Forward Plan Strategy – Board Statement Evidence

1. Forward Plan Strategy – Board Statement Evidence May 29th 2013

2. Quality • The board is satisfied that, to the best of its knowledge and using its own processes and having assessed against Monitor’s Quality Governance Framework (supported by Care Quality Commission information, its own information on serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), its NHS foundation trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients. • 2. The board is satisfied that plans in place are sufficient to ensure on-going compliance with the Care Quality • commission’s registration requirements. • Board Assurance regarding Monitor’s Quality Governance arrangements: • The Integrated Governance Framework presents the quality and accountability framework for the Trust. The framework sets out the key strategies that support delivery of the Trust’s vision around clinical quality, risk management, the workforce, the estate, economy, efficiency and productivity, information, communications and technology and communication and involvement. • The Trust currently has five Executive led Quality Improvement Committees which are each responsible for monitoring compliance against a set of the CQCs essential regulations and outcomes for the quality and safety of services. The committees report to the Integrated Governance Committee chaired by the Trust Chair. • The clinical governance structure within Oxford Health NHS FT has been embedded over a number of years and is now firmly established within corporate and the four clinical divisions. There are systems in place that manage and monitor the various areas of governance, for example, patient safety including SIRI’s, clinical effectiveness and patient experience including complaints. For SIRI’s the system ensures that: • Incidents are reported accurately • Investigations take place in the time frame outlined within national guidance • Service users and carers/families are involved • There is organisational, team and individual learning from incidents

3. Serious Incidents, complaints quality concerns, key workforce issues and service pressures are reviewed weekly at a clinical governance meeting jointly chaired by the Medical Director and the Director of Nursing and Clinical standards, outcomes/ exceptions are reported weekly into the Executive Director meeting. Actions to be taken are agreed and managed with directorates through the Professional and Clinical Standards Team. This team has a ‘learning from incident’ post whose remit is to develop means of ensuring organisational learning from incidents using a variety of methods including individual and team feedback; workshops; newsletters; risk notes. The Board is active in the monitoring of incidents and complaints; it receives quarterly reports via the Integrated Governance Committee and monthly information via the narrative Quality and Safety Report. Non Executive Directors sit on review panels of all serious untoward incidents. All cost improvement projects undergo a clinical and quality review by the Medical Director or Director of Nursing and Clinical Standards prior as part of the project development process. • How the Board will ensure that clinical quality improvements will be monitored over the period: • The Trust will use a variety of systems and processes to enable the organisation to deliver and monitor good quality and safe patient services, including: • Annual Trust Clinical Audit Programme Internal Audit programme. • Measurements of clinical performance centred on CQC regulations and outcomes, continuously in clinical team and clinical divisions reviewed in quarterly directorate performance meetings and monthly at the Board of Directors. Clinical Dashboards have been developed within divisions. • Implementation of NICE HTAs and developmental work to meet NICE guidelines • Mandatory training matrix and Continuing Professional Development (CPD) programmes and other key HR measures linked to the improving staff experience • Soliciting feedback from service users and their families and carers using a variety of formats and demonstrating actions taken on this feedback • Monthly Quality and Performance Reports to the Board including: a dashboard of measures on patient experience; clinical effectiveness and safety; key audit results; quarterly progress with developmental priorities arising from the quality account and CQUINs

4. The Trust’s Quality Improvement Committees report to the Board through the Integrated Governance Committee. This includes specific focus on: • Risks to achieving the Trust’s objectives and linked to core standards as identified in the Assurance Framework • All aspects of governance, clinical quality and safety, information, HR, financial and estates • The Board of Directors receives reports on compliance with the CQC regulations and has satisfied itself that it is meeting, and will continue to meet the standards. • Both the Integrated Governance Committee and Audit Committee receive reports on extreme, high and moderate risks at each of their meetings to ensure that action is being taken to mitigate the risks of not achieving the Trust’s objectives, compliance with standards and terms of the FT authorisation. • Quality indicators form part of the monthly performance report presented to the Board of Directors. The Board of Directors and the Integrated Governance Committee receives reports on the outcomes and actions arising from Clinical Audits. • In addition Board members undertake visits to clinical teams to ensure teams are visited by a non executive or executive a minimum of once per year. During these visits there are opportunities to talk with patient and carers as well as staff about the quality of our services. • Routine quality and safety themed seminars are attended by Board members. • The Council of Governors have established a Quality and Safety Sub Committee to review quality and safety matters in more detail and report back to Council. • The Quality Account sets out annually the priorities for Quality Improvement based on measured outcomes for quality and safety improvement. Progress is reported on a quarterly basis to Board and the Council of Governors and 6 monthly to stakeholders. • Monthly clinical governance forums with PCT and CCG colleagues provide further opportunity for system assurance.

