Annual Report Overview 2021/22

This is a short and accessible overview of some of the Key sections of the Trust’s Annual Report and Account 2021/22. The full report and accounts are available.

Chair’s Foreward

Thank you for taking the time to read our Annual Report and Accounts for 2021/22.

I have only been with the Trust for a short few months, having started in the role in February 2022. I’m the second person with the privilege of doing both this role at Northern Lincolnshire and Goole NHS Foundation Trust (NLaG) and the same role at Hull University Teaching Hospitals NHS Trust (HUTH). The ambition of having one person chairing both trusts was established a few years ago with the aim to facilitate and foster greater strategic alignment and partnership working.

Throughout this report you can read more about how the two trusts are working more closely together across a range of areas and services, something we need to build on in the coming years as we look to deliver, as two trusts, better and more accessible healthcare for the populations we serve.

As I write this Foreword in May 2022, I reflect on the past two years and what dominates that time is, of course, the COVID-19 pandemic. The emergence of coronavirus tested the trust, and the NHS more widely, like nothing else ever before. Over those 24 months the challenges changed – from learning how to tackle the disease and keep our patients and staff safe to putting in place services to help reduce the backlog of planned care the pandemic created.

Through every challenge the staff at the Trust have responded superbly and faced every issue and problem with a ‘can do’, positive and motivated attitude. That was not easy in the last year, as they cope with the exhaustion and stress of the first year of the pandemic. How they managed to keep going through those difficult days and challenging shifts is remarkable. I want to thank them on behalf of myself, the Trust Board and all our local communities: we are very proud of everything you have achieved.

What is equally remarkable, if not more so, is the progress the Trust has made in 2021/22 on so many other fronts alongside responding to the pandemic. Anyone who has visited the hospitals at Grimsby or Scunthorpe in the past few years will have seen the extensive building working which is taking place. This has been to improve scanning capacity in new purpose-built facilities at both sites and to create state-of-the-art spaces to house our emergency departments. The latter will open on both sites during 2022/23.

There’s also been investment in many areas which are not so immediately obvious. The Trust has started, in partnership with HUTH, to transform its IT and digital infrastructure, for example, and work has also been on-going to improve vital fire alarm and oxygen systems.

In terms of our performance against national targets the year as a mixed picture. Unfortunately, our emergency departments faced significant pressure throughout the year which meant too many patients had to wait longer than four hours, with many having to wait much longer than that. I’d like to apologise to all those patients. Improving this figure is a key challenge, and a top priority, for 2022/23.

Our performance in planned care, where we look to make sure patients get their booked procedures and operations, was much better and bucked the national trend. We managed to keep planned operations going throughout the year and this meant we started to make inroads into our waiting lists and, in particular, reducing the number of patients who had been waiting the longest time. I would like to thank our surgical and diagnostic teams for this work which needs to continue in the year ahead.

Another key area for the Trust, for many years, has been stabilising the financial position. You will see in this report that in 2021/22 the Trust managed to deliver its financial plan, something it has achieved for the past three years. I am hopeful the Trust will build on this in 2022/23 and that it will not need the close oversight of regulators in a way it has in the past.

Each and every member of staff plays an important part in running our Trust. Whether they are involved in the delivery of care directly to patients or not, the Trust couldn’t run without them. I would like to thank them for their unstinting professionalism in caring for our patients day in and day out. Thanks also to our team of Governors for their challenge throughout the year and our partners across the health system for their support, without which we could not have achieved many of the things we did.

I hope you will find the report interesting and informative and that it provides you with assurance that the Trust is, in many areas, really starting to gain momentum and embed improvements.

Chair: Sean Lyons

Date: 15 June 2022

Chief Executive’s Performance statement

In my performance statement in the Annual Report for 2020/21 I made the point that the year had been the most challenging the NHS had ever faced. Whilst that is still the case the 2021/22 financial year comes a close second. The year was dominated by three competing operational priorities: continuing to respond and manage the on-going COVID-19 pandemic; doing everything we could to ensure as many patients as possible could get their planned procedures and operations; and caring for those patients needing our urgent and emergency care services. This statement, and the majority of this chapter of the Annual Report, sets out the detail how the Trust responded to these competing priorities as well as a number of other priorities we set ourselves at the start of the year. I will say straightway it wasn’t easy and, in urgent and emergency care in particular, we would have liked to do much better. However, we did everything we could to make sure patients remained safe and got the care and treatments they needed as quickly as possible, despite the many challenges we faced including those related to our ageing buildings and digital infrastructure.

Once again the response of our staff to the challenges they faced was magnificent. Their care and compassion shone through everything they did and everything they achieved. To come to work day in and day out, after a year like no other, showed remarkable levels of courage, resilience, and motivation. In my regular communications to staff I tried to thank them as much as possible – they truly earned all that appreciation, and more.

I have said this before, but make no apologies for repeating it, they deserve enormous credit for what they have done – and continue to do every single day – to keep our hospitals running. And by that I mean all our staff, whatever job they do, whatever shift they work and whatever location they work at. It is humbling being their Chief Executive and a real privilege. Thank you once again to them all.

COVID-19 and the pandemic response

During the course of the year the Trust saw a high volume of COVID-19 patients, with different waves throughout the year presenting a number of challenges. The main challenge related to managing the flow of patients in our two main hospital sites (Diana Princess of Wales Hospital in Grimsby and Scunthorpe General Hospital) whilst maintaining high standards of infection prevention and control. I’m proud to report the Trust was shortlisted for a Health Service Journal / Nursing Times Patient Safety Award for its work in reducing COVID-19 transmission within our hospitals, not least with the use of Redirooms, pop-up units so individual patients can be isolated from other patients in the same area. The rate of COVID-19 transmission in our hospitals for the year was 7%, a significant reduction to the previous year and overall lower than our peers within our region. Over the course of the year I discussed these transmission rates with our local councils’ Health Overview and Scrutiny Committees.

The pandemic continued to be a significant challenge for the Trust with different variants of COVID-19, such as Delta, BA1 and BA2, with these causing surges in hospital admissions and staff sickness. In total there were more than 2,000 COVID-19 swabs detected in patients who were admitted into one of our hospitals during the year and, unfortunately, 152 patients died within 28 days of a positive COVID-19 test result. 

Our plans to offer operations and other procedures were affected by the influx of COVID-19 patients, staff absences related to COVID-19 and the reduced functioning of some theatres due to their age and associated maintenance issues. Despite this the Trust managed and prioritised waiting lists carefully and regularly to make sure those patients with the most urgent needs and those who had been waiting the longest could get the treatments they needed. The number of patients waiting more than 104 days for cancer treatment was steadily decreasing until November 2021 (23 patients), when another wave of COVID-19 hit and the figure remained static after that. This remains a key priority for the Trust in 2022/23. In terms of long waiters for planned procedures the Trust made good progress. At the end of March 2022 there was one patient waiting more than 104 weeks and 211 patients waiting 52 weeks or more, down from 1,187 at the end of March 2021.

The Trust maintained its Urgent and Emergency Care, known as Accident and Emergency (A&E), service for the full year although the Trust was frequently at the highest level of escalation, meaning it was struggling with the demands for A&E services and finding beds in the hospital for patients needing to be admitted. The Trust failed to meet its target to see and treat people in A&E within four hours and ended with a yearly average of 63.4%. Given the demands on the A&E service and the hospital capacity in general the Trust often struggled to get patients off ambulances in a timely manner or to admit patients quickly to wards. This means a high number of patients (1,802) having to wait longer than 12 hours in the A&E department and more than 15,500 patients who had to wait more than 30 minutes on an ambulance. I would like to apologise to every one of these patients who waited longer than they expected. We will be doing everything we can in 2022/23 to tackle the underlying causes for these waits to make sure our patients as seen as quickly as possible.

Workforce and leadership

As I have already stated the Trust could not provide the services it does without our staff. As such a key area of focus in 2021/22 was making sure we focused our effort on recruiting new staff and ensuring our current staff has the resources and support they needed to stay healthy, both physically and, crucially, mentally. Recruitment continued across all staff groups throughout the year and at an increased rate compared to previous years. Around 1,700 new staff started in the year.  In terms of registered nurses’ recruitment was undertaken through a variety of methods including international recruitment, newly qualified nurse recruitment, and sourcing candidates directly both locally and regionally. All of this work resulted in 235 registered nurse appointments in 2021/22. As a result of this the vacancy factor for nurses reduced from 10.84% in 2020/21 to 7.41% in 2021/22, within the Trust target of 8%.

In 2022/23 the Trust has set a priority to develop and launch a nursing apprenticeship scheme which will also help to improve the number of registered nurses employed by the Trust. Medical staff recruitment showed a similar positive trend with 34 new Consultants starting and another 10 in the pipeline, as of April 2022. A further 314 medical staff started at levels below Consultant. All these new staff resulted in a reduction in the vacancy position for medical staff to around 12%, within the Trust target of 15%.

