26 June 2014 - South Devon and Torbay CCG

Transcription

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NHSSouthDevonandTorbayClinicalCommissioningGroup
GoverningBodyPublic
JUNE2014PUBLICGOVERNINGBODY
26June2014-09:30
PomonaHouseOakViewCloseTorquayTQ27FF
AGENDA
1
WelocomeandApologies
09:30
Owner:DrDerekGreatorex,ClinicalChair
2
DeclarationofInterests
09:35
ThisitemprovidestheGoverningBodymemberswiththeopportunitytodeclareanyconflictsof
interestrelevanttotheitemsontodaysAgenda.
SDandTCCGDeclarationofInterests26June2014
3
6
Approvetheminutesofthelastmeeting
ReviewActionLog
09:40
ThisitemisfortheGoverningBodytoapprovetheMinutesandActionLogoftheprevious
meetingandreviewmattersarisingandanyactionsoutstanding.
DraftPublicGoverningBodyMinutesApril2014
ExtraordinaryPublicGoverningBodyMinutes
Non-ConfidentialActionsApril2014
4
QuestionsfromthePublic
14
21
25
09:50
TheallowstheopportunityforanymembersofthepublicattendingtheGoverningBodytoask
questionssubmittedinadvanceofthemeeting.
Top
5
PatientStory
09:55
Owner:DrEllieRowe,ClinicalCommissioningLead
ThepurposeofthePatientStoryistoprovidetheGoverningBodywithapatientcentredcontext
andgroundingforthebusinessanddiscussionthatwilltakeplacewithinthemeeting.
6
ChairandChiefClinicalOfficerReport
10:05
ThisitemdescribestheactivitiesoftheClinicalChairandChiefClinicalOfficersincethelast
reportaswellashighlightinganynationalannouncementsthatmayhavealocalimpact.
CCOCCReportNON-CONFIDENTIAL(2)
7
27
QualityandPerformanceReport
10:25
Owner:DrNickD'Arcy,ClinicalQuality&SafetyLead
Thisreporthighlightsqualityandsafetyissuesidentifiedinconnectionwithcommissioned
ControlQRJune2014v3
201406Scorecard
31
65
8
TEA&COFFEEBREAK
10:55
9
Finance&PerformanceReport
11:20
Owner:SimonBell,ChiefFinanceOfficer
ThisreportexplainsthefinancialandcontractualperformanceoftheClinicalCommissioning
2014-6-26FinancePerformanceandContractingRepo
10
69
PlanningandPrioritiesupdate
11:40
Owner:SimonTapley,DirectorofCommissioning
ThisreportprovidestheGoverningBodywithprogressmadeineachworkstreamagainstthe
‘PlanonaPage’,aswellasaidingtheworkstreamleadstodelivertheirworkprogrammesin
respectofgivingsupportoncontracting,finance,performance,communicationsandqualityand
ensuringtheduediligencearoundalloftheaforementionedareasiscomplete
PlanningandPriorities
11
78
CorporateAffairsReport
12:00
Owner:MarkProcter,DirectorofCorporateAffiars&MedicinesOptimisation
ThisitemisfortheinformationoftheGoverningBodyupdatingonthedifferentworkstreamsthat
feedintotheCorporateAffairsdirectorate.Anyrecommendationsonstyleorcontentare
DirectorateReportJun14
90
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12
AssuranceFramework
12:20
ThisreportprovidesassurancetotheGoverningBodythattheCCGhaseffectiveprocessesin
placetoidentify,assess,manageandmitigaterisk,andinformstheGoverningBodyofany
changessincethelastreportwaspresentedtoit.Thereporthasbeendiscussed,andapproved,
attheAuditCommitteeonthe13March2014.
GBRiskReportJune2014v2
AssuranceFrameworkJune2014
RiskHeatMap13June20142
RiskDashboard13June2014
RiskRegister13June2014
13
Committees
13.10
SeniorLeadershipCommitteeMinutes
112
123
126
127
128
12:40
ThisreporthighlightsimportantinformationanddecisionsmadebytheSeniorLeadership
Committee
SLCreporttoGoverningBodyJune2014
13.20
143
CommissioningandFinanceCommittee
Owner:DrCharlieDaniels,ClinicalFinanceandPerformanceLead
ThisreporthighlightsimportantinformationanddecisionsmadebytheFinanceCommittee
2014-6-26CFCToRHeaderSheet
ToR
13.30
144
145
AuditCommittee
Owner:NickBall,Non-ExecutiveDorectpreandGovernance
ThisreporthighlightsimportantinformationanddecisionsmadebytheAuditCommittee
AuditCommitteeReportJune2014
15
148
CLOSEOFMEETINGLUNCH
13:00
Attendees
ChrisPeach
A
DrCarolineDimond
A
DrCharlieDaniels
A
DrDavidGreenwell
A
DrDerekGreatorex
A
Non-ExecutiveDirectorforPatient&PublicInvolvement-SouthDevon&TorbayCCG
InterimDirectorofPublicHealthforTorbay-TorbayCouncil
ClinicalLeadforFinanceandGovernance-SouthDevon&TorbayCCG
ClinicalLeadforIntegration-SouthDevon&TorbayCCG
ClinicalChair-SouthDevon&TorbayCCG
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DrEllieRowe
A
DrNickD'Arcy
A
DrSimonKnowles
A
KarenGrimshaw
A
MarkProcter
A
NickBall
A
SimonBell
A
SimonTapley
A
DrJoRoberts
D
DrSamBarrell
D
GillGant
D
SteveWallwork
D
ClinicalLeadforCommissioning
ClinicalLeadforPatientSafetyandQuality-SouthDevon&TorbayCCG
Non-ExecutiveDirector-SecondaryCare-SouthDevon&TorbayCCG
Non-ExecutiveDirector-Nursing-SouthDevon&TorbayCCG
DirectorofCorporateAffairsandMedicinesOptimisation-SouthDevon&TorbayCCG
Non-ExecutiveDirectorforFinanceandGovernance-SouthDevon&TorbayCCG
ChiefFinanceOfficer-SouthDevon&TorbayCCG
DirectorofCommissioning-SouthDevon&TorbayCCG
ClinicalLeadforInnovation,Engagement,Communication&MedicinesOptimisation-SouthDevon&TorbayCCG
ChiefClinicalOfficer-SouthDevon&TorbayCCG
DirectorofQualityGovernance-SouthDevon&TorbayCCG
ManagingDirector-SouthDevon&TorbayCCG
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Index
SDandTCCGDeclarationofInterests26June2014.docx.................................................... 6
DraftPublicGoverningBodyMinutesApril2014.docx........................................................... 14
ExtraordinaryPublicGoverningBodyMinutes.docx...............................................................21
Non-ConfidentialActionsApril2014.doc................................................................................ 25
CCOCCReportNON-CONFIDENTIAL(2).docx................................................................... 27
ControlQRJune2014v3.docx................................................................................................31
201406Scorecard.pdf............................................................................................................ 65
2014-6-26FinancePerformanceandContractingReport(Month.........................................69
PlanningandPriorities.docx................................................................................................... 78
DirectorateReportJun14.docx............................................................................................... 90
GBRiskReportJune2014v2.docx........................................................................................112
AssuranceFrameworkJune2014.xlsx................................................................................. 123
RiskHeatMap13June20142.xlsx..................................................................................... 126
RiskDashboard13June2014.xlsx...................................................................................... 127
RiskRegister13June2014.xlsx...........................................................................................128
SLCreporttoGoverningBodyJune2014.doc..................................................................... 143
2014-6-26CFCToRHeaderSheet.docx..............................................................................144
ToR.DOCX............................................................................................................................145
AuditCommitteeReportJune2014.docx............................................................................. 148
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Register of interests
NHS South Devon and Torbay Clinical Commissioning Group
This Register of Interests (Register) includes all interests declared by members, employees, governing body members and
members of committees or sub-committees, (including committees and sub-committees of the governing body) of NHS South
Devon and Torbay Clinical Commissioning Group (the CCG).
In accordance with the CCG’s constitution and section 14O of The National Health Service Act 2006, the CCG’s accountable officer
must be informed of any interest which may lead to a conflict with the interests of the CCG and the public for whom they commission
services in relation to a decision to be made by the CCG, that needs to be included in the Register within 28 days of the individual
becoming aware of the potential for a conflict. The Register will be updated regularly (at no more than 3-monthly intervals).
Interests that must be declared (whether such interests are those of the individual themselves or of a family member, close friend or
other acquaintance of the individual) include:








roles and responsibilities held within member practices;
directorships, including non-executive directorships, held in private companies or PLCs;
ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with
the CCG;
shareholdings (more than 5%) of companies in the field of health and social care;
a position of authority in an organisation (e.g. charity or voluntary organisation) in the field of health and social care;
any connection with a voluntary or other organisation contracting for NHS services;
research funding/grants that may be received by the individual or any organisation in which they have an interest or role;
any other role or relationship which the public could perceive would impair or otherwise influence the individual’s judgement or
actions in their role within the CCG.
SDandTCCGDeclarationofIn
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NHS South Devon and Torbay Clinical Commissioning Group
Register of Interests – Governing Body – 26 June 2014
Name
Date
Position/ Role
Potential or actual area where interest
could occur
Action taken to mitigate risk
Comments
Mr Nick Ball
01/05/2013
Member of Governing
Body - Non-Executive
Director, Independent
Lay member – Finance
and Governance
1.Devon & Cornwall Probation Trust
(Non-Executive Director)
Where a Governing Body
agenda item concerns an area
where this member has declared
an interest, the member would
be allowed to listen to and
contribute to the discussion, but
would be excluded from any
vote on that item.
26 June 2014 agenda
contains no items
which present a
potential conflict of
interest.
vote on that item.
26 June 2014 agenda
contains no items
which present a
interest.
Chair of Audit
Committee
Member of CCG
Commissioning Finance
Committee
2.Cornwall Housing (Chair)
3.SW Panel of Clinical Excellence Award
Scheme (Chair)
4.Virgin Care (spouse/partner is a
Portage Home Visitor)
Member of
Remuneration
Committee
Dr Sam
Barrell
15/04/2014
Member of Governing
Body - Chief Clinical
Officer
Member of Senior
Leadership Committee
Member of CCG
Committee
1.Compass House Surgery (GP)
2.DDOC (GP practice is a shareholder)
3.Peninsula Medical School (GP practice
is a teaching practice)
4.Torbay and Southern Devon Health and
Care Trust (GP practice holds a
contract to provide services for Brixham
Hospital)
5.Pure Dental Care, Dartvale, Moor and
Fresh Dental Care (spouse/partner is
part-owner)
6.Innovation Health and Wealth
Implementation Board (board member)
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7.Kings Fund (member of National
Advisory Council)
8.British Medical Association (BMA)
(Member)
9.Institute for Public Policy Research
(IPPR) Health Advisory Board member
Mr Simon
Bell
19/11/2012
Member of Governing
Body - Chief Finance
Officer
Care Trust (spouse/partner is a nonexecutive director)
vote on that item.
26 June 2014 agenda
contains no items
which present a
interest.
1.Chilcote Surgery (GP)
vote on that item.
26 June 2014 agenda
contains no items
which present a
interest.
Member of Senior
Member of CCG
Committee
Member of Clinical
Commissioning Network
Member of Audit
Committee
Dr Charlie
Daniels
08/04/2014
Member of Governing
Body - Clinical Lead for
Finance and
Performance
Member of Audit
Committee
2.DDOC (Sessional GP and GP practice
is a shareholder)
4.Goldmay Ltd (Director)
Chair of Commissioning
Finance Committee
5.Devon Local Medical Committee
(elected member)
Member of Clinical
(Member)
7.Haytor Health (GP practice is a
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member)
Dr Nick
D’Arcy
28/02/2013
Member of Governing
Body - Clinical Lead for
Quality and Patient
Safety
Chair of Quality
Committee
Council of Members Kingskerswell and
Ipplepen Medical
Practice
1.Kingskerswell and Ipplepen Medical
Practice (GP)
4.South Devon Healthcare NHS
Foundation Trust (spouse/partner is an
associate specialist paediatrician)
vote on that item.
26 June 2014 agenda
contains no items
which present a
interest.
5.Kingskerswell and Ipplepen Medical Ltd
(Director)
(Member)
Dr Caroline
Dimond
Mrs Gill Gant
02/04/2013
Co-opted member of
Governing Body – Public
Health
Torbay Council (Interim Director of Public
Health for Torbay)
vote on that item.
26 June 2014 agenda
contains no items
which present a
interest.
Member of Governing
Body - Director of
Quality Governance
None
vote on that item.
26 June 2014 agenda
contains no items
which present a
interest.
Member of Governing
Body – Chair
1.Kingsteignton Medical Practice (GP
Partner)
Member of Senior
26 June 2014 agenda
contains no items
which present a
Member of Senior
Member of Quality
Committee
Dr Derek
Greatorex
02/08/2013
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Member of CCG
Committee
Chair of Remuneration
Committee
Care Trust (GP practice holds a
contract for medical cover at Newton
Abbot Hospital)
vote on that item.
interest.
vote on that item.
26 June 2014 agenda
contains no items
which present a
interest.
vote on that item.
26 June 2014 agenda
contains no items
which present a
interest.
5.Kingsteignton Medical Limited
(shareholder)
(Member)
Dr David
Greenwell
06/03/2013
Member of Governing
Body - Clinical
Integration Lead
1.Southover Medical Practice (GP
Partner)
Member of CCG
Committee
3.TorDoc (Director of limited company
that provides out of hours GP cover to
Channings Wood and Exeter prisons)
Member of Clinical
Council of Members Southover Medical
Practice
Mrs Karen
Grimshaw
25/09/2012
Member of Governing
Nurse
Member of Quality
Committee
Member of
Remuneration
5.Southover Pharmacy (spouse/partner is
the freehold owner)
6.Upton Vale Baptist Church (member)
1.Plymouth Hospitals NHS Trust (Nurse)
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Committee
Member of Audit
Committee
Dr Simon
Knowles
25/09/2012
Member of Governing
Secondary Consultant
1.Yeovil Hospitals NHS Trust (Consultant)
2.Founding Director of Lead2Improve
Community Interest Limited Company.
Member of
Remuneration
Committee
vote on that item.
26 June 2014 agenda
contains no items
which present a
interest.
vote on that item.
26 June 2014 agenda
contains no items
which present a
interest.
vote on that item.
26 June 2014 agenda
contains no items
which present a
interest.
Member of Audit
Committee
Mr Chris
Peach
14/11/2013
Member of Governing
Body – Non-Executive
Lay Member – Patient
and Public Involvement
1. South and West Devon Magistrates
Bench
2. Magistrate’s Association (Council
member)
3. Diptford Parish Council (Councillor)
Member of Audit
Committee
Chair of Strategic
Patient Involvement
Group (SPIG)
Mr Mark
Procter
22/08/2013
Member of Governing
Body - Director of
Corporate Affairs and
Medicines Optimisation
1.South Devon Healthcare NHS
Foundation Trust (Governor)
2.Director of Hallbarton Ltd
3.Director of Allerton Land Ltd
Member of Senior
Attends CCG Audit
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Committee
Attends CCG
Remuneration
Committee
Dr Jo
Roberts
31/07/2013
Member of CCG
Governing Body Clinical Lead for
Innovation,
Communication and
Engagement
Member of CCG Quality
Committee
Member of CCG
Committee
1. Mayfield Medical Practice (Locum
GP)
2. South Devon Healthcare NHS
Foundation Trust (spouse/partner is
an anaesthetist)
3. South West Staff grade speciality
doctors and associated specialists
association of the BMA
(spouse/partner is regional chair)
vote on that item.
26 June 2014 agenda
contains no items
which present a
interest.
vote on that item.
26 June 2014 agenda
contains no items
which present a
interest.
4. Novartis (undertaking a study of
patients with type 2 diabetes)
5. Association of British Pharmaceutical
Industry (Paid £500 in 2011 to consult
on partnership working with industry)
6. Director on the Board of the
Academic Health Science Network
Dr Ellie
Rowe
19/11/2012
Member of Governing
Body – Clinical Lead for
Commissioning
Member of CCG
Committee
Chair of Clinical
1.Croft Hall Medical Practice (GP)
4. Practice receive rent from on-site
pharmacy
5. Practice has an independent
chiropractor and independent counsellors
on site
6.Greenswood Medical (spouse/partner is
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a GP)
Mr Simon
Tapley
22/07/2013
Member of CCG
Governing Body Director of
Commissioning
Care Trust (spouse/partner is manager
of Continuing Healthcare)
2.Devon Partnership Trust (Governor)
Member of Senior
Member of CCG
Committee
vote on that item.
26 June 2014 agenda
contains no items
which present a
interest.
vote on that item.
26 June 2014 agenda
contains no items
which present a
interest.
Member of Clinical
Member of CCG Quality
Committee
Mr Steve
Wallwork
22/07/2013
Member of CCG
Governing Body Managing Director
Member of Senior
Member of CCG Audit
Committee
1.South West Ambulance Service NHS
Foundation Trust (Governor)
Member of CCG
Committee
Member of Clinical
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Governing Body Report
Date
24 April 2014
Report title
Governing Body Draft Public Board Minutes
Author(s)
Jennifer Baker, PA to Director of Corporate Affairs and
Report purpose (for
consultation, approval and
information)
Executive Summary
Key Recommendations and
Actions Requested
Which other committees
has this been to?
For Approval
The minutes of the Governing Body Board meeting
The Governing Body are asked to approve the contents of
the report
None
Corporate Impact Assessment
What, if any, are the
financial implications?
What, if any, are the quality
and safety implications?
What, if any, are the QIPP
implications?
What, if any, are the legal
implications?
None
None
None
None
Equality Impact Assessment
Who does the
proposed piece of
work affect?
Staff
Patients
Carers
Public




Yes No
Will the proposal have any impact on discrimination, equality of

opportunity or relations between groups?
Is the proposal controversial in any way (including media, academic,

voluntary or sector specific interest) about the proposed work?
Will the users or workforce be disadvantaged as a result of the

proposed work?
Is there doubt about answers to any of the above questions (e.g. there

is not enough information to draw a conclusion)?
If the answer to any of the above questions is yes or you are unsure of your answers to any
of the above you should provide further information using Screening Form One available
from Corporate Services
If an equality assessment is not required briefly explain why and provide evidence for the
decision.
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MINUTES
Meeting: South Devon and Torbay Governing Body, Pomona
House, Oak View Close, Torquay, TQ2 7FF
Date of Meeting: Thursday 24 April 2014
Chaired by Nick Ball
Prepared by Jennifer Baker
Date prepared
24 April 2014
Board Members:
Mr Nick Ball*
Dr Sam Barrell*
Mr Simon Bell*
Dr Charlie Daniels*
Dr Nick D’Arcy *
Mrs Gill Gant
Dr Derek Greatorex
Dr David Greenwell*
Ms Karen Grimshaw*
Dr Simon Knowles
Mr Chris Peach*
Mr Mark Procter
Dr Jo Roberts*
Dr Ellie Rowe*
Mr Simon Tapley*
Mr Steve Wallwork*
Non-Executive Director for Finance and Governance
Chief Clinical Officer
Chief Finance Officer
Clinical Lead for Finance and Governance
Clinical Lead for Patient Safety and Quality
Director of Quality Governance
Clinical Chair
Clinical Lead for Integration
Non-Executive Director – Nursing
Non-Executive Director – Secondary Care
Non-Executive Director for Patient & Public Involvement
Director of Corporate Affairs and Medicines Optimisation
Clinical Lead for Innovation, Engagement, Communication &
Clinical Lead for Commissioning
Director of Commissioning
Managing Director
Co-opted Members:
Dr Caroline Dimond*
Interim Director of Public Health for Torbay
In Attendance:
Jennifer Baker
(Jo Turl)
(Shona Charlton)
(Yvonne)
(Si)
(Dr Nick Roberts)
(Ann Bailey)
(Paul Hurrell)
(Wendy Bull)
PA to Director of Corporate Affairs and Medicines Optimisation
Head of Planning & Performance
Commissioning Manager, Joint Commissioning
Patient representative
Yvonne’s Support Worker
Clinical Lead, Newton Abbot Locality
Newton Abbot Locality Lead
Head of Innovation
Innovation and IT Project Support
* Denotes member present
() Denotes present for part of meeting
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1. Welcome and Apologies
In advance of the formal business of the Governing Body meeting the Chair welcomed members of the
Governing Body and members of the public.
Apologies were noted from:
Dr Sam Barrell, Chief Clinical Officer
Gill Gant, Director of Quality Governance
Mark Procter, Director of Corporate Affairs and Medicines Optimisation
Simon Knowles, Non-Executive Director – Secondary Care
2. Declaration of Interests
The Governing Body noted the register of declared interests:
3. Minutes of Meeting
The Governing Body approved the minutes of the Governing Body meeting held on Feb 2014
with no amendments.
Action: Ensure the Senior Leadership Team carry out a thorough review of Governing Body actions two
weeks prior to the board meeting.
4. Patient Story
Shona Charlton, Commissioning Manager, Joint Commissioning introduced Yvonne and her support
worker, Si to the Governing Body.
Si shared video on Learning Disabilities which will also be shown at the Health and Wellbeing Board.
Yvonne previously had a polyp removed and cancer was detected but caught early on, Yvonne will
continue to have follow up appointments. The hospital staff knew Yvonne and were very kind to her but at
times struggled to support someone with learning disabilities. Yvonne gave feedback to members of the
Governing Body on her experiences in hospital and of the care and understanding she experienced.
Yvonne pointed out the gowns do not cover dignity, when a cannula was inserted the process was not
explained and hurt Yvonne. There ought to be pictures for explanation as Yvonne cannot read and
struggled to comprehend some information, Yvonne would prefer a side room as she is better to have
peace and quiet, it is important that support workers are involved as this familiar face is calming. Yvonne’s
day to day support worker, Paul attends all appointments with her including the GP and dentist and takes
her everywhere. Some of the doctors she sees do not understand people with learning disabilities, there
should be better information in rebus with clear pictures to aid understanding. Yvonne lives alone and was
one of the first people in Torbay to receive a direct payment through which she pays for Paul.
Karen Grimshaw asked Yvonne if she has a patient passport, Yvonne says no however she likes the
specialist learning disabilities nurses, Yvonne noted there can be a lack of communication between doctors
and nurses. There should be learning disabilities nurses covering weekends and have champions on each
ward.
The Governing Body thanked Yvonne and Si for attending the meeting.
Shona Charlton, Yvonne and Si left the meeting.
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5. Question from the Public
No questions were received in advance of the meeting.
6. Newton Abbot Locality
Dr Nick Roberts, Clinical Lead, Newton Abbot Locality and Ann Bailey, Newton Abbot Locality Lead
presented to the Governing Body on the ongoing work in the locality.
Dr Nick Roberts gave a presentation which included the IT plans, the challenge fund and issues faced,
local participation, the frailty hub and the creation of a community alliance.
Karen Grimshaw asked about minority groups such as those patients in care homes, with substance abuse
issues and those suffering from alcohol dependency. Dr Nick Roberts admitted it can be difficult to get
people to engage, this can provide a challenge to resources however different voluntary agencies are
involved in improving this engagement. Chris Peach noted Newton Abbot has an empowered local forum,
Ann Bailey would like this group to be flexible and have a network approach. Dr Jo Roberts acknowledged
that Newton Abbot locality is particularly ahead in terms of information sharing; both ePrescribing and the
Clinical Portal are benefitting from this. Ann Bailey noted that much has been set up but individual
practices need continue to lead this work. Simon Tapley highlighted the Newton Abbot community hospital
which is a very beneficial resource. The intentions going forward include maximising resources, supporting
practices, allying with health professionals in a joined up manner
The Governing Body thanked Dr Nick Roberts and Ann Bailey for their presentation.
Dr Nick Roberts and Ann Bailey left the meeting.
7. Chair’s Report
Dr Derek Greatorex written report was presented in his absence.
8. Chief Clinical Officer’s Report
Dr Sam Barrell presented her written report.
Clarified the membership of the JoinedUp board for Karen Grimshaw, all minutes are uploaded to
eKnowledge.
Dr Sam Barrell left the meeting.
9. Managing Director’s Report
Steve Wallwork presented his report and highlighted the following:
As yet no additional information has been received on the Stakeholder survey.
Thanks was expressed to all those who attended and presented at the Integrated Health and Care
seminar, especially to Viki Kirby, Business Support Manager who organised the event.
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NHS South Devon & Torbay CCG is working alongside the Academic Health Science Network (AHSN) in
three areas, economic wealth, innovation and supporting Pioneer.
10. Strategic Plan
Jo Turl, Head of Planning and Performance joined the meeting and presented the NHS South Devon &
Torbay CCG Strategic Plan.
The Strategic Plan reflects all changes received and is aimed to be reader friendly for the public and shall
be available via the organisation’s website.
The Governing Body approved the Strategic Plan and expressed thanks to Jo Turl and her team.
11. Quality and Performance Report
Dr Nick D’Arcy and Jo Turl presented the report to the Governing Body. Dr Nick D’Arcy thanks those
involved in the production of the report.
Jo T discussed performance and noted exceptions on the scorecard. Alcohol attributable admissions, this
is a local quality indicator this year, going forward more detail on a workplan to monitor this will be
included.
Eliminating mixed sex accommodation breaches, in February 2014 there were several breaches recorded
due to patient flow, on two different occasions breaches occurred effecting wards of five and six patients.
There were six recorded incidents in March.
There have been several initiatives to improve response rates to the Friends and Family Test which is
carried out in Accident and Emergency (A&E) however still not meeting targets, work is ongoing to meet
these.
The number of cancelled operations is considered to be in response to A&E and hospital flow through
pressures.
Mental health indicators; there are patients waiting over twenty-eight days for a first therapeutic session
however resource has been put in to improve this. Access to Psychological Therapies (IAPT) recovery
rates show a difference between how patients rate themselves pre and post therapy, Devon Partnership
Trust (DPT) are working to establish more informative local measures.
Steve Wallwork asked when performance is depicted as red are the team happy that providers are
actioning this. Jo Turl informed any issues are escalated at contract review meetings, any specific issues
would be raised through the Governing Body.
Dr Nick D’Arcy noted work is ongoing to prevent pressure ulcers as many patients already have the ulcers
when arriving in secondary care.
Internal Audit have rated the safeguarding process as green, which shows robustness. The clostridium
difficle (c diff) target has been met for this year and the yellow card reporting from GOs has increased. A
case of MRSA was reported at South Devon Healthcare Foundation Trust (SDHFT) earlier in the year, the
target was zero.
The Governing Body noted the Quality and Performance report.
Jo Turl left the meeting.
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12. Finance Report
Simon Bell presented his report and highlighted the following:
NHS South Devon & Torbay CCG has delivered the planned underspend and in the first year as an
organisation has remained within our running costs. The annual accounts have been submitted to our
accounts in accordance with targets. External Audit, Grant Thornton will be with the finance team for three
weeks to review these.
The Annual Accounts and Annual Report will be signed off at an extraordinary Audit Committee and
extraordinary Governing Body meeting on 4 June 2014.
The Governing Body noted the report and expressed thanks to Simon Bell and his team.
13. Planning & Priorities Report
Simon Tapley presented his report and highlighted the following:
Work plans have been redesigned and all of the workstream areas have been submitted to the next
Business Planning and Performance (BPP) meeting. The intention is line up resources against workplans,
which will include plans for the hubs and localities. The structure of BPP has changed and will be clinically
led, Clinical Commissioning Committee will combine with Finance Committee, Dr Charlie Daniels will chair
this meeting. A Clinical Commissioning Network will occur quarterly and be the opportunity for
engagement, Dr Ellie Rowe will chair this meeting. Terms of reference will be discussed at the inaugural
meetings.
There are issues of how the acute hospitals judge their escalation issues, recently A&E at SDHFT and
Derriford hospital have been declared black. Within six hours SDHFT went to amber and then within
twenty-four hours back to green, the weekly performance has been poor against a target of 95%.
Attendance has not increased hugely but one patient in three is waiting longer than the four hour target.
SDHFT is carrying out work to improve this.
There are ongoing issues with Child and Adolescent Mental Health Services (CAMHS) and capacity at
Louise Carey ward at SDHFT.
In terms of practice mergers and developments, four practices within Coastal Locality are merging into two
practices, one practice in Paignton is merging with another in Torquay. Karen Grimshaw asked what the
implication to these mergers is. Simon Tapley this is for information sharing, patients would be consulted in
any merge.
The Governing Body noted the content of the report.
14. Corporate Affairs Directorate Report
This report was presented in Mark Procter’s absence for information.
Karen Grimshaw stated she was very pleased to receive this report. The Governing Body praised the
report and noted the content.
An updated version to be shared at the June Governing Body meeting.
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15. Assurance Framework
Steve Wallwork presented the Assurance Framework and highlighted the risk movement. Five risks have
reduced following management action. There are seventy-risks on the register, the profile of adequacy of
assurance is moving in the right direction.
16. Sustainability
Paul Hurrell, Head of Innovation and Wendy Bull, Innovation and IT Support joined the meeting to
introduce the Sustainable Development Management Plan.
The plan provides baseline data on carbon emissions and includes good corporate citizen, sustainability
champions and working with Commissioning Support Unit colleagues. NHS South Devon & Torbay CCG
are providing support to other CCGs as our sustainability plan is more developed.
A base line of travel arrangements has been analysed for rail, plane and road travel. Changes have been
made to waste bins under desks, a can collection instigated, locked print option installed. The impact of
utilities in the building have been considered, a relationship has been built with the landlord for automatic
reporting on how to measure the value of the changes being made. NHS South Devon & Torbay CCG are
required to make a 5% co2 emission reduction, this would show our commitment to achieving carbon
neutral status, locally a tree planting scheme is being set up to offset our carbon footprint.
Dr Charlie Daniels asked if there are penalties of not achieving these milestones. Karen Grimshaw
highlighted that staff could be informed of five key things to do to reduce consumption and encourage
sustainability.
The Governing Body endorsed the Sustainable Development Management Plan.
Paul Hurrell and Wendy Bull left the meeting.
17. Senior Leadership Committee
The Governing Body received the report.
18. Finance Committee
The Governing Body received the report and minutes..
19. Audit Committee
The Governing Body received the report and minutes.
20. Clinical Commissioning Committee
The Governing Body received the report and minutes.
Meeting closed at 4.20pm.
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Date
04 June 2014
Report title
Extraordinary Governing Body Board Minutes
Author(s)
Jennifer Baker, PA to Director of Corporate Affairs and
Report purpose (for
information)
Executive Summary
Actions Requested
Which other committees
has this been to?
For Approval
The minutes of the Governing Body Board meeting
The Governing Body are asked to approve the contents of
the report
None
What, if any, are the
financial implications?
implications?
implications?
None
None
None
None
Who does the
proposed piece of
work affect?
Staff
Patients
Carers
Public




Yes No
Will the proposal have any impact on discrimination, equality of

opportunity or relations between groups?
Is the proposal controversial in any way (including media, academic,

voluntary or sector specific interest) about the proposed work?
Will the users or workforce be disadvantaged as a result of the

proposed work?
Is there doubt about answers to any of the above questions (e.g. there

is not enough information to draw a conclusion)?
decision.
Page 1 of 4
ExtraordinaryPublicGoverning
Page1of4
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MINUTES
Meeting: South Devon and Torbay Governing Body, Pomona
House, Oak View Close, Torquay, TQ2 7FF
Date of Meeting: Wednesday 4 June 2014
Chaired by Nick Ball
Prepared by Jennifer Baker
Date prepared
04 June2014
Board Members:
Mr Nick Ball*
Dr Sam Barrell*
Mr Simon Bell*
Dr Charlie Daniels*
Dr Nick D’Arcy *
Mrs Gill Gant*
Dr Derek Greatorex
Dr David Greenwell*
Ms Karen Grimshaw*
Dr Simon Knowles*
Mr Chris Peach
Mr Mark Procter*
Dr Jo Roberts
Dr Ellie Rowe
Mr Simon Tapley*
Mr Steve Wallwork
Clinical Chair
Clinical Lead for Integration
Non-Executive Director for Patient & Public Involvement
Clinical Lead for Innovation, Engagement, Communication &
Clinical Lead for Commissioning
Managing Director
Co-opted Members:
Dr Caroline Dimond
Interim Director of Public Health for Torbay
In Attendance:
Jennifer Baker
Catherine Brown
Geri Daly
Sallie Ecroyd
Louise Hardy
Rob Loader
Manager, Assurance, Grant Thornton
Associate Director, Assurance, Grant Thornton
Communications Lead
Director of Organisation Development
Deputy Director of Audit, Audit South West
* Denotes member present
() Denotes present for part of meeting
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1. Welcome and Apologies
In advance of the formal business of the extraordinary Governing Body meeting the Chair welcomed
members to the meeting.
Apologies were noted from:
Dr Derek Greatorex, Clinical Chair
Chris Peach, Non-Executive Director for Patient & Public Involvement
Dr Jo Roberts, Clinical Lead for Innovation, Engagement, Communication & Medicines Optimisation
Dr Ellie Rowe, Clinical Lead for Commissioning
Steve Wallwork, Managing Director
Dr Caroline Dimond, Interim Director of Public Health for Torbay
2. Annual Accounts and Annual Report
Simon Bell, Chief Finance Officer introduced the annual accounts and highlighted the achievement of the
planned and agreed underspend.
Nick Ball asked if there were any questions from the membership, none noted.
The Annual Report was presented, with no questions noted.
The Non-Executive Directors provided helpful feedback with improvements for future reports.
The Annual Accounts and Annual Report will be available on the NHS South Devon & Torbay CCG
website.
3. Head of Internal Audit Opinion
Rob Loader, Deputy Director of Audit, Audit South West presented the report based on audit work
undertaken over the course of the year. This report has previously been presented to the Audit Committee.
This is report is in line with the agreed audit plan and underpins the annual governance statement included
in the annual report. Report is in two parts.
The overall audit opinion is positive, the report shows a range assurances. Rob Loader thanked the
officers of the organisation for their assistance over the year.
No questions were noted on the Head of Internal Audit Opinion report.
4. Audit Findings Report
Geri Daly, Associate Director, Assurance, Grant Thornton presented the report and summarised the work
of external audit over the course of the year.
The intention of meeting is to approve the annual accounts and annual report. Assurance will then be given
by external audit. Further guidance is awaited from the Department of Health on how GP pension
contributions are depicted.
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Dr Nick D’Arcy queried that the figure for Kingskerswell and Ipplepen Medical Practice, Simon Bell assured
this related to dispensing activity and the prescribing budget.
Nick Ball asked all members of the Governing Body to agree that there is no information of which audit
colleagues are not aware, this was agreed.
The Governing Body approved the annual accounts and annual report.
Dr Sam Barrell and Simon Bell signed the documents as instructed.
Meeting closed at 11.45am
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Date
24 April 2014
Report title
Governing Body Actions
Author(s)
Jennifer Baker, PA to Director of Corporate Affairs &
Report purpose (for
information)
Executive Summary
For Approval and Action
The actions from the Governing Body Board meeting
Actions Requested
Which other committees has
this been to?
The Governing Body are asked to approve and action the
items on the report
None
What, if any, are the financial
implications?
implications?
implications?
None
None
None
None
Who does the proposed piece
of work affect?
Staff
Patients
Carers
Public




Yes
No
Will the proposal have any impact on discrimination, equality of opportunity or
relations between groups?
Is the proposal controversial in any way (including media, academic, voluntary
or sector specific interest) about the proposed work?

Will the users or workforce be disadvantaged as a result of the proposed work?


Is there doubt about answers to any of the above questions (e.g. there is not

enough information to draw a conclusion)?
decision.
Non-ConfidentialActionsApril
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South Devon and Torbay CCG Governing Body Actions
Outstanding Actions as at 24 April 2014
No.
Issue
232.
239.
240.
243.
245.
246.
247.
248.
249.
Report to the Governing Body on the
Commitments on a Page (COAP)
Consider whether amendments need to
be made to the SD&T CCG Terms of
Reference and Scheme of Delegation
Establish details and assurance for any
organisation whom the SD&T CCG have
contracts with which are not Care
Quality Commission Registered (CQC)
Ensure all Governing Body actions are
reviewed prior to the board meeting at a
Senior Leadership Team meeting
Update on visit to Somerset to see leg
ulcer services
Date
action was
added
September
2013
December
2014
Lead Person
Gill Gant
Mark Procter
December
2014
Gill Gant
February
2014
Steve
Wallwork
February
2014
Gill Gant
Add NEDs to circulation of Yellow
Submarine newsletter
February
2014
Gill Gant
Take “Innovation and Intellectual
Property Policy” for discussion at SLC
February
2014
Dr Jo Roberts
Paul Hurrell
Establish quoracy and attendees for
extraordinary board meeting on 4 June
2014
Updated Corporate Affairs Directorate
Report to be brought back to the
Governing Body
April 2014
Mark Procter
Non-ConfidentialActionsApril
Progress since the last Meeting
Will be included within the Quality
Report
This is an ongoing piece of work
Target Date
for Action
Status
April 2014
June 2014
Follow up with JoAnne PanitzkeJones
June 2014
June 2014
June 2014
June 2014
June 2014
April 2014
Mark Procter
June 2014
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Date
Report title
Author(s)
Report purpose
Executive
Summary
Key
Recommendations
and Actions
Which other
committees has
this been to?
26 June 2014
Activity Update
Dr Sam Barrell, Chief Clinical Officer
Dr Derek Greatorex, Clinical Chair
Information and discussion
This report provides a snapshot of current activity and issues
Receive update and comment as necessary
N/A
implications?
implications?
implications?
Yes – various as report covers several areas
Yes – various as report covers several areas
N/A
N/A
of work affect?
Staff
Patients
Carers
Public
X
X
X
X
Yes
No
x
x
x
x
If the answer to any of the above questions is yes or you are unsure of your answers to any of the
above you should provide further information using Screening Form One available from Corporate
Services
If an equality assessment is not required briefly explain why and provide evidence for the decision.
Page 1 of 4
CCOCCReportNON-CONFIDENTIAL
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Governing Body June 2014
Chief Clinical Officer and Clinical Chair Report
Co-commissioning Primary Care
NHS England asked CCGs to submit expressions of interest by 20 June, to develop new arrangements
for co-commissioning of primary care services. We were asked to include:
 Intended benefits and benefits realisation
 Scope
 Nature of co-commissioning
 Timescales
 Governance
 Member practices and stakeholder engagement
 Monitoring and evaluation
 Resource implications
To complete the expression of interest, we developed a strategic view on the form and scope outlining
how co-commissioning would work best across the CCG footprint to maximise the benefit for our patients.
The submission was developed with close input from the Senior Leadership Committee, Clinical
Commissioning Network and South Devon and Torbay Urgent Care Board. A full copy of the submission
is available on request.
Clinical Lead Posts
Children’s services and safeguarding are key areas of focus for the CCG. There are areas of children’s
services where swift improvement is needed, including in health assessments for looked-after children
(children in care) and in waiting times for assessments for autistic spectrum condition. In line with this, we
want to recruit two clinical leads to help make sure these improvements happen. One is for maternity,
children's and young people, and the other for safeguarding. These posts are being advertised via NHS
Jobs. Both roles will involve:
 Addressing inequalities and priorities
 Ensuring the development and delivery of commissioning plans and objectives
 Improving pathways and ensuring adherence to them and commissioning policies
Pioneer Update
The Department of Health has announced a grant of £90,000 for each of the 14 national pioneer sites for
integrated care. The criteria and conditions for these grants have not yet been made available.
Louise Hardy, director of organisation development, is returning to the CCG following her secondment to
launch the pioneer JoinedUp programme. This work has now been made mainstream, with several
programmes running simultaneously, including those for integrated community hubs and joined-up IT.
Consequently, the pioneer partners will be advertising a secondment position to co-ordinate and lead the
Joined-Up Board and Cabinet work, and be the local link for the national pioneer programme.
Metrics for the workstreams are being developed by the CCG head of performance with the director of
public health for Torbay.
360 Stakeholder Survey
Overall we had a very positive survey with a 73% response rate (including 70% for GPs). We do
better or considerably better than the national CCG average on engaging partners (86%) satisfaction
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with engagement (81%) clear and visible leadership (82%) listening, confidence in our ability to
commission high quality services and to improve outcomes, the way we explain our commissioning
and communicate decisions, knowledge of our plans and priorities, and giving people the opportunity
to influence our plans.
It is clear that we need to continue to work in close partnership with organisations in the South Devon
part of our area, to counter any perception that the CCG is focused more particularly on Torbay.
Findings from the survey as a whole will be built in to the new organisation development strategy and
the new communications and engagement strategy, with an action plan available CCG-wide.
NHS Clinical Commissioners (NHSCC)
Dr Sam Barrell and North Somerset CCG chief clinical officer, Dr Mary Backhouse, have put themselves
forward jointly for a position on the NHSCC Board, representing the South West region. This is a solid
platform from which to influence and challenge policy decisions. NHSCC member organisations have
been asked to vote by Friday 27 June 2014. One other South West CCG officer is competing for the role.
Children’s Services – Care Quality Commission inspection
A report from the recent CQC inspection is still pending, and when it becomes available, the
recommendations will be circulated to the Governing Body. Designated quality leads are driving system
improvements, working closely with provider organisations.
Devon Partnership NHS Trust (DPT)
Gill Gant, director for quality and patient safety, will be attending DPT’s Quality Improvement Group
which will:
 Provide assurance on the delivery of DPT’s Quality Improvement Plan (developed in response to
the CQC inspection February-April 2014).
 Highlight issues that require Chief Officer attention.
Following the meetings:
 Gill Gant will update the Mental Health and Learning Disability Redesign Board.
 An assurance briefing will be circulated summarising progress against the plan, specifically:o DPT organisation plan
o Multi-agency acute care pathway workstream
o Multi-agency integrated psychological therapies workstream
o Multi-agency individual patient placements workstream
o Risks and issues
o Recommended / requested action from the Chief Officers
Horizon Institute
Gill Gant, director of quality and patient safety, has been asked to take a role in the inception and
development of the Horizon Institute, which the JoinedUp pioneer partners see as critical to supporting
whole system integration and improvement. The institute is planning a soft launch on 27 June 2014. then
the work of ensuring that the HI moves from a concept to a reality.
The health and social care system needs a practical, working and transparent process which makes
quality improvement a core element, in other words cycles of quality improvement are seen as the norm
and fundamental to the way our system works, rather than something that some people choose to do
(and others not). Everyone needs to see quality improvement as part of their own role, and the Horizon
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Institute should offer the whole system the ways and means to support this culture through innovation
and research.
Longer term, the role will support development of the strategy, shaping the institute, and developing the
supporting faculties.
NHS England annual assurance meeting
On 13 June 2014, the Senior Leadership Team met the NHS England Area Team for Devon, Cornwall
and the Isles of Scilly, to discuss the CCG’s first year, and specifically to:
 Recognise key achievements
 Identify and reflect on CCG challenges and learning points
 Identify key priorities for the year ahead
 Agree CCG development needs
The meeting was extremely positive and a good opportunity to discuss some key challenges for all
partners in the system.
Page 4 of 4
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Date
June 2014
Report title
Integrated Quality and Performance Report
Author(s)
Report purpose (for
consultation,
approval and
information)
Page
1
Executive Summary
Gill Gant, with contributions from:
JoAnne Panitzke-Jones, Cathy Hooper, Delia Gilbert, Linda Churm, Sam
Holden, Sue Drew, Val Morrell, Marissa Cockfield
The purpose of this report is to provide NHS South Devon and Torbay CCG
Governing Body with a monthly briefing of serious incidents, complaints and
quality concerns. The report is structured in two parts; the first sets out
identified quality issues for the major providers and where known, any
quality issues in primary care, or for other providers.
The second element of the report discusses wider quality issues, risks and
concerns.
The key issues identified within this report are identified within by a red
flag and are:
 SDHFT - A&E Handover delays and 4 hour waits potentially causing
poor patient experience and possible patient safety issues; poor
performance in the Friends and Family Test, especially in the A&E
returns. CQC review into safeguarding children has found that
Looked after Children initial health assessments are not being
completed in a timely way. Good performance reported re harm
free care – 98%.
 TSDHCT – waiting times in CAMHS remains an issue and referrals
into the service continue to rise with demand exceeding service
capacity. High levels of reported Pressure ulcers also a continuing
patient safety issue. Leading to 87% harm free care. Low
performance on Friends and Family Test in MIU still problematic for
the trust.
 DPT – responding to recent CQC Wave 1 inspection of whole trust.
action plan approved and being monitored by NEW Devon, and SDT
CCGs, National Trust Development Agency and NHS England
 SWAST – a recovery plan is in place to improve the quality of the
NHS 111 service. The trust is still experiencing problems at various
acute trusts with delayed handovers.
 RD&E performance in A&E is good, - just below target of 95% seen
in 4 hours. Achieved 95% harm free care.
 PHT – increased number of handover delays and reduced
performance on 4 hour waits in A&E. Harm free care 94%
 Virgin Healthcare – CAMHS waiting times and timeliness of
assessments continues to be an issue
The Quality Report June 2014
ControlQRJune2014v3.docx
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Key
Recommendations
and Actions
Requested
Which other
committees has this
been to?
That the Governing Body notes the content of the report.
None but the content will be considered at the Quality Committee
What, if any, are the quality and safety This paper is for assurance and risk awareness
implications?
What, if any, are the QIPP implications?
none
What, if any, are the legal implications?
none
Staff
Who does the proposed Patients
piece of work affect?
Carers
Public


 All

Yes
No
Will the proposal have any impact on discrimination, equality of opportunity or relations
between groups?
Is the proposal controversial in any way (including media, academic, voluntary or sector
specific interest) about the proposed work?