5. The board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on behalf of the trust have met the relevant registration and revalidation requirements. • All medical practitioners employed within the Trust have met registration and are appropriately participating in revalidation requirements. • The new appraisal and revalidation arrangements are working well. The Medical Director, as the Responsible Officer, was the first Trust doctor to be revalidated. The Trust is fully on course with its processes and was rated as Green by the SHA regarding revalidation.

6. Finance • The board anticipates that the trust will continue to maintain a financial risk rating of at least 3, as defined in Monitor‘s Compliance Framework, over the next 12 months • The FY14 budget and Financial Plan FY14-FY16 was presented to (and approved by) the Finance & Investment Committee and Board of Directors in March 2013, and demonstrates that a financial risk rating of ‘3’ is maintained during FY14. • The board is satisfied that the trust shall at all times remain a going concern, as defined by relevant accounting standards in force from time to time. • The Director of Finance prepared the draft ‘Going Concern Statement’ for the Trust’s Audit Committee of 19th April 2013 covering the key assumptions supporting the preparation by management of the annual statement of accounts on a going concern basis. The final Going Concern Statement was presented to the Audit Committee on 23rd May 2012. • The Audit Committee, on behalf of the Board of Directors, scrutinised the Going Concern Statement, which forms the basis for preparing the statement of accounts on a going concern basis, confirming that they were not aware of any material issues that have not been taken into account and the Trust is clearly a going concern and it is appropriate for the accounts to be presented on a going concern basis.

7. Governance • The board will ensure that the trust remains at all times compliant with its licence and has regard to the NHS Constitution • The Assurance Framework contains likely risks to the Trust not being compliant with its Authorisation and legislation. The key provisions of the NHS Constitution are monitored through the Trust’s Assurance Framework. This Assurance Framework is reviewed on a regular basis through the Executive team. Integrated Governance Committee, Audit Committee and Board. • The quarterly in-year reporting to Monitor is reviewed and approved by the Board which provides an opportunity for compliance with terms of Authorisation to be monitored. During the year the Board of Directors will review the changes to NHS constitution and its implications for the terms of authorisation for the Trust. • The Trust has in place a Trust Secretary post which provides advice to the Board on corporate governance and associated legal matters; this includes providing advice on compliance with Authorisation. • All current key risks to compliance with the trust’s licence have been identified (raised either internally or by external audit and • assessment bodies) and addressed – or there are appropriate action plans in place to address the issues – in a timely manner • The Board, through it sub-committees’ consideration of the Assurance Framework and on-going identification of risk, ensures itself that key risks to authorisation are being addressed and maintained within the Trust’s Assurance Framework (managed through the Chief Executive's Office). The Trust also maintains a Risk Registers (managed through the Director of Nursing and Clinical Standard’s directorate). • During 2012/13 the Trust reported to Monitor that all targets and indicators had been met during the year. • In Q4 2012/13, issues relating to the way data was counted for the crisis service indicator were identified and, whilst the indicator was self assessed as being met, Monitor was alerted to the broader issues. Work is required during 2013/14 to resolve this.

