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Derbyshire�Community�Health�Services

Council�of�Governors

Council�of�Governors�-�12�July�2016

12�July�2016�-�14:00

The�Postmill�Centre,�Market�Street,�South�Normanton�Derbyshire,�DE55�2EJ

AGENDA

71 Chairman’s�WelcomeOwner:�Chair

Verbal

72 Apologies:�Owner:�Chair

Tracy�Allen,�William�Jones,�Tim�Broadley,�Jim�Austin,�Chris�Bentley,�Emma�Brooks,�Sally-annCoope,�Valerie�Broom,�Roger�Green,�Paul�Kirtley,�Tabitha�Crapper,�Paul�Jones

73 Declarations�of�InterestOwner:�Chair

Verbal

74 Draft�Minutes�of�the�meeting�held�on�9�May�2016Owner:�Chair

Paper�for�Decision

74�Minutes�May�2016.doc 5

75 Matters�ArisingOwner:�Chair

Verbal

http://www.eshareuk.com

76 Actions�MatrixOwner:�Chair

Paper�for�Information

76�Actions�Matrix�July�2016 12

77 Patient�StoryOwner:�Carolyn�White


77�Patient�Story 14

78 Performance�and�Quality�-�Holding�to�Account

79 Care�Quality�Commission�Inspection�UpdateOwner:�Carolyn�White


79�CQC�Inspection�Update 16

80 Quality�and�Performance�ReportOwner:�Chris�Sands/�Carolyn�White


80�Quality�and�Performance�Report 18

81 Patient�Experience�Annual�ReportOwner:�Carolyn�White


81�CoG�Patient�Experience�Annual�Report�2015�-�201 27

82 Quality�Business�CommitteeOwner:�Ian�Lichfield

Presentation

82�QBC�Presentation 43

83 Update�from�Governor�Groups:�Strategy�Group,�Quality�Group,Engagement�Group,�and�Governance�GroupOwner:�Governors

Verbal


84 Nominations�and�Remuneration�Committee�Summary�ReportOwner:�Prem�Singh

Paper�for�Information�and�Decision

84�Nominations�and�Remuneration�Committee�Summary� 65

85 Strategy�and�Planning

86 Chief�Executive’s�ReportOwner:�Chris�Sands


86�Chief�Exec�Report 67

87 Governance

88 Trust�Secretary’s�ReportOwner:�Kirsteen�Farrar

Paper�for�Information�

88�Trust�Secretary's�Report 73

89 Concluding�Items

90 Any�Other�BusinessOwner:�Chair

Verbal

91 Council�of�Governors�-�Review�of�MeetingOwner:�Chair

Verbal

92 Date�of�Next�Meeting:�Wednesday�7�September�at�2.00pm�at�The�Post�MillCentre,�Market�Close,�South�Normanton,�DE55�2EJChair

93 Key�Dates�and�Future�EventsOwner:�Gary�Roe


93�Key�Dates�and�Future�Events 76


Index74�Minutes�May�2016.doc.pdf...................................................................................................5

76�Actions�Matrix�July�2016.docx........................................................................................... 12

77�Patient�Story.docx..............................................................................................................14

79�CQC�Inspection�Update.docx............................................................................................ 16

80�Quality�and�Performance�Report.pdf................................................................................. 18

81�CoG�Patient�Experience�Annual�Report�2015�-�2016.docx................................................27

82�QBC�Presentation.pptx...................................................................................................... 43

84�Nominations�and�Remuneration�Committee�Summary�Report.doc...................................65

86�Chief�Exec�Report.pdf........................................................................................................67

88�Trust�Secretary's�Report.docx........................................................................................... 73

93�Key�Dates�and�Future�Events.docx................................................................................... 76


Council of Governors

Minutes of the Meeting held on 9 May 2016 Postmill Centre, Market Close, South Normanton, Alfreton, DE55 2EJ

Present Name Job title

Barbara-Anne Walker PS Vice Chair - Non-Executive Director Ray Asher RA Deputy Lead Governor - Public Governor - Amber

Valley, Erewash & South Derbyshire Valerie Broom VBr Public Governor - Amber Valley, Erewash &

South Derbyshire Roz Coldicott RC Public Governor - Amber Valley, Erewash &

South Derbyshire Bridget Leech BLe Public Governor - Amber Valley, Erewash &

South Derbyshire Barry Jex BJ Public Governor - Bolsover, Chesterfield & NE

Derbyshire Maureen Strelley MS Public Governor - Bolsover, Chesterfield & NE

Derbyshire Andrea Cooke AC Public Governor - Derbyshire Dales & High Peak Brenda Greaves BG Public Governor - Derbyshire Dales & High Peak Roger Green RG Public Governor - Derbyshire Dales & High Peak Paul Kirtley PK Public Governor - Derbyshire Dales & High Peak Diana Wood DW Public Governor - Rest of England Bernard Thorpe BT Lead Governor - Public Governor - City of Derby Emma Brooks EM Staff Governor - Other Registered Professionals Tabitha Crapper TC Staff Governor - Healthcare Support Staff Joan Johnson JJ Staff Governor - Healthcare Support Staff Amanda Smith ASm Staff Governor - Medical and Dental Sally-Ann Coope SAC Staff Governor - Nursing Veronica Hunting-Young

VH-Y Staff Governor - Nursing

Adam Short ASh Staff Governor - A and C and Managers Paul Jones PJ Appointed Governor - Derbyshire County Council Mark Smith MSm Appointed Governor - North Derbyshire Clinical

Commissioning Group Apologies Prem Singh PS Chairman - Non-Executive Director

Peter Ashworth PAs Public Governor - Amber Valley, Erewash & South Derbyshire

Lorraine Culpin LC Public Governor - Bolsover, Chesterfield & NE Derbyshire

Sara Nash SN Staff Governor - Other Registered Professionals Maggie Parry-Hughes MP-H Staff Governor - Nursing Michael John Perry MP Public Governor - Amber Valley, Erewash &

South Derbyshire Jenny Swatton JSw Appointed Governor - Southern Derbyshire

Clinical Commissioning Group 74�Minutes�May�2016.doc.pdf

Overall�Page�5�of�76Page�1�of�7


Tracy Allen TA Chief Executive Tim Broadley TB Deputy Director of Corporate Strategy Carolyn White CW Rick Meredith RM Medical Director William Jones WJ Chief Operating Officer

Apologies Not Given

In Attendance

Jim Austin (on behalf of William Jones)

JW Associate Director of Transformation

Melanie Curd MC Deputy Trust Secretary Kirsteen Farrar KF Trust Secretary Sally Isaac SI Senior Physiotherapist Ian Lichfield IL Non-Executive Director Chris Sands CS Director of Finance, Information and Strategy Claire Scott CSc Strategy and Planning Manager Simon Harvey SH Engagement Officer Suzanne Pancisi SP Corporate Governance Officer Nigel Smith NS Non-Executive Director David Boddy DB Corporate Governance Manager (minute taker)

Item Description Action 46/16

Chairman’s Welcome and Introduction of Governors BAW welcomed the governors to the meeting. BAW explained that apologies had been received from the Chairman, Chief Executive and Chief Nurse owing to their attendance at a meeting with the Care Quality Commission who are inspecting DCHS this week.

47/16 Apologies for Absence Apologies were noted as above.

48/16 Declarations of Interest None.

49/16 Draft Minutes of the meeting held on 7 March 2016 The minutes were approved as an accurate record of the meeting.

50/16 Matters Arising None.

51/16 Actions Matrix The actions were noted as completed.

52/16 Patient Story The governors discussed the positive impact of the musculo-skeletal physiotherapist in the Creswell Primary Care setting in North East Derbyshire. The meeting discussed a range of issues regarding access to services for patients living in rural communities with a low socio-economic status and made suggestions how communications to patients about our services could be improved:

• BG said that services provided by physiotherapists were not always immediately well known and asked if they should be more widely

RS

74�Minutes�May�2016.doc.pdfOverall�Page�6�of�76Page�2�of�7


Item Description Action advertised. Leaflets and newsletters in DCHS locations should advertise services.

• It was also noted that GPs still refer patients to services provided by Derby Teaching Hospitals. Governors asked whether services provided in DCHS locations (like St Oswalds) could be better communicated

• Televisions in DCHS settings might be a good way to advertise our services

The Council of Governors thanked SI for taking the time to attend the Council meeting in order to tell the story

53/16 Performance and Quality - Holding to Account 54/16 Quality and Performance Report

Quality Report – the Council discussed the inspection this week by the Care Quality Commission. A Quality Summit will take place following the visit and a report will be presented to the next Council of Governors meeting. The Council discussed:

• The internal triangulation review and the reporting of two inadequate ratings at Wheatbridge. SAC said that these had been addressed and rectified.

• The Quality reasons behind the closure of the Ilkeston Endoscopy Unit • The potential impact of the new procurement regulations on the

Erewash Vanguard initiative Regulatory Performance Report Performance against the regulatory performance indicators for the month were all RAG rated green. The position for month 12 showed that the Trust had no area of risk with a red rating. Thanks were given to all the staff for successfully delivering care against the performance targets. Finance Report The Trust reported a surplus position of £2.65m for the financial year, which slightly exceeds the Trust’s forecast plan of £2.6m. Subject to audit confirming the figures, the Trust has met all its statutory financial duties for the year. CS discussed the difficult national financial setting and how DCHS have appropriately managed the year end accounts with respect to judgements about future liabilities. CS also provided detail about management of the slippage on the capital programme. Big 9 VB asked about the 94% completion of quality annual appraisals against the target of 100%. CS said that some of the underperformance may be a reporting issue and that a review of performance across an 18 month period showed that performance was much higher. DCHS performance is favourable when benchmarked against national performance (which averages at 75-80%). Appraisal completion is an area the Board is very focused on. The report was received for information

CW



Item Description Action 55/16 Annual Quality Report Draft 9

CS updated the Council regarding the progress of the report. The report is an account of the work of the Trust over the preceding year and is expected to report on quality improvements, areas of concern and service developments. The report remains in draft form until final end of year data has been validated and included. The Annual Quality Report will be presented to the May 2016 Board of Directors for final approval prior to submission to Monitor on 30th May 2016. The CoG reviewed the draft report and recommended:

• Priority Audit Programme – Audit Focus and Outcomes section – standardise the wording regarding aims, goals and objectives

• Page 18 Section 3.1.4 Falls Management – make clear in the narrative the incidence of inpatient and community related falls. Current focus is on the reduction of inpatient falls, yet the chart shows an overall increase

• Page 25 Table - Breakdown of Catastrophic harm incidents reported – requires narrative to explain the incidents

The Council also talked about the strategic thinking behind potential DCHS involvement in future Primary Care opportunities. CS said that DCHS are to review the added value provided for the services that we are now managing. This will help shape our future thinking. The report was received for information

CW

56/16 Mental Health Act Committee (MHAC) BAW described the work of MHAC including:

• The work of the Associate Mental Health Act Managers. • The work achieved by the Committee in 2015 • How DCHS compliance has been strengthened

BAW highlighted the work for 2015/16 including :

• Compliance with the new Mental Health Act Code of Practice – good progress has been made against what is a huge task

• 360 Audit – MHA compliance – the audit provided very positive results • MHA training compliance – there are less than 12 staff that remain to

be trained • Restrictive interventions – how they are secured consistently across

the Trust BT discussed in more detail the work of the Associate Mental Health Act Managers (AMHAMs). The content of the presentation was discussed by the Council.



