The State Hospital

The State Hospital, Carstairs, Lanark ML11 8RP
Phone: 01555 840293 Fax: 01555 840024 email: tsh.info@nhs.net

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In this section:

 

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Corporate Governance and Accountability

The State Hospitals Board for Scotland allocates resources and monitors organisational and executive performance, delegates operational matters to management and oversees senior management arrangements and appointments.

In line with good governance, transparency and accountability, public notices advertising Board Meetings are placed on The State Hospital’s website alongside Board agendas, papers and minutes.

The Board met six times during the year 2016/17 (in public) to progress strategy and review performance. 

The Board’s statutory responsibility to embrace the three strands of statutory governance: Clinical Governance, Staff Governance and Corporate Governance is overseen by the Clinical Governance Committee, Audit Committee, Staff Governance Committee and the Remuneration Committee. 

There is a range of supporting frameworks, strategies and action plans in place to ensure delivery of high standards of governance.  Corporate governance arrangements are set out in Standing Orders, Standing Financial Instructions and the Scheme of Delegation.

Each Committee produces an annual report to meet the requirements of its Terms of Reference. 

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Audit Committee

The Audit Committee oversees arrangements for internal and external audit of the Board’s financial and management systems and considers the Board’s overall systems of internal control.

The Internal Audit Operational Plan from KPMG for 2016/17 was approved in June 2016.  The plan was kept under review for the remainder of the year.  The plan was designed to target priority issues and structures to allow the Chief Internal Auditor to provide an opinion on the adequacy and effectiveness of internal controls to the Committee, the Chief Executive (as Accountable Officer) and the External Auditors.

During financial year 2016/17, the Committee met on four occasions.  Details of activity can be found in the Annual Report of the Audit Committee 2016/17.

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Remuneration Committee

The Remuneration Committee seeks to support the Board’s aim to be an exemplar employer with systems of corporate accountability for the fair and effective management of all staff.  The Committee met on three occasions during the year 2016/17.

The Remuneration Committee Annual Report 2016/17 outlines the key achievements and key developments overseen by the Committee.  The stock-take also includes the Committee’s Terms of Reference, reporting structures and work programme which is largely determined by the requirement to implement Executive and Senior Managers’ pay with reference to relevant Scottish Government instruction and performance appraisal. In addition oversight of the application and award of discretionary points is a routine consideration of the Committee as is consideration of ad-hoc issues relating to remuneration.

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Performance Management

Clear lines of reporting and robust performance management systems are in place. The Local Delivery Plan (LDP) sets out the strategic plan for the Board and is the product of an inclusive planning process with integration of risk management with service, financial and workforce planning.  The LDP sets out how success is measured against a set of Key Performance Indicators (KPIs). 

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Risk Management

During the year 2016/17 close working continued with Police Scotland.  On three occasions The State Hospital supported Police Scotland:

  • By supplying role players for the Police’s national negotiators course.
  • Police Scotland led on a four day refresher course for State Hospital negotiators.
  • Supported by Police Scotland, Incident Command ‘Golden Hour’ training (in response to Critical Incident Review (CIR) recommendations) was delivered to Senior Clinical Cover.

In 2016/17, 30 policies were either introduced or reviewed and strengthened.  MetaCompliance was introduced on 1 September 2016. Twelve policies were released through MetaCompliance; seven to all staff and five to clinical staff.

In terms of resilience:

  • A self-assessment against the NHS Standards for Organisational Resilience (published in May 2016 and updated in October 2016) was completed and submitted to Scottish Government. 
  • 71% of Business Impact Assessments and Equality Impact Assessments for all resilience plans were completed, with the remaining 29% scheduled for completion in early 2017/18.
  • A piece of work was also undertaken to create an Equality Impact Assessment (EQIA) book that covered all resilience plans, removing the requirement for these to be created and updated individually. 

Additionally, the following plans were tested in line with the Resilience Committee’s 2016/17 work plan:

  • Loss of Patient Accommodation.
  • Electricity Supply Failure.
  • Adverse Weather.
  • Shortage of Fuel Supplies.
  • Laundry Provision Interruption.
  • Lack of Food Supplies.

An audit of Health & Safety Control Books was undertaken and e-Control Book guidance and associated documentation / assessment forms were either revised or developed.

The year saw a slight increase in incidents reported; from 1,878 in 2015/16 to 1,897 in 2016/17.  Two level three incidents requiring the establishment of the Incident Command Team occurred, and there were also four level two incidents. 

