University Hospitals Bristol NHS Foundation Trust Minutes of the public Trust Board Meeting held on Wednesday 28 October Present.

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1 University Hospitals Bristol NHS Foundation Trust Minutes of the public Trust Board Meeting held on Wednesday 28 October 2009 John Savage Chair Graham Rich Iain Fairbairn Lisa Gardner Paul May Jonathan Sheffield Kelvin Blake Present Emma Woollett Paul Mapson Irene Scott Sue Clark Steve Aumayer Alison Moon Selby Knox Peter Wilde Mike Nevin Lis Kutt Peter Harrowing Sarah Pinch Xanthe Whittaker In attendance Chris Monk Jackie Cornish Jim Catterall Anne Reader Chris Perry Charlotte Barron (Minutes) 169/09 Apologies were received from Robert Woolley and Sarah Blackburn.. 170/09 Royal Visit Formal Opening of the Bristol Heart Institute Peter Wilde informed the Board that Princess Anne had formally opened the Bristol Heart Institute on Monday 19 th October The ceremony was also attended by the Lord Lieutenant of Bristol and the High Sherriff of Bristol. The Princess met a range of staff and patients. Peter Wilde said that he had received a letter of gratitude from the Princess and that she was very impressed and complimentary in her remarks. John Savage thanked Peter Wilde on behalf of the Board for the enormous effort that had gone into preparing for the Royal visit. 171/09 Swine Flu Video The Board were shown a short video clip featuring members of senior staff receiving their swine flu vaccination. The video has been complied to encourage Trust staff to be vaccinated and will be placed on Connect and advertised in Newsbeat for staff to view. 172/09 Declarations of Interests The Board noted that Paul May had applied for the position of Chairman of North Bristol NHS Trust 173/09 Minutes The minutes of the meeting held on the 30 September 2009 were approved and signed by the Chairman as a correct record. 174/09 Matters Arising There were no matters arising. 175/09 Chief Executive s Report. Graham Rich reported on the following. Page 1 of 12 : University Hospitals Bristol NHS Foundation Trust: Public Trust Board: Minutes September 2009 Page 1

2 Interim Company Secretary David Seabrooke had been appointed as an interim Company Secretary for 6 months starting on the 9 th November. He has 20 years experience advising local authorities on governance. Research & Development Funding The Trust has received 1.2 million funding for Research and Development. Care Quality Commission The result of the 2008/09 Annual Health check was reported. The Trust had received Excellent for financial management, an improvement on the previous year, and Good for quality of services, a repeat of the position of the preceding year. Child Protection Training Level 1 The Trust was now at 97% compliance. Bristol Royal Infirmary Redevelopment Because the BRI Redevelopment Project was a reportable transaction under the Trust s terms of authorisation, Graham Rich, Robert Woolley and Paul Mapson were to discuss it with Monitor during the ensuing week as it 176/09 Control of Infection Report Alison Moon presented the report. She highlighted the continued good progress with Clostridium Difficile and the current focus on improving compliance with antibiotic prescribing protocols. She also reported that the Governors had been invited to nominate one of their number to join the Infection Control Committee. Clostridium Difficile Chris Perry reported 5 cases of Clostridium Difficile during October. Mark Calloway, leading the work on antibiotic prescribing, would provide further information to the Board in November. MRSA There had been no cases of Methicillin-resistant Staphylococcus Aureus (MRSA) bacteraemia in October to date. Further analysis was being carried out on MRSA screening data and a report would be provided to the Board in November. Glycopeptide-resistant Enterococci (GRE) bacteraemia There were three cases of glycopeptide resistant Enterococci reported in September,an increase on the number of cases in the preceding three months. Two cases were in specialised areas where infections of this type are not uncommon as patients in these areas were more prone to infection and antibiotic use is greater than on general wards. The third was a sporadic case, not a trend of infection in this area. Hand Hygiene Audits There has been no increase in compliance with Hand Hygiene results for medical staff. Communication with staff required further improvement and Chris Perry was working to ensure that divisional action was completed. Cleanliness Page 2 of 12 : University Hospitals Bristol NHS Foundation Trust: Public Trust Board: Minutes October 2009 Page 2

3 Cleanliness results indicated 94% overall compliance and the Trust was currently rated at amber. Chris Perry reminded the Board that the Trust had recently chosen to raise the minimum level for green compliance. Matrons Quarterly Report The Matrons quarterly report for cleanliness was included in the month s Board report. The Matrons were currently concerned about the quality and availability of clean linen. Alison Moon indicated that she would intervene if the situation was not resolved promptly. Irene Scott added that the Trust s contract with the external linen provider was due for renewal in 2010 and that the Trust needed to see an improvement in the next few months if renewal with the existing supplier, Sunlight, was to be considered. Emma Woollett asked what suppliers other local Trusts used. Paul Mapson responded that most used Sunlight and that North Bristol NHS Trust had a partial in-house service in addition to an external supplier. Emma Woollett re-iterated her concern about the poor quality of the linen and Alison Moon stated that availability was also a problem with some incidents of failure to supply. Irene Scott reported on recent action: Sunlight had dedicated one plant to the NHS and was open 7 days a week. They run an NHS tracking system for damaged linen but it was important that Trust staff reported unsuitable linen. Infection Prevention and Control Compliance and Improvement Plan Chris Perry drew the Board s attention to red areas on the plan in respect of a designated microbiologist with responsibility for Infection Control, and assured the Board that there were no areas where delay in implementation of the programme was causing clinical risk. Actions to deal with amber ratings were underway. Compliance for infection control training had improved from 64% to 75%. Jonathan Sheffield confirmed that the Infection Control designated doctor would continue to be the on call microbiologist. If the Trust were to require a named microbiologist as the designated doctor the possibility would be investigated further. Kelvin Blake asked when the Board could expect improvement in hand hygiene results and antibiotic compliance. Alison Moon agreed the importance of this issue and that results were good but needed to be better. Mark Calloway s appointment as Deputy Medical Director would help. She confirmed that the Heads of Nursing and Matrons were intensely engaged and were focussed on ensuring that staff completed infection control training. Chris Perry explained that there had been a change in data collection of hand hygiene audits with a non-return now scoring zero, making some results non compliant, but she assured the Board that the overall monthly result was compliant with the 95% set by the Safer Patient Initiative. Graham Rich reiterated that the key message to clinical staff was that all wash hands but felt that the Trust could not guarantee that all staff would do this. The Chairman felt that there was a need to rethink the message to the outside world that 95% compliance gave. Mike Nevin said that there were still practical considerations that prevented some areas from achieving compliance, for example some do not have enough sinks. He stressed the ongoing importance of providing sufficient hand washing facilities as a priority. Page 3 of 12 : University Hospitals Bristol NHS Foundation Trust: Public Trust Board: Minutes October 2009 Page 3

4 In response to a question from the Chairman Irene Scott confirmed that the second stage if the bathroom and toilet refurbishment was nearing completion with the third stage due to start in January Both were on schedule. The Board received the Infection Control Report. 177/06 Emma Woollett presented a Report from the Audit and Assurance Committee and minutes of 15 September on behalf of Sarah Blackburn Key points in the report were on records management and the ward staffing. The Chairman noted a key theme in the report of delay in sign off of internal audit reports, specifically those pertaining to statutory and mandatory training, glaucoma and consultant productivity. Graham Rich confirmed that a summary of audits with limited assurance would go to the Trust Executive Group to address outstanding actions and the issue would be pursued until it was resolved. Paul Mapson explained that the Trust was holding back on certain actions such as IT Strategy due to uncertainty about merger with North Bristol. It was difficult to bring this strategy to the Board because of unresolved cost implications in pursuing a course of action that might be incompatible with North Bristol s system. Emma Woollett welcomed the discussion as it assisted the Committee members to understand the situation better, and agreed that the Trust needed to reconsider some major actions in the light of a potential merger. It was noted for the record that Kelvin Blake took no part in this discussion due to his potential conflict of interest as an employee of British Telecom. The Board received the report and minutes of the Audit and Assurance Committee. 178/06 Quality Report Jonathan Sheffield presented the report which outlined the Trust s approach to producing a Quality Report and the Department of Health s consultation on a framework for quality reports. He highlighted the increasing profile of quality and the need to involve a range of stakeholders including governors and members in developing the Trust s approach. He felt that the Board might wish to consider the formation of a Quality Committee to further develop the quality agenda and requested a Board seminar for more detailed discussion on this topic. The Board agreed to hold the seminar on quality at the November meeting. Emma Woollett said it was difficult to comment on the report and would have liked an Executive perspective. Jonathan said that an away day on Quality Metrics to be held on 25 th November for a range of staff and governors could be extended to all Non- Executive Directors. Graham Rich asked Paul May if he was satisfied after his previous concern on the Trust s progress on this matter. Paul May confirmed this was the case as he could see the developments and requested that accountability was included as an outcome of the process. Alison Moon clarified that the annual quality account received by the Board would be a demonstration of the nature of patient care and this would be strengthened by more frequent regular reports to the Board. Emma Woollett highlighted the need to involve stakeholders as soon as possible. Page 4 of 12 : University Hospitals Bristol NHS Foundation Trust: Public Trust Board: Minutes October 2009 Page 4

5 The Board received the report and noted progress to date and the deadline for responding to the Department of Health consultation of 10 th December Research and Development Report The July to September 2009 Research and Development report was presented by Jonathan Sheffield. He said that the Trust had 146 trials in progress and that recruitment figures for trials would become part of future metrics. Irene Scott asked for clarification on the term appropriately trained staff. Jonathan said that this referred to researchers having information governance training in addition to the required research qualifications. Irene Scott asked for more information on types of research by professional group and Jonathan agreed that this would be included in future reports. Paul Mapson commented that there was great success in this Trust on trials and that the Board should congratulate the Research and Development team for their work. He said that the money the Trust received from trials would be returned to Divisions. The Board formally expressed its gratitude to Mary Perkins, Head of Research and Development, Mike Stevens Director of Research and Development and their team for their achievements. Prof. Selby Knox requested benchmarking data on Research and Development. Jonathan Sheffield replied that there were no measureable tools at present but performance management data would be developed to improve benchmarking between Trusts. Paul May re-iterated the impact and importance of research on hospitals and the need to invest to improve health. Selby Knox concurred and advised the Trust to prepare for the future performance management of Research and Development. The Board received the Research and Development report. 179/09 Safeguarding Children Alison Moon presented an update of the Safeguarding Children action plan and commented that the Trust was making good progress. She summarised two key issues: Child Protection Training Child protection training Level 1 was close to 100% compliance, and Levels 2,3 and 4 needed to be at 90% compliance by end of March 2010 (90% was an unpublished Care Quality Commission target). Alison Moon reported that the Trust was now able to understand the breakdown in training compliance by staff group and would provide this information in future reports. She also stressed that this work would take time. She was engaged in the process of benchmarking with other Trusts, both those who were in the same position as UHB in March 2009 at 60% compliance and those Trusts reporting 100% compliance, to learn from them. Paul May welcomed this second Board report on Safeguarding Children and asked for figures on timescales to achieve the training. Alison Moon agreed to provide this for the next meeting. Multiple Notes Alison Moon updated the Board on action to resolve the longstanding issue of multiple sets of notes for children. A working group chaired by Pat Fields and Andrew Hooper had been Page 5 of 12 : University Hospitals Bristol NHS Foundation Trust: Public Trust Board: Minutes October 2009 Page 5

6 set up and had met once. Alison planned to contact North Bristol NHS Trust to learn from its experience and agreed to report timescales for this work at the next meeting. Kelvin Blake expressed his concern that training compliance should be a basic standard. Steve Aumayer agreed that the Trust needed to ensure this and that the Board should encourage ownership within the organisation. The Trust planned to put Statutory and Mandatory training on the back of annual leave forms and also to linking it to other training. Irene Scott said the Trust needed to improve accountability for every employee and that this required monitoring as part of performance. Alison Moon reassured the Board that the Trust was fully committed to safeguarding children. The Board received the Safeguarding Children report and noted progress with the action plan. 180/09 Finance Report from Finance Committee Lisa Gardner provided the summary report of the main issues discussed at the Finance Committee meeting on Friday 23 rd October UH Bristol reported a deficit of million for six months to the 30 th September. The principal reason for change was the inclusion of an estimated charge for asset impairments following the revaluation of the Trust s land and buildings on a Modern Equivalent Assets basis; a requirement for all NHS organisations by March Activity for September was in line with financial plan. Income remained on target. The Committee had also expressed concern about the slippage of Cash Releasing Efficiency Savings programmes. The Divisions of Surgery Head & Neck and Women & Children s had been invited to the December Finance Committee to discuss overspend. Lisa confirmed that the financial downside scenarios had been submitted to Monitor. The Board received the report from the Finance Committee. Finance Report Paul Mapson presented the Finance Report and further explained the reporting of an actual deficit due to revaluation. This had the impact of slightly improving the Trust s financial risk rating with Monitor. Earnings before Interest, Tax, Depreciation and Amortisation had not been affected. He confirmed that the Trust had submitted its application for a long term loan to support the BRI Redevelopment to the Department of Health Loans Unit. Paul May expressed concerns about the level of overspend and asked if the Trust was looking at staffing, in particular the bank and agency overspend. Steve Aumayer responded that skill mix across Trust was being reviewed and that there were areas where staffing could be provided differently. He emphasised that the flexible use of agency and bank staff was vital in responding to winter pressures, and that following the skill mix exercise this would need further review. Steve agreed to report on timescales for completion of this review at the next Board meeting. Paul May reiterated the need to control the pay overspend. Irene Scott clarified that the CRES Committee looked at pay issues across the Trust and that it was important to get corporate agreement from Divisions on this review. Page 6 of 12 : University Hospitals Bristol NHS Foundation Trust: Public Trust Board: Minutes October 2009 Page 6