Item Description Action 57/16 Updates from Governor Groups:

The Council received the following updates: Governance Group – AS said the group:

• Discussed the MHAC presentation in detail • Received observational feedback from the March Board meeting

about how well the Non-Executive Directors challenged the Board • The plan for a governor to attend each Board meeting and a number

of Quality Committee meetings • Governor elections and how governors can support the election

activities Strategy Group – EB said the group discussed:

• Equality diversity and inclusion with respect to the Monitor Operational Plan guidance

• Details in the Operational Plan regarding the Sustainable Transformational Plan; risks to delivery of the Operational Plan; and the Big 9, particularly with respect to the Information Management and Technology connectivity target

The updates were received for information.

58/16 Strategy and Planning 59/16 DCHS Operational Plan 2016/17

The Council reviewed the Operational Plan that supports the detailed financial, activity and workforce plans for 2016/17. NHS Improvement will conduct a high level review of the final operational plans of all NHS Trusts and will monitor delivery during 2016/17. CSc presented some of the themes and details of the plan. AS asked about the impact of the transformation of services on the workforce, particularly with respect to retention and recruitment. CS said that the transformation is Derbyshire wide. This will involve an evaluation of the right number of professionals to deliver the new models of patient care. Staff engagement is also important so that staff know about the changes and how they can influence the Sustainable Transformational Plan. CS explained in detail the meaning of “place based care”. JA said that “place based care” is consistent with the DCHS thinking about delivery of services. RG thanked the Strategy team for the good quality of their plans. The Council of Governors received the Operational Plan for 2016/17.

60/16 Chief Executive’s Report CS discussed highlights of the report with the governors. These included: progress with transformation initiatives; system collaboration regarding tissue viability equipment ordering; and the forthcoming Extra Mile Awards. The paper was received for information.

61/16 Governance



Item Description Action 62/16 Audit and Assurance Committee Terms of Reference

The Council of Governors was consulted on the Terms of Reference for the Audit and Assurance Committee. The Terms of Reference will be presented to the Board for approval.

KF

63/16 Process for Elections to the Nominations and Remuneration Committee The Council discussed and approved the proposed process for the governor membership of the Nominations and Remuneration Committee. It was agreed that in order to support the continuity of membership, the elections for the committee will be arranged for November 2016 following the conclusion of the governor elections in September 2016.

64/16 Trust Secretary’s Report KF updated the governors regarding:

• Progress with the Council of Governors Self-Assessment • The updated Council of Governors Register of Interests • Progress with receiving signed copies of the new version of the

Code of Conduct from all the governors The paper was received for information. The Council also approved the updated Terms of Reference for the Council of Governors subject to amendment of the word “auditor” to “external auditor”. CS discussed what is meant by “significant transaction” and “mergers and acquisitions”.

DB

65/16 Report from the “Governor Focus” 2016 Conference BT shared with the meeting the experience of the National Conference for Foundation Trust Governors and discussed the headlines that emerged from the programme presentations. BT reported that the conference presentations reflected on the difficult economic environment that NHS Foundation Trusts currently experience. He found that the DCHS Council of Governors was performing well compared to others. BT has joined a Lead Governor Forum to share best practices. The paper was received for information.

66/16 Concluding items 67/16 Any Other Business

KF explained that the date for the Annual Governors Meeting (AGM) has yet to be announced; the intention was to organise it to coincide with the July meeting however a number of statutory reports need to be presented and this cannot be done until after they are laid before parliament. There is a risk if the meeting is arranged for July that it would be too early and may have to be cancelled. A new date for the AGM is being organised and as soon as it is confirmed Governors will be informed.



Item Description Action 68/16 Council of Governors - Review of Meeting

The governors agreed that it had been a good meeting.

69/16 Time and Date of Next Meeting: Monday 11 July 2016 at 2.00pm at The Post Mill Centre, Market Close, South Normanton, DE55 2EJ

70/16 Key Dates and Future Events The Council were advised of the dates, times and venues for meetings in 2016.



COUNCIL OF GOVERNORS - ACTIONS MATRIXDATE: July 2016

Date/Item No:

Item/subject:

Decision taken and/orAction required:

Progress: Responsible Person:

Deadline: Outcome:

May 201652/16

Patient Story Suggestions were made on how communications to patients about services could be improved, as follows: Leaflets and newsletters in

DCHS locations should advertise services

Governors asked whether services provided in DCHS locations (like St Oswalds) could be better communicated

Televisions in DCHS settings might be a good way to advertise our services

An update to be provided to Governors at the July meeting.

Rob Steel July 2016 The communications and engagement team would be happy to support this work if Operational teams would value it and have the necessary budget available.

It is worth reminding governors, though, that we're in a period of transformation, particularly in the north of the county, so the team's recommendation would be to continue with the use of the newly-installed TV screens on sites for this propose. This way we could avoid printing a series of leaflets that may become quickly out-of-date.

The more generic ‘welcome to DCHS’ booklets could be usefully re-printed though, given that they will have a longer shelf life.

May 201654/16

Quality Report A Quality Summit will take place following the CQC visit and a report will be presented to the next Council of Governors meeting

Carolyn White

July 2016 Agenda item July meeting

76�Actions�Matrix�July�2016.doOverall�Page�12�of�76Page�1�of�2


Date/Item No:

Item/subject:

Decision taken and/orAction required:

Progress: Responsible Person:

Deadline: Outcome:

May 201655/16

Annual Quality Report Draft 9

The Council recommended some amendments

Carolyn White

July 2016 Complete

May 201662/16

Audit and Assurance Committee Terms of Reference

The AAC Terms of Reference to be presented to the Board for approval

Kirsteen Farrar

July 2016 Complete - Agenda Item at May 2016 Board Meeting

May 201664/16

Trust Secretary’s Report

Terms of Reference for Council of Governors approved subject to one amendment

David Boddy July 2016 Complete

76�Actions�Matrix�July�2016.doOverall�Page�13�of�76Page�2�of�2


COUNCIL OF GOVERNORS Title of Paper: Fred’s Story- The importance of volunteer support

Paper for: Information

Presenter: Carolyn White, Chief Nurse/ Director of Quality

Author: Jo Blackburn, Volunteer Programme [email protected] 01773 525024

Date of Meeting: 12 July 2016 AgendaItem No: 77/16

No of pagesinc. this one: 2

Appendices: None

Purpose of Paper

This story highlights: the impact that the Volunteer made on Fred’s quality of life in the context of a life limiting

condition the value and importance of the Home from Hospital Programme to support discharge

from DCHS’ hospitals until required support is in place from hospital

How the existing Volunteering resource is being used to support patients after discharge.

Summary

That Governors understand the impact of volunteering and the potential for future growth.

Further Information and Appendices

Fred had been referred to the Home from Hospital Volunteer team whilst he was an in-patient at Ilkeston Community Hospital.

Fred had worked as security guard at Boots for over 24 years. He has been married to Doris, his childhood sweetheart for 42 years. He had been diagnosed with terminal oesophageal cancer.

The Volunteer Programme Co-ordinator (VPC) and Alan Chambers (Volunteer) met Fred at home after his stay in hospital. We were saddened and appalled to find how he was living. Only one room of the house was heated, and Fred had to sleep on a two seater sofa as he couldn’t get up the stairs to bed. The house desperately needed cleaning. Fred had no-one to help and support him with his shopping, washing or personal hygiene. We both felt it was important to try and make the remainder of his life as comfortable as possible. Additionally Fred’s wife was also in hospital. It was clearly distressing as Fred had been too poorly to get to visit her and was missing her terribly. Alan offered to take Fred to see her when he felt up to it, and in the

77�Patient�Story.docxOverall�Page�14�of�76Page�1�of�2

mailto:[email protected]


meantime Alan visited her by himself to take her some clothes.

The VPC contacted social services, the care co-ordinator, Macmillan and Erewash Community Voluntary Services regarding shopping for Fred. All these services are now on board in helping Fred and plans are slowly being put in place to give him more support. To quote Fred ‘Alan has been an absolute godsend’ throughout the whole of this process but especially until health and social care services was in place and I’m not sure how Fred would have coped without Alan’s practical help.

Alan immediately starting suggesting what he could offer in terms of support. He organised to take the washing to the local CVS to get it washed, and 2 days later he picked Fred up to take him to the bank as Fred didn’t have any money and couldn’t physically go by himself, as well as returning the clean washing. Within the same week Alan had been shopping, and shopped for him for the following 6 weeks until the volunteer shopper took over, fetched Fred some clothes that fitted him, and collected some overdue medications. Fred had some help to have the house cleared so a new bed could be delivered and Alan offered to be around to help with all of this. Alan also offered to take him out for a ride in the car for some fresh air and to meet up with friends at a community venue so he had something pleasurable to look forward to.

This has been a challenge for Alan because whilst he has gone the extra mile it has been apparent that what Alan has been doing is way and beyond his remit as a volunteer, but Alan had that determination and commitment to making a difference to Fred’s life. This also demonstrates the importance and on-going need for volunteers like Alan and there is a need to recognise that volunteers are an intrinsic part of patient care and support and many times bridge the gap until the relevant support is in place.