The staff survey results, published in March 2022, made for disappointing reading overall and it was clear improving the Trust culture was a key issue for our staff. During 2021/22 the Trust was putting in place the foundations for a structured and long-term cultural change programme which will be the key workforce priority for the coming year. Progress made in 2021/22 included: commissioning targeted analysis to identify cultural concerns across the Trust; revamping network groups for Black and Minority Ethnic, disabled and LGTBQ+ staff; shaping a Just and Learning Culture framework to deal with bullying and harassment complaints and disciplinary issues; and designing and implementing a Health and Wellbeing Plan for all staff for the next two years.

Crucial to the success of the cultural change programme is to enhance the capabilities of clinical and non-clinical leaders at all levels. Work was kicked off in 2021/22 on leadership development based around a three strand Leadership Development Strategy. These strands – Foundations in Leadership (including core people leader skills), Professional Development and Values-based leadership – will form the basis of the programmes the Trust will be launching and embedding in 2022/23.

Quality and safety

When it comes to priorities the quality of our services and the safety of our patients is absolutely paramount. So at the start of 2021/22 we set ourselves a number of key objectives to ensure we made progress in these crucial areas. I’m pleased to say our Quality Improvement (QI) offer continued to grow and develop. We invested in our QI team, launched a new strategy and, most importantly, launched a number of projects across the Trust to tackle some longstanding issues. At the end of April 2022 we celebrated all the work we have been doing in relation to QI at a special conference attended by more than 100 of our staff. We’ll be building on this work in 2022/23.

At the start of 2021/22 we expected the Care Quality Commission (CQC), the agency which inspects healthcare services, to have visited at some point and to have reinspected our services. This did not happen although we expect it will at some point in 2022/23. Our last inspection report was published in February 2020 and since then we have been making sure we work through all the ‘must do’ and ‘should do’ actions set out in that report. At the end of March we had made steady progress on these actions, achieving 117 of 145 of them. At that time three ‘must do’ actions were rated as off track, and these were related to appraisals in our surgery division and mandatory training rates in our paediatric and maternity specialties. Progress on progressing these as quickly as we would want were due to operational pressures from the effects of the pandemic, however compliance remained a focus in these areas as we headed into 2022/23.

I’m pleased to report we made good progress on the five quality priorities we set ourselves for 2021/22:

• End of Life care and related mortality indicators: The Trust sustained a statistically significant and sustained improvement with regards to the overall Summary Hospital-level Mortality Indicator (SHMI, a complex calculation of the number of deaths seen against those expected), with a score of 106.4 in March 2022, which remains in the ‘as expected range’. Work continues within the organisation on the delivery of End of Life care, with continued work to embed new documentation as well as QI support in the management of pain.

The system across Northern Lincolnshire has recognised the need for greater palliative care support across the community to support people to remain in their own place of residence towards the end of life rather than coming to hospital (unless appropriate), and funding has been identified to enable recruitment to additional consultant posts.

• The deteriorating patient and sepsis: Recording of patient observations using nationally recognised tools in line with timescales was achieved against a target of 90%. Screening patients for sepsis did not achieve the desired 90% target, but this improved to 80% in January 2022, from 34% in May 2021.

• Reduction of medication errors: The target of reducing the number of medication omissions (without a valid reason) for ward areas reduced from 13.7% in April 2021 to 2% in February 2022 and so the target was achieved, as was the target for administering insulin on time. Operational pressures and staffing shortages impacted on the priority to sustain any improvements in recording patient weights in relation to paracetamol prescribing in the Trust’s Integrated Acute Assessment Unit (IAAU) and this priority is being carried forward to 2022/23.

• Safety of discharge: Performance against discharge indicators was significantly affected by the pandemic and continued pressures on services. Delayed discharges occurred for many reasons, including social care constraints. A discharge improvement plan has been implemented to drive progress.

• Diabetes Mellitus management: Compliance with diabetes mandatory training remained above 85%, and performance for the diabetes audit on inpatient ward areas remained at the target of 80%. Unfortunately, recording of children’s blood glucose in our A&E departments showed occasional fluctuations in compliance (although improved) but did not show sustained assurance, and so will remain a Quality priority for the coming year.

Strategic service development and improvement

Our plans to transform how we offer hospital services, being developed in collaboration with Hull University Teaching Hospitals (HUTH), continued to progress through the year. We developed strategies and plans for seven clinical specialties and these will start to be implemented in 2022/23. We plan to develop plans for three more clinical services which we have identified as needing extra support in 2022/23. The longer-term piece of work to look at how we might offer the key services of acute hospitals – urgent and emergency care, planned care and diagnostics and maternity and paediatrics – in the future continued to progress. This included wide-ranging engagement with more than 8,000 people to support the programme’s design/ development. The programme is on-track to compete a Pre-Consultation Business Case (PCBC) by Spring 2022. The PCBC is a document which enables the Trust and its partners to gain formal approval to consult the public on a number of options for future services and, at the time of writing, this consultation was set to launch in Autumn 2022.

Estates, equipment and digital capital Investment

Over the past couple of years, the Trust has been managing the largest capital investment programme it has had for many years. Bidding for, winning and then designing these new building and equipment developments is no easy task at the best of times so it has been incredibly challenging to deliver during the pandemic. My thanks go to all the teams involved in this work which is really starting to take shape across our hospitals. In 2021/22 this work included:

• Diana Princess of Wales (DPOW) Hospital. Grimsby
  • A new back-to-back MRI suite was opened successfully.
  • Building a new Emergency Department (ED), Same Day Emergency Care and Acute Assessment Unit was started. The new ED is due to open in Summer 2022.
  • Oxygen works – the installation of two new plants (primary and secondary) to support the increase of oxygen across the site. This included the successful installation of a new ring main surrounding the site as part of Phase 1 works. Phase 2 work included the installation of pipework to the clinical areas.
  • A new Fire Alarm system. This work included going into all public, staff and patient live areas to install the new system.
• Scunthorpe General Hospital (SGH)
  • A new MRI unit opened in March 2022.
  • Building a new ED, Same Day Emergency Care and Acute Assessment Unit was started. The new ED is due to open in Autumn 2022.

Work has also been taking place to secure significant investment for the long-term development of a new hospital for Scunthorpe and redevelopment of DPOW. In September 2021 the Trust, in partnership with HUTH, submitted a capital Expression of Interest (EOI) for £720m (which included £350m for SGH and £120m for DPOW).At the time of writing (May 2022) the Trust has not heard the outcome of the EOI submission.

In terms of the Trust’s digital infrastructure in 2021/22 we delivered the first phase of the Trust’s Digital Strategy, including investment of £2.5 million Digital Aspirant capital plus £2.5 million Trust ‘matched’ capital. This included work on: improved access to patient information by linking various systems in different organisations together; upgrading the Trust’s data warehouse to improve business intelligence and data management; upgrading versions of current inhouse systems to support paper-lite/paperless working; investing in solutions and devices to enable real time clinical data entry and single sign on; and piloting a scalable automation platform (Robotic Processing Automation – RPA) to reduce the burdens of repetitive data entry.

Finance

I’m pleased to report the Trust delivered its 2021/22 Financial Plan. Our accounts show a marginal improvement of a £0.04 million surplus against a planned balanced position. Despite the very difficult operational position of the Trust we still managed to deliver savings of £11.99 million, against a plan of £10.55 million, and the Trust also achieved its capital investment plan of £59.77 million. The Trust has faced a challenging financial situation for many years. It has been placed by its regulators (NHS England and NHS Improvement, NHSE/I) in what used to be known as Financial Special Measures, and is now called Recovery Support Programme (RSP). This decision has been made to make sure the Trust’s financial plans are delivered. This means the Trust is given extra support and oversight to ensure its financial position stays on track. NHSE/I set out a number of conditions the Trust must meet before it is taken out of the RSP. At the time of writing most of these conditions relating to finances have been met and we are confident we will exit the financial element of the RSP in 2022/23. 

Conclusion

Looking back at the year overall it has been dominated by the continued COVID-19 pandemic and the imperative to restore as many other services as possible back to pre-pandemic levels. This has not been easy and has led to many challenges. I am proud the Trust managed to tackle many of those challenges and delivered so many of the priorities we set ourselves at the start of the year. We could not have done that without our brilliant staff. Our challenge for 2022/23 is to continue to look after them and support them as they recover from two such difficult years. And we need to do this whilst we do everything we can to bring down waiting lists across the Humber and North Yorkshire area. As I said in the 2020/21 Annual Report that’s an incredibly tough balancing act. If anyone can manage to do this, our staff can – thanks to them all once again.