7 Alison Moon highlighted the link between pay costs and opening of additional capacity and the need to manage the performance of staff. Paul May remained concerned that the issues contributing to the financial situation were still unresolved. Paul Mapson agreed it was important for the run rate to be brought back into balance and that agency use should be an exception. Kelvin Blake requested clarification of the circumstances surrounding SHA levies. Paul Mapson responded that this was a one off payment arising from Strategic Health Authorities passing on cuts in central budgets to foundation trusts. Review of Standing Financial Instructions and Standing Orders The Board approved the reviewed Standing Financial Instructions and Standing Orders Terms of Reference Finance Committee The Board ratified the Terms of Reference of the Finance Committee. International Financial Reporting Standards (IFRS) In line with the requirements for all NHS Trusts, Paul Mapson reported the Trust had been required to restate the accounts for the periods April to May 2008 and June 2008 to March 2009 using the new International Financial Reporting Standards. These restated accounts had been subject to external audit. The main adjustment required under IFRS was an increased accrual for holiday pay of 5million in the 10 month accounting period covering June 2008 to March The Board received the main IFRS restatement adjustments for the 2 months ended 31 May 2008 and 10 months ended 31 March 2009 and the audit reports thereon. The Board received and approved the letters of representation for both periods and appropriate certificates for the 2 month period. 181/09 Performance Report Workforce Steve Aumayer presented the workforce report. He reported Sickness and Absence at 3% which was equal to the previous year s figures and better than most other Trusts. It compared with an overall public sector figure of 4.3%. He reported the granting of derogation against the European Working Time Directive for a further three rotas, bringing this to a total of five rotas. Action plans were in place to ensure compliance of these rotas by the end of the derogation period. He introduced the new workforce reports on Page 18, which were to be further developed for the November Board meeting. He highlighted that the Trust was currently below budget on permanent staffing but bank and agency use reversed the effect of this. He drew the Board s attention to Page 20 of the report showing breakdown of reasons for the bank and agency use. Steve commented that the Trust needed to look at the appropriate level of bank and agency use for each individual area in order to monitor performance accurately. Paul May noted that the figure of bank and agency use to cover training was small. Steve Aumayer responded that an allowance for staff training was built into rotas and therefore it would not be routine to use bank and agency to cover release of staff for training. Steve added that a review of teaching and learning across Trust was currently underway. Paul Mapson welcomed the revisit of performance indicators for workforce. Mike Nevin said that he valued this information and requested a breakdown for divisions. He highlighted the need to balance the unpredictability of care needs with the importance of training. He requested more emphasis on training in the workplace. Page 7 of 12 : University Hospitals Bristol NHS Foundation Trust: Public Trust Board: Minutes October 2009 Page 7

8 Chris Monk reported that the Division of Medicine hasd benefitted from the transformed Temporary Staffing Bureau using lean methodologies, which was now filling 95% of requests with bank staff, and had helped the division deliver its services and lowered costs. Irene Scott noted the work of the Temporary Staffing Bureau included changing agency contracts and warned that a significant number of bank shifts were filled by Trust employees working extra shifts; there was a need to be cautious about staff working excessive hours. Patient Experience Jonathan Sheffield reported a red alert from Dr Foster for readmission rates. This was currently being looked at and would be reported back to the Board. He updated the Board on a previous red alert from Dr Foster regarding outcomes in a particular procedure and confirmed that the Care Quality Commission had agreed that there was not a problem in the Trust with the particular procedure and that the red alert had stemmed from a reporting anomaly. Alison Moon presented the Complaints Report. Lisa Gardner queried the timeliness of responses in the Division of Surgery, Head and Neck. Anne Reader replied that the Divisional Manager had confirmed that this was due to an issue in the prioritisation of complaints in one part of the division, which was being addressed. Access Targets Irene Scott presented the report on access targets. She said that there had been an increase in activity resulting in BRI admissions of the equivalent of three wards of patients per day. This increase in activity during September was unpredicted. The target for the 4 hour wait for September was 98%, but the Trust was currently at 94%. The increase in activity was across the whole health authority and not just at UHB. Great Western Ambulance Trust had reported the same level of activity increase. The Trust was also experiencing an impact from the closure of a ward at Weston Hospital. Irene reported that the Short Stay ward had opened in the previous week with investment in additional staff, although one physician vacancy remained. The Trust Executive Group agreed to a further expansion of the medical assessment unit, currently the unit has 10 beds and 6 chairs but capacity will double. In the previous 3 weeks delayed discharges continued to rise with the equivalent of one ward of patients who could be discharged and were not because of complex discharge plans. The Trust was working with NHS Bristol to ease the situation. In the light of the very recent performance on the 4 hour access target, Irene Scott advised the Board to consider declaring this target at risk to Monitor in addition to the cancer targets highlighted in the performance report. This would take the Trust to a red risk rating for governance. She stressed that although the Trust was under performing at present it could achieve 98% by December. Graham Rich commented that there had been a clear step change in activity and highlighted the need for the health community to work together to co-ordinate activity. Iain Fairbairn agreed that the Quarter 3 position for the 4 hour access target was clearly at risk and stressed that strong actions were needed. The Chairman requested an indication of the time scale to recover the situation. Irene Scott replied that expanding the Medical Assessment Unit would take a week to implement and that all Divisions were helping with staffing the unit and that the Division of Medicine was charged with setting this up. Ward 16 has recently been closed for refurbishment and would reopen as the extended unit. She added that the level of demand on services forecast for February 2010 was being experienced currently. Page 8 of 12 : University Hospitals Bristol NHS Foundation Trust: Public Trust Board: Minutes October 2009 Page 8

9 Emma Woollett stressed her view that the Trust needed to focus on the key actions which would produce significant results in this situation and drive these forward. Graham Rich thanked Emma for her comment and assured the Board of appropriate response. Prof Selby Knox asked why the expansion of the Medical Assessment Unit had not been implemented earlier. Xanthe Whittaker responded that the Trust had received independent advice that provision of a Short Stay was a preferred course of action, and explained that the Short Stay Unit had only been open for a few weeks. She explained that the Medical Assessment Unit was having difficulty in maintaining turnover and there was need to balance speed of turnover with the risk that patients could go to an inappropriate inpatient ward and not follow the best care pathway, which in turn could lead to increased length of stay. Kelvin Blake understood that the 4 hour access target was very complex with multiple drivers but expressed his concern and felt there had been no change since the previous year. He stressed that the Trust needed to work with partners such as the ambulance service and other Trusts in the area to improve the situation. Irene Scott agreed and reported that she had asked the Great Western Ambulance Service to look at their figures. She stressed that the BRI Accident and Emergency attendance figure s almost 2,000 a month higher than any other Trusts within the South West Region, excluding Walk-In Centre attendances. She said that the numbers of short length of stay (2 days) had increased whereas the long length of stay (3 days) had decreased. Irene did not think that this increase at this time of year could have been predicted and that, although the Trust had been concentrating on swine flu, the increase in admissions did not appear to be related to this. Kelvin Blake said that he had recently reviewed some benchmarking data across the South West and was concerned about UH Bristol s performance in relation to that of other Trusts. He stressed that the Trust clearly needed to take action to restore confidence it its performance. Irene Scott explained that UH Bristol was the only Trust whose Accident and Emergency attendance figures were recorded differently i.e. UH Bristol Walk-In Centre figures are attributed to NHS Bristol Primary Care Trust which has the effect of reducing the Trust s performance figures. Chris Monk reiterated that the Trust had completed a great deal of work to address the situation and reminded the Board that patients generally received good care. He continued that a system wide approach was required but comparative data across the whole of the South West had not been available. The Chairman concurred with the need to work with NHS Bristol to control demand and agreed that he and Graham Rich would take this up. Paul May asked what the impact of a red governance rating by Monitor would be. Graham Rich replied in the first instance key Board members would be invited for a meeting with Monitor to discuss the situation and seek assurance that the Trust was considering all avenues of action. There was the potential for Monitor to request external assistance for the Trust. Lisa Gardener expressed her concern on figures against the national average for cancer targets and on stroke care. Xanthe Whittaker agreed that further work was needed on this. Graham Rich commented that meeting cancer targets was critical for patients the reputation of the Trust. Chris Monk confirmed that stroke figures had dropped. He explained that the ward refurbishment programme had had an impact on this and the planned use of Ward 18 as the stroke ward had now been superseded by the decision to use it to expand the Medical Assessment Unit. The location of stroke ward will be given further consideration and the implications would be added to the corporate risk register. Page 9 of 12 : University Hospitals Bristol NHS Foundation Trust: Public Trust Board: Minutes October 2009 Page 9

10 The Board received the performance report and agreed the 4 hour access target was at risk and should be reported to Monitor as such. 182/09 Update on Transformation Programme Jonathan Sheffield presented an update to the Board. The programme has focussed on the productive ward and feedback from staff. He said that transformation posters were now displayed in Trust Headquarters and offered a tour to Board members. Lisa Gardener asked for timescales on the programme. Jonathan agreed to report this at the next Board meeting. Emma Woollett asked how the programme would make a difference to patients, for example did freeing time for nutritional care result in nutritional improvement. Jonathan responded that many patients report that nutrition is good if their hospital experience is good and that the two are linked. Alison Moon clarified that the Trust s aiming to link the Productive Ward programme with improved nutrition. The Board received the update on the Transformation Programme. 183/09 Quarter 2 Report for Monitor Submission a) Governance - the discussion on access targets had been covered earlier in the performance report. A detailed action plan would be provided to Monitor on all areas at risk of non-compliance. The Board agreed to sign governance declaration 2 and that the 62 day and 31 day cancer target were at risk, as well as the 4 hour emergency access target and core standard 11b Statutory and Mandatory training, giving total compliance framework score of 3.4 and a red risk rating for governance. The Board agreed the remaining non-financial elements of the governance submission to Monitor in the report. b) Finance Paul Mapson reported there were no current risks. The finance submission to Monitor was approved by the Board. 184/09 Update on progress against Annual Plan 2009/2010 Irene Scott presented the update on progress against the Annual Plan on behalf of Robert Woolley and drew the Board s attention to the ten objectives flagged as red. Emma Woollett expressed her disappointment there was no funding to expand the McKinsey patient experience work to other parts of the Trust and requested more information on the patient experience strategy. Alison Moon explained that the patient experience strategy would form part of the quality strategy. Emma asked if any funding for the patient experience was available. Paul Mapson replied this was not the case at present and that the Trust was unable to access Clinical Quality Indicators (CQUIN) money for this purpose. The Board received the update on progress against the Annual Plan 2009/10 185/09 Redevelopment Programme Update Graham Rich presented the report to the Board for information. Paul Mapson informed the Board that a report would also be submitted to the specialist commissioners and that Robert Woolley would provide further information at the next meeting. The Board received the Redevelopment Programme Update 186/09 Governance and Risk Management Committee Minutes 20 August 2009 Page 10 of 12 : University Hospitals Bristol NHS Foundation Trust: Public Trust Board: Minutes October 2009 Page 10

11 The minutes of the Governance and Risk Management Committee were received by the Board. 187/09 Annual Report from Clinical Ethics Committee Iain Fairbairn presented the report. He informed the Board that Dr Sally Masey s term of office as Chair of the Committee was due for renewal and that she was keen to continue. Mike Nevin supported the proposal that Sally should continue as Chair and provided positive feedback on her performance in this role. The Board received the report and approved the continuation of Dr Sally Masey as Chair of the Committee for a further term of office. 188/09 Any Other Business Irene Scott reported that the Divisional Managers Post for Women and Children s remained vacant. Interviews were scheduled to be held that afternoon but had been cancelled due to lack of candidates. This was the third time that the post had been advertised. Alison Moon handed out a copy of a research publication on behalf of Jonathan Sheffield for information. 189/09 Date of next meeting Monday 30 th November 2009 Page 11 of 12 : University Hospitals Bristol NHS Foundation Trust: Public Trust Board: Minutes October 2009 Page 11

