Annual report and accounts 2015/16

Transcription

1 NHS Foundation Trust Derbyshire Community Health Services NHS Foundation Trust

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3 Derbyshire Community Health Services NHS Foundation Trust Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act

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5 Contents Page Foreword 6 Performance report 7 Performance overview from the chief executive 7 Performance analysis, including: Strategic priorities and opportunities Sustainability Financial performance analysis Our performance against standards and targets Accountability report 36 Directors report 36 Remuneration report 40 Staff report 55 Disclosures set out in the NHS foundation trust code of governance 76 Regulatory ratings 99 Statement of accounting officer s responsibilities 100 Annual governance statement 102 Sustainability report 114 Equality, diversity, inclusion and human rights 120 Quality report 126 Appendices 197 Appendix 1 Workforce Appendix 2 Trust risk ratings Appendix 3 Information governance toolkit Appendix 4 Progression of Quality Always, the DCHS Way Appendix 5 Third party statements CCGs/Healthwatch Appendix 6 Statement of directors responsibilities Appendix 7 Independent auditors Appendix 8 The core quality account indicators Appendix 9 Auditors' report on financial statements Annual accounts 2015/

6 Foreword is one of the largest providers of specialist community health services in the country, with nearly 1.5 million patient contacts each year. We care for patients in hospitals, health centres, clinics, GP practices, schools, care homes and, increasingly, in people s own homes, as we develop further new models of care designed to help transform the way care is provided to people at home and in their own communities. Our ethos is to deliver care and run our organisation in The DCHS Way, which sets out principles and ways of working to guide and safeguard the quality of our care. The following pages provide a detailed account of our work during 2015/16 which we hope will provide a good insight and overview of our performance throughout the year. Tracy Allen Chief Executive Are we accessible to you? This publication is available on request in other formats (for example, large print, easy read, Braille or audio version) and languages. For free translation and/or other formats please call , or us at: dchstcommunications@nhs.net To see the full list of the services we provide, please visit or call us on for support. 6

7 Performance report Overview of performance Our purpose and activities is one of the largest providers of specialist community health services in the country, with nearly 1.5 million patient contacts each year. We care for patients across a wide range of services, delivered from 133 sites including 11 community hospitals, 30 health centres and a learning disability service in Derbyshire, as well as specialist dental services in parts of Leicestershire. We care for patients in hospitals, health centres, clinics, GP practices, schools, care homes and, increasingly, in people s own homes, as we develop further new models of care designed to help transform the way care is provided to people at home and in their own communities. We employ more than 4,500 staff, making us one of the largest providers of specialist community health services in the country, serving a widespread local patient population in both urban and rural parts of Derbyshire. Our annual budget during 2015/16 was 176m, with the main purchasers of our services being the four clinical commissioning groups acting on behalf of patients in Derbyshire, which in 2015/16 comprised: NHS Hardwick CCG represents 16 GP practices, acting on behalf of over 102,000 patients living in North Eastern Derbyshire NHS North Derbyshire CCG represents 36 GP practices, acting on behalf of just over 290,000 patients covering North Derbyshire. NHS Southern Derbyshire CCG represents 56 GP practices and is responsible for the healthcare of 546,911 people. NHS Erewash CCG represents 12 GP practices, acting on behalf of nearly 97,000 patients in Ilkeston, Long Eaton and surrounding villages. We have operated as a standalone NHS organisation since April 2011 and became a fullyfledged foundation trust on 1 November Our 30strong Council of Governors is responsible for holding the Board of Directors to account, sharing opinions and providing appropriate challenge on any major decisions. You can read more about them on page 76. 7

8 Our area Derbyshire covers an area of approximately 1,016 square miles. The population of Derbyshire is predominantly white with higher than average employment, and has a relatively high proportion of rural residents. The characteristics of Derbyshire s population reflect both the largely rural nature of the county and its industrial heritage. The north east of the county is closely associated with the former mining industry and its legacy of relatively deprived communities with poor health. The percentage of people aged over 65 is significantly higher than the average for the whole country. This is currently the case for all local authority areas, except South Derbyshire and will continue to be the forecast position by The number of people aged over 65 is also growing faster in Derbyshire than in the rest of the country, and is projected to increase from 134,400 (2008) to 197,000 (2025). This is a 47% increase for Derbyshire against a projected increase for England of 37%. Our strategy Our integrated business plan (IBP) was first produced in 2009, reviewed throughout the foundation trust application process and formally updated in June Since then, the trust board has continued to review the strategy through a series of board development sessions, IBP planning meetings and governor strategy subgroups, as well as through regular discussion and review at board meetings. As a result the board has confirmed that: The trust strategy (set out within the IBP) remains relevant and that the strategic vision is clear. Whilst the IBP has developed over time it remains coherent and consistent and continues to be effectively delivered. Despite the significant and ongoing changes to the external environment the strategy remains relevant and consistent with our key stakeholders and the work to integrate services across the county. Going concern s accounts have been prepared on the basis that we run the Trust as a going concern. This means that our assets and liabilities reflect the ongoing nature of our activities. Because risks and uncertainties change over time as an organisation develops and as its operating environment changes, therefore, each year in supporting evidence of our accounts submissions, the directors consider a detailed assessment of the evidence supporting our assertion that we are a going concern. This evidence provides assurance that it is correct to compile our accounts on such a basis and is presented to our audit and assurance committee. 8

9 Our directors have considered and declared that: After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Our performance 2015/16 marked our first full year as a foundation trust and we performed well operationally and financially amid many challenges which are facing the wider NHS. We ended the year with a surplus of 2.65m while also achieving ratings consistently above average in measures to test the quality of our care for patients and our workplace for staff. Having achieved a clean bill of health from the Care Quality Commission to mark the start of our FT status in November 2014 we have maintained that position throughout 2015/16 and in May 2016 welcomed back the CQC team for a routine, comprehensive reinspection visit. Our main objective has remained to provide the highest possible standard of care to patients. In order to achieve this we have focused our strategies on good governance, driving forward the quality of all we do and sound financial control of our services as a vital basis for developing services into the future. We remain focused on ensuring our daytoday performance is as good as possible, by supporting our staff to do their jobs well, while our strategic direction is towards greater integration with the wider local health and social care network. This year has seen unprecedented challenge, working with partners to develop joinedup plans for transforming local services which move more care into the community and support a sustainable health service for the future. Significant increases in attendance at A&E departments and emergency admissions nationally continue to place local health and care systems under extreme pressure. Our staff have worked hard to support flow in and out of Chesterfield Royal Hospital, Derby Teaching Hospital and surrounding acute trusts. We are working together as a local health economy to overcome the pressures on the system, due to higher demand and an ageing population requiring more frequent and greater levels of support. We are aware of the risks this places on us all, as we become more interdependent, and the provision of care is increasingly carried beyond organisational boundaries to a much more integrated model. 9

10 Our teams have worked incredibly flexibly and responsively, along with local authority colleagues, to ensure that community care capacity is maximised. However unprecedented levels of demand have continued to place the whole system under real strain. Beyond the immediate priorities of managing demand during 2015/16 we have worked closely with our health and social care colleagues to focus on developing systemwide, long term and sustainable plans for the future. Together we are working on significant service transformation in both the north and south of Derbyshire, known as 21st Century (21C) Joined Up Care and JoinedUpCare in the south of Derbyshire respectively, which are now in their second year of fruition. We hosted a series of Clinical Vision events in December and January to enable our staff to feed into this transformation process, helping to formulate a strong vision and strategy about community services that we can feed into these wider plans. It ties in with the NHS Five Year Forward View, published by NHS England in October 2014, putting greater emphasis on community providers like us and getting people out of traditional hospital settings. It is recognised that frail patients particularly are at risk of deconditioning in hospital, with loss of mobility and independence while they are away from their usual home surroundings. Frailty A major piece of work has been underway during 2015/16 with our partners in north Derbyshire to improve the diagnosis and treatment of the symptoms of frailty. Frailty is a frequent condition which increases with age. It affects between 2550% of people over 80 years. About 10% of people over 60 will be affected by frailty. Older people living with frailty are the highest users of services across health and social care and have the highest levels of unplanned admissions to hospital, so we risk even greater pressures on our services by not addressing it. We made significant progress during 2015/16 in developing a truly innovative whole system response to help people to age well, whilst providing high quality collaborative care and integrated support for those identified as having frailty in both primary and secondary care, all the way through the frailty spectrum to the end of life. Working with Chesterfield Royal Hospital NHS Foundation Trust, Hardwick and North Derbyshire Clinical Commissioning Groups, Derbyshire Healthcare NHS Foundation Trust, social care and the voluntary sector including the Alzheimer s Society and Age UK, the project has achieved two key deliverables this year: 10

11 A Discharge to Assess and Manage process to ensure the best possible discharge from a bed back into the community The development of a delirium care pathway. This is a significant example of how our collaborative approach in north Derbyshire is already working towards a better integrated health and social care community. Joined up care Our 21st Century (21C) Joined Up Care Programme in north Derbyshire continues to be centred on developing community hubs. A very successful assurance panel was held with NHS England (NHSE) in March 2016 as a gateway to our 'Better care closer to home' consultation, which, at the time of writing, we anticipate will go out to public consultation in June Sustainability and Transformation Plan With our partners we have also worked together on the development of the Derbyshire Five Year Plan, reviewing our service data, health profiles and finances in readiness to submit a Derbyshire Sustainability and Transformation Plan to NHS England at the end of June Work is now underway to develop the plans which we believe will meet the identified priorities before sharing them and seeking the public s views on what these plans look like. This work comes in response to NHS Shared Planning Guidance which asked every health and care system to come together to create their own ambitious local blueprint for accelerating implementation of the Five Year Forward View. Sustainability and Transformation Plans (STP) will be placebased, multiyear plans built around the needs of local populations. They will help ensure that the investment secured in the Spending Review is used to drive a genuine and sustainable transformation in patient experience and health outcomes over the longerterm. The Sustainability and Transformation Plan aims to address: The health and wellbeing gap how can we prevent unnecessary illhealth and early death The care quality gap how can we ensure we meet care targets and improve quality The finance gap how can we make sure that we can deliver improved services within the available money. STPs are not an end in themselves, but a means to build and strengthen local relationships, enabling a shared understanding of where we are now, our ambition for 2020 and the concrete steps needed to get us there. This will require a different type of planning process one that releases energy and ambition and that focuses 11

12 on the right conversations and decisions. It will require the NHS, at both the local and national level, to work in partnership across organisational boundaries and sectors. Work on the STP runs in parallel with the 2016/17 operational plans. The DCHS Way We have continued to operate our services in The DCHS Way. This is a fundamental pledge to our staff and patients which promises in simple terms how we will govern and manage our organisation. It has three elements; quality service, quality people and quality business; each reflecting our major organisational objectives and each with its own trust board committee to provide the scrutiny and assurance that our performance in each of the three areas is on track, and to require action if necessary. Clinical and operational performance We routinely monitor and review our performance across a total of 190 performance indicators. These include externally agreed targets and internal performance indicators which are monitored through a dynamic system known as the Big 9, which ensures we keep focus on the key priorities for action on the Big 9 dashboard each month. During 2015/16 we achieved 100 per cent of our CQUIN (Commissioning for Quality and Innovation) targets which are set by our commissioners to support ongoing innovation and improvement in care across our clinical services. We also met all our Monitor risk assurance framework targets for 2015/16. More details about our CQUIN and Monitor performance targets can be found on page 30 under the Performance Analysis heading. Within the internal Big 9 performance measurement system, it is easy to see any areas which are red rated and which might pose a risk to the quality of our care. More details about the Big 9 can be found on page 33. Risk management All risks have continued to be reviewed by a dedicated team and this has resulted in the closure of risks, down from 142 in January 2015 to 86 in January Pressure relief care remains our single most significant clinical risk (as outlined in the table opposite). We have taken steps to ensure that staff working at weekends have easier access to pressure relieving equipment and the reduction in patients experiencing pressurerelated damage is now one of our Big 9 priorities for the 2016/17 reporting year. More details about this can be found in the quality report section of this annual report. 12

13 Top 10 Patient Incidents 01/04/15 to 31/03/ Interdependence By far the most important part of our foundation trust authorisation has been the stability and control it gives us to influence and shape local health services with local people, as a key player in the local health network. Our directional shift also falls into line with national policy changes including the Carter Report, published in June 2015 and updated in February 2016, to boost productivity in acute trusts; and the Dalton Review of December 2014, calling on NHS trusts to look at how new organisational forms may be most suited to support the delivery of safe, reliable, high quality and economically viable services for local populations. By focusing on our services as interdependent we are in the process of evolving stronger care models which meet the challenges of caring for an ageing population at a time of unprecedented financial challenge within the NHS. This is already happening on the ground in many parts of our service. Since the announcement that we, and our partners in Erewash, had won a share of NHS England s 200 million Vanguard fund in March 2015 we have been working on transformational ways of working, as described in the NHS Five Year Forward View under the banner of Wellbeing Erewash. This work is described in more detail on page 19 and in the quality report section of this annual report. 13

14 Primary care In 2015 we were asked to manage primary care facilities at Creswell and Langwith Medical Centres, initially in a caretaker capacity. During February 2016, following a successful tendering process we were awarded a contract to manage these services going forward. Primary care is a new, potentially challenging environment for us as a community provider. We have taken the opportunity to review the staffing skill mix in order to create a multispecialty primary care team to support the General Practitioners. We anticipate the changes will dovetail well with our integrated communitybased care teams, with the potential to bring many further benefits to patients who have easier access to a broader range of services. In addition to Creswell and Langwith Medical Centres we are working with Ripley Medical Centre and Castle Street Practice in Bolsover and exploring options for future models of working. Together we are breaking down traditional organisational and professional barriers in order to provide care which is more integrated and flexible in meeting the needs of our patients. Our guiding principles are to deliver better outcomes, safeguard quality and improve value and patient/staff experience. New services The year has seen a number of new services offered, in addition to the general practice developments. We won two competitive tenders with Derbyshire County Council commissioners: to provide a new integrated sexual health service, which was launched in April 2015, and a new onestop service called Live Life Better Derbyshire for people who are struggling to beat smoking, lose weight, eat more healthily or get more active. The new sexual health service, under the banner your sexual health matters, is a partnership with Chesterfield Royal and Derby Teaching Hospitals. It has been a credit to the teams who have led its development. Both new services sat well with our strategic ambition of becoming a public health organisation, focused on prevention, which is discussed in more detail further on. We were involved in a number of service realignments as part of restructuring care locally. We took on the employment of 437 new colleagues from our neighbouring acute trusts (at Derby Teaching Hospitals, Chesterfield Royal and Stepping Hill Hospitals NHS Foundation Trusts) in late 2015, introducing them to the DCHS Way. This realignment enabled us to extend our role in adult communitybased care in the city of Derby and in children s services across Derbyshire. Part of the closer working with our colleagues in our local acute hospitals has been to develop alternatives to admission whenever appropriate for patients in urgent need of care. This ongoing transformation of how we model services together across 14

15 organisational boundaries looks to Sir Bruce Keogh s review of urgent and emergency care, now focused on how wholesystem change can be delivered. Capital developments During the year we also saw planned capital developments to modernise our facilities getting off the ground. Plans for a brand new healthcare facility at Heanor were approved and work is on course for the new facilities to open during At Walton Hospital, Chesterfield, a phased redevelopment of the whole site has been underway during 2015/16 and we opened the new Peter McCarthy Suite in December Peter was a community diabetes specialist nurse with us who tragically died from leukaemia in March His friends and colleagues wanted to create a lasting memorial to him and it was agreed to name the new purposedesigned outpatient and therapy suite at Walton Hospital in his memory. Measuring ourselves against national standards A number of our services were recognised in national awards and performance tables during the year. In December 2015 our musculoskeletal occupational health team were honoured at the Chartered Society of Physiotherapy annual awards for excellence in "promoting activity and healthy lifestyles for NHS staff. And in the same month the Trust Board team was named as the East Midlands NHS Board of the Year by the East Midlands Leadership Academy. In August 2015 the national PLACE assessments revealed that our hospitals had achieved among the best ratings for providing a good care environment for patients. We exceeded the national average across all five inspection areas, looking at the standard of our cleanliness, hospital food, privacy and dignity, building upkeep and the suitability of the environment for patients with dementia. The table below shows how we performed against the national average in the PLACE assessments: National average Derbyshire Community Health Services NHS Foundation Trust Cleanliness Food Privacy and dignity 97.57% 88.49% 86.03% 90.11% 74.51% 99.67% 94.13% 87.43% 94.86% 79.73% Building Dementiacondition friendly and maintenance 15

16 In July 2015 we were named as a top 10 NHS employer in the UK, in a list by the Health Service Journal and NHS Employers. This was based on results from the NHS Staff Survey 2015, as voted by our own staff. We were also the runnerup in a category to find the best NHS community trust employer. The results were particularly significant for reflecting the views of our staff, our greatest asset. High levels of staff morale and engagement are inextricably linked with quality for patients. Even where our services have been subject to tender and redesign during the year staff have maintained high standards of professionalism and a focus on patients. In April 2015 we received results above the national average in the Friends and Family Test, which had been rolled out to community and mental health services for the first time in January It gave us further valuable feedback about the attitude of our patients to the care received. Our scores were based on returns from 2,049 patients the highest number of feedback returns from patients in the area and sixth highest out of 116 trusts nationally for the number of responses received. We continue to monitor satisfaction scores closely to ensure we maintain these excellent standards of care. It is a credit to our staff that the feedback is so overwhelmingly positive and that they are described as friendly, helpful and caring. On the small number of occasions where we get things wrong we have demonstrated our ability to review our practice, with the patients and families involved, and really reflect and learn how we can improve. Quality Always During the year we launched our new Quality Always assessment accreditation system, driving quality improvements across our services. The longterm aim is for the Quality Always standards to become embedded in the DNA of the organisation. By the end of March 2016 all inpatient units, all four minor injury units and nine other communitybased services had participated in an initial assessment. A bespoke quality improvement plan was put in place based on each of these initial assessments. The majority of inpatient units have also had a followup assessment and received an updated rating. All five older people s mental health inpatient wards and all four minor injury units are now rated green, with the first of these well on the way to achieving full accreditation the gold standard. Challenge and support Board members carry out insight visits around the organisation, and hear patient stories at each Board meeting. It helps to keep our finger on the pulse of what is happening on a daytoday basis, and to understand the pressures on staff and how we can overcome the barriers which might inhibit a more integrated approach. 16

17 Our Council of Governors is adding real value to our work with the challenge and support they bring. We would like to thank them and our wider membership for helping us to increase our accountability to the patients and local communities we serve and we look forward to continuing those valuable partnerships in the year ahead. We are fortunate to have a large number of volunteers working in such varied ways across our sites for the benefit of patient comfort. We are tremendously grateful for their ongoing support which enhances and enriches the care we provide in numerous ways, from fundraising to befriending, and so many other guises. Our operational plan for 2016/17 The operational plan has been developed with colleagues across the organisation, capturing the priorities and issues that are important to us all as well as how we respond to the national and local challenges of delivering the NHS mandate and closing the gaps in finance, quality and wellbeing. Under our usual three quality domains, we have identified the key objectives as being: Quality Service To deliver high quality and sustainable services that echo the values and aspirations of the communities we serve Quality People To build a high performance work environment that engages, involves and supports staff to reach their full potential Quality Business to ensure an effective, efficient and economical organisation that promotes productive working and which offers good value to its community and commissioners. The areas where we need to focus most attention in the coming year to meet our operational plan objectives are: Engagement and integration Innovation and best practice Leadership Digitalisation and agileworking Commercially sustainable and viable services. We are fully engaged in targeted action to meet the objectives we have set in each of the five specific areas listed and work is progressing well. 17

18 Conclusion During the year we have worked hard to ensure we have robust governance structures in place to support and promote the delivery of high quality care for our patients. It remains to thank the people who have helped us to achieve so much during the past year, most notably our staff for their continued hard work, loyalty and commitment. We are also grateful to our Council of Governors and our wider membership; our League of Friends colleagues for their ongoing support, and our many external stakeholders and supporters, in particular our local authorities, MPs, clinical commissioning groups and other NHS organisations in Derbyshire with whom we work closely. Tracy Allen Chief executive Tracy Allen was named as a Top 50 NHS leader in the Health Service Journal s third annual list celebrates the NHS leaders whose contributions and vision stand out in challenging times. Tracy Allen won praise from the judges for her record of delivery, in a very complex organisation which operates in different localities and environments, and for her work supporting other women. 18

19 Performance analysis Overview of our national and local context The economic climate, changes in leadership, ageing population and workforce pressures all place significant financial, clinical and operational challenges upon the NHS. Current national estimates project a 30 billion challenge for the NHS over the next five years. Within Derbyshire a combined funding shortfall of 300 million over that period has been estimated. This does not include the social care challenges. In addition to these pressures we have, in the local NHS, seen significant changes to commissioning arrangements and leadership, a growing emphasis on joint working and a more innovative approach to future delivery models. In response to these changes our Trust Board has led work to understand and evaluate how these changes impact on the organisation s future strategic direction and how it should evolve as a result. This has also involved a focus on policy changes, especially in relation to the NHS Five Year Forward View, and its implications for organisational structures, such as the development of hospital chains, alliances and multispecialty community providers. Within Derbyshire, changes have included transformational developments through the Joined Up Care and 21C programmes in south and north Derbyshire respectively and the Erewash Vanguard development, now known as Wellbeing Erewash. We have pursued a proactive approach to these developments which will shape the future strategic direction of the NHS in Derbyshire. Our Trust Board recognises that the ability to lead and influence across a health economy, drawing in partners from the voluntary and private sector, as well as trusts and local authorities, is key to success. Alongside these systemwide developments we have continued to strengthen our commercial position through success on a range of tenders within our health and wellbeing division, the transfer of Derby city community services from Derby Teaching Hospitals NHS Foundation Trust and an increasing involvement in the delivery of primary care services. Strategic priorities and opportunities Through strategic development work, the Trust Board identified the need to move from an incrementallyresponsive approach to the challenges it faces to being more 19

20 proactive and willing to consider radical approaches to future organisational structures. In so doing it has developed five key principles which will underpin the organisation s future development: A more inclusive approach to engaging our communities, building on models of integration of primary care, community services and social care to deliver better outcomes, improve health and address inequalities A focus on developing academic links to support our service delivery to be leading edge, using innovation and driving best practice A continued emphasis on engaging our people and developing leadership to promote a culture of high performance and service transformation Embracing the use of technology and digital solutions in our delivery of services, which improves care and productivity Defining our service and commercial aspirations to continue our journey on service integration and transformation. Our approach will continue to be based on our aspiration to be a good partner and to add value across the health and social care system, bringing services together and promoting integrated care based on the needs of patients. Such an approach will, by necessity, require innovation and transformation to ensure that our organisation is efficient and new models are delivered within future resource constraints. Ongoing engagement with staff, service users and other key stakeholders will support identification of future priorities and allow refresh of the strategy, and ensure it continues to fit with the wider NHS and social care organisations across Derby and Derbyshire. Through effective communication and engagement we will ensure the strategy is understood across the organisation and can be presented in the most appropriate forms to enable this. Sustainability At we have a Boardapproved sustainable development management plan (SDMP) which identifies how we will meet our corporate and social responsibilities, including our carbon reduction targets. We continue to meet or exceed our targets making excellent carbon and cost reductions and putting us on target to achieve 34% carbon reduction emissions by There is a detailed account of our environmental work at the end of the performance report on page 114. The Trust Board needs to remain vigilant to ensure our strategy remains responsive to the future national and local trends and developments. We understand the need 1 Using 2007/8 baseline 20

21 to continue to review our performance regularly, as well as to foster our role as an effective and resilient partner, who can go on adding value to the communities we serve and promote social capital, health and wellbeing across Derbyshire. We will continue to evolve and strengthen services through an evaluation and learning approach and continue to strengthen commercial capabilities and the effectiveness of our supply chains. The continued development of integrated and joinedup care models will require a flexible and innovative approach and the development of appropriate organisational structures that promote effective delivery. We will be proactive in this respect and receptive to the emerging proposals. Innovation in areas of sustainability has been recognised. Our car club scheme, in association with Cowheels, won a 2015 national sustainable travel award for reducing the impact on the environment, at the national Modeshift Annual Convention in November Electric vehicle charging points were another innovation at some of our key sites during the year. In March 2016 we won two national NHS Sustainability Awards (energy and innovation) and were highly commended in a further two categories (waste and carbon). The awards organised by the NHS Sustainable Development Unit, are designed to encourage, benchmark and reward action on creating a more sustainable NHS. In May 2016 we were named as one of the first 11 organisations in the UK, and the only NHS organisation, to be awarded Go Ultra Low status for our use of electric vehicles, in the governmentbacked Go Ultra Low campaign. More details about our progress on sustainability can be found within the chapter on accountability. Equality, diversity, inclusion and human rights In accord with the Equality Act we are committed to eliminate the unlawful discrimination of our staff and service users, to advance equality of opportunity for all and to foster good relations between all people. We are implementing NHS England s equality delivery system 2 (EDS2), which provides a framework for us to monitor and improve our equalities practice. We have an equalities strategy which identifies our current priority objectives and the actions we are taking to achieve these, which are covered in detail in a separate section on page 120. A public health organisation The Trust Board is committed to the development of a public health approach to the delivery of our services which encompasses: A duty to achieve the greatest good for the greatest number of people and to prevent missed opportunities 21

22 Improving the wider health of the population by educating staff to refer patients on to other services, as the isolated treatment of medical conditions does not impact upon their underlying causes Health improvement through a preventative approach which helps to address problems at an early stage and to prevent deterioration and crisis intervention such as hospital admissions Health protection through, for example, the effective delivery of integrated sexual health, childhood vaccination and immunisations and flu vaccination services and by maintaining the strength of our emergency preparedness responses. Development priorities From the development work to date the key priorities going forward are: Continued support for more efficient and joinedup working with other NHS and social care organisations across the county Developing primary care, as appropriate to the agreed strategy and approach Developing the clinical workforce, strengthening the medical (GP) leadership and promoting a culture which supports sevenday services Becoming a centre of teaching excellence Improving internal efficiencies and structure: o Ensuring our structures remain effective o Maximising corporate capacity and streamlining governance arrangements o Improving facilities management and rationalising our estate o Developing agile working practices and digitalisation o Working across the health community to seek appropriate back office and support function efficiencies. Risk management The Trust Board has undertaken a review of the board assurance framework, which encapsulates the key risks facing the organisation. This enables the board and its committees to ensure their focus remains on the management and mitigation of these key risks. Monitor produce a strategy toolkit which also provides a useful framework for assessing the achievability of a strategy and this will be utilised to ensure that our strategy remains relevant and deliverable. See also page 12 for details about our risk management work. Remaining resilient Board development sessions have enabled the Trust Board to identify and address the important strategic questions facing the organisation. Through this work we have taken assurance that the integrated business plan continues to remain relevant, coherent and consistent with the plans of our key stakeholders. 22

23 Through the identified key priorities and engagement sessions the Trust Board will continue to review the internal and external landscape, understand its impact upon current performance and consider a range of potential future scenarios that may be appropriately developed across the local NHS to ensure the best outcome for patients. Through this, the Trust Board will be able to set the right level of ambition for our organisation and ensure we truly understand the anticipated future needs of patients and remain sustainable and resilient in the future. Financial performance analysis In 2015/16 we delivered a net surplus of 2.65m was which was in excess of our original plan of 1.6m by 1.05m. The Trust s set of primary financial statements and supporting notes to the Accounts are provided at Appendix 9. The Trust s external auditors, PwC, have provided an opinion on the accounts. A copy of the full annual report and accounts can be obtained from the Director of Finance, Information and Strategy at Derbyshire Community Health Services NHS Foundation Trust Headquarters, Newholme Hospital, Baslow Road, Bakewell, Derbyshire DE45 1AD. Financial statements Our annual report and accounts covers the 12 month period from the 1 April 2015 to 31 March Our accounts have been prepared in accordance with directions given by the Department of Health and Monitor. They are also prepared to comply with International Financial Reporting Standards (IFRS) and are designed to present a true and fair view of our financial activities. Going Concern Our accounts have been prepared on the basis that the Trust is a going concern. This means that our assets and liabilities reflect the ongoing nature of our activities. Our directors have considered and declared that After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. 23

24 External audit During 2015/16, PwC (details provided below) were appointed as external auditors for a three year term with the option of two 1 year extensions, following a competitive tendering process. The appointment was approved by the Council of Governors on 9 September PricewaterhouseCoopers LLP (PwC) Donington Court Pegasus Business Park Herald Way Castle Donington East Midlands DE74 2UZ. The total fees for external auditors for 2015/16 accounts were 77,202 (plus VAT) in respect of the completion of the statutory audit work, made up of: KPMG (outgoing auditors) 29,920 (plus VAT) PwC (appointed auditors) 47,282 (plus VAT) NHS foundation trusts are required to seek external assurance over their annual quality report. The audit work undertaken by the PwC in relation to quality reports must be done in accordance with the detailed guidance issued by Monitor. The only nonaudit services provided were for the quality account. A charge of 7,314 (plus VAT) was made for the quality account audit. The fee for the quality account audit is immaterial in the context of the audit fee to both the Trust and PwC, as the work has no correlation or impact on the financial audit and focuses on an entirely separate scope. The audit and assurance committee provides the Board with an independent and objective view of arrangements for internal control within the Trust and to ensure the internal audit service complies with mandatory auditing standards, including the review of all fundamental financial systems. A subcommittee (governance group) of the Council of Governors has a series of update meetings scheduled with PwC. The first of such meetings took place on 2 March 2016, with further meetings scheduled for June and December. These meetings provide an opportunity for PwC to report on the cycle of audit work and the Governors to ask questions on points of clarification. Counter fraud activities We receive a dedicated local counter fraud specialist advice service from 360 Degree Assurance and have developed a comprehensive counter fraud work plan in accordance with guidance received from NHS Protect. We also have a counter fraud policy approved by the Board of Directors. 24

25 Anyone suspecting fraudulent activities within our services should report their suspicions to our local counter fraud specialist by telephoning the confidential hotline on: Charitable funds The Trust Board acts as corporate trustee for our charitable trust, which is a charity registered with the Charity Commission under number These charitable funds have resulted from fundraising activities and donations received over many years by our respective organisations, and are used to purchase equipment and other services in accordance with the purpose for which the funds were either raised or donated. The charity also has a general purpose fund which is used more widely for the benefit of patients and staff. Following HM Treasury s ruling IAS27, that consolidated and separate financial statements should apply to all NHS bodies for accounting periods from 1 April 2013, we undertook an assessment against the two key criteria of materiality and control. As a result of this assessment we concluded that it was not necessary to consolidate the accounts of the charity with those of the NHS body. The financial activities of the charity for the 2015/16 financial year will continue to be reported within a separate annual report and accounts for the funds held on trust. This report is published on the Charity Commission website. Political and charitable donations We did not make any political or charitable donations from our exchequer or charitable funds during 2015/16. Financial performance Despite the current financial difficulties facing the NHS and economy as a whole, we have ultimately performed well during 2015/16. We made a surplus of 2.65m, which was above our original plan for the year by about 1.0m. We have had a number of financial targets to meet and our performance against these is set out below: 2015/16 Performance 000 Surplus Adjustments Reclassifications of impairment as loss on disposal Deficit EBITDA 2,654 (2,817) (163) 8,515 Cash Balance at period end 16,974 Better Payment Practice Code % 94.4% 25

26 EBITDA stands for Earnings before Interest, Tax, Depreciation and Amortisation and in simple terms is a way of representing how much of our operating income exceeds our operating costs. Our EBITDA for 2015/16 was 8.515m which equates to 4.85%. This measure demonstrates sound financial health and the efficient use of our resources. Financial Sustainability Risk Rating (FSRR) The Financial Sustainability Risk Rating (FSRR) measures the Trust s financial health using four key metrics. Each metric is given equal weighting to derive an overall score. The metrics assess the Trust s liquidity or cash position, its ability to service any debt that the Trust may hold, level of margin achieved and accuracy of planning. Under this rating system in 2015/16 the Trust achieved the maximum score of 4 as detailed in the table below. Measure Indicator Weight Rating as at 31st March 2016 Value Rating Liquidity days Number of days operating expenditure covered by current working capital balances 25% Capital servicing Revenue cover available to service debt repayments 25% I&E margin (%) Year to date I&E margin as a % of total income 25% I&E margin Variance (%) Year to date variance from plan 25% Overall rating 4 Investments The Trust made no investments through joint ventures or subsidiary companies and no other financial investments were made. No financial assistance was given by the Trust. Working capital and liquidity Our cash position is maximised through efficient working practices regarding the daytoday management of our working capital. We have appropriate governance in place to monitor performance in key areas and additional metrics are embedded into the routine reporting to the Quality Business Committee which is chaired by a non executive director. 26

27 We ended 2015/16 with a healthy cash balance of approximately 17m which equates to 36 days worth of operating expenditure. We have continued to invest surplus cash in 2015/16 in the National Loans Fund to generate a modest return on investment. Events after the reporting period There are no events after the reporting period that will have a material impact upon the financial statements. Overseas operations We have no overseas operations. Capital expenditure Our capital plan for 2015/16 was 5.0m. In year the Board approved additional investments of 500k, giving a revised plan of 5.5m. However, to support the national financial position, in the fourth quarter of 2015/16, we agreed to defer a number of schemes into 2016/17. The table below summarises our capital expenditure for 2015/16. Scheme 000 Estate Ilkeston Hospital additional car park 365 Estate Ilkeston Hospital various schemes 35 Estate Walton Hospital development 1,078 Estate Heanor Hospital development 212 Estate Chapel Health Centre, asbestos removal and window replacements 130 Estate Ripley Hospital development 93 Estate Cavendish Hospital various schemes 60 IM&T Mobile working 841 IM&T PAS replacement 755 IM&T Desktop renewal 186 IM&T Other schemes 151 Equipment Ilkeston Hospital, full load generator 156 Equipment Ilkeston Hospital, various equipment 115 Equipment fire alarm Ash Green Other schemes Total capital expenditure ,380 27

28 Accounting policies We have detailed accounting policies approved by our Audit and Assurance Committee which comply with the Financial Reporting Manual (FReM) and International Financial Reporting Standards (IFRS) for NHS foundation trust accounts. Our accounting policies are detailed in the full set of financial accounts. Insurance cover We have insurance cover through the NHS Litigation Authority (NHSLA) to cover the risk of legal action against our directors and officers. We also have insurance cover for public and products liability to cover income generating activities. NHS pensions and directors remuneration The accounting policy in relation to employee pension and retirement benefits is set out in the full set of the financial accounts for 2015/16. The detail of the directors remuneration is contained within the remuneration report section of this annual report. Policy and payment of creditors The non NHS trade creditor payment policy of the NHS is to comply with both the Confederation of British Industry prompt payment code and government accounting rules. The government accounting rules state: The timing of payment should normally be stated in the contract. Where there is no contractual provision, departments should pay within 30 days of receipt of goods and services or on the presentation of a valid invoice, whichever is the later. As a result of this policy, we ensure that: A clear consistent policy of paying bills in accordance with contracts exists and that Finance and procurement divisions are aware of this policy Payment terms are agreed at the outset of a contract and are adhered to Payment terms are not altered without prior agreement of the supplier Suppliers are given clear guidance on payment terms A system exists for dealing quickly with disputes and complaints Bills are paid within 30 days unless covered by other agreed payment terms. Efficiency During 2015/16 we generated efficiency savings of 6.15m against a target of 6.09m. The savings were required to deliver a 4% national efficiency requirement for commissioners. This was a national requirement for NHS providers. 28

29 A summary of our main savings delivered during 2015/16 is shown below: Service Area m Clinical Environments 1,429 Health, Wellbeing & Inclusion 1,149 Integrated Facilities Management 901 Planned Care & Outpatients 588 Corporate & Estates 2,079 Total 6,146 Future financial performance The Board of Directors has set out a detailed financial plan for 2016/17. We intend to achieve a surplus of 3.3m in 2016/17. This will achieve the maximum continuity of service rating of a 4 against which we will be assessed as an NHS foundation trust. Our 2016/17 financial plan is predicated upon the successful delivery of a challenging efficiency requirement of 5.0m. We have taken further measures through 2015/16 to improve our financial governance processes to prepare for the more challenging times ahead. Our project management office, which was set up in 2012, has become embedded across the trust to ensure that a structured process is in place for the delivery of our major change programmes, which will result in future efficiencies. We also continue to improve our financial reporting to ensure we are more forwardlooking and have the information to enable us to manage performance proactively. In our future plans, it is clear that we need to maintain our core business by providing high quality and efficient services to our patients and commissioners. We have produced our quality account in 2015/16 and have plans in place to ensure quality improvements in our services are included, measured and evidenced. The future economic environment continues to become more challenging as public spending on health and social care services slows. There will be increasing pressure on provider organisations to make further efficiencies and to work in partnership with commissioners and other partners to secure effective and efficient care pathways. The scale of the efficiencies required will demand fundamental changes in how services are provided across health and social care communities and closer collaboration and joint planning between organisations. We are working to develop a Sustainability and Transformation Plan (STP) across the planning footprint of Derbyshire with statutory NHS commissioners and providers and Derby City Council and Derbyshire County Council. 29