Chief Executive and Accountable Officer: Dr Peter Reading

Date: 15 June 2022

Director’s Remuneration

Notes to table

1 – Benefit in kind relates to Lease Cars 
2 – Mr T Moran was also Chair at Hull University Hospitals NHS Trust. The table above represents remuneration relating to Northern Lincolnshire and Goole NHS Foundation Trust only
3 – Mr L Bond is Chief Financial Officer, this is a joint role with Hull University Teaching Hospitals NHS Trust. The table above represents remuneration relating to Northern Lincolnshire and Goole NHS Foundation Trust only. The pension benefit is excluded from this table as this will be reported by Hull University Teaching Hospitals
4 – Mrs L Jackson receives a combined remuneration of £51k as Interim Chair, Vice Chair of Northern Lincolnshire and Goole NHS Foundation Trust and Associate Non-Executive Director of Hull University Hospitals NHS Trust 
5 – Mr S Hall receives a combined remuneration of £40.5k as Associate Non-Executive Director of Northern Lincolnshire and Goole NHS Foundation Trust, Interim and Vice Chair of Hull University Hospitals NHS Trust
6 – Mr S Lyons is also Chair at Hull University Hospitals NHS Trust. The table above represents remuneration relating to Northern Lincolnshire and Goole NHS Foundation Trust only

7 – NHS foundation trusts are required to disclose the relationship between the remuneration of the highest-paid director in their organisation and the lower quartile, median and upper quartile remuneration of the organisation’s workforce. The remuneration of the employee at the 25th percentile, median and 75th percentile is set out above. Total remuneration includes salary, benefits-in-kind , but not severance payments. The pay ratio shows the relationship between the total pay and benefits of the highest paid director (excluding pension benefits) and each point in the remuneration range for the organisations workforce. The ratio is obtained by dividing the highest paid directors salary by the median salary, the 25th percentile salary and 75th percentile salary . The median remuneration is the middle item salary when the annualised salaries of all members of staff including agency and seconded  staff, (excluding bank staff and the highest paid director) are arranged in descending order. The pay and benefits of the highest paid Director increased by 5% in the year, due to a non consolidated pay award for 2021/22, arrears for Clinical Excellence Awards and back dated arrears on the Consultant pay element.
8 – The percentage change in average employee remuneration is based on total for all employees on an annualised basis divided by full time equivalent number of employees 
9 – The number of employees that received remuneration in excess of the highest paid director is based on the full time equivalent cost.  

Consolidated Statement of Comprehensive Income for the year ended 31 March 2022

* The adjusted financial performance breakdown does not form part of the primary statement

Consolidated Statement of Changes in Equity for the year ended 31 March 2022

Annual Governance Statement

Scope of responsibility

As Accountable Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the Northern Lincolnshire and Goole NHS Foundation Trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the Northern Lincolnshire and Goole NHS Foundation Trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accountable Officer Memorandum.

The purpose of the system of internal control

The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness.  The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of the Northern Lincolnshire and Goole NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in Northern Lincolnshire and Goole NHS Foundation Trust for the year ended 31 March 2022 and up to the date of approval of the annual report and accounts.

Capacity to handle risk

COVID-19 meant a fundamental change to the way in which the Trust Board, staff and patients interacted. During 2021/22, the Trust Board stepped down some of its Trust Board sub-committees in January 2022 due to national guidance and operational pressures from the COVID-19 omicron variant. The sub-committee meetings were re-instated again in February 2022.

Leadership and Accountability

Leadership Generally

During 2021/22 and up to the date of publishing this report, the Northern Lincolnshire and Goole NHS Foundation Trust (the Trust) appointed a joint Trust Chair (replacement) with Hull University Teaching Hospitals NHS Trust (HUTH), to continue the strategic alignment between the two organisations in support of the Humber Acute Services Review (HASR) and as the NHS moves into closer financial alignment between NHS organisations within the emerging Integrated Care System (ICS) Provider Collaborative structure. 

The HASR is the collaboration between the Trust, HUTH and the four Humber Clinical Commissioning Groups (CCGs), which was created to ensure the long-term provision of high quality, safe and sustainable services for our local populations. 

During 2021/22 the Trust and Trust Board continued to embed the changes arising from the Care Quality Commission (CQC) Well Led Review undertaken in September 2019. This included a Trust Board Well Led self-assessment at its meeting on 5 October 2021, and work is ongoing to address the outcomes of that session. The Trust remains at ‘Requires Improvement’ in the ‘Well Led’ domain pending re-inspection by the CQC.

The Divisional leadership teams have continued a range of leadership training and coaching to strengthen their contribution to the organisation, building on the Trust’s clinical leadership. Work continued to consider and support the ability of our clinical leadership structure to respond to the wide demands throughout the seven-day week and some theatre and outpatient work is being undertaken at weekends. 

The recent merging of the Family Services division with the Community and Therapies division, as well as the disestablishment of the Clinical Support Services division will make the group governance and leadership stronger. In addition to this, to ensure divisional leadership teams are recognised across the system, the job titles have been revised for Divisional Clinical Directors who became Divisional Medical Directors, Divisional Head of Nursing became Associate Chief Nurse and Divisional General Managers became Associate Chief Operating Officers. Each division has then subsequently revised the job titles of those reporting into these individuals.

The Trust’s People Strategy continues to be embedded and focuses on three main themes: Workforce, Culture and Leadership. The Leadership development programmes were on hold during 2021/22 due to the COVID-19 pandemic, however a review was undertaken which included an external needs analysis. The leadership development framework for all leaders within the Trust was approved at Trust Board in April 2022. Planned areas of work around Leadership development were put on hold during the pandemic as staff from within the People directorate were redeployed to focus on and support the COVID-19 response. The key focus during 2021/22 was on health and wellbeing of our staff, the vaccination and booster programme and the COVID-19 vaccination as a condition of deployment. The Senior Leadership Community (SLC), brings together every month all of the organisation’s senior clinical and managerial leaders, is embedded and provides a mechanism for communication and engagement within the Trust on priorities and key messages

Leadership – Governance and Risk Management

In respect of governance and risk management, responsibility for corporate governance remains within the remit of the Director of Corporate Governance. Responsibility for quality and clinical governance sits within the portfolio of the Medical Director ensuring greater clinical engagement and ownership of these arrangements across the Trust. The Medical Director is supported by a Deputy Medical Director, Associate Director of Quality Governance and Associate Medical Director. 

The Deputy Medical Director provides a focus on clinical governance and is leading work on improving clinical engagement with the Trust’s clinical/quality governance arrangements. The Associate Director of Quality Governance leads on Quality Governance. Patient Experience sits outside the Quality Governance remit, in the Chief Nurse directorate, however the Patient Safety Partner volunteer roles which advise on the patient perspective, sit with the Associate Director for Quality Governance as does the Trust Patient Safety Specialist. The Associate Director for Quality Governance leads on risk for the Medical Director. The Risk Management Strategy continues to be implemented, training has been reinstated (paused during COVID-19) and Risk Clinics held with each division. 

Accountability

The Trust has in place a Performance Review and Improvement Management Framework, which outlines the approach to holding Divisions to account for delivery of objectives and improvements including those relating to governance and risk management. This includes monthly Performance Review Improvement meetings for the Clinical Divisions, chaired by the Chief Operating Officer and attended by other Executive Directors. The outcomes of the Performance Review Improvement meetings (PRIMs) are presented to the Finance and Performance Committee of the Board for oversight. To ensure weekly operational challenges and issues are managed in a timely manner and the risks relating to them mitigated or reduced, the Chief Operating Officer holds weekly Operational Management Group meetings with all the divisional leaders. The above arrangements made during 2020/21 reflect the Trust’s ongoing commitment to effective governance and quality governance including risk management processes. 

The Trust’s Internal Audit Programme is used to test key aspects of the Trust’s governance and risk management arrangements annually; not least the annual review of the Board Assurance Framework (BAF) and the risk management systems and process which underpin it. The Head of Internal Audit produces an opinion at the end of the financial year on the effectiveness of our control environment, and this opinion forms part of this AGS.

Training

The Trust has in place a mandatory training programme which includes training on specific risk topics such as fire safety, safeguarding, information governance, moving and handling, infection control etc. The majority of programmes continue as on-line learning as a result of the pandemic and social distancing where possible.   

Staff are regularly made aware of their duties and responsibilities in respect of reporting incidents and duty of candour. Whilst not mandatory, training is provided on Root Cause Analysis in support of the Trust’s arrangements for investigating and managing incidents. External Training is provided, as required, for example, risk register training. The Trust continues to utilise virtual learning for leadership and management and mandatory training. Further training needs have been addressed as part of the strengthening of the divisional governance arrangements already referred to above. 

This ensures that staff are trained and equipped to identify and manage risk in a manner appropriate to their authority, duties, and experience.  Mandatory training compliance is reviewed at the monthly PRIMs meetings; escalation of support can be requested to achieve compliance.

The Trust’s mandatory training programme is regularly reviewed to ensure that it remains responsive to the needs of Trust staff.  There is regular reinforcement of the requirements of the Trust’s Mandatory Training Policy and Training Needs Analysis and the duty of staff to complete training deemed mandatory for their role and in order to mitigate risk. The Trust’s Training Needs Analysis is regularly reviewed to ensure that mandatory training remains targeted and appropriate as well as manageable for staff.  