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13 UNIVERSITY HOSPITALS BRISTOL NHS FOUNDATION TRUST Audit and Assurance Committee Minutes of a meeting held on Thursday 12 November 2009 Present: In attendance: Apologies: Sarah Blackburn (Chair), Non Executive Director Paul May, Non Executive Director Graham Rich, Chief Executive Paul Mapson, Director of Finance Jennifer McCall, Head of Internal Audit Chris Swonnell, Assistant Director for Audit and Assurance Jonathan Sheffield, Medical Director Steve Aumayer, Director of Workforce and Organisational Development Pat Fields, Deputy Chief Nurse Irene Scott, Chief Operating Officer Melanie Fewkes, Head of Health and Safety Services Iain Fairbairn, Lisa Gardiner, Emma Woollett 82/09 Minutes 15 September 2009 (Agenda item 2) The minutes of the meeting of the committee held on 15 September 2009 were agreed as accurate. 83/09 Draft Minutes: Governance and Risk Management Committee 14 October 2009 (Agenda item 3) Noted. 84/09 Overview of the Core Standards Declaration Process to Date (Agenda Item 4) The Committee received a report from the Assistant Director for Audit and Assurance setting out the main points of the process and a timetable of activities from April 2009 through to mid October The report was noted. 85/09 Consideration of Governance and Risk Management Committee s Recommendation for Declaration on Core Health Standards (Agenda Item 5) The committee received a report compiled by the Assistant Director for Audit and Assurance detailing proposed declarations in relation to the mid-year Healthcare Standards 2009/10. Standards C2, C4c, C9/13c, C11b, C15, and C18 had been requested by the Audit and Assurance Committee for greater scrutiny with detailed assurance reports. An additional report had been requested by the Governance and Risk Management Committee, Standards C9/13c. A further report had been requested by the Chief Nurse, Standard C15. Page 13

14 The remaining core standards were the subject of Item 6 on the agenda. Core Standard 2 Child Protection The Deputy Chief Nurse informed the committee that the principal area of risk was around records and this area had been subject to continuous review in recent months. Work was in progress outside the Trust to improve the co-ordination of records with partner organisations involved in child protection and treatment of potentially vulnerable children. The Committee agreed subject to further assurance that information sharing protocols were in place that Core Standard 2 be recommended as compliant. Core Standard 4c Decontamination It was noted that this standard did not form part of the formal declaration as it related to Healthcare Acquired Infection Control for which Registration had already taken place. The Deputy Chief Nurse informed the Committee that an improved reporting mechanism was now in place and that funds had been identified for further training on decontamination techniques. The Trust would be compliant by the end of the year. The Chair of the Decontamination Committee had passed to a Divisional Manager, but the Deputy Chief Nurse continued to receive action notes and reporting-up arrangements were in place. The Committee identified the issues set out below for follow through and clarification: Levels of compliance in relation to weekly testing schedules on decontamination equipment appeared to be very low (e.g. 15 out of 51 areas compliant) were these the latest available figures? Had the steriliser issue at Kingsdown been resolved eg through Procurement? Had this been considered by the Trust Executive Group as yet? Was there a typo for the entry in relation to the endoscope processor at St Michael s? The meaning of the traffic light indicators in relation to water samples would be clarified The Committee agreed that a further audit review of the issues identified in respect of this standard was required which should be reported at a future Audit and Assurance Committee meeting. Core Standard 15 Food Provision and Services The Committee received additional papers tabled at the meeting in relation to this item. Page 14 2

15 The Deputy Chief Nurse informed the Committee that residual risks in relation to metabolic disorder diets were being addressed by a newly-appointed consultant. As a result of this work, the catering service was responding to the challenge of providing a range of diets which it had not been able immediately to provide. It was agreed that nutritional screening needed to be increased, but should be targeted towards patients with higher inherent risk. The Committee considered that the PEAT scores that the Trust had attained would be worth adding to the documented list of assurance on this issue. The Committee agreed that this area should be put forward as compliant, subject to ongoing update on the roll-out of a dietary screening process. Core Standard 11b Mandatory/Statutory Training The Head of Health and Safety Services informed the Committee that the Training target was a matter for local determination and the Chief Executive confirmed that the Trust had elected to aim for 90%. Publicity for training opportunities had been increased to tackle a high non attendance and no-show rate and these indicators had improved as a result. There was also activity to improve training records for all employees of the Trust. It was agreed that this standard be declared as compliant and the follow-up actions set out below were requested: The Director of Workforce and Organisational Development undertook to investigate whether further training activity was required on basic skills. This theme should be linked with the Trust s wider training programme. Core Standards 9 and 13c Information management The Medical Director acting as Senior Information Risk Owner (SIRO) for the Trust updated the Committee on improvements to the Trust s information governance regime and the recent introduction of new staffing resources to take forward this work. A tracking system for patients paper records was in place and additional training for administrative staff had been provided. Work was also under way to better control shared passwords and ensure that these were kept to a minimum. Software was being tested that would enable each user to have an individual profile allowing them access only to the systems they required for work purposes. Page 15 3

16 There would be a further audit of clinical coding through the Audit Commission Payment by Results Data Assurance Audit. The SIRO described the following actions to improve information security: Software that would block the transfer of large quantities of data onto portable media. Encrypting office desktops in addition to laptops. Protocols for information sharing with other organisations. The improvement to the management of data should lead to better knowledge and learning management systems. It was agreed that subject to continued monitoring by the Committee these indicators should be put forward as compliant. Core Standard 18 Equality of Access to Services The Chief Operating Officer informed the Committee that the Trust was achieving a rating of 90% in relation to Choose and Book. As a result of patient feedback an improved leaflet had been produced about choice which had led to an improvement in the patient rating of this facility to 37%. Committee members noted the discrepancy between these ratings and agreed that, although this theoretically placed the Trust in the top 20% of Trusts nationally, more work was needed to improve patient access both in fact and in perception. The Committee agreed to recommend a declaration of compliance on this standard. 86/09 Consideration of other core standards (Agenda item 6) The Committee received a report setting out the proposed mid year Healthcare Standards Declaration for 2009/10 and the following principal points were made: 1b Patient safety notices this refers to circulars aimed at professionals. 7a and b Non-Executive Directors would need to discuss the Trust s risk assessment at a strategic level. 5b The Chief Operating Officer undertook to clarify the meanings of the ABC ratings set out in the report connection with this indicator. 4b How was the training on high-risk equipment progressing and was it improving this indicator? 6. It was noted Bristol PCT had strengthened their co-ordination and leadership of the Bristol Intermediate and Long-term Care Development Group. 10a There had been significant improvement on pre-employment checks since the last audit. It was agreed that the Director of Workforce and Organisational 4 Page 16

17 Development would provide the Committee with a report on progress with the introduction of real-time checks. 87/09 Recommendation to the Trust Board 30 November 2009 (Agenda item 7) It was agreed that the standards should be rated as compliant with the exception of Standard 4c Decontamination. 88/09 Any other business (Agenda item 8) It was noted that the Management Letter would be considered by the 30 November meeting of the Trust Board. 88/09 Date of next meeting (Agenda item 9) Friday 4 December 2009 at 9.00 am Page 17 5

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19 Trust Board Meeting Date: 30 November 2009 Agenda Item 8 Title of Report Healthcare Standards Declaration 2009/10 Recommendations Actions Required Which Corporate Objective(s) are supported by this paper? To enable the Trust Board to make its declaration on the Core Standards for 2009/10 The recommendation is that: Standard C4c (Decontamination) is Not Met for the year 2009/10 All other Core Standards are Compliant Submission of the declaration in accordance with the deadline. To ensure that the Trust continues to meet the requirements set out by Monitor, the regulator for Foundation Trusts. Is this on the Trust s risk register? no Which Healthcare Commission standard does this report provide evidence for? Financial Implications All reportable standards Revenue 0 Capital 0 Prepared by: Name & Title Chris Swonnell, Assistant Director Assistant Director for Audit & Assurance Presented by: Name & Title Sarah Blackburn, Chair of Audit & Assurance Committee/ Alison Moon Chief Nurse Previous Meetings Please insert the date the paper was presented under to the relevant group Exec Team Audit & Assurance Committee Governance Risk and Risk Management Finance Committee Trust Executive Group Other Meeting (Please state) 14 October September, 12 November November 09 Page 19

20 1. Executive Summary 2. Background /9 Declaration 4. Core Standards Compliance 2009/10 Appendices 1. Core Standards Process /9 Declaration Statement 3. Papers received by Audit and Assurance Committee 12 th November Executive Summary The information and data contained within this paper and its appendices is provided to enable the Trust Board to make its declaration on the Core Standards for 2009/10. The introduction of the new system of Registration with the Care Quality Commission in April 2010 means that the 2009/10 Healthcare Standards Declaration will be the last of its kind. It also means that the Declaration is being made mid-year rather than at the end of the financial year. The context and background to the Declaration is outlined in this report, including the process and the Declaration made last year. The recommendations from the Governance and Risk Management Committee, and the Audit and Assurance Committee are made from the meetings held on 14 th October and 12 th November 2009 respectively. The recommendation is that: Standard C4c (Decontamination) is Not Met for the year 2009/10 All other Core Standards are Compliant It should be noted that the view of the respective Committees is that Standard C4c is currently compliant. The recommended Declaration of Not Met is a technical one due to the fact that this Standard was declared as Not Met for 2008/9 and elements of the action plan were addressed during the current financial year. It should further be noted that on this occasion Standard C4c is not in fact part of the formal Declaration to the Care Quality Commission as this is deemed to be covered by the Trust s existing Registration form Healthcare Associated Infection. 2. Background The then-healthcare Commission and Department of Health introduced the Standards for Better Health in The Standards are applicable to the whole of the NHS and trusts are required to monitor compliance with them and make an annual declaration on compliance at the end of each year. The introduction of the new system of Registration with the Care Quality Commission in April 2010 means that the 2009/10 Healthcare Standards Declaration will be the last of its kind. It also means that the Declaration is being made mid-year (covering the period 1 st April 31 st October 2009) rather than at the end of the financial year. The Core Standards remain in force until 31 st March 2010: the Trust will continue to monitor the Core Standards on an exception for the remainder of 2009/10, and will continue to report Core Standards compliance through quarterly self-certification reporting to Monitor. Page 20

21 Previous Declarations have been subject to random and targeted inspections from the Care Quality Commission, however the Commission has announced that there will not be a programme of inspections associated with the mid-year Declaration. The Commission will however continue to cross-check trusts Declaration with available intelligence and any concerns may be raised by the Commission as part of its assessment of trusts readiness for Registration from 1 st April Third Party Commentaries are not part of the mid-year Declaration (the term Third Parties in this context includes Local Involvement Networks, Local Authority Overview and Scrutiny Committees, local Primary Care Trusts, and Foundation Trust Boards of Governors). Instead Third Parties have the opportunity to submit comments directly to the Care Quality Commission. The Assistant Director for Audit & Assurance will be meeting with fellow Governors on 24 th November to explain the process for submitting comments and to provide a briefing on preparation for Registration. Although the Board will be considering all Core Standards, it should be noted that Standards relating to Healthcare Associated Infection, i.e. 4a, 4c and 21b, are not part of the Declaration which the Trust will make to the Care Quality Commission. These Standards are deemed to be covered by the terms of the Trust s existing Registration for Healthcare Associated Infection. In 2005 the University Hospitals Bristol NHS Foundation Trust introduced an assurance framework structured largely upon the Core Standards. The monitoring system is explained in more detail for newer members of the Trust Board, at Appendix One /9 Declaration A copy of the 2008/9 Declaration statement is at Appendix Two. The Board declared compliance with all Core Standards with the exception of Standard C4c (Decontamination). The Trust did not receive a random inspection from the Care Quality Commission on this occasion. 4. Core Standard Compliance 2009/10 The Executive Directors and Operational Leads have considered the position for their Standards and have completed a summary sheet for each Standard. In the case of Standard C15, significant lapse assessments have also been completed. The Audit and Assurance Committee met on 15 th September, at which time it asked that the Governance and Risk Management Committee place particular scrutiny on the declaration for the following Standards: Standard 2 Child Protection Standard 4c Decontamination Standard 11b Mandatory and Statutory Training Standard 18 Access, Equality, Choice The Governance and Risk Management Committee considered the evidence and recommendations for the Declaration at a special meeting on 14 th October The Committee requested that, in addition to the above Standards, detailed assurances be provided to the Audit and Assurance Committee in respect of the following Standards: Standard 9 Records Management Standard 13c Confidentiality Subsequent to discussion at Governance and Risk Management Committee on 14 th October 2009, the Chief Nurse requested a further detailed assurance report for the following Standard: Page 21

22 Standard 15 Nutrition The Audit and Assurance Committee met on 12 th November 2009 to consider the information in detail and make a recommendation to the Board. The papers submitted to the Audit and Assurance Committee are at Appendix Three. These include copies of the summary statements and any lapse assessments. The Chair of the Audit and Assurance Committee will verbally report to the Trust Board on the discussions of the Committee and the recommendation to the Board. Page 22