30 The STP sets out a 5 year plan as to how the organisations will work collaboratively to improve health and wellbeing, improve the quality of services provided, and to provide services that are financially sustainable. We are well positioned to manage in the more difficult financial environment and will ensure we work positively with partners to maintain best use of public resources. In summary, 2015/16 has been another successful year for us. The environment for 2016/17 and beyond is becoming more challenging, however we believe that we are well placed to meet these challenges. Our performance against standards and targets Our performance is monitored against a range of standards and targets. The Board of Directors also monitors performance against our objectives and a range of other measures. Delivery against our priorities, and all measures of quality, are closely monitored by the trust s quality service, quality business and quality people committees which regularly report to the board of directors. This ensures we routinely monitor and review our performance across a total of 190 performance indicators, so that action can be taken where we are falling behind target. Our operational performance in 2015/16 was a tribute to the hard work of our staff and reflects some significant achievements. The list below outlines our performance during the year against the 10 indicators applicable to us as a community trust within Monitor s risk assurance framework. Monitor uses a number of national measures, looking at access to services and outcomes, to make an assessment of governance at NHS foundation trusts. At the end of March 2016 we were achieving the following results against Monitor s risk assurance framework (see also the table on page 32): Admitted patients seen within 18 weeks: achieving 94.4 % against a target of 90% Nonadmitted patients seen within 18 weeks: achieving 96.6% against a target of 95% Waits incomplete pathways seen within 18 weeks: achieving 98.1% against a target of 92% Four hour wait for A & E attendance: achieving 100% against a target of 95% Delayed transfers of care for older people s mental health services: achieving 2.4% against a target of no more than 7.5% Mental health data completeness identifiers: achieving 100% against a target of 97% Certification against compliance with requirements for access to healthcare for people with a learning disability Data completeness for community services: achieving 91.9%, 84.7% and 84.7% respectively against targets of 50%. 30

31 Performance against Monitor s key performance indicators in the risk assurance framework schedule: Since 1 April 2013 all NHS foundation trusts need a licence from Monitor stipulating specific conditions that they must meet to operate. Key among these are financial sustainability and governance requirements. The aim of Monitor s assessment under the risk assurance framework is to show when there is: a significant risk to the financial sustainability of a provider of key NHS services which endangers the continuity of those services; and/or poor governance at an NHS foundation trust. We have met all our Monitor risk assurance framework targets for 2015/16. More details about these are included on the table on the following page. 31

32 Da ta compl etenes s : communi ty s ervi ces Da ta compl etenes s : communi ty s ervi ces Certifi ca tion a ga i ns t compl i a nce wi th requi rements rega rdi ng a cces s to hea l thca re for peopl e wi th a l ea rni ng di s a bi l i ty Da ta compl etenes s : communi ty s ervi ces Mental Hea l th da ta compl etenes s : i dentifi ers Hea l thca re Ca re As s oci a ted Infections Cl os tri di um di ffi ci l e l a ps es (no.) Del a yed Tra ns fer of Ca re for OPMH Moni tor compl i a nce fra mework ca l cul a tion (%) RTT Wa i ts a dmi tted pa tients s een wi thi n 18 weeks 90% (target) (%) RTT Wa i ts non a dmi tted pa tients s een wi thi n 18 weeks 95% (target) (%) RTT Wa i ts Incompl ete pa thwa ys s een wi thi n 18 weeks 92% (target) (%) A&E 4 Hour Wa i t for A&E Attenda nces (%) Measure 94.4% 96.0% 94.4% 50% 74.7% 69.0% 83.1% 50% 50% Yes 100% 2.6% Yes 97% 7.5% 74.7% 69.0% 83.1% Yes 100% 6.7% Yes 100% 0.0% 84.7% 84.7% 84.7% 84.7% 91.9% 91.9% Yes 100% 5.2% 84.7% 84.7% 91.9% Yes 100% 0.0% 97.5% 99.9% 84.7% 84.7% 91.9% Yes 100% 0.0% 95.2% 97.0% 84.7% 84.7% 91.9% Yes 100% 0.0% 97.6% 98.0% 84.7% 84.7% 91.9% Yes 100% 0.4% 98.0% 97.3% 84.7% 84.7% 91.9% Yes 100% 0.4% 97.9% 97.3% 84.7% 84.7% 91.9% Yes 100% 0.3% 97.7% 97.7% 84.7% 84.7% 91.9% Yes 100% 3.1% 97.7% 97.3% 84.7% 84.7% 91.9% Yes 100% 2.4% 98.1% 96.6% 100.0% 100.0% 99.9% 100.0% 100.0% 99.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 94.0% 95.0% 97.9% 97.6% 99.2% 94.9% 97.9% 94.9% 92% 97.0% 97.8% 98.4% 97.5% 98.1% 95.0% 95% 95.7% 96.6% 95.3% 90% 96.5% RAF Target Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar /16 Performance against Monitor s risk assurance framework indicators North Ea s t Derbys hi re l recently depl oyed North Ea s t Derbys hi re l recently depl oyed North Ea s t Derbys hi re l recently depl oyed To be reported to EDS & q to QSC Moni tor qua rterl y ca l cu Not a ppl i ca bl e DCHS d ha ve a target RTT a dmi tted a nd nona da ta wi l l no l onger be c from M4 onwa rds by M Narrative 32

33 CQUIN targets CQUINs are qualityrelated goals which are agreed with our commissioners each year. The goals are linked to a proportion of our income which we receive on achievement of the targets. CQUIN stands for Commissioning for Quality and Innovation and the targets which are set support ongoing innovation and improvement in care across our clinical services. During 2015/16 we agreed nine CQUIN measures, and acquired a further two CQUINs in October 2015 in association with the transfer into our organisation of the Derby City Community Services, as part of our strategic shift programme. We achieved 100% of our CQUIN targets during the year. The CQUINs covered: Patient assessment and referral for dementia (national target) Training in dementia awareness (national target) Support for carers of dementia patients (national target) Improving urgent care (national target) Pressure ulcers (local target) Compassion and culture (local target) End of life care (local target) Community nursing, staffing for quality (local target) Patient flow and discharge planning (local target) Transition of services (local target) Therapy outcomes (local target Derby city). More details about our CQUINs are included within the quality account. Big 9 As well as our externally agreed performance targets we monitor many other quality indicators. As part of fulfilling our commitment to quality and to achieving our objectives, we have created the Big 9. Within each element of the DCHS Way (quality service, quality business and quality people) nine priorities were identified for 2015/16. The Big 9 performance is updated monthly and shared with staff across the organisation to enable us to see how we are doing against those priorities. Achieving them will ultimately mean we provide the best quality care for our patients and provide a good environment for staff. 33

34

35 The latest Big 9 results focus our attention on the forecast redrated indicators: Looking at how to increase the number of referrals to the smoking cessation service Meeting our stretch target for identifying when patients with a learning disability access our services, building on the work we have done to meet our Monitor target in achieving certification against compliance with requirements for access to healthcare for people with a learning disability Within our quality people agenda, we have identified a need within the Big 9 to ensuring all staff receive an annual appraisal. The Big 9 system ensures we do not lose focus of the priorities for action as flagged up for attention. More details about our governance arrangements and quality targets are available in the quality report. Our annual quality accounts are also published separately and are available online at NHS Choices ( as well as on our website ( 35

36 Accountability section Directors report The directors report has been prepared in accordance with sections 415 to 418 of the Companies Act 2006 (section 415(4) and (5) and section 418 (5) and (6) would not apply to NHS foundation trusts) as inserted by SI 2013 (1970), regulation 10 and schedule 7 of the large and mediumsized companies and groups regulations Directors of the trust The following directors were appointed to membership of the board of directors, and were in post during the year 1 April 2015 to 31 March 2016: Designation Date Name Chairman 1 April 2015 to 31 March January 2016 to 31 March 2016 Prem Singh Chief executive 1 April 2015 to 31 March 2016 Tracy Allen Director of finance, information and strategy 1 April 2015 to 31 March 2016 Chris Sands Director of operations/chief operating officer 1 April 2015 to 31 March 2016 William Jones Director of quality/chief nurse 1 April 2015 to 31 March 2016 Carolyn White Director of people and organisational effectiveness 1 April 2015 to 31 March 2016 Amanda Rawlings Medical director 1 April 2015 to 31 March 2016 Dr Rick Meredith Trust secretary 1 April 2015 to 31 March 2016 Kirsteen Farrar Nonexecutive director 1 April 2015 to 31 March 2016 BarbaraAnne Walker* Nonexecutive director 1 April 2015 to 31 March 2016 Ian Lichfield Nonexecutive director 1 April 2015 to 31 March 2016 Chris Bentley Vice chairman BarbaraAnne Walker* 36

37 Nonexecutive director 1 April 2015 to 31 March 2016 Nigel Smith Nonexecutive director 1 November 2015 to 31 March 2016 John Coyne The trust considers each of the listed nonexecutive directors to be independent. John Coyne was appointed as a nonexecutive director on 1 November *BarbaraAnne Walker was appointed as vice chairman on 13 January Amanda Rawlings was also appointed to the board of directors of Chesterfield Royal Hospital. Her daytoday operational management responsibility is split equally between us at and Chesterfield Royal Hospital NHS Foundation Trust. Further details about the board of directors and the directors of the trust can be found in the following pages. Register of interests for directors and governors All directors and governors are required to comply with the trust s code of conduct and declare any interests that may result in a potential conflict of interest in their role as a director or governor of the trust. For the purpose of meeting annual report guidance, we report that our chairman Prem Singh has no significant external interests, and his interests are included in the register. The register of interests is maintained and available to the public via the trust s secretary at the following address: Chief executive s department, Babington Hospital, Derby Road, Belper, Derbyshire, DE56 1WH. Cost allocation and charging requirements We have complied with the cost allocation and charging requirements set out in HM Treasury and Office of Public Sector information guidance. Political and charitable donations We did not make any political or charitable donations from our exchequer or charitable funds during 2015/16. Better payment practice code performance The better payment practice code requires the payment of undisputed invoices by the due date or within 30 days of receipt of goods or a valid invoice, whichever is later, for 95% of all invoices received. We have a policy of paying suppliers within 30 days of receipt of a valid invoice. 37

38 Our trust is a signatory to the prompt payment code and committed to paying our suppliers within clearly defined terms. We also commit to ensuring there is a proper process for dealing with any invoices that are in dispute. Our trust s performance is detailed below: NHS Non NHS 94.67% 94.23% Volume 95.43% 92.23% Value There has been no interest paid under the Late Payment of Commercial Debts (Interest) Act Disclosures relating to quality governance Supporting the DCHS Way is the trust s quality improvement and assurance framework (QIAF) which describes the mechanisms used by the organisation to assure our Board of Directors and our Council of Governors regarding the quality and safety of patient care. The QIAF uses the four domains within Monitor s quality governance framework to describe its arrangements. Strategy Capability and culture Processes and structures Measurement. During March and April 2016 the organisation has reviewed its board assurance framework and aligned this with the strategic risks of the organisation going forwards. The QIAF model has four levels of governance: Selfgovernance by individuals or teams Peer review Board Insight or quality visits External review. At we are confident that there are no material differences between our annual governance statement, annual and quarterly board statements to Monitor and the findings of the Care Quality Commission s most recent inspections. Please see the quality report, from page 126, for further information. 38

39 Income disclosures During the year ending 31 March 2016, our trust generated income of 176m for the provision of services, principally to the people of Derbyshire. Of that total, 172m income was for patient care activities, as shown in note three of the accounts. In addition to clinical income, our trust generated other operating income of 3m as shown in note four of the accounts. This income related to recharges to other bodies for staff and supplies provided to them, research and development, education and training and many other various services that supported healthcare services being provided. Disclosure of information to auditors So far as the directors are aware, there is no relevant audit information of which the auditors are unaware, and the directors have taken all of the steps that they ought to have taken as directors to make themselves aware of any relevant audit information and to establish that the auditors are aware of that information. 39

40 Remuneration report Annual statement on remuneration This report contains details of how the remuneration of senior managers is determined. A senior manager is defined as those persons in senior positions having authority or responsibility for directing or controlling the major activities of the Trust'. The Trust deems this to be the Executive and NonExecutive members of the Board of Directors. As Chair of the Remuneration and Terms of Service Committee I have reviewed the definition of senior manager and can confirm that this covers the members of the Trust Board only. I also confirm that the remuneration report complies with: Section 420 to 422 of Companies Act 2006 Regulation 11 parts 3 and 5 of schedule 8 of the large and mediumsized companies and groups regulations 2008 Parts 2 and 4 of schedule 8 of the regulations as adopted by Monitor in this manual Elements of the NHS Foundation Trust code of governance. Major decisions on senior managers remuneration Two major decisions on senior managers remuneration have been made by the remuneration and terms of service committee in 2015/16: To pay the director of people and organisation effectiveness a duty and responsibility payment of 10,000 in recognition of the additional responsibilities she has assumed as director at Chesterfield Royal Hospital NHS Foundation Trust. The payment is to be nonconsolidated in the first instance as this is a 12 month secondment post to test if the arrangement will work. The committee felt there was a valid value for money argument as there is a net saving to both organisations and a net value to be gained as the arrangement will support the wider integration agenda. To pay the director of finance and performance and the director of operations/chief operating officer additional duties payments following the departure of the director of strategy and the decision not to replace this post but to share the duties amongst these two directors. 40

41 The committee felt there was a valid value for money argument as portfolio changes have resulted in a restructure of the supporting functions and provided an annual cost saving of 49,000 per annum. Substantial changes to senior managers remuneration during the year and the context for these There were no substantial changes to senior managers remuneration during 2015/16. Prem Singh Chairman 41

42 Senior managers remuneration policy Future policy table executive directors Component How this operates Annual flatrate salary reviewed regularly with reference to the wider NHS Directors pay and the pay award to other NHS staff in any given year (applies to all executive directors with no specific differences for individual directors). This is set out below under the section headed Remuner ation policy. How this supports the short and long term strategic objectives of the trust Maximum that can be paid Framework used to assess performance and performance measures that apply Provisions for recovery or withholding of payments It enables executive directors to take a balanced view between short and long term objectives which are based on key items determined by the Annual Plan Flat rate salary Remuneration is based on flatrate salary, it is not performance related and measures do not therefore apply Provision is made for termination of the contract without notice in certain circumstances. Notes on future policy table No new components of the remuneration package have been introduced in 2015/16, nor have any changes been made to existing components. The differences between the policy on senior managers remuneration and the general policy on employees remuneration are set out below under the section headed Remuneration policy. No senior managers were paid more than 142,500 during 2015/16. 42

43 Nonexecutive directors Component Additional fees Other remuneration Annual flatrate non pensionable fee, with a higher rate payable for the chair of the trust Not applicable flat rate Not applicable fees Use of external advisors The trust s remuneration and terms of service committee have not used external advisors to provide advice or services on remuneration matters. Service contracts for senior managers The service contract for the chief executive and executive directors is the contract of employment. This is substantive and continues until the director retires; otherwise, the notice period for termination by the Trust is six months and for termination by the director, three months. The contract does not provide for any other payments for loss of office, but does provide for compensation for early retirement and redundancy in accordance with the provisions in section 16 of the Agenda for Change: NHS terms and conditions of service handbook. The trust s approach to executive director remuneration is to ensure that the trust can attract, motivate and retain the high calibre executives it needs through paying a market remuneration package, taking account of our financial condition and providing value for money for tax payers. The Remuneration and Terms of Service Committee has the responsibility of ensuring that the remuneration packages that are paid to the Executive and Associate Directors is in line with boardroom pay in the NHS, and reflects the performance of the organisation and the individual. The exact remuneration package is determined by the committee based on market position to comparable Trusts and the Trust s performance and the individual s contribution. The process for reviewing executive remuneration is as follows: Recruiting executive directors For new appointments the trust will undertake a market review of salaries with comparable organisations from data available both nationally and locally Before determining the salary the trust will take into account the salary paid to the previous incumbent and to the parity with other executive directors For appointments with a salary level of over 142,500 the trust will follow the requirements to seek Treasury approval. 43

44 The remuneration and terms of service committee determines the remuneration of the executive committee with the aim of attracting and retaining high calibre directors who will ensure the continued success of the trust in providing the highest quality patient care. Salary levels are reviewed regularly with reference to the wider NHS directors pay and the pay award to other NHS staff in any given year. All nonmedical employees at the trust including senior managers are remunerated in accordance with the nationally agreed NHS pay structure, Agenda For Change. Medical staff are remunerated in accordance with the national terms and conditions of service for doctors and dentists. Nonexecutive directors The service contract for nonexecutive directors is not an employment contract. Nonexecutive directors are appointed for an initial term of up to three years and are eligible to be considered for further terms of appointment up to the shorter of a maximum of three to four years. The notice period for termination is one month on either side and the contract does not provide for any other payments for loss of office. The Council of Governors determines the pay and terms of office of our chair and nonexecutive directors, on recommendation of the trust s nomination and remuneration committee. 44

45 Annual report on remuneration Information not subject to audit Details of the service contract for each executive director at 31 March 2016 Name Service contract start date *Date of new service contract 2 January April 2015 Chris Sands Director of finance, information and strategy 1 August April 2015 Carolyn White Chief nurse, director of quality 2 September April 2015 Amanda Rawlings Director of people and organisational effectiveness 10 April April 2015 Rick Meredith Medical director 6 June April 2015 William Jones Director of operations/chief operating officer 17 April April 2015 Kirsteen Farrar Trust secretary 18 June April 2015 Tracy Allen Title Chief executive Unexpired term (years) As default retirement age has been phased out, state pension age has been used to calculate the unexpired term on the assumption that senior managers planned to retire at state pension age. * Executive directors signed new contracts of employment to incorporate the duty of candour and fit and proper persons test. 45

46 Chair of remuneration and terms of service committee report The remuneration and terms of service committee, chaired by the trust chairman Prem Singh, comprises nonexecutive directors. The committee has delegated responsibility to determine the remuneration, allowances and other terms and conditions of the executive directors. The committee met on 10 occasions during the period 1 April 2015 to 31 March The membership and attendance at the Remuneration and Terms of Service committee is detailed in the table below. Chris Bentley Nigel Smith BarbaraAnne Walker Ian Lichfield John Coyne 29 October December February September January September 2015 Nonexecutive director (1 April 30 June 2015) Nonexecutive director Nonexecutive director Nonexecutive director Nonexecutive director Nonexecutive director (1 Nov March 2016) 6 August 2015 Tony Okotie 30 July 2015 Title Chair 26 June 2015 Name Prem Singh 30 April 2015 Attendance 46

47 The remuneration and terms of service committee receives support from the chief executive and executive directors to assist the committee in their consideration of any matter. Use of external advisors The trust s remuneration committee has not used external advisors to provide advice or services on remuneration matters. Remuneration policy The remuneration committee determines the remuneration of the executive directors with the aim of attracting and retaining high calibre directors who will ensure the continued success of the Trust in providing the highest quality patient care. Remuneration for executive directors, who are voting members of the Board, consists of a salary plus pension contributions. Salary levels are reviewed regularly with reference to the wider NHS directors pay and the pay award to other NHS staff in any given year. No director is involved in, or votes in, any matter pertaining to their own remuneration. Performance is assessed through the annual appraisal process in line with our Trust s policies. The appraisal of all the executive directors is carried out by the chief executive. All the executive directors have a six month notice period written into their contracts. The only noncash element of remuneration is the pensionrelated benefit which accrues under the NHS Pension Scheme. Contributions are made by both the employee and the employer under the rules of the scheme which are applicable to all NHS staff in the scheme. We do not make termination payments to executive directors in excess of contractual obligations. There have been no such payments during 2015/16. Nonexecutive directors, including the chairman, do not hold service contracts and are appointed for between three to four years. Nonexecutive directors do not receive pensionable remuneration. There were no amounts payable to third parties in respect of the services of a nonexecutive director and they received no benefits in kind. Expenses properly incurred in the course of the Trust s business were reimbursed in line with the trust s policies. 47

48 Expenses Expenses paid to governors, executive and nonexecutive directors are detailed in the table below: 2014/15 1 November 2014 to 31 March /16 Number Total Number Receiving expenses Expenses 00 Total Receiving expenses Expenses 00 Directors Nonexecutive directors Governors Total Payments for loss of office There have been no payments for loss of office in 2015/16 for Derbyshire Community Health Services NHS Foundation Trust. Payments to past senior managers There have been no payments to past senior managers in 2015/16 for Derbyshire Community Health Services NHS Foundation Trust. 48

49 Information subject to audit Trust board salaries and allowances All pension related benefits (bands of 5,000) (bands of 5,000) (bands of 2,500) Name Title Total Longterm performance related bonuses (Rounded to the nearest 00) Taxable benefits (bands of 5,000) Salary and fees Annual performance related bonuses 1 April 2015 to 31 March 2016 (bands of 5,000) Chief executive Chris Sands Director of finance, performance and Information Carolyn White Chief nurse/director of quality Tim Broadley Acting director of strategy (from to ) Amanda Rawlings Director of people and organisational effectiveness Rick Meredith Medical director William Jones Director of operations (now chief operating officer) Kirsteen Farrar Trust secretary Melanie Curd Trust secretary Prem Singh Chairman Tracy Allen ( to ) Tony Okotie Nonexecutive director ( to ) Chris Bentley Nonexecutive director Nigel Smith Nonexecutive director BarbaraAnne Walker Nonexecutive director Ian Lichfield Nonexecutive director John Coyne Nonexecutive director ( to )

50 Tony Okotie resigned as a nonexecutive director on 30 June John Coyne was appointed as a nonexecutive director on 1 November Tim Broadley s role as acting director of strategy ceased on 31 May Melanie Curd acted as trust secretary between 5 June and 31 July 2015, to cover for Kirsteen Farrar. Amanda Rawlings, director of people and organisational effectiveness, was also appointed to the board of directors of Chesterfield Royal Hospital NHS Foundation Trust. Her daytoday operational management responsibility is split equally between our trust and Chesterfield Royal Hospital NHS Foundation Trust. The allocation of her remuneration to the trust is shown on the previous page and her total remuneration is shown in the table below: (bands of 5,000) Name Amanda Rawlings Title Director of people and organisational effectiveness (bands of 2,500) Total (bands of 5,000) All pension related benefits Longterm performance related bonuses (Rounded to the nearest 00) Taxable benefits (bands of 5,000) Salary and fees Annual performance related bonuses 1 April 2015 to 31 March 2016 (bands of 5,000) 50

51 Trust board salaries and allowances All pension related benefits (bands of 5,000) (bands of 5,000) (bands of 2,500) Name Title Total Longterm performance related bonuses (Rounded to the nearest 00) Taxable benefits (bands of 5,000) Salary and fees Annual performance related bonuses 1 November 2014 to 31 March 2015 (bands of 5,000) Prem Singh Chairman Tracy Allen Chief executive (2.5) Chris Sands Director of finance, performance and Information (2.5) Carolyn White Chief nurse/director of quality Tim Broadley Acting director of strategy (from to ) Amanda Rawlings Director of people and organisational effectiveness Rick Meredith Medical director William Jones Director of operations (now chief operating officer) (5) (2.5) Kirsteen Farrar Trust secretary (5) (2.5) Anthony Okotie Nonexecutive director Christopher Bentley Nonexecutive director Nigel Smith Nonexecutive director BarbaraAnne Walker Nonexecutive director Barry Steans Nonexecutive director ( to )

52 (bands of 5,000) (bands of (bands of Employer s contribution to stakeholder pension (bands of 5,000) Cash equivalent transfer value at 31 March 2016 Total accrued pension at age 60 at 31 March 2016 (bands of 2,500) Real increase Real increase cash equivalent transfer value Real increase in pension lump sum at age 60 (bands of 2,500) Lump sum at age 60 related to accrued pension at 31 March 2016 Cash equivalent Transfer Cash equivalent transfer value at 31 March 2015 Real increase in pension at age 60 Pensions (bands of 1,000) (bands of 1,000) Name Title Tracy Allen Chief executive (2.5) Chris Sands Director of finance, performance & information Carolyn White * Chief nurse/ director of quality Tim Broadley Acting directory of strategy (1 April 2015 to 31 May 2015) (2.5) 0 (2.5) (2) Amanda Rawlings Director of people & organisational effectiveness (2.5) William Jones Director of operations/c hief operating officer Rick Meredith * Medical director Kirsteen Farrar Trust secretary Melanie Curd Acting trust secretary ,000) 1,000) (5 June 2015 to 31 July 2015) 52

53 * There are no entries for Carolyn White and Rick Meredith as they have opted out of the NHS Pension Scheme. Certain members do not receive pensionable remuneration therefore there will be no entries in respect of pensions for nonexecutive directors. The pension benefits, being the annual increase in pension entitlement, of those directors indicated above revealed a number of negative increases during 2015/16. The reasons for this relate to the implementation of 2015 scheme benefits, and adjustment for inflation factor. There are no additional benefits that will become receivable by directors in the event that the senior manager retires early. There are no senior managers who have rights under more than one type of pension. Cash equivalent transfer value A cash equivalent transfer value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member s accrued benefits and any contingent spouse s pension payable from the scheme. A CETV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which disclosure applies. The CETV figures and the other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries. Real increase in CETV This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end of the period. 53

54 Fair pay multiples Reporting bodies are required to disclose the relationship between the highest paid director and the median remuneration of the organisation s workforce. The banded remuneration of the highest paid director at the Trust during 2015/16 was 135k140k (2014/ k), this was 5.93 times more than the median pay of 23,443 (2014/ times or 22,570). In 2015/16 one employee (2014/15, one) received remuneration in excess of the highest paid director at 153,630 (2014/15 153,255) on a full time annualised basis. The Trust is required to calculate the fair pay multiple based on all staff in post as at the end of March 2016 on an annualised basis. Where staff are employed on a parttime basis, their salary is calculated as if they were in the Trust s fulltime employment. This is to ensure that the actual salary cost of parttime staff does not distort the overall median pay value. On this basis in 2015/16 one employee received remuneration in excess of the highest paid director, although they only worked for the Trust during the year on a parttime basis. This employee provided medical sessions. Their full time equivalent remuneration would have been 153,630. Total remuneration includes salary, nonconsolidated performance pay and benefits in kind. It does not include severance payments, employer pension contributions or the cash equivalent transfer value of pensions. During 2015/16, there are no significant changes on either side of the ratio. Tracy Allen Chief executive Staff report We employ just over 4,500 staff, making us one of the largest providers of specialist community health services in the country, serving a widespread local patient population in both urban and rural parts of Derbyshire. In addition, we have approximately 1,000 bank staff who support us in keeping agency usage to an absolute minimum, in fact only 1% of our nursing budget is spent on agency staff, significantly lower than the national average. We are 54

55 Staff report committed to staffing our clinical areas wherever possible with our own staff as we We employ just over 4,500 staff, making us one of the largest providers of specialist believe this is the best way to deliver high quality care. community health services in the country, serving a widespread local patient population in both urban and rural parts of Derbyshire. Staff turnover has remained stable over the past 12 months and the rate stands at 9.04% which is significantly lower than the East Midlands NHS turnover average of In addition, we have approximately 1,000 bank staff who support us in keeping Annual report accountsnhs 2015/ % and and a national turnover rate of 10.09%. Analysis looking into the agency usage to an absolute minimum, in fact only 1% of our nursing budget is reasons staff left us has not highlighted any trends or causes for concern. Currently spent on agency staff, significantly lower than the national average. We are our vacancy rate is 6.23%. All of this assures us that Derbyshire Community Health committed to staffing our clinical areas wherever possible with our own staff as we Services Foundation Trust has largely stable Derbyshire NHS Community Health Services NHSaFoundation Trust workforce which can only serve54 believe this is the best way to deliver high quality care. to allow us to provide high quality care. Staff turnover has remained stable over the past 12 months and the rate stands at Developing and supporting our people the DCHS Way 9.04% which is significantly lower than the East Midlands NHS turnover average of Our ambition is to be the best provider of local healthcare and a great place to work % and a national NHS turnover rate of 10.09%. Analysis looking into the To achieve the latter, we know that we must engage, involve and grow our teams to reasons staff left us has not highlighted any trends or causes for concern. Currently reach their full potential. our vacancy rate is 6.23%. All of this assures us that Derbyshire Community Health Services NHS Foundation Trust has a largely stable workforce which can only serve This is why we have been working towards our fiveyear people strategy: quality to allow us to provide high quality care. people the DCHS Way since it was launched in This is the framework which is enabling us to engage, involve and support our people to reach their full Developing and supporting our people the DCHS Way potential. The framework is underpinned by a number of key work streams such as Our ambition is to be the best provider of local healthcare and a great place to work. our aspiration to be a centre of teaching excellence, and our commitment to ensuring To achieve the latter, we know that we must engage, involve and grow our teams to is a harmfree reach their full potential. environment for our staff. This is why we have been working towards our fiveyear people strategy: quality During 2015/16, we have continued to work in partnership with health and social people the DCHS Way since it was launched in This is the framework care colleagues to transform the way services are delivered to patients, having an which is enabling us to engage, involve and support our people to reach their full aspiration to reduce dependency on inpatient services, both in acute and community potential. The framework is underpinned by a number of key work streams such as hospitals. With this in mind, the way in which we supported our people the DCHS our aspiration to be a centre of teaching excellence, and our commitment to ensuring Way during 2015/16 has had to adapt to this new environment. is a harmfree environment for our staff. We have led significant work across Derbyshire to increase our understanding of our future workforce requirements through use of a modelling tool, which was trialled in During 2015/16, we have continued to work in partnership with health and social Derbyshire but is now receiving national interest. This workforce modelling has been care colleagues to transform the way services are delivered to patients, having an undertaken in conjunction with scoping of the organisational development needs aspiration to reduce dependency on inpatient services, both in acute and community arising from transformation and in conjunction with systemwide work to streamline hospitals. With this in mind, the way in which we supported our people the DCHS our people processes across local health and social care partners. The aim of this Way during 2015/16 has had to adapt to this new environment. work is to develop systemwide approaches to drive up quality, sustain transformation and ensure a holistic, personcentred approach to care, with an We have led significant work across Derbyshire to increase our understanding of our increased emphasis on empowering people and their communities. future workforce requirements through use of a modelling tool, which was trialled in Derbyshire but is now receiving national interest. This workforce modelling has been Charts of average staff numbers (whole time equivalent (WTE) basis) undertaken in conjunction with scoping of the organisational development needs arising from transformation and in conjunction systemwide workoftopermanently streamline Averagewith of fixed Average Staff group term temporary employed staff our people processes across local health and social care partners. The aim of this work is to Community develop systemwide to drive Derbyshire Health Servicesapproaches NHS Foundation Trust up quality, sustain 55 transformation and ensure a holistic, personcentred approach to care, with an increased emphasis on empowering people and their communities. Charts of average staff numbers (whole time equivalent (WTE) basis)

56 our people processes across local health and social care partners. The aim of this work is to develop systemwide approaches to drive up quality, sustain transformation and ensure a holistic, personcentred approach to care, with an Annual report and accounts increased emphasis on 2015/16 empowering people and their communities. Charts of average staff numbers (whole time equivalent (WTE) basis) staff Average of fixed Administration and estates staff Average of permanently Staff group term temporary employed staff Ambulance staff staff General payments 0.00 Derbyshire Community Health Services NHS Foundation Trust Administration and estates staff Health care assistants and other support staffstaff Ambulance Healthcare science General payments Health Medicalcare andassistants dental staffand other support Nursing,staff midwifery and health visiting learners Healthcare science Nursing, midwifery and health Medical and dental staff visiting staff Nursing, midwifery and health Scientific, therapeutic and technical visiting learners staff Nursing, midwifery and health visiting staff Scientific, therapeutic and technical Total staff staff as at 31 March 2016 * Gender Total Female 3, Total Male staff as at 31 March 2016 * Gender Total Total 3, Female 3, Male Executive directors as at 31 March 2016* Total 3, Gender Total Female 4.00 Executive directors as at 31 March 2016 * Male 3.00 Gender Total Total Female 4.00 Male 3.00 Senior managers as at 31 March 2016* Total Gender Total Female 9.80 Senior Male managers as at 31 March 2016* 6.35 Gender Total Total Female 9.80 * Based on staff employed at 31 March 2016 as wholetime equivalents. Male 6.35 Total Average number of employees (WTE basis) * Based on staff employed at 31 March 2016 as wholetime equivalents. 2015/16 Permanent Other total Average number of employees (WTE basis) number number number 2015/1647 Medical and dental 45 Permanent Other 2 total number 1 numberambulance number 1 Medical and dentalhealth Services NHS Foundation 45 Trust Derbyshire Community Ambulance /15 total number 2014/1548 total number

57 Male Total 6.35 report and accounts 2015/16 *Annual Based on staff employed at 31 March 2016 as wholetime equivalents. Average number of employees (WTE basis) Administration and estates Other49 number /16 1,020 total number 1, / total number ,020 3, , , , , , Healthcare assistants and other support staff 971 Permanent number Nursing, midwifery and health 1,033 Annual report and accounts 2015/16 visiting staff Medical and dental 45 Scientific, therapeutic and 583 Ambulance 1 technical staff Administration and estates 759 Derbyshire Other Community Health Services NHS Foundation 1 Trust Healthcare assistants and 971 Total averagestaff numbers 3,392 other support Of which: 3 Nursing, midwifery and health 1,033 Number of employees (WTE) visiting staff engaged on capital projects Scientific, therapeutic and 583 technical staff Expenditure on consultancy Other 1 Total average numbers Of which: Vanguard Number of employees (WTE) engaged on capital projects Workforce development Public Relations and IT Improvement 57 Expenditure on consultancy Business Development 42 Business Development Other Vanguard Total Workforce development Public Relations and IT Improvement 57 Business Development 42 Business Development 28 Other 15 Total 497 Offpayroll engagement Following the Review of Tax Arrangements of Public Sector Appointees published by the chief secretary to the treasury on 23 May 2012 the Trust must publish information on their highly paid and/or senior offpayroll engagements. During 2015/16 there was one off payroll engagement in place costing more than 220 per day and for a period in excess of six months, as detailed in the table below. We have sought assurance that this individual is appropriately registered with HMRC Offpayroll engagement for tax purposes. Following the Review of Tax Arrangements of Public Sector Appointees published by the chief secretary the treasury on Foundation 23 May 2012 Derbyshire Communityto Health Services NHS Trustthe Trust must publish information on their highly paid and/or senior offpayroll engagements. 57 During 2015/16 there was one off payroll engagement in place costing more than 220 per day and for a period in excess of six months, as detailed in the table below.