Is there doubt about answers to any of the above questions (e.g. there is not enough

information to draw a conclusion)?
If the answer to any of the above questions is yes or you are unsure of your answers to any of the above you
should provide further information using Screening Form One available from Corporate Services
Page
2
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Governing Body
Quality and Performance Report
June 2014
Authors:
Page
3
Quality Team
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Quality Report
Contents
Part 1: Provider Quality and Performance
Page
6
The most current Quality and Performance data about the following providers:








South Devon Healthcare Foundation NHS Trust (Torbay Hospital)
Torbay and Southern Devon Health and Care Trust
Devon Partnership Trust
South Western Ambulance NHS Foundation Trust
Royal Devon and Exeter NHS Foundation Trust
Plymouth Hospitals NHS Trust (Derriford)
Devon Doctors Ltd
Virgin Healthcare Ltd (Integrated Children’s Services
Part 2: Quality Issues
Information about the following issues:



Care Act 2014
Hard Truths Commitments –publishing staff data
All Parliamentary Group on sepsis
Part 3: Patient Safety
Information about the following:







28
Risk Register
Serious Incidents and Never Events
CAS alerts
Safeguarding Adults update
Current Safeguarding Processes
Safeguarding Children update
Healthcare associated infections
Part 4: Patient Experience
31
PALS and complaints
You said, we did – complaints and feedback
Patient experience work
Friends and Family Test
Yellow card scheme
Equality and Diversity and Human Rights
Page
4






26
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Glossary
A&E
Accident and Emergency
AT
Area Team NHS England
CQC
Care Quality Commission
CRM
Contract Review Meeting
DDoc
Devon Doctors Ltd.
DGH
District General Hospital
DoLS
Deprivation of Liberty Safeguards
DPT
Devon Partnership Trust
FFT
IPAM
Integrated Performance Assurance Meeting (NEW Devon CCG contract review meetings)
JTWG
Joint Technical Working Group
JSNA
Joint Strategic Needs Assessment
LGBT
Lesbian Gay Bisexual Transgender
LOS
Length of stay
NICE
National Institute for Health and Care Excellence
PU
Pressure Ulcer(s)
SALT
Speech and language therapies
SDHFT
South Devon Healthcare NHS Foundation Trust
SIRIs
Serious Incidents (Requiring Investigation)
SWASFT South Western Ambulance NHS Foundation Trust
SWCSU South West Commissioning Support Unit
Page
5
TSDHCT Torbay and Southern Devon Health and Care NHS Trust
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Part 1: Provider Quality and Performance
The data below comes from a variety of sources, including the provider Board reports and internal
assurance documents; from the area team Quality Surveillance Group; and from our own Performance
data, as well as information from Contract Review meetings.
South Devon Healthcare Foundation Trust (SDHFT):
Quality issue identified and further information
Action taken and planned
Source
Handovers
2300 ambulance handovers in April, 87 were
over 30 minutes (3.7%) and of these 10 were
over an hour reflects the difficulties in
maintaining patient flow throughout the hospital
to ensure assessment cubicles and emergency
assessment unit beds are available beds are
available at peak times of ambulance arrivals.
Achieved 82.3% in April, and 84.8% in May target of 95%. This is a significant dip in
performance and the recovery plan is being
managed by the Chief Operating Officer.
A 4 hour action plan is in
place
Board
Report 28
May 2014
In April - there were 2913 elective admissions.
42 operations were cancelled on the dayequates to 1.4% which is above the target of
0.8%. 17 patients were cancelled because of
incoming emergencies, 9 were cancelled because
there were no ICU beds, reflecting the overall
bed pressures within the hospital during April.
For patients requiring readmission in April,
following previous “on the day” cancellation by
the hospital, one patient was not readmitted
within the 28 day standard
The trust archived 84.8% - target of 90%.
Reviewed through Joint
Technical Working Group
(JTWG) and CRM.
Referral to
Treatment
Serious
2 SIRIs reported in April 2014 and 1 in May 2014.
Board
Report 28
May 2014
CRM 30 May
2014
Action plan in place. Joint
Technical Working Group
(JTWG) and CRM.
Board
Report 28
May 2014
Continue to monitor and
CRM 30 May
2014
CRM 30 May
6
Cancelled
Operations
CRM 30 May
2014
Page
4 hour
performance
The key elements are
 Senior clinical workforce
plan including business case
for increased consultant
numbers.
 Phlebotomy business case
to release A+E nursing time
 Trial of GP working in A+E
 Service improvement
support for the department
teams
 Review and trial of new
model of care for the “front
door” specifically for
medical patients requiring
admission.
 Introduction of ambulatory
care approach supported by
acute physicians
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Incidents
2 were grade 4 pressure ulcers, with 1 of these
referred as a safeguarding adult alert with the
third a delayed diagnosis. The hospital has
developed a database to review progress with
SIRI action plans and have provided one update
so far.
review at CRM.
2014
Harm Free
Care
Pressure
Ulcers (PUs)
April 14 - Achieved 98% harm free care - target
of 95%
There were 4 grade 2 pressure ulcers reported in
April, this is in part due to improved reporting.
There were no grade 3 or 4 PU.
0 breaches in April 14.
review at CRM.
review at CRM.
CRM 30 May
2014
CRM 30 May
2014
review at CRM.
Continue to Monitor and
review at Workstream 2.
CRM 30 May
2014
Workstream
2 16 May
2014
A&E (Response Rate): 4%
Extremely Likely: 53%
Extremely Unlikely: 3%
Inpatient Overall (Response Rate): 27%
Medical Division (Response Rate): 26%
Surgical Division (Response Rate): 30%
Women’s, Children’s diagnostics &Therapies
(Response Rate): 20%
Maternity Services (Response Rate): 9%
HCAI
3 C.difficile cases reported in April 14 (against a
target of 11 for the year), with 0 MRSA
bacteraemia reported.
Maternity Services have an
action plan in place. The Trust
are working with the senior
clinical staff to ensure the
they understand that
importance of the test and
why it is beneficial to see it
completed. Generally the low
completion rate for Maternity
Services has been down to the
difficulties in establishing an
appropriate time to ask the
questions. The Trust is
promoting FFT within
Maternity Areas and extra
staff will be used to assist
clinical staff in securing
responses.
The Trust is looking at ways to
improve responses overall,
this includes a new software
solution in conjunction with
Healthwatch Torbay that will
mean that respondents can
complete FFT online and the
Trust can receive greater
analytics, this is due to launch
in July 2014. Additionally the
trust has installed a token box
in ED for respondents to place
a token in the box that
matches their response to the
F&F test.
review at CRM.
Board
Report 28
May 2014
CRM 30 May
7
Trust wide (excluding maternity) completion rate
12% for April for the FFT. Despite the low
response rate the responses that the trust
receive are to predominately positive. The break
down per division is a follows:
Page
EMSA
breaches
Friends and
Family (FFT)
Page7of34
OverallPage37of153
Top
Ward
transfers and
discharges
Patient
Experience
Stroke
Fractured
Neck of
Femur
review at CRM.
2014
Board
Report 28
May 2014
CRM 30 May
2014
Board
Report 28
May 2014
Family and Friendly Test: This has been
introduced for staff from 1st April 2014
Each quarter a sample of staff will be asked the
following:
 How likely are you to recommend this
organisation to friends and family if they
needed care or treatment?
 How likely are you to recommend this
organisation to friends and family as a place
to work?
Staff will answer using a six-point response scale,
ranging from ‘extremely likely’ to ‘extremely
unlikely’. There will also be a free-text follow-up
question, to enable staff to provide more
detailed feedback, should they wish.
Each quarter a sample of staff will receive an email containing a link which will enable them to
complete anonymously online.
This will commence with the Medical Services
Division on 1st May 2014 and close on 31st May
2014. The results will be collated and reported
both nationally and locally.
review at CRM.
SD&T CCG are working with SDHFT to look at a
new measure of care around ward transfers and
discharges, as it is recognised as potentially a
poor experience to be transferred or discharged
during the night. The experience for the
individual patients can be confusing and can
cause a disturbance for other patients in ward
areas. For this reason the trust is monitoring the
% of transfers and discharges undertaken over
night to be able to track any changes in
performance and identify underlying causes.
In April - 25 complaints received.
review at CRM.
CRM 30 May
2014
review at CRM.
Board
Report 28
May 2014
57 people admitted with a stroke in April 14. Of
these 36 spent 90% of their time on a stroke
ward. This equates to 63% against a target of
80%.
The % of people achieving the best practice
indicator in relation to the time to theatre from
admission remains an operational challenge. In
It has been suggested that
staff experience will be
reviewed as part of the
Contract Review Process, with
a staff story, and then
discussion about staff metrics.
Included in this will be in date
appraisal, sickness absence,
vacancies, staff with in date
supervision and staffing ratios
(Hard Truths).
review at CRM.
review at CRM.
CRM 30 May
2014
CRM 30 May
2014
Board
Report 28
May 2014
CRM 30 May
2014
Board
Report 28
May 2014
8
Staff
Experience
There are no CQC regulatory risks identified in
April 14.
Page
CQC
Page8of34
OverallPage38of153
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April it was 71%.
Choose and
Book
A new indicator measuring the availability of
clinic appointments on the Choose and Book new
appointment booking system has been included
in the Quality section of the performance
dashboard. This is seen as an important indicator
of patient experience when choosing an
appointment at SDHFT. The recent performance
is flagging a red score as the number of patients
not being able to be allocated an appointment is
above the tolerance set against historical
performance.
Teams are reviewing their
capacity plans and taking
actions to increase the
number of available slots.
CRM 30 May
2014
Board
Report 28
May 2014
CRM 30 May
2014
Torbay and South Devon Health and Care Trust (TSD)
Action taken/planned
CAHMS
The number treated who waited >18 weeks for
treatment in the year to March 14 was 44. This
is rated red. The number not treated and waiting
>18 weeks for treatment at the end of March
was 18, and is rated red. The number who
waited > 18 weeks is 6 and rated red.
6 children were treated in month that had
waited longer than 18 weeks, there are 18 more
that have waited longer than 18 weeks and have
yet to be seen (12 that don’t have an
appointment date set, 6 that have a date).
Referrals for the year were 536 compared to 358
for 2012/13.
Whilst short and medium
term steps are being taken to
support the teams to care for
an increased number of young
people in need of support,
TSD are working with
commissioners and other
providers to find sustainable
solutions to this area of care.
The number of urgent referrals increased in
March (20- average is usually 12)- these have
taken priority over current cases waiting. The
number of these seen within one week is 63%.
This dramatic increase is having a significant
impact on waiting times, and demand is
exceeding service capacity.
The service continues to use a
number of agency staff to
reduce waiting times and
backfill against vacancies and
long term sickness absence.
There will be 3 wte additional
vacancies in the next month.
This will place additional
pressure on the service. It has
been difficult to recruit to
posts but recent adverts have
been positive.
CRM 30 May
2014.
A self-harm deep dive has
been completed and shared
with commissioners.
The new IT system IAPTUS is
currently being transferred
across with support from the
performance team with a go
9
The service is continuing to
progress work around early
intervention in schools with
primary mental health
workers.
Page
In the last year, 7 young people were admitted to
a specialist psychiatric unit, 6 of which were out
of area which increases the pressure within the
service to maintain contact and attend 6 weekly
review meetings. In previous years the average
admission rate was 1-2 and usually in the local
area
Discussed
at/Source
Board
Report 28
May 2013
Page9of34
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Top
live date for end of June.
Training is booked for staff.
Serious
Incidents
3 SIRIs reported in April and 7 in May 2014. All of
these were grade 3 or 4 pressure Ulcers.
Patient
Experience
Patient Quality and Safety Visits:
A programme of Care Quality Commission (CQC)
style visits has been launched by the Professional
Practice Team across the community hospitals.
The purpose of this is to review quality, safety,
compassion and effectiveness. On completion of
the visit a report is produced highlighting both
areas for improvement and sharing good
practice. These reports will be shared throughout
the Trust and published on the Trust’s website.
As part of the IAPT (Improving
Access to Psychological
Therapies) the service
continues
to support a young people’s
participation group – ‘Have
Your Say’. This group has
recently been successful in a
grant bid to Starbucks for a
sum of £1850 to help support
a mental health awareness
event in July in Torbay and to
develop a resource pack for
secondary school teachers on
how to identify and talk to
young people who are
experiencing mental health
difficulties.
Monitor through monthly
meetings with the patient
safety lead. Issues will be
escalated to the Contract
Review meeting and JTWG
Continue to review at CRM
CRM
Board
Report 28
May 2013
CRM 30 May
2014.
The first visit took place in February 2014 at
Teignmouth Hospital. The review team included
representation from Healthwatch and League of
Friends as well as a Zone Manager, a Matron
from another hospital and members of the
Professional Practice Team. The final report will
be published on the Trust’s website in June 2014.
Page
Complaints this year (140) are down 11% from
last year (157). Both years saw a sharp rise in
October, the increase was predominantly in
Community Nursing. During that period, Newton
Abbot, Torquay and Paignton were reporting
amber and red scores on the Quality, Safety and
Effectiveness Trigger Tool (QuESTT) - this
10
Complaints:
In April – there were 13 complaints and 10
concerns raised
Page10of34
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Top
Bed Days Lost
Harm Free
Care
CQC
Unannounced visit to Occombe House, formal
report is awaited however initial feedback
suggests some improvements needed around
Outcome 4- Care and welfare of people who use
services.
Board
Report 28
May 2013
CRM 30 May
2014.
Board
Report 28
May 2013
CRM 30 May
2014.
All relevant Hospital and
Community Service Clinicians
and Managers as well as
Assistant Directors are aware
of the
situation. A joint Zone
Manager and Hospital
Matrons meeting to has been
organised to review the
existing processes,
in early June.
Board
Report 28
May 2013
CRM 30 May
2014.
Board
Report 28
May 2013
Management action is being
taken to address each of
these areas and the plan will
be reviewed and further
developed in the light of any
further
recommendations in the final
CQC report. The action plan
will be monitored
through the Learning
CRM 30 May
2014.
Board
Report 28
May 2013
CRM 30 May
2014.
11
Friends and
Family
Of the 8, 6 were acquired on community nursing
caseload, 1 was acquired on a community
podiatry caseload and 1 was acquired within a
community hospital.
Inpatient response rate 14.9% and MIU response
rate was 6.5% for April 14. The combined
response rate is 7.3%. Work is currently
underway to address the fall in response rates.
Tokens are now in use in Newton Abbott
Hospital to make it more convenient for patients
to respond.
There were a total of 277 Bed Days lost to
Delayed Discharges in April:
• 112 (40%) of these were attributable to
Healthcare and 165 (60%) to Social Care
• The most common reason was for patients
awaiting ‘Completion of Assessment (NHS or
ACS)’ accounting for 123 days (55 due to
Healthcare and 68 to Social Care), followed by
those awaiting a ‘Care Package in Own Home’
(42 days to Social Care)
• Hospital-wise, the most significant figures were
in the following areas:Brixham accounted for 72 days lost to delays,
comprising of three patients.
Tavistock accounted for 51 days, also three
patients.
Newton Abbot Teign (Stroke) Ward accounted
for 46 days, once again 3 patients.
The rate of Harm free care for 2013-14 was 87%
against a target of 90%. Pressure Ulcers remain
the top harm.
Page
Pressure
Ulcers (PUs)
indicates that there were concerns about
capacity and workload in these areas
72 grade 3 and 4 PU were reported in February,
47 were present on admission- i.e. acquired
outside TSD care. 5 were acquired in the care of
TSD, 2 were the same patient. This totals 23
acquired in TSD care, 21 from community nursing
caseloads, and 2 from community hospitals. Of
these 15 were found to be unavoidable, 8 as
avoidable.
Page11of34
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Staff
Experience
The staff turnover rate has risen above the set
range of 14% (14.7%).
4.3% in April against a target of 4%.
Stroke
The average LOS for non-stroke patients in the
community hospitals remains within the
expected and planned levels, stroke patients in
particular have stayed longer in Newton Abbot
Hospital than planned. Due to delays in
assessment and planning onward care primarily
in the face of increased patient complexity and
clinical need.
Disabilities Development
Board.
Investigation into staff groups
and areas affected have been
started and will be reported
to the Board.
All teams are working to
reduce their sickness rates.
It has been suggested that
staff experience will be
reviewed as part of the
Contract Review Process, with
a staff story, and then
discussion about staff metrics.
Included in this will be in date
appraisal, sickness absence,
vacancies, staff with in date
supervision and staffing ratios
(Hard Truths).
Work on going with the
operational teams to address
and improve this. It is
anticipated by the early part
of the new financial year an
improvement will have been
seen.
Board
Report 28
May 2013
CRM 30 May
2014.
Board
Report 28
May 2013
Devon Partnership Trust (DPT)
Source
DPT Board
Papers 29
May 2014
Monitored by NEW Devon
CCG
IPAM
Review underway and action
plan in place.
DPT CRM 27
May 2014
12
SIRI
The CQC attended for an unannounced
st
inspection on the 21 May (in line with the CQC
enforcement process) They verbally confirmed
that the ward had met requirements in full and
that they will be removing the warning notice.
They noted a visible change in the culture,
leadership and experience that people were
having from named nursing staff and
personalised care planning. The service will
continue to embed these changes.
DPT reported 4 SIRIs in April and 3 in May, with 2
in April taking place within SDT CCG boundaries.
Backlog of SIRI past deadline - for SDT CCG Area
there are 2 that are not Stop the Clock
A Quality Summit was held on
15 April 2014 which approved
an action plan ‘Wave 1 Quality
Improvement Plan’. All actions
identified in the CQC report
will be overseen by this
group- which is jointly chaired
by The Directors of Quality for
SD&T CCG and NEWD CCG.
Page
CQC
The CQCs formal response into DPTs services was
inspection
published on 17 April following a rigorous
inspection at the start of February, during which
37 inspectors visited almost all of the teams over
the course of a week. CQC found some excellent
services, some good ones and some with
challenges.
Page12of34
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Staff
Experience
Patient
Experience
Friends and
Family Test
Health
Service
Journal
Staff with in date appraisal 89.7% against a target
of 95%. Staff with in date supervision is currently
85.3% against a target of 90%. Sickness absence
is 5.35% against a maximum target of 5% in April.
For the period 12 April – 10 May there were 20
complaints received and 3 compliments across
SD&T CCG and NEWD CCG. There was 1 health
Service ombudsman review request received and
3 SIRI subject to Root Cause Analysis (of 330
incidents reported) and no new Coroners Rule 28
reports.
There has been an improvement position of 96%
of complaints acknowledged within three days in
Q4.
The F&F will be operational from December
2014, however further government guidance is
awaited. The staff F&F test will be operational
from June with reporting available from
September.
It has been agreed that staff
experience will be reviewed as
part of the Contract Review
Process, with a staff story, and
then discussion about staff
metrics. Included in this will
be in date appraisal, sickness
absence, vacancies, staff with
in date supervision and
staffing ratios (Hard Truths).
It has been agreed that
patient experience will be
reviewed as part of the new
CRM meetings between SD&T
and DPT. This will include a
patient story relating to a
complaint or compliment, and
discussion around numbers
and themes of complaints.
DPT Board
Papers 29
May 2014
To be discussed and reviewed
at CRM
DPT Board
Papers 29
May 2014
DPT CRM 27
May 2014
DPT Board
Papers 29
May 2014
DPT CRM 27
May 2014
DPT CRM 27
May 2014
DPT Board
Papers 29
May 2014
DPT have been chosen as a finalist on 2
categories of the Health Service Journals 2014
Patient Safety and Care Awards.
South Western Ambulance Services NHS Foundation Trust (SWASFT) 999 and 111
KPIs
Red 1: Performance in April 2014 for Red 1 was
above the national performance target of 75% at
76.1%.
For SD&T CCG area there were 72 incidents in
April 14 and 87.5% of these were responded to
within 8 minutes.
Monitored and reviewed by
CSU
Source
Board
Report
29
May 2014
SWCSU CRM
The small Red 1 incident volume results in high
variability in daily performance and continues to
Page
Red 1 performance targets are extremely
challenging across all operational areas within
the Trust with very small numbers of Red 1
incidents recorded (less than 50 calls per day
across 10,000 square miles).
13
In April 2014 the Trust reported a total of 1,363
Red 1 incidents (compared to 24,151 Red 2
incidents), which accounted for less than 3% of
all incidents reported across the Trust.
Page13of34
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have a disproportionate impact on performance
if one incident is missed.
Red 2: The Trust delivered Red 2 performance of
76.84% in April 2014, 1.84% above the national
target for its whole area. For SD&T CCG there
were 1, 598 Red 2 and SWAST achieved 97.72%
against the target of 75%.
Green 1, 2 & 4: call performance in April was
slightly below target for these standards.
Accident and Emergency activity is measured for
contracting and performance management
purposes. For 2014/15 the Trust is contracted on
the basis of ‘incidents’.
Incidents are defined as any unique call resulting
in the ambulance service providing a service
which could include telephone advice only or
referral to another service where appropriate.
Incidents are split into three categories:
SIRIs
In April 2014 there were 40, 866 incidents across
the whole patch- this was up by 1, 682 from April
13. For SD&T CCG there were 4, 481 incidents,
an increase of 12.22% from April 13.
Individual incidents and extended delays at acute
hospitals are managed on a day to day basis and
subject to locally agreed handover escalation
procedures.
• Delays are extremely variable between
hospitals. There are a number of clear outlier
hospitals.
• SWASFT continues to experience a high number
of delays overall and the operational resources
absorbed in managing these incidents continues
to be of significant concern.
• There were a total of 1,201 handover delays in
excess of 30 minutes in April 2014, of which 233
were over 60 minutes in length (compared to
1,233 delays in excess of 30 minutes in March
2014).
• Handover delays are subject to a fining regime
for 2014/15 with a material impact on trust
finances
SWASFT reported 11 incidents during April and
May. 5 of which were classified as ambulance
(general) and two delays. SWCS have taken on
responsibility for monitoring the 999 SWASFT
SIRIs, clarity has been provided regarding the
CSU
Managed locally through an
agreed escalation plan.
CSU.
Board
Report
29
May 2014
CSU CRM
CSU CRM
14
Handovers
Hear & Treat/Refer
See & Treat/Refer
See & Convey
Page



Page14of34
OverallPage44of153
Top
Staff
process for incidents that are combined 111/999
or 999/urgent care , out of area incidents and
discussions will take place between the SWCS
and the relevant CCG commissioners of the other
SWASFT service to identify who will take the lead
in monitoring the SIRI. Agreement has been
reached with SWCS regarding the assurance they
provide in relation SWASFT 999 service. AS of 1st
June 2 SIRIS were incomplete and overdue –
however agreement had been reached with the
SWCS unit regarding extensions
Staff sickness was high in April 5.45% against a
target of 4%.
CSU.
Board
Report
29
May 2014
SWAST has worked closely
with NHS Commissioners to
identify the areas of concern
and has developed an NHS
111 Performance Recovery
Plan and associated
improvement trajectory to
deliver improvements in
performance
to deliver sustained
improvements in Trust
performance against the
National and Local Quality
Requirements within the NHS
111
Board
Report
29
May 2014
Staff turnover was 12.84% with a vacancy rate of
5.85% in April 14.
Appraisal levels were lower than anticipated, at
48.68% (against an internal target of 85%) in
April 2014.
Call answering performance for April 2014 was
below the 95% target.
Dorset 88.66%
Devon 85.88%
Cornwall 88.39%
Somerset 86.88%
In May, 35,258 calls were answered, 80.2% were
answered in 60 seconds (target is > 95%).
15,266 calls (43.3%) were passed to DDOC
Ambulance dispatch is 9.5% against a local target
of <10%. Of these patients 47.9% were nonconveyed which is very close to the general nonconveyance rate.
5.6% of patients were advised to attend local ED.
17.97% of cases were closed - no further medical
input required.
12.7% received a call back from a clinical advisor.
NEW Devon
CCG IPAM
Monitoring of progress
against the plan is undertaken
through a weekly internal
Steering Group overseen by
the Executive
Director of Nursing and
Governance. This Steering
Group reports directly to the
Directors
Group.
15
The Trust established a Performance Recovery
Plan for the NHS 111 Service in April 2014 .
Page
NHS 111
The 2013 NHS Staff Survey results have revealed
that the Trust has significantly improved the
quality of appraisals completed. The appraisals
establish and agree clear work objectives and
identify training and development needs more
effectively than the previous appraisal process.
Deterioration of performance of calls answered
within 60 seconds during March 2014 continued
through to April 2014.
Page15of34
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The percentage of calls abandoned remains
better than (below) KPI level of 5% in all four CCG
areas in April.
Royal Devon and Exeter NHS Trust (RDE)
4 hour
performance
Monitored by NEWD CCG
IPAM
IPAM
Harm Free
Care
95% received Harm Free Care in April
IPAM
Patients with
hospital
pressure
ulcers
Patient falls
in hospital
that have
caused harm
F&F
In March the proportion of people with PU per
1000 bed days was 0.28, 0 of these were grade 3
or above.
IPAM
In March there were 18 falls, 4 of these caused
harm.
IPAM
44.5% for ED and 24.4% for inpatients in April.
IPAM
UTI
141 people were catheterised, 7 of these
developed an infection.
IPAM
Patient
Experience
From March to April there has been an increase
in the number of complaints and concerns, from
IPAM
Board
Report 28
May 2014
NEWD
Patient
Quality
Dashboard
NEWD
Patient
Quality
Dashboard
NEWD
Patient
Quality
Dashboard
NEWD
Patient
Quality
Dashboard
Board
Report 28
May 2014
NEWD
Patient
Quality
Dashboard\
Board
Report 28
16
During April, 30% of the days saw over 300
attendances, with spikes in activity overnight and
at weekends. ED has an average attendance of
270 patients per day and 80% of the days in April
saw higher than average attendance rates. In
addition high volumes of admissions and delays
in transport by the new provider NSL have led to
pressures on patient flow, which has also
contributed to breaches of the 4 hour target.
0 CDiff in April
0 MRSA in April
The Trust will be subject to
CCG contractual fines as a
result of the contract 4 hour
target performance failure,
however the Trust will be
contesting the application of
fines due to the issues
Page
HCAI
Emergency Department activity and pressure has
increased significantly since March resulting in
adverse performance in April against the CCG
contract 4 hour A&E target (excluding Walk in
Centre attendances) at 94.22% for the month
against the target of 95%. However the Trust
achieved the Monitor 4 hour target which
includes Walk In Centre activity with
performance at 95.28%.
Discussed
at/Source
Board
Report 28
May 2014
Page16of34
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68 (March) to 76 (April).
May 2014
During April 89% of complaints and concerns
were acknowledged within the 3 working day
timeframe. The 11% beyond 3 working days
relates to 8 cases. Improvement plans are in
place.
During April there were no clinically unjustified
single sex accommodation breaches.
Stroke
Stroke performance has slipped against the
target of 80% of patients spending greater than
90% of their hospital stay in a designated stroke
bed and currently sits at 75%.
IPAM
Work continues to identify all
issues relating to timely
transfer from ED/AMU to the
Stroke Unit within three hours
and
Cancer
Performance for April for the 62 day wait for first
treatment following urgent GP referral was
83.0%, against a target of 85%, with 23 breaches
for the month of April.
62 Day Wait for First Treatment following
referral from NHS Cancer Screening Programme:
In April two patients who were referred to
treatment following participation in an NHS
cancer screening programme did not receive
treatment within 62 days, equating to
performance of 84.62% in April, against a target
of 90%. In both instances the delay to receiving
treatment was patient initiated.
Two Week Wait for Symptomatic Breast
Patients:
In April there were 70 countable patients, 7 of
whom have breached the 14 day referral to
appointment target.
IPAM
A consistent element of the
monthly breach total for this
target has been in relation to
Inter Trust Transfers; where
the Trust as a tertiary centre
has been exposed by late
referrals (after day 42) from
other hospitals. Therefore on
14th May 2014 the Trust
notified referring hospitals
and Monitor of its intention
to implement a revised
process to both reduce late
referrals in order to improve
patient pathways and also
Board
Report 28
May 2014
NEWD
Patient
Quality
Dashboard
Board
Report 28
May 2014
Board
Report 28
May 2014
17
EMSA
An action plan is in place to
address any outstanding
issues in relation to the case
partially upheld within the
Emergency Department (ED)
where following presentation
to the department a decision
was made not to undertake
further investigations of the
patient. The Ombudsman has
particularly highlighted the
need for documentation
when a decision is made not
to offer a routine test.
IPAM
Page
There were three new cases referred to the
Ombudsman during April. For the current
outstanding cases, two final reports were
received with outcomes, one of which was
partially upheld and one not upheld
Page17of34
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highlight to Monitor those
breaches which RD&E
considers should not be
attributed to the Trust.
For the month of April
application of this process
would have resulted in two
fewer breaches which would
improve performance from
83.03% to 84.87% and
support improved
performance for the quarter.
IPAM
CQC
The Trust has now received reports from the two
planned unannounced inspections that occurred
in March 2014 at Tiverton Hospital, in relation to
Safe Site Surgery and the RD&E (Wonford) in
relation to Discharge. The Trust was found to
fully compliant in relation to both inspections.
Staff
Staffing Numbers and Turnover:
There has been a slight decrease in the overall
turnover rate from 11% to 10.8%. This remains
slightly higher than the average of 10% for other
NHS QUEST organisations and reflects the
expected higher turnover rate of nurses recruited
from overseas.
The plan to reduce the turnover rate continues to
focus on registered and unregistered nurses as
these are showing an above average turnover
rate of 13.7% and 12.4% respectively. This
Duty of Candour
Compliance with the contractual requirements of
the Duty of Candour for quarter 3 and quarter 4
of 2013-14 was 100% for all moderate, major or
catastrophic incidents
0 Never Events in April
IPAM
Board
Report 28
May 2014
IPAM
Board
Report 28
May 2014
IPAM
Rule 28
Coroner
Report
The Trust has received one Rule 28 Report from
the Coroner, relating to medication on discharge
where the Coroner has ruled that discharge
communication needs to be improved upon. The
Trust is currently reviewing its response to the
Coroner.
IPAM
Board
Report 28
May 2014
Board
Report 28
May 2014
Fractured
Neck of
Femur
When numerous patients with a fractured neck
of femur are admitted on the same day, theatre
capacity is not sufficient to ensure all patients
will have surgery within 36 hours. Peaks such as
these are expected to continue, but increased
operating capacity will come into effect in stages
over the coming 6-12 months. The risk therefore
remains high
A thorough review of capacity
and demand is underway with
the clinical, administration
and management teams
involvement, in order that
RDE can accurately plot the
breach
numbers
going
forward, whilst longer term
solutions are considered. It is
likely that breaches in May
and June will continue before
Board
Report 28
May 2014
18
Never Events
Page
Duty of
Candour
Board
Report 28
May 2014
Page18of34
OverallPage48of153
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some of the actions being
taken start to take effect.
Diagnostic
Waiting
Times
Referral to
Treatment
Maximum Time of 6 Weeks from Point of
referral to Key Diagnostic test:
As at the end of April 2014, 5061 patients were
on a waiting list for one or more of the 15 key
diagnostic tests. Of these, 312 patients (6.16%)
were waiting longer than 6 weeks. These patients
were predominantly within the imaging
modalities (105 patients awaiting a CT, 171
patients awaiting an MRI, 27 patients awaiting a
non-obstetric ultrasound test).
18 Weeks Referral to Treatment:
The 18 week Referral to Treatment Waiting Time
Standard was achieved in aggregate for admitted
patients (92.9%), non-admitted patients (97.6%)
and for patients waiting on an incomplete
Referral to Treatment pathway (94.2%) in April.
In April as part of ongoing validation of patients
with open pathways 2 patients were identified
who had waited longer than 52 weeks for
treatment. Both patients are being treated in
May, neither of whom experienced harm as a
result of their wait. Robust processes continue to
operate to ensure that any patients identified are
assessed and offered treatment as quickly as
possible.
The Trust has received higher than forecast GP
referrals for the month of April with a 10.87 %
increase in comparison to April 2013 which
equates to an additional 689 referrals. This
increase is primarily across the four specialties of
Orthopaedics (24.97%), Urology (31.4%),
Ophthalmology (10.53%) and Radiology (over
100% due to the new flow of work via ‘Any
Qualified Provider’).
A further analysis of referrals growth compared
to 2013/14 and to contracted levels will be
undertaken.
This increase will be formally escalated to NEW
Devon CCG as referral growth presents the Trust
and commissioners with a risk in relation to RTT
target delivery and contract over performance.
The Trust will consider the referrals growth as a
possible mitigation factor in relation to any
future RTT contract penalties.
IPAM
Board
Report 28
May 2014
IPAM
Board
Report 28
May 2014
4 hour and
Ambulance
Handover
IPAM
Ambulance handover delays increased to 1.6%
in April. The number of ambulance handover
delays greater than 30 minutes increased
significantly in April to 52 from 29 in March.
Discussed
at/Source
Board Report
30 May 2014
Page
19
Plymouth Hospitals NHS Trust (PHNT)
Page19of34
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There were two April delays of >60 mins.
(This should been seen in the context of an
increasing number of ambulance handovers
at PHNT). The reason for this is being reviewed.
Contract penalties totalling £12.4k have been
applied in April for ambulance handovers (52
at £200 per breach for 30-min breaches; 2 at
£1k for 60-min breach).
Falls
The Trust failed the A&E 4hr wait standard in
April at 94.2%. Fines of £88k have been
incurred as a result.
In March - 24 falls across the hospital with 16
causing harm. Falls rates across the Trust have
been variable. Since the review and
implementation of the Falls Reduction
package, noted overall trend of decreasing
falls, compared month by month to the
previous year.
Never Events
0 Never Events reported in April 14
Pressure Ulcers
The proportion of patients presenting with PU
per 1000 bed days was 0.69 in March 14
Cancer
Friends &Family
Test
PU continue to be a concern and a target
reduction of 50% of all hospital acquired PU
has been agreed with NEWD CCG.
Eight of the nine cancer standards were
achieved in April.
Significant capacity shortfalls in Breast Surgery
have resulted in 100 breast symptomatic
patients breaching their 2ww date in April. A
significant rise in demand has resulted in
symptomatic patients waiting up to 1 month
for their appointment although suspected
cancer patients are being prioritised and seen
within the 2 week window.
Inpatient rate 36%, ED response rate 25%
IPAM
Board Report
30 May 2014
NEWD Patient
Quality
Dashboard
IPAM
IPAM
Board Report
30 May 2014
IPAM
NEWD Patient
Quality
Dashboard
Board Report
30 May 2014
IPAM
Board Report
30 May 2014
3 C-Diff in April 14 and 0 MRSA in March 14
IPAM
Board Report
30 May 2014
EMSA
0 EMSA breaches in March 14
IPAM
Stroke
The Trust failed to achieve the stroke target in
April with 72% of stroke patients spending 90%
or more of their stay on the acute stroke unit
against a national target of 80%. For those
patients who breached the standard in April,
the most common breach reason was a short
length of stay. When a patient’s overall LOS is
IPAM
NEWD Patient
Quality
Dashboard
Board Report
30 May 2014
Page
Work is ongoing with the
CCG to agree improved
pathways to onward stroke
care
20
HCAI
Page20of34
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Referral to
Treatment
Patients
receiving harm
free care
Patient
Experience
short, any time spent off the stroke unit,
however short, is more likely to cause them to
breach.
The Trust failed the admitted standard in April
with only 83.6% of patients treated in the
month receiving their treatment within 18
weeks
94% of patients received Harm Free Care in
March.
outside PHNT
306 PALS enquiries were received 306 during
April 2014:
 Top 3 Issues
 Outpatient delays / cancellations (34)
 Waiting List Issues (20)
 Inpatient delays / cancellations (28)
IPAM
IPAM
Board Report
30 May 2014
IPAM
NEWD Patient
Quality
Dashboard
Board Report
30 May 2014
There were 71 formal complaints received in
April 2014.




Top 3 Issues
Quality of clinical and nursing care (14)
Communication with patients & relatives
(7)
Outpatient delays (6)
Patient Feedback- the National Survey
Programme Results for the eleventh survey of
adult inpatients commissioned by the CQC
were published in April 2014. The final
response rate for the Trust was 52%, above the
average of 49%. Results have been compared
to 2012 National Inpatient Survey and the
lowest and best scores from other Trusts for
2013. The Trust improved its score from the
last inpatient survey in 2012 in 42 (out of 60)
areas.






Patients were admitted as soon they felt
necessary
The level of noise at night by other
patients has improved
Patients received assistance at mealtimes
when required
Information was provided to families or
someone close to patients in order to care
for them
Hospital staff talked to patients about
additional equipment or adaptions needed
for their return home
Information about what medication side
effects to look for once home is shared
with patients
Patients felt there were enough nurses on
Page

21
Areas of marked improvement include:
Page21of34
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


duty to care them whilst in hospital
Staff provided enough emotional support
Patients were involved in decisions about
their discharge from hospital
More patients were asked to give their
views on the quality of care provided
The Trust’s score has gone down marginally in
eight areas from 2012. Six areas stand out for
priority improvement, these are:

Diagnostics
12.7% are currently over the 6 week target for
a diagnostic test.
Fractured Neck
of Femur
The Trust has made significant strides in
improving the % of fractured neck of femur
patients operated on within 36hrs of admission
over the last 18 months. In April, 89%
of patients achieved this standard, an 11%
Board Report
30 May 2014
IPAM
It is acknowledged that the
Trust are following up too
many patients by default
and that this is
unsustainable.
IPAM
Board Report
30 May 2014
IPAM
Board Report
30 May 2014
Board Report
30 May 2014
22
To be seen by
date
There were 4 breaches of the 28-day rebooking
standard in April which has resulted in a Month
1 contract penalty of £45k.
110,349 patients are currently on a follow-up
waiting list. As at 30 April, the number of these
patients who have breached their see-by-date
(i.e. backlog) had risen by 1,555 patients to
33,491.
IPAM
Page
Cancelled
Operations
Receiving copies of letters sent between
the hospital doctors and GP
 Ensuring the hospital specialist has all
information about the patient’s condition
from the person who made the referral
 Patients understanding the purpose of
their medication and how to take it in a
way they could understand
 Anaesthetists to explain how patient
would be put to sleep or control pain
 Doctors talking in front of patients as if
they are not there
90 operations were cancelled on the day of
admission for non-clinical reasons in April,
representing 1.9% of all elective admissions.
This represents deterioration on the March
position (1.2%, 60 ops) but still an
improvement on April last year (2.6%, 130
ops). The availability of general beds continues
to be the most prevalent reason for
cancellation.
Performance has deteriorated further in May
with 76 operations cancelled as at 19 May.
However 30 of these were as a consequence of
the trust’s involvement in a major incident on
13 May.
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Major incident
Staff Experience
improvement on this time last year. Of the
4 April patients who did not make it to theatre
within 36hrs, 1 was medically unfit whilst 3
were delayed due to overrun theatre lists
On Tuesday 13 May 2014, the Trust declared a
major incident, in response to a coach
Crash involving 54 casualties. The Major
Incident Control Centre was opened to
coordinate the response, the Emergency
Department was emptied to receive and treat
the more seriously injured, staff and essential
equipment were deployed to key areas
and capacity created in the SAU, theatres and
critical care. Arrangements were also
put in place to support relatives.
Annual turnover for Month 1 is 9.81% in
comparison to 8.32% in the same period in
the previous year.
Appraisal completion rates (for non-medical
staff) have decreased in Month 1 by 4%
to 76%.
IPAM
Board Report
30 May 2014
The Trust will conduct a post
incident review to see
whether it can further
improve its response to
similar incidents in future
IPAM
Board Report
30 May 2014
Following the recent spike in January, sickness
has now fallen again in Month 1 to 3.84%
(from 4.31% in Jan). Historically, the November
to February period does report an increase in
absence in comparison to the rest of the year.
The current 12 month sickness rate is 3.73%.
Staff Survey undertaken between September
and December 2013:
The Trust’s response rate was 45%, against an
average 49% of all participating organisations.
There had been four statistically significant
(>5%) positive changes from 2012:

Page
In comparison with all other acute trusts in the
survey there were five significant positive
comparisons for PHNT:
 Staffing having received an appraisal in the
last twelve months.
 A reduction in physical violence from
patients or public.
 Equality and diversity training.
23
Good communication with senior
management.
 Effective team working
 Fairness and effectiveness in incident
reporting.
 Recommending the Trust as a place to
work.
There was one statistically significant negative
change:
 Percentage of staff working extra hours.
Page23of34
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

