Item 8 - Sheffield Health and Social Care

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of the systems of internal control. All residual risksand actions will carry forward into the 2013/2014Board Assurance Framework and the underlyingrisks will be entered onto the Trust’s CorporateRisk Register.Internal Audit has undertaken a review of theorganisation’s Assurance Framework and relatedassurance processes to ensure that they areembedded and effective and thus provide evidenceto support the Annual Governance Statement.The overall conclusion drawn from this review is thatthe Trust has maintained an Assurance Frameworkthroughout 2012/13 that is consistent withDepartment of Health guidance. The framework isconsidered to be fit for purpose and reflective of theprincipal risks that could impact on the achievementof the Trust’s strategic objectives, thereby acting asa key evidence source for the Trust in its preparationof the Annual Governance Statement.13.4.4 Public Stakeholder Involvementin Managing RisksService users and carers are members of the servicegovernance structures at Trust, directorate andteam level and contribute to planning and serviceimprovement groups such as the In-patient Forumand Service User Safety Group. Their contributionincludes addressing issues of service user safety andimproving the quality and effectiveness of care.Service user views are also actively sought throughsurveys and focus groups.During the past year, successful and well attendedimproving quality events for service users, carersand Governors have been held to review qualityin the Trust and build greater service user andcarer involvement in work to improve the qualityof services throughout the Trust. The Trust is alsoa partner to Sheffield Local Involvement Network(LINk) to be replaced by Healthwatch Sheffield fromApril 2013. Governors played a large role in thedevelopment of the Trust’s Quality Accounts andLINk members were also consulted.Service users and carers, who are part of thePartners in Improving Quality Group, haveundertaken various site visits across the Trust inrelation to checking compliance against the CQC’sEssential Standards of Quality and Safety, as well asbeing involved in the former Patient EnvironmentAction Team (PEAT) assessments (replaced withPLACE (Patient-Led Assessments of the CareEnvironment) from April 2013.As a Foundation Trust Sheffield Health andSocial Care has public members and a Councilof Governors. The overall role of the Council ofGovernors is to assist the Trust in the drive to raisestandards by providing services of the highestpossible quality that meet the needs of the peopleof Sheffield. The Council of Governors receives updateson the Trust’s compliance against regulationsand standards and helps plan and steer the Trustand assists in setting priorities for improvementsand changes. Governors are also members of keygovernance meetings where they can represent theinterests of the local community, service users andcarers and make sure that the Trust does what itsays it will do.13.4.5 Quality Governance ArrangementsThe Foundation Trust is fully compliant with theregistration requirements of the CQC.The CQC carried out a Review of Complianceat the following locations during the year:Hurlfield View (June 2012)Mansfield View (July 2012)Longley Meadows (July 2012)Bolehill View (January 2013 and March 2013)Wainwright Crescent (February 2013)136a Warminster Road (February 2013)Grenoside Grange (February 2013)From these inspections all locations with theexception of Bolehill View, were deemed to befully compliant against the Essential Standards ofQuality and Safety that were reviewed. Bolehill Viewreceived two compliance actions against outcome2 (consent to care and treatment) and outcome21 (records). However, during a further review inMarch 2013, both compliance actions were liftedand the location is fully compliant again.Ongoing compliance with the CQC’s EssentialStandards of Quality and Safety is assessedthroughout the year by individual teams withintheir internal governance processes. Any areasof concern are escalated through directorates andto the Head of Integrated Governance. The Trustalso holds Quality Check meetings throughout theyear, which includes stakeholders and membersof the Partners in Improving Quality Group,which provides assurance to the Trust on ongoingcompliance and shares the learning from anyinspection reviews. The Trust has devised a templatethat senior managers and volunteers use, to assesscompliance against the standards, when carryingout site visits at registered locations.The Trust assesses itself against Monitor’s QualityGovernance Framework on a quarterly basis andthis is reported to the Board of Directors.Sheffield Health and Social Care reports progresson the Trust’s Quality Objectives to the QualityAssurance Committee of the Board of Directorsquarterly and also regularly monitors progressagainst the quality indicators contained withinthe Quality Schedule that is agreed with ourcommissioners, NHS Sheffield.The Trust has maintained Level 1 of the NHSLitigation Authority’s Risk Management Standardsfor