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COUNCIL OF GOVERNORS Title of Paper: Care Quality Commission Inspection Update


Presenter: Carolyn White Chief Nurse/Director of Quality

Author: Carolyn White Chief Nurse/Director of Quality



Appendices:

Purpose of PaperTo present to the Council of Governors an update on the recent care Quality commission comprehensive inspection of DCHS services

SummaryThe Care Quality Commission (CQC) undertook their comprehensive inspection of DCHS as planned week commencing 9th May 2016. The team of approximately 70 inspectors visited the majority of trust services including inpatient wards, community nursing and therapy services, podiatry, learning disability, OPMH, sexual health and children's services. Dental services were inspected two weeks after the comprehensive inspection due to unavailability of inspectors during the planned inspection week. In addition Cresswell and Langwith and Ripley Medical Centre practices were both inspected.

At the end of week one the CQC lead inspectors provided verbal feedback to the executive team. Overall feedback was extremely positive with CQC noting significant improvements in personalised care, mental health act application and consent to care. This was particularly pleasing as these had all been areas identified in our pilot inspection in 2014 where we have been focusing our attention in terms of improvement. The inspection team singled out our community learning disability services, approach to diversity and inclusion and end of life care as very impressive and were able to identify areas where staff had gone over and above what was expected of them to provide a good service to patients. Further unannounced visits were undertaken during week two. During the inspection the trust was requested to provide over 600 pieces of additional information to provide assurance that what was observed was being appropriately managed. Each piece of information was quality assured before being sent to the CQC.

There were some areas where the inspection team felt we could improve and these generally focused on our new services and were areas we had flagged up to them at the start of the inspection. These areas included sexual health and primary care. The issues in primary care were primarily transactional issues which are now being addressed by the team and in sexual health the focus was on the results management arrangements. Further assurance in terms of audit information and a follow up visit by the CQC provided sufficient assurance to inspectors that

79�CQC�Inspection�Update.docxOverall�Page�16�of�76Page�1�of�2


results were being managed in a safe way.

Next StepsThe CQC will now prepare their reports based on the findings of their visit. In total there will be twelve reports focusing on different areas of service delivery. These reports will be presented to the CQC quality review panel on 7th July and will be available to DCHS for accuracy checking on the 1st August.

A quality summit has been booked for 19th August at which the CQC will formally present the outcome of their visit and DCHS will be able to respond to any issues identified. It is likely that the reports will be published some time in this week.

In the interim clinical teams are actioning any issues identified during inspection week notified to them by inspectors and this is being managed with a weekly telecom between the quality directorate and operational managers.

SummaryOverall this has been a positive experience for the trust and to date no issues that we were not aware of have been identified. The inspection was extremely thorough and the collection of all the additional data sets put a huge pressure on operational services, however, it was completed in a timely way by services.

RecommendationsThe Council of Governors are asked to note the informal feedback from the inspection

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COUNCIL OF GOVERNORS Title of Paper: Quality and Performance Report May 2016


Presenter: Carolyn White, Chief Nurse / Director of Quality and Chris Sands, Director of Finance, Performance and Information

Author: Carolyn White, Chief Nurse / Director of Quality and Chris Sands, Director of Finance, Performance and Information

Date of Meeting: 12 July 2016 Agenda Item No: 80/16

No of pages inc. this one: 9

Appendices:

Appendix 1, Quality Report (pages 3 - 5) Appendix 2, Regulatory Framework (page 6) Appendix 3, Referral To Treatment Waiting Times (page 7) Appendix 4, Finance Report (pages 8 - 9) Appendix 5, Big 9 (page 10)

Purpose of Paper The purpose of this paper is to provide the Council of Governors with an overview of the Trust’s performance against our quality objectives, and regulatory performance targets. 1. Quality Report The Trust has set itself a number of quality objectives to support the delivery of its Quality Strategy. The objectives are: • Keep patients safe • Put patients (and family) at the centre of care • Get the basics right The quality section of this report provides Governors with an overview of the Trust’s performance against key performance indicators in each of these three areas for the month. 2. Regulatory Performance Report The third part of the report provides an update on the Trust’s performance against the regulatory performance indicators included within the Provider License by the regulator of foundation trusts, Monitor, for the first two months of 2016/17. The position for month 2 shows that the Trust has no area of risk with a red rating. The quarterly percentage of OPMH Delayed Transfer of Care is 3.0% against a target of 7.5%. There is continued focus on discharge planning and escalation of issues. 3. Referral to Treatment Waiting Times RTT Waiting Times information is now enclosed at Appendix 3. 4. Finance Report The Trust is reporting a surplus position of £4.56m for the financial year, which exceeds the

80�Quality�and�Performance�RepOverall�Page�18�of�76Page�1�of�9


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Trust’s original forecast plan of £3.42m. This increase is due to an additional allocation from the Sustainability and Transformational Fund. 5. Big 9 The Quality and Performance report provides an update of Trust progress against the “Big 9” key performance indicators which were agreed as part of the Annual Planning process. Summary See appendices below. Recommendations The Council of Governors is asked to receive this report for information.



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APPENDIX 1 QUALITY REPORT

1. Quality performance

Key Messages • Harm free care continues to fall below target levels in month • Falls with harm across DCHS continue to reduce • No medication incidents resulting in significant harm were reported in May • The Patient Experience data continues to provide a positive story

1.2 Harm free care During May Harm Free Care (HFC) Scores across all Services equalled 92.28% a reduction in performance from Aprils score of 92.96% this is against a target of 94%. Specific services scored as follows: Rehab Wards April HFC – 92.09% an improvement from 89.51% in April OPMH Wards April HFC –97.67% a small deterioration from 97.73% in April DN Teams April HFC – 92.11% a small deterioration from 93.07% in April LDS Teams April HFC – 100% remains at 100% 1.3 Falls Management Overall falls with injurious harm continue to fall however there were 5 falls in April and 2 in May resulting in harm which are currently being investigated to ensure that any learning regarding prevention can be ascertained.

Rate of all Injurious Inpatient Falls per 1,000 Occupied Bed Days (OBD's)

Mar-16 Apr-16 May-16 All Rehab Injurious Falls 3.87 3.21 1.89 All OPMH Injurious Falls 9.03 7.25 6.13

All LDS Injurious Falls 0 0 1.86 All Injurious Falls 4.87 4.00 2.79

1.4 Pressure ulcers There were 5 Avoidable Pressure Ulcers confirmed since the beginning of April 2016. There were 2 new avoidable incidents during May, both of which related to recognising a deterioration and need to upgrade equipment. When analysing these incidents it has become apparent that there is a cluster in derby City, additional support has been put into this area. 1.5 Medication Incidents Whilst there have been no medication incidents resulting in serious harm there has been a cluster of insulin related incidents again in the Derby City area . The Chief Nurse is meeting with clinical leaders to discuss issues underpinning these incidents.



4

1.6 Patient Experience and Engagement The annual patient experience and engagement report was presented to QSC in June. This provides a comprehensive overview of activity in year and can be made available to governors on request .

2. Insight Visits Insight visits continue to provide valuable information about our services and have been used in triangulating information when preparing for CQC inspections. Initially the visits were limited to public governors due to pressure on staff governor time however any staff governor wishing to participate would be very welcome if they can commit to the additional time requirements. Concerns have also been raised that governors are becoming too operational and their role should be more strategic. The purpose of the Insight visist is to give ‘insight’ into trust services so this knowledge and patient and carer feedback can be used when considering broader strategic issues. Anyone with specific concerns is invited to meet with the Chief Nurse to discuss these.

3. Quality Always Over 60 staff attended a Quality Always away day on the 14th June 2016 to explore and celebrate the successes achieved with this initiative to date. Most popular amongst the speakers were those staff who have completed the leadership development program and who have been active participants in the clinical assessment and accreditation process. Their personal testimonies gave real credence to Quality Always and demonstrated the real improvements that can be made and sustained. This month has also seen the first Gold Award panels. The panels are the final step in the accreditation process where teams are invited to show case the work of their team and provide a portfolio of evidence to the panel to demonstrate their commitment to continuous quality improvement. The clinical team will also make a presentation to the panel and there will be opportunities for panel members to hear from patients and clients about their experiences as well as discussing issues with the team. Panels will consist of : • Executive Director • Public Governor • Staff Partnership • Front Line Care Council • Senior Service Managers Teams achieving gold award status will receive a plaque, staff badges and a letter of acknowledgement and will be able to call themselves a Quality Always team. Board members will be advised of successful teams on the day of he meeting. Pennine Care NHS Foundation Trust have expressed interest in visiting DCHS to look at Quality Always with a view to adopting it in their own organization.



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4. Flu Planning The first of this seasons flu planning meetings was held in June with a view to ensuring that we are well prepared ahead of the vaccination season. This year we have an exacting CQUIN target associated with our staff vaccination program with a target of 75% of front line staff to be vaccinated. This year’s campaign will focus on the broader public health benefits of having the vaccine and staffs personal and professional responsibility to their patients. Agreed actions include the development of a local promotional video, training of additional flu champions, ensuring ease of access to vaccinations and vaccinators and clear clinical leadership.

5. Back to the Floor Arrangements are being made for a Back to Floor initiative to commence in August. This will see all clinical leaders committing to one day a week working with their clinical teams and senior managers committing one day per month. It is expected that this initiative will improve patient outcomes with the direct input of senior staff in support of more junior colleagues. An initial pilot day is to be held on Wednesday 10th August 2016 to identify any unforeseen problems with a view to full roll out during September. Wednesdays have been identified as the protected days. Staff working in the Derby City locality have had previous experience of back to the floor days or (‘on the community carpet’) and have agreed to support the roll out of the initiative using some of their personal experiences to evidence the benefits.



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APPENDIX 2 – REGULATORY PERFORMANCE

Monitor Risk Assurance Framework Indicators 2016 -17

All DCHS Services

Measure Measure-Sub Group Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Narrative

RTT Waits - admitted patients seen within 18 weeks - 90% (target) (%)

See note 1 92.2% 95.1%

RTT Waits - non admitted patients seen within 18 weeks - 95% (target) (%)

97.1% 98.9%

RTT Waits - admitted patients seen within 18 weeks - 92% (target) (%)

97.7% 97.3%

A&E 4 Hour Wait for A&E Attendances (%) 100.0% 100.0%

Healthcare Care Associated Infections - Clostridium difficile lapses (no.)

