterprise: NHS foundation trusts and NHS trusts controlling hospital, ambulance

services, mental health service, community services or individual services or

specialities may be enterprises for the purpose of merger control.

Change in control: Two enterprises (or services) cease to be distinct if they are

brought under common ownership or control. There must be a change in the level of


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control over the activities of one or more enterprises (or services) for merger control

to apply.]

26.4 Competition test

The CMA assesses qualifying mergers to decide whether they are likely to lead to a

substantial lessening of competition (‘SLC’). An SLC occurs when competition is

substantially less after the merger.

26.5 SLC assessment

The CMA will require detailed information about the reconfiguration. This will include:

• service overlaps;

• GP referral data / catchment area analysis; and

• Hospital share of GP practice referrals.

26.6 CMA merger assessment timetable

The process is divided into two stages:

• Phase I: an initial 40 working day investigation; and

• Phase II: a possible 24 weeks in-depth investigation, which can be extended

if the CMA considers it necessary.

27 Liability and indemnities.

27.1 In accordance with section 14Z3 of the NHS Act 2006, the Member CCGs retain

liability in relation to the exercise of the Joint Functions.

28 Breach of this Manual and Remedies

28.1 Any breach of this manual will be raised by the Chair and identified senior office.

Disputes will be dealt with under 28 below.

29 Dispute Resolution

29.1 Where any dispute arises within the JC CCG in connection with this Manual, the

relevant Member CCGs must use their best endeavours to resolve that dispute on an

informal basis within the JC CCG.

29.2 Where any dispute is not resolved under clause 0 on an informal basis, any CCG

Representative (as set out in Column 2 of Schedule 2 (Member CCGs) may convene a

special meeting of the JC CCG to attempt to resolve the dispute.

29.3 If any dispute is not resolved under clause 0, it will be referred by the [Chair] of the JC

CCG to the Chief Executives of the relevant Member CCGs, who will co-operate in

good faith to resolve the dispute within ten (10) days of the referral.


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29.4 Where any dispute is not resolved under clauses 0, 0 or 0, any CCG Representative

may refer the matter for mediation arranged by an independent third party to be

appointed by [the Chair of the JC CCG] [CEDR], and any agreement reached through

mediation must be set out in writing and signed by and the relevant Member CCGs.

30 Leaving the JC CCG

30.1 Should this joint decision making arrangement prove to be unsatisfactory, the governing

body of any of the Member CCGs can decide to withdraw from the arrangement, but

has to give a minimum of six months’ notice to partners, with consideration by the JC

CCG of the impact of a leaving partner - a maximum of 12 notice could apply.

30.2 The Member CCG who wishes to withdraw from the JC CCG will work together with the

other Member CCGs to ensure that there are suitable alternative arrangements in

place in relation to the exercise of the Joint Functions.

30.3 After leaving the JC CCG, that CCG shall no longer be a Member CCG but shall remain

bound by Clauses 23

31 Termination of the Manual

31.1 This Manual shall no longer apply if the JC CCG is terminated.

31.2 Such termination shall be effective if all Member CCGs agree in writing that the JC

CCG shall end and withdraw the delegation of their functions to the JC CCG.

32 Notices

32.1 Any notices given under this Manual must be in writing, must be marked for the [CCG

Representative noted in Column 2 to Schedule 2 (Member CCGs”)].

32.2 Notices sent:

32.2.1 by hand will be effective upon delivery;

32.2.2 by post will be effective upon the earlier of actual receipt or five (5) working

days after mailing; or

32.2.3 by email will be effective when sent (subject to no automated response being

received).

33 Variations

33.1 Any variation to the Delegation, Terms of Reference or this Manual will only be effective

if it is made in writing and signed by each of the Member CCGs.

33.2 All agreed variations to the Delegation, Terms of Reference or this Manual must be

appended as a Schedule to this Manual.

34 Counterparts


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This Manual may be executed in any number of counterparts, each of which when executed

and delivered shall constitute an original of this Manual, but all the counterparts shall

together constitute the same agreement.

35 Applicable Law

This Manual shall be interpreted in accordance with the laws of England and Wales and

each party to this Manual submits to the exclusive jurisdiction of the courts of England and

Wales.


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Schedule 1

Definitions and Interpretation

In this Manual, the following words and phrases will bear the following meanings:

Manual means this agreement between the Member CCGs

comprising the body of the Manual and its Schedules;

Data Controller shall have the same meaning as set out in the DPA;

Data Subject shall have the same meaning as set out in the DPA;

Delegation means the delegation of functions set out in Appendix 1

to this Manual;

DPA means the Data Protection Act 1998;

Good Practice means using standards, practices, methods and

procedures conforming to the law, reflecting up-to-date

published evidence and exercising that degree of skill

and care, diligence, prudence and foresight which would

reasonably and ordinarily be expected from a skilled,

efficient and experienced commissioner;

Guidance means any applicable health and social care guidance,

guidelines, direction or determination, framework,

standard or requirement issued by NHS England or any

other regulatory or supervisory body, including the

Information Commissioner, to the extent that the same

are published and publicly available;

Information Law

the DPA, the EU Data Protection Directive 95/46/EC;

regulations and guidance made under section 13S and

section 251 of the NHS Act; guidance made or given

under sections 263 and 265 of the Health and Social

Care Act 2012; the Freedom of Information Act 2000;

the common law duty of confidentiality; the Human

Rights Act 1998 and all other applicable laws and

regulations relating to processing of Personal Data and

privacy;

JC CCG means the joint committee of the Member CCGs


25

established on the terms set out in the Terms of

Reference;

Joint Functions

means the functions jointly exercised by the Member

CCGs through the decisions of the JC CCG in

accordance with the Terms of Reference and as set out

in detail in clause [add] of the Delegation;

Law means:

(i) any applicable statute or proclamation or any

delegated or subordinate legislation or regulation;

(ii) any enforceable EU right within the meaning of

section 2(1) European Communities Act 1972; or

(iii) any applicable judgment of a relevant court of law

which is a binding precedent in England and Wales,

in each case in force in England and Wales;

Member CCG means the CCGs which are part of the JC CCG and are

set out in the Terms of Reference and Column 1 of

Schedule 2 (Member CCGs) to this Manual.

NHS Act 2006 means the National Health Service Act 2006 (as

amended by the Health and Social Care Act 2012 or

other legislation from time to time);

NHS England means the National Health Service Commissioning

Board established by section 1H of the NHS Act, also

known as NHS England;

Non-Personal Data means data which is not Personal Data;

Personal Data shall have the same meaning as set out in the DPA and

shall include references to Sensitive Personal Data

where appropriate;

Data Sharing Agreement means the agreement governing Information Law issues

completed further to Schedule 3 (Further Information

Sharing Provisions);


26

Sensitive Personal Data shall have the same meaning as in the DPA; and

Terms of Reference means the terms of reference for the JC CCG agreed

between the CCG(s).


27

Schedule 2

Member CCGs

Column 1

Clinical Commissioning Groups

Column 2

CCG Representatives






NHS North Derbyshire Clinical Commissioning

Group;

NHS Hardwick Clinical Commissioning Group;

and


Nick Balac, Lesley Smith

Andrew Perkins, Phil Mettam

David Crichton, Jackie Pederson

Julie Kitlowski, Chris Edwards

Tim Moorhead, Maddy Ruff

Ben Milton, Steve Allinson

Steve Lloyd, Andy Gregory

Philip Earnshaw, Jo Webster


28

Schedule 3

Data Sharing Agreement

[to be added]

To be added currently being reviewed by host CCG information governance lead.


29

Appendix 1- Delegation

Delegation by CCGs to JC CCGs

A. The CCG functions at B will be delegated to the JC CCGs by the member CCGs in

accordance with their statutory powers under s.14Z3 of the NHS Act 2006 (as amended)

(“the NHS Act”). Section 14Z3 allows CCGs to make arrangements in respect of the

exercise of their commissioning functions and includes the ability for two or more CCGs

to create a Joint Committee to exercise functions.

B. The delegated functions relate to the health services provided to the member CCGs by

all providers they commission services from in the exercise of their functions. The CCGs

delegate their commissioning functions so far as such functions are required for the Joint

Committee to carry out its role, as set out in the Terms of Reference (appendix 2).

The CCGs delegate the above functions to enable the Joint Committee to take decisions

around future transformation projects, specifically and limited to transformation and

redesign of Hyper Acute Stroke services and Children’s Surgery and Anaethesia

services.

C. Each member CCG shall also delegate the following functions to the JC CCGs so that it

can achieve the purpose set out in (B) above:

1. Acting with a view to securing continuous improvement to the quality of

commissioned services. This will include outcomes for patients with regard to clinical

effectiveness, safety and patient experience to contribute to improved patient

outcomes across the NHS Outcomes Framework

2. Promoting innovation, seeking out and adopting best practice, by supporting

research and adopting and diffusing transformative, innovative ideas, products,

services and clinical practice within its commissioned services, which add value in

relation to quality and productivity.

3. The requirement to comply with various statutory obligations, including making

arrangements for public involvement and consultation throughout the process. That

includes any determination on the viability of models of care pre-consultation and

during formal consultation processes, as set out in s.13Q, s.14Z2 and s.242 of the

NHS Act.

4. The requirement to ensure process and decisions comply with the four key tests for

service change introduced by the last Secretary of State for Health, which are:

Support from GP commissioners;

Strengthened public and patient engagement;

Clarity on the clinical evidence base; and

Consistency with current and prospective patient choice.

5. The requirement to comply with the statutory duty under s.149 of the Equality Act

2010 i.e. the public sector equality duty.


30

6. The requirement to have regard to the other statutory obligations set out in the new

sections 13 and 14 of the NHS Act. The following are relevant but this is not an

exhaustive list:

ss.13C and 14P - Duty to promote the NHS Constitution

ss.13D and 14Q - Duty to exercise functions effectively, efficiently and economically

ss.13E and 14R – Duty as to improvement in quality of services

ss.13G and 14T - Duty as to reducing inequalities

ss.13H and 14U – Duty to promote involvement of each patient

ss.13I and 14V - Duty as to patient choice

ss.13J and 14W – Duty to obtain appropriate advice

ss.13K and 14X – Duty to promote innovation

ss.13L and 14Y – Duty in respect of research

ss.13M and 14Z - Duty as to promoting education and training

ss.13N and 14Z1- Duty as to promoting integration

ss.13Q and 14Z2 - Public involvement and consultation by NHS England/CCGs

s.13O - Duty to have regard to impact in certain areas

s.13P - Duty as respects variations in provision of health services

s.14O – Registers of Interests and management of conflicts of interest

s.14S – Duty in relation to quality of primary medical services

7. The JC CCGs must also have regard to the financial duties imposed on CCGs under

the NHS Act and as set out in:

s.223G – Means of meeting expenditure of CCGs out of public funds

s.223H – Financial duties of CCGs: expenditure

s.223I - Financial duties of CCGs: use of resources

s.223J - Financial duties of CCGs: additional controls of resource use

8. Further, the JC CCGs must have regard to the Information Standards as set out in

ss.250, 251, 251A, 251B and 251C of the Health & Social Care Act 2012 (as

amended).

9. The expectation is that CCGs will ensure that clear governance arrangements are put

in place so that they can assure themselves that the exercise by the JC CCGs of

their functions is compliant with statute.

10. The JC CCGs will meet the requirement for CCGs to comply with the obligation to

consult the relevant local authorities under s.244 of the NHS Act and the associated

Regulations.

11. To continue to work in partnership with key partners e.g. the local authority and other

commissioners and providers to take forward plans so that pathways of care are

seamless and integrated within and across organisations.


31

12. The JC CCGs will be delegated the capacity to propose, consult on and agree future

service configurations that will shape the medium and long terms financial plans of

the constituent organisations. The JC CCGs will have no contract negotiation powers

meaning that it will not be the body for formal annual contract negotiation between

commissioners and providers. These processes will continue to be the responsibility

of Clinical Commissioning Groups (and NHS England) under national guidance,

tariffs and contracts during the pre-consultation and consultation periods.


32

Appendix 2 – JC CCGs Terms of Reference

1. Introduction

1.1 The NHS Act 2006 (as amended) (‘the NHS Act’), was amended through the

introduction of a Legislative Reform Order (“LRO”) to allow CCGs to form joint

committees. This means that two or more CCGs exercising commissioning functions

jointly may form a joint committee as a result of the LRO amendment to s.14Z3

(CCGs working together) of the NHS Act.

1.2 Joint committees are a statutory mechanism which gives CCGs an additional option

for undertaking collective strategic decision making and this can include NHS

England too, who may also make decisions collaboratively with CCGs.

1.3 Individual CCGs and NHS England will still always remain accountable for meeting

their statutory duties. The aim of creating a joint committee is to encourage the

development of strong collaborative and integrated relationships and decision-making

between partners.

1.4 The Joint Committee of Clinical Commissioning Groups (‘JC CCGs’) is a joint

committee of:

(1) NHS Barnsley Clinical Commissioning Group;

(2) NHS Bassetlaw Clinical Commissioning Group;

(3) NHS Doncaster Clinical Commissioning Group;

(4) NHS Rotherham Clinical Commissioning Group;

(5) NHS Sheffield Clinical Commissioning Group;

(6) NHS North Derbyshire Clinical Commissioning Group;

(7) NHS Hardwick Clinical Commissioning Group; and

(8) NHS Wakefield Clinical Commissioning Group.

It has the primary purpose of enabling the CCG members to work effectively together, to

collaborate and take joint decisions in the areas of work that they agree.

1.5 In addition the JC CCGs will meet collaboratively with NHS England to make

integrated decisions in respect of those services which are directly commissioned by

NHS England.


33

1.6 Guiding principles:

Collaborate and co-operate. Do it once rather than repeating or duplicating

actions and increasing cost across the CCGs. Establish and adhere to the

governance structure set out in these Terms of Reference and in the JC

CCGs Manual (as updated from time to time), to ensure that activities are

delivered and actions taken as required;

Be accountable. Take on, manage and account to each other for performance

of the respective roles and responsibilities set out in these Terms of

Reference and in the JC CCGs Manual (as updated from time to time);

Be open. Communicate openly about major concerns, issues or opportunities

relating to the functions delegated to the JC CCGs, as set out in Schedule 1;

ensuring our collective decisions are based on the best available evidence,

that these are fully articulated, heard, and understood.

Learn, develop and seek to achieve full potential. Share information,

experience, materials and skills to learn from each other and develop effective

working practices, work collaboratively to identify solutions, eliminate

duplication of effort, mitigate risk and reduce cost whilst ensuring quality is

maintained or improved across all the CCGs;

Adopt a positive outlook. Behave in a positive, proactive manner;

Adhere to statutory requirements and best practice. Comply with applicable

laws and standards including EU procurement rules, data protection and

freedom of information legislation.

Act in a timely manner. Recognise the time-critical nature of the functions

delegated to the JC CCGs as set out in Schedule 1, and respond accordingly

to requests for support;

Manage stakeholders effectively;

Deploy appropriate resources. Ensure sufficient and appropriately qualified

resources are available and authorised to fulfil the responsibilities set out in

these Terms of Reference and in the JC CCGs Manual (as updated from time

to time);

Act in good faith to support achievement of the Key Objectives as set out in

the JC CCGs Manual and compliance with these Principles.

1.7 The JC CCG has a commitment to ensuring that in pursuing its Key Objectives it

does not increase inequalities or worsen health outcomes for any local populations.

1.8 From time to time programmes boards may be established to oversee individual

programmes of work. Where these are established under the direction of the JC

CCG these will be accountable to the JC CCG.


34

2. Statutory Framework

2.1 The NHS Act which has been amended by LRO 2014/2436, provides at s.14Z3 that

where two or more clinical commissioning groups are exercising their commissioning

functions jointly, those functions may be exercised by a joint committee of the groups.

2.2 The CCGs named in paragraph 1.5 above have delegated the functions set out in

Schedule 1 to the JC CCGs.

3. Role of the JC CCGs

3.1 The role of the JC CCGs shall be:

• Development of collective strategy and commissioning intentions;

• Development of co-commissioning arrangements with NHS England;

• Joint contracting with Foundation Trusts and other service providers;

• System transformation, including the development and adoption of service redesign and best clinical practice across the area – which may include the continuation or establishment of clinical networks in addition to those nationally established;

• Representation and contribution to Alliances and Networks including clinical networks nationally prescribed;

• Work with NHS England on the outcome and implication of national or regional service reviews;

• Work with the NHS England Area on system management and resilience;

• Collaboration and sharing best practice on Quality Innovation Productivity and Prevention initiatives; and

• Mutual support and aid in organisational development.

3.2 At all times, the JC CCGs, through undertaking decision making functions of each of

the member CCGs, will act in accordance with the terms of their constitutions. No

decision outcome shall impede any organisation in the fulfilment of its statutory

duties.

4. Geographical coverage

4.1 The JC CCGs will comprise those CCGs listed above in paragraph 1.5 and cover the

South Yorkshire and Bassetlaw, North Derbyshire and Hardwick and Wakefield

areas.

4.2 NHS England Specialised Commissioning will also be involved through a

collaborative commissioning arrangement.


35

5. Membership

5.1 Membership of the committee will combine both Voting and Non-voting members and

will comprise of: -

5.2 Voting members:

• Two decision makers from each of the member CCGs, who will be the Clinical

Chair and Accountable Officer;

5.3 Non-voting attendees:

• Two Lay Members chosen from the member CCGs.

• One Director of Finance chosen from the member CCGs.

• A representative from NHS England;

• A Healthwatch representative nominated by the local Healthwatch groups; and

• Two Local Authority representatives.

5.4 The JC CCG may invite additional non-voting members to join the JC CCG to enable

it to carry out its duties.

5.4 Committee members may nominate a suitable deputy when necessary and subject to

the approval of the Chair of the JC CCGs. All deputies should be fully briefed and the

secretariat informed of any agreement to deputise so that quoracy can be

maintained.

5.5 No person can act in more than one role on the JC CCGs, meaning that each deputy

needs to be an additional person from outside the JC CCGs membership.

5.6 Commissioners Working Together will act as secretariat to the Committee to ensure

the day to day work of the JC CCGs is proceeding satisfactorily. The membership will

meet the requirements of the constitutions of the CCGs named above at paragraph

1.5.

5.7 The JC CCG will be Chaired by a respective CCG Clinical Chair.

6. Meetings

6.1 The JC CCGs shall adopt the standing orders of NHS Sheffield Clinical

Commissioning Group insofar as they relate to the:

a) notice of meetings;

b) handling of meetings;

c) agendas;


36

d) circulation of papers; and

e) conflicts of interest.

7. Voting

7.1 The JC CCGs will aim to make decisions by consensus wherever possible. Where

this is not achieved, a voting method will be used. The JC CCG has eight CCG

members and sixteen voting members. The voting power of each individual present

will be weighted so that each party (CCG) possesses 12.5% of total voting power.

7.2 It is proposed that recommendations can only be approved if there is approval by

more than 75%.

8. Quorum

At least one full voting member from each CCG must be present for the meeting to

be quorate. The Healthwatch representative must also be present.

9. Frequency of meetings

Frequency of meetings will usually be bi-monthly, on the first Tuesday of every other

month but the Chair has the power to call meetings of the JC CCGs as and when

they are required.

10 Meetings of the JC CCGs

10.1 Meetings of the JC CCGs shall be held in public unless the JC CCGs considers that

it would not be in the public interest to permit members of the public to attend a

meeting or part of a meeting. Therefore, the JC CCGs may resolve to exclude the

public from a meeting that is open to the public (whether during the whole or part of

the proceedings) whenever publicity would be prejudicial to the public interest by

reason of the confidential nature of the business to be transacted or for other special

reasons stated in the resolution and arising from the nature of that business or of the

proceedings or for any other reason permitted by the Public Bodies (Admission to

Meetings) Act 1960 as amended or succeeded from time to time.

10.2 Members of the JC CCGs have a collective responsibility for the operation of the JC

CCGs. They will participate in discussion, review evidence and provide objective

expert input to the best of the knowledge and ability, and endeavor to reach a

collective view.

10.3 The JC CCGs may call additional experts to attend meetings on an ad hoc basis to

inform discussions.


37

10.4 The JC CCGs has the power to establish sub groups and working groups and any

such groups will be accountable directly to the JC CCGs.

10.5 Members of the JC CCGs shall respect confidentiality requirements as set out in the

Standing Orders referred to above unless separate confidentiality requirements are

set out for the JC CCGs, in which event these shall be observed

11. Secretariat provisions

The secretariat to the JC CCGs will:

a) Circulate the minutes and action notes of the committee within five working days

of the meeting to all members; and

b) Present the minutes, decisions and action notes to the governing bodies of the

CCGs set out in paragraph 1.5 above.

12. Reporting to CCGs and NHS England

The JC CCGs will make a quarterly written report to the CCG member governing

bodies and NHS England and hold at least annual engagement events to review

aims, objectives, strategy and progress and publish an annual report on progress

made against objectives.

13. Decisions

13.1 The JC CCGs will make decisions within the bounds of the scope of the functions

delegated.

13.2 The decisions of the JC CCGs shall be binding on all member CCGs.

13.3 All decisions undertaken by the JC CCGs will be published by the Clinical

Commissioning Groups set out in paragraph 1.5, above.

14. Review of Terms of Reference

These terms of reference will be formally reviewed annually by Clinical

Commissioning Groups set out in paragraph 1.5 and may be amended by mutual

agreement between the CCGs at any time to reflect changes in circumstances as

they may arise.

15. Withdrawal from the JC CCG

15.1 Should this joint commissioning arrangement prove to be unsatisfactory, the

governing body of any of the member CCGs can decide to withdraw from the


38

arrangement, but has to give a minimum six months’ notice to partners, with

consideration by the JC CCG of the impact of a leaving partner - a maximum of 12

notice could apply.

16. Signatures


39

Schedule 1 - Delegation by CCGs to JC CCGs

A. The CCG functions at B will be delegated to the JC CCGs by the member CCGs in

accordance with their statutory powers under s.14Z3 of the NHS Act 2006 (as amended)

(“the NHS Act”). Section 14Z3 allows CCGs to make arrangements in respect of the

exercise of their commissioning functions and includes the ability for two or more CCGs

to create a Joint Committee to exercise functions.

B The delegated functions relate to the health services provided to the member CCGs by

all providers they commission services from in the exercise of their functions. The CCGs

delegate their commissioning functions so far as such functions are required for the

Joint Committee to carry out its role, as set out in the Terms of Reference (appendix 2).

The CCGs delegate the above functions to enable the Joint Committee to take decisions

around future transformation projects, specifically and limited to transformation and

redesign of Hyper Acute Stroke Services and Children’s Surgery and Anaethesia

services.

C Each member CCG shall also delegate the following functions to the JC CCGs so that it

can achieve the purpose set out in (B) above:

1. Acting with a view to securing continuous improvement to the quality of

commissioned services. This will include outcomes for patients with regard to clinical

effectiveness, safety and patient experience to contribute to improved patient

outcomes across the NHS Outcomes Framework

2. Promoting innovation, seeking out and adopting best practice, by supporting

research and adopting and diffusing transformative, innovative ideas, products,

services and clinical practice within its commissioned services, which add value in

relation to quality and productivity.

3. The requirement to comply with various statutory obligations, including making

arrangements for public involvement and consultation throughout the process. That

includes any determination on the viability of models of care pre-consultation and

during formal consultation processes, as set out in s.13Q, s.14Z2 and s.242 of the

NHS Act.

4. The requirement to ensure process and decisions comply with the four key tests for

service change introduced by the last Secretary of State for Health, which are:

Support from GP commissioners;

Strengthened public and patient engagement;

Clarity on the clinical evidence base; and

Consistency with current and prospective patient choice.

5. The requirement to comply with the statutory duty under s.149 of the Equality Act

2010 i.e. the public sector equality duty.


40

6. The requirement to have regard to the other statutory obligations set out in the new

sections 13 and 14 of the NHS Act. The following are relevant but this is not an

exhaustive list:

ss.13C and 14P - Duty to promote the NHS Constitution

ss.13D and 14Q - Duty to exercise functions effectively, efficiently and economically

ss.13E and 14R – Duty as to improvement in quality of services

ss.13G and 14T - Duty as to reducing inequalities

ss.13H and 14U – Duty to promote involvement of each patient

ss.13I and 14V - Duty as to patient choice

ss.13J and 14W – Duty to obtain appropriate advice

ss.13K and 14X – Duty to promote innovation

ss.13L and 14Y – Duty in respect of research

ss.13M and 14Z - Duty as to promoting education and training

ss.13N and 14Z1- Duty as to promoting integration

ss.13Q and 14Z2 - Public involvement and consultation by NHS England/CCGs

s.13O - Duty to have regard to impact in certain areas

s.13P - Duty as respects variations in provision of health services

s.14O – Registers of Interests and management of conflicts of interest

s.14S – Duty in relation to quality of primary medical services

7. The JC CCGs must also have regard to the financial duties imposed on CCGs under

the NHS Act and as set out in:

s.223G – Means of meeting expenditure of CCGs out of public funds

s.223H – Financial duties of CCGs: expenditure

s.223I - Financial duties of CCGs: use of resources

s.223J - Financial duties of CCGs: additional controls of resource use

8. Further, the JC CCGs must have regard to the Information Standards as set out in

ss.250, 251, 251A, 251B and 251C of the Health & Social Care Act 2012 (as

amended).

9. The expectation is that CCGs will ensure that clear governance arrangements are put

in place so that they can assure themselves that the exercise by the JC CCGs of

their functions is compliant with statute.

10. The JC CCGs will meet the requirement for CCGs to comply with the obligation to

consult the relevant local authorities under s.244 of the NHS Act and the associated

Regulations.

11. To continue to work in partnership with key partners e.g. the local authority and other

commissioners and providers to take forward plans so that pathways of care are

seamless and integrated within and across organisations.


41

12. The JC CCGs will be delegated the capacity to propose, consult on and agree future

service configurations that will shape the medium and long terms financial plans of

the constituent organisations. The JC CCGs will have no contract negotiation powers

meaning that it will not be the body for formal annual contract negotiation between

commissioners and providers. These processes will continue to be the responsibility

of Clinical Commissioning Groups (and NHS England) under national guidance,

tariffs and contracts during the pre-consultation and consultation periods.


42

Schedule 2 - List of Members from each Constituent CCG and non-voting members

Column 1

Organisation or nomination

Column 2

Representatives

Voting members






NHS North Derbyshire Clinical Commissioning

Group;

NHS Hardwick Clinical Commissioning Group;

and


Nick Balac, Lesley Smith

Andrew Perkins, Phil Mettam

David Crichton, Jackie Pederson

Julie Kitlowski, Chris Edwards

Tim Moorhead, Maddy Ruff

Ben Milton, Steve Allinson

Steve Lloyd, Andy Gregory

Philip Earnshaw, Jo Webster

Non-voting members

Commissioners Working Together

Nominated Director of Finance

Nominated lay members

Nominated Healthwatch member

Local Authority members

SYB STP lead

Will Cleary-Gray Julia Newton John Boyington Steven Hardy TBC TBC Sir Andrew Cash


43

Appendix 3 – Checklist of Statutory Duties and Protocols

Public Law Issues (including for service change)

1. Case For Change

The starting point is to have established a clear Case for Change that both commissioners

and providers agree is clinically and financially sound.

2. Engagement with Public and Patients

You must comply with various statutory obligations to engage with and consult the public

and patients throughout the process. That includes any determination on the viability of

models of care pre-consultation and during formal consultation processes. – see s.13Q,

s.14Z2 and s.242 of the NHS Act 2006 (as amended) (‘the Act’)

3. Four Key Tests

It is important throughout the reconfiguration process to have in mind the four key tests

introduced by the last Secretary of State for Health, which are:

(i) strong public and patient engagement;

(ii) consistency with current and prospective need for patient choice;

(iii) a clear clinical evidence base; and

(iv) support for proposals from clinical commissioners.

Decision makers will need to show compliance when making a final decision on service

change.

4. Equality

All NHS statutory bodies must also ensure compliance with their duty under s.149 of the

Equality Act 2010 that is their public sector equality duty.

5. Statutory obligations

Commissioners must also have regard to the other statutory obligations set out in the new

sections 13 and 14 of the Act. In looking at CCG duties the following, amongst others, are

relevant:

• 14P – Duty to promote NHS Constitution

• 14Q – Duty as to effectiveness, efficiency etc

• 14R – Duty as to improvement in quality of services

• 14T – Duty as to reducing inequalities


44

• 14V – Duty as to patient choice

• 14X - Duty to promote innovation

• 14Z1 – Duty as to promoting integration

• 14Z2 – Public involvement and consultation by CCGs (see above)

6. Cabinet Office

All consulting NHS bodies should consider and comply with Cabinet Office Guidance on

Consultation. This sets out what the CO recommends needs to be done to undertake a

lawful public consultation exercise.

7. Seven criteria for consultation

• When to consult – that is when you have all relevant information available for

consultees to give informed responses.

• Duration of consultation exercises – CO guidance is at least 2 weeks but no more

than 12 weeks.

• Clarity of scope and impact – you should clearly set out what is proposed and how

that may impact on patients within any consultation document.

• Accessibility of consultation exercises – you should make sure that you obtain the

views of all relevant people and run an open consultation process.

• The burden of consultation – that is you should not over burden the public with

consultations.

• Responsiveness of consultation exercises – your process should operate so that

appropriate consideration is given to all responses from the consultation exercise.

• Capacity to consult – you should make sure you devote sufficient resources so that a

lawful exercise is undertaken

8. Governance

As to decision making it is important that clear governance arrangements are put in place

that are compliant with statute.

9. Local authorities

Equally you must comply with your obligation to consult the relevant local authorities under

s.244 of the Act and the associated Regulations.

10. Clear plan

As to consulting you need to have a clear plan in place which ensures that you give the

public sufficient information for them to provide informed responses.

11. Analysis and report

Once the public consultation is complete, you must be able to collate and analyse responses

for the decision makers to consider, often in the form of a consolidated report. Equally, you


45

need a clear analysis of compliance with your obligations under the public sector equality

duty.

12. Compliance with statutory obligations and four Key Tests

Commissioners will also want to ensure that decisions comply with their other statutory

obligations and the four Key Tests, as set out above.

13. IRP

Consideration should be given to those issues which the IRP have indicated in annual

reviews cause the most concern to the public an patients. (See separate note for a list of the

issues).

Procurement Issues

Commissioners are required to ensure that their decisions to procure services comply with

the National Health Service (Procurement, Patient Choice and Competition) (No. 2)

Regulations 2013. Key questions are set out under each heading below to assist you when

considering whether you are meeting these requirements. Commissioners are also required

to comply with EU/UK general procurement law but this is not covered in the list below.

1. Procurement objective

‘To secure the needs of patients and improve quality and efficiency of services’.

• What have you done to assess patient need and do you have evidence to support

your findings?

• How are you assessing the quality of services and the performance of the current

providers? How have you assessed whether the service is offering value for money?

• Have you reviewed the current service specification to ensure it is working well and

whether there is scope for further improvement? In particular, it would be helpful to

have a schedule of all existing contracts and relationships, including performance

monitoring on contracts.

• What steps have you taken to assess equitable access to services by all patient

groups?

2. Three general requirements

I. To act transparently and proportionately and in a non-discriminatory way.

• What steps have you taken to make providers and stakeholders aware of your plans?

Have you provided reasons to support your decisions?

• Are you publishing details in a timely manner and have you kept records of decision

making, e.g. board minutes and briefing papers?

• Do providers understand the selection criteria you are using and are they able to

express an interest in providing the services? Can you show that you have not

favoured one provider over the other?


46

• Is your approach proportionate to the nature of the services in relation to the value,

complexity and clinical risk associated with the provision of the services in question?

II. To contract with providers who are most capable of meeting the objectives and provide

best value for money

• How have you identified existing and potential providers and objectively evaluated

their relative ability to deliver the service specification, improve quality and meet the

needs of patients?

• Are you satisfied providers are capable and robust enough to deliver a safe and

efficient service and provide the best value for money in doing so?

III. Consider ways of improving services through integration, competition and patient choice

• What evidence do you have to show the steps you taken to determine whether it

might be better for patients if the services are integrated with other health care

services?

• Have you asked providers, patients, and other stakeholders for their views?

• Does your specification or performance monitoring process incentivise delivery of

care in a more integrated manner?

• Have you considered whether competition or choice would better incentivise

providers to improve quality and efficiency? Do you have evidence to support your

findings?

3. Advertisements and expressions of interest

To ensure providers are able to express an interest in in providing any services which

includes the requirement to publish opportunities and awards on a website

• How have you gathered evidence about the existing and potential providers on the

market?

• Have you published your intentions to the market by way of commissioning intentions

or publication on a website?

4. Award of a new contract without a competition

A new contract may be awarded without publishing a contract notice where the

commissioner is satisfied that the services in question are capable of being provided only by

that provider, e.g. A&E services in a particular area or where it is not viable for providers to

provide one service without also providing another service.

• What steps have you taken and what evidence are you relying on to satisfy yourself

that there is only one capable provider?

5. Conflict of Interests

Commissioners are prohibited from awarding a contract where conflicts, or potential

conflicts, between the interests of Commissioners in commissioning services and the


47

interests involved in providing the services affect, or appear to affect, the integrity of the

award of the contract.

• Have you recorded how you have managed any conflict or potential conflict?

6. Anti-competitive behaviour

Not to engage in anti-competitive behaviour unless to do so would be in the interests of

people who use NHS services

• Are you acting in an anticompetitive manner – for instance have you prevented new

providers from entering the market or caused a provider to exit the market?

• If so, is it objectively justifiable as being in the interests of users and stakeholders?

What evidence do you have to support this?

Competition Issues

1. Requirement to Notify to the Competition and Markets Authority (CMA)

Any undertakings given to the CMA or its predecessor, the Competition Commission, may

prohibit a statutory transaction and should be checked. They may not apply to a merger by

reconfiguration but the merger regime set out below will still apply.

2. Merger control rules

The merger control regime may apply to NHS service reconfigurations where two or more

services are merged and the transaction meets the jurisdictional tests.

3. Jurisdictional Tests

The CMA has jurisdiction to examine a merger where:

1. two or more enterprises cease to be distinct (change of control)

2. and either

• the UK turnover of the acquired enterprise exceeds £70 million; or

• the enterprises which cease to be distinct together supply or acquire at least 25% of

all those particular services of that kind supplied in the UK or in a substantial part of

it. The merger must also result in an increment to the share of supply, i.e. the

merging providers must supply or acquire the same category of services.

[ Enterprise: NHS foundation trusts and NHS trusts controlling hospital, ambulance

services, mental health service, community services or individual services or specialities

may be enterprises for the purpose of merger control.

Change in control: Two enterprises (or services) cease to be distinct if they are brought

under common ownership or control. There must be a change in the level of control over the

activities of one or more enterprises (or services) for merger control to apply.]


48

4. Competition test

The CMA assesses qualifying mergers to decide whether they are likely to lead to a

substantial lessening of competition (‘SLC’). An SLC occurs when competition is

substantially less after the merger.

5. SLC assessment

The CMA will require detailed information about the reconfiguration. This will include:

• service overlaps;

• GP referral data / catchment area analysis; and

• Hospital share of GP practice referrals.

6. CMA merger assessment timetable

The process is divided into two stages:

• Phase I: an initial 40 working day investigation; and

• Phase II: a possible 24 weeks in-depth investigation, which can be extended if the

CMA considers it necessary.

Enc C

Finance Report


Meeting date 15th September 2016

Title of paper

2016/17 Finance Report July 2016 (Month 4)


Hayley Tingle Chief Finance Officer

Author(s) Tracy Wyatt Deputy Chief Finance Officer

Purpose of Paper - Executive Summary This report sets out the financial position as at the end of July 2016. At this early stage in the year the CCG is forecasting to achieve all of its financial targets for 2016/17. The report also outlines:

• The key risk areas identified in 2016/17 and any current issues

• A summary of the CCG Efficiency Savings plan for 2016/17 (Appendix 2)

• A summary of the CCG’s Resource Allocation (Appendix 3) • A summary of the CCG’s Reserve position (Appendix 4)

Recommendation(s) Members are asked to receive the report and note the financial position.

Impact analysis Quality impact None identified

Equality impact

None identified


Nil


As highlighted within the report

Legal implications

None identified


Interest None Identified




N/A

Report previously

presented at None

Risk analysis

The CCG has identified a number of risks as part of the Financial planning for 2016/17. These include:

• Prescribing and High Cost Drugs Expenditure

• Over performance against the main acute contracts

• Individual Placements

• Non delivery of parts of the Efficiency Savings programme

A small contingency fund which equates to 0.5% of the CCG’s allocation has been set aside to mitigate against these risks as required by the

business rules. It will not be possible to flex investment reserves due to the national ring fencing of the 1% headroom and therefore should the

contingency fund not be sufficient the CCG will have to increase efficiencies, seek to risk share with other organisations or seek additional

support from NHS England. Assurance Framework

1.2, 1.4, 2.4, 3.1, 3.2, 6.2

NHS DONCASTER CCG 2016/17 FINANCE REPORT MONTH 4 – JULY 2016 1. Introduction

This report provides the final financial position for NHS Doncaster CCG for 2016/17 as at the end of July (Month 4). At this early stage in the year, the CCG is forecasting to achieve all of its financial targets for 2016/17. 2. Current Position The year to date position reflects a surplus of £2,573k which is consistent with the year to date target of £2,574k. The annual target is a surplus of £7,722 which the CCG is forecasting to achieve at this early stage in the year. Information is starting to feed through from providers and issues are highlighted below. The year to date and forecast position is summarised in the Operating Cost Statement included at Appendix 1. 3. Key Messages and Risks

The largest financial risks identified as part of the Financial Planning process were Prescribing and High Cost Drugs. Work to address the variations in both outcomes and costs will be taken forward as part of the Primary Care Strategy, specifically the medicine optimisation work. A prior approval process has been initiated with the Acute Trust and implemented from 1st April 2016; this will address any non-compliance with NICE guidance and correct charging through the PbR tariff mechanism. Other risks identified include the over performance on acute contracts, increased Individual placements ( including Continuing Healthcare , Specialist Placement and Section 117 packages) and the non-delivery of parts of the efficiency savings. If the efficiency savings fail to deliver there will be increased pressure on the CCGs statutory duty to breakeven. Some early pressures are beginning to materialise in the contract with DBH NHS FT mainly around Emergency activity and work is underway to understand this. There are also some pressures in relation to S117 and Specialist Placement activity due to increased activity levels however some of this is offset by a reduction in Continuing Healthcare activity. This will be closely monitored in year. An additional risk has arisen in year in relation to the nationally agreed rates for Funded Nursing Care (FNC) which will cause an additional cost pressure of approximately £600k. The rate has increased by 39% from £112 per week to £156.25 per week following a national review. The CCG has no choice but to implement this rate for FNC patients, however it may also impact on the locally agreed care home rates. The CCG is currently in discussion with the Local Authority to work this through but it may potentially increase costs by a further £200k. The impact of this has been included in the position.

To help manage and offset these risks a small contingency fund of £2.2m has been established. This equates to 0.5% of the CCG’s allocation and is in line with planning guidance. If this is insufficient the following actions would need to be considered;

• Seeking further efficiencies and decommissioning opportunities

• Risk sharing with other CCGs

• Seeking repayable financial assistance from other NHS organisations.