A reduction in experiencing discrimination
at work.
Fairness and effectiveness of incident
reporting procedures.
There were three significant negative
comparisons:
 Having received a well‐structured
appraisal.
 Hand washing materials always available.
 Witness potentially harmful errors, near
misses or incidents.
CQC
IPAM
Board Report
30 May 2014
IPAM
Board Report
30 May 2014
NHS 111
In March, the GP out of hours call handling
switched to 111 (no known initial concerns)
National
No known issues
Quality
requirements
Total number
13847 (April 14)
routine calls
14840 (May 14)
Total no.
12241 (April 14)
routine calls
13549 (May 14)
assessed 1hr
NEW Devon CCG
monitoring
NEW Devon CCG
monitoring
Source
IPAM
NEW Devon CCG
monitoring
NEW Devon CCG
monitoring
IPAM
Serious
Incidents
Never Events
Complaints
Alerts
These data will shortly be
available on a new
performance dashboard
IPAM
SIRI
On 13 March 2014, the CQC published its latest
series of intelligent monitoring reports for NHS
trusts. The report for PHT places trust in Band
5, representing the second lowest level of risk.
It identifies elevated risks for diagnostic
waiting times and whistleblowing alerts. The
report also highlighted the NHS Trust
Development Authority ‘Escalation Score’ as a
risk area. These are areas which continue to be
the focus of attention by the Trust
Management Executive and the Board
Currently the Trust has 72 open serious
incidents on STEIS. 33 of these are current
investigations whilst 38 investigations are with
NEWD CCG awaiting closure.
Themes for the current 33 active SIRIs:
‐ Pressure ulcers
‐ Falls
‐ Failure to act on test results
Devon Doctors Ltd (Out of Hours)
24
None reported
No data available
No data available
IPAM
Page
No data available
IPAM
Page24of34
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Virgin- Integrated Children’s Services
Discussed
at/Source
CAMHS
Quality and timeliness of Child & Adolescent
Mental Health Services (CAMHS) for planned
care and Quality and timeliness of Child &
Adolescent Mental Health Services
(CAMHS) for unscheduled care were raised
as concerns at the NEWD CCG Board. This
includes the timeliness of being able to access
national Tier 4 beds which can cause delay and
pressures on local services.
NEW Devon CCG
monitoring
NEWD CCG
Board Report
21 May 2014
Mandatory and
Safeguarding
training (%)
83.6% of staff have received essential and
mandatory training including Safeguarding
Level 1. 77.3% against a target of 100% had
safeguarding adult training in March 14.
NEW Devon CCG
monitoring
IPAM
Dashboard
Waiting Times
Excessive waiting times autistic spectrum
conditions in Virgin Care Limited. Additional
staffing has been taken on to address the issue
whilst amendments and improvement made in
the existing pathway.
NEW Devon CCG
monitoring
NEWD CCG
Board Report
21 May 2014
SIRIs
0 SIRI were reported in March
NEW Devon CCG
monitoring
IPAM
Dashboard
EMSA
0 breaches in March 14
NEW Devon CCG
monitoring
IPAM
Dashboard
Patient
Experience
1 complaint, 4 comments, 2 compliments
and 80 comments were received in March 14
NEW Devon CCG
monitoring
IPAM
Dashboard
HCAI
There were 0 MRSA reported in March 14
NEW Devon CCG
monitoring
IPAM
Dashboard
GP Discharge
Summaries
86.7% against a target of 100% had the
summary signed and dated appropriately.
81.9% against a target of 100% had a clear
diagnosis shown
82.3% against a target of 100% had a patients
care clearly documented.
80% against a target of 100% had a clear care
management plan
70.8% against a target of 100% had a discharge
summary sent within the contractual
timeframe of 24 hours.
NEW Devon CCG
monitoring
IPAM
Dashboard
Page
25
Page25of34
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Part 2: Quality Issues
Care Act 2014 - The Care Bill becomes law
After passing through the House of Lords, the government’s Care Bill has received royal assent,
becoming law on May 14, and bringing with it sweeping reform for care and support across the
country. Under the legislation, there are provisions in place for delivering a minimum eligibility
threshold – a set of criteria that makes it clear when local authorities will have to provide support to
people.
Additionally, local authorities will have a duty to consider the physical, mental and emotional
wellbeing of the individual needing care. They will also have a new duty to provide preventative
services to maintain people’s health.
There will be a new Chief Inspector of Social Care with the power to hold providers of care to account
when poor care is identified. The care system will also be built around each person .There are reforms
to the way in which adults receive financial support to pay for social care– through Personal Budgets; a
new single failure regime for hospital trusts (recommended by the Francis Review)
The Bill also includes provisions to introduce mandatory training and certification of health and care
support workers (HCSWs).
Hard Truths Commitments regarding the publishing of staff data
On 16 May, Jane Cummings, Chief Nursing Officer, wrote to all trusts in England with inpatient beds,
setting out plans for the publication of staff data on NHS Choices. Trusts will be required to publish
their staffing fill rates (actual versus planned) in hours, covering nurses, midwives and care staff.
Figures for May will need to be submitted by 10 June ready for publication on NHS Choices website by
24 June.
Patients and the public will be able to see how hospitals are performing on this indicator in an easy
and accessible way. The ward by ward data will sit alongside a range of other safety indicators.
Trust reports to their Boards in respect of staffing must follow National Quality Board (NQB) guidance.
Commissioners will be responsible for ensuring that all trusts submit on time, and that they also report
to their Boards as per guidance.
This is a significant amount of work for the acute, community and mental health trusts but all have
signalled readiness to comply with this requirement. Compliance will be monitored at contract
review meetings with each provider.
DPT, SDHFT and TSDHCT have uploaded on time.
All Party Parliamentary Group on Sepsis – first report
1. Organisations need to develop collaborative care pathways for sepsis
Page
The key recommendations are:
26
The report highlights the importance of a joined-up approach to permit the reliable delivery of basic
interventions within hospitals, and at the interface between pre-hospital and hospital-based care.
These are all issues identified locally following the tragic death of a young boy three years ago in South
Devon.
Page26of34
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2. Places where patients at risk are cared for outside hospital environments should ensure staff
are adequately trained in sepsis recognition
3. Resources should be allocated to ensure that personnel can deliver optimum care
4. Sepsis should be included on risk registers
5. Improvement work undertaken should be supported by NHS England
6. CCGs should commission for streamlined care.
7. Data should be collected on sepsis incidence and management on regional basis
8. National guidance should be developed for coding re sepsis
9. Professional and educational bodies should assess their provision of education on sepsis.
In South Devon and Torbay, work is already well under way to address all of the above points which
are within local control, and providers and the CCG are working with the AT to ensure quality
improvement and better patient safety. The Sepsis 6 bundle of care has been agreed and all providers
worked together recently to agree a care pathway that stretches from primary care through pre
hospital services into emergency departments and then into paediatric care.
Patient Safety
Risk Register – Quality
Currently there are 32 open risks that fall under the Quality and Patient Safety remit.
There are 4 very high risks (Red risks) currently being monitored:
1. Relates to 4 hour performance standard and risk of handover delays from ambulance to
Emergency Department at SDHFT. There is a risk that patient safety and experience of care might
be compromised. Risk score of 20
2. Relates to the CCG not being in receipt of consistent, accurate and reliable data identifying
children and young people in South Devon who are subject to Child Protection Plans or Looked
After by the Local Authority. Risk score of 20
The remaining 2 high risks relate to pressure ulcers and to Placed People. Both have a risk score of
16.
There are actions plans in place to address all the identified risks.
All the risks on the Quality risk register and their action plans are monitored regularly though the
Quality Committee and the Quality Directorate.
Serious Incidents and Never Events
In total 31 SIs were reported during April and May 2014:-
The chart below relates to those incidents that occurred within SDT CCG borders according to location
of the GP practice. DPT are being asked to specifically attribute SIRIs to either SDT CCG or NEW Devon
CCG, whilst SWCSU are working with SWASFT to make them easier to identify.
27
Number of SI’s reported
11
10
7
3
Page
Trust
SWASFT (whole trust all services)
TSDHCT
DPT (whole trust pan Devon)
SDHFT
Page27of34
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The data shows that there are no consecutive data point of 5 or more either above or below the
median, which indicates that any variation depicted is due to common cause variation. There are no
consecutive runs of 5 or more in either an upward or downward direction which means that no
definitive trend has been identified. It is worth noting that there is a downward trend in all SIRIs
reported by Providers, that began in September 2013 and ended in February is not echoed by SIRIs
reported within the SDT CCG boundaries.
Page
The data below shows that though there is great variation between individual months, there are no
consecutive data points of 5 or more either above or below the median, which demonstrates that
any variation depicted is due to common cause variation. There are also no runs of 5 or more in one
direction so this means there is not a definitive trend. Please note though a consecutive run of four
upwards between October and March 2014. Conjecture could attribute this to the roll out of the
28
Pressure Ulcers remain the most frequently reported type of SIRI during over April and May 2014.
Page28of34
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collaborative Pressure Ulcer Prevention Project raising awareness across the health and Social Care
Community.
The number of overdue incomplete incidents that are not subject to STOP the CLOCK has reduced. At
the first of June there were 17 that were reported from first April 2013 and 34 from before 1st April
2013. The majority of those over 4 weeks overdue are STOP the CLOCK (STC). DPT has made significant
progress and on of SDT CCGs is overdue and not subject to STC.
35 SIRIS were closed in April and May – leaving a total of 67 either currently being reviewed or STC.
The Area Team monitors this aspect of performance and we recently provide an update to their
quality and safety team.
Never Events
There were 0 Never Events reported during April and May 2014 by services where we are the lead
commissioner.
CAS Alerts
21 alerts were published during April and May 2014. SWASFT closed 6 outside of timescales which is
being discussed with the provider.
SDT CCG patient safety team now has access to the CAS system and will be producing reports from
June onwards
Safeguarding Adults Update
Deprivation of Liberty Safeguards
Page
Where there is reason to suspect that any person receiving health or social funded care, lacks capacity
to consent and are subject to continuous supervision and control and not be free to leave, DoLS
applications should be made.
29
The Judgement by the Supreme Court relating to Cheshire West and the application of DoLS is
beginning to impact on the Deprivation of Liberty Safeguards (DoLS) teams within local authorities.
Whilst specific advice is awaited from the local authorities regarding applicability to A&Es and
hospitals, more general advice implies that:
Page29of34
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Current Safeguarding Processes
There were 9 safeguarding processes in April and May that required active involvement of the
Safeguarding Adult and Patient Safety lead either as an independent chair, supporting whole home
processes or participation in serious case reviews. There have been a further 6 cases in June so far,
bringing it a total of 20 current cases requiring input. The recent review of the quality team has seen
an expansion of support to the SIRI process which enables more support to be given to safeguarding
adult processes. However this level of engagement creates pressure on the CCGs ability to undertake
strategic activity.
The Joint Learning and Improvement Sub Group chaired by the Safeguarding Adult and Patient Safety
Lead is currently reviewing the output of a recent workshop to develop the Safeguarding Adult / MCA
training Strategy for Devon and Torbay. An independent peer review of safeguarding processes in
Torbay is due to commence at the end of June 2014.
Safeguarding Children update
A CQC review of safeguarding children and looked after children took place during the week beginning
19 May 2014. The team of two inspectors visited all sections of health provision and tested the way in
which children were safeguarded in Torbay. The inspection did not look into arrangements in the
South Devon area.
Initial findings were relayed by the inspectors at the end of the review week. There was some very
good practice identified across all providers but there were also some areas where improvement is
needed. These latter areas were already known to both the CCG and to the providers, and the written
report, when received, will serve to add impetus to the need to improve the quality of care for
vulnerable children.
In particular, there appears to be poor performance in ensuring that looked after children, when first
taken into care, are initially assessed for their health needs within a given timeframe (IHA’s – initial
health assessment). Between January 13 – May 14 only 3% of IHAs achieved the 4 week target time
(A total of 5 out of 153). 27 IHAs were done by 6 weeks (27/153).
Much of the delay is due to the transfer of paper work between Children’s Services and health
departments when children come into care as well as difficulties in gaining parental consent for the
medicals. New systems have now been put in place which should improve this. However, some of the
delay is due to lack of choice of venues and times for IHAs (if a clinic appointment is missed it can be
another 3 weeks to reschedule the appointment)
The CQC report is also expected to contain recommendations about the need to improve record
keeping, sharing of information, timely intervention and ensuring care leavers are given adequate
attention in respect of their health needs. As expected, the issue of mental health service for children
and young people was also identified.
When the report is published, the CCG will lead the joint improvement plan to ensure that all provider
adequately address the recommendations to ensure quality improvement across all sectors, including
primary care.
Page
Clostridium difficile – 2013/14 a very successful year where Torbay and South Devon remained on
target for the number of cases of c.difficile with a total of 66 community cases against a target of 77.
The acute service reported 17 cases against a target of 18. In April There have been 4 reported cases
in the Community against a target of 70 cases and there have been 3 reported cases to date in the
Acute Trust against a target of 11 cases
30
Healthcare Associated infections
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MRSA
There has been 0 MRSA bacteraemia cases reported during the year against a target of 0.
Outbreaks of D&V for March


One community Hospital
Three wards in the Acute Trust
Patient Experience
PALS and Complaints
From April 01 2014, PALS and Complaints were bought in house having previously been outsourced to
Northern Eastern and Western Devon Clinical Commissioning Group. Complaints Numbers remain low;
however PALS and informal cases have seen a steady increase.
Total Complaints received (01 April 2014 – 31 May 2014): 8
Number of Complaints by Subject
2
2
1
1
1
1
1
1
0
Complaints received about Providers:
4 complaints have been closed
1 was the responsibility of Devon County Council to address.
1
1
1
1
1
1
1
1
31
Devon County Council
NEW Devon CCG
Multi-agency
Southern Devon Healthcare NHS Foundation Trust
Devon Referral Support Services (DART/TRAC)
Torbay and South Devon Health and Care NHS Trust
NHS England (Primary Care)
Devon Doctors Limited
Number
Page
Provider
Page31of34
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1 was fully responded to and the case was closed.
1 is already under investigation by the hospital complaints team so we are unable to investigate; we
are contributing to the response.
1 was passed to NHS England to respond as the complaint related to Primary Care.
4 remain open
3 actively under investigation due 10/07, 27/07 and 12/08 respectively
1 has been self-referred to the Parliamentary and Health Service Ombudsman for further investigation
following a comprehensive local investigation and response, this case is on-going with the
Ombudsman.
Total PALS (01 April 2014 – 31 May 2014): 33
Overwhelmingly, the highest number of enquiries has fallen into the category of Information,
Communication and Choice, with 16 cases related to this, the next highest is Access and Waiting with
10.
Number of Cases
PALS Cases by subject
20
15
10
5
0
Information
Communication and
Choice
Safe, High Quality Care
Access & Waiting
Subject
Of the 33 cases, 10 were not in our remit and related to Primary Care issues which should be dealt
with by NHS England. NHS England does not have a PALS function and this suggests a service gap for
those people who have a concern to express that they do not wish to be raised as a complaint.
The Quality Team supports a ‘you said, we did…’ function, which is designed to show what action was
taken in response to learning (from complaints, from incidents, from feedback).
You Said, We Did – complaints and feedback
You Said: A number of concerns were raised by patients undergoing gender reassignment who were
having difficulty accessing the correct medication for the treatment they needed. It could not be
prescribed in Primary Care and as such it meant that these vulnerable patients were unable to receive
timely, effective treatment.
Page
You Said: Healthwatch Devon raised a concern about patients from South Devon who are travelling to
the Royal Devon and Exeter Hospital rather than Torbay, and are finding that blood tests and samples
are not being sent to the relevant hospital, resulting in delay and cancellation.
32
We Did: The Equality and Diversity Officer, Patient Experience Lead and the relevant commissioners
alongside NHS England and the LMC are creating a task group to tackle this issue and to look at the
barriers to prescribing and why this arises and how the situation can be improved.
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We Did: The CCG are looking to understand how many people are affected by this and whether
courier routes can be extended to incorporate surgeries further out so that samples that need to go to
the Royal Devon and Exeter can be split and sent by courier to the relevant hospital.
Patient Experience Work
Some of the key areas of work for the Patient Experience Team:
-
Launch of Staff Friends and Family Test (July 2014)
Creating a learning from complaints meeting – this will be a meeting with both CCG’s and key
providers to understand and action learning from complaints received (August 2014)
Patient Experience Strategy (End of June 2014)
The Friends and Family Test continues to be an area of concern within SDHFT. The acute hospital has
seen a small overall increase in response rate but still figures remain low especially in A&E. Despite the
low completion rate the actual responses have been very favourable and overall, patients are
extremely like to recommend the hospital to friends and family if they need similar care or treatment.
The response rates can be seen in the individual provider section of this report, the completion of
Friends and Family continues to be monitored through Work Stream 2 and at Contract Review. .
The number of services using Friends and Family will be increasing this year and it will be extended to
the Ambulance Service, Mental Health and Primary Care. Each of these providers will have their own
challenges in terms of how well the test will be carried out. The completion of the test will be
monitored through existing contract review meetings for key providers.
Yellow Card Scheme (YCS)
The second edition of the ‘Yellow Submarine’ newsletter was sent to GPs in early May.
Following GP feedback, the Yellow card form is being redeveloped to make it easier to complete and
analyse. Some free text boxes will now be drop down tick boxes and some boxes will only become
available if the appropriate option is selected.
One key change to the form relates to a request for GPs/reporters to identify if harm occurred or if
there was potential for harm to a patient. A significant number of concerns reported have also been
possible clinical incidents and providers have requested a more efficient system to alert them to the
concern so they can be investigated in a more timely manner.
If either harm or potential harm has been identified an automatic email will be sent to the relevant
providers patient safety team with the NHS number that the GP has entered upon request by the
system. This will allow investigation to commence appropriately and is due to be tested during June
2014.
Equality and Diversity, and Human Rights
EDHR reports have been submitted within the following: Safeguarding Section 11 self-evaluation;
Corporate annual report; revised strategic plan; documentation re CQC inspection for young peoples’
commissioning; Equality Impact Assessment on Healthwatch Devon engagement provision
Participation: in Stonewall Health Equality Index programme; Totnes Caring community event;
EDS2 workforce conference; DAS Recovery Fayre; TSDHFT EDS grading;
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33
EDHR activity over the last quarter includes:
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Training: as Wellbeing at work champion (with Lorraine Carlisle); PFD/ED updates within
departments and at commissioning update meeting

Actions: Operating Principle provider review meeting; setting up of regular meetings with
Marianna Gray and Lorraine Carlisle (Union Rep) to monitor workforce issues and develop
management induction training; promoting of external support networks for staff sharing
protected characteristics; establishment of new regional EDHR leads meeting; successful bid
for Stonewall Health Champion programme (£6,500 worth of consultancy support over 1 year
to develop projects, workforce and leadership – members of steering group are: Dr Jo
Roberts, Karen Grimshaw, Derek O’Toole, Sam Holden, Marisa Cockfield)

Current and Future Projects: develop Stonewall programme; working with Public Health to
develop LGBT strategy; setting up project (with safeguarding, public health, Devon and
Cornwall Police, Hikmat, Devon Grapevine and Refugee Support Devon) on honour
violence/female genital mutiliation, mapping population and needs; working with Sam Holden
to develop peninsular transgender medication protocol; dementia/homelessness awareness
day (Healthwatch, Paignton Library); participation in Totnes Pride; follow-up on OP event to
include: setting up an Equality and Diversity and Human Rights Network; addressing
inequalities of access in the community; developing and improving feedback opportunities
(including characteristic monitoring; improving the data we hold about all protected groups in
South Devon and Torbay (using revised JSNA and targeted projects); Devon Blue Light Day.
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
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Quality & Performance Scorecard
Indicator
Period
Current
Target
YTD
Target
Previous
Current
YTD
Year's
Performance Performance
Performance
Trend Chart Benchmark Trend
Local/
Notes
National
Outcomes Framework
Domain 1 - Preventing people from dying prematurely
Summary Hospital-level Mortality Indicator (SHMI)
Lower is better
(ISR)
Lower is better
100.00
(ISR)
Apr-14
100.00
100.00
83.00
81.00
Oct-12 - Sep-13
100.00
100.00
92.57
96.00
1,996.0
1,996.0
2,039.4
1,940.2
2,232.2 Lower is better
N
Directly standardised by age and sex
1,701.0
1,701.0
1,649.2
2,666.8
N
57.1
57.1
56.4
60.45
65.5 Lower is better
N
21.1
21.1
30.2
25.99
N
110.5
110.5
122.1
118.37
123 Lower is better
N
16.3
16.3
27.9
22.2
N
Hospital Standardised Mortality Rate (HSMR)
Potential years of life lost from causes amenable to healthcare: directly
2012
standardised rate per 100,000 population (male)
Potential years of life lost from causes amenable to healthcare: directly
2012
standardised rate per 100,000 population (female)
Under 75 mortality from Cardiovascular disease: directly standardised rate
2012
per 100,000 population
Under 75 mortality from respiratory disease: directly standardised rate per
2012
100,000 population
Under 75 mortality from cancer: directly standardised rate per 100,000
2012
population
Emergency Admissions for alcohol related liver disease: directly standardised
Apr-13 - Mar-14
rate per 100,000 population
100.00
N
N
Number of alcohol-attributable admissions
Apr-Mar-14
149.62
1795.45
147.98
1846.32
1832.09
Lower is better
L
New indicator - benchmark in progress
Admissions from care homes (variance shows percentage reduction on
previous year - target minimum 2%)
Apr-Mar-14
132
1585
124
1446
1617
Lower is better
L
New indicator - benchmark in progress
Maternal smoking at delivery
2013/14 Q3
20.0%
20.0%
17.0%
19.1%
12.0% Lower is better
N
Dec-13
47.5%
47.5%
58.6%
Higher is better
N
Apr-13 - Mar-14
753.0
753.0
726.5
906.0
N
Apr-13 - Mar-14
247.0
247.0
277.1
412.8
N
837.0
837.0
1,052.5
987.8
N
11.0
11.0
11.1
N
261.0
261.0
307.6
275.9
N
80.0%
80.0%
61.7%
61.7%
76.1%
83.8% Higher is better
N
Benchmark = national average from SSNAP
0.086
0.086
0.078
0.078
0.086 Higher is better
N
EQ-5D index, benchmarked against whole England
0.439
0.447
0.450
0.450
N
0.261
Small numbers suppressed by
0.261
HSCIC
N
0.330
0.339
N
N
N
Breastfeeding prevalence at 6-8 weeks
Not Available
WIP to move to local data - updated for Dec-13 from national data
Domain 2 - Enhancing quality of life for people with long term conditions
Unplanned hospitalisation for chronic ambulatory care sensitive conditions
(adults) per 100,000 population
Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s
Domain 3 - Helping people to recover from episodes of ill health or following injury
Emergency admissions for acute conditions that should not usually require
Apr-13 - Mar-14
hospital admission per 100,000 population
Emergency readmission within 30 days of discharge from hospital - indirectly
2011/12
standardised rate per 100 discharges
Emergency admissions for children with Lower Respiratory Tract Infections
Apr-13 - Mar-14
People who have had a stroke who spend 90% of their time on a stroke ward
Apr-Apr-14
(SDHFT)
Patient-Reported Outcome Measures (PROMS) for Groin Hernia: adjusted
Apr-13 - Dec-13
average reported health gain
Patient-Reported Outcome Measures (PROMS) for Hip replacement:
Apr-13 - Dec-13
adjusted average reported health gain (Primary)
Patient-Reported Outcome Measures (PROMS) for Hip replacement:
Apr-13 - Dec-13
adjusted average reported health gain (Revision)
Patient-Reported Outcome Measures (PROMS) for Knee replacement:
Apr-13 - Dec-13
adjusted average reported health gain (Primary)
Patient-Reported Outcome Measures (PROMS) for Knee replacement:
Apr-13 - Dec-13
adjusted average reported health gain (Revision)
Patient-Reported Outcome Measures (PROMS) for Varicose Vein: adjusted
Apr-13 - Dec-13
average reported health gain
201406Scorecard.pdf
0.230
0.101
10.0
0.362
0.362
0.255
HSCIC
0.102
HSCIC
WIP to move to local data; RAG updated to match NHS England
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Indicator
Period
Current
Target
Previous
Current
YTD
Year's
Performance
YTD
Target
Local/
Notes
National
Domain 4 - Ensuring people have a positive experience of care
Percentage of respondents rating GP services as 'Good' or 'Very Good'
overall
Percentage of respondents rating Out-of-Hours services as 'Good' or
'Very Good' overall
Percentage of respondents rating Dental services as 'Good' or 'Very
Good' overall
Patient experience of primary care - GP Services
Jul-13 - Sep-13
91.0%
91.0%
91.0%
91%
N
Patient experience of primary care - GP Out of Hours Services
Jul-13 - Sep-13
83.0%
83.0%
79.0%
83%
N
NHS Dental Services
Jul-13 - Sep-13
85.0%
85.0%
83.0%
85%
N
Lower is better
L
WIP to replace this with proportion acknowledged within timescale
Lower is better
N
Four breaches at Plymouth Hospitals Jul-13 and Jan-14, 1 at King's
College Dec-13, 11 at SDHFT Feb-14, 6 at SDHFT Mar-14
Number of Complaints and 'High'- and 'Moderate'-rated PALS cases received
by CCG
Apr-May-14
Eliminating Mixed Sex Accommodation breaches
Apr-Mar-14
0
0
6
Friends & Family Test response rate for Inpatient (SDHFT)
Apr-14
15%
15%
26.9%
Not Available
N
Friends & Family Test score for Inpatient (SDHFT)
Apr-14
73
73
69
69 Not Available
73 Higher is better
N
Friends & Family Test response rate for A&E (SDHFT)
Apr-14
15%
15%
4.3%
Not Available
N
Friends & Family Test score for A&E (SDHFT)
Apr-14
54
54
38
38 Not Available
54 Higher is better
N
YTD is average of scores
651
95
996
Lower is better
L
For pressure ulcers developed subsequent to admission/addition to
caseload
18
488
46 Lower is better
L
10
22 Not Available
22
0
YTD is average of scores
Domain 5 - Treating and caring for people in a safe environment and protecting them from avoidable harm
Pressure ulcers
Apr-Mar-14
Falls
Apr-Mar-14
Risk Assessment for patients with venous thromboembolism (VTE)within 24
hours (SDHFT)
Risk Assessment for patients with venous thromboembolism (VTE)within 24
hours (T&SDHT)
61
61
Apr-Apr-14
95%
95%
91.0%
93.7%
80.1%
N
Apr-Apr-14
90%
90%
99.3%
97.4%
92.8%
N
Incidence of healthcare associated infection (HCAI) - MRSA Bacteraemia
Apr-Apr-14
0
0
0
0 Not Available
0 Lower is better
N
Incidence of healthcare associated infection (HCAI) - C.Difficile
Apr-Apr-14
8
8
7
7 Not Available
8 Lower is better
N
Incidence of healthcare associated infection (HCAI) - E coli
Apr-Apr-14
0
148
27
27
215
0 Lower is better
N
Incidence of healthcare associated infection (HCAI) - MSSA
Apr-Apr-14
0
40
6
6
71
0 Lower is better
N
SIRIs: percentage completed by expected date
Apr-Apr-14
100.00%
100.00%
Higher is better
L
Never events reported (cumulative, by reporting organisation)
Apr-Apr-14
0
0
0
0
0
Lower is better
L
Number of CAS Alerts not closed within the deadline
Apr-14
0
0
6
6
0
Lower is better
L
Percentage of continuing healthcare placements overdue for a review
Mar-14
Lower is better
L
Percentage of independent patients placements (IPPs) overdue for a review
(mental health)
Q2 2013/14
43.47% Not Available Not Available
0.00%
Not Available
Lower is better
L
70.59%
Not Available
Higher is better
L
Safeguarding
Safeguarding Adults
Level 1 training (SDHFT)
Apr-May-14
New indicator - target and benchmark in progress
NHS Constitution
Planned Care
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Indicator
Period
Current
Target
Previous
Current
YTD
Year's
Performance
YTD
Target
Local/
Notes
National
Referral to Treatment waiting times for non-urgent consultant-led treatment
Admitted patients to start treatment within a maximum of 18 weeks from
referral
Non-admitted patients to start treatment within a maximum of 18 weeks
from referral
Patients on incomplete non-emergency pathways (yet to start treatment) 18
weeks from referral
Apr-Mar-14
90.0%
90.0%
84.8%
90.6%
92.8%
N
Apr-Mar-14
95.0%
95.0%
95.5%
96.2%
96.0%
N
Apr-Mar-14
92.0%
92.0%
94.9%
94.6%
93.4%
N
Apr-Mar-14
0
0
1
18
144
Lower is better
N
Apr-Mar-14
1.0%
1.0%
0.9%
0.9%
0.5%
N
Apr-Mar-14
93%
93%
96.3%
95.6%
97.2%
N
Apr-Mar-14
93%
93%
98.4%
96.6%
99.8%
N
Apr-Mar-14
96%
96%
98.8%
97.9%
98.1%
N
Apr-Mar-14
94%
94%
95.1%
97.0%
96.9%
N
Apr-Mar-14
98%
98%
98.0%
99.5%
99.9%
N
Apr-Mar-14
94%
94%
98.1%
97.6%
97.0%
N
Apr-Mar-14
85%
85%
91.5%
89.0%
89.8%
N
Apr-Mar-14
90%
90%
100.0%
97.5%
93.1%
N
Apr-Mar-14
85%
85%
100.0%
92.3%
94.3%
N
All patients who have operations cancelled on or after the day of admission
(SDHFT)
Apr-Apr-14
0.8%
0.8%
1.4%
1.4%
1.2%
N
No urgent operation to be cancelled for a 2nd time (SDHFT)
Apr-Apr-14
0
0
0
0
Lower is better
N
Cancelled patients not treated within 28 days of cancellation - month in
arrears (SDHFT)
Apr-Apr-14
0
0
0
0 Not Available
Lower is better
N
May-14
95%
95%
84.8%
83.6%
96.5%
Higher is better
N
Apr-Apr-14
0
0
0
0
0
Lower is better
N
Apr-Apr-14
75%
75%
76.0%
76.0%
71.25%
N
Number of over 52 week waiters
Current performace is a planned dip in order to treat patients who
have been waiting longer
One at RD&E in Mar-14
Diagnostic test waiting times
Patients waiting longer than six weeks from referral for a diagnostic test.
Cancer waits - 2 weeks
Maximum 2 week wait for first outpatient for patients referred urgently with
suspected cancer by a GP (SDHFT)
Maximum 2 week wait for first outpatient for patients referred urgently with
breast symptoms (SDHFT)
Cancer waits - 31 days
Maximum 31 day wait from diagnosis to first definitive treatment for all
cancers (SDHFT)
Maximum 31 day wait for subsequent treatment where that treatment is
surgery (SDHFT)
Maximum 31 day wait for subsequent treatment where that treatment is an
anti-cancer drug regimen (SDHFT)
Maximum 31 day wait for subsequent treatment where the treatment is a
course of radiotherapy (SDHFT)
Cancer waits - 62 days
Maximum 62 day wait from urgent GP referral to first definitive treatment
for cancer (SDHFT)
Maximum 62 day wait from referral from and NHS screening service to first
definitive treatment for all cancers (SDHFT)
Maximum 62 day wait for first definitive treatment following a consultant's
decision to upgrade (SDHFT)
Cancelled Operations
Emergency Care
A&E Waits
Patients should be admitted, transferred or discharged within 4 hours of
arrival at A&E (SDHFT)
No waits between decision to admit and admission (trolley waits) over 12
hours
Category A ambulance calls
Category A calls resulting in an emergency response arriving within 8
minutes - Red 1
201406Scorecard.pdf
Now provider-based
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Indicator
Category A calls resulting in an emergency response arriving within 8
minutes - Red 2
Category A calls resulting in an ambulance arriving at the scene within 19
minutes
Period
Current
Target
YTD
Target
Previous
Current
YTD
Year's
Performance
Local/
Notes
National
Apr-Apr-14
75%
75%
76.8%
76.8%
77.84%
N
Now provider-based
Apr-Apr-14
95%
95%
95.4%
95.4%
95.87%
N
Now provider-based
May-14
94%
94%
62.7%
62.0%
71.7%
N
The proportion of people under adult mental health illness specialties on
CPA who are followed-up within 7 days of discharge (DPT)
Apr-Apr-14
95%
95%
94.1%
94.1%
100.0%
N
Waiting times from referral to assessment - Urgent (5 days)
Apr-Apr-14
90%
90%
57.0%
58.8%
Higher is better
L
Waiting times from referral to assessment - Routine (10 days)
Apr-Apr-14
90%
90%
63.0%
38.5%
Higher is better
L
Mar-14
20%
20%
54.0%
Not Available
N
Apr-Mar-14
95%
95%
84.2%
91.8% Not Available
Higher is better
N
Mar-14
95%
95%
66.7%
69.3% Not Available
Higher is better
N
Apr-14
50%
50%
43.3%
43.3% Not Available
N
Apr-Apr-14
73%
73%
77.3%
77.3% Not Available
N
Apr-Apr-14
1.25%
15%
1.0%
1.0% Not Available
Higher is better
N
Ambulance handovers
All handovers between ambulance and A&E must take place within 15
minutes (SWAST at SDHFT)
Mental Health
Percentage of active referrals who have waited more than 28 days from
referral to first treatment/ first therapeutic session
CAMHS: percentage of referrals beginning treatment within 18 weeks
(T&SD)
CAMHS: percentage of referrals beginning treatment within 18 weeks
(Virgin)
IAPT recovery rate
Improving access to psychological therapies (IAPT) - proportion of people
referred who enter treatment (DPT)
IAPT - percentage of people entering treatment against the level of need in
the general population (Access rate)
Previous year's data available as percentage only; comparable PYTD
calculation not possible
Recording method changed in July '13; no historical figures available
with new method
Workforce
Sickness
Turnover
Appraisal
Mandatory
Training
Devon Partnership NHS Trust
Apr-14
5.35%
14.00%
89.70%
No data
South Devon Healthcare Foundation Trust (sickness one month in arrears)
Apr-14
3.87%
10.98%
59.75%
No data
Plymouth Hospitals NHS Trust
Apr-14
3.84%
9.81%
76.00%
No data
South Western Ambulance Service Foundation Trust
Apr-14
5.45%
12.84%
48.68%
No data
Torbay & South Devon Care Trust (sickness one month in arrears)
Apr-14
4.30%
14.73%
80.13%
No data
Royal Devon & Exeter Foundation Trust
Apr-14
3.68%
10.80%
No data
No data
Targets: Sickness=5% Turnover upper=0% Turnover lower=12%
Appraisal=95% Training=188%
Targets: Sickness=4.2% Turnover upper=10% Turnover lower=14%
Appraisal=85% Training=No Target
Targets: Sickness=3.5% Turnover upper=No Target Turnover lower=No
Target Appraisal=85% Training=85%
Targets: Sickness=No Target Turnover upper=No Target Turnover
lower=No Target Appraisal=85% Training=No Target
Targets: Sickness=4.2% Turnover upper=10% Turnover lower=14%
Appraisal=85% Training=No Target
Targets: Sickness=No Target Turnover upper=No Target Turnover
lower=No Target Appraisal=No Target Training=No Target
As CCG data is not available for some metrics yet Provider or PCT data has been used as a proxy
Ongoing work is underway to add in additional outcomes measures as and when data becomes available
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Date
Report title
Author(s)
Report purpose (for consultation,
approval and information)
26th June 2014
Finance, Performance & Contracting Report
Simon Bell
Finance, Performance & Contracting Teams
For Information
At this early stage in the year overall performance is in line with
that described within the plan for 2014-15 as not all data has
yet been received in respect of provider performance for
Month 1.
A summary of the key risk areas detailed further within the
report are as follows:
i)
Executive Summary
agreeing contracts with main providers and managing
overspends which emerge in year;
ii) management of particularly volatile areas of expenditure
such as placed people (continuing healthcare) and
prescribing (primary and secondary care drugs costs);
iii) ensuring the alignment of budgets and commissioning
responsibilities both between CCGs and with NHS
England;
iv) the evaluation of retrospective continuing healthcare
claims received in 12/13 and management within the
risk pooling arrangement.
After consideration based on early draft information available
as set out in the report the CCG is reporting achievement of the
planned underspend of £3.844m. At present forecast
overspends highlighted are offset by corresponding
underspends and the utilisation of the headroom/contingency
reserve.
Actions Requested
Which other committees has this
been to?
That the Governing Body notes the content of the report.
N/A
implications?
What, if any, are the quality and
safety implications?
implications?
implications?
As set out in the report
N/A
N/A
1
2014-6-26FinancePerformance
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Who does the proposed piece of
work affect?
Staff
Patients
Carers
Public




Yes
No
Is the proposal controversial in any way (including media, academic, voluntary or
sector specific interest) about the proposed work?




Services
May 2014
2
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1
Introduction
The presentation of the Clinical Commissioning Group (CCG) financial position in this report
seeks to provide the necessary assurance to the Governing Body. Feedback on the presentation
or content is always welcome.
2
Financial resources & allocations
The resources allocated to the CCG for 2014-15 comprise two main elements, revenue and
capital. The CCG has been notified of a provisional capital sum (£60,000) to be used as the basis
for submitting a project initiation document (PID) to NHS England.
Revenue resources contained within our financial plan and financial systems are set out below:
Planned revenue resources
£'000
Recurrent resources for the purchase of healthcare
371,984
Running costs allowance
6,778
Total recurrent revenue resources
378,762
Non-recurrent resources & income (incl. return of planned 13/14 underspend)
Total revenue resources (per 5 year financial plan)
384,348
Total Forecast Expenditure Plan
380,504
Total planned underspend (surplus)
3
5,586
3,844
Financial duties & requirements
We have a statutory duty to live within the total capital and revenue resources we are allocated
and to manage the running costs of the organisation. The following section sets out the key
financial duties and requirements as part of our financial management arrangements:
Financial management requirements
£'000
Delivery of planned underspend (1% of
allocated revenue resources)
3,844
GREEN
On track following month-end assessment
of financial position
Manage the running costs of the
organisation with the prescribed limit
6,778
GREEN
Forecast underspend contained within
overall financial position
Financial risks covered by headroom &
contingency reserve
2,500
GREEN
Headroom & contingency reserve fully
utilised in reported position
Unplanned financial risks covered by
supplementary risk mitigation plan
-
GREEN
No alternative risk mitigation plans are
included in this position
Use of resources (capital) does not
exceed the amount specified
-
GREEN
Provisional allocation of capital resources
notified at £60,000
Assessment of delivery risk
3
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4
Financial management
In year financial management and monitoring of provider performance is facilitated through
detailed financial and performance monitoring information received from each of our main
providers as well as through regular Contract Review for the majority of our contracts. In
addition to these arrangements monthly finance meetings exist to review expenditure and risk
across the entire range of budgetary areas.
Detailed financial monitoring against the CCG’s financial plan approved by the Governing Body
is set out in Appendix 1. Each month as information is received and the financial position is
assessed as described, any variances which result will be set against the plan and analysed
across each the following areas:
4.1 Contract monitoring
The objective of our financial planning was for planned spending on the main healthcare
provider services to remain at a similar level to that in 2012-13 where possible. Spending with
regard to the CCG’s contracted services will need to be reviewed and where appropriate,
renegotiated with any reductions in spending being a key component in contributing to a
sustainable financial plan.
This will be an area of particular challenge and focus given the level of unplanned financial risk
experienced during 2013-14 and the basis on which the financial plans has been developed with
exposure to the volatility of payment by results contractual arrangements.
Agreements were reached in respect of the majority of our healthcare contracts, with agreed
financial values for block contract arrangements or agreed opening plans where the basis is
likely to be largely variable (e.g. payment by results).
At this point in the financial year we have yet to receive contract monitoring information from
all of our respective providers. As a result the forecast financial performance information set
out in Appendix 1 is as per our plan except in the following areas:
4.1.1
South Devon Healthcare NHS Foundation Trust
Draft financial information for Month 1 (April) highlights an overspend position for the year
of £1.321m for the CCG against an agreed contract value of £156.592m. This is largely as a
result of variances from the budgeted plan in relation to secondary care drugs expenditure,
which is being reviewed through the CCG medicines optimisation team in conjunction with
counterparts within the provider’s pharmacy and prescribing team.
4.1.2
Royal Devon & Exeter NHS Foundation Trust
As yet no draft financial information has been received detailing the position for Month 1
but the latest version of the providers activity plan suggests an overspend against budget
(£14.372m) for the CCG of £0.988m. This assessment includes outstanding costs in relation
to 2013-14 which have only recently been notified to us and appear in the region of
£120,000. This is under review and it is anticipated that this will be finalised in line with the
provider reporting the position for month 2.
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4.1.3
Draft financial information for Month 1 shows an underspend against the provider’s activity
plan (£3.931m) suggesting expenditure is broadly in line with the CCGs budget (£3.637m).
This information is currently being validated and as a result the forecast is based on this
initial plan rather than the actual.
4.1.4
Ramsey Healthcare (Mount Stuart Hospital)
The financial information received for April is higher than anticipated when set against the
budgeted plan of £5.365m. This draft information is currently being reviewed but would
result in a forecast overspend as reported in the region of £736,000.
4.2 Medicines optimisation (prescribing)
Practice budgets are in the process of being finalised in conjunction with the medicines
optimisation team. The respective budgets including centrally funded elements total
approximately £47.802m.
There is a key work stream being developed in support of achieving a sustainable financial
position which is being progressed through the medicines optimisation team and will be part of
our financial management review each month.
Monthly information is provided by the Prescription pricing authority and has just been
released for April. This draft information reports expenditure at £3.730mwhich is slightly below
that experienced in the same period of the last financial year (£3.812m) but cannot really be
used to draw any meaningful conclusions at this stage.
Forecasts based on this early information are not normally calculated until the end of the 1st
quarter so that there is a reasonable data set on which to base the information.
4.3 Placed people (continuing healthcare)
This area of expenditure is largely managed and monitored for the CCG by Torbay & Southern
Devon Health & Care NHS Trust against our plan of £26.731m. This area as reported also
includes the retrospective risk pool contribution of £1.457m and other placement budgets not
managed through route.
There is a key work stream currently being developed and reviewed through the placed people
governance group in order to ensure that the processes are in place to gain the necessary
assurances and place reliance on the financial information and which contributes to achieving a
sustainable financial position.
Draft summary financial information has been received based on expenditure in relation to
these placements for April. It is anticipated that there will continue to be pressure on these
areas with the current forecast reflecting an overspend of £344,000. The agreement in place is
that this is shared equally between the provider and that reported here against the CCG’s
budget. The detailed information is currently being reviewed but Individual patient placements
are predicted to underspend (£266,000) with the increase in clients in relation to continuing
healthcare (£610,000) accounting for the overspend predicted within this overall position.
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4.4 Running Costs (administration)
The CCG is required to manage the running costs of the organisation within an allowance of
£6.778m for 2014-15. These costs are deemed to be those which are not for or related to the
purchase of healthcare services. The budgets are in the process of being finalised for these
areas and agreed with the respective budget holders to ensure that this is the subject of careful
monitoring.
The current position is under review but is presented as an underspend of £667,000 based on
the information available to date. This is largely in line with that experienced in 2013-14 but
also contains negotiated reductions to a few of the CCG’s service level agreements in addition.
The announcement of two year allocations means that the figure for 2015-16 falls to £6.083m.
As a result there is a key piece of work required to develop a revised workforce plan to be
shared through Senior Leadership Committee, Commissioning & Finance Committee &
Governing Body. Action to deliver the plan will likely need to be effective during 2014-15 to
eliminate the risk of breaching the allowance in 2015-16.
4.5 Other financial risks
Baseline adjustments between commissioners incl. specialised commissioning
There are likely to be proposals over the next few months which seek to review the current
funding arrangements for a range of responsibilities which have passed between respective
commissioning organisations. This will be particularly between CCG’s and the Bristol, North
Somerset, Somerset & South Gloucestershire Area Team responsible for specialised services.
This will consider the way in which movements between commissioners have been agreed and
transacted over the course of the last financial year and put in place a more coordinated and
consistent national process to enact any further baseline and contract changes required as a
result.
Further discussions will also need to take place between ourselves and NEW Devon CCG in
respect of contracts and the associated baseline funding inherited from predecessor
organisations. This has resulted in a few areas remaining outstanding where further work was
required to determine the correct proportion attributable to each organisation. Some of these
areas are expected to be cost neutral however some will result in a financial risk or benefit.
Retrospective continuing healthcare
The process for the management of retrospective continuing care claims received prior to 1st
April 2013 has been set out and is being controlled through NHS England. At present this is
defined on the basis of a risk pool to which respective organisations contribute in accordance
with their share of national allocations and subject to the assessment and review of claims
outstanding.
The initial contribution required and included in our plan is £1.457m but this still exposes CCGs
to the risk determined by the extent to which claims are reviewed and settled during the
financial year and the contributions increase over that planned. It is anticipated that payments
will be made by the CCG and monitored against this plan and will therefore need to be kept
under review as we progress through the year.
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5
Financial position
It is anticipated that this financial year will be particularly challenging as we try to consolidate
the good progress made in 2013-14 and seek to make further progress towards eliminating the
recurrent over-commitments which remain within our financial plans. Several key areas of
focus have been identified throughout this report which begins to describe work streams which
we believe can contribute to achieving a sustainable financial position for the CCG within the
current planning horizon.
These specific areas will form part of normal financial monitoring updates through existing
committees within the CCG and as part of this report.
The following presents a view of our summary financial position based on our draft outturn
expenditure as at 31st May as a result of a review of the areas described in the sections above:
Summary forecast expenditure as at 31st May 2014
Acute
Plan
£'000
Forecast
£'000
Variance
£'000
Ytd
Trend
Plan
risk
196,464
199,460
2,996
R
Community health services
57,684
57,681
-3
G
Continuing care
28,644
28,816
172
R
Mental health
29,446
29,446
0
G
Primary care
54,628
54,629
1
G
6,860
4,360
-2,500
G
6,778
6,111
-667
G
380,504
380,504
0
G
Other (including contingency/headroom reserve)
Corporate
This expenditure plan as described results in the planned underspend of £3.844m when set
against our available revenue resources of £384.348m set out in section 2.
6
Finance, performance & contracting update
6.1 Quality premium
The CCG has the potential to earn £1.343m (£5 per head of population), based on achievement
against a set of six national and local measures as part of the ‘quality premium’ in 2014-15. This
is at present based on 13/14 population but is expected to be uplifted for the current year.
Achievement against these specific measures is then further refined through the assessment
against the four NHS constitution indicators, each of which can reduce the proportion earned by
25%. The initial assessment presented in Appendix 2 forecasts achievement of approximately
35% of the available funding at £470,202, which would ultimately be payable in 2015-16.
6.2 Contracting
In accordance with the NHS Procurement, Patient Choice and Competition Regulations 2013, a
list of all of our current contracts entered into for the provision of health care services is
available on our website. This includes details of the provider, a description of the service, the
contract value, the duration of the contract and the process adopted for selecting the provider.
This information can be found via the following link:
http://southdevonandtorbayccg.nhs.uk/index.php/about-us/what-we-spend/current-contracts
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Appendix 1
Analysis of Monthly Financial Position incl. NHS & Non-NHS provider performance monitoring against contract
Category of expenditure
Type of service
Provider / Area of expenditure
Programme (healthcare)
Acute
Acute
South West Ambulance Foundation Trust
Acute
South Devon Healthcare Foundation Trust
Acute
Royal Devon & Exeter Foundation Trust
Acute
Acute
Programme (healthcare)
Forecast
£'000
Variance
£'000
3,637
3,931
294
10,377
10,377
0
155,774
157,095
1,321
14,372
15,360
988
Non-Contract Activity
3,325
3,325
0
Mount Stuart
5,365
6,101
736
Acute
Other services & providers
3,615
3,272
-343
Northern Devon Healthcare NHS Trust
1,597
1,597
0
Torbay & Southern Devon Health & Care Trust
45,959
45,959
0
Rowcroft Hospice
2,035
2,035
0
Virgin Care/Complex Placements
5,904
5,904
0
2,189
2,186
-3
Continuing care
Placed people, Continuing healthcare
28,644
28,816
172
Mental health
Devon Partnership NHS Trust
27,368
27,368
0
Mental health
2,078
2,078
0
Primary care
Prescribing
47,802
47,802
0
Primary care
6,825
6,827
1
366,866
370,033
3,167
Ytd
Trend
Plan
risk
R
G
R
R
G
R
G
G
G
G
G
G
R
G
G
G
G
Other
Contingency / headroom reserve
2,529
29
-2,500
Other
Other healthcare services
4,331
4,331
0
G
G
373,726
374,393
667
R
6,778
6,111
-667
G
380,504
380,504
0
G
Total expenditure plan against revenue resources allocated for programme (healthcare)
Administration
Plan
£'000
Corporate
Running costs
Total expenditure plan against revenue resources allocated
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Appendix 2
Quality Premium 2014/15 - June Assessment
Quality premium per head
£
Total Available
£ 1,343,435
Population
5.0
268,687
Pre-requisites:
Inconsistent with managing public money
Unplanned deficit / financial support
Qualified audit report
Serious quality failure
Threshold
yes/no
yes/no
yes/no
yes/no
National / local measures:
Threshold:
1. Potential years of life lost (PYLL) from causes
considered amenable to healthcare; adults,
children and young people
2. Improving access to psychological therapies
(IAPT)
3. Avoidable emargency admissions (composite
measure):
a) Unplanned hospitalisation for chronic
ambulatory care sensitive conditions (adults);
b) Unplanned hospitalisation for asthma,
diabetes and epilepsy in under 19s;
c) Emergency admissions for acute conditions
that should not usually require hospital
admission (adults);
d) Emergency admissions for children with
lower respiratory tract infection
Likely Outcome
Proportion earned
if achieved:
RAG
(last month)
RAG
(this month)
Notes:
Reduce by at least 3.2% between 2013 and
2014
15%
G
G
Based on historic trend
Achieve access rates of at least 15% by end
2014/15
15%
G
A
Currently 12.3%
G
G
G
A
G
A
Need to re-set baselines
and targets
G
G
and targets
A
R
Based on historic
performance and no signs
of improvement
G
G
Based on historic
achievement; hard to
infulence
Reduction or 0 change in emergency
admissions between 2013/14 and 2014/15;
or
indirectly standardised rate less than 1,000
per 100,000 pop
25%
and targets
and targets
a) agree plan with providers to address any
remaining issues from 2013/14, and achieve
roll-out for 2014/15, and reduce negative
responses between Q1 and Q4 of 2014/15;
b) improved average score of 'Patient
experience of hospital care' indicator
15%
5. Improving reporting of medication-related
safety incidents
a) agree a specified increased level of
reporting with providers between Q3
2013/14 and Q4 2014/15;
b) local providers must achieve the
specified increase
15%
A
R
Increased reporting levels
not yet agreed with
providers
6. Local measure:
Dementia diagnosis rate
Achieve dementia diagnosis rate of at least
50% by end 2014/15
15%
g
a
Most recent data is for
2012/13 (45%) and CCG
cannot access data; this is
also a local BCF indicator
4. Friends and Family Test:
a) Roll-out of Friends & Family Test in 2014/15
and remaining issues from 2013/14;
b) Improvement in 'Patient experience of
hospital care' indicator
100%
Total Achievement
Total Earned
NHS Constitution indicators:
70%
£
940,405
Proportion lost if
not achieved:
Threshold:
RAG:
Notes:
Patients on incomplete pathways waiting no
longer than 18 weeks (CCG based)
92%
25%
G
G
Patients should be seen within 4 hours of their
arrival at A&E (Provider based)
95%
25%
R
R
100%
25%
R
R
75%
25%
G
G
Maximum two week wait from urgent GP
referral to first outpatient appointment for
suspected cancer (CCG based)
Category A Red 1 ambulance calls resulting in an
emergency response arriving within 8 mins
(Provider based)
Total Achievement
Total after deductions
100%
No issues to note
Based on current preformance, and no
improvement planned in the immediate
future
The national target, within acute contracts
is 93%, therefore providers not working to
100%
Target was met for Q4 2013/14, and should
be maintained
50%
£
470,202
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Date
June 2014
Report title
Planning & Priorities
Author(s)
Report
purpose
consultation, approval
information)
Executive Summary
Simon Tapley & Jo Turl
(for
and For information
The report provides an update on the progress of
work streams on the plan on a page.
Actions Requested
That the Governing Body note the content of the report.
Which other committees has
Commissioning & Finance Committee
this been to?
implications?
implications?
implications?
High
High
High
High
Staff
Who does the proposed piece Patients yes
of work affect?
Carers
yes
Public
yes
Yes
No
x
x
x
X
decision.
Report June 2014
02/06/2014
PlanningandPriorities.docx
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Planning & Priorities Report – June’14
Summary
On track/achieved
312
Milestones
Off track
22
(Risk: High - 2, Medium - 10,
Low - 9, Unknown - 1)
Blank status
25
Prevention
Key Priorities of the work stream
Promoting self-care, prevention and personal responsibility.
1. Develop prevention strategy creating vision for CCG for next 5 years.
2. Develop a 'Promotion of personal responsibility' work plan, underpinning prevention strategy.
3. Identify priorities and opportunities for commissioning prevention.
Key achievements in last 3 months
None as of yet, strategy and engagement still in early stages.
On track/achieved
11
Milestone
Milestones
Off track
0
Areas off track
Mitigation
Blank status
0
Risk
N/A
Work plan last updated
02/06/14
BPP comments

Primary Care
1. Provide support to practices to collaborate on the provision of primary medical services and
additional services for which they may become providers.
2. Support collaboration between practices to provide 7 day services, to avoid A&E attendance and
admissions.
3. Continually optimise access to primary care, including all practices offering non face to face
forms of consultation.
4. Working alongside acute and community specialists, optimise care for patients in residential and
nursing homes.
 The Challenge Fund bid was successful, although not at the amount requested.
On track/achieved
18
02/06/2014
Milestones
Off track
2
Blank status
0
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Milestone
Small scale local pilots for 7 day
services following successful
Challenge Bid.
Undertake baseline assessment
of extent to which telephone
and other consultations are
offered in primary care.
Areas off track
Mitigation
Off-track due to delays in national process. CCG
has a plan to support implementation.
Milestones to be reviewed once allocation detail
known, will though be less focussed on 7 day
provision than currently worded.
Challenging to date given lack of contractual
levers and legitimate variation in models. Would
though be part of Challenge Fund evaluation
(baseline and change) if scheme approval
received. Work with localities to deliver and
ensure information is available.
Risk
Medium 
Medium 
07/05/14
BPP comments

Children’s Services
1. Review pathways for conduct disorders, including Autistic Spectrum Condition.
2. Review existing services and pathways in relation to ensuring joined up services in appropriate
settings.
3. Encourage C&YP to be responsible for their own condition in order to prepare for their transition
to adulthood.
4. Agree a Mental Health Model for C&YP and Emotional Health & Wellbeing Strategies for Torbay
and Devon.