Not applicable - DCHS does not have a target

Delayed Transfer of Care for OPMH - Monitor compliance framework calculation (%)

0.0% 3.0% Monitor quarterly calculation.

Mental Health data completeness: identifiers 100.0% 100.0%

Certification against compliance with requirements regarding access to healthcare for

people with a learning disabilityYes Yes

To be reported to EDS & quarterly to QSC

Data completeness: community services , comprising:

referral to treatment information %

91.9% 91.9%North East Derbyshire locality

recently deployed.


referral information % 84.7% 84.7%North East Derbyshire locality

recently deployed.


treatment activity information %

84.7% 84.7%North East Derbyshire locality

recently deployed.

Risk Score Rating 0 0

RTT admitted and non-admitted data will no longer be collected

from M4 onwards by Monitor



7

APPENDIX 3 – RFERRAL TO TREATMENT WAITING TIMES



8

APPENDIX 4 – FINANCE REPORT

1. Financial Duties

The financial risk of the Trust is measured by the Financial Sustainability Rating as part of the provider license. A rating of 4 is low risk, whilst a rating of 1 is high risk. The Trust is forecasting a rating of 4 at the year-end. This reflects the strong balance sheet of the Trust and the forecast surplus position. The Trust is forecasting a surplus of £4.56m. This is supported by £2.14 million non-recurrent income, and £0.21m non recurrent efficiencies. Therefore the underlying forecast outturn surplus position of the Trust is £2.21m surplus.

2. Registered Nursing Agency Spend metrics

The Trust’s performance against the Agency Spend metric is detailed below which shows our spend is behind the submitted planned run rate due to the impact of Flexing the number of beds DCHS have open and the complexity of patients currently in the beds and out in the Community.

Measure Indicator Year to date Year End Outturn Actual

£m Target

£m Actual

£m Target

£m Agency Spend Spend against

Planned Trajectory

0.35 0.18 1.46 1.46

4. Month 2 Financial Position The Trust is reporting a surplus position of £0.94m at month 2, which represents a £0.05m surplus variance against the planned surplus of £0.89m. A year end surplus of £4.56m is forecast. This is an increase of £1.14m over the original control total of £3.42m. The £1.14m increase is due to additional funding of £1.14m from the “targeted element” of the Sustainability and Transformation Fund. This increases the Trust’s share from this fund to £1.64m. The Trust has a SQIP target of £5.0m for 2016/17. As at month 2 there is an under achievement against the planned schemes but mitigations have been found to offset this resulting in an over achievement of £0.02m. The year end forecast is currently a 0.5% under achievement of £0.02m by year end. At the end of May the cash balance was £0.6m below plan (actual: £14.8m, plan £15.4m)..



9

APPENDIX 5 – “BIG 9”

Objective Priorities 2016/17 Target Plan to end of May

Clinical Effectiveness - Assess frailty in our over 75 years population by the introduction of

a frailty screening tool – Prisma 795% 0% 0% (GREEN) 95% (GREEN)

Patient Experience - Improvement in time to respond to complaints 80% Within 40 Days 50% 57% (GREEN) 80% (GREEN)


Ensuring all staff are complaint w ith essential learning 96% 96% 95.4% (AMBER) 96% (GREEN)

Improving staff w ellbeing by reducing w ork related stress and anxiety

20% reduction in days lost to stress and anxiety based on 15/16

averages to below (1200 days)1,200 1,840 (RED) 1,200 (GREEN)


Demonstration of eff iciency across all DCHS services through the delivery of the

Sustainable Quality Improvement Plan (SQIP)

£5m Sustainable Quality Improvement Plan (£000) 627.41 651.5 (GREEN) 5,000 (GREEN)

Measuring the progress tow ards becoming a more agile organisation by reducing the spend

on non-Clinical estateLess than 5,399m2 5,399m2 4,649m2 (GREEN) <5,399m2 (GREEN)

Responding to the main issue raised through staff feedback by monitoring the perceived

improvement in IT connectivity for staff

Less than 35% of staff Often or Alw ays Experiencing Connectivity

Problems35% 33% (AMBER) <35% (GREEN)

Big 9 - May 2016

Quality Service

Achieved to end of May Forecast

To deliver high quality and sustainable services that echo the

values and aspirations of the community w e serve

Patient Safety - To reduce the overall number of patients w ho incur pressure damage

20% Reduction in Baseline of 793 Pressure Ulcers 132 243 (RED) 634 (GREEN)

Quality Business


To ensure an effective, eff icient and economical organisation w hich

promotes productive w orking and w hich offers good value to its community and commissioners

Increase (GREEN)

Quality People


To build a high performance w ork environment that engages, involves and supports staff to reach their full

potential Improved position of staff reporting incidents of violence and aggression they encounter at

w ork

Month on month increase in reporting compared to 15/16 data 42 64 (GREEN)



1

COUNCIL OF GOVERNORS Title of Paper: Patient Experience Annual Report 2015-16

Paper for: Information and Discussion

Presenter: Carolyn White – Director of Quality/Chief Nurse

Author: Lana-Lee Jackson – Head of Patient and Family Centred CareJoy Keeton – Complaints Manager



Appendices: None

Purpose of PaperThe following report is intended to provide an overview of Patient Experience and Involvement activity at Derbyshire Community Health Services NHS Foundation Trust (DCHS) from 1 April 2015 - 31 March 2016, including a summary of:

Complaints and general feedback Friends and Family Test survey (patients and staff results are provided which describes

how likely people are to recommend our services) Overall patient experiences Patient Involvement Volunteers Patient Experience Team priorities to strengthen processes and systems for obtaining

patient feedback and learning 2016-17

DCHS is committed to acquiring and responding to good intelligence about patients’ individual experiences so that we always put our patients at the heart of every decision we make.

SummaryThis report has received significant assurance from the Quality Services Committee that patients, families and their carers continue to have positive experiences of DCHS services.

RecommendationsFor Council of Governors to receive the Patient Experience Annual Report for information.

81�CoG�Patient�Experience�AnnuOverall�Page�27�of�76Page�1�of�16


2

Patient Experience Annual Report(1 April 2015 - 31 March 2016)



3

98% of people would recommend

our services

22544 FFT Cards Returned

23 patient groups

established

24028 patient feedback

124 comments via Healthwatch

126 complaints

investigated & 3 PHSO requests

111 posts on NHS Choices & Patient Opinion

90% of staff would

recommend our services



4

Complaints and Concerns

Complaints are just one of the many ways we capture the views of our patients and service users to ensure we are detecting shortfalls in service early, acting to put things right and learning to prevent similar events recurring in the future.

During 2015-16 the Patient Experience Team received and responded to 511 enquiries, concerns and complaints which is a decrease in overall activity by 12.5% when compared to 2014-15 (584 contacts). This is not necessarily indicative of all frontline enquiries informally resolved by operational teams.

During 2015/16 DCHS provided a total of 660,000 patient contacts. 126 (0.019%) of those contacts resulted in a complaint.

2831

33

26

2933

24

40

Quarter 1 Quarter 2 Quarter 3 Quarter 40

5

10

15

20

25

30

35

40

45

2014/152015/16

Complaints Level 2, 3 4 received year to date 2015/16compared to 2014/15

Tota

l num

ber o

f com

plai

nts



5

A total of 126 complaints were investigated under the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. A total of 113 complaints were closed and 22 complaints are on-going, these will be carried forward to 2016-17. 385 concerns & enquiries were resolved. 2 complaints were referred to the Parliamentary and Health Service Ombudsman and both were partially upheld. When compared to overall activity across the trust each quarter complaints account for 0.02% of activity.

Outcomes Please note that the language used to describe complaint outcomes in the table below is in accordance with national reporting requirements within the K041a return. Response letters to complainants do not include this terminology as we are committed to producing compassionate and personalised letters.*complaint status is subject to changeOutcomes 2014-15 2015-16Not upheld 43 26Partially upheld 37 57Upheld 30 29Closed 0 1Ongoing 8 22Total 118 135

Investigation TimescalesAcknowledged within 72 hours 100%Responses sent within 25 working days or under 14%Responses sent 25-40 working days 46%Responses sent over 40 working days 40%

During the year we acknowledged all complaints within 72 hours and remain compliant with national targets. 60% of responses to complaints were provided in under 40 working days, which is an improvement from last year by 9%. However, we are committed to improving complaint response timescales. As part of the Trust’s Big 9 objectives for 2016-17 a key quality target is to achieve 80% of complaint responses in under 40 working days.



6

Risk AssessmentDuring 2015-16 the Patient Experience Team introduced a more robust methodology for risk assessing complaints. This has resulted in a more accurate record of ‘Low’, ‘Moderate’ and ‘High’ complaint concerns. In Q4 there was a notable increase in ‘Moderate’ complaints when compared to the same time period the previous year. There are no known reasons for this increase in terms of trends and themes, however, there was a significant increase in the total number of complaints received during March, in which the highest number of complaints were received demonstrating an overall increase in activity.

Level 2 % Level

3 % Level 4 % Level

2 % Level 3 % Level

4 %

Apr-14 3 2 0 Apr-15 7 2 1 May-14 5 3 0 May-15 5 3 0 Jun-14 9 6 0 Jun-15 4 7 0 Jul-14 6 3 0 Jul-15 12 3 0 Aug-14 5 4 0 Aug-15 5 3 0 Sep-14 9 4 0 Sep-15 4 6 0 Oct-14 7 3 0 Oct-15 6 4 0 Nov-14 9 7 0 Nov-15 5 2 0 Dec-14 5 2 0 Dec-15 4 3 0 Jan-15 7 3 0 Jan-16 6 6 2 Feb-15 4 1 0 Feb-16 5 5 0 Mar-15 8 3 0 Mar-16 6 10 0 TOTAL 2014/15 77 66% 41 34% 0 0% TOTAL

2015/16 69 56% 54 42% 3 2%

K041 Submissions and National Complaints ComparisonsThe Hospital and Community Health Services Complaints Collection (K041a) is a mandatory data submission to the Health & Social Care Information Centre (HSCIC). Data on all complaints received by the NHS is collected on a quarterly basis.

Link to review national complaints data:http://www.hscic.gov.uk/searchcatalogue?q=title%3A%22Data+on+Written+Complaints+in+the+NHS%22&area=&size=10&sort=RelevanceDesc National data is available for 2015-16 Q1-3. A total of 27836 new complaints have been received nationally, of which 0.37% related to DCHS services.