• Seeking further support from NHS England In previous years flexing of investment funds have supported mitigation to manage unexpected risks however this is not an option for 2016/17. 4. Efficiency Savings Programme

All contract values negotiated with providers are net of efficiency saving targets where appropriate. The targets are phased to assume delivery in the latter half of the year therefore savings will be reported from Q3. However, progress in relation to the Right Care work streams including prescribing will be reported each month to outline any risks to delivery as they arise. A summary of the high level efficiency plans and current progress are shown in Appendix 2. The Prescribing LES scheme was launched earlier in the year and all practices have now signed up to the scheme which started in August. The scheme aims to reduce overall spend across several areas of prescribing and rewards practices with a percentage of the savings made. Due to the timing of reports from the BSA savings will not be able to start being quantified until late October. 5. 1% Non Recurrent Headroom The CCG has set aside £4.8m, (1% of the CCG’s recurrent allocation) as per the business rules for non-recurrent investment. However, the CCG is required to ring-fence this funding to provide funds to insulate the wider health economy from financial risk. If evidence emerges that the risks are being effectively mitigated it is anticipated that this will be released for use. 6. Further Allocations Additional allocations were received in Month 4 for Learning Disability Transformation Funding £570k and a minor allocation of £1k in relation to the transfer of services from the CSU to the new provider EmBed. 7. Capital Resource

The CCG has not received any capital funding in 2016/17.

8. Other Key Financial Targets Below is a summary table outlining the other key financial targets for the CCG, the current performance and the forecast.

Key Duty Target Actual Forecast

BPPC

95% + invoices paid within 30 days (NHS)

96.86% 98%

95% + invoices paid within 30 days (non NHS)

98.99% 98%

95% + invoice values paid within 30 days (NHS)

99.91% 98%

95% + invoice values paid within 30 days (Non NHS)

99.04% 98%

Cash Drawdown

1.25% of monthly drawdown remaining at period end

1.57% 1.25%

Running Costs

Maintain spend within annual target of £6,806k, YTD £2,085k

£1,756k £6,567k

Key Red High risk - significant risk of target not being achieved

Amber Medium Risk - some issues around current performance, actions in place

Green Low risk - target being achieved, no areas of concern The cash position at the end of July was higher than expected due to an unexpected payment of £265k on the last working day of the month from DMBC. Had this not been received the CCG would have met the target by having 0.78% of the monthly drawdown left at month end. The CCG is working closely with DMBC to agree monthly cash flows so that this does not happen again. There are no specific implications of not meeting this target in year but should this reoccur then the CCG will be under close scrutiny from NHS England. It is vital that this target is met at year end. 9. Better Care Fund The Section 75 Framework Agreement with Doncaster Council has been signed and the fund remains broadly the same as last year at £23,907k. The governance structure surrounding the BCF has been reviewed and more detailed monitoring will take place in 2016/17. The Quarter 1 report to NHS England was due to be submitted in August but the deadline was slipped by NHSE to early September due to a change to the reporting templates. The final report will be shared with the Health and Well Being Board and the Governing Body.

10. Conclusion and Recommendations Members are asked to: Receive and note the Finance Report for July 2016 (Month 4).

NHS DONCASTER CLINICAL COMMISSIONING GROUP Appendix 1

2016/17 FINANCE REPORT JULY 2016

Recurrent

Budget

£000s

Non Rec

Budget

£000s

Total

Budget

£000s

Recurrent

Budget

£000s

Non Rec

Budget

£000s

Total

Budget

£000s

Forecast

Outturn

£000s

Variance

(Under)/ Over

£000s

Recurrent

Budget

£000s

Non Rec

Budget

£000s

Total Budget

£000s

YTD Actual

£000s

Variance

(Under)/

Over

£000s

Baseline Allocation -479,863 -9,722 -489,585 -479,863 -9,722 -489,585 0 -489,585

Running Cost Allowance -6,806 0 -6,806 -6,806 0 -6,806 0 -6,806

Initial Allocation -486,669 -9,722 -496,391 -486,669 -9,722 -496,391 0 -496,391

In year changes

Vanguard Q1 Sheffield Teaching Hospitals 0 0 -175 -175 0 -175

Q1 Eating Disorder Service 0 0 -173 -173 0 -173

PYE Transfer of One Health July-March 2017 0 0 -22 -22 0 -22

PYE Transfer of Claremont July-March 2017 0 0 -5 -5 0 -5

NHS Carcroft Colposcopy Contract transfer from NHS England 0 -67 0 -67 0 -67

Transfer of NHSE support re Embed and Third Party Contracts 0 0 -1 -1 0 -1

Learning Disability transformation Funding to TCPs 0 0 -570 -570 0 -570

0 0 0

0 0

TOTAL ALLOCATIONS -486,669 -9,722 -496,391 -486,736 -10,668 -497,404 0 -497,404 -162,153 -162,153 0

Acute Contracts - DBHFT 186,060 907 186,967 185,940 907 186,847 188,457 1,610 62,282 0 62,282 62,819 537

Acute Contracts - Other NHS 35,728 81 35,809 35,865 1,026 36,891 34,372 -2,519 11,147 0 11,147 11,334 187

Acute Contracts - Other Providers Non NHS 4,267 0 4,267 4,253 28 4,281 4,311 30 1,423 0 1,423 1,436 13

Acute Contracts - Urgent Care 2,608 0 2,608 5,829 -28 5,801 5,801 0 1,927 0 1,927 1,928 1

Acute - Non Contract Activity 5,773 0 5,773 2,608 0 2,608 2,608 0 869 0 869 869 0

Total Acute Services 234,436 988 235,424 234,495 1,933 236,428 235,549 -879 77,649 0 77,649 78,386 737

Mental Health Contracts - RDaSH FT 34,104 610 34,714 34,175 539 34,714 34,714 0 11,513 0 11,513 11,478 -36

Mental Health Contracts - Other NHS 347 0 347 348 0 348 348 0 116 0 116 116 0

Mental Health Contracts - Other Providers 15,704 0 15,704 15,704 0 15,704 18,167 2,463 5,235 0 5,235 5,919 684

Mental Health - Non Contract Activity 29 0 29 29 0 29 0 -29 10 0 10 0 -10

Total Mental Health Services 50,184 610 50,794 50,256 539 50,795 53,229 2,434 16,874 0 16,874 17,513 639

Community Contracts - RDaSH FT 30,945 82 31,027 30,963 82 31,045 31,057 12 10,310 0 10,310 10,316 6

Community Contracts - Other NHS 366 0 366 366 2 368 368 0 122 0 122 122 0

Community Contracts - Other Providers 10,650 0 10,650 10,632 0 10,632 10,685 53 3,544 0 3,544 3,570 26

Total Community Services 41,961 82 42,043 41,961 84 42,045 42,110 65 13,976 0 13,976 14,008 31

Prescribing 61,738 0 61,738 61,738 0 61,738 61,738 0 20,750 0 20,750 20,750 0

Oxygen Services 573 0 573 573 0 573 584 11 191 0 191 197 6

Other Primary Care Services 2,030 1,559 3,589 3,656 0 3,656 3,669 13 1,218 0 1,218 1,212 -6

GPIT 800 0 800 800 0 800 800 0 232 0 232 261 29

Medical Recommendations 0 0 0 0 0 0 0 0 0 0 0 0 0

Delegated Co-Commissioning 41,348 0 41,348 41,348 0 41,348 41,348 0 13,123 0 13,123 12,950 -173

Primary Care Services 106,489 1,559 108,048 108,115 0 108,115 108,139 24 35,514 0 35,514 35,370 -144

Continuing Healthcare 34,146 1,117 35,263 34,146 1,116 35,262 34,141 -1,121 12,498 0 12,498 11,557 -941

Continuing Healthcare Services 34,146 1,117 35,263 34,146 1,116 35,262 34,141 -1,121 12,498 0 12,498 11,557 -941

Non Recurrent Programmes 0 0 0 0 0 0 0 0 0 0 0 0 0

Non Recurrent Programmes 0 0 0 0 0 0 0 0 0 0 0 0 0

Medicines Management 507 0 507 507 0 507 503 -5 169 0 169 176 7

Safeguarding 39 0 39 39 0 39 39 0 13 0 13 13 0

Mental Health Assessments 60 0 60 0 0 0 0 0 0 0 0 0 0

NHS Property Services Recharge 2,404 0 2,404 2,404 0 2,404 2,404 0 801 0 801 801 0

Corporate non running costs 3,010 0 3,010 2,950 0 2,950 2,945 -5 983 0 983 990 7

Chief Pharmacist 87 0 87 87 0 87 87 0 29 0 29 28 -1

Admin & Business Support 896 0 896 896 0 896 896 0 107 0 107 107 0

Contract Management 413 0 413 413 0 413 424 11 143 0 143 156 13

Finance 792 0 792 792 0 792 746 -46 267 0 267 231 -36

Corporate Costs & Services 397 0 397 397 0 397 397 0 132 0 132 104 -28

Human Resources 82 0 82 82 0 82 82 0 27 0 27 19 -8

Health & Safety 20 0 20 20 0 20 20 0 7 0 7 6 0

Patient & Public Involvement 186 0 186 186 0 186 170 -16 62 0 62 47 -15

Communications & PR 5 0 5 5 0 5 5 0 2 0 2 3 1

Performance 823 0 823 823 0 823 819 -5 274 0 274 262 -12

Quality Assurance 614 0 614 614 0 614 562 -51 205 0 205 163 -41

Primary Care Support 208 0 208 208 0 208 176 -32 69 0 69 42 -27

Strategy & Development 962 -171 790 962 -171 790 776 -15 263 0 263 156 -108

Governing Body 1,493 0 1,493 1,493 0 1,493 1,408 -85 498 0 498 432 -66

Corporate Running Costs 6,978 -171 6,806 6,977 -171 6,806 6,567 -239 2,085 0 2,085 1,756 -329

Total Corporate Costs 9,988 -171 9,816 9,927 -171 9,756 9,512 -244 3,068 0 3,068 2,746 -322

1% Non Recurrent Headroom Reserve 4,799 4,799 4,799 4,799 4,799 0 0 0 0 0 0

Contingency Reserve 0.5% 2,482 0 2,482 2,482 0 2,482 2,202 -280 0 0 0 0 0

Investments 0 0 0 0 0 0 0 0 0 0 0 0 0

Total Reserves 2,482 4,799 7,281 2,482 4,799 7,281 7,001 -280 0 0 0 0 0

TOTAL APPLICATION OF FUNDS 479,686 8,983 488,669 481,383 8,299 489,682 489,681 -1 159,579 0 159,579 159,580 1

SURPLUS 1% REQUIREMENT* 7,722 7,722 0 -7,722 2,574 0 -2,574

TOTAL 496,391 497,404 489,681 -7,723 162,153 159,580 -2,573

OPERATING COST STATEMENT

Opening Budget YEAR TO DATE

NHS DONCASTER CLINICAL COMMISSIONING GROUP APPENDIX 2

Savings / Efficiency Programme 2016/17

Programme Area Project 2016/17 Target Risk

Right Care incl prescribing Endocrine, respiratory, MSK and Neurological Medium

Other Schemes Review of Procedures with Low Clinical value Medium

Other schemes as part of Working Together and STP Medium

2016/17 TOTAL 8,882

Note: Risk assessed on the basis of management experience

There is not a specific target for each right care stream but the overall potential savings per the Right Care reports is £22m, based on achieving

the same performance as the best 5 similar CCG's. To achieve the same as the 10 similar CCG's that are in our 'cluster' there is potential

savings of £13.7m. The CCG has assumed that there will be a lead in time to understand the right care data and implement any pathway changes

but that a minimum of 25% could be achieved. An overall workplan combining the four workstreams is currently being completed.

The prescribing LES has been launched and all practices have signed up to the scheme which started in August. Due to timing delays in receipt

of information from the BSA the impact will not be known until November.

Other areas are being developed as part of the Working Together and STP work streams.


SUMMARY OF RESOURCE ALLOCATIONS AS AT MONTH 4 JULY 2016

Recurrent Non Recurrent Total

£000's £000's £000's

Recurrent Baseline -438,097 -438,097

Primary Care Delegation -41,766 -41,766

Non Recurrent Surplus from prior years -9,722 -9,722

Running Cost Allowance -6,806 -6,806

Total Resources Available at Plan Stage -486,669 -9,722 -496,391

Adjustments to the Resource Limit:

Month 01 April

No adjustments 0 0 0

0 0 0

Month 02 May

No adjustments 0 0 0

0 0 0

Month 03 June

Vanguard Q1 Sheffield Teaching Hospitals 0 -175 -175

Q1 Eating Disorder Service 0 -173 -173

PYE Transfer of One Health July-March 2017 0 -22 -22

PYE Transfer of Claremont July-March 2017 0 -5 -5

Colposcopy Contract transfer from NHS England -67 0 -67

-67 -375 -442

Month 04 July

Transfer of NHSE support re Embed and Third Party Contracts -1 -1

Learning Disability transformation Funding to TCPs -570 -570

0

0 -571 -571

Revised Resources available as at Month 4 July 2016 -486,736 -10,668 -497,404


SUMMARY OF RESERVES AS AT MONTH 4 JULY 2016

RESERVES Recurrent Non Total

Recurrent

£000's £000's £000's

RISK RESERVES AND CONTINGENCIES

1% Non Recurrent Headroom

Initial Plan 0 4,799 4,799

Budget Transfers

No transfers as at Month 4 - funding uncommitted and ringfenced as per 0

NHSE Guidance 0

0

0

0

0

0

0

0

0

0

0

0

0 4,799 4,799

0.5% Contingency

Initial Plan 2,482 0 2,482

Budget Transfers

No transfers as at Month 4

2,482 0 2,482

2,482 4,799 7,281

Cross Check to Operating Cost Statement 2,482 4,799 7,281

Enc D

Emergency Preparedness, Resilience & Response

Assurance 2016/17



Title of paper

Emergency Preparedness, Resilience & Response Assurance 2016/17


Sarah Atkins Whatley, Chief of Corporate Services

Author(s) As above

Purpose of Paper - Executive Summary The 2016/17 Emergency Preparedness, Resilience and Response (EPRR) assurance process is based on the NHS England Core Standards for Emergency Preparedness, Resilience and Response v4.0 which are available on the NHS England website http://www.england.nhs.uk/ourwork/eprr To comply with the national requirements, Accountable Emergency Officers are required to:

1. Undertake a self-assessment against the relevant core standards identifying the level of compliance for each standard - red, amber, green.

2. Review the improvement plans developed as part of the 2014/15 assurance process (not applicable to NHS Doncaster CCG as we were fully compliant with all standards), and if applicable include further actions required from this year’s self-assessment.

3. Complete the Statement of Compliance identifying the organisation’s overall level of compliance - full, substantial, partial, non-compliant.

4. Present the above outcomes to the governing body. 5. Submit the governing body paper to the Local Health Resilience Partnership

by Tuesday 18th October 2016.

NHS Doncaster CCG has worked in partnership across the South Yorkshire CCGs on EPRR compliance since our establishment and we continue to do so. The draft self-assessment has therefore been developed and reviewed jointly across the South Yorkshire CCGs. The self-assessment has been reviewed by the Chief of Corporate Services as NHS Doncaster CCG’s operational EPRR Lead, and by the Accountable Emergency Officer (Chief Officer). The self-assessment has resulted in a green rating across all criteria and no separate action plan has therefore been devised. The Governing Body receives assurance on ongoing EPRR action and testing via the quarterly Corporate Assurance Reports, via the Governing Body approved EPRR Policy, via the Audit Committee approval of the Business Continuity Policy and Plan, via EPRR risks captured on the Assurance Framework and via operational oversight by the Chief of Corporate Services and Corporate Assurance Management Group which reports to the Audit Committee.

Recommendation(s) It is recommended that the Governing Body reviews the draft assurance and agree submission to the Local Health Resilience Partnership of the EPRR Compliance Statement (Appendix 1) signed by the Accountable Emergency Officer based on the EPRR core standards self-assessment (Appendix 2) which this year includes business continuity management.

Impact analysis Quality impact Nil.

Equality impact

Neutral.


Nil.


Nil.

Legal implications

Legal compliance is required with the Civil Contingencies Act 2004 and with NHS England statutory guidance on EPRR.


Interest No conflicts identified.




South Yorkshire CCG EPRR Leads

Report previously

presented at None.

Risk analysis

If we are non-compliant with EPRR guidance, then we may be in breach of our statutory duties.

Assurance Framework

5.1, 5.4

of 1

Yorkshire and the Humber Emergency Preparedness, Resilience and Response (EPRR)

Assurance 2016-2017

STATEMENT OF COMPLIANCE

NHS Doncaster CCG has undertaken a self-assessment against required areas of the NHS

England Core Standards for EPRR v4.0.

Following assessment, the organisation has been self-assessed as demonstrating the Full

compliance level (from the four options in the table below) against the core standards.

Compliance Level Evaluation and Testing Conclusion

Full Arrangements are in place that appropriately addresses all the core standards that the organisation is expected to achieve. The Board or Governing Body has agreed with this position statement.

Substantial

Arrangements are in place however they do not appropriately address one to five of the core standards that the organisation is expected to achieve. A work plan is in place that the Board or Governing Body has agreed.

Partial

Arrangements are in place, however they do not appropriately address six to ten of the core standards that the organisation is expected to achieve. A work plan is in place that the Board or Governing Body has agreed.

Non-compliant

Arrangements in place do not appropriately address 11 or more core standards that the organisation is expected to achieve. A work plan has been agreed by the Board or Governing Body and will be monitored on a quarterly basis in order to demonstrate future compliance.

Where areas require further action, this is detailed in the attached core standards improvement

plan and will be reviewed in line with the organisation’s EPRR governance arrangements.

I confirm that the organisation has undertaken the following exercises on the dates shown below:

A live exercise (required at least every three years) 21 April 2015

A desktop exercise (required at least annually) 16 May 2016

A communications exercise (required at least every six months) 6 June 2016

I confirm that the above level of compliance with the core standards has been confirmed by the

organisation’s board / governing body.

________________________________________________________________

Signed by the organisation’s Accountable Emergency Officer

15/09/2016 01/09/2016 Date of board / governing body meeting Date signed

Core standard Clarifying information

CC

Gs

Suggested evidence of assuranceActual evidence of assurance

Self assessment RAG

Red = Not compliant with

core standard and not in the

EPRR work plan within the

next 12 months.

Amber = Not compliant but

evidence of progress and in

the EPRR work plan for the

next 12 months.

Green = fully compliant with

core standard.

Action to be taken Lead Timescale

1

Organisations have a director level

accountable emergency officer who is

responsible for EPRR (including business

continuity management)Y

An Accountable Emergency Officer is in place for each of the South Yorkshire CCGs:

- Barnsley: Jamie Wike, Head of Planning and Performance

- Doncaster: Jackie Pederson, Chief Officer, with operational delegation to Sarah Atkins Whatley, Chief of Corporate Services

- Rotherham: Chris Edwards, Chief Officer, with operational delegation to Ruth Nutbrown, Assistant Chief Officer

- Sheffield: Tim Furness, Director of Delivery

GREEN N/A N/A N/A

2

Organisations have an annual work

programme to mitigate against identified

risks and incorporate the lessons identified

relating to EPRR (including details of training

and exercises and past incidents) and

improve response.

Lessons identified from your organisation and other partner

organisations.

NHS organisations and providers of NHS funded care treat EPRR

(including business continuity) as a systematic and continuous

process and have procedures and processes in place for updating

and maintaining plans to ensure that they reflect:

- the undertaking of risk assessments and any changes in that risk

assessment(s)

- lessons identified from exercises, emergencies and business

continuity incidents

- restructuring and changes in the organisations

- changes in key personnel

- changes in guidance and policy

Y

The South Yorkshire CCGs' annual EPRR work programmes respond to the hazard analysis and risk assessment undertaken by

the Local Health Resilience Partnership (LHRP). Like anywhere in the UK, South Yorkshire has a number of natural and manmade

hazards. To ensure we are prepared for these hazards the South Yorkshire Local Resilience Forum (LRF) has created a

Community Risk Register which identifies the wide range of risks and emergencies we could potentially face.

A number of specific risks that the CCGs may potentially have are listed in our EPRR policies (developed joinltly across the South

Yorkshire CCGs) alongside the planned response. Assurance is obtained through the contracting route with commissioned services

by the Head of Contracting or equivalent, and also via local partnership emergency planning fora within our local geographic areas.

The CCGs receive feedback via the LHRP on local incidents so that lessons can be learned e.g. the North Yorkshire Boxing Day

floods. Any learning for CCGs from the incidents is taken into the organisation for internal action.

GREEN N/A N/A N/A

3

Organisations have an overarching

framework or policy which sets out

expectations of emergency preparedness,

resilience and response.

Arrangements are put in place for emergency preparedness,

resilience and response which:

• Have a change control process and version control

• Take account of changing business objectives and processes

• Take account of any changes in the organisations functions and/ or

organisational and structural and staff changes

• Take account of change in key suppliers and contractual

arrangements

• Take account of any updates to risk assessment(s)

• Have a review schedule

• Use consistent unambiguous terminology,

• Identify who is responsible for making sure the policies and

arrangements are updated, distributed and regularly tested;

• Key staff must know where to find policies and plans on the intranet

or shared drive.

• Have an expectation that a lessons identified report should be

produced following exercises, emergencies and /or business

continuity incidents and share for each exercise or incident and a

corrective action plan put in place.

• Include references to other sources of information and supporting

documentation

Y

The South Yorkshire CCGs' Emergency Preparedness Resilience & Response (EPRR) Policies confirm the processes following an

EPRR incident in order to ensure that lessons are learned. We take responsibility for debriefing and providing support to staff where

required following an emergency via individual line managers coordinated by the Emergency Accountable Officer. De-briefing may

also be on a multi-agency footprint. Any lessons learned from the incident will be fed back to staff and actioned appropriately.

The South Yorkshire CCGs' Emergency Preparedness Resilience & Response Policies cover all the core standards required of

CCGs and are published on our websites. The Policies:

• Have a change control process via the Corporate Governance Teams which includes version control (see coversheet and

following page).

• Take account of changing business objectives and processes via annual review by the Accountable Emergency Officer and

refresh if needed (delegated on coversheet).

• Take into account any changes in our functions and/or organisational structural and staff changes by listing job titles rather than

individuals (action cards).

• Make clear our contracting responsibilties (section 3.2 of procedure).

• Take account of any updates to risk assessment(s) by the LHRP or LRF (sections 3.4, 3.5 & 3.6 of procedure).

• Have a maximum 3-year review schedule and were reviewed during 2016 (section 5.3.2 of the policy).

• Use consistent EPRR terminology throughout.

• Make clear the policy dissemination and review arrangements (section 5 of the policy).

• Are published on our websites.

• Include the requirement to review following an incident and learn lessons (section 6 of the procedure).

• Include references to other sources of information and supporting documentation (section 2 of the policy).

A Business Continuity Policy is in place within each of the South Yorkshire CCGs. These policies are based on a common template

and cover all the good practice areas of business continuity - hazard identification, mitigation, planning etc.

GREEN N/A N/A N/A

4

The accountable emergency officer ensures

that the Board and/or Governing Body

receive as appropriate reports, no less

frequently than annually, regarding EPRR,

including reports on exercises undertaken by

the organisation, significant incidents, and

that adequate resources are made available

to enable the organisation to meet the

requirements of these core standards.

After every significant incident a report should go to the Board/

Governing Body (or appropriate delegated governing group) .

Must include information about the organisation's position in relation to

the NHS England EPRR core standards self assessment.

Y

Corporate Governance/Assurance Reports received by the South Yorkshire CCGs' Governing Bodies capture EPRR assurance,

including any response to incidents (no incidents to date).

Operational managers within the South Yorkshire CCGs support both the EPRR and Business Continuity agendas. The

Communications Leads are part of the resilience arrangements. The corporate communications budgets and the CCG 0.5%

contingency reserves cover any unforseen EPRR costs.GREEN N/A N/A N/A

Governance

• Ensuring accountaable emergency officer's

commitment to the plans and giving a member of the

executive management board and/or governing body

overall responsibility for the Emergeny Preparedness

Resilience and Response, and Business Continuity

Management agendas

• Having a documented process for capturing and taking

forward the lessons identified from exercises and

emergencies, including who is responsible.

• Appointing an emergency preparedness, resilience and

response (EPRR) professional(s) who can demonstrate

an understanding of EPRR principles.

• Appointing a business continuity management (BCM)

professional(s) who can demonstrate an understanding

of BCM principles.

• Being able to provide evidence of a documented and

agreed corporate policy or framework for building

resilience across the organisation so that EPRR and

Business continuity issues are mainstreamed in

processes, strategies and action plans across the

organisation.

• That there is an approporiate budget and staff

resources in place to enable the organisation to meet

the requirements of these core standards. This budget

and resource should be proportionate to the size and

scope of the organisation.


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next 12 months.


core standard.


Governance

5

Assess the risk, no less frequently than

annually, of emergencies or business

continuity incidents occurring which affect or

may affect the ability of the organisation to

deliver it's functions.

Y GREEN N/A N/A N/A

6

There is a process to ensure that the risk

assessment(s) is in line with the

organisational, Local Health Resilience

Partnership, other relevant parties,

community (Local Resilience Forum/

Borough Resilience Forum), and national

risk registers.

Y GREEN N/A N/A N/A

7

There is a process to ensure that the risk

assessment(s) is informed by, and consulted

and shared with your organisation and

relevant partners.

Other relevant parties could include COMAH site partners, PHE etc.

Y GREEN N/A N/A N/A

Incidents and emergencies (Incident Response Plan (IRP) (Major

Incident Plan))Y

corporate and service level Business Continuity (aligned to current

nationally recognised BC standards)Y

HAZMAT/ CBRN - see separate checklist on tab overleaf

Severe Weather (heatwave, flooding, snow and cold weather) Y

Pandemic Influenza (see pandemic influenza tab for deep dive 2015-

16 questions)Y

Mass Countermeasures (eg mass prophylaxis, or mass vaccination)

Mass Casualties

Fuel Disruption Y

Surge and Escalation Management (inc. links to appropriate clinical

networks e.g. Burns, Trauma and Critical Care)Y

Infectious Disease Outbreak Y

Evacuation Y

Lockdown

Utilities, IT and Telecommunications Failure Y

Excess Deaths/ Mass Fatalities

having a Hazardous Area Response Team (HART) (in line with the

current national service specification, including a vehicles and

equipment replacement programme) - see HART core standard tab firearms incidents in line with National Joint Operating Procedures; -

see MTFA core standard tab

9

Ensure that plans are prepared in line with

current guidance and good practice which

includes:

• Aim of the plan, including links with plans of other responders

• Information about the specific hazard or contingency or site for which

the plan has been prepared and realistic assumptions

• Trigger for activation of the plan, including alert and standby

procedures

• Activation procedures

• Identification, roles and actions (including action cards) of incident

response team

• Identification, roles and actions (including action cards) of support

staff including communications

• Location of incident co-ordination centre (ICC) from which

emergency or business continuity incident will be managed

• Generic roles of all parts of the organisation in relation to responding

to emergencies or business continuity incidents

• Complementary generic arrangements of other responders

(including acknowledgement of multi-agency working)

• Stand-down procedures, including debriefing and the process of

recovery and returning to (new) normal processes

• Contact details of key personnel and relevant partner agencies

• Plan maintenance procedures

(Based on Cabinet Office publication Emergency Preparedness,

Emergency Planning, Annexes 5B and 5C (2006))

Y

• Being able to provide documentary evidence that plans

are regularly monitored, reviewed and systematically

updated, based on sound assumptions:

• Being able to provide evidence of an approval process

for EPRR plans and documents

• Asking peers to review and comment on your plans via

consultation

• Using identified good practice examples to develop

emergency plans

• Adopting plans which are flexible, allowing for the

unexpected and can be scaled up or down

• Version control and change process controls

• List of contributors

• References and list of sources

• Explain how to support patients, staff and relatives

before, during and after an incident (including

counselling and mental health services).

The South Yorkshire CCGs' EPRR Policies and Business Continuity Plans are refreshed upon changing circumstances or changing

national guidance and are based on NHS England guidance.

• The South Yorkshire CCGs' original EPRR Policies were shared with the LHRP for peer review and comment, and through the

representative Director of Public Health with our local Category 1 Responders - the Local Authorities.

• The South Yorkshire CCGs' EPRR Policies have been prepared to encompass our commissioning role and our role as statutory

NHS Bodies. Policies include an activation flowchart (Action Card 2), and action cards for key roles and actions of incident response

team and support staff including Communications and Loggists (action card 1) .

• The location of incident co-ordination centres (ICCs) are noted in policies from which emergency or business continuity incidents

will be managed. If the building is compromised, mutual aid via partner CCGs has been agreed.

• Generic roles of all parts of the organisations in relation to responding to emergencies or business continuity incidents are

captured in our business continuity plan.

• Stand-down procedures, including debriefing and the process of recovery and returning to normal processes are captured in both

EPRR and Business Continuity policies.

• Contact details of key personnel and relevant partner agencies are held separately in "pick-up packs".

The South Yorkshire CCGs' EPRR Policies are approved by Governing Bodies. Approval of the Business Continuity Policy & Plan

may be delegated through organisational structures. They have been refreshed in the last year.

GREEN N/A N/A N/A

Duty to assess risk

• Being able to provide documentary evidence of a

regular process for monitoring, reviewing and updating

and approving risk assessments

• Version control

• Consulting widely with relevant internal and external

stakeholders during risk evaluation and analysis stages

• Assurances from suppliers which could include,

statements of commitment to BC, accreditation,

business continuity plans.

• Sharing appropriately once risk assessment(s)

completed

GREEN8

Effective arrangements are in place to

respond to the risks the organisation is

exposed to, appropriate to the role, size and

scope of the organisation, and there is a

process to ensure the likely extent to which

particular types of emergencies will place

demands on your resources and capacity.

Have arrangements for (but not necessarily

have a separate plan for) some or all of the

following (organisation dependent) (NB, this

list is not exhaustive):

Risk assessments should take into account community risk registers

and at the very least include reasonable worst-case scenarios for:

• severe weather (including snow, heatwave, prolonged periods of

cold weather and flooding);

• staff absence (including industrial action);

• the working environment, buildings and equipment (including denial

of access);

• fuel shortages;

• surges and escalation of activity;

• IT and communications;

• utilities failure;

• response a major incident / mass casualty event

The South Yorkshire CCGs' EPRR risk assessments take account of the community risk register including:

• Fuel shortage

• Flooding

• Evacuation & Shelter

• Pandemic

• Heatwave

• Severe winter weather

The South Yorkshire CCGs' organisational Business Continuity Contingency Plans include plans and mitigation for the short term

(under 72 hours) and the longer term for:

• Fire

• Flood

• Terrorist or criminal attack

• Significant chemical contamination

• IT failure / loss of data

• Loss of power

• Loss of water

• Loss of telephone (landline)

• Simultaneous resignation of a number of key staff

• Staff illness / epidemic

• Commissioning Support contract unable to deliver

• Travel disruption

• Widespread industrial actions

The South Yorkshire CCGs' EPRR risk assessments take account of the community risk register including:

• Fuel shortage

• Flooding

• Evacuation & Shelter

• Pandemic

• Heatwave

• Severe winter weather

The South Yorkshire CCGs' organisational Business Continuity Contingency Plans include plans and mitigation for the short term

(under 72 hours) and the longer term for:

• Fire

• Flood

• Terrorist or criminal attack

• Significant chemical contamination

• IT failure / loss of data

• Loss of power

N/A N/A N/A

Relevant plans:

• demonstrate appropriate and sufficient equipment (inc.

vehicles if relevant) to deliver the required responses

• identify locations which patients can be transferred to if

there is an incident that requires an evacuation;

• outline how, when required (for mental health services),

Ministry of Justice approval will be gained for an

evacuation;

• take into account how vulnerable adults and children

can be managed to avoid admissions, and include

appropriate focus on providing healthcare to displaced

populations in rest centres;

• include arrangements to co-ordinate and provide

mental health support to patients and relatives, in

collaboration with Social Care if necessary, during and

after an incident as required;

• make sure the mental health needs of patients

involved in a significant incident or emergency are met

and that they are discharged home with suitable support

• ensure that the needs of self-presenters from a

hazardous materials or chemical, biological, nuclear or

radiation incident are met.

• for each of the types of emergency listed evidence can

Duty to maintain plans – emergency plans and business continuity plans


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next 12 months.


core standard.


Governance

10

Arrangements include a procedure for

determining whether an emergency or

business continuity incident has occurred.

And if an emergency or business continuity

incident has occurred, whether this requires

changing the deployment of resources or

acquiring additional resources.

Enable an identified person to determine whether an emergency has

occurred

- Specify the procedure that person should adopt in making the

decision

- Specify who should be consulted before making the decision

- Specify who should be informed once the decision has been made

(including clinical staff)

Y

• Oncall Standards and expectations are set out

• Include 24-hour arrangements for alerting managers

and other key staff.

The South Yorkshire CCGs have activation action cards and incident manager action cards in place in the event of incidents.

GREEN N/A N/A N/A

11

Arrangements include how to continue your

organisation’s prioritised activities (critical

activities) in the event of an emergency or

business continuity incident insofar as is

practical.

Decide:

- Which activities and functions are critical

- What is an acceptable level of service in the event of different

types of emergency for all your services

- Identifying in your risk assessments in what way emergencies and

business continuity incidents threaten the performance of your

organisation’s functions, especially critical activities

Y

The South Yorkshire CCGs' critical activities are captured in our Business Continuity Plans. Teams have clear plans in place for how

these are managed.

GREEN N/A N/A N/A

12

Arrangements explain how VIP and/or high

profile patients will be managed.

This refers to both clinical (including HAZMAT incidents) management

and media / communications management of VIPs and / or high

profile management

N/A

N/A N/A N/A N/A

13

Preparedness is undertaken with the full

engagement and co-operation of interested

parties and key stakeholders (internal and

external) who have a role in the plan and

securing agreement to its contentY

• Specifiy who has been consulted on the relevant

documents/ plans etc.

The South Yorkshire CCGs' EPRR Policies were developed as a framework across the South Yorkshire CCGs to support mutual aid

arrangements and consistency in the local patch. The template was peer-reviewed by the LHRP. Once localised, Polices were

consulted on and approved by our Governing Bodies. We retain the same template policy which is coordinated by NHS Doncaster

CCG as the lead CCG for our EPRR policies and On Call arrangements.

The South Yorkshire CCGs' Business Continuity Policies and Plans were developed by our staff teams supported by the Corporate

Governance Leads and approved within our governance structures.

GREEN N/A N/A N/A

14

Arrangements include a debrief process so

as to identify learning and inform future

arrangements

Explain the de-briefing process (hot, local and multi-agency, cold)at

the end of an incident.

Y

Section 6 of the South Yorkshire CCGs' EPRR procedures capture de-brief arrangements.

6.1. The CCG will be responsible for debriefing and provision of support to staff where required following an emergency. This is the

responsibility of individual line managers coordinated by the Emergency Accountable Officer. De-briefing may also be on a multi-

agency footprint.

6.2. Debriefs will be held as follows:

• Hot debrief – immediately after the incident or period of duty

• Cold/Structured/Organisational debrief – within two weeks post incident

• Multi-agency debrief – within four weeks of the close of the incident

• Post incident reports – within six weeks of the close of the incident

6.3. Any lessons learned from the incident will be fed back to staff and actioned appropriately.

GREEN N/A N/A N/A

15

Arrangements demonstrate that there is a

resilient single point of contact within the

organisation, capable of receiving notification

at all times of an emergency or business

continuity incident; and with an ability to

respond or escalate this notification to

strategic and/or executive level, as

necessary.

Organisation to have a 24/7 on call rota in place with access to

strategic and/or executive level personnel

Y

Explain how the emergency on-call rota will be set up

and managed over the short and longer term.

The South Yorkshire & Bassetlaw CCGs have a shared On Call system across the 5 CCGs which has been in place since 1 April

2014 and has been successfully tested throughout the year. The system is coordinated by NHS Doncaster CCG as the lead CCG

for our EPRR policies and On Call arrangements. The arrangements are supported by an On Call Procedure and an On Call Pack.

Both the On Call Pack and the Procedure have been updated within the last year.

A procedure has been developed and provided to partners and providers of the 5 CCGs, and this was refreshed in the last year.

Incidents within Providers are noted through the South Yorkshire CCGs' normal switchboard number in-hours.

The South Yorkshire CCGs have generic EPRR email addresses used routinely for EPRR communications and these acocunts are

checked daily.

We have access to the Resilience Direct service.

GREEN N/A N/A N/A

16

Those on-call must meet identified

competencies and key knowledge and skills

for staff.

NHS England publised competencies are based upon National

Occupation Standards .

Y

Training is delivered at the level for which the individual

is expected to operate (ie operational/ bronze, tactical/

silver and strategic/gold). for example strategic/gold

level leadership is delivered via the 'Strategic

Leadership in a Crisis' course and other similar courses.

All those individuals who are On Call as part of the South Yorkshire & Bassetlaw CCG on call rota have significant experience at

Executive Level which they bring to the On call role.

The South Yorkshire & Bassetlaw CCG on call rota coordinator has undertaken the "Strategic Leadership in a Crisis" training. This

training has also been accessed by some of the other on call leads on the rota dependant on their own training and development

needs assessment.

As Category 2 organisations, the South Yorkshire & Bassetlaw CCGs have evaluated that further training beyond that already

accessible through peer support within local areas and through the LHRP is not necessary.

GREEN N/A N/A N/A

17

Documents identify where and how the

emergency or business continuity incident

will be managed from, ie the Incident Co-

ordination Centre (ICC), how the ICC will

operate (including information management)

and the key roles required within it, including

the role of the loggist .

This should be proportionate to the size and scope of the

organisation.

Y

Arrangements detail operating procedures to help

manage the ICC (for example, set-up, contact lists etc.),

contact details for all key stakeholders and flexible IT

and staff arrangements so that they can operate more

than one control/co0ordination centre and manage any

events required.

The South Yorkshire CCGs' Incident Control Centres are supplied with hard copies of all relevant EPRR / Business Continuity

documents and activation / action cards alongside useful contact lists. Remote IT working has been enabled. IT Providers have

continuity systems in place which are assessed and reported through the Information Governance Toolkit.

Mutual aid arrangements with partner CCGs provide for additional or replacement Incident Control Centres if required.

GREEN N/A N/A N/A

18

Arrangements ensure that decisions are

recorded and meetings are minuted during

an emergency or business continuity

incident.

Y

An action card is included in the South Yorkshire CCGs' EPRR procedures for a Loggist. Log books are provided in the Incident

Control Centre. Loggists participate in local training as required.GREEN N/A N/A N/A

19

Arrangements detail the process for

completing, authorising and submitting

situation reports (SITREPs) and/or

commonly recognised information pictures

(CRIP) / common operating picture (COP)

during the emergency or business continuity

incident response.

Y

Situation report arrangements for the South Yorkshire CCGs are determined by the Incident Lead Executive in line with the

escalation action card and the Incident Lead Executive action card.

E.g. Sit reps were provided to NHS England over the Easter bank holiday weekend. GREEN N/A N/A N/A

Command and Control (C2)


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next 12 months.


core standard.


Governance20 Arrangements to have access to 24-hour

specialist adviser available for incidents

involving firearms or chemical, biological,

radiological, nuclear, explosive or hazardous

materials, and support strategic/gold and

tactical/silver command in managing these

events.