8. The board has considered all likely future risks to compliance with its licence and has reviewed appropriate evidence regarding • the level of severity, likelihood of a breach occurring and the plans for mitigation of these risks to ensure continued • compliance. • The Executive team has reviewed the Compliance Framework 2013/14 and risks to compliance will be highlighted as part of the 2013/14 annual plan submission. • The Assurance Framework contains likely future risks to the Trust not being compliant with its authorisation and legislation. • In Q4 2012/13, issues relating to the way data was counted for the crisis service indicator were identified and, whilst the indicator was self assessed as being met, Monitor was alerted to the broader issues. Work is required during 2013/14 to resolve this. • The long-term financial plan has been updated to reflect the latest Monitor assumptions and sensitivity analysis has been carried out to evaluate potential risks and the severity of their impact.

9. The necessary planning, performance management and corporate and clinical risk management processes and mitigation plans • are in place to deliver the annual plan, including that all audit committee recommendations accepted by the board are • implemented satisfactorily. • Monitor’s Compliance Framework requires NHS foundation trusts to submit an annual plan which covers past and future performance, and risk analysis in relation to finance, governance and mandatory services. The Board approves the annual plan after taking into account the views of the Council of Governors. The annual plan is supported by detailed divisional activity plans and the performance against these together with the Trust’s plan are reviewed by the executive team each quarter and confirmed by the Board. • During 2012/13, the Audit Committee made no formal recommendations to the Board. There are processes in place to support the Audit Committee monitoring the implementation of recommendations made and the Committee regularly reports on its deliberations through presenting its minutes to the Board. The Audit Committee also submits an annual report to the Board which provides an opportunity for recommendations to be made. • An extended executive leadership group including clinical and nursing leaders has been established to take responsibility for the development, implementation and monitoring of the Trust’s Business Plan. The Board of Directors retains overall oversight of the Trust’s annual plan and will receive quarterly monitoring reports that contain updates on progress against plans, KPIs and risk management identified in the assurance framework.

10. An Annual Governance Statement is in place pursuant to the requirements of the NHS Foundation Trust Annual Reporting • Manual, and the trust is compliant with the risk management and assurance framework requirements that support the • Statement pursuant to the most up to date guidance from HM Treasury (see www.hm-treasury.gov.uk ) • The Trust has an Annual Governance Statement (AGS) which is included in the 2012/13 annual accounts/annual report. The accounts have been considered by the Audit Committee and are due to be finalised in May 2013. The Trust is compliant with the risk management and assurance framework requirements that support the AGS. The Head of Internal Audit gave an opinion to the Audit Committee in April 2013 that the AGS provided satisfactory assurance. The Assurance Framework is undergoing review as part of the recent transfer of responsibility to the Chief Executive's Office and to take account of Internal Audit recommendations. • 11. The board is satisfied that plans in place are sufficient to ensure: on-going compliance with all existing targets (after the • application of thresholds) as set out in Appendix B of the Compliance Framework; and a commitment to comply with all • known targets going forwards. • All known, new and existing targets are integrated into the Board’s performance framework dashboard reports. Performance dashboards are reviewed annually to incorporate changes in targets. The Board receives monthly performance reports at its meetings of the Board of Directors and is informed of action plans to rectify poor performance. The Board also considers the quarterly in year reports to Monitor against the requirements of its Terms of Authorisation. • Infection control indicators in relation clostridium difficile remain a potential risk for the trust as proposed targets do not take into account increases in episodes of care and throughput. Consideration needs to be given to defining avoidable cases to ensure appropriate reporting .This is in line with actions that have taken place in other trusts that have identified a number of cases that were deemed as unavoidable and that did not therefore contribute to targets. Constant monitoring of compliance with infection controls procedures and completion of action plans arising from investigations will be maintained to reduce risk improve services • In Q4 2012/13, issues relating to the way data was counted for the crisis service indicator were identified and, whilst the indicator was self assessed as being met, Monitor was alerted to the broader issues. Work is required during 2013/14 to resolve this.