Outcomes National Q1-3 (%) DCHS Q1-3 (%)Not upheld 36 20Partially upheld 27 48Upheld 38 31

When compared to national outcomes, DCHS upholds a higher proportion of complaints. We recognise opportunities for learning following complaint investigations and therefore partially uphold a higher proportion of complaints received. From the table above we can conclude that complaint handling at DCHS is aligned to standards of good practice, in that we are committed to learning from patient experiences and take action to improve any identified shortfalls.

A total of 1437 complaints have been received regionally in Q3, of which a small proportion relates to DCHS services. When comparing our complaints performance to other local trusts we see that the percentage of resolved complaints within the quarter is lower than neighboring areas. We recognise that on-going improvement in complaint response timescales is needed and that we must improve the % of closures, which will be a priority objective in the coming year.


http://www.hscic.gov.uk/searchcatalogue?q=title%3A%22Data+on+Written+Complaints+in+the+NHS%22&area=&size=10&sort=RelevanceDesc

http://www.hscic.gov.uk/searchcatalogue?q=title%3A%22Data+on+Written+Complaints+in+the+NHS%22&area=&size=10&sort=RelevanceDesc


7

Complaints by Subject126 primary complaint subjects were recorded on Datix. The Patient Experience Team has developed sub-subject coding as part of the national reporting changes to the K041 and will be able to incorporate this into future reports.

There has been an overall decrease in concerns raised about all aspects of clinical care (15%), aids and appliances (38%), appointments (62%) and an increase in concerns relating to communications (43%) and attitude/ behaviours (14%).

Subject 2014-15 2015-16Admissions & Discharge 0 3Aids & Appliances 8 5All Aspects of Clinical Care 67 57Appointments 13 5Attitude 12 14Communication 16 28Complaints Process 0 0Consent 0 1Hotel Services & Premises 0 4Other 0 1Personal Records 0 0Policy 2 4Privacy & Dignity 0 3Transport 0 1Totals 118 126

During February 2016, the Patient Experience Team completed an in depth review of all complaints received relating to communication and staff attitude/ behaviours to establish if there were any common trends and/or themes emerging. The review concluded that the proportion of complaints against overall activity was low. There were no concerns relating to any specific

0

10

20

30

40

50

60

Admissions&

Discharge

Aids&

Appliances

AllAspects

ofClinicalCare

Appointments AttitudeCommunicationComplaintsProcess Consent

HotelServices

&Premises

Other PersonalRecords Policy

Privacy&

DignityTransport Totals

Apr-Mar2014/15 0 8 67 13 12 16 0 0 0 0 0 2 0 0 118

Apr-Mar2015/16 3 5 57 5 14 28 0 1 4 1 0 4 3 1 126

Complaints by Subject (Levels 2,3,4 ) Comparisons 2014/2015 to 2015/2016



8

employees. No significant connection could be made between the concerns raised and any one service. These subjects of complaint continue to be monitored through reporting schedules.

Learning and putting things right:

Throughout the year we have learned from the shortfalls identified in patient experiences in relation to ‘upheld’ and ‘partially upheld’ complaints. The Patient Experience Team has also participated in a peer review with Chesterfield Royal Hospital NHS Foundation Trust, facilitated by the Patients Association and supported by North Derbyshire CCG.

Patient’s Association Complaints Peer Review A review of complaints handling was undertaken to help the trusts to identify improvements in the way they deal with and respond to complaints. The 2 day review was focused on shared learning across organisations to improve complaints handling processes and systems.

12 closed complaint cases, 6 from CRHFT and 6 from DCHS were assessed by a mixture of experienced external peer reviewers and clinicians, complaints managers and lay representatives from the trusts and other nominated individuals were appointed. Together they reviewed the files, using the Patient Association standardised scorecard approach.

The results of the review showed that both trusts had significantly improved their complaints handling in 2015. DCHS had all six complaints graded by the reviewers as satisfactory, and four were graded as demonstrating good practice. The Patient’s Association made some recommendations on how complaints handling could be improved and actions are to be taken forward in the coming year.

Patient Experience Network (PEN) National Awards

DCHS, alongside North Derbyshire CCG, The Patients Association and Chesterfield Royal Hospital NHS Foundation Trust (CRHFT) were shortlisted for the Team of the Year Award for the work undertaken in the Complaints Peer Review Panel. The PEN National Awards provides an opportunity for recognition, celebration and sharing of best practice, with the overall goal of promoting and ultimately stimulating and accelerating improvement of patients’ experience.

Our nomination demonstrated DCHS & CRHFT’s team working by sharing information, discussing our processes and learning together during the peer review. Both teams had taken a positive attitude to make necessary improvements. Teams also demonstrated a clear commitment and dedication to improving complaints handling processes, which included a focus on the PHSO Principles of Good Complaint Handling.



9

Learning and Improvements Identified Following Complaints InvestigationsService Summary of Complaint/s Outcome Learning/ Improvement Identified

Hospital Nursing (Rehab)

DNACPR Form Continence management Patient discomfort in wearing

wrist band

Upheld Review of DNACPR policy and re-introduction across all clinical areas

Continence Service visits increased from monthly to weekly

Falls wrist bands now issued in different sizes

Older Person’s Mental Health

Number of patients visiting Confidentiality - computer was

left unlocked in an unattended office with door left open.

Partially Upheld

Trust introduced visiting policy Ward looking into fully adopting John’s campaign re visiting

Digital Lock fitted to ward managers’ office and time reduced on automatic screen saver.

Dentistry (Leicestershire)

Delay in accessing clinical treatment. Patient referred to general dentist practice.

Partially Upheld

Patients are given Healthwatch number to ensure contact with an NHS dentist can be made.

Community Nursing

Avoidable pressure damage. Duty of candour letter sent. RCA investigation undertaken

Upheld Wound assessments and care plans now undertaken on identification of any wound on first assessment and reviewed weekly

Community Nursing

District Nurses failed to recognise deterioration in patient's condition

Continuity of care and documentation concerns.

Partially Upheld

Toughbooks are used by District Nurses in the patient’s home to document their care.

Named nurse system implemented to provide continuity of care

Community Therapy

Physiotherapy push test caused patient pain and discomfort.

Partially Upheld

Therapists to be aware of potential for 'push test' to cause distress and to consider consent. Discussed at Clinic Meeting, Lessons Learned Group and Falls Group.

Sexual Health Services

Appointment and transfer due to full clinic

PartiallyUpheld

Receptionist Handbook developed to assist patient flow and booking

Community Nursing

Care to patient's leg ulcers & recognising cellulitis signs.

PartiallyUpheld

Staff in Derby City Community Teams provided with the equipment required to record Early Warning Scores

Health Visiting Letter sent in error by Health Visitor to bereaved family.

Upheld Discussed with team to enable staff to improve communication with GPs and midwives before letters are issued

Wheelchair Service

Assessment outcome for powered wheelchair.

Upheld Expert opinion is now sought before a final decision is reached.

Podiatry Services

(Community)

Patient expected to have fitting of shoe insert but this did not take place.

Partially Upheld

Shoe inserts not detailed in referral - Podiatrists to share content of referrals with patients and ask if they have any additional problems that need attention.



10

Parliamentary and Health Service Ombudsman (PHSO)

All complainants have the option to contact the PHSO to review their complaint and the way in which it has been handled should they remain dissatisfied with the Trust’s investigation findings and response to their concerns. The PHSO will assess complaints to determine if further investigation is required. If the PHSO accept a complaint for investigation, the Trust receives a full report detailing their findings and recommendations.

The following table provides a summary of PHSO referrals, investigations and outcomes 2015-16:

PHSO Request

Reference Service Outcome Received

PHSOStatus

Action/Recommendations

2015/1614-Sep-15 P2679JK Community

Nursing Service

15-Mar-16 Partially Upheld

DCHS failed to fully record the actions its nurse took on 9 May 2014. PHSO recommendation that the Trust apologise by letter, with a copy to the PHSO

18-Nov-15 P2984JE Dentistry Derbyshire

8-Mar-16 Partially Upheld

PHSO recommended for DCHS to write to the complainant to apologise for failing to take an x-ray and treating abscess. Redress: £18.50 to refund the appointment costs and £300 for the pain, distress and suffering experienced.



11

Friends and Family Test (FFT) 22544 Friends and Family Test responses were received during 2015-16.

*(%) of people who would recommend our services is provided in accordance with national reporting requirements and is calculated as follows:

𝑅𝑒𝑐𝑜𝑚𝑚𝑒𝑛𝑑 (%)

=𝑒𝑥𝑡𝑟𝑒𝑚𝑒𝑙𝑦 𝑙𝑖𝑘𝑒𝑙𝑦 + 𝑙𝑖𝑘𝑒𝑙𝑦

𝑒𝑥𝑡𝑟𝑒𝑚𝑒𝑙𝑦 𝑙𝑖𝑘𝑒𝑙𝑦 + 𝑙𝑖𝑘𝑒𝑙𝑦 + 𝑛𝑒𝑖𝑡ℎ𝑒𝑟 + 𝑢𝑛𝑙𝑖𝑘𝑒𝑙𝑦 + 𝑒𝑥𝑡𝑟𝑒𝑚𝑒𝑙𝑦 𝑢𝑛𝑙𝑖𝑘𝑒𝑙𝑦 + 𝑑𝑜𝑛'𝑡 𝑘𝑛𝑜𝑤× 100

𝑁𝑜𝑡 𝑟𝑒𝑐𝑜𝑚𝑚𝑒𝑛𝑑 (%)

=𝑒𝑥𝑡𝑟𝑒𝑚𝑒𝑙𝑦 𝑢𝑛𝑙𝑖𝑘𝑒𝑙𝑦 + 𝑢𝑛𝑙𝑖𝑘𝑒𝑙𝑦

𝑒𝑥𝑡𝑟𝑒𝑚𝑒𝑙𝑦 𝑙𝑖𝑘𝑒𝑙𝑦 + 𝑙𝑖𝑘𝑒𝑙𝑦 + 𝑛𝑒𝑖𝑡ℎ𝑒𝑟 + 𝑢𝑛𝑙𝑖𝑘𝑒𝑙𝑦 + 𝑒𝑥𝑡𝑟𝑒𝑚𝑒𝑙𝑦 𝑢𝑛𝑙𝑖𝑘𝑒𝑙𝑦 + 𝑑𝑜𝑛'𝑡 𝑘𝑛𝑜𝑤× 100

Our target in 2014-15 was to achieve an FFT return of 2000 cards per month. This was an ambitious target which we have not been able to consistently achieve. We will need to consider how we can support frontline staff to promote the FFT and improve our return rate in 2016-17. There is great value in receiving comments from the FFT free-text option and this gives us a greater insight into people’s experiences of services. Our patient and staff percentage recommendating are 98% and 90% respectively which indicate the positive experiences people have at DCHS.