The Trust continues to work hard to achieve good levels of compliance with mandatory training requirements. In the first phase of the pandemic, mandatory training compliance did improve, however during the second surge, compliance dropped to 91% as of 26 April 2022 for core mandatory training above the target of 90%, and 76% for role-specific training (as at 26 April 22), against the target of 85% to the end of December 2021, which was then revised to 80%. Monitoring and escalation arrangements are in place to ensure that the Trust maintains good performance and can ensure targeted action in respect of areas or staff groups where performance is not at the required level. 

Monthly reporting is in place and work continues with the Information Team to produce infographics and forecasting for divisions. The training and development team are working closely with the mandatory training subject matter experts and the divisions to ensure that mapping to competencies is correct and staff are only undertaking the training they require for their role. 

Control Mechanisms including ‘Learning Lessons’ 

During 2021/22, the Trust replaced the Datix system with the Ulysses System as its IT enabled Risk Management System. The system enables individual actions to be tracked and monitored and enables oversight of all incidents via a daily report to not only clinical divisions, but also to the Medical Director and Chief Nurse. The Learning Strategy continues to develop and serves as a roadmap for the Trust’s approach to embedding learning.

The Trust maintains effective mechanisms for identifying and triangulating themes from a variety of intelligence sources using a refocused Collaborative Learning In Practice (CLIP) report. Serious Incidents have remained a key area of focus with the regular reporting of themes and an annual report to the Quality and Safety Committee. The SI Review Group provides a further mechanism for the sharing of transferrable lessons and for testing that this learning and associated agreed actions have led to sustained improvements.

Effective processes ensure that key themes are available to inform Quality and Safety Committee’s oversight of quality risks. This supported the Non-Executive Director (NED) confirm and challenge of the steps taken to mitigate against the identified quality risks in response to the significant risks faced by all NHS organisations.

The Trust provides assurance to commissioners on its arrangements for investigating and learning from SIs via a community-wide Serious Incident Collaborative Group, which in turn links with the Local Maternity Specialist. The Quality and Safety Committee and CCG Quality Review Meetings continue to receive updates on the outcome of clinical harm reviews. The clinical harm review process in turn dovetails in to existing governance processes, including the SI and Being Open and Duty of Candour Policy and Procedures. Instances of harm are being escalated as potential SIs to the weekly Executive-led SI panel for discussion as to whether they meet the criteria for reporting or, if not, would benefit from the added resource that an SI investigation would bring. This Panel also identifies learning in each meeting to be then shared through the organisation via the Learning Manager.

The Trust Board routinely considers specific risk issues and receives minutes and highlight reports from Board sub-committees including the Audit, Risk and Governance Committee, Finance and Performance Committee, Workforce Committee, Quality and Safety Committee and the Strategic Development Committee. These sub-committees provide oversight and challenge in respect of key areas of Trust business and in turn provide assurance and/or escalate concerns to the Trust Board. The Trust also has in place the Health Tree Foundation Trustees Committee, which is responsible for overseeing and managing the affairs of the Northern Lincolnshire and Goole NHS Foundation Trust Charitable Funds.

The Trust actively encourages networking and has strong links with relevant central/external bodies, e.g. NHS England / Improvement (NHSE/I), NHS Resolution, Health and Safety Executive, local CCGs, Local Authorities and Members of Parliament (MPs) and acts on recommendations / alerts from these bodies as appropriate. The Trust registers external visits and seeks assurance on the outcomes following external agency visit recommendations. This has remained a focus during 2021/22 and will continue during 2022/23 with emphasis on the ICS and place-based partnership working.

The Trust has maintained and developed its relationship with the CQC – escalating risks and concerns in respect of patient safety / quality as they occur, together with the actions taken or proposed. Monthly relationship meetings are held. The Trust has proactively sought CQC representative engagement at internal meetings to discuss local improvement plans and share progress and challenges with CQC linked improvement plans. The Trust is keen to promote an open and transparent relationship with the CQC viewing it as a key stakeholder in the organisation’s improvement journey.

The risk and control framework

The Management of Risk 

The Trust is committed to the clinical and non-clinical management of risk in order to improve the quality of care and provide a safe environment for the benefit of patients, staff and visitors by reducing and, where possible, eliminating the risk of loss, harm or damage, protecting its assets and reputation. This is achieved through a process of identification, analysis, evaluation, control, action, elimination, or transfer of risk.

The Trust has in place a Governance and Risk Management Strategy for 2019 to 2024 which provides a framework for the ongoing monitoring and review of risks, linked to the Trust’s Strategic Objectives. The overall responsibility of this strategy sits with the Medical Director. The Strategy is an integral part of the Trust’s approach to continuous quality improvement and supports the delivery of key quality objectives. This in turn, ensures that staff understand and act on the risks to the achievement of those objectives as well as achieving compliance with external standards, duties and legislative requirements.

The Trust recognises that risks can change, and new risks can emerge over time.  The review and updating of risks on the risk register and within the BAF is an ongoing, dynamic process. A Risk Management Group is in place to review and monitor risks added to the Risk Register and to ensure that the appropriate mitigation actions are in place. The Audit Risk and Governance Committee has the delegated authority on behalf of the Trust Board for monitoring effectiveness, scrutiny, and oversight of these arrangements. The BAF and risk register are used to inform the agenda of the Trust Board and Board sub-committees with the relevant risks being aligned to and reviewed by the relevant sub-committees quarterly. The Trust Board sub-committees undertake deep dives into their aligned strategic risks within the BAF and the Trust Board annually reviews the organisation’s ‘Risk Appetite’. 

An annual Internal Audit review of the BAF and the associated risk management processes is undertaken to ensure they are fit for purpose and comply with good practice. A rating of ‘significant’ assurance was again received following the 2021/22 Internal Audit review.

The Trust’s strategic risks as summarised within the BAF are:

• The risk that patients may suffer because the Trust fails to deliver treatment, care and support consistently at the highest standard (by national comparison) of safety, clinical effectiveness and patient experience. 

• The risk that the Trust fails to deliver constitutional and other regulatory performance or waiting time targets which has an adverse impact on patients in terms of timeliness of access to care and/or risk of clinical harm because of delays in access to care                                                

• The risk that the Trust (with partners) will fail to develop, agree, achieve approval to, and implement an effective clinical strategy (relating both to Humber acute services and to Place), thereby failing in the medium and long term to deliver care which is high quality, safe and sustainable   

• The risk that the Trust’s estate, infrastructure and engineering equipment may be inadequate or at risk of becoming inadequate (through poor quality, safety, obsolescence, scarcity, backlog maintenance requirements or enforcement action) for the provision of high quality care and/or a safe and satisfactory environment for patients, staff and visitors  

• The risk that the Trust’s failure to deliver the digital strategy may adversely affect the quality, efficacy or efficiency of patient care and/or use and sustainability of resources, and/or make the Trust vulnerable to data losses or data security breaches      

• The risk that the Trust’s business continuity arrangements are not adequate to cope without damage to patient care with major external or unpredictable events (e.g. adverse weather, pandemic, data breaches, industrial action, major estate or equipment failure)

• The risk that the Trust does not have a workforce which is adequate (in terms of diversity, numbers, skills, skill mix, training, motivation, health or morale) to provide the levels and quality of care which the Trust needs to provide for its patients                                        

• The risk that either the Trust or the Humber Coast and Vale Health and Care Partnership fail to achieve their financial objectives and responsibilities, thereby failing in their statutory duties and/or failing to deliver value for money for the public purse                 

• The risk that the Trust fails to secure and deploy adequate major capital to redevelop its estate to make it fit for purpose for the coming decades          

• The risk that the Trust is not a good partner and collaborator, which consequently undermines the Trust’s or the healthcare systems collective delivery of: care to patients; the transformation of care in line with the NHS Long Term Plan; the use of resources; the development of the workforce; opportunities for local talent; reduction in health and other inequalities; opportunities to reshape acute care; opportunities to attract investment

• The risk that the leadership of the Trust (from top to bottom, in part or as a whole) will not be adequate to the tasks set out in its strategic objectives, and therefore that the Trust fails to deliver one or more of these strategic objectives

• As referred to above, the Trust Board and its sub-committees have reviewed the BAF in order to ensure:

• that the risks are an accurate reflection of the organisation’s current risk profile; 
  • the focus on the areas of strategic importance is maintained (i.e. those which have the potential to threaten the achievement of the Trust’s strategic objectives); and
  • the necessary controls and assurances are established and effective

The Board sub-committees review and challenge their associated sections of the BAF, with escalation of issues or concern to the Trust Board through their highlight reports.  

The Audit Risk and Governance Committee has the overarching lead role for ensuring the arrangements for underpinning the BAF are in place and are robust.

The Trust Board holds an annual self-certification event to assess and confirm compliance or otherwise with the requirements of its NHS Provider Licence including condition FT4 (8) relating to governance. This work is supported by an Internal Audit review of the assurances in place, which support the required declarations in order to test and confirm their validity.