Mental Health and Learning Disability, beingassessed in March 2013 and is aiming to beassessed at Level 2 during 2014/15.13.4.6 Information Governance and Data SecurityThe Trust has an Information Governance Policy whichprovides a framework that incorporates a range ofpolicies relating to the creation, use, safe handlingand storage of all records and information. Policiesincluded within this framework are InformationSecurity Policy, Remote Working and Mobile DevicesPolicy, E-mail Policy, Internet Acceptable Use Policy,Information Quality Assurance Policy, RecordsManagement Policy, Confidentiality Code of Conduct(including Safe Haven Procedures), Starter andLeaver Procedures, Subject Access Procedures andIncident Reporting Procedures. The management andmonitoring of information risks is the responsibility ofthe Trust’s Senior Information Risk Owner (the DeputyChief Executive) and information risks and incidentsare reviewed and monitored through the InformationGovernance Steering Group, which is a sub-group ofthe Quality Assurance Committee. The InformationGovernance Steering Group has a sub-group, theCare Records Group, reporting to it.The Trust continues to adhere to the InformationGovernance Toolkit. The Trust submitted theInformation Governance Toolkit in March 2013and has met the required level on all items. A workprogramme is in place to ensure further progressover the following year.The IT department has ensured all laptops havebeen encrypted locally and has rolled out anationally procured encryption solution, ‘Safeboot’,for portable computers and storage devices.The Trust has implemented an encryption systemfor external e-mails.Information Governance training is included aspart of the core training for new starters and othertraining sessions have been provided for managers.Information Governance is also covered in the Trust’slocal induction checklist for all new staff. Remindersare presented to staff when accessing the Trust’smain patient information system. and all staff areexpected to complete annual online informationgovernance training.Information governance and data security incidentsand risks are recorded and reported through the Trust’srisk management processes, as described above. Therewere no serious incidents of severity 3 – 5 (as classifiedby the Department of Health Checklist for Reporting,Managing and Investigating Information GovernanceSerious Untoward Incidents, Gateway Ref. 13177)reported in the Trust between 1st April 2012 and31st March 2013.13.4.7 NHS Pensions Scheme RegulationsAs an employer with staff entitled to membershipof the NHS Pension Scheme, control measures are inplace to ensure all employer obligations containedwithin the Scheme regulations are compliedwith. This includes ensuring that deductions fromsalary, employer’s contributions and payments intothe Scheme are in accordance with the Schemerules, and that member Pension Scheme recordsare accurately up-dated in accordance with thetimescales detailed in the Regulations.13.4.8 Equality, Diversity and Human RightsControl measures are in place to ensure that allthe organisation’s obligations under Equality andHuman Rights legislation are complied with.The Trust is committed to eliminating discrimination,promoting equal opportunity and fostering goodrelations in relation to the diverse communities itserves and its staff, taking account of all protectedcharacteristics as defined within the EqualityAct 2010. Policy, procedure, systems and leadposts (for example safeguarding) are in place tooversee practice and ensure that Human Rightsare considered and maintained in Trust services.141142
The Trust has identified Equality Objectives andpublished these in April 2012. Progress on thePublic Sector Equality Duty is published in theTrust Annual Equality and Human Rights Reportalongside a report which contains detailed data andinformation relating to people who use Trusts servicesand people employed by the Trust. These are madepublicly available through the Trust’s website.The Trust has a lead Director responsible forEquality and Human Rights who reports to theTrust’s Executive Directors’ Group.An update on Equality and Diversity for 2012/13can be found in Section 2.16.2.13.4.9 Carbon Reduction PlansThe Foundation Trust has undertaken riskassessments and carbon reduction delivery plansare in place in accordance with emergencypreparedness and civil contingency requirementsas based on UKCIP2009 weather projects, toensure that this organisation’s obligations underthe Climate Change Act and the AdaptationReporting requirements are complied with.13.5 Review of Economy, Efficiency andEffectiveness of the Use of ResourcesThrough its infrastructure, the Committees of theBoard of Directors, namely the Audit and AssuranceCommittee, Finance and Investment Committeeand the Quality Assurance Committee, togetherwith various operational groups, ensure that theBoard of Directors’ is assured that the organisationis monitored. This is undertaken by a number ofreports received by the Board and its Committees,which are produced via the operational governancegroups and consider areas including