On track/achieved
19
Milestone
Assertive outreach service up
and running.
Implement new autism
assessment pathway.
Milestones
Off track
Blank status
2
0
Areas off track
Mitigation
Risk
It has been agreed this will be funded 50:50 by
SCG: CCGs. Implementation is now being
Low 
worked-up.
An interim arrangement is in place for SDHFT to
continue with service. They have been asked to
produce financial data to inform the service spec
Medium 
for the new service. This has been escalated to
the DoC.
17/04/14
BPP comments
 Work plan needs to be updated monthly.
Community Services
1. Build on existing work with care homes to provide training, education and proactive care from
GPs within localities.
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2. Ensure good practice of existing virtual wards is maintained with new primary care DES for
identification and case management of 2% of patients.
3. Full evaluation of the effectiveness of weekend working, leading to the roll-out of 6-7 day
services.
 Steering group met to agree next steps regarding the unplanned admissions DES.
 Second community hospital pilot over 3 weekends is complete (including social care and
therapies).
On track/achieved
10
Milestone
Milestones
Off track
0
Areas off track
Mitigation
Blank status
0
Risk
N/A
27/05/14
BPP comments

Urgent Care
1. Seven day services in hospital and community.
2. The redesign of MIU services, ensuring consistency of services across units.
3. Working with NEW Devon CCG, to ensure "fit for the future" GP out of hours service and a high
quality 111 service.
4. Review unplanned pathways to deliver best outcomes using the most appropriate models of
care e.g. FLS, leg ulcers.
5. Develop Urgent Care Strategy based on Keogh Review.
 The Torbay/Plymouth peer review of A&E and the ECIST Review have both been arranged to
take place in the next few months.
On track/achieved
15
Milestone
Evaluate the current awareness
campaign and amend future
promotions in light of this.
Redesign the specification for
the FLS to proactively case
manage all fragility fractures
across all care settings.
15/05/14
BPP comments

02/06/2014
Milestones
Off track
Blank status
2
0
Areas off track
Mitigation
Risk
Consciously paused given inability to evaluate
and desire to understand impact of 111.
Low  
CCG clinical lead has written to provider but still
awaiting a response. This has now been raised
with the COO and a response is expected.
Low 
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Planned Care
1. Review the whole musculoskeletal pathway, looking at prevention and self-care, shared
decision-making, patient experience, waiting times and current and future population needs.
2. Implement tiered models of care for dermatology to minimise reliance on secondary care.
3. Review referral management /optimisation of all planned care referrals.
 Locality MSK/Joint Injection event held, with 50 GPs attending.
 Audit of 100 secondary care dermatology referrals is complete.
 Stakeholder events and options appraisal have been completed for referral management.
On track/achieved
18
Milestone
Establishing the need for an
improved pathway for patients
that fall between Orthopaedics,
Rheum and Pain
Foot and Ankle consultant-led
assessment
Milestones
Off track
Blank status
2
2
Areas off track
Mitigation
Risk
Undertaking audit of patients who have been
referred to three or more different specialities
Low 
within three years to try to identify scale of
problem.
Awaiting proposal from F&A Consultants, which
was due end of March. On agenda for next MSK
Medium 
CPG (9th June) so will be chased as part of that.
Funding runs out for existing service in June.
20/05/14
BPP comments

Mental Health
1. Case Manage patients through community teams with a single point of access.
2. To improve access to, and patient experience of, psychological therapies and crisis services.
3. Implementation of the local dementia and mental health strategy.
4. Develop suicide prevention strategy.

Milestones
On track/achieved
Off track
Blank status
36
1
6
Areas off track
Milestone
Mitigation
Risk
Section 12 – timely access to
DPT are producing a business case
Medium  
doctors
04/04/14
BPP comments
 There are a lot of milestones on this work plan compared to other work plans, are the team
happy they are reporting consistently with other work streams?
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Learning Disabilities
1. Review of community, specialist and crisis learning disability provision.
2. Contribute to group that will review current primary care and out of hours provision for LD/MH
inpatients in private hospitals.
3. To review information that was collected for the completion of the Self-Assessment Framework
and use it as a basis for future development/work plans.
4. To ensure that there is a robust system in place for appropriate placement planning and move
on discharge planning for all learning disability patients.
 Confirmation was provided by private hospitals that primary care provision is still in place for
those patients who are inpatients.
 KPIs are agreed and included in the DPT contract; to include an LD flag, and other health related
indicators. The provider will be required to report on the agreed KPIs as part of the management
of the contract.
On track/achieved
12
Milestones
Off track
Blank status
1
1
Areas off track
Mitigation
Risk
Audit results are currently being reviewed and
due back within the next few weeks.
Low
Milestone
Validation of Audit Plus data in
Primary Care to establish
outliers with regards to Health
Action Plans and Annual Health
Checks
30/04/14
BPP comments
 Milestones off track need mitigation.
Long-term conditions
1. To develop an index for people with multiple long term conditions to risk stratify patients that
will benefit from enhanced multi-disciplinary management and develop a range of integrated
multi morbidity services for patients who would benefit from them.
2. To develop a supported self-care service for people with long term conditions.
3. Ensure that all long term condition services (including cancer) provide cost effective high quality
services, which deliver better than average survival rates.
4. Review of all mortality rates for long term conditions to understand priority areas for cancer and
inform early diagnosis work priorities.
 Review numbers of patients appearing on 3 or more disease registers.
 Self-care consultation, specification and procurement.
On track/achieved
37
02/06/2014
Milestones
Off track
4
Areas off track
Blank status
0
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Milestone
Pulmonary Rehab - ensure that
the provider produces service
reconfiguration plan to improve
access
Bronchiectasis - Provider to
share current patient pathways
to facilitate mapping.
Home Oxygen Assessment SDHFT to provide detail of
service model and cost.
Diabetic foot care - Awaiting
outcome of provider
agreement regarding business
case for enhanced IP foot care.
02/06/14
BPP comments

Mitigation
Current services continue with referrals open to
all patients however risk around uptake so
communications exercise to ensure awareness.
Risk
Low
Current service remains in place. Escalated via
Senior Managers/LTC Network.
Low
Discussions as part of contract agreement existing service remains in place.
Low
On-going local stakeholder meetings throughout
financial year with full engagement from diabetes
team.
Low
1. Support evidence-based prescribing as defined by the Joint Formulary.
2. Utilise a wide range of tools and opportunities to understand, control and influence growth in
secondary care prescribing.
3. Action plan to be implemented for better management of medicines in care homes.
4. To improve joined-up pharmaceutical care with community pharmacy to enhance pathways.
 DEFINE used to describe the variation in secondary care prescribing.
On track/achieved
5
Milestones
Off track
1
Areas off track
Mitigation
Milestone
To agree process with localities
for better management of
medicines in care homes
01/04/14
BPP comments
 Milestone status needs to be added so progress can be assessed.
Blank status
4
Risk

Joint commissioning
1. Continuing healthcare and complex care.
2. Personalisation and the use of personal health budgets (PHBs).
3. Improve the approach of all commissioned carers services.
4. Better understanding and awareness of military veterans.
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5. Alcohol - services to minimise the risks, harm and costs caused by alcohol.
 PHBs - Communication and resources developed for the public.
 Alcohol - Updated resources and training for primary care to identify and offer brief advice on
self-management of alcohol intake.
On track/achieved
24
Milestone
CHC - Retrospective cases
assessed and decisions
communicated to claimants
CHC – Outstanding reviews
completed
Milestones
Off track
Blank status
7
0
Areas off track
Mitigation
Risk
Holding letters sent to claimants and 3 monthly
updates planned. Live cases being prioritised.
High
Additional staff brought into central team
dedicated to addressing reviews. Review
decision making panels set regardless of
attendance by social care.
CHC - Robust quality assurance Reporting through Placed People Governance
system in place for all placed
Group offers assurance although coverage and
people service providers
capacity for S. Devon remains and issue.
CHC - Development of market
Contract block agreed with Marie Curie for EoL in
provision for complex high end S. Devon. EMI outstanding. Mtgs held regarding
needs
WBV individual cases and where possible move
on care.
PHBs - Agree service
Draft specification received from DCC awaiting
specifications with providers to review and need to develop with Torbay. Contact
provide direct payment systems within Care Trust being identified.
PHBs - Develop market for care Outstanding.
and support planning
PHBs - Provide training and
Sessions provided to CHC team in using the
support to workforce
Manchester Tool and pilot testing on a number of
interested patients in S Devon for PHB.
Information resources have been updated for
patients and staff. Draft CCG policy developed
awaiting wider consultation.
16/05/14
BPP comments
High
Medium 
Medium 
Medium 
Medium 
Medium 
Frailty Hub
1. Development of Community Hubs with our Pioneer partners, based on Single Point of Access.
 Establish project board, agree overarching aims and timescales.
 Identify stakeholders and brief them on objectives. Scoping and SWOT analysis of existing
services.
 PID to JoinedUp Board including definition of frailty & cohort for Hub.
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On track/achieved
13
Milestone
Milestones
Off track
0
Areas off track
Mitigation
Blank status
0
Risk

N/A
27/05/14
BPP comments

Children’s Hub
1. Torquay Hub, focusing on Children and Young People.
 Initial engagement questionnaire completed with key stakeholders. Outcomes to be shared with
JoinedUp Board.
 Agree governance arrangements between JoinedUp Board, Delivery Group, existing Boards and
Groups. Agree membership of the steering group and set dates for the year.
On track/achieved
8
Milestone
Milestones
Off track
0
Areas off track
Mitigation
Blank status
0
Risk

N/A
19/05/14
BPP comments

Coastal Locality
1. Achieving a single locality based approach to primary and community services.
2. Developing an IT strategy that supports the mobile delivery of services.
3. Develop a single point of access and a multi-agency community hub building.
4. Developing a Care Home forum to support joined up working and provision of high quality care.
5. Creating a dementia friendly community.
 Hold initial meeting with care homes to explore ways to work together.
 Develop Care Home Strategy.
 Write discussion paper on future of primary care and hold primary care event.
On track/achieved
39
Milestone
N/A
02/06/2014
Milestones
Off track
0
Areas off track
Mitigation
Blank status
2
Risk

Version 2.0
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13/5/14
BPP comments

Moor to Sea Locality
1. Development of Community Hubs with our Pioneer partners, based on Single Point of Access.
2. Build on existing work with care homes to provide training, education and proactive care from
GPs within Localities.
3. Provide support to practices to collaborate on the provision of primary medical services and
additional services, utilising shared clinical records.

On track/achieved
5
Milestones
Off track
0
Areas off track
Mitigation
Blank status
2
Milestone
N/A
30/04/14
BPP comments
Risk

Newton Abbot Locality
1. To develop integrated IT infrastructure, which supports efficient and timely delivery of care
regardless of provider.
2. To work with all providers to establish a local "knowledge" base of health and wellbeing
information, including access to services, known by all Newton Abbot residents.
3. To work with the Newton Abbot Caring Alliance to develop a shared vision of how the voluntary
sector in Newton Abbot are able to provide services with statutory provider organisations.
4. Improving appropriate access to services, including seven day delivery.
5. To examine and, if appropriate, extend the range and availability of services provided at Newton
Abbot Hospital MIU.
6. Ensuring patients get the right choice of medicine(s) at the right time and place facilitated by
using the Joint Formulary.
 Establish Locality IT Learning Group.
On track/achieved
14
Milestone
N/A
28/04/14
BPP comments
02/06/2014
Milestones
Off track
0
Areas off track
Mitigation
Blank status
5
Risk

Version 2.0
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

Work plan needs to be updated monthly.
Milestone status needs to be added so progress can be assessed.
Torquay Locality
1. Improve management of patients in care homes to reduce emergency admissions.
2. Development of locality IT strategy that enables mobile working and sharing of information with
community services and others where appropriate.
3. Development of a community services locality hub.
4. Achieve fully joined up and cost effective 7 day services.
5. Optimise the number of GP practices inc. federating opportunities and improving access.
6. Review high referral areas and identify services that can be provided outside of the hospital.
7. Work with Alcohol Team and Public Health to develop effective alcohol services.
 Run care home pilot with 1 home in Torquay (with Paignton & Brixham).
 Hold MSK event for GPs with hospital consultants.
 Meet with Alcohol team re work of Targeted Alcohol Worker and liaison with practices.
On track/achieved
13
Milestone
Milestones
Off track
0
Areas off track
Mitigation
Blank status
2
Risk

N/A
28/04/14
BPP comments
Paignton & Brixham Locality
1. Improve management of patients in care homes.
2. Review the use of beds and community services in the two community hospitals.
3. Development of locality IT strategy that enables mobile working and sharing of information with
community services and others.
4. Developing a patient centred hub or hubs of healthy living services for Living & Ageing well.
5. Explore ways of optimising resources between practices by running shared clinics.
6. Review the number of GP practices in each town and look at federating opportunities.
7. Review high referral areas and identify services that can be provided outside of the hospital.
 Set up and run pilot with 2 homes in Paignton and 1 in Brixham.
 Appoint project IT lead and run pilot between 3 practices and community nursing staff.
 Hold MSK event for GPs with hospital consultants.
On track/achieved
15
Milestone
02/06/2014
Milestones
Off track
0
Areas off track
Mitigation
Blank status
1
Risk
Version 2.0
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N/A
25/04/14
BPP comments
02/06/2014

Version 2.0
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CORPORATE AFFAIRS & MEDICINES OPTIMISATION GOVERNING BODY
REPORT
Date: 18th June 2014
Report by: Mark Procter, Director of Corporate Affairs & Medicines Optimisation
Report to: Governing Body
Purpose of Report:
The purpose of this highlight report is to provide the Governing Body with an update as to key
activities of the Corporate Affairs and Medicines Optimisation Directorate in supporting the
organisation in meeting its business and service delivery objectives.
MEDICINES OPTIMISATION
Budget position
The budget for 2014/15 £47.8M, the primary care prescribing element is £46.1M. This does not
include the budget for pass through prescribing.
Prescribing Budget
Primary Care Element
Budget 13/14
£47.0M
£45.1M
Out-turn 13/14
£48.3M
£46.1M
Budget 14/15
£47.8M
£46.1M
The primary care prescribing budget element 2014/15 is £46.1M, this is 2.35% higher than the
budget for 2013/14.
Incentive Scheme
The GP prescribing incentive scheme is being constructed alongside colleagues in NEW Devon CCG.
The framework document has been agreed with the LMC, along with the first of the activities to
support cost effective prescribing. This focuses on one of the CCGs largest areas of prescribing;
pregabalin. The second activity is being revised in conjunction with NEW Devon and the LMC,
discussions are moving forward and agreement is anticipated by the end of June. Other significant
increases in spend have arisen from the use of novel oral anticoagulation agents and the change in
price of temazepam.
The prospect of further engagement with GP practices is being considered under the umbrella title
of “Potential Gain Share”. The ramifications of this are considerable; the framework has been
discussed at SLC and with NEW Devon CEMO colleague’s The proposal is to be discussed at the LMC
local sub-committee week-commencing 16th June, it is likely this will be agreed by the end of July.
Project Progress
An important tool that the CCG has used over the last three years is the computer decision support
tool; ScriptSwitch. One of the downsides is that it is not yet currently compatible with the Microtest
GP clinical system. Currently both parties are testing with a view to delivering this additional
compatibility. We are informed that formal piloting will commence in July, with the first practice
nationally being a practice in our CCG.
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Electronic prescription Service (EPS)
EPS enables GPs to send prescriptions electronically to a dispenser of the patient’s choice. It makes
the prescribing and dispensing process easier and more convenient, often without the need for
paper. There is less wastage, no need to sort and file prescriptions, fewer people at the main desk,
fewer phone calls, better clinical safety, and electronic cancellation means more control of
medication regimes.
The use of EPS in the CCG area is increasing month on month, and we have a number of practices
processing more than 60 per cent of their prescriptions through EPS. We now have 24 GP practices
using the electronic prescription service (EPS), four with planned go live dates and we are aiming to
book dates for other practices before the end of the year. The use of EPS in the CCG area is
increasing month on month, and we have a number of practices processing more than 65 per cent of
their prescriptions through EPS.
The following table shows the average usage of EPS within the local CCGs, the national average at 2
June 2014 for EPS usage is 33%.
CCG Name
NHS Kernow CCG
NHS Northern Eastern and Western
Devon CCG
NHS South Devon and Torbay CCG
First go live
Date
11/06/2013
23/02/2012
May-14
Apr-14
Mar-14
13%
12%
11%
9%
10%
9%
12/04/2013
31%
27%
27%
Overall the EPS percentage usage trends for NHS England Area Teams places Devon Cornwall and
Isles of Scilly Area Team ranked 3rd.
Area Team Name
London Area Team
Cheshire Warrington and Wirral Area Team
Devon Cornwall and Isles OF Scilly Area Team
Cumbria Northumberland Tyne and Wear
Area Team
Greater Manchester Area Team
Kent and Medway Area Team
First go live
date
11/01/2011
17/03/2012
23/02/2012
19/08/2010
May-14
Apr-14
Mar-14
20%
18%
15%
13%
18%
15%
12%
11%
16%
14%
13%
11%
20/04/2010
01/12/2011
13%
13%
12%
11%
10%
12%
High Cost Drugs
Medicines optimisation continues to work with colleagues across Devon and with South Devon
Healthcare Trust in order to manage the cost growth in high cost, pass through drugs.
The expenditure and growth for all commissioners on high cost pass through drugs by SDHFT over
the last 3 years is as follows:
Financial Year
2011/12
2012/13
2013/14
Overall spend (£ million)
7.997
9.552
12.435
19.4%
30.2%
Growth
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These figures include spend on drugs financed by the Cancer Drugs Fund (CDF) which amounted to
£1.34 million in 2013/14.
For CCG-commissioned pass through drugs overall expenditure was £6.35 million in 2013/14,
increased from £5.86 million the year before, an increase of 8%. However, the true growth was
higher than this as commissioning of a number of drugs (e.g. parenteral nutrition, paediatric
biologics drugs, inhaled therapies for cystic fibrosis) moved from local funding to NHS England in
2013/14, leading to a drop in expenditure in several therapeutic areas.
The Medicines Optimisation team have started to engage with clinicians who prescribe these drugs.
A series of meetings with specialties took place in May/June 2014 which were attended by
representatives from the CCG Medicines Optimisation team, SDHFT Pharmacy and Finance teams.
Reports from these meetings were shared with the High Cost Drugs and Joined up Medicines
Optimisation Groups on 11th June.
The aim of the meetings was to:
1.
2.
3.
4.
Review expenditure and share benchmarking data where available
Identify changes in clinical practice that may impact on expenditure in 2014/15
Project growth and expenditure in 2014/15
Seek assurances to provide evidence of compliance with NICE or national commissioning
policies
5. Identify support that could be provided to specialties or initiatives to minimise growth
Overall response to the data shared was positive. Some general themes were identified in the
meetings:






Interest in the data provided and support for receiving this regularly.
A general willingness from specialties to engage in work to manage this area with an
acknowledgement of resource needed to do so.
A lack of existing audit programmes in most specialties.
Differences between clinicians in choice of treatment offered in some specialties.
IT issues and the need to design data collection systems which do not create additional
workload/encourage box ticking.
Reports of problems with homecare delivery as reported nationally and suggestions for an
in-house service.
It has been agreed that engagement should continue and the resource to continue this work now
needs to be identified. Discussion with NHS England is also required to determine whether they can
contribute resource to help manage this shared financial risk.
Top 25 drugs
The top 25 drugs equate to approximately 29% of the CCG prescribing spend.
The Top 25 drugs for the period April 2013 to March 2014y 2014 are detailed overleaf:
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Sum of Total Act Cost
Column Labels
Row Labels
1st Quarter 2013/2014 2nd Quarter 2013/2014 3rd Quarter 2013/2014 4th Quarter 2013/2014
Pregabalin
£363,357
£392,362
£412,045
£402,266
Seretide
£253,846
£262,681
£279,140
£272,866
Proprietary Co Enteral Nutrit
£212,987
£221,189
£220,894
£220,453
Tiotropium
£185,571
£196,122
£207,775
£204,032
Fluticasone Prop (Inh)
£192,385
£195,837
£204,076
£200,781
Paracet
£143,679
£147,365
£143,027
£142,124
Levothyrox Sod
£130,752
£140,852
£137,998
£137,547
Budesonide (Inh)
£125,827
£133,108
£138,688
£136,309
Qvar
£121,289
£119,037
£129,428
£121,260
Ezetimibe
£117,188
£117,354
£118,720
£111,877
Omeprazole
£114,719
£116,864
£113,103
£112,199
Solifenacin
£103,928
£106,450
£109,110
£108,679
Co-Codamol
£94,610
£101,504
£97,230
£95,804
Influenza
£377,258
Proprietary Co Emollients
£95,736
£91,498
£91,088
£96,886
Proprietary Co Foods For Spec Diets
£90,970
£87,307
£90,465
£100,569
Symbicort
£84,206
£86,466
£94,101
£90,477
Salmeterol
£87,739
£88,001
£86,322
£76,560
Metformin HCl
£81,431
£85,834
£85,342
£85,681
Simvastatin
£85,062
£87,563
£83,169
£78,833
Ins Biphasic Aspart (Novo-Nordisk)
£83,430
£83,535
£84,735
£78,159
Ins NovoRapid
£79,799
£82,469
£83,506
£80,812
Sitagliptin
£77,074
£78,026
£78,214
£75,745
Buprenorphine (Opioid Analgesic)
£83,369
£89,768
£90,065
Temazepam
£89,857
£88,117
£80,246
Rosuvastatin Calc
£75,248
£72,780
Grand Total
£1,570,029
£1,068,532
£875,522
£793,500
£793,080
£576,195
£547,149
£533,931
£491,014
£465,140
£456,885
£428,167
£389,148
£377,258
£375,209
£369,311
£355,249
£338,622
£338,289
£334,627
£329,858
£326,585
£309,058
£263,202
£258,220
£148,028
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Sum of Total Act Cost
Row Labels
Sertraline HCl
Candesartan Cilexetil
Nortriptyline
Grand Total
Column Labels
1st Quarter 2013/2014 2nd Quarter 2013/2014 3rd Quarter 2013/2014 4th Quarter 2013/2014
£96,734
£85,349
£75,833
£3,197,526
£3,268,157
£3,635,445
£3,268,597
Grand Total
£96,734
£85,349
£75,833
£13,369,725
Top spend on products 2013-2014
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£450,000
£400,000
1st Quarter 2013/2014
2nd Quarter 2013/2014
£350,000
3rd Quarter 2013/2014
£300,000
4th Quarter 2013/2014
£250,000
£200,000
£150,000
£100,000
£50,000
£0
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INFORMATION GOVERNANCE
The CCG published its annual Information Governance Toolkit return for the 2013/14 year
on 30 September 2013, some 6 months earlier than normal, but this enabled the CCG to
apply for and receive authorisation to become an Accredited Safe Haven, which allowed the
CCG to process certain personal data for invoice validation purposes; the CCG was also
able to apply to become a Controlled Environment for Finance (CEfF) which is the practical
side of invoice validation.
It is anticipated that, following the HSCIC’s successful application to the Confidentiality
Advisory Group (CAG), the CCG will soon be able to receive more patient data so that risk
stratification analysis can be carried out and the results passed onto our GPs in order to
further improve the care of “at risk” patients.
In order to support these criteria and activities, the CCG will complete its 2014/15
Information Governance Toolkit (version 12) to a Satisfactory level as soon as possible after
this is made available at the end of June 2014. The CCG has plans in place to be ready to
publish its evidence in time for any future deadline set by the Health and Social Care
Information Centre (HSCIC) in 2014/15.
The CCG is registered as a Data Controller under the Data Protection Act 1998. One aspect
of this is that the CCG must provide copies of any personal data held upon request. To
date, one individual has made a request and the data held has been provided in full.
The CCG holds a great deal of staff and business information, although little in the way of
patient information. Access to the data held and the physical assets used to access this
data is closely monitored and any breaches or losses are reported and investigated. To
date, there have been 2 “near misses” where portable assets were thought to have been
lost, but on both occasions the assets were later found intact. No other security incidents
have been recorded.
A set of Key Performance Indicators (KPIs) have been developed by the IG Forum to
provide focus on the main issues that would affect the CCG’s performance and reputation
with regard to Information Governance:
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NHS South Devon and Torbay CCG
Information Governance KPIs 2014/2015
Description
Last Year
This Year
31/03/2014
31/05/2014
No. KPIs
17
17
% Red
18%
29%
% Amber
35%
29%
% Green
IG Toolkit score
53%
Published level 2
IG Toolkit Audit action
responses
All recommendations
agreed and responded to.
Keep working on IGT
evidence to fully complete
all requirements.
2 received
2 processed in time
Data Protection Act requests
processed within 40 days
41%
Waiting for v12 to be
published - due end June
2014
IG Toolkit audit due Q4
2014/15.
Target
Published level 2
All recommendations
agreed and responded to
KPI range limits
Red
Amber
Green
level 0, 1
n/a
level 2
Not completed
In progress
Completed
<95%
processed in
time
<95%
processed in
time
<90% staff
trained
95% processed
in time
>95%
processed in
time
>90% staff
trained
100%
processed in
time
100%
processed in
time
>95% staff
trained
None received.
All requests received
processed in time
215 received
215 processing complete 1 after deadline
99% of staff training on IG
Training Tool module (104
out of 105)
15 staff trained at face-toface Induction
SIRO and 5 IAOs trained
39 received
28 processing complete
0 after deadline
IG Training Tool modules
due for completion by all
staff in Q2 2014/15
All requests received
processed in time
SIRO and 5 IAOs to be
trained
All IAOs identified and
IGTT modules completed
<90% staff
trained
>90% staff
trained
>95% staff
trained
Reported as 100% for
laptops and desktops
5 iPads do not have Mobile
Iron installed
None reported to date
[2 "near misses" reported
and managed initially as if
they were incidents]
Awaiting first report for
2014/15
All desktops, laptops,
iPhones, iPads and tablets
are encrypted before
issue.
All incidents are reported
and managed; all learning
points communicated.
<99%
encrypted
>99%
encrypted
100% encrypted
Not reported or
managed
In progress
All managed
IG / IS Risks are recorded on
iKnow Risk Register, managed
by CCG expert)s) and reported
through the CCG Committee
structure
Policy Tracking
6 IG / IS risks on the CCG
Risk Register
9 IG / IS risks on the CCG
Risk Regsiter.
All IG / IS risks are
recorded, managed and
reported
Not reported or
managed
Risks not
signed off by
Exec Lead or
SMC
All managed
All CCG IG policies listed
on Tracker, along with the
key SDHIS policies used
by the CCG
All CCG IG policies listed
on Tracker, along with the
key SDHIS policies used
by the CCG
Policies
incomplete or
no Tracker in
use
In progress
All policies
listed on
Tracker
IT Assets not used within past
60 days - report generated by
SDHIS
Report regularly presented
to PDG (attended by
SIRO)
Report regularly presented
to PDG (attended by
SIRO)
>5 CCG
devices on list
<5 CCG
devices on list
No CCG
devices on list
Accessing NHS Mail from a nonencrypted mobile device - report
from HSCIC - CCG staff
As above, for Non-CCG staff
assigned to the CCG on NHS
Mail, e.g. GPs
1
2014/15
2 or above
1
0
2
2014/15
2 or above
1
0
All projects have Privacy Impact
Assessments carried out
3 completed PIAs: iKnow,
Website, Engagement Hub
PIA questions embedded
in BPP template
No further projects started.
All the IG / IS policies
required by the CCG have
been written and are
regularly reviewed and
updated
All the devices issued to
CCG staff are in regular
use - i.e. no CCG devices
appear on the list
All CCG staff use
encrypted mobile devices
to access NHS Mail
All NHS Mail users
assigned to the CCG use
encrypted mobile devices
to access NHS Mail
All projects are listed and
PIA produced for each
project
Project list
incomplete or
some PIAs not
started
In progress
All PIAs
completed
Results of website security
(Penetration) tests - data
security, resistance to hacking.
Al necessary work carried
out on CCG website. New
website expected to be
fully compliant in 2014/15
Al necessary work carried
out on CCG website. New
website expected to be
fully compliant in 2014/15
All websites containing
CCG data pass annual
security (Penetration)
tests
Penetration
Tests failed or
not carried out
Issue and Disposal of IT Assets
Records held by SDHIS
and will be shared with
CCG for 2014/15.
CCG for 2014/15.
Starters / Leavers processes
ensure initial training and final
removal of Assets and Access
CCG for 2014/15.
CCG for 2014/15.
Accurate records
maintained of all IT Assets
issued to CCG staff, plus
recorded disposal of IT
Assets
Accurate records
maintained showing all
Starters receive full
training and the retrieval /
cancellation of all Leaver's
Assets and Access
Records not
In progress
available or IT
Assets not
disposed of
correctly
Records not
In progress
available or
Starters not
trained or
Leaver's Assets
/ Access not
retrieved /
cancelled
Freedom of Information
requests processed within 20
working days
IG Training for all CCG staff
IG Training for all Information
Asset Owners
All electronic devices issued by
to CCG staff are encrypted
IG / IS incidents are recorded
and managed, and learning
points are communicated to all
staff
1 incident involving a CCG
GP practice (and NEW
Devon CCG) recorded on
iKnow database - closed.
Minimum 95% of CCG
staff trained on IGTT
module(s)
In progress
Successful
Penetration
Tests carried
out in past year
All records
available and
meet
requirement in
full
All records
available and
meet
requirement in
full
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FREEDOM OF INFORMATION
The CCG received 215 Freedom of Information (FOI) requests for the year 1 April 2013 to
31 March 2014. Between 1 April and 31 May 2014, 39 requests have been received which is
an increase of 30% compared to the same period last year.
The CCG has responded to every request received within the 20 working day time limit.
In general terms, the CCG has responded in a very open manner to all requests received,
making information available whenever this is held by the CCG. As more information is
posted on the CCG’s website, the FOI exemption for “information accessible by other
means” (Section 21) is being applied more often, which does save staff time and effort.
A Disclosure Log of the CCG’s FOI responses, in anonymised form, is on the CCG’s website
for anyone to view, in line with the Information Commissioner’s Office (ICO) guidance.
Freedom of Information Report
April & May 2014
Requests received
Total received
39
15
24
April
May
Requests received
No. On Hold / Withdrawn
No. Responded to within 20 days
No. Responded to after 20 days
Internal processes
No. in progress
Exemptions applied:
All data provided
Some data provided (rest not held)
Data not held by CCG
Section 12 Fees limit >18 hours work
Section 21 Available on website
Section 22 Future publication
Section 38 Health & safety
Section 40 Personal information
Section 41 Provided in confidence
Section 43 Commercial interests
Section 44 Other legislation
0
32
0
7
14
7
11
0
4
0
0
0
0
0
0
Source of Requests
Charity
Commercial
Media
NHS
No.
1
9
5
1
%
3
23
13
3
Political
Private
Professional
8
17
0
21
44
0
Academic
0
0
Other
Total
39
Request difficulty
Easy
Year by Year Comparison
e.g. Structure charts (1-2 hours)
Medium e.g. Detailed figures (3 - 6 hours)
Difficult e.g. Multi-part requests (>6 hours)
29
3
0
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HR
General Human Resources & Employee Relations
 South Devon & Torbay CCG Policies
The CCG continues to develop its policies and procedures considering and comparing the
benefits of existing policies in NHS Devon and Torbay Care Trust. The latest draft policies
include a Stress Management Policy, Acceptable Behaviour Policy and Standards of
Business Conduct. All policies are currently available to view in draft format on the internal
iKnow system.
 Job Evaluation Process
A new process to submit a job evaluation request has been developed, as defined in the
draft CCG Job Matching and Evaluation Policy (HR23). This policy is currently being
presented for approval, requiring agreement from Staff Council and the Senior Leadership
Committee. The aim of this process is to ensure a consistent and controlled procedure
throughout the organisation.
 Staff Council
The next Staff Council meeting is scheduled for Thursday 19 June. CCG draft policies
continue to be considered and agreed by Staff Council Representatives.
Agenda for Change/Pension Updates
 Mileage rates changes
From 1 July 2014, the standard mileage rate for NHS staff who use their vehicles for CCG
business will be reduced from 67p to 54p. There will also be changes to the rate paid for
miles travelled beyond 3,500 in a year (20p) and the motorcycle (27p) rates.
This is set from the Agenda for Change national review based on estimates of motoring
costs made by the Automobile Association. The review looked at all motoring costs in the
12-month period ending in March 2014. Downward changes in motoring costs since the
rates were first calculated in May 2013 have had an impact of around 20 per cent on the
standard mileage rate. (The rates change if the impact on the standard rate is five percent or
greater, which was the case this time.)
The CCG travel claim form and Car Use and Subsistence Expenses Policy (HR15) will be
updated to reflect these changes, while communication with staff advising the new rates
continue.
 Pension
There is a number of NHS pension updates including amendments to the NHS Pension
Scheme Regulations, contributions and allowances. Full updates can be accessed by the
NHS Pensions website: http://www.nhsbsa.nhs.uk/4417.aspx
Electronic Staff Record (ESR)
 ESR Training
Training employees on the use of ESR Self Service is on-going. There are also a number of
ESR user guides available on iKnow for staff.
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 Performance Development Review
Personal Development Review (PDR) information is in the process of being added to ESR
for the last year. Once entered, employees will be able to access the information via
Employee Self Service and managers will receive a report with the information.
 Continuous Service Date (CSD)
Following the transfer of payroll provider to Shared Business Services (SBS). An audit of the
employee data was carried out, which revealed inaccuracies with CSDs. CSD provides
entitlement to maternity, sickness, redundancy and annual leave benefits. Initially a large
number of employee records were inaccurate, this has reduced to 16.5% who are waiting for
their CSD to be confirmed.
 NHS Audit
NHS Audit South West carried out an audit of payroll services, ESR and travel claims. The
report concluded the overall assurance opinion on the design and operation of controls is
Amber/Green. The amber risks relate to concerns with travel claim forms. A management
action plan has been developed jointly with the finance team. A number of the HR actions
have already been completed, with an aim for all actions to be complete by end of June
2014.
Training, Learning and Development
 Mandatory Training
The CCG mandatory training framework will primarily be delivered through e-learning
packages. The aim is to develop a user-friendly compressive e-learning package for staff to
access the mandatory training package at ease. The competencies for the training are
currently being set up, and the e-learning package will be available shortly. Super user
training will be provided to a selection of staff in the CCG, available to support those with any
queries.
 Training Needs Analysis (TNA)
A training needs analysis is currently on-going for the CCG. The TNA will be a rolling live
system for training needs in the organisation. We have received the following PDRs from
departments:
Board Members
(Including 3 at the top)
Clinical Leads
Commissioning
Corporate Affairs
Finance
Medicines
Optimisation
Quality
38%
26%
82%
100%
94%
69%
100%
 Project Management
Following the results of TNA revealing limitations on project management courses available.
A short project management training course has been designed from Level 3 (A-level
equivalent) to Level 7 (post graduate equivalent) encompassing the theory of management
and practical components. A number of staff have booked places from different departments.
Upcoming courses to be developed for the CCG will include a day of training based on the
theory of project management and another on customer service training.
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 Managers Toolkit
The framework for the managers toolkit has now been developed. This is based on the
information managers have provided to scope the framework. The topics will include
policies and procedures, training and development opportunities, recruitment legislation and
more. Discussions with the relevant trainers are in progress.
Modern Apprentices/ Work Experience/ Graduate Scheme
 Apprenticeship Awards
Following our application to the National Apprenticeships Awards for Newcomer Small to
Medium Employer of the Year (1-249 employees). We have been shortlisted for the regional
awards! Further information has been submitted before the formal announcements.
 Work Experience
We currently have one work experience student at the CCG, and will be placing a further
student in the next month. We will continue to support work placements from the local
community.
 NHS Leadership Graduate Scheme
Our application to the NHS Leadership Academy to support a graduate placement was
successful. The CCG has been offered as a second year student placement for general
management.
CCG Workforce Dashboard
Workforce reports have been developed to show trends in absence. A copy of the
organisation’s dashboard report is included below. Trends at directorate level will be
available to the relevant Director shortly and provide managers with visibility of workforce
information. Training will be scheduled in due course to show the full capacity of the
reporting system at directorate level.
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CCG Workforce Dashboard
This dashboard is currently under development to give the CCG and its manager’s visibility of workforce information showing the information by directorate
rather than cost centre.
Monthly Staff Report (End May 2014)
Division / Directorate
143 Clinical Support 756291
143 Commissioning 756296
143 Patient and Public Involvement 756406
Commissioning
143 Corporate Costs & Services 756316
143 Medicines Management - Clinical 754656
143 Medicines Management 756391
Corporate Affairs & Medicines Optimisation
143 Contract Management 756311
143 Finance 756351
143 Performance 756411
Finance
143 Business Development 756261
143 CEO/ Board Office 756271
143 Chair and Non Execs 756276
143 Communications & PR 756301
Governing Body, Comms & Clinical Leads
143 Equality and Diversity 756341
143 Quality Assurance 756426
Quality
Grand Total
Staff
FTE
2
25
1
28
16
11
2
29
4
9
6
19
1
8
4
3
16
1
9
10
102
1.80
21.35
1.00
24.15
16.00
9.84
2.00
27.84
4.00
8.80
5.89
18.69
0.67
7.05
1.52
3.00
12.23
0.70
8.09
8.79
91.71
Starters
(headcount)
12mth
Rolling
(8mths)
Starters
FTE
12mth
Rolling
(8mths)
Leavers
(headcount)
12mth
Rolling
(8mths)
Leavers
FTE
12mth
Rolling
(8mths)
1
1.00
1
6
1
6.00
2
1
3
1.69
1.00
2.69
Valid
Appraisals
(May)
12 mth
rolling
May
0%
13%
1
0.43
1
0.43
7%
0.00
17%
5%
6
6
1
1.00
1
1
1
1
1
4
1
0.67
0.40
0.12
1.00
2.18
0
0
0.00
100%
100%
33%
81%
1
1
13
1.00
1.00
11.18
1
1
5
1.00
1.00
4.12
16%
0%
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Commissioning
Corporate Affairs & Medicines Optimisation
Finance
Governing Body, Comms & Clinical Leads
Quality
Grand Total
Skill Mix
Fixed
Term
Contract
Work Pattern
% Band 8
above/
Band 1-7
FTE of
staff on
FTC
%
FullTime
%
PartTime
%
Reporting
a
Disability
%
Ethnic
Minority
%
Female
%
Male
% of Age
over 55
36% / 64%
34% / 66%
21% / 79%
88% / 13%
40% / 60%
41% / 59%
0.00
4.37
0.00
5.22
0.00
9.59
62%
93%
91%
65%
80%
79%
38%
7%
9%
35%
20%
21%
4%
0%
0%
6%
10%
3%
0%
0%
0%
0%
0%
0%
93%
76%
68%
38%
90%
75%
7%
24%
32%
63%
10%
25%
11%
14%
11%
38%
30%
Staff
FTE
Apr % 12
mth
rolling
(8mths)
28
29
19
16
10
102
24.15
27.84
18.69
12.23
8.79
91.71
22%
3%
0%
0%
23%
9%
Disability/Ethnicity
Gender
Age
18%
S10 Anxiety
/stress
/depression/
other psychiatric illnesses
S11 Back Problems
S12 Other musculoskeletal problems
S13 Cold, Cough, Flu - Influenza
S15 Chest & respiratory problems
S16 Headache / migraine
S21 Ear, nose, throat (ENT)
S23 Eye problems
S25 Gastrointestinal problems
S98 Other known causes - not
elsewhere classified
S99 Unknown causes / Not specified
Commissioning
Corporate Affairs & Medicines
Optimisation
Finance
Governing Body, Comms &
Clinical Leads
Quality
Grand Total
Turnover
0.00%
0.00%
1.41%
67.61%
4.23%
4.23%
5.63%
5.63%
8.45%
0.00%
2.82%
25.00%
2.14%
0.00%
30.71%
12.14%
3.57%
0.71%
0.00%
5.71%
19.29%
0.71%
0.00%
27.27%
0.00%
9.09%
0.00%
0.00%
0.00%
0.00%
0.00%
63.64%
0.00%
0.00%
47.83%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
52.17%
0.00%
0.00%
2.06%
0.00%
21.65%
51.55%
5.15%
0.00%
0.00%
3.09%
16.49%
0.00%
9.31%
8.78%
0.27%
30.32%
18.62%
3.46%
1.33%
1.06%
4.52%
21.54%
0.80%
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Provider Workforce Dashboard
The table below contains some key workforce indicators from the CCGs main providers. Work is on-going to secure the missing information.
Trust
Item
Sickness
performance
Apr-13
19.78%
May-13
18.44%
Jun-13
19.11%
Jul-13
19.56%
Aug-13
18.67%
Sep-13
19.33%
Oct-13
19.11%
Nov-13
Dec-13
Jan-14
-7.00%
-6.60%
Sickness actual
Sickness target
Turnover
performance
Turnover actual
Turnover target
min
Turnover target
max
Appraisal
performance
5.39%
4.50%
39.17%
16.70%
5.33%
4.50%
41.67%
17.00%
5.36%
4.50%
41.67%
17.00%
5.38%
4.50%
40.00%
16.80%
5.34%
4.50%
46.17%
17.54%
5.37%
4.50%
43.92%
17.27%
5.36%
4.50%
46.58%
17.59%
5.35%
5.00%
47.33%
17.68%
5.33%
5.00%
25.00%
15.00%
12.00%
12.00%
12.00%
12.00%
12.00%
12.00%
-6.32%
-7.37%
-6.32%
-7.16%
-7.58%
-8.74%
12.00%
10.95%
12.00%
12.53%
89.00%
95.00%
88.00%
95.00%
89.00%
95.00%
88.20%
95.00%
87.80%
95.00%
86.70%
95.00%
84.60%
95.00%
DPT
DPT
Appraisal actual
Appraisal target
Training
performance
Training actual
-6.82%
82.00%
-6.82%
82.00%
-6.82%
82.00%
-5.68%
83.00%
-5.68%
83.00%
-5.68%
83.00%
DPT
Training target
88.00%
88.00%
88.00%
88.00%
88.00%
Sickness
performance
Sickness
Sickness target
Turnover
performance
No
Data
13.04%
4.00%
4.60%
14.35%
3.94%
4.60%
14.13%
3.95%
4.60%
-8.50%
-7.70%
-8.80%
DPT
DPT
DPT
DPT
DPT
DPT
DPT
DPT
DPT
DPT
SDHFT
SDHFT
SDHFT
SDHFT
13.40%
Mar-14
Apr-14
-6.60%
Feb-14
17.00%
-7.20%
-7.00%
5.33%
5.00%
5.85%
5.00%
5.36%
5.00%
-8.33%
13.00%
-8.33%
13.00%
-8.33%
13.00%
5.35%
5.00%
16.67%
14.00%
12.00%
11.89%
12.00%
12.00%
12.00%
12.00%
-9.26%
-7.68%
-5.89%
-5.58%
83.10%
95.00%
83.70%
95.00%
86.20%
95.00%
87.70%
95.00%
89.40%
95.00%
89.70%
95.00%
-4.55%
84.00%
-3.41%
85.00%
-2.27%
86.00%
-2.27%
86.00%
-2.27%
86.00%
0.00%
No data
88.00%
88.00%
88.00%
88.00%
88.00%
88.00%
88.00%
0.00%
No data
188.00
%
14.57%
3.93%
4.60%
15.65%
3.88%
4.60%
16.30%
3.85%
4.60%
17.83%
3.78%
4.60%
18.04%
3.77%
4.60%
18.04%
3.77%
4.60%
18.04%
3.77%
4.60%
8.81%
3.83%
4.20%
7.86%
3.87%
4.20%
-8.30%
-5.50%
-3.20%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
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Trust
SDHFT
SDHFT
SDHFT
SDHFT
SDHFT
SDHFT
Item
Turnover
Turnover target
min
Turnover target
max
Appraisal
performance
Appraisal
SDHFT
SDHFT
Appraisal target
Training
performance
Training
SDHFT
Training target
PHNT
PHNT
PHNT
PHNT
PHNT
PHNT
PHNT
PHNT
PHNT
PHNT
PHNT
Sickness
performance
Sickness
Sickness target
Turnover
performance
Turnover
Turnover target
min
Turnover target
max
Appraisal
performance
Appraisal
Appraisal target
Training
performance
Apr-13
8.66%
May-13
9.15%
Jun-13
9.23%
Jul-13
9.12%
Aug-13
9.17%
Sep-13
9.45%
Oct-13
9.68%
Nov-13
10.54%
Dec-13
10.11%
Jan-14
10.39%
Feb-14
10.06%
Mar-14
10.22%
Apr-14
10.98%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
14.00%
22.35%
66.00%
14.00%
23.53%
65.00%
14.00%
17.65%
70.00%
14.00%
14.12%
73.00%
14.00%
15.29%
72.00%
14.00%
17.65%
70.00%
14.00%
17.65%
70.00%
14.00%
16.47%
71.00%
14.00%
16.47%
71.00%
14.00%
22.35%
66.00%
14.00%
24.71%
64.00%
14.00%
25.88%
63.00%
14.00%
29.71%
59.75%
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
24.29%
4.35%
3.50%
-9.14%
3.82%
3.50%
-1.14%
3.54%
3.50%
-0.86%
3.53%
3.50%
7.43%
3.24%
3.50%
8.29%
3.21%
3.50%
12.57%
3.06%
3.50%
0.00%
No data
3.50%
2.00%
3.43%
3.50%
24.29%
4.35%
3.50%
10.57%
3.87%
3.50%
0.00%
No data
3.50%
-9.71%
3.84%
3.50%
0.00%
0.00%
No
target
No
target
0.00%
8.50%
No
target
No
target
No
target
No
target
No
target
No
target
0.00%
8.97%
No
target
No
target
0.00%
9.05%
No
target
No
target
0.00%
8.91%
No
target
No
target
0.00%
No data
No
target
No
target
0.00%
9.35%
No
target
No
target
0.00%
No data
No
target
No
target
0.00%
9.40%
No
target
No
target
0.00%
No data
No
target
No
target
-3.53%
82.00%
85.00%
-3.53%
82.00%
85.00%
-2.35%
83.00%
85.00%
-4.71%
81.00%
85.00%
-7.06%
79.00%
85.00%
-5.88%
80.00%
85.00%
-7.06%
79.00%
85.00%
-5.88%
80.00%
85.00%
-3.53%
82.00%
85.00%
0.00%
No data
85.00%
-8.24%
78.00%
85.00%
0.00%
No data
85.00%
0.00%
9.81%
No
target
No
target
10.59%
76.00%
85.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
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Trust
PHNT
Item
Training
Apr-13
No data
May-13
No data
Jun-13
No data
Jul-13
No data
Aug-13
No data
Sep-13
No data
Oct-13
No data
Nov-13
No data
Dec-13
No data
Jan-14
No data
Feb-14
No data
Mar-14
No data
Apr-14
No data
PHNT
Training target
85.00%
85.00%
85.00%
85.00%
85.00%
85%
85%
85%
85%
85%
85%
85%
85%
SWAST
Sickness
performance
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
SWAST
Sickness
SWAST
Sickness target
Turnover
performance
Turnover
Turnover target
min
Turnover target
max
Appraisal
performance
Appraisal
5.89%
No
target
5.60%
No
target
5.18%
No
target
5.10%
No
target
5.09%
No
target
No data
No
target
5.28%
No
target
No data
No
target
5.90%
No
target
No data
No
target
6.36%
No
target
No data
No
target
5.45%
No
target
0.00%
10.43%
No
target
No
target
17.27%
74.46%
0.00%
8.92%
No
target
No
target
11.28%
75.41%
0.00%
8.92%
No
target
No
target
10.40%
76.16%
0.00%
11.31%
No
target
No
target
15.35%
71.95%
0.00%
11.71%
No
target
No
target
21.81%
66.46%
0.00%
No data
No
target
No
target
0.00%
No data
No
target
No
target
43.15%
48.32%
0.00%
13.86%
No
target
No
target
46.99%
45.06%
0.00%
No data
No
target
No
target
48.62%
43.67%
0.00%
13.92%
No
target
No
target
47.56%
44.57%
0.00%
No data
No
target
No
target
0.00%
No data
0.00%
12.84%
No
target
No
target
42.73%
48.68%
90.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
0.00%
61.35%
No
target
No
Data
No data
No
target
0.00%
13.45%
No
target
No
target
36.05%
54.36%
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
1.30%
4.54%
4.60%
2.83%
4.47%
4.60%
3.48%
4.44%
4.60%
3.04%
4.46%
4.60%
4.13%
4.41%
4.60%
6.09%
4.32%
4.60%
6.74%
4.29%
4.60%
6.74%
4.29%
4.60%
6.30%
4.31%
4.60%
6.30%
4.31%
4.60%
-2.62%
4.31%
4.20%
-2.38%
4.30%
4.20%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
-3.14%
-5.21%
SWAST
SWAST
SWAST
SWAST
SWAST
SWAST
SWAST
SWAST
SWAST
Appraisal target
Training
performance
Training
SWAST
Training target
T&SD
T&SD
T&SD
T&SD
Sickness
performance
Sickness
Sickness target
Turnover
performance
No
Data
0.00%
Page 17 of 22
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Trust
T&SD
Item
Turnover
Turnover target
min
Turnover target
max
Appraisal
performance
Appraisal
Apr-13
12.29%
May-13
12.89%
Jun-13
13.17%
Jul-13
13.60%
Aug-13
13.60%
Sep-13
13.08%
Oct-13
13.32%
Nov-13
13.40%
Dec-13
13.40%
Jan-14
13.99%
Feb-14
13.82%
Mar-14
14.44%
Apr-14
14.73%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
14.00%
14.00%
14.00%
14.00%
14.00%
14.00%
14.00%
14.00%
14.00%
14.00%
14.00%
14.00%
14.00%
-7.06%
79.00%
-7.06%
79.00%
-4.71%
81.00%
-3.53%
82.00%
-3.53%
82.00%
-4.08%
81.54%
-4.71%
81.00%
-4.71%
81.00%
-3.53%
82.00%
-7.06%
79.00%
-7.06%
79.00%
-3.53%
82.00%
-5.73%
80.13%
T&SD
T&SD
Appraisal target
Training
performance
Training
T&SD
Training target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
85.00%
No
Data
No data
No
target
RD&E
RD&E
Sickness
performance
Sickness
0.00%
3.88%
No
target
0.00%
3.90%
No
target
0.00%
No data
No
target
0.00%
3.89%
No
target
0.00%
No data
No
target
0.00%
No data
No
target
0.00%
No data
No
target
0.00%
4.03%
No
target
0.00%
4.19%
No
target
0.00%
4.33%
No
target
0.00%
4.23%
No
target
0.00%
3.91%
No
target
0.00%
3.68%
No
target
0.00%
9.80%
No
target
No
target
No
Data
No data
No
target
0.00%
9.79%
No
target
No
target
No
Data
No data
No
target
0.00%
No data
No
target
No
target
No
Data
No data
No
target
0.00%
9.85%
No
target
No
target
No
Data
No data
No
target
0.00%
No data
No
target
No
target
No
Data
No data
No
target
0.00%
No data
No
target
No
target
No
Data
No data
No
target
0.00%
No data
No
target
No
target
No
Data
No data
No
target
0.00%
No data
No
target
No
target
No
Data
No data
No
target
0.00%
10.20%
No
target
No
target
No
Data
No data
No
target
0.00%
10.65%
No
target
No
target
No
Data
No data
No
target
0.00%
10.53%
No
target
No
target
No
Data
No data
No
target
0.00%
11.00%
No
target
No
target
No
Data
No data
No
target
0.00%
10.80%
No
target
No
target
No
Data
No data
No
target
T&SD
T&SD
T&SD
T&SD
T&SD
RD&E
RD&E
RD&E
Sickness target
Turnover
performance
Turnover
Turnover target
min
Turnover target
max
Appraisal
performance
Appraisal
RD&E
Appraisal target
RD&E
RD&E
RD&E
RD&E
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Trust
RD&E
RD&E
Item
Training
performance
Training
RD&E
Training target
Apr-13
No
Data
No data
No
target
May-13
No
Data
No data
No
target
Jun-13
No
Data
No data
No
target
Jul-13
No
Data
No data
No
target
Aug-13
No
Data
No data
No
target
Sep-13
No
Data
No data
No
target
Oct-13
No
Data
No data
No
target
Nov-13
No
Data
No data
No
target
Dec-13
No
Data
No data
No
target
Jan-14
No
Data
No data
No
target
Feb-14
No
Data
No data
No
target
Mar-14
No
Data
No data
No
target
Apr-14
No
Data
No data
No
target
Page 19 of 22
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ORGANISATIONAL DEVELOPMENT
An OD plan was discussed at the Area Team’s assurance meeting in June, and this was updated and
discussed at Senior Leadership Team on 24 June (with a particular focus on workforce). We built on
the Stalker (2000) model of OD described to the Governing Body in April of last year, this time using
the McKinsey ‘7S’ model (see left) to describe progress to date and some of our future plans. Now
that Louise Hardy is back in post as our Director with responsibility for OD a more detailed plan will
be brought to the Governing Body towards the end of 2014.
The purpose of the Area Team’s discussion was primarily to demonstrate that we have an emerging
action plan to address the issues arising out of our recent 360 degree stakeholder survey.
The Governing Body will be interested to know that we presented our 360 response like this:
This section describes our relationship with external stakeholders and the behaviours of our staff
and leadership within those relationships. It is based on the results of our recent 360 stakeholder
survey and is high-level, pending further analysis of the survey. We had, overall, a very positive
survey. The detail throws up three main areas for action:



We have 12-15% of GPs who are disengaged, and another group that is well engaged but
wants to see more results
We need to keep working at relationships in our South Devon patch to counter any
perception that we are Torbay focussed
We have evident disenchantment in one of the four Healthwatch/patient groups consulted;
this needs to be explored
Findings at a glance:
 Good response rate at 73% (including 70% for GPs)
 We do better or considerably better than the national CCG average on: engaging partners
(86%) satisfaction with engagement (81%) listening, confidence in our ability to commission
high quality services and to improve outcomes, the way we explain our commissioning and
communicate decisions, clear and visible leadership (82%), knowledge of our plans and
priorities, giving people the opportunity to influence our plans.
 One out of four Healthwatch/patient groups is dissatisfied with almost everything we do in
engagement
Page 20 of 22
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




The percentage of GPs saying that arrangements for member participation and decision
making are effective has fallen from 94 last year to 73 this year.
31% of GPs say they are not very or not at all involved in decision making (this is probably a
statement of fact)
Despite good engagement, only 49% think we have acted on their suggestions (AT 41%,
national 51%)
We get only 59% for the extent to which we have contributed via quality surveillance and
urgent care working groups (national 62%)
People think their working relationship with us is very or fairly good (82%) but only 43%
think it has got better in the last year (this suggests they think it did not need to particularly
improve)
There are some areas where we do better than the national average but would consider,
nonetheless, that we do not do well enough:



61% think we communicate our decisions with them effectively (AT 54%, national 58%)
63% say our plans will deliver continuous improvement (AT 42%, national 58%)
62% understand the financial implications of our plans
We have constructed the following action plan against the generality of the analysis above, and also
the narrative provided through the survey:
Domain
Action
Engagement and
listening to views
(GPs)
Take detailed feedback
on GP newsletter and
act on it
Engagement and
listening to views
(public/other
organisations)
Actively seek
engagement –
particularly from
Devon County Council
and lower-tiers
Work more closely
with PHE, particularly
on the JSNA
development
Acting on suggestions
and working
relationships
Commissioning
decisions (involving,
confidence in,
understanding)
Commissioning
decisions and
leadership
(communicating,
continuous quality
improvement, skills of
Need clear strategy for
meaningful
engagement of
voluntary care sector
(VCS) including clarity
of relationships at
Practice-level
Need to establish
which involvement
group/HealthWatch
gave negative
feedback – and meet.
Further develop
Council of Members:
more bottom-up and
consultative
Continue to build on
1:1 senior relationships
Further partnership
working at levels other
than board – e.g.,
sharing of social
marketing
Urgent action required
to ensure clear link
between
commissioning
strategy and VCS
involvement
More actively promote
areas where CCG is
making demonstrable
improvements – eg,
MSK, stroke,
Support development
of provider network
(Haytor Health)
Continue with Boardto-Board programmes
of development,
seeking feedback and
acting on it
Meet this head-on
with meeting to
discuss within the next
month
CCG website
improvement and
update to ensure key
documents (e.g. GB
minutes) are up to
date and available
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Domain
leadership)
Overall leadership
(clear and visible,
delivering, CQM)
Overall leadership and
clinical leadership
(improved outcomes
for patients, clear and
visible, delivery)
Action
Overall confidence in
leadership is high.
However, there is
scope to improve
visible external
stakeholder
relationships
Continue to support
clinical and non-clinical
leadership
development through
NHS Leadership
Academy and
coaching.
Need to engage
Practices involved in
locality plans – not just
the ‘willing followers’.
Requires bold
leadership.
Develop Council of
Members and locality
support.
Ensure clinical
leadership develops on
the ‘distributed’
model.
Need a clear
framework for talent
management,
particularly of clinical
roles. Action by end
2014 (in line with
national framework)
The Area Team were assured of our plans and generally happy with our 360 responses. In terms of
the OD paper, they did ask for further thought and work on our succession plans, and in particular
being able to identify ‘mission critical’ staff in the CCG and how these roles would be covered in an
emergency.
Louise will be working on this as part of her overall OD plan.
Mark Procter
June 2014.
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Date
Report title
Author(s)
Report purpose
Executive
Summary
20 June 2014
Risk Report
Mark Procter, Director of Corporate Affairs and Medicines Optimisation
Phil Stimpson, Corporate Affairs Manager
To inform the Governing Body of the current position regarding the CCG’s
risks.
The Assurance Framework comprises the CCG’s “very high” risks, scoring 16-25;
there are currently 9 very high risks.
The risk profile is a “bell-shaped” curve which shows that the CCG is recording
risks at all levels across the organisation and that high scoring risks are managed
down to a more acceptable level over time.
Risks have been aligned to the Plan on a Page (PoaP) and all elements of the
PoaP have at least one risk, as shown on the Risk Dashboard. The Risk Score
and Adequacy of Assurance Score are plotted on the Risk Dashboard, and a
number of elements have Strong assurance overall.
The Risk Heat Map shows that 8 risks have recently had their scores reduced by
management action.
Key
Recommendations
and Actions
Which other
committees has
this been to?
To consider the content of the report and the attached documents.
-
implications?
implications?
implications?
of work affect?
Staff
Patients
Carers
Public
 yes
 yes
 yes
 yes
Yes
No
Will the proposal have any impact on discrimination, equality of opportunity or relations between
x
groups?
Is the proposal controversial in any way (including media, academic, voluntary or sector specific
x
interest) about the proposed work?
x
Is there doubt about answers to any of the above questions (e.g. there is not enough information
x
to draw a conclusion)?
Services
Page 1 of 11
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Risk Report
Risk Report
Report to the Governing Body June 2014
1.
Purpose
1.1
This report provides assurance to the Governing Body that the CCG has effective processes
in place to identify, assess, manage and mitigate risk, and informs the Governing Body of
any changes since 1 April 2014.
1.2
The report provides the Governing Body with the opportunity to consider the adequacy and
effectiveness of the controls and assurances identified, including measures to address gaps
in controls and assurances and to identify any further measures that should be taken to
manage its risks.
2.
Review of the corporate risk register and Assurance Framework
2.1
The CCG has articulated its risk appetite by creating the following risk statements:




2.2
When it comes to safety, the CCG will ensure high quality and has very limited
tolerance of risk
In the areas of quality, capacity and capability, environment and infrastructure, the
CCG will support innovation – as long as it demonstrates commensurate rewards.
Developments in systems and technology will be used routinely to help operational
delivery. Responsibility for decisions that are not critical may be delegated.
The CCG will be prepared to invest for a positive return, and will minimise the
possibility of financial loss by managing the risks to a tolerable level. It will consider
the value and benefits of investment, not just the cheapest price. Where the balance
of probability is that the investment will yield a return, the CCG will use its resources
without requiring an absolute guarantee that a return will be made.
In the spheres of general business management and reputation, the CCG will be
prepared to take decisions that are likely to invite scrutiny of the organisation, where
the potential benefits outweigh the risks. New ideas will be seen in the light of
potentially enhancing the CCG’s reputation.
The CCG scores risk using the recommended 5 x 5 impact and likelihood matrix (Appendix 1
contains the current risk scoring matrix) and uses the following categorisation of:
 Public, Patient and Staff Safety
 Quality
 Finance
 Capacity & Capability
 Business Management & Reputation
 Environment, Estate and IT
2.3
The risks are mapped to the CCG’s Plan on a Page (1415-1819 version). Each risk is
reviewed to assess the adequacy of the controls and assurances linked to each risk.
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Risk Report
2.4
The risk dashboard (attached separately) shows which risks are linked to which PoaP
element and summarises the average level of risk and controls with an associated adequacy
score for these controls and assurances.
2.5
By overlaying the risk scoring matrix with the four responses to managing risk,
(reduce/transfer, contingency plan, manage and accept, the following risk management grid
is created:
Risk Response Grid
5
5
6
Contingency
10
8
Reduce/Transfer
15
12
25
16
20
Impact
Manage and Contingency
9
2
1
1
4
3
Accept
8
6
1
12
15
Manage
10
5
5
Likelihood
2.6 After identifying which risk response category the individual risks should reside in, it is
possible to identify the CCG Risk profile using the current risk score and the target risk score
after the potential impact of actions, controls and assurances have been considered.
2.7 The CCG risk profile which should resemble a ‘Bell Curve’ type distribution due to covering
all the CCG risks and can be represented by the following graph:
2.8 The CCG Adequacy of Assurance profile can be represented by the following graph. Work
has been targeted at raising assurance from Weak to Moderate, and then to Strong. Data
and reports presented to one of the CCG’s formal committees form good internal assurance;
data and reports presented to the Health and Wellbeing Boards and to NHS England’s Area
Team form good external assurance; Internal and External Audit reports also form good
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Risk Report
external assurance. This external assurance means that 43% of the CCG’s risks currently
have Strong assurance.
3
9
12
3
4
12
12
3
3
9
12
4
4
16
11
3
3
9
10
08/05/2014
3
3
9
12
08/05/2014
08/05/2014
30/04/2014 01/01/2014
Opened
3
08/05/2014
105
There is a risk that there is insufficient resource to support
both the JoinedUp plans and also the business as usual
work within Commissioning.
Adequacy Score
104
Risk Score
103
There is a risk to JoinedUp that plans will not be properly
communicated to the population and to staff without
additional resource in the form of specific marketing
expertise. From this, there is also a risk that we won't get
adequate progress on plans because the "mission critical"
people are not sufficiently engaged.
There is a risk to JoinedUp that the integration of South
Devon Healthcare NHS Foundation Trust with Torbay and
Southern Devon Health and Care NHS Trust will not
support the whole-system transformation required of
Pioneer sites.
Impact
102
There is a risk to JoinedUp that the system resource will be
aligned to the Integrated Care Organisation (ICO), at least
over the next year.
Likelihood
101
Risk to the delivery of the financial duty to live within the
revenue resources allocated and delivery of the planned
1% surplus. This would be at risk as a result of in year
unplanned overspends in relation to our identified risks and
if recovery actions are not successful.
Risk Category
100
GP Out of Hours service. NEW Devon leading on the respecification of and procurement of new service to
commence from April 2016.
Finance
ID
Infrastructure Infrastructure Infrastructure Infrastructure
Risk Description
Finance
2.9 There have been 7 new risks added to the risk register since 1 April 2014:
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4
3
12
10
08/05/2014
106
There is a risk that the CCG does not have clarity on the
key milestones for the Pioneer programme, nor how these
will be managed and owned across the different
organisations.
Infrastructure
Risk Report
8
11
2
6
9
3
9
8
4
16
8
38
There is a risk that the process for the completion of Patient
Group Directives (PGD's) is not sufficiently swift to allow for
them to be signed and circulated in a timely manner.
RISK CLOSED BY QUALITY COMMITTEE 28 August 2013
3
40
There is a risk that moving patients as a result of
Winterborne Review may have an adverse financial impact
on the CCG.
Risk Closed by Finance Committee 30 April 2014.
3
56
There is a risk that the a change to allocations policy sets
the CCGs target allocation significantly below baseline
resources (£26m in latest estimated version). Depending on
radical or conservative pace of change policies this could
significantly impede the CCGs responsibility to achieve
required underspends against resource limits.
Risk closed by Finance Committee 30 April 2014.
4
Closed
2
30/04/2014 14/04/2014 30/04/2014 30/04/2014 30/04/2014 12/06/2014
12
4
Risk closed by Finance Committee 30 April 2014.
30/04/2014
16
There is a risk of increased costs in implementing AQP.
9
There is a risk of material overspends against main
contracts.
Opened
4
19
24/07/2013 23/07/2013 08/02/2013 01/06/2012 10/01/2013 14/02/2013
12
4
There is a risk of Running Costs overspend.
7
22/08/2013
4
Finance
2
2
Finance
10
Finance
5
Reputation
1
Finance
5
Finance
Risk closed by Senior Leadership Committee 24th June
2014
Adequacy Score
1
Risk Score
There is a risk that HR records will be missing after
Transition
Impact
Risk Description
Likelihood
ID
Infrastructure Risk Category
2.10 7 risks have been closed since 1 April 2014. The Audit Committee (13 March 2014) made
the decision that a risk can only be closed be by a CCG Committee, not solely by a Director,
so the decisions to close some risks will need to be ratified by a CCG Committee (CCC,
Finance, Quality, SLC).
2.11 The risk movement grid (“Risk Heat Map”) allows identification of risks that need further
investigation, discussion or assurance. There have been 8 risks that have had their risk
score decreased and no risks have had their risk score increased since 1 April 2014.
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4
Information
There is a risk that personal data stored locally
may be lost.
17
1
4
4
There is a risk that there are errors in the ESR
records for CCG staff.
83
84
There is a risk that the CCG's Payroll system
will not reliably process Salaries, Childcare
Vouchers and Travel Claims.
2
4
2
2
4
2
2
4
There is a risk that the Data Sharing
Agreements needed for the information sharing
projects will not be available in time and that
the projects will fail as a result.
20/06/2013: CCG involved in national
discussions.
07/10/2013: CCG received confirmation from
HSCIC that IG Toolkit submission was
sufficient for ASH accreditation.
29/11/2013: CCG to submit a second Data
Sharing Contract with the HSCIC to cover
activities up to 30/11/2014.
Jan 2014: CCG achieved ASH level 1 status.
CEfF set up.
SDHFT agreed to start sending backing data
for invoices to the CCG.
10/03/2014: Virtual Ward data is flowing again
and reports are being generated for Practices.
21/05/14: Due to sign a contract with a
DSCRO within next month.
Audit South West to carry out an audit of the
CCG's Payroll system and report back.
Audit completed and 1 action raised.
12/06/2014: Staff have received ESR selfservice training to access their records.
Supported by on-going training dates available
in addition to ESR manuals available on
iKnow.
Audit completed.
8 actions identified. As at 12/06/2014 6 of
these have been completed.
8
12
4
4
16
11
3
4
12
8
4
4
16
11
3
3
9
10
3
3
9
9
4
3
12
11
3
4
12
20/03/2013
20/03/2013
Opened
4
Quality
8 Jan 14 - work underway to procure self care
services
Information
93
Need to ensure that patients have access to
self care and preventative services to support
alongside Healthcare Professionals.
CCG to apply for S251 exception.
CCG to apply for Safe Haven Accreditation.
CCG to ascertain the cost of a DMIC service.
CCG to explore possibility of seconding staff to
our local Data Management Information Centre
(DMIC), Best West (SWCSU)
Audit South West to carry out an audit on the
process for, and content of, the CCG's ESR.
There is a risk of ever growing demand on
services supporting patients with Long Term
conditions.
87
Personal drives available for all staff on SDHIS
network.
Accellion rolled out, with training, to all
directorates April 2014.
8
Infrastructure
18
Infrastructure
Information
There is a risk that the CCG is unable to
receive patient data
Turn IT Strategy into CCG Policy.
Make Accellion data storage available to all
CCG staff.
Jan 2014: Migration of personal drives into the
CCG's secure area started 20/01/2014.
2
20/03/2013
4
10
11/01/2012
1
Corporate Affairs Manager adds / removes staff
access to N Drive folders.
Regular reviews of Folder access carried out.
performance Safe Haven folder set up with
access for 5 staff on a role-based basis.
16
18/03/2013
5
Meeting arranged with South Devon HIS to
define and refine permissions and process for
controlling access.
Additional folders added to the N Drive where
access is restricted to 2 -3 members of staff
only, for specific purposes - e.g. CEfF folder.
CCG able to add / remove permissions to all
folders on N Drive
4
13/12/2013
Information
There is a risk that the Safe Haven on the N
shared drive is not secure.
4
13/12/2013
8
Information Security team to extend routine
screening of NHSMail access by mobile
devices to include all CCG users, including
associated GPs, and follow up any usage on
unencrypted devices found.
12
09/01/2014
3
24/02/2014
4
Corporate Affairs have control of N Drive folders
and user permissions.
User permissions are audited at least quarterly
(including a leavers process) - 01 October
2013, Dec 2013, March 2014, May 2014.
Work on Accellion is proceeding - storage will
be hosted by SDHIS.
Accellion rolled out to all directorates April
2014.
Risk Score Previous
2
3
Meeting arranged with South Devon HIS to
define and refine permissions and process for
controlling access.
Accellion being worked up as an alternative
secure data store, with role-based permission
access a prerequisite.
Impact Previous
4
1
Actions Progress
Likelihood Previous
There is a risk that mobile devices will receive
NHS Mail in an unsecure manner
Information
Information
There is a risk that the Commissioning team
hold patient data on an insecure part of the N
shared drive.
3
Actions
Risk Score
Impact
ID
Likelihood
Risk Category
Risk Description
Adequacy Score
Risk Report
3
3
9
3 Jun 14 - new self-care service provider
secured. Service live to new referrals from 1st
July 14.
Prevention strategy in development and will
engage with redesign group to capture other
prevention initiatives.
To write and agree Data Sharing Agreements Regular item at Information Sharing Group.
for all the IT projects involving patient data that
the CCG is involved with.
2
4
8
2.12 The Risk Dashboard shows that all elements of the CCG’s Plan on a Page have risks
identified.
2.13 The Dashboard also highlights that some areas of the Plan on a Page have multiple risks
whilst some have just one risk aligned. This may be more of a recording issue rather than
there actually being very few risks to the CCG in these areas.
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Risk Report
3
Recommendations
3.1
The Governing Body is recommended to:

Support the risk co-ordinators in ensuring that all risks are recorded, updated and
have all the assurances, controls and mitigating actions recorded with regular
reviews undertaken by all the teams.

Consider the adequacy and effectiveness of the controls and assurances identified
in the management of risk including measures to address gaps in controls and
assurances and identify any further action that should be taken to manage the key
risks.