Both acute and ambulance providers are expected to have in place

arrangements for accessing specialist advice in the event of incidents

chemical, biological, radiological, nuclear, explosive or hazardous

materials

N/A

N/A N/A N/A N/A

21 Arrangements to have access to 24-hour

radiation protection supervisor available in

line with local and national mutual aid

arrangements;

Both acute and ambulance providers are expected to have

arrangements in place for accessing specialist advice in the event of a

radiation incident

N/A

N/A N/A N/A N/A

22 Arrangements demonstrate warning and

informing processes for emergencies and

business continuity incidents.

Arrangements include a process to inform and advise the public by

providing relevant timely information about the nature of the unfolding

event and about:

- Any immediate actions to be taken by responders

- Actions the public can take

- How further information can be obtained

- The end of an emergency and the return to normal arrangements

Communications arrangements/ protocols:

- have regard to managing the media (including both on and off site

implications)

- include the process of communication with internal staff

- consider what should be published on intranet/internet sites

- have regard for the warning and informing arrangements of other

Category 1 and 2 responders and other organisations.

Y

• Have emergency communications response

arrangements in place

• Be able to demonstrate that you have considered

which target audience you are aiming at or addressing in

publishing materials (including staff, public and other

agencies)

• Communicating with the public to encourage and

empower the community to help themselves in an

emergency in a way which compliments the response of

responders

• Using lessons identified from previous information

campaigns to inform the development of future

campaigns

• Setting up protocols with the media for warning and

informing

• Having an agreed media strategy which identifies and

trains key staff in dealing with the media including

nominating spokespeople and 'talking heads'.

• Having a systematic process for tracking information

flows and logging information requests and being able to

deal with multiple requests for information as part of

normal business processes.

• Being able to demonstrate that publication of plans and

An Action Card for the Communications Lead is included in the South Yorkshire CCGs' EPRR Procedures. The majority of

communications will be via Providers or via Category 1 Responders, who the CCGs shall support as required.

In respect of EPRR for incidents/risks that affect all multi-agency partners, the Yorkshire & Humber Area Team provides strategic co-

ordination of the local health economy and represents the NHS at the South Yorkshire Local Resilience Forum (LRF). The initial

communication of an incident alert is to the first on-call officer of the Yorkshire & Humber Area Team.

The Loggist action card and recording proforma ensures a systematic process for tracking information flows and logging information

requests and being able to deal with multiple requests for information as part of normal business processes.

These arrangements are complemented by the South Yorkshire CCGs' "business as normal" communications channels which

include assessments of all key stakeholders.

The On Call Pack has media liaison guidance, and suggested approaches for managing media communications.

GREEN N/A N/A N/A

Duty to communicate with the public


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next 12 months.


core standard.


Governance

23

Arrangements ensure the ability to

communicate internally and externally during

communication equipment failures Y

• Have arrangements in place for resilient

communications, as far as reasonably practicable,

based on risk.

The South Yorkshire CCGs' IT providers have resilience arrangements in place.

Back-up mobile phones are available.GREEN N/A N/A N/A

24

Arrangements contain information sharing

protocols to ensure appropriate

communication with partners.

These must take into account and inclue DH (2007) Data Protection

and Sharing – Guidance for Emergency Planners and Responders or

any guidance which supercedes this, the FOI Act 2000, the Data

Protection Act 1998 and the CCA 2004 ‘duty to communicate with the

public’, or subsequent / additional legislation and/or guidance. Y

• Where possible channelling formal information

requests through as small as possible a number of

known routes.

• Sharing information via the Local Resilience Forum(s) /

Borough Resilience Forum(s) and other groups.

• Collectively developing an information sharing protocol

with the Local Resilience Forum(s) / Borough Resilience

Forum(s).

• Social networking tools may be of use here.

As Category 2 Responders, the South Yorkshire CCGs have a duty to share information and cooperate. In the event of an incident,

we will use our generic email addresses used for EPRR as the main route of communication and the Incident Control Centre

number as the main telephone number. The Communications Leads will coordinate communications.

We share information via the Local Health Resilience Partnership and via local Emergency Planning Meetings.

We have local Information Sharing Agreements (ISA) / Policies for "business as normal" across our local strategic partnerships

which also support EPRR. We also have social media accounts which are useful for rapid dissemination of information.

We have a mutual aid agreement for premises with our partner CCGs.

GREEN N/A N/A N/A

25

Organisations actively participate in or are

represented at the Local Resilience Forum

(or Borough Resilience Forum in London if

appropriate) Y

The South Yorkshire CCGs are representated at the Local Resilience Forum by the Yorkshire & Humber Area Team for NHS

England. Key action points from the Local Resilience Forum are reported through the Local Health Resilience Partnership, on which

the South Yorkshire & Bassetlaw CCGs are represented by the Chief of Corporate Services for NHS Doncaster CCG. Full post-

meeting feedback is provided to CCG Accountable Emergency Officers and operational EPRR leads. The South Yorkshire &

Bassetlaw CCGs are also represented on the Health Resilience Sub Group of the Local Health Resilience Partnership.

GREEN N/A N/A N/A

26

Demonstrate active engagement and co-

operation with other category 1 and 2

responders in accordance with the CCA

Y

The South Yorkshire CCGs have active EPRR engagement with partners through:

• Attendance at local area-specific Emergency Planning Meetings.

• The Chief of Corporate Services of NHS Doncaster CCG attending the LHRP as the representative of all South Yorkshire &

Bassetlaw CCGs.

• Representation on the Health Resilience Sub Group across South Yorkshire & Bassetlaw.

• Taking lessons learned from all resilience activities and partner exercises.

• Having a list of contacts among both Category 1 and Category 2 responders within South Yorkshire.

• Strategic contracting meetings with those we commission where emergency planning issues can be raised.

• System Resilience Group meetings.

• Regular assurance meetings with the Area Team and inclusion of NHS England within our escalation flowchart.

GREEN N/A N/A N/A

27

Arrangements include how mutual aid

agreements will be requested, co-ordinated

and maintained.

NB: mutual aid agreements are wider than staff and should include

equipment, services and supplies.

Y

The South Yorkshire CCG's EPRR Policies clearly detail the processes for requesting mutual aid of their partner CCGs.

The decant plan, should the Incident Control Centre be compromised, will be the premises of one of the other South Yorkshire &

Bassetlaw CCGs. This has been agreed with the partner CCGs under mutual aid.

GREEN N/A N/A N/A

28

Arrangements outline the procedure for

responding to incidents which affect two or

more Local Health Resilience Partnership

(LHRP) areas or Local Resilience Forum

(LRF) areas.

N/A

N/A N/A N/A N/A

29

Arrangements outline the procedure for

responding to incidents which affect two or

more regions.

N/A

N/A N/A N/A N/A

30

Arrangements demonstrate how

organisations support NHS England locally in

discharging its EPRR functions and duties

Examples include completing of SITREPs, cascading of information,

supporting mutual aid discussions, prioritising activities and/or

services etc. Y

The South Yorkshire CCG's EPRR Policies clearly detail the supportive role to NHS England in managing local incidents, if activated

in a "support" role to NHS England as a Category 2 Responder.GREEN N/A N/A N/A

31

Plans define how links will be made between

NHS England, the Department of Health and

PHE. Including how information relating to

national emergencies will be co-ordinated

and shared

N/A

N/A N/A N/A N/A

32

Arrangements are in place to ensure an

Local Health Resilience Partnership (LHRP)

(and/or Patch LHRP for the London region)

meets at least once every 6 months

N/A

N/A N/A N/A N/A

33

Arrangements are in place to ensure

attendance at all Local Health Resilience

Partnership meetings at a director level

Y

The Chief of Corporate Services of NHS Doncaster CCG attends the LHRP as the representative of all South Yorkshire CCGs and

feeds back action points to Emergency Accountable Officers after each meeting. GREEN N/A N/A N/A

34

Arrangements include a training plan with a

training needs analysis and ongoing training

of staff required to deliver the response to

emergencies and business continuity

incidents

• Staff are clear about their roles in a plan

• Training is linked to the National Occupational Standards and is

relevant and proportionate to the organisation type.

• Training is linked to Joint Emergency Response Interoperability

Programme (JESIP) where appropriate

• Arrangements demonstrate the provision to train an appropriate

number of staff and anyone else for whom training would be

appropriate for the purpose of ensuring that the plan(s) is effective

• Arrangements include providing training to an appropriate number of

staff to ensure that warning and informing arrangements are effective Y

The South Yorkshire CCGs' EPRR Policies (section 5.2) note that all staff will be offered relevant training commensurate with their

duties and responsibilities. Staff requiring support are asked to speak to their line manager in the first instance. Support may also

be obtained through their HR Department. Training can be accessed via the Local Resilience Forum (LRF).

We have also arranged Strategic Leadership in a Crisis training across the LHRP patch in the last year - this is linked to the

Occpuational Standards.

The JESIP framework and Decision Making Tool is included within the On Call Packs as an aide memoire.

GREEN N/A N/A N/A

• Taking lessons from all resilience activities and using

the Local Resilience Forum(s) / Borough Resilience

Forum(s) and the Local Health Resilience Partnership

and network meetings to share good practice

• Being able to demonstrate that people responsible for

carrying out function in the plan are aware of their roles

• Through direct and bilateral collaboration, requesting

that other Cat 1. and Cat 2 responders take part in your

exercises

• Refer to the NHS England guidance and National

Occupational Standards For Civil Contingencies when

identifying training needs.

• Developing and documenting a training and briefing

programme for staff and key stakeholders

• Being able to demonstrate lessons identified in

exercises and emergencies and business continuity

incidentshave been taken forward

• Programme and schedule for future updates of training

and exercising (with links to multi-agency exercising

where appropriate)

Information Sharing – mandatory requirements

Co-operation

Training And Exercising

• Attendance at or receipt of minutes from relevant Local

Resilience Forum(s) / Borough Resilience Forum(s)

meetings, that meetings take place and memebership is

quorat.

• Treating the Local Resilience Forum(s) / Borough

Resilience Forum(s) and the Local Health Resilience

Partnership as strategic level groups

• Taking lessons learned from all resilience activities

• Using the Local Resilience Forum(s) / Borough

Resilience Forum(s) and the Local Health Resilience

Partnership to consider policy initiatives

• Establish mutual aid agreements

• Identifying useful lessons from your own practice and

those learned from collaboration with other responders

and strategic thinking and using the Local Resilience

Forum(s) / Borough Resilience Forum(s) and the Local

Health Resilience Partnership to share them with

colleagues

• Having a list of contacts among both Cat. 1 and Cat 2.

responders with in the Local Resilience Forum(s) /

Borough Resilience Forum(s) area


CC

Gs


Self assessment RAG




next 12 months.




next 12 months.


core standard.


Governance

35

Arrangements include an ongoing exercising

programme that includes an exercising

needs analysis and informs future work.

• Exercises consider the need to validate plans and capabilities

• Arrangements must identify exercises which are relevant to local

risks and meet the needs of the organisation type and of other

interested parties.

• Arrangements are in line with NHS England requirements which

include a six-monthly communications test, annual table-top exercise

and live exercise at least once every three years.

• If possible, these exercises should involve relevant interested

parties.

• Lessons identified must be acted on as part of continuous

improvement.

• Arrangements include provision for carrying out exercises for the

purpose of ensuring warning and informing arrangements are

effective

Y

As statutory organisations the South Yorkshire CCGs learn lessons from all resilience activities (e.g. the North Yorskshire Boxing

Day floods) and use the Local Resilience Forum and the Local Health Resilience Partnership and network meetings to share good

practice.

The South Yorkshire are invited by our local Category 1 organisiations to participate in exercises and took part in Exercise Albireo in

April 2015. We take part in all NHS England led exercises, and in the past year have participated in the Blackout Exercise. We plan

to participate in the re-organised Exercise Cygnus in October 2016.

The South Yorkshire CCGs run local exercises where a "real" event has not already tested our resilience e.g. loss of power.

Our communications routes are tested by our Communications Leads.

GREEN N/A N/A N/A

36

Demonstrate organisation wide (including

oncall personnel) appropriate participation in

multi-agency exercises

Y

As statutory organisations the South Yorkshire CCGs learn lessons from all resilience activities (e.g. the North Yorskshire Boxing

Day floods) and use the Local Resilience Forum and the Local Health Resilience Partnership and network meetings to share good

practice.

The South Yorkshire are invited by our local Category 1 organisiations to participate in exercises and took part in Exercise Albireo in

April 2015. We take part in all NHS England led exercises, and in the past year have participated in the Blackout Exercise. We plan

to participate in the re-organised Exercise Cygnus in October 2016.

The South Yorkshire CCGs run local exercises where a "real" event has not already tested our resilience e.g. loss of power.

Our communications routes are tested by our Communications Leads.

On On Call Leads are given feedback from exercises to use within their roles, and also have access to Strategic Leadership in a

Crisis training.

GREEN N/A N/A N/A

37

Preparedness ensures all incident

commanders (oncall directors and

managers) maintain a continuous personal

development portfolio demonstrating training

and/or incident /exercise participation.

Y

Those individuals nominated within the South Yorkshire CCGs' policies have been briefed on their roles and offered training via the

LRF if desired. Most of the individuals have undertaken a similar role in the past and have not needed further training. All those who

may receive action cards in the event of an incident have received a pack with information. We have access to the NHS England

guidance on roles and responsibilities to support team members. All training needs and training accessed are recorded in annual

Personal Development Reviews.

GREEN N/A N/A N/A

where appropriate)

• Communications exercise every 6 months, table top

exercise annually and live exercise at least every three

years

Enc E

Chair & Chief Officer Report

1



Title of paper

Chair and Chief Officer Report


Dr David Crichton, Clinical Chair Mrs Jackie Pederson, Chief Officer

Author(s) Mrs Sarah Atkins Whatley, Chief of Corporate Services

Purpose of Paper - Executive Summary

The purpose of this report is to update the Governing Body on issues relating to the activity of the CCG of which the Governing Body needs to be aware, but which do not themselves warrant a full Governing Body paper. This month the paper includes updates on the following areas:

• Planning

• Consolidated data sharing with NHS Digital

• Member engagement model consultation

• Central Locality Lead vacancy

• Locality meeting feedback to Governing Body Recommendation(s)

The Governing Body is asked to:

• Note the report.

2

Impact analysis Quality impact Neutral

Equality impact

Neutral


Nil


Nil

Legal implications

Nil


Interest Paper is for information. No relevant interests.




Engagement with Governing Body members on the Doncaster

Place Plan at Strategy & Organisational Development Forum on 1 September 2016.

Consultation with Member Practices during July/August 2016 on

the Member Engagement model.

Report previously

presented at None

Risk analysis

None

Assurance Framework

3.2, 5.1, 6.2

3

Chair and Chief Officer Report September 2016

1. Planning Over the summer period we have continued to work in partnership on the Sustainability & Transformation Plan (STP), and particularly the finances to support the plan. Work continues on developing our approach to the Doncaster Place Plan (DPP) through regular meetings with senior representatives from local commissioning and provider organisations. Our Strategy & Organisational Development Forum received a presentation on the draft direction of travel at its meeting on 1 September 2016. The draft Place Plan is being developed by all parties in Doncaster and will include the vision of integrated community based services within a neighbourhood setting and the ambition to test this new neighbourhood model in the first instance in the commissioning of the new Intermediate Care model. It will also demonstrate an aspiration to commission in partnership with Local Authority commissioning colleagues, and articulate an ambition to move to a new model of service provision aligned to an Accountable Care Partnership approach. A draft Place Plan should be available by the end of September 2016 and the STP should be available by the end of October 2016. These will be presented to the Governing Body in due course. 2. Consolidated data sharing with NHS Digital NHS Digital is the new name for the Health & Social Care Information Centre. As a CCG, we have a number of information sharing agreements for information from NHS Digital which are supported by an overarching Data Sharing Contract. NHS Digital are now aligning all the individual information sharing agreements into a consolidated agreement, and we are working with NHS Digital towards this goal. Effective information sharing work is imperative, and the success of this will impact upon our Local Digital Roadmap ambitions and the opportunity to connect all IT systems together in Doncaster. 3. Member engagement model consultation Feedback from the CCG 360 Stakeholder Survey in 2016 and from discussions with Localities indicated that the CCG could potentially improve the way in which we engage with Member Practices and maximise the added value of clinical leadership / clinical engagement moving forwards. Building on the feedback from Member Practices, the following three member engagement options were developed by Governing Body members for Member

4

Practices to consider, and a consultation exercise on these options was run from Wednesday 20 July 2016 to Wednesday 31 August 2016. One vote was permitted per GP (there are approximately 240 GPs in total in Doncaster), with votes submitted via Survey Monkey, email, or paper. A discussion opportunity was afforded at Locality meetings scheduled in August.

Option 1: Current locality model, but with greater clarity of purpose on the

role of Locality Leads (5 Localities)

Option 2: Council of Members across Doncaster (in effect, 1 Locality)

Option 3: Constituency / MP model (no Localities, no direct member

engagement in clinical commissioning)

No matter which option was chosen by Members, a commitment was given to maintain the current level of elected clinical leadership i.e. 10 elected clinical leaders. The results of the consultation are:

Option Number of votes

% of vote

Option 1 – Current Locality model 45 56.25% Option 2 – Council of Members 30 37.5% Option 3 – Constituency / MP model 5 6.25%

TOTAL 80 Members have given a clear steer that they wish to retain the current Locality model of 5 Localities. Further discussions on refining the current model in line with feedback received will take place during September/October 2016. 4. Central Locality Lead vacancy Our Locality Lead for the Central Locality, Dr Sam Feeney, is leaving Doncaster at the end of September. The Central Locality requested that interim posts for between 3 and 6 months be advertised for both the current vacancy and to replace Dr Feeney. Permanent posts will be advertised when the recommendations from the member engagement model consultation have been finalised and agreed with Member Practices. We are pleased to confirm that Dr Nick Tupper has been appointed as Central Locality Lead and joined us week commencing 12th September 2016 for a period of 3 to 6 months. 5. Locality meeting feedback Individual Localities discussed the following topics:

5

North East Locality

• 1 hour commissioning meeting held.

o Member engagement structures – discussion of potential future models.

o Prescribing.

North West Locality



o Evaluation of the Social Prescribing pilot.

o GP collaboration.

Central Locality


o Transforming Primary Care – Proactive Primary Care specification


o Continuing Healthcare update.

o Prescribing gain-share local enhanced service.

o Central Locality Lead vacancy.

South East Locality


o Ambulance services feedback.


o Prescribing.

o Issues Log.

South West Locality



o Prescribing update.

o Pharmacy pilot evaluation.

6. Recommendations The Governing Body is asked to:

• Note the report.

Enc F

Items to Note

Enc F

Quality & Performance Report


Meeting date 15th September 2016

Title of paper

Quality & Performance Report


Mr Andrew Russell, Chief Nurse Mr Anthony Fitzgerald, Chief of Strategy & Delivery

Author(s) Performance and Intelligence Team Quality Team

Purpose of Paper - Executive Summary This report sets out the key quality and performance issues to be noted by the NHS Doncaster Clinical Commissioning Group (NHS Doncaster CCG) Governing Body. The report covers 5 main sections this month:

• Provider Performance - main local healthcare providers

• Other services commissioned by NHS Doncaster CCG

• Items for escalation regarding Local Delivery Plan in year delivery

• Doncaster Mental Health and Well Being Local Transformation Plan

• Doncaster Safeguarding Adults Board Annual Report 2015/16 The performance rating, indicated by Red, Amber or Green status, denotes the current month performance and does not reflect the historic trends. This is supported by a detailed appendix (Appendix 1) which highlights performance for NHS Doncaster CCG and all local providers with regards to the main performance indicators. The key areas of change, both positive and negative, to note since the last report are: Doncaster & Bassetlaw Hospitals NHS Foundation Trust (DBHFT)

• 5 patients were waiting over 52 weeks at the end of July

• August A&E performance was 91.9% against the NHS Improvement trajectory of 94%

• Cancer 62 day measures – all measures were met by the Trust again in June 2016 which is the fifth month running.

• Diagnostics met target in July 2016 for 4 months running, which is the first time since 2013.

Rotherham, Doncaster & South Humber NHS Foundation Trust (RDASH)

• IAPT Recovery Rate failed to meet target, at 46.6%, for the fifth consecutive month

Other Commissioned Services

• N/A

2

Local Delivery Plans

• None applicable

Recommendation(s) The NHS Doncaster CCG Governing Body is asked to:

• Note the key quality performance areas for attention

Impact analysis

Quality impact As identified in the report

Equality impact

Neutral


Nil


As identified in the report

Legal implications

Nil


Interest

The report is for information – no conflicts of interest identified. It should be noted that some Governing Body members may be

employed in secondary employment by organisations referenced in this report: please see Register of Interests for details.




N/A

Report previously

presented at N/A

Risk analysis

Risks are captured in the Executive Summary

Assurance Framework

2.1, 2.2, 2.4

3

INTRODUCTION This report sets out the key quality and performance issues to be noted by the NHS Doncaster Clinical Commissioning Group (NHS Doncaster CCG) Governing Body using July data unless noted. The report covers 5 main sections this month:

• Provider Performance - main local healthcare providers

• Other services commissioned by NHS Doncaster CCG

• Items for escalation regarding Local Delivery Plan in year delivery

• Doncaster Mental Health and Well Being Local Transformation Plan

• Doncaster Safeguarding Adults Board Annual Report 2015/16

The report is supported by a detailed appendix (Appendix 1) which highlights performance for NHS Doncaster CCG and all local providers with regards to the main performance indicators.

SECTION 1: PROVIDER PERFORMANCE REPORT

The following section of the report details performance for each main local provider, namely DBHFT and RDASH. Performance is across a range of quality and more traditional “performance” measures. As such the report includes performance as a whole for DBHFT and Doncaster sites for RDASH, and does not simply relate to the service provided to NHS Doncaster CCG.

Doncaster & Bassetlaw Hospitals NHS Foundation Trust

Governance

Time Period

June 2016 July 2016 August 2016

Changes to the Board

None Applicable

New Chair; Suzy Brain England OBE is set to

replace outgoing Chair, Chris Scholey, from 31 December

2016 and will serve a three year term.

Kirsty Edmondson-

Jones has been appointed as Director

of Estates and Facilities.

Jon Sargeant has been appointed as Director of Finance. He will commence in post on 31 October

2016

NHS Improvement Governance Rating

Red – Subject to enforcement action



Financial sustainability risk rating

1 1 1

4

The CCG have been attending a monthly Turnaround Board which reviews both the quality impact of the programme and any contractual impact, at this point the CCG are satisfied that all the appropriate risks have been identified. Further work is on-going to ensure the CCG and DBHFT wider delivery/transformational plans and the wider Sustainability and Transformation Plan (STP) align.

Mortality

The Trust's rolling 12 month Hospital Standardised Mortality Rate (HSMR) fell again to 92.42 at the end of May (a reduction from over 105 in the rolling annual position from July 2014 to June 2015).

Contractual actions

2016/17 Contract Queries: A contract query was issued during August 2016. This related to data quality concerns around DBHFT’s referral and Patient Tracking List (PTL) data and the resulting uncertainty of waiting times. A partial response was received following the query, however the formal response due by the 30

th August is awaited at the time of writing.

Performance Notices: zero. Number of serious incidents reported

(CCG)

Q4 2015/16 - 30 Q1 2016/17 – 22 July 2016 - 4

Please note that the above figures include incidents which may be subsequently de-logged as a SI.

Patient Experience

Time Period

April 2016 May 2016 June 2016 July 2016

Complaints/concerns Opened

119 124 138 85

Complaints and concerns fell in July 2016 and the response times in resolving these remains low with just over 30% being resolved within the required timescale. There continues to be an overall reduction in the amount of complaints and concerns received (22% fewer than Q4 2015/16 and 10% fewer than Q1 2015/16). Numbers of complaints relating to children and families have seen a particular reduction. The main reasons for complaints are related to:

- communication, - staff attitude - admissions, transfers and discharge procedures - sleepers out.

No complaints were referred to the Ombudsman in quarter 1. None of the two investigations undertaken in quarter 1 were upheld. DBHFT are reviewing response rates and ways to improve performance and the CCG has requested further information once available.

5

Friends & Family Test

Inpatients

A&E

Outpatients

DBHFT remain above the national average on all indicators except for A&E response rates. While the A&E response rate has improved further work is required with the Care Group to improve performance.

Friends & Family test

Antenatal

Birth

6

Postnatal

Workforce

Time Period

July 2016 Following the initial reporting of care hours per patient day data this has now been updated for May to July 2016. For the first three months of data collection (May 2016 – July 2016) information has been consistent; It is still not currently clear how these figures compare nationally, however moving forward it is anticipated that DBHFT will be able to see how our CHPPD relates to other Trusts within a specialty and by ward to identify how we can improve our staff deployment and productivity.

Site Registered

midwives/nurses Care Staff Overall

Bassetlaw 5.1 3.8 8.9

Doncaster Royal Infirmary

4.2 2.9 7.1

Montagu 2.2 2.5 4.7

Trusts 4.2 3.0 7.2

Safety

Time Period Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16 July 16

Number of Never Events

(cumulative during financial

year)

1 1 2 2 0 0 0 0

There were no never events in July 2016.

MRSA (cumulative

during financial year)

1 1 1 2 0 0 1 1

There were no cases of MRSA in July 2016.

7

C-diff Actual

Trajectory (NHSE cum. target 40)

26 27 29 32 0 4 7 10

36 40 44 45 3 6 9 12

Hospital Acquired Pressure Ulcers

(category 3, 4 and ungradeable,

target of less than 60 in 2016/17)

Q4 2015/16 - 10 Q1 2016/17 – 9 July 2016 - 3

The July position is prior to the Root Cause Analysis process being completed.

Serious Falls (target of less than 29 during

2016/17)

Q4 2015/16 - 5 Q1 2016/17 – 1 July 2016 - 2

The July position is prior to the Root Cause Analysis process being completed.

Operational Effectiveness

Time Period

Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May

16 Jun 16 Jul 16

18 week Referral to Treatment Times Incomplete Waits

(target 92%)

92.1% 92.3% 92.1% 92.1% 92.9% 93.1% 92.8% 92.6%

The position for Incomplete pathways in June fell by 0.2% to 92.6% which is compliant with the standard (92% of patients waiting under 18 weeks). Four specialities failed to meet the standard:

• General Surgery, 89.8%

• General Medicine 90.9%

• Urology 88.8%

• Trauma and Orthopaedics 90.4%

General Surgery performance has been adversely affected by the lack of junior medical staff at Bassetlaw District General Hospital, which led to a reduction in operating capacity. The service has an action plan in place which includes: - training existing staff - releasing them from other duties - recruitment. A review of General Medicine RTT performance took place with the service and the CCG in August to further understand the issues and actions to be taken. These include recruitment to a consultant vacancy, a new post of Patient Pathways Administrator to support management of waiting lists and a review of capacity and demand modelling to improve efficiency. Urology demand has been raised with Commissioners and alternative pathways are being reviewed to increase internal capacity. Trauma and orthopaedics had workforce issues at consultant level which impacted on performance. A review of T&O RTT performance is taking place with the service and the CCG in September to further understand the issues and determine remedial actions.

R

8

6 week referral to Diagnostic test

times (target 99%)

Dec 15 Jan 16

Feb 16 Mar 16 Apr 16 May 16

Jun 16 Jul 16

96.5% 99.5% 99.7% 98.3% 99.2% 99.5% 99.6% 99.2%

52 Week Waits – Incomplete Pathway

Nov 15

Dec 15

Jan 16

Feb 16

Mar 16

Apr 16

May 16

Jun 16

Jul 16

DCCG 0 0 0 0 0 0 0 4 3

Other 0 0 0 0 0 0 0 0 2

NHSE 0 0 0 0 0 1 0 0 0

There were 3 ENT patients waiting over 52 weeks at the end of July at DBHFT of whom 2 were Doncaster CCG patients. These patients were identified through continuing data validation work on the waiting lists following the implementation of CaMIS. All 3 patients have now been seen and breach reports for each have been produced and shared with Doncaster CCG. A further Doncaster CCG patient was waiting over 52 weeks for a General Medicine appointment, with the final patient from Bassetlaw CCG waiting for a Musculoskeletal appointment; both patients were seen in August 2016. All patients have been clinically reviewed and no undue harm has come to these patients due to the delay in their pathway. An exclusions report is now in place to ensure that any patients who have the wrong code input following their outpatient appointments are reviewed to ensure that patients are seen in a timely manner.

4 Hour access - total time in the A&E department

(target 95%)

FCMS – Urgent Care Centre (UCC)

Performance contributing to

Dec 15

Jan 16

Feb 16

Mar 16

Apr 16

May 16

June 16

July 16

Aug 16

95.5% 92.1% 92.5% 92.5% 95.1%

93.1%

92.2%

92.8%

91.9%

100% 100% 100% 100% 100% 100% 100% 100% 100%

DBHFT’s August position fell to 91.9% below the 95% standard of patients being discharged or transferred within 4 hours and also the Q2 94% recovery trajectory set with NHS Improvement.

R

9

Total A&E Performance above

Together with NHS Improvement, NHS England are mobilising a plan to support recovery of A&E performance in 2016/17. The plan focuses on ensuring that all health systems adopt a standard approach to urgent and emergency care best practice as set out in the NHS England report on transforming urgent and emergency care services: Safer, Faster, Better. At a local level, all systems are asked to implement five mandated initiatives to improve performance:

• Introduce primary and ambulatory care streaming in the Emergency Department.

• Increase the proportion of NHS 111 calls handled by clinicians. • Implement the Ambulance Response Programme (Dispatch on

Disposition and improved Clinical Coding). • Implement measures to improve in-hospital flow. • Implement discharge best practice to reduce Delayed Transfers of Care

(Discharge to Assess, Trusted Assessor). Nationally A&E Delivery Boards will be set up across local regions with NHS England and NHS Improvement teams to support delivery, manage high risk systems, report progress, and deploy improvement support.

Cancelled Operations

(target <0.8%)

Nov 15 Dec 15

Jan 16 Feb 16

Mar 16 Apr 16

May 16

Jun 16

Jul 16

1.3% 2.0% 2.9% 2.1% 1.1% 1.2% 1.2% 1.4% 1.2%

Cancelled operations (cancelled on the day of operation) fell to 1.2% in July 2016 (1.0% in July 2015).

Cancelled Operations-28 Day

Standard

Nov 15

Dec 15

Jan 16 Feb 16

Mar 16 Apr 16

May 16

June 16

July 16

1 2 5 2 2 0 2 2 1

There was 1 breach of the 28 day standard in July where a patient was not offered another appointment for their operation within the 28 days. This was for spinal surgery in the T&O specialty and the revised appointment date for the patient is currently being checked.

Outpatient DNA rate of total

appointments

9.5% 7.9% 7.6% 8.2% 8.2% 8.7% 10.1% 8.8%

Two week wait from referral to date first seen: symptomatic

breast patients (target 93%)

Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 June 16

94.6% 93.3% 94.9% 97.4% 96.3% 93.4% 95.8% 93.8%

Two week wait from referral to date first

seen: all urgent cancer referrals

(cancer suspected) (target 93%)

95.0% 95.0% 93.5% 96.6% 94.9% 93.1% 93.1% 94.0%

10

31 day wait from diagnosis to first

definitive treatment (target 96%)

98.2% 99.4% 97.6% 97.6% 98.0% 99.3% 99.4% 98.6%

31 day wait for subsequent

treatment – surgery (target 94%)

90.0% 100% 100% 100% 100% 100% 100% 100%

31 day wait for subsequent

treatment – anti cancer drug

regimen (target 98%)

100% 100% 100% 100% 100% 100% 100% 100%

31 day wait for subsequent treatment –

Radiotherapy (target 94%)

100% 100% 100% 100% 100% 100% 100% 100%

62 day wait for first treatment from

urgent GP referral to treatment (target

85%)

81.5% 89.3% 76.3% 85.2% 90.2% 86.6% 89.7% 86.0%

62 day wait for first treatment from NHS

cancer screening service referral

(target 90%)

91.5% 95.8% 82.4% 91.9% 100% 93.3% 100% 100%

Cancer Summary All cancer measures met the respective standards in June 2016, for the fifth month running.

Outliers (Daily averages)

Medicine to Orthopaedics Medicine to S12 Medicine to surgery Medicine to gynaecology

June 2016 July 2016

Most Outliers

Least Outliers

Average Outliers

Most Outliers

Least Outliers

Average Outliers

16 6 10 18 0 6

9 0 2 6 1 3

24 7 13 19 6 12

12 5 8 11 3 6

11

The number of outliers is monitored and is raised through appropriate joint Trust and CCG Groups as necessary.

CQUINs

Local Intelligence Issues

Time Period April 2016 May 2016

Stroke: Proportion of patients scanned under 1 hour of clock start (target 48%)

42.9% 52.5%

Stroke: Proportion of patients directly admitted to a stroke unit under 4 hours

(target 90%)

69.6% 70.0%

Stroke: Proportion of eligible patients (according to the RCP guideline minimum threshold) given thrombolysis (target 90%)

100% 100%

2016/17

Quarter 1 The quarter 1 evidence has now been received by the Trust. Commissioners have met with the Trust and attainment has been agreed. A full attainment breakdown will be included within the next report following sign off at the Clinical Quality Review Group.

Quarter 2 The quarter 2 evidence is due from the Trust at the end of October 2016.

Quarter 3 The quarter 3 evidence is due from the Trust at the end of January 2017.

Quarter 4 The quarter 4 evidence is due from the Trust at the end of February 2017.

12

Stroke: Proportion of applicable patients receiving a joint health and social care plan

on discharge (target 90%)

87.5% 77.1%

Stroke: Percentage of patients treated by a stroke skilled early supported discharge

team (target 40%)

73.6% 67.6%

Stroke: Percentage of applicable patients who are discharged who were given a

named person to contact after discharge (target 95%)

79.2% 73.0%

Stroke: TIA patients assessed and treated within 24 hours (target 60%)

66.7% 60.5%

Stroke Summary Performance measures have been refreshed from April to reflect those measures most underperforming. The key pathway remains direct admission to a stroke unit, this month’s performance levels are based on 48 discharges. 29 patients were directly transferred within 4 hours, an additional 5 patients were admitted within 4hours 20minutes and a further 6 within 4 hours 50minutes. 5 patients were admitted after 10 hours as their presenting symptoms were not suggestive of a stroke. If these 5 patients had been admitted performance would have been 93.8%. A service review is currently being undertaken by CCG and DMBC with the provider. It is proposed that as part of the review an away day with provider staff will be held in October/November to address some of the pathway issues.

13

Rotherham, Doncaster & South Humber NHS Foundation Trust

Governance

Time Period

May 2016 June 2016 July 2016 Aug 2016

Number of serious incidents reported

12 12 7 13

Monitor Governance Rating

Green Green Green Green

Monitor Financial sustainability risk rating

3 3 3 3

No evident concerns.

Contractual Actions

No contractual actions were undertaken during August 2016.

Patient Experience

Friends and Family Test Mental Health

Performance recovered in June and was above the England average but remains sporadic. Detailed comments for all FFT areas are shared with DCCG’s Patient Experience Manager and the Trust share learning across their service teams.

Friends and Family Test Community

The percentage of people recommending community services continues to perform at around 75-80%. As above these results are shared with DCCG’s Patient Experience Manager and the Trust share learning across their service teams. A further response has been requested from the Trust in relation to improving performance.

14

Workforce

Time Period

June 2016

Overview by exception Cusworth – The day shift during June for Qualified staff was red rated at 83.2%. Further information around this is awaited at the time of writing. Skelbrooke – There were 7 red, 6 amber/red and 1 amber shift up to the 22

nd May. Early ratings were due to sickness and bank cancellations

and ratings later in the month were due to staff and bank sickness and vacancies. Early red and amber/red shifts were primarily over the second half of each week but were spread across all days and shifts for the week commencing 16/05/2016. An increase in staff is required to meet the needs of service users. Hawthorne - There were 13 amber/red shifts across the month primarily due to sickness. These shifts were supported by additional Non Professionally Qualified staff and senior managers were available for support if required. No incidents occurred and the Ward remained safe. Staffing from Hazel was utilised to provide support.

Safety

Operational Effectiveness

Time Period

Jan 16 Feb 16 Mar 16 Apr 16 May 16 June

16 July 16

Improved access to psychological services - the

proportion of people

61.6% 57.2% 46.4% 44.1% 46.1% 44.4% 46.6%

The IAPT recovery rate has not achieved target for the last 5 months. A meeting with the provider, lead Commissioner and Performance Team

Time Period

Oct 15

Nov 15

Dec 15

Jan 16

Feb 16

Mar 16

Apr 16

May 16

June 16

July 16

Number of Never Events

0 0 0 0 0 0 0 0 0 0

MRSA (cumulative during financial

year)

0 0 0 0 0 0 0 0 0 0

C-diff Actual

(cumulative during financial year)

6 6 6 6 6 6 0 1 1 1

These cases are attributed to NHS Doncaster CCG and apportioned to RDASH. If RDASH services are involved in the clinical management of the patient the root cause analysis is carried out by the RDASH Infection Prevention and Control Team.

15

who complete treatment who are

moving to recovery (Target – 50%)

was held in August and an action plan developed. Further meetings will be held monthly to review these actions and their impacts. One of the main reasons for under performance has been identified as increasingly complex patients being referred into the service, some of whom would be more appropriately treated in other settings. Initial unvalidated reports suggest performance has begun to improve but all actions from the plan should be completed by October 2016.

Improving Access to Psychological

Therapies (IAPT), cumulative – Access

(Target 4.38% per quarter, 17.5%

annually)

14.7% 16.3% 17.4% 1.7% 3.3% 5.1% 6.8%

IAPT – Reliable Improvement (no

target)

66.3% 68.8% 66.1% 65.7% 67.9% 67.8% 66.0%

Percentage of referrals to IAPT who

have received 1st

treatment within 6 weeks (target 75%)

82.8% 86.7% 87.5% 76.6% 82.6% 81.1% 84.9%

Percentage of referrals to IAPT who

have received 1st

treatment within 18 weeks (target 95%)

99.4% 98.9% 99.4% 99.0% 98.7% 99.2% 99.2%

IAPT DNAs 13.0% 13.3% 10.6% 12.9% 12.1% 11.8% 11.2%

Adults receiving a 12 month S117 review compliance (Target

95%)

91.3% 92.0% 91.6 91.0% 94.5% 93.8% 93.4%

The Doncaster Borough wide S117 group is currently reviewing the processes around patients with outstanding reviews.

The percentage of older people

requiring non urgent treatment (mental

health) who receive treatment within 6

weeks of assessment (8 week pathway)

(Target 85%)

78.4% 78.5% 86.3% 78.4% 77.3% 78.8% 78.8%

Following a review by RDASH the majority of breaches are due to delays in receiving results from diagnostic tests from other providers. Meetings have been arranged to work through the issues around these transfers to ensure that no unnecessary delays occur. This part of the pathway is also being discussed as part of the potential reduction in waiting times, as per national guidance, that dementia patients are diagnosed within 6 weeks by 2020.

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The percentage of new patient waits for

podiatry within 18 weeks incomplete waits (target 95%)

100% 100% 100% 100% 100% 100% 100%

The percentage of patients seen within 18 weeks of referral to Evergreen Falls Prevention Service incomplete waits

(target 95%)

88.8% 100% 100% 100% 100% 100% 100%

The percentage of patients seen within 18 weeks of referral

to Dietician incomplete waits

(target 95%)

99.0% 100% 95.7% 95.7% 95.7% 96.1% 100%

There continues to be capacity and demand issues which are highlighted on the DCIS risk register. The service currently has a locum member of staff employed to increase capacity within the team. Commissioners are fully aware and performance will continue to be monitored via monthly contract monitoring meetings.