workforce,quality, risk and business related matters on amonthly basis. The Executive Directors’ Groupprovides operational governance for all plans todevelop new or reconfigured services, supportedby the Business Planning Group.The Trust has continued to review a number ofoperational efficiency metrics throughout the year,including the results of benchmarking exercises.Alongside this, the roll out and implementation ofservice line reporting of income and expenditurehas been developed to further focus on areas ofoverspending or inefficiency. This has enabledthe Trust to focus on service elements that can beconsidered in terms of the delivery of the Trust’sCost Improvement Programme (CIP) targets. Inaddition, the Trust has put in place a MutuallyAgreed Resignation Scheme (MARS) that has beenutilised to facilitate enabling schemes and servicetransformations in order to deliver efficiency savingsand a more effective use of resources.The Trust has continued to take a Quality,Innovation, Prevention and Productivity (QIPP)approach to the delivery of Cost Improvementand Cash Releasing Efficiency (CIP/CRES) targets.Detailed plans have been presented to the Boardof Directors and regular reports are provided tothe Board regarding delivery against these targets.The organisation has strong leadership throughits operational Directors, where a Service andClinical Director have joint management of clinicaldirectorates and Support Directors have the sameresponsibility for Central or Corporate Directorates.Each of these Directors have had budget trainingand are responsible for ensuring that the resourcesthey manage are done so effectively and efficientlyand are economic. Budget managers are providedwith monthly budget reports and activity statementsfor their areas of responsibility to assist them inundertaking this role. A service review, includingfinancial matters, is undertaken on a six monthlybasis and a financial sign off for current yearbudgets is performance managed by therespective Executive Directors.During 2012/13 internal audit has, as part ofthe Trust’s annual internal audit plan, conductedoperational/value for money reviews, including areview of Clover Group Governance and; in humanresources, in respect of Performance DevelopmentReviews (PDRs). The areas reviewed by internalaudit link to the efficient and effective operationof the Trust.13.6 Annual Quality ReportThe Directors are required under the Health Act 2009and the National Health Service (Quality Accounts)Regulations 2010 (as amended) to prepare QualityAccounts for each financial year. Monitor has issuedguidance to NHS foundation trust Boards on theform and content of annual Quality Reports whichincorporate the above legal requirements in the NHSFoundation Trust Annual Reporting Manual.During the year the Board of Directors hascontinued to review performance against its qualityindicators and designated quality objectives. TheBoard does this through the reports and reviewsundertaken to the Quality Assurance Committee(a formal sub-Committee of the Board of Directors)and to the Directors directly. This has enabledthe Board to remain appraised of our currentperformance in respect of quality.Additionally, joint meetings of the Board ofDirectors’ and Council of Governors have reviewedareas of importance to be progressed in the future.In preparing the Quality Report, directors satisfiedthemselves that the report presents a balanced viewand that there are appropriate controls in placeto ensure the accuracy of the data taken from theTrust’s systems for patient records (Insight) andrisk management (Ulysses Safeguard) and publicwebsites, e.g. the CQC. Service user feedback andinformation collected through team governance hasalso been used in the production of the report.National reviews and guidance reports on QualityAccounts from Monitor, and the Audit Commissionwere reviewed as well as the Audit Commission’sassurance report on Sheffield Health and SocialCare NHS Foundation Trust’s Quality Accountsfrom last year.The Quality Report has been consulted upon withSheffield City Council’s Healthier Communities andAdult Social Care Scrutiny Committee, HealthwatchSheffield and NHS Sheffield Clinical CommissioningGroup. It has also been received and considered bythe Board of Directors’ Quality Assurance Committee,Audit and Assurance Committee and by the Board ofDirectors itself.In reviewing and confirming its Quality objectivesthe Trust supported the Governors to undertakeengagement with our Members on their opinionsand thoughts on our planned improvement areas.Over 150 members commented on our proposalsand their views and opinions have informed ourfinal plans as outlined in the Quality Account.Our Quality Report is contained in Section 11of this Annual Report.13.7 Review of EffectivenessAs Accounting Officer, I have responsibility forreviewing the effectiveness of the system ofinternal control. My review of the effectiveness ofthe system of internal control is informed by thework of the internal auditors, clinical audit and theexecutive managers and clinical leads within theNHS Foundation Trust who have responsibility