In line with the previous year, two claims were paid in 2016/17.

There was a good uptake of risk management training:

  • Health and safety awareness training was completed by 95.5% of staff; a decrease of 0.9% from 2015/16.
  • Manual handling training was completed by 98% of staff; an increase of 1.4% from 2015/16.
  • The online fire safety training module was completed by 98.2% of staff.
  • At 31 March 2017, 93.2% of eligible staff were fully compliant with Level 1 ‘Personal Safety & Breakaway’ training requirements (a decrease of 2.4% from 2015/16).
  • At 31 March 2017, 87.3% of eligible staff were fully compliant with Level 2 ‘Prevention & Management of Violence & Aggression’ training requirements; a decrease of 7.2% from 2015/16.
  • A workshop for Raising Awareness of Prevent (WRAP) training sessions began in September 2016 with an average turnout of 80%.

Participation in the Scottish Patient Safety Programme for Mental Health (SPSP-MH) continued.

A Risk Management Annual Report for 2016/17 has been produced.

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Financial Targets

The Board is required to operate within three budget limits:

  • A revenue resource limit - a resource budget for ongoing operations.
  • A capital resource limit - a resource budget for capital investment.
  • A Cash requirement – a financing requirement to fund the cash consequences of the ongoing operations and the net capital investment.

During the financial year ended 31 March 2017, the Board was within all three of its statutory financial targets and reported a carry-forward of £50k on its revenue resource limit. 

The table below illustrates the Board’s performance against agreed financial targets.  The limit is set by the Scottish Government Health & Social Care Directorates.

 

Limit
As Set

Actual
Outturn

Variance
(Over) /
Under

 

£000

£000

£000

Revenue Resource Limit
- Core
- Non Core

 

32,169
934

 

32,119
934

 

50
-

Capital Resource Limit
- Core

 

323

 

323

 

-

Cash Requirement

33,224

33,224

-

 

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Revenue Resources

The Statement of Comprehensive Net Expenditure provides analysis in the annual accounts between clinical, administration and non-clinical activities. Excluding the effect of annually managed expenditure, net expenditure in 2016/17 increased by £8k from the previous year.  This reflects a £803k increase in clinical costs, an increase of £14k in administration costs, an increase of £15k in non-clinical costs, and an increase in income of £824k.


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Capital Resources

The Board’s Capital Programme for 2016/17 focused on improving Hospital security, maintenance of the estate, improvements to eHealth systems and the purchase of vehicles. 

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Sustainable Economic Growth

The Board is committed to the continuous delivery of a high quality professional service based on the principles of sustainable development and their relevance to State Hospital activity.  As in previous years, an Logo: Resource Efficient Scotlandequitable balance continued to be sought between meeting the needs of patients, staff and the community; delivering value for money; and minimising environmental impacts and ensuring protection of environmental resources within the Hospital’s sphere of control.

Winter Plan 2017/18Opens in a new window 2016/17Opens in a new window

Climate Change Report (November 2016)Opens in a new window

Property and Asset Management Strategy 2015/20Opens in a new window

Sustainability Development Action Plan (Report to the Board August 2014)Opens in a new window

Wind Turbine - Report to the Board (June 2013)Opens in a new window

Modernisation

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Fraud

The State Hospital continues to take a zero-tolerance approach to fraud.  In 2016/17 the Hospital reviewed its top ten fraud risks, completed a Counter Fraud Assessment Tool, participated in the National Fraud Initiative exercise which is carried out bi-annually.  Up to 31 March 2017 over three quarters of staff completed the non-mandatory e-learning fraud module.  A new e-learning fraud module has been developed and will be mandatory from April 2017.

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Annual Review

The State Hospitals Board for Scotland is the governing body of the Hospital. It is accountable to Scottish Ministers, through the Scottish Government, for the quality of care and the efficient use of resources. 

Every year an annual review of performance is undertaken by the Scottish Government.  The Board completes and submits a composite assessment report to the Scottish Government.  A review meeting between the Board and the Scottish Government then takes place.  Members of the general public can attend if they so wish.

Thursday, 28 September 2017 is the date of the 2016/17 Annual Review of The State Hospitals Board for Scotland.  This is a non-ministerial review.  Annual Review Feedback LettersOpens in a new window are placed on the Board’s website.

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