58 Number Number of existing engagements as of 31 March Of which the number that have existed: for less than 1 year at the time of reporting for between 1 and 2 years at the time of reporting for between 2 and 3 years at the time of reporting for between 3 and 4 years at the time of reporting 1 for 4 or more years at the time of reporting All existing offpayroll engagements, outlined above, have at some point been subject to a risk based assessment as to whether assurance needs to be sought that the individual is paying the right amount of tax and, where necessary, that assurance has been sought (annex 8 FTARM). Off payroll arrangements are considered by exception and where there is no practical alternative to the trust employing directly. The trust s policy covers the process to follow in deciding how to fill a service gap, as below: First formal recruitment should be considered Only if not suitable should agency then be considered in liaison with the procurement team Only if those methods are not appropriate should offpayroll arrangements be considered, following the usual procurement rules With the addition of a tax status checklist that is required from all contractors employed via that route, to provide assurance Practical arrangements for collecting and validating the information necessary to meet HM Treasury s reporting and assurance requirements The consequences of failing to correctly identity whether an individual is an employees in terms of HMRC s employment tests and Documentation maintained to identify the individuals requiring assurance. New offpayroll engagements During 2015/16 there were no new offpayroll engagements put in place. Offpayroll engagements of board members, and/or senior officials with significant financial responsibility During 2015/16 there were no offpayroll engagements put in place for senior managers or those with significant financial responsibility. 58

59 2015/16 number of engagements Number of offpayroll engagements of board members, and/or, senior officials with significant financial responsibility, during the financial year. Number of individuals that have been deemed "board members and/or senior officials with significant financial responsibility". This figure should include both offpayroll and onpayroll engagements. 13 Exit packages NHS foundation trusts are required to disclose summary information of their use of exit packages agreed in the year, as required by the FReM (paragraph (h)). The figures disclosed in the accounts relate to exit packages agreed in the year, irrespective of the actual date of accrual or payment. The actual date of departure may be in a subsequent period, and the expense in relation to the departure costs may have been accrued in a previous period. Redundancy and other departure costs have been paid in accordance with the provisions of the Agenda for Change NHS terms and conditions. Exit costs in this note are accounted for in full on agreement of departure date. Where the Trust has agreed early retirements, the additional costs are met by the Trust and not by the NHS Pensions Scheme. Illhealth retirement costs are met by the NHS Pensions Scheme and are not included in the table. There are no payments included in the above outside the NHS terms and conditions. This disclosure reports the number and value of exit packages taken by staff leaving in the year. 59

60 Total number of exit packages by cost band Number of other departures agreed Exit packages cost band Number of compulsory redundancies Exit packages 0 10, ,001 25, ,001 50, , , , , , , , , ,000 Number of compulsory redundancies Number of other departures agreed Total number of exit packages by cost band 2015/16 Total number of exit packages by type Total resource cost Exit packages cost band 2014/ , ,001 25, ,001 50, , , , , , , , ,922 Total number of exit packages by type Total resource cost Exit packages: noncompulsory departure payments During 2015/16 we made numerous mutually agreed resignation payments. 60

61 2015/16 Mutually agreed resignations (MARS) contractual costs Total value of agreements Permanent agreed number Total value of agreements Permanent agreed number 2014/15 Number 000 Number Of which: Noncontractual payments requiring HMT approval made to individuals where the payment value was more than 12 months of their annual salary Counter fraud activities We receive a dedicated local counter fraud specialist advice service from 360 Degree Assurance and have developed a comprehensive counter fraud work plan in accordance with guidance received from NHS Protect. We also have a counter fraud policy approved by the board of directors. Anyone suspecting fraudulent activities within our services should report their suspicions to our local counter fraud specialist by telephoning the confidential hotline on: Healthy workplace At we take health and safety very seriously, our objective is to ensure that all our staff to go home safely at the end of each and every day. Our approach to staying safe is simple: we believe that all injuries are preventable and through good leadership and engagement of staff we can create a safety culture in which everyone takes responsibility for health and safety both on a personal and a collective level. During 2015/16 our staff health and safety agenda was progressed by launching a Stay Safe brand with associated training and support materials. We have also been doing comprehensive audits with our community teams to ensure they are safe in our patients homes as well as on our sites. Our average absence rate for 2015/16 is 4.63 per cent. National and regional absence statistics, obtained through figures provided by the Health & Social Care 61

62 Information Centre, have not been released since December 2015, but at that time we were slightly higher than the national and regional average. The top three reasons for absence remain: stress/anxiety, musculoskeletal conditions and gastrointestinal problems. During 2015/16 we have worked on a number of initiatives to improve the support we offer to staff who are unwell, focusing on maintaining their attendance at work. It is well documented that those who are able to maintain employment when unwell have a quicker and fuller recovery. We undertook a full review of our staff support service, called Resolve. Resolve offers onetoone counselling and general workplace support to our staff through a team of trained counsellors and volunteers. We remodelled the service during 2015/16, ensuring the service was providing the support our people told us they needed, as well as setting new key performance indicators to measure the success of the service. Furthermore, to support staff outside of normal office hours we procured an outofhours telephone helpline service called Care First, which complements the work of the Resolve team when they are not there! Care First offer 24/7 telephone counselling support as well as a wide range of other services such as legal and financial advice. The newly remodelled service has received very positive feedback from staff accessing the service. For example, 100 per cent of clients receiving counselling said they would recommend the service to a colleague, and 87 per cent of those accessing the service stated that it had prevented them from having to take time off work. To enhance the work of Resolve in supporting our staff with emotional health concerns, we have this year also launched an emotional wellbeing toolkit, which provides tools for staff and managers in recognising and supporting signs of mental health issues. We launched this toolkit during mental health awareness week. The work of Resolve is complemented by support from our occupational health department. This year we have renegotiated our contract for this service with a renewed focus on preventative action around staff wellbeing. Our musculoskeletal occupational health service continues to go from strength to strength. After winning an NHS innovation challenge award of 75,000 to develop the service in 2014/15, this year the team won a Chartered Society of Physiotherapists award for excellence in "promoting activity and healthy lifestyles for NHS staff. 62

63 This year we have also revised our attendance management policy and have developed an accompanying training package which is currently being rolled out across our organisation. The focus on the new policy is working with our staff to maintain their attendance at work through support from their line manager. We have also continued to champion workplace wellbeing by encouraging our staff to engage in a range of health promoting activities including: Dry January, our inaugural pedometer challenge, cycle to work and weight loss management programmes. This is supported by our workplace wellbeing champions and a specific section for staff on our Staff Zone to inform them of all available options. A centre for teaching excellence Achieving business excellence relies on us having a workforce with the right skills, competencies and professional capabilities to deliver excellent care against a background of unprecedented change both nationally and locally. Our ambition is to be: the best provider of local healthcare and a great place to work. Education and training is critical to achieving our vision. We know we must ensure our staff receive first class training and education if we are to fulfil our aim to build a high performance work environment that engages, involves and supports staff to reach their full potential. It means providing our workforce with appropriate development opportunities so as to ensure they acquire the requisite knowledge and skills to provide high quality care and practice at the top of their license. We have a dedicated development centre which provides a wide range of inhouse training opportunities for our staff. The development centre houses a skills lab, IT training suite plus clinical and nonclinical training rooms. Training programmes are also commissioned from external providers to meet workforce needs. In 2015/16 we revised our annual training needs analysis process so as to ensure better alignment with Health Education England s commissioning cycle. We have strengthened our reporting of education and workforce requirements through our workforce planning and development subgroup, ensuring we have regular discussions about our requirements. We have refreshed our study leave policy and aim to strengthen our internal training needs analysis approach in 2016 to ensure our clinical workforce can access regional learning beyond registration education and that we offer our nonclinical workforce opportunities to develop. 63

64 We have encouraged our clinical facing support staff to apply for Open University education to become registered general nurses. Three staff commenced this four year programme in 2015 and a further round of applications is in train for 2016 places. We have strengthened the clinical practice facilitator role to support changes in the delivery of care while ensuring quality is maintained, in line with the remit of the whole organisation. We are committed to provide a learning environment that supports and enables our workforce to attain the right skills, competence and professional capabilities to deliver excellent care in a challenging and changing environment. As we develop new services and models of care we will use a broad range of development opportunities to equip our staff with the qualities, skills and competencies to fulfil and enhance their roles and career progression to deliver high quality, efficient and effective services. This will be achieved through the provision of development opportunities such as rotations to enhance job enrichment and growth opportunities supported by strong preceptorship and mentorship. We have increased the number of advanced clinical practitioners (ACPs) within the trust and have contributed to the establishment of a Derbyshirewide ACP academy approach which will help ensure we have the right people with the right skills to deliver new models of care. All new staff take part in an inhouse induction programme for up to five days, to ensure they each receive all relevant training for their particular role, before starting in post. We have an Equality, Diversity and Inclusion Policy which exists to ensure that our human resources practice actively supports the recruitment, training and career development of those with a protected characteristic. A chapter on our approach to equality, diversity and inclusion is included at the end of the accountability chapter of this report. 64

65 Staff completing essential training programmes (The table below excludes staff members who transferred to us partway through the year from Chesterfield Royal Hospital and Derby Teaching Hospitals NHS Foundation Trusts) Training programmes reported against a target of 95% of available staff Compliance 31 March Compliance 31 March % DCHS target Essential learning 93% 96% 95% Information governance 95% 95% 95% Fire training 92% 95% 95% Appraisal 93% 94% 100% We have reviewed our essential and clinical essential training, streamlining these programmes with other NHS organisations in the East Midlands. In 2015/16 we developed a centre of teaching excellence programme of activity; where the commitment is to continue to develop as a learning organization, promoting a culture of reflection, innovation and shared learning and passion for continuous professional development. We have applied for the Skills for Health quality mark and have undertaken training and development of all of our trainers to provide quality assurance of the programmes of training we provide. We have plans in 2016 for a range of experience in the workplace for people who have a learning disability, those who may have had a period of unemployment, participants in the Prince s Trust and an increased engagement with schools with the aim of increasing and strengthening the number of apprentices within Derbyshire Community Health Services NHS Foundation Trust. Leadership development During the year we invested in our leaders through our own Quality Always leadership development centres. The scheme involves nominated participants undertaking a 360 review and attendance at an inhouse development centre. Eightysix leaders took part in the process during 2015 and the feedback has been extremely positive, with participants and observers commenting how constructive the experience had been. 65

66 As part of the process, 43 senior leaders attended an accredited training programme, so that we have our own pool of inhouse observers to support the future roll out of this initiative. This training has brought added benefits to those leaders, as it has built confidence and competence in observing, evaluating and feeding back on behaviours. This will in turn benefit the quality of appraisals and recruitment also saw a refresh of our intranetbased leadership development learning portal as a onestop shop for information that is helpful to them as leaders, such as courses, conferences, coaches, mentors, career case studies, and more. We are also about to launch a leadership chat room within the site so that leaders can share best practice and access support from each other. We have also launched a leadership twitter account and weekly newsletter to market leadership development opportunities. We have piloted new courses, for example: outward bound team building, social media for engagement, personal impact workshops and better decisionmaking. These are externally facilitated along with some basic getting to grips two hour information sessions for leaders that are facilitated by inhouse experts. Engaging with our staff At we are very aware of the importance of staff engagement. For this reason, we have developed and maintain a number of avenues for staff to engage with our senior leadership team, and to be able to express their views or any concerns they may have. Our Council of Governors we chose from the outset to include a strong staff representation. We made this decision in recognition of the importance of involving staff closely in decisions affecting our organisation and the services we provide. Our Staff Forum our quarterly meeting where staff representatives (including governors, partnership colleagues and frontline care council members) meet to discuss matters affecting staff and work closely with the executive team to make our trust a better place to work. The agenda is set and managed by staff and the outcome of every meeting is a you said we did communication, and we really do what we say we are going to! Our Staff Partnership Committee our monthly meeting with our staff partnership/union colleagues. This is a formal subcommittee of the trust board and has the remit of providing assurance that at Derbyshire Community 66

67 Health Services NHS Foundation Trust we engage, consult and involve our people in the management of change, and the development of people policy. We have an excellent relationship with our local union colleagues and work together to ensure that Derbyshire Community Health Services NHS Foundation Trust is a great place to work. Our Team Talks where staff can find out more about what's happening at the trust over tea and coffee with members of the executive team. Staff can dropin and find out more about what's planned and raise any questions facetoface. Every other month the team talk is conducted by open teleconference, to reflect the geographical spread of our services and to give all staff the opportunity to participate. Our Frontline Care Council a forum for staff to guide and inform frontline care; maximise positive experiences of patients, and inform the learning and development needs of those working at the interface with patients and the public. We know we still have work to do on this important agenda, but have confidence that our work is having an impact. In September 2015 the trust was named in the Health Service Journal s top 10 best places to work list, compiled in partnership with NHS Employers. We were also very proud to be runnersup in the community trust category. The 2015 NHS staff survey again rated us highly for our level of staff engagement. We are looking at all the results to see how we can improve on those areas where feedback was less positive. You can read more about this further on in this chapter. We also ask staff to fill out quarterly pulse checks to provide a quick snapshot of how people are feeling about work to flag any issues we can improve. You can read more about this, too, further on in this chapter. In addition we have a strong culture of appraisals, training, learning, development and raising concerns which are all designed to promote our approach to staff engagement and which are covered in more detail elsewhere in this chapter. We hold topic specific engagement events and also arrange for these to be held at locations across the patch. Assistant directors host local focus groups to gather intelligence on and respond to issues that relate to specific teams or localities. We have invested time in trying to understand the best way to communicate with our harder to reach workforce i.e. those not necessarily on or with easy access to computer terminals in the workplace. 67

68 Our Raising Concerns initiative, developed in 2014, is another mechanism by which we are committed to achieving the highest possible standards and actively encourage openness in the workplace as a means of good engagement and being able to recognise and resolve any arising issues quickly. We are committed to seeking, and acting on feedback throughout the year; gauging how staff are feeling; getting an early headsup on areas we might need to address to attract and retain the best staff, maintain staff wellbeing, and ultimately improve patient experience. We have plans in place to continue our investment in staff engagement and these include: Development of a staff engagement toolkit to support leaders. The first dedicated leadership conference was organised for 6 May 2016 and will become a regular event. An increase the number of engagement officers employed. An additional post has been approved to work with the transformation team from April 2016 to help deliver staff engagement activity. Development of an easy to access intranet, with improved functionality eg discussion forums, made ready in March 2016 for full rollout during summer Deployment of smart phones to around 1,000 frontline healthcare workers (mostly district nurses and healthcare assistants) from April 2016 will have a positive impact on staff engagement. Better connectivity because of 4G technology, will enable staff to have easier access to s, diaries and the intranet. An increased number of assistant directorled staff focus groups/staff engagement events to encourage more instant local feedback. Ongoing development of targeted approaches to ensure tools and tactics currently in place are refined to engage harder to reach teams be they not easily accessible via /have limited access to computers/intranet. Introduction of TV screens in prominent locations in hospitals and health centres, to help disseminate relevant staff and patient messages, were implemented over the summer NHS Staff Survey 2015 We invited our staff to complete the annual NHS Staff Survey 2015 to provide valuable feedback on how they feel about the NHS and our organisation as a place to work. This was performed independently by the Picker Institute Europe which ensured absolute confidentiality and supported detailed analysis. 68

69 2,257 staff at took part in the NHS staff survey This is a response rate of 57.1% which is above average for community trusts in England, and compares with a response rate of 62% in our trust in NHS Staff Survey Response rate 2014/ /16 Trust improvement / deterioration Trust National Trust average National Increase/decrease average in % points 62% 44% 48% 57% 5% decrease The table below gives a summary of ranking, compared with all community trusts in 2015, for the 32 key findings in the survey: Our staff survey ranking compared with other community trusts Above (better than) average Below (better than) average 7 Average 6 Above (worse than) average 2 Below (worse than) average 0 Overall staff engagement 69

70 The overall staff engagement score for 2015 is 3.92 and was above (better than) average when compared with trusts of a similar type. This has increased from 3.83 in 2014 and 3.76 in It also compares favourably with the national average community trust engagement score of 3.82 for The overall indicator of staff engagement is calculated by NHS England using the questions that make up key findings seven, four and one. These key findings relate to the following aspects of staff engagement: Staff members perceived ability to contribute to improvements at work Staff members willingness to recommend the trust as a place to work or receive treatment The extent to which staff feel motivated at work. Areas of improvement from previous year There are four key findings where staff experiences have improved the most within the trust since the 2014 survey: Staff motivation at work (key finding 4) Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or public in the last 12 months (key finding 25) Percentage of staff feeling pressure in the last three months to attend work when feeling unwell (key finding 18) Percentage of staff witnessing potentially harmful errors, near misses or incidents in the last month (key finding 28). Areas of deterioration from previous year There are three key findings where staff experiences have deteriorated since the 2014 survey: Percentage of staff/colleagues reporting most recent experience of harassment, bullying or abuse (key finding 27) Percentage of staff/colleagues reporting most recent experience of violence (key finding 24) Percentage of staff working extra hours (key finding 16). Top four ranking scores According to the National NHS England data the four key findings for which our trust compares most favourably with other community trusts are: Percentage of staff reporting good communication between senior management and staff (key finding 6) Staff recommending the organisation as a place to work or receive treatment (key finding 1) Staff satisfaction with resourcing and support (key finding 14) Organisation and management interest in and action on health and wellbeing (key finding 19). 70

71 Top four ranking scores NHS Staff Survey 2014/ /16 Trust improvement / deterioration Top four ranking scores Trust National Trust National Increase/decrease average average in % points Percentage of staff reporting good communication between senior management and staff 42% 33% 40% 30% 2% decrease Staff recommendation of the organisation as a place to work or receive treatment % increase Staff satisfaction with resourcing and support N/A Organisation and management interest in, and action on, health and wellbeing N/A (Staff survey rating system) 71

72 Bottom four ranking areas According to the National NHS England data the key findings for which we compare least favourably with other community trusts are: Percentage of staff experiencing physical violence from patients, relatives or the public in the last 12 months (key finding 22) Percentage of staff experiencing physical violence from staff in the last 12 months (key finding 23) Percentage of staff/colleagues reporting most recent experience of harassment, bullying or abuse (key finding 27) Percentage of staff agreeing that their role makes a difference to patients/service users (key finding 3). NHS Staff Survey 2014/ /16 Trust improvement / deterioration Bottom four ranking scores Trust National Trust average National Increase/ average decrease in % points Percentage of staff experiencing physical violence from patients, relatives or the public in last 12 months 9% 8% 10% 7% 1% increase Percentage of staff experiencing physical violence from staff in last 12 months 2% 1% 1% 1% 1% decrease Percentage of staff / colleagues reporting most recent experience of harassment, bullying or abuse 42% 43% N/A Percentage of staff agreeing that their role makes a difference to patients/service users 91% 91% N/A 72

73 Focus areas for action what we will do next Using the findings from the Staff Survey, we are focusing on five key areas for this coming year. The proposed action areas are based on the key findings where we had achieved a below average ranking and were: Staff safety at work Staff able to contribute to improvements at work Staff working extra hours Staff feeling like they are making a difference at work Staff recommending DCHS as a place to work The fifth finding, Staff recommending DCHS as a place to work, will likely improve if factors one to four are addressed in detail. Progress on a more detailed action plan of what we are going to do to improve staff satisfaction in each of these key areas will be reported bimonthly at the quality people committee. Since March, we have consulted a number of key groups to get to a position where we now have a plan of actions we are going to take against each focus area over the next 12 months. These groups have included: people and organisational teams, Staff Forum and operational managers. This year we have decided to have one organisational Staff Survey Action Plan rather than lots of local plans. Leaders are instead being engaged with to contribute to the overall organisational direction on this, but in their own areas to consider their own local results and put in any bespoke initiatives that might be needed. For example: In the Health, Wellbeing and Inclusion Division, the leadership team is holding regular Getting it Right sessions with staff, where staff are invited and encouraged in a supportive environment to share concerns at work so that managers may act upon these. In the IFM (Integrated Facilities Management) Division, the leadership team has recognised that the majority of staff do not have easy access to computers and their accounts, and this has put their teams at a disadvantage in an organisation that relies increasingly on ecommunication to cascade messages. Measures are being introduced, for example: a local monthly printed newsletter which highlights key organisational issues, division issues and locality messages and the chief executive s VLOG which can be played at team meetings to staff to try and improve the sense of belonging 73

74 and understanding of the organisation that can help staff feel like they are making a difference at work. The proposed focus areas of action following the 2015 Staff Survey results are identified in the table below. These have been based on the areas where our trust was ranked in the bottom against other community trusts and where results have deteriorated the most against the 2014 results. Staff Survey 2015 focus areas Safety staff and patients 2015 results 42% of staff/colleagues reporting most recent experience of harassment, bullying or abuse (key finding 27) 64% of staff/colleagues reporting most recent experience of violence (key finding 24) 10% of staff experiencing physical violence from patients, relatives or the public in the last 12 months (key finding 22) 1% of staff experiencing physical violence from staff in the last 12 months (key finding 23) Staff able to contribute to improvements at work 72% of staff able to contribute towards improvements at work (key finding 7) Staff working extra hours 71% of staff working extra hours (key finding 16) Making a difference 91% of staff agreeing that their role makes a difference to patients/service users (key finding 3) Recommendation as a place to 3.97 staff recommendation as a place to work or work receive treatment (key finding1) Pulse checks Three times a year we encourage all our staff to complete a ninequestion (threeminute) pulse check to test the mood and wellbeing of employees and teams, as a miniinternal staff survey. This helps us pinpoint where and how we need to give extra support and intervention on a rolling basis to maintain staff morale. 74

75 Pulse checks were launched in 2013 to give quick anonymous feedback on how well staff feel they are being managed, engaged and supported. This is now linked with our staff Friends and Family Test. The positive impact high staff engagement can have on other key performance indicators such as attendance, patient safety and productivity is recognised and well researched. It also shows leaders how well they are engaging with their teams to deliver the results we need, primarily around quality care for our patients. The overall engagement scores for each quarter to date are: July 2013: 77% October 2013: 77% January 2014: 79% April 2014: 76% July 2014: 76% January 2015: 77% April 2015: 75% July 2015: 76% January 2016: 74% In recent pulse checks these are the responses we received to the following questions: How likely are you to recommend Derbyshire Community Health Services NHS Foundation Trust to friends and family if they needed care or treatment? April 2015: 89% July 2015: 91% January 2016: 90% How likely are you to recommend Derbyshire Community Health Services NHS Foundation Trust to friends and family as a place to work? April 2015: 69% July 2015: 70% January 2016: 68% 75

76 NHS Foundation Trust Code of Governance has applied the principles of the NHS Foundation Trust Code of Governance on a comply or explain basis. The NHS Foundation Trust Code of Governance, most recently revised in July 2014, is based on the principles of the UK Corporate Governance Code issued in Council of Governors Our Council of Governors play a vital role in the work of the trust. They work with our trust board in ensuring the organisation develops services which best meet the needs of patients, families and carers. Our governors hold the nonexecutive directors individually and collectively to account for the performance of the board of directors. They play a vital role in representing the views of, and providing a link to our members, public, staff and our partner organisations. Their other statutory roles include: Appointing and removing the chair and other nonexecutive directors Agreeing the terms and conditions of the chair and the other nonexecutive directors Approving the appointment of the chief executive Receiving the trust s annual accounts and annual report Commenting on the Trust s strategic planning Appointing and removing the external auditors Approving changes to the constitution Expressing a view on the board s plans for the NHS foundation trust, in advance of submitting plans to Monitor Taking decisions on nonnhs income Taking decisions on significant transactions. 76

77 Our Council of Governors has 17 elected public governors, 10 elected staff governors and three appointed governors from partner organisations. Their terms of office and attendance at council of governors meetings from 1 April 2015 to 31 March 2016 were: Elected public governors Ray Asher Peter Ashworth Valerie Broom Roz Coldicott Bridget Leech Michael Perry Linda Barker Sandra Moody Lorraine Culpin Barry Jex Maureen Strelley Andrea Cooke Constituency Term of office Term of began office ends Amber Valley, Erewash & South Derbyshire Amber Valley, Erewash & South Derbyshire Amber Valley, Erewash & South Derbyshire Amber Valley, Erewash & South Derbyshire Amber Valley, Erewash & South Derbyshire Amber Valley, Erewash & South Derbyshire Bolsover, Chesterfield & North East Derbyshire Bolsover, Chesterfield & North East Derbyshire Bolsover, Chesterfield & North East Derbyshire Bolsover, Chesterfield & North East Derbyshire Bolsover, Chesterfield & North East Derbyshire Derbyshire Dales & High Peak 1 November October /6 1 November October /6 1 November October /6 1 November October /6 1 November October /6 1 November October /6 1 November October 2015 (resigned) 3/3 1 November November 2015 (resigned) 2/3 1 November October /6 1 November October /6 1 November October /6 1 November October /6 Attendance (actual/possible) 77

78 Brenda Greaves Derbyshire Dales & High Peak 1 November October /6 Paul Kirtley Derbyshire Dales & High Peak 1 November October /6 Roger Green Derbyshire Dales & High Peak 1 November October /6 Bernard Thorpe City of Derby 1 November October /6 Diana Wood Rest of England 1 November October /6 Elected staff governors SallyAnn Coope Constituency Term of office began Term of office ends Attendance (actual/possible) Nursing 1 November October /6 Veronica HuntingYoung Nursing 12 March October /6 Denise Sanderson Nursing 1 November June 2015 (resigned) 0/1 Maggie ParryHughes Nursing 23 June October /5 Amanda Smith Medical and dental 1 November October /6 Sara Nash Other registered professionals 1 November October /6 Emma Brooks Other registered professionals 1 November October /6 Tabitha Jane Crapper Healthcare support 1 November staff October /6 78

79 Joan Johnson Healthcare support 2 March 2015 staff 31 October /6 Gavin Sykes Facilities and estates 1 November Feb 2016 resigned 0/5 Adam Short Administration, clerical and managers 1 November October /6 Appointed governors Jackie Pendleton Organisation NHS Commissioners (North Derbyshire Clinical Commissioning Group) Mark Smith NHS Commissioners (North Derbyshire Clinical Commissioning Group) Jenny NHS Commissioners Swatton (Southern Derbyshire Clinical Commissioning Group) Paul Jones Derbyshire County Council Term of office began 1 November 2014 Term of Attendance office ends (actual/possible) 30 October 2/ (resigned) 2 November October /3 22 September September /3 1 November October /6 Two staff governors, Denise Sanderson and Gavin Sykes and two public governors, Linda Barker and Sandra Moody, resigned during the year. Denise was replaced by Maggie ParryHughes. We are in the process of securing replacement governors for the seats of Gavin, Linda and Sandra. In September 2015 Southern Derbyshire Clinical Commissioning Group became the replacement organisation for the partner governor seat held previously by Healthwatch. Jenny Swatton became the appointed governor on behalf of Southern Derbyshire Clinical Commissioning Group. In November 2015 Mark Smith replaced Jackie Pendleton as the appointed governor on behalf of North Derbyshire Clinical Commissioning Group. In September 2015 the Council of Governors elected the lead governor, Bernard Thorpe, and deputy lead governor, Ray Asher. 79

80 Governor elections In July 2016 we are due to begin the nomination process in elections for 14 of our 30 governors who are coming to the end of their terms of office. This will involve five staff governor posts and nine public governor posts in the constituencies of Bolsover, Chesterfield and north east Derbyshire (four posts); Amber Valley, Erewash and south Derbyshire (three posts) and Derbyshire Dales and High peak (two posts). The election date is set for 30 September with notification of results on 3 October Contacting the Council of Governors Members and the public can contact the Council of Governors via DCHST.Governors@nhs.net Council of Governors meetings In March 2015 the council of governors increased the number of meetings from four to six per year: Wednesday 13 May 2015 Wednesday 1 July 2015 Wednesday 9 September 2015 Wednesday 4 November 2015 Wednesday 13 January 2016 Monday 7 March During the regular meetings the governors are updated on the performance of our trust. Members of the public can attend and information about these meetings is available on our website: Governor groups An important development in 2015/16 has been the formation of four informal governor subgroups of the council. The groups support governors to be involved in key areas of our organisation s work and to meet with the executives and nonexecutives that lead that work. Governors report back to the full council meetings regarding the work of each of the groups. The strategy group contributed to the review of the strategic and operational plans for 2016/17, tenders, new service implementation and winter planning. The quality group focused on activities to maintain quality and service. This included involvement in the production of the annual quality report, a deeper understanding of the work of the quality service committee and shaping the insight visits to our sites and community services. 80

81 The governance group recommended amendments to the Constitution, reviewed the council s terms of reference key performance indicators and reviewed external auditor plans. The engagement group reviewed the membership strategy and also discussed how to build clear engagement with members, public and patients. Governors were also involved and gained insight into many different activities across the organisation. Some of these were: Participation in insight visits to our wards and community teams Involvement in important internal groups such as the clinical effectiveness group and patient engagement and experience group Participation in PLACE (patient led assessments of the care environment) visits Attendance at meetings and workshops regarding the system transformation programmes for integrated services in north and south Derbyshire Providing a governor perspective for our initiatives and events. Constitution The Council of Governors provided valuable input to the review of the Trust s constitution. The latest version of our constitution is available on our website: Nominations and remuneration committee In 2015/16 the committee: Took assurance from the completed annual appraisals, including key successes and objectives for 2015/16, for the chairman and nonexecutive directors Amended the code of conduct for governors Recommended the appointment of the new vice chair Recommended the extension of tenure for named nonexecutive directors Recommended the recruitment of an additional nonexecutive director. The process for appointing a new nonexecutive director involves the post being advertised nationally; applicants are then longlisted and shortlisted, with shortlisted applicants asked to complete an assessment process. Following completion of the recruitment process the committee makes a recommendation for appointment to the full council of governors. 81

82 Board and governors relationship The Board works closely with the Council of Governors to ensure it understands their views and those of our members. The Trust s chairman Prem Singh also chairs the Council of Governors and is supported at every meeting by the chief executive Tracy Allen and the appointed vice chairman BarbaraAnne Walker. The chairman also chairs the nominations and remuneration committee. The chairman works closely with the nominated lead and deputy lead governors and also meets regularly with each constituency of governors to discuss matters that interest or concern them. The senior independent director is Nigel Smith and the other nonexecutive directors attend the council of governors meetings, along with all the executive directors and take part in open discussions that form part of each meeting. Council of Governors meetings have a regular agenda item to support and promote holding to account whereby each of the nonexecutive directors in turn makes a presentation and receives questions about the work of the board subcommittees that they chair. We have an engagement policy for the Council of Governors around their engagement with the trust board, in compliance with the NHS Foundation Trust Code of Governance, which provides the process by which the council can raise concerns related to the overall wellbeing of the NHS foundation trust if the need arises. Training and development activities in 2015/16 involved: An induction programme for new governors to ensure they fully understand their statutory duties. New governors are also paired with a buddy governor to ensure they successfully join the council Development of the knowledge of the existing governors through their chosen areas of interest via involvement with the new governor groups Workshops included strategic developments and membership engagement activity Governors took part in a leadership development forum to build the knowledge of our organisation s leaders about the council of governors Attendance at national conferences. 82

83 Attendance at the Council of Governors meetings by Board members 1 April 2015 to 31 March 2016 Name Prem Singh (chairman) Attendance (actual/possible 5/6 Tracy Allen (chief executive) 5/6 Chris Bentley (nonexecutive director) 3/6 Tim Broadley (acting director of strategy) 1/1 Melanie Curd (acting trust secretary) 1/1 Kirsteen Farrar (trust secretary) 4/5 William Jones (director of operations/chief operating officer) 2/6 Rick Meredith (medical director) 4/6 Tony Okotie (nonexecutive director) 0/1 Amanda Rawlings (director of people and organisational effectiveness) 3/6 Chris Sands (director of finance, performance and information) Nigel Smith (nonexecutive director) 5/6 BarbaraAnne Walker (nonexecutive director) 4/6 Carolyn White (chief nurse/director of quality) 4/6 Ian Lichfield (nonexecutive director) 4/6 John Coyne (nonexecutive director) 2/3 3/6 To enhance the board and governor relationship, governors and nonexecutive directors work closely together in the governor subgroups. The governance group governors also attend meetings held by the nonexecutive directors. Governors are encouraged to attend our public board meetings and also our board subcommittee meetings. These meetings provide governors with the opportunity to reflect on the business discussed by the board and to ask questions of the board. 83

84 Meetings held Attendance at trust board meetings by executive and nonexecutive members April 2015 Prem Singh, Tracy Allen, Tim Broadley, Kirsteen Farrar, William Jones, Ian Lichfield, Rick Meredith, Amanda Rawlings, Chris Sands, Nigel Smith, BarbaraAnne Walker, Carolyn White May 2015 Prem Singh, Chris Bentley, Tim Broadley, Kirsteen Farrar, William Jones, Ian Lichfield, Rick Meredith, Tony Okotie, Amanda Rawlings, Chris Sands, BarbaraAnne Walker, Carolyn White June 2015 Prem Singh, Tracy Allen, Chris Bentley, Melanie Curd, William Jones, Ian Lichfield, Rick Meredith Tony Okotie, Amanda Rawlings, Chris Sands, Nigel Smith, BarbaraAnne Walker, Carolyn White July 2015 Prem Singh, Tracy Allen, Chris Bentley, Kirsteen Farrar, Ian Lichfield, Rick Meredith, Tony Okotie, Amanda Rawlings, Chris Sands, Nigel Smith, BarbaraAnne Walker September Prem Singh, Tracy Allen, Chris Bentley, Kirsteen Farrar, William Jones, 2015 Ian Lichfield, Rick Meredith, Amanda Rawlings, Chris Sands, BarbaraAnne Walker, Carolyn White October 2015 Prem Singh, Tracy Allen, Chris Bentley, Kirsteen Farrar, William Jones, Ian Lichfield, Rick Meredith, Amanda Rawlings, Chris Sands, Nigel Smith, Carolyn White November 2015 Prem Singh, Tracy Allen, Chris Bentley, John Coyne, Kirsteen Farrar, William Jones, Ian Lichfield, Amanda Rawlings, Chris Sands, Nigel Smith, BarbaraAnne Walker December 2015 Prem Singh, Tracy Allen, Chris Bentley, John Coyne, Kirsteen Farrar, William Jones, Ian Lichfield, Rick Meredith, Amanda Rawlings, Chris Sands, Nigel Smith, BarbaraAnne Walker, Carolyn White January 2016 Prem Singh, Tracy Allen, Chris Bentley, John Coyne, Kirsteen Farrar, William Jones, Ian Lichfield, Rick Meredith, Amanda Rawlings, Chris Sands, Nigel Smith, Carolyn White February 2016 Prem Singh, Tracy Allen, Chris Bentley, Kirsteen Farrar, William Jones, Ian Lichfield, Rick Meredith, Amanda Rawlings, Chris Sands, Nigel Smith, BarbaraAnne Walker, Carolyn White March 2016 BarbaraAnne Walker, Tracy Allen, Chris Bentley, Kirsteen Farrar, William Jones, Ian Lichfield, Rick Meredith, Amanda Rawlings, Chris Sands, Nigel Smith, Carolyn White. 84

85 Audit and assurance committee The audit and assurance committee, chaired by Nigel Smith, provides the board of directors with an independent review of financial and corporate governance and risk management. It provides an assurance of independent external and internal audit, ensures standards are set and monitors compliance in nonfinancial, nonclinical areas of the trust. Our internal clinical audit function is described in more detail in the quality report within this annual report. The trust has an internal audit function, provided by 360 Assurance, which provides: An independent objective opinion to the accounting officer, the board of directors and the audit and assurance committee on the degree to which risk management, control and governance, support the achievement of the trust s agreed objectives. An independent and objective consultancy service specifically to help line management improve the trust s risk management, control and governance arrangements. Recommendations from internal audit reports are tracked by the Audit and Assurance Committee to ensure prompt implementation. During the year there were no high risk recommendations identified. The audit and assurance committee provides board oversight of data quality and monitors implementation of the data quality improvement plan on a quarterly basis. The trust routinely reports on data quality to the Board of Directors on a monthly basis as part of its performance dashboard. The information management and technology (IM&T) group has lead responsibility for data quality. Meetings held 2015 April May July October 2016 January Members attended Attendees Nigel Smith, Ian Lichfield, BarbaraAnne Walker Nigel Smith, Ian Lichfield, BarbaraAnne Walker Nigel Smith, Ian Lichfield Nigel Smith, Ian Lichfield, BarbaraAnne Walker Tony Okotie, Chris Sands Nigel Smith, Ian Lichfield Kirsteen Farrar, Chris Sands, Rick Meredith Kirsteen Farrar, Chris Sands, Carolyn White Chris Sands, Melanie Curd Kirsteen Farrar, Chris Sands, Rick Meredith, Prem Singh 85

86 Nominations and remuneration committee The nominations and remuneration committee, chaired by Prem Singh, considers and makes recommendations relating to the appointment, remuneration and other relevant issues, for the chairman and nonexecutive directors. Meetings held Members attended Attendees 2015 May Prem Singh, Brenda Greaves, Kirsteen Farrar, Amanda Barry Jex, Paul Kirtley, Adam Short, Rawlings, BarbaraAnne Bernard Thorpe Walker October Prem Singh, Brenda Greaves, Kirsteen Farrar, Amanda Barry Jex, Paul Kirtley, Adam Short, Rawlings Bernard Thorpe 2016 January Prem Singh, Brenda Greaves, Barry Jex, Paul Kirtley, Sallyann Coope, Bernard Thorpe Kirsteen Farrar, Amanda Rawlings March Prem Singh, Barry Jex, Paul Kirtley, Adam Short, Bernard Thorpe Kirsteen Farrar, Amanda Rawlings Our Board of Directors The Board of Directors brings a wide range of experience and expertise to their leadership of the trust and continues to demonstrate the vision, oversight and encouragement required to enable it to thrive. In 2015/16 the Board membership consisted of the following executive directors: Tracy Allen (chief executive); Tim Broadley (acting director of strategy); Kirsteen Farrar (trust secretary); William Jones (director of operations/chief operating officer); Rick Meredith (medical director); Amanda Rawlings (director of people and organisational effectiveness); Chris Sands (director of finance, information and strategy) and Carolyn White (chief nurse/director of quality). 86