Consider the report content making any recommendations for changes.
Mark Procter, Director of Corporate Affairs & Medicines Management
Phil Stimpson, Corporate Affairs Manager
June 2014.
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Appendix 1 Current Risk Scoring Matrix
Assessing the impact of risk
5 Catastrophic
Score
Public, staff and
Patient Safety
Incident leading
to avoidable
death or serious
permanent harm
due to a failure of
process, breach
of policies /
procedures or
safe working
practices.
H&S: Probable
fatality due to lack
of maintenance or
failure in process.
Multiple deaths;
out of control
infection.
4 Severe
Major avoidable
injury leading to
long term
incapacity /
disability
H&S: Probable
serious injury or
illness due to lack
of maintenance or
failure in process.
Major clinical
intervention;
Unexpected
death
Quality
Individual
consultant clinical
outcome in lower
10% for in excess
of 3 months
Specialty clinical
outcomes in lower
25% for over 1
month
Non delivery of
key objective /
service due to
lack of staff
Serious impact on
financial position
of CCG
Increase in length
of stay for large
number of
patients > 10
days
Increase in length
of stay for a
significant
number of
patients > 10
days
Ongoing unsafe
staffing levels or
competence
Loss of several
key staff
Individual
consultant clinical
outcome in lower
10% for up to1
month
Specialty clinical
outcomes in lower
25% for up to 1
month
Capacity &
Capability
Finance
Uncertain delivery
of key objective /
service due to
lack of staff
Significant impact
on financial
position of CCG
Unsafe staffing
levels or
competence (>5
Days)
Loss of key staff
Business
Management &
Reputation
Sustained failure
to meet standards
and / or national
requirements.
Serious impact on
overall
performance and
possible
intervention
Serious long term
impact (nationally
and locally) on
reputation,
prolonged interest
and DoH / Select
Committee
overview
Serious breach
with potential for
ID theft or over
1000 people
affected
Major impact on
overall
performance
which puts
achievement of
standards and / or
national
requirements at
risk.
National and local
interest and
impact on
reputation specific
to an issue –
prolonged interest
Serious breach
with either
particular
sensitivity e.g.
sexual health
details, or up to
1000 people
affected
Environment,
Estate and IT
Permanent loss of
service or facility
Catastrophic
impact on
environment,
multiple breach
and prosecution
Damage will
spread beyond
one item of
equipment and
take over 1 week
to repair
Loss / interruption
of service or
facility > 1 week
Major impact on
environment,
multiple breach
and prosecution
notice issued
Equipment will be
out of action less
than 1 week to
repair
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Public, staff and
Patient Safety
Moderate
avoidable injury
requiring
professional
intervention.
H&S: Moderate
chance of injury
or illness due to
lack of
maintenance or
failure in process.
Further treatment
needed, referred
to other dept /
hosp / A&E.
Additional
treatment
required up to 1
year
1 Minimal
2 Minor
Score
3 Moderate
Risk Report
Minor avoidable
injury requiring
minor
intervention.
H&S: Small
chance of injury
or illness due to
lack of
maintenance or
failure in process.
Extra observation
/ treatment; first
aid; major cuts;
bruising; minor
illness
None or minimal
harm no
intervention
required.
H&S: Little
chance of injury
or illness due to
lack of
maintenance or
failure in process.
No injury or
incident
prevented; minor
cuts; bruising
Quality
Individual
consultant clinical
outcome in lower
25% for up to 1
month
Increase in length
of stay for a
significant
number of
patients <15 days
Significant impact
on financial
position of CCG
No impact on
outcome
Late delivery of
key objective /
service due to
lack of staff
Unsafe staffing
levels or
competence (>1
Day)
Business
Management &
Reputation
Failure to meet
internal standards
with some impact
on overall
performance of
the CCG.
Local interest and
impact on
reputation specific
to an issue
Serious breach of
confidentiality e.g.
up to 100 people
affected
Clinical outcome
not affected
Increase in length
of stay 3 - 10
days
Capacity &
Capability
Finance
Minor impact on
financial position
of CCG
Minor impact on
financial position
of CCG
Low staffing
levels that
reduces the
service quality
Nil
Failure to meet
internal standards
with some impact
on overall
performance
Short term local
interest and
impact on
reputation specific
to an issue
Serious potential
breach & risk
assessed high
e.g. unencrypted
clinical records
lost. Up to 20
people affected
Failure to meet
individual
employee
objectives
Minimal impact
Potentially
serious breach.
Less than 5
people affected or
risk assessed as
low, e.g. files
were encrypted
Environment,
Estate and IT
Loss / interruption
of service or
facility > 1 day
Moderate impact
on environment,
improvement
notice issued
Equipment shut
down immediately
and restarted in
less than half a
day.
Loss / interruption
of service or
facility > 1 day
Minor impact on
environment,
single breach of
legal requirement
Moderate
damage to
equipment easily
repairable.
Loss / interruption
of service or
facility > 1 hour
Minimal or no
impact on
environment
Little damage to
equipment
Assessing the likelihood of risk
Score Description
Definition
Very likely. The event is expected to occur in most circumstances as there
5
Almost Certain
is a history of regular occurrence at the CCG or within the NHS.
There is a strong possibility the event will occur as there is a history of
4
Likely
frequent occurrence at the CCG or within the NHS.
The event may occur at some time as there is a history of ad-hoc
3
Possible
occurrence at the CCG or within the NHS
2
Unlikely
Not expected but there is a slight possibility it may occur at some time.
Highly unlikely, but it may occur in exceptional circumstances. It could
1
Rare
happen but probably never will.
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Risk scoring matrix (5x5 scores for impact & likelihood)
1 Rare
2 Unlikely
3 Possible
4 Likely
1
2
3
4
5
2
4
6
8
10
3
6
9
12
15
4
8
12
16
20
1 None
2 Minor
3 Moderate
4 Severe
5 Catastrophic
5 Almost
Certain
5
10
15
20
25
Risk scoring categorisation
1-4
Low risk
6-9
Medium risk
10-15
High risk
16-25
Very high risk
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Appendix 2 Adequacy of Assurance scoring
This score is used to inform the CCG of the degree of reliance they can place on an
item of assurance.
1
Does this assurance provide evidence
that the controls are achieving the
desired outcome?
Yes - proceed to Section 2
No - Do not proceed with this assessment. If
the item highlights areas where controls are
not in place or are not achieving the desired
outcome, please add this information to the
"gaps in Controls" section of the Risk.
2 Scope of Positive Assurance
2a Does it provide positive assurance on all aspects of the issue?
For example, CCG is fully compliant / achieving the target.
2b Does it provide partially positive assurances?
For example, compliance in some areas.
Score
3
3 Sufficiency
3a Is this a key/definitive source of assurance for this area?
For example, CQC, WCC, formal reports, data.
3b Is this one of a number of sources of assurances contributing to an overall
picture?
3c Is this an indicator of likely achievement of the outcome rather than evidence
of actual achievement?
Score
3
4 Basis for Assurance
4a What is the Assurance based on?
Evidence - Audited externally
Evidence - audited internally
Self assessment - externally validated
Self assessment - without audit or validation
Score
5 Timeliness
5a How old is the most recent information on which the Assurance is based?
Within the last 6 months
between 6 and 12 months
More than 12 months
Score
Score 4 - 7
Score 8 - 10
Score 11 - 13
1
2
1
4
3
2
1
3
2
1
Weak assurance.
Very limited reliance can be placed on this as
an indicator.
Moderate assurance.
Limited reliance can be placed on this as
evidence.
Strong assurance.
This evidence can be strongly relied upon.
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Yes
1
1
3
3
8
1
4
4
Yes
3
2
3
3
11
2
4
8
Yes
1
3
4
3
11
4
3
12
4
4
16
4
4
16
Opened
6
16
23/12/2013
2
4
17/09/2013
3
4
08/05/2014
9
16/08/2013
3
Risk Score Previous
2
Impact Previous
3
Likelihood Previous
1
Review Date
Yes
24/04/2014
2
16/01/2014
10 Apr 14 a & b) TSDHCT have provided
evidence of their monitoring of quality
of placements and regular reports
which include action being taken where
concerns are flagged. This is
comprehensive for Torbay and CCG
are assured however the roll out and
process for placements made in South
Devon remains outstanding.
c) A final number of South Devon
retros was received in January 2014
however additional unknown by SDT
CCG further cases were received in
March. Decision taken at PPGG that
no further cases would be expected
and those considered not to be SDT
CCG would be returned.
d) Discussion with the TSDHCT
provider in prioritising the allocation of
additional £250k in areas of greatest
impact as part of Service Development
Improvement Plan.
e) TSDHCT report due PPGG May
2014 which should cover source,
application and function of the Placed
People Function. Following this CCG
can take decision as to where there is
any duplication as well as gaps to
address. Identified gap is market
development and discussion with
colleagues in Torbay council
commenced to look at joint working
opportunities.
5 Jun 14 - Continuing to monitor risk
still - considered high risk
1
08/05/2014
Work is now ongoing to achieve
sustained improvement through the
matrons and the work streams. The
‘Point of Care to Chair’ (C2C) Quality
and Safety Report for the Board will
ensure that the Board is kept aware of
all issues to enable a prompt response
when required.
12/12/13 Agreement with provider to
undertake SDevon retros reached.
Notification given that no further
investment will be made as information
required as to source and application
of current staffing required. Significant
financial pressure of CHC, recovery
action plan as been requested.
2
05/06/2014
Reporting to Quality Committee.
No assurance coming from SDHFT
06/08/2013: Risk discussed by SMC
A placed people governance meeting
has now been arranged for 4th October
co-chaired by Simon Tapley and Sonja
Manton, Chief Operating Officer of the
Community Provider, to explore those
placements and the associated risks
raised and whether there are
alternative models of providing the
service.
Gill Gant will be a part of the
governance structure.
A report will be brought to November's
Quality Committee.
Discussed / presented at CCG :
TSDHCT Exec to Exec meeting
17/03/2014
NHS England Quality Surveillance
Group 03/02/2014
Adequacy Score
Gap in data on dashboard and
reporting for South Devon. Dependent
on Devon County Council providing a
report of patient names and GP.
Regular meetings set up with NEW
Devon and provider to try and clarify
capacity, controls, and agree business
models for delivery. Internal meetings
between CCG commissioners,
contracting, and quality to scope
options for future models and assure of
CCG robust mechanism in place.
Timeliness
Gail Searle
Draft Service Specification has been
written and with the provider who are
holding off any further comments until
a decision has been made for
investment of £39,500 to take on
quality function for South Devon.
Reporting dashboard is in draft which
provides a summary view of numbers
of patients, reviews undertaken, cost
etc. this is populated for Torbay and
limited for South Devon
Provider has been asked to scope a
business case to undertake the South
Devon (deceased) retrospective
appeals, how many, how much and
how long it will take. Funding will be
sought as a one off.
Following meeting with Provider Head
of Procurement agreed that contracts
will be raised for the 2 LD patients and
responsibility lies with provider when
making a placement.
Basis
JoinedUp Board is considering a
proposal to rectify this risk. It will
require significant system investment.
Sufficiency
None identified.
Scope
Joined-Up Board are currently
considering a proposal from the
Director of Pioneer about hosting the
resource allocated to JoinedUp
concerns. Will go to SLC for further
discussion.
Re-consider staff structure and
especially size of Director portfolios, in
light of CCG wide roles and
responsibilities and ensure balanced
with sufficient clarity about sub
structure (deputy and or acting up lead
senior manager). May require changes
to the staff structure that impacts upon
total costs and running cost allowance
Evidence
JoinedUp Board is discussing this risk None identified
with a view to properly resourcing
Pioneer concerns, however this is a
significant risk and we are already
behind other Pioneer sites.
None
Riskscoretarget
Working with finance team to ensure
regular reporting and review of the
plan.
Gaps reported to and discussed by
SLC / SLT 21/01/2014.
Impacttarget
Director of OD working with finance
None identified
and performance leads to obtain
accurate and up to date information
about workforce. Seminar and report
to GB to ensure that a medium to longterm workforce plan is in place by end
December 2013.
SLC regularly discussing capacity /
availability issues as they arise and
formulate contingency plans as
required.
Likelihoodtarget
24 April 2014 - Pass through drugs is
on the agenda for the hospital Clinical
Management Group on 28th April.
The next stage is to seek engagement
from the five specialties which are the
highest users of these drugs; namely
rheumatology, ophthalmology,
gastroenterology, dermatology and
neurology. A report for each specialty
will be brought back to the High Cost
Drugs group in June and how to
resource the work required will be
discussed. The position of NHS
England with regards to collaborative
working remains unclear so work will
be progressed in CCG commissioned
areas first of all.
Reporting
•Paper about the management of PbR
excluded drugs produced to raise
awareness at board level of the risk
and seek support to develop a
management plan for these drugs
•Collective engagement of acute trust
chief pharmacists
Senior Management Committee
Governing Body
At the SD&T High Cost Drugs meeting
on 23rd April a commitment was made
by senior leadership from SDHFT to
jointly manage this area with the CCG.
Medicines optimisation continues to
work with colleagues across Devon
and with SDHFT in order to manage
the cost growth in pass through drugs.
Actions Progress
•Lack of ownership of the budget by
SDHFT
•Little resource within the current CCG
structure to manage this risk
•Lack of clarity about relationships
between NHS England Specialised
Commissioning and the CCG
Actions
Governing Body
•High cost drugs group reporting to
Joined Up Medicines Optimisation
Group (JUMOG) agenda in place to
manage this agenda
•Pharmacist resource in Medicines
Optimisation team to work on
mitigating the risk
Assurances Gaps
Risk Coordinator
Assurances
Theresa Farris
Jen Baker
Risk Owner
Planona Page Element
Executive Lead
Mark Procter
Larissa Sullivan
Mark Procter
Siobhan Grady
16
Simon Tapley
4
Quality
Safety
Community Services
4
Our Responsibilities
Quality
Quality
54
54 Placed People.xml
Our Responsibilities, Quality
There are a number of risks associated with Placed People in
terms of numbers, financial cost of care and lack of assurance that
these placements are providing safe, effective care. Placed
people encompass Continuing Healthcare (CHC), Learning
Disability, Complex care (Adults and Children).
A summary of the risks are:
a. There is a risk that the CCG will not receive the assurance it
needs to be sure of the quality and safety of care provided to
Placed People in Torbay and South Devon
b. Risk associated with a lack of or weak assurance of quality of
provision for patients placed in South Devon from within the
existing resource.
c. Risk associated with a lack of confirmation of the numbers of
retrospective CHC (deceased) in South Devon (unknown currently).
d. Risk associated with a lack of capacity to undertake
retrospective CHC or appeals for South Devon within existing
resourcing.
e. Risk associated with a lack of clarity on roles and responsibilities
for contracting and ‘strategic commissioning’ where issues of
provision arise including the developing and management of the
NHS care market.
[Includes previous risk 30.]
Controls Gaps
Quality Committee
Governing Body
16
Controls
Jen Baker
4
Louise Hardy
4
Steve Wallwork
16
Our Priorities
4
Our Priorities
Infrastructure
4
There is a risk to JoinedUp that plans will not be properly
communicated to the population and to staff without additional
resource in the form of specific marketing expertise. From this,
there is also a risk that we won't get adequate progress on plans
because the "mission critical" people are not sufficiently engaged.
Infrastructure
103
103 Pioneer Communication.xml
64
64 Succession planning and Resilience.xml
Our Responsibilities, Our Priorities
There is a risk that the organisation's staff structure may be reliant
on key individuals in whose absence is unable to be adequately
covered by other team members. This impacts on capacity and
resilience and delivery of essential services.
Steve Wallwork
16
Sustainable Financial Balance
4
Proud, motivated and skilled Workforce
Achieving National Requirements
4
Excellent Customer Experience and
Outcomes
Collaborative working for all
Finance
86
86 Pass through drugs.xml
There is a risk that drugs which are excluded from payment by
results (Pass through drugs) are the highest growth area of
prescribing and represent significant financial challenge for
SDTCCG. The growth in spend in SDHFT is around 20% and this
cost is passed directly to commissioners. Clarity and robust plans
for the future management of this area of prescribing is required to
mitigate the clinical and financial risks associated with pass
through drugs.
Risk Score
Impact
Likelihood
Name
ID
Risk Category
Risk Description
Planona Page Link
NHS South Devon and Torbay CCG Assuarance Framework - 13 June 2014
Our Priorities
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3
3
8
2
2
4
Yes
3
3
3
3
12
2
4
8
Yes
1
2
3
3
9
09/06/2014
1
4
4
Yes
3
2
4
3
12
30/04/2014
Opened
1
0
4
4
17/09/2013
1
16/01/2014
Yes
27/03/2014
9
16
25/05/2012
Adequacy Score
Risk Score Previous
Timeliness
Impact Previous
Basis
Likelihood Previous
Sufficiency
Review Date
Scope
18/11/2013
Evidence
13/02/2014
Riskscoretarget
4/10/13 organisational pressure Ulcer
Action plan s are monitored in the
CRMs, The appropriate Boards
receives assurance regarding pressure
ulcer activity.
30/04/2014 There is focus on
prevention across the healthcare
community. TSDHCT and SDHFT are
working together. TSDHCT have
agreed a CQUIN to reduce incidence
of G2,3,4 PU by 10%. The number of
inpatient G3 /4 pressure ulcers repoted
by TSDHCT have reduced. This is
monitored monthly as part of their
dashboard. TSDHCT have now
implemented a new Pressure Ulcer
Investigation Tool. SDHFT have
introduced pressure relving mattresses
as standard on A&E trolleys after a
recent safeguarding investigation. The
Safety Thermometer is going to be
monitored as more closley following
recent changes by NHS England. Work
is still ongoing and from some aspect
impact of this work is still awaited.
4
Impacttarget
"A wide range of work has been
implemented to address this issue
including working with Care Homes to
implement a Quality and Effectiveness
Safety trigger tool.
17.06.2013: Progress is reviewed via
the CQRM process.
"
GG is to work to support TSDHCT in a
renewed PUP (Pressure Ulcer
Prevention) initiative and is visiting
Somerset provider in January to see
examples of good practice.
2
Likelihoodtarget
Information has been provided relating None identified
to the provenance of the pressure
ulcers. An in-depth review of reporting
patterns. An annual report on pressure
ulcer related activity. Pressure Ulcers
continue to be reported as SIRIs - work
is underway across the Care homes
and the community teams but
implementation and embedding of the
learning is still required.
17.06.2013: TSDHCT have appointed
a project manager to implement their
Action Plan within their services and in
Care homes.
As part of the requirements for the
Trust Development Authority, TSDHCT
are providing monthly updates to their
Board which they will share with us. All
providers report all grade 3 and 4
pressure ulcers that are reviewed as
part of the SIRI process.
24/07/2013: Quality Committee:
Additional assurance has been
received from TSDHCT - additional
resource recruited. The overall trend is
improving, along with improved data
analysis. The reasons for the relatively
high numbers of pressure ulcers in the
Community is not better understood patients often have this existing
condition when first seen by Health
Visitors, which is the first recording of
the condition.
Group 03/02/2014
A DCC link has been identified through 9.6.14 Reviewed at Quality Directorate,
the Devon CIB, the Designated Nurse remains the same
for Looked After Children has made
initial contact with her and we are
awaiting a response. Any delay in this
will be reported to the QC.
Presence at the Devon LISG and
Devon CIB will improve the access to
up to date information .
2
Reporting
None identified
16
Senior Management
Committee
The controls are opportunistic ways of The Safeguarding Children Report to
gathering the data, the organisation
the QC provides an update against
requires a formal reporting mechanism progress
from DCC to the CCG.
Maintain all local contacts.
Media statement issued.
Staff updated.
Letter sent to providers asking for
assurance.
4
3
Audit Committee
Governing Body
Val Morrell
Quality issues are fed into the CCG's None identified
Quality Committee.
Strategy and non-quality reputational
issues are fed into the CCG's Senior
Leadership Committee.
Risk is on the CCG's Assurance
Framework, and so is seen regularly by
Audit Committee and Governing Body
17/03/2014
Group 16/12/2013, 03/02/2014
4
3
Quality Committee
Val Morrell
Cathy Hooper
Delia Gilbert
Gill Gant
16
Community Services
4
Workstreams and Key Outcomes
Safety
22 Pressure ulcers.xml
The Designated Professionals are
communicating with Devon County
Council representatives regarding how
to obtain the data we require.
The Designated Nurse for
Safeguarding Children now sits on the
Learning & Improvement Sub Group
(LISG) which receives and monitors
the performance data for Devon.
The Director of Quality
Governance,(Executive Lead for
Safeguarding) sits on the DCC
Children’s Safeguarding &
Improvement Board (Devon CIB)
The Designated Professionals Forums
facilitate the sharing of information and
the escalation of concerns
Developmental work has been agreed None identified
and includes working with Care Homes
to implement a Quality and
Effectiveness Safety Trigger tool.
4
Actions Progress
Risk Coordinator
Senior leadership team maintains
None identified
relationships with local NHS leaders
Senior leadership receives advice from
communications team, which maintains
links with communications colleagues
across the provider system.
There is a risk that patients will not receive the appropriate care to
prevent them from developing pressure ulcers.
22
Actions
Katie Ward
Risk Owner
Sallie Ecroyd
Executive Lead
Steve Wallwork
Gill Gant
20
Childrens Services
4
Our Commissioning Priorities
Safety
99 Safeguarding children data.xml
5
Assurances Gaps
Ongoing development (leadership),
Are the communications mechanisms Constant review required
coaching to be available. Constant
adequate to ensure good engagement
review of communications mechanisms for the future?
There is a risk that SDTCCG will be unable to discharge it’s duties
in respect of Section 11 of the Children Act 2004, due to the fact
we do not receive consistent, accurate and reliable data identifying
the children and young people in South Devon who are subject to
Child Protection Plans or Looked After by the Local Authority.
99
Assurances
Quality Committee
25
Controls Gaps
Jen Baker
5
Sallie Ecroyd
5
Our Priorities
Reputation
90
90 CCG Reputation.xml
There is a risk to the CCG's reputation as part of an integrated care
system, through association with adverse behaviour in provider
organisations.
Controls
Steve Wallwork
16
Proud, motivated and
skilled Workforce
4
Our Priorities
4
Outcomes
Risk Score
Impact
Likelihood
Name
There is a risk that clinical engagement will be compromised by
lack of support and adequate focus
Infrastructure
67
67 Clinical engagement.xml
ID
Risk Category
Risk Description
Planona Page Link
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Adequacy Score
Review Date
Likelihood Previous
Impact Previous
Risk Score Previous
2
4
8
Yes
3
2
4
3
12
22/05/2014
5
4
20
11/02/2014
Opened
Timeliness
Daily health community tele22/5/14 - 1) Daily community wide
conferences. Established and in place escalation calls have been supporting
all organisations to pin point pressure
areas and ensure that flow is at an
increased level.
2) Full winter debrief took place on
23rd April 2014 to provide a full review
of pressures experienced and actions
taken by all providers including
processes used in accordance with
(and compliance to) NHS England and
the SD&T Community Wide Escalation
plan. The CCG have requested
expertise from NHS England to
facilitate this session, given the
significant pressures that have been
experienced this winter.
3) The CCG are looking at an
alternative consultant expert in
Emergency department operational
processes to support SDHFT with
reviewing current practice and
identifying opportunities for
improvement
4) Secured an offer from Plymouth
Hospitals NHS Trust to spend some
time with them to understand how they
achieved and sustained particular
improvements in A&E performance
following a period of poor performance
Basis
None identified
Sufficiency
Reporting to Clinical Commissioning
Committee, Senior Leadership Team
and Governing Body in place.
Operational health community
ownership sits with the Urgent Care
Board.
Daily reporting to CCG On Call
Director.
CCG Presentation to NHS England
Area Team: 28/01/2014, 25/02/2014
Group 16/12/2013, 03/02/2014
Scope
None identified
Evidence
Application of escalation funds.
Daily health community teleconferences regarding 4 Hour
operational performance.
Weekly meetings regarding handover
performance.
Riskscoretarget
Actions Progress
Impacttarget
Actions
Likelihoodtarget
Assurances Gaps
Reporting
Assurances
Clinical Commissioning Committee
Governing Body
Controls Gaps
Gail Searle
20
Paul Baker
4
Simon Tapley
5
Quality
Urgent Care
Excellent Customer Experience and Outcomes
Quality
Safety
91 SDHFT 4 Hour performance.xml
There is a risk that patient safety may be compromised if patients
are not being seen within the 4 Hour performance standard and risk
of handover delays from the ambulance to A&E department.
91
Controls
Risk Coordinator
Risk Owner
Executive Lead
Risk Score
Impact
Likelihood
Name
ID
Risk Category
Risk Description
Planona Page Link
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Movement of South Devon and Torbay CCG Risks
April 2014 - June 2014
New risk = 7
Risk closed = 7
Risk movement
Risk at this level < 3 months
= 28
Risk at this level 3-6 months
= 19
Risk at this level 6-12 months
= 24
Risk at this level >1 year
Contingency
=1
Reduce / Transfer
5
90 CCG Reputation
4 NHS Mail
4 NHS Mail
5 Safe Haven
8 Cdiff
5 Safe Haven
9 Contract overspend
14 Secure data
67 Clinical engagement
6 SQL Safe Haven
69 Shared Care
17 Stored data
17 Stored data
22 Pressure ulcers
74 District Nursing
18 CCG receive patient
56 Budget allocation
75 Health indicators
25 Norovirus
86 Pass through drugs
54 Placed People
24 SIRI investigations
4
64 Succession planning
76 Community hospitals
91 SDHFT 4 Hour Wait
103 Pioneer
Communication
26 Privacy Impact
99 Safeguarding children data
82 ICO
93 Data Sharing Agreements
93 Data Sharing Agreements
97 Website security
3 Patient data
94 Leg Ulcers
3 Patient data
31 NICE Hip Fracture
Impact
33 NICE Depression
40 Winterborne View
finance
57 Training Needs Analysis
3
43 CCG budget
87 Long term conditions
87 Long term conditions
44 CHC finance
96 Action reporting
59 Research
27 Children's neurology
89 Looked after children 2
98 NHS 111
73 CAMHS
28 NICE Dementia
100 GP OOH Service
48 Practices federate
78 18 Week RTT
102 Pioneer ICO
61 Management skills
41 Winterborne View Quality
62 Mandatory Training
45 Procurement decisions
15 Meds incidents
50 Primary Care capacity
55 Adult safeguarding
81 Running costs
83 ESR records
88 Looked after children
65 CCG values
104 Pioneer ICO
95 Safeguarding Adults lead
101 Delivery of Financial
performance
71 Personal Health Budgets
84 Payroll
106 Pioneer governance
105 Pioneer project
79 Blood tests
85 Fracture Liaison Service
7 Running costs
2
52 ADHD Prescribing
46 Watcombe Hall
39 Contaminated Drugs
53 Independent hospitals
72 Children's IPPs
63 Induction Training
83 ESR records
19 Cost of AQP
38 Patient group
directives
84 Payroll
1 HR records
35 Paediatric review
1
Accept
1
2
Manage
3
4
5
Likelihood
1 - 3 Low Risk
RiskHeatMap13June20142.x
4 - 6 Medium Risk
7 - 15 Medium Risk
16 - 25 Very High Risk
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Risk Dashboard : 13 June 2014
Reducing Inequalities
Overall Risk Rating
Overall Assurance Rating
75
87
94
106
85
102
105
94
102
105
106
75
Overall Risk Rating
85
71 82 88 89 31 33 45 55 96 102 102 82 89 55 88 96 31 33 45 71
87
Overall Risk Rating
86
101
43
44
78
81
43
100
44
81
100
101
78
86
Our Priorities
90
Excellent customer experience & effective outcomes
Overall Risk Rating
103
79
87
78
85
104
78
103
104
85
87
90
79
Collaborative working with communities
Overall Risk Rating
103
106 102 104 105
90
102
105 103 104
106
90
Proud, motivated & skilled workforce
Overall Risk Rating
64
67
65
63
57
61
62
57
62
61
63
65
64
67
Quality
Overall Risk Rating
79
Patient Experience
79
Safety
Overall Risk Rating
74
79
55
96
98
24
39
24
39
55
74
96
98
79
Clinical Effectiveness
Overall Risk Rating
59
59
Promoting self-care, prevention and personal responsibility
Overall Risk Rating
87
87
Developing joined up community hubs closer to home, for all
Overall Risk Rating
76
76
Leading a sustainable health and care system, encompassing workforce,
Overall Risk Rating
76
93
3
83
84
4
5
14
17
26
97
6
18
97
14
17
83
3
4
84
5
6
26
18
76
93
Workstreams & Key Outcomes
Children's Services
Overall Risk Rating
99
27
73
72
35
73
35
27
72
Community Services
Overall Risk Rating
99
Overall Risk Rating
41
53
54
41
54
53
Overall Risk Rating
69
79
50
50
48
46
69
79
Planned Services
Overall Risk Rating
95
78
95
74
28
46
8
25
22
25
8
74
Mental Health Services
Overall Risk Rating
Primary Care
48
22
52
52
28
Long Term Conditions
Overall Risk Rating
87
87
Urgent Care
Overall Risk Rating
78
91
91
Overall Risk Rating
86
69
38
15
39
15
38
39
86
69
Key
Risk rating
15 - 25
Very high risk
- reported to Audit Committee
High Risk
- reported to Senior Management
8 - 12 Committee
4- 6
Medium risk
- managed by Directors
Low risk
1 - 3 - managed by teams
No risks recorded in this area
RiskDashboard13June2014.xl
Assurance RAG
Weak assurance.
Very limited reliance can be placed on
0 - 7 this evidence
Moderate assurance.
Limited reliance can be placed on this
8 - 10 as evidence
Strong assurance.
This evidence can be strongly relied
11 - 13 upon
No risks recorded in this area
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3
10
1
4
4
Yes
3
3
3
3
12
1
4
4
Yes
1
2
3
3
9
1
4
4
Yes
1
3
4
3
11
1
4
4
Yes
3
2
3
3
11
2
4
8
4
4
16
2
4
8
3
4
12
3
4
12
Opened
3
20/03/2013
3
20/03/2013
1
20/03/2013
Yes
16
20/03/2013
4
4
10/01/2013
4
4
21/02/2013
1
Risk Score Previous
12
Impact Previous
3
Likelihood Previous
3
Review Date
3
21/05/2014
3
21/05/2014
Yes
21/05/2014
4
22/01/2014
4
27/03/2014
1
21/05/2014
None Identified
Adequacy Score
To form a part of Information
Governance update to Quality
Committee 3 times per year.
Regular item on IG Forum agenda.
Timeliness
Staff initially set up with wider access
than necessary.
SDHIS also have the ability to move
staff between groups without the
CCG being informed.
Regular audits in 2014 show that
user access remains true from one
audit to the next.
Basis
Jen Baker
All new staff have access granted
through a nomination process,
checked by the CCG Information
Governance team.
All new requests for access to the N
drive are made by the IG team.
An audit of N drive users is underway
- any staff with wider access than
necessary for their role will be
removed from certain folders where
needed.
Jan 2014: Monthly audits of user
access carried out, and compared to
records of newly-granted access.
leavers / Starters built into the access
process.
Action 1:
13.06.2013: Although there is still a
risk that the trusts may exceed the
total number of C.difficile cases this
year, since this was added to the RR
we have work streams in place from
various disciplines throughout the
trusts looking at ways of reducing the
risks. Many disciplines are looking at
various ways to reduce the figures
for example auditing antibiotic use,
raising awareness in the media, and
researching the use of probiotics and
other risk factors.
19.08.13 work on C.difficile to reduce
cases continues. At the moment we
are running at target.
Action 2:
14/11/2013 - update from Linda
Churm - IP&C meeting identified that
GPs are currently unable to flag
patients with c.diff because still
waiting for new computer system.
IP&C have decided to turn their
equivalent risk to White because this
risk is out of their control.
27/3/2014 - update from Linda
- GPscarried
in process
of tagging
1. Define process for staff access to N Churm
Audits now
out routinely.
drive. COMPLETE 25/02/2013
2. Complete audit of N Drive users.
3. Remove access where appropriate.
4. Repeat audit of N drive under the
guidance of the Information Security
specialist.
Sufficiency
Quarterly report to Quality
None Identified
Committee.
Monthly report to Governing Body.
Cdiff data is now included in the
Quality Dashboard.
Area Team: 13/08/2013, 4/12/2013,
28/01/2014, 25/02/2014
Group 16/12/2013, 03/02/2014
Meeting arranged with South Devon
HIS to define and refine permissions
and process for controlling access.
Jan 2014 : no issues with the SQL
server reported. Current risk score
has reduced to target score.
Scope
Reported to Information Governance None Identified
Forum on a monthly basis, and
escalated to Quality Committee by
exception.
No overview of access permissions
available to CCG.
Corporate Affairs Manager adds /
removes staff access to N Drive
folders.
Regular reviews of Folder access
carried out.
performance Safe Haven folder set
up with access for 5 staff on a rolebased basis.
Evidence
Staff access to data stored on SQL
server is by Head of Dept authority.
Additional folders added to the N
Drive where access is restricted to 2 3 members of staff only, for specific
purposes - e.g. CEfF folder.
CCG able to add / remove
permissions to all folders on N Drive
Riskscoretarget
Reported to Information Governance None identified
exception.
Impacttarget
Staff access to N drive folders is
None identified
through a formal request process
overseen by the Corporate Affairs
team.
Additional folders have been created
with much narrower role-basedaccess permissions granted.
Information Security team to extend
routine screening of NHSMail access
by mobile devices to include all CCG
users, including associated GPs, and
follow up any usage on unencrypted
devices found.
Likelihoodtarget
Reported to IG Forum monthly as
None identified
part of the KPIs report and to Quality
Committee by exception.
Reporting
Access to NHS Mail by NHS Devon
None identified
users has been monitored previously
and is planned to continue.
User reports for the CCG's area are
sent by the HSCIC and received by
Gary Kennington in TSDHCT for
analysis and onward reporting to the
CCG.
Unsafe users are notified by email
and are expected to improve their
practice.
Quality Committee
Corporate Affairs have control of N
Drive folders and user permissions.
User permissions are audited at least
quarterly (including a leavers
process) - 01 October 2013, Dec
2013, March 2014, May 2014.
Work on Accellion is proceeding storage will be hosted by SDHIS.
Accellion rolled out to all directorates
April 2014.
Quality Committee
Accellion being worked up as an
alternative secure data store, with
role-based permission access a
prerequisite.
Quality Committee
Reported to Information Governance None identified
exception.
Val Morrell
Linda Churm
Phil Stimpson
Mark Procter
4
Leading a sustainable health and care system
4
Information
14 Secure data.xml
RiskRegister13June2014.xls
1
Actions Progress
Risk Coordinator
Gail Searle
Jen Baker
Risk Owner
Paul Baker
Phil Stimpson
Executive Lead
Mark Procter
Gill Gant
12
Community Services
4
3
There is a risk that data on shared
drive is not secure
14
Staff access to N drive folders is
None identified
through a formal request process
overseen by the Corporate Affairs
team.
User access audited monthly by
Information Asset Owner (Corporate
Affairs Manager).
Ongoing monitoring and reporting at None Identified
Quality Committee.
Action plan with SDHFT.
Safety
8 C Diff.xml
There is a risk that the Cdiff targets
will be exceeded in the health
community, which includes both
secondary and community care. The
target is 77 community, 18 acute
with a total of 95
8
Actions
Quality Committee
4
Assurances Gaps
Governing Body
Quality Committee
4
Assurances
Quality Committee
1
Jen Baker
4
Controls Gaps
Leanne Willey
4
Phil Stimpson
Information
1
There is a risk that the SQL Safe
Haven is not effective.
Information
6
6 SQL Safe Haven.xml
5
5 Safe Haven.xml
There is a risk that the Safe Haven on
the N shared drive is not secure.
Sian Faulkes
8
Mark Procter
4
Mark Procter
2
Controls
Mark Procter
Information
4
4 NHS Mail.xml
There is a risk that mobile devices will
receive NHS Mail in an unsecure
manner
Infrastructure
Infrastructure
Leading a sustainable health
Leading a sustainable health and care Leading a sustainable health and care Leading a sustainable health and care system Planona Page Element
and care system
system
system
3
3
1
Information
3
3 Patient data.xml
There is a risk that the
Commissioning team hold patient
data on an insecure part of the N
shared drive.
Risk Score
Impact
Likelihood
Name
ID
Risk Category
Risk Description
Planona Page Link
NHS South Devon and Torbay CCG Risk Register - 13 June 2014
1.Action plan with SDHFT
2. GPs to flag notes of patients with
c.diff on GP IT systems.
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Yes
3
2
3
3
11
2
2
4
Yes
1
2
2
3
8
1
4
4
Yes
3
2
4
3
12
3
4
12
4
4
16
4
4
16
Opened
4
9
28/02/2013
4
3
11/01/2012
1
3
18/03/2013
9
25/05/2012
3
Risk Score Previous
3
Impact Previous
2
Likelihood Previous
1
Review Date
4/10/13 organisational pressure
Ulcer Action plan s are monitored in
the CRMs, The appropriate Boards
receives assurance regarding
pressure ulcer activity.
30/04/2014 There is focus on
prevention across the healthcare
community. TSDHCT and SDHFT are
working together. TSDHCT have
agreed a CQUIN to reduce incidence
of G2,3,4 PU by 10%. The number of
inpatient G3 /4 pressure ulcers
repoted by TSDHCT have reduced.
This is monitored monthly as part of
their dashboard. TSDHCT have now
implemented a new Pressure Ulcer
Investigation Tool. SDHFT have
introduced pressure relving
mattresses as standard on A&E
trolleys after a recent safeguarding
investigation. The Safety
Thermometer is going to be
monitored as more closley following
recent changes by NHS England.
Work is still ongoing and from some
aspect impact of this work is still
awaited.
Yes
12/03/2014
"A wide range of work has been
implemented to address this issue
including working with Care Homes
to implement a Quality and
Effectiveness Safety trigger tool.
17.06.2013: Progress is reviewed via
the CQRM process.
"
GG is to work to support TSDHCT in a
renewed PUP (Pressure Ulcer
Prevention) initiative and is visiting
Somerset provider in January to see
examples of good practice.
20/06/2013: CCG involved in national
discussions.
07/10/2013: CCG received
confirmation from HSCIC that IG
Toolkit submission was sufficient for
ASH accreditation.
29/11/2013: CCG to submit a second
Data Sharing Contract with the HSCIC
to cover activities up to 30/11/2014.
Jan 2014: CCG achieved ASH level 1
status.
CEfF set up.
SDHFT agreed to start sending
backing data for invoices to the CCG.
10/03/2014: Virtual Ward data is
flowing again and reports are being
generated for Practices.
21/05/14: Due to sign a contract with
a DSCRO within next month.
3
21/05/2014
Information has been provided
None identified
relating to the provenance of the
pressure ulcers. An in-depth review
of reporting patterns. An annual
report on pressure ulcer related
activity. Pressure Ulcers continue to
be reported as SIRIs - work is
underway across the Care homes and
the community teams but
implementation and embedding of
the learning is still required.
17.06.2013: TSDHCT have appointed
a project manager to implement their
Action Plan within their services and
in Care homes.
As part of the requirements for the
Trust Development Authority,
TSDHCT are providing monthly
updates to their Board which they
will share with us. All providers
report all grade 3 and 4 pressure
ulcers that are reviewed as part of
the SIRI process.
24/07/2013: Quality Committee:
Additional assurance has been
received from TSDHCT - additional
resource recruited. The overall trend
is improving, along with improved
CCG to apply for S251 exception.
CCG to apply for Safe Haven
Accreditation.
CCG to ascertain the cost of a DMIC
service. CCG to explore possibility of
seconding staff to our local Data
Management Information Centre
(DMIC), Best West (SWCSU)
3
21/05/2014
Developmental work has been
None identified
agreed and includes working with
Care Homes to implement a Quality
and Effectiveness Safety Trigger tool.
Cost of the DMIC solution.
Long term situation regarding the
CCG receiving and processing data.
Lack of information on longer term
"Data Services for Commissioners
Regional Office" (DSCRO) solution.
1
30/04/2014
Issue discussed at CCG SMC
19/03/2013.
Chief Operating Officer briefed by
SIRO.
Risk to be discussed in more detail at
SMC on 17 June 2013.
Senior leadership team and
Governing Body briefed on latest
developments by SIRO and head of
performance.
Due to sign a contract with a DSCRO
within the next month.
Adequacy Score
CCG are developing with NEW Devon Lack of national guidance and
CCG, Dorset CCG and Kernow CCG.
worked examples to indicate how
NHS England Area Team are involved this work should proceed.
in discussions.
Regular discussions by email and
teleconference with local colleagues
in Business Intelligence and with the
Health and Social Care Information
Centre (HSCIC).
CCG have achieved ASH level 1 status this means that the backing data for
Invoice Validation can be received by
the CCG within a new Controlled
Environment for Finance (CEfF)
Timeliness
Personal drives available for all staff
on SDHIS network.
Accellion rolled out, with training, to
all directorates April 2014.
Basis
Turn IT Strategy into CCG Policy.
Make Accellion data storage available
to all CCG staff.
Jan 2014: Migration of personal
drives into the CCG's secure area
started 20/01/2014.
Sufficiency
None Identified
Scope
The SDHIS IT Strategy specifically
includes Accellion storage for the
CCG.
Information security issues are
reported to CCG Information
Governance Forum and Quality
Committee.
Evidence
Personal network drives are available Personal network drives now
from SDHIS on request.
provided to CCG staff by default.
Accellion will be the data storage
solution of choice in future, and will
avoid the need for any local data
storage.
Jan 2014: program of work started
within SDHIS to move all data on
personal drives (G, M etc) within the
CCG's N Drive area.
Riskscoretarget
4 Feb 2014 No reported incidents
received or information from the
area team suggesting shared learning
is not in place. The area team are
dealing with incidents and we are no
longer part of the process but would
like assurance that shared learning is
taking place.
12 March 2014 Discussion at Quality
Committee following Area Team
response. Assurance is improving but
risk remains. Likelihood reduced.
Recent MHRS PSA document
ref:NHS/PSA/D/2014/005 suggests a
new structure for networking,
waiting on response.
Impacttarget
26 June 2013 We are keeping an
audit trail of incidents that are
received and subsequently directed
to the Area Team (AT) to ensure that
all reports received are passed on
appropriately until the reporting
route has been cascaded to providers
from the AT.
4 Feb 2015. Request issue is
discussed at area team meetings
Likelihoodtarget
Regular reporting to Quality
None Identified
Committee, where these issues will
be discussed with the managerial and
clinical leads.
Reporting
None Identified
Actions Progress
Quality Committee
Report written for discussion within
CCG.
Actions
Quality Committee
Assurances Gaps
Governing Body
Leanne Willey
Val Morrell
Delia Gilbert
16
Gill Gant
4
Community Services
4
Safety
22 Pressure ulcers.xml
There is a risk that patients will not
receive the appropriate care to
prevent them from developing
pressure ulcers.
22
Assurances
Theresa Farris
Mark Procter
Iain Roberts
Jo Turl
8
Mark Procter
4
2
Information
18 CCG receive patient data.xml
There is a risk that the CCG is unable
to receive patient data
18
Controls Gaps
Quality Committee
4
Jen Baker
4
Phil Stimpson
1
Information
17
17 Stored data.xml
There is a risk that personal data
stored locally may be lost.
Mark Procter
4
2
2
Safety
15 Learning from medicines incidents.xml
There is a risk of lack of clarity on
responsibility for sharing the learning
in response to medicines incidents
15
Controls
Risk Coordinator
Risk Owner
Executive Lead
Risk Score
Impact
Likelihood
Name
ID
Risk Category
Risk Description
Planona Page Link
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2
4
3
12
1
4
4
Yes
1
2
3
3
9
1
3
3
Yes
1
2
3
3
9
1
3
3
Yes
1
2
2
3
8
4
4
16
3
4
12
5
3
15
5
3
15
Opened
Yes
25/05/2012
4
12
25/05/2012
4
3
15/06/2012
1
4
15/06/2012
12
Risk Score Previous
3
Impact Previous
4
Likelihood Previous
2
Review Date
3
12/06/2014
Yes
02/06/2014
4
21/05/2014
4
05/06/2014
1
01/04/2014
Benchmark the Dementia NICE
Quality Standards against current
activity at the Mental Health CPG.
From BPP 15/08/2013 part 3.4.4:
Progress locally against the dementia
strategy is considered to be ahead of
the trajectory, with work well
underway in engagement, education
and prevention.
Adequacy Score
An implementation plan has been
None identified
developed based on the National
Dementia Strategy A self-assessment
against National objectives (including
NICE) has been carried out by the
Devon Cluster Dementia Steering
Group.
Timeliness
None identified
Discussions are in progress with
Torbay's Children's Services around
the use of CAF and the long-term
development of the pathway. Plan
developed by provider to manage the
waiting list.
Awaiting assurance regarding
progress of the action plan.
From BPP 15/08/2013 part 3.7.1:
Joint commissioning intentions for
community services for 0-19 year
olds are being scoped with local
authority colleagues and partners
from primary care and education.
Basis
Jo Hooper
Simon Tapley
Childrens Services
New pathway compliant with NICE
guidelines
Gail Searle
Gail Searle
12
Derek O'Toole
3
Simon Tapley
4
Discussion with community provider None identified
who are keen to lead pathway.
BPP process modified to include PIA
considerations.
20/06/2012
Privacy Impact Assessment policy to
be written and approved by Quality
Committee. This may be as part of
the CCG's Data Protection Policy.
SDHIS policy shared with CCG.
PIA questions to be included within
BPP process.
Sufficiency
Reporting to Information Governance None Identified
Forum and Quality Committee
monitored by the Infection Control
Lead; review of recent RCA reports to
determine if incidents are from inpatients from other organisations or
from the community i.e. relatives.
02.06.14: The risk remains low but
with Norovirus there is always the
possibility that numbers will increase
over a short space of time. The
hospitals always remain alert.
Scope
Privacy Impact Assessments will form
a part of early work in all new
projects identified within the CCG.
PIA carried out for eShare.
Basic PIA questions are included in
the Business Planning and
Performance project template.
Reporting to Quality Committee; SIRI 24.06.2013: Action taken to manage 24.06.2013: Further action is
reports identifying learning following on-going outbreaks that are linked to required i.e. review/changes of
reporting of Norovirus ward closures fulfilling the category of a SIRI
community deep clean processes.
24/07/2013: Quality Committee
satisfied that norovirus is at a low
rate locally and so risk score can be
reduced.
Actions taken at senior level have not
been recorded.
24/07/2013: Much improved
reporting of incidents from providers.
Area Team: 13/08/2013, 4/12/2013,
28/01/2014, 25/02/2014
Evidence
Val Morrell
Linda Churm
24.06.2013: HPA community Tools
e.g (vomitometer) may not be
routinely used.
Riskscoretarget
Fourteen are currently at the review
process stage and eight are awaiting
SHA Action.
The number of outstanding SIRIs
grade 2 is 7. A request has been sent
to the Cluster on 24/7/12 to stop the
clock to await the outcome of a
serious case review meeting.
4/10/13 The SIRI Policy has now been
approved by the Quality Committee. .
The Child Health Safeguarding
Assurance group - is leading on the
development of a flow chart for the
CCG but this will be shared with the
DCIOS Area Team who are leading on
this for the peninsula. Regular
monitoring meetings continues with
providers - monthly reports have
shown a steady reduction in overdue
incomplete investigations and these
are either 0 or less than 5 excluding
DPT.
21/2/14 DPT have been given a
target of 5 overdue incomplete
investigations by the IPAM. SDT CCG
will be meeting with the Director of
Nursing on a monthly basis
3.6.14
- DCIOS
are also
monitoring
24.06.2013:
These
are being
Impacttarget
SIRIs are regularly reviewed and
extensions granted where
appropriate.
Have liaised closely with Providers
and have encouraged them to send
in their outstanding report as soon as
possible.
Provide Investigation training to
acute trust.
17.06.2013: Develop a Newsletter
21/2/14 Monthly reports include
themes and trends. The Yellow
Submarine Newsletter has contained
some key learning from individual
SIRIS that are relevant to GPs. The
format of the Yellow submarine will
now be used for the SIRI learning. A
flow chart delineating the
relationship between Child deaths
and SIRIS has been sent to NEW
Devon CCG Designated Nurse and the
DCIOS Area team who are leading the
CDOP review.
3.6.14 - The draft CDOP process
includes the flow chart but has not
been ratified yet.
Likelihoodtarget
None Identified
4/10/13 SDHFT are currently not able
to provide assurance regarding
completion of Investigation action
plans. This has been escalated to the
Director of Professional Practice at
SDHFT via the CRM.
21/2/14 SDHFT have agreed to
provide quarterly updates on all
actions following SIRI investigations SDT CCG are awaiting the first update
.
Reporting
Update STEIS with progress of
investigation. Provide details of the
investigation including root cause,
actions and any learning from the
incident.
17.06.2013: Monitoring sheet to
provide data regarding providers'
and CCGs performance.
Report to Quality Committee
development of Newsletter for
dissemination of further learning.
3/10/13 Regular monthly reports are
presented to the Quality committee providing detail on themes and
trends as well as specifics.
Group 16/12/2013, 03/02/2014
Quality Committee
The CCG has set up its own internal
processes for the monitoring and
reviewing of incidents, including a
SIRI panel which reviews all Serious
Incidents before advising on closure.
Further clarity is required regarding
the interrelationship between the
Child Death Overview process, the
role of the Child Death Rapid
Response Team and the SIRI process.
Quality Committee
Val Morrell
Delia Gilbert
Gill Gant
Safety
Continue to work with and
encourage timely reporting with
Provider services. Monitor at Quality
Committee. Increased capacity within
the Quality Team has improved the
review turn around time. Extensions
are granted where there are Serious
Case Reviews, Inquests or internal
staffing issues. The revised process
(March 2012) for reporting and
learning from SIRIs has been
circulated to the major providers.
17.06.2013: The Area Team has
circulated a revised process for the
framework for managing SIRIs. The
draft CCG policy incorporating the
revised framework and
recommendations from an internal
audit review carried out across the
Cluster in February 2013 is due to go
to the Quality Committee in June
2013. The Area Team will be having
bi-monthly meetings with the CCG
SIRI lead to monitor progress.
21/2/14 The Safeguarding adult and
patient safety lead and / or patient
safety administrator continues to
meet
on a monthly
basis with
Monitoring
by the Infection
control
Monitor at Mental Health Redesign
Board and IPAM
12
3
Safety
4
There is a risk that NICE guidance on
Dementia is not embedded in service
redesign.
Actions Progress
Joint working with Devon on
None identified
community based pathways and
service specification supported by
clinical leads and health care
professional.
Close scrutiny by BPP. Raised through
JTWG.
Safety
28 NICE Dementia guidance.xml
28
27 Children's neurological assessments.xml
There is a risk of long waits for
children's neurological assessments
and lack of clarity for future provider
of assessments
27
Actions
Quality Committee
8
Assurances Gaps
Quality Committee
4
Assurances
Quality Committee
2
Phil Stimpson
Information
26
26 Privacy Impact.xml
There is a risk that patient / person
confidentiality is not considered
during projects.
Phil Stimpson
8
Gill Gant
4
Mark Procter
2
Controls Gaps
lead, Quality Committee, HCAI
committee
(Devon/SD&Torbay/Plymouth)
Community Services
Safety
25
25 Norovirus.xml
There is a risk of widespread
disruption across the healthcare
community due to norovirus.
8
Quality
4
2
Safety
24 SIRI investigations.xml
There is a risk that there may be
delays in implementing
improvements in care if SIRI
investigation reports are not
completed within set timescales.
24
Controls
Risk Coordinator
Risk Owner
Executive Lead
Risk Score
Impact
Likelihood
Name
ID
Risk Category
Risk Description
Planona Page Link
RTT action plan established and
additional staffing to be funded via
SDHFT. Pathway development to
change referral route in ongoing with
Torbay and South Devon CIS, SDHFT
and CPG.
Summer 2012 - waiting list split
between Torbay and South Devon.
25/11/13 - Action plan being taken to
BPP today.
8/1/14 - Continued meetings with
SDHCT. Data requested to better
understand waiting list. Further
report to go to BPP.
6/2/14 - negotiations through
contracting and JTWG re new
pathway
11/3/14 - discussed at Paediatric
CPG, concern raised at lack of patient
awareness of pathway issues.
Meeting between senior provider
and commissioner managers
scheduled end of March 14.
5/6/14 - Both providers (Care Trust
and Acute) to provide costings and
comments on new service
specification.
Was
to be to be
18/12/14 - DoH
selfdue
assessment
completed in next month. This will
be used to inform dementia
implementation plan for 2014
1/4/14 - Devon wide dementia
strategy agreed. Local action plan
being developed. Public engagement
event scheduled for 12th May 2014
to inform improvement plan
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Opened
1
15/06/2012
Yes
15/06/2012
3
15
12/10/2012
3
3
24/07/2013
1
5
24/07/2013
8
Risk Score Previous
3
Impact Previous
2
Likelihood Previous
2
Review Date
1
06/03/2014
Yes
05/06/2014
3
04/02/2014
3
12/03/2014
1
04/06/2014
Adequacy Score
03/06/2014 update below:
Pt 1 - was discharged to a residential
home in March 2014. The longer
term plan is for Pt 1 to return to
Torbay and be supported in
supported living accommodation
Pt 2 - remains in in-patient treatment
and assessment accommodation. It
is anticipated that Pt 2 will be
discharged from In-patient services
within 12 months.
Pt 3 - remains in In-patient treatment
and assessment accommodation. It
is anticipated that Pt 3 will be
discharged from In-patient services
within 3 months.
Pt 4 - remains on section 37/41. Pt 4
moved to a locked but not secure
unit in January 2014 as part of
recovery plan. It is anticipated that
Pt 4 will be discharged from Inpatient services within 6 months.
Pt 5 - remains in In-patient services
and has been assessed as not yet
ready for discharge. is hoped that Pt
5 will be discharged from In-patient
services within 3 months.
Pt 6 - remains on section 117
Timeliness
From BPP 15/08/2013 part 3.8.2:We
have 5 patients currently in inpatient
care. A case review has been held for
all within the required timeframe.
03/06/2014 - Advice sought as to
reporting on those patients where
alternative placements in area are
inappropriate to meeting complexity
of need.
Basis
NHS England has set up a Quality
None identified
Surveillance Group which is attended
for the CCG by Gill Gant and Sam
Barrell.
Sufficiency
No comprehensive alerting system in Public health, Torbay working to raise 3.10.13 The risk to the population
operation. A new alerting system
awareness of any contaminated
has reduced as there is a now a
drugs getting into circulation.
system in place - however the
default is that every one recieves all
alerts as there is no screening in the
Area team to determine the
appropriateness of each alert. Om
discussion with Bruce bell in Public
Health the risk rating is now 2x2.
4 Feb 2014 A new alerting system
launched by NHS England will ensure
warnings of potential risks to the
safety of patients can be developed
much more quickly and be rapidly
disseminated right across the NHS.
detailed information not yet received
to assess if this will mitigate this risk.
12 March 2014 - Risk was discussed
at Quality Committee and is to
remain open subject to clarification
from Public Health
Scope
Val Morrell
CCG will have to work with patient's
wishes regarding their move to Home
care. Patients may choose to stay in
Hospital setting.
Public Health at Torbay Council are
aware of the problem and are
working with local knowledge and
liaising with the Area team .
Commissioner and Provider Meeting The actions taken to-date by SDHFT
to discuss improvement plans.
offer very positive assurance - risk
04.072013: A stakeholder meeting
much reduced.
was held in May 2012 which
established some key principles of
care to which the CPG could aspire.
At the Quality Review Meeting in
August 2012 it was noted that SDHFT
have achieved outstanding
milestones within their selfassessment against 34 standards.
Evidence will be required at the next
follow-up meeting.
Evidence
Val Morrell
Child Health Review Action Plan 2012 None Identified
Riskscoretarget
Gail Searle
Derek O'Toole
Shona Charlton
Gill Gant
9
3
3
None Identified
Impacttarget
25 Nov 13 - no update
30 Apr 14 - Derek O'Toole emailed
Vanessa Ford at Devon Partnership
Trust to request evidence of
assurance in relation to NICE
guidance. 6 May 14 - reply from
Vanessa advising will respond asap.
5 Jun 14 - Derek sent email to chase
response - requested by end of Jun
14.
Likelihoodtarget
Liaise with the commissioner and
CPG re: benchmarking the
Depression QS
Reports from CPG does not include
this measure.
6/3/14 - Flagged through the
Fracture Liaison Service Task & Finish
Group and will be reported to ECN
group in April or May 14
Reporting
25/11/13 - Ongoing action with Falls
CPG
Quality Committee
Commissioner/Service re-design
Manager to add NICE Quality
Standards to the next CPG meeting to
identify data requirements in order
to benchmark current activity against
the quality indicators.
Quality Committee
None Identified
Quality Committee
Risk Coordinator
Reports from CPG does not include
this measure.
Gail Searle
Risk Owner
Jon Sewell
Executive Lead
Simon Tapley
Simon Tapley
Achieving National Requirements Planona Page Element
Monitor at Urgent and Emergency
Care Network
CCG are aware of 5 patients who
should be moved from Hospital care
to Home care as a result of the
Winterborne Review
recommendations.
Quality
41 Winterborne View - quality.xml
Actions Progress
The Area Team have responsibility
Replacement CAS cascade not
for the process and are aware of the working effectively following NHS
Gap and putting temporary systems commissioning reorganisation .
in place.
launched February by NHS England
will ensure warnings of potential risks
to the safety of patients can be
developed much more quickly and be
rapidly disseminated right across the
NHS
There is a risk that patients cannot be
moved in line with Winterborne
Review recommendations
41
Actions
Quality Committee
4
Assurances Gaps
Quality Committee
2
Assurances
Theresa Farris
2
Jo Hooper
1
Iain Roberts
1
Controls Gaps
Monitored at the Performance,
None Identified
Contracting, Quality Review Meetings
Gill Gant
Quality
1
There is a risk that knowledge
concerning contaminated drugs will
not be alerted across the CCG
footprint as responsibility for
cascading alerts (Local and national
CAS) to independent providers has
passed to the Area team and systems
are not yet in place .
Safety
39
39 Contaminated drug alerts.xml
35
35 Paediatric review.xml
There is a risk that actions from
Paediatric review are not completed.
Controls
Monitor at Mental Health Redesign
Board and IPAM
Mark Procter
9
3
Childrens Services
3
Depression is not embedded in
service redesign.
9
3
Risk Score
Impact
Likelihood
Name
Safety
3
33
Hip Fracture is not embedded in
service redesign.
Safety
31
33 NICE Depression guidance.xml 31 NICE Hip Fracture guidance.xml
ID
Risk Category
Risk Description
Planona Page Link
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3
3
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1
3
4
3
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3
3
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3
3
9
3
4
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4
3
12
Opened
3
24/07/2013
Yes
24/07/2013
6
9
24/07/2013
3
3
18/07/2013
2
3
30/07/2013
12
Risk Score Previous
3
Impact Previous
4
Likelihood Previous
2
Review Date
31 Oct 13 - Discussions with Area
Team on level of practical and
financial support still underway
9 Jan 14 - Discussions on level of
practical and financial support are
still underway with Area Team as
part of co-commissioning of primary
care arrangements.
22 May 14 - Locality commissioning
groups continuing discussions on
collaboration.
3
31/05/2014
Discussion/debate underway with
NHS E area team about this,
researching how this has been
approached in other areas.
From BBP 15/08/2013 part 3.1.1: The
Primary Care Strategy has now been
signed off by the Primary Care
Network. Practices are actively
meeting to discuss the future
configuration of practices as well as
exploring the possibility of
developing a provider organisation
which covers the CCG area; these are
medium to long-term plans.
The majority of LES’s have now been
reviewed, only two remain
outstanding, which will be completed
before the end of August 2013.
Yes
31/05/2014
PCRB strategic committee, taking
None identified
responsibility for this decision.
Area Team: 4/12/2013, 28/01/2014,
25/02/2014
13/11/2013: Graham Lockerbie
provided an update: on behalf of
NHS England, Capsticks (firm of
lawyers) have sent a letter to the
Huntercombe Group regarding the
NHS England view and are waiting for
a response from the Huntercombe
Group.
10/4/14 - Meeting held with GP
practice, commissioners and Area
Team (Graham Lockerbie) to discuss
options for provision of primary care
services to the Huntercombe Group
(Watcombe Hall). Agreed that
practice would need to consider the
primary healthcare needs of each
individual patient in terms of
registering and meeting need under
GMS or whether each is considered
complex and out of general GMS.
Practice will be in communication
with Huntercombe and copy to CCG
so that arrangements for meeting
patient health needs is flagged and
covered at contract review meeting.
9
31/05/2014
Gail Searle
Christine Branson
Simon Tapley
Primary Care
12
3
CCG to work with NHS England Area
Team to ensure Watcombe Hall
private hospital provide adequate
primary care for their registered
patients, and do not try and rely on
local GP cover. [cf GPs do not attend
to Torbay Hospital patients for
primary care needs.]
3
10/04/2014
Reporting to CCG Committees.
None identified
NHS England are working closely with
the Huntercombe Group at a national
level on this issue, using Capsticks
(firm of lawyers) to communicate
with the Huntercombe group.
Establish contract database and
undertake basic risk assessment to
identify high risk contracts for further
review. Identify current status of all
contracts and timeline to complete
reviews for non-high risk contracts.
Process led by BPP group.
3
22/05/2014
Monitored via Contracts meetings
with Huntercombe Group.
None identified
None identified
Adequacy Score
Monthly performance reporting to
Governing Body. Further in depth
review at Finance Committee.
Controls assurance process through
Governing Body. BPP oversight of
contracts database.
Timeliness
Development of a contracts database None identified
and minimum dataset configured
around commissioner responsibilities
in procurement regulations 2013.
Procurement strategy and ongoing
procurement workplan. Support and
advice from SW CSU procurement
function.
Being reviewed/discussed at primary None identified
care re-design board with includes
NHS E area team colleagues. Will
need to agree position statement as
a result of this discussion.
4
None identified
Basis
Ongoing difficulty around
management capacity in TSDHCT to
undertake work and business cases
to support the reviews. NHSE now
proposing risk pool solution for 14-15
and centralised management of
retrospective claims prior to
01/04/13 on NHSE balance sheet.
Impact to be evaluated.
Governing Body. Discussed /
presented at CCG : TSDHCT Exec to
Exec meeting 17/03/2014
Sufficiency
Continually refresh intitial risk review
and evaluation, including claim
process timeline by June '14.
Monthly/Quarterly monitoring
process through report as part of
NHS England Non-ISFE route.
Review of retrospective claims
None identified
ongoing with establsihed team.
Establish intitial risk assessment of
claims outstanding and review
timeline. Reporting progress through
to NHS England Central Team as part
of 2013-14 year-end.
Scope
Discussions ongoing with respective
commissioning organisations with
regard to three broad areas: i) NEW
Devon issues include £454k for RD&E
specialised commissioning and
£4million for the west Devon element
of the TSDHCT contract. Other issues
may emerge as discussions proceed.
Some issues are cost neutral to both
CCGs (west Devon issue) others are
not (RD&E issue).
ii) Specialised commissioned revised
algorithm if based on 13/14 outturn
iii) Any others not yet known about.
Evidence
Continue to work with finance
colleagues to evaluate the nature
and extent of financial risk and
how/where this has arisen. Consider
escalating to DCIOS Area Team if not
locally resolveable. Impact across
DCIOS Area Team reviewed by
Regional finance team. Agreement
reached between BNSSSG and DCIOS
Area Teams and CCG to transact
required adjustments for 14/15 at
Month 4 was identified and agreed.
Riskscoretarget
None identified
Impacttarget
Governing Body.
Likelihoodtarget
None identified
Reporting
Reconciliation of contract
information. Ongoing contact with
respective leads from NEW Devon
CCG and BNSSSG & DCIOS AT.
Recurrent impact on the CCG's
finances from 13/14 adjustments.
Review of specialist algorithm in
2014/15 could impact further.
Continue to review until final
transactions enacted.
Quality Committee
Actions Progress
Finance Committee
Governing Body
Actions
Finance Committee
Governing Body
Assurances Gaps
Finance Committee
Governing Body
Assurances
Gail Searle
Siobhan Grady / Shona Charlton
Simon Tapley
6
Primary Care
2
Safety
3
There is a risk of lack of clarity on
who should or could provide support
and or funding to practices wishing
to collaborate (federate or merge).
This could impact on the POAP
priority to “encourage collaboration
between practices to deliver the best
services for patients at a time it is
needed.”
Finance
48 GP Practices federate.xml
48
46 Watcombe Hall.xml
There is a risk that patients at
Watcombe Hall are not receiving
adequate primary care
46
Controls Gaps
Finance Committee
Leanne Willey
Derek Blackford
Derek Blackford
Simon Bell
Simon Bell
Leanne Willey
Leanne Willey
9
Sam Morton
3
9
Simon Bell
3
3
9
3
3
3
Finance
There is a risk that procurement
decisions taken by the CCG will be
challenged legally or else reviewed
and/or declared ineffective by
Monitor
Finance
44 CHC - finance.xml
There is a risk that retrospective
continuing care claims received prior
to 1st April will be more expensive
than the associated provision
inherited from precursor
organisations. NHS England is
responsible for theses arrangements
through the Risk Pool Arrangements
for 2014-15. This still exposes CCGs
to the risk determined by the extent
to which claims are reviewed and
settled during the financial year and