23 Appendix One University Hospitals Bristol NHS Foundation Trust Core Standards Process - Summary Core Standards There are 24 Core Standards which could be likened to our licence to practice. One Core Standard relates to targets and is not included in the declaration as this is separately assessed for a trust s rating. The Standards cover seven domains and are split into sub-areas so in fact there are 42 Standards to declare on. Accountability For each of the 42 Standards an Executive Director is the named officer with Board responsibility, for example the Medical Director leads for Standard 1a (Patient Safety). Each Director will have an Operational Lead, for example for Standard 1a this is the Trust Patient Safety Manager, and in some instances a corporate committee which will have oversight of a Standard. All corporate committees are expected in their terms of reference to specify the Standards they are either responsible for or have an interest in. For example, the Infection Control Committee is responsible for Standards 4a (infection control and prevention) and 4c (decontamination), and has an interest in core standards 4e (clinical waste disposal) and 21a (cleanliness). Assurance Framework For each Standard the Assurance Framework is in place to monitor: Evidence of controls e.g. systems and processes such as a committee or a policy Evidence of assurance that the systems and controls are effective; the assurance can be internal (e.g. clinical audit) or external (e.g. accreditation from a national body). Action plan to address the gaps or risks in either controls or assurance. A robust assurance framework should: Have a balance between evidence which is system based and assurance based. A continual and active action plan to improve assurance and controls OR address risks / gaps which emerge. The Assurance Framework is monitored by the Executive Directors and committees where appropriate. The Governance and Risk Management Committee, and the Audit and Assurance Committee both receive detailed quarterly reports providing assurance of compliance and highlighting any issues of concern. Compliance It is to be expected that where there is a large range of evidence some individual items might be considered non-compliant. Where this is the case, they are all considered to see whether any noncompliant items are deemed to push the whole Standard into non-compliance. The Board approved in 2005 a significant lapse assessment framework to ensure that serious concerns on compliance are assessed consistently. Page 23

24 Appendix Two 2008/9 Declaration Statement The Trust Board of the University Hospitals Bristol NHS Foundation Trust met in public on 29th April 2009 to make its declaration of compliance with the Core Standards for Better Health. Those members who were absent had received the papers and evidence in advance, and had the opportunity to submit questions and comments. The Board was quorate. There was unanimous support for the declaration that was made. There had been extensive Board involvement in the process of gaining assurance on compliance with the Core Standards throughout the relevant year; 1st April 2008 to 31st March Consequently the declaration was the conclusion of an inclusive and thorough process. The Trust had been able to work effectively in 2008/9 from a basis of established and clear governance and assurance systems. Each Core Standard has both an Operational (management) and Executive Lead. Arrangements for monitoring performance against each Core Standard have been strengthened during the year so that the relevant sub-committees of the Board now receive full quarterly reports on Standards compliance (replacing the previous system of exception reports). In addition, the Audit and Assurance Committee undertakes to review particular Core Standards in depth at each of its meetings (the Committee chooses Standards according to current local or national issues/concerns). The Governance and Risk Management Committee also monitors all seriously high and high residual risks across all of the Core Standards and reports directly to the Board on this. As in previous years, a local process for assessing possible significant lapses in order to ensure consistency of approach has been adopted. The Trust is making a declaration of "Compliant" with all of the Core Standards, with the exception of Core Standard 4c Decontamination. For the Core Standards where the declaration of compliance has been made, it is not one which indicates complacency or that the status quo is simply to be maintained. There are systems to both develop and increase levels of assurance in each case as well as improving practice. For all of the compliant Core Standards there is a range of evidence that has directed the Board towards the decision to declare compliance. For the 2008/9 Declaration, the Trust has placed particular focus on the following Core Standards: C2 (Child Protection): this Standard has received particular scrutiny following the high public profile of child protection matters as a consequence of 'Baby P' C4a (Healthcare Acquired Infection): this Standard continues to be the subject of regular detailed Board reporting, assuring the Trust of compliance. C4c (Decontamination): C9 (Records Management) & C13b (Confidentiality): this Standard has received particularly scrutiny due to the high public profile of matters of Information Governance C11b (Statutory & Mandatory Training): this Standard was declared compliant at year end for 2006/07, but not compliant for the entirety of that year, and continues to be subject to detailed scrutiny by the Board and its sub-committees C14b (Complaints - Discrimination): The Trust declared compliance on C14b for 2007/8 but was subsequently qualified following random inspection. This Standard has therefore been the subject of detailed scrutiny during 2008/9 and a series of actions (including a survey of all complainants) has been actioned. In respect of Core Standard C4c, the Trust Board received a further report regarding the outcomes of a detailed internal review of the Trust's compliance with this Standard, and concluded that this Standard had not been met for 2008/2009. Following review at the end of March 2009, the Executive Directors were made aware of areas of non-compliance within this Standard and an urgent review and action was put in place to address these issues. The action plan, produced at the end of March 2009, has target dates set within the first quarter of 2009/2010. At its meeting on 29 April 2009, the Board received and considered a range of evidence which included the Standard statement, the related Page 24

25 requirements within the Code of Practice for the Prevention of Healthcare Associated Infection and was presented with the current position against the seven elements of the inspection guide for each of the areas in the Trust undertaking decontamination activities. The Board considered that the evidence demonstrated some aspects of the responsibility and reporting structure which needed to be improved and implementation of appropriate testing schedules was not in place in some areas. Although action had been taken in March 2009 (in-year), completion of these actions could not be evidenced to state compliance in 2008/2009. There were no significant lapses or evidence of failure of decontamination or of patient harm. Therefore a declaration of 'not-met' was agreed. Page 25

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27 University Hospitals Bristol NHS Foundation Trust Report to Audit and Assurance Committee Subject: Author: Description of the process leading up to review of Core Standards recommendations by the Audit and Assurance Committee on 12 th November Chris Swonnell, Assistant Director for Audit & Assurance Date: 3 November 2009 Introduction The Healthcare Commission and Department of Health introduced the Standards for Better Health (aka Core Healthcare Standards, Core Standards) in The Standards are applicable to the whole of the NHS and trusts are required to monitor compliance with them. 2009/10 is the final year when the Core Standards will be in force. From 1April 2010 a new system of Registration will apply. For 2009/10 the Care Quality Commission has therefore announced that the usual end of year Declaration on the Core Standards will be replaced by a mid-year Declaration covering the period 1 April 31 October Members of the Committee may wish to note the following points/reminders: For each Core Standard the Trust has assigned an Executive Lead and Operational (management) Lead. In most cases there is also a lead committee. The Audit and Assurance Committee will be required to make a recommendation which will be discussed by the Board on 30 November, prior to the Trust submitting its Declaration to the Care Quality Commission by 7 December. There are three possible declaration positions for each Standard: Compliant, Insufficient Assurance and Not Met On this occasion the views of stakeholders (e.g. Governors, Overview & Scrutiny Committees, Local Involvement Networks, etc) do not form part of the Declaration that the Trust will make, however the stakeholders do instead have the opportunity of submitting comments directly to the Care Quality Commission. The CQC has announced that it will not be carrying out a programme of random or targeted inspections associated with the mid-year Declaration process. It is understood however that the CQC will be following up a randomly selected 5% of trusts as part of the initial Registration phase under the new standards. Although the Declaration is only for a seven month period, the Core Standards remain in force until 31 March Following an discussion with our CQC area manager, the Trust s understanding is that if the Trust was to declare a Core Standard as Not Met or Insufficient Assurance, there would still be an opportunity to address any identified gaps/lapses by 31 March 2010 Page 27

28 This paper has been written to provide Committee members with a understanding of the process that has led up to the mid-year Declaration. For ease of reference, and to assist internal audit, this information has been presented in table form. Timetable leading up to discussion at Audit and Assurance Committee April 2009 The Trust made its Declaration for 2008/9. Core Standard C4c (Decontamination) was declared Not Met. June CQC inspection guides were disseminated to Executive and Operational Leads for review as part of ongoing process of ensuring local compliance. July Based on advice issued by the CQC, it was agreed with the Chief Executive to monitor Core Standards compliance on an exception basis during 2009/10. For the purpose of Monitor self-certification for Quarter 1, Operational Leads were asked to their Operational Leads outlining any material changes to compliance since 1 April Executive Leads were asked to retain a record of correspondence as an audit trail if this process was subjected to external scrutiny in the future. The request was sent to Operational Leads on 6 July. Executive Directors met on 16 July to discuss the Standards and subsequently agreed that all Core Standards should be recorded as compliant. 9 September Paper to Trust Executive Group outlining the process for the mid-year Declaration. This paper was also shared with the Audit and Assurance Committee on 15 September. 9 September from CS to Operational Leads setting out requirements and timescales for the Declaration. The included a link to the crosschecking data used by the CQC in relation to the Trust s 2008/9 Declaration (note that a number of Operational Leads subsequently experienced problems accessing this data on the CQC site). This also included a short paragraph alerting Operational Leads to the impending arrival of new Registration Standards, replacing the Standards for Better Health. 21 September Summary templates were distributed to Operational Leads for completion by 9 October. The process for each Operational Lead was as follows: 1. conduct a thorough review of the relevant sections of the Assurance Framework on the Ulysses Safeguard system. 2. use this updated information to populate the appropriate Core Standard template 3. discuss this with the relevant Executive Lead and the lead committee (either at a meeting or, given the short timeframe, virtually), resulting in a provisional recommended declaration position. 15 September Audit & Assurance Committee met. Members of the committee requested detailed assurances on four Core Standards: 2, 4c, 11b and 18. A standard format for these additional reports was subsequently issued to Operational Leads on 19 October (this was essentially the same form that was used for 2008/9). 2 October from CS to Operational Leads with a reminder of actions and 9 October deadline. 8 October Further from CS to all Operational Leads with a reminder to ensure that Executive Leads were appropriately briefed for GRMC. 14 October Governance & Risk Management Committee met to agree a Page 28

29 recommendation to the Audit & Assurance Committee. GRMC requested an additional detailed assurance report for Information Governance, covering Standards 9 and 13c. For the purposes of this meeting, Executives had sight of the draft Core Standards templates, however these were not formally distributed as committee papers. On the basis of discussion at GRMC, the Executives agreed that the Quarter 2 Monitor self-certification should record that the Trust was at risk of non-compliance with Standard 11b. 16 October A request was received from the Head of Internal Audit to review the declaration process in respect of four Standards: 2, 9, 13c and 24. CS notified Operational Leads on 19 October and circulated a simple template to gather relevant information by the end of October. 20 October CS reviewed draft Core Standards templates and discussed any queries re. content with Operational Leads. In particular, a rationale was requested wherever the Estimated Risk to Compliance for the remainder of the year was anything except Very Low. Final templates were requested by the end of October. Page 29

30 Appendix Example of declaration preparation process for a Core Standard C5d (Clinical Audit) September 2009 Operational Lead (Chris Swonnell) reviewed and updated the relevant section of the Assurance Framework. This information was used to draft a summary report for C5d. This was discussed briefly with the Chair of Clinical Audit Committee shortly before the CAC meeting on 16 September. 16 September Clinical Audit Committee met to discuss. The relevant (currently ungratified) CAC minute reads as follows: CS gave a verbal update to the Committee on compliance with Core Standard C5d (Clinical Audit). CS stated his view that there had not been any material negative changes to the Trust s compliance status since 31 st March The BCIS failure was a major concern and disappointment for the CAC, nevertheless this was a technical issue, not material to C5d compliance as a whole. KPI scores were very similar to six months ago. The Trust remained complaint with the CQC s Engagement in Clinical Audits indicator. Members thanked CS for his report, however CI requested on behalf of the Committee that the updated evidence template be ed to members for their personal scrutiny. 28 September CS circulated the C5d summary report (template) by requesting any additional comments by 7 October. In the event, no further comments were received. CS and the Chair of CAC therefore agreed that a provisional recommendation of Compliant should be made to the Medical Director. 9 October CS ed the Medical Director (Executive Lead) with a copy of the completed template and a summary explanation supporting a recommendation of compliance. The Medical Director subsequently used this information to inform discussion at GRMC on 14 October. GRMC supported the recommendation that C5d be declared Compliant. Page 30

31 Core Standards with detailed assurance reports Reports requested by Audit & Assurance Committee: C2, C4c, C11b, C18 Additional report requested by Governance & Risk Management Committee: C9/13c Additional report requested by the Chief Nurse: C15 Page 31

32 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 2 - Child Protection Healthcare organisations protect children by following national child protection guidelines within their own activities and in their dealings with other organisations. Executive Lead A Moon Operational Lead C Sawkins Group Safeguarding Children Steering Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The Trust Safeguarding arrangements are guided by Section 11 of Children Act 2004 supported by, Working Together to Safeguard Children (2006), including systems, standards and protocols for information sharing. Trust Safeguarding activity is monitored quarterly by the Safeguarding Children Steering Group. No. of Internal No. of individual noncompliant Internal 52 No. of External 0 No. of individual noncompliant External 10 1 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Compliance with Mandatory Child Protection Training. Is this KPI Annual / quarterly / monthly / other? Monthly at Trust Executive Group. Most recent measurement of performance against KPIs Date if action being taken Concern remains about slow rate of improvement in compliance for all levels of child protection training. Care Quality Commission requires all (100%) eligible staff to have completed Level 1 (induction) child protection training. The Trust requires that 90% of staff should be compliant with all mandatory training by end March Quarterly at Safeguarding Children Steering Group and Women s & Children s Division Child Protection Operational Group. NB Most recent figures available Oct 2009 Level 1 New starters over last 12 months 85%. Level % Level % Level % Additional Child Protection training to be delivered over the next 4 months to ensure capacity for all identified non- Oct 2009 March 2010 Page 1 of 4 Page 32