87 The Board included the following nonexecutive directors: Prem Singh (chairman); Chris Bentley (nonexecutive director); Nigel Smith (nonexecutive director) and BarbaraAnne Walker (nonexecutive director and also appointed vice chairman from 13 January 2016). Ian Lichfield (nonexecutive director) joined the board from 1 April 2015 after the resignation of Barry Steans as a nonexecutive director, effective from 31 December Tony Okotie (nonexecutive director and vice chairman) resigned his post effective from 30 June Professor John Coyne joined as a nonexecutive director on 1 November In order to develop an understanding of the views of governors and members about the NHS foundation trust, members of the Board have regularly attended Council of Governors meetings. Governors are able to share the views of their constituent members at these meetings. Members and governors are actively encouraged to attend the monthly public board meetings to influence discussion and make the Board aware of constituents views. Feedback channels and engagement opportunities are routinely publicised via our regular membership communications, e.g. participation in PLACE visits and sharing opinion on corporate publications. Trust Board The Trust Board leads by undertaking three key roles: Formulating strategy Ensuring accountability by holding the organisation to account for the delivery of the strategy and through seeking assurance that systems of control are robust and reliable Shaping a positive culture for the board and the organisation. The Board has a number of subcommittees and has chosen to delegate some of its powers to those committees and some individual officers of the trust. The matters reserved for the board and the matters delegated are detailed within the scheme of delegation. The scheme of delegation also includes a statement on the roles and responsibilities of the council of governors. Membership of the Trust Board is balanced, complete and appropriate. We are confident that all the nonexecutive directors are independent in character and there are no relationships or circumstances which are likely to affect or could appear to affect their judgement. The Board of Directors is not aware of any relevant audit information that has been withheld from the Trust s auditors, and members of the board take all the necessary 87

88 steps to make themselves aware of relevant information and to ensure that this is passed to the external auditors where appropriate. There has been no external evaluation of the board and the board has reviewed the effectiveness of its systems of internal control. Directors consider the annual report and accounts, taken as a whole, is fair, balanced and understandable and provides the information necessary for patients, regulators and stakeholders to assess our performance, business model and strategy. Board members executive directors Chief executive: Tracy Allen Tracy Allen was appointed to the post of chief executive of Derbyshire Community Health Services NHS Trust on 1 April 2011, having previously worked as managing director when the services operated as an autonomous provider organisation within NHS Derbyshire County Primary Care Trust. She led the creation of Derbyshire Community Health Services from the provider arms of six predecessor primary care trusts, its successful development into an autonomous provider organisation and its establishment as a community NHS trust. Her previous role was as executive director of strategy and service improvement at Sherwood Forest Hospitals NHS Trust where she led the development of the service development strategy underpinning the organisation s successful authorisation as a foundation trust. Tracy is an exnhs management trainee and has a wide range of operational and strategic management experience in NHS organisations. Director of finance, information and strategy: Chris Sands Chris is a chartered management accountant by profession, and an economics graduate. He has extensive experience of operating at board level, and for the previous six years has held the post of director of finance and compliance for Lincolnshire Partnership NHS Foundation Trust. He has 17 years experience of working in the NHS in the acute, community and mental health sectors. He brings to the Trust strong experience of operating in a foundation trust environment at board level, and experience of governing a large complex organisation. Chris has experience, at director level, of successfully navigating the foundation trust application process. Chris joined the Trust in August 2011, and along with his executive responsibility for finance, performance, contracting and information management and technology he is also deputy chief executive. 88

89 Trust secretary: Kirsteen Farrar Kirsteen has worked as the trust secretary since the formation of Derbyshire Community Health Services and previously held a similar position within Derbyshire County Primary Care Trust. Kirsteen has worked within the NHS since Initially participating in a graduate training scheme in human resources in Manchester she then worked in various HR roles in Sheffield and Derby. She has held a number of positions in primary care development, clinical governance and training and development within Derbyshire. Kirsteen is a graduate of the Institute of Personnel and Development and has gained an MSc in healthcare governance. Kirsteen is a nonvoting member of the Trust Board. Director of operations/chief operating officer: William Jones William qualified as a podiatrist in 1984, specialising in the care of patients with diabetes. He moved into general management having completed the Trent general management training scheme and membership of the Institute of Health Service Management in Previous executive roles include director of planning for an NHS Trust and deputy chief executive for North Eastern Derbyshire Primary Care Trust. In 2008 he was appointed as chief executive of Derbyshire Health United, a social enterprise, providing urgent care and care in custody services for local health commissioners and Derbyshire Constabulary. He has a strong interest in primary care and leads the Trust s liaison with GP commissioners. William joined the Trust in June 2011 and is responsible for the delivery of all the operational services provided by the trust. Medical director: Rick Meredith Rick joined the Trust in December 2012 following a secondment to the organisation. He was appointed clinical director for the integrated communitybased services division and was our acting medical director from September 2013 until his substantive appointment in November Rick has a background in primary care and was a GP in Chesterfield from 1984 to November Rick has a specific interest in care of the elderly and is very involved in working with partner organisations to integrate and improve services for patients. 89

90 Director of people and organisational effectiveness: Amanda Rawlings Amanda was appointed as director of human resources and organisational development on 1 April Previously Amanda was the director of human resources and organisational development across Derbyshire County Primary Care Trust and Derbyshire Community Health Services as one statutory organisation. Amanda joined the NHS in April 2007, having previously spent her career in the private sector; mainly for Caterpillar, Perkins Engines Co Limited and British Sugar. Amanda has an MSc in management, is a fellow of the Chartered Institute of Personnel and Development and is coopted into a Peterborough housing association, Cross Keys Homes. She was named HR director of year in the UKwide Healthcare People Management Association awards in Director of quality/chief nurse: Carolyn White Carolyn joined the Trust in September 2013 as chief nurse and director of quality, following a successful secondment into the same post earlier in the year. Carolyn trained as a registered sick children s nurse and a registered general nurse in Liverpool and spent all her clinical practice in children s specialist intensive care services in several leading children s hospitals, including ward sister in the paediatric intensive care unit at Great Ormond Street Hospital for Sick Children and as a research nurse for the British Heart Foundation. In 1992 she was appointed to her first NHS management role at Royal Hull Hospitals NHS Trust where she worked for nine years, during which time she completed an MSc in health services research. In 2001 she was appointed as the executive nurse director for Sherwood Forest Hospitals NHS Foundation Trust, where she worked for 11 years, developing the role from new and latterly serving as the trust s interim chief executive for nearly two years before joining the executive team at Derbyshire Community Health Services. Carolyn has a passion for ensuring that high quality patient care is delivered consistently and that staff, supported by welldeveloped clinical leaders, are consistently able to meet and sustain high standards of compassionate care. Board members nonexecutive directors Chairman Prem Singh Prem joined the Trust as chairman on 1 December He has spent most of his career working in the NHS in the East Midlands and South Yorkshire and also worked in social services in Sheffield for seven years. 90

91 Prem has extensive experience of health and social care management, having served on board level positions for over 23 years. He was chief executive of Derby City Primary Care Trust and previously Chesterfield Primary Care Trust, and he has a general and psychiatric nursing background. He has previously led community, mental health and learning disability services, including as an executive director of nursing and quality at board level. Prem is an Institute of Leadership and Management (ILM 7) qualified executive coach. Prem has extensive networks and a national reputation. He was previously appointed to take the lead on inclusive leadership on the National Leadership Council and named in the inaugural Health Service Journal listing, as a (Top 50) black and minority ethnic BME pioneer. More recently he was appointed as a trustee of the NHS Confederation board and invited by the chairman of NHS Improvement to join a group of 25 chairs nationally to form the first chairs advisory partnership. As a chief executive and now as a chairman, Prem has expertise in developing high performing boards with clear strategic direction, robust governance arrangements with clear accountability frameworks for executives and nonexecutives. Delivery, performance and results orientated, he has a proven track record in leading transformational change, developing and improving high quality and safe services. As an experienced leadership mentor and accredited executive coach, his independent consultancy business portfolio includes executive coaching, organisational and leadership development, executive team and board development support. Nonexecutive director: Chris Bentley Chris Bentley, who lives in the Hope Valley, is a medical doctor and Fellow of the Royal College of Physicians and a fellow of the Faculty of Public Health. He qualified as a doctor in 1977 and worked in London teaching hospitals for five years before joining the emergency refugee programme in Somalia and acting there as a government advisor on behalf of UNICEF on issues of primary health care. On returning to the UK, Chris held posts as director of public health in West Sussex, Sheffield and South Yorkshire. In 2006 he was appointed head of the health inequalities national support team for the Department of Health, which he led until Chris was awarded a visiting chair in public health at Sheffield Hallam University in He is now working as an independent consultant, with contracts at local, regional and national level in the UK as well as in Europe. In 2014 he was appointed as chair of the technical advisory committee of the national Advisory Committee on Resource 91

92 Allocation (ACRA). He is chair of our quality service committee and sits on our quality people committee. Nonexecutive director: John Coyne Professor John Coyne is an economist who graduated from the University of Nottingham and has spent over forty years in academia. He began as a lecturer in industrial economics at Nottingham University and his most recent post before his retirement in July 2015 was vicechancellor of the University of Derby. His career included being a founding director of The Centre for Management Buyout Research, the founding director of Leicester Business School and pro vice chancellor of de Montfort University. He has published widely in the field of buyouts, corporate change, enterprise and small firms. He has consulted for a wide range of organisations and is the director of a specialist research company Cfe Research Ltd which he cofounded in He has served on the board of many regional organisations and was for four years a commissioner of the UK Commission on Employment and Skills. He was awarded an honorary doctor of laws degree by Nottingham University in 2014 and a CBE in the New Year honours list Nonexecutive director: Ian Lichfield Ian Lichfield has a wealth of experience in the commercial sector. From 2008 to 2011 he was chief financial officer of Tarmac Building Products Ltd and went on to be the company s chief executive from 2011 until 2014, when he completed the successful sale of the company. Previously he held several senior finance and commercial roles and has extensive board level general management and functional leadership experience, including managing a number of jointventures. He has significant experience in restructuring, reorganising and rationalising businesses and has led the acquisition, integration and sale of several companies. He is particularly interested in delivering cultural and behavioural change in organisations as well as ensuring a safe and healthy working environment. Ian is a qualified chartered accountant and has enjoyed an international career, living in the Czech Republic, France, Germany, Hong Kong and the People s Republic of China. He is the chair of our quality business committee and sits on the audit and assurance committee. 92

93 Nonexecutive director: Nigel Smith Nigel Smith joined us as a nonexecutive director in April 2012 and is our appointed senior independent director. He is a qualified accountant who has performed a variety of senior finance roles in the Post Office, Consignia and more recently Royal Mail. He is currently head of health & safety for Royal Mail Group, which includes responsibility for health & safety compliance across all the group companies. He has an honours degree in economics from Lancaster University, is a member of the Chartered Institute for Public Finance and Accountancy and holds a national general certificate in health & safety. Nigel is also a director and treasurer of a local housing association, and a citizens panel member for North East Derbyshire. Nonexecutive director: BarbaraAnne Walker BarbaraAnne Walker has been a nonexecutive director with us since December 2009 and was appointed vice chairman in January 2016; having previously served as a nonexecutive director with Rushcliffe Primary Care Trust from 2001 to BarbaraAnne has an MA in psychology and has worked in the charity sector for almost 30 years, managing health and social care services. After a number of years working in HIV and sexual health in Scotland, BarbaraAnne subsequently held a range of local and national roles including national training manager with the Family Planning Association and programme manager for social care with Macmillan Cancer Support. She currently works as an operations director for the British Red Cross. Evaluation There has not been an external evaluation of the Trust during the financial year. The trust and its governance arrangements were reviewed extensively as part of its foundation trust application during 2014 and in line with Monitor s code of governance a further external review is being planning for However, there has been significant internal evaluation. The Board has undertaken a selfassessment against Monitor s wellled framework, building on the work that was completed for the quality governance assurance framework. All of our committees and groups undertake an annual review and a paper on the work of the main subcommittees of the Board is discussed at the audit and assurance committee. 93

94 All of our directors and nonexecutive directors undergo an annual appraisal. The chief executive and directors appraisals are discussed at the remuneration and terms of service committee by the nonexecutive directors. The chair and nonexecutive directors appraisals are discussed at the nomination and remuneration committee by our governors. All of our nonexecutive directors are considered to be independent according to the criteria set out in Monitor s code of governance. The term of office may be terminated by resignation or by the approval of threequarters of the members of the council of governors. The nonexecutive directors have the following terms of office: Name Prem Singh Role Chair Appointment date 1 December 2013 Expiry date 30 November 2017 BarbaraAnne Walker Nonexecutive director 31 March 2015 extended to 1 November May 2015 given extension to 31 March 2017 Chris Bentley Nonexecutive director 1 April 2011 (started as independent committee member 1 December 2009) Reappointed 1 April November 2011 Nigel Smith Nonexecutive director 1 April March May 2015 given extension to 31 March 2018 Ian Lichfield Nonexecutive director 1 April March 2018 John Coyne Nonexecutive director 1 November October November May 2015 given extension to 31 October 2017 Our membership Our membership is a vital asset in ensuring we remain accountable to the public we serve. Members are kept informed via newsletters, s and invitations to events, such as our annual general meeting, regular Trust Board and Council of Governor meetings. 94

95 Our strategy for membership is to maintain our current levels and representative mix of membership and move towards introducing more opportunities for our members to engage in our work and encourage involvement in shaping services from the outset of any proposed changes. We constantly monitor our membership to ensure that it is representative of our population so that we are ready to take proactive steps to address any representation issues which may arise. During 2015/16 we have worked with our equality and diversity team to identify opportunities to recruit and engage with members of the public with defined protected characteristics. This was facilitated via our Access to Healthcare Forums, healthrelated community groups and other ethnic and cultural communitybased groups. In 2015 we held open days at two of our community hospital sites. These events gave members and the general public an opportunity to view the range of facilities and services available to them. It was also a chance to talk to members of staff and learn more about what we do and to promote opportunities for member involvement. These pilots were successful and we are holding three more open days in Public members of the trust have been invited to join our readers panel. The panel comments on documents and patient information before it is published. We recruited 20 new readers panel members during the year and recent information sent to the panel for comment includes the care home advisory services leaflet and the male and female triage forms for our sexual health services. Members were invited to take part in our 2016 PLACE visits (patient led assessments of the care environment) across our sites during March. We initially approached individuals who were trained and involved in the visits in previous years, before also opening up the opportunity to other members of the public. Over the year, there were a number of consultation events around the redevelopment of healthcare facilities in Heanor and the Belper health review. These were publicised to members and the general public as opportunities to give their views. Members were invited to attend Heart Start courses (CPR) held in partnership with East Midlands Ambulance Service. More than 100 members took part in this vital training and the feedback was excellent with nearly everyone saying how worthwhile 95

96 the course had been; raising their confidence levels in delivering CPR if needed. We are offering this training again in 2016 and will augment it with other health information sessions for our members. The Board of Directors monitors how representative the NHS foundation trust's membership is by receiving detail as part of its performance report and approving the membership strategy. The Board also monitors the level and effectiveness of member engagement via its subcommittee reporting structure. There are two membership categories and we strive for a membership that represents the communities we serve: Public anyone over the age of 12 living in England who has an interest in the services that we provide. This includes past and present patients, carers and members of the public. Staff employees and volunteers of the Trust are automatically enrolled as a staff member unless they choose to opt out. Our membership stands at 17,416 members, comprising 12,380 public members and 5,036 staff members* (figures accurate at 31 March 2016). See below for a breakdown of constituencies in both public and staff membership and an illustration of constituency boundaries. In summary, our strategy for membership is to maintain our current levels and representative mix and to introduce more opportunities for our members to engage in our work. It is vital that our members are encouraged to shape services from the outset of any proposed changes. 96

97 Membership profile by constituency Public Derbyshire Dales and High Peak 1,388 City of Derby 2,334 Bolsover, Chesterfield & North Derbyshire 2,767 Amber Valley, Erewash & South Derbyshire 3,291 Rest of England 2,586 Out of trust area 14 Total: 12,380 Staff Medical and dental 85 Nursing 1,503 Other registered professionals 775 Admin, clerical and managers 1,017 Healthcare support staff 1,109 Facilities & Estates 547 Total: 5,036 Our overall membership target by volume is to maintain more than 1% of the population we serve in Derbyshire while ensuring it is as representative as possible. This is measured and reported to Trust Board monthly. We are always keen to hear members views and anyone who wants to find out more or get in touch should contact: Membership Office Walton Hospital Whitecotes Lane Chesterfield Derbyshire S40 3HW Tel:

98 Illustration of constituency boundaries You can securely sign up to be a public member online at: Trust members and members of the public who wish to contact the Council of Governors can do so via DCHST.Governors@nhs.net 98

99 Regulatory ratings report 2015/16 Overall financial sustainability risk rating Continuity of service rating Governance rating 2014/15 Annual plan 4 Q1 Q2 Q3 Q N/A N/A N/A Green Green Green Green Green Annual plan 4 Continuity of service rating Governance Green rating Q1 Q2 Q3 Q4 N/A N/A 4 4 n/a n/a Green Green 99

100 Statement of accounting officer s responsibilities Statement of the chief executive's responsibilities as the accounting officer of The NHS Act 2006 states that the chief executive is the accounting officer of the NHS foundation trust. The relevant responsibilities of the accounting officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by Monitor. Under the NHS Act 2006, Monitor has directed Derbyshire Community Health Services NHS foundation trust to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of Derbyshire Community Health Services NHS foundation trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. In preparing the accounts, the accounting officer is required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to: observe the accounts direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis make judgements and estimates on a reasonable basis state whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance and prepare the financial statements on a going concern basis. The accounting officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS foundation trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. 100

101 The accounting officer is also responsible for safeguarding the assets of the NHS foundation trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor's NHS Foundation Trust Accounting Officer Memorandum. Tracy Allen Chief executive Date: 26 May

102 Annual governance statement 1 April March Scope of responsibility 1.1 As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS foundation trust s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also personally responsible for ensuring that the NHS foundation trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum. 2. The purpose of the system of internal control 2.1 The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to: identify and prioritise the risks to the achievement of the organisation s policies, aims and objectives of Derbyshire Community Health Services NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. 2.2 The system of internal control has been in place in Derbyshire Community Health Services NHS Trust for the year ended 31 March 2016 and up to the date of approval of the annual report and accounts. 3. Capacity to handle risk 3.1 The Board has the ultimate responsibility for risk management and the review and approval of high risk treatment options. The Trust s risk management framework encompasses a Risk Management Policy which describes DCHS 102

103 approach to risk management including the processes, roles and responsibilities which underpin it. 3.2 The Trust has an effective Board, with an appropriate balance of skills and experience and with constructive challenge from the NonExecutive Directors. There is an induction and development programme in place for Board members and a formal and rigorous evaluation of Board effectiveness has been undertaken. 3.3 The Chief Executive has overall responsibility for the management of risk by the Trust. The Director of Quality / Chief Nurse is responsible for the risk management strategy and policy. The Executive Team exercise lead responsibility for specific types of risk. 3.4 The Quality Services Committee takes the lead Committee role for ensuring the risk register is robust. The Committee undertakes monthly reviews of the Top X risk register, and quarterly reviews of the full risk register. 3.5 The Audit and Assurance Committee takes the lead role in ensuring the risk management control system is robust. The Audit and Assurance Committee reviews the Board Assurance Framework at each meeting to ensure risks to the achievement of strategic objectives are being effectively managed. 3.6 The Audit and Assurance Committee annually reviews attendance at Trust committees, and will report any concerns around quoracy through to the Board for action 3.7 The role of each Executive Director is to ensure that appropriate arrangements are in place for the: Identification and assessment of risks and hazards. Elimination or reduction of risk to an acceptable level. Compliance with internal policies and procedures, and statutory and external requirements. Integration and implementation of functional risk management systems and development of the assurance framework. 3.8 These responsibilities are managed operationally through corporate managers supporting the Executive Directors and working with designated lead managers within Operational Divisions. 3.9 The Trust has a Risk Management Strategy in place, which is reviewed annually and approved by the Board. The objectives in the strategy are 103

104 regularly reviewed during the year to ensure that risk is fully embedded in the day to day management of the organisation and conforms to best practice. The Strategy defines risk and identifies individual and collective responsibility for risk management within the organisation. It also sets out the Trust s approach to the identification, assessment, scoring, treatment and monitoring of risk Staff are equipped to manage risk in a variety of ways and at different levels of strategic and operational functioning. These include: Formal inhouse training for staff as a whole in dealing with specific everyday risk, e.g. fire safety, health and safety, moving and handling, infection control, information governance and security. Training and induction in incident investigation, including documentation, root cause analysis, steps to prevent or minimise recurrence and reporting requirements. Developing shared understanding of broader business, financial, environmental and clinical risks through collegiate clinical, professional and managerial groups. Use of a reporting database to support risk management, Datix, which is recognised as best in class The organisation s key strategic risks are identified in the Board Assurance Framework, which is reported to the Board of Directors quarterly. These risks are categorised as Quality Service, Quality People, Quality Business and Governance risks. The appropriate committee reviews these risks on a quarterly basis to ensure the risk assessment is current, and to ensure risks are removed when closed, and added when new risks emerge. 4. The risk and control framework 4.1 The system of internal control is based upon an ongoing risk management process designed to identify the principal risks to the achievement of the organisation s objectives; to evaluate the nature and extent of those risks; and to manage them efficiently, effectively and economically 4.2 The key elements of the Risk Management Strategy are that: Risk is a key organisational responsibility. All staff must accept the management of risks as one of their fundamental duties. Every member of staff must be committed to identifying and reducing risk 104

105 The management of risk is best achieved through an environment of honesty and openness, where mistakes and untoward incidents are identified quickly and dealt with in a positive and responsive way and lessons learnt are communicated throughout the organisation and best practice adopted. 4.3 The tools used to identify, evaluate and control risks are those outlined in the Australian/New Zealand AS/NZ 4360:1999 using the 5x5 matrix for consequence and likelihood. The use of this tool ensures consistency of risk assessment across the organisation. 4.4 Risks that are assessed as low indicate management by routine procedures. Moderate risks require specific management responsibility and action. High risks require senior management attention. Extreme risks require immediate action, including informing the Board of Directors. 4.5 The key ways in which risk management is embedded in the activity of the organisation is through ensuring staff are aware of their responsibilities and accountabilities as set out in the risk management strategy. Assurances on how effectively the Risk Management System is working is through inspections such as, environmental, infection control, security, workplace and fire safety and through the health and safety and clinical governance activities 4.6 This is supported through the Trust s induction programme, training updates and individual training as a result of needs assessments. The Trust has introduced a performance management framework which includes the effective management of risk as a key element. The organisation undertakes Equality Impact Assessments on all functions it carries out to ensure that service delivery and employment practices comply with legal requirements. 4.7 The Trust involves key stakeholders in the management of risks. This includes: Patients and their carers. The general public through consultations. Council of Governors Trust membership Staff Partnership Committee Staff Forum Frontline Care Council Mental Health Act Committee (MHAC) Health and Safety Committee (HSC) 105

106 Operations Senior Management Team Clinical Commissioning Groups (CCG) Local Authorities (LAs) Improvement and Scrutiny Committee (ISC) Care Quality Commission (CQC) NHS England NHS Improvement Healthwatch. 4.8 The Trust has developed an integrated Assurance Framework to ensure that there are proper internal and independent assurances given on the soundness and effectiveness of the system and on the processes in place for meeting its objectives and delivering appropriate outcomes. 4.9 The Board of Directors determines the strategic objectives of the Trust. Achievement of these strategic objectives is performance managed through the Board Committee structure. Strategic risks, which threaten the achievement of strategic objectives, are identified and key controls put in place to manage these risks. The Board is provided with reports to enable it to monitor the effectiveness of each element of the Assurance Framework The Board of Directors has considered the key controls that are in place to identify risks, and has assessed whether these controls are adequate. Where gaps in controls have been identified, action plans have been put in place to address the weaknesses The Board of Directors has mapped out how assurances relate to strategic objectives, and identified where gaps exist. Action plans are in place to ensure further assurance is given in these areas. The Trust uses external bodies to provide assurance, where available, and targets the internal audit and clinical audit programmes at specific areas to provide assurance The recommendations from internal audit reports are tracked by the Audit and Assurance Committee to ensure prompt implementation. During the year there were no high risk recommendations identified 4.13 The Trust ensures a strong relationship between the assurance framework and risk register. The two documents are cross referenced, with the assurance framework including strategic risks, and the risk register operational risks. 106

107 4.14 Sections of the assurance framework have been assigned to the Board and its Committees to ensure that there is clear oversight of all areas. Where lack of assurance, or gaps in control are identified, these are escalated to the Board of Directors. The Audit and Assurance Committee is responsible for maintaining the overview of the framework The Board of Directors uses the assurance framework to provide assurance when signing declarations to third parties The Directors are required to satisfy themselves that the Trust s Annual Quality Account is fairly stated. In doing so the Trust is required to put in place a system of internal control to ensure that proper arrangements are in place. The Trust has appointed a member of the Board, the Director of Quality / Chief Nurse, to lead, and advise on all matters relating to the preparation of the Trust s Annual Quality Account. To ensure that the Trust s Quality Account presents a properly balanced view of performance over the year, the Quality Services Committee provides scrutiny and challenge over Trust clinical performance. The Trust also has quarterly Quality meetings with its main commissioner The Quality Service Committee has responsibility for reviewing assurances over clinical quality. The Board Committees have responsibilities for ensuring assurance is obtained routinely on compliance with CQC registration requirements. The Audit and Assurance Committee maintains an overview of compliance The Trust routinely reports on data quality to the Board of Directors on a monthly basis as part of its performance Dashboard. The Audit and Assurance Committee provides Board oversight of data quality and monitors implementation of the data quality improvement plan on a quarterly basis. The Information Management and Technology (IM&T) Group has lead responsibility for data quality The Trust has a process in place for the revalidation of medical staff. This process is overseen by the medical director The Trust also has a process in place for ensuring that clinical staff renew their professional registration. Where staff s registration is at risk of lapsing, this is flagged to the chief nurse/director of quality. This process is overseen by the director of people and organisational effectiveness 107

108 4.21 The Trust has a Raising Concerns Policy in place. The policy sets out how these concerns will be investigated. The Trust has also developed a Raising Concerns The DCHS Way App 4.22 Control measures are in place to ensure that all the organisation's obligations under equality, diversity and human rights legislation are complied with As an employer with staff entitled to membership of the NHS Pension scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer s contributions and payments in to the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations The foundation trust has undertaken a climate change risk assessment and developed an Adaptation Plan, to support its emergency preparedness and civil contingency requirements, as based on the UK Climate Projections 2009 (UKCP09), to ensure that this organisation s obligations under the Climate Change Act are met The Trust has a Major Incident and Business Continuity Plan. This document has been reviewed inyear to reflect the latest guidance from NHS England and the learning from incidents, training and exercises. The Quality Business Committee receives a quarterly assurance report on progress with the plan The foundation trust is fully compliant with the registration requirements of the Care Quality Commission PwC are the Trust s external auditors and 360 Assurance are the internal auditors and providers of Counter Fraud services The Trust has a director responsible for Security Management and has access to a local security management advisor as required by NHS Protect. The Quality Business Committee receives a quarterly assurance report with progress against the plan. 5 Review of economy, efficiency and effectiveness of the use of resources 5.1 The Trust uses a range of key performance indicators (KPIs) which include nonfinancial measures, to manage the day to day business. This approach 108

109 helps to provide a comprehensive and balanced view of performance. More information about KPIs can be read in our Quality Report. 5.2 During the year, the Board of Directors has received regular reports providing information on the economy, efficiency and effectiveness of the use of resources. The reports provide detail on the financial and clinical performance of the Trust during the previous period and highlight any areas through benchmarking or a traffic light system where there are concerns around economy, efficiency and effectiveness of the use of resources. The reports, supplied by general and service managers of the Trust, show the integrated financial, risk and performance management which support efficient and effective decision making by the Board of Directors. 5.3 Internal audit has reviewed the systems and processes in place during the year and has published reports detailing the required actions within specific areas to ensure economy, efficiency and effectiveness of the use of resources is maintained. The internal audit reports provided to the Audit and Assurance Committee throughout the year gave an assessment of assurance in these areas 5.4 The Board of Directors has also received assurances on the use of resources from agencies outside the Trust, including Monitor. The Board of Directors selfassess on a quarterly basis and Monitor scores this assessment using its Financial and Governance Risk Ratings 6 Information governance 6.1 The Trust has systems and processes in place to govern access to confidential data and to ensure certain standards are followed when data and information is in transit. Any new system or process needs to meet these standards as does any hardware (e.g. computers or software). All system developments whether new or existing need to follow a process and be signed off by the IM&T Group to ensure they meet the required criteria and that hardware and software is compatible. 6.2 The Trust monitors its information governance risks through the Information Governance Group. Incidents and risks are managed in accordance with Trust policy and serious risks are escalated through either Information Management and Technology (IM&T) Group or more urgent ones through the Executive Team, Quality Services Committee and Board of Directors. 109

110 6.3 During the financial year, the Trust had two data security breaches at Level 2 that were reported to the Information Commissioner. Of these breaches: The first incident originally occurred in October 2013 and involved several documents containing patient information found in the home of a clinician who had since left the employment of the Trust. Following the receipt of further information, the incident was reviewed and a full disclosure to the ICO was made in November The ICO have investigated and confirmed that they are assured as to how the incident has been dealt with. The second incident relates to the loss of a box of between pieces of inactive personal identifiable information consisting of entries around diabetic care. The records had been stored in a locked cupboard in a locked room but have since been moved and now cannot be found. DCHS is awaiting a response from the ICO in relation to this incident. 6.4 The Trust investigates all Level 2 incidents, and reviews these through the Information Governance group so that learning can be shared and actioned. 7 Annual Quality Report 7.1 The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended) to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports which incorporate the above legal requirements in the NHS Foundation Trust Annual Reporting Manual. 7.2 The Directors are required to satisfy themselves that the Trust s Annual Quality Report is fairly stated. In doing so the Trust is required to put in place a system of internal control to ensure that proper arrangements are in place. The Trust has appointed a member of the Board, the director of quality/chief nurse, to lead and advise on all matters relating to the preparation of the Trust s Annual Quality Report. 7.3 To ensure that the Trust s Quality Report presents a properly balanced view of performance over the year, the Quality Services Committee provides scrutiny and challenge over Trust clinical performance. The Trust also has quarterly Quality meetings with its main commissioner, and submits quarterly information to Monitor as part of the Governance Risk Rating review. 110

111 7.4 To ensure that there are appropriate controls in place to ensure the accuracy of data, the Trust has a data quality improvement plan in place. Progress with improving data quality is reported through to the Audit and Assurance Committee. 8. Review of effectiveness 8.1 As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of internal auditors, clinical audit and the executive managers and clinical leads within the NHS foundation trust who have responsibility for the development and maintenance of the internal control framework. I have drawn upon the content of the quality report attached to this Annual report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the sytem of internal control by the board, audit and assurance committee, quality service committee, quality people committee and quality business committee and a plan to address weaknesses and ensure continuous improvement of the system is in place. 8.2 Executive directors within the organisation who have responsibility for the development and maintenance of the system of internal control provide me with assurance. The Assurance Framework itself provides me with evidence that the effectiveness of controls that manage the risks to the organisation achieving its principal objectives have been reviewed. My review is also informed by major sources of assurance detailed below. 8.3 I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Board of Directors, the Audit and Assurance Committee, the Quality Service Committee, the Quality People Committee and the Quality Business Committee. A plan to address weaknesses and ensure continuous improvement of the system is in place. 8.4 The processes that have been applied in maintaining and reviewing the effectiveness of the system of internal control include the roles of the following: The Head of Internal Audit provides me with an opinion on the overall arrangements for gaining assurance through the Assurance Framework 111

112 and on the controls reviewed as part of the internal audit work. The Head of Internal Audit Opinion for 1st April 2015 to 31st March 2016 is as follows: Significant assurance can be provided that there is a generally sound system of internal control, designed to meet the organisations objectives, and that controls are generally being applied consistently. The Assurance Framework itself provides me with evidence that the effectiveness of controls that manage the risks to the organisation achieving its strategic objectives have been reviewed. The work of our external auditors to review the arrangements in place for producing the quality report, and to advise us of best practice to inform our development in this area, provides me with assurance. The work of our external auditors to review the arrangements in place for producing the financial accounts, and providing an opinion on them, provides me with assurance. The work of our internal auditors in completing their riskbased targeted programme of reviews provides me with assurance on the effectiveness of controls. The work of our clinical audit team provides me with assurances of the effectiveness of controls in clinical areas. The quarterly returns to Monitor provide me with assurance that the trust met the requirements of its License conditions in 2014/15 from when we became a foundation trust. The Audit and Assurance Committee provides the Board with an independent and objective view of arrangements for internal control within the Trust and to ensure the Internal Audit service complies with mandatory auditing standards, including the review of all fundamental financial systems. The Trust undertook an internal audit against the information governance toolkit, which provided evidence to support the Trust s view that it was compliant with the standards. The Trust continues to take action to ensure the standards of information governance are improved further in line with best practice. 112

113 The Board of Directors has identified the strategic risks facing the organisation during the period and has monitored the controls in place and the assurances available to ensure that these risks are being appropriately managed. 9. Significant Control Issues 9.1 During the year, there have been no significant control issues: 10. Conclusion 10.1 My review confirms that Derbyshire Community Health Services NHS Foundation Trust has a generally sound system of risk management and internal control that supports the achievement of its policies, aims and objectives The Trust will continue to use the assurance framework to assure the Board of Directors and others that the Trust s key controls to manage strategic risks are being assessed and continuously improved Where areas of concern are identified, action plans have been put in place to close the gap in control or assurance. Signed (on behalf of the Board of Directors) Tracy Allen Chief executive Date: 26 May

114 Sustainability At we have a Boardapproved sustainable development management plan (SDMP) which identifies how we will meet our corporate and social responsibilities, including our carbon reduction targets. We continue to meet or exceed our targets making excellent carbon and cost reductions and putting us on target to achieve 34% carbon reduction emissions by To measure our overall progress across a range of sustainable development areas we use the NHS Sustainable Development Unit (SDU) good corporate citizenship toolkit3. This is a tool to help us assess how sustainable we are. It provides us with a benchmark to measure our progress, not just by measuring fuel bills, waste or water usage, but by evaluating sustainability across a range of areas. The toolkit requires us to assess ourselves against a series of statements and awards a score which is converted to a percentage. The target percentage scores in this toolkit are: Year NHS Sustainable Development Unit targets 25% 50% 75% Our scores, using this toolkit, continue to improve across all areas. The following table clearly shows we have exceeded the 2015 targets and are well on the way to meeting the 2020 targets: Good corporate citizen area Organisation Travel Procurement Facilities management Workforce Community engagement Buildings Adaptation Models of care Total score 2 3 Score (%) 56% 64% 50% 92% 61% 54% 90% 86% 66% 70% Using 2007/8 baseline 114

115 As well as using this toolkit to measure our wider sustainable development, we also specifically measure our energy, waste, water and travel carbon emissions. Energy Energy is one of the most difficult assets to manage in a large, complex and diverse organisation like ours. In addition, increasingly unpredictable seasonal temperature changes and oil price volatility make it extremely challenging to stay on course to meet our targets. Despite this, we are making good and persistent savings year on year and staying on target. This is due to capital investments in recent years and a sustainable culture now embedded within the organisation. In 2015/16 we reduced our energyrelated carbon emissions (CO2) by 12%, (1,177 tonnes) compared with 2014/15. Resource Use (kwh) Gas tco2e Use (kwh) Oil tco2e Use (kwh) Electricity tco2e Total Energy CO2e Total Energy Spend 2013/14 25,651,268 5, , ,091,626 4, ,960 1,750, /15 25,186,564 5,284 84, ,481,356 4, ,861 1,692, /16 21,278,536 4,464 78, ,449,372 4,193 8, ,700,828 Carbon (tco2e) Carbon emissions energy use 12, , , , , , Gas 2013/14 Oil 2014/15 Coal 2015/16 Electricity Waste A good waste management system is key to ensuring legal compliance is met and costs are reduced. We have made significant savings for the past several years. The past year, however, was an exception due to major staff accommodation 115

116 relocation programmes, overall waste related carbon emissions increased by 16% (18 tonnes). Waste Recycling/ reuse (tonnes) tco2e (tonnes) Incineration tco2e (tonnes) Landfill tco2e Total waste (tonnes) Percentage recycled or reused Total waste tco2e 2013/ / / Weight (tonnes) Waste breakdown Recycling/ reuse 1, Other Landfill Water We have comprehensive measures for water conservation and are able to detect leaks and other issues quickly when they occur. We continue to look at ways in which we can reduce our water usage, but options are relatively limited compared with the other areas of energy and waste. Water usage related carbon emissions have increased by 7% (4 tonnes). Water Mains m 3 tco2e Water and sewage spend 2013/ / /16 72,145 65,632 69, , , ,