11. The board is satisfied that its NHS foundation trust can operate in an economic, efficient and effective manner. • Further to the assurances gained that the Trust can maintain a financial risk rating of at least 3 through out the coming twelve months and will remain a going concern throughout that period, the Board has considered the current contracts with its commissioners in light of the wider health care economy and the various risks and opportunities contained therein and through sensitivity analysis applied to the long term financial plan considered the risks and is satisfied that, with the Trust’s initiatives to improve care quality and productivity, operations can be carried out in an economic, efficient and effective manner. • 13. The board will ensure that the trust will at all times operate effectively within its constitution. This includes: maintaining its • register of interests, ensuring that there are no material conflicts of interest in the board of directors; that all board positions • are filled, or plans are in place to fill any vacancies; and that all elections to the board of governors are held in accordance with • the election rules. • The Trust has in place a Trust Secretary post which provides advice to the Board and Council of Governors on the Trust Constitution (including Standing Orders), ensuring that the required provisions are complied with. • A Register of Directors’ Interests and Register of Governors’ Interest are maintained and regularly reviewed by Board and Council. • All Board positions are filled with the exception of one Non-Executive Director post. The Board also has the ability, through constitutional provisions, to recruit two further Executive Director posts. The Council of Governors agreed to hold the NED vacancy as a consequence of changes to the Executive team structure. • All elections to the Council of Governors are held in accordance with the Trust’s Constitution and election rules. During 2012/13 the Trust commissioned Electoral Reform Services to act as the independent Returning Officer for all elections.

12. 14. The board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience, skills and • training to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, and • ensuring management capacity and capability. • 15. The board is satisfied that: the management team has the capacity, capability, training and experience necessary to deliver the • annual plan; and the management structure in place is adequate to deliver the annual plan. • Qualification of Directors • The Trust proactively consider she skills and competencies of the Board to ensure that both Executive and Non-Executive Directors have the required experience and behaviours to manage the organisation successfully and the particular challenges it is facing at any particular time. • This has involved: • Appraisal by the Chairman of individual Non-Executive Directors and the Chief Executive. • A revised Non-Executive Appraisal system which was introduced in 2011/12 to ensure that robust personal development plans are in place for Non-Executive Directors. • Appraisal by the Chief Executive of the Executive Team and the development of Personal Development Plans. • Continued review of the roles of the Trust Chair, Non-Executive Directors, Chief Executive and Director of Finance in Foundation Trusts and revision to job descriptions to ensure compliance with Monitor’s guidance. • Board members have also attended FT Network meetings, national workshops and regularly visited other organisations outside the healthcare sector. • Non Executive selection process and training • Non-Executive Directors have been fully involved in the Board Development programme and to enhance the range of experience and competencies present at the Board the Trust has used the processes outlined above to identify the skills needed to complement the Board when filling current Non-Executive vacancies. • Induction programmes for newly appointed Non-Executive Directors have been geared towards ensuring familiarity with the Trust’s services, healthcare standards and targets, strategic objectives and the long term financial model. Non-Executives have attended Board Seminars throughout the year and have contributed to the development of the Trust’s long term strategy and business development.

13. Capability and experience • Strong leadership, vision and direction are the cornerstone of the Trust’s capabilities as an NHSFT and as such individual appraisals by the Chief Executive ensure that the Team has the necessary skills and experience to lead the organisation effectively. • In addition to appraisal and development programmes offered at Board level, the Trust offers management development to the wider management group to ensure managers are more business focussed and aware of the market in which the Trust operates. This includes: • Biannual Senior Staff Conferences • First Line Management Development Programmes • Supporting staff to obtain masters and post graduate qualifications • Mentoring, coaching and secondment opportunities • Governance Awareness sessions • Planned OD and Leadership development for • Commercial • Clinical Leadership • Skills/competency • Management Structure • In October 2012 Stuart Bell was appointed as CEO of the Trust, following the retirement of Julie Waldron from that position, who has considerable senior experience in the NHS including 13 and a half years as the CEO of the South London and Maudsley NHS FT. On 1st June 2012 Sue Dopson, a Professor at the Said Business School in Oxford joined the Board as a Non-Executive Director , further strengthening the Board’s organisational and strategic skills in particular. Yvonne Taylor on her appointment as COO, after a successful period as the director for the Children & Families Division, brings considerable expertise and experience of operational delivery and growth to the Board. Following the departure of the Director of HR and OD, the role has been revised and allocated with OD to the CEO, Learning & Development to the Director of Nursing and HR to the Director of Finance, each of which has significant experience in the respective functions. • The relationship between the Executive Team and Non-Executive Directors continues to be strong, providing significant and healthy challenge on strategy and planning. These are clear indications of the team’s ability to deliver the key objectives and goals and successfully manage the organisation as an NHS Foundation Trust. • The Executive team and the Trusts senior management meet regularly to review performance and to develop the Trust’s short and medium term development plans.