In line with the principles of devolution within the Trust, and in accordance with the Scheme of Delegation, responsibility for the management/control and funding of a particular risk rests with the Directorate/Division concerned. However, where action to control a particular risk falls outside the control/responsibility of that domain, such issues are escalated to the Executive Team/Trust Management Board or Trust Board for a decision to be made as follows:

• Where local control measures are considered to be potentially inadequate
• Where local control measures require significant financial investment
• The risk is ‘significant’ and simply cannot be dealt with at that level

Supporting this devolved structure are corporate Directorates (non-clinical). These Directorates have experienced and appropriately qualified staff to support and advise staff at all levels across the organisation with the identification and management of risk for both clinical and non-clinical.

Risk Management is embedded in the activity of the organisation by virtue of robust organisational and sub-committee structures.

The role of the Freedom to Speak Up (FTSU) Guardian and promotion of the role to staff continues to be of great importance for the Trust. The Trust has worked closely with the National Guardian’s Office, Regional and National Networks and other Guardians from peer trusts. This includes the following objectives with defined actions which are being implemented:

• Encourage Everyone to Speak Up Better
• Create a Culture where staff are listened to
• Use information provided by FTSU concerns to help develop a ‘learning culture’ within the organisation
  

The Trust Board receives quarterly independent reports for oversight and the FTSU Guardian continues to work with Executives and the Trust Board to support development and training sessions with them and the wider Trust – during 2021/22 there have been two board development sessions around FTSU and further sessions are planned for 2022/23. The Guardian participated in the National Speak Up month in October (a dedicated communication and marketing plan was shared with all staff to promote the role and how to access the Guardian. The Guardian continues to work in partnership with the Trust and Unions to promote ‘Speaking Up’ as business as usual.

The Culture theme within the Trust’s People Strategy supports this and focuses priorities around building a culture and staff experience which will strengthen our recruitment attraction strategy, improve employee experience, and enhance our aim to meet the preferred employer standards defined in the CQC Well Led criterion.  Our staff survey results for 2021 illustrate we have maintained a strong Health and Wellbeing offer and our leadership development strategy and culture transformation agenda will continue to improve on all staff survey scores.  

Relevant governance and risk management Key Performance Indicators (KPIs) are shared through the performance management framework and are reported up to the Trust Board through the Integrated Performance Report (IPR).  Business Planning and Service Development proposals do not proceed without:

• Recognition and acceptance of the risks involved
• Involvement of the relevant risk management expertise e.g. health and safety and fire, infection control
• An appropriate assessment

Executive Directors individually and collectively have responsibility for providing assurance to the Trust Board on the controls in place to identify, manage and mitigate risks to compliance with the Trust’s NHS Provider Licence. The sub-committees of the Trust Board in turn have responsibility for providing assurance in respect of the effectiveness of those controls. A system of ‘highlight’ reports to the Trust Board is in place to highlight any risks to compliance. Board sub-committees are chaired and attended by NEDs as core members, with relevant Executive Directors as well as by other key Trust staff being ‘in attendance’. There is a clear separation between Board sub-committees and day to day management meetings.

Patient and Public Involvement (PPI) 

The Trust ensures public stakeholders are involved in understanding the risks which impact upon the organisation through a variety of routes. This includes: the operation and meetings of the Council of Governors (CoG); the publishing of the CoG and Trust Board papers on the Trust’s website; and the holding of Board meetings in public. The CoG normally meets at least four times per year with these meetings being held in public. The agenda includes appropriate highlight reports from Board sub-committees. During the ongoing COVID-19 pandemic in 2021/22 the CoG met virtually three times as well as held the Annual Review of the Council meetings online. The Annual Members’ Meeting in September and the October CoG meeting were held in person at public venues.  

The Trust continues to work with its local Healthwatch partners to ensure a wide breadth of patient views are heard. As well as this the Trust continued to work on the Humber Acute Services programme which included a number of engagement activities. These included: online surveys; face-to-face meetings with specific groups of services users such as sex workers and new and expectant mothers; and meetings with the programme’s Citizens’ Panel. During 2022/23 the programme is planning to run a full public consultation on possible options for hospital services in the future.

The Trust launched a new website in the year which is fully compliant with the latest accessibility requirements. The website provides members of the public with easy and timely access to information across all areas of Trust activity. The Trust also make efforts to publicise timely information – such as changes to visiting arrangements throughout the pandemic – via email, social media channels such as Twitter and Facebook and, where appropriate, by liaising with the local media. 

Quality Risks 

The Trust also has in place a range of mechanisms for managing and monitoring risks in respect of quality including:

• The Trust agrees annual quality priorities 
• The Trust has in place the Trust Board’s Quality and Safety Committee which meets monthly and is chaired by a Non-Executive Director. The Quality and Safety Committee is responsible for monitoring performance against the agreed annual quality priorities and other quality issues, and minutes of the Committee are submitted to the Trust Board. The Quality Governance Group (QGG) in turn provides assurance on quality and safety activities to the Quality and Safety Committee
• The Trust publishes an Annual Quality Account, which is subject to consultation with key external stakeholders
• Performance against key quality indicators is routinely reported to the Trust Board through the IPR and to the Quality and Safety Committee via quality reports
• The Trust Board is implementing/developing the Quality Strategy, a Quality Improvement Strategy and the Quality Improvement Training Faculty
• The Trust has in place arrangements and monitoring processes via the Register of External Agency Visits, to ensure ongoing compliance with other service accreditation standards (e.g. including Clinical Pathology Accreditation (CPA), Medicines and Healthcare products Regulatory Accreditation (MHRA) (for blood products) and Human Tissue Authority (HTA) licences for mortuary and post mortems)
• The Trust’s QGG monitors performance with the National Institute for Health and Care Excellence (NICE) guidance implementation and assurance relating to Patient Safety Alerts and other safety alerts received via the Central Alerting System. The Quality and Safety Committee approves any deviations from NICE guidance
• The Medical Director has the lead for mortality supported by an appointed clinical lead. A Mortality Improvement Group, reporting to the QGG, is in place and includes as part of its membership Divisional clinical leads, a Non-Executive Director and relevant external stakeholders
  
• The Quality and Safety Committee retains a challenge and assurance role in respect of mortality ensuring improvements are sustained or escalated appropriately. Reporting on mortality improvement to the Trust Board occurs through the IPR and, where relevant, through the highlight report from the Quality and Safety Committee. A key part of the Mortality Strategy centres on the National Quality Board (NQB) guidance on learning from deaths. During 2021/22 continued improvements in the process for screening a higher proportion of deaths for learning opportunities were achieved. Further work during 2022/23 will be focused on feedback and sharing of themes and learning with key stakeholder partners in and outside the organisation
• The Trust has in place robust methods of pro-actively looking for potential clinical harm, through the Ulysses reporting system, but also in the risk stratification and tracking of our waiting lists and reviewing all patients waiting for a prolonged period of time on our waiting lists. This data is captured in a system called COBRA, and the output is overseen via regular reporting to Quality and Safety Committee
• End of Life has remained a high priority for 2021/22 as demonstrated by the retention of quality measures in the approved Quality Priorities for 2021/22.  Good engagement is evident within divisions and supports the detailed plan which incorporates actions from CQC actions, local audits and learning from deaths. These feed into the monthly Trust End of Life meeting for monitoring.  NHSE/I continue to work alongside the Trust and key stakeholder partners across the system. The Trust’s End of Life Group reports into the Mortality Improvement Group, which in turn reports to the QGG
• The Trust continues to utilise the checklist for wards and departments, based on the 15 Steps Programme which is aligned to the CQC Key Lines of Enquiry, ensuring the ongoing monitoring of key standards and the early identification and escalation of risk issues. This work has involved training staff (including Board members), to be able to conduct peer review visits
• The 15 Steps Assurance Programme was suspended due to the pandemic however supportive visits were maintained throughout by the Quality Assurance Officer and the Lead Nurse for 15 Steps on areas where it was deemed appropriate and safe to do so and the Programme restarted fully in June 2021. This remains a priority for 2022/23
• Some informal visits to wards and departments were undertaken during 2021/22 by Executives and NEDs, but these were limited due to COVID-19 restrictions. These arrangements enable staff to showcase good practice but also to talk directly to members of the Trust Board on quality and safety and other issues or concerns
• NEDs have oversight and assurance roles in respect of specific aspects of governance, quality governance and risk. These roles are reviewed annually
• The Medical Director is the Trust Board lead for quality and safety although in discharging this responsibility works closely with the Chief Nurse (the Trust Board Lead for patient experience) and the Chief Operating Officer
• The Chief Nurse developed and is implementing the nursing, midwifery and allied health professional’s strategy called ‘The Future 5 and Beyond 2021-24’

• A nursing dashboard is in place to monitor the nursing contribution to safety and quality. This is supported by a Nursing Metrics Panel which ensures the early identification and mitigation of risk issues
• The Trust has in place an annual safe staffing review process in respect of nursing and midwifery, which is reviewed by the Trust Board with ongoing monitoring undertaken by the Quality and Safety Committee
• The Trust routinely considers and acts upon the recommendations of national quality benchmarking exercises, e.g. National patient surveys
• The Trust acts upon patient feedback from complaints and concerns and from feedback from PPI representatives (e.g. Health Watch)

The effectiveness of the Trust’s governance, quality governance and risk management arrangements also continued to be tested during 2021/22 via internal and external testing including internally via the Annual Internal Audit Programme and externally via relevant external reviews and visits. 