117 Travel We have to travel around the county quite extensively in order to carry out our services effectively. The table below shows our travel CO2 increased during Due to changes in the way we provide services, with a greater focus on caring for patients in the community and, in particular, the transfer of over 400 additional staff from Derby city community services, it is not appropriate to make a direct comparison of our total mileage during 2015 to the previous year. Category Business travel Mode km tco2e 2013/14 4,451,340 1, /15 4,578,325 1, /16 4,967,186 1,490 We are continuing to find ways to reduce our travel carbon emissions, using teleconferencing and other agile working technology, developing our low emissions pool car fleet and looking at other ways to support our staff to reduce their travel. We use teleconferencing in order to reduce the need to travel, particularly to meetings. During 2015 our staff carried out over 2,350 teleconferences saving an estimated 34 tonnes of CO2. We have been working with Cowheels car club to provide pool cars for our staff to use for business travel since During 2015 we increased the availability of cars on our own sites from 10 to 20, but our staff also have access to a further 15 cars across Derby and Derbyshire through the Cowheels car club system. The fleet on our sites are all low emission cars, and they now include a fully electric vehicle, seven plugin hybrid Outlanders and five further hybrid cars. Our staff can book these cars, replacing the need for them to use their own cars, using an online booking system. Our pool fleet cars have average carbon emissions well below that of most cars. Following the introduction of the additional cars during 2015, business travel in the low emission pool cars has increased to over 8,000 miles per month (at an average of 72g/Km CO2 emissions), which gives us estimated savings of eight tonnes of CO2 per year, compared with staff using their own cars. We introduced a new lease policy in 2014 which aimed to increase the take up of low emission cars. The new scheme has an upper CO2 limit of 135g/Km, but also provides additional incentives to staff who select a car below 110g/Km. 117

118 The result of this lease car scheme has been excellent. The average CO2 of all new cars bought in the UK in 2014 is reported4 as 124.6g/Km. The average CO2 of cars on our new lease scheme during 2015 was just 106.3g/Km. Modelled carbon footprint These tables and diagrams show our overall carbon footprint using a model developed by the NHS sustainable development unit. Category Energy Travel Procurement Commissioning % CO2e 87% 11% 2% 0% Proportions of carbon footprint 2% 11% Energy Travel Procurement 87% Commissioning 118

119 Carbon footprint CO2e baseline to 2020 with climate change targets Derbyshire Community Health Services NHS Trust Modelled 1990 baseline Modelled 2007 baseline 10% target from 2007 Trajectory to 2020 Modelled forecast YearChange Act Trajectory Climate 34% target from 1990 baseline Key Gas Electricity Travel, waste and water 119

120 Equality, diversity, inclusion and human rights We are committed to achieving equality, celebrating diversity, fostering a culture of inclusion and respecting human rights. As an NHS organisation, we have both a legal and moral duty to demonstrate fairness and equality to our patients and services users, their carers and families, and to our employees. We understand and appreciate that everyone is an individual, with different needs and requirements. People have very different life experiences and sometimes face many challenges and barriers to accessing our services and opportunities. We also recognise that it isn t simply access to our services that s a challenge it s important to ensure that people get equitable outcomes from the care they receive from us. We want to provide a wide range of quality health services that are designed to meet people s individual needs. We are committed to personalising our services to ensure that the most positive outcomes are achieved for all. We take seriously our duties, under the Equality Act, to eliminate the unlawful discrimination of our staff and service users, to advance equality of opportunity for all and to foster good relations between all people. We are implementing NHS England s equality delivery system 2 (EDS2), which provides a framework for us to monitor and improve our equalities practice. Our equalities strategy and priority equality objectives We have an equalities strategy which identifies our current priority objectives and the actions we are taking to achieve these: Objectives Consider the impact of what we do (or are planning to do) on all sections of the community/protected characteristics Increase and improve our awareness and understanding of equality, diversity, inclusion and human rights issues Actions include: Complete equality impact assessments (EIAs) to make sure we understand the impact of our decisions on people Use monitoring information collected to analyse trends and inform decisions Raise profile of equality, diversity, inclusion and human rights across the whole trust. Develop staff, public governors and board members understanding and build competencies around equality, diversity, inclusion and human rights Raise awareness across the trust of the importance of 120

121 Better understand, and more effectively meet, the needs of all our service users/patients Better understand the profile and experiences of our employees and achieve a diverse workforce Progress the equalities agenda within Derbyshire Community Health Services NHS Foundation Trust understanding who our service users are and ensuring we provide them with individualised, personalised care (equality monitoring). Ensure all the trust s buildings are accessible to all All service areas to complete action plans to improve access to, and outcomes from, individual services and improve patient experience. Produce and publish annual workforce equality data reports reporting performance against key metrics for all protected characteristics Produce and publish performance against NHS England s workforce race equality standard Improve employees declaration of race, disability and sexual orientation Analyse Staff Survey data by protected characteristic Participate in NHS England s learning disability employment project Continue to improve our ranking in the Stonewall workplace equality index. Participate in NHS Employers equality and diversity partners programme Benchmark our performance on equalities with other trusts Audit against the EDS2 and involve staff and service users in confirming the trust s grading Prepare and publish information to comply with the public sector equality duty, i.e. our equality objectives and the actions we plan to take, monitoring information for our workforce and service users. 121

122 Our governance structures Our equality, diversity and inclusion leadership forum (EDILF) coordinates action across the trust to reduce disadvantage, discrimination and inequality of opportunity for all our employees and service users. EDILF is a formal sub group of the quality people and quality service committees, which report directly to the Trust Board. It provides support and assurance to these committees and determines our equalities priorities, objectives and actions. The forum oversees the implementation of the NHS equality delivery system 2 and workforce race equality standard, as well as ensuring compliance with the Equality Act 2010 s public sector equality duty. It manages and monitors progress made towards achieving the trust s aspirations to be an exemplar of best equalities practice. Our achievements During 2015/16 we: held four meetings of our access to healthcare forum which is a representative group of service users with protected characteristics. This forum is helping us to improve the services we provide and how they are delivered as well as supporting us with our equalities progress trained staff to understand and address issues of inequality and discrimination through our awardwinning equalities forum theatre group, which has travelled across the county to deliver engaging and participative training sessions improved our approach to equality impact assessments ensuring that all key decisions taken by our trust board and the three quality committees have been considered in terms of their effect on all members of the community improved coverage of equality, diversity, inclusion and human rights in our induction training sessions for new employees and in our refresher essential learning sessions for staff continued to support our three employee network groups for our black minority ethnic (BME), lesbian, gay, bisexual and transgender (LGB&T) and disabled staff and their allies improved our ranking in the Stonewall workplace equality index to 171st began to implement our internship programme for people with a learning disability, in collaboration with Chesterfield College, as part of NHS England s programme to increase the employment of adults with a learning disability across the NHS 122

123 were chosen to participate in the NHS Employers equality and diversity partners programme to help us to develop equalities best practice audited our performance against the requirements of EDS2 and working with our access to healthcare forum on our grading marked the 2015 national equality, diversity and human rights week ran a development session with our trust board, which resulted in the creation of our board equalities action plan. Board commitment The Trust Board is leading the agenda to secure a real step change in our equalities progress. A Trust Board development session in May 2015 focused on progress from good to great in equality issues. Board members have established an equalities forum which enables employees from underrepresented groups a direct line to the Trust s most senior leaders, to raise issues and concerns and to secure support. The first meeting of this forum took place in March We also held an inaugural DCHS inclusion event on 16 March 2016, targeting leaders across the organisation and highlighting where we want to be as an organisation on this important agenda. Attendees were taken on an inspiring journey with the aim of creating a social movement and raising awareness of the unconscious bias many of us carry. The outcome was a genuine and collective commitment to improve, supported by a full action plan. Executive and nonexecutive members of the Trust Board have offered to mentor members of the Trust s employee network groups; two mentor/mentee relationships have already been established with more in the pipeline. We are establishing our equality allies programme to engage the whole workforce, governors and trust board in the agenda and to ensure we achieve positive and sustainable change. About our workforce Our annual workforce equality data and analysis report (published on the website) has been produced to provide a detailed analysis of our workforce by the protected characteristics of age, gender, disability, race, religion or belief, sexual orientation and marital status. It shows how representative our workforce is of the local population, i.e. our service users and the wider community. It also contains an indepth look at a wide range of workforce metrics by protected characteristic, such as service area, salary band, 123

124 staff group, applicants for jobs, disciplinary performance management, grievances, dignity at work cases, redundancies, leavers and staff development (training). The report compares data from this and previous years to provide a greater insight into the pace of change within the trust. In summary, the data shows: the highest proportion of our employees are aged years; younger workers (1625 years) are underrepresented in comparison to the local population (3.8 per cent compared with 11.4%). 2.7% of our employees currently declare a disability or longterm condition. We do not know the disability status of 14% of our workforce. 88% of our employees are female; 95% of nursing, midwifery and health visiting staff are female, as are 71% of medical and dental staff. 3.3% of our workforce are BME (from a black or other ethnic minority background), which compares to a Derbyshire population of 2.4%, an East Midlands population of 10.6% and 14% in England. 16.2% of our BME staff are in bands 8 9 or VSM (WRES, 2014); 92% of all appointments to jobs were from the white ethnic group. 49% of our employees define themselves as being Christian, compared to a figure of 58% in the East Midlands. 66% of our workforce has defined themselves as heterosexual and 10% have not stated their sexual orientation. 60.2% of employees are married and 24.2% are single; 1.1% are in a civil partnership. About our service users We use the electronic patient records systems TPP SystmOne and PAS to gather information about our service users to improve the quality of care they receive from us. We have designed an equality monitoring questionnaire so that our staff can ask patients and service users questions that will improve the care being delivered. Answers to these questions will also help us to make sure we provide the right level of information about the care we are providing and ensure that it is tailored to meet individual needs. The equality data we currently have is limited to the protected characteristics of age, gender, ethnicity and religion/belief. We have produced an analysis for our community services, inpatient services, outpatients services and minor injury units. 124

125 In summary, an analysis of our community service users shows: the majority of our service users describe themselves as white British. A significant proportion of our service users ethnicity is still unknown. we provide services to people from the ages of 0 to 119; the age profile of our service users depends on the services they access men and women access our services, however the actual proportion of users of one sex or the other depends on the type of service being provided we do not have religion or belief (including no belief) data for the majority of our service users, however the data that has been gathered indicates that the majority of those people whom we have information about identify themselves as Christian. Our future plans We have identified that, over the coming 12 months, we need to address these particular areas of focus: getting better at collecting information about our employees and our service users; we need to ensure that we always know what people s individual needs are and that we can meet them ensuring that we provide information and communication in an accessible way that meets the needs of individual service users and employees implementing actions to achieve a more diverse workforce, including tackling unconscious bias in our recruitment and selection processes building cultural competence and raising awareness around equality, diversity, inclusion and human rights across the whole organisation at every level. Further information about our approach to equality, diversity, inclusion and human rights can be found on our website at: 125

126 Quality report Part 1 Introduction Welcome to the 2015/16 Annual Quality Report I am delighted to introduce this Quality Report which sets out how we have been working in the last year to assure and improve the quality of the services we provide and achieve our vision of being the best provider of local healthcare and a great place to work. Highlights of the year have included: 98% of the more than 16,000 patients we surveyed recommending the Trust to their family and friends. Developing the provision of vital children s, sexual health and wellbeing services across Derbyshire with a range of partner organisations following competitive tender processes managed by Derbyshire County Council. Expanding the range of integrated services we provide to include general practice and taking over responsibility for adult community services provision in Derby City. Delivering a sustained reduction in avoidable pressure ulcers within our services, recognising that the overall level of pressure damage across our communities remains a significant concern. Playing an important role in enabling an increasing number of patients with complex needs to avoid hospital admission or leave hospital earlier, particularly over the winter period when local hospitals have experienced unprecedented pressures. Maintaining a positive, open, quality focused culture as evidenced by our high levels of incident reporting and our national staff survey results, where our colleagues reported performance that was average or above average against 30/32 key areas compared to our peer community trusts. Increasing again our overall level of staff engagement reported through the national staff survey to one of the highest levels amongst peer trusts. Developing our Quality Always Clinical Assessment and Accreditation Scheme across the Trust to underpinning our approach to making sustainable quality improvements and providing assurance about the care we deliver. This report reflects on our achievements and challenges in improving quality during 2015/16. We hope that you will agree that much progress has been made as a result of the great commitment of our staff and I would like to take this opportunity to recognise and thank them for their continued dedication. Our staff are at the heart of the way we care for our patients and looking after them effectively is one of the most important things we can do to deliver excellent care. 126

127 During 2016/17 we will continue to develop our staff health and wellbeing services, focus on staff safety and on ensuring a culture across the Trust where everyone feels comfortable and supported to raise concerns and speak out about things which need to improve. We continue to set ourselves high ambitions on behalf of the people we care for and support across the community. There is more that we want, and need, to achieve to continue to improve the quality of our services for them and we have set out in this report our priorities for 2016/17. These build on what we know about our services and learning from our staff at the frontline of care delivery, what our patients have told us is important to them and in response to local commissioners and national priorities. Declaration of accuracy I can confirm on behalf of the Trust s Board that to the best of or our knowledge and belief, the information contained in this Quality Report is accurate and represents our performance in 2015/16 and our priorities for continuously improving quality in 2016/17. Tracy Allen Chief Executive 127

128 Part 2 Priorities for improvement and statements of assurance from the board 2.1 Priorities for improvement This quality report demonstrates our achievements for the year 2015/16, describes the areas where we would still like to make improvements and our quality objectives for the coming year. Each year DCHS sets itself stretching improvement targets referred to as The Big 9 The Big 9 are split into three domains quality services quality people and quality business in line with the DCHS Way. During 2015/16 our three key quality priorities focused the whole organisation on quality improvement in areas of patient safety, clinical effectiveness and patient experience. These priorities were: To improve information sharing Information Governance regulations restrict clinicians from sharing patient information with colleagues unless the patient has given their informed consent. Sometimes this inhibits the way in which we care for our patients as uptodate information related to their condition is not readily available, this objective was set to ensure clinicians have uptodate information regarding their patient whilst maintaining the patients right to confidentiality. To increase the number of referrals to Smoking Cessation services made by DCHS staff. We know that smoking has one of the biggest negative impacts on our population s wellbeing and as responsible health providers want to support our patients wherever we can to quit smoking. To identify where patients with a learning disability access our services Patients with a learning disability may need additional help and support to ensure equitable access to our health services. During 2105/16 we set out to try to identify patients with a learning disability to ensure that they were appropriately supported when using our services. 128

129 Whilst progress has been made against all three of these stretch quality improvements we are disappointed that we have not achieved the targets that we set ourselves. Improvements in information sharing. We set out to improve access to health records by asking our staff to ask their patients at each contact for permission for their health records being shared with other health practitioners to ensure better continuity of care. Many services have made good improvements with this target and some have excelled although there is still room for improvement. Significant progress has also been made across the health and social care community with the development and agreement of information sharing protocols which allow the sharing of information between health professionals where it is in the patients best interest and meets stringent information governance standards. Further work is required to develop our information technology infrastructure to improve data flows and information accessibility. This work will be continued during 2016/17 and will be supported by our continual roll out of our electronic patient management system. Progress against this target will be reported to and monitored by the information governance group. Increase the number of referrals to smoking cessation services. This target has proved most challenging in terms of data capture again due to our information systems not having the facility to easily capture smoking cessation referrals. We will continue to work with our staff to make improvements and to use the Making Every Contact Count framework (MECC) the mechanism by which we achieve this. Performance will be reported through our performance dashboard which is updated on a monthly basis. Identify where patients with a learning disability access our services. This target was chosen in an attempt to better understand where patients with a LD access DCHS services so that we can ensure access to appropriately trained staff and information. It has proven difficult to capture this information 129

130 due to the broad spectrum of learning disability and some patients not declaring a particular need when accessing the services. Through our equality, diversity and inclusion forum we will continue to work toward improving our data capture and have a particular work stream regarding development of more accessible information. In addition to our organisationwide quality improvement targets in 2015/16 we have been working to achieve a combination of quality objectives and service improvements which we set ourselves, together with quality targets which are set out in our contract with local health service commissioners. These are reported in more detail in the body of this report. Our quality priorities build upon what we already know about our services, what our patients have told us are important to them and in response both to commissioners and national priorities. We also place a great emphasis on learning from our staff who are at the frontline of care delivery and we have developed an effective network of ways to engage with them and hear their feedback. We are particularly proud of our annual staff survey results 2015, which listed us as one of the best performing trusts, based on feedback from our staff. 2.2 Things we want to do better in 2016/17 We are continually striving to improve the quality of the services we provide and to learn from things that did not go so well. For 2016/17 our Board of Directors has agreed three strategic quality improvement objectives: Quality Objectives 1) Patient Safety to decrease the overall burden of pressure damage within our health community by a reduction of pressure ulcer incidents as a percentage of patients looked after by our services 2) Clinical Effectiveness to introduce across our services a nationally recognised measure of frailty which will help us to identify patients at risk and proactively manage their care Monitoring progress Implementation of our pressure ulcer reduction plan will be monitored monthly through the patient safety group and reported monthly to Quality services committee (QSC) and board via the Big 9 performance framework. A six monthly deep dive on progress and issues will be presented to QSC. The frailty screening measure will be reported monthly via the BIG 9 performance framework and will be monitored through the clinical effectiveness group on an exception reporting basis 130

131 3) Patient Experience to improve our performance in relation to complaint response rates ensuring that patients receive a response to any concerns raised within a reasonable timeframe Complaints response times will continue to be monitored by the patient engagement and experience group on a monthly basis and reported monthly via the Big 9 performance framework to the board These three quality improvements have been chosen as a result of feedback from our board of directors, our governors, our staff and most importantly our patients. Pressure ulcers and increasing frailty have been identified as significant issues within our local population and account for a large percentage of the resources we deploy. Ensuring services are appropriately aligned for these issues will mean that our services are delivered as effectively and efficiently as possible and bring benefit to the greatest number of patients. Ensuring that patients who raise concerns about our services receive a comprehensive and timely response is a trust priority, however, we know from feedback from our patients and commissioners that we could improve further hence our third improvement target. Metrics for each of these improvements will be identified and will be measured on and reported on a monthly basis as part of our performance monitoring to the board. In addition we will continue to strengthen our internal processes for quality improvement and assurance using our Quality Improvement and Assurance Framework. We are committed to being able to demonstrate the consistency and quality of our services and we want our patients and their families to feel safe and well looked after. 131

132 We recognise the need for a continuous focus on improving our quality assurance measures so during 2015/16 we have developed our processes for assuring the quality of services and are very proud of the work we have completed towards out clinical assessment and accreditation peer review Quality Always see section Statements of assurance from the board Contracted services This section includes text and reports mandated by NHS England and Monitor During 2015/16 DCHS provided and/or subcontracted 36 relevant health services. Of these services, 30 were NHS commissioned services and a further 6 were commissioned by local authorities. Services included rehabilitation, community nursing, health visiting, school nursing, sexual health services, community dental services for patients with mental health problems and learning disabilities services, as well as a wide range of planned care services such as podiatry, physiotherapy, speech and language therapy and occupational therapy. Strategically we have continued to redesign our services with an aim to support our patients as close to home as possible. As part of our duty of care we have continuously reviewed the quality of all of our services. DCHS has reviewed all the data available to them on the quality of care in all of these NHS services. The income generated by the relevant health services reviewed in 2015/16 represents 100% of the total income generated from the provision of relevant health services by DCHS for 2015/ Core Indicators Since 2012/13 all NHS Foundation trusts are required to report performance against a set of core indicators using data made available to them by the Health and Social Care Information Centre. Many of the core indicators are not relevant to community services. Those that are applicable to us appear in the table below. For completeness we have included the full set of core indicators at appendix 8. Prescribed information 21 Related NHS Outcomes Framework Domain & who will report on them 4: Ensuring that people have a positive experience of care The data made available to the National Health Service trust or NHS foundation trust by Trusts providing relevant acute the Health and services 2014/15 89% 2015/16 (national average) 90% (69%) 132

133 Prescribed information Related NHS Outcomes Framework Domain & who will report on them 2014/ /16 (national average) Social Care Information Centre with regard to the percentage of staff employed by, or under contract to, the trust during the reporting period who would recommend the trust as a provider of care to their family or friends. DCHS considers that this data is as described for the following reasons: we have worked actively with our staff to engage them in service development and delivery. DCHS has reported consistently excellent staff survey results for the last two years. DCHS intends the following actions to improve this percentage score and so the quality of its services, by continuing to actively engage with staff and to focus on the support of new staff to the service. Comparative Data taken form National staff survey in England in 2015 When asked whether, if a friend or relative needed treatment, they would be happy with the standard of care provided by their organisation, 69% of staff agreed or strongly agreed Friends and Family 4: Ensuring that people 98.7% 98% Test Patient. The have a positive experience of (95%*) data made available care by National Health Service Trust or Trusts providing relevant acute NHS Foundation services Trust by the Health and Social Care Information Centre for all acute providers of adult NHS funded care, covering services for inpatients and patients discharged from Accident and Emergency (types 1 and 2). Please note: there is not a statutory requirement to include this indicator 133

134 Prescribed information Related NHS Outcomes Framework Domain & who will report on them 2014/ /16 (national average) in the quality accounts reporting but NHS provider organisations should consider doing so. DCHS considers that this data is as described for the following reasons: we have worked with our patients to ensure effective and robust feedback from across the breadth of our services and this is monitored by our patient experience and engagement group. DCHS has taken the following actions to improve this percentage score: engage with patients and carers, actively seek feedback, encourage completion of FFT cards, collate the findings from feedback and report on changes through our patient experience and engagement group and so the quality of its services, by improving car parking, furniture, accessible information and confidentiality. Comparative Data taken from NHS England Friends and Family Test data website Data for March 2015* shows average of 95% of patients would recommend their local community services to friends and family. Annual data not available. 23 The data made 5: Treating and caring for 99.3% 99.8% available to the people in a safe environment and National Health protecting them from avoidable Service trust or NHS harm foundation trust by the Health and Trusts providing relevant acute Social Care services Information Centre with regard to the percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period. DCHS considers that this data is as described for the following reasons: DCHS has trained its staff well and has clear clinical policies. DCHS has taken the following actions to improve this percentage score and so the quality of its services, by reviewing in detail any venous thromboembolism case to ensure any learning is shared throughout the organisation. Comparative data for community trusts is not available. 134

135 Prescribed information Related NHS Outcomes 2014/ /16 Framework Domain & who will (national report on them average) 25 The data made All trusts Total ,227 available to the 5: Treating and caring Patient National Health for people in a safe Safety Service trust or NHS environment and Incidents foundation trust by protecting them from Severe 6 39 the Health and avoidable harm harm or Social Care death Information Centre with regard to the % severe 0.06% 0.38% number and, where harm or available, rate of death patient safety incidents reported within the trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death. DCHS considers that this data is as described for the following reasons: DCHS has a culture of high reporting of clinical incidents as reported by national reporting and learning scheme NRLS. The increase in severe harm incidents is related to a higher threshold for severe pressure ulcers being introduced. DCHS has taken the following actions to improve this rate and so the quality of its services, by developing a supportive reporting culture and ensuring that lessons learned from clinical incidents are shared organisation wide. Comparative data NRLS April Sept 2015 DCHS has highest reporting culture rate per 1000 bed days compared with19 NHS community trusts.<1% of incidents in this period were reported as resulting in severe harm or death National audits During 2015/16 six national clinical audits and no confidential enquiries covered relevant health services that DCHS provided. During that period DCHS participated in 50% of the national clinical audits and 0% national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits that DCHS participated in, and for which data collection was completed during 2015/16, are listed below alongside the 135

136 number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by terms of that audit or enquiry. The reports of 2 national audits (COPD and PROM) were reviewed by the provider in 2015/16 and DCHS intends to take the actions outlined in table 2 below to improve the quality of healthcare provided. The UK Parkinson Audit report was not available at the time of writing this document. Table 1 National Chronic Obstructive Pulmonary Disease (COPD) Audit Elective Surgery (National PROMs Programme UK Parkinson s Audit National Audit of Intermediate Care Yes Yes % Submitted 100% Yes Yes 62.5% Yes Yes 100% N/A Sentinel Stroke National Audit Programme (SSNAP) National Diabetes Foot Care Audit (Part of the National Diabetes Audit) Yes Yes Did not participate due to capacity, data collection requirements and expected outcomes. Participation in this audit will be reviewed during Postponed until 2016/17 Postponed until 2016/17 data collection is being integrated into the organisations Electronic Patient Record in 2016/17. N/A Title Eligible Yes Participated N/A Local audits The reports of 24 local clinical audits were reviewed by the provider in 2015/16 and DCHS intends to improve the quality of healthcare provided as described within the table below. Priority Audit Programme Audit Focus and Outcomes Table 2 No Title 1 National Chronic Obstructive Pulmonary Disease (COPD) Audit Outcome This is a two part national audit, with a clinical audit reviewing service delivery and quality and a snap shot audit of resources and organisation of COPD 136

137 No Title 2 Sentinel Stroke National Audit Programme (SSNAP) 3 Elective Surgery (National PROMs Patient Reported Outcome Measures Programme) 4 National Diabetes Foot Care Audit (Part of the National Diabetes Audit) 5 UK Parkinson s Disease Audit Outcome services in secondary care and pulmonary rehabilitation. Results demonstrate that DCHS provides high quality pulmonary rehabilitation in line with national expectations. Improvement actions identified include: review and enhance referral pathway, review patient information leaflets, consider patient video s to educate others about the service. Review venue provision. This is a two part national audit, with an organisational audit of postacute stroke services to establish what services are commissioned and a clinical audit of patient pathway from admission to 6 months after discharge. The organisational audit is complete for Southern Derbyshire. All appropriate services have been identified and will be registered for the clinical audit in January. Our electronic patient record is being configured to collect data for this audit. This national audit seeks patient feedback regarding outcomes of selected surgical interventions, and measures health gain for patients via pre and postsurgery questionnaires. DCHS recruits groin hernia surgery patients to this audit. We have achieved a significant increase in patient recruitment in recent returns from less than 30% to 71.1%. Results show that 45.5% of our patients improved compared to a national average of 51%. Patient recruitment needs to increase further to support clinical learning as our activity for these procedures is small compared to acute trusts. This national audit enables services to measure their performance against NICE clinical guidelines and to monitor adverse outcomes for people with diabetes who develop diabetic foot disease. Before completing this audit a costing exercise was undertaken and we are now configuring our electronic patient record (ESR) to record the audit data as part of clinician patient contact and plan to be participating fully from April This national audit assists healthcare professionals to measure their service against national guidelines. We have completed our data collection. Reports will 137

138 No Title 6 Mental Capacity Act 7 Clinical Records 8 End of life Mortality audit 9 Identifying Learning Disability Outcome be available in April The goal for this audit is to make sure that people who lack the capacity to make decisions are cared for in a way that is consistent with their known wishes, and supported in the least restrictive and safe way. We are implementing the audit improvement plan re Deprivation of Liberties (DoLs) guidance for staff from last year s baseline audit for Older Peoples Mental Health Wards and Learning Disability Wards, before setting the reaudit date and a rollout plan for all other inpatient wards and other clinical services. The audit aims to ensure that optimum patient care is supported by clinical records that meet our standards. All clinical services participate on a rolling basis. The overall results for the last quarter are the highest since the July 2013 relaunch of the audit, which may in part be due to the rollout of our electronic patient record to many clinical teams and services. The goal of this audit is ensuring that patients and carers have the right support and care at the end of their life according to the 5 Priorities of Care is. The overall results for Oct to Dec 2015 (the latest period reported) shows that there has been a significant improvement in addressing social and spiritual needs of our patients. A review of unexpected deaths did not identify any failings in care. We are addressing the problems some community teams have in participating in the audit, but for the majority who are participating, standards remain high. Triangulation with Quality Always data suggests that some resuscitation discussions with family members are not always recorded. We are strengthening feedback of results to clinical teams and promoting discussion about resuscitation with patients and carers. Death classified as unexpected will be reviewed urgently. The audit tool questions are being reviewed to ensure that they reflect all aspects of care. The objective of this audit is to ensure that people with a Learning Disability using any DCHS service 138

139 No Title 10 Equality and Diversity 11 Pressure ulcers 12 Escalation of Care 13 Diabetes Flo tele health Outcome are identified so that reasonable adjustments are made to personalise their care. Initial half year results indicate that significant work is required to utilise our electronic patient record effectively for this purpose. A communication plan will be developed to educate staff about the need for this information and how it can relate to improvements in patient care. This audit aims to ensure that patients cultural, religious, gender and disability needs are documented sensitively, so that adjustments are made to ensure accessibility to our services. Data for this audit is collected via clinical records audit sample, and will report at the end of the financial year. This is a baseline audit of key standards for prevention and management of pressure ulcers. This includes the capture of clinicians perceived barriers to the delivery of consistent care, and links with the introduction and evaluation of motivational interviewing training. The staff consultation is now complete and the clinical records audit is on schedule. The findings have been widely shared and improvement actions planned include a review to free up tissue viability team time to work more closely with teams (e.g. looking at how Skype could be used for consultations) and the development of electronic patient record templates. The goal of this audit is to ensure that patients receive the correct clinical intervention when their conditions deteriorate and are transferred appropriately is. Findings to date indicate that the early warning score tool was used correctly. Patients were transferred appropriately and in a timely fashion. This is an audit of the extended roll out of the Flo tele health project which supports people with diabetes through smartphone messaging. A patient experience evaluation was completed. Results indicated that patients were very positive about their experiences, Flo was enabling them to manage their diabetes care, actions identified included working 139

140 No Title 14 Falls Prevention Wrist Bands Evaluation 15 Falls Prevention Assessment and Care Planning 16 Frail Elderly 17 Treatment Cards (Medicine management) 18 Omitted Doses (Medicine management) 19 Community Prescribers 21 Antipsychotic Prescribing 22 Control of infection Outcome with the specialist team to develop electronic records, and to review working practices to ensure consistent use of Flo telehealth. The prevention of falls for those at risk is an essential part of maintaining the independence of people and avoiding further health problems. This audit is to review the impact of the coloured wrist bands project on inpatient wards. The results for July to September 2015 (the latest period reported) indicate that there were less inpatient falls than the same period in Inconsistencies between wards using wristbands and those that did not suggest that this needs a longer period to validate. The audit is ongoing. This is an audit of the falls assessment and care planning data collected as part of the clinical records audit. The provisional data analysis for the half year shows an overall improvement in scores compared to the previous two years. The aim of this audit is to look at the clinical effectiveness of admission avoidance/early acute discharge services for the frail elderly population. Audit taking place in Quarter 4. The objective of this audit is to ensure that all inpatients receive the correct medication to enhance their recovery and that medication treatment cards comply with prescribing and administration requirements on our wards. In this audit the standard to be measured is that prescribed medicines not given to inpatients for any reason are correctly recorded, to ensure that patient care is safe and effective. The goal of this audit is to ensure that patients in the community receive safe and effective care from community prescribers. Audit currently taking place within Heart Failure and Minor Injury Units. The aim for this audit is to ensure that all inpatients on Older People s Mental Health wards are prescribed medication that complies with NICE antipsychotic prescribing guidance. The audit is shared with the Derbyshire Healthcare NHS FT. This audit checks that staff prevent cross infection to 140

141 No Title Hand Hygiene 23 Assess school readiness of children 24 UTI and catheter management in Community Nursing Outcome patients by appropriate hand washing. In the most recently reported results 93.75% of services achieved 100% hand hygiene compliance which is a decrease of 3.85% from the previous quarter. This audit is to examine the impact of children s services on school readiness. The audit identified that the highest number of children not achieving all expected outcomes relating to school readiness were in areas of increased levels of deprivation. Further analysis of the data is underway, results will be shared with clinical teams and an action plan developed. This audit is to measure practice against Urinary Tract Infection and Catheter Management standards. The aim is to reduce inappropriate prescribing of antibiotics and develop nurses knowledge of catheter management and adherence to policy. Clear learning needs have been identified around the use of antibiotics in catheterised patients. An action plan has been completed, including: Adding training to Clinical Essential training Follow up with individuals when incident reports identify incorrect practice. Training of safe care champions. A publicity strategy to circulate information to nursing staff Provision of thermometers to the nurses within the continence team to check patient s temperature and a section to be added on DATIX form regarding recording the patient s temperature. ReAudit 2016/17 The number of patients receiving relevant health services provided by or subcontracted by DCHS in 2015/16 that were recruited during that period to participate in research approved by a research ethics committee 70 in total Commissioning for Quality and Innovation (CQUIN) CQUINs are qualityrelated goals which are agreed with our commissioners each year. The goals are linked to a proportion of our income which we receive on achievement of the targets. CQUIN stands for Commissioning for Quality and 141

142 Innovation and the targets support ongoing innovation and improvement in care across our clinical services. A proportion of DCHS s income in 2015/16 was conditional on achieving quality improvement and innovation goals agreed between DCHS and any person or body they entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for 2015/16 and for the following 12 month period are available in section % of DCHS s income in 2015/16 was conditional on achieving quality improvement and innovation goals agreed between DCHS and North Derbyshire and South Derbyshire Clinical Commissioning Groups (CCG) as the lead commissioners on behalf of our four local CCGs. This was part of our contract for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. The total CQUIN contract value for 2015/16 was 3,181,922 and we are predicted to earn approximately 100% of this value, this indicates a total CQUIN payment of 3,181,922. During 2015/16 we agreed nine CQUIN measures, and acquired a further two CQUINs in October 2015 in association with the Derby City Community Services transfer to DCHS as part of our Strategic Shift programme. The themes for our CQUINs included: Patient assessment and refer for dementia (national target) Training in dementia awareness (national target) Support for carers of dementia (national target) Improving urgent care (national target) Pressure ulcers (local target) Compassion and culture (local target) End of life care (local target) Community nursing, staffing for quality (local target) Patient Flow and Discharge planning Stockport model) ( (local target) Transition of services (local CQUIN) Therapy Outcomes (local target Derby City) 142

143 2.3.6 Care Quality Commission (CQC) DCHS is required to register with the CQC and its current registration status is: registered with the CQC with no conditions attached to registration. The CQC has not taken enforcement action against DCHS during 2015/16. DCHS has participated in special reviews or investigations by the Care Quality Commission relating to the following areas during 2015/16 Looked After Children review conducted in Derby City. There were no specific recommendations for DCHS as a consequence of this review. DCHS is subject to periodic reviews by the CQC and the last comprehensive inspection was between 26 February and 4 March 2014, where DCHS volunteered to be in the first wave of new style CQC inspections, with a further focused inspection between 11 and 12 November The CQC s assessment following that review was that the Trust is fully compliant with all essential standards. As a pilot site within the new inspection regime we were not awarded a service rating. DCHS is scheduled for a further inspection by the Care Quality Commission from 9 th13th May 2016 with formal reporting back on this inspection planned for autumn During 2015 DCHS assumed responsibility for delivery of adult community care services in the Derby City area. At the point of transfer these services had been inspected by the CQC as part of the Royal Derby Teaching Hospitals NHSFT CQC inspection. At this time the adult community services were found to be noncompliant in three areas: Numbers of community nurses to deliver services Mandatory training for community teams Access to adequate numbers of computers Compliance actions were not transferred to DCHS, however we have, as would be expected, continued to work with the clinical teams to address these deficits. A comprehensive action plan was developed at the point of transfer and is subject to regular review through our governance arrangements. Our clinical quality and governance team meet regularly with local CQC representatives and keep them informed of progress and other local issues Secondary uses service data DCHS submitted records during 2015/16 to the Secondary Uses service for inclusion in the Hospital Episode Statistics, which are included in the latest published data. The percentage of records in the published data up to and including March 2016: 143

144 which included the patient s valid NHS number was: 100.0% for admitted patient care 99.1% for outpatient care 99.5% for accident and emergency care which included the patient s valid General Medical Practice Code was: 99.3% for admitted patient care 99.9% for outpatient care 99.9% for accident and emergency care Information Governance DCHS Information Governance Assessment Report overall score for 2015/16 was 73% and was graded green. 95% of staff completed information governance training in year against a target of 95% Payment by Results DCHS was not subject to the Payment by Results clinical coding audit during 2015/16 by the Audit Commission but we did initiate our own internal audit the results of which are detailed in the table below: NB. It is important that results should not be extrapolated beyond the actual sample audited. Coding Field DCHS Percentage Correct IG Req 505 Level 2 IG Req 505 Level 3 Primary diagnosis 93.5% 90% 95% Secondary diagnosis 94.6% 80% 90% Primary procedure 95.3% 90% 95% Secondary procedure 91.6% 80% 90% The following services were included within the audited sample: ICBS North and South inpatients Podiatric Surgery daycase Consultant led daycase 144

145 As a result of our internal audit results DCHS will be taking the following actions to improve data quality: o Collate all existing clinical coding policies and procedures into a single policy o Create a table of abbreviations used by all clinicians, to ensure clinical coders are translating abbreviations appropriately o Undertake regular audits of respite care records, in order to ensure the information collected is sufficient to adequately code o Introduce bimonthly internal audits, ensuring all sites have received one audit per year 2.4 Emergency Preparedness, Resilience and Response (EPRR) In line with the Civil Contingencies Act 2004 and NHS England s national programme for Emergency Preparedness, Resilience and Response (EPRR), we are actively engaged in developing and reviewing plans which ensure our ability to respond to incidents, both internally and out in the communities which we serve. We have a named Accountable Emergency Officer (Chief Operating Officer) who is a member of the Local Health Resilience Partnership (LHRP). The LHRP provides a strategic forum for joint planning across the local health community and supports the local health community s contribution to wider multiagency planning. In 2015, the Trust was awarded full assurance against NHS England s Core Standards for EPRR, following a peer review from the lead CCG. During the last year the Trust has faced a number of minor operational challenges, such as a flood at Ilkeston Hospital, telecommunications outage affecting Walton Hospital, and the Junior Doctors industrial action. These incidents allowed us to test our contingency arrangements and we are pleased to report that the affected services were either speedily recovered or redirected to alternative facilities until the affected areas and equipment were recovered and declared safe to operate. 145