33 2010. compliant staff to complete the required level. There is currently no waiting list for training. Compliance with submitting Individual Management Reports for Serious Case Reviews within deadlines and in the monitoring and implementation of recommendations of these serious case reviews. Quarterly at Safeguarding Children Steering Group. Bi-monthly by the W&C Division Child Protection Operational Group. The most recent Serious Case Review in South Gloucestershire to which UHBristol submitted an Individual Management Review (IMR) has been judged as good following Ofsted Inspection. Recommendations from the report when published to be incorporated into UHBristol combined Serious Case Reviews (SCR) action Plans. A second IMR has just been submitted by UHBristol within the required timescales. No other reports are currently required. Completed Ongoing Child Protection Operational Group (CPOG) continues to monitor child protection activity including the delivery of SCR recommendations. CPOG to report to Trust Safeguarding Children Steering Group. Ongoing Care Quality Commission Safeguarding Children Review. In response to this review a five month action plan has been developed, including a training recovery plan to address areas of concern, First Annual Review of Safeguarding by Care Quality Commission. Awaiting publication of results, possible Gaps in Assurance Framework / Safeguarding will be identified. May result in Trust Site visit by CQC. Statement of compliance published on public web internet site as requested by Monitor Awaiting Results Completed Current Gaps in the Assurance Framework Continuing poor compliance with Mandatory Child Protection Training, measured against Training Matrix. New Care Quality Commission guidance for Level 1 (induction) training emphasised the need for a comprehensive face to face session for all eligible staff Need to continue to raise the profile/ culture of Safeguarding Children / Young Page 2 of 4 Summary of action being taken to address these Gaps Mandatory Training highlighted by Chief Nurse, Chief Executive and Divisional Mangers, individual staff appraisals and in Child protection Policy. Compliance figures monitored by TEG, Safeguarding Children Steering Group. Areas of low compliance highlighted at Child Protection Link Meetings. Increased capacity for all Levels of training has been introduced. Child Protection trainer to be appointed. Compliance figures for all Levels of mandatory child protection training are now reviewed monthly at TEG. Data for extraction reports for reporting of training figures has been updated for accuracy. Corporate Induction training to be reviewed to include a face to face session for all staff. Terms of Reference and Membership of Trust Safeguarding Steering Group have been reviewed to include wider Senior Divisional Representation. Page 33 Timescale March 2010 March 2010 Dec 2009 Completed

34 People across the Trust. Child Protection must be embedded in all Trust activity. Actions from Serious Case Reviews remain outstanding/ ongoing, Trust wide implications. Lack of additional funding to support to Multi-Agency Risk Assessment Conferences (MARAC) for high Risk victims of Domestic Violence. ( Including staff awareness training) Lack of additional funding (unsuccessful bid by Emergency Department for Band 6 Nurse liaison role) to address the Safeguarding Risks to Children as a result of Risky behaviours in their parents/carers e.g. Drug and Alcohol misuse, Domestic Violence, Mental Health issues, Learning Disabilities Additional work required to training staff in adult areas to consider risks to children, developing an information sharing system between adult and child s notes Job Descriptions to be reviewed to incorporate statement of commitment, all staff have a responsibility to safeguard children. Serious Case Reviews Action Plans to be monitored closely and implemented through Child Protection Operational Group Recommendations with Multi Agency implications to be raised by Trust Lead at Bristol Safeguarding Children Board (BSCB) Trust Serious Case Reviews Combined Action plans updated Sept Child Protection Team, within their current roles, attends the MARACs with as much information as possible. Awaiting information from Bristol PCT re process to bid for additional funding. Weekly meeting to review/action all Cause for Concern Forms completed in both Emergency Departments. Documentation developed, with consultation from legal department, to share information of concerns from parent/cares notes to child s health records, including PCT. BRI Emergency Department business plan for 6 hours Band 4 A&C, for Child Protection Team to support this role. Safeguarding Team to be reviewed to provide Safeguarding training provision/referral procedures review etc in adult inpatient areas. Marc 2010 Quarterly / Bi-Monthly Ongoing Ongoing /Awaiting Result Weekly / Ongoing Ongoing Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale Ongoing risks posed by multiple sets of records of medical records (Non-Compliant with Laming Recommendation) Category B Report completed: Entered on Trust Risk Register. Measures introduced to mitigate risks. In patient Safeguarding children documentation review ongoing. Ongoing work at National and Local Levels for Computerised Patient Database Ongoing Other current entries on the Assurance Framework Action Plan Timescale Five month action plan (including training recovery plan) based on Care Quality Commission Safeguarding Review March 2010 Ratification of amended Child Protection Policy. Dec 2009 Details of any significant new controls or assurances added during this reporting period Recruiting to Band 6 Child Protection Trainer to support the delivery of Trust wide child protection training. Review of Safeguarding Team roles and capacity. Publication of monitor statement of compliance on public website. Maternity notes amended to include recording of father s details as a clear requirement for staff completing the form. To be audited. Page 3 of 4 Page 34

35 Review of Safeguarding Children Communication and Chronology inpatient documentation. Development of Child Abduction Policy Completion of Healthcare Commission Safeguarding Review. Awaiting publication of results. Please comment on any other issues relevant to this Standard not covered above Links with Vulnerable Adults and Domestic Violence Agendas continue. Links in polices, training and representation at Trust meetings Working Together to Safeguard Children currently being updated in response to Lord Lamings Second report, will have implications for Trust Safeguarding arrangements. Care Quality Commission Individual Trust findings due to be published Oct The Trust is preparing for the requirements of the new Independent Safeguarding Authority Vetting and Barring Scheme which is being rolled out from 12 October Details of any non-compliant evidence items relevant to the current year 2008/9: (please reproduce the boxes below for each individual item ) Evidence item: Ongoing risks posed by multiple sets of records of medical records. Reason for non-compliance judgement: Actions being taken: If an assessment of significant lapse was done please attach: Is it a significant lapse?: Non Compliance with Laming Recommendation (2003) Category B Report completed: Entered on Trust Risk Register. Measures introduced to mitigate risks. In patient Safeguarding children documentation review ongoing. Ongoing work at National and Local Levels for Computerised Patient Database Was one done? Yes Nox No Summary statement on rationale / outcome of decision above: Page 4 of 4 Page 35

36 University Hospitals Bristol NHS Foundation Trust Declaration on Healthcare Standard C2 Child protection Additional assurance report requested by Audit and Assurance Committee 1. Purpose The considered view of the Audit and Assurance Committee at its meeting held on 15 th September 2009 was that detailed evidence should be presented to the Committee in respect of Standard C2 Child Protection. This view was reached for the following reasons: Safeguarding Children remains high on the National agenda following the Baby Peter case, with a high level of public and patient concern. The new recommendations from Lord Laming s Second Report (March 2009). The Care Quality Commission individual Trust report ( Sept 2009) The request by Monitor for a Trust public declaration of compliance for Safeguarding. For Trusts to register with the Care Quality Commission by April Key controls and assurances for Standard C2 Child Protection Core Standard 2 for Acute Trusts, consists of three elements and fifteen lines of enquiry. Detailed evidence providing assurance in respect of this Standard for the year 2009/10 to date is provided in Appendix One. Two lines of enquiry have on going action plans, discussed below. 3. Issues/concerns In March 2009 the Trust took part in the Care Quality Commission Review of Safeguarding within the NHS; individual Trust results have just been published. The Trust s Safeguarding arrangements are in the main, on a par with other Acute Trusts, including those with a Children s Hospital. The review highlighted some areas of weakness within the existing Trust processes and systems which are being addressed over the next six months in a detailed action plan. Monitoring of the action plan is through the Safeguarding Children Steering group, the Women s and Children s Division Child Protection Operational Group and with the support of the Chief Nurse and the Named Professionals. Upon completion of the action plan safeguarding arrangements will be more clearly demonstrable, with improved evidence of compliance. The area of risk remaining will be the continuing use of multiple sets of notes for one child. Page 36

37 Below is a summary of current issues/concerns in relation to Standard C2, including relevant mitigating evidence which might direct the Committee towards a recommendation of compliance. 3.1 Healthcare organisation ensures that all staff working with or in contact with children undertakes training including refresher training Current Position: existing, training matrix and strategy. Percentage staff completion of training according to matrix (Oct 2009): Level One (Induction) 97% Level Two 59 % Level Three 63.8% Level Four 43 % Aims: To achieve 100% compliance with Level One training by the end of October 2009, as required by Monitor and the Care Quality Commission, and to achieve 90% with all other levels of training by end March 2010 Prediction: current rate of improvement must be sustained and improved to declare compliance Monitor requires 100% for Level One training. Actions Taken: From Sept 2009, a six month remedial action plan in place (safeguarding children steering group) to improve the evidence of compliance with training: Additional training provision (Levels 2, 3, and 4) Message from CEO and chief nurse, to line managers across all divisions to promote importance of staff attendance. Monthly review of training completion by the Trust Executive Group, quarterly by the Safeguarding Children Steering Group. 3.2 The Healthcare organisation has agreed systems, standards and protocols about sharing information about a child and their family both within the organisation and with outside agencies. Current Position: The Trust has in place agreed protocols and standards for information sharing following South West Child Protection Procedures and Government Information Sharing Guidance (2008) (see evidence in Appendix one). Although not detailed as a standard by the CQC the outstanding area of risk is the continuing non compliance with Lord Laming s original 2003 recommendation (no 78): Within a given location, health professionals should work from a single set of records for each child The Trust continues to have multiple sets of notes for children within the organisation. In addition the transfer of Children s Community Child Health Services in April 2009 to North Bristol Trust has resulted in further fragmentation of children s services and difficulties with information sharing. All Community Child Health notes, which include most of the child Page 37 Carol Sawkins, Nov

38 protection information, are currently located outside the Trust, increasing the Safeguarding risks for children. Actions Taken: Category B report submitted to Board in May 2009, detailing mitigating actions taken to address risks. An action plan led by the Deputy Chief Nurse has been agreed ongoing within the Women s and Children s Division, to deliver a more robust system in notes management. Locally (NBT led) there is development of a Community Child Health electronic data base Care Plus with which the Trust will need to actively engage. 4. Summary It is anticipated that the Trust s Safeguarding Arrangements over the next twelve months will require ongoing amendment and review in light of the expected Care Quality Commission findings, the revision of the 2006 Working Together to Safeguard Children guidance and the recommendations (including Key Performance Indicators) from the National Safeguarding Delivery unit. The recommendation to the Audit and Assurance Committee is that Standard C2 be declared Compliant. Alison Moon Chief Nurse 2 nd November 2009 Page 38 Carol Sawkins, Nov

39 Appendix One:. Core Standard Two. Review of Compliance. 0ct 2009 ( Base on April 2009 Guidance) Core Standard 2 Core Standard 2 - Healthcare organisation protect children by following National child protection guidance within their own activities and in their dealings with other organisations. Core standard consists of 3 elements and 15 lines of enquiry (3 lines of enquiry relate to PCTs only). Element 1 - The healthcare organisations have made arrangements to safeguard children under Section 11 of the Children s Act 2004, having regard to statutory guidance entitled Statutory Guidance or making arrangements to safeguard and promote the welfare of children s Section 11 of the Children s Act a Line of Enquiry Evidence Current Position Named professionals, Dr, Nurse and Midwife Compliant. in place. The healthcare organisation identifies a named doctor and a named nurse / midwife with specific roles and responsibilities for safeguarding children. A review of Named professionals job descriptions and protected time is currently being undertaken as part of the Trust Five month action plan in response to the Care Quality Commission Safeguarding Review. b PCT only c The healthcare organisation ensure that all staff working with, or in contact with children undertake training including refresher training so they: know how to safeguard and promote the welfare of children can be alert to potential indications of abuse or neglect in children know how to act upon their concerns know who to contact in their organisation to express concerns about a child s welfare - Child Protection training is mandatory for all staff that work with, or are in contact with children. The training is guided by the Intercollegiate document (2006) - Specific requirements for staff is detailed in the Trust Child Protection Policy which includes a Child protection training Strategy and training matrix. Available on the Connect intranet site and reviewed annually. - Attendance at training is recorded as part of the electronic staff records, monitored monthly by TEG and quarterly by the Safeguarding Children Steering group. d Healthcare organisations with A&E -Emergency Department staff are made Compliant Previously declared as compliant. Overall compliance rate for all levels of child protection training is too slow to improve. To be reviewed as part of the Trust Five month action plan in response to the Care Quality Commission Safeguarding Review. Page 39