Percentage of urgent referrals to CAMHS triaged within 24 hours of receipt

(target 95%)

100% 100% 98.0% 98.5% 99.4% 97.3% 100%

Percentage of urgent referrals to CAMHS assessed within 24

hours of receipt (target 98%)

100% 100% 100% 71.4% 100% 100% 100%

Percentage of assessed CAMHS

patients starting their treatment plan within

8 weeks of referral (target 98% for

2016/17)

85.2% 86.0% 97.0% 84.8% 87.3% 84.8% 97.5%

There was one patient who breached during July but was still seen within the month. Exception reports to understand the reasons for breaches are provided to NHS Doncaster in quarterly review meetings.

(New local measure) Percentage of

patients classed as an emergency who

are assessed within a maximum of 4 hours

(target =>98%)

N/A N/A N/A 100% 100% 100% 100%

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Percentage of non-urgent referrals

assessed within 4 weeks

75.0% 92.4% 93.5% 78.1% 80.7% 80.3% 66.0%

There were a total of 16 breaches during July, all of which were assessed during the month. Further information has been requested from the Trust to understand the underlying pressures on the service in relation to reaching this assessment target.

CQUINs

2016/17

Quarter 1

The quarter 1 evidence has now been received by the Trust. Commissioners have met with the Trust and attainment has been agreed. A full attainment breakdown will be included within the next report following sign off at the Clinical Quality Review Group.

Quarter 2

The quarter 2 evidence is due from the Trust at the end of October 2016.

Quarter 3

The quarter 3 evidence is due from the Trust at the end of January 2017.

Quarter 4

The quarter 4 evidence is due from the Trust at the end of February 2017.

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SECTION 2: OTHER COMMISSIONED SERVICES 2.1 FCMS

Patient Satisfaction Patient Satisfaction Questionnaires and the Friends and Family Test are distributed regularly to patients of FCMS services. The results for Q1 are summarised below: Emergency Care

Practitioner Urgent Care Centre and Out of Hours

Same Day Health Centre

Percentage of patients rating the overall service they received as good or excellent

98.5% 97.6% 96.1%

FFT – percentage of service users likely to recommend the service

April May June

FCMS Total 92.8% 94.3% 90.5% Unplanned Care Centre 89.3% 94.0% 97.3% Same Day Health Centre 100% 94.7% 83.8%

Clinical Audits Call Handlers and Clinicians are audited on a monthly basis against a set of criteria appropriate to the role. For Call Handlers, two cases are audited each and if they fall below a set standard, further cases are audited and feedback provided to the staff member. For clinicians, nine criteria are marked by the auditor from 0 to 2 (highest showing that expectations have been met). The results have then been grouped below by GP and Nurse Practitioner or Emergency Care Practitioner. May shows the highest results of the 3 months. GP Responses March April May

% of audits scoring 8 or below 2.59% 4.89% 1.82% % of audits scoring 9-13 9.48% 8.65% 7.30% % audits scoring 14 and above 87.93% 86.47% 88.69%

NP/ECP Responses March April May

% of audits scoring 8 or below 0% 0% 2.36% % of audits scoring 9-13 7.62% 2.94% 3.15% % audits scoring 14 and above 92.38% 92.16% 94.21%

Urgent Care Centre

Dec 15

Jan 16

Feb 16

Mar 16

Apr 16

May 16

June 16

July 16

Aug 16

FCMS – Urgent Care Centre (UCC) Performance against

4 hour A&E target

100% 100% 100% 100% 100% 100% 100% 100% 100%

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Of the patients who have been streamed to the Urgent Care Centre by the Front Door Assessment and Signposting Service since October, all patients waited less than 4 hours to be seen in the UCC. Out of Hours

Definitive Clinical Assessment

Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16 Jul 16

Telephone clinical assessment - <20 min

(target 95%)

93.16% 92.12% 95.70% 97.33% 97.34% 97.89% 98.87% 98.34% 97.35%

Telephone clinical assessment - <60 min

(target 95%)

89.49% 62.03% 79.81% 92.28% 89.59% 97.48% 97.10% 96.50% 89.45%

For those patients requiring definitive clinical assessment via telephone within 60 minutes, 369 of 3494 were not assessed within the hour. The majority of the breaches occurred on specific days in the month where FCMS had difficulties filling shifts due to short notice cancellations for various reasons. In these circumstances business continuity arrangements were enacted and FCMS made all efforts to cover shifts, including the use of agencies, ECPs, Nurses and Nurse Prescribers.

Surgery Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16 Jul 16

Face to face assessment (base) – triaged as emergency in <1 hour (target 95%)

33.33% (1/3)

50.00% (1/2)

50.00% (1/2)

25.00% (2/8)

50.00% (2/4)

33.33% (2/6)

100.00%

(5/5)

80.00% (4/5)

54.55% (6/11)

Face to face assessment (base) –

triaged as urgent in <2 hours (target 95%)

78.26% (72/92)

62.77% (86/ 137)

68.89% (93/ 135)

90.91% (100/ 110)

74.87% (140/ 187)

87.58% (134/ 153)

84.69% (166/ 196)

88.39% (137/ 155)

71.00% (142/ 200)

Face to face assessment (base) –


98.48% 97.26% 97.46% 98.61% 97.72% 98.72% 97.67% 97.67% 97.30%

For the 5 patients requiring a face to face attendance within an hour who breached, 2 appear to be due to patient choice of appointment time and the remaining 3 appointments took place just beyond the hour which may have been a combination of patient choice and slot utilisation.

Of the 58 patients not having an attendance within 2 hours, 25 took place within 2 hours of the GP triage but missed the 2 hour window from the start of the NHS Pathways assessment on which this indicator is measured. 19 were due to either

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patient choice or slot utilisation, 3 patients did not attend the appointment and these were not completed as such in Adastra; 4 patients were late for their appointment and 7 were due to clinician delay. FCMS is working with clinicians to improve utilisation of appointments and to ensure enough time is given for delays within the time window for the priority of the patient.

Visits Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16 Jul 16

Face to face assessment (visit) –

triaged as emergency in <1 hour (target 95%)

55.56 %

(5/9)

33.33% (1/3)

66.67% (2/3)

50.00% (1/2)

40.00% (2/5)

75.00% (3/4)

100.00%

(2/2)

50.00% (2/4)

60.00% (3/5)



69.09% (38/55)

83.64% (46/55)

62.82% (49/78)

63.27% (31/49)

78.87% (56/71)

82.69% (43/52)

78.46% (51/65)

72.00% (36/50)

89.23% (58/65)



97.54% 91.89

% 92.29% 91.61% 97.45% 97.03% 98.94% 96.61% 96.28%

For the 2 patients requiring a visit within 1 hour who weren’t seen in time, one patient was in fact seen within the hour and has been reported incorrectly in the system, the other patient was seen 4 minutes over the hour. 7 patients were not visited within 2 hours, for 1 of these the time seen was not documented due to a failure with the remote device; 3 patients were actually seen within the 2 hours but has been reported incorrectly in the system; 1 patient was seen within 2 hours of the GP triage but not from the NHS Pathways assessment which is the start time for this measure; for 2 patients the clinician arrived after the 2 hour window. Actions are ongoing to ensure cases are recorded correctly in Adastra, and a reporting change is being implemented to correct the definition for visit cases, so only true breaches are reported. Same Day Health Centre

Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16 Jul 16

Face to face appointment – triaged as emergency seen in <1 hour (target 95%)

28.57% (16/56)

28.57% (18/63)

20.00% (22/ 110)

11.22% (12/ 107)

17.00% (17/ 100)

16.67% (9/54)

39.39% (13/33)

32.00% (8/25)

66.67% (20/30)

Face to face appointment – triaged as emergency seen in

53.42% (86/ 161)

50.30% (83/ 165)

48.17% (92/ 191)

49.21% (94/ 191)

47.19% (109/ 231)

55.17% (112/ 203)

68.54% (122/ 178)

74.09% (143/ 193)

72.56%(119/ 164)

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<2 hours (target 95%)

Face to face appointment – triaged as emergency seen in <24 hours (target 95%)

100.00%

99.48% 99.47% 99.59% 99.55% 99.03% 99.57% 99.21% 99.69%

For the 10 patients who did not have an appointment within 1 hour, and the 45 patients who did not have an appointment within 2 hours, it is likely the patients chose an appointment outside the timeframe. FCMS is implementing a process for these to be recorded as such. 2.2. Yorkshire Ambulance Service (YAS) NHS Doncaster CCG YAS Performance: Original Category Performance

October November December January February March

R1 MTD

72.03% 68.18% 59.13% 68.97% 62.88% 64.47%

R1 YTD 71.05% 70.66% 69.24% 69.21% 68.50% 68.04% R2 MTD

66.96% 65.54% 64.41% 65.79% 64.01% 64.80%

R2 YTD 67.99% 67.65% 67.22% 67.05% 66.75% 64.48%

Performance during Ambulance Response Programme Pilot April (21

st

– 30th

) May June July August YTD

Red < 8 min 68.5% 66.1% 62.5% 63.2% 66.8% 65.0% Amber R < 19 min 86.8% 79.9% 89.4% 58.8% 83.4% 79.0% Amber T < 19 min 76.2% 66.5% 66.7% 53.4% 73.6% 68.0% Amber F < 19 min 87.0% 73.4% 62.5% 55.7% 74.1% 73.0% Green F <60 min 86.2% 76.3% 100% 76.0% 82.5% 74.8% Green T <60 min 77.5% 75.9% 78.9% 68.1% 74.9% 73.3% Green H <60 min 100% 100% 100% 97.5% 99.2% 99.8%

Please note that performance standards for the new categories have not yet been confirmed.

YAS, NHS England and wider partners continue to review the new Ambulance Response Programme pilot. They will assess the impact on the patients both in terms of quality and performance, the clinical codes within both NHS Pathways and the Advance Medical Priority Dispatch System (AMPDS) to ensure the most appropriate clinical response is made to every call and will see significant changes to the way the service responds to patients. It will also enable decisions on the most appropriate response for patients’ needs. Initial findings suggests the acuity of calls is higher than anticipated so may result in the requirement to move ambulance response vehicles to a higher ratio of transport vehicles.

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2.3 Nursing / Care Homes / Domiciliary Care Providers

The information provided within this section is taken up to 31st August 2016. Since the last Governing body meeting there has been 1 new embargo against admissions / new care packages placed.

At present there are 3 providers within Doncaster with embargoes in place and 0 providers with restrictions in place.

2.4 Serious Case Reviews / Lesson Learnt Reviews

No new Serious Case Reviews or Lessons Learnt Reviews have been recommended or commissioned since the last Governing Body Report.

SECTION 3: NHS Doncaster CCG Local Delivery Plans- Items to note There were no items of escalation this month.

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SECTION 4: Doncaster Mental Health and Well Being Local Transformation Plan

Doncaster Mental Health and Well Being

Local Transformation Plan

Quarter 1 Update 2016/17

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Contents 1. Executive Summary 2. Progress to Date 3. Local Priority Scheme Summary 4. Appendices

4.1 Issues & Risks to Delivery 4.2 Spend & Activity Overview

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1. Executive Summary The report provides an update on our local transformation plan at the end of Quarter One 2016/17, looking at each of the areas and offers a local progress rating. On the whole there has been good progress made with no areas scoring below a satisfactory rating and some areas with a very good rating. There has been a very positive response from education, particularly in terms of nominated named mental health leads, which is being further reinforced by the locality meetings and on-going communication. There has been lots of focus has been in this area in this quarter and it is paying dividends. The workforce audit has been an excellent piece of work that gives a solid base to build the subsequent strategy and one that captures all the key points. Young Minds are making very good progress with engagement and the development of a Youth participation approach. Recruitment has been positive with only three posts vacant and although there will be a slight delay in some elements of the transformation, things are moving forward positively. Slight areas of concern are perinatal mental health and the development of a regional section 136 suite. 2. Progress to Date It is worth noting that there is a clear implementation plan that underpins delivery. 1. Resilience, Prevention and Early Intervention for the Mental Well-Being of Children and Young People Aim: To act early to prevent harm by investing in universal services, supporting families and those who care for children, building resilience through to adulthood. We also want to develop and implement strategies that support self-care. A local task and finish group has been set-up to lead on the implementation of this area of the LTP. Membership has been agreed and initial meetings held. Membership is at the right level and there is an underlying philosophy of accountability. 1.1. Support universal services Why is this a priority? The lack of a co-ordinated early help offer has led to high levels of inappropriate referrals into CAMHs and therefore children and young people not being seen by the right person at the right time. There are gaps in universal service workforce expertise around mental health and wellbeing and significant variance in links between education and CAMHs and Primary Care and CAMHs. There is a single point of access into CAMHs but not to the wider mental health and wellbeing services. How will we do this:

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• Named mental health leads in schools/ academies

• Create a single point of access Progress to Date: A letter has been sent out to all schools/ academies in the Borough from the Assistant Director for Education, asking for nominations for named mental health and wellbeing leads. The current number of schools who have responded is really positive. A breakdown per locality is as follows: North 23/35 - 66% East 19/27 - 70% South 31/37 - 84 % Central 23/26 - 88% 96/ 125 schools in total Response rate 77% Interestingly the overall KPI target for March 2017 is 75% so already we have achieved this. We fully expect this number to grow once schools are back in September. The plan thereafter is that once the new consultation and advice model is implemented, schools/ academies will sell it to their colleagues as they realise the benefits. There is a fairly even split between the schools and academies that haven’t responded and work is on going to engage with these. Work is on going with the 14 pilot schools and we are delighted with how this is progressing. There are representatives from some pilot schools on the respective task and finish groups that are charged with overseeing the implementation. The (1WTE) CAMHs worker remains in the Early Help Hub, and is now in the latter stages of completing the necessary proprietary work and establishing joint working relationships. Two other CAMHs workers that will deliver the consultation and advice functions to enable skill sharing and an understanding of roles have supported them. There has been a change of management of the Hub that has led to some slight changes and these are being worked through at a strategic level. There is still a clear intent to have a SPOA linked to Early Help but this may also extend to include higher end Social Care issues, in effect creating one front door. We are in the later stages of moving the CAMHs duty functions into this SPOA, which will add greater resource and opportunities for skill sharing, i.e. joint home visits between CAMHs and Social Care. Progress rating: Very Good 1.2. Apps and digital Tools Why is this a priority? We know that children and young people value digital support, but there is not a co-ordinated and validated offer locally. Currently support for mental health and wellbeing predominantly comes from CAMHs. How will we do this:

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• Work with local CYP to review existing tools and trial new ones. Progress to Date: Young Minds have established local links (see section 4.3) and are in the process of recruiting Youth Participation Champions, who will act as the expert reference group in terms of this area of work. Work is ongoing to develop an options paper that short-lists some possible digital options and will be presented to the mental health and wellbeing strategy group in July for discussion. Progress Rating: Good 1.3. Perinatal mental health Why is this a priority? There are 1,256 women in Doncaster who are likely to suffer from some degree of mental illness during pregnancy or within one year of giving birth How will we do this:

• By learning from a local pilot and national guidance. Progress to Date: The interim evaluation report of the pilot was submitted on 8th April 2016. There are some key learning points from this and a decision will be made on future commissioning decisions once the final evaluation paper is submitted in July 2016. We are also waiting on confirmation on future funding as per previous guidance and the recent prime ministers statement. Progress Rating: Satisfactory 2. Improving Access to Effective Support

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Aim: To change how care is delievered and build it around the needs of children, young people and their families. We will move away from a system of care delievered in terms of what services, organisations provide, to ensure that children and young people have early access to the right support at the right time in the right place. A local task and finish group has been set-up to lead on the implementation of this area of the LTP. Membership has been agreed and initial meetings held. Membership is at the right level and there is an underlying philosophy of accountability. 2.1. Move away from the current tiered system of mental health services. Why is this a priority? There is variance in the skills and competencies of staff in universal services (including schools and Primary Care). There is very little consultation with CAMHs prior to referral and a high number of inappropriate referrals. How we will do this:

• By having new CAMHs workers based within the community who act as dedicated named contact points for all schools and GP practices.

• Implementation of a consultation and advice CAMHs outreach service Progress to Date: The model has been agreed locally and is captured within the main service specification. There has been lots of on-going engagement with stakeholders at both strategic and operational levels to ensure the new consultation and advice functions fit within the wider system. This has involved a big focus on communicating the wider LTP and to keep it on every-one’s radar during the recruitment phase. There are currently 1.5WTE practitioners in post (0.5WTE phasing into post) with 3WTE more appointed in April. The final post is back out to advert and we expect the whole 6WTE resource to be in place ready for a full go live date in September when the schools return. Staff will be phasing into role when relevant checks are done and notice periods completed. They will build upon the work already completed by the in-post practitioners who have been building links with the pilot schools and testing the model, which has received positive feedback. Doncaster is split into four localities and each locality will have a named worker, supported by two floating staff (holiday cover etc). The staff will share resource and expertise to best meet need. Progress Rating: Good 2.2. Ensure the support and intervention for young people in the mental health concordat are implemented. Why is this a priority?

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Children and young people in Doncaster were admitted to hospital for attempted suicide and we have others in crisis. All elements of the crisis care concordat are not currently being implemented. How will we do this:

• New 24/7 all age crisis telephone helpline.

• CAMHs interface and liaison nurse placed in acute hospital setting.

• Liaison and diversion service to be aware of CYP services.

• Explore options of regional section 136-suite and crisis accommodation. Progress to Date: here The 24/7 crisis support helpline went live in September and up to 31st March 2016 had received 37 enquiries for under 18 year olds. A high level analysis was completed to give an insight into this cohort and the destination after the helpline. Further detail will be available at the year-end review in Oct 2016. There is a current issue regarding the workforce’s competencies to deal with under 18 year olds so a training programme will begin from July 2016 and we expect all staff to have completed the training by Oct 2016 inline with the pre-set target. We have completed with partners a mapping of current psychiatry liaison services for all ages, that details current pathways and resources. This will now shape decisions moving forward to ensure we move towards a core 24 service. The actions are held on the local crisis care concordat action plan. The CAMHs interface and liaison function has been detailed in the service specification and the model of delivery is clear. There is agreement from the acute provider on the model and an agreement with the provider in terms of the relevant governance arrangements etc. Successful recruitment to the post in May with an expected Sept start date. The liaison and diversion service has identified gaps in their knowledge of Children and Young People services and a training plan has been agreed and is being facilitated. Local services are supporting the liaison and diversion service around their understanding. This work is developing and on-going. The thoughts and discussions around the regional provision of suitable accommodation for Children and Young People have been on going. Doncaster supported Sheffield in a funding bid to develop a regional Section 136 suite. No decision made as yet. With regard to

• Crisis Response

• Crisis House (supported accommodation) Regional discussions are continuing whilst we await the outcome of the section 136 bid. Simultaneous to this, strategic discussions are happening locally to see if we can jointly commission crisis beds for Children and Young People in crisis. We are exploring if and how best this could be achieved. Once a decision has been made we can be clearer on future time scales.

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We have local systems in place that mean no Child or Young Person will be detained in a police cell as a place of safety from 1st January 2016. This has been communicated via regional meetings and the regional work will further enhance the local provision. Progress Rating: Satisfactory to Good 2.3. Development of intensive home treatment provision. Why is this a priority? We have high numbers of children and young people referred into inpatient services with an average length of stay of approximately 101 days. We are high when compared to our neighbours regionally and currently do not have an intensive home treatment service. How will we do this:

• Developing and implementing a new intensive home treatment service to act as an alternative to tier 4 provision.

Progress to Date: The service specification is complete and funding arrangements have all been agreed. The intensive home treatment service will offer an alternative to tier 4 and provide the paediatric liaison functions. The service provider is in the final stages of developing a service model to be agreed by the mental health strategy group in July. They have visited other intensive home treatment services to help their thinking. All posts were successfully recruited to in April and we expect the service to begin to deliver from Sept. Progress Rating: Good 2.4. Promote best practice in transition Why is this a priority? Transition remains a problem for some young people; in particular it isn’t started early enough. How will we do this:

• Implementing model specification for transition.

• Work with YH SCN to develop guidance documents for transition.

• Add resource to peer mentoring service. Progress to Date: Further training to develop and evolve the peer mentoring service has been agreed for July 2016 and this will enhance the transition functions. The lead commissioner

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continues to work with the Yorkshire and Humber Clinical Network to develop guidance for commissioners and a provider toolkit that could be used across all services. The specification has been included in the main (new) CAMHs specification. Progress Rating: Good 2.5. Eating disorder community service Why is this a priority? There has been a year on year increase in referrals into CAMHs for eating disorders as well as an increase in those accessing inpatient services. How will we do this:

• New community eating disorder service adhering to access and waiting time standards.

• Robustly evaluate the new model. Progress to Date: The three commissioners have agreed a local service specification based upon the Access and Waiting Time Standard for Children and Young People with an Eating Disorder, and contract and procurement routes have been agreed and established. Rotherham is the lead commissioner on this. The service specification has been agreed and there is a clear implementation plan to underpin delivery. The phased delivery started on the 1st March and in Doncaster there is currently 1.6WTE of specialist CAMHs nurses. The diagram below shows the proposed model and capacity across the three areas.

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All vacancies for Doncaster have been filled except the consultant psychiatrist, which failed to get any suitable applicants when first advertised. It is back out to advert. It is important to note the service is achieving the prescribed access and waiting standards at this point, albeit without the full multi-agency resource in place. This is evidenced in the newly developed performance dashboard. RDaSH (main provider) have sub-contracted SYEDA to provide the early help, prevention and education elements of the service specification, this is a new area in Doncaster so we are keen to understand need and impact. The new resource in SYEDA is 2WTE and these are an education and training manager and education worker. This work has begun. Doncaster has led on the commissioning of an evaluation study of the new community eating disorder model. Pacec have been awarded the contract and have been in contact with RDaSH to begin developing the evaluation framework. This work commenced on 1st March 2016.n and they are liaising with the CEDS providers and local commissioners in terms of setting up the evaluation framework. The evaluation will be completed at 16 months with an evaluation report submitted to commissioners at 18 months. Progress Rating: Good 3. Caring for the most Vulnerable Aim:

To dismantle barriers and reach out to children and young people in need, through a flexible integrated system that provides services in a way that they feel safe and are evidence based. A local task and finish group has been set-up to lead on the implementation of this area of the LTP. Membership has been agreed and initial meetings held. Membership is at the right level and there is an underlying philosophy of accountability. 3.1. Trauma focussed care Why is this a priority?

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There is a need for greater awareness of the impact of trauma, abuse and or neglect on mental health. CAMHs assessments do not routinely include sensitive enquiry about the possibility of neglect and sexual abuse (including CSE). There is variance in staff’s competencies in working with vulnerable children and young people. How will we do this:

• Audit of current practice, skills and competencies

• Enhanced training package for staff working with vulnerable CYP. Progress to Date: The audit of current practice was delayed and is to be completed by end of July (dip sample of 50 cases) and this will shape any enhanced training package that is needed, which will lead to greater professional awareness. It is likely that any training needed would be provided quickly. As an interim measure there has been the delivery of internal training to CAMHs staff on this area. The current mental heath assessment is in review and changes are being identified to support an improved routine assessment of our most vulnerable Children and Young People. There is still an intention to look at the provision of specialised psychology/ psychiatry support for Children and Young People where there is suspected sexual abuse, this will happen in year three. Progress Rating: Satisfactory 3.2. Make sure that children and young people or their parents who do not attend appointments are not discharged from services, rather actively followed up. Why is this a priority? DNA rates for 2014/15 were 9.5% and the current policy whilst robust needs modification so that no child or young person leaves service because of DNA’s. How will we do this:

• Build on current policy and ensure staff compliance. Progress to Date: This was implemented and has been finalised through the new service specification and contract. The provider is currently amending policies and procedures and we have asked for an audit on staff’s compliance to the policy. This audit has been completed and the findings and recommendations will shape future thinking. Progress rating: Good 3.3. Develop multi-agency teams available with flexible acceptance criteria for referrals concerning vulnerable children and young people.

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Improve the care of children and young people who are most excluded from society, i.e. those sexually exploited, homeless or in contact with the youth justice system. Why is this a priority? There is variance in the provision across services. How will we do this:

• Build on multi-agency approach

• Progress to Date: The plan is to develop these teams by March 2019, so no work done on this to date. Progress Rating: n/a 3.4. Learning Disability specialist provision: Why is this a priority? The care and treatment review guidance and policy are not currently being implemented locally. How will we do this:

• Ensure we are CTR compliant. Progress to Date: Local systems have been set-up for Children and Young People that are compliant with the mandated guidance and policy; this was completed by November 2015. To date there have been no requests for a CTR. To ensure best practice a local MOU underpinned by a policy has been completed and agreed by specialised commissioning. Progress Rating: Very Good

4 To be Accountable and Transparent Aim:

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To drive improvements in the delivery of care and standards of performance, to ensure we have a much better understanding of how we get the best outcomes for children, young people and their families. 4.1. Lead Commissioner arrangements Why is this a priority? To ensure we have a strategic lead and a figurehead to co-ordinate. How will we do this:

• Designated lead commissioner. Progress to Date: The lead commissioner remains in place and the mental health and wellbeing strategy group continue to have direct oversight of the LTP implementation. There are two task and finish groups that sit under the strategy group that are leading on the detailed implementation. The lead commissioner chairs these meetings and feeds directly into the strategy group and health and wellbeing board. There is good representation and accountability across partners. Progress Rating: Very Good 4.2 Collaboration with specialist commissioners Why is this a priority? To reduce any duplication in commissioning and to ensure that services locally, regionally and nationally are commissioned to meet need. How will we do this:

• Collaborative working. Progress to Date: The lead commissioner plays an active role in Yorkshire and Humber Clinical Network and has regular communication with regional specialised commissioners. This includes chairing the mental health commissioners steering group. There is a direct link both ways and we are confident that there is strong and efficient collaboration. Progress Rating: Very Good 4.3. Engagement Why is this a priority?

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This plan is for our children and young people, to improve their outcomes around mental health and wellbeing and as such we must provide the services they need. Only through effective sustained engagement can we provide the services they need in a way they want. How will we do this:

• Giving Children, Young People and their families a voice.

• Commission organisation to lead on this piece of work.

• Develop sustainable model. Progress to Date: Young Minds won the contract and began working on 1st March 2016. Local links have been established and this work is starting to move forward at a pace. The aim is to have 15 mental health champions that help shape the evolution of future LTP’s and to test implementation ideas. The model will ensure that at the end of the LTP (Young Minds have a four year contract) Doncaster has a sustainable model for engagement and young people participation. Work is progressing as per the work plan/ schedule with no concerns, primarily in quarter one this has been the arrangements and deliver of workshop events with Children, Young People and Families. Progress Rating: Very Good 4.4. Local Offer Why is this a priority? To make sure every-one knows about the plan, it’s aims, objectives and intentions. How will we do this:

• Publish on a number of websites Progress to Date: The Local Transformation Plan was sensed checked locally and was felt to be Child and Young Person friendly, this was backed up by the Yorkshire and Humber Strategic Clinical Network. It and the data collection template were published on the following websites as per the mandate. Published on the following websites:

• Doncaster Clinical Commissioning Group – published 4th December 2016

• Doncaster Metropolitan Council – published 4th December 2016

• Doncaster Local Offer – published 11th December 2016

• Doncaster Council for Voluntary Services – published 11th December 2016 The two outstanding sites are as follows:

• Doncaster Safeguarding Children’s Board – the board want to have the presentation on the LTP before ageing to publish. This is booked in for 21st April. We are in the final stages of getting it uploaded.

37

• NHS England – DCCG communications lead in discussion with NHSE counterpart about this. Progress Rating: Good 4.5. Commissioning and procurement Why is this a priority? To ensure we act within the regulations and to commission services compliant with Health and Social Care Act and Equality Act. How will we do this:

• Adherence to NHS procurement regulation.

• Adherence to Equality Act.

• Adherence to Health and Social Care Act. Progress to Date: Whilst at times this has slowed the process down, we have followed and adhered to NHS procurement regulations 2013 for everything procured using the LTP funding. This has been a challenge in terms of timescales and the volume of subsequent work created but we are confident that we are compliant. We will commission two-year contracts whilst stimulating the market to drive innovation and choice moving forward, in particular around the provision of community eating disorder services. The plan has and continues to take into full consideration the above acts. Progress rating: Very Good 4.8. Development of Outcome Measures Why is this a priority? So we can measure performance and outcomes effectively. This underpins the Commissioning cycle. How will we do this:

• Continue to up skill staff via CYP-IAPT programme.

• Express interest in becoming a pilot site for CORC. Progress to Date: There is currently 1 CAMHs practitioner on the CBT CYP-IAPT course. The service will be submitting a request for a place on a therapy pathways course and up to two places on the EEBP course. The CCG will support this by covering the shortfall in funding. Unfortunately we were unsuccessful in our bid to CORC to become a pilot site.

38

Locally as part of the service transformation plan; we have commissioned some additional resource to inform the measures in the CAMHs contract for next year. The proposed reports will include:

• An enhanced report related to use of Goal Setting and scoring across the

cohort during the patient journey

• Improvements to the existing SDQ reporting (to include sub scales and clinical

interpretation)

• Exploration of wider measures that span the cohort and how they can be used

to demonstrate outcomes

Unfortunately this report didn’t provide the outcome expected and the provider has been asked to resubmit a report. There is a requirement and expectation that the CAMHs service provider will adhere to the provision of the new mental health data set and data was successfully submitted to HSCIC for February 2016. We are waiting for the first published extract. Progress Rating: Good 5. Developing the Workforce Aim:

That every-one who works with children, young people and families are ambitious for every child or young person to achieve goals that are meaningful and achievable. They will be excellent in practice and able to deliver the best-evidenced care, be committed to partnership working and be respected and valued as professionals. 5.1. Universal services Why is this a priority? There is variance in the skills and competencies of staff in universal services and a lack of high level co-ordination of this. How will we do this:

• Identify workforce lead.

• Workforce audit.

39

• Workforce strategy. Progress to Date: The workforce development lead service specification has been completed and the provider selected. The post commenced on 14th March and the first function was to complete a workforce audit that will directly shape the subsequent workforce strategy. The audit was completed and is an excellent piece of work. It focussed on three areas:

• School/ Academy staff

• CAMHs

• Universal Services There are series of key findings and subsequent recommendations for each of the three areas that will form the basis of a workforce strategy. The strategy is to be completed by 31st October 2016 in-line with the LTP refresh. An existing task and finish group will be the arena to house this work. Progress Rating: Very Good 5.2. Targeted and specialist services Why is this a priority? There is variance in the skills and competencies of staff in targeted and specialist services and a lack of high-level co-ordination of this How will we do this:

• Training staff. Progress to Date: This relates to the 5.1. Progress Rating: Good 5.3. Future workforce Why is this a priority? To have a workforce that is able to deliver evidenced based interventions. How will we do this:

• By using the platform of the CYP-IAPT programme. Progress to Date:

40

By using CYP-IAPT as a platform to embed evidence based interventions into CAMHs. There is one practitioner attending the CBT course this year. Progress Rating: Good

4. Local Priority Scheme Summary

Local Priority Scheme Current Stage of Implementation Establish named mental health and wellbeing leads in schools (internal)

77% positive response from schools/ academies

Continuous consultation and engagement with children, young people and families

Delivery of engagement workshops with CYP and Parents

Appointment of workforce development lead

Workforce audit completed. Strategy to be completed by 31st October 2016 (in-line with LTP refresh)

Audit and rolling training programme As above Develop an 'innovation partnership’ approach with a local university to deliver an accredited training programme with nationally recognised modules

Not intended for 2016/17 implementation

CAMHs worker to be embedded in the Early Help Hub

Currently 1WTE in post developing links and working through the logistics of embedding into the hub.

Named CAMHs leads in schools & Primary Care

All staff recruited to post (6WTE) and will go live in September when schools return.

Supporting self care An options paper to be presented to strategy group in July 16.

Development of single point of access

Proprietary work is underway to integrate CAMHs referrals into Early Help Hub to form a single point of access. On-going evolution of roles and functions. Agreement to move CAMHs duty functions into a SPOA.

Further develop evidence base One CAMHs worker booked onto CBT course. CAMHs submitted expression of interest for 2016/17 course(s)

Implement all areas of the crisis care 24/7 crisis helpline went live in September 2016;

41

concordat CAMHs liaison and interface function model agreed with eight applicants, expect someone in post in July 2016. Liaison and diversion service is increasing it’s understanding of CYP services. On-going regional work on crisis response based on recent workshops. Police cell not to be used as a place of safety from 1st January 2016 and local system set-up. The mapping of all age psychiatry services has been completed. Exploring local crisis solutions in parallel with regional work.

Intensive home treatment service to be provided

Service model being explored and all posts filled

Expansion of peer mentoring service Further training to be provided to develop mentors

Enhance the current assessment process to include sensitive enquiries

Audit of 50 cases files to check current skills and if the questions are routinely being asked.

Enhance the current do not attend policy

Dip sample audit of policy compliance completed and subsequent findings and recommendations to be considered.

Develop multi-agency teams Not intended for 2016/17 implementation

Improved community paediatric services (inc ASD and ADHD)

Both are NICE compliant, however there have been resource issues that has led to an increase in the autism waiting list. A new community paediatric model has been agreed and financials redistributed to increase capacity within the autism pathway.

Development of domestic violence multi-agency teams

Multi-agency teams are in place

Provision of eating disorder community services

Services began on 1st March 2016 and this will be a phased evolution of service. Consultant psychiatry post is only new post vacant. SYEDA are delivering education sessions. 100% of CYP are meeting access and waiting time standards.

Redeploy generic staff currently seeing ED cases now seen by community team to improve access to self harm and crisis and invest underspend from ED funds

Not intended for 2016/17 implementation

4. Appendices 4.1 Issues & Risks to Delivery

CAMHS Transformation Plans – Issues and risks to delivery Q1 2016/17 Please complete for any issues or risks that prevented or delayed the delivery of your 2016/17 Local Priority Schemes (LPS) in Q1

2016/17

CCG Name: PLEASE INSERT

LPS

Number

Description of local

priority scheme

Description of issue of risk to

delivery of 2016/17 plan Mitigating Actions

*Date

expected to

deliver All LPS Funding placed within CCG baselines. At a

time of a reduction in actual published

allocation, and a mandate to hold headroom

reserves across the STP footprint as

mitigation, in case any provider doesn’t meet

their financial requirement.

This is potentially a significant risk over the

next four years.

Held the funding for 2016/17 at

2015/16 levels.

From 1st April

2016

1 Establish named mental health

and wellbeing leads in school

Failure to achieve 100% compliance and as

such there is an inequity of offer across the

Borough

Currently have 77% of schools

engaged.

Pro-active engagement strategy that

is working well.

Expect to achieve 90% in new

school year.

Use engaged schools to sell it to

From Sept

2017

43

non-engaged schools

11 Implement all areas of the crisis

care concordat

Still unclear if there is funding for a regional

section 136 suite

Local offer deemed to be clinically

appropriate by clinical lead

Sept 2016

19 Provision of eating disorder

community services

Failure to appoint a consultant psychiatrist Job back out to advert Aug 2016

Please

insert more

lines as

needed

*Please highlight in red any areas not delivered by 30th

June 2016 that were planned for delivery or spending during Q1 2016/17.

44

Local Priority Stream Expected Outcome Q1 Apr - Jun 16 Q2 Jul - Sep 16 Q3 Oct - Dec 16/17 Q4 Jan - Mar 17 Activity Q1 Apr - Jun 16 Q2 Jul - Sep 16 Q3 Oct - Dec 16/17 Q4 Jan - Mar 17

Local priority stream 1

Establish named mental health and

wellbeing leads in schools (internal) 0 12500 0 3070 77% of schools with named lead 0


Continious consultation and engagement

with children, young people and families0 0 0 0 3/9 workshops completed 0


Appointment of workforce development

lead 10000 10000 10000 10000 audit complete 10000

Local priority stream 4 Audit and rolling training programme 0 0 13750 25000 strategy to be completed by 31st oct 16 0


Develop an 'innovation partnership'

approach with a local university to

deliver an acredited training programme

with nationally recognised modules0 0 0 0 n/a 0


CAMHs worker to be embedded in the

Early Help Hub 10000 10000 10000 10000 1WTE in post 10000


Named CAMHs leads in schools &

Primary Care 20000 20000 20000 20000 All staff (6WTE) recruited to post 20000

Local priority stream 8 Supporting self care 0 0 0 0 Options Paper being developed 0

Local priority stream 9Development of single point of acess

0 0 0 0

Later stages of proprietary work and establishing

joint working relationships 0

Local priority stream 10 Further develop evidence base 0 0 13125 16875 Submission for Therapy pathway (CYP-IAPT) 0


Implement all areas of the crisis care

concordat 12500 12500 12500 12500 CAMHs Liaison & Interface Nurse in Post 12500


Intensive home treatment service to be

provided 55000 55000 55000 55000 Service model being explored and posts filled 55000

Local priority stream 13Expansion of peer mentoring service

0 0 0 0

Training to be delivered in July 16 (previously

paid for) 0


Enhance the current assessment process

to include sensitive enquiries 0 0 0 0 Audit to be completed 0

Local priority stream 15Enhance the current do not attend policy

0 0 0 0 Audit complete 0

Local priority stream 16 Develop multi-agency teams 0 0 0 0 n/a 0


Improved community paediatric services

(inc ASD and ADHD) 63035 63035 63035 63035 New model agreed and funding redistributed 63035


Development of domestic violance multi-

agency teams 8750 8750 8750 8750 Multi-disciplinary teams in place 8750


Provision of eating disorder community

services 44491 44491 44491 44491 Recruitment is almost complete 44491


Redeploy generic staff currently seeing

ED cases now seen by community team

to improve access to self harm and

crisis and invest underspend from ED

funds 0 0 0 0

Services began on 1st March and this will be a

phased evolution of service 0

223776 236276 250651 268721 223776 0 0 0

979424 223776

Planned Spend Actual Spend

Funding

45

SECTION 5: Doncaster Safeguarding Adults Board Annual Report 2015/16

Indicator Pass Condition Fail Condition Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

TA&E waiting time -Maximum waiting time of 4 hours in the A&E department

(DBHFT)

Equal to or greater

than 95%Less than 95% 95.1% 93.1% 92.2% 92.8% 91.9%

11365 12632 11834 12165 11798

Less than baseline Greater than 5% 11762 11950 12487 12047 11453

14396 15058 14729 14396 14396

Less than baseline Greater than 5% 13550 13797 13547 14046 14217

7540 7935 7902 8139 7825

N/A N/A 7811 7701 8365 8656 8245

% of patients seen within 4 hours at DRIEqual to or greater

than 95%Less than 92% 93.3% 89.0% 89.2% 90.1% 88.0%

3825 4020 3932 4026 3973

N/A N/A 3951 4249 4122 4492 4139

% of patients seen within 4 hours (Bassetlaw)Equal to or greater

than 95%Less than 95% 96.3% 96.1% 94.7% 94.9% 95.9%

T Trolley waits in A&EEqual to or less than

12 Hours

Greater than 12

Hours0 0 0 0

TAll handovers between ambulance and A&E must take place within 15 minutes -

those over 30 minutes0 Greater than 1 75 76 75 40

TAll handovers between ambulance and A&E must take place within 15 minutes -

those over 60 minutes0 Greater than 1 11 12 11 4

Red Under 8- 8 minute response time DONC TBC TBC 68.5% 66.1% 62.5% 63.2% 66.8%

Amber R- 19 minute response time DONC TBC TBC 86.8% 79.9% 89.4% 58.8% 83.4%

Amber T- 19 minute response time DONC TBC TBC 76.2% 66.5% 66.7% 53.4% 73.6%

Amber F- 19 minute response time DONC TBC TBC 87.0% 73.4% 62.5% 55.7% 74.1%

Green F- 60 minute response time DONC TBC TBC 86.2% 76.3% 100.0% 76.0% 82.5%

Green T- 60 minute response time DONC TBC TBC 77.5% 75.9% 78.9% 68.1% 74.9%

Green H- 60 minute response time DONC TBC TBC 100.0% 100.0% 100.0% 97.5% 99.2%

Red Under 8- 8 minute response time YAS TBC TBC 73.0% 71.0% 68.1% 66.3% 70.5%

Amber R- 19 minute response time YAS TBC TBC 83.1% 77.7% 74.7% 71.6% 78.5%

Q4Q3

T A&E Attendances (Type1) DBHFT

Baseline

T A&E Attendances (All) DBHFT

Baseline

A&E Attendances (DRI)

Baseline

Doncaster CCG 2016/17 Performance Report Q1 Q2

A&E

Ambulance

A&E Attendances (Bassetlaw)

Baseline

Doncaster CCG 2016/17 Performance ReportCCG

DBHFT

RDaSH

Misc Delivery Plans

Key: T = Trust Targets

C = CCG related Targets

ND No Data Available

1


Q4Q3Doncaster CCG 2016/17 Performance Report Q1 Q2


DBHFT

RDaSH

Misc Delivery Plans




Amber T- 19 minute response time YAS TBC TBC 76.8% 68.6% 66.4% 60.5% 69.6%

2




DBHFT

RDaSH

Misc Delivery Plans




Amber F- 19 minute response time YAS TBC TBC 86.8% 75.6% 72.2% 66.4% 70.9%

Green F - 60 minute response time YAS TBC TBC 92.2% 87.4% 85.1% 85.4% 88.4%

Green T- 60 minute response time YAS TBC TBC 84.2% 79.5% 77.6% 73.9% 79.2%

Green H- 60 minute response time YAS TBC TBC 99.8% 99.6% 99.7% 99.3% 99.4%

C All cancer two week waitEqual to or greater

than 93%Less than 88% 93.7% 94.0% 93.5%

C Two week wait for breast symptoms (where cancer was not initially suspected)Equal to or greater

than 93%Less than 88% 92.1% 97.0% 93.7%

CPercentage of patients receiving first definitive treatment within one month of

a cancer diagnosis

Equal to or greater

than 96%Less than 91% 93.0% 98.1% 97.2%

C 31-day standard for subsequent cancer treatment - anti cancer drug regimensequal to or greater

than 98%Less than 87% 100.0% 100.0% 100.0%

C 31-day standard for subsequent cancer treatments- radiotherapyEqual to or greater

than 94%Less than 89% 100.0% 100.0% 100.0%

C 31-day standard for subsequent cancer treatments- surgeryEqual to or greater

than 94%Less than 89% 88.9% 100.0% 100.0%

CPercentage of patients receiving first definitive treatment for cancer within two

months (62 days) of an urgent GP referral for suspected cancer

Equal to or greater

than 85%Less than 80% 81.1% 82.8% 81.5%

CPercentage of patients receiving first definitive treatment for cancer within 62-

days of referral from an NHS Cancer Screening Service

Equal to or greater

than 90%Less than 85% 92.3% 100.0% 100.0%

CPercentage of patients receiving first definitive treatment for cancer within 62-

days of a consultant decision to upgrade their priority status

Equal to or greater

than 90%Less than 85% 86.4% 70.6% 69.2%

* The new standards are defined at the bottom of the report. The Data provided is prior to signoff via YAS and is subject to change.