146 Part 3 Review of Quality Improvements 2015/16 This section provides information on performance against our quality and performance indicators agreed internally by the Trust and also performance against relevant indicators and performance thresholds set out in Appendix A of Monitor s Risk Assessment Framework. The Trust has an established Performance Management Framework which includes a monthly Integrated Performance Report (IPR) to the board. The content of the IPR is reviewed and approved each year by the Quality Business Committee (QBC) and the Audit and Assurance Committee (AAC) on behalf of the Board of Directors. This includes all Monitor targets as defined within their Risk Assessment Framework and locally agreed indicators. This report provides performance information at Trust level and is structured around CQC s five domains: Safe, Caring, Effective, Responsive and WellLed. Data Quality Kitemark scoring Accurate information is fundamental to support the delivery of high quality care; we therefore strive to ensure all data is as accurate as possible. The Trust s Data Quality Kite Mark scoring enables the Trust to ensure that each indicator on the Trust integrated performance summary dashboard is assessed against six dimensions of data quality given as a summary of the quality of the indicator data. Using data collected interview sessions with service staff; each system has been marked on the criteria of Audit, Timeliness, Sign off, Granularity, Completeness and Source/Process. A system can score as Not Sufficient, Sufficient or Exemplary in each of the six areas. These areas make up the outer segments of the Data Quality Kitemark Shield e.g.: A score of Sufficient or Exemplary marks the system as Green on the Kitemark Shield for that section and a score of Not Sufficient marks the system as red. Where an indicator has not yet been assessed a white symbol is used. These dimensions and the definitions of the ratings are outlined below. Key to colour coding Indicator / Measure has met or exceeded target Indicator / Measure has not met target but is within acceptable tolerances. An action plan is in place and is being monitored Indicator / Measure has not met target and is beyond accepted tolerances. Immediate action and investigation has been instigated. An action plan is in place and is being monitored. Indicator / Measure is not available or in development 146

147 Key to symbols Performance has improved / is above target Performance has declined / is below target Performance is stable and on target to be delivered Data Confidence Score Audit Each system will receive a Data Confidence Score calculated by Source/process the total overall scoring given by Timeliness four key members of staff relating to the specified system from 16 Information, Performance and Completeness Sign off within the service. Each contact is asked to give the system a Granularity confidence rating out of 5 to state how accurately the system data reflects service activity, where 5 is Complete Confidence and 1 No Confidence. The total of the four scorings will be displayed in the centre of the Data Quality Kitemark Shield. Information Systems The Trust has various information systems in which data is collected from which performance with local and national indicators is calculated. These include nationally available systems: SystmOne Clinical information used in community services used for community data completeness indicators ESR Electronic staff record for sickness, training and appraisal rates Oracle Finance system for turnover and vacancy rates PCMIS for IAPT indicators Datix for incident, risk and complaint indicators Some of the data from these systems is extracted into national datasets such as National Reporting and Learning System (NRLS). In addition the Trust utilises local systems for patient experience, training and clinical supervision. 147

148 Performance against Locally Agreed Quality and Performance Indicators The Trust has chosen to include a range of performance indicators reported to the Board of Directors rather than specifically select three patient safety, three clinical effectiveness and three patient experience indicators. This section also describes in more detail our successes during the last year. We are also keen to present examples of where we could do better, to ensure we give an open and balanced account. To help understand this information we have presented this information in line with the Care Quality Commissions 5 domains of inspection including examples related to Safety, effective, caring, responsive and well led services. 3.1 What have we done to improve patient safety? Monitor requires that we report on at least 3 performance indicators relating to safety. In this section you will find performance reported against the following key patient safety issues: Patient safety thermometer including: Falls Pressure ulcers Venous thromboembolism (deep vein thrombosis) Urinary catheter related infections Medicines management Infection prevention and control As well as a broad range of other patient safety issues Safety Thermometer The NHS safety thermometer is a national improvement tool for measuring, monitoring and analysing patient harms and harm free care. The safety thermometer measures performance against a number of key patient safety indicators including pressure ulcers, falls, urinary tract infections and venous thromboembolism (deep vein thrombosis). The tool works through the collection of prevalence data a snapshot on a single day each month. The tool was designed to measure local improvement over time and should not be used to compare organisations due to differences in patient mix and data collection methods. During 2015/16 DCHS set itself a Harm Free Care stretch target of 94%. We recognised that this was a challenging target particularly for our inpatient wards and community nursing teams due to the high prevalence of pressure ulcers in the local community. 148

149 Harm free care scores 2014/15 as of Mar 2015 (Target for year 93%) Harm free care Performance scores in year 2015/16 as of Mar 2016 (Target for year 94%) 92.77% Across DCHS 92.37% Rehabilitation wards 87.22% 91.07% 100% 100% 92.65% 92.70% 100% 100% Older people s mental health wards(opmh) District nursing Learning disability services Whilst we did not achieve our stretched improvement target in year there was improvement in our overall score and in two service areas. Learning disability services continue to perform at 100% Sign up to Safety Campaign Sign up to Safety is a national Patient Safety campaign intended to harness the commitment of staff across the NHS in England to make care safer. It is one of a set of national initiatives to help the NHS improve the safety of patient care. Collectively and cumulatively these initiatives aim to reduce avoidable harm by 50% and support the ambition to save 6,000 lives. The campaign requires that organisations commit to five safety pledges. DCHS formally signed up to the Campaign in February We anticipate that by making this commitment it will help to bring the pledges to life and support our staff to understand their role in promoting and providing safer care. Monitoring of the pledges, the associated actions and its progress will occur through the Clinical Safety Group and inform the Quality Service Committee. We will report on our pledges in our annual quality report 2016/17. DCHS sign up to safety pledges Pledge 1 Putting Safety First Commit to reduce avoidable harm in the NHS by half and make public our locally developed goals and plans Ensure a Patient Safety culture where serious harm is minimised and preventable harm in health care is eliminated. Reduce the number of low harm medication incidents. Reduce the number of pressure ulcers resulting from lapses of care. Reduce the number of falls resulting from lapses of care. 149

150 Ensure if patients require restraint, that this in line with the Mental Health Act and NICE guidance. Ensure a zero harm environment where our staff, visitors, contractors and members of the public go home safely at the end of each and every day. Ensure that continence clinic venues across our Trust have risk assessments in place to ensure that they are fit for delivering safe care. Ensure that Medical Devices (NB either electrical or requiring calibration) have a planned preventative maintenance process in place and that staff are deemed competent in their use Pledge 2 Continually learning Make our organisation more resilient to risks, by acting on the feedback from patients and staff and by constantly measuring and monitoring how safe our services are Pledge 3 Being Honest be transparent with people about our progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong Pledge 4 Collaborating take a lead role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use Ensure that the Duty of Candour is exercised when serious harm occurs and those patients or their advocates are informed of any lessons learned. That any lessons are communicated to operational staff via the Trust s Learning the Lessons process. Ensure that the Duty of Candour is exercised when serious harm occurs and those patients or their advocates are informed of any lessons learned. Work closely with our Commissioner stakeholders and the Serious Incident Network so that wider learning can occur. We will actively consult with our workforce and nurture an open attitude to health and safety issues, encouraging staff to identify and report hazards and suggest innovative solutions so that we can all contribute to creating and maintaining a safe working environment. 150

151 Pledge 5 Being Supportive Help our people understand why things go wrong and how to put them right. Give them the time and support to improve and celebrate progress Adopt a Human Factors approach to understand the crux of a problem and provide our staff with the training, support and confidence to learn and improve. Strive to create a positive health and safety culture, providing the right conditions to create a just culture where employees are not punished for health and safety actions, omissions or decisions taken by them which are commensurate with their experience and training, but where gross negligence, wilful violations, deliberate acts or breaches are not tolerated Quality safe care champions Quality Safe Care Champions (QSC champions) keep teams up to date with the latest professional standards and evidence base for best practice. During 2015/16 67 staff from a range of clinical backgrounds and services have participated in the appropriate training to become recognised as Safe Care Champions and provide local support to clinical colleagues in a range of evidenced based practice Falls management Many of our services are focused on the rehabilitation of elderly patients. Obtaining optimal independence is not without risk and on occasion patients fall. Our aim is to reduce the overall number of falls and especially those that result in patient harm. During 2015/16, we have made significant progress in establishing and refining the pathways of care and governance for falls management. We have seen a continuation in the decrease in the number of falls incidents within inpatient care during this period. 151

152 Total number of falls within DCHS services TOTAL Falls Mean No. of Falls UCL Dec15 Oct15 Nov15 Sep15 Jul15 Aug15 Jun15 May15 Apr15 Mar15 Feb15 Jan15 Dec14 Oct14 Nov14 Sep14 Aug14 Jul14 Jun14 May14 Apr14 Mar14 Jan14 Feb14 Dec13 Oct13 Nov13 Sep13 Aug13 Jul13 0 LCL Data source DCHS Datix incident management system Of particular concern are the patients we care for in our older peoples mental health services. We know that the annual incidence of falls in patients with dementia is twice that of older people who are not cognitively impaired and so have focused our efforts in this area. In the last year, we have: Introduced two robotic seal devices. Research has demonstrated that robotic seals reduce anxiety and agitation and therefore the risk of falls where patients with cognitive impairment are deemed at higher risk. Provided dedicated Physiotherapy support across all Older Person s Mental Health wards. Implemented a coloured wristband scheme to rehabilitation wards. The wristbands identify patients in need of mobility support. Provided mandatory falls awareness training for all Registered Nurses, additional awareness training is also available for other clinical staff to embed knowledge across all services (nonmandatory). Appointed a Falls Prevention Lead, working across all clinical settings. Developed and approved the DCHS falls strategy which outlines our actions to continue to reduce falls and the impact of falls amongst DCHS care, with focused work to identify and reduce falls and associated injuries which occur in a patient s home Pressure ulcers Pressure ulcers affecting skin integrity continue to be one of the most challenging areas of quality improvement for our clinical teams at any one time the trust will be managing in the region of 800 patients with actual or potential pressure damage 152

153 which is a huge draw on resources particularly in the community setting. There are a wide range of influencing factors which impact on our prevention strategy, including input from a variety of care teams across the health and social care community, patient choice and compliance, ability to monitor and supervise care delivered by other care providers in a home setting, use and availability of equipment. In addition there are the increasing challenges of an ageing and frail population, the rising incidence of longterm conditions and the drive to move from hospital based services into the community. One of the key priority areas relating to quality improvement in 2015/16 was to reduce the number of pressure ulcers developing and/or deteriorating while patients are in the care of our staff. Whilst we are continuing to see a downward trend in severity of the pressure ulcers developing within our care, the overall numbers reported remain a concern with approximately 50% of cases developing or deteriorating in our care. Associated include a positive reporting culture, increased frailty of our patients and an upward trend of more complex patients on our caseloads as a result of earlier discharges from acute hospitals. Whilst we have seen improvements in a number of service areas unfortunately we have not yet achieved zero avoidable pressure ulcers across all of our services. Pressure Ulcers Reported DCHS 2015/16 The chart below provides a breakdown of where the reported incidents of pressure damage within DCHS have occurred. We are working with other healthcare providers to identify how the number of patients referred to our services with existing pressure damage can be reduced. This has included collaborative work with other agencies including a training day for 90 care home staff, and the development of a patient information leaflet which will help to increase awareness and ownership of the problem throughout the wider health community. Data source DCHs Datix reporting system 153

154 The majority of pressure damage reported within DCHS occurs within patient s own homes where there is less control of the patient s environment. Our community staff are working closely with patients, carers, family members and other organisations to increase awareness of how to prevent pressure damage occurring. We have engaged our therapy staff in supporting work in pressure ulcer prevention and where therapy staff are the first point of contact for a patient they have been trained to screen patients and assess their risk of pressure damage. There has also been a reduction in the incidence of pressure ulcers within community hospitals from last year where 6% of incidents occurred within the hospital setting. Whilst the incidence remains small, we are mindful that this is a controlled environment and ongoing work is required to continue to reduce this number even further. The graphs below compares the numbers of ulcers by grades categorised as being avoidable following root cause analysis investigations undertaken between /16. Comparison of avoidable pressure ulcers /6 70 Grade Grade Grade Multiple pressure ulcers (highest grade is either 1 or 2) NB there will be differences in the comparative data reported in 2013/14 and 2014/15 annual quality reports due to root cause analysis of incidents which occur over the year end and which determine whether a pressure ulcer was eventually classified as avoidable or unavoidable Data source DCHS Datix reporting system The data demonstrates a sustained reduction in avoidable pressure ulcers, over the past 2 years confirming that clinical teams are demonstrating a more consistent approach to delivering preventative care standards. Whilst this is encouraging we recognise that there is still a significant amount of work to be undertaken and will be 154

155 focusing our efforts in the coming year on supporting our community clinical teams to utilise all the resources available to them to reduce the burden of pressure ulcers across our whole community Venous thromboembolism (VTE) Venous thromboembolisms are blood clots in major veins which can lead to serious complications. As a service we ensure all our patients at risk of VTE undergo an appropriate risk assessment and have a personalised care plan in place for avoidance of VTE. During 2014/15 and 2015/16 we have seen very few VTEs, suggesting that our risk management strategies are appropriate. There is an increase in sample size from November 2015 due to Derby City services being integrated into DCHS. Apr15 May15 New 1 1 VTE s % Sample size Apr14 May14 Jun15 Jul15 Aug Sep Oct Nov Dec Jan Feb16 Mar Jun14 Jul14 Aug Sep Oct Nov Dec Jan Feb15 Mar15 New VTE s % Sample size Data Source Patient Safety Thermometer Urinary catheter related infections Some of our patients need help with continence which is supported by the use of a catheter. Catheters bypass the body s natural defences against infection and therefore, if not managed carefully, can be a source of patient harm. At DCHS we minimise the use of catheters as far as possible, and where infections do occur we ensure that each case is carefully investigated to understand the cause. During 2013/14 there were 94 cases of catheter related infections and in 2014/15 this number had reduced to 55 cases. For the current year 2015/16 we have had 80 reported cases of catheter related infections the majority of which following investigation have been classed as unavoidable. This equates to an infection rate of 0.27% overall which is well below the national target limit of 1.5%. During 2016/17 we will continue to review carefully those patients requiring a catheter. 155

156 3.1.8 Medicines management The use of medicines to support and improve patients health is the most common medical intervention used within the NHS and as such we have a responsibility that this is undertaken by staff who have been adequately trained and who can practice safely. Given the very large volume of medicines prescribed, dispensed and administered each day across our service it is inevitable that some errors do occur. Our high level of reporting in relation to errors is important and demonstrates that our staff understand the significance of errors and the opportunity to learn from errors when shared with colleagues. We are pleased to report that during 2015/16 we have had no medication errors resulting in significant harm to a patient and that we have an excellent reputation for the reporting of nearmisses from which we can review policies, procedures and training. Medication Incidents 2014/ /16 Total number of incidents Significant harm to patient 0* 0 Minor or no harm to patient Data source DCHS Datix reporting system *The one incident that caused significant harm (W ) was reported from the Ophthalmic outpatients department at Market Harborough hospital and was due to a patient having a severe reaction to an eye drop used in clinic (oxypropacaine 0.4% eye drops) when used as intended. This was under root cause analysis at the time of reporting and was subsequently downgraded. Antimicrobial prescribing Audits of antimicrobial prescribing are carried out in the Community Hospitals of DCHS twice yearly to ensure continued compliance with national guidance. The guidance helps practitioners ensure optimal patient care and safety by reducing inappropriate antibiotic prescribing to prevent health care associated infections and contribute to slowing the development of antimicrobial resistance. The results for the last two years of audits are summarised in the table below which focus on all courses of antibiotics prescribed on each ward on the day of the audit: Antimicrobial Prescribing Audit Stop/review date recorded on the treatment card Allergy status recorded on the treatment card JulyAug 2015 % for 20 courses JulySept 2014 for 19 courses 100% 94.7% 100% 100% 156

157 Antimicrobial Prescribing Audit Indication recorded on the treatment card Indication recorded in the medical notes Antibiotic prescribed / dose / frequency / course length recorded in medical notes Courses prescribed which follow the Antimicrobial Treatment Guidelines Audit of the DCHS Minor injury departments (MIUs) Audit of prophylactic antibiotics used in Ilkeston Diagnostic and Treatment Centre Audit of antibiotics used by the DCHS podiatry service JulyAug 2015 % for 20 courses JulySept 2014 for 19 courses 85% 68.4% 100% 85% Antibiotic 85% Dose/frequency 85% Course length 100% Dose 100% Frequency 100% Course length 100% 100% Antibiotic 52.6% Dose/frequency 36.8% Course length 100% Dose 100% Frequency 100% Course length Purpose An annual audit of antimicrobials supplied via Patient Group Directions (PGDs) is carried out to ensure the continued safe and appropriate supply of antimicrobials via PGD in the DCHS MIUs. Best practice surgical antibiotic prophylaxis guidelines for upper gastrointestinal (GI) surgery state that doses should be given within 60 minutes before knife to skin as recommended in DOH Antimicrobial Stewardship: Start Smart then Focus guidance November To demonstrate compliance with the current antimicrobial Patient Group Directions for surgical prophylaxis, diabetic and nondiabetic foot infections and postoperative foot infections Results Results of the September 2015 showed that for 170 courses supplied 100% followed the PGD inclusion criteria. This compares favourably with the 2014 results where of 151 courses supplied, 100% followed the PGD inclusion criteria. Results of the February 2015 audit show that three prophylactic antibiotics given by surgical staff from Queens Medical Centre Nottingham follow the Nottingham University Hospitals NHS Trust. The results of the February 2015 audit showed that all antibiotics supplied via PGD by the podiatry service follow the PGD inclusion criteria, dose, frequency and recommended course length. 157

158 3.1.9 Infection prevention and control Reducing the risk of infection and preventing cross infection continues to be an important aspect of our daily work in our hospitals and in the wider community. We continue to be monitored nationally on the incidence of methicillin resistant staphylococcus aureus (MRSA) blood stream infections (bacteraemia) and clostridium difficile infections. We are pleased to report that for another year there have been no MRSA bacteraemia (blood borne infection) reported within our services. During 2015/16 we have seen a 33% reduction, from 12 to 8 cases of clostridium difficile infection diagnosed within our services. To achieve this we have been working with our clinical teams to ensure that antibiotic prescribing is appropriate and that patient s continence needs are met e.g. avoiding constipation which can change the bacteria within the bowel making patients more susceptible to infections. This preventative approach has contributed to the reduction in incidents within our organisation. Year on Year reduction of Clostridium difficile cases Number of cases Number of Clostridium difficile cases 5 0 Year Data source ICNET Norovirus We have followed the national trend this year and have only had four incidents of diarrhoea and vomiting caused by Norovirus that resulted in ward closure. Hand hygiene compliance Good hand hygiene is the singular most effective way to prevent the spread of infection. Our infection control safe care champions have continued to promote good hand washing practice through regular audits and training sessions with their teams. We have seen a slight increase of 0.05% in performance when compared with last 158

159 year, with the overall compliance rate reporting 99.27% against our target of 100%. We continue to work with the teams and infection control champions to ensure that good practice is consistently adopted across the whole organisation. Data source ICNET Patient manual handling team Our fundamental aim is to ensure that whenever we assist a patient to move, we do so in the safest way possible without causing any harm to the patient, whilst at the same time protecting staff from injury. Our specialist team work with all clinical staff to make sure that they have the correct skills to do this safely. Training is designed to allow staff to develop skills for their individual roles, and patient manual handling key trainers play a vital role in this process. This year has continued to see an increase in the referrals of patients with complex needs, both to our inpatient areas, and in the community, particularly bariatric patients. We continue to work closely with the Clinical Navigation team, to ensure that all equipment required to care for and provide rehabilitation for bariatric patients is in place in a timely manner, and that an appropriate environment is prepared prior to admission. A bariatric bed was purchased at the end of the previous financial year along with a set of bed shoe scales. These are moved from site to site as the need is identified, and have been invaluable assets in improving the quality of care for this patient group. Development plans for 2016/17 include: To capture all patient manual handling incidents in a timely manner To improve reporting of incidents caused or suspected to be caused by slings or any manual handling task 159

160 Develop closer relationships with the Safeguarding Adults team to ensure that any safeguarding issues related to the way that people are assisted to move are shared Carry out root cause analysis investigations for all incidents reported where there has been a problem with the hoist or sling within DCHS as a response to the audit carried out in October Safeguarding children and adults All staff working within DCHS have a duty to safeguard and promote the welfare of children and vulnerable adults in line with the Children Act 1989 and 2014 and the Health and Social Care Act We have a large Safeguarding Team comprising specialist nurses and a doctor who work with staff and patients/clients to ensure that as an organisation we discharge this function effectively. During 2015/16 We have continued to work in partnership with social care to ensure that vulnerable children and adults receive the best care, treatment and outcomes and have played an active part in our local safeguarding boards. The agenda for our safeguarding team is continually expanding and includes work related to domestic abuse, substance misuse, child sexual exploitation and all aspects of exploitation and modern slavery as a consequence of this we have recruited a new Named Nurse for Safeguarding Adults who will be the lead for victims of exploitation. As well as advice and guidance to our staff our safeguarding team has provided formal safeguarding supervision to all staff working with children and in year we have extended this to include staff working within our sexual health services. We have delivered Safeguarding Training including PREVENT (counter terrorism strategy) to 1728 staff. We aim for 95% compliance and our yearend figures are: Safeguarding Children training at level 1 is 98% Safeguarding Adults training at level 1 is 97% Safeguarding Children training at level 2 is 92% Safeguarding Adults training at level 2 is 94% Patient safety incident reporting & culture DCHS Staff continue to report a high number of Patient Safety Incidents (PSI), highlighted by NHS England s National Reporting & Learning System (NRLS) as a strong Patient Safety Culture. The high volume of incidents reported sometimes results in managers having incidents which are overdue a review and conversely, this is considered by the NRLS as a potential threat to this strength as assurance is lacking around the vigour of prompt follow up to address required actions. 160

161 Serious Incidents are those considered when harm caused is Moderate or Significant and in the majority of cases, will require further investigation and reporting to our commissioners. The Patient Safety Team process all serious incidents and check that where appropriate learning is shared across the organisation. National Reporting & Learning System (NRLS) The majority of Patient Safety Incidents reported onto the DATIX Risk Management System are communicated to NHS England s National Reporting & Learning System through an established coding system (with NRLS guidance) set up within DATIX and administered by the Patient Safety Team. Incidents shared at this national level are pertinent in determining national trends and promoting national improvements e.g. the Four Harms and the related Patient Safety Thermometer. During the period 1st April 2015 to 31st March 2016, there have been a total of 10,227 patient safety incidents reported. Of these 6,491 have already been communicated to the NRLS and a further 47 are in progress. At the time of reporting there were 248 in the DATIX system in the review process i.e. 236 awaiting review by Manager and 12 waiting follow up by the Patient Safety Team. Never Events Never Events are defined as incidents that are wholly preventable. Never Events are revised and relisted on an annual basis by NHS England. During 2015/16 there have been no Never Events reported by DCHS which meet the NHS England s Never Events listed fields. Incidents by Severity Table 3: During the reporting period 01/04/15 to 31/03/16, a total of 10,227 patient safety incidents were reported. Of the 39 resulting in major harm 35 related to grade 4 pressure ulcers (the most severe grade). There were 7 catastrophic incidents reported, additional details are provided in table 4 below. Table 3 : Incidents by Severity No injury or harm Minor harm/injury Significant harm/injury Major harm/injury including permanent disability Death or multiple deaths or catastrophic event affecting DCHS (e.g. flood/fire) Totals:

162 Table 4: Breakdown of catastrophic harm incidents reported Cardiac Arrest 4 0 Discharged with complications 0 1 Cardiac Arrest Discharge or transfer problem Exposure to 0 0 harmful agent Unwell/illness 0 0 Totals: 4 1 Data source DCHS Datix reporting system Exposed to smoke 0 0 Ill health Total Table 5 Shows the top five reported incidents and trends over the past three years. Incidents by category 2015/2016 Pressure relief 4,432 care Slips, trips and 1,093 falls (patient) Medication /2015 Pressure relief 3,941 care Slips, trips and 1,186 falls (patient) Injury or 573 damage to skin (not pressure ulcer) Medication 457 Injury or Damage 548 to Skin (not Pressure ulcer) Discharge or 467 Ambulance/taxi transfer problem transport issue Totals: 7,108 Totals: Data source DCHS Datix reporting system 398 6, /2014 Pressure relief 3,705 care Slips, trips and 1,456 falls (patient) Ambulance/taxi 659 transport issue Violence/abuse/ harassment 615 Medication 528 Totals: 6,963 Pressure ulcer management see pressure ulcer management Ambulance/transport /taxi issues there has been a significant decrease in reported incidents and this category no longer features in the top 5 incidents. Work is currently in progress with ambulance providers to review the standard provision of equipment on vehicles due to recent concern around the provision of headrests. Partnership work continues on a regular basis. 162

163 Violence/abuse/harassment there has been further decrease in reported incidents related to patient violence and aggression. This is attributed to improved staff/patient ratios, resulting in improved levels of observation by staff, increased anticipatory/intervention measures and a reduction in the numbers of inpatients. This category no longer features in the top 5. Slips, trips and falls see falls management Risk Management Identification and mitigation of risks is a core element of our governance processes. Risks are reviewed on a regular basis by managers and all high risks are reviewed at least monthly by the senior operational and management teams and the Quality Services Committee (QSC). The whole risk register is reviewed on a quarterly basis by the QSC. The graph below provides a trend line for period February 2015 to March Open risks trend April 2015 to March High Medium Low Total Data source DCHS Datix reporting system Central Alert System (CAS) & Strategic Executive Information System (STEIS) The Central Alert System (CAS) is a national reporting system which distributes alerts from NHS England, alerting health organisations to safety issues. During April 2015 to February 2016 a total of 60 alerts were received. Each alert is reviewed for its relevance to DCHS and distributed to the services where the alert applies. All alerts were responded to within the required timeframes. 163

164 Explanation of STEIS Serious incidents requiring investigation in healthcare are rare, but when they do occur, everyone must make sure that there are systematic measures in place to respond to them. These measures must protect patients and ensure that robust investigations are carried out, which result in organisations learning from serious incidents to minimise the risk of the incident happening again. When an incident occurs it must be reported to all relevant bodies Staffing for Quality (Safer Staffing) DCHS has continued to carefully monitor and manage its nurse staffing to ensure that optimal staffing numbers and skill mix are available within our clinical areas. DCHS has published its staffing ratios of Registered Nurses and nonregistered nursing staff on a monthly basis throughout the year and has been able to evidence how it has maintained optimal staffing ratios in line with best practice. Building upon the national requirement to monitor nurse staffing levels on inpatient areas DCHS has undertaken a significant project looking at the ratio and skill mix of nurse staffing numbers required within our integrated community teams. The project called BRAVO (Baseline Recording of Activity for Valued Outputs) measured the workload and case mix of community nursing teams in 10 minute vignettes over a week long period of activity. Analysis of the data has clearly illustrated the amount of time clinical staff spend on direct patient care, work that supports patients in their own homes, travelling time and other important activity such as meetings with colleagues and training. The analysis also shows the breakdown of time spent with patients on specific aspects of care such as pressure area management and leg ulcer management and will help us with planning for improvement and innovation plans for the coming year and priorities for staff training. Looking forward to 2016/17 we will continue to implement BRAVO using the tool to assess workload within our therapy services. It is hoped that the output of this project will in the longer term support investment by our commissioners in community services. 3.2 Ensuring services are clinically effective Clinical Effectiveness DCHS seeks to ensure that the services we provide achieve meaningful outcomes for patients and carers in a variety of ways. Clinical Audit is one part of these. Our focus is to ensure that all clinical audit activity results in learning. We aim to demonstrate the clear links between clinical effectiveness measurement and improvements in patient care. We value participation in clinical audit to ensure that the care we provide is effective, responsive and safe. Monitor requires us to report on at least 3 areas where we can demonstrate clinically effective services. Within this report we have included details of 5 clinical audits where we have been able to demonstrate clinical effectiveness. In addition to this we 164

165 have provided information for you on the national and the priority audits we have undertaken in year in the mandatory reporting section in part 2. To complement the priority audits we also have a service level audit programme. The table below gives examples of outcomes from a sample of audits from each division Service Level Audits Examples of outcomes from each division Directorate / Service Health Wellbeing & Inclusion Psychology Planned Care Speech & Language Therapy Audit Title Outcome Health Psychology Service: Routine audit of impact of service on clients 88.2% of those asked felt that their aims had been completely and mostly met. Satisfaction impact remains extremely high; quality of life and ability to cope are experienced as improved in excess of 90% of respondents; and over half of respondents report that they are reducing medical visits. There were 95 respondents. Of these 29.5% (28) hoped to reduce medication and, following treatment, 64.3% (18) of those who wanted to had done so. Occasional comments about waiting times not being satisfactory. An action plan has been completed including: patients optin for first appointment, institute a robust but compassionate DNA and cancellation policy, offer immediate assessments give priority to the most urgent cases offer a variety of active wait options (including providing advice, direction and signposting; offering relaxation skills training from our assistants; providing a distanceleaning mindfulness course, offering a 2 session group intervention with an assistant). The audit has shown that more intensive therapy for speech sound disorders led to quicker achievement of therapy aims for the selected children. An action plan has been completed including: Disseminate audit findings and discuss offering intensive sessions for children with speech disorders at team meetings in city and county SLTs consider factors that indicate whether child is suitable e.g. maturity levels of child, child s resilience, motivation; level of engagement form school and family. Dosage of therapy delivered by Speech and Language Therapists (SLT) to children with Speech Disorders 165

166 Directorate / Service Audit Title Outcome Planned Care Physiotherapy & Occupational Therapy Integrated Community Based Services (ICBS) Erewash & Amber Valley (Babington) To review compliance with injection policy and clinical reasoning for choice of injection Audit of patient feedback from the 4 harms group SLTs to plan diary time when offering intensive sessions. SLTs consider needs of whole caseload before offering intensive sessions and consider that child may be discharged in a quicker timescale The aim of the audit was to ensure that injecting service are as effective and efficient as possible in order to maximise the benefits for our patients. Results 83% of known outcomes were improved. Timing of outcomes was recorded as there is much literature indicating that injections have better short term outcomes. The outcomes from this sample indicate that outcomes can be improved >12weeks post injection A Final outcome was recorded for 94% of clinicians. When the notes were assessed none of the urgent cases had referred themselves back to either the MSK or physiotherapy injection services so it is possible that the injections had a good long term outcome. An action plan has been completed including: Audit report to be shared and discussed with all clinicians who were audited and the DCHS injection special interest group Patient Management pathways to be reviewed to ensure that patients are referred to the correct clinician Audit to be rolled out to other injecting clinicians in DCHS Most patients chose the informative, useful or enjoyable box. 1 patient in the last 6 months found the session not enjoyable (no comments why). A range of topics are effectively covered including pressure sores, falls, urine infections and blood clots. The size of the group has always been "good", An action plan has been completed including: Trying to do the groups more regularly for appropriate patients. Staff from different community hospitals have been offered to come and shadow the groups. 166

167 Directorate / Service ICBS / South Derbyshire & Community Amber valley Audit Title Outcome Leg Ulcer Audit The results from this audit have enabled the auditors to identify the most appropriate place of care for different diagnoses of leg ulcer and as a result a leg ulcer care pathway was developed to identify which patients should be cared for by DCHS and which should be cared for by Primary Care Research and development DCHS is committed to developing its research capacity and capability. Our Research Team provides support to staff across the Trust and works in partnership with other key research organisations in Derbyshire. In 2015/16 DCHS patients have been recruited to the following national research studies which were approved by a Research Ethics Committee: Dementia and Imagination 36 Behavioural Activation Therapy for Depression after Stroke (BEADS) 8 Cost effectiveness of aphasia computer treatment versus usual stimulation or attention control long term post stroke 14 Development of a guided selfhelp Cognitive Behavioural Therapy Resource for the reduction of dental anxiety in young people aged 9 to 16 years 12. A total of 33 clinical staff participated in these projects. They work in several areas within DCHS including speech and language therapy, older people s mental health and stroke services. All these studies are on the National Institute of Health Research portfolio which means that this research is seen as having national significance. Our participation in clinical research demonstrates our commitment to improving the quality of care we offer and to making our contribution to wider health improvement. It means that our clinical staff are more likely to stay up to date with the latest possible treatments and active participation in research leads to successful patient outcomes. A Strategy for further development of research activity in DCHS has been approved by our Trust Board Speech and language therapy improving outcomes for patients An important area of patient safety for the speech and language therapy service is the harm that can arise from eating/drinking and swallowing difficulties (dysphagia), including chest infections, malnutrition and dehydration. Speech and language therapists work with people who have dysphagia (and their carers) to increase their ability to eat and drink safely and effectively. 167

168 This year has seen the implementation of our new Early Intervention model, which allows adults with dysphagia to get help from our service much more quickly. This followed a period of higher than average referrals, which lead to longer waiting times for patients. We now triage and prioritise patients differently, and have employed some additional staff. As a result, our average waiting time for an appointment has reduced from 49 days in January 2013, to 8 days in July The longest wait has reduced from 223 days in January 2014, to 26 days in July This is despite a continuing significant increase in referrals (increase of 34% between July 2014 and July 2015). Patients and carers have commented positively on our improvement in service. We have also trained key staff in Community Hospitals to deliver basic awareness training in Dysphagia to their colleagues, so that all ward staff understand the impact of dysphagia on patients and how to ensure their patients can eat and drink as safely and effectively as possible Making every contact count Making every contact count (MECC) has been a successful initiative across DCHS since 2010, raising staff awareness of their responsibility to help patients, carers, families, friends and colleagues to adopt a healthier lifestyle. We have increased staff awareness of MECC by providing training and raising awareness sessions to over 3,500 DCHS staff. We have amended our documentation to make sure we can identify and audit MECC activity, which helps patients and staff to address lifestyle choices that are impacting on their personal health. The initiative is now truly embedded in the culture and ethos of the Trust with staff seeing MECC as part of their role Older people s mental health physiotherapy service Evidence from our falls management programme has demonstrated that patients with cognitive impairment are at greater risks of falls and mobility issues as a consequence of this finding we have invested in 2 experienced and highly motivated physiotherapists to support our patients in the older people s mental health wards. Whilst it is too early to draw definite conclusions from the evaluation of the impacts of their service on reducing patient falls, early indications are positive both in terms of the effective management of the risks of patient falls as well as positive patient experience of these services overall Mental Health Act Code of Practice (MHA CoP), published April 2015 DCHS Service leads from LD and OPMH have worked throughout 2015 in order to ensure that the mental health care we provide is of the highest quality, is safe and of course, is lawful. In order to achieve this, we have undertaken comprehensive and 168

169 exhaustive review and revision of our mental health care governance framework to ensure that it is fully compliant with the changes that have been made to the new MHA CoP. Included in this review we have reviewed areas of policy and procedures which guides the practice of our clinicians, and Mental Health Act Managers. In addition, we have identified a number of significant areas of essential learning required by our clinical staff and Mental Health Act Managers which the new MHA CoP makes specific and particular reference too. These areas of essential learning include redesigned Mental Health Act process training and the training of clinical staff in support of them understanding and deploying the principles of Positive Behaviour Support Planning (PBSP). PBSP is a vitally important tool in care planning for individuals who have behaviours that challenge as a feature of their mental illhealth. As an approach, it ensures that the individual is a partner in planning their care and therefore at the centre of the process and that through this approach, care can be delivered which supports the principles of high quality safe care which is least restrictive Starting Point Starting Point is a multiagency and multidisciplinary process for ensuring that all referrals into Derbyshire County Council Children s Services (Call Derbyshire) are effectively dealt with and that information between agencies is appropriately shared and assessed in a timely manner. DCHS has supported a proof of concept pilot during the year. Starting Point provides a seamless approach to a child s journey through early help and safeguarding services and brings together the skills and expertise of a wide variety of staff to ensure the best possible outcomes for Children and Families. Derbyshire Children s Community Health Services staff (consisting of Specialist Community Public Health Nurses (SCPHN), supported by a community support worker and an administrator), police officers, social workers, family resource workers, youth workers, early years practitioners, business services and customer care assistants all work together to provide an integrated and consistent approach to this very important work. Early indications from this pilot show that: Colocation of partner agencies sharing the same accommodation and information improves responses to children in need Relevant information for robust decision making is readily available and prevents delays. The health team have been able to support the triage of domestic abuse referrals working alongside the police and social care 169