CQC: Registration and Essential Standards of Quality and Safety

The Trust underwent its last CQC inspection in September 2019. The full visit report was published in February 2020. Arising from that inspection the Trust retained its overall rating of ‘Requires Improvement’ and moved from ‘Inadequate’ to ‘Requires Improvement’ for ‘Well Led’. The Trust also received a rating of ‘Requires Improvement’ for ‘Use of Resources’, the first such assessment and a significant achievement given the Trust’s being in the Single Operating Framework level 4 of the Recovery Support Programme. However, the Trust received a rating of ‘Inadequate’ in the ‘Safe’ domain’. This was due to ongoing waiting list backlogs in some specialties, the backlog in diagnostic reporting, concerns in relation to end of life care and some issues in the Trust’s two emergency departments; specifically training, paediatric pathway, safe environment and sustaining improvements in ambulance handover. The Trust is in the Single Operating Framework level 4 of the Recovery Support Programme for quality and continues to benefit from the support package put in place by NHSE/I; specifically support from an NHSE/I Improvement Director to implement and embed the required improvements. 

The detailed Divisional improvement plans incorporating CQC feedback continue to be embedded and delivered. The Trust continues to report on progress to the Performance Review and Improvement Meetings, the relevant Trust Board sub-committees and the Trust Board. 

The NHSE/I-chaired Quality Board brings together all relevant stakeholders to support the Trust in the delivery of its improvement plan and continues to have oversight of delivery of the required improvements. The Trust reports its progress to and discusses any issues or concerns directly with the CQC through the monthly engagement meeting.

Whilst the Trust is in the Single Operating Framework level 4 of the Recovery Support Programme for quality it has no conditions on its registration, and the Foundation Trust is fully compliant with the registration requirements of the Care Quality Commission.

Workforce 

The Trust has in place a NED chaired and populated Workforce Committee which is a sub-committee of the Trust Board. Its focus is to seek assurance on all workforce matters including compliance against our people metrics and the delivery of the People Strategy and NHS People Plan. Our annual workforce plan for the sub-committee is being implemented following the review to allow reporting and focus on workforce, culture, leadership and to evidence improvements made. The Trust continually reviews compliance with the safer staffing care standards ensuring that establishments and job plans are reviewed periodically, enabling the resource requirements for the delivery of safe care to our patients. The Trust continued to invest in new clinical roles to supplement the clinical workforce during 2021/22 which include Newly Qualified Nurses, Advanced Clinical Practitioners, Nursing Associates, Care Navigators and Medical Support Workers.

In addition, the Trust has worked closely with NHSE/I in the recruitment of international registered nurses to supplement the domestic workforce supply and achieved the target reduction of Health Care Support Worker vacancies to an operational zero status in 2021. To ensure compliance with developing Workforce Safeguards, a triangulated approach is used by the Chief Nurse to determine safe staffing levels. This combines the use of evidence-based tools (e.g. Safer Nursing Care Tool and BirthRate Plus, professional judgement and outcomes to ensure the right staff with the right skills are in the right place at the right time). Safecare Live is used to support the deployment of staff and escalation processes and procedures are in place. Quality impact assessments are undertaken for any ward and department reconfigurations. Workforce data and information from the nursing and midwifery quality assurance dashboards are scrutinised monthly in a Metrics Panel chaired by the Chief Nurse, and a monthly Assurance Report is presented to the Quality and Safety Committee which has oversight of safe staffing.

NHS pension scheme

As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments into the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations.

Equality, diversity, and human rights

Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. The Trust has an Equality and Diversity Strategy which encompasses our Equality Objectives.  Our Equality Objectives focus on achieving legal and contractual compliance and progress against them is reported to Trust Board and our commissioners bi-annually by our dedicated Equality and Diversity lead. The organisation has an Equality Impact Assessment (EIA) policy and procedure which ensures the integration of EIAs into Trust core business and to support this training continues to be delivered across the Trust.

Carbon reduction 

The Trust is committed to embedding sustainability and Net Zero carbon principles into all our services. We are committed to improving health outcomes for our patients by actively addressing our carbon impacting activities in line with the Climate Projections 2018 (UKCP18) whilst actively addressing the challenges within the “Delivering a Net Zero” National Health Service.

The Foundation Trust has undertaken risk assessments and has plans in place which take account of the ‘Delivering a Net Zero Health Service’ report under the Greener NHS programme. The Trust ensures that its obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with.

The Trust has built upon the Net Zero Health Service report to create the Northern Lincolnshire and Goole NHS FT Green Plan (2021/22) replacing the previous Sustainable Development Management Plan (SDMP). The Green Plan utilises the Net Zero report to produce a document with which we can guide the Trust to address both the emissions we control directly, and the emissions we can influence, working towards a Net Zero target by 2040 for directly controlled emissions, and 2045 for emissions we can influence.  

In addition to the Trust’s Green Plan (2021/22), we have taken further steps to align our Travel Plan with our Green strategy. To be approved in 2022, our revised Green Plan for 2022/2025 will incorporate our carbon impact from travel, waste to landfill, utilities, active travel, and low emission fleet, reviewed by our working group formed to address the Trusts carbon impact.  

The Green Plan incorporates a working action plan to address our progress towards Net Zero, a document which will grow as the impact of our work, projects and capital investments develop. The actions set out in our action plan will support us to achieve legislative requirements alongside the most important issues our Trust aims to address as identified in the strategic framework (2019/2024).

During this reporting period £3m of funding has been invested into the energy infrastructure at Goole, this work was funded via the Public Sector Decarbonisation Scheme (PSDS).  The scheme will save 1,418 tonnes of CO2 a year. The following works were completed:

• Replacement of the coal fired boilers with condensing gas fired units incorporating a Combined Heat and Power (CHP) unit
• New LED light fittings installed
• Loft and cavity wall insulation installed
• New Building Management System (BMS) installed
• New hot water services system installed
• Variable Speed Drives (VSDs) on ventilation plant installed

At the Scunthorpe site, the teams have completed a full set of Royal Institute of British Architects (RIBA) stage 4 designs for the following schemes:

• Ground source heat pump to enable de-steam to take place
• LED lighting
• BMS
• PV solar power
• Replacement roofing
• New windows
• Ventilation fan upgrades

The following works have been completed at Scunthorpe:

• New upgraded high voltage (HV) electrical ring main
• Upgraded electrical supply
• Completion of 2 boreholes (part of the ground source heat pump design and construction)
• New autoclave machines (as part of longer de-steam)
• All of the above design and construction works will enable the Trust to apply for grant energy funding to upgrade the energy centre at Scunthorpe General Hospital and install energy conservation measures in the future.

Our reporting processes are robust and will ensure the Trust complies with the UK Climate Change Act (2008) projections for the reduction of carbon. In addition to this, working with partners to reduce energy consumption, the Trust will be supported in the development of a road map to Net Zero, ensuring we comply with the targets set within the Net Zero report. This road map will be incorporated into the Green Plan advancing from 2022/25, and beyond.

Conflicts of Interest 

The Trust maintains a register of Directors’ interests which is reviewed by the Trust Board annually and is published through the Trust Board public meeting papers and within the Trust’s Freedom of Information publication scheme. The Trust has published on its website an up-to-date register of interests, including gifts and hospitality, for other decision making staff (as defined by the Trust with reference to the ‘Managing Conflicts of Interest in the NHS’ guidance) within the last 12 months as required by the Managing Conflicts of Interest in the NHS23 guidance.

Business continuity

The Trust has in place robust emergency preparedness and business continuity arrangements, which are considered and signed off by the Trust Board annually.  These arrangements have been tried and tested in response to the COVID-19 pandemic crisis and continue to be reviewed and monitored. In order to ensure both organisational and individual resilience, specifically in respect of those leading the Trust’s response given the likely duration of the crisis, these arrangements are continuously reviewed in line with NHSE/I’s emergency planning guidance and instructions. The emergency preparedness and business continuity workplan includes annual training and testing arrangements to ensure that leaders and staff across the organisation learn from previous events and build the resilience required to manage the ongoing challenges.

Review of economy, efficiency and effectiveness of the use of resources  

The Trust’s clinical activities are managed under a devolved management structure, governed by a scheme of delegation renewed and refreshed annually. The Trust has in place a clinical management structure to support effective leadership of clinical services and ensure effective care.