Cancer

3




DBHFT

RDaSH

Misc Delivery Plans




T All cancer two week wait.Equal to or greater

than 93%Less than 88% 93.1% 93.1% 94.0%

T Two week wait for breast symptoms (where cancer was not initially suspected)Equal to or greater

than 93%Less than 88% 93.4% 95.8% 93.8%

TPercentage of patients receiving first definitive treatment within one month of

a cancer diagnosis

Equal to or greater

than 96%Less than 91% 99.3% 99.4% 98.6%

T 31-day standard for subsequent cancer treatments-anti cancer drug regimensEqual to or greater

than 98%Less than 87% 100.0% 100.0% 100.0%

T 31-day standard for subsequent cancer treatments-surgeryEqual to or greater

than 94%Less than 89% 100.0% 100.0% 100.0%

TPercentage of patients receiving first definitive treatment for cancer within two

months (62 days) of an urgent GP referral for suspected cancer

Equal to or greater

than 85%Less than 82% 86.6% 89.7% 86.0%

TPercentage of patients receiving first definitive treatment for cancer within 62-

days of referral from an NHS Cancer Screening Service

Equal to or greater

than 90%Less than 85% 93.3% 100.0% 100.0%

0 0 0 0

0 Greater than 0 0 0 0 0

0 0 0 0


0 0 0 0


6 13 20 26

Equal to or less than

46Greater than 46 3 4 10 11

3 6 9 12

41

115

27

230C

5% Reduction in emergency admissions for upper respiratory tract infections by

April 2015


5%Greater than

Greater than

C Incidence of healthcare associated infection: MRSA bacteraemia

T Incidence of healthcare associated infection: MRSA bacteraemia

CEmergency admissions for children with lower respiratory tract infections

(LRTIs)


382 per annum

T Incidence of healthcare associated infection: C. difficile

Childrens

Infection Control

C Incidence of healthcare associated infection: C. difficile

T Incidence of healthcare associated infection: MRSA bacteraemia

4




DBHFT

RDaSH

Misc Delivery Plans





20Greater than 21 0 4 7 10

T

Mental Health Measure – Care Programme Approach (CPA) - The proportion of

those patients on Care Programme Approach (CPA) discharged from inpatient

care who are followed up within 7 days (stretch local target)

Equal to or greater

than 95%Less than 90.25% 100% 100% 100% 96.0%

1.7% 3.3% 5.1% 6.8%

T

Mental Health Measure- Improved access to psychological services - The

proportion of people who complete treatment who are moving to recovery

(Target)

Equal to or greater

than 50%Less than 47.50% 44.1% 46.1% 44.4% 46.6%

C Mixed Sex Accommodation (MSA) Breaches CCG 0 Greater than 0 0 0 0 0

T Mixed Sex Accommodation (MSA) Breaches (DBHFT) 0 Greater than 0 0 0 0 0

T Mixed Sex Accommodation (MSA) Breaches (RDASH) 0 Greater than 0 0 0 0 0

TCancelled Operations - All patients who operations cancelled for non clinical

reasons to be offered another binding date within 28 days0 Greater than 0 0 2 2 1

T Stroke: proportion of patients scanned within 4 hours of arrival at hospitalEqual to or greater

than 90%Less than 85.5% 69.6% 70.0%

T Stroke: proportion of patients scanned within 1 hour of arrival at hospitalEqual to or greater

than 50%Less than 45% 42.9% 52.5%

TStroke: Proportion of patients scanned within 24 hours of first contact with a

professional

Equal to or greater

than 60%Less than 57% 66.7% 60.5%

TStroke: Proportion of eligible patients (according to the RCP guideline minimum

threshold) given thrombolysis

Equal to or greater

than 90%Less than 89.9% 100.0% 100.0%

TStroke: Proportion of applicable patients receiving a joint health and social care

plan on discharge

Equal to or greater

than 90%Less than 89.9% 87.5% 77.1%

Mixed Sex Accommodation

Mental Health Measure- Improved access to psychological services - The

proportion of people that enter treatment against the level of need in the

general population (the level of prevalence addressed or ‘captured’ by referral

routes)

Other

Stroke & TIA

T Incidence of healthcare associated infection: C. difficile

T

Mental Health

Equal to or greater

than 7.5%Less than 7.125%

5




DBHFT

RDaSH

Misc Delivery Plans




TStroke: Percentage of patients treated by a stroke skilled early supported

discharge team

Equal to or greater

than 40%Less than 39.9% 73.6% 67.6%

TStroke: Percentage of applicable patients who are discharged who were given a

named person to contact after discharge

Equal to or greater

than 95%Less than 94.9% 79.2% 73.0%

C

Number of 52 week Referral to Treatment Pathways - the number of admitted

pathways greater than 52 weeks for admitted patients whose clocks stopped

during the period on an adjusted basis

0 Greater than 0 1 0 0

C

Number of 52 week Referral to Treatment Pathways - the number of non-

admitted pathways greater than 52 weeks for non-admitted patients whose

clocks stopped during the period


C

Number of 52 week Referral to Treatment Pathways - the number of

incomplete pathways greater than 52 weeks for patients on incomplete

pathways at the end of the period


Waiting Times

6




DBHFT

RDaSH

Misc Delivery Plans




T Diagnostic test waiting timesEqual to or greater

than 99%Less than 99% 99.2% 99.5% 99.6% 99.2%

C Diagnostic test waiting timesEqual to or greater

than 99%Less than 99% 99.0% 99.5% 99.6%

TThe percentage of incomplete pathways within 18 weeks for patients on

incomplete pathways at the end of the period

Equal to or greater

than 92%Less than 87% 92.9% 93.1% 92.8% 92.6%

CPercentage of incomplete pathways within 18 weeks for patients on incomplete

pathways at the end of the period

Equal to or greater

than 92%Less than 87% 93.6% 93.7% 93.2%

Red – Life-threatening; Time critical life-threatening event needing immediate intervention and/or resuscitation; 8 minute target.

Amber – Emergency; Potentially serious conditions (ABCD problem) that may require rapid assessment, urgent on-scene intervention and/or urgent transport; 19 minute

target.

Green – Urgent; Urgent problem (not immediately life-threatening) that needs transport within a clinically appropriate timeframe or a further face-to-face or telephone

assessment and management; 60 minute target.

Further Detail on Amber Codes

Amber R– a patient who does not have an immediately life threatening condition but requires an emergency response. Their condition/problem requires

assessment/management on scene and it is likely that they will require conveyance to hospital. Example – patients having a heart attack (MI) require on scene management

by a clinician AND conveyance to an appropriate facility (PPCI).

Amber T – a patient who does not have an immediate life threatening condition but requires an emergency response. Their condition/problem is time dependant on

reaching definitive care and therefore a conveying resource is the most important. Example Stroke (CVA) patients require rapid transport to a hyper-acute stroke unit or

other appropriate facility.

Amber F – a patient who does not have an immediate life threatening condition but does require an emergency response. Their condition/problem may well be managed on

scene by a clinician and may or may

not require onward referral. Example – hypoglycaemia.

7

Annual Report2015/16

2

Glossary 3

Chairs foreword 4 Membership of the board 5Board Structure 6 DSAB Objectives 2015/16 7Working Together to Safeguard Children and Adults 10

DSAB Priorities 2016/17 14Sub Group Chair reflections 14Safeguarding Adults Review Panel 17Keeping Safe Forum 19Reports from Safeguarding Adults Board Partners 20 NHS England 22 Doncaster Clinical Commissioning Group 24 South Yorkshire Police 26 Doncaster and Bassetlaw Hospitals NHS Foundation Trust 27 Rotherham Doncaster and South Humber NHS Foundation Trust 28 St Leger Homes of Doncaster 30 South Yorkshire Fire and Rescue 31 National Probation Service (South Yorkshire) 32

Mental Capacity Act - Deprivation of Liberty Safeguards 33 Case Study 34

Safeguarding Adults Activity 2015/16 35Multi-agency Safeguarding Adults Learning and Development 44Safeguarding Adults, MCA and DOLS E-Learning Courses 46

Single Agency training 51Safeguarding Adults Support Unit 54Funding 55Attendance Monitoring DSAB and Sub Groups April 2015– March 2016 56Doncaster Safeguarding Adults Partnership Board Strategic Objectives 59

Contents

Safeguarding AdultsAnnual Report 2015/16

3

Glossary CQC - Care Quality Commission

DBHFT - Doncaster & Bassetlaw Hospitals NHS Foundation Trust

DCCG - Doncaster Clinical Commissioning Group

DMBC - Doncaster Metropolitan Borough Council

DSAB – Doncaster Safeguarding Adults Board

DSCB - Doncaster Safeguarding Children Board

HMPS - HM Prison Service

KSF - Keeping Safe Forum

RDaSH - Rotherham Doncaster and South Humber Mental Health NHS Foundation Trust

SYF&R - South Yorkshire Fire & Rescue Service

SYP – South Yorkshire Police

4

Chair’s ForewordI am pleased to introduce myself as the interim Director of Adults Health and Wellbeing and Chair of the Doncaster Safeguarding Adults Board. Although I have only been in the role for a short while I can clearly say that it has been a busy and challenging year for the Doncaster Safeguarding Adults Board and its partners.

April 2015 saw the implementation of the Care Act 2014 which placed Safeguarding Adult Boards on a statutory footing and led us to develop a new Board Constitution, setting out the requirements of the Board and its members. In addition the Board and its partners have been working hard in Doncaster, alongside our regional partners to ensure systems, policies, procedures and assurance frameworks are aligned to the requirements of the Care Act so that adults at risk are safeguarded and receive the best service that is personal for them.

The Board has continued to pursue its engagement agenda with great focus through a ‘Keeping Safe Campaign’ helping communities to respond to abuse and neglect. It has worked with the Doncaster Keeping Safe Forum, a community based forum that has been supported by the Board to grow in capacity and membership with the primary aim of getting the message out in Doncaster.

In addition the Board requested a Safeguarding Adults Peer Challenge which was undertaken in November 2015. The process identified a number of strengths and areas for development which are being responded to through a partnership action plan.

The Board has continued to meet on a quarterly basis and has been well attended by a range of agencies with commitment to working in partnership to safeguard adults at risk. The Board held its annual away day in February to assess progress against its strategic objectives, refresh the strategic plan and revise the Board structure to make sure it is fit for the future. The day was productive with a clear direction established and expressed in the new Strategic Plan 2016-19.

The Board are looking forward to pursuing their strategic objectives through 2016-17 and working in partnership with the community of Doncaster to make sure that safeguarding is everyone’s business.

Kim Curry, Interim Chair Doncaster Safeguarding Adults BoardDirector of Adults, Health and Wellbeing


5

Membership of the boardJo MillerChief Executive, Doncaster Metropolitan Borough Council

Kim Curry Interim Director of Adults Health and WellbeingDoncaster Metropolitan Borough Council

Pat HiggsAssistant Director Care Management Doncaster Metropolitan Borough Council

Councillor Glynn JonesLead for Safeguarding Adults

Mary ShepherdChief Nurse, Doncaster Clinical Commissioning Group

Andrew RussellDeputy Chief Nurse, Doncaster Clinical Commissioning Group

Neil ThomasSuperintendent, South Yorkshire Police

Susan JordanChief Executive, St Leger Homes

Chris PrewettHead of Nursing and SafeguardingRotherham Doncaster and South Humber NHS Foundation Trust

Deborah OughtibridgeHead of Safeguarding Doncaster and Bassetlaw Hospitals NHS Foundation Trust

Judith WildSub-regional Senior Nurse, NHS England

Dawn PeetSouth Yorkshire Fire and Rescue

Rosie FaulknerBoard Manager, Doncaster Safeguarding Children’s Board

Bill HotchkissHead of Service Community Safety Doncaster Metropolitan Borough Council

Maryke Turvey Assistant Chief Executive, South Yorkshire Community Rehabilitation Service

Julia Gordon Inspector Manager, Care Quality Commission(attends Board on annual basis by invitation)

Andrew BosmansNon-Executive Director, Healthwatch Doncaster

Sarah Mainwaring Assistant Chief Officer, SY National Probation Service

Yorkshire Ambulance Servicerepresented by Doncaster Clinical Commissioning Group

Angela BarnesProject Support Officer, Doncaster Keeping Safe Forum(attends Board on annual basis by invitation)

Governance during 2015/16

The Board has met on four occasions; overall there has been excellent multi-agency attendance (see Appendix 4). For transparency the Board’s annual reports, safeguarding adults reviews and Board minutes are publically available and can be found at; www.doncaster.gov.uk/safeguardingadults. All work of the Board is underpinned by the six key principles of safeguarding;

Empowerment: Presumption of person led decisions and informed consent.

Prevention: It is better to take action before harm occurs.

Proportionality: The least intrusive response appropriate to the risk presented

Protection: Support and representation for those in greatest need.

Partnership: Local Solutions through services working with communities

Accountability: Accountability and transparency in delivering safeguarding

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Board StructureDuring 2015/16 the Board has had the following sub groups;

Business Coordination Sub GroupChaired by Roger Thompson, Independent Chair of DSABThe group coordinates and manages the core operational business of the Board allowing for the Board to focus on strategic safeguarding adults issues.

Engagement Sub GroupChaired by Susan Jordan, Chief Executive of St Leger HomesThe group takes its work from the objectives set out in the DSAB Strategic Plan. Its main aim is to raise awareness of safeguarding adults in the community and get the message out that safeguarding is everyone’s business.

Workforce Sub GroupChaired by Chris Prewett, Head of Nursing and Safeguarding, RDASHThe group takes its work from the objectives set out in the DSAB Strategic Plan. Its main aim this year has been to develop a National Competency Framework for Safeguarding Adults and agree a multi-agency training programme for 2015/16.

Performance Sub GroupChaired by Pat Higgs, Assistant Director of Care Management, DMBCThe group is responsible for developing a performance and assurance framework and monitoring the performance and quality of safeguarding adults work in line with national and regional data.

Policy and Practice Sub GroupCo-chaired by Deborah Oughtibridge, Head of Safeguarding, DBHFT and Pat Higgs, Assistant Director of Care Management, DMBCThis group has been on hold throughout 2015/16 due to a lack of attendance. The Board were informed of the issues relating to attendance of this group and this informed the Board away day in considering a revised Board structure for 2016/17.

Safeguarding Adults Review PanelChaired by Peter Horner, Public Protection Unit Manager, SYPThis group is responsible for establishing whether there are multi-agency lessons to be learned through the Safeguarding Adults Review process. Monitoring recommendations and action plans arising from Safeguarding Adult Reviews (SAR) / Learning Lessons Reviews (LLR) and sharing lessons learned across the partnership.

DSAB Key Achievements 2015/16The Board set out to deliver its strategic objectives as identified in its strategic plan 2013-16 (refer to appendix 5). The Boards progress against its strategic plan during this period is presented overleaf.


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DSAB Strategic Objectives 2015/16

Strategic Objective 1To review the constitution of the DSAB in line with current legislation, statutory guidance, national and local priorities to safeguard adults at risk across Doncaster

What we said we’d do What we’ve done Still to do

1.1 Embed South Yorkshire Procedures across Doncaster through the development and roll out of a formal launch.

1.2 Revise the Board constitution to reflect the DSABs relationship with other Partnerships. 1.3 Engage with Prison Services to understand the needs of the prison population with a view to embedding safeguarding.

1.4 Develop Process for Overarching Safeguarding Cases.

1.5 To revise the Memorandum of Understanding with CQC to clarify role and responsibilities across the multi-agency partnership to safeguard adults at risk 1.6 Embed Joint Safeguarding Multi-agency Capability Framework in practice across the partnership.

1.7 To review Doncaster Safeguarding Adults Policy and Procedures every 3 years

1.8 Develop multi-agency training quality assurance process.

1.1 DSAB launched and embedded revised SY Procedures across Doncaster through a formal launch event.

1.2 DSAB revised its constitution as a Board, all agencies have signed up to this and it has been published on the Boards webpage

1.3 DSAB engagement with Prisons is not representative nor consistent, further work has commenced to engage with Prisons

1.4 DSAB have developed a process for overarching safeguarding cases and this is accessible to the workforce

1.5 The Memorandum of Understanding has been revised to clarify interagency relationships

1.6 DSAB have worked in collaboration with Bournemouth University to revise the National Competency Framework, further work will be needed to embed this once adopted by the Board

1.7 DSAB have revised the following policies during 2013-16;• South Yorkshire Procedures • Safeguarding Adults Review

Policy • Policy on Development and

Management of Procedural Documents

DSAB have worked closely with Bournemouth University to revise the National Competency Framework in line with the Care Act 2014 requirements.

DSAB will need to embed this once adopted by the Board. This is currently placed on the Workforce sub group work plan for progressing.

DSAB have still to develop a multi-agency training quality assurance process. This is currently placed on the Workforce sub group work plan for progressing.

Further work is on-going to engage Prisons and ensure representation at Board level is effective.

Work is on-going to develop a new operational model for Safeguarding Adults to respond to the recommendations set out in the Safeguarding Adults Peer Review report and support the requirements of the Care Act.

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Strategic Objective 2To deliver the DSAB Strategy through a Performance Framework, holding agencies to account and embedding lessons learned through robust governance and quality assurance processes.


2.1 To review agencies and board substructure representation at Board to safeguarding adults at risk

2.2 To review multi-agency representation at Board to safeguard adults at risk

2.3 Revise the Board Strategic plan 2013-16 in line with emerging guidance / legislation

2.4 Ensure robust work plan governance is in place to deliver the strategic plan and inform Board of its progress

2.5 Ensure robust governance in place to assure the Board that actions from SCR/LLRs are being implemented 2.6 Ensure robust risk management processes are in place (risk register) to identify, mitigate and inform the Board about risk in relation to achieving the Boards strategy

2.7 To produce an Annual Report that provides clear and accessible information for the public and agencies detailing the work and achievements of the DSAB.

2.8 To undertake a rolling programme of audit to provide; process and quality measures, quality assure appropriateness of referrals and implementation of actions to improve practice

2.9 To produce a quarterly report that collates a dashboard of information relating to; • Performance, outcome,

process and quality measures, themes and trends

2.1 DSAB reviewed its substructure and multi-agency representation.

2.2 DSAB reviewed its multi-agency representation at Board to include wider agencies as included within the Care Act 2014

2.3 DSAB revised its Strategic Plan 2013-16 in line with the Care Act and emerging demands

2.4 DSAB continued to provide robust work plan governance to inform the Board of its progress against its strategic plan

2.5 DSAB revised the SAR Policy and Toolkit to ensure the Board have a robust process for considering and undertaking SAR’s and learning and sharing lessons.

2.6 DSAB continue to provide robust processes for identifying and managing risk in relation to achieving the Boards strategic objectives

2.7 DSAB redesigned and produced a timely Annual Report with accessible information for the public and agencies, including a case study.

2.8 DSAB undertook a re-audit of case files to measure improvement since the previous audit to drive continuous improvement in practice

The DSAB Performance and assurance framework needs to have a focus on outcomes for adults at risk.


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Strategic Objective 3To develop a Safeguarding Adults Preventative Strategy that empowers adults at risk to protect themselves from abuse, supporting communities and people through effective risk management in personalisation of their care.


3.1 Develop a Safeguarding Adults Preventative Strategy that outlines Doncaster’s approach to preventing adults at risk from abuse to include;• Board’s responsibility for self-neglect to inform management of adults at risk inform Strategy• Proposed model to manage adults at risk through reportable concerns (low level concerns)

3.2 Implement Making Safeguarding Personal across the multi-agency partnership

3.3 Implement Safeguarding Adults Communication Plan

3.4 Embed a consistent approach to assessing mental capacity across partnership through assurance;• sign up to MCA Joint Agency

Agreement • formal launch of MCA1,2,3 forms

across multi-agency partnership

3.5 To develop user satisfaction feedback mechanism

3.2 DSAB have developed a strategy to implement and embed Making Safeguarding Personal in practice however further work needs to take place to ensure it is embedded in practice across the partnership and will need to be considered as a priority in the revised strategic plan.

3.3 DSAB have continued to implement its Communication and Engagement Plan. A public consultation is taking place to inform a new revised plan for 2016/17.

3.4 DSAB have developed and signed up to the MCA Joint Agency Agreement across the partnership to provide a consistent approach to the Mental Capacity Act. In addition the MCA forms have been revised and launched and are accessible for use. on performance matters including information relating to performance, process, quality measures, themes and trends

DSAB have still to agree and develop a preventative strategy that outlines Doncaster’s approach to prevention and early intervention, this will need to be considered as a priority in the revised strategic plan.

DSAB should continue to drive the implementation of the Making Safeguarding Personal strategy across the partnership, holding agencies to account for embedding MSP in practice. Work to embed MSP and revise an operational model that can facilitate this is underway.

DSAB should develop and implement a service user feedback mechanism to evaluate the effectiveness of services provided to adults at risk.

Strategic Objective 4To review the needs of adults at risk with due regard to economic, social and legislative changes regarding factors such as social issues, criminal behaviour, mental and physical health and wellbeing, with a view to improving / shaping services to better meet their needs.


4.1 Engage with Joint Strategic Needs Assessment process to identify and assess the needs of adults at risk to prevent abuse across Doncaster.

4.2 Assess the impact of legislation and statutory guidance providing regular updates to Board

4.1 DSAB have engaged with the Joint Strategic Needs Assessment process and is awaiting the outcome of this work.

4.2 Regular updates regarding the review of welfare spending have been presented to the Board for information and consideration.

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Working Together to Safeguarding Adults and ChildrenThe Board have worked in partnership with Doncaster Safeguarding Children’s Board to develop a joint safeguarding self-assessment and challenge process to facilitate participation of partner agencies, increase efficiency and reduce duplication.

The purpose of the self-assessment and challenge process is to assess and audit the effectiveness of safeguarding arrangements across partnership agencies. Providing an arena where partners will be held to account and challenged to provide evidence to support the information they have provided within their self-assessment.

This process was rolled out during 2015/16 and has been positively received by partner agencies. Joint work is on-going to identify key themes and an evaluation of the process itself, which includes learning and improvement of the process. The process will be repeated bi-annually.

Implementing Making Safeguarding Personal in Doncaster

Building on the Boards previous involvement in a national pilot for Making Safeguarding Personal the Board received and approved the Strategy to Implement Making Safeguarding Personal in July 2015. The strategy identifies a 2 phase approach to implementing the required changes, to a shift from process to outcomes for adults at risk. The strategy focussed on a number of areas including;

• Supporting the required culture change of the workforce• Revising documentation, systems, policies and procedures to focus on outcomes for adults at risk• Widening the DSAB Performance framework to include outcomes• Preparing wider independent providers of health and social care for undertaking S42 enquiries• Robust governance arrangements to drive the strategy through service delivery

Phase 1 of the strategy has focused on supporting statutory health and social care services, ensuring that outcomes are sought at the beginning of the safeguarding adults process and services are designed to meet this expectation. The strategy has been well received and continues to be driven by the multi-agency MSP Project Group who report to the Board. Moving forward Phase 2 of the strategy will be commenced to ensure wider agencies are engaged and have the required skills to undertake Section 42 enquiries where appropriate.

DSAB Keeping Safe Campaign

The Engagement sub group have been working hard to deliver the Board’s Communication and Engagement Strategy of which the Keeping Safe Campaign is a key part.

In order to do this effectively consultations were carried out with staff and general public at the Keeping Safe Event held in November 2015 in addition a questionnaire was sent out to the public via St Leger Homes House Proud magazine.

The consultations highlighted three themes;• Communication – the need to reach the most vulnerable people not linked to existing services• Raising awareness and education – the need to continue to deliver training around safeguarding adults

and keeping safe across Doncaster, with a focus on educating young people• Empowerment – supporting people to feel comfortable to report abuse through peer support, training and

appropriate feedback


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In response to this and in line with the Communication and Engagement Strategy a ‘Keeping Safe Campaign’ is continuing to be rolled out to empower adults at risk to protect themselves from abuse by raising awareness of safeguarding adults and the reporting process.

The key messages of the campaign are;• Everyone has the right to be safe, to be respected, to be heard• Everyone has a role to play to make this happen• If you see something, say something (If you see, hear or suspect that someone is being abused, report it)

A number of methods have been used to support the campaign such as; consistent branding, marketing, press and public relations, social media, safeguarding film, leaflets, posters, banners and business cards, see below;

Moving forward the campaign will be refreshed in line with the revised DSAB Communication and Engagement Strategy to ensure it continues to get the message out to the communities of Doncaster that safeguarding adults and keeping safe is everyone’s business.

Launch of Revised South Yorkshire Procedures

The Doncaster Safeguarding Adults Board have worked closely with Shef-field, Rotherham and Barnsley Safeguarding Boards to review regional South Yorkshire Multi-Agency Safeguarding Adults Policy and Procedures. These were formally launched across Doncaster in October 2015.

Reviewing the procedures has been a challenging piece of work given the differing local systems in place across the region, however the procedures will further support organisations to deliver a high standard of service and ensure that safeguarding has a focus on outcomes for adults at risk.

www.doncaster.gov.uk/safeguardingfilm

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Keeping Safe Event 2015

We held our annual event at the Doncaster Keep Moat Stadium on 19 November 2015 with 162 people attending with a mixture of professionals and members of the public. This is an increase from last year where 105 people attended.

The overall aim of the day was to raise staff and public awareness of developments within Doncaster to keep adults at risk safe within our communities.

The day focused on the following;

• Introductions - DSAB Independent Chair and the South Yorkshire Police and Crime Commissioner • “You said, we did” - Communication and Engagement Strategy 2012-2015 Susan Jordan – Chief

Executive of St. Leger Homes of Doncaster / Doncaster Safeguarding Adults Board member and Engagement Sub Group Chair

• “If you see something, say something” – Safeguarding film• “Our journey” - Doncaster Keeping Safe Forum • “Growing the Safeguarding tree” – working together activity• Care Act 2014 – what it means for Safeguarding Adults - Anne Graves – Head of Service, Safeguarding

Adults and Partnerships, Doncaster Council• “The white stuff – The individual behind the disability” Blake Williamson – Independent employer and

disability equality trainer• Making Safeguarding Personal - Shabnum Amin, Safeguarding Adults Learning and Development

Manager, Doncaster Council and Dead Earnest Theatre Company and members of Keeping Safe Forum• Phil’s story – Case Study - Shah Rauf – Principal Social Worker Safeguarding Adults, Doncaster Council• Closing comments - Jo Miller, Chief Executive, Doncaster Council


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What people told us about the eventThere was positive feedback about the event, with 64% of evaluation respondents rating it good. People in particular, welcomed the opportunity for networking and the sharing of information. Feedback provided will be used to inform and develop future events.

Safeguarding Adults Peer Review

The Director of Adults, Health and Wellbeing requested a peer review of the Doncaster Safeguarding Adults Board and operational Safeguarding Adults services in July 2015 and the following areas of focus included;

1. The ability of the Board to understand safeguarding in relation to the Care Act and embed across Partnership

2. There is a robust strategy in place to embed Making Safeguarding Personal in practice3. The Board has good working relationships and is effective4. How does the Board know it is effective at safeguarding adults

The Peer Review Team visited Doncaster on 17 November 2015 for 3 days and assessed a range of documents, interviewed the key strategic leads for safeguarding adults and attended 5 focus groups which gave them an insight to safeguarding adults practice across the multi-agency partnership.

The findings included areas of strength, areas for improvement and areas requiring urgent review. In response the DSAB have developed a multi-agency action plan to address the areas identified within the report. The full Safeguarding Adults Peer Review Report can be found at www.doncaster.gov.uk/safeguardingadults

Mental Capacity Act Review

The DSAB are committed to ensuring the Mental Capacity Act 2005 (MCA) is embedded and a consistent approach is being applied across Doncaster. The MCA Joint Agency Agreement was developed and formally launched across the partnership in July 2014 to seek a strategic approach to embedding the Mental Capacity Act across the partnership.

To follow on from this an independent review of compliance with the Mental Capacity Act 2005 was commissioned by partner agencies to assure the Board that MCA was being implemented by health and social care providers. The findings of the review will be used to inform the Board and improve practice in this area moving forward.

Revision of the National Competency Framework

Doncaster has played a key role in reviewing the National Competency Framework for Safeguarding Adults in collaboration with Bournemouth University throughout 2015/16. Ensuring the revised framework meets the requirements of the Care Act 2014 and is fit for purpose. This document is a resource for staff and managers across all agencies to support and assess the capability and needs of the workforce. Moving forward Doncaster will be implementing the competency framework across the partnership to ensure the multi-agency workforce have the required range of skills and abilities to enable them to support all people who may be at risk of harm and abuse.

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DSAB Priorities for 2016/17Good progress has been made during 2015/16 to the delivery of the Strategic Plan 2013-16 with 17 key deliverables completed and 7 on-going to be carried forward. This report demonstrates the commitment of DSAB partners during times of significant change in the architecture of Public Sector organisations, independent providers and increasing pressures due to budget restraints.

The Care Act 2014 puts a duty on Safeguarding Adults Boards to develop its strategic plan with local community involvement and the local Healthwatch organisation.

The Board held its annual away day in February 2016 to reflect and refocus on a long term direction for the Board in line with the requirements of the Care Act 2014 and the findings from a local community consultation facilitated by Healthwatch to ensure priorities were in line with public expectations. The day resulted in a refreshed strategic vision and plan for the Board and a revised sub structure that would support delivery of the 3 year Strategic Plan for 2016-19.

The following four refreshed key objectives were collectively agreed;

1. Sharing and engaging – Sharing information and engaging with the people of Doncaster2. Helping, empowering and supporting - Provide quality safeguarding services when abuse or neglect is

identified and putting adults at risk at the centre of what we do3. Prevention - Ensure agencies are working together to prevent abuse or neglect and take appropriate

action when needed4. Prepare - Hold agencies to account for the services they provide

The draft Strategic Plan 2016-19 will be presented to the Board for approval and embedded across the partnership commencing April 2016.

Sub Group Chairs Reflections 2015/16Business Coordination Group The Business Coordination Group (BCG) is represented by the sub group chairs and is responsible for coordinating the core business for Safeguarding Adults on behalf of the Board in line with the Board constitution. The Business Coordination Group; • Receives all core business on behalf of the Board to direct and respond to the needs of the sub groups. Through promoting a culture of positive challenge it will achieve the Boards strategic objectives, identifying strategic issues and escalating risks as appropriate.• Monitors, reviews and reports all performance issues to the board;

1. Coordinating the boards business 2. Holding sub groups to account through positive challenge 3. Oversee all escalated risks to achieve the Boards strategic priorities, identifying action and making

recommendations where appropriate to mitigate risk.

Although it is in its early days, the Business Coordination Group, has met six times during 2015/16 and has been well attended by the sub group chairs. In moving forward during the next twelve months, the Business Coordination Group will transform into the Prepare Group in line with the revised sub group structure and will continue to develop its agenda to ensure sub groups are held to account for delivering the strategic objectives and the core business and risks of the Board are managed as appropriate.Pat HiggsChair, Business Coordination GroupAssistant Director of Care Management, DMBC


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Engagement Sub Group

2015/16 has been yet another busy and successful year for the Engagement Sub Group. Attendance at our group meetings and additional Task & Finish Group Meetings has been good and a small but committed group of people from across a range of agencies continue to work together to deliver some very positive results.

Our activities continued to be in line with the Strategic Priorities determined by the Safeguarding Adults Board and focus mainly on raising awareness and involving a wider audience in understanding how it is everyone’s’ business to keep adults safe in Doncaster.

Our key objectives and achievements in 2015/16:

• We continued to build on the successful launch of our “Keeping Safe” campaign and got our message out (via posters, leaflets, cards and visits to other agencies) to a wider audience.

• We continued to support the “Keeping Safe Forum” which grew both in number of engaged attendees and in terms of the positive impact it continued to make. None of this would have been possible without the commitment and dedication of Angela Barnes, our Keeping Safe Co-ordinator. A big thank you to Angela.

• We held an extremely successful “Keeping Safe Event” on 19th November 2015, which was well attended and well received. The South Yorkshire Police & Crime Commissioner spoke at the event and was extremely complimentary about how we promote and address “Keeping Safe” in Doncaster.

• We used the Keeping Safe Event to kick start our consultation on developing our new Keeping Safe Communication and Engagement Strategy; the Keeping Safe Forum have continued this consultation and work has continued throughout the year to draft the Strategy for 2016-2020 (this will be presented to Safeguarding Adults Board at its July 2016 meeting).

Overall, 2015/16 has been a very busy and rewarding year and our work in Engagement Sub Group was recognised as making a valuable contribution, through our Keeping Safe Campaign, Keeping Safe Forum and our Annual Keeping Safe Event, by the Peer Review Team who visited Doncaster in November 2015.

As Chair of the Engagement Sub Group, I would again like to take this opportunity to thank my colleagues on the group for their dedication, enthusiasm, expertise and commitment. Special thanks to my Vice Chair, Julie Jablonski for ‘always being there’, to Sharon Fung and Shabnum Amin respectively in their roles as lead officer, both of whom, at different times of the year, have worked tirelessly to ensure we achieve our objectives:-

• Keeping Safe is everyone’s’ business• Everyone has the right to be safe, respected and heard• Everyone has a role to play to make this happen

Susan JordanChair, Engagement Sub GroupChief Executive St Leger Homes Ltd

Performance Sub Group

The Performance sub group is responsible for the monitoring and reporting of key performance indicators to ensure effective delivery of procedures relevant to the Doncaster Safeguarding Adults Board agenda.

Our key objectives are to progress and update the Board on a regular basis on the progress of the Boards strategic objectives and a range of performance indicators on a quarterly basis, identifying key themes and trends to inform Board. Also to further develop the Performance Framework to include measures relating to quality, process and outcomes.

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The Performance sub group have met 6 times and it has been a challenging year in terms of attendance. Despite this the sub group has maintained a good level of productivity.

The most significant challenge this year has been holding health and social care agencies to account over the timeliness of the safeguarding process. This has been an on-going risk throughout 2015/16 and to address this the sub group have escalated this risk to the Board for strategic challenge and action, in addition the membership of the sub group has been extended to include statutory health and social care providers to promote ownership of safeguarding adults’ performance information and identify ways to address shortfalls.

The DSAB performance framework will change significantly moving forwards. The introduction of the Care Act 2014 and principles of Making Safeguarding Personal stress the need for performance frameworks to move away from traditional process and focus on outcomes for adults at risk. Work is on-going through the MSP Strategy to revise systems, processes and reporting frameworks to measure outcomes to ensure that services are in line with the Care Act 2014 and are meeting the needs and wishes of adults at risk.

Pat HiggsChair, Performance Sub GroupAssistant Director of Care Management, DMBC

Workforce Sub Group

This year has seen the Workforce Sub Group grow and become a stronger through active engagement from its members. Attendance and the beginning of the year was highlighted as a risk however with clarity of member roles and a real focus on a partnership approach to achieving the Boards priorities the group has made a lot of ground and remains to be a well-attended sub group.

One of the key successes has been the revision of the Bournemouth University National Competency Framework which the sub group took a leading role to develop. A committed group of members took a new approach and developed a framework that can be practically implemented across the workforce from independent providers, to Health Services and Adult Social Care. These changes were welcomed by Bournemouth University who have used this to develop the National framework.

The Workforce Sub Group continues to monitor the delivery of training and in particular this year a real need was identified to ensure the workforce receives updated training in line with the Care Act 2014. In response to this a number of enhanced courses have been arranged and are accessible to the workforce.

All training now reflects the principles of Making Safeguarding Personal and the requirement to focus on outcomes for adults at risk. This will ensure Making Safeguarding Personal is embedded within the workforce.

The Sub Group is also committed to the South Yorkshire Working Together Programme for Continued Professional Development conferences and training courses on specialised subjects.