In 2015-16

98% of people said they

would recommend our services

0

500

1000

1500

2000

2500

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-161. Extremely Likely 1526 1403 2065 1641 1601 1851 1662 1772 1458 1694 1804 16792. Likely 163 136 202 142 153 198 164 244 130 137 159 1553. Neither likelynor unlikely 6 5 13 8 13 8 23 9 8 8 3 14

4. Unlikely 1 4 7 4 5 6 6 3 5 2 2 145. Extremelyunlikely 13 12 18 12 7 6 15 11 13 7 23 30

6. Don't Know 10 5 5 5 3 4 2 9 4 3 5 6

Year to Date FFT Returns 2015-16

In 2015-16

90% of staff said they

would recommend our services



12

98.0% 98.0% 98.0% 98.0% 98.0%

98.8%

97.5%

98.4%98.1%

98.9%

98.4%

96.6%

95%

95%

96%

96%

97%

97%

98%

98%

99%

99%

100%

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16National 96% 95% 95% 95% 96% 95% 95% 95% 95.0% 95.0% 95.0% 97.0%Regional 98% 98% 97% 98% 98% 98% 97% 95% 97.0% 98.0% 95.0% 95.0%DCHS 98.0% 98.0% 98.0% 98.0% 98.0% 98.8% 97.5% 98.4% 98.1% 98.9% 98.4% 96.6%

% Recommended DCHS Comparison with National and Area Results

Examples of Comments from FFT 2015-16“Good sound advice that allowed me to help myself get back to pain free life. Never kept waiting past appointment time (Occupational Therapy, Ilkeston Community Hospital)”

“I am always grateful for the care the NHS provides but the Whitworth seem to go the extra mile to make you feel welcome. (MIU, Whitworth Hospital)”

“It's a pity that all the NHS departments don't provide such a superb service as this one does. (Podiatry, St Oswalds Hospital)”

“Nice people. I have no complaints about any of the staff, it always a pleasure to see them. They listen to what I want to say, are very caring and friendly. (Community Nursing, South Normanton & Blackwell)”

“Keep appointments or keep people informed of waiting times” – (Sexual Health Services)

“Very friendly and polite made feel welcome” – (Health Visiting)

“The staff at Ripley Hospital have been very thorough and professional during my stay which has resulted in a pleasant experience for me. The food was also very good. (Butterley ward, Ripley Hospital)”

“Felt welcomed-everything explained well” – (Ilkeston Diagnostic Treatment Centre)

“Totally different to what I expected. I thought I would not be in control of my life, but find that I am. The staff help me do that, (Continence Service, Alfreton Primary Care Centre)”

“Reception staff, nursing staff and Dr R in particular are friendly and helpful at all times” – (Primary Care)



13

Patient Involvement

Throughout the year we have seen the number of active patient groups across the organisation increase. The trend is very positive, with services embracing the involvement of patients and carers to shape services. This has also enabled some of our most vulnerable patients to ensure their voices are heard.

A total of 23 groups are active across the Trust and the Patient Involvement Officer is also working with services to establish other patient involvement activities

The ‘working together to improve services using experience based co-design’ methodology is being used as a pilot at our Diagnostic & Treatment Unit.

The Access to Healthcare Forum continues to support the healthcare for all agenda and effective partnership working across the protected characteristic groups. The picture below was taken at their meeting in 2015 where the group planned the priorities for the forum and how best for volunteers to support services with projects.

We continue to work closely with Healthwatch Derbyshire and Healthwatch Derby, including providing support for ‘enter & view’ training on our wards.

PLACE visits were undertaken with patient representatives during 2015. The outcome of were very positive. We await the outcomes of the 2016 assessments.



14

HealthwatchDuring the year we have received a total of 124 comments via Healthwatch Derbyshire, the majority of comments were received through engagement work. Healthwatch Derbyshire launched an online feedback centre in October 2015 which allows comments to be left online, so the proportion of comments received this way is likely to increase in future.

Further information on the Healthwatch Derbyshire annual report can be found on their website http://www.healthwatchderbyshire.co.uk/

The graphs below provide an overview of the sentiment of people’s experience and are taken from the Healthwatch Derbyshire Annual Report. 60% of comments have been extremely positive about DCHS services.

13%

27%60%

Mixed Negative Positive

S E N T I M E N T O F E X P E R I E N C E

DCHS continues to work closely with Healthwatch Derbyshire and since 1 October 2015 with the transition of Derby City Community Services to DCHS, we have also established a new working relationship with Healthwatch Derby.


http://www.healthwatchderbyshire.co.uk/


15

VolunteersThere are currently 29 active Home from Hospital Volunteers. In addition to the Home from Hospital Project we have identified volunteer activity across the organisation in varying forms from hairdressing, therapy dogs, social activities and supporting cafes/ shops and includes our very active Leagues of Friends.

During the year our focus has been on establishing the scope of the volunteer service which involved finding out about the various volunteers operating across the Trust. Many volunteers have offered their time to the organisation over many years and it became apparent there was an inconsistency to the checks undertaken prior to volunteers beginning their roles. Following the publication of the Lampard Report in 2015 it was important for the Trust to ensure all volunteers received a basic standard of induction and that all DBS checks were in place. A significant amount of work was therefore undertaken by the Volunteer Service to develop a central database of all volunteers, as well as to deliver training sessions and to support volunteers through the DBS process.

A total of 218 volunteers completed training and DBS checks were completed.

Home from Hospital Project (NESTA):

The Home from Hospital Volunteers have received over 100 referrals and have supported 87 patients through over 500 visits (based on weekly visits during the 6 weeks following discharge). Quarterly supervision sessions included training, and an opportunity to share feedback as a team.

The initial data analysis provided by NESTA shows positive findings although, as the sample size was small, the results are not statistically significant. Patients who used the Home from Hospital service were asked to complete the Friends and Family Test (FFT). They all reported that they would be extremely likely to recommend the service.



16

In summary

The feedback we have received during 2015-16 indicates that patients and their families have a very positive experience of using DCHS services. They describe professional and caring staff and services which are delivered to a high quality. We do not always get things right. On those occasions, we recognise where shortfalls have occurred and we take action to put things right. We view feedback as an opportunity to learn and to improve people’s experiences in the future.

Status of Patient Experience 2015-16 Objectives:Summary of Objective Status CommentsImproving response timescales to complaints

Partially achieved

There has been an improvement in response timescales 2014-15 (51%) to 2016 (60%) and we have reviewed our target for 2016-17. The 2016/17 target is to respond to 80% of complaints within 40 working days.

Increasing the number of Friends and Family Test returns

Partially achieved

We have maintained a high return rate on FFT returns throughout the year and continue to perform well nationally.

Working with our partners to ensure online options for feedback are maximised

Achieved We worked closely with Patient Opinion and Healthwatch to increase options for online feedback. Where engagement with online options was low we reviewed alternatives.

Working with our service users to ensure we learn from their experiences and identify meaningful actions to achieve real and sustainable change

Achieved Learning from complaint investigations and general concerns.Sharing learning at the Learning the Lessons Group.Sharing patient stories at committees and Board.

Improving the options available for all service users (including seldom heard groups) to provide feedback and for their voices to be heard

Achieved Establishment of patient groups.Growth of the volunteer service.Access to Healthcare Forum (equality focus)

Patient Experience Objectives for 2016-17

1. Achieve Target: 80% of complaints closed in under 40 working days2. To support complaint investigating officers through the development of a comprehensive

training programme, resources and documentation3. To review satisfaction with the complaints process through a survey/ focus group4. Develop systems to track and monitor patient involvement activity e.g. patient groups5. Continue to work with Healthwatch Derbyshire and Healthwatch Derby 6. Support the work of the Access to Healthcare Forum to ensure seldom heard groups are

involved in projects across DCHS7. To identify a sustainable model for the volunteering within DCHS8. Support staff to promote the Friends and Family Test in their areas to maximise opportunities

to learn from this valuable feedback9. To strengthen the Lessons Learned processes10.To implement NHS England’s Accessible Information Standards11.To develop Family Centred Care across DCHS



Quality Business Committee

Council of Governors12th July 2016

Ian Lichfield Chair of the QBC, Non-Executive Director

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Introduction• Welcome• Context – Five year forward view• Why have a Quality Business Committee?• Committee Overview • Our Approach• The Quality Business Committee Agenda• 2015/16 Financial Score Card• Areas of Focus 2016/17 – From Good to Great• Questions



Five year forward view“ Our values haven’t changed, but our world has ” Introduction, Five Year Forward View (2014)

“ To sustain a comprehensive high-quality NHS, action will be needed on three fronts – demand, efficiency and funding.”



“England will see a 100% increase in those aged 85+ between 2010 and 2030”

Ready for Ageing? Report Parliamentary Select Committee (2012)

“People are living longer but the duration of healthy living hasn’t changed ”

Duncan Selbie, Chief Executive Public Health England (2016)

Demand – Demographic time Bomb



“ A slow motion car crash…..If as a nation

we keep piling on the pounds around the waistline, we’ll be piling on the pounds in terms

of future taxes just to keep the NHS afloat” Simon Stevens, Chief Executive NHS England (2016)

Demand - Lifestyle Related Conditions



• Alcohol £2.8bn

• Smoking £2.0bn Source: Clare Foges, The Times (May 2016)

• Type 2 Diabetes in 2012 £11.7bn Source: Kanavos, van den Aardweg and Schurer: Diabetes expenditure, burden of disease and management in 5 EU countries, LSE (Jan 2012)

Demand – Annual cost of Lifestyle Related Conditions:



DEFINITION of 'Efficiency' A level of performance that describes a

process that uses the lowest amount of inputs to create the greatest amount of outputs. .