40 departments, ambulatory care units, walk in centres and minor injury units. Each healthcare organisation ensure that staff in these units are familiar with local procedures for making enquiries to find out whether a child is subject to a child protection plan and acting on the outcome of such enquiries. aware of local procedures to find out if a child is subject to a Child Protection Plan through mandatory training. -System are in place to flag up Bristol children/ inborn babies who are know to be subject to a plan on computer system, as well as staff having direct access to PARIS system. -Hospital Social Work Team available in normal working hours -Staff in Children s Emergency department, on site, routinely asks about Social Work involvement as part of Triage process. e f The healthcare organisation reviews their arrangements for safeguarding children to ensure their effectiveness, for example, by ensuring learning occurs and required action is taken as a result of serious case reviews, child death reviews, local management reviews and other investigations or from reports from National bodies (such as from Ofsted reviews, Joint Area Reviews etc). The healthcare organisation has a clear line of accountability for work on safeguarding and promoting the welfare of children. -Safeguarding arrangements are reviewed and monitored quarterly at the Safeguarding Children Steering Group (SCSG). - Ongoing work plan including audits is recorded as part of the Clinical Assurance Framework, reviewed quarterly. -Actions from Serious Case Reviews and Internal Management Reviews are reviewed and implemented through the Child protection Operational Group within the Women s and Children s Division. Trust wide actions through the SCSG. - Child Death Review Process fully established. Chief Executive has the ultimate accountability for safeguarding, supported by the Trust Board. All Trust employees have an individual responsibility, supported by professional codes of conduct. Clear areas of accountability detailed in Trust Child Protection Policy. Previously declared as Compliant Outstanding area of high risk/ non compliance with Lord Laming original recommendations remains multiple sets of notes for children. Category B report submitted to Board in May 2009, detailing mitigating actions taken to address risks. However additional work needed to address this issue. Compliant g The healthcare organisation ensures that - Taken into account in mandatory child Compliant Individual staff accountability is to be highlighted in the generic /core job description Page 40 Carol Sawkins, Nov

41 racial heritage, language, religion, faith, gender and disability are taken into account when working with a child and their family for example the use of interpreters or by making adjustments to enable access for disabled children. protection training. - Trust staff have access to interpreters via language, interpreters via bank, speech and language and play staff as required. -Taken into account in Safeguarding Communication and Chronology paperwork. Taken into account through all Trust polices through equality impact assessment. The Trust employs a youth worker to represent the child/young persons voice. - Trust has disabled access and appropriate facilities. Element 2 The healthcare organisation works with partners to protect children and participate in reviews as set out in Working Together to Safeguard Children (HM Government 2006). Line of Enquiry Evidence Current Position a The healthcare organisation cooperates with the local authority in the operation and management of the Local Safeguarding Children Board (LSCB), and as partners must share responsibility for the effective discharge of its functions. Chief Nurse is member of Bristol Safeguarding Children Board, Named nurse deputises as required.. Named professionals participate in sub groups. Chief nurse, with Named Nurse as a deputy will also be a member of South Glos Safeguarding Children Board. Compliant b The healthcare organisation, through its LSCB representation, ensures that arrangements for the protection of children join up with those of other local organisations. c PCT only d Staff in contact with children or with access to sensitive information Named professionals are members of a range of Bristol Safeguarding Children s Boards sub committees and work in partnership with other professionals and local and regional organisations. -Multi Agency training provided by the Bristol Safeguarding Children s Board is Compliant Compliant Page 41 Carol Sawkins, Nov

42 e relating to children participate in interagency training to ensure that services are co-ordinated. This should compliment the training available to staff in single agency or professional settings. The healthcare organisation participates in and co-operates with child death review processes and serious case reviews. available to all Trust staff. -Multi agency training is promoted alongside Trust single agency training. - Named professionals have completed multi agency training -Child Death Review process is fully established, including the Over view panels. -Designated doctor for child deaths employed by Trusts has regional responsibility - Consultant Community Paediatricians covering the Trust have been trained or have access to training in the Rapid Response action necessary. - Trusts participates in the Serious Case Review process locally and regionally. Name professionals trained in the Serious Case Review process Compliant F PCT only Element 3 The healthcare organisation has agreed systems, standards, and protocols about sharing information about a child and their family both within the organisation and with outside agencies, having regard to Statutory guidance on making arrangements to safeguard and promote the welfare of children under section 11 of the Children Act Line of Enquiry Evidence Current Position a The healthcare organisation has in place an information sharing protocol and agreed standards for sharing information about children and their families within the organisation and with outside agencies. -Agreed protocols and standards for information sharing following South West Child Protection Procedures and Government Information Sharing Guidance ( 2008) b Appropriate agency-specific guidance - Latest government information sharing Compliant Previously Declared as Compliant Outstanding area of high risk/ non compliance with Lord Laming original recommendations remains multiple sets of notes for children. Category B report submitted to Board in May 2009, detailing mitigating actions taken to address risks. However additional work needed to address this issue. Page 42 Carol Sawkins, Nov

43 and training on information sharing is made available to existing and new staff of the health care organisation in contact with children, as part of their induction and ongoing training. guidance is highlighted at all mandatory child protection training, including induction. -Available to all staff via Connect intra net site. - South West Child Protection Procedures ( including information sharing) are available to all staff via Connect intra net site - Relevant staff groups within the Trust, e.g. Community and clinical nurse specialists are Common Assessment Training and will therefore e able to access Contact Point Page 43 Carol Sawkins, Nov

44 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 4c Decontamination Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that all reusable medical devices are properly decontaminated prior to use and that the risks associated with decontamination facilities and processes are well managed. Executive Lead A Moon Operational Lead M Hornsby Group Decontamination Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Not Met Moderate Likely Recommended Declaration 2009/10 Not Met, but action Low Possi ble plan completed inyear Estimated Risk to Compliance for remainder of 2009/10 Very low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) Significant progress has been made to ensure compliance to this standard. A revised governance and reporting structure has been implemented. Key performance indicators are in place and are monitored by the Decontamination Committee. Actions that were outstanding for the partly met decontamination criterion for the Care Quality Commission registration under Health Care Associated Infection are now completed. Mitigating actions for residual high risks have been strengthened. No. of Internal No. of individual noncompliant Internal 9 No. of External 3 No. of individual noncompliant External 2 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Percentage compliance to carrying out daily testing schedules on decontamination equipment Percentage compliance to carrying out weekly testing schedules on decontamination equipment Percentage compliance to carrying out quarterly testing schedules on Page 1 of 3 Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Monthly 39/45 areas compliant August 2009 Monthly 15/51 areas compliant August 2009 Monthly 41/48 areas compliant August 2009 Page 44

45 decontamination equipment Percentage compliance to carrying out annual testing schedules on decontamination equipment Number of equipment failures on testing or in use Age and compliance profile of decontamination equipment Number of endoscope water samples above set standard Number of decontamination related adverse events Number of needlestick incidents related to decontamination Monthly 47/47 areas compliant August 2009 Monthly 29 areas no failures, six areas 1-5 failures, 3 areas more than 5 failures in month August 2009 Quarterly 20 items less than 5 years old and compliant August items 5-10 years old but with service/spares available and compliant 16 items more than 10 years old or 5-10 years old with no service/spares available or are non compliant Monthly Red (high levels of bacteria) = 6 machines August 2009 Amber (acceptable levels of bacteria = 3 machines Green (no bacteria detected) = 1 machine Monthly Non e August 2009 Monthly None August 2009 Current Gaps in the Assurance Framework Monitoring of compliance to training requirements Performance dashboard agreed but not fully embedded as first data collection point August 2009 Overarching decontamination policy in place but more detailed local policies and procedures outstanding Summary of action being taken to address these Gaps Timescale Monitoring agreed quarterly. Data to be collected Autumn /12/09 Decontamination Committee responsible for monitoring compliance to provision of data for dashboard. Plan for full data entry in place 31/12/09 Required policies and procedures in draft format to undergo approval and ratification 31/10/09 Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale There are three sterilizers in the main Capital funding agreed. Procurement in process December 2009 sterilization unit that do not conform to current requirements for clean steam. There is ability to generate clean steam for Review of options to provide clean steam being undertaken at present December 2009 the operation of sterilizers in the main sterilization unit. This is considered best practice Use of endoscope processor that does not Limited use of machine unless essential at present. Reviewing equipment needs and costs March 2010 meet current standards due to insufficient equipment Equipment being disinfected as opposed to Funding for high risk equipment agreed. Procurement in process December 2009 sterilized due to lack of equipment Bacterial counts in endoscope rinse water Costs to provide reverse osmosis (bacteria free) water are being organised. A protocol for December 2009 Page 2 of 3 Page 45

46 are high in a number of machines and locations management of high results in being developed to ensure high risk procedures are not carried out if results are very high. Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period Training and competence matrix for local decontamination produced Dashboard for monitoring key performance indicators initiated Capital programme for replacement of sterilizers Internal Audits of local decontamination practice. Quarterly audit of local dental decontamination and bi-annual audit of endoscopy areas required for Decontamination Board KPIs. Not commenced as of August 2009 but planned to commence Autumn 2009 Please comment on any other issues relevant to this Standard not covered above Internal audit are carrying out an audit of how the Trust ensures that it effectively manages the implementation of decontamination procedures for flexible endoscopes and dental instruments used on Trust premises, or by dental services provided in satellite buildings by the Trust, as required by the Health Technical Memorandums. The audit will commence October Page 3 of 3 Page 46

47 University Hospitals Bristol NHS Foundation Trust Declaration on Healthcare Standard C4c - Decontamination of Medical Devices Additional assurance report requested by Audit & Assurance Committee 1. Purpose The considered view of the Audit and Assurance Committee at its meeting held on 15 th September 2009 was that detailed evidence should be presented to the Committee in respect of Standard C4c Decontamination of Medical Devices. This view was reached for the following reasons: Non compliance was declared for 2008/9 2. Key controls and assurances for Standard C4c Below is a summary of the key pieces of evidence providing assurance in respect of this Standard for the year 2009/10 to date: Decontamination Committee terms of reference revised 2009 to include strengthened governance and reporting arrangements. These are now implemented with evidence of monthly Committee meetings and reporting to key governance committees available. Roles and responsibilities of key personnel defined and individuals appointed to these roles A decontamination improvement and compliance plan for 2009/10 approved by Trust Executive Group with implementation monitored by Decontamination Committee and Clinical Risk Assurance Committee Provision of quarterly reports including key risks and actions to Clinical Risk Assurance Committee Key performance indicators for decontamination are produced and reviewed as follows: o Compliance to daily, weekly, quarterly and annual testing schedules for decontamination equipment o Age, compliance to current standards and reported failures of decontamination equipment o Adverse incidents relating to decontamination processes including needlestick injuries and failure to sterilise events o Percentage compliance to essential standards in self and external audits o Percentage of staff trained and competent to required standards Formal review of the risk register and the assurance framework for decontamination at least quarterly at Decontamination Committee Summary policies and procedures for decontamination are in date with more detailed policies and procedures in development and scheduled for completion by end of year Compliance to decontamination equipment has improved following the appointment of additional engineers Failures to carry out testing of decontamination equipment to required schedules are predominantly in areas where medical devices, including instruments, are not decontaminated i.e. Health Protection Agency Laboratories, Dental and Eye Laboratories. Page 47

48 Compliance to testing of decontamination equipment to required schedules is at 92.5% compliance for equipment used to reprocess medical devices at end of September 2009 Additional training for key personnel (Users) is booked and will be completed by end of March Issues/concerns Below is a summary of current issues/concerns in relation to Standard C4c, including relevant mitigating evidence which might direct the Committee towards a recommendation of compliance. Three sterilizers in Kindgsdown Sterile Services Unit do not have the ability to run from filtered steam and are, therefore, not compliant to latest standards. Funding has been secured to replace these sterilizers and the purchasing process commenced with an anticipated completion for end of March There is no facility to generate clean steam for the operation of the Department s sterilizers and they are, therefore, not compliant to latest standards. A review of the department and options has taken place. A paper is being produced on the future needs of the Department for consideration at the Trust Executive Group. ENT scopes are currently undergoing manual decontamination and not an automated process. A new reprocessing facility that will remove manual decontamination has been completed. Validation of the machines and staff training is currently taking place. This will be resolved by the end of November Paediatric theatres are processing rigid scopes by disinfection as opposed to sterilization due to lack of equipment. Funding has been agreed and the purchasing process commenced. This is expected to be complete by end of December Summary The recommendation to the Audit and Assurance Committee is that Standard C4c be declared Not Met, but with related action plans completed in-year. Alison Moon Chief Nurse 22 nd October 2009 Page 48

49 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 11b Mandatory and Statutory Training Healthcare organisations ensure that staff concerned with all aspects of the provision of healthcare participate in mandatory training programmes. Executive Lead S Aumayer Operational Lead M Fewkes Group Governance and Risk Management Committee Declaration 2007/8 Compliant Key for estimated risk High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possible Estimated Risk to Compliance for remainder of 2009/10 Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) Staff participate in mandatory training programmes, however there continue to be concerns about accuracy of data - to be investigated in 2009/2010. A report accompanying this declaration sets out in detail how the issues of data accuracy and compliance are to be addressed. The Trust has a detailed statutory and mandatory training matrix which includes information about how frequently training needs to be updated. This is supported by policy guidance which insists on this training being up to date before any discretionary training is undertaken. No. of Internal No. of individual noncompliant Internal 15 No. of External 0 No. of individual noncompliant External 5 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Ensure statutory and mandatory compliance rates increase by 5% by year end Increase Appraisal compliance to 80% by end November 2008 Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Monthly As at 31st July 2009: Induction 79.9%; Health & Safety 70.5%; Infection control 64.1%; Manual handling 69.9%; Fire safety 70.2%; Managing violence & aggression 66.5%. Being monitored monthly 72% reported to Trust Board on 2nd December % in March % achieved Trust-wide April September 2009, except for May (78.7%). 86.4% achieved September 2009 Ongoing Ongoing Page 1 of 2 Page 49