Chris PrewettChair of Workforce Sub GroupHead of Nursing & Safeguarding, RDASH


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Safeguarding Adults Review PanelIn 2013, the Safeguarding Adults Review Panel (SARP) was set up by the Board to take responsibilities for the following tasks:

• To consider whether a case meets the criteria outlined in the ‘DSAB Safeguarding Adult Review Policy and Toolkit ’.

• Where a case is assessed as meeting the Safeguarding Adult Review (SAR) criteria, the SARP will be responsible for the appointment of an independent author.

• Where the case does not meet the SAR criteria and there are lessons to be learned, the SARP should consider whether any single agency review is required.

• To oversee the quality of all SAR’s and monitors recommendations and action plans and hold agencies to account for these.

• To identify key themes for audit once actions have been completed.

Safeguarding Adult ReviewsDuring the period 2015/16, the Panel has met on 5 occasions, has functioned well and made good progress ensuring that high priority has been given to the key task of the monitoring the actions in relation to serious case reviews/ safeguarding adult reviews, some involving significant public interest and media attention.

Previously some difficulties have been experienced with quoracy of the SAR Panel, as the requirement is for the three statutory agencies of Police, Health and Adult Social Care always to be present. This has improved throughout 2015/16 and no meetings have had to be cancelled.

Lessons LearnedThe SAR Panel have concluded 1Lessons Learned Review throughout 2015/16 and the following lessons were learnt and have been shared with the relevant agencies;

• Agencies involved are required to adequately document and communicate effectively. There is evidence within this review that this did not always happen.

• The Mental Capacity Act was not actively used when decisions were being made in relation to the Adults health care needs. These included decisions made in relation to wider screening and health care interventions. Use of this framework would have contributed to robust decisions being made that were in adults Best Interest.

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• There is evidence within the review that there was a challenge bringing the multidisciplinary team together to discuss and agree a plan in relation to Adults health care needs. Although in this instance there may not have been a direct impact upon the Adults health, there is the potential, in the future for other people to be adversely affected by any delay.

Monitoring actions from Safeguarding Adult ReviewsIn addition 2 action plans from previous Serious Case Reviews were completed and presented to Board for final approval and sign off.

Moving forward the Board has restructured to ensure it is fit for the future and a decision has been taken to hold the SAR Panel on an ‘as and when required’ basis. The Quality and Performance sub group will pick up the responsibility for monitoring outstanding actions arising from SAR’s and audit processes to ensure lessons are learned throughout the partnership.

Pete HornerChair, SAR PanelPublic Protection Unit Manager, SYP


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Doncaster Keeping Safe ForumThe Doncaster Keeping Safe Forum continues to be an enthusiastic group of people who are committed to working alongside the Doncaster Safeguarding Adults Board to raise awareness of Keeping Safe in Doncaster. Over the year the forum has attracted new members and worked to promote the Keeping Safe campaign in local communities.

• The forum have held regular events for forum members during the year, with 10 meetings taking place over 2015/16. An average of 20 members have attended each of the meetings.

• The forum have had a presence at a number of events and meetings to promote the Keeping Safe Campaign, these have included information provided to groups for example MG Dons, DON Mag and at events including the Cantley Carnival and the Dragon Boat Race.

• The forum have continued to hold regular meetings at set times providing members with advance notice of the date, time and topic.

• Representation for the forum at the Engage and Share sub-group has continued throughout the year with regular updates provided to the group on the work and activities of the forum

• The forum supported the planning and delivery of the DSAB Annual Keping Safe event in November 2015

• Forum members have received Safeguarding Training during the year to help in their understanding of Keeping Safe and how to raise concerns

• The forum have responded to a number of consultations in relation to strategies and plans produced by the DSAB including Making Safeguarding Personal and the Communication and Engagment Strategy

• Forum members have continued to cascade information about the Keeping Safe campaign to colleagues, friends, family and within their communities.

• The forum has welcomed 54 new members during 2015/2016 and information about Keeping Safe is now distributed to 88 members.

• Forum events and meetings have encouraged all to become involved and share information about Keeping Safe within their organisation and community.

• The forum has provided information on Keeping Safe at events and meetings on a range of topics, including Hate Crime, Scam Awareness, Personal Safety, Healthy Eating and Fire Safety.

• The forum has provided information via the dedicated Twitter feed @DoncasterKSF the account has 561 followers and averages 47 new followers each month. We have tweeted information about Adult Safeguarding, Fire Safety, Scam Awareness, Domestic Violence & many other Keeping Safe intitiatives.

• The forum have represented the views of members in relation to the DSAB communication strategy, the Making Safeguarding Personal campaign, the Keeping Safe campaign material and the DSAB website.

• In November 2015 several members of the forum contributed to the Peer Review of services in Doncaster

• In March 2016 the forum invited members of the DSAB to attend their meeting to discuss engagement and the way forward, 5 members of the DSAB attended and they worked alongside forum members to look at engagement around adult safegaurding in the borough. From this meeting a wish list of actions and activities was produced .

• The model of engagement was shared with Barnsley Safeguarding Adults Board in December 2015 and a meeting is also planned to discuss the model with the East Riding Safeguarding Board in June 2016

To promote Keeping Safe in Doncaster

To be reliable

To be the Eyes, ears, voice & action for

Keeping Safe

To be inclusive

To provide information

To represent the views of all in

Doncaster

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Reports from Safeguarding Adult Board PartnersCare Quality CommissionIn our approach to regulating, inspecting and rating services our inspectors use their professional judgement, supported by objective measures and evidence, to assess services against our five key questions.

Our approach includes our use of Intelligent Monitoring to decide when, where and what to inspect, methods for listening better to people’s experiences of care, and using the best information across the system.

We rate services to highlight where care is outstanding, good, requires improvement or inadequate and to help people compare them.

The five key questions we ask To get to the heart of people’s experiences of care, the focus of our inspections is on the quality and safety of services, based on the things that matter to people. We always ask the following five questions of services.

• Are they safe? • Are they effective? • Are they caring? • Are they responsive to people’s needs? • Are they well-led?

For all health and social care services, we have defined these five key questions as follows:

Safe By safe, we mean that people are protected from abuse and avoidable harm.

Effective By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is evidence-based where possible.

Caring By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect.

Responsive By responsive, we mean that services are organised so that they meet people’s needs.

Well-led By well-led we mean that the leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

Sector Total Locations

Adult social care 136

Hospital 18

Primary medical services 108

Total 262

Our approach was launched on 1 October 2014. This approach was developed over time and through testing and consultation with the public, people who use services, providers and organisations with an interest in our work. We will continue to learn and adapt how the approach is put into practice. However, the overall frame-work, including our five key questions, key lines of enquiry, characteristics of ratings and ratings principles will remain the same until we have rated every adult social care service at least once.

Number of active registered locations in Doncaster


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Sector Outstanding Good RequiresImprovement

Inadequate Total Locations

Adult social care 71 15 3 89

Hospital 2 3 5

Primary medical services

1 20 3 24

Total 1 93 21 3 118

Sector Compliance action Improvement action Report to another agency

Requirement notice

Warning notice

Adult social care 43 18 1 11 8

Hospital 4 3 2

Primary medical services

8 1 5 1

Total 55 22 1 16 11

Sector Outstanding Good RequiresImprovement

Inadequate

Adult social care Doncaster 79.8% 16.9% 3.4%

Hospitals Doncaster 40.0% 60.0%

Primary medical services Doncaster

4.2% 83.3% 12.5%

Adult social care Yorkshire & Humber

0.9% 66.4% 27.7% 5.1%

Hospitals Yorkshire & Humber 32.5% 62.5% 5.0%

Primary medical services Yorkshire & Humber

3.0% 90.0% 5.9% 1.1%

All sectors National 1.4% 70.5% 25.1% 3.0%

Latest published ratings on those registered locations in Doncaster

Latest published ratings on registered locations in Doncaster, Yorkshire & Humber and National

CQC Regulatory action in Doncaster

CQC role in safeguardingAs a regulator the main responsibility of the Care Quality Commission (CQC) is to ensure that all health and adult social care providers have clear and robust systems in place to keep people who use their services safe, that there is clear governance and oversight of those systems and that they employ staff who are suitably skilled and supported.

The role and overarching objective of the CQC in safeguarding is to protect peoples’ health, wellbeing and human rights; enabling them to live free from harm, abuse and neglect.

As a regulator we are keen to work with local safeguarding teams and to establish effective working relation-ships and we see this as part of our function. These relationships help keep people safe.

We commit to CQC representation at a SAB meeting at least once per year in each local authority area.

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As a partner, as opposed to a member of the SAB, and a national regulator, the focus of our local inspection teams is on inspecting regulated services against our five key questions of safe, effective, caring, responsive and well–led. In doing this we work in partnership with local authorities and local CCGs to highlight areas of concern within regulated services. We will take regulatory action as appropriate.

We have implemented a specialist approach to the inspection of health and social care services informed by intelligent monitoring. This informs when and how we inspect health and social care services.

CQC has, and continues to, raise awareness amongst the general public about our role. We receive a signifi-cant number of contacts from members of the public, community organisations, local authorities and providers raising safeguarding issues. We use data to inform our intelligence and this results in appropriate and timely action in relation to safeguarding. The CQC statement on our role in safeguarding is available on our website here http://www.cqc.org.uk/content/safeguarding-people

NHS EnglandNHS England ensures the health commissioning system as a whole is working effectively to safeguard adults at risk of abuse or neglect, and children. NHS England is the policy lead for NHS safeguarding, working across health and social care, including leading and defining improvement in safeguarding practice and outcomes. Key roles are outlined in the Safeguarding Vulnerable People Accountability and Assurance Frame-work 2015.

GovernanceThis role is discharged through the Chief Nursing Officer (CNO) who has a national safeguarding leadership role. The CNO is the Lead Board Director for Safeguarding and has a number of forums through which to gain assurance and oversight, particularly through the NHS England National Safeguarding Steering Group (NSSG). The National Safeguarding Adults and Children Sub Groups and its Task and Finish Groups report into NSSG.

Yorkshire and the Humber has an established Safeguarding Network that promotes an expert, collaborative safeguarding system, which strengthens accountability and assurance within the NHS commissioning and adds value to existing NHS safeguarding work across Yorkshire and the Humber. Representatives from this network attend each of the national Sub Groups/Task and Finish Groups, which include topics around FGM, MCA, CSE, Prevent, Safeguarding Adults and Children. NHS England Yorkshire and the Humber aims to focus on working in collaboration with colleagues across the north region on the safeguarding agenda and the work on FGM and the CCG peer review process and regional conference is evidence of this.

Financial contributionA financial contribution to local Safeguarding Adults Boards is made via the local Clinical Commissioning Groups.

Safeguarding Adults TrainingIn February 2016 NHS England published Safeguarding Adults: Roles and competencies for healthcare staff - Intercollegiate Document on behalf of the following contributing organisations - The Royal College of Nursing, The Royal College of Midwifery, The Royal College of General Practitioners, National Ambulance Safeguarding Group and The Allied Health Professionals Federation. The purpose of this document is to give detail to the competences and roles within adult safeguarding. The guidance is to be used for the training of healthcare based staff in the safeguarding of adults who may be at risk of harm, abuse or neglect. https://www.england.nhs.uk/?s=intercollegiate+document Designated safeguarding professionals are jointly accountable to CCGs and NHS England and oversee the provision of level 3 training for primary care medical services. The main source of training for other primary care independent contractors is via e-learning training packages.


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Preventative safeguarding adults workNHS England Yorkshire and the Humber Safeguarding Network hosted a safeguarding conference on Chal-lenges for Modern Day Safeguarding Practice on 11 March 2016. This conference was aimed at providing level 4 training for healthcare safeguarding adults and children professionals and leads in the North region. The aim was to increase understanding of challenges and issues of modern day safeguarding practice in re-lation to suicide and self-harm; trafficking and modern day slavery; trafficking victim/survivor support; Court of protection, community deprivation of liberty and CCGs responsibilities; Mental Capacity Act and Safeguarding Children; Think family primary care implementation and Self neglect and the Care Act.

On 1 February 2016 NHS England North region held a React to Red Conference to share innovation on safe-guarding practice and the prevention and management of pressure ulcers across health and social care settings.

NHS England Yorkshire and Humber and Yorkshire and Humber Safeguarding Network have produced an FGM guide for health care professionals, which can be accessed in the link below:-https://www.england.nhs.uk/north/our-work/safeguarding/

NHS England has also developed a Safeguarding Adults pocket book and Prevent pocket book for health care professionals.

Safeguarding Adults Performance All safeguarding serious incidents and domestic homicide’s requiring a review are reported onto the national serious incident management system – Strategic Executive Information System (STEIS). There is a process in place to jointly sign off GP IMRs relating to these safeguarding serious incidents as CCGs responsibilities for commissioning of primary care services is increasing. NHS England works in collaboration with CCG designated professionals to ensure recommendations and actions from any of these reviews are implemented. Prior to publication of any child serious case reviews, serious adult reviews or domestic homicide reviews NHS England communication team liaise with the relevant local authority communications team regarding the findings and recommendations for primary care medical services.

Future intentions / direction for safeguarding Over the last 12 months a focus on improving the lives of people with a with learning disabilities and/or autism (Transforming Care) has been led jointly by NHS England, the Association of Adult Social Services, the Care Quality Commission, Local Government Association, Health Education England and the Department of Health.

The focus for the coming year will be on improving care and services for patients with mental health problems.

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Doncaster Clinical Commissioning GroupAs commissioners of high quality, safe healthcare, Doncaster Clinical Commissioning Group (DCCG) has responsibility for ensuring that the health contribution to safeguarding is discharged effectively across the whole local health economy through its commissioning arrangements and partnership working.

All healthcare providers commissioned by Doncaster CCG are accountable for the quality of the service they provide. The Doncaster CCG Safeguarding Assurance Group has the responsibility for Safeguarding within Doncaster and covers the commissioning responsibilities of the Doncaster CCG.

Governance Doncaster CCG continues to monitoring quality via the safeguarding standards and safeguarding annual declarations which are included within existing and new contracts. During 2015/16 Doncaster CCG has received quarterly safeguarding reports from both main provider organisations which have been discussed and reviewed by the Doncaster CCG Safeguarding Assurance Group.

Doncaster Safeguarding Adults Board

Doncaster Clinical Commissioning

Group (Governing Body)

Doncaster Children’s

(Improvement) Board

Doncaster CCG Safeguarding

Assurance

Specialist Named &

Designated Professionals

DBHFT Strategic Safeguarding People Board

RDaSH Safeguarding

Forum

RDaSH Clinical & Quality Review

Doncaster CCG Quality & Patient

Safety

DBHFT Clinical & Quality Review

Doncaster Safeguarding

Children’s Board


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Doncaster CCG is required to have a Lead Professionals for Safeguarding Adults and a Lead Professional for Mental Capacity. These roles are fulfilled by a single post holder. The Designated Nurse provides professional advice on safeguarding adults matters to the Doncaster CCG, health professionals, Local Authority and Doncaster Safeguarding Adults Board. Doncaster CCG continues to commission Strategic Leads and Lead Professionals in the main health providers to ensure:

• Accountability for safeguarding adults within their organisation. • Provide representation at the Doncaster Safeguarding Adults Board at a strategic level. • Robust and effective governance systems exist within their organisation.

Safeguarding Adult Board Contribution Doncaster CCG contributes both financial and with resource to the Doncaster Safeguarding Adults Board. The CCG is represented at the Board and Sub Group meetings by the Chief Nurse, Deputy Chief Nurse and/or Designated Nurse for Safeguarding Adults. Doncaster CCG supports all appropriate Safeguarding Adults work streams accordingly.

Safeguarding Adults Training Safeguarding Adults Training sits in the mandatory training requirements for the Clinical Commissioning Group and is required on an annual basis or induction by all Clinical Commissioning Group staff. As of March 2016 there were 88% of Clinical Commissioning Group staff trained on level one safeguarding adults.

Low Level Concerns The low level concerns that are raised within Doncaster CCG relate the patients within a Care Home setting or patients receiving Domiciliary Care. These concerns are managed via the Weekly Risk Meeting which is attended by the Local Authority and Doncaster CCG. Clear escalation processes are in place to support the more complex issues.

Future Intentions In light of the organisational changes within Doncaster CCG and the Safeguarding Team, ongoing review of capacity and demand will take place during 2016/17.

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South Yorkshire PoliceIn September 2015, the Safeguarding Adults Teams (SAT) were established at Doncaster and co-located with partners in Local Authority premises. Previously the team were incorporated within different departments across the organisation, and the restructure has provided specific police resources, delivering services at a local level. The team comprises of two detective sergeants, detective constables, and civilian investigators.

GovernanceThe roles and responsibilities of the team include the safeguarding and investigation of high-risk domestic abuse cases, including honour based abuse/force marriage, the investigation of adult rape and serious sexual offences, and the investigation of instances involving serious harm committed against vulnerable member of the community. The team work closely with partners from across the Borough, as well as local police officers and staff.

All reports of Adults at Risk are recorded by police officers, whether or not an investigation is required. In all cases where an Adult at Risk has suffered harm or is likely to suffer harm or is at risk of abuse, officer complete the relevant referral, and forwarded it to the Local Protecting Vulnerable People Unit, and relevant local Social Care agency. A specialist resource from the SAT is allocated to deal with the more serious and complex cases, and local officers continue to investigate low level concerns and crime.

South Yorkshire Police have policies and procedures that provide guidance to all staff, in relation to dealing with Adults at Risk and the investigation of potential offences. They have also worked closely with partners to revise procedures and instructions to support the Care Act 2014.

Safeguarding Adults TrainingAll frontline police officers and staff receive training in relation to Adults at Risk and safeguarding. There is also specific training in relation to domestic abuse. South Yorkshire Police specialist officers (SAT), also attend multi-agency training.


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Doncaster and Bassetlaw Hospitals NHS Foundation Trust The Director of Nursing, Midwifery and Quality is the Trust Executive Lead for Safeguarding supported by the the Deputy Director of Nursing Midwifery and Quality and the Named Nurse. There is a Professional Lead for Safeguarding Adults and a Specialist Nurse for Safeguarding Adults. The Executive Lead chairs the Trust SSPB which oversees the safeguarding arrangements. Membership includes Safeguarding professionals and among others Heads of Nursing, Heads of Therapies, Medical staff and Matrons. Assurance is provided to the group by members representing their areas and care groups.

GovernanceThe SSPB oversees the safeguarding arrangements in the trust. Its purpose is to:-• Provide leadership and strategic direction for maintaining, developing and implementing safe and reliable

safeguarding systems and processes within the Trust.• Provide the Trust Executive Group and the Board of Directors with assurance of the Trusts compliance with

statutory regulations, obligations and standards in relation to safeguarding.• To receive feedback and assurance from the Clinical Care Groups

AssuranceAs well as the safeguarding board assurances are also provided to the CQC, CCGs, the Trust’s Board of Directors through the Clinical Governance and Quality Committee and to Monitor (regulators of Foundation Trusts) compliance framework.

Safeguarding Adults activityThe safeguarding team deal with a range of enquiries and calls for advice and support, ranging from a brief query to responding to complex issues, complaints and incidents. A total of 647 telephone contacts were made to the safeguarding team in 2015/2016.Two audits have been undertaken in 2015/2016 by the Lead Professional and Specialist Nurse for Safeguarding Adults in relation to staff awareness of the MCA 2005 and compliance with DoLS. The findings suggested an increased awareness of the MCA evidenced by an increase in the number of applications for DoLS from 7 requests for authorisation in 2013/2014; to 64 in 2015/2016.

Safeguarding Adults TrainingA key priority for the corporate safeguarding team in 2015/16 was delivery of the trust training programme and demonstration of improvements in practice. The training has been quality assured by local safeguarding boards and in total 2323 staff have attended the new training programme in 2015/16.

With specific regard to MCA/DoLS, additional training has taken place with 70 staff, primarily Medical staff attending a lecture delivered by a solicitor and a further 44 clinical staff attending workshops also delivered by the solicitor.

Future intentionsKey priorities in 2015/16 included “getting the ‘safeguarding’ message across to all staff” and “Visibility and accessibility of the safeguarding team”. A range of activities have taken place to meet these objectives, including publication of a Trustwide newsletter, Emergency Department drop in sessions for staff, targeted work as part of the preceptorship programme and attendance at the trust’s annual members meeting to raise awareness of safeguarding.

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Rotherham Doncaster and South Humber NHS Foundation TrustTo support the delivery of adult safeguarding, within RDaSH and across the wider partnership arena, there is a clear governance and accountability framework in place, specific to each of the localities that it covers. The framework provides assurance to the DSAB’s and commissioner’s that whilst the ultimate responsibility and accountability for adult safeguarding lies firmly with the Trust Board, every member of staff is accountable and is responsible for safeguarding and protecting adults at risk

As a multi-agency partner working with the DSAB, the RDaSH safeguarding adult team has been able to act as a link between strategic and operational objectives and share the learning and development across all areas of the Trust.

A comprehensive workforce development programme is in place and staff are able to access both single and multi-agency training that allows them to meet their safeguarding competency framework. A model of clinical supervision is in place and embedded across the Trust to ensure safeguarding cases are managed in line with the Care Act 2014 and making Safeguarding personal.

Responsibility for SafeguardingOverall responsibility for safeguarding adults at risk within the organisation rests with the Board Executive Lead Dr Deborah Wildgoose and the Board Non Executive Lead Pete Vjestica.


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Safeguarding Adult Board Contribution A financial contribution comes from Doncaster CCG on behalf of the Health Community. RDASH contribute through Board and Sub group membership and provide support to multi-agency training programme.

Governance arrangementsThe following governance arrangements are embedded within the organisation;• South Yorkshire Multi-agency Safeguarding Adults Procedures • RDaSH Safeguarding Adults Policy• DSAB Safeguarding Adults Process for Health Staff• DSAB Policy for Co-ordination of Overarching Safeguarding Investigations• DSAB Guidance on the Co-ordination of S42 Enquiries (with other Investigations)• Mental Capacity Act Policy• Making Safeguarding Personal• Risk assessments• Local Authority Designated Officer (LADO) process in place• Reports to Safeguarding and Quality Group and Trust Board• Results of any inspections or audits undertaken within the year ie.Trust clinical records audit, Quality

Reviews.

Oversight of safeguarding cases Safeguarding Adult Leads review and quality assure cases and escalate to the Head of Safeguarding for complex and sensitive cases.

Safeguarding Adults TrainingSafeguarding adults training is embedded within the organisation through the Trust Safeguarding Adult Policy through;

• Multi agency training• Single agency training• Clinical supervision

In addition through raising awareness and understanding of safeguarding adults, proactive risk assessments and planning for individuals and services and reporting and review of incidents (IR1’s).

Safeguarding Adults Low level concerns Low level concerns are managed through the organisations Incident Management Policy. These concerns are reviewed by the safeguarding adult leads and those identified as potential safeguarding adults concerns are reported as appropriate. Senior managers review all safeguarding adults concerns.

Future intentions The organisation will continue to embed the changes with regard to Care Act 2014 and the principles of Making Safeguarding Personal. Provide continued support with the development of the Safeguarding Adults Hub through the secondment of a 0.5 whole time equivalent practitioner.

Moving forward it will develop a Safeguarding Strategy and support the organisational Transformation agenda to ensure safeguarding remains a high priority.

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St Leger HomesSafeguarding is a key priority for St Leger Homes as it places the needs of its customers and their families at the heart of its work. St Leger Homes has a Duty of Care (Care Act 2014) to keep all of our customers safe from harm. There are a number of routes through which concerns raised in relation to our customers will be appropriately handled, including via health and safety procedures, tenancy management and the provision of support to adults at risk.

Our safeguarding policy and procedure fits within this overall Duty. They relate specifically to abuse and/or neglect – adults who are at risk of or are being abused or neglected by others. Across the organisation, we all play a part in preventing, being alerted to and responding appropriately to abuse and/or neglect.

Specifically we:- • raise awareness about the abuse and or neglect of adults at risk• continue to develop a culture that does not tolerate such abuse and which encourages people to raise

concerns• prevent abuse from happening wherever possible• respond promptly and proportionately where abuse does happen, to stop the abuse from continuing and to

ensure the person harmed receives effective support

Governance Susan Jordan, Chief Executive of St Leger Homes has overall responsibility for adults at risk and provides strong leadership and a clear vision to St Leger Homes. Susan is a member of the DSAB, and chairs the engagement subgroup which delivers the DSAB Communication Plan.

In addition, there is a Designated Safeguarding Lead Officer whose role is to ensure we fulfil our responsibilities and promote positive practice within our organisation. The designated safeguarding lead officer is a member of a number of sub groups and task groups of the DSAB and is also delegated to Serious Case Review Panels and Domestic Homicide Review Panels as and when required.

We have a Safeguarding Children and Adults Policy and Procedure for all staff. We completed the Safeguarding Children and Adults Board audit assessment in June 2015. We also complete an internal Business Assurance Review of the way we deliver safeguarding services. All challenges are received positively, noted, and action taken. In addition, St Leger Homes has been listed as a best practice case study by the Social Care Institute for Excellence, SCIE.

Safeguarding Adults TrainingSafeguarding adults training is firmly embedded within our organisation. We deliver a rolling programme of mandatory safeguarding awareness training to every member of staff. In addition safeguarding awareness training is also part of new staff inductions. Dependent on role, our staff also complete training on a range of topics including Domestic Abuse, Neglect, Prevent, and Mental Health.

During 2015/16, various levels of safeguarding training were completed by 234 staff members.Procedures and safeguarding services are available to staff and customers who either make enquiries or wish to report a safeguarding concern. Integral to this process, we have a ‘single point of contact’ available by telephone to continue best practice and safeguarding awareness throughout the organisation. This is used by employees and representatives of St Leger Homes to report any concerns they may have regarding an adult or child.

The designated safeguarding lead closely monitors the organisations day-to-day performance to ensure all cases are responded to within the required timeframe and the case is being dealt with correctly.


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Safeguarding Adults ActivityDuring 2015/16, St Leger Homes received 308 safeguarding concerns which, following case management resulted in 495 referrals for varying support services. All safeguarding concerns received are treated as a high priority and visits are made to the individuals address within 24 hours. All concerns are case-managed by an Estates Officer and monitored centrally by the designated safeguarding lead. This approach has proved successful. Through engagement with the individual concerned, support services can be best identified, offered and arranged to meet their personal needs at an early stage.

Future Intentions for Safeguarding Adults St Leger Homes will continue to learn, develop and fulfil its safeguarding responsibilities to the highest standards by:-

• Continuing to build on our collaborative approach to safeguarding children and adults, and continue to be a key partner in delivering the vision for Doncaster.

• Remaining visible and influential in the delivery of Doncaster’s approach to safeguarding through effective engagement with other multi-agency partnerships, partner agencies, frontline practitioners and adults at risk.

• Continue to deliver our rolling programme of safeguarding training and refresh training, both for our own staff and partners through the workforce subgroup and training pool of DSAB.

South Yorkshire Fire and Rescue ServiceSouth Yorkshire Fire & Rescue (SYFR) is an emergency responder for operational fire fighting and rescue services, committed to reducing deaths and injuries and safeguarding property. In addition to the emergency response, SYFR provide services within the Prevention and Protection directorate to create a safer environment for people to work and live. This includes the Technical Fire Safety teams with responsibility for improving fire safety in business premises, public buildings and enforcing legislation and the Community Safety teams working to improve fire safety in the home and wider community.

Responsibilities and Designated LeadA Safeguarding Officer was appointed into a newly created post for SYFR in May 2009. This role sits within the Community Safety function under the Prevention and Protection Directorate and is championed by both the Area Manager for the Directorate and also Group Managers with Community Safety Leads. Contribution to Safeguarding BoardsThe Safeguarding Officer as the designated lead for safeguarding adults and safeguarding children is the named representative for SYFR at Safeguarding Boards and also attends the Workforce Subgroups.

Governance ArrangementsThe Safeguarding Officer is responsible for the development of Safeguarding policy and procedure which are reviewed annually subject to internal consultation and completion of an Equality Analysis

The Safeguarding Officer is responsible for Safeguarding policy development, management and coordination and monitoring of all internal safeguarding alerts and referrals. Group Managers deputise out of hours and in the absence of the Safeguarding Officer

AssuranceThe Safeguarding Officer provides reports and is responsible for SCR, IMR, Action Plans and implementation into the SYFR policy & practice. SYFR has undertaken a number of self-assessment audits i.e. Section 11/Care Act Compliance audits and attended respective joint safeguarding children’s and adults Challenge Meetings in the last 12 months.

Safeguarding Adults TrainingThe Safeguarding Officer is responsible for the development and delivery of Safeguarding training. From 2015 to 2016 159 staff has received Safeguarding training; this includes staff from Community Safety, Youth Engagement, Technical Fire Safety, Operational Response and also volunteers. The SYFR Safeguarding

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Training programme includes: -

• Induction,• Basic Awareness• Updates & Refreshers• Mental Capacity & Dementia Awareness• Running Safe & Effective Activities and Events• Case Conferences & Core Groups (Strengths Based Approach – Signs of Safety and Making Safeguarding

Personal – Outcome focus

Preventative Work and Safeguarding ActivitySafeguarding Performance is reported internally in the quarterly SYFR Prevention and Protection Performance Reports which are scrutinised by the Fire Authority. From 2015 to 2016 144 Safeguarding concerns were raised internally an increase of nearly 100%. 45 of these cases were specific to Doncaster, the majority relate to self-neglect and are linked to fire risk but 3 were linked to Care Homes and 19 to suspected abuse.Fire Safety

Between 2015 and 2016 South Yorkshire Fire and Rescue has seen an increase in the number of fire incidents leading to a fatality. 4 out of the 9 cases were in the Doncaster area and all are reviewed internally by the SYFR Fire Death and Review Panel.

Future directionA proposal and terms of reference for an internal SYFR Safeguarding Executive Board and the Reference Sub-group have been drafted and approved and membership and meeting dates established.

National Probation Service – South YorkshireIn terms of promoting and developing its role as a relevant partner in Adult Safeguarding, the National Probation Service (NPS) continues on a journey to embed the safeguarding of adults into everyday practice and to improve co-operation with all relevant partner agencies.

At a national level, the recently published National Probation Service Policy Statement and associated Practice Guidance (Jan 2016) makes clear the NPS commitment to safeguarding and promoting the welfare of adults at risk. It recognises the importance of people and organisations working together to prevent and stop both the risk and the experience of abuse and neglect, whilst at the same time making sure an individual’s well-being is being promoted with due regard to their views, wishes, feelings and beliefs. It also identifies that Offenders in the community should experience the same level of care and support as the rest of the population and acknowledges the contribution NPS staff can make to the early identification of an offender who may have care and support needs, or of an offender who may benefit from preventative support to help prevent, reduce or delay needs for care and support. We are also aware of the NPS role with Victims under the Victims Charter and how they are often vulnerable adults.

GovernanceIn terms of the practical application of this policy statement, 2016 has seen the rolling out of mandatory training on adult safeguarding for all staff. The development of policy and guidance has been accompanied by the introduction of a new process mapping system (EQUIP) which provides front-line staff with easily accessible information on policies, processes and guidance around adult safeguarding. Each National Probation Service Division has a designated strategic lead for Adult Safeguarding. As part of the National Probation Service NE, the responsible strategic lead is Julie Allan, but our South Yorkshire Lead is Sarah Mainwaring.

It is explicitly recognised that Safeguarding is everyone’s responsibility and that the need to promote individuals welfare and protect them from abuse, neglect and serious harm will apply at every point of an offenders journey. However, we recognise the importance of identifying at an early stage whether an offender


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has care and support needs, is a carer of a person with care and support needs, poses a risk of harm to adults at risk, and/or if they themselves are an adult at risk. There is a specific expectation that staff at pre-sentence report stage are pro-active in identifying adult safeguarding concerns. There is also a specific expectation that any identified offenders are appropriately ‘flagged.’

Future IntentionsHowever, it is recognised that practice locally needs to be developed. From a strategic management perspective there is a need to ensure that we get better at identifying and ‘flagging’ relevant cases, to help promote learning and improve service delivery. This has been identified as a priority for the next year. From a frontline service perspective, there is a need to develop partnership working and to identify and promote those services which appear to be most effective, such as the provision of social workers within the South Yorkshire custodial estate. To help achieve this, Doncaster LDU have recently identified that Sally Beadle, Senior

Probation Officer, will have a specific responsibility for Adult Safeguarding in Doncaster.

Mental Capacity Act – Deprivation of Liberty SafeguardsThe Mental Capacity Act continues to be a focal point of the legislative framework that supports safeguarding adults work. The Mental Capacity Act 2005 and subsequent Deprivation of Liberty Safeguards 2007 became statutory from April 2009. Since this time the Council has developed and implemented robust systems and processes to ensure that people who lack capacity to consent to their care and treatment are safeguarded to ensure;

• A deprivation of liberty is a last resort• Their care and treatment is in their best interest and least restrictive• They have someone appointed to represent them • The person is given the right of appeal• The arrangements are reviewed and not continued for longer than necessary

On 19th March 2014 the interpretation of the law by the Supreme Court changed, which has had a dramatic impact on Councils nationally due to a significant increase in Deprivation of Liberty Safeguard authorisation requests with no additional resources nationally identified to meet the increased demand. Over the period of April 2015 to end of March 2016 there have been 1362 requested authorisations to deprive individuals of their liberty, this is a further 230% increase on 2015/16 figures.

0

300

600

900

1200

1500

2013/14 2014/15 2015/16

MCA / DOLS Authorisation requests

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In response DMBC have targeted resources to deal with the significant increase in DOLS requests. A pro-gramme of recruitment has been undertaken throughout 2015/16 to be able to meet future demands on the organisation as a supervisory body.

The Doncaster MCA / DoLS Team provides a single point of contact for organisations , professionals and the public in relation to Deprivation of Liberty issues. For further information visit http://www.doncaster.gov.uk/ser-vices/adult-social-care/raising-concerns or email [email protected]

CASE STUDY – Mr BAMr BA is an 84-year-old gentleman who has a history of hallucinations, confusion and aggression coupled with episodes of restlessness, aggression and paranoia. Mr BA was previously sectioned under Section 3 of the Mental Health Act 1983 however he was moved to an out of area care home in February 2015 following an incident whereby his wife was injured. Mr BA’s current out of area placement was arranged by his daughter, who is also the donee of his Lasting Power of Attorney, under the Mental Capacity Act 2005 best interests procedures.

A referral was made to the Local Authority (DoLS supervisory body) by the care home (managing authority) for a DoLS authorisation as they believed that Mr BA might be deprived of his liberty.

The Mental Health Assessor appointed under the DoLS process reported that Mr BA no longer meets the grounds for detention under the Mental Health Act 1983. However, he reported that the care home may need additional support from the local mental health team in supporting Mr BA with his care and treatment needs. The Best Interest Assessor appointed under the DoLS process confirmed that Mr BA is being deprived of his liberty in his current placement as his circumstances meet the ‘acid test’ with regard to the Supreme Court judgement, in that he is “not free to leave” and he is “under continuous control and supervision” due to his own care and treatment needs. It is reported that the care home staff use distraction techniques rather than intervention to manage Mr BA’s behaviour and he is also prescribed anti-psychotic medication to manage his mood and aggression. Mr BA’s family confirm that he is settled in his current placement and his care and treatment needs are met effectively. His daughter lives locally and visits frequently. His wife states she is able to visit Mr BA frequently as she now has more time to travel, she is even considering locating to an area near Mr BA’s placement so that she can visit him more often. Mr BA’s son-in-law visits regularly and has had a great deal of input into care and support plans at Mr BA’s current placement, he is also appointed as the Relative Person’s Representative in order to prevent a conflict of interest from arising for his daughter as the donee of the Lasting Power of Attorney.

The Best Interest Assessor recommends that a DoL authorisation is granted for a period of 12 months as Mr BA is settled in his placement and there is strong evidence that his care and treatment needs were being met effectively. All parties consulted by the BIA were also in agreement that this placement was in Mr BA’s best interests and the least restrictive in his circumstances. The DoLS process provides Mr BA with independent oversight to ensure that deprivation of his liberty is a proportionate response to the likelihood that he will otherwise suffer harm and to the seriousness of that harm and that his current care and treatment arrangements including his residency are in his best interests and are the least restrictive given his circumstances.


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Safeguarding Adults Activity 2015/16The Care Act 2014 was introduced in April 2015 and has resulted in a number of changes to safeguarding adults terminology as listed below;

Who is an adult at risk?The safeguarding duties apply to an adult (person aged 18 or over) who:

1. Has needs for care and support (whether or not the local authority is meeting any of those needs) and;2. Is experiencing, or at risk of, abuse or neglect and; 3. As a result of those care and support needs is unable to protect themselves from either the risk of, or the

experience of abuse or neglect.

The above is termed the three stage test under the Care Act 2014.

What is abuse or mistreatment?• Can be a violation of an individual’s human or civil rights by another person or persons.• May consist of a single act or repeated acts.• Can occur in any relationship.• May result in harm to, or serious exploitation of, the person subjected to it.• May be physical, including hitting, slapping, punching, kicking, misuse of medication, restraint, or inappro-

priate sanctions.• Could be sexual, including rape and sexual assault or sexual acts to which the person has not consented, or

was pressured into consenting.• May be psychological, including emotional abuse, threats, humiliation, intimidation, verbal abuse.• May be financial or material, including theft, fraud, exploitation, the misuse or misappropriation of property,

possessions or benefits.• May be neglect, including neglect of medical or physical care needs, the withholding of adequate food, heat,

clothing, medication or other forms of similar mistreatment.• Can take the form of discrimination, including racist, sexist or disability. • May be organisational abuse which can take the form of neglect, poor professional practice - by way of

isolated incidents which are poor or unsatisfactory - through to ill treatment or gross misconduct, resulting in the needs of the organisation/agency overriding the needs of the person.

From April 2015 the SAC (Safeguarding Adults Collection) replaced the SAR (Safeguarding Adults Return). This is a mandatory requirement for all Local Authorities in England to complete and submit to the Health and Social Care Information Centre (HSCIC).

Previously under ‘No Secrets Guidance’ Care Act 2014

Vulnerable adult Adult at Risk

Alleged Perpetrator Source of Harm

Safeguarding Alert Safeguarding Adult Concern

Safeguarding Referral Section 42 Enquiry

Serious Case Reviews Safeguarding Adult Reviews

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2015/16 Concerns S42 Enquiries Total

Total 1946 456 2402

Number of Safeguarding Concerns and Section 42 Enquiries received 2015/16

Number of Safeguarding Concerns and Section 42 Enquiries received 2011/12 – 2015/16

The data illustrated within the graph may include people who have been referred into the system more than once

The number of concerns continues to increase year on year since 2009/10 and has risen from 1291 in 2014/15 to 1946 in (an increase of 51%). In contrast the number of referrals has risen from 399 last year to 456 (an increase of 14.5%) for the year ended 31 March 2016. The introduction of the Care Act 2014 has seen a broad-ened definition of abuse and people defined as adults at risk. In addition people are becoming more aware of abuse and how to report safeguarding concerns. The overall increase also suggests that we are improving awareness of safeguarding adults across Doncaster.

Doncaster underwent a Safeguarding Adults Peer Review during November 2015. An outcome from the review criticised the Local Authority for funnelling too much through the Safeguarding Adults process which on closer analysis could be dealt with by other means and signposted appropriately.

In response to this recommendation a piece of work has been identified to develop guidance that will support managers from all agencies to make decisions when identifying abuse and the need to report. It is intended that the guidance will reduce the number of inappropriate safeguarding concerns being reported to the Local Authority which could be dealt with through internal risk or incident management procedures.