TARGET £22 billion efficiency savings by 2020/21

Five Year Forward View (2014)

Efficiency – More for Less



£22bn Efficiency Savings ChallengeNHS

£22bn by 20/21

NHSProviders

£8.6bn

Derbyshire Providers

£159m

DCHS £25m

NHS£22bn

by 20/21

National Efficiencies

£6.7bn

43 Systems identified

across the UK £15.3bn

Derbyshire Sustainability & Transformation

Plan £244m

Quality Care EfficiencyPrevention



The Sino Century / Pan-Western financial slow-down

UK dependency ratio 43.6% by 2040 [Germany 62.4%]

Net £8bn + £100bn NHS funding by 2022 …

7 day service … knock on impact of £12bn+ welfare ‘savings’

2015/16: Provider sector ended with a deficit of £2.45bn (2014/15: £0.8bn)

Funding



“The requirement of me will be for the provider system to get in balance next year, and I think it’s possible.”

Jim Mackey, Chief Executive NHS Improvement(December 2015)

Funding - 2016/17 ‘Fire break year’

“The plans agreed by trusts for 2016-17 would not show the sector overall returning to breakeven,

and would be very stretching” Jim Mackey, Chief Executive NHS Improvement

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Funding – Unprecedented Provider Sector Financial Deficit

Source: Chris Hopson, Chief Executive NHS Providers (April 2016)



Funding - NHS Budget Annual Spending Increases 2016-21

Historical NHS 3.6% average annual funding increase and 3.5% to 4% average

annual cost and demand increase

Source: Chris Hopson, Chief Executive NHS Providers (April 2016)



"Dark and difficult times lie ahead. Soon we must all face the choice between what is right

and what is easy.“

– Dumbledore, Harry Potter and the Goblet of Fire



Why do we have a Quality Business Committee?

The DCHS Way:

“ To ensure an effective, efficient and economical organisation that promotes productive working and

offers good value to it’s community and commissioners”



Committee Overview

A Committee that reports to a Unitary Board

Membership consists of:Non Executive Directors

Trust officersInvited Attendees driven by the Agenda

Governance visits – Chair, Chief Executive, Governors Meets on a bi-monthly basis



The Quality Business Committee Approach

“ I want to think like a patient and act like a tax payer”

Simon Stevens, Chief Executive NHS England (2014)

COST

QUALITY



A clear governance narrative • We listen, we learn & live the ‘DCHS way’ values.• We represent our local communities’ & patients’ interests & the NHS itself• We seek assurance • We reach judgements, make decisions and hold the organisation to account



STRA

TEGY

• Sustainability & transformation Plans

• Financial Plan• Information

Management & Technology

• Transformation• Capital &

Estates• Security &

Emergency Preparedness

• Security

PERF

ORM

ANCE

• Group Reports• Performance

Report (KPI’s)• Financial

Performance• Cost

Improvement• Treasury

Management• Policy approval• Benefits

realisation BUSI

NES

S DE

VELO

PMEN

T • Tender Oversight Group

• Business Development Opportunities

• Business case review & implementation plans

• Agile Working

Our Agenda

Governance & Risk Management



Sustainable Quality £’000 £’000Improvement 6,146 6,091

Retained Surplus 2,654 2,600

Cash 16,974 13,189

Capital Expenditure 4,380 5,521

2015/16 Score Card ACTUAL TARGET 2015/16 2014/15

Actual Target Variance £’000 £’000 £’000Recurring 5,695 5,968 (273)Non- recurring 123 451 328



Key activities in 2016/17

Sustainability & Transformation Plan

Estate & Infrastructure

ReviewVanguard – Erewash

MCPPrimary Care

Sustainable Quality Improvement Plans

2016/17 £5mIT Connectivity

KPI’s & Reporting

Heanor Hospital Health Development

£3.4mWalton Hospital

Agile Working and technical innovation

Tender Review

SPSP

SPSP

SPSP SPSPBig 3

Big 3 Big 3



Areas of Focus – From Good to Great

Transformation:- transition plans

- Benefits measurable /reporting

Innovation:- to find new and

innovative approaches to our challenges

Information Management

- Information v’s data- Benefits realisation

- Development of a cost improvement pipeline

Risk Management

Improve Investment & capital expenditure

appraisal Implementation Plans (Project Management)

Procurement & Sustainability

Capitalise on tenders



QUESTIONS

“LOGIC WILL GET YOU FROM A TO Z; IMAGINATION WILL GET YOU EVERYWHERE.”

― ALBERT EINSTEIN



Summary Report from Nominations and Remuneration Committee

Report To: Council of Governors

Date: 12 July 2016

Name of Reporting Committee / Group: Nominations & Remuneration Committee

Date of Meeting: 28 June 2016

Presenter: Prem Singh, Chairman

Author: David Boddy, Corporate Governance Manager

Key Issues discussed at meeting:Include:

Brief summary of issue Decision made/action to be taken Agenda number and title of paper Risks identified

Board Assurance Framework Reference and Level of Assurance Agreed

17/16 Appraisal, Key Success and Objectives 2016/17 for the Chair - the Committee disussed the formal objective setting and performance appraisal process undertaken for the Chair.

The appraisal process took into account feedback from Non-Executive Directors, Executive Directors and governors.

It was acknowledged that the Chair had made an important contribution to a very successful year for DCHS. Feedback was overwhelmingly positive. All the Chair’s objectives had been achieved.

The Committee took Significant Assurance that the Chair had fulfilled his role and had been subject to a formal objective setting and performance appraisal process for 2015-16.

4.1 Significant Assurance

20/16 Non-Executive Director Appraisals 2015/16 - the Committee discussed the formal objective setting and performance appraisal process for all the Non-Executive Directors (NEDs), including the highlighted performance of each NED.

The Committee acknowledged the good quality of the work of the NEDs. The NEDs had contributed particularly well with respect to the Board and to the Council of Governors.

The Committee took Significant Assurance that all Non-Executive Directors had fulfilled their roles and had been subject to a formal objective setting and performance appraisal process for 2015-16.

4.1 Significant Assurance

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21/16 Appointment of Additional Non-Executive Director - the Committee discussed the recent process undertaken to secure additional Non-Executive Director (NED) support for DCHS.

The DCHS recruitment process had been very successful. The advertisement attracted an overwhelming response in terms of quantity and quality, with 55 applications received. 21 of the applicants were long listed for telephone interview and a short list of six candidates attended a selection process on 9th June.

The selection process involved a formal interview and a discussion panel comprising Executives, NEDs and governors. The shortlist was then reduced to three particularly strong candidates.

The Nominations Committee agreed to recommend to the Council of Governors the interview panel’s recommendation that Kaye Burnett is appointed to the position. The discussion panel had been in agreement with the recommendation.

The Committee acknowledged that Kaye has not yet stepped down from her role in Leicestershire as an Independent Chair and may hold the position for a limited period of time. However, her position in Leicestershire is not a decision making role and is therefore not considered to present a conflict of interest.

The Committee discussed the attributes of the two remaining strong candidates. One candidate in particular, James Riley, has a strong knowledge of our sector, especially with respect to transformation work. James is a retired Community Trust Chief Executive.

The Committee agreed to recommend to the Council of Governors that DCHS appoint James as an Associate NED for a fixed period of a year, on the same (remuneration) terms as the other NEDs, in order that DCHS can secure his skill set, particularly with respect to our important work around system changes.

The Committee also agreed that the appointment of James would help support the continuity of the benchmark of NEDs, particularly as Barbara-Anne Walker will come to the end of her term as a NED in March 2017.

The Committee acknowledged that the recruitment process took into consideration the skills, background, experience and diversity of the candidates.

Paper for Decision

Policies ApprovedNone.Issues to be escalated to Board or a CommitteeNone.

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COUNCIL OF GOVERNORS Title of Paper: Chief Executive’s Report


Presenter: Chris Sands, Deputy Chief Executive and Director of Finance, Information and Strategy

Author: Tracy Allen, Chief Executive

Date of Meeting: 12 July 2016 Agenda Item No: 86/16

No of pages inc. this one:

Appendices: Big 9 Performance Report May 2016

Purpose of Paper The Chief Executive's report provides the Council of Governors with information about key national and local strategic issues affecting Derbyshire Community Health Services NHS Foundation Trust. Summary The paper includes updates on:

• Update on the development of the Sustainability and Transformation Plan • 21st Century Better Care Closer to Home consultation launch • NHS Improvement 2015/16 Quarter 4 Trust Monitoring • Progress with Care Quality Commission Inspection • Quality Always Accreditation • Transition to NHS Mail 2

Recommendations The Council is recommended to note the paper.

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6


Chief Executive Report July 2016

1. Purpose of report This report provides the Council with information about policy, legislative and developmental issues and changes which affect the organisation and local initiatives across the organisation in the past month. 2. System Transformation Updates 2.1 Developing the Derbyshire/ Derby City Sustainability and Transformation Plan (STP) The draft Derbyshire/ Derby City Sustainability and Transformation Plan will be submitted on the 30th June to NHS England in line with national planning requirements. This is a ‘checkpoint’ stage in the development of the plan and system leaders will be working over the summer to continue to refine and work up the plan alongside an NHSE led review process prior to sign off in the autumn. The plan describes how we will move to a place based care system which is effectively joined up with specialist services and managed as a whole system. There are 5 key levers which will be used to address the addressing the health and wellbeing, care quality and finance and efficiency gaps we have quantified between now and 2020 and drive transformation as illustrated below.



To translate the key levers into specific actions the system has identified 5 priority areas for transformation:

• Developing place based care • Prevention • Our urgent care network • Delivering efficiency and • Managing more effectively as a joined up system.

The plan is very consistent with DCHS's strategy and we will be working with the Governors strategy group to develop our approach to implementation over the coming months. 2.2 21st Century Joined Up Care Programme – Better Care Closer to Home Consultation North Derbyshire and Hardwick Clinical Commissioning Groups will be launching their Better Care Closer to Home public consultation at 12pm on Wednesday 29 June. This is the first formal consultation of the wider 21st Century Joined Up Care Programme, and will look at how the health and social care organisations in North Derbyshire provide inpatient and community services for older people with physical issues and for people with dementia. It builds on a great deal of detailed clinical and community engagement work that the Trust has been involved in as a partner in the programme over the past two years. The consultation will close at 12pm on Wednesday 5 October. The consultation proposals have significant implications for the way in which Derbyshire Community Health Services NHS Foundation Trust may be providing services in the future. It is vital that we play an active role in the consultation supporting colleagues across the Trust, along with the public in the communities we serve, to contribute fully to the process. A series of initial staff briefings have been organised for Tuesday 28th and Wednesday 29th June in order to begin this work and the Board will be focusing its ‘local service spotlight’ session before the Public Board meeting on the consultation proposals. 3. Trust highlights and key operational issues 3.1 NHS Improvement 2015/16 Quarter 4 Trust Monitoring The Trust has received formal notification from NHS Improvement of our organisational ratings for 2015/16 quarter 4 as follows:

• Financial sustainability rating – 4 • Governance rating – Green.