50 Current Gaps in the Assurance Framework Non-attendance at Statutory & Mandatory Training remains an issue. There is a risk of the gap widening because of swine flu and winter pressures. Summary of action being taken to address these Gaps High level action plan in progress from September Awareness raising to all staff with access to Connect. Timescale Ongoing Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale Other current entries on the Assurance Framework Action Plan Timescale Details of any significant new controls or assurances added during this reporting period Revised Risk Management Strategy 2009 completed May 2009, from which Risk Management Training Plan and Training Needs Analysis developed. NHSLA Assessment in September 2009 Passed Level 1 (covers Corporate Induction and Risk Management). Report back from NHSLA assessor due late October 2009 the outcome of which will develop an action plan to progress towards Level 2 Please comment on any other issues relevant to this Standard not covered above None Page 2 of 2 Page 50

51 University Hospitals Bristol NHS Foundation Trust Declaration on Healthcare Standard C11b Mandatory and Statutory Training Additional assurance report requested by the Audit and Assurance Committee 1. Purpose The considered view of the Audit and Assurance Committee at its meeting held on 15 th September 2009 was that detailed evidence should be presented to the Committee in respect of Standard C11b This view was reached for the following reasons: The Audit and Assurance Committee were not happy to sign off this Standard due to the rates of compliance which are set internally as there is no national framework. 80% is the internally set rate of compliance although child protection needs to be 100% for Level 1 2. Key controls and assurances for Standard C11b Below is a summary of the key pieces of evidence providing assurance in respect of this Standard for the year 2009/10 to date: Corporate and local induction policy Study Leave Policy Appraisal Policy Risk Management training plan Risk Management training needs analysis Risk Management training prospectus Risk Management implementation plan Quarterly compliance reports by Division/ staff group and individual High level action plan to progress compliance with a target of 90% in all areas by March 2010 NHSLA assessment Level 1 achieved in October 2009 which includes the areas of induction and risk management full report due back in mid October Issues/concerns Following executive discussion at Governance & Risk Management Committee on 14 th October 2009, the compliance target set by the Trust for statutory and mandatory training may need to increase from 80% to 90%. Child Protection Level 1 compliance is expected to be 100% but Monitor has advised that they will accept 90% minimum. If this is the case and there are no documented compliance levels then 90% should be the acceptable level across all statutory and mandatory training. This target may not be achievable due to: Resource implications (trainers and venues) Clinical implications with winter pressures and risk of swine flu outbreaks impacting on the ability to release staff for training Page 51

52 Other training requirements also a being priority e.g. swine flu training Non attendance remains an issue - currently running at 30% (165 places lost in September). 4. Summary The recommendation to the Audit and Assurance Committee is that Standard C11b be declared Compliant because: We have no specific guidance from the Care Quality Commission Figures have improved year on year, and within the current financial year Training topic Nov- Nov-07 Nov Induction 75.60% 57.80% 96.5% 387 Health & Safety 75.10% 58.70% 79.3% 387 Infection Control 75.50% 60.80% 73.4% 387 Manual Handling 69.50% 51% 78.0% 387 Fire Safety Training 76% 58.70% 80.7% 387 Managing Violence & Aggression L2 De es 58% 51.70% 75.9% 387 Level 2 Award in Food Safety in Catering 48% 63% 55.6% 387 Level 3 Award In Supervising Food Safety in Catering 64.30% 60.70% 79.2% 387 Child Protection, Level % 57.80% 96.6% 387 Child Protection, Level 2 Safer Practice 49.00% 49.20% 59.3% 387 Child Protection Level 3 What To Look 50.50% 61.30% 63.6% 387 Child Protection Level 4 Case Conferences 19.60% 29.90% 42.9% Colour codes Less <60% % 80%> Our target completion rate by year end is 90% in all areas Steve Aumayer Director of Workforce and Organisational Development 9 th November 2009 Page 52

53 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 18 Equality of Access to Services Healthcare organisations enable all members of the population to access services equally and offer choice in access to services and treatment equitably. Executive Lead I Scott Operational Lead X Whittaker Group Trust Operational Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possible Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The Trust aims to provide services equally and with choice, and has taken steps to improve access for potentially disadvantaged patients groups. There is a range of internal systems/controls, internal and external assurance that indicate compliance on balance including: full range of outpatient services offered on Choose & Book described on the Directory of Services, flexible administrative systems that enable specific patient needs for information (e.g. large font letters) to be met, policies in place to support equality of access (Single Equality Scheme), good standard of recording of ethnic group category to support service planning, training of staff and resource packs to cater for patients with additional requirements (e.g. interpreters). The overall scores of the National Patient Survey on access and waiting times are consistently good year on year. However, patients have indicated they don t feel they had been offered a choice of date of admission. A leaflet is now being sent to patients prior to arranging their date for admission, which advises them of the choices available and explains the booking process. Significant improvements have also been made in one particular area where there have been gaps in assurance (i.e. Choose & Book appointment slot availability), for which the Trust is now compliant with the national standard. However, as appointment slot availability via Choose & Book continues to have to be closely managed to maintain compliance, and is dictated by demand and short-term changes in available capacity, it is felt that overall the risk of non-compliance against the standard is Low rather than Very Low. No. of Internal No. of individual noncompliant Internal 24 No. of External 0 No. of individual noncompliant External 12 1 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Choose & Book (C&B) slot availability Use of disability field when available on PAS Page 1 of 3 Is this KPI Annual / quarterly / monthly / other? Monthly TBA Most recent measurement of performance against KPIs Date if action being taken Currently achieving the 90% national slot availability standard each month, although performance did dip below the required standard at the start of the year. To be reported when available on Patient Administration System (enhancement to the system now in place and in the Page 53 September 2009 September 2009 Action taken on an ongoing basis, with weekly monitoring of performance in place.

54 Choice/access measures from National Inpatient survey Quarterly process of being implemented) Results from the National Inpatient Survey 2008 suggest that only 16% of patients surveyed felt they had been given a choice of admission date. This is a similar figure to the two previous surveys. A quarterly survey is now being undertaken, to determine whether this is due to patients perception of the range of choices being offered, and what can be done and to improve patient experience of booking. The most recent survey of 585 patients, undertaken in August 2009, showed that 37% felt they had been offered choice, which is the same as the lower band for the Best performing 20% of trusts (37% to 56%) in the 2008 National Patient Survey. Sixty-one (61%) percent of patients that received the Choices leaflet responded in the survey to say they had been offered a choice of date of admission, although only 29% of patients surveyed had received the leaflet. This suggests that the low reported figures in the 2008 National Patient Survey of choice being offered was at least in part due to patients perception of the choices available and the booking process. September 2009 Further action being taken to ensure a) patients receive the Choices leaflet, and b) areas identified in the quarterly survey as not always offering a choice of admission dates, do offer choice to patients. Current Gaps in the Assurance Framework Lack of assurance that patients are being offered choice according to results of National Inpatient Survey Patients experiencing difficulties booking through Choose & Book Summary of action being taken to address these Gaps 1) Further work being undertaken to ensure the Choices leaflet, explaining how admissions are arranged and the choices available, is being sent to patients that are sent a booking letter for their admission 2) Choice & Booking survey to be undertaken again 3) Further actions have been identified, from the recent Choice & Booking survey (August 2009) to improve patient experience and choices offered. 1) More than 10% (national standard) of patients were experiencing problems booking appointments via Choose & Book in April to June 2009, due to appointments not always being available; a new system was implemented to help to match demand for appointments with the window of appointments slots made available to patients, using tool developed to help identify future capacity bottlenecks. Timescale December 2009 December 2009 December 2009 Complete Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Not applicable Not applicable Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period Quarterly patient survey being carried-out, using questions used in the National Patient Survey Page 2 of 3 Page 54

55 Please comment on any other issues relevant to this Standard not covered above None Details of any non-compliant evidence items relevant to the current year 2009/10: (please reproduce the boxes below for each individual item ) Evidence item: Perception of choice in admission dates being offered to patients, as measured by the National Inpatient Survey. Reason for non-compliance judgement: Actions being taken: If an assessment of significant lapse was done please attach: Is it a significant lapse?: Summary statement on rationale / outcome of decision above: Lack of agreement between internal booking figures and patients perception of choice offered. The Care Quality Commission identified performance as worst performing 20% of trusts Leaflet produced and sent to patients, explaining the booking processes and the choices being offered. Survey undertaken to provide assurance that levels of choice measured in the 2008 National Patient Survey are low due to patients perception of choice being offered, and not levels of choice being in the bottom 20% nationally. Evidence from survey in August 2009 suggests reported levels of choice now consistent with top 20% of trusts. Was one done? No (as in previous year s not considered to be a significant lapse). No Nationally, scores for the question on choice of admission dates in the National Inpatient Survey, are low. Evidence from the Trust s internal survey (August 2009), using an identical question to that used in the National Patient Survey, suggests that reported level of choice is now consistent with top 20% best performing trusts. Page 3 of 3 Page 55

56 University Hospitals Bristol NHS Foundation Trust Declaration on Healthcare Standard C18 Equity, Choice Additional assurance report requested by Audit & Assurance Committee 1. Purpose The considered view of the Audit and Assurance Committee at its meeting held on 15 th September 2009 was that detailed evidence should be presented to the Committee in respect of Standard C18. This view was reached for the following reasons: Insufficient assurance provided from an internal survey earlier in 2009/10, and the National Patient Survey (2008), that patients were being offered a choice of when to be admitted to hospital 2. Key controls and assurances for Standard C18 Core standard 18: Equity, Choice Healthcare organisations enable all members of the population to access services equally and offer choice to access to services and treatment equitably Below is a summary of the key pieces of evidence providing assurance in respect of this Standard for the year 2009/10 to date: Interpreter and advocacy services made available via the Choose & Book system Outpatient services provided in a range of locations, and bookable via Choose & Book Policy in place to promote and develop equality across all aspects of the Trust s business, with an associated work programme (Single Equality Scheme) Good standard of recording of ethnic group (exceeding the national requirement), to support service planning by PCTs and the Trust System for enabling additional requirements for arranging appointments and admissions (e.g. appointments arranged by phone, large font letters) to be provided for patients that request them Admission and appointment letters translated into the top ten languages spoken by the population of greater Bristol Regular review of comments, compliments and complaints information, to identify equality and choice issues 3. Issues/concerns Below is a summary of current issues/concerns in relation to Standard C18, including relevant mitigating evidence which might direct the Committee towards a recommendation of compliance. Page 56

57 Issue 1: Results from the National Inpatient Survey 2008 suggest that only 16% of patients surveyed felt they had been given a choice of admission date. This is a similar figure to the two previous surveys. A quarterly survey is now being undertaken, to determine whether reported levels of choice are due to patients perception of the range of choices being offered, and what can be done to improve patient experience of booking. The survey of over 1500 patients on our elective waiting lists was undertaken in August 2009, with 585 patients responding. This showed that 37% of patients felt they had been offered choice, which is the same as the lower limit on the band of the Best performing 20% of trusts (37% to 56%) in the 2008 National Patient Survey. Sixty-one (61%) percent of patients that received the Choices leaflet responded in the survey to say they had been offered a choice of date of admission, although only 29% of patients surveyed had received the leaflet. This suggests that the low reported figures in the 2008 National Patient Survey of choice being offered was at least in part due to patients perception of the choices available and the booking process, which the patient leaflet has helped to address. Issue 2: Not meeting the national standard for availability of outpatient appointments via Choose & Book Although performance dipped below the required standard at the start of the year, the Trust took action to address appointment availability and is now consistently achieving the 90% national slot availability standard each month. 4. Summary The recommendation to the Audit and Assurance Committee is that Standard C18 be declared Compliant. Irene Scott Chief Operating Officer 28 th October 2009 Page 57

58 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 9 Records Management Healthcare organisations have a systematic and planned approach to the management of records to ensure that, from the moment a record is created until its ultimate disposal, the organisation maintains information so that it serves the purpose it was collected for and disposes of the information appropriately when no longer required. Executive Lead J Sheffield Operational Lead L Nasey Group Information Governance Steering Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possible Estimated Risk to Compliance for remainder of 2009/10 Very Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) 1) General Issues within the Information Governance Toolkit that refer to corporate (non-clinical) Records Management are not yet met to Level 2, the required standard for Trusts by the Strategic Health Authority. Plans in place to achieve. 2) The Senior Information Risk Owner has been identified. The associated network of responsibilities, including identification of all Information Assets and their owners not yet done. 3) Use of NHS number Requirement has been revised for 2009/10 and certain compliances require the Trust to notify the patient of their NHS number, also to promote its use by staff. The Trust assigns an NHS number when the patient is registered or is referred to the organisation for treatment as an Outpatient. All major Trust IT systems i.e. PAS, CRIS and Ultra store the number but it is not the primary number for identifying the patient, nor is it placed before the Hospital number on labels etc. All Midwives give Mothers the babies NHS numbers when registered at birth. 4) Internal audit of record keeping standards being undertaken for 2009/10 No. of Internal No. of individual noncompliant Internal 10 No. of External 1 No. of individual noncompliant External 3 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Information Governance Toolkit Annual Score* Corporate Records Assurance Requirements scored at 2 or above 31 st March 2009 NHSLA Standards for Records Annual Assessment CNST level 1 achieved October, Management 2009 Page 1 of 3 Page 58