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Source of Referral Number2014/15

Number 2015/16

Voluntary 7 6

Police 74 67

Primary Health Care 87 122

Regulator 22 27

Relative / Family Carer 100 121

Community Health Care 50 55

Secondary Health Care 124 104

Social Care staff (statutory and independent) 1059 1585

Individual - Unknown / Stranger 31 15

Individual - Known but not related 28 47

Other private sector 41 159

Other public sector 64 94

Not recorded 3 0

Total number of concerns received 1690 2402

Number of Safeguarding Concerns and Section 42 Enquiries received by Source of Referral

The above table considers all safeguarding concerns received by operation services including those that progress to a Section 42 enquiry, therefore the number is 2402.

The highest proportion of safeguarding concerns were received (66%) from social care support staff many from within the private sector i.e. statutory social care staff, care homes, domiciliary care agencies etc. This demonstrates a good level of education, awareness and robust reporting mechanisms across the social care sector.

12% of alerts referrals were reported in by health care staff across a range of primary care, community care and secondary health care services which indicates a 3% decrease. Relatives and families carers reported 5%, closely followed by Police with 3% which have remained relatively static. In addition housing services are included withi other public / privtes sector catagory.

In above data indicates that a range of agencies are reporting safeguarding concerns in line with the South Yorkshire Procedures for Safeguarding Adults which indicates a healthy level of awareness across the partnership. However it is highlighted that the voluntary sector are low in relation to other areas.Moving forward this information will be used to inform the DSAB Communication and Engagement Plan to target certain groups within the Keeping Safe Awareness Campaign.

38

Ethnicity Number of individuals for whom a Sec-tion 42 Safeguarding Enquiry has been made

White 378

Mixed / Multiple 5

Asian / Asian British 6

Black / African / Caribbean / Black British 6

Other Ethnic Group 0

No Data 14

Total 409

Ethnicity Number of individuals for whom a Sec-tion 42 Safeguarding Enquiry has been made

Male 184

Female 220

Gender Unknown 4

Total 409

Number of Concluded Section 42 Enquiries by Ethnicity

Number of Concluded Section 42 Enquiries by Ethnicity

For purposes required by the Safeguarding Adults Collection only 1 count is permitted per adult at risk therefore the number is 409.


The majority of individuals for whom referrals had been made in 2015/16 (92%) were categorised as ‘White’ (NB – not solely White British) as this reflects the proportion of the total population of Doncaster that are cate-gorised as such in the latest census return (March 2011). This notes a slight increase (2%) in Black and Minor-ity Ethnic groups accessing the safeguarding adults service.

The Board need to continue to improve engagement with black and minority ethnic groups. Work is on-going in the Engagement sub group through the implementation of the Communication and Engagement Strategy to raise awareness of safeguarding adults, including those hard to reach groups to promote the recognition and reporting of abuse or potential abuse. This Board will continue to promote safeguarding adults through-out 2016/17 through the Keeping Safe Awareness Campaign using mechanisms such as awareness raising events, the Safeguarding Adults DVD, posters, leaflets and the Keeping Safe Forum.

45% of all referrals made during 2015/16 were male, 54% female. This is a slight shift when compared with last year which indicated that 39% were male and 60% female.


39

Age band Number of individuals for whom a Sec-tion 42 Safeguarding Enquiry has been made

18-64 170

65-74 38

75-84 83

85-94 100

95+ 17

Not known 1

Total 409

Number of Section 42 Safeguarding Enquiries by Age Band

Percentage of Concluded Section 42 Enquiries by Primary Support Reason


Physical Disability, Farialty and Sensory Impairment

Mental Health

Learning Disability

Substance Misuse

Other Vulnerable People

0.2%

3.7%

49.6%

22.7%

23.7%

The largest proportion of safeguarding adults Section 42 enquiries comes from people with physical support needs at 38%. This has risen by 10% from 28% as reported for 2014/15.

The second highest group is those with a learning disability support need at 24%, again this has risen slightly when comparing year on year from 19% for 2014/15. People with a learning disability are more vulnerable in situations where they may be befriending strangers or misinterpreting social situations, which exposes them to abuse or potential abuse.

The most significant shift is the number of people with social support reasons, this has reduced by 10%, re-ported as 14% during 2014/15 to 4% for 2015/16.

All other categories have remained static when comparing with last year’s annual report data.

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Discriminatory

Institutional

Physical

Sexual

Psychological / Emotional

Neglect and acts of omission

Financial and material

0.3%

8.1%

29.9%

7.0%18.5%

18.5%

17.7%

Percentage of Concluded Section 42 Enquiries by Long Term Health Conditions

The Safeguarding Adults Collection has introduced the requirement to report on ‘Long Term Health Conditions’ for 2015/16 this is a new data table therefore it is not possible to make comparisons. The largest proportion of safeguarding adults Section 42 enquiries relates to people with a mental health long term condition such as dementia.

The second highest group is those with a ‘Learning Development or Intellectual Disability’ reported as 25%.

In addition Doncaster has a number of large care providers which offer placements to people with learning disabilities. This has a significant impact on the number of concerns and Section 42 enquiries received by Doncaster. Work is on-going with these providers through Doncaster Clinical Commissioning Group and NHS England to strengthen assurance mechanisms where current contractual gaps exist in order to promote safe-guarding adults and prevent abuse from occurring wherever possible.

A significant proportion 23% of Section 42 enquiries related to people who were reported as not having a long term relevant health condition, indicating that health is not always a factor of vulnerability or abuse.


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Other

Care homes

Hospital

Own home

Service within the community

8.6%

42.7%

7.8%

32%

8.9%

18.5%

Percentage of Concluded Section 42 Enquiries by Abuse Type (n=421)

Number of Concluded Section 42 Enquiries by Abuse Type and Source of Risk

Source of Risk

Abuse category Social Care Support Other – Known to individual Other – Unknown to individual

Physical 28 49 4

Sexual 1 19 1

Psychological 21 43 6

Financial and Material 9 68 10

Discriminatory 0 1 0

Organisational 8 4 0

Neglect and Acts of Omission

77 61 3

Domestic Abuse 0 1 0

Sexual Exploitation 0 0 0

Modern Slavery 0 0 1

Self-Neglect 1 4 1

Total 145 250 26

NB: for the purposes of the Safeguarding Adults Collection multiple categories of abuse may be counted therefore the number is 421

The majority of ‘neglect or acts of omission’ was alleged to be caused by social care and support workers closely followed by someone other than a social care worker who was known to the adult at risk. Whereas the majority of ‘financial and material abuse’ was alleged to be caused by someone other than a social care worker who was known to the individual.

NB for the purposes of the Safeguarding Adults Collection multiple categories of abuse may be counted therefore the number is 421

42

The largest category of abuse that is reported and is concluded through a Section 42 enquiry is ‘neglect and acts of omission’ reported as 34% for 2015/16 an increase of 4% from last year’s figures. Doncaster is not an outlier for this category of abuse as the Health and Social Care Information Centre reports that this is a national trend across Local Authorities.

There are a number of reasons that could contribute to the continued increase in reporting of neglect and acts of omission;

• Raised general awareness of safeguarding adults across Doncaster• The robust reporting and contract monitoring arrangements within the independent provider sector. • Doncaster Safeguarding services are more aware of the type, nature and number of repeat incidents that

constitute potential neglect and are recording this abuse type rather than viewing other abuse types in isolation.

On analysis of incidents regarding ‘neglect acts of omission’ the most common location of abuse relates to the Care Home sector. Issues identified within these enquiries relate to staffing levels, dependency of service users not assessed adequately to meet complex needs, lack of training for agency staff and a high turnover of staff within the independent sector.

The second largest category of abuse is ‘financial and material’ reported as 21%, this is a significant shift on last year’s figures which was report as 14%. Followed by physical abuse which is slightly reduced when comparing with last year’s figures and reported as 19% for 2015/16.

Both ‘psychological/emotional’ and ‘sexual’ abuse has remained at similar figures to last year with 17% and 5%. Doncaster is aligned to the national trend which was reported as 15% for ‘psychological/emotional’ and 5% for ‘sexual’.

The Care Act 2014 has introduced four additional categories of abuse under the remit of safeguarding adults; Domestic abuse, sexual exploitation, modern slavery and self-neglect. These new categories have been embedded with Doncaster’s safeguarding adults systems, policies, procedures, training and awareness raising campaigns to ensure staff and the public are aware of what abuse is and how to report it. Doncaster will continue to get the message out that abuse will not be tolerated.

0

50

100

150

200

20

20

19

55

9

109

20

41

2

10

5 1

1

5

20

Own Home CommunityService

Care Home Hospital Other

Social care support

Other - known to individual

Other - unknown to individual

Concluded Section 42 Enquiries by Location and Source of Risk (n=421)


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Not determined / inconclusive

Substantiated

Partly substantiated

Inconclusive

Not substantiated

27.1%

7.8%

11.5%

52.3%

1.3%

18.5%Concluded Section 42 Enquiries by Action, Result and Source of Risk (n=421)

41% of all cases of alleged abuse occurred in a ‘Care Home’ this is a 3% decrease when comparing this with last years’ data. Safeguarding awareness in Care Homes is well established and therefore issues are reported routinely in line with robust governance and contractual requirements. There are a number of factors which may lead to safeguarding issues i.e. the care setting may not meet the service user’s needs, there may be deterioration of the adults condition, or training needs of staff may not be meeting the needs of the service.

Intelligence continues to be analysed and shared at the multi-agency weekly risk meeting monitoring and escalating themes and trends across a range of commissioned services, to proactively improve quality, pre-vent abuse and respond appropriately and proportionately to safeguarding concerns within the independent care provider sector. Representation includes the Care Quality Commission, Contract Monitoring from Social care and Health Services, the Safeguarding Adults Board Support Unit and Operational Safeguarding Servic-es. This model pools a plethora of intelligence on which to inform sound and equitable decision making, also to identify and support improvements to quality. Further work will continue to develop this model to assess its effectiveness in practice during 2016/17.

The second largest category is 34% for alleged abuse occurring in the individuals ‘own home’ which is an increase of 3.5% on last year.

The decrease in abuse occurring within a Care Home and increase in abuse with an adults own home marks a shift towards the national trend as Doncaster has been an outlier in this area previously. The Keeping Safe Campaign will continue to be rolled out throughout 2016-17 raise awareness deep within the community about abuse and how to report it.

Section 42 enquiries relating to abuse occurring within hospitals has seen a decrease from 10.3% last year to 5% in 2015/16. The low number of cases from this area is consistent with both regional and national trend resting at 6%, this appears to be linked to the use of more established mechanisms such as complaints, inci-dent and serious incidents reporting.

The number of Section 42 enquiries relating to a Community Service has risen from 3.5% during 2014/15 to 6% during 2015/16 which is slightly above the national benchmark of 5%.

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While there has been an overall increase in the number of Section 42 enquiries the proportion of enquiries resulting in reduced risk has increased from 42% in 2014/15 to 44% in 2015/16.

In 3% of cases the risk was reported as remaining. Safeguarding supports people in how they choose to live their lives in line with the wishes, feelings and identified outcomes of the adult at risk. As a person may decide not to accept support or to live in circumstances that place them at risk, safeguarding may not always be able to reduce the risk. For example, a person may choose to live with a family member that has abused them. However, safeguarding will always look to provide people with options, that will help the person to be safe and in control of their own life.

In 53% of cases it was reported that no further action under safeguarding was taken. This could be due to a number of reasons as the adult at risk retains the right to cease the enquiry and exit the safeguarding process at any time unless there are doubts in relation to their capacity.

Mental CapacityThe percentage of adults at risk who were assessed as lacking mental capacity in relation to the Safeguarding process and for whom Section 42 Enquiries were concluded is 44% of during 2015/16. This is a significant proportion of enquiries undertaken on behalf of our most vulnerable.

Independent Mental Capacity Advocates (IMCA’s) provide additional support and representation for people who lack mental capacity in relation to certain important or significant decisions. Where the person lacks ca-pacity and there is no suitable person to represent the adult at risk’s wishes and views in a safeguarding case an IMCA should be sought.

In many cases relatives or friends represent the person’s wishes and views, however referrals to Independent Mental Capacity Advocates have risen from four cases last year to six cases during 2015/16.

Looking ahead 2016/17The Care Act 2014 strengthens the need to identify person centred outcomes and the requirement for advo-cacy both where mental capacity is lacking and where significant support needs are required. The Board has worked hard to revise its framework during 2015/16 in line with the Care Act 2014 and national data reporting requirements and will be implementing this moving forward.

Multi-agency Safeguarding Adults Learning and DevelopmentMulti-Agency training courses are widely accessed by the workforce with attendance high demonstrating a demand for need. All courses are now booked and monitored through DMBC Organisational Development and are reported to the Board on a quarterly basis.

Safeguarding Adults training delivered for 2015/16 introduced changes to the Safeguarding Adults process in line with the requirements of the Care Act 2014, therefore a number of extra courses were delivered to support the embedding of the Care Act within the Safeguarding process to ensure that the workforce received updated information. Below are figures per quarter for the previous year for all Safeguarding Adults, MCA and DOLS courses.

Safeguarding Adults Number Attended MCA/DOLS Number Attended

Quarter 1 (Apr-Jun) 162 Quarter 1 (Apr-Jun) N/A

Quarter 2 (Jul-Sep) 240 Quarter 2 (Jul-Sep) 49

Quarter 3 (Oct-Dec) 347 Quarter 3 (Oct-Dec) 95

Quarter 4 (Jan–Mar) 343 Quarter 4 (Jan – Mar) 108

Total 1092 Total 252


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The opposite data shows that 2023 people accessed the multi-agency training during 2015/16. We are every year seeing a sustained committment to multi-agency training.

Feedback received for training has been highly positive. Delegates have expressed that the training has helped to raise further awareness of Safeguarding Adults and raised confidence to report concerns.

• Safeguarding Adults Basic Awareness Course• Safeguarding Adults Raising Concerns Course• Safeguarding Adults within the Care Act

• Safeguarding Adults Managers Course• Safeguarding Adults Managers Refresher Course• Safeguarding Adults Enquirers Course• Safeguarding Adults Enquirers Refresher Course

• Safeguarding Adults Making Safeguarding Personal

Delivered by CQM

Delivered by Safeguarding Adults Learning and Development Manager

Delivered by Celia Harbottle (external trainer)

As well as the above courses the Learning and Development Manager also delivered safeguarding training to a number of different organisations:

• Practice Managers Training (Petergate Medical |Centre)• Anchor House• St Catherine’s

• New Horizons

• Active Care Homes• Stoneacre Lodge• Deaf Community Trust• Healthwatch

The above courses have been delivered due to a large number of staff needing training within an organisation or as a result of a request from DMBC Contracts Team having identified a gap in training with provider organisations.

Making Safeguarding PersonalThere has been a real focus within all training courses to embed the principles of Making Safeguarding Per-sonal. The Safeguarding Adults Basic Awareness and Raising Concerns courses have been updated to en-sure that multi-agency staff are aware of Making Safeguarding Personal. In addition more specialist courses have focused on applying Making Safeguarding Personal in practice such as undertaking face to face meet-ings and seeking the outcomes of the adult at risk.

As part of the Making Safeguarding Personal Strategy, a survey was undertaken with Adult Social Care and Health Practitioners that would be involved in the Safeguarding process and would have the role of Safe-guarding Manager or undertaking Section 42 Enquiries.

The results demonstrated that the majority of people felt confident to discuss outcomes with adults at risk, however a small number did feel less confident especially where family members disagree. The results of the survey have been used to inform further training for Making Safeguarding Personal.

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Quality Assurance of the TrainingThe Learning and Development Manager has worked together with the DMBC Adult Workforce Team to review and implement a training quality assurance framework that can be used across all multi-agency training. The aim of the framework is to evaluate from pre-course training to post-course training with delegates as well as trainers. Together with the implementation of the Safeguarding Adults Competency Framework the Doncaster Safeguarding Adults Board will be able to monitor the quality of training as well as how effective learning out-

comes are translated into practice.

Safeguarding Adults, MCA and DOLS E-Learning CoursesThe E-learning courses continue to be accessed across a wide range of services. This year we have seen an increase in Children’s services accessing adults courses. There has also been a significant increase from voluntary organisations.

Safeguarding Adults E-Learning Number completed

DMBC 72

RDASH 2

St Leger Homes 1

Children’s Services 30

Care Homes/ Domiciliary Care 125

Voluntary Organisations 62

Other 119

Total 411

Mental Capacity Act E-Learning Number completed

DMBC 145

RDASH 4

St Leger Homes 2




Other 388

Total 858


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Deprivation of Liberty Safeguards Number completed

DMBC 175

RDASH 5




Other 362

Total 899

Half Day Safeguarding Adults Basic Awareness Course

Number Attended

DMBC 59

RDASH 81



Other 2

Total 304

Raising Concerns Number Attended

DMBC 113

RDASH 13



Personal Assistant 1

Total 147

Safeguarding Adults Basic Awareness CourseThis course is aimed at all staff who may work with adults that experience or are at risk of experiencing abuse or neglect. The course aims to deliver the following Learning Outcomes:

• Demonstrate awareness of what Safeguarding is and your role in Safeguarding Adults• Recognise an adult potentially in need of Safeguarding and take action• Be able to follow procedures for making a ‘Safeguarding Concern‘• Appreciate the importance of dignity and respect when working with individuals• Have knowledge of policy, procedures and legislation that supports Safeguarding Adults activity

Safeguarding Adults Raising ConcernsThis training is for managers of services, team leaders, supervisors, and staff who have responsibility within their role to refer safeguarding concerns to health and adult social care.

Learning Outcomes:• Demonstrate awareness of Safeguarding Adults is and what your role is.• Ensure the Making Safeguarding Personal approach is used throughout any concern reported.• Recognise an adult at risk of abuse or neglect.• Have knowledge of national legislation, local policy and procedures for Safeguarding Adults.• Be able to know procedures for reporting Safeguarding Adults concerns

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Safeguarding Adults Managers TrainingThe Safeguarding Manager training is aimed at managers and senior managers within statutory health and adult social care who have significant experience of working with Safeguarding Adults procedures. They have the responsibility for decision making and overseeing and co-ordinating the process.

Learning Outcomes:• Define the roles and responsibilities of a Safeguarding Manager.• Describe the criteria used to determine thresholds into the safeguarding processes.• List the purpose and outcomes of a strategy meeting.• Describe the Safeguarding Manager’s role in chairing a strategy meeting.• Describe the Safeguarding Manager’s role in supervision, investigation stage and role in Case Conference.• Apply learning to professional practice and identify personal and organisational barriers to effective practice

Safeguarding Adults Section 42 EnquiriesA 2 day training course for practitioners from statutory health and social care. People attending this course should be able to demonstrate experience of working within Safeguarding Adults Procedures and will have a role in undertaking safeguarding referrals.

Learning Outcomes:• Describe legal and other frameworks surrounding Safeguarding Adults work.• Outline joint organisational roles and responsibilities for investigating safeguarding concerns.• Explain the principles, processes and best practice skills involved in undertaking investigative work.• Describe the Safeguarding Manager’s role in supervision, investigation stage and role in Case Conference.• Apply learning to professional practice and identify personal and organisational barriers to effective practice.

Multi- Agency Safeguarding Manager training

Number Attended

DMBC 10

RDASH 11

Total 21

Multi- Agency Safeguarding Manager training

Number Attended

DMBC 32

RDASH 30

Total 62

Making Safeguarding PersonalA 2 day course for practitioners that have competed the Section 42 Enquiries course. This course enables practitioners to learn skills and techniques with adults to determine outcomes. It explores methods for complex situations and decisions.

Learning Outcomes:• Explain the purpose and process of a safeguarding adults interview to an individual who will have no

familiarity with the local policy and procedures. • Apply the principals and emerging techniques of Making Safeguarding Personal within all face-to-face

interviews. • Recognise and work with issues of anti-discriminatory practice in the interview process. • Encompass the Principles of the MCA and the role of the IMCA service. • Recognise the balance between interview content and the balance/relationship between enquiry and

assessment of a person’s needs.


49

Half Day Mental Capacity Act Basic Awareness CourseThis training is aimed at social and health care workers, housing officers, public health workers, police, fire and ambulance services. The aim of the course is to develop an awareness of the Mental Capacity Act and its implications.

Introduction to Deprivation of Liberty Safeguards This course helps to identify a possible Deprivation of Liberty and appreciate responsibilities under the Depri-vation of Liberty Safeguards. It is aimed Senior staff in care homes and hospitals, social workers, assessment officers, reviewing officers, CPNs, Ward Managers, Modern Matrons, contracts and commissioning officers.

Making Safeguarding Personal Number Attended

DMBC 17

RDASH 9

Total 26

• Demonstrate interviewing skills, including reference to Achieving Best Evidence (revised) guidance (establishing rapport, free narrative, questioning and closure) exploring issues around leading questions and closed questions.

• Engage with people who are reluctant to participate in the safeguarding process and work with those who require clear, communication.

• Understand when a decision may need to be made to share information with either the police or other agencies to further the enquiry.

• Demonstrate skills for contemporaneous note taking. • Facilitate development of a personal action plan for using good practice and methods of capturing positive

interventions and evidencing good practice even if the outcomes are more complex and less concrete. • Understand responsibilities around information sharing and confidentiality, keeping the person safe,

promoting good practice in multi-agency working and the duty of care.

Half Day Mental Capacity Act Basic Awareness Course

Number Attended

DMBC 20

RDASH 70


Other 5

Total 210

Introduction to Deprivation of Liberty Safeguards

Number Attended

DMBC 59

RDASH 15


Other 3

Total 115

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Assessing Capacity and Best Interests Decision MakingThis course refreshes existing knowledge of the statutory principles and focuses on two of the key areas of the Mental Capacity Act: assessing capacity and best interest decision making. This course considers rele-vant guidance in the Code of Practice, documentation to be used in Doncaster, and approaches adopted by the Court of Protection in a number of legal cases. This course is suitable for Health and social care workers responsible for assessing capacity and making best interests decisions.

MCA 2005 – Complex Decision MakingThis course focuses on best practice when making complex decisions within the framework of the Mental Ca-pacity Act 2005 and appreciate the requirements of the Court of Protection.

Deprivation of Liberty Safeguards for Care Homes and HospitalsThis course is aimed at Care Homes and hospital staff only. It highlights the key principles of the Mental Capacity Act (MCA), identify a possible Deprivation of Liberty (DOL) and appreciate responsibilities under the Deprivation of Liberty Safeguards (DOLS)

Working Together ProgrammeThe Doncaster Safeguarding Adults Board works together with Sheffield, Barnsley and South Yorkshire Police to deliver regional two-day training and development conferences. The courses are designed to provide prac-titioners from health and social care and South Yorkshire Police with key information relating to Safeguarding Adults work and to explore their joint roles within it. Each region is allocated 20 places.

People attending this training must have attended Safeguarding Adults Enquirers training and/or demonstrate significant experience in working within Safeguarding Adults procedures.

Assessing Capacity and Best Interests Decision Making

Number Attended

DMBC 45

RDASH 12


Other 4

Total 123

Deprivation of Liberty Safeguards for Care Homes and Hospitals

Number Attended

DMBC 33

RDASH 4


Total 60

Complex Decision Making Number Attended

DMBC 24

RDASH 10


DBHFT 1

Other 4

Total 55


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Single Agency Training

DBHFTThe Trust took a new approach to delivering Safeguarding training in 2015. This was to ensure the Trust meets its obligations in respect of safeguarding training and the best use is made of resources. Our safeguarding training from February 2015 has included Safeguarding Adults, Safeguarding Children, Domestic Abuse, Men-tal Capacity Act and Deprivation of Liberty, Prevent, Child Sexual Exploitation and Female Genital Mutilation.

South Yorkshire PoliceWith regard to frontline Police Officers, over the 2015/16 curriculum the following training was delivered: Hu-man Trafficking, Rape, Coercive Control, Forced Marriage and Female Genital Mutilation.

St Leger Homes

Courses:• 5th and 6th October 2015 – Barnsley

• 2nd and 3rd December 2015 – Sheffield• Development Conferences:• 14th July 2015 - Sheffield• 16th February 2016 - Doncaster

Training Number attended

Induction 48

Safeguarding Children & Adults (Level 1) 78

Child Sexual Exploitation 21

Care Act 2014 32

Working Together to Safeguard Children (Level 6-12) 1

Child Protection Level 3 11

Domestic Abuse & Risk Management 12

Early Help Children 22

Signs of Safety 18

Early Help (Children) 42

Total 285

Level 1 Trained 2015/2016 Level 2 Trained 2015/2016

676 1647

Total 2323

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Training / Level Method Figures trained between Apr 15 – Mar 16

Safeguarding Adults Level One Leaflet 548

000 Safeguarding Adults - Level 1 Online e-Learning 1202

000 Safeguarding Adults - Level 2 – Basic Awareness

Online e-Learning 856

Safeguarding Adults: Raising Concerns Level 3 Face to face – classroom based

197

RDaSH Safeguarding Conference 2015 Face to face 70 Doncaster staff (94 attended in total)

Totals (across Level 1, 2 and 3) 2803

RDASH

South Yorkshire Police

Safeguarding Training Q1 Q2 Q3 Q4 Annual Total

Community Safety 9 New Starters 14 23

Youth Engagement/Cadet Instructors

8 Life/PTrust 8

Group Managers – Annual update

6 6

Group Managers - new 4 4

Crew Manager Induction

New Starter Induction

Stake Holder Engagement Board/Fire Authority

Sheffield Safeguarding Adults Training Pool

14 14

Volunteers 4 7 11

TFS 24 24

Operational Crews 16 8 Recruits 24

Control

Other 25 Middle Managers

Update

20 Lunchtime Seminar

45

Total 24 25 52 58 159


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South Yorkshire Fire & Rescue Internal Trainig programmes

In SummaryThe training delivered over the year has had a real focus on embedding the Care Act 2014. This has meant in a change in procedures to focus on outcomes for adults at risk. A number of refresher courses and update sessions were organised to ensure the workforce receive these updates.

The response to these changes has been positive and shows a real commitment to Safeguarding Adults. There has been increase overall in accessing training, especially e-learning courses.

This year has marked a start to implementing the changes. As we move forward we will also deliver training to providers to undertake Section 42 Enquiries and continue to deliver training to embed Making Safeguarding Personal in practice.

We are also working to implement the National Competency Framework across the multi-agency partnership to assist organisations to identify staff skills and training needs.

Safeguarding Training Staff Groups Training modules

Community Safety & Youth Engagement Running Safe & Effective Events & Activities

Case Conferences - Strengths Based Approach – Signs of Safety

Child Fire Setters – Review & Develop-ment (1 DAY COURSE)

New Community Safety Staff Safeguarding & Child Fire Setters (1 DAY COURSE)

Technical Fire Safety Update & Refresher (IHOUR)

Recruits & New Starters Child Protection E Learning

Group Managers Care Act 2014 - Making Safeguarding Personal

Strengths Based Approach – Signs of Safety (2HOUR)

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Safeguarding Adults Support Unit The Safeguarding Adults Unit is based within the Council’s Directorate of Adult Services. Established nine years ago, its purpose is to support safeguarding activity across all agencies. Overall management responsibility for the unit is located within the Modernisation and Commissioning functions of Adult Services.

Key responsibilities of the unit include:• Arranging and co-ordinating Safeguarding meetings, providing administrative support, including distribution

of minutes and reports.• Logging and recording Safeguarding referrals, contacts and Safeguarding activity for partners.• Collecting data and analysing Safeguarding activity and outcomes, monitoring and reporting performance in

relation to progress of cases and Serious Case Reviews.• Providing support to the Safeguarding Board.• Providing support, guidance and advice to a range of professionals, organisations, agencies and the

general public.• Developing strong multi-agency engagement in line with the South Yorkshire Safeguarding Adults Policy and

Procedure.• Providing support in complex, high risk Safeguarding Adults Investigations• Providing the link between strategic and operational activity through attendance at meetings, training and

multi-agency internal boards.• Providing support and guidance for the implementation of the Mental Capacity Act (MCA) 2005.• Providing a joint administrative function to support the Council to carry out its statutory duties relating to

Deprivation of Liberty Safeguards (DOLS)• Supporting the on-going planning, commissioning and delivery of Safeguarding Adults training across the

Partnership.

The Safeguarding Adults Board Support Unit has provided admin support for the following during 1st April 2015 to 31st March 2016;

Meeting type Arranged 2015/16 Minuted 2015/16

Safeguarding case conference meetings 44 41

Strategic meeting 66 21

DSAB and Sub Group meetings 35 32

Team Meetings 7 7

Total 152 101

Contact details DSAB Support UnitCivic OfficeWaterdaleDoncasterDN1 3BUPhone (01302) 736230 Email: [email protected]


55

Partner Agency ContributionsFor 2015/16

DMBC – (Adult Social Care) £215,860

CCG (including funding of Independent Chair)

£106,180

SY Police Crime Commissioner £5000

Total income £327,040

Total Spend £320,164

Underspend £6876

Carried forward from 14/15 £46,844

Total Spend in 15/16 £14,675

Underspend £32,169

Carry forward to 16/17 £39,045

Funding

56

Agency Attendance

Independent Chair 100%

DMBC 100%

SYP 100%

DCCG 100%

SAU 100%

HMPS 50%

RDASH 100%

DBHFT 75%

SYF&R 25%

St Leger Homes 100%

NHS England 100%

Healthwatch 50%

Agency Attendance

Chair 100%

DMBC 100%

SYP 15%

DCCG 60%

SAU 100%

RDASH 30%

DBHFT 85%

Agency Attendance

Independent Chair 85%

DMBC 85%

SYP 65%

DCCG 85%

SAU 100%

RDASH 65%

DBHFT 85%

St Leger Homes 65%

Attendance Monitoring DSAB and Sub Groups April 2015– March 2016

Board Attendance – 4 meetings held

Safeguarding Adults Review Panel – 5 meetings held

Business Coordination Group – 6 meetings held


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Agency Attendance

Chair 70%

DMBC 70%

SYP 40%

DCCG 0%

SAU 100%

RDASH 30%

SYF&R 40%

St Leger Homes 85%

Doncaster Advocacy 0%

Public Health 15%

Agency Attendance

Chair 80%

DMBC 40%

SYP 80%

DCCG 100%

SAU 100%

RDASH 80%

DBHFT 100%

Agency Attendance

Chair 50%

DMBC Care Management 65%

SYP 35%

DMBC Performance 15%

DCCG 100%

SAU 100%

RDASH 85%

DBHFT 85%

Engagement sub group attendance - 7 meetings held

Workforce sub group – 7 meetings held

Performance sub group - 6 meetings held

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SO1. To review the constitution of the DSAB in line with current legislation, statutory guidance, national and local priorities to safeguard adults at risk across Doncaster.

SO2. To deliver the DSAB Strategy through a Performance Framework, holding agencies to account and embedding lessons learned through robust governance and quality assurance processes.

1.1 Embed South Yorkshire Procedures across Doncaster through the development and roll out of a formal launch.

1.2 Revise the Board constitution to reflect the DSABs relationship with other Partnerships - On-going

1.3 Engage with Prison Services, understand the needs of the prison population with a view to embedding safeguarding - On-going

1.4 Develop Process for Overarching Safeguarding Cases.

1.5 To revise the Memorandum of Understanding with CQC to clarify role and responsibilities across the multi-agency partnership to safeguard adults at risk

1.6 Embed Joint Safeguarding Multi-agency Capability Framework in practice across the partnership. - On-going

1.7 To review Doncaster Safeguarding Adults Policy and Procedures every 3 years

1.8 Develop Multi-agency training quality assurance process. - On-going

• DSAB ensures high quality, effective and up to date policies, procedures and guidance is accessible and embedded in practice across the Partnership

• Updated Board constitution with an emphasis on positive challenge

• Risk Management Framework for adults at risk• Systematic and transparent approach to Serious Case

and Lessons Learned Reviews• The DSAB receives assurance that the Safeguarding

workforce have the skills and competence to deliver a full range of social and legal interventions.

The Strategic objectives have been aligned to sub groups for accountability purposes, however it is recognised that the strategic objectives are cross cutting and interrelated therefore sub groups will be required to contribute to other strategic aims where appropriate.

2.1 To review agencies and board substructure to ensure it is fit for purpose

2.2 To review multi-agency representation at Board to safeguard adults at risk2.3 Revise the Board Strategic plan 2013-16 in line with emerging guidance / legislation




2.8 To undertake a rolling programme of audit to provide; • Process and quality measures • Quality assure appropriateness of referrals • Implementation of actions to improve practice

2.9 To produce a quarterly report that collates a dashboard of information relating to; • Performance, outcome, process and quality measures,

themes and trends On-going

• DSAB membership ensures the right agencies at the right managerial level are members of the Board and are held to account for their agencies engagement and attendance at the Board and sub group meetings

• The Board will be fit for purpose to deliver the strategic plan through its structure, robust governance arrangements and multi-agency representation

• Through its annual report the DSAB provides rigorous and transparent assessment of performance and the effectiveness of local services, including lessons learned from Serious Case reviews.

• The Board is able to make strategic decisions based on information it receives

• Safeguarding practice continues to improve

SO3. To develop a Safeguarding Adults Preventative Strategy that empowers adults at risk to protect themselves from abuse, supporting communities and people through effective risk management in personalisation of their care.

3.1 Develop a Safeguarding Adults Preventative Strategy that outlines Doncaster’s approach to preventing adults at risk from abuse to include;• Board’s responsibility for self-neglect to inform

management of adults at risk (VARMM) to inform Strategy

• Proposed model to manage adults at risk through reportable concerns (low level concerns) On-going

3.2 Implement Making Safeguarding Personal across the multi-agency partnership On-going3.3 Implement Safeguarding Adults Communication Plan

3.4 Embed a consistent approach to assessing mental capacity across partnership through assurance; • sign up to MCA Joint Agency Agreement • formal launch of MCA1,2,3 forms across multi-agency

partnership

3.5 To develop user satisfaction feedback mechanism On-going

• Clear approach to preventing abuse in Doncaster and how it intends to do this.

• Personalisation embedded in the Safeguarding Adults process to support and empower adults at risk

• Effective engagement with the population of Doncaster • Raised awareness of Safeguarding Adults, preventing

abuse and reporting• Increased alerts and referrals from hard to reach

groups• Assurance a consistent approach to the Mental

Capacity Act 2005 embedded across multi-agency partnership

• Outcome measures in place and embedded in performance framework

“Working together to safeguard vulnerable adults in Doncaster and prevent abuse, enabling them to live safely with dignity and respect, and empowering them to take charge of decisions about their own safety and wellbeing.”


59

SO2. To deliver the DSAB Strategy through a Performance Framework, holding agencies to account and embedding lessons learned through robust governance and quality assurance processes.

The Strategic objectives have been aligned to sub groups for accountability purposes, however it is recognised that the strategic objectives are cross cutting and interrelated therefore sub groups will be required to contribute to other strategic aims where appropriate.

2.1 To review agencies and board substructure to ensure it is fit for purpose

2.2 To review multi-agency representation at Board to safeguard adults at risk2.3 Revise the Board Strategic plan 2013-16 in line with emerging guidance / legislation




2.8 To undertake a rolling programme of audit to provide; • Process and quality measures • Quality assure appropriateness of referrals • Implementation of actions to improve practice

2.9 To produce a quarterly report that collates a dashboard of information relating to; • Performance, outcome, process and quality measures,

themes and trends On-going

• DSAB membership ensures the right agencies at the right managerial level are members of the Board and are held to account for their agencies engagement and attendance at the Board and sub group meetings

• The Board will be fit for purpose to deliver the strategic plan through its structure, robust governance arrangements and multi-agency representation

• Through its annual report the DSAB provides rigorous and transparent assessment of performance and the effectiveness of local services, including lessons learned from Serious Case reviews.

• The Board is able to make strategic decisions based on information it receives

• Safeguarding practice continues to improve

SO3. To develop a Safeguarding Adults Preventative Strategy that empowers adults at risk to protect themselves from abuse, supporting communities and people through effective risk management in personalisation of their care.

3.1 Develop a Safeguarding Adults Preventative Strategy that outlines Doncaster’s approach to preventing adults at risk from abuse to include;• Board’s responsibility for self-neglect to inform

management of adults at risk (VARMM) to inform Strategy

• Proposed model to manage adults at risk through reportable concerns (low level concerns) On-going

3.2 Implement Making Safeguarding Personal across the multi-agency partnership On-going3.3 Implement Safeguarding Adults Communication Plan

3.4 Embed a consistent approach to assessing mental capacity across partnership through assurance; • sign up to MCA Joint Agency Agreement • formal launch of MCA1,2,3 forms across multi-agency

partnership

3.5 To develop user satisfaction feedback mechanism On-going

• Clear approach to preventing abuse in Doncaster and how it intends to do this.

• Personalisation embedded in the Safeguarding Adults process to support and empower adults at risk

• Effective engagement with the population of Doncaster • Raised awareness of Safeguarding Adults, preventing

abuse and reporting• Increased alerts and referrals from hard to reach

groups• Assurance a consistent approach to the Mental

Capacity Act 2005 embedded across multi-agency partnership

• Outcome measures in place and embedded in performance framework

“Working together to safeguard vulnerable adults in Doncaster and prevent abuse, enabling them to live safely with dignity and respect, and empowering them to take charge of decisions about their own safety and wellbeing.”

SO4. To review the needs of adults at risk with due regard to economic, social and legislative changes regarding factors such as social issues, criminal behaviour, mental and physical health and wellbeing, with a view to improving / shaping services to better meet their needs.

4.1 Engage with JSNA process to identify and assess the needs of adults at risk to prevent abuse across Doncaster

4.2 Assess the impact of legislation and statutory guidance providing regular updates to Board

• Increased knowledge of the needs of Doncaster population to inform future service development

• Board able to make strategic decisions in relation to emerging legislative and statutory guidance

• Service design is based on local need

Doncaster Safeguarding Adults Partnership Board Strategic Objectives 2013-16

Enc G

Receipt of Minutes from Committees

1

Minutes of the Audit Committee

Held on Thursday 14 July 2016 at 9:00am In Meeting Room 3, Sovereign House, Heavens Walk, Doncaster, DN4 5HZ

Committee Members present:

Miss Anthea Morris (Chair) – Lay Member Dr Emyr Wyn Jones – Secondary Care Doctor Member Dr Andy Oakford – Locality Lead

Formal Committee Attendees present:

Mrs Sarah Atkins Whatley – Chief of Corporate Services Mrs Annette Tudor – Director, 360 Assurance Mrs Tracy Wyatt – Deputy Chief Finance Officer Mrs Clare Partridge – External Auditor, KPMG Mr James Boyle – External Auditor KPMG Mrs Amanda Smith – Local Counter Fraud Specialist (item 6.2)

In attendance: Miss Lindsay Moore (Minutes)

ACTION

1. Apologies Apologies for absence were received from the following members:

• Dr Karen Wagstaff – Locality Lead

• Mrs Hayley Tingle – Chief Finance Officer

• Mrs Julia Holmes – Assistant Head of Finance

• Mrs Linda Tully – Lay Member

2. Declarations of Interest No new declarations of interest were made.

3. Minutes of the Previous Meeting The minutes of the meeting held on 7 May 2015 were approved as a correct record pending the following changes:

• p.3, 6.1 bullet point 3 should read “work is progressing around the Browne Jacobson Follow up Review”

• p.11, Item 10 should read if we do not complete the reviews by 31/03/17.