forthe development and maintenance of the internalcontrol framework. I have drawn on the content ofthe quality report attached to this Annual Reportand other performance information available to me.My review is also informed by comments madeby the external auditors in their reports. I havebeen advised on the implications of the result ofmy review of the effectiveness of the system ofinternal control by the Board of Directors, the Auditand Assurance Committee, the Quality AssuranceCommittee, the Finance and Investment Committee,the Information Governance Steering Group, theHuman Resources and Workforce Group, theBusiness Planning Group, the Operational DeliveryGroup, the Strategic Leadership Group, the QualityImprovement Group and the Executive Directors’Group and a plan to address weaknesses and ensurecontinuous improvement of the system is in place.These Committees/groups and their accountabilityand reporting relationships are described more fullybelow and in the Trust’s Business Plan. I believethat they form an effective and robust system ofgovernance for the Trust.The Head of Internal Audit provides me with anopinion based on an assessment of the designand operation of the underpinning AssuranceFramework and supporting processes and anassessment of the individual opinions arising fromrisk-based audit assignments contained withinthe internal audit risk based plan that have beenreported throughout the year. This assessmenthas taken into account of the relative materialityof these areas and management’s progress inrespect of addressing control weaknesses. Theoverall opinion of the Head of Internal Audit is thatsignificant assurance can be given that there is agenerally sound system of internal control, designedto meet the organisation’s objectives and thatcontrols are generally being applied consistently.Executive managers within the organisation, who haveresponsibility for the development and maintenanceof the system of internal control, provide me withassurance. The Assurance Framework itself providesme with evidence that the effectiveness of controlsthat manage the risks to the organisation achievingits principal objectives have been reviewed.My review is also informed by:• Reports from the Board of Directors and theBoard Committees;143144
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ANNUAL REPORT AND ACCOUNTS2012 - 20
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2.0 Directors’ Report2.1 Foundati
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• The directorate manages beds fo
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• Changes in demand are starting
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2.5 An overview of our arrangements
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This development is an important st
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2.16.5 Sickness AbsenceThe Trust re
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2.17.7. Key financial risks and cha
Page 21 and 22: SHSC Headquarters at Fulwood House3
Page 23: B) Pension benefitsAs Non-Executive
Page 26 and 27: Governors at the Annual Members mee
Page 28 and 29: Number ofseats2 YoungService user/C
Page 30 and 31: 6.0 MembershipFoundation Trust stat
Page 32 and 33: Service User artwork at Moncrieffe
Page 34 and 35: Name Position Term Number of meetin
Page 36 and 37: 7.3.4 Remuneration and Nominations
Page 38 and 39: Paul RobinsonACMA, CGMAExecutive Di
Page 40 and 41: 8.0 Staff SurveyThe Trust employs a
Page 42 and 43: Art therapy session on ward G1In ad
Page 44 and 45: 10.0 Sustainability ReportOur appro
Page 46 and 47: Part 2A: A review ofour priorities
Page 48 and 49: How did we do?We believe we are mak
Page 50 and 51: How did we do?We have made positive
Page 52 and 53: 101How do our structures help ensur
Page 54 and 55: Improving the management of Violenc
Page 56 and 57: National audit of psychological tre
Page 58 and 59: Part 3: Review of ourquality perfor
Page 60 and 61: Drug and alcohol servicesThe servic
Page 62 and 63: 3.3 Service user experienceComplain
Page 64 and 65: Memory servicesSurveys have led to
Page 66 and 67: It was harder for the Committee to
Page 68 and 69: This report, including the conclusi
Page 70 and 71: 13.0 Annual Governance Statement13.
Page 74 and 75: • Reports from External Audit;•
Page 76 and 77: We are not required to assess, nor
Page 78 and 79: The Accounts of Sheffield Health an
Page 80 and 81: SUPPORTING NOTESTO THE ACCOUNTSNote
Page 82 and 83: Revaluation gains and lossesIncreas
Page 84 and 85: of all assets less the value of all
Page 86 and 87: 3.4 Operating income by type compri
Page 88 and 89: The aggregate of remuneration recei
Page 90 and 91: No assets were held under finance l
Page 92 and 93: 13. Cash and cash equivalents15. Tr
Page 94 and 95: A provision of £729,000 relates to
Page 96 and 97: The value of transactions with boar
Page 98 and 99: Actuarial gains and losses are reco
Page 100: 17.0 ContactsSheffield Health and S
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Item 8 - Sheffield Health and Social Care

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