The Clinical Divisions report to the Chief Operating Officer, but the Divisional Clinical Directors within each clinical division also have a professional reporting line to the Medical Director. Each Clinical Director has a team of clinical leads covering individual service areas. The Trust has in place a system of monthly PRIMs with each Division, which cover quality, finance, and performance issues.

The Finance Directorate provides dedicated support to each clinical division and non-Clinical Directorate through nominated Business Accountants. Business planning is led by the Chief Operating Officer and the role of the Director of Strategic Development provides a close link between the Trust and:

• The Humber and North Yorkshire ICS
• The System Collaboratives with a focus on Acute and Community
• Place based Boards within North East and North Lincolnshire and the East Riding of Yorkshire

The Trust is currently leading a major review of clinical services within the Humber and will be consulting on those during 2022/2023. The emerging models of care will improve quality, access and outcomes for patients whilst addressing the workforce challenges we face.

The Trust continues to adopt a project-based approach to savings delivery. The Trust has enhanced governance and oversight arrangements in respect of savings delivery coupled with comprehensively documented plans. Savings are subject to a full Quality Impact Assessment sign off process undertaken jointly by the Chief Nurse and Medical Director.

The Trust maintains focus on performance management. Directorates and Divisions are responsible for the delivery of agreed financial and other performance targets through a system of performance agreements, documented as part of the annual business planning cycle and monitored through a series of regular performance review meetings.  During 2021/22 the Trust did not meet all its constitutional and other regulatory performance requirements, namely:

• A&E:

Whilst the Trust did not treat as many patients within 4 hours than in the previous year (2020/21: 99,913, 2021/22: 93,357), the performance improved in January and February 2022. The COVID-19 pandemic then affected the ongoing improvements and therefore performance during 2021/22 remained problematic. Recovery actions have been in place, and although these have not continuously delivered improvement, they have contributed to an ability to manage the challenges of the pandemic. 

From Quarter 3 the position improved, directly related to the opening of the Urgent Care Service (UCS) in Scunthorpe on the 18 October 2021 and followed by Grimsby on 18 January 2022. The UCS is holding a performance since that date of 98.65%.

Demand at this time was at almost pre-COVID-19 levels and the environment for both departments (modified to cope with COVID-19 Infection Prevention Control constraints) struggled to cope with safely meeting this demand with the March 2022 position of 61.93% and a current position (April 2022 month to date (25 April 2022)) of 58.71%. The Trust continues to work on the nine programmes of improvement to increase the performance and improve the patients experience through the urgent and emergency care service. The flow of patients through the Trust has seen a continued positive measure with discharge to assess for 21 days being held at 12.4%, demonstrating the continued partnership working to reduce the pressure on Inpatients services and improve the Trust’s ability to manage the urgent care demands.

• Cancer performance:

Whilst the Trust continues to deliver against the 2 Week Wait target, compliance with the 62-day cancer metric remained below target during 2021/22. Tertiary capacity also continues to be very stretched. The Trust continues to focus on its improvement efforts, including collaboration with Hull University Teaching Hospitals (HUTH) by the development of the joint Humber Cancer Board. The COVID-19 pandemic has impacted on our ability to manage and treat patients with cancer. That said, our 62-day cancer performance through 2021/22 was 63.4%. The Trust maintained cancer treatments and outpatients throughout the pandemic. It has also worked closely with HUTH and the cancer alliance on the development of the “28-day faster access to diagnostics” with the March 2022 performance of 56.2%. Work is underway to assess the impact on planned improvement trajectories and to assess the risk to patients waiting. The Trust is also an active participant in the Humber, Coast and Vale Cancer Alliance, which is reviewing all cancer pathways across the region.

• RTT and OPD follow-ups:

During 2021/22, the Trust continued to make progress against all waiting list metrics.  In relation to Referrals to Treatment (RTT), performance has averaged 69.0% for 2021/22 (2020/21: 61.4%), as the amount of elective surgery and outpatient procedures was 98.6% compared to 2019/20. Outpatient transformation plans have contributed to a reduction in overdue follow-ups during the second half of 2021/22.  The Trust has continued to see 52 week waits reduce (March 2021: 1,187, March 2022: 211), with the remainder of patient waits being primarily due to patient choice.  This is as a result of mutual aid provided to the Humber and North Yorkshire ICS.

The Trust has continued throughout the COVID-19 pandemic with pathway and data validation ensuring the quality and transparency of our elective activity. Capacity issues remain specifically in Ears, Nose and Throat (ENT), Ophthalmology and Gastroenterology. Work is underway to assess the impact on planned improvement trajectories. The risk to patients waiting has been assessed in line with national guidance from the various Royal Colleges.  Patients have been categorised into clinical priorities within their waiting lists to mitigate the risks to patients waiting from the perspective of clinical harm.

A combination of the implementation of advice and guidance, patient initiated follow ups and the use of technology to support out-patient appointments has contributed to minimising the growth of the waiting list during the COVID-19 pandemic period.

The Finance and Performance Committee provide the detailed scrutiny and challenge in respect of performance – including, A&E, cancer, RTT and Outpatient Department (OPD) Follow Ups and waiting list performance; with reporting to the Board through the IPR and highlight report from the Finance and Performance Committee. Improvement actions are also monitored through the system-wide A&E Delivery Board, the Cancer Alliance and Elective Care Board and the Humber and North Yorkshire Oversight and Assurance Meeting, with stakeholder support being seen as key to a return to improvement trajectory. In addition, weekly scrutiny of waiting lists and urgent care performance is assessed at the Weekly Operational Management Group Meeting.

The Financial Plan adopted annually by the Trust Board reflects the strategic framework set out each year by NHSE/I. It sets out the mechanisms by which the key risks emanating from the strategic context are to be managed. The plan reflects the national planning context and its application at a regional level. The plans are developed and agreed as part of an overarching approach to financial governance that spans the Humber Coast and Vale ICS.

The Trust’s Finance and Performance Committee provides assurance to the Trust Board as to the achievement of the Trust’s financial plan and, in addition, it acts as the key forum for the scrutiny of the robustness and effectiveness of all cost efficiency opportunities. It interfaces with other Trust Board sub-committees and the Trust Executive Team. It provides this assurance through scrutiny of regular reports and deep dives into areas of particular concern.

Governance and control are further assured through quarterly monitoring and annual planning processes with internal and external auditors. Each year the Trust agrees a risk based internal audit programme designed to provide assurance and to encourage improvement across the full breadth of the Trust’s activities.

The Trust understands that delivering effective quality outcomes for patients within agreed resources is the main priority for the Trust. The Trust is proactive and continuously reviews and realigns its structures where necessary, to allow it to adapt and respond to the rapidly changing business environment brought about by the changes in the economy, the NHS environment, competitive markets and patient pathway best practice.

During 2021/22 the Trust underwent its second Use of Resources Assessment.  Despite receiving a rating of ‘Requires Improvement’ the Trust was not judged as being able to exit its financial Single Operating Framework level 4 status of the Recovery Support Programme. In 2020/21, the Trust achieved its financial control total of £0.16 million and delivered its cost improvement programme target of £10.55 million with a saving of £11.99 million.  Building on this, the Trust has gone on to achieve the financial targets set by NHSE/I for the 2021/22 financial year and is now looking to deliver a balanced financial plan across the Humber Coast and Vale ICS as we enter 2022/23.

Information governance

The Trust continues to strengthen its arrangements for Information Governance and has the following arrangements in place:

• The Medical Director as the Caldicott Guardian
• An active Information Governance Steering Group which meets monthly

An Information Governance Strategy and collection of Information Governance related policies along with a number of dedicated IT Security policies

• A dedicated Data Protection Officer is in post
• A dedicated IT Security Manager
• The Trust continues to monitor Information Governance Incidents to ensure that if required they are reported to the Information Commissioner’s Office within 72 hours
• Complete and submit the new Data Security and Protection Toolkit (DSPT) work programme by 30 June 2022
• Annual audit of the Trust’s compliance with the Data Security and Protection Toolkit by Internal Audit for the 2021/22 submission. This will be undertaken in two phases as in 2020/2021

The Information Governance Steering Group, which is chaired by the Data Protection Officer, monitors the Trust’s compliance with National Data Protection Regulations and with the DSPT, which encompasses the National Data Guardian standards. The new DSPT also covers Cyber Security Essentials. This group reports to the Audit Risk and Governance Committee which reports directly to the Trust Board. The Trust’s Audit, Risk and Governance Committee receives a regular highlight report from the Information Governance Steering Group including details of audits undertaken and subsequent recommendations and actions for further improvement. The continued work on the action plan will be closely monitored by the Information Governance Steering Group. The Trust’s Data Protection Officer is the Chair of the Yorkshire and Humber Strategic Information Governance Network and represents the region on the National Strategic Information Governance Network. This ensures any national guidance and initiatives are fed directly into the organisation.