the contributions increase over plan.
Finance
45
45 Procurement decisions.xml
44
43 CCG budget.xml
There is a risk that budgets and
commissioning responsibilities will be
misaligned in the process to establish
CCG and NHS England budgets.
43
Controls
Risk Coordinator
Risk Owner
Executive Lead
Risk Score
Impact
Likelihood
Name
ID
Risk Category
Risk Description
Planona Page Link
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3
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Opened
2
3
29/07/2013
12
15/08/2013
3
15/08/2013
4
Risk Score Previous
2
Impact Previous
3
Likelihood Previous
Yes
Review Date
3
09/01/2014
9 Jan 14 - Temporary resolution
reached locally by ensuring the
extension of an SLA between the
independent provider and the GP
surgery in one case, and the other
providers have confirmed that they
have adequate arrangements in
place (either their residents are
registered with local practices or they
have an SLA) for both in hours and
out of hours.
12/06/14 - There is still an
outstanding issue with one private
provider who has received 4
registration application forms this
week.
Two GP’s from the practice are
meeting with the Lead Clinician at the
hospital to individually assess each
case and to discuss the particular
healthcare issues affecting the 4
patients in particular prescribing.
Practice is also contacting the MDU
to establish what would be covered if
practice were to enter into any
SLA/Shared care agreement and also
the issue of patients who are under a
section. We are awaiting an update
3
12/06/2014
From BPP 15/08/2013 part 3.8.1:To
ensure mainstream care for people
with Learning Disabilities by
commissioning inclusive services.
A risk was highlighted relating to
assurance of independent hospitals
in our patch where we may or may
not have patients placed (this is not
specific to learning disabilities
patients). It was noted by the group
that work was underway to mitigate
against this risk but that Governing
Board members should be made
aware.
1
12/06/2014
None identified
Adequacy Score
Reporting up through CCC, BPP and
Quality Committee to GB.
Area Team: 13/08/2013
Timeliness
None identified
Basis
25/11/13 - meeting today with Chris
Roome, NEW Devon Meds ops lead Derek O'Toole to attend and agree
actions
12/6/14 - Situation remains the
same. Issues being picked up by Area
Team and Mental Health Redesign
Board
Sufficiency
From BPP 15/08/2013 part 3.4.1:To
assertively manage patients in
primary care, through joined up
mental health community teams.
The first and current phase of this
major redesign is engagement with
our key stakeholders, with several
events which occurred throughout
May and June. Feedback from the
events has been very useful in
informing this work stream and is
broadly in line with the outcomes
already described on the POAP.
The current risk being highlighted for
this work stream is ADHD shared care
prescribing. Prescribing has not
transferred into primary care as
expected. A meeting with the
relevant clinical leads is set up. If this
does not progress discussions with
Devon Partnership will need to take
place.
Scope
None identified
Evidence
Reporting to CCC and then onto the
BPP.
Riskscoretarget
None identified
Impacttarget
9 Jan 14 - The evaluation has been
completed which showed positive
practice feedback on the schemes,
particularly Doctor First, but no
consistent effect on hospital use or
patient satisfaction. This will be
reviewed again in six months.
Likelihoodtarget
From BPP 15/08/2013 part 3.2.1: The
three schemes to help increase
capacity in primary care are now
underway in many practices (Dr First,
Productive General Practice and
Urgent Access General Practice). An
assessment and comparison of their
value will be undertaken by end
December 2013 for BPP to
recommend which scheme should be
promoted across the CCG.
Work to develop and implement a set
of metrics to understand and review
primary care capacity is behind the
timeframe but progress has been
made and continues to develop.
Reporting
Discussed at Clinical Commissioning
Committee
Area Team: 4/12/2013
Actions Progress
Actions
Quality Committee
Gail Searle
Shona Charlton
4
Simon Tapley
2
2
Mitigation work underway.
Safety
53 Independent hospitals.xml
There is a risk that the CCG is not
able to receive assurance that
patients placed by other
commissioners are safe in
independent hospitals within our
geographical area.
53
Assurances Gaps
Gail Searle
Derek O'Toole
Simon Tapley
8
2
Infrastructure
52 ADHD prescribing.xml
Meeting with relevant clinical leads
set up.
4
Assurances
Gail Searle
Christine Branson
9
Simon Tapley
3
Primary Care
3
Discussed at BPP
There is a risk that ADHD prescribing
has not been transferred into
primary care.
52
Controls Gaps
Risk Coordinator
Risk Owner
Controls
Executive Lead
Risk Score
Impact
Likelihood
Name
There is s risk that the CCG is not able
to increase capacity in primary care
sufficiently to allow practices to cope
with increasing rates of consultation
and provide prompt patient access to
reduce reliance on other services.
Not all practices engaged in a CCG
funded “development” initiative to
address this. This will affect the
ability to deliver the POAP priority of
“optimise and increase capacity in
primary care in order to treat more
patients, only going to secondary
care when necessary.”
Infrastructure
50
50 Primary Care capacity.xml
ID
Risk Category
Risk Description
Planona Page Link
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1
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Opened
6
16
16/08/2013
3
4
16/08/2013
2
4
22/08/2013
11
06/09/2013
3
17/09/2013
4
Risk Score Previous
3
Impact Previous
1
Likelihood Previous
Yes
Review Date
8
05/06/2014
4
12/06/2014
2
10/03/2014
Jen Baker
Paul Hurrell
CCG engagement with the Academic
Health Science Network (AHSN) and
local Primary Care Research Network
(PCRN) to find innovative ways to
promote and encourage research
within the member practices of the
CCG.
Adequacy Score
Research activity and promotional
activity carried out in primary care is
reported at Quality Committee and
within the GP bulletin
Timeliness
Publication of Research Governance
Policy on provider websites
Regular research activity reports
from PenCLAHRC and PCRN
Training Needs Analysis now
completed using the data from staff
PDPs.
Some PDPs remain outstanding.
Talent Manageent process is being
developed.
The SLA with South Devon Healthcare
NHS Foundation Trust for HR services
is being reviewed.
Basis
None identified
Sufficiency
Regular reporting to Senior
The HR Group meets monthly to
discuss the issue, keeping it under
review - Steve Wallwork, Mark
Procter, Louise Hardy, Ian Leather,
Marianna Gray
work - the first peninsula
Safeguarding Adult network meeting
is due to be held in October 2013 led
by the CDIOS Area Team.
21/2/14 The DCIOS Area team has
had two forum meetings so far - the
aim of these is to determine the role
and purpose of the group and how it
relates to local authorities. The TORs
are currently being redrafted for
agreement at the next forum
meeting
3.6.14 - The DCIOS area team have
had a business case agreed for a
safeguarding nurse to be asked by
each CCG to cover children and
adults. Each local area also will have
1 GP session per week.
The forum will continue to develop
once these people are in post.
Scope
To work with the Area team to
provide clarity regarding areas of
responsibilities for Independent
Contractors.
Develop relationships with
independent hospital providers to
provide support to enable providers
to provide safe effective care.
Continue to implement the CCG
safeguarding work plan
21/2/14 Impelment the four
recomendations from the external
safegaurding review:- completion of
the mapping of training needs within
the CCG; development of
comprehensive guidance regarding
the sharing of information with
external agencies in the light of the
recent reorganisation of the NHS;
the impact of the review of the
Caldicott Principles which identify key
principles which should be adhered
to when sharing information;and
updating the existing safeguarding
adults policy and strategy upon
publication of the Care Bill.
Evidence
A process by which the CCG can gain
assurance from providers in relation
to the specific criteria within the
operating principles.
Riskscoretarget
The CCG has a statutory
responsibility to gain assurance that
providers are safeguarding their
patients from harm and are providing
safe effective care to their patients
and have systems and processes in
place by which to achieve this.
The CCG has close working
relationships with Devon and Torbay
Safeguarding Teams, membership of
Devon and Torbay Boards and sub
committees and the partner
agencies, NEW Devon safeguarding
leads, the Area Team and providers.
The Area Team are responsible for
managing the contracts of
independent contractors (GPs,
dentists, Optometrists and
community pharmacists)
These relationships will provide
indications of any issues
Impacttarget
The CCG has a statutory
.Non identified
responsibility to gain assurance that
providers are safeguarding their
patients from harm and are providing
safe effective care to their patients
and have systems and processes in
place by which to achieve this.
The CCG has close working
relationships with Devon and Torbay
Safeguarding Teams, membership of
Devon and Torbay Boards and sub
committees and the partner
agencies, NEW Devon safeguarding
leads, the Area Team and providers.
There is a CCG safeguarding strategy
and policy in place with the CCG
working to both Devon and Torbay
Multi-agency policies and
procedures. Providers, dependent
upon location, work to the relevant
local authority multiagency policies
and procedures.
Each provider has a NHS contractor
where safeguarding is identified as a
specific item – the CCG supports the
contract by the use of Operating
principles.
The
jointbudget
commissioning
lead woks
Training
now in place:
need None identified
to commission a training needs
analysis, to include full review of
personal development plan outputs,
team reviews and benchmarking with
other CCGs.
Reporting to Senior Leadership
Committee in April 2014.
10 Apr 14 a & b) TSDHCT have provided
evidence of their monitoring of
quality of placements and regular
reports which include action being
taken where concerns are flagged.
This is comprehensive for Torbay and
CCG are assured however the roll out
and process for placements made in
South Devon remains outstanding.
c) A final number of South Devon
retros was received in January 2014
however additional unknown by SDT
CCG further cases were received in
March. Decision taken at PPGG that
no further cases would be expected
and those considered not to be SDT
CCG would be returned.
d) Discussion with the TSDHCT
provider in prioritising the allocation
of additional £250k in areas of
greatest impact as part of Service
Development Improvement Plan.
e) TSDHCT report due PPGG May
2014 which should cover source,
application and function of the
Placed People Function. Following
this
CCG This
can take
to of
4/10/13
is andecision
ongoing as
piece
Likelihoodtarget
Work is now ongoing to achieve
sustained improvement through the
matrons and the work streams. The
‘Point of Care to Chair’ (C2C) Quality
and Safety Report for the Board will
ensure that the Board is kept aware
of all issues to enable a prompt
response when required.
12/12/13 Agreement with provider
to undertake SDevon retros reached.
Notification given that no further
investment will be made as
information required as to source
and application of current staffing
required. Significant financial
pressure of CHC, recovery action plan
as been requested.
Reporting
Reporting to Quality Committee.
No assurance coming from SDHFT
06/08/2013: Risk discussed by SMC
A placed people governance meeting
has now been arranged for 4th
October co-chaired by Simon Tapley
and Sonja Manton, Chief Operating
Officer of the Community Provider,
to explore those placements and the
associated risks raised and whether
there are alternative models of
providing the service.
Gill Gant will be a part of the
governance structure.
A report will be brought to
November's Quality Committee.
17/03/2014
Group 03/02/2014
Quality Committee
Governing Body
Actions Progress
CCG Ratified Research Governance
Strategy.
Mark Procter
9
Clinical Effectiveness
3
Quality
3
Actions
Governing Body
Quality Committee
Gap in data on dashboard and
reporting for South Devon.
Dependent on Devon County Council
providing a report of patient names
and GP.
Regular meetings set up with NEW
Devon and provider to try and clarify
capacity, controls, and agree
business models for delivery.
Internal meetings between CCG
commissioners, contracting, and
quality to scope options for future
models and assure of CCG robust
mechanism in place.
Assurances Gaps
Senior Management
Committee
Draft Service Specification has been
written and with the provider who
are holding off any further comments
until a decision has been made for
investment of £39,500 to take on
quality function for South Devon.
Reporting dashboard is in draft which
provides a summary view of numbers
of patients, reviews undertaken, cost
etc. this is populated for Torbay and
limited for South Devon
Provider has been asked to scope a
business case to undertake the South
Devon (deceased) retrospective
appeals, how many, how much and
how long it will take. Funding will be
sought as a one off.
Following meeting with Provider
Head of Procurement agreed that
contracts will be raised for the 2 LD
patients and responsibility lies with
provider when making a placement.
Quality schedules within Provider
AHSN not active until 2014
contracts states ‘Research
Audit+ software and training not yet
Governance Policy - the provider
available at CCG
should actively promote and monitor
the uptake of research in clinical
practice’.
Reputation
59 Research.xml
fulfilling its statutory duty in
promoting research and the use of
research evidence.
59
Assurances
Quality Committee
Governing Body
Val Morrell
Jen Baker
Gill Gant
Safety
Delia Gilbert
Marianna Gray
3
Mark Procter
3
9
Proud, motivated and skilled
Workforce
1
3
3
Our Priorities
Safety
There is a risk that staff will not be
able to access sufficient training in
role, due to lack of clarity around
training needs analysis.
Infrastructure
57 TNA Risk.xml
57
55 Adult Safeguarding.xml
will not be sufficiently safeguarded
by independent healthcare
providers.
55
Controls Gaps
Senior Management
Committee
Gail Searle
Siobhan Grady
16
Simon Tapley
4
Quality
Safety
Community Services
4
Quality
Quality
54
54 Placed People.xml
There are a number of risks
associated with Placed People in
terms of numbers, financial cost of
care and lack of assurance that these
placements are providing safe,
effective care. Placed people
encompass Continuing Healthcare
(CHC), Learning Disability, Complex
care (Adults and Children).
A summary of the risks are:
a. There is a risk that the CCG will not
receive the assurance it needs to be
sure of the quality and safety of care
provided to Placed People in Torbay
and South Devon
b. Risk associated with a lack of or
weak assurance of quality of
provision for patients placed in South
Devon from within the existing
resource.
c. Risk associated with a lack of
confirmation of the numbers of
retrospective CHC (deceased) in
South Devon (unknown currently).
d. Risk associated with a lack of
capacity
undertake
retrospective
There is atorisk
that vulnerable
adults
Controls
Risk Coordinator
Risk Owner
Executive Lead
Risk Score
Impact
Likelihood
Name
ID
Risk Category
Risk Description
Planona Page Link
Plan to roll out a ‘Manager’s Toolkit’ None identified
training system to ensure consistent
and high standards of management.
The CCG's HR Group meet monthly to
discuss this issue - Steve Wallwork,
Mark Procter, Louise Hardy, Ian
Leather, Marianna Gray.
This will be provided either internally, None identified
or through future SLA with external
provider. Budget in place
SLA with South Devon Healthcare
NHS Foundation Trust to provide HR
services is under review.
The Management Toolkit is under
development.
10/03/2014
Jen Baker
Marianna Gray
3
Mark Procter
3
skilled Workforce
1
Our Priorities
There is a risk that management skill
will not be of a sufficiently high
standard in the CCG to guarantee
performance against objectives
Infrastructure
61
61 Management skills.xml
Procurement of software (Audit+) to
enable local research activity to take
place
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3
9
3
2
6
Yes
1
1
3
3
8
3
2
6
Yes
1
2
3
3
9
3
3
9
Yes
1
1
3
3
8
1
1
1
Yes
1
3
1
3
8
2
2
4
4
3
12
4
3
12
4
4
16
3
4
12
Opened
3
17/09/2013
2
17/09/2013
1
17/09/2013
Yes
8
17/09/2013
4
4
17/09/2013
2
2
25/09/2013
2
Risk Score Previous
10
Impact Previous
3
Likelihood Previous
3
Review Date
3
13/03/2014
31 Oct 13 - Pan-Devon progression
on review and development of the
shared care monitoring specification
remains slow and it remains
unchanged.
9 Jan 14 - A pan Devon proposal for
shared care is now available and has
been discussed with the LMC.
However, there is not yet clarity on
agreeing prices or turning the
proposal into a specification in time
for 1st April.
1
13/03/2014
A commitment has been given by
None identified
NEW and SDT CCG to review the
shared care local enhanced services
in operation across Devon (as the
medicines optimisation
arrangements that support it are panDevon);
Yes
16/01/2014
None identified
3
13/03/2014
Gail Searle
Christine Branson
Simon Tapley
2
Primary Care
Developing joined-up patient centred services
2
1
Are the communications mechanisms Constant review required
adequate to ensure good
engagement for the future?
3
18/11/2013
Ongoing development (leadership),
coaching to be available. Constant
review of communications
mechanisms
None identified
1
22/05/2014
Working with teams and individuals
to agree behaviours and ensure
accountability mechanisms in place
Re-consider staff structure and
especially size of Director portfolios,
in light of CCG wide roles and
responsibilities and ensure balanced
with sufficient clarity about sub
structure (deputy and or acting up
lead senior manager). May require
changes to the staff structure that
impacts upon total costs and running
cost allowance
Adequacy Score
Ongoing focused work with teams
and whole organisation to ensure
buy-in to espoused values and
behaviours.
Induction Training delivered for 15
newer members of staff on
15/11/2013.
Timeliness
Working with finance team to ensure None
regular reporting and review of the
plan.
Gaps reported to and discussed by
SLC / SLT 21/01/2014.
Organise Induction training for all
new starters.
Basis
Director of OD working with finance None identified
and performance leads to obtain
accurate and up to date information
about workforce. Seminar and
report to GB to ensure that a
medium to long-term workforce plan
is in place by end December 2013.
SLC regularly discussing capacity /
availability issues as they arise and
formulate contingency plans as
required.
No clear mechanism for ensuring
people are held accountable for
behaviours
None
Sufficiency
To be reviewed after one year
Scope
A new corporate induction is being
Is this often enough?
designed and will be delivered twiceyearly. Meanwhile new staff can
attend corporate induction at SDHFT
Evidence
Induction Training for 15 members of
staff held on 15/11/2013.
Riskscoretarget
ESR leads to advise on best access
routes to e-learning on ESR.
Organise Induction and Mandatory
face-to-face training for all staff.
Impacttarget
None
Likelihoodtarget
Working with ESR leads to ensure
smooth implementation.
Reports scheduled to go to Quality
Committee - May 2014.
Reporting
Lack of accessibility and ease of use
of ESR may be a barrier to uptake
Currently setting up e-learning
through ESR.
ESR being populated.
Programme now agreed.
HR SLA under review.
Actions Progress
Quality Committee
Actions
Senior Management
Committee
Quality Committee
Assurances Gaps
Senior Management
Committee
Assurances
Senior Management
Committee
Controls Gaps
Primary Care Redesign Board
Quality
69
69 Shared Care.xml
There are a number of risks relating
to Shared Care:
•A commitment has been given by
NEW and SDT CCG to review the
shared care local enhanced services
in operation across Devon (as the
medicines optimisation
arrangements that support it are panDevon);
•Chris Roome has made a good start
pulling together a discussion paper
but not aware that anything else has
happened since.
•Our timescale for all local enhanced
service reviews was that review
process would need be complete by
the end of June. That gave us time to
complete the procurement decision
making process in July and August.
Final sign off etc would then take
place in September, to ensure that
providers have six months notice of
our intentions from April 2014.
•The six months also allowed us to rewrite specifications and draw up new
contracts, and if contestability was
indicated, run a procurement
Controls
Risk Coordinator
Jen Baker
Jen Baker
Jen Baker
Jen Baker
Katie Ward
Risk Owner
Marianna Gray
Marianna Gray
Mark Procter
Executive Lead
Mark Procter
Mark Procter
Our Priorities
skilled Workforce
skilled Workforce
Proud, motivated and skilled Workforce
Steve Wallwork
Steve Wallwork
Steve Wallwork
Sallie Ecroyd
16
Our Priorities
Risk Score
Impact
4
12
Steve Wallwork
4
3
16
Workforce
4
4
4
Our Priorities
Infrastructure
Infrastructure
Likelihood
4
2
3
Workforce
There is a risk that clinical
engagement will be compromised by
lack of support and adequate focus
2
3
Our Priorities
There is a risk that staff are unclear
about how to translate the agreed
values of the organisation into
acceptable behaviours, and that this
will have a material impact on
motivation
Infrastructure
Name
There is a risk that the organisation's
staff structure may be reliant on key
individuals in whose absence is
unable to be adequately covered by
other team members. This impacts
on capacity and resilience and
delivery of essential services.
1
Our Priorities
67
There is a risk that a lack of a regular
corporate induction means that new
staff are unclear of their roles and
about the organisation
Infrastructure
65
There is a risk to the organisation as
a result of no clear mandatory and
essential training framework.
Infrastructure
64
64 Succession planning and Resilience.xml 63 Induction training.xml 62 Training framework.xml
63
65 CCG Values.xml
62
67 Clinical engagement.xml
ID
Risk Category
Risk Description
Planona Page Link
22 May 14 - Pan-Devon specialised
medicines service agreed with the
LMC, including prices. With minor
local variations, adopted by south
Devon and Torbay CCG. Risk
essentially now closed - needs to be
agreed by committee.
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3
3
Yes
1
2
3
3
9
1
3
3
Yes
1
3
4
3
11
3
12
2
3
6
3
3
9
Opened
1
4
10/10/2013
8
09/09/2013
3
10/10/2013
3
Risk Score Previous
1
Impact Previous
1
Likelihood Previous
No
Review Date
4
05/06/2014
1
05/06/2014
4
05/06/2014
Adequacy Score
5 Jun 14 - On going vacancies remain
an issue with agency staff covering
where possible.
Agreement reached with SCG who
will fund £250k towards Assertive
Outreach Service with CCGs picking
up the remainder. Virgin Healthcare
have begun recruitment with service
up and running expected by
September. This will cover Devon incl
South in phase 1 with Torbay being in
Phase 2.
Negotiation between Torbay CAMHs
and Torbay schools underway to
invest in additional Tier 2 work and
discussion with children social care as
to the model of service delivery for
Children looked after.
Demand continues with priority given
to clinical need. Crisis referrals
(those requiring next working day
assessment) has increased by 34% in
2013/14 in Torbay, both Torbay and
South Devon service are
experiencing not only an increase in
demand but also complexity and
acuity of cases presenting.
Working with NEW Devon CCG and
Timeliness
9/1/14 - Vacancies within service
have been recruited to with staff
commencing in Jan/Feb. Contract
review with South Devon service is
considering the proposed staffing
increase as well as progressing the
business case for Assertive Outreach
Team across Devon and Torbay with
confirmation of funding from SCG
outstanding. Urgent referrals are
being prioritised. Despite this the
services are reporting increasing
referrals and impact on wait and
treatment times with capacity being
able to meet demand.
Basis
Gail Searle
Gail Searle
No assurances identified
Sufficiency
Jo Hooper
Siobhan Grady
None identified
17/03/2014
Group 16/12/2013, 03/02/2014
Scope
Gail Searle
Simon Tapley
Simon Tapley
No controls identified
Evidence
Siobhan Grady
Childrens Services
Childrens Services
None identified
Quality
73 CAMHS.xml
5 Jun 14 - Information and resources
have been developed for patients
and websites updated informing
them of PHBs.
Living Options Devon (having secured
a funding bid) will begin a one year
project across Devon (incl Torbay) in
9 Jan 14 - CCG part of accelerated
raising awareness of PHBs.
learning programme for Personal
Testing of the assessment tool and
Health Budgets being run in the
indicative allocations have been
region, which provides resources and piloted on a small number of adult
access to support and advice. Local patients in South Devon.
meeting held between CCG and
Awareness training for staff is
TSDHCT and DPT to discuss actions. arranged and information for staff
Workforce awareness and training
developed.
date to be arranged. SDT CCG
Draft CCG policy for PHB has been
implementation plan is to be part of written and being further developed
the wider NEW Devon CCG who had with relevant staff in TSDHCT who
dedicated project manager leading
administer the PHB on behalf of the
implementation.
CCG.
Further discussion with Devon
County Council is underway for
agreeing support planning and
payment system.
Further work still remains in relation
to a readiness for an increase in
requests as well as being able to
requests
fromwith
children.
Torbay Council has a dedicated
Where placements are made by the Monthly meetings established
TC has reported they are unable to
Meeting arranged for early October respond
6 Feb 14 to
- CCG
is working
local A
specialist commissioner for children’s local authority the CCG does not hold between NEW Devon and SDT CCG
achieve high levels of quality
with commissioners involved in CYP and national parties to prepare for
placements. Placements are made
quality or safeguarding assurances
Children’s Commissioners.
monitoring for DP’s provided on our IPPs including Safeguarding to better education, health and care plans
using a Peninsular AQP framework, and does not manage quality
From Apr 14 Virgin takes on joint
behalf.
understand LA quality assurance
(EHC plans) and introduction of
unless needs and outcomes cannot monitoring.
funded IPP from DCC which will bring
processes.
personal budgets.
be met for very specialist EHC.
Devon County Council and Virgin
all children and young people into
TC has been asked to scope the
5 Jun 14 - i) In addition to work with
South Devon and Torbay CCG are
Care Limited remain responsible for one process. SDT CCG receiving more
assurances they can provide where Local Authority parties, the CCG
included in quality and contract
Children’s IPPs in South Devon.
detailed information from virgin
DP’s are made and indicate to the
appointed personal health budget
monitoring where NEW Devon are
Direct payments as part of IPP
CCG any financial implication to their consultant for a 3 month period to
the lead commissioner for a health
packages are intrinsically difficult to
continued management of this
get the CCG into state of readiness
focused service.
provide appropriate assurances for,
quality assurance.
for PHBs. ii) Torbay Council have
given that finances are managed by
Children’s Commissioning Manger
been asked to detail the quality
individual members of the public.
and Designated Nurse Safeguarding assurance process for existing Direct
and LAC have agreed to visit, during payments. This may result in
2014/15, those organisations
additional costs to CCG.
providing the greatest number of
placements to enable additional
quality assurance and build
relationships.
Riskscoretarget
Simon Tapley
6
9
Need to define a mechanism to
process all requests for Personal
Health Budgets across the whole
CCG's area.
Raise staffing issue - no capacity
within the CCG at present.
Impacttarget
3
3
No assurances defined.
Likelihoodtarget
2
3
None
Actions Progress
Reporting
12
There is a risk that the CAMHS service
is not meeting the needs of the
service users. This includes autistic
spectrum disorder.
73
Actions
3
72 Children's IPPs.xml
72
Assurances Gaps
Quality Committee
4
There is a risk that assurances for
Children’s IPPs and direct payments
made to parents, are not effectively
managed by those making
placements/ payments, to which the
CCG contribute, including placements
made by education and local
authority. [Was Risk 60]
Assurances
Quality Committee
Infrastructure
CCG are aware that Devon County
No controls defined.
are able to process these requests, at Pilot schemes carried out in the
a cost of c.£500 a time.
Torbay area in recent years are
unlikely to now be good enough for
the CCG to use.
Quality
71 Personal Health Budgets.xml
prepared for receiving applications
for Personal Health Budgets.
71
Controls Gaps
Risk Coordinator
Risk Owner
Controls
Executive Lead
Risk Score
Impact
Likelihood
Name
ID
Risk Category
Risk Description
Planona Page Link
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Yes
1
2
3
3
9
1
4
4
Yes
1
1
3
3
8
2
2
4
Yes
1
3
4
3
11
3
4
12
3
4
12
4
3
12
Opened
4
16
11/10/2013
4
4
30/09/2013
1
4
17/10/2013
9
22/10/2013
3
Risk Score Previous
4
Impact Previous
1
Likelihood Previous
1
Review Date
Yes
12/02/2014
4
03/06/2014
4
06/03/2014
1
03/06/2014
waiting over 52 weeks identified and
prioritised. Patient Access Policy in
draft.
4 Feb 14 - Work plan still in progress
and SPIG consulted on Patient Access
Policy. 52 week waiters are being
monitored via Joint Technical
working group.
3/6/14 - Good progress with
orthopaedics in line with backlog
reduction plan. Upper GI and
Ophthalmology issues reported - to
be monitored through JTWG.
Adequacy Score
Theatre efficiencies work plan in
place at Torbay Hospital, Patient
Access Policy revisited, MSK CPG
work streams targeted at Ready,
Willing and Able- ensuring that
Patients and Trust prepared for
surgery.
Timeliness
Performance report to Governing
None identified
Body, Planned Care Strategic
Network work plan
Area Team: 13/08/2013, 28/01/2014,
25/02/2014
Basis
None identified
Sufficiency
Theatre efficiencies work plan in
place at Torbay Hospital, Patient
Access Policy revisited, MSK CPG
work streams targeted at Ready,
Willing and Able- ensuring that
Patients and Trust prepared for
surgery.
[02/08/2013 15:09:53 Jennifer Mills,
TSDHCT Risk 218] The consultation
period has concluded and the Board
has had to decide to pause the
process. The CCG are now developing
engagement proposals to take
forward planning around the future
use of community hospitals. This has
reduced the likelihood of
reputational risks materialising for
the Trust, but our ability to move to
cost effective service models which
maximise the the utilisation of assets
is significantly constrained and
maintaining the agreed clinical
staffing ratios (of 1.2 per bed) and
essential hotel services it will only be
possible to find savings in hospital
services on a non-recurrent basis
through reduction in non-staff
budgets and keeping tight control on
bank / agency spend. The suggested
revised risk rating of 12 is as agreed
through the CIP impact assessment
process and reflects the operational
pressures inherent in maintaining the
current spread & configuration of
community
beds.
Work plan inhospital
progress,
patients
Scope
Work with TSDHCT Medical Director
on reviewing medical cover
arrangements in community
hospitals.
Evidence
None identified
Reporting to Clinical Commissioning
Committee
6 Feb 14 - Emma Herd meeting with
Caroline Dimond w/c 10 Feb 14 and
will discuss possible options,
including a joint commissioning
reporting process or CCG forum.
3 Jun 14 - CCG Governing Body
agreed on 22nd May 14 prevention
plan would report to Joint
Commissioning Group. Workplan
currently being developed.
Riskscoretarget
None identified
Reporting mechanism to be agreed.
Impacttarget
As above - this needs to be further
discussed internally within the CCG.
Likelihoodtarget
There is currently no specific forum Reporting to Quality Committee
to discuss the progress of these plans
and bring to the attention of relevant
bodies. There has been a suggestion
this could be through the Joint
Commissioning reporting process
and this will be explored.
Reporting
The referral assessment tool
continues to be used and clinics have
been set up for mobile patients in NA
and Torbay which has eased some of
the pressures
Recruitment is ongoing and there has
been success in recruiting to a
peripatetic team (2 staff so far)
The situation continues to be
monitored at a local level between
Zones and Practices.
Gail Searle
Simon Tapley
Simon Tapley
There is an action plan in place:
Triage processes have been put in
place to ensure that cases are
appropriately triaged. Tools are
being introduced to ensure that
patients are directed to the most
appropriate services. The measures
in place are anticipated to be for 3
months duration. A letter has been
sent to all practices asking for help
and support for the DN service.
Risk Coordinator
Val Morrell
Risk Owner
Solveig Sansom
Executive Lead
Gill Gant
The situation will be monitored
None identified
closely by the commissioning team
and the senior management at
TSDHCT. Quality performance
indicators will be kept under review.
Situation is being monitored by the
provider through their usual
mechanisms ( eg QuESTT)
Group 16/12/2013, 03/02/2014
Quality Committee
9
Gail Searle
3
Rebecca Foweraker
3
Simon Tapley
Also refer to Risk Entry 10 (Closed risk logged by Finance team)
Quality
There is a risk that, due to demand
and capacity at Torbay Hospital,
waiting times will exceed 18 weeks
and failure to achieve key RTT
performance standards at SDHFT.
Planned Services
12
4
Our Priorities
Infrastructure
76 Community hospitals.xml
78 18 week RTT.xml
78
Formal consultation process was
approved by TSDHCT Board in
November 2013.
Regular discussions with TSDHCT on
this issue.
3
Actions Progress
The referral assessment tool
continues to be used and clinics have
been set up for mobile patients in NA
and Torbay which has eased some of
the pressures
Recruitment is ongoing and there has
been success in recruiting to a
peripatetic team (2 staff so far)
Health Inequalities assessment
embedded within Business planning
process
Specific Plan to address Health
Inequalities
There is a risk that the Community
Provider's improved use of
community hospitals will not result in
targeted financial savings. [This risk
links with TSDHCT risk 218]
76
Actions
Quality Committee
9
Assurances Gaps
3
Assurances
Governing Body
3
Controls Gaps
There is an action plan in place and No control over sickness levels and
the CCG has asked for support from being able to fill vacancies
Primary care. Triage processes have
been put in place to ensure that
cases are appropriately triaged.
Tools are being introduced to ensure
that patients are directed to the most
appropriate services. The measures
in place are anticipated to be for 3
months duration.
Gail Searle
There is a risk that some sectors of
the population have worse health
indicators and outcomes than others
and hence consume greater
proportions of resources over time.
Not addressing these Health
inequalities therefore will have
significant impacts on the reputation,
the financial position and the quality
of the overall offer.
Health inequalities is a key target
area
Emma Herd / Caroline Dimond
The situation has improved however
there remain pockets of pressure
within the teams and this is being
managed at a local level between
zones and practices
Controls
Simon Tapley
12
Safety
Community Services
4
3
Quality
Quality
Concern that this is likely to increase
pressure on Primary Care at a time
when likely to be under winter
pressures
Quality
75
75 Health indicators.xml
74
74 District Nursing.xml
There is a risk that patient safety
could be compromised by the current
unprecedented situation in District
Nursing, where the staff sickness
levels and difficulty recruiting has
reduced DN capacity during a time of
high levels of demand.
Risk Score
Impact
Likelihood
Name
ID
Risk Category
Risk Description
Planona Page Link
Page10of15
OverallPage137of153
Top
4
2
8
Yes
1
3
4
3
11
1
3
3
Yes
1
3
4
3
11
1
3
3
Yes
3
4
3
10
1
3
3
Yes
1
3
2
3
9
2
1
2
Yes
1
3
2
3
9
3
3
9
3
4
12
3
3
9
3
3
9
3
3
9
4
4
16
Opened
12
22/10/2013
3
13/11/2013
4
25/11/2013
2
13/12/2013
3
12
13/12/2013
Yes
3
04/11/2013
4
4
23/12/2013
24 April 2014 - Pass through drugs is
on the agenda for the hospital
Clinical Management Group on 28th
April.
The next stage is to seek engagement
from the five specialties which are
the highest users of these drugs;
namely rheumatology,
ophthalmology, gastroenterology,
dermatology and neurology. A
report for each specialty will be
brought back to the High Cost Drugs
group in June and how to resource
the work required will be discussed.
The position of NHS England with
regards to collaborative working
remains unclear so work will be
progressed in CCG commissioned
areas first of all.
2
Risk Score Previous
•Paper about the management of
PbR excluded drugs produced to
raise awareness at board level of the
risk and seek support to develop a
management plan for these drugs
•Collective engagement of acute
trust chief pharmacists
2
Impact Previous
At the SD&T High Cost Drugs meeting
on 23rd April a commitment was
made by senior leadership from
SDHFT to jointly manage this area
with the CCG.
Medicines optimisation continues to
work with colleagues across Devon
and with SDHFT in order to manage
the cost growth in pass through
drugs.
•Lack of ownership of the budget by
SDHFT
•Little resource within the current
CCG structure to manage this risk
•Lack of clarity about relationships
between NHS England Specialised
Commissioning and the CCG
8
Likelihood Previous
•High cost drugs group reporting to
Joined Up Medicines Optimisation
Group (JUMOG) agenda in place to
manage this agenda
•Pharmacist resource in Medicines
Optimisation team to work on
mitigating the risk
3
Review Date
3/4/14 - Matter to be discussed at
CCC on 9th Apr 14. Task & Finish
group will then reconvene and
discuss redesigning service
specification.
2
12/06/2014
6 Feb 14 - service is being
recommissioned - will be stripped
back but with same assurances.
There is a risk that this will not cover
all elements previous service
covered. Spec meeting taking place
on 11 Feb with Task & Finish group to
be set up to eliminate risk. Planned
for service to be in place by 1st April
14.
None Known
2
31/05/2014
12 monthly reviews / FLS monthly
dashboards / under Trust policies
and procedures internal agreed by
CCG
1
31/05/2014
CCG Dashboard monitored at
None known
Monthly steering group meetings /
Chair of Steering group reports to
Emergency Care Network meeting /
Key performance indicators in service
specification / All FLS nurses working
to national bone health frameworks
under lead consultant, Dr N Viner
who has clinical accountability
Yes
12/06/2014
Audit South West to carry out an
Audit completed.
audit of the CCG's Payroll system and 8 actions identified. As at 12/06/2014
report back.
6 of these have been completed.
1
12/06/2014
Payroll errors are actioned as soon as No proactive control
Audit South West audit carried out in No assurances identified
staff bring these to the attention of 12/06/2014: Action plan agreed with Q1 2014.
HR and Finance
SBS to ensure Payroll errors are
raised and actioned quickly.
1
03/04/2014
Audit South West to carry out an
Audit completed and 1 action raised.
audit on the process for, and content 12/06/2014: Staff have received ESR
of, the CCG's ESR.
self-service training to access their
records. Supported by on-going
training dates available in addition to
ESR manuals available on iKnow.
1
24/04/2014
None identified
Adequacy Score
Individual checking of entries by staff None identified
and supervisors
Ongoing meetings. Expectation that
ICO risk share is signed off for IBP
timeline. Torbay H&WBB agree
current proposal to keep BCF within
ICO assumptions. Positive meetings
with DCC officers about prospect of
applying Torbay-style risk share
agreement. Not yet shared with
members. Further work required to
secure agreement in south Devon.
Timeliness
Maintain active communication
about i) BCF being already committed
and ii) BCF being thought as
equivalent to ICO finance. With Local
health ICO partners, with both local
authority members and officers, Area
and Regional teams at NHS England.
Also communication with Pioneer
partners.
Basis
None Identified
Area Team: 28/01/2014, 25/02/2014
17/03/2014
Sufficiency
Attendance and communication at
Torbay more aligned with issue of ITF
both Health & Wellbeing Boards.
within ICO than Devon County
Attendance and communcation at
Council currently.
Devon Joint Commissioning Meeting
and Torbay ICO Risk share meetings.
Joint Health & Social care finance
meetings also taking place and feed
into the groups referred to above. .
No assurances
Complete workforce plan and ensure
alignment with Running Cost
Allowance 15/16.
Scope
Review of forward financial plan.
None Identified
Area Team: 13/08/2013, 4/12/2013,
28/01/2014, 25/02/2014
Evidence
Gail Searle
Leanne Willey
Leanne Willey
A revised workforce plan which aligns None Identified
with new Running Cost Allowance for
15/16 will need to be developed and
shared through Senior Leadership
Committee, Commissioning &
Finance Committee & Governing
Body.
Riskscoretarget
3 Apr 14 - IT solution will require
significant investment. Alternative
solutions being sought.
Jun 14 - Matter being investigated by
Healthwatch following a number of
patients raising the matter with
them. Awaiting response from
Healthwatch advising if this is only
patients from Chillington or from
other practices as well.
Impacttarget
Oct 13 - John Whitehead wrote to
heads of Pathology and IT in local
providers flagging issues and
requesting these were addressed.
Nov 13 - response received from one
provider and awaiting responses
from others.
4 Feb 14 - Responses received from
majority of providers who we wrote
to. Summary of replies provided to
John Whitehead and Chris Branson
has cascaded to Mark Procter, Phil
Stimpson, Gary Kennington and
Eileen Deakin for their comments
Likelihoodtarget
None identified
Reporting
Updates required for Primary Care
Redesign Board taking place on bimonthly basis
Quality Committee
None identified
Quality Committee
Primary Care Redesign Board
Finance Committee
Governing Body
Actions Progress
Finance Committee
Governing Body
Actions
Senior Management
Committee
Assurances Gaps
Senior
Management
Committee
Assurances
Risk Coordinator
Controls Gaps
Jen Baker
Jen Baker
Gail Searle
Risk Owner
Sally Blackford
DEREK BLACKFORD
DEREK BLACKFORD
Marianna Gray
Marianna Gray
Jon Sewell
Executive Lead
Simon Tapley
Simon Bell
Simon Bell
Steve Wallwork
Mark Procter
Safety
Patient Experience
Primary Care
Leading a
Leading a sustainable
sustainable health
health and care system
and care system
Our Priorities
Quality
Our Commissioning
Priorities
Safety
Finance
Finance
Infrastructure
Controls
Governing Body
16
Theresa Farris
4
9
Larissa Sullivan
4
3
4
Simon Tapley
3
2
4
Mark Procter
There is a risk that drugs which are
excluded from payment by results
(Pass through drugs) are the highest
growth area of prescribing and
represent significant financial
challenge for SDTCCG. The growth in
spend in SDHFT is around 20% and
this cost is passed directly to
commissioners. Clarity and robust
plans for the future management of
this area of prescribing is required to
mitigate the clinical and financial
risks associated with pass through
drugs.
2
2
12
Outcomes
Quality
There is a risk that decommissioning
of the Fracture Liaison Service will
drastically impact the bone health
care for patients, the financial
implications for the CCG and the
wider health care community. This
well established service is now
integrated into primary, secondary
and community care which
decommissioning would remove.
2
4
9
Our
Commissioning
Priorities
There is a risk that the CCG's Payroll
system will not reliably process
Salaries, Childcare Vouchers and
Travel Claims.
Infrastructure
There is a risk that there are errors in
the ESR records for CCG staff.
3
3
12
Quality
Risk Score
Impact
Likelihood
Name
79 Blood tests.xml
81 Running Costs.xml
82 Integrated Care Organisation.xml
There is a risk that the use of the
Better Care Fund (Integration
Transformation Fund) to support the
Integrated Care Organisation will not
be supported by both Local
Authorities equally.
3
3
86
The announcement of two year
allocations in relation to the Running
Cost allowance requires a CCG plan
to live within the reduced allowance
for 2015-16 (£6.083m). The risk
being that action to deliver the plan
will need to be effective in 2014-15
to limit the risk of breaching the
allowance.
4
85
GP practices are being asked to fax or
phone results to provider where
patient is receiving treatment causing
extra work for practices and risk re
patient identifiable information and
accuracy of results given.
Quality
84
There is a risk that Blood tests are
being processed in one Acute
hospital whilst the patient opts to
have their care in another Acute
hospital. Staff at one provider
unable to view results detailed on
another hospital provider systems.
Finance
83
83 ESR records.xml
82
84 Payroll.xml
81
85 Fracture Liaison Service.xml
79
86 Pass through drugs.xml
ID
Risk Category
Risk Description
Planona Page Link
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1
3
3
Yes
1
3
3
3
10
2
2
4
Yes
3
3
3
3
12
2
4
8
Yes
3
2
4
3
12
1
4
4
Yes
3
2
3
3
11
3
4
12
Yes
3
2
4
3
12
4
3
12
4
3
12
2
2
4
5
4
20
3
4
12
3
4
12
Opened
9
09/01/2014
3
15/01/2014
3
15/01/2014
2
16/01/2014
1
12
11/02/2014
Yes
3
24/02/2014
3
4
26/02/2014
3
Risk Score Previous
1
Impact Previous
9
Likelihood Previous
3
Review Date
3
03/06/2014
2
05/06/2014
1
05/06/2014
Yes
13/02/2014
29/5/14 - Task and finish group
established to work with all existing
providers to explore service
development that move provision
materially toward that defined within
AQP specification, but is deliverable
within existing financial envelope
4
22/05/2014
Escalated to and discussed by
None identified
Director of Commissioning. Flagged
at BPP and CCC. Finance Committee
also aware
Area Team: 28/01/2014, 25/02/2014
Agreements for all the IT projects
Group.
involving patient data that the CCG is
involved with.
2
21/05/2014
Information Sharing Group (chaired
by CCG Clinical lead) taking the
overview on this activity.
2
29/05/2014
Regular item on Information
Governance Forum Agenda.
Reported to Quality Committee as
part of the IG KPIs.
Adequacy Score
Daily health community tele22/5/14 - 1) Daily community wide
conferences. Established and in place escalation calls have been supporting
all organisations to pin point
pressure areas and ensure that flow
is at an increased level.
2) Full winter debrief took place on
23rd April 2014 to provide a full
review of pressures experienced and
actions taken by all providers
including processes used in
accordance with (and compliance to)
NHS England and the SD&T
Community Wide Escalation plan.
The CCG have requested expertise
from NHS England to facilitate this
session, given the significant
pressures that have been
experienced this winter.
3) The CCG are looking at an
alternative consultant expert in
Emergency department operational
processes to support SDHFT with
reviewing current practice and
identifying opportunities for
improvement
4) Secured an offer from Plymouth
Hospitals NHS Trust to spend some
time
with
them
to understand
how
To write and agree Data Sharing
Regular
item
at Information
Sharing
Timeliness
Reporting to Clinical Commissioning None identified
Committee, Senior Leadership Team
and Governing Body in place.
Operational health community
ownership sits with the Urgent Care
Board.
Daily reporting to CCG On Call
Director.
Area Team: 28/01/2014, 25/02/2014
Group 16/12/2013, 03/02/2014
Basis
Maintain all local contacts.
Media statement issued.
Staff updated.
Letter sent to providers asking for
assurance.
Sufficiency
Quality issues are fed into the CCG's None identified
Quality Committee.
Strategy and non-quality reputational
issues are fed into the CCG's Senior
Risk is on the CCG's Assurance
Framework, and so is seen regularly
by Audit Committee and Governing
Body
17/03/2014
Group 16/12/2013, 03/02/2014
Gail Searle
Jen Baker
Paul Baker
Phil Stimpson
Urgent Care
Quality
Simon Tapley
Mark Procter
Data Sharing Agreements is an IG KPI. None identified
Information Sharing Group,
comprising clinicians and managers
from providers and commissioners,
to start in March 2014.
Additional admin hours are being
5.6.14 No change
collocated on a short term basis with
Children Social care to improve
essential communication around the
shift in paperwork
Scope
12
Gail Searle
4
Paul Baker
3
None identified
Evidence
Senior leadership team maintains
None identified
relationships with local NHS leaders
Senior leadership receives advice
from communications team, which
maintains links with communications
colleagues across the provider
system.
Progress will be reported to the
Torbay Child Health and
Safeguarding Meeting
None identified
Riskscoretarget
None identified
Progress will be reported to the
Torbay Child Health and
Safeguarding Meeting
Impacttarget
The timeliness of All Health
assessments are monitored on a
monthly basis and reported to the
Designated Nurse LAC
None identified
Likelihoodtarget
The Designated Nurses LAC from
Devon and Torbay and the
Designated Nurse Safeguarding
Children Devon meet regularly and
are trying to identify this cohort of
children
Reporting
Gail Searle
Val Morrell
Val Morrell
Stakeholders in partnership
organisations
3 Jun 14 - new self-care service
provider secured. Service live to new
referrals from 1st July 14.
Prevention strategy in development
and will engage with redesign group
to capture other prevention
initiatives.
None identified
5.6.14 No change
Quality Committee
8 Jan 14 - work underway to procure
self care services
Quality Committee
None identified
Quality Committee
Reporting to Long Term conditions
Network
Quality Committee
None identified
Audit Committee
Governing Body
Long Term Conditions Network
Actions Progress
Governing Body
Actions
Risk Coordinator
Risk Owner
Emma Herd
Linda Village
Linda Village
Executive Lead
Simon Tapley
Gill Gant
Assurances Gaps
Negotiation meetings being held with Post 1 April 2014 current service
current providers to agree continuity from all providers has been served
of service and care
notice
Simon Tapley
Risk to the CCG wide provision of leg
ulcer care post 1 April 2014 based on
lack of accreditation from recent AQP
process.
Leading a sustainable health and
care system
8
Quality
Excellent Customer Experience
4
20
2
4
Quality
5
Quality
Safety
Information
93 Data Sharing Agreements.xml
There is a risk that the Data Sharing
Agreements needed for the
information sharing projects will not
be available in time and that the
projects will fail as a result.
Assurances
Application of escalation funds.
None identified
Daily health community teleconferences regarding 4 Hour
operational performance.
Weekly meetings regarding handover
performance.
Safety
94
94 Leg Ulcers.xml
93
91 SDHFT 4 Hour performance.xml
There is a risk that patient safety may
be compromised if patients are not
being seen within the 4 Hour
performance standard and risk of
handover delays from the ambulance
to A&E department.
91
Controls Gaps
Clinical Commissioning
Committee
25
Jen Baker
5
Our Priorities
5
Excellent Customer Experience
and Outcomes
Promoting Self-care
Our Priorities
Quality
Reputation
90
90 CCG Reputation.xml
There is a risk to the CCG's reputation
as part of an integrated care system,
through association with adverse
behaviour in provider organisations.
Controls
Self Care Procurement
Sallie Ecroyd
12
Gill Gant
3
12
Steve Wallwork
4
3
9
4
3
Achieving National
Requirements
There is a risk of a delay in the
timeliness of both Initial Health
Assessments and Review Health
Assessments of LACYP
Quality
There is a risk that the CCG does not
currently have an accurate LACYP
profile population for the South
Devon Patch. This is due to the LAC
health Service being provided across
3 different health providers and 2
different Local Authorities using
different IT systems that aren’t
compatible, . There is a risk that the
CCG is not able to accurately report
on the Health Needs of this group
3
Risk Score
Impact
Likelihood
Name
87 Long term conditions.xml
Need to ensure that patients have
access to self care and preventative
services to support alongside
Healthcare Professionals.
89
There is a risk of ever growing
demand on services supporting
patients with Long Term conditions.
Quality
88
88 Looked after children.xml
87
89 Looked after children 2.xml
ID
Risk Category
Risk Description
Planona Page Link
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1
2
3
3
9
1
1
1
Yes
3
3
4
2
12
1
3
3
Yes
1
2
3
3
9
2
4
8
Yes
1
2
3
3
9
Risk Score Previous
Impact Previous
Opened
27/02/2014
13/03/2014
Yes
3
3
9
2
4
8
3
3
9
25/03/2014
3
0
27/03/2014
3
0
A DCC link has been identified
9.6.14 Reviewed at Quality
through the Devon CIB, the
Directorate, remains the same
Designated Nurse for Looked After
Children has made initial contact
with her and we are awaiting a
response. Any delay in this will be
reported to the QC.
Presence at the Devon LISG and
Devon CIB will improve the access to
up to date information .
24/03/2014
Carry out annual Penetration Test on Date of test to be confirmed.
new CCG website.
NHS 111 performance data needs to 22/5/14 - The Devon wide
be brought to the Quality Committee. programme board continues to meet
monthly to monitor implementation
of the SWASFT recovery plan. Overall
111 performance is monitored at the
monthly IPAM meeting. Following
the GP out of hours call handling
transfer, there were difficulties
matching staffing capacity with call
demand. However, there is a revised
improved performance trajectory
which will see a return to top
performance for the NQR for 95% of
calls answered in 60 seconds by midJune (at the latest).
The Safeguarding Children Report to None identified
the QC provides an update against
progress
1
09/06/2014
Quality Committee
Reporting
The controls are opportunistic ways
of gathering the data, the
organisation requires a formal
reporting mechanism from DCC to
the CCG.
12
Quality Committee
The Designated Professionals are
communicating with Devon County
Council representatives regarding
how to obtain the data we require.
The Designated Nurse for
Safeguarding Children now sits on
the Learning & Improvement Sub
Group (LISG) which receives and
monitors the performance data for
Devon.
The Director of Quality
Governance,(Executive Lead for
Safeguarding) sits on the DCC
Children’s Safeguarding &
Improvement Board (Devon CIB)
The Designated Professionals Forums
facilitate the sharing of information
and the escalation of concerns
3
Quality Committee
Monthly performance reports
No controls identified
discussed on a monthly basis at
Integrated performance and
assurance meeting involving SWASfT
/ NEW Devon (lead commissioners)
and South Devon and Torbay CCG.
Monitored against national quality
requirements.
None identified
3
Likelihood Previous
Penetration Test carried out in July
2013 identified some security issues
with the current website - the most
serious of these have been
addressed.
The new CCG website (currently
under development) will be
inherently more secure.
IG KPIs are presented to and
discussed by the Quality Committee
every 4 months.
None identified
Review Date
None identified
3
12/06/2014
Website security is a Key
Performance Indicator (KPI) for the
Information Governance (IG)
function; Ig KPIS are presented to
and discussed by the IG Forum
monthly.
Discussed at Audit Committee 15
May 2014 - solution needed that will
cover all audits and resulting actiosn.
3
13/06/2014
Audit Reports are presented in full to The CCG is not able to report on how A recording and reporting
the Audit Committee.
many actions have been received /
mechanism for the CCG's accepted
accepted and how many of these are actions is required.
overdue.
Yes
21/05/2014
Actions arising from Safeguarding
reports are not centrally recorded
and actioned.
Actions arising from Internal Audit
(ASW) and External Audit (Grant
Thornton)reports are not centrally
recorded and actioned.
0
22/05/2014
Internal and External Audit reports
are circulated to all relevant
managers for consideration of the
recommended management actions.
Adequacy Score
3.6.14 - The number of referrals fell
in March and April but has increased
again at the end of May.
Discussions with TSAB and DSAB
Chair are underway re any potential
impact. A paper will be presented to
the DSAB in June.
Timeliness
To be raised with the joint chair of
Devon and Torbay Safeguarding
Adult Boards.
Basis
Assurance is gained from a variety of None at present
sources regarding providers more
strategic responsibility such as
attendance as both Devon and
Torbay Safeguarding Adult Boards
and sub groups and also attendance
at providers safeguarding forums.
The CCG also holds an annual review
with providers regarding the
safeguarding adult operational
principle. Performance and issues are
also monitored at the contract
review meetings.
Sufficiency
There has been an increase in the
number of such referrals regarding
specific provision of healthcare by
healthcare staff from two in January
to 5 in February 2014 which has
prompted concern regarding the
capacity of the Safeguarding Adult
and Patient Safety Lead . The
Safeguarding Adult and Patient
Safety Lead has both strategic and
operational responsibilities for task
such as chairing or/ attending
safeguarding processes.
The arrangement is manageable
within NEW Devon where the
safeguarding adult lead has strategic
responsibility and shares the
operational responsibilities with
three Patient Safety and Quality
manager and two heads of Patient
Safety and Quality. Somerset CCG
does not undertake the operational
role as the local authority has not
devolved responsibility and in
Kernow CCG there are independent
chairs as there are for the statutory
child protection across England.
Scope
The Safeguarding Adult and Patient
Safety Lead currently attends both
Devon and Torbay Safeguarding
Adult Board’s and sub groups. She
also chairs safeguarding referrals
regarding specific concerns about
inpatient healthcare provision by
healthcare providers or whole service
community healthcare care. This
provides assurance regarding
healthcare provider’s response to
their safeguarding adult
responsibilities and also provides
independent objective
knowledgeable assurance to
vulnerable adults and their families,
the CCG and the providers.
The current arrangement is in place
for both Torbay and Devon and
Plymouth Local Authorities and
developed over a period of time as
there have been historical concerns
regarding the processes lead and
investigated by healthcare providers .
Evidence
Actions Progress
Riskscoretarget
Actions
Impacttarget
Assurances Gaps
Likelihoodtarget
Assurances
Quality Committee
Christine Branson
Simon Tapley
Controls Gaps
Risk Coordinator
Val Morrell
Jen Baker
Risk Owner
Delia Gilbert
Phil Stimpson
Executive Lead
Gill Gant
Steve Wallwork
Community Services
Urgent Care
Planned Services
Safety
Gail Searle
Val Morrell
20
Cathy Hooper
4
Gill Gant
5
Childrens Services
9
Quality
3
Safety
3
There is a risk that SDTCCG will be
unable to discharge it’s duties in
respect of Section 11 of the Children
Act 2004, due to the fact we do not
receive consistent, accurate and
reliable data identifying the children
and young people in South Devon
who are subject to Child Protection
Plans or Looked After by the Local
Authority.
Safety
99 Safeguarding children data.xml
99
98 NHS 111.xml
There is a risk that NHS 111 will fail to
meet demand and call response
times and appropriate dispositions of
calls.
98
Controls
Quality Committee
Senior Management
Committee
8
Jen Baker
4
Phil Stimpson
2
Mark Procter
There is a risk that personal data held
in the Member area on the CCG's
website is not secure.
Achieving National
Requirements
Safety
9
12
Leading a sustainable health and
care system
3
Risk Score
Impact
Likelihood
3
3
Quality
Quality
Infrastructure
95 Safeguarding Adults Leads role.xml
Name
There is a risk that actions from
Audits and Reports and Multiagency
Reviews are not captured and
actioned by the CCG
4
97
There is a risk that SDT CCG may not
be able to adequately fulfil its
strategic responsibilities in relation to
Safeguarding Adults if the current
rise on safeguarding referrals
regarding the provision of inpatient
healthcare by healthcare providers
that we commission within our
boundaries continues and directs an
increased proportion of the
Safeguarding Adult and Patient
Safety Lead’s role to operational
roles.
Information
96
96 Action reporting.xml
95
97 Website security.xml
ID
Risk Category
Risk Description
Planona Page Link
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If the ICO business plan is not
sufficiently robust, the CCG will
consider a separate plan for
integration.
Currently there is some resource in JoinedUp Board has been asked to
place (provided by the CCG) to
consider how it will release system
progress Pioneer. However there are resource more widely.
gaps in provision of project support
from constituent organisations.
Monthly report to both SLC and
Governing Body.
Some gaps around reporting to other JoinedUp Board currently considering
constituent Boards.
refreshed arrangements for Pioneer
resourcing.
Review Date
3
3
3
3
12
0
1
3
3
Yes
3
3
3
3
12
1
4
4
Yes
3
2
3
3
11
1
3
3
Yes
1
3
3
3
10
1
3
3
Yes
3
3
3
3
12
Opened
Adequacy Score
Yes
01/01/2014
Timeliness
9
30/04/2014
Basis
3
3
3
9
4
4
16
3
3
9
3
3
9
08/05/2014
08/05/2014
Sufficiency
Risk Score Previous
Scope
Impact Previous
Evidence
Likelihood Previous
Riskscoretarget
Impacttarget
3
08/05/2014
None identified
0
08/05/2014
CCC, SLC and GB will take assurance
via the submission of ICO business
plan at end June 2014.
12
31/05/2014
JoinedUp Board is considering a
proposal to rectify this risk. It will
require significant system
investment.
3
31/05/2014
Joined-Up Board are currently
None identified.
considering a proposal from the
Director of Pioneer about hosting the
resource allocated to JoinedUp
concerns. Will go to SLC for further
discussion.
3
08/05/2014
JoinedUp Board is discussing this risk None identified
with a view to properly resourcing
Pioneer concerns, however this is a
significant risk and we are already
behind other Pioneer sites.
ICO Workstreams meet regularly.
Business Plan to be approved.
Execs have regular 1:1s.
3
08/05/2014
ICO Business Plan to be approved by None identified.
the CCG by end June 2014.
3
08/05/2014
The 6 ICO Workstreams meet
None identified.
regularly to look at the ICO delivery
plans.
Work is in hand to align the ICO to
JoinedUp.
Simon Tapley on partial secondment
to SDHFT.
Yes
08/05/2014
Continually refresh intitial plan,
financial risk review and evaluation.
Monthly/Quarterly monitoring
process through report as part of
NHS England Non-ISFE route and
inclusion in Finance Committee &
Governing Body report.
Likelihoodtarget
Reporting
Monthly review through existing
None Identified
performance and contracting and
financial management arrangements.
Finance Committee
Governing Body
Detailed monthly finance reports to None Identified
Finance Committee and Governing
Body which highlight risks and
mitigations as a result of the latest
contract financial information each
month. Recovery actions monitored
and progress reported monthly to
DCIOS Area Team.
0
Governing Body
Finance Committee
Ongoing monitoring and reporting
Governing Body
All risks monitored and reported via
programme board. Exceptions
reported to Finance Committee.
Governing Body
Gail Searle
Actions Progress
Governing Body
A detailed risk register listing all risks None identified
associated with the project is
managed and monitored by the GP
OOH programme board. The
programme board group is a key part
of the agreed governance structure
and is attended by both NEW Devon
CCG and South Devon and Torbay
CCG.
Leanne Willey
Leanne Willey
Risk Coordinator
Actions
Jen Baker
Louise Hardy
Assurances Gaps
Jen Baker
Risk Owner
Samantha Morton / Christine Branson
DEREK BLACKFORD
Louise Hardy
Louise Hardy
Executive Lead
Simon Bell
Simon Bell
Simon Tapley
Steve Wallwork
Our Priorities
Assurances
Clinical Commissioning
Committee
9
Gail Searle
3
9
Controls Gaps
The ICO Prgramme Board will have
None identified
completed the ICO business case by
end June 2014. The CCG will judge
whether this adequately contributes
to system transformation.
Louise Hardy
3
3
16
Steve Wallwork
3
4
9
4
3
12
Controls
Simon Tapley
There is a risk that there is
insufficient resource to support both
the JoinedUp plans and also the
business as usual work within
Commissioning.
3
4
There is a risk to JoinedUp that the
integration of South Devon
Healthcare NHS Foundation Trust
with Torbay and Southern Devon
Health and Care NHS Trust will not
support the whole-system
transformation required of Pioneer
sites.
Infrastructure
Finance
There is a risk to JoinedUp that plans
will not be properly communicated to
the population and to staff without
additional resource in the form of
specific marketing expertise. From
this, there is also a risk that we won't
get adequate progress on plans
because the "mission critical" people
are not sufficiently engaged.
Infrastructure
There is a risk to JoinedUp that the
system resource will be aligned to the
Integrated Care Organisation (ICO),
at least over the next year.
3
Our Priorities
Finance
9
Our Priorities
Risk Score
Impact
Likelihood
Name
GP OOH service.xml
Delivery of Financial Performance, Financial Risk Management.xml
3
Our Priorities
105
3
Risk to the delivery of the financial
duty to live within the revenue
resources allocated and delivery of
the planned 1% surplus. This would
be at risk as a result of in year
unplanned overspends in relation to
our identified risks and if recovery
actions are not successful.
Infrastructure
104
GP Out of Hours service. NEW Devon
leading on the re-specification of and
procurement of new service to
commence from April 2016.
Infrastructure
103
102 Pioneer ICO resource.xml
102
103 Pioneer Communication.xml
101
104 Pioneer ICO Integration.xml
100
105 Pioneer project support.xml
ID
Risk Category
Risk Description
Planona Page Link
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Sufficiency
Basis
Timeliness
Adequacy Score
Review Date
Likelihood Previous
Impact Previous
Risk Score Previous
Opened
1
3
3
Yes
1
3
3
3
10
08/05/2014
4
3
12
08/05/2014
JoinedUp Board currently considering
refreshed programme management
arrangements.
Scope
There is a gap around system
ownership of the JoinedUp work
programme. Not all constituent
Boards are reporting.
Evidence
Reported through JoinedUp Board
and the SLC.
Riskscoretarget
Two projet managers now in post
None identified
who wil be putting measureable
plans in place. From these plans will
derive the decision-making
mechanisms needed across the
health and care economy.
Work is underway with the JoinedUp
Board to establish system-wide
ownership of Pioneer programme
management.
Actions Progress
Impacttarget
Actions
Likelihoodtarget
Assurances Gaps
Reporting
Assurances
Controls Gaps
Risk Coordinator
Jen Baker
Executive Lead
Risk Owner
Louise Hardy
12
Controls
Sam Barrell
3
Our Priorities
4
Risk Score
Impact
Likelihood
Name
There is a risk that the CCG does not
have clarity on the key milestones for
the Pioneer programme, nor how
these will be managed and owned
across the different organisations.
Infrastructure
106
106 Pioneer governance and decision making.xml
ID
Risk Category
Risk Description
Planona Page Link
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Governing Body Committee Report
Committee title
Date of meeting(s)
Chair
Recommendation
Senior Leadership Committee
15, 29 April / 6, 13, 20, 27 May / 3, 10, 17 June 2014
Steve Wallwork, Managing Director
For Approval
For Discussion
For Information
x
Key discussions to note:
 NHS Staff Survey action plan / ensuring key remedial actions included.
 A&E delays and support for improvement.
 Review of work-plans to deliver the ‘Plan on a Page’ objectives.
 Review of organisational structure (clinical leads, directors and general staffing)
to ensure resource appropriate for management / delivery of planned projects.
 Funding for community based plans.
 Integrated Care Organisation (ICO) progress and related relationships with key
organisations.
 Financial Plan.
 Outcome based commissioning (COBIC) next steps.
 Joined-Up Board remit and management.
 Exception report on quality risks.
 Risk Register review and update.
 Torbay Hospital’s friends and family test approach.
 CAMHS improvement work.
 Better Care Fund progress.
 Referral management review.
 Gain Share prescribing scheme in Primary Care.