4. Matters Arising via the Action Tracker The Committee noted the actions which were marked as complete on the Committee Action Tracker. The following updates against outstanding actions were noted

2

• Update relating to Review of Internal Audit SLA to be brought to next meeting. – Mrs Wyatt advised that this review has been postponed due to changes to hosting arrangements and further updates will be provided at a future meeting.

The following actions were noted as complete:

• Proposal around appointment of External Auditors to be taken to Governing Body on 17 March along with a proposal to set up a sub group to take work forward.

• Modern Slavery Act to be added to the Performance Statement

• Teams to be made aware that some narrative is required on certain parts of the risk register report

• Quarterly meeting dates for the RDaSH meetings around PBR to be sent to Dr Wagstaff

5. EXTERNAL AUDIT

5.1. External Audit Technical Report Mr Boyle presented the External Audit Technical Report to the Committee, noting that this completes the Audit cycle for the last financial year. There are no actions outstanding on the report and it is submitted for information purposes. Dr Jones queried if there are any implications expected in light of the recent data guardian review. Mr Boyle agreed to enquire about this and feed back to the Committee. The Committee noted that there could be significant risks around data sharing for our organisation and we need to be aware of this and how work can be taken forward. The Committee thanked Mr Boyle and noted the report.

Mr Boyle

5.2. ISA 260 Annual Governance Report Mr Boyle advised that the ISA 260 Annual Governance Report is a report from External Audit to those charged with governance, concluding that NHS Doncaster CCG has put in place proper arrangements to secure economy, efficiency and effectiveness in the use of resources. There were no significant adjusted or unadjusted audit differences Identified as part of the audit. It was noted that a new accounting policy (Better Care Fund) has been implemented and this will be monitored however no issues are currently highlighted in this area. The report has already been received by the Governing Body at its extraordinary meeting on 26 May 2016. It was presented to the Audit Committee for noting. The Committee noted the ISA 260 Annual Governance Report.

3

5.3. Annual Audit Letter Mr Boyle presented the Annual Audit Letter to the Committee which summarised External Audit’s 2015/16 audit for NHS Doncaster CCG. The letter confirmed issue of an unqualified regulatory opinion and opinion on the CCG’s 2015/16 financial statements and concluded that there were no matters arising from the CCG’s use of resources to report for the year ending 31 March 2016. The letter confirmed the Audit Fees of £67,500. There were no recommendations arising from the Audit. The Committee thanked Mr Boyle and External Audit colleagues for their work and noted the Annual Audit Letter. The letter is scheduled to be presented to Governing Body on 21st July 2016 and will also be published on the CCG website at this date.

5.4. Offer of private discussions with External Audit Miss Morris offered External Audit private discussions with the Audit Committee members (without Audit Committee attendees present). These discussions are to be scheduled for after the September Audit Committee meeting.

Miss Moore

6. INTERNAL AUDIT & COUNTER FRAUD

6.1. Internal Audit Progress Report Mrs Tudor presented the Internal Audit Progress Report to the Committee, confirming that since the last Audit Committee meeting the following reports have been issued:

• Better Care Fund Implementation

• Review of the Effectiveness of the Quality and Patient Services Committee (follow up)

Mrs Tudor also advised that a follow up on the recommendations arising from the Budgetary Control and Key Financial Systems review in 2015/16 has also been completed and all recommendations have been implemented The following reviews are in progress:

• Clinical Quality: Follow up of Browne Jacobson review

• Monitoring the Quality of Care in Care Homes

• Review of Section 117 Arrangements

• Governing Body Assurance Framework

Mrs Tudor advised that In line with discussions held during the

4

planning process for 2016/17, more detail has been added to the summary of the scope of audits which have been discussed and agreed with the CCG and are due to commence in this quarter. Mrs Tudor advised the Committee that there is one Key Performance Indicator (KPI) highlighted as red in relation to the Browne Jacobson follow up review but this has been reported to Audit Committee on 12th May and the Amber rating KPI relates to the Better Care Fund review of draft report by the CCG, which was delayed to allow liaison with the CCG’s partner in the Better Care Fund, Doncaster Council, and whilst the deadline was missed there are no risks identified with this. The Audit and Governance Workshop took place on 16th June and included presentations on:

• New Procurement regulations

• Conflicts of Interest

• 3 Lines of Defence and risk maturity An information pack containing the presentations has been issued to Audit Committee members and Governance Leads. The next workshop is planned for 26th September 2016 and there are plans for this to be a joint session with providers around Sustainability & Transformation Plans and collaborative working. Dr Oakford and Mrs Partridge joined the meeting at this point.

Mrs Atkins Whatley asked if Internal Audit were aware of the new NHS England requirement for a Conflict of Interest Audit in Quarter 3 or 4 of 2016/17. Mrs Tudor advised that they are aware of this and a meeting has been arranged with Mrs Tingle for August and the NHS England template may be issued over the summer. Mrs Tudor advised that her team are developing a 2 page ‘must do’ document for CCGs and this should be finalised by the end of July. Mrs Tudor reported that at the next Audit Committee she hoped to present the list of HFMA expected audits compared to the Internal Audits which have been completed over the past few years. Mrs Tudor also reported that Mr Shead has moved on from 360 Assurance, and Mr Kevin Watkins will return as our day-to-day liaison lead for the interim period. In addition the following reports were noted by the Committee : Internal Audit Technical Update: This report highlighted areas of interest and reference for the CCG.

5

Better Care Fund Implementation Report: This is the second review of arrangements established for managing the Better Care Fund: the first review was reported on in September 2015, and provided a Significant Assurance on the governance arrangements in place and in development when the Better Care Fund went live in April. This second review was designed to follow up on how the CCG and Doncaster Council had completed developments that were in progress in early 2015/16, and to evaluate the arrangements put in place for establishing whether schemes within the BCF are performing to expectations. Based on this Significant Assurance was provided that there is a generally sound system of control designed to meet the system’s objectives. However, some weakness in the design or inconsistent application of controls put the achievement of particular objectives at risk and 2 medium risks have been identified around:

• Improvements to the business case template by including the requirement to show how stakeholder engagement / consultation has taken place in respect of the proposal being submitted; and

• Completion of a performance matrix as part of the standard documentation of each business case, in order to establish a basis for later evaluation of the proposal’s effectiveness.

The Committee noted the report, assurances, and recommendations. Quality and Patient Safety Committee Governance Review Follow-Up Report: A follow-up review has recently been completed to examine whether actions agreed as a result of our 2015/16 review Quality and Patient Safety Committee Governance have been implemented and to what extent. The original report was issued with Significant Assurance in relation to the control frameworks established. Based on the review of the evidence provided, it was concluded that all of the recommendations agreed during the original audit have been implemented. The Committee noted the report and agreed it was useful and thanked Mrs Tudor and her team for the work that has been put into this.

Cyber Security Briefing Paper: This paper followed on from the benchmarking report carried out last year and provided an update and raised awareness of cyber security to IT teams and Governing Body members. The Committee noted the report and agreed it would be shared with IT team members.

6

Three Lines of Defence Briefing Paper: This is a detailed document that can be shared with all staff and was presented at the Audit Governance Workshop. Other CCGs are using the document as an awareness raising exercise and are also running short training and feedback sessions. The Committee noted the report and acknowledged its usefulness.

6.2 . Counter Fraud Progress Report and Annual Report Mrs Smith presented Counter Fraud Progress report alongside the Annual Report to the Committee and advised that the annual report correlates all the reports that have been previously submitted. The counter fraud self-review tool (SRT) has been completed and submitted to NHS Protect and has resulted in an amber rating. An action plan is being formulated to increase ratings and standards. Mrs Smith advised that she is currently liaising with Mrs Holmes in the CCG finance team to look at setting up counter fraud budget holder training. Mrs Smith advised that there has recently been a scam email or letter from a company requesting people to contact them to change address and bank details and team members have been advised to carefully review and check such emails or letters. There is also one currently open information report; this is an old report that was not picked up on the NHS Protect system as the member of staff who inputted it has left the team and only the inputter could see their records. This has now been investigated by the Care Quality Commission (CQC) as there were other issues raised alongside potential fraud; clarity is needed before this case can be closed. Mrs Smith confirmed that action plans are reviewed quarterly and reported back to Audit committee. The point of contact for monitoring actions is Mrs Atkins Whatley for Governance and Mrs Tingle for Finance. Miss Morris asked if the Corporate Governance Management group could look at taking some of this work forward. Mrs Atkins Whatley agreed to raise this at the next meeting The Committee thanked Mrs Smith and noted the reports.

Mrs Atkins Whatley

7

6.3 . Offer of private discussions with Internal Audit Miss Morris offered Internal Audit private discussions with the Audit Committee members (without Audit Committee attendees present). These discussions are to be scheduled for after the November Audit Committee meeting.

Miss Moore

7. FINANCIAL REPORTING

7.1. Financial Exception Report Mrs Wyatt presented the financial report to the Committee. Losses and special payments: There were no losses or special payments to report since the last meeting of the Audit Committee. Application of Standing Financial Instructions – waiving of tender and quotes procedures: Two new applications to waive the tenders and quotes procedures have been added to the report (Storage King and Healthcare Gateway). Concerns were raised by Audit Committee members regarding the rationale for the Storage King exemption, and requested further work to be done to prove the assumption. Mrs Wyatt will review this and report back to the next meeting. Schedule of Debtor and Creditor Balances: There are two outstanding Debtors over six months old and over £5,000. Both invoices relate to DMBC, one is for £98,248.58 and the other is for £88,931.10. The CCG has been asked to provide a Purchase Order number, but has been unable to obtain one thus far. This is being actively pursued with DMBC service managers and Mrs Wyatt is now escalating this matter with DMBC. Mrs Wyatt will provide an update at the next meeting. There was one outstanding Creditor balance over six months old and over £5,000 reported. This relates to Virgin Media Business Ltd. for £26,683.98. There was a technical issue regarding incorrect supplier set up details which was being actively pursued with SBS before payment could be released, and this has now been resolved. There was one Creditor credit balance reported with NHS Property Services Ltd for £14,943.44. The CCG has now received invoices which have enabled the credit balance to be cleared. The Committee noted the report.

Mrs Wyatt

Mrs Wyatt

8

8. INTEGRATED GOVERNANCE, RISK MANAGEMENT AND

INTERNAL CONTROL

8.1. Review of Standing Orders, Standing Financial Instructions and scheme of delegation

Mrs Wyatt presented the report and advised that these were last considered by the Governing Body in March 2016. At this point, the Standing Orders required a refresh to ensure alignment to the changes in Constitution which was amended to include the addition of a Lay Member for Primary Care Commissioning and the formation of a Primary Care Commissioning Committee. The Scheme of Reservation and Delegation was also updated to reflect these changes. These due for review in July 2016 and the Chief of Corporate Services and Chief Finance Officer have confirmed that there are no further amendments are required at the moment. This will be noted at Governing Body as part of the Audit Chair Report.

8.2. Review of Implementation of Audit Recommendations The Committee noted that three new Internal Audit Reports have been added to the Matrix and there are 13 recommendations that are recommended for closure. The Committee reviewed the document and approved the closure and carry forward of the recommendations listed in the report. Additionally, recommendation 30/01 was agreed for closure.

8.3. Integrated risk issues arising from other Committees

Dr Oakford reflected an emerging feeling of disconnection between clinical members and the remainder of the organisation, and it was noted that this would be taken forward as part of the planned organisational development programme. Remuneration Committee: no meetings held. Quality & Safety Committee: no issues to report. Engagement & Experience Committee: no issues to report. Executive Committee: has met for the first time. Primary Care Commissioning Committee: quoracy of meetings and taking work forward needs to be considered. Mrs Atkins Whatley advised that there are currently risks around continuing healthcare Previously Un-assessed Periods of Care

9

(PUPOC) that have been added to the risk register. 9. ADMINISTRATIVE ARRANGEMENTS

9.1 Self -assessment of Committee Effectiveness in 2016/7 The group agreed that a meeting to look at this is needed, ideally before Governing body in September. Mrs Partridge suggested a tool available from External Audit, which will be considered. Miss Morris agreed to look at potential dates for the meeting Post meeting note: this meeting will be before the October Governing Body, Miss Morris to confirm available dates with Miss Moore

Miss Morris

Miss Morris / Miss Moore

9.2 Audit Committee Forward Planner The Committee reviewed and noted the Audit Committee forward planner and noted that the Draft Head of Internal Audit Opinion needs to be added onto the March 2017 meeting.

Miss Moore

9.3 Audit Committee Annual Report Miss Morris presented to the Committee her Chair’s Annual Report of the Audit Committee. The Committee thanked Miss Morris for a comprehensive report and noted the report and agreed for it to be taken to the Public Governing Body meeting on 21 July 2016.

9.4. Minutes of the Corporate Governance Management Group held on 22 June 2016 The Committee noted the minutes of the Corporate Governance Management Group held on 22 June 2016 and the intention to evolve the group towards more exception reporting to enable the group to focus on some of the key governance issues arising such as implementation of the General Data Protection Regulation.

10 Any Other Business None was declared.

11 Date and Time of Next Meeting Thursday 8 September 2016 at 9:00am – 12noon in Meeting Room 1, Sovereign House, Heavens Walk, Doncaster, DN4 5HZ

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Minutes of the Quality & Patient Safety Committee Held on Thursday 7th July 2016 at 9.00am

Boardroom, Sovereign House

Formal Committee Members Present:

Committee Members Present Dr Emyr Jones (Chair) Secondary Care Doctor Member Dr Lindsey Britten GP Lead for Quality Mrs Suzannah Cookson Head of Quality, Designated Nurse for

Safeguarding & LAC Mrs Andrea lbbeson Named Nurse for Children's

Safeguarding Dr Victor Joseph Consultant in Public Health, Doncaster

Council Mrs Chris Quinn Complaints Manager Mr Mark Randerson Head of Medicines Management Mrs Jenny Rayner Senior Officer for Quality Mrs Mary Shepherd Chief Nurse Mrs Andrea Stothard Quality & Patient Safety Manager

Formal Committee Members in Attendance:

None

In attendance: Lesley Twigg Minutes

Action

1. Welcome and Apologies Dr Jones welcomed everyone to the meeting. Apologies for absence were received from:

• Mr Boldy, Named Nurse Safeguarding Adults

• Mr Booth, Specialist Placements Manager

• Mrs Bradley, Deputy Head Medicines Management Team

• Dr Bradley, GP Representative

• Mrs Feirn, Senior Nurse, Quality & Patient Safety

• Mr A Russell, Deputy Chief Nurse

• Mrs K Tyler, CHC Operational Lead

2. Declarations of Interest Dr Britten registered a declaration of interest as a GP.

3. Minutes and Actions of the Previous Meeting – Enclosure A & B

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The minutes of the meeting held on Thursday 5th May 2016 were approved as a true record with the following amendments: - Throughout document amend Mr Joseph to Dr Joseph - Page 1; Amend ‘Mrs Randerson’ to ‘Mr Randerson’. - Throughout document amend ‘Kitchen’ to ‘Kitching’. Please refer to the action log for updates on all outstanding actions. NOTE: Dr Jones asked that the minutes acknowledge that this is Mrs Shepherd’s last committee meeting as she will retire in August 2016. Dr Jones said that the committee owed her a debt of gratitude for all her support to him and to the rest of the committee and wished that his personal thanks and good wishes for the future were recorded.

4. Matters Arising not on the Agenda The Committee went through the action log for the meeting. All updates will be recorded on the action log. There were no other matters arising raised by Committee members.

5. Terms of Reference for Quality & Patient Safety Committee – Enclosure C Dr Jones updated the committee that when the ToR were brought to the committee earlier in the year that they were not formally recorded as ratified and asked if the committee were happy to ratify them today. Dr Britten queried where research is mentioned within the ToR, Mrs Shepherd responded that this is via the contracts with DBHfT and RDaSH. Dr Britten asked if the CCG had an overarching view of all research being undertaken in Doncaster, following discussion Dr Jones said it would be useful to have a report on research come to the committee on an annual basis; Mrs Shepherd asked if Mrs Stothard could look to try and pull a paper together on all research being undertaken. Action 01 / 07.07.16: Mrs Stothard to produce a paper on all research being undertaken in Doncaster for a future meeting.

AS

6. QUALITY

6.1 Medicines Management Report – Enclosure D

Mr Randerson highlighted the following to the committee from his report:

Medicines Management Workplan

The work plan has been developed to allow for emerging in year priorities e.g.

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target now for diabetes.

Primary Care

Prescribing Gain Share LES launch held on the 6th July 16. Lots of challenges on equality of scheme but this was expected.

Sharp Bins

There is resolution now regarding collection of sharp bins in the community. DMBC will collect the bin and provide a new bin. Dr Jones said that this made sense and that we would be recharged for the service.

Digital Roadmap

Electronic Repeat Dispensing is the national policy direction. Mr Randerson updated that this is efficient functionality for practices, patients and pharmacies, which we are pushing locally on the back of the EPS platform.

Pharmacies in Doncaster are now eligible to go live for Summary Carer Record access. Dr Jones updated that Weldrick’s are now up and running with this.

Key Performance Indicators

Mr Randerson updated that there is an issue with co-amoxiclav in A&E and that he is discussing the issue with Mr Singh, he added that there is a challenge in undertaking an audit in ED. Dr Jones asked if the audit can be done via the CQUIN; Mrs Stothard said that she will check the guidance and then discuss with Mr Randerson.

Action 02 / 07.07.16: Mr Randerson and Mrs Stothard to discuss an A&E audit on co-amoxiclav prescribing in ED.

Secondary / Primary Care Interface

Mr Randerson updated that they had an audited 30 patient records to provide a benchmark on quality of medication related information for discharge and medicines reconciliation. The audit did not red flag any specific concerns but did highlight areas of good practice and areas that can be improved. Dr Jones said that this was a useful tool and that it was good that there was dialogue with DBH and Primary Care; Mr Randerson added that Dr Bradley is fully involved in this work.

RDaSH

Mr Randerson updated regarding T2 and T3 breaches, Mrs Shepherd asked if the breaches met the SI criteria with Mrs Stothard saying that we would also need to understand the level of harm. Mr Randerson responded that the trust are taking the breaches seriously and developing an action plan through their Clinical Directors Group. Dr Jones asked that this be discussed at the RDaSH CQRG sub-group.

MR / AS

MR

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Action 03 / 07.07.16: Mr Randerson to raise the breaches at the next RDaSH CQRG sub-group.

Prescribing for Protected Groups – Transgender

Mr Randerson updated that this a refreshed shared care and transfer model is being developed between SYB CCGs and Porterbrook Clinic. This should allow patients safe access to treatment through their GP and free Porterbrook capacity.

Dr Jones asked the committee if they had any further questions for Mr Randerson, nothing further asked.

6.2 DBHfT Quality Report – Enclosure E

Mrs Cookson informed the committee that the next ACQRG meeting will be held on the 12th July and this is why some of the information in the report may feel a bit dated.

Mrs Cookson said that a line had been drawn under Q4 CQUINs; we did receive some evidence but not all.

Mrs Cookson said that the Trust’s QIA feels open and honest despite their financial position and that we have not seen any impact on quality with the implementation of this.

The DBHfT Sub Group is very rarely meeting and that Mrs Cookson said that she is considering making the CQRG monthly again, Mrs Shepherd said that she is meeting with the Trust frequently regarding the QIA and we have a place on their Turnaround Board and we as both Mr Russell and Mrs Hudson attend we do not want to feel overbearing. Dr Jones asked about quality concerns and Mrs Shepherd responded that we are making our views / presence felt and that we should not increase ACQRG frequency as we can maintain our presence without appearing overbearing or judgmental.

Dr Jones asked if the concerns with Maternity Services have been addressed, Mrs Cookson replied that there is a Spotlight meeting with another booked for 26th July 16, there have been a few more SI’s, action plans are in place. Mrs Stothard added that some actions are smart and it is about reviewing and how learning is communicated / cascaded. Dr Jones asked for the committee’s opinion on whether an external view was needed, Mrs Cookson said that there is a new consultation with the Local Supervision Authority (LSA) with Mrs Shepherd adding that this is dealt with at SI level and if it requires escalating this would go to the Strategic Contracting meeting. Dr Jones asked that this was taken to that meeting and that a constructive discussion took place regarding an external review.

Action 04 / 07.07.16: Mrs Cookson to raise at the next Strategic Contracting meeting and provide an update at the next meeting in September.

Dr Jones asked the committee if they had any further questions for Mrs

SC

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Cookson, nothing further asked.

6.3 FCMS Quality Update – Verbal

Mrs Shepherd informed the committee that the first quality meeting with FCMS had taken place on the 22nd June 16, prior to this quality was discussed at the FCMS Contracting meeting where a decision was made to have two separate meetings.

FCMS have developed their first Quality Report and Mrs Shepherd is happy to share this with anyone who would like to see it, she added that the report is really comprehensive and prompted a good conversation at the meeting, there are no quality concerns following the meeting.

Mrs Shepherd informed the committee that at present they are achieving 12% streaming and they would like to get too 20% or higher, they use the Manchester Tool and this is risk averse for clinicians. Mrs Shepherd added that the key issue for FCMS is workforce issues with GP cover in UCC and that our GPs are not taking this up, Dr Jones asked if we had a feel for why local GPs were not taking this up and Mrs Shepherd said that she is doing a lot of work with FCMS on this as they are now looking at different skills mix model and we are fully involved in this. Dr Britten asked if Andrew Oates was involved and Mrs Shepherd confirmed he was and that this is a good provider. Dr Britten said that we ought to get the message out to GPs that FCMS are a good provider and to build that relationship, she will have a look at the FCMS Quality Report and then share with locality leads.

Action 05 / 07.07.16: Dr Britten to share the FCMS Quality Report with Locality Leads.

Dr Jones asked the committee if they had any further questions for Mrs Shepherd, nothing further asked.

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6.4 RDaSH Quality Report – Enclosure F

Mrs Cookson updated that the Trust are still doing their system wide transformation and that there are some frustrations over the CIP but that there is a meeting on Monday 11th July. Dr Jones asked if the CIP was challenging and Mrs Shepherd responded that it was. Mrs Cookson said that there is a lot of buzz on transformation in the Trust and that they are moving to a locality model. Dr Jones asked if the CCG were being kept up to date on this work and Mrs Cookson confirmed that we were and that there were conversations with both Trusts to bring some services together.

Mrs Cookson updated regarding a recent SI in the Trust, further information on this can be found in the RDaSH report.

Mrs Cookson updated that the young gentleman in Sapphire Lodge has now moved to a new facility, the CPS decision on this case is still outstanding. Dr Jones asked if we were comfortable regarding this and Mrs Cookson said that

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we were and we were kept fully informed. Mrs Cookson added that Sapphire Lodge is part of the Trusts transformation programme with Mrs Shepherd adding that this forms part of the wider LD work and that Mrs Pederson is attending a meeting in Leeds on Transforming Care for LD Patients and that we have some concerns regarding the NHS England approach and that these will be raised at that meeting.

Dr Jones asked the committee if they had any further questions for Mrs Cookson, nothing further asked.

6.5 Care Home Report – Enclosure G

Mrs Shepherd updated that a meeting has taken place to discuss Care Home Strategy Implementation and joint chairing of the Implementation meeting moving forward. The Care Home Executive Group will now become the Care Home Implementation Board with five sub-groups sitting underneath. On-going monitoring is going well, Dr Jones said that it is a complex but comprehensive document.


6.6 Individual Placements, Including CHC, S117, Children’s IP & Quality Assessments’ – Verbal

CHC

Mrs Shepherd said that CHC work is on-going with Q4 benchmark data has been received and shows some significant improvement in our position nationally.

Brown Jacobsen report: 360 Assurance are undertaking an audit of the Brown Jacobson report.

Fully funded patients should be reviewed at 3 and then 12 months, We currently continue to have a significant number of outstanding reviews. The CCG are considering options to buy capacity in to do this for us. We have the capacity to maintain once the entire backlog is cleared. Some challenges in respect of Social worker capacity has been raised in a variety of forums, resulting in a rise in the number of deferred cases Dr Joseph said that he is being told that there is a system in place and that it is working but Mrs Shepherd expressed concern about the capacity. Mrs Shepherd agreed to discuss these range of concerns with Pat Higgs Assistant director of adult social care. Dr Britten asked if the data could be collected on the numbers of delayed decisions and presented back to this committee. Mrs Shepherd informed the committee that this is monitored through the individual steering group.

Mrs Shepherd updated the committee that work with the local authority is more integrated and that this is getting better.

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Section 117

Mrs Shepherd said that a lot of work had been done on Section 117, all patients have been reviewed and this has identified some quality issues with OoA cases and these are being addressed with the provider. 360 Assurance are doing a review if this at the moment.

PUPOC

Mrs Shepherd updated that the trajectory been set by NHS England for September 2016 remains a big challenge, we don’t have the capacity to meet this. September 16 is a soft trajectory and the March 17 is a hard trajectory and all our plans to outsource cases is now aligned to meet the march 2017 deadline. Mrs Shepherd added that she had done an options paper and this had been discussed with Dr Crichton and other senior colleagues and the paper will go the next Strategy and Development meeting, Mr Russell is fully sighted on this work.


6.7 Primary Care Quality Report – Enclosure I

Mrs Cookson updated that the dashboard is being developed; she has not seen this herself as it is still in development. Mrs Shepherd asked if the committee would be able to see an early draft of this and Mrs Cookson said that she could bring this to the next meeting in September 16. Dr Jones thanked her and said it would be good to see this progressing.

Mrs Cookson updated that the CQC had visited the GP Practice that had been reported by a whistleblower, all actions have been completed and a new practice manager recruited. Dr Jones asked if the whistleblower allegations had been proven, Mrs Cookson said that they weren’t and that when she visited last week there were no concerns.

Mrs Cookson updated regarding a delay for a cancer patient, this has been returned to the practice for more information when it will come back to IMG. There was also an independent audit on a Nurse Practitioner, NMC has closed this as no case to answer, the practice have done an independent report but we have not received this as yet. Dr Jones asked if regular liaison with the Primary Care Committee and Mrs Cookson responded that they receive reports on ad hoc concerns.

Q4 Case Conferencing Report – Enclosure J

Mrs Cookson updated that despite consistent messages going out to practices there are still peaks and troughs, she added that she had just completed the PDR with the named GP for Safeguarding and she is keen to get him into practices to identify where the blockages are and that she also wants to get him involved with the Head of Safeguarding. Dr Britten said that there is a challenge regarding the outcome for children as a lot of the children are not

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known to the practice.


Action 06 / 07.07.16: Mrs Cookson to bring a copy of the Primary Care dashboard to the September 16 meeting, Mrs Twigg to include on the agenda.

SC / LT

6.8 Transforming Care Update – Verbal

Mrs Shepherd said that this had been covered in the Individual Placements feedback on agenda item 6.6.

6.9 Patient Experience Annual Report – Enclosure K

Mrs Quinn asked that the committee noted this report.

Primary Care Highlights

Mrs Quinn updated that Access to Services is the top negative theme for 2015-16 with 53%. Access to Services is also the top positive them for the same period with 34.5%.

Secondary care Highlights

Treatment attracted 33.5% of positive comments; negative themes include waiting for treatment and pain relief.

Complaints

Mrs Quinn highlighted that these have increased this year; Dr Britten asked if Mrs Quinn dealt with the CCG complaints and Mrs Quinn confirmed that she does. Dr Jones said that the figures look as expected with Dr Britten asking if the CHC complaints were starting to come through, Mrs Shepherd responded that they were. Dr Jones added that we do everything we possibly can. Dr Joseph asked if there was an increase and Mrs Shepherd responded that there was but that we reviewed all fully funded patients and the complaints are from patients who are not entitled.

Dr Jones asked the committee if they had any further questions for Mrs Quinn, nothing further asked.

6.10 Q4 DBHfT CQUIN Attainment – Enclosure L

Mrs Stothard updated that not all Q4 evidence had been received from the Trust and that the Q4 CQUINs are not formally signed off. Mrs Stothard added that she will do a post meeting note as Q4 had not yet gone to ACQRG. Dr Jones said that given where the Trust are we need to help / support and that our focus is now on this year. Mrs Stothard agreed and said that the focus for this year is on maintenance of quality. Dr Jones asked the committee to note

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the position of Q4 CQUIN Attainment and no further action need be taken.

Dr Jones asked the committee if they had any further questions for Mrs Stothard, nothing further asked.

7. PATIENT SAFETY

7.1 IPC Update – Verbal

Mrs Shepherd updated that Mrs Feirn was unable to attend as she was at an MRSA meeting today. Dr Joseph updated that he had attended a meeting yesterday to go through the IPC process, Dr Jones asked if there were any other IPC issues and Dr Joseph said that there was a cluster of MRSA cases in Rotherham and 2 of those cases were linked to a Doncaster Nursing Home and this is currently being looked into.


7.2 NHS England North Final LAC Summary Report May 2016 – Enclosure M

Mrs Cookson updated the committee that this work had been instigated by NHS England and that Doncaster had been proactive and had already done a lot of the work. Dr Jones asked what happens to the report now and Mrs Cookson responded that she had presented the report to the Governing Body, there are some issues and action points identified and these are being worked through. Dr Jones thanked Mrs Cookson and said well done.


7.3 Safeguarding Adults Update

This agenda item was covered under other agenda items today.

7.4 Safeguarding Children Update

This agenda item was covered under other agenda items today.

7.5 Safeguarding Adults & Children Training Strategy Safeguarding Policy – Enclosure N

Mrs Cookson informed the committee that Mrs Rayner, Mr Boldy, Mr Russell, Mrs Ibbeson and she had been involved in the development of this policy. The next step is Doncaster CCG to ensure a training matrix is developed to incorporate individual’s staff roles. Dr Jones asked the committee if they had any further questions for Mrs Cookson, nothing further asked, he then asked if the committee were happy to approve the policy, the committee approved. The policy will now be implemented with Mrs Devanney having full sight of this work.

Policy noted as approved.

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7.6 Caldicott Update

Caldicott Log 2016-17 – Enclosure P

Mrs Shepherd informed the committee that there was one new entry to sign off the decommissioning of the GP OOH TPP module for DMSL, this had been completed. Mrs Shepherd updated that Mr Boldy has pulled together a list of CHC Practitioners but that more work is needed to sense check the children’s element.

Caldicott Management Statement 2016-17 – Enclosure Q

Mrs Shepherd asked the committee to approve the Management Statement.

NOTE: Caldicott Management Statement approved.

Caldicott Work Plan 2016-17

Mrs Shepherd asked the committee to approve the Caldicott Work Plan.

NOTE: Caldicott Work Plan approved.

Dr Jones asked the committee if they had any further questions for Mrs Shepherd on Caldicott, nothing further asked.

7.7 CQC Update – Verbal

Mrs Shepherd updated that she meets with CQC each quarter and had nothing further to feedback.

Mrs Cookson updated that RDaSH have informed us that CQC are visiting the Trust in September 16.

Dr Jones asked the committee if they had any further questions for Mrs Shepherd or Mrs Cookson, nothing further asked.

7.8 Quality & Safety Risk Register – Enclosure S

Mrs Shepherd updated that all risks on the register were medium risks and said that no new risks have been identified today. Mrs Cookson said that she would update the children’s risk. Dr Jones asked who looked after the Risk Register and went through it, Mrs Shepherd responded that Mrs Hague and Mr Russell get together and go through the register.

Action 07 / 07.07.16: Mrs Cookson to update the children’s risk on the Risk Register.

SC

7.9 Quality & Safety Work Plan 2015-16 – Enclosure T

Mrs Shepherd informed the committee that the 2015-16 Workplan has come to the committee for sign off. The 2016-17 Workplan will come to the next

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meeting in September 16.

NOTE: The 2016-16 Work Plan was signed off by the committee.

Action 08 / 07.07.16: Mrs Rayner to bring the 2016-17 Workplan to the next meeting in September.

JR

8. Any Other Business None was raised.

9. Date and Time of Next Meeting Thursday 1st September 2016 at 09.30 - 11.30 in the Boardroom, Sovereign House.

FUTURE MEETING DATES

DATE TIME VENUE

Thursday 3rd November 2016 0930 - 1130 Boardroom, Sovereign House

Thursday 5th January 2017 0930 - 1130 Boardroom, Sovereign House

Thursday 2nd March 2017 0930 - 1130 Boardroom, Sovereign House

Thursday 4th May 2017 0930 - 1130 Boardroom, Sovereign House

Thursday 6th July 2017 0930 - 1130 Boardroom, Sovereign House

Thursday 7th September 2017 0930 - 1130 Boardroom, Sovereign House

Thursday 2nd November 2017 0930 - 1130 Boardroom, Sovereign House

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Minutes of the Engagement & Experience Committee Held on Thursday 7 July 2016, commencing at 10.00am,

Meeting Room 1, Sovereign House

ACTION

1. Apologies for Absence Apologies for absence were received from:

• Mr Ian Carpenter – Head of Communications & Engagement

• Mrs Christina Quinn – Patient Experience Manager

• Mr Curtis Henry – Engagement and Equalities Officer

• Mr Adam Tingle – Communication and Engagement Officer

• Mrs Debbie Hilditch – Health watch Doncaster

• Dr Sam Feeney – Locality Lead

2. Welcome and Introductions Mrs Tully welcomed all attendees to the meeting and a round of introductions were made. Mr Atkin was welcomed to the group as the new Chair of the Health Ambassadors scheme.

3. Declarations of Interest There were no declarations of interest made.

4. Minutes of the Previous Meeting held on 2 June 2016 The minutes of the meeting held on 2 June 2016 were agreed as an

Present:

Mrs Linda Tully – Lay Member (Chair) Mrs Sarah Atkins Whatley – Chief of Corporate Services Dr Khaimraj Singh – Locality Lead Mrs Claire Larner – Finance and Performance Team Representative Mrs Kayleigh Wastnage – Primary Care Team Representative Mr Mike Young – Assistant Head of Performance and Intelligence Mr Wayne Goddard – Head of Strategy and Delivery Mrs Maria Wilson – Quality & Safety Team Representative Miss Sue Womack – Doncaster CVS Mr Dennis Atkin – Health Ambassador Representative Ms Sarah Smith – Public Health Representative Ms Sandra Hodson – Healthwatch Doncaster Representative

In Attendance:

Miss Lindsay Moore – Senior Corporate Services Support Officer (Minutes) Ms Gilly Ennals – Shadowing Mrs Atkins Whatley

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accurate record.

5. Matters Arising not on the Agenda – Action Tracker The actions on the tracker were agreed and noted as complete.

6. Terms of Reference and feedback from the Development Session Mrs Atkins Whatley updated the Committee on the outputs from the development session held at the last meeting to focus on Patient Engagement and Experience and the role of the Committee. It proved to be a very useful session which showed consistency about our vision and highlighted the areas of feedback required from patients and the 3 levels of engagement with patients and their carers. It was felt that it would be useful to set up a sub group to take forward an annual work plan to focus on the Committee lead areas in line with our strategic plan priorities and feed back into the Committee at regular intervals. Mrs Atkins Whatley asked if anyone would be willing to be involved in the subgroup, the following attendee’s said they are happy to be a part of this. Miss Moore will set up a meeting.

• Miss Sue Womack – Doncaster CVS

• Mrs Maria Wilson – Quality and Patient Safety Support Officer

• Mr Wayne Goddard - Integrated Lead for Dementia Mrs Tully said that we need to keep a balance between sending out messages and obtaining feedback and that the work plan would need to be taken to Governing Body for approval. The Committee noted that we need to understand the needs of the Doncaster people and also raise their awareness and understanding of how we can change or improve things and how they can be involved in these changes.

Miss Moore

7. Key engagement themes and trends from Partners Doncaster CVS:

• Miss Womack has met with Sarah McNally from DMBC in relation to DMBC Health and Social Care commissioning as the Doncaster Health and Social Care forum felt there was a lack of communication around this area. Mrs Womack was advised that there is a focus on internal services at the moment with 5 pieces of work being put in place alongside 5 year plans, it is expected that wider communication will be provided in due course.

• Social Prescribing has seen an increase in referrals with 126 in May and 136 in June this year compared with around 80 in the same time period last year.

• The Health Ambassador for the homeless community has reported that the questions submitted around primary care had to be

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translated into 14 different languages. There were 5 outreach staff involved in collecting the responses and the final figures will be reported in due course.

Healthwatch Doncaster:

• Ms Hodson advised that as of the 1st July Healthwatch Doncaster has become a Community Interest Company and is now based at Cavendish Court.

Public Health:

• Ms Smith advised that work on the BME Health Needs Assessment is due to commence; this will be taken to Health and Wellbeing Board in January and feedback will be provided at a future Committee meeting.

8. Developing a Stakeholder Engagement Plan: Primary Care NHS Doncaster CCG assumed full responsibility for the commissioning of general practice services on 1 April, 2016. Primary care commissioning was one of a number of changes set out in the NHS Five Year Forward View. It aims to support the development of integrated out-of-hospital services based around the needs of local people and is part of a wider strategy to join up care in and out of hospital. It could lead to a number of benefits for patients and the public, including:

• Improved access to primary care and wider out-of-hospital services with more services available closer to home.

• High quality out of hospital care

• Improved health outcomes, better access to services and reduced health inequalities

• A better patient experience through more joined up services Mrs Atkins Whatley advised that this report had been presented to the Primary Care Commissioning Committee and they had recommended that it was brought to this Committee as it links in to patient engagement. The Committee noted the report and recommended that the subgroup that is being set up from the development session should take this work forward. Miss Womack presented the feedback report from Ambassador engagement on primary care. Miss Womack advised that the responses from Veterans have been added to the report and the responses from the Homeless community are still awaited, this will account for approximately 200 responses and take the total response rate to 385. The main issue arising is around making appointments and people felt that a receptionist is not the appropriate person to be offering advice. The group acknowledged that a bad experience at the first point can follow through the entire pathway. Miss Womack and Mr Atkin advised that the same issues have been reported amongst

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several of the ambassador groups and that this will need to be considered within primary care commissioning. Mr Atkin highlighted that the Health Ambassador scheme links with seldom heard groups of people so methods of communication will need to be looked at alongside the standard forms of communication e.g. noticeboards. We also need to work together to make sure information is kept up to date. The Committee acknowledged that we need to consider how we communicate and how we make providers aware of communication issues and methods.

9. Update on health inequalities action plan development Mrs Atkins Whatley advised that this a joint presentation on health inequalities between herself and Dr Suckling was delivered to the Strategy Development Forum in May 2016. The Forum agreed the development of an action plan. The key areas which have been identified and on which work is commencing are:

• A Black, Asian & Minority Ethnic Health Needs Assessment. This was last updated 12 years ago and with recent changes in our ethnic minority population in Doncaster has been prioritised for refresh. We are working closely with Public Health colleagues and the work is being led by the Health & Wellbeing Board. Mr Henry is attending the first meeting today at which the planning for the health needs assessment will commence.

• Performance data – looking at how this can be used to identify health inequalities.

• Variations in primary care health inequalities.

10. Action notes of the Health Ambassador Scheme Meeting held on 4th July 2016 The Committee noted the minutes and their content and thanked Miss Womack for submitting them and asked for thanks to be passed on to the volunteers involved in the Ambassador Scheme.

11. Action notes of the Patient Participation Group Meeting held on 24 June 2016 The Committee noted the minutes and that an elected chair of the PPG Group will be happy to attend future Committee meetings.

12. Any Other Business There were no items of business raised.

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13. Date and Time of next meeting Thursday 4 August at 10:00am, Meeting Room 1, Sovereign House.

A - Front cover · Governing Body To be held on Thursday 15 September 2016 Commencing at 12.30pm...

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