These ratings will be published on NHS Improvement’s website later this month. 3.2 Care Quality Commission (CQC) Inspection The Trust is awaiting draft inspection reports following the comprehensive inspection at the beginning of May. Since the main inspection week the CQC have revisited the Trust to inspect our dental services (they were unable to include them in the main inspection week due to a shortage of dental inspectors). Verbal feedback was very positive with the CQC commenting that they were impressed by how efficiently the teams work with each other and the compassion for patients. We have also been working intensively to provide additional assurance to the CQC about the robustness and safety of the results management systems within the Integrated Sexual Health service following a request for follow up information relating to concerns that the Commission identified in this area on the inspection. The CQC have confirmed that they are assured by the additional information provided. It is likely that the draft reports won’t be received within the organisation until the beginning of August, with the Quality Summit still scheduled for the 19th August. Action planning work is continuing across the Trust addressing issues highlighted in the verbal feedback and subsequent high level summary letter in advance of receiving the reports. 3.3. Quality Always Gold Accreditation The Chief Nurse and I, along with a number of governors, will be holding the first Quality Always Gold Accreditation Panel on the 28th June to consider the award of gold accreditation to Linacre Ward and the Amberley Core Unit. Both teams have achieved successive ‘green’ quality always ratings and have submitted comprehensive portfolios of evidence about how the Quality Always process has supported sustainable quality improvement across the service and made a real difference to their patients/clients. Reaching this point has taken a huge amount of effort by the teams involved and I would like to thank them for the energy and commitment that they have demonstrated up to this point. We will be able to update the Council on the results of the panel at the meeting. 3.4 NHS Mail 2 Governors will be aware that one of the Big 9 organisational improvement priorities this year is the development of better IT connectivity to support colleagues. This month we have taken an important step forward with our infrastructure to help achieve this priority.



DCHS is in the final throes of transitioning from NHS Mail 1 to NHS Mail 2. On the surface this apparently minor change would be unremarkable, but in reality the change will mean a significantly increased e mail capacity for every user in DCHS and allows future developments like Skype calling and Instant Messaging. The transition has not been without some difficulties but the IMT and Communications teams have been working hard to provide hints and tips on how to keep working and we will be monitoring the impact through our adapted Pulse Check surveys over the coming months. 4. Organisational Performance April 2016 The Trust’s performance against our 2016/17 ‘Big 9’ for May is attached for information. Appendix A: Headline organisational performance – ‘the Big 9’



Objective Priorities 16/17 TargetPerformance to the end of May

Forecast

Quality Service

To deliver high quality and sustainable services that

echo the values and aspirations of the

community we serve

Patient Safety - To reduce the overall number of patients who incur

pressure damage

20% Reduction in Baseline 243 634

Clinical Effectiveness - Assess frailty in our over 75 years

population by the introduction of a frailty screening tool – Prisma 7

95%0% 95%

Patient Experience - Improvement in time to respond to complaints

80% within 40 days57% 80%

Quality People

To build a high performance work

environment that engages, involves and supports staff to reach their full potential

Ensuring all staff are complaint with essential learning

96%95.4% 95%

Improving staff wellbeing by reducing work related stress and anxiety

20% reduction in days lost to stress and anxiety based on 15/16 averages

to below (1200 days)

1.840 1,200

Improved position of staff reporting incidents of violence and

aggression they encounter at work

Month on month increase in reporting

compared to 15/16 data64% Increase

Quality Business

To ensure an effective, efficient and economical

organisation which promotes productive

working and which offers good value to its community and commissioners

Demonstration of efficiency across all DCHS services through the delivery of the Sustainable Quality Improvement

Plan (SQIP)

£5m Sustainable Quality Improvement Plan (£000) 550.5 5,000

Measuring the progress towards becoming a more agile organisation

by reducing the spend on non-Clinical estate

Less than 5,399m24,649m2 <5,399m2

Responding to the main issue raised through staff feedback by monitoring

the perceived improvement in IT connectivity for staff

Less than 35% of staff Often or Always

Experiencing Connectivity Problems

33% <35%

The Big 9The Big 9 priority indicators: These are the key areas, which have been endorsed by the Board, where staff can make the greatest impact in delivering the Trust’s key operational and strategic objectives.

(RED)

GREEN

GREEN

GREEN

GREEN

GREEN

GREEN

GREEN

GREEN

GREEN

GREEN

GREEN

GREEN

GREEN

AMBER

AMBER

AMBER

RED

Complaints Response

Pressure Care

Staff Health and Wellbeing


Suzanne_Pancisi

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Appendix A


COUNCIL OF GOVERNORS

Title of Paper: Trust Secretary’s Report


Presenter: Kirsteen Farrar, Trust Secretary

Author: Kirsteen Farrar, Trust Secretary David Boddy, Corporate Governance Manager


No of pagesincluding this one: 3

Appendices:

Purpose of PaperThe purpose of this paper is to update Governors regarding relevant issues.

SummaryCouncil of Governors Self-AssessmentThe Council of Governors were advised at the May meeting that, as part of good governance practice, Governors were going to be asked to give their views about the effectiveness of the Council’s own performance and to identify areas for improvement and any training needs.

The Council of Governors Self-Assessment exercise has now been completed. We are grateful to Governors for their participation in the survey. The response rate was high, with 23 out of 27 governors providing responses to the questionnaire.

A summary of the responses and comments will be reviewed and discussed by the Governance Group. The Governance Group were involved in finalising the self-assessment questionnaire. Governors will recall that the questions were shaped around assessment criteria such as holding to account, influencing strategy, membership engagement, Non-Executive Director appointments and appraisals.

A report on the findings from the Council of Governors Self-Assessment will then be presented to the Council of Governors with recommendations for the next steps to be undertaken.

Council of Governors elections Our Communications Department have prepared a schedule of activities to promote awareness of the forthcoming governor elections. The range of communications to our Members and members of the public will include: Community and Our Voice magazine election specials; meet and greet sessions in our hospitals and health centres; notices, posters and leaflets to community forums, groups and GP surgeries across the county. The election will be promoted through Twitter. Governors are encouraged to visit Twitter, using the hashtag #DCHSGovElections, and consider re-tweeting our tweets which are scheduled for the duration

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of the election.

Our election agents Electoral Reform Services are providing a full election website that will give helpful information throughout the election. The website, which will include video messages that have been kindly provided by governors, is www.ersvotes.com/DCHSGovElections.

Governors will recall that the key dates during the election are:Notice of Election /Nominations Open Monday, 18 July 2016Nominations deadline Monday, 15 August 2016Final date for candidate withdrawal Thursday, 18 August 2016Notice of Poll published Tuesday, 6 September 2016Voting packs despatched Wednesday, 7 September 2016Close of election Friday, 30 September 2016Declaration of results Monday, 3 October 2016

Annual Governors/Members MeetingIn line with our constitution, DCHS plan to hold an annual meeting of the Council of Governors (AGM) and an Annual Members’ Meeting (AMM). Plans are underway to hold the 2015/16 meetings as one joint Annual Governors Meeting/Annual Members Meeting. The Governance Group discussed and agreed the arrangements for the joint meeting.

Governors will recall that in 2015: We held the AGM as part of the regular Council of Governors meeting on the 9th

September. Overall governor feedback was that this created an agenda that was too long for the governors

The AMM was held on the same day as the Board meeting on 24th September. This did not work as well as hoped because holding the two meetings on the same day was onerous.

Taking into account the lessons learnt from 2015, the preferred option is to hold the AGM and the AMM on the same day (but this will not be the same day as the Board meeting). Both meetings consider the Trust’s Annual Accounts, any report of the auditor on the annual accounts and the Annual Report including the Quality Report and can therefore be combined in order to achieve this. It will encourage a good attendance by governors and it will provide an opportunity for DCHS Members and members of the public to talk to their governors.

The Governance Group discussed the plans to hold the AGM/AMM on one of the dates scheduled for a CoG meeting and it has been decided that the Council of Governors meeting on 7th September is the preferred choice. Careful thought will be given to planning the agenda so that it is not too long but covers essential business. The Governance Group has recommended that the broad outline for the combined meeting is:12.30pm – 1.30pm Council of Governors meeting (featuring a short agenda of essential business)1.30pm – 1.45pm Tea break1.45 - 3.45pm Annual Governors/Members Meeting

It may be possible to consider adding to the end of the meeting an event featuring a particular service or initiative such as the Memory Market Place in order to provide information and


http://www.ersvotes.com/DCHSGovElections


opportunities for patients and their carers to meet and talk with staff and services.

The Governance Group and the Council of Governors will be updated regarding the final arrangements for the meeting.

RecommendationsThe Council is asked to consider and discuss the information provided in the paper.



Key Dates and Future Events

2016Date Event Time Venue

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

Thursday, 28th July 2016

Board Meeting

1.30pm

Enterprise Centre, University of DerbyBridge StDerby DE1

Wednesday 7th September 2016

Council of Governors Meeting

2.00pm

Postmill CentreMarket CloseSouth NormantonAlfretonDE55 2EJ

Tel: 01773 860296Thursday 29th September

Board Meeting 1.30pm Peel CentreHigh StDronfield S18 1PX

Thursday 27th October

Board Meeting 1.30pm Training RoomSt OswaldsClifton RoadAshbourneDerbyshire DE6 1DR

Thursday 10th November 2016

Council of Governors Meeting

2.00pm Postmill CentreMarket CloseSouth NormantonAlfretonDE55 2EJTel: 01773 860296

Thursday 24th November

Board Meeting 1.30pm Arena Church 1 Rutland StIlkeston DE7 8DG

Thursday 15th December

Board Meeting 1.30pm Belper Town FCChristchurch MeadowBridge StreetBelper Derbyshire DE56 1JJ

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