170 The process for undertaking strategy meetings following a safeguarding referral can be undertaken much more quickly if it is considered that a child or young person is at imminent risk of significant harm. A full evaluation of this pilot will be conducted during Caring What we have done to improve patient experience? Caring Always The DCHS Experience We have made 8 promises about what it should feel like to use our services. We call these promises Caring Always. 1. During your time with us you will feel welcomed and valued. You will feel that your care meets your individual needs. 2. You will have the opportunity to discuss with us what is going to happen at every stage. 3. You will understand the choices that you can make about your care. You will be supported to make the best choices for you. 4. You will have all the support you need to feel comfortable and safe. 5. You will know who is providing your care and what to expect. You will have clear information about how and when they can be contacted. 6. You will feel confident that you are being looked after by well trained staff who have the time to care. 7. You will feel able to choose how much we involve your family, friends and carers. 8. You will feel able to tell us how we could improve. Feedback 10. The promises tell patients and their families how it should feel when they access our services. We ask for comments about how we keep these promises and we use this feedback to make improvements. There is a range of ways for people to give us that feedback Friends and Family Test (FFT) 22,544 patients completed the Friends and Family Test cards this year and 98.2% would recommend DCHS to friends and family. This compares with 97% in the 170

171 previous year. We also ask patients to tell us about their experiences and how we could improve the services they used. The comments we receive are used to make improvements in local services and are shared across the organisation through You Said, We Did. This data is governed by standard national definitions. Percentage % Recommended DCHS comparison with national and area results 2015/ % 98.0% 96.0% 94.0% 92.0% MayJun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 15 National 96.00% 95.00% 95.00% 95.00% 96.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% Apr15 Regional 98.00% 98.00% 97.00% 98.00% 98.00% 98.00% 97.00% 95.00% 97.00% 98.00% 95.00% DCHS 98.00% 98.00% 98.00% 98.00% 98.00% 98.80% 97.50% 98.40% 98.10% 98.90% 98.40% 96.60% National and regional data is from NHS England and will not be available until 26 May 2016 beyond the reporting period for this document. 171

172 Examples of improvements are given below: Duty of Candour DCHS expects that its staff will always be honest and open with the patients and families they care for. A Duty of Candour (DoC) policy has been approved in year and its introduction supported by training sessions for staff. The trust is committed to providing an open and honest explanation to patients and an apology where serious harm has occurred. 172

173 Since September 2015 there have been 125 incidents meeting the Duty of Candour criteria. Patients have been contacted and a full explanation provided following investigation Complaints During 2015/16 the Patient Experience Team received and responded to 511 enquiries, concerns and complaints compared with 584 in the previous year (these figures have not been adjusted for any change in our service or activity). Of these, 126 complaints required an investigation under the NHS complaints process. Two complaints were referred to the Parliamentary and Health Service Ombudsman, one of which was upheld and the other partially upheld. Complaints by subject (levels 2,3,4) comparisons 2014/2015 to 2015/ All Hotel AdmissServices Aids & Aspects Complions & AppointCommApplianaints Consent Attitude of & ments unication DischaClinical Premices Process rges Care ses Other Personal Privacy TransPolicy Records & Dignity port Totals April March 2014/15 April March 2015/16 173

174 Data source DCHS Datix reporting system Patient Led Assessments of the Care Environment (PLACE) Results summary for DCHS for 2015 PLACE is a system for assessing the quality of the care environment and involves local people working alongside trust staff in assessing the quality of patient areas across a range of criteria including privacy and dignity, food cleanliness and general building maintenance. For the first time this year assessments of the environment meeting the needs of patients with dementia have been included. The percentage scores for each category below have been awarded by the NHS Information Centre based on the information returned by us for our 2015 assessments. All assessments were delivered through selfassessment. The programme was undertaken between March and June

175 Hospital Cleanliness Food Privacy & Dignity Condition & Maintenance Ash Green Babington Bolsover Cavendish Clay Cross Ilkeston Newholme Ripley St Oswalds Walton Whitworth *Dementia 2014 not reported on in 2014, new for 2015 Dementia 2014 * * * * * * * * * * * DementiaFriendly Environment this element is drawn up from environmental assessments produced by The King s Fund and Stirling University. The assessment covers: flooring, toilets, toilet signage, general signage, décor and catering for patients with dementia. The overall scores for our hospitals were very favourable, as indicated below: DCHS 2014 DCHS 2015 National Average Score 2015 Cleanliness Food Privacy & Dignity Condition & Maintenance 99.59% 94.97% 88.51% 96.60% Not reported on 99.67% 94.13% 87.43% 94.86% 79.73% 97.57% 88.49% 86.03% 90.11% 74.51% Dementia Data source PLACE audit results DCHS Hospitals have achieved a score above the National Average for Cleanliness, Food, Condition and Maintenance, Privacy & Dignity and Dementia Dementia friendly environments This was the first year that the hospitals were scored against the Dementia Environment standards, the OPMH wards fared better than the general medical wards and the outpatient areas. 175

176 Some of the areas DCHS scored low on were: That the flooring in most areas has either a pattern or fleck in the design A lot of wards and outpatient areas did not always use contrasting colours for the hand rails in corridors and contrasting toilet seats / hand rails in the bathrooms and toilets. Most of the ward areas did not have the name of the hospital displayed (only the ward name) Signage was not always at a recommended height of 1.21 metres Toilet doors are not always painted in a single distinctive colour (yellow is the normal colour used) The trust is committed to significantly improving its score in this area and will be working with the estates team during the coming year to address deficits Healthwatch Derbyshire DCHS continues to work in partnership with Healthwatch Derbyshire and their ongoing programme of service reviews which focus on direct feedback from service users is a helpful source of information informing our service development. DCHS has worked with Healthwatch Derbyshire this year on a number of key initiatives including: Young People not just Young Carers this report led to a series of jointly coordinated young carers summits between DCHS and Healthwatch Children and Young People in Derbyshire have their say about healthcare and social care services this report was received by our Patient Engagement and Experience group and will help to influence the way we provide service in the future Access to health services for people with learning disabilities this patient experience report was formally responded to by DCHS and as a consequence we have agreed specific actions for improvement. Healthwatch Derbyshire Intelligence reports continue to provide a rich source of information for us in planning and redesigning our services Equality, Diversity, Inclusion and Human Rights DCHS is committed to achieving equality, celebrating diversity, fostering a culture of inclusion and respecting Human Rights. We understand and appreciate that everyone is an individual, with different needs and requirements. People have very different life experiences and sometimes face many challenges and barriers to accessing our services and opportunities. 176

177 We also recognise that it isn t simply access to our services that s a challenge it s important to ensure that people get equitable outcomes from the care they receive from us. We want to provide a wide range of quality health services that are designed to meet people s individual needs. We are committed to personalising our services to ensure that the most positive outcome is achieved for all. We take seriously our duties under the Equality Act to eliminate the unlawful discrimination of both our staff and service users, to advance equality of opportunity for all and to foster good relations between all people. We are implementing NHS England s Equality Delivery System 2 (EDS2), which provides a framework for us to monitor and improve our equalities practice. In support of this Board members have established an Equalities Forum which enables employees from underrepresented groups a direct line to the Trusts most senior leaders, to raise issues and concerns and to secure support. They are also mentoring members of the Trusts Employee Network Groups. We are establishing our Equality Allies programme to engage the whole workforce, Governors and Board in the agenda and to ensure we achieve positive and sustainable change. We have continued to assess ourselves against the Healthcare For All (HC4A) standards related to access to healthcare for people with learning disabilities and have been able to declare compliance with each of the standards. 2015/16 has been a successful year for us and we are particularly proud of our award winning equalities forum theatre group which we have formed to help train our staff and raise awareness nationally New sensory rooms at Ashgreen In May 2015 Service users and their families, along with staff and governors celebrated the reopening and official naming of the Robert Frederick Sensory Rooms at Ashgreen, Specialist Learning Disability Service. Following a generous bequest, the sensory rooms underwent a major refurbishment to create stateoftheart sensory facilities for therapeutic and treatment purposes for people with learning disabilities. The refurbishment allows us to provide a safe environment from which we can provide a quality service and user experience and by providing very specific equipment and systems we are able to respond to the individual needs of service users who have sensory integration problems this in turn will help support them in managing their daily lives within the community Home from Hospital Home from hospital provides 6 weeks of practical support to help patients settle back into a normal routine and to build their confidence and independence after a stay in 177

178 hospital. Volunteers provide support with activities such as shopping, dealing with bills and utility suppliers, making sure pets are looked after, collecting/returning library books, collecting medication, and generally befriending the person when they return home. The project currently has 35 trained volunteers, all having completed a bespoke volunteer training day and having an up to date enhanced DBS certificate in place in line with the requirements of the Lampard report. Since the first visit took place in April 2015 the service has received over 90 patient referrals. The feedback using the Friends and Family Test shows that all the patients that have received volunteer support would be extremely likely to recommend the service. The Home from Hospital project was initially funded by NESTA (an independent charity that works to increase the innovation capacity of the UK) and the service will continue to develop over the year to come Patient stories Patient stories provide a very powerful and human account of the way that the care DCHS staff delivers the impacts on individual people and families. Every meeting of our Trust Board, Quality Services Committee, Council of Governors and Patient Experience and Engagement Group starts with a Patient Story. The stories are either told by a member of staff or by a person who used our services. We aim to hear about the positive impact of our services (for example from a patient who had been empowered to lose over half of her body weight) as well as where improvements have needed to be made (for example where our care fell short of what we expect to provide and how this experience impacted on the patient). Members of the Board or committee that hear the story are often challenged and moved by what they hear, lessons are identified and actions agreed. The telling of the story at the start of the meeting sets the tone for the remainder of the agenda, putting the patient in the room, and ensuring that the patient is at the centre of everything we do. Our Quality Services committee has followed this lead and now present a staff story at the start of each of their meetings these stories help us to better understand the issues and challenges our staff face and how we can support them and become a better employer Improving care for patients at Bolsover DCHS prides itself on being a learning organisation and we have worked hard to improve our trust wide assurance processes. In the spring of 2015 we identified that care in our inpatient service at Bolsover hospital was falling below the standards we would normally expect. A series of clinical incidents including two serious patient falls and complaints from some of our patients resulted in us undertaking a systematic review of this clinical area. This identified further concerns regarding clinical leadership. Over the course of a number of months our professional standards team worked with staff to review practice standards and to implement an action plan to drive improvements. A change in clinical leadership and focused effort from a reconfigured clinical team is now resulting in consistently high standards of 178

179 care evidenced through improving Quality Always peer review outcomes and good feedback from patients and carers. A lessons learned exercise was undertaken at the end of the year which identified important learning for the wider organisation. 3.4 Ensuring our services are responsive to patients needs Using feedback from our patients A key element of our work and planning at DCHS is to ensure that services are as responsive to patients needs as possible. Feedback from patients and their families provides vital information mechanism for future service planning. Monitor requires the trust to report on at least 3 key performance indicators which measure the responsiveness of our services for patients. Suggested indicators include: Referral to treatment times emergency readmissions 62 day cancer wait indicators DCHS does not receive emergency readmissions to its inpatient rehabilitation beds and does not provide diagnostic and treatment services for patients with cancer and therefore these latter two indicators are not considered relevant for the Trust. Our Council of Governors have considered alternative indicators for reporting and these are detailed below and include: Minor injuries waiting times Referral to waiting times Delayed transfers of care waiting times in older peoples mental health services Minor injury unit waiting times DCHS has four Minor Injury Units providing urgent care as part of the wider out of hours and emergency care pathway across the health community. Ensuring our patients receive timely care is a key priority and this is measured against a fourhour standard set by the Department of Health. As the table below illustrates we have performed well in this area. DCHS considers that this data is as described for the following reasons: there are proper internal controls for the collection and reporting of this measure of performance and the controls are subject to quality assessment using the trusts data kite mark quality assurance system. 179

180 This data is governed by standard national definitions. Data Source System1 TPP PAS 180

181 DCHS will continue to monitor the quality of its services using its quality improvement and assurance framework and to work with the wider health community to maintain the high percentage performance within its minor injuries departments. Comparative Data A&E 4 Hour Wait It should be noted that DCHS emergency provision is limited to four minor injury units and that comparative data includes data from type 1 accident and emergency departments. Period Q3 2015/16 Q4 2015/16 Performance Rank 100% 100% Joint 1st Joint 1st Total Nat. In Highest Average Cohort % Trusts % Trusts Lowest Tameside Hospital NHS Foundation Trust North Middlesex University Hospital NHS Trust Referral to treatment times When our patients need care we aim to see them and undertake their treatment as quickly as possible. The table below reports on our performance in year against the 18 week referral to treatment times and demonstrates that performance has been consistently good in all areas. DCHS considers that this data is as described for the following reasons: there are proper internal controls for the collection and reporting of this measure of performance and the controls are subject to quality assessment using the trusts data kite mark quality assurance system. This data is governed by standard national definitions. 181

182 Referral to treatment times 2014/15 Referral to treatment times 2015/16 Data Source System1 TPP PAS 182

183 Criteria for percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period We confirmed the Trust uses the following criteria for measuring the indicator for inclusion in the Quality Report: The indicator is expressed as a percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the period; The indicator is calculated as the arithmetic average for the monthly reported performance indicators for April 2015 to March 2016; The clock start date is defined as the date that the referral is received by the Foundation Trust, meeting the criteria set out by the Department of Health guidance; and The indicator includes only referrals for consultantled service, and meeting the definition of the service whereby a consultant retains overall clinical responsibility for the service, team or treatment. Consultant led Referral to Treatment Schedule in Weeks (January 16) Clocks ended in January: Admitted Patient Care (Part 1A unadjusted) Speciality Total weeks waiting 06 Derbys Dental Leics Dental 18 weeks % >6 7 13Total Max waiting 18+ week Waiters Waiter over 6 waiter wks % >18 waiting week over waiter 18 total weeks % 0 0% % 4 0% Consultant led Referral to Treatment Schedule in Weeks Clocks still running (Part 2) Speciality Total weeks waiting weeks % >6 7 13Total Max waiting 18+ week Waiters Waiter over 6 waiter wks Derbys Dental Leics Dental Data Source System1 TPP PAS % >18 waiting week over waiter 18 total weeks % 0 0% % 3 0% 183

184 Comparative data Referral to Treatment Times Incomplete Pathway Total Nat. Period Performance Rank In Highest Lowest Average Cohort Brighton and Sussex 13 Feb % % University Hospitals Trusts NHS Trust Brighton and Sussex 12 Mar % % University Hospitals Trusts NHS Trust Delayed transfers of care DCHS considers that this data is as described for the following reasons: there are proper internal controls for the collection and reporting of this measure of performance and the controls are subject to quality assessment using the trusts data kite mark quality assurance system. Comparative data DTOC Monitor Compliance Calculation is not available This data is governed by standard national definitions. 2013/14 Target April 2013 May 2013 June 2013 July 2013 Aug 2013 Sept Oct % Delayed Transfers of Care Inpatients including 7.8% 7.9% 8.4% 7.5% 9.0% 10% Older People s Mental Health 2014/15 Target April 2014 May 2014 June 2014 July 2014 Aug 2014 Nov 2013 Dec 2013 Jan 2014 Feb 2014 March 2013/ YTD 8.7% 9.7% 9.2% 8.1% 10.3% 8.6% Sept 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb % 2014 March / YTD 12.5% Delayed Transfers of Care Inpatients including 10.7% 9.2% 8.2% 7.9% 8.1% 7.9% 9.7% 6.2% 7.9% 6.9% 6.6% 4.9% Older People s Mental Health %

185 2015/16 Target 7.5% April 2015 May 2015 June 2015 July 2015 Aug 2015 Sept 2015 Oct 2015 Nov 2015 Dec 2015 Jan 2016 Feb 2016 March /16 Year to date Delayed Transfers of Care Inpatients Including 9.8% 7.8% 7.5% 8.2% 6.9% 8.9% 6.8% 5.3% 7.1% 8.4% 10.7% 11.26% 8.4% Older People s Mental Health Data Source System1 TPP PAS Older People s Mental Health (OPMH) data 2013/14 April 2013 May 2013 June 2013 July 2013 Aug 2013 Sept 2013 Oct 2013 Nov 2013 Dec 2013 Jan 2014 Feb 2014 Mar /14 Outturn Delayed Transfers 2.4% 4.9% 6.0% 2.8% 4.5% 8.3% 7.7% 10.0% 10.6% 6.2% 7.8% 7.0% 6.6% of Care OPMH 2014/15 April 2014 May 2014 June 2014 July 2014 Aug 2014 Sept 2014 Oct 2014 Nov 2014 Delayed Transfers 7.1% 3.2% 4.6% 4.3% 5.3% 3.8% 8.7% 8.7% of Care OPMH 2015/16 April 2015 May 2015 June 2015 July 2015 Aug 2015 Sept 2015 Oct 2015 Nov 2015 Delayed Transfers 2.6% 6.7% 5.2% 0.0% 0.0% 0.0% 0.0% 0.9% of Care OPMH Dec 2014 Jan 2015 Feb % 4.7% 3.7% 1.0% 6.1% Dec 2015 Jan % 0.3% 4.8% 1.2% 1.83% Feb 2016 Mar 2015 Mar 2016 Year to Date Year to Date Data Source System1 TPP PAS 185

186 DCHS has taken the following actions to improve the delayed transfers of care percentage in our older peoples mental health services (OPMH) and rehabilitation wards: we have reviewed the clinical pathway management within our older peoples mental health wards and rehabilitation wards to optimise discharge planning and worked with partners across health and social care to ensure that effective discharge plans are in place for patients. DCHS has continued to proactively manage the flow of patients across inpatient beds in our Community Hospitals to minimise the overall incidence of Delayed Transfers of Care (DTOC). We have observed an increased demand for Health and Social Care services across Derbyshire and the complexity of the discharge planning for some individual patients. Key areas for delay include patients waiting for Continuing Health Care Assessments, patients waiting for care home of choice and patients waiting complex home care packages through social service provision Monitor risk assessment framework key performance indicators As a foundation trust we are required to monitor our performance against a set of key performance indicators identified within Monitors risk assessment framework. During 2015/16 DCHS met all of these key targets. This table is reproduced in larger scale on page 32. This data is governed by standard national definitions. 186

187 3.4.6 Patient Experience/New Service Breakfast Club Baron Ward Babington Hospital Breakfast club is a therapy lead group that is currently run on Baron Ward 2/3 times per week from am with a maximum of 4 patients per group session. The group is run by two members of the therapy team with support from housekeeping. Patients attending the breakfast club are referred by therapy staff (OT/PT) following ward based assessments. Priority is given to all patients who are approaching discharge with the aim of ensuring that patients have optimal independence on their return home. Mobility, functional tasks and equipment are all considered within the group which aims to increase patient confidence and reestablish roles and routines. The group also offers patients the opportunity to socialise with other patients planning for discharge. Feedback from patients participating has been very positive. Following a recent Insight Visit in October 2015 on Baron Ward, Carolyn White (Chief Nurse) highlighted how valuable the Breakfast Club was. Therapists from other DCHS sites have shadowed the breakfast club and have now implemented the group at Ripley, Ilkeston and St. Oswald s. Plans are also being developed to implement the breakfast club at Clay Cross Hospital. Insight visits are discussed in more detail at section Discharge Home Visits Ilkeston Discharge home visits have been carried out since 2014 and are an important aspect of our safe planning for patient discharge. The Occupational Therapist (OT) anticipates equipment, services and support required prior to discharge so that these can be assessed in patient s own home enabling the therapist to leave them if it is safe to do so. To increase our responsiveness to patients therapists are carrying out discharge visits using pool cars so there is more flexibility to carry out the visit to fit in with times family members, OT and when social services are available. Verbal feedback from the patients has demonstrated that they feel confident to remain at home as the OT will go through discharge arrangements such as medication and any follow up by community rehabilitation team or outpatient appointments. It has also improved the patient s experience as the patients have reported that they feel reassured that they will manage at home and the OT can settle the patient in especially if there are no family/friends present. By carrying out discharge visits it has led to reduced length of stay on the wards as the patient is not waiting for a care package to be arranged following a home assessment. 187

188 3.4.8 Changes to the 519 Public Health Nursing Service School nursing services have faced major change over the last 12 months following the full transfer of public health commissioning to local authority. This generated the tender process of the 019 services which resulted in DCHSFT successfully winning the contract to deliver the public health services to children, young people and their families across Derbyshire. October 2015 saw the start of the new contract for the 519 school nursing service. Following the transfer of staff from other organisations, DHCSFT became the sole provider of this service and began to deliver elements of the healthy child programme which supports children and young people s health and development. School nurses, with their teams, are coordinating and planning delivery of public health interventions for schoolaged children. The nature of their work requires clinical input and effective leadership, which qualified school nurses are equipped to provide. They are the single biggest workforce specifically trained and skilled to deliver public health for schoolaged children (519). Being in a unique position within community and education settings allows them to support multidisciplinary teams, provide a link between primary and secondary care, promote healthy lifestyles, manage relationships between child, family and school settings and are trusted and valued by children and young people Care home advisory service The care home advisory service provides professional guidance to local care homes. During this year we have worked on developing one to one training on falls prevention for care home managers. This has taken into account the specific development needs of each manager, which varies hugely between care homes. The main aim has been to increase each manager's understanding of predisposing factors to falls and by this, to try and prevent falls occurring. The training has included: supporting development of written records, more effective risk assessment, onward referral to other services and staff education. We have also helped to review specific extrinsic factors that could be made safer within the care home environment. Positive results have included care homes improving their reporting process via staff education to give more specific information for the manager to review. They are able to better identify any patterns of causes of falls, which can then be addressed appropriately for prevention purposes. Care homes have improved their risk assessment information and analysis in particular to look at those residents who frequently fall. They have also added to their documentation to include monthly checks of extrinsic factors that could cause falls, taking the appropriate actions as needed. Analysis of number and type of falls is ongoing and we hope to be able to evidence an improvement in this risk are over time. 188

189 Development of the Care Home Support Service in Erewash After successfully bidding for one of the Prime Minister Challenge fund projects commissioned by Erewash CCG we are working with our GP and pharmacy colleagues to provide services to residents in care homes across Erewash. A team of Advanced Nurse practitioners, care coordinators and staff nurses carry out ward rounds and medical reviews within the care homes on a regular basis and provide an emergency response to residents in crisis. The team can monitor people health needs and offer advice and support to the care home staff and relatives. Our aim is to keep people healthy in their care home, prevent them from going into hospital and free up GP time so that this can be redirected to other people visiting their practice. Since the project started in October 2014 we believe we have prevented over 350 unnecessary admissions in the 17 care homes we are now working with and we hope to expand to cover the remaining homes in Erewash over the next year. One GP said the positives of having the Care home support service working with me is that it has reduced the number of visits and phone calls I get ; both of which we used to get daily. A care home manager said The range of care home services and care which has been available directly to the residents through this service to ensure they receive the care they need has been and still is outstanding Virtual Ward Derby Hospital Foundation Trust, Derbyshire Community Health Services, Derbyshire Healthcare NHS Foundation Trust, Southern Derbyshire Clinical Commissioning Group & Derby and Derbyshire Social Care services have been working together to improve and streamline the care of acute care based patients through the development of a new care pathway called the Virtual Ward. The virtual ward is a model which provides an enhanced package of health and social care, provided within a patient s own home. The current service model enables existing inpatients to be discharged home from hospital earlier than would have traditionally been possible. It is an alternative pathway for those patients who do not require acute medical inpatient support, but do require ongoing intensive therapy and/or nursing care. Whilst on the virtual ward, the medical responsibility remains with the patient s own registered GP. An integrated team of clinical therapy and nursing staff provide care to patients on the virtual ward, with the assistance of support staff. The team aim to support people to leave hospital earlier and prevent any unnecessary readmissions. Every patient 189

190 on the virtual ward is reviewed on a weekly basis, or more frequently if required, by a senior clinician and their care is discussed with the wider multidisciplinary team at the virtual ward round. An initial rapid assessment is undertaken within the patient s own home and includes delivery of an immediate personalised care plan including both health and social care as required. This is supplemented by close monitoring and reassessment of progress and need, with care packages amended accordingly. Staff provide training and education for patients in order to support selfcare and management of any long term conditions, rehabilitation and reablement needs, with the aim to discharge or transfer into mainstream community services when intensive support is no longer required Primary Care In 2015 DCHS was asked to manage Creswell and Langwith Medical Centres initially in a caretaker capacity. During February 2016, following a successful tendering process the trust were awarded a contract to manage these services going forward. Primary care is a new, potentially challenging environment for us as a community provider. We have taken the opportunity to review the staffing skill mix in order to create a multispecialty primary care team to support the General Practitioners. We anticipate the changes will dovetail well with our integrated communitybased care teams, with the potential to bring many further benefits to patients who have easier access to a broader range of services. In addition to Creswell and Langwith practice we are working with Ripley Medical Centre and Castle Street practice on Bolsover and exploring options for future models of working. Together we are breaking down traditional organisational and professional barriers in order to provide care which is more integrated and flexible in meeting the needs of our patients. Our guiding principles are to deliver better outcomes, safeguard quality and improve value and patient/staff experience Integrated sexual health services During 2015 DCHS worked in partnership with Chesterfield Royal Hospital and Derby Royal Teaching Hospital to integrate the sexual health and genitourinary medicine services provided by the three organisations into a single managed service. DCHS has taken over responsibility for the overall coordination of the service and in response to feedback from our patients have redesigned the service to improve access by increasing the number of available clinics and providing a wider range of appointment slots. During 2016 we will continue to work with our staff to increase their skills and knowledge so that we are able to offer a truly integrated service and ensure that as many patients as possible are able to receive a one stop service. 190

191 Specialist Learning Disability services Transforming Care The Department of Health, Winterbourne Review, Transforming Care Concordat commits to a programme for change to transform health and care services and improve the quality of the care to ensure better care outcomes for people with a learning disability. DCHS specialist learning disability services are actively involved in the Derbyshire wide Transforming Care project. We attend the joint Transforming Care Operational group to review each of the cases and assist in the development of plans for those service users who are moving back into North Derbyshire. Where service users move back and require ongoing support from specialist services we work jointly to develop patient centred plans that meet individual s needs. A number of people have returned to North Derbyshire communities and our Community Learning Disability Teams (CLDT) have played a key role in their ongoing management and support of their individual plans. Our learning disability staff are continuing to develop the Challenging Behaviour Pathway which is in line with Positive Behavioural Support and the Department of Health s guidance on positive and proactive care. Care and treatment reviews (CTR S) have taken place for all individuals who meet the Transforming Care criteria and for those people who have required an inpatient admission. This is National identified good practice which we have embedded into our operating procedures Home intravenous therapy DCHS works collaboratively across the health community to support the increasing demand on our acute hospital services. We are constantly looking for ways to reduce demand on hospital beds and avoid unnecessary admissions. Our community staff in north and south Derbyshire administer intravenous (IV) antibiotics to patients in their own home to prevent them needing to be admitted into an acute hospital for this procedure. This is of benefit to the patient and frees up valuable hospital beds. This service is provided in conjunction with both Chesterfield Royal Hospital and Royal Derby Teaching Hospital 3.5 Ensuring our services are well led Strong leadership is at the heart of high quality care services and DCHS continues to invest in its staff to ensure the very best outcomes for patients Quality Always Clinical Assessment and Accreditation Scheme DCHS is committed to providing high quality care throughout the full range of the services it delivers. The Quality Always scheme underpins our approach to making 191

192 sustainable quality improvements and providing assurance about the standards of care we deliver. There are two key facets of our Quality Always approach. Clinical Assessment and Accreditation Scheme (CAAS) We have developed a comprehensive suite of quality standards based upon the Care Quality Commissions fundamental standards. These standards have been developed on a bespoke basis for specialist teams. Individual teams are responsible for ensuring that they meet the standards set through a process of selfassessment and clinical audit. Independent peer assessment is undertaken by the Quality Always central team who undertake unannounced reviews against the core standards. On completion of a peer review teams receive a rating and a detailed report so they can develop a quality improvement plan. Their rating dictates the frequency of their next assessment. (red, reassess in 2 months, amber reassess in 4 months, green reassess in 8 months, following accreditation reassess in 12 months). To become an accredited Quality Always area a team must be able to sustain a green rating over 2 successive reviews and undergo a panel assessment of the quality of their care. This process is expected to take teams a minimum of 16 months to achieve. Teams that have participated to date have demonstrated a high level of commitment to the scheme and evidence of sustained improvements in many areas. We now have several teams achieving their first green rating. The charts in appendix 4 demonstrate the progression of improvements and progress of the scheme Leadership Development Scheme A cornerstone of DCHS vision and values is the development of a workforce who support clinical excellence. Clinical leaders directly influence the quality of patient care and their development is seen as key in achieving our Quality Always goals. As part of this development clinical team leaders are assessed on strengths and development areas, in relation to 5 key behaviours (NHS Leadership Academy Framework): managing services, working with others, setting direction, leading change, and demonstrating personal qualities. A development centre approach has been developed compromising: 360 degree appraisal and feedback, staff appraisal Development Centre day 192

193 detailed feedback based on the development day, appraisal and 360 appraisal a personal development plan for each leader. To date 114 clinical leaders have taken part. It is anticipated that this approach will facilitate clinical leaders in the development of change management skills needed to sustain clinical improvement in their area of responsibility Insight visits As part of the DCHS Assurance model; our newly designed Insight visits commenced in July 2015 and superseded our quality and safety visits. The visits take place in all care settings across the trust. Insight teams include a senior staff manager from the visited service, a member of the Trust Board and a public Governor. The Insight visits offer a great opportunity for staff to share successes, achievements, suggestions and the day to day challenges they face; as well as to showcase the area which staff work. As part of the visit the Insight team talks to patients and clients, to find out more about their experiences Health Education East Midlands visit to DCHS, Feedback Report 10th February 2016 Health Education England Working Across the East Midlands (HEE(EM)) visited Derbyshire Community Health Services (DCHS) NHS Foundation Trust on 10th February The visiting team reported that they encountered a Trust that demonstrates a culture which truly values education and learning and is keen to train students and support the continuous development of existing members of staff. This culture was evident across all levels of the organisation. DCHS was consistently described as supportive, welcoming and friendly by the learners and educators. The team reported that DCHS demonstrated that they are being proactive in transforming its workforce to meet the future needs of its service users. The visiting team heard about several areas of good practice and innovation: in particular the training of staff in using the University of Stirling s Best Practice in dementia Care training package, the Quality Always programme of ongoing audit and development and a new face to face forum for students Appraisals At DCHS we provide our staff with an annual appraisal, which not only reviews their progress against their objectives, but also provides an opportunity to assess how they performed their duties in line with the DCHS Way values and behaviours. 193

194 In 2015/16, 94% of our available staff received an Annual Appraisal. We are committed to ensuring this figure increases further in 2016/17. We are keen to ensure that appraisals are not only undertaken on time, but are also of a high standard and quality. To understand this even further, in late 2015, we commissioned an independent external audit into our appraisal systems and processes. We shall be acting upon the feedback received through that audit during Nonmedical prescribing DCHS employs more nonmedical prescribers, mainly nurses, than any of the other NHS Trusts in Derbyshire and in April we hosted our annual nonmedical prescribing conference, attended by over 120 prescribers. Nonmedical prescribers now include community matrons, advanced nurse practitioners, emergency care practitioners, therapists, sexual health practitioners, podiatric surgeons and specialists working with patients who have diabetes, respiratory problems or Parkinson s disease Staff health and safety At DCHS we take Health and Safety very seriously, our objective is to ensure that all our staff go home safely at the end of each and every day. Our approach to Staying Safe is simple. We believe that all injuries are preventable and through good leadership and engagement of staff we can create a safety culture in which everyone takes responsibility for health and safety both on a personal and a collective level. In 2015/16 we have had 876 reported incidents of which 446 were no harm, 411 were minor harm and there were 19 RIDDOR reportable injuries. This is in comparison to updated 2014/15 figures which were 927 reported incidents of which 545 were no harm, 365 were minor harm and there were 17 RIDDOR reportable injuries Staff health and wellbeing At DCHS, we know that if our staff are healthy, they are able to provide better quality care for our patients. We are passionate about creating a healthy workplace for our employees. During 2015/16 we have remodelled our internal Staff Support and Counselling service (Resolve) including provision of a new outofhours helpline; launched a new online emotional wellbeing toolkit for staff; held a summer Pedometer Challenge which saw over 500 staff take part and started our own staff weight loss programme, facilitated by our Live Life Better Service and attended by over 150 staff. 194

195 3.5.9 Raising Concerns (whistleblowing) We are committed to encouraging staff to speak up regarding any issues that are concerning them. We have established a small working group consisting of staff side representatives and managers to ensure that DCHS implements all the recommendations in the Freedom to Speak Up Campaign. This year we have extensively reviewed and rewritten our Raising A Concern Policy to make it easier for staff to raise a concern in a way that they feel comfortable and we have strengthened our mechanisms for ensuring that any learning from issues raised are implemented. We have identified our Trust Secretary as the Local Guardian for concerns (Whistleblowing) and highlighted in our new policy the numerous different ways staff can both raise a concern and receive support to do so. Within DCHS our Executive Team have a high visibility with front line staff, this means that they are often able to deal with concerns raised directly with them when they are out visiting sites and services and very few concerns are raised formally. In the last year we have received 5 formal concerns, one of which is still ongoing. A number of these issues have been reported anonymously. Our plans for the following year include: implementation of Raising A Concern communications campaign supported by additional training materials including a video which can be accessed from our web site. looking at ways to identify whether the low numbers of concerns raised are due to staff s reluctance to speak up or because issues are dealt with effectively by managers Quality impact assessments Assessing the impact that changes we make to our services has on our patients and their carers is an important part of our quality control. The QIA involves weighted quality assessments against the domains of patient safety / safeguarding, clinical effectiveness, patient experience, impact on staff / other services, and impact on stakeholders / reputation. Key performance indicators (KPIs) against which the impact of the project will be measured throughout the year are also confirmed. All QIAs are signed off by the Chief Nurse and Director of Quality, Medical Director and a NonExecutive Director. Where necessary a confirm and challenge session is held with the service managers to check assumptions. Ongoing monitoring of key indicators and risk factors ensure any unforeseen circumstances are identified early. All cost improvements during 2015/16 underwent a quality impact assessment. 195

196 Celebrating success the Extra Mile Awards Each year the trust celebrates the contribution of its staff in the Extra Mile Awards. This year the awards attracted 300 entries from which judges selected 51 finalists who were invited to the awards evening. These are individuals and teams who have been nominated by their colleagues for their dedication and caring. One of the awards for outstanding care and compassion is also open for patients and families to nominate. Awards were made in a broad range of categories including: Healthcare Hero Award Behind the Scenes Hero Award Innovation Award Celebrating Diversity Award Winner: Winner: Winner: Winner: Gill Jones Megan Campbell Welcome Home Service The Equality & Diversity Theatre Forum Volunteer of the Year Winner: John Hart Leadership Excellence Award Winner: Jackie Rawlings Partnership Working Award Winner: Falls Partnership Team Outstanding Care and Compassion Award Winner: Gill Jones Team of the Year Award Winner: Ilkeston & Heanor Inpatients Wards Lifetime Achievement Award Winner: Sue Renshaw The Chairman s Award Winners: Kay Bradley, Lisa McKenzie, Ruth Keen and Steven Ratcliffe NHS Board of the Year East Midlands During 2015 the trust board of Derbyshire Community Health Services NHS Foundation Trust was named as the NHS Board of the Year in the East Midlands in December The judges commented on the Boards handson leadership style, with regular backtothefloor sessions, and for making a priority of learning from patient feedback in how services are improved. Every trust board meeting starts with hearing about the experiences of a particular patient. The team was responsible for leading the organisation to become one the first specialist community foundation trusts in the country, earning the organisation a clean bill of health from the Care Quality Commission inspectorate and a consistently above average position in most national measures. Further information regarding our workforce can be found in appendix 1 196