14. For an NHS foundation trust engaging in a major Joint Venture, or Academic Health Science Centre (AHSC), the board is • satisfied that the trust has fulfilled, or continues to fulfil, the criteria in Appendix C4. • On 17th September health and social care partners1 from across Oxfordshire came together to launch the Oxford Academic Health Consortium (OAHC). The main aims of this collaboration between commissioning, service delivery, research, education and training organisations, as set out in its Statement of Intent (Appendix X) are: • To establish a strong partnership that develops and implements strategies to strengthen the existing Oxford academic and clinical partnerships, ensuring improvements in healthcare, effective translational research, and strengthened multi-professional education and teaching. • To provide strong links and support for the Oxford Academic Health Science Network (AHSN) • To provide the platform for a successful Academic Health Science Centre (AHSC) application in 2013 • The OAHC unanimously agreed that improving dementia care in Oxfordshire would act as one of its first exemplars and involve all partners from the OAHC. • The Oxford Academic Health Consortium is in the process of preparing to respond to the Department of Health call for applications to become an Academic Health Science Centre (AHSC). Selected AHSCs will be confirmed by the Department of Health in December 2013 for commencement in April 2013. • During the establishment of the OAHC and throughout the application process consultation and engagement through existing governance arrangements with Council of Governors and Board of Directors has been and will continue to be maintained. Further collaborations with existing Local Clinical Research Networks will be established to ensure appropriate clinical input. Patient and carer input will be coordinated through the new and existing NHS infrastructure such as Healthwatch, the Health and Overview Scrutiny Committee and the Local Health and Wellbeing Boards. • 1Oxford Brookes University (OBU), Oxford Health NHS FT (OHFT), Oxford University Hospitals NHS Trust (OUHT), Oxfordshire Clinical Commissioning Group (OCCG), Oxfordshire and Buckinghamshire PCT (OBPCT), Oxfordshire County Council (OCC), Oxfordshire Learning Disabilities NHS Trust (OLDT), University of Oxford (OU)

15. The board is satisfied that plans are in place to ensure that the trust will at all times comply with all applicable legal • requirements • The Assurance Framework contains likely risks to the Trust not being compliant legal requirements. The Trust also has in place a Trust Secretary post which provides advice to the Board on legal matters, as well as a Legal Services team and Mental Health Act Office both of which ensure legal requirements are met. • The board is satisfied that during 2013 the Trust has provided the necessary training to its governors, as required in s151(5) of • the Health and Social Care Act, to ensure they are equipped with the skills and knowledge they need to undertake their role. • The Council of Governors approved a report in May 2013 relating to Governor training and development which saw the establishment of a Council sub-group to consider this area and develop recommendations and proposals relating to Governor development. • Members of the Board of Directors have attended routine seminars throughout the year that provide opportunities to discuss Trust or system-wide priorities such as improving service quality, business planning or cost improvement as well as discuss issues related governance or management structure.

16. 19. • After making enquiries the Directors of the Licensee have a reasonable expectation that the Licensee will have the Required Resources available to it after taking account distributions which might reasonably be expected to be declared or paid for the period of 12 months referred to in this certificate. • The Board of Directors and the Finance and Investment Committee have reviewed the Trust’s detailed financial plan for 2013/14 and the following 4 years, including risk and sensitivity analysis in relation to income and expenditure, capital expenditure, working capital and overall cash flow. After considering these the Board has confirmed a reasonable expectation that the required resources will be available to the Trust  after taking account of distributions which might reasonably be expected to be declared or paid for the period of 12 months referred to in this certificate.