59 NHS Number Data Quality and use in clinical correspondence Medical Director nominated as Senior Information Risk Owner (SIRO) Annual Requirement of the Trust revised by DSCN 32/2008. PAS user group in discussion with EDS about changes required to IT systems needs to be completed by 31 Dec Main gaps around Awareness, Communications and Training Requirements, which should be completed by 31 Dec st March, 2009 Other Minuted at the Information Governance Steering Group. 30 th October 2009 Current Gaps in the Assurance Summary of action being taken to address these Gaps Timescale Framework Missing patient case notes Problem created by poor use of electronic tracer card module. Much re-training Ongoing Major storage problems at BCH and StMH Spoken to Divisional Manager and other appropriate managers. Trust wide review by Christmas 2008 Duplicate pathology reports ~ VPLS and Problem should be resolved providing move to paperless as Order Communications Ongoing manual implemented. Staff uptake for ICE training has been poor and consequently the implementation has been delayed. This has been discussed at TOG and the IT Committee and revised dates are being considered. Loose filing problems Trust wide Problem should be helped dramatically providing move to paperless as Order Communications Ongoing implemented. Staff uptake for ICE training has been poor and consequently the implementation has been delayed. This has been discussed at TOG and the IT Committee and revised dates are being considered. Actions relating to Information Risk Ownership. SIRO training and education to be completed October 2009 Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period Above regularly reviewed by Assurance of Record Keeping Group, Trust Health Records Managers Forum and Information Governance Steering Group. Trust Health Records Policies and Procedures document recently reviewed, thus ensuring a common approach to Health Records. Please comment on any other issues relevant to this Standard not covered above KPI information routinely produced for BRI Medical Records Healthcare Commission has confirmed that this requirement relates to ALL records of the Trust not just clinical ones. Details of any non-compliant evidence items relevant to the current year 2009/10: (please reproduce the boxes below for each individual item ) Evidence item: Review of Training materials to be given out at Corporate Induction. Reason for non-compliance Page 2 of 3 Review of Standards criteria and CQC cross-check shows that main weakness is the around the degree of training staff Page 59

60 judgement: Actions being taken: If an assessment of significant lapse was done please attach: Is it a significant lapse? Summary statement on rationale / outcome of decision above: receive in Information Governance. Policy reviewed this year and standard template produced; an audit to be performed to check adherence to standards. Was one done? No No All indicators used by CQC and based on the Information Governance Toolkit scored in the expected or tending towards better than expected range. Page 3 of 3 Page 60

61 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 13c Confidentiality Healthcare organisations have systems in place to ensure that staff treat patient information confidentially, except where authorised by legislation to the contrary. Executive Lead J Sheffield Operational Lead L Nasey Group Information Governance Steering Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possible Estimated Risk to Compliance for remainder of 2009/10 Very Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) No serious untoward incidents for information security reported. Dr J Sheffield (Medical Director) identified as Senior Information Risk Owner Encrypted USB sticks available for staff to use when transferring data. Encryption methods available to all staff when sending s. Encrypted Tunnel available to SHA. Independent audit of Information Governance Standards performed some actions identified, taken to IG steering group on 10 th March, Concerns that not all laptops have been identified by staff within the Trust. Decisions to be made regarding ways to ensure any data extracted from Trust IT systems is done so safely particular issues relate to removable media (e.g. IPods, USB sticks, Smart phones etc) No. of Internal No. of individual noncompliant Internal 8 No. of External 0 No. of individual noncompliant External 2 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Information Governance Toolkit version 7. Requirements for 25 requirements (IG Assurance Framework - IGAF) to be scored at level 2 or above Is this KPI Annual / quarterly / monthly / other? Annual Serious Untoward Incidents Adhoc None during reporting period Most recent measurement of performance against KPIs Date if action being taken 1 IGAF requirement not currently scored as a 2 which relates to SIRO and Information Asset Owners and Administrators. 3 other requirements not scored as a 2, including the results of the Clinical Coding audit to be performed in November, Requirement 208 mapping of flows of person identifiable information scored at level 2 31 October 2009 Page 1 of 2 Page 61

62 Current Gaps in the Assurance Framework IGT requirement Information Data Flow mapping to assure that no patient identifiable information is communicated insecurely Uncertainty about whether staff have identified all laptops Summary of action being taken to address these Gaps Assistant Information Governance Manager appointed to support the performance of this audit Staff information in Newsbeat articles. Internal audit of data security performed and to be reported at steering group. Articles in Newsbeat and need to identify all assets as part of other initiatives. All new laptops are encrypted by IM&T Department Timescale Ongoing Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale Staff refusing encryption for their laptops All identified laptops encrypted. Conference call with Strategic Health Authority confirmed approval of current actions Staff sharing passwords Helpdesk logging when staff are discovered sharing passwords training to be available for advanced Outlook use, therefore, using delegate access. Also advising staff to get group shares on the network. Other current entries on the Assurance Framework Action Plan Timescale Details of any significant new controls or assurances added during this reporting period None Please comment on any other issues relevant to this Standard not covered above None Page 2 of 2 Page 62

63 University Hospitals Bristol NHS Foundation Trust Declaration on Healthcare Standards C9 & C13c Information Governance Additional assurance report requested by Governance and Risk Management Committee 1. Purpose The considered view of the Governance and Risk Management Committee at its meeting held on 14 th October 2009 was that detailed evidence should be presented to the Audit and Assurance Committee in support of a recommended declaration of compliance with Standards C9 and C13c. This view was reached for the following reasons: Because of the level of public and patient concern around the possibility of the Trust losing data and breaching patient confidentiality (C13c). C9 - Working with the PCTs on the requirements of standard C9, element 2. The Trust already achieves the standard of 95% of active patients on the Master Patient Index with an NHS number, however, some of the functionality required of IT systems would be difficult to achieve with the current EDS Patient Administration System. The Head of IM&T is in contact with EDS and the Strategic Health Authority with regard to this 2. Key controls and assurances for Standards C9 and C13c Below is a summary of the key pieces of evidence providing assurance in respect of this Standard for the year 2009/10 to date: The majority of the evidence is contained within the scoring of the Information Governance toolkit. This year the Information Governance team are working with IG workstream leads to gather the hard copy evidence that relates to each requirement. Other evidence relates to Survey of NHS Staff and PEAT scores 3. Issues/concerns Below is a summary of current issues/concerns in relation to Standards C9 and C13c, including relevant mitigating evidence which has directed the Governance & Risk Management Committee towards a recommendation of compliance. Compliance with the Information Governance toolkit requires that the Trust s Senior Information Risk Owner completes relevant training for the role. Until recently this training has not been available and concerns have therefore persisted about a possible technical breach of the Healthcare Standards. However the SIRO (the Medical Director) has now completed this training. Page 63

64 4. Summary The recommendation to the Audit and Assurance Committee is that Standards C9 and C13c be declared Compliant. Dr Jonathan Sheffield Medical Director 23 rd October, Page 64

65 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 15 Food Provision and Services Where food is provided, healthcare organisations have systems in place to ensure that patients are provided with a choice and this it is prepared safely and provides a balanced diet Where good is provided, healthcare organisations have systems in place to ensure that patients individual nutritional, personal and clinical dietary requirements are met, including any necessary help with feeding and access to food 24 hours a day. Executive Lead A Moon Operational Lead Helen Brown Group Nutrition Steering Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possible Estimated Risk to Compliance for remainder of 2009/10 High Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) In 2009 a new approach to monitoring Standard 15 was introduced in the form of a Catering Ward Rounds audit and development of a Dashboard that identifies how each ward is performing on a range of nutritional and catering practices which are key indicators for implementation of the standard. A fundamental requirement is to screen patients for their risk of malnutrition within 24 hours of admission in order to then provide meals and snacks that meet their individual needs according to clinical and personal nutritional needs. This screening will also identify whether a patient requires assistance with feeding. Prior to this form of monitoring being in place (prior to 2009), we were unable to be clear that the most appropriate food was being provided to each individual. Our first audit (Jan-July 2009) identified that 53% of UHB wards were not carrying out this screening. We are in the stages of carrying out a second audit which to date has shown that this figure is now at 40%. UHB is therefore screening 60% of its patients. Our task now is to bring about a steady increase in this level. We have drawn on our experience over 2009 to identify a framework of controls that will bring about sustained improvement in nutritional screening, these include continuing with the audits and dashboard development and reporting on these at ward level, Food Group level (within each Hospital) and at the level of the Nutrition Steering Group which in turn reports to CRAC. It is planned that with these clear lines of reporting and accountability that areas of poor practice and / or high risk regarding food provision arrangements can be swiftly identified and acted on at both ward and management level. From April 2010 the ability to continue to monitor Standard 15 at ward level, update the dashboard and enable timely communication to wards that are performing poorly will require investment. This is being addressed within the Trust s business planning process. No. of Internal No. of individual noncompliant Internal 15 No. of External 1 No. of individual noncompliant External 4 0 See below for details of non-compliant evidence items Page 1 of 6 Page 65

66 Key Performance Indicators (measurables) Nutrition screening to occur within 24 hours of admission, in all Units except Bristol Children s Hospital and St. Michael s Maternity Wards All patients have a nutritional care plan that meets their personal nutritional, dietary and clinical requirements The Trust has an active Nutrition Steering Group The Trust has an updated Food and Treatment Policy Patients are involved in the planning and monitoring of food service provision Is this KPI Annual / quarterly / monthly / other? Quarterly Quarterly Most recent measurement of performance against KPIs Date if action being taken 23 Catering Ward Rounds took place in this quarter. 60% of all patients are screened for risk of malnutrition in 24 hours. No patients at BRCH are screened Ward 72 & ward 78 have introduced nutrition screening Nutrition care plans for nutrition support, palliative care and children are available on the document management system September 2009 September 2009 September 2009 September 2009 Quarterly 4 nutrition steering group meeting have been held. September 2009 Quarterly The Food and Treatment Policy is currently being updated. Publication planned Dec 2009 Quarterly The Protected Mealtimes Policy is in its final stages of development protected mealtimes is to commence in the Old Building December 7 th 2009 Essence of Care Food & Nutrition standard has been updated. 62 Catering Ward Rounds have been carried out so far in 2009 COREC approval to be obtained for further analysis of patient questionnaires September 2009 September 2009 September 2009 March 2010 Temporary funding for a catering ward rounds Dietetics Assistant from February 2009 until end March NA Updating the Food & Treatment policy has been stated as a key objective in the Food Policy Manager s IDPR Trust-wide protected meal times policy Quarterly Facilities undertook patient satisfaction surveys during June 2009, the numbers surveyed were: BHOC 19 BEH 29 StM s 42 BGH 17 BRI 154 The Protected Mealtimes Policy is in its final stages of development. A work plan for its implementation is to be developed in time for December 7 th launch. December 2009 The Food Policy Manager is working with Senior Nursing staff and facilities Page 2 of 6 Page 66

67 Key Performance Indicators (measurables) Numbers of staff trained in the competencies and skills needed to ensure that a patient s nutritional needs are met Is this KPI Annual / quarterly / monthly / other? Quarterly Most recent measurement of performance against KPIs Date if action being taken 7 e-learning sessions held 2 Food education sessions 1 communication focus group 1 nutrition roadshow Nutrition screening now included on induction September 2009 management on the development of this Policy. Training plan to be approved by nutrition steering group for 2010 Number of wards where 24 hour food provision is available New HACCUPs developed as appropriate, re food safety Food Groups occur regularly at Bristol General Hospital, Bristol Haematology and Oncology Centre, Bristol Royal Infirmary, St. Michael s Hospital and Bristol Children s Hospital & Eye Hospital Food Groups have good attendance from all appropriate staff Quarterly Quarterly Quarterly Quarterly 24 hour food is available in all areas. Hot food is only available 24 hours in St. Michael s Central Delivery Suite. Up-to-date Hazard Analysis Critical Control policies are in each hotel service managers department. 12 operational Food Groups have occurred across all Trust Sites BGH, BHOC & BRI always have good attendance with appropriate staff. Other Food Groups are more variable. March September 2009 September 2009 September 2009 September 2009 NA NA NA Efforts are being made to enable improved attendance Terms of Reference and Annual Workplans have been identified for the Food Groups. Current Gaps in the Assurance Framework Nutrition Screening at 60% within 24 hours at BRI (excluding Women & Children s Division). In Spring 2008 this was 47%. A tool (the STAMP tool) was piloted early in 2009, roll out is not complete and Bristol Children s Hospital is currently not compliant with screening Food Policy requires updating Page 3 of 6 Summary of action being taken to address these Gaps Nutrition Screening training has been added to Induction for clinical staff as a case study and nurses attending training are planned to be added to ORACLE. The monitoring of nutrition screening is dependent on funding a Band 3 Catering Ward Rounds Dietetic Assistant. This funding ends in March A paper went