Councillor Sylvia Russell and Sue Aggett (Business Lead for Housing & Health),
Teignbridge District Council shared details about the pivotal Health Exchange
meeting which involves representatives from various partner organisation. The
CCG were welcomed. Increased collaboration opportunities were also discussed.

Discussions with Jennie Stephens (Strategic Director People, Devon County
Council) included Children’s Services, safeguarding, improved collaboration
between organisations, voluntary sector links, and the ICO.
Decisions made:
 Ratification of the central southern DSCRO plan.
 Submit an expression of interest for co-commissioning of primary care to NHSE.
 Welcoming Monitor’s request to work with us for a few months to better understand
commissioning.
 Approval of the Business Continuity Plan.
Minutes are available on request from the Corporate Office
SLCreporttoGoverningBodyJ
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Date
Report title
Author(s)
Report purpose (for consultation,
approval and information)
26th June 2014
Commissioning & Finance Committee Terms of Reference
Simon Bell
For Decision
Following agreement by Senior Leadership Committee, Finance
Committee, and Clinical Commissioning Committee the Finance
and Clinical Commissioning Committees of the CCG have
merged.
Executive Summary
The terms of reference of the new Commissioning and Finance
Committee are attached for reference.
Actions Requested
Which other committees has this
been to?
The Governing Body is asked to approve the proposed
committee structure and the new committee’s terms of
reference.
That the Governing Body approve the proposed committee
structure and the Commissioning and Finance Committee’s
terms of reference.
N/A
implications?
What, if any, are the quality and
safety implications?
implications?
implications?
N/A
N/A
Who does the proposed piece of
work affect?
Staff
Patients
Carers
Public




Yes
No
Is the proposal controversial in any way (including media, academic, voluntary or
sector specific interest) about the proposed work?




Services
2014-6-26CFCToRHeaderSheet
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Commissioning and Finance Committee (CFC)
Terms of Reference (June 2014)
Constitution
The Clinical Commissioning Group’s Governing Body hereby resolves to establish a
Committee of the Governing Body known as the Commissioning and Finance Committee.
The Committee is established in accordance with South Devon and Torbay Clinical
Commissioning Group’s Constitution, Standing Orders and Scheme of Delegation. These
terms of reference set out the membership, remit responsibilities and reporting
arrangements of the group and shall have effect as if incorporated into the CCG’s
constitution
Purpose
To provide assurance to the Governing Body that the CCG is achieving the commissioning,
financial and performance elements of its plan.
To provide assurance that the CCG is commissioning services in line with the needs of the
local population and the strategic objectives of the CCG and is evidence based and is
inclusive of national and local requirements.
The Committee will have an oversight of budget and financial plans and have oversight of
any financial recovery plan.
The Committee will review and approve commissioning, finance and performance reports
prior to submission to the Group.
The Committee will commit resource in line with the scheme of delegation.
Responsibilities
The Commissioning and Finance Committee will review and have oversight of finance,
performance and commissioning in relation to the following areas:








ToR.DOCX
Performance against national and local targets.
‘In year’ financial position. Receive a detailed report of the financial position and
progress towards meeting the targets within the CCG financial plan.
Implement & monitor recovery schemes. Receive updates on both the financial and
activity performance of each scheme
Monitor achievement against CCG incentive schemes. Receive a report of the actual
and forecast.
Implement & monitor investments/transformation schemes. Receive updates outlining
financial, activity and delivery against key performance indicators for each scheme.
Oversee and recommend to the Governing Body the development of a Commissioning
Strategy for the organisation, ensuring the meaningful involvement of stakeholders and
the public in its development.
To agree and oversee the workplan for the Business Planning & Performance Group
and to receive updates and recommendations from the Group.
Work with the Business Planning & Performance Group and Localities on the
development of an Annual Business Plan for the CCG, ensuring it encompasses
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









national and local requirements together with CCG objectives for the commissioning
and delivery of healthcare.
Oversee and recommend to the Governing Body the development of annual
commissioning intentions for all providers.
Oversee the contribution to the Joint Strategic Needs Assessment, making
recommendations as appropriate to the Governing Body and ensuring that the
outcomes are reflected in the priorities set by the CCG for its commissioning and
decommissioning of healthcare services.
Recommend to the Governing Body joint commissioning arrangements with other
partners as appropriate.
Oversee the development of care pathways, t h r o u g h a p p r o p r i a t e r e d e s i g n
b o a r d s , and services that support the vision of the CCG and promote clinical quality
and safety in all commissioned services, making recommendations to the Governing
Body as appropriate.
Receive and act appropriately on evaluations of pilot projects and services.
Receive and review departmental delivery plans for indicators or performance areas
by exception.
Challenge delivery plans produced to achieve targets or improve performance.
Resolve key performance issues raised by accountable members of the Senior
Management Team.
Identify and allocate resources where appropriate to improve performance.
Report new risks to the Audit Committee.
Membership
The membership of the Commissioning and Finance Committee will be:








GP Lead for Finance & Governance – Committee Chair
Clinical Integration Lead
Clinical Commissioning Lead – Vice Chair
Managing Director
Membership will be reviewed regularly to adjust for changes as required by the purpose of
the Committee.
Members who cannot attend should send a named deputy. Deputies will have the decisionmaking and voting rights of the person he/she is representing.
Business Planning & Performance Group members will be in attendance at the Committee.
Quorum
A minimum of three members will constitute a quorum, so long as this includes either the
Chair or Vice Chair or clinical representation, managerial deputies are permitted.
A decision put to a vote at the meeting shall be determined by a majority of the votes of
members and deputies present. In the case of an equal vote, the Chair of the Committee
shall have a second and casting vote.
ToR.DOCX
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Frequency
The Commissioning and Finance Com m itt ee will m eet on a m ont hly basis and
extraordinary meetings to be held as required.
Reporting arrangements
The minutes of the Commissioning & Finance Committee shall be formally recorded and
submitted to the CCG Governing Body on a bi-monthly basis.
The Commissioning and Finance Committee will report monthly through the Finance report
and the Planning & Priorities reports to the CCG Governing Body.
Administration
Administration and taking minutes of the Commissioning and Finance Committee is the
responsibility of the Chief Finance Officer.
Conduct of the Committee
The Committee shall conduct its business in accordance with national guidance, relevant
codes of practice including the Nolan Principles and the Conflict of Interest policy.
An annual report will of its performance, membership and terms of reference will be
submitted to the governing body.
Sub-groups
The Committee shall establish such sub-groups or short life task and finish groups as
required and in the discharge of its responsibilities. Currently the Business Planning and
Performance Group is established and reports to the Committee and provides detailed
support across the range of the Committees responsibilities.
Review
These Terms of Reference will be reviewed on a 6 monthly basis or sooner if
required with recommendations made to the CCG Governing Group for approval.
Date approved:
ToR.DOCX
Review date:
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Governing Body Committee Report
Committee title
Audit Committee
Date of meeting(s)
15 May 2014 and 04 June 2014
Chair
Nick Ball, Non-Executive Director Finance and Governance
Recommendation
For Approval
For Discussion
For Information
x
Key points for the Governing Body to note:

The Audit Committee received the draft annual accounts and the draft annual report
in the May meeting.

The Assurance Framework was presented and highlighted ten new risks have been
added to the risk register including those around Pioneer, this was reported at the May
meeting.
Decisions made:

The Audit Committee approved the annual accounts and annual report at an
extraordinary audit committee meeting on 4 June 2014
Minutes are enclosed for the 13 March 2014 meeting
Audit Committee
Thursday 13 March 2014
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Pomona House, Oak View Close, Torquay
MINUTES
Members Present:
Nick Ball
Sue Finch
Karen Grimshaw
Non-Executive Director – Finance and Governance (Chair)
Practice Manager, Chilcote Surgery
In Attendance:
Simon Bell
Catherine Brown
Joan Clark
Geri Daly
Dr Charlie Daniels
Rob Loader
Mark Procter
Phil Stimpson
Steve Wallwork
Alun Williams
External Audit – Grant Thornton
Counter Fraud Manager, Audit South West
Deputy Director, Audit South West
Corporate Affairs Manager
Managing Director
Apologies:
Dr Simon Knowles
Chris Peach
Non-Executive Director for Patient and Public Involvement
Minute Taker:
Jennifer Baker
1
Welcome and Apologies
The Chair welcomed attendees to the seventh meeting of the South Devon and Torbay
Clinical Commissioning Group (CCG) Audit Committee.
The apologies received were noted.
2
Declaration of Interests
The Declaration of Interests for the Audit Committee were noted, any amendments to be
sent to Jen Baker or Phil Stimpson.
3
Minutes of Audit Committee 13 February 2014
Action: Code of Governance with responses to be included in 15 May 2014 Audit
Committee agenda.
Page 1: Steve Wallwork is an attendee of the Audit Committee, not a member.
Alun Williams asked about future Audit Committee dates; Mark Procter replied that the dates
should be agreed shortly and then dates will be communicated to the membership.
Action: Communicate future dates as soon as agreed.
Page 6 within the Internal Audit report, Rob Loader suggested that the phrase “both unusual
and good” should be amended:
Rob Loader presented the Report on Financial Systems – the conclusion is that systems are
adequate and no serious weaknesses. Again, no changes reflected.
Page 7 within the Counter Fraud section, an amendment is needed that NHS Protect have
issued new statements to CCGs.
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4
Risk Report and Assurance Framework
Mark Procter, Director of Corporate Affairs and Medicines Optimisation presented this report.
The reports included a more detailed snapshot of the CCG’s risks (Risk Movement) to show
recent movements, new and closed risks, and how long a risk has remained at a particular
score. It is hoped that this will be a useful tool in viewing the entirety of the CCG’s risks in
one view.
Karen Grimshaw discussed risks which have remained at the same level for 12 months;
these risks were discussed at the previous day’s Quality Committee. The CCG should
consider having a greater degree of confidence to move risks like these where small
movements may be appropriate in both directions on a monthly basis.
Simon Bell pointed out that the CCG’s risk appetite describes a lower level for clinical risks,
so making small and regular changes may be appropriate.
Karen Grimshaw replied that, with more confidence, the C Diff risk could have been moved
down earlier in the year.
Nick Ball commented that the CCG should not be afraid of seeing risks move up one month
and then back down the next month because some risks are balanced on very small
margins. The current risk score should reflect what is actually happening, so long as we
understand why.
Nick Ball asked for more work to be done on the colours used on the Risk Movement
diagram and for a similar diagram to be created for the adequacy of assurance scores.
Action: Phil Stimpson to modify the colours used on the Risk Movement diagram to make it
easier to read, and to create a similar diagram for the adequacy of assurance scores.
Mark Procter made reference to section 2.8 of the report which shows a fairly static risk
position.
Mark Procter referred to section 2.9 which shows that the majority of risks only have
moderate assurance; the Cornwall PCT reporting model has been looked at again to identify
ways of evidencing more sources of assurance.
Simon Bell suggested producing a guide for users of the risk register on what makes for
good assurance, such as a report to NHS England.
Nick Ball agreed to look for a list of possible sources of assurance from the Cornwall report.
Action: Nick Ball to look for and pass on a list of sources of assurance.
Simon Bell commented on the closed risks and that the reason given should be based upon
a CCG Committee’s decision not just a Director’s decision.
Action: Phil Stimpson to bring the Closed Risks section to the next Audit Committee
showing the Committee decision to close each risk.
Alun Williams queried why risk 1 had moved, Mark Procter informed that this movement was
based on the potential impact of the risk and the likelihood of it occurring.
The Risk on a Page view shows that all elements of the CCG’s Plan on a Page have at least
one risk.
Nick Ball asked why risk 73 relating to Children and Adolescents Mental Health Services
(CAMHS) has an adequacy score of zero – no controls or assurance have been identified for
this risk. The committee discussed CAMHS in general and concluded that two separate
risks may need to be recorded – one for the CAMHS service in Torbay (run by Torbay &
Southern Devon Health & Care Trust, TSDHCT) and one for the CAMHS service in South
Devon run by Virgin Care.
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Action: Phil Stimpson to report back to the next Audit Committee on the CAMHS risks.
At this point Karen Grimshaw left the meeting, the Audit Committee continued but was no
longer quorate.
5
Internal Audit
Rob Loader, Deputy Director of Internal Audit presented this report.
Audit South West are on track to complete the Audit Plan. There are no significant issues to
bring to the Audit Committee’s attention at this time. The draft Shared Business Services
(SBS) Payroll audit report has been issued and there are no major issues raised. There are
no outstanding audit recommendations. Following feedback the 2014/15 audit plan will
contain an improved Continuing Health care (CHC) audit.
Mark Procter queried the Information Governance audit report which was red and high, it
would be better to show a lower rating at this point. Rob Loader explained that all identified
actions had been completed and the risk rating is now green, which represents a clean bill of
health which will be reported in the Head of Internal Audit Opinion. Alun Williams
commented that the ratings of individual audits would not affect the External Audit opinion.
Nick Ball asked why the report shows that more days than planned have been used in
Planning and Management. Rob Loader replied that this reflects the extra time in reporting
to and attending the Audit Committee; there is no compromise on the rest of the plan and
there has been no reduction in the time spent on audits; no additional charges will be made
to the CCG; Audit South West still aim to deliver the whole plan within 125 days.
6
Counter Fraud
Joan Clark, Counter Fraud Manager of Internal Audit presented this report.
The Anti-Fraud draft plan for 2014-15 was presented which shows 30 days’ planned work;
there are no national standards for CCG’s apart from having a counter fraud service in place.
Nick Ball asked about the costs associated with this plan; Joan Clark replied that the current
day rate is £300, giving a planned cost of £9,000, and that the Consortium Board will be
meeting soon to set the 2014/15 day rate.
Since this meeting was not quorate, Nick Ball asked for this plan to be brought to the next
Audit Committee for approval.
Action: Include this report on the next Audit Committee agenda for approval.
6
External Audit
Alun Williams introduced Geri Daly and Catherine Brown who will be representing Grant
Thornton at future Audit Committee meetings.
The audit of the CCG’s accounts is planned for April / May 2014 and Grant Thornton will
present an update at the next Audit Committee.
Alun Williams described that national guidance for CCGs indicates that the key focus
regarding Value for Money (VFM) is on the establishment of governance arrangements,
including those for the Better Care Fund (BCF); VFM would normally consider financial
resilience and effectiveness.
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This report also contained a number of “challenge questions” for the Audit Committee:
Going Concern assumption
The CCG’s response to this should be minuted at Governing Body, and is inherent in the
Governing Body’s approval of the annual accounts.
Simon Bell commented that all financial reports are approved on the basis that the CCG is a
going concern; Geri Daly replied that the national emphasis is on this concept due to
financial failures elsewhere in the system. Steve Wallwork asked if evidence from the
Finance Committee should be used. Nick Ball commented that looking at the longer-term
financial balance and the Year 1 forecast shows that the CCG model is good. Alun Williams
stated that this is not a major issue for this CCG.
Simon Bell commented that the CCG is a going concern because we are a public body.
Alun Williams commented that NHS England Area Teams are less willing to support NHS
bodies that are failing financially; this is a bit of a formality for this CCG, but it is a good
exercise to go through.
Closing the Gap
Is the Governing Body aware of this and have the implications been considered?
Steve Wallwork responded that Derek O’Toole (Mental Health lead) has the report. Dr
Charlie Daniels commented that this has been discussed at the Mental Health Redesign
Board, and offered to take this back to that Board.
Action: Dr Charlie Daniels to take the “closing the gap” challenge questions back to the
Mental Health Redesign Board.
Steve Wallwork said that he would ask Simon Tapley, Director of Commissioning to include
a paragraph on this in his Commissioning report to Governing Body.
Action: Steve Wallwork to ask Simon Tapley to include “closing the gap” in the
Commissioning report to Governing Body.
CCG Assurance
Steve Wallwork informed the meeting that stakeholder surveys have been sent out and we
have started to receive the surveys from other CCGs. This will be covered in detail in the
Annual Report.
Everyone Counts – 5 year plan
Steve Wallwork informed the meeting that the CCG has one 5 year plan which includes this
work; the plan was discussed at the Governing Body Away Day and was approved at
Clinical Commissioning Committee held the previous day.
7
Annual Governance Statement
Mark Procter presented the annual statement to support the annual accounts that explains
how the CCG works through peaks and troughs and work to all the requirements of
corporate governance; this includes sustainability and carbon reduction activities.
Mark Procter described that the key points in the guidance are contained in section 6.1.4.
Annex 1 is the statement that the CCG has to expand upon.
Meeting closed, Internal and External Audit do not wish to meet separately.
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26 June 2014 - South Devon and Torbay CCG

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