197 Appendix 1 Workforce Workforce summary As at 31st December 2015 DCHS employed 4,529 substantive staff. Twothirds of our staff are in clinical roles. In addition to the above we have approximately 1,000 bank staff who support us in keeping agency usage to an absolute minimum, in fact less than 2% of our nursing budget is spent on agency staff, significantly lower than the national average. We are committed to staffing our clinical areas wherever possible with DCHS staff as we believe this is the best way to deliver high quality care. Staff turnover has remained stable over the past 12 months and the rate stands at 9.04% which is significantly lower than the East Midlands NHS turnover average of 14.68% and a national NHS turnover rate of 10.09%. Analysis undertaken on the reasons staff have left DCHS has not highlighted any trends or cause for concern. Currently our vacancy rate is 6.23%. All of this assures us that DCHS has a largely stable workforce which can only serve to allow us to provide high quality care. Our average absence rate for the last 12 months as at 31st March 2016 was 4.57%. National and regional absence figures have not been released since summer 2015, when we were slightly below the national and regional average. The top three reasons for absence remain as stress/anxiety, MSK and gastrointestinal. Staff Survey In 2015 we used the NHS Staff Survey to invite all of our staff to take time out to tell us what they thought about the organisation and their working lives. This was performed independently by the Picker Institute Europe which ensured absolute confidentiality and supported detailed analysis. We received a 57% response rate to our full census which enables us to have a rich source of data to look at the key areas we can improve for our staff. NHS England published its Staff Survey results in February The key findings for DCHS, benchmarked against other Community NHS Trusts are detailed below: Details of key findings from the latest NHS Staff Survey response rates A total of 2,256 staff at Derbyshire Community Health Services NHS Foundation Trust took part in this survey. This is a response rate of 57% which is above average for community trusts in England, and compares with a response rate of 62% in this trust in the 2014 survey. 197

198 The table below gives a summary of ranking, compared with all Community Trusts in 2015 for the 32 key findings in the survey: Above (better than) average Below (better than) average Average Above (worse than) average Below (worse than) average Overall staff engagement The overall staff engagement score for 2015 was 3.92 and was above (better than) average when compared with trusts of a similar type, this has increased from 3.83 in 2014 and was at 3.76 in It also compares favourably with national average Community Trust engagement score of 3.82 for The overall indicator of staff engagement is calculated by NHS England using the questions that make up key findings 7, 4 and 1. These key findings relate to the following aspects of staff engagement: Staff members perceived ability to contribute to improvements at work Staff members willingness to recommend the trust as a place to work or receive treatment The extent to which staff feel motivated at work Areas of improvement from prior year There are four Key Findings where staff experiences have improved the most at DCHS since the 2014 survey: 1) KF4: Staff motivation at work 2) KF25: % of staff experiencing harassment, bullying or abuse from patients, relatives or public in the last 12 months 3) KF18: % of staff feeling pressure in the last 3 months to attend work when feeling unwell 198

199 4) KF28: % of staff witnessing potentially harmful errors, near misses or incidents in the last month Areas of deterioration from prior year There are three Key Findings where staff experiences have deteriorated since the 2014 survey: 1) KF27: % of staff/colleagues reporting most recent experience of harassment, bullying or abuse 2) KF24: % of staff/colleagues reporting most recent experience of violence 3) KF 16: % of staff working extra hours Top 4 ranking scores According to the National NHS England data the four key findings for which DCHS compares most favourably with other Community Trusts in England are: KF6: % of staff reporting good communication between senior management and staff KF1: staff recommendation of the organisation as a place to work or receive treatment KF14: staff satisfaction with resourcing and support KF19: organisation and management interest in and action on health and wellbeing Bottom 4 ranking areas According to the National NHS England data the five key findings for which DCHS compares least favourably with other Community Trusts in England are: KF22: % of staff experiencing physical violence from patients, relatives or the public in the last 12 months KF23: % of staff experiencing physical violence from staff in the last 12 months KF27: % of staff/colleagues reporting most recent experience of harassment, bullying or abuse KF3: % of staff agreeing that their role makes a difference to patients/service users The proposed focus areas of action following the 2015 staff survey results are identified in the table below. These have been based on the areas where DCHS were ranked in the bottom against other community trusts and where results have deteriorated the most against the 2014 results. The areas will now be discussed with staff and senior managers for final decision and once agreed, actions aligned and progress tracked. 199

200 Focus Area 1) Safety staff and patients 2) Staff able to contribute to improvements at work 3) Staff working extra hours 4) Making a difference 5) Recommendation as a place to work 2015 results KF27: 42% of staff/colleagues reporting most recent experience of harassment, bullying or abuse KF24: 64% of staff/colleagues reporting most recent experience of violence KF22: 10% of staff experiencing physical violence from patients, relatives or the public in the last 12 months KF23: 1% of staff experiencing physical violence from staff in the last 12 months KF7: 72% of staff able to contribute towards improvements at work KF16: 71% of staff working extra hours KF3: 91% of staff agreeing that their role makes a difference to patients/service users KF1: 3.97 staff recommendation as a place to work or receive treatment 2014/15 Response rate Trust 2015/16 National Trust Average 44% 57% 62% Trust improvement / deterioration National Average 48% Increase / decrease in % points 5% Top 4 ranking scores 2014/15 Top 4 ranking scores Trust KF6 Percentage of staff reporting good communication between senior management and staff KF1 Staff recommendation of the organisation as a place to work or receive treatment 2015/16 Trust improvement / deterioration 42% National Trust Average 33% 40% National Average 30% Increase / decrease in % points 2% decrease Increase / decrease in % points 0.07 increase 200

201 KF14 Staff satisfaction with resourcing and support KF19 Organisation and management interest in and action on health and wellbeing /15 Bottom 4 ranking scores Trust KF22 Percentage of staff experiencing physical violence from patients, relatives or the public in last 12 months KF23 Percentage of staff experiencing physical violence from staff in last 12 months KF27 Percentage of staff / colleagues reporting most recent experience of harassment, bullying or abuse KF3 Percentage of staff agreeing that their role makes a difference to patients / service users 2015/16 Increase / decrease in % points N/A Increase / decrease in % points N/A Trust improvement / deterioration 9% National Trust Average 8% 10% National Average 7% Increase / decrease in % points 1% increase 2% 1% 1% 1% Increase / decrease in % points 1% decrease 42% 43% Increase / decrease in % points N/A 91% 91% Increase / decrease in % points Staff Pulse Checks The DCHS pulse check was launched in July 2013 and provides an indicator throughout the year as to how staff, as employees, are feeling. The pulse checks are run on a quarterly basis and provide an opportunity for staff to give anonymous feedback on how well they feel they are being managed, engaged and supported. This is now linked with our Staff Friends and Family Test. It allows DCHS leaders to gain valuable insight into how their teams are feeling, and thus the opportunity to work closely with their teams about the issues that are 201

202 important to them. The way they are structured facilitates swift feedback after the questionnaire has been completed. The positive impact high staff engagement can have on other Trust KPIs such as attendance, patient safety and productivity is recognised and well researched. It is also a significant measure for the leader as to how well they are engaging with their teams to deliver the results we need, primarily around quality care for our patients. The trust wide response rates for each quarter to date are: Jul 13 39% Oct 13 37% Jan 14 36% Apr 14 31% Jul 14 38% Jan 15 33% Apr 15 35% Jul 15 36% Apr 15 75% Jul 15 76% The overall engagement scores for each quarter to date are: Jul 13 77% Oct 13 77% Jan 14 79% Apr 14 76% Jul 14 76% Jan 15 77% Our Staff FFT scores for the past 2 Pulse Checks are as follows: How likely are you to recommend DCHS to friends and family if they needed care or treatment? April 2015: 89% July 2015: 91% How likely are you to recommend DCHS to friends and family as a place to work? April 2015: 69% July 2015: 70% As a result of the DCHS Pulse Check process/staff engagement it can be confirmed that: a review of existing practice has been started examples of good practice are being identified and will be shared there is a plan to reenergise staff engagement and work specifically with teams with low participation rates/staff engagement scores to foster a new attitudes and improved results. What we will be doing during 2016/17 1. Review and refresh all the current staff engagement activities including Pulse Check/Staff Survey questions; survey methodology e.g. frequency, sampling; survey mechanisms e.g. paper vs online; Staff Forum; recognising talent (EMAs) and supporting innovation. 2. Ensure Pulse Check data hierarchy is correct improve understanding of match between data held on ESR and teams managed 202

203 3. Review staff engagement communication channels, visual identity and messaging 4. Review examples of good practice and identify any that can be shared and mechanisms for spreading the learning 5. Develop the Moving from good to great staff engagement strategy; 6. Focus on increasing participation rate in low performing teams through understanding barriers, introducing bespoke action plans and supporting change and improvement 7. Align with other key DCHS programmes e.g. DCHS Way; Caring Always, Quality Always 8. Evaluate and introduce new initiatives that will support improvement in staff engagement. Focus on four key areas communication, opportunity to engage, leadership training/development and visibility Training and Development Achieving business excellence relies on DCHS having a workforce with the right skills, competencies and professional capabilities to deliver excellent care against a background of unprecedented change both nationally and locally. DCHS ambition is to be the best provider of local healthcare and a great place to work. Education and training is critical to achieving that vision. Inaddition, if we want to fulfil the DCHS Way to build a high performance work environment that engages, involves and supports staff to reach their full potential we know that we must ensure staff receive first class training and education and provide the workforce with appropriate development opportunities so as to ensure they acquire the requisite knowledge and skills to provide high quality care and practice at the top of their license. DCHS currently provides a range of inhouse training programmes however, changes in population health needs, service transformation and the move toward integrated care calls for the development of new and or additional workforce skills so as to deliver new models of care. This will require significant change to the current education and training offer not least an increase in the current portfolio but development of robust quality assurance processes such as achieving the Skills for Health Quality Mark. We recognise that if we want to remain an employer of choice within the local and national labour market, we must go from good to great in terms of our training and education offer. It is our vision To become a Centre of Excellence for Training and Education. 203

204 Leadership Development During 2015, we have invested in our leaders through the Quality Always Leadership Development Centres (QALDS). The scheme involves nominated participants undertaking a DCHS 360 review and attendance at a DCHS Development Centre. During 2015, 114 leaders took part in the process and the feedback has been extremely positive, with both participants and observers at the Development Centres commenting how constructive the experience had been. As part of the process we have had 43 senior leaders attend an accredited training programme, so that we have our own pool of in house observers to support the future roll out of QALDS. This training has brought benefits to those leaders beyond supporting QALDS as it has built confidence and competence in observing, evaluating and feeding back on behaviours. This will in turn benefit the quality of appraisals, recruitment etc. The review of our leadership offer during 2015 has also seen a refresh of our leadership development learning portal (leading the DCHS way) available for all leaders to access on our intranet. This holds all information that is helpful to leaders e.g. details of all leadership development courses, conferences, coaches, mentors, career case studies, live news feed re NHS leadership etc. We are also about to launch a leadership chat room within the site so that leaders can share best practise and access support from each other. We have also launched a leadership twitter account and weekly newsletter to market leadership development opportunities. We have piloted new courses e.g. team building, social media for engagement, personal impact workshops, better decision making etc. which are externally facilitated along with some basic getting to grips 2 hours information sessions for leaders that are facilitated by in house experts. 204

205 Appendix 2 Trust Risk Ratings As a foundation trust DCHS is required to meet certain conditions including those in respect of: Continuity of services a measure of financial sustainability and resilience. The purpose of this measure is to identify any significant risks to the financial sustainability of the foundation trust which would endanger the delivery of key services. Continuity of service is measured on a scale of 14 with 1 being the highest risk and 4 the lowest risk. Governance how a foundation trust oversees care for patients, delivers national standards, and remains efficient, effective and economic. Trusts are rated from Green (low risk) to Red (high risk) DCHS is given a rating for continuity of services and a rating for governance to indicate where there is a cause of concern and to determine the extent of any intervention required Monitor. DCHS has performed in line with its annual plan during 2015/16 and has achieved consistently good ratings and continues the success of the previous year. There have been no formal interventions in year. Table of analysis 2015/16 Continuity of service rating Governance rating 2014/15 Continuity of service rating Governance rating Annual Plan Q1 Q2 Q3 Q Green Green Green Green Green Annual Plan Q1 Q2 Q3 Q4 4 4 Green Green 205

206 Appendix 3 Information Governance Toolkit submission for 2015/16 We are required to make sure that the information we hold about patients and staff is held and managed safely and confidentially and that it is used only for the purpose for which it was collected. The Information Governance Group is responsible for maintaining and improving the Information Governance Toolkit scores. We can confirm that we had no requirements that were not applicable and all requirements were answered. Level 0 Level 1 Level 2 Level 3 Total Req ts Overall Score (%) Information Governance Management % Confidentiality and Data Protection Assurance % Information Security Assurance Clinical Information Assurance % Secondary Use Assurance % Corporate Information Assurance % Overall % Assessment 206

207 Appendix 4 Progression of Quality Always, the DCHS Way It is important to note that teams are recruited to this programme at different times and some areas have had fewer assessments than others. Whilst a red rating indicates areas for improvement it does not signify that poor care is being delivered in this clinical environment. Assessment number A1 A2 A3 A4 A A A G R R A A5 A6 A A Babington Hospital Baron Ward Bolsover Hospital Hudson Ward* Bolsover Hospital Linden Ward R Bolsover Hospital Rowan Ward R Cavendish Hospital Fenton Ward A A A A Cavendish Hospital Spencer Ward R A G G Clay Cross Hospital Alton Ward A A A G Ilkeston Community Hospital Heanor Wards R A A A Ilkeston Community Hospital Hopewell Ward R A A A Newholme Hospital Riverside Ward R A A A A Newholme Hospital Rowsley Ward R A A R R Ripley Community Hospital Butterley Ward A A A A St Oswalds Hospital Okeover R A A A A Walton Hospital Linacre Ward OPMH R A G G G Walton Hospital Melbourne Ward OPMH R R A G Whitworth Hospital Oker Ward R R A A Ashgreen Hospital Valley View A A G Ashgreen Hospital Hillside A A G Core Unit Rockley A A A Core Unit Amberley A G G Core Unit Robertson Road A A G Core Unit Orchard Cottage A A G Buxton MIU A G Ilkeston MIU A G Ripley MIU A G Whitworth MIU G East Chesterfield integrated teams R Chesterfield Central integrated R Lea Hurst Day Unit OPMH OPMH OPMH A Health Visiting Team A Speech and Language Therapy A Chesterfield Podiatry A Dental A Diagnostic Treatment Centre (DTC) Ilkeston A A G A A *Combined results for Linden and Rowan wards which were replaced by Hudson Ward 207

208 Appendix 5 Third party statements CCGs/Healthwatch Healthwatch Derbyshire collects experiences of health and social care services, as told by patients, their families and carers. These genuine thoughts, feelings and issues that have been conveyed to Healthwatch Derbyshire form the basis of this response. During this period, Healthwatch Derbyshire has heard about services delivered by (DCHS) in a number of different ways. We have carried out several pieces of themed engagement to explore specific topics, such as collecting the experience of people with learning disabilities when using health services. Themed engagement has been drawn together into reports published on the Healthwatch Derbyshire website. DCHS has been invited to respond to the recommendations made in each report, and responses received can be found at the end of relevant reports. Additionally, Healthwatch Derbyshire has drawn together the individual comments received about the Trust into an Annual Information Summary, which can be found on the Healthwatch Derbyshire website under the Our Work section. The Annual Information Summary covers the 124 comments received by Healthwatch Derbyshire about the Trust, collected from either general engagement activity or volunteered to us by people calling, ing or using the Healthwatch Derbyshire website to share their experiences. Out of the 124 comments received, 74 were positive, 34 were negative and 16 had a mixed sentiment, i.e. had both a positive and negative element. The comments received cover a range of services with 33 comments relating to outpatients, and 12 comments relating the Minor Injuries Units. The most recurrent negative themes were access to a service and waiting times. The most recurrent positive theme was quality of treatment. It should be remembered that this information contains comments from a relatively small number of patients and so should be seen in the wider context of patient experience at the Trust, as reported in this Quality Account. 208

209 Healthwatch Derbyshire would like to thank Derbyshire Community Health Services NHS Foundation Trust for their timely and thorough responses to comments which are then, when possible, fed back to patients. Helen Hart Intelligence and Insight Manager 6th May 2016 response: DCHS enjoy the partnership that they have developed with Healthwatch and will continue to work with them to improve access to services for patients and on key improvement initiatives and reviews. 209

210 North Derbyshire Clinical Commissioning Group Commissioner Statement General Comments NHS North Derbyshire Clinical Commissioning Group (NDCCG) is responsible for providing the commissioner statement on the quality account provided by Derbyshire Community Health Services Foundation Trust (DCHSFT) and in doing so has provided NHS Hardwick Clinical Commissioning Group, NHS Southern Derbyshire Clinical Commissioning Group and NHS Erewash Clinical Commissioning Group as associate commissioners with the opportunity to make comments and contribute to the commissioner statement. Careful consideration has been given to the content and accuracy in line with the national guidance. NDCCG can confirm that DCHSFT has produced a Quality Account that meets the guidance and that the information provided appears to be accurate and representative of the information available to NDCCG through contract monitoring and quality assurance processes during the year. Measuring and Improving Performance The Quality Account describes the quality of services provided this year by DCHSFT measured against national, regional and local standards as detailed within the NHS contract and also within the local quality schedule and quality incentive scheme (CQUIN). The Trust has worked hard to achieve all of the requirements set out for them in the Quality Schedule and have achieved all of the required CQUIN measures. There have been significant improvements demonstrated with CQUIN indicators. In 2015/16 DCHSFT outlined three key quality priorities for improvement over the year, unfortunately while there has been significant improvements made against all 3 of these targets, they have not yet been achieved, work will continue on these in 2016/17. For 2016/17 the Board of Directors has agreed three further quality improvement objectives as listed below, these have been chosen as a result of feedback to the Board and the CCG are pleased to note that they are reflective of the 2016/17 CQUINs, Quality schedule and in the case of frailty 21C work programme. Patient Safety to decrease the overall burden of pressure damage within our health community by a reduction of pressure ulcer incidents as a percentage of patients looked after by our services 210

211 Clinical Effectiveness to introduce across our services a nationally recognised measure of frailty which will help us to identify patients at risk and proactively manage their care Patient Experience to improve our performance in relation to complaint response rates ensuring that patients receive a response to any concerns raised within a reasonable timeframe DCHSFT continue to perform very well against the Friends and Family Test as a measure of patient experience with 98% of patients who completed the Test stating they would recommend services to their friends and family. The Trust also proactively ask patients how they could improve and these improvements are shared across the organisation through a "You Said, We did format. A significant amount of work and focus has gone into falls prevention across the year, in the establishment and refining of pathways and governance for falls management. A falls prevention lead is now in post working across all clinical settings with a focus on older people s mental health services. We are pleased to see this focused work and the resulting continued decrease in falls incidents within in patient care. The Trust developed a Quality Always Clinical Assessment and Accreditation Scheme consisting of a set of quality standards based around the CQC fundamental standards. Part of the assessment includes unannounced reviews and visits against the standards from the Quality Always central team, Commissioners have been welcomed as part of these teams and are impressed by the assessment process. The results have shown sustained improvements in the areas visited. One of the key priority areas for improvement in 2015/16 was to reduce the numbers of pressure ulcers developing and or deteriorating while patients are under the care of DCHSFT staff. We are pleased to see a downward trend in the severity of pressure ulcers developing in DCHSFT care, and a sustained reduction in avoidable pressure ulcers, while recognising that this remains an area of focus for both DCHS and the wider health economy. To address the recommendations of the new national Serious Incident framework around the threshold of harm from pressure ulcers and levels of learning commissioners are working in partnership with DCHSFT to reduce the burden of RCA reporting and increase back to the floor clinical time of senior nursing staff. In relation to patient safety Commissioners continue to receive all serious incident reports and root cause analysis (RCA) work. 211

212 Additional comments The Quality Account is an annual report to the public that aims to demonstrate that the Trust is assessing quality across the healthcare services provided. The Trust has worked collaboratively with commissioners and all key stakeholders to ensure patients receive high quality care in the right care setting. NHS North Derbyshire Clinical Commissioning Group and associate commissioners look forward to continuing to work with the Trust to commission and deliver this high quality patient care. Jayne Stringfellow Chief Nurse & Quality Officer On behalf of NHS North Derbyshire Clinical Commissioning Group 25th April 2016 response: DCHS enjoys a productive working relationship with NDCCG and will continue to work with them in 2016/17 on the reduction of the burden of pressure ulcers across our health community. We will continue to welcome commissioners to review with us the quality of our services as part of our Quality Always teams. 212

213 Commissioner Statement General Comments NHS Southern Derbyshire Clinical Commissioning Group (SDCCG) is the coordinating commissioner for services provided to the population of Southern Derbyshire by (DCHSFT). SDCCG took over this responsibility from 1st April DCHS took over the running of Derby City Community Services from October 2015 from Derby Teaching Hospitals NHS Foundation Trust. SDCCG, in this role, can confirm that the content of the annual quality account is in line with national guidance. Measuring and Improving Performance The quality account has been subject to detailed review, ensuring that the data and information reported in the account is consistent with the evidence submitted to the CCG which is measured against national, regional and local standards as detailed within the NHS contract, the local quality schedule and quality incentive scheme (CQUIN). Commentary The Trust has worked hard to achieve the targets and outcomes detailed in the quality schedule and have met the requirements of all nine of the National and Local CQUINS. The Trust overcame the challenge of data collection for the Dementia CQUIN to achieve a commendable result in the number of people being assessed for dementia. The Trust set three key priorities for 2015/16: 1. Improvements in information sharing significant progress has been made in developing information sharing protocols and staff now ask patients for agreement to share health records. The CCG acknowledge that the Trust needs to continue to improve its IT infrastructure. 2. Increasing referrals for smoking cessation the Trust has been unable to demonstrate that it has achieved against this priority due to problems with capturing data which again highlights the further work required on the IT infrastructure. The CCG will continue to monitor progress through 2016/ Identifying where patients with a learning disability access services this priority has also proven difficult to achieve due to data capture relating to the broad spectrum of learning disability. The Trust has developed an equality and diversity inclusion forum which will work towards achieving better data capture. Progress will continue to be monitored by the CCG. 213

214 The Trust has made continued progress in improving patient safety and the CCG is pleased to see they have committed to the five pledges in the Sign up to Safety Campaign and introduced Safe Care Champions across the service. It is apparent that the work in the prevention of falls has shown a considerable reduction in inpatient falls especially in relation to patients with dementia where innovative solutions have been identified. The Trust have seen a sustained reduction in the numbers of avoidable pressure ulcers (developed or deteriorated in their care) although they have not yet met their target of zero. The continued reduction in numbers reported continues to be a substantial challenge for the service but this is supported by achieving a consistent approach to prevention. Infection prevention and control is an important aspect of daily work in inpatient areas and community services. It is notable that there have been no reported cases of MRSA (a type of blood infection) and a 50% reduction in the numbers of C Difficile (diarrhoea infection) cases. The Trust has maintained optimal staffing levels in line with best practice and has developed a tool to measure workload and case mix in community teams with the intention of rolling this out to therapy teams in the near future. There is evidence that clinical effectiveness is measured by participation in national and local audits and research and development. Inservice developments have seen a reduction in waiting time for assessment for patients with dysphagia despite increasing referrals. The Friends and Family Test has shown positive outcomes for patient experience with 98% of patients who responded recommending the service to their family and friends. Duty of Candour has been undertaken when incidents have occurred and full investigation and explanation provided to affected patients. The Trust have developed a clinical assessment and accreditation scheme Quality Always that incorporates unannounced peer review against core standards. Clinical leaders also undertake a leadership development scheme to underpin the achievement of Quality Always within clinical areas. The CCG is invited to attend visits. Wards have made significant improvements in standards since the introduction of the scheme. 214

215 Priorities for 2016/17 The Trust has listened to feedback from patients, board members and staff to identify three priorities for 2016/17: Patient safety reduce the numbers of pressure ulcers as a percentage of the patients looked after by the service. Clinical effectiveness to introduce a measure of frailty to identify patients at risk and manage effective care. Patient experience to improve complaint response times. The CCG looks forward to reviewing the evidence of the achievements and successes that will be delivered during the next twelve months. Lynn Woods Chief Nurse & Director of Quality On behalf of NHS South Derbyshire Clinical Commissioning Group 16th May 2016 response: DCHS has established a positive working relationship with SDCCG within its revised remit as a lead commissioner and welcomes the positive feedback on the 2015/16 annual quality report. The Health Scrutiny Committee is pleased to receive the Quality Account for for 2015/16 and Members have noted the information it imparts. The Committee will take the opportunity, over the coming year, to monitor the activities and progress of the Trust and both support and challenge the Trust as appropriate Chair of the Health Scrutiny Committee 25th April 2016 response: DCHS is grateful to the Health Scrutiny committee for its interest in our work throughout the year and we look forward to sharing our quality improvements in the year to come. 215

216 DCHS governor opinion I've read the Quality Report which appears to be open, honest and very informative. The objectives set for the coming year are clear and definitely relevant. I like the fact that we highlight what hasn't been fully achieved, the reasons why and what we aim to do about it. Rosaline Coldicott DCHS Pubic Governor 24th April 2016 response: DCHS is grateful to its Governors for the support in preparing this annual quality report and the feedback that we have had with regard to the various iterations. 216

217 Appendix 6 Statement of Directors responsibilities in respect of the Quality Account The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the quality report. In preparing the Quality Report, directors are required to take steps to satisfy themselves that: the content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2015/16 and supporting guidance; the content of the Quality Report is not inconsistent with internal and external sources of information including: o Board minutes and papers for the period April 2015 to May 2016 o Papers relating to Quality reported to the board over the period April 2015 to May 2016 o Feedback from the commissioners dated 25/04/2016 and 16/05/2016 o Feedback from governors dated 20/04/2016 and 24/04/2016 o Feedback from local Healthwatch organisation dated 06/05/2106 o Feedback from Overview and Scrutiny Committee dated 25/04/2016 o The trust s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 24/05/2016 o The [latest] national patient survey n/a to DCHS o The [latest] national staff survey February 2016 o The Head of Internal Audit s annual opinion over the trust s control environment dated 26/05/16 o CQC Intelligent Monitoring Report dated n/a to DCHS the Quality Report presents a balanced picture of the NHS foundation trust s performance over the period covered; the performance information reported in the Quality Report is reliable and accurate; there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice; the data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Report has been prepared in accordance with Monitor s annual reporting guidance (which incorporates the Quality Accounts regulations) as well as the standards to support data quality for the preparation of the Quality Report 217

218 The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report. By order of the board 26 May 2016 Chairman 26 May 2016 Chief Executive 218

219 Appendix 7 Independent Auditors Independent Auditors Limited Assurance Report to the Council of Governors of on the Annual Quality Report We have been engaged by the Council of Governors of Derbyshire Community Health Services NHS Foundation Trust to perform an independent assurance engagement in respect of Derbyshire Community Health Services NHS Foundation Trust s Quality Report for the year ended 31 March 2016 (the Quality Report ) and specified performance indicators contained therein. Scope and subject matter The indicator for the year ended 31 March 2016 subject to limited assurance (the specified indicator ) marked with the symbol in the Quality Report, consist of the following national priority indicators as mandated by Monitor: Specified Indicators Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period Specified Indicators Specified indicator criteria (exact page number in the Quality Report where the criteria can be found) Page 39 In the combined annual report and quality report document the page reference is page 180 Respective responsibilities of the Directors and auditors The Directors are responsible for the content and the preparation of the Quality Report in accordance with the specified indicator criteria referred to on page 39 of the Quality Report as listed above (the "criteria"). The Directors are also responsible for the conformity of their criteria with the assessment criteria set out in the NHS Foundation Trust Annual Reporting Manual ( FT ARM ) and the Detailed requirements for quality reports 2015/16 issued by the Independent Regulator of NHS Foundation Trusts ( Monitor ). Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that: The Quality Report does not incorporate the matters required to be reported 219

220 on as specified in Annex 2 to Chapter 7 of the FT ARM and the Detailed requirements for quality reports 2015/16 ; The Quality Report is not consistent in all material respects with the sources specified below; and The specified indicator has not been prepared in all material respects in accordance with the criteria set out in the NHS Foundation Trust Annual Reporting Manual ( FT ARM ) and the 2015/16 detailed guidance for external assurance on quality reports. We read the Quality Report and consider whether it addresses the content requirements of the FT ARM and the Detailed requirements for quality reports 2015/16 ; and consider the implications for our report if we become aware of any material omissions. We read the other information contained in the Quality Report and consider whether it is materially inconsistent with the following documents: Board minutes for the financial year, April 2015 and up to 26th May 2016 (the period); Papers relating to the quality report reported to the Board over the period April 2015 to the date of signing this limited assurance report; Feedback from the Commissioners, NHS North Derbyshire Clinical Commissioning Group and NHS Southern Derbyshire Clinical Commissioning Group dated 25/04/2016; Feedback from Council of Governors meeting dated 09/05/2016; Feedback from Healthwatch Derbyshire, dated 06/05/2016; Feedback from the Health Scrutiny Committee, Derbyshire County Council, dated 25/04/2016; The draft Trust s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, which forms part of the Patient Experience Annual Report 2015/16, which is due to be approved on 24/05/16; The 2015 National NHS staff survey; and The Interim Head of Internal Audit s annual opinion over the Trust s control environment dated 15/04/2016. We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents (collectively, the documents ). Our responsibilities do not extend to any other information. Our Independence and Quality Control We applied the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics, which includes independence and other requirements founded on 220

221 fundamental principles of integrity, objectivity, professional competence and due care, confidentiality and professional behaviour. We apply International Standard on Quality Control (UK & Ireland) 1 and accordingly maintain a comprehensive system of quality control including documented policies and procedures regarding compliance with ethical requirements, professional standards and applicable legal and regulatory requirements. Use and distribution of the report This report, including the conclusion, has been prepared solely for the Council of Governors of as a body, to assist the Council of Governors in reporting Derbyshire Community Health Services NHS Foundation Trust s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31 March 2016, to enable the Council of Governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors as a body and Derbyshire Community Health Services NHS Foundation Trust for our work or this report save where terms are expressly agreed and with our prior consent in writing. Assurance work performed We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 (Revised) Assurance Engagements other than Audits or Reviews of Historical Financial Information issued by the International Auditing and Assurance Standards Board ( ISAE 3000 (Revised) ). Our limited assurance procedures included: Reviewing the content of the Quality Report against the requirements of the FT ARM and Detailed requirements for quality reports 2015/16 ; Reviewing the Quality Report for consistency against the documents specified above; Obtaining an understanding of the design and operation of the controls in place in relation to the collation and reporting of the specified indicators, including controls over third party information (if applicable) and performing walkthroughs to confirm our understanding; Based on our understanding, assessing the risks that the performance against the specified indicators may be materially misstated and determining the nature, timing and extent of further procedures; Making enquiries of relevant management, personnel and, where relevant, third parties; Considering significant judgements made by the NHS Foundation Trust in preparation of the specified indicators; 221

222 Performing limited testing, on a selective basis of evidence supporting the reported performance indicators, and assessing the related disclosures; and Reading the documents. A limited assurance engagement is less in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement. Limitations Nonfinancial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in materially different measurements and can impact comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision thereof, may change over time. It is important to read the Quality Report in the context of the assessment criteria set out in the FT ARM the Detailed requirements for quality reports 2015/16 and the Criteria referred to above. The nature, form and content required of Quality Reports are determined by Monitor. This may result in the omission of information relevant to other users, for example for the purpose of comparing the results of different NHS Foundation Trusts. In addition, the scope of our assurance work has not included governance over quality or nonmandated indicators in the Quality Report, which have been determined locally by Derbyshire Community Health Services NHS Foundation Trust. Conclusion Based on the results of our procedures, nothing has come to our attention that causes us to believe that for the year ended 31 March 2016: The Quality Report does not incorporate the matters required to be reported on as specified in Annex 2 to Chapter 7 of the FT ARM and the Detailed requirements for quality reports 2015/16 ; The Quality Report is not consistent in all material respects with the documents specified above; and 222

223 The specified indicator has not been prepared in all material respects in accordance with the Criteria set out in the NHS Foundation Trust Annual Reporting Manual ( FT ARM ) and the Detailed guidance for external assurance on quality reports 2015/16. PricewaterhouseCoopers LLP PricewaterhouseCoopers LLP Donington Court, Pegasus Business Park, Castle Donington, DE74 2UZ 26th May 2016 The maintenance and integrity of Derbyshire Community Health Service s website is the responsibility of the directors; the work carried out by the assurance providers does not involve consideration of these matters and, accordingly, the assurance providers accept no responsibility for any changes that may have occurred to the reported performance indicator or criteria since they were initially presented on the website. 223

224 Appendix 8 The Core Quality Account Indicators Where the necessary data is made available to the NHS Trust and Non NHS bodies by the Health and Social Care Information Centre, a comparison of the numbers, percentages, values, scores or rates of the trust and non NHS bodies (as applicable) should be included for each of those listed in the table with a) The national average of the same; and b) With those NHS trusts and NHS Foundation Trusts with the highest and lowest of the same for the reporting period. DCHS considers that this data is as described for the following reasons [insert reasons]. DCHS [intends/has taken] the following actions to improve this [percentage/proportion/score /rate/number] and so the quality of its services, by [insert description of actions]. This section needs to include national averages and NHS trusts with highest and lowest score and moved to section 2 Prescribed information The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to (a) the value and banding of the summary hospitallevel mortality indicator ( SHMI ) for the trust for the reporting period; and (b) The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust for the reporting period. *The palliative care indicator is a contextual indicator. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients on Care Programme Approach who were followed up within 7 days after discharge from psychiatric inpatient care during the reporting period. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of Category A telephone calls (Red 1 and Red 2 calls) resulting in an emergency response by the trust at the scene of the emergency within 8 minutes of receipt of that call during the reporting period. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of category A telephone calls resulting in an ambulance response by the trust at the scene of the emergency within 19 minutes of receipt of that call during the reporting period. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients with a preexisting Related NHS Outcomes Framework Domain & who will report on them 1: Preventing People from dying prematurely 2: Enhancing quality of life for people with longterm conditions 2014/ /16 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a Trusts providing relevant acute services 1: Preventing People from dying prematurely 2: Enhancing quality of life for people with longterm conditions Trusts providing relevant mental health services 1: Preventing People from dying prematurely Ambulance trusts 1: Preventing People from dying prematurely Ambulance trusts 1: Preventing People from dying prematurely 3: Helping people to recover from episodes of ill health or 224

225 Prescribed information diagnosis of suspected ST elevation myocardial infarction who received an appropriate care bundle from the trust during the reporting period. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients with suspected stroke assessed face to face who received an appropriate care bundle from the trust during the reporting period. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of admissions to acute wards for which the Crisis Resolution Home Treatment Team acted as a gatekeeper during the reporting period. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the trust s patient reported outcome measures scores for (i) groin hernia surgery, (ii) varicose vein surgery (iii) hip replacement surgery, and (iv) knee replacement surgery, during the reporting period. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients aged (i) 0 to 15; and (ii) 16 or over, Readmitted to a hospital which forms part of the trust within 28 days of being discharged from a hospital which forms part of the trust during the reporting period. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the trust s responsiveness to the personal needs of its patients during the reporting period. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of staff employed by, or under contract to, the trust during the reporting period who would recommend the trust as a provider of care to their family or friends. Friends and Family Test Patient. The data made available by National Health Service Trust or NHS Foundation Trust by the Health and Social Care Information Centre for all acute providers of adult NHS funded care, covering services for inpatients and patients discharged from Accident and Emergency (types 1 and 2). Related NHS Outcomes Framework Domain & who will report on them following injury Ambulance trusts 1: Preventing People from dying prematurely 3: Helping people to recover from episodes of ill health or following injury Ambulance trusts 2: Enhancing quality of life for people with longterm conditions Trusts providing relevant mental health services 3: Helping people to recover from episodes of ill health or following injury 2014/ /16 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 89% 90% 98.7% 98% Trusts providing relevant acute services 3: Helping people to recover from episodes of ill health or following injury All trusts 4: Ensuring that people have a positive experience of care Trusts providing relevant acute services 4: Ensuring that people have a positive experience of care Trusts providing relevant acute services 4: Ensuring that people have a positive experience of care Trusts providing relevant acute services 225

226 Prescribed information Please note: there is not a statutory requirement to include this indicator in the quality accounts reporting but NHS provider organisations should consider doing so. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the trust s Patient experience of community mental health services indicator score with regard to a patient s experience of contact with a health or social care worker during the reporting period. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the rate per 100,000 bed days of cases of C difficile infection reported within the trust amongst patients aged 2 or over during the reporting period. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the number and, where available, rate of patient safety incidents reported within the trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death. Related NHS Outcomes Framework Domain & who will report on them 2: Enhancing quality of life for people with longterm conditions 4: Ensuring that people have a positive experience of care Trusts providing relevant mental health services 5: Treating and caring for people in a safe environment and protecting them from avoidable harm Trusts providing relevant acute services 5: Treating and caring for people in a safe environment and protecting them from avoidable harm Trusts providing relevant acute services 5: Treating and caring for people in a safe environment and protecting them from avoidable harm 2014/ /16 n/a n/a 99.3% 99.8% n/a n/a % 10, % All trusts 226

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235 Foreword to the accounts These accounts, for the year ended 31 March 2016, have been prepared by Derbyshire Community Health Services NHS Foundation Trust in accordance with paragraphs 24 & 25 of Schedule 7 within the National Health Service Act Signed Name Tracy Allen Job title Chief Executive Date 26 May