Data security and protection incidents

All incidents reported within the organisation were investigated and appropriate action taken. This could be the strengthening of policies or a change to process. Lessons learnt are disseminated through face-to-face Information Governance Awareness Training and through staff briefings. The incidents are reviewed monthly by the Senior Management Team and action plans agreed.

During 2021/2022, the Trust, using NHS Digital’s Incident Reporting Guide and Tool developed in conjunction with the Information Commissioner’s Office, reported one Data Security and Protection Incidents, which is an improvement on 2020/2021.

The incident was reported on the 16 April 2021 and related to personal data being inappropriately shared with a third party due to an incorrect email being supplied and recoded on the system. The Information Commissioner’s Office responded stating that no further action was necessary following the Trusts investigation and mitigations put in place straight away.

Data Security

The following arrangements are in place:

• A dedicated IT Security Manager

Aa security feature at login to the Trust network, giving guidance to users and requiring acceptance of ‘rules of use’; this is to be further strengthened following the recent review and updating of the duty of confidence statement that all new starters complete as part of their induction process. Key points of the duty of confidence declaration, specifically those sections relating to users responsibilities will be added to the log-in screen of the Trust’s network. The review and acceptance of the duty of confidence will also be an ongoing reminder, as well as at the commencement of an employee’s work in the Trust

• IT policies which take account of updated national requirements are reviewed annually
• A ‘best practice’ IT security awareness leaflet alongside a dedicated email security and best practice leaflet
• All computer hard drives are physically destroyed on decommissioning prior to disposal
• Released security patches are rolled out in a timely manner
• NHS Digital CareCert Notifications are reviewed and actioned, where relevant
• Annual Penetration Test was conducted and completed by end of April 2021
• Third party Security Operations Centre (SOC) remote monitoring
• The encryption of all removable / portable devices including laptops, USB pens and CDs, specifically:
  • Laptop encryption has been completed on all laptops / clinical tablets
  • Encrypted USB flashdrives have been allocated to staff
  • No machines are purchased with floppy drives as standard and port blocking software has been implemented
  • CD/DVD writers are not issued as a standard piece of equipment  Where the use of these writers is required, the creation of data on these devices is covered by Trust policies
  • The creation of data on PACs CDs is governed by Trust policy and encryption ability is available. Tracking procedures are in place for CDs sent off site
  • The encryption of all new desktop hard drives that have been purchased since 2021
• Windows10 migration complete.

Data quality and governance

The following measures are in place to assure the Trust Board that appropriate controls are in place to ensure the accuracy of data:

Governance and leadership:

• The Trust has a dedicated Chief Information Officer, who is a Non-voting Member of the Trust Board and is responsible for ensuring that arrangements are in place for providing timely, accurate and appropriate information and performance data
• The Chief Information Officer is responsible for ensuring that there are mechanisms in place for assuring the quality and accuracy of the performance data including external testing as appropriate
• The Digital Strategy 2021/2024 was completed and approved by the Trust Board in January 2021. 

Policies and plans in ensuring quality of care provided:

• Policies and procedures are in place in relation to the capture and recording of patient data.

Systems and processes:

• Systems and processes are in place for the audit and validation of performance data. A new Data Warehouse will strengthen the tools to support this. Procurement is underway and will be implemented by Q3 2022
• The Trust will be completing a planned replacement of both its Data Warehouse and its Patient Administration System in 2022, which will provide an opportunity to review all the systems business rules during the migration. This is to allow further validation and reassurance on the accuracy of these

People and skills:

• All staff involved in collecting and reporting on quality metrics are suitably trained and experienced
• All PAS users have to receive training before being issued a password, and individual user activity is auditable
• Clinical Coding is regularly audited both internally and externally and audits also take place with individual clinicians
• Digital Services staff are now registered with the British Computer Society. Providing specialist training opportunities and recognised accreditation and qualifications

Data use and reporting:

• A monthly IPR which outlines the Trust’s key performance indicators (KPIs) including benchmarking and comparative data is submitted to the Trust Board monthly with the detailed review and challenge taking place at Trust Board sub-committee level first. The Trust continues to use a format which follows best practice which was created with NHSE/I oversight in 2020/21. 

Review of effectiveness of risk management and internal control

As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit and the executive managers and clinical leads within the Trust who have responsibility for the development and maintenance of the internal control framework.  I have drawn on the performance information available to me. My review is also informed by comments made by the external auditors in their Management Letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Trust Board, the Audit Risk and Governance Committee and the Quality and Safety Committee and a plan to address weaknesses and ensure continuous improvement of the system is in place.

The Head of Internal Audit provides me with an opinion on the overall arrangements for gaining assurance through the Assurance Framework and on the controls reviewed as part of the internal audit work. The BAF and the monthly IPR provide me with evidence that the effectiveness of the controls in place to manage the risks to the organisation achieving its principal objectives have been reviewed. Maintenance and review of the effectiveness of the system of internal control has been provided by comprehensive mechanisms already referred to in this statement. Further measures include:

• Regular reports to the Trust Board from the Trust’s BAF and Risk Register including review and challenge through the relevant Board sub-committees
• Regular risk management activity reports to the Trust Board sub-committees and / or the Trust Board covering incidents / SIs, complaints/PALS and claims analysis and including details of lessons learned / changes in practice
• Receipt by the Trust Board of minutes / reports from key forums including the Audit Risk and Governance Committee, Finance and Performance Committee, Workforce Committee and the Quality and Safety Committee
• The ongoing development of the BAF and Risk Register is tested through the Internal Audit Programme
• Annual independent external review by the Internal Auditors of the Trust’s board assurance and self-certification processes
• The provision and scrutiny of a monthly IPR to the Trust Board, which covers a combination of specific KPIs and priorities including the identification of key risks to future performance and mitigating actions. The Trust’s performance management arrangements are embedded utilising PRIMS to cover finance, performance, quality and governance

The validity of the Annual Governance Statement has been provided to me by the Audit Risk and Governance Committee, which has considered and commented on this statement, and by the external auditors. All of the above measures serve to provide ongoing assurance to me, the Executive Team and the Trust Board of the effectiveness of the system of internal control. The above measures also ensure that any internal control issues are identified. During 2021/22 significant internal control issues arose in three key areas, namely Finance and Sustainability, CQC, Information Governance and Performance – further details are provided overleaf.

Conclusion

In conclusion, the following significant internal control issues arose or continued during 2021/22:

Finance and Sustainability

Whilst the Trust achieved its 2021/22 Control Total, the Trust remains in breach of its Licence, specifically conditions CoS3 (1) (a) and (b), CoS3 (2) (c), and FT4 (5) (a), (d), and (f), and Trust is in the System Oversight Framework level 4 of the Recovery Support Programme for finance.

The Trust has successfully met all of the various “exit” criteria laid down by NHSE/I as part of the Financial System Oversight Framework level 4 of the Recovery Support Programme, which revolve around the strengthening of financial governance arrangements and the achievement of financial targets.

The incidence of the pandemic and the changing and uncertain financial environment within the NHS  has meant that the Trust has been asked to meet a number of additional requirements as part of this process.  The Trust was successful in achieving the financial targets set by NHSE/I during 2021/22 and is now working hard to agree plans across the Humber and North Yorkshire Health and Care System that will enable it to exit level 4 of the Recovery Support Programme.

Looking ahead the financial stability of the organisation remains a significant risk due to the level of uncertainty regarding the level of clinical activity that the organisation can deliver in a cost effective, post-COVID-19 environment and the ability of the organisation to deliver that activity from a workforce perspective.

CQC  As outlined earlier, the Trust retained its overall rating of ‘Requires Improvement’, with a rating of ‘Inadequate’ in the ‘Safe’ domain’. This was due to ongoing waiting list backlogs in some specialties, the backlog in diagnostic reporting, concerns in relation to end of life care and some issues in the Trust’s two emergency departments; specifically training, paediatric pathway, safe environment and sustaining improvements in ambulance handover. The improvement plan is embedded and ongoing with greater internal assurance mechanisms with regular input from CQC. This is overseen by Divisions and also by the sub-committees of the Board on a monthly basis and regular reporting to Board. 

Information Governance – Data Breaches

As outlined 7 above since the end of 2020/21 and up to the date of publication of this report, the Trust identified one data breach in April 2021 which is now concluded.

Performance 

As outlined earlier the COVID-19 pandemic affected the ongoing improvements and performance during 2021/22 in A&E, Cancer and RTT and OPD Follow Ups; and this has continued up to the date of the publication of this report. The Finance and Performance Committee provide the detailed scrutiny and challenge in respect of performance – including cancer, A&E, RTT and OPD Follow Ups performance, reporting to the Board through the IPR and a highlight report from the Finance and Performance Committee.

There remains a significant risk due to the level of uncertainty regarding the level of clinical activity that the organisation can deliver in a post-COVID-19 environment, and the achievement of constitutional and regulatory performance requirements.

Chief Executive and Accountable Officer: Dr Peter Reading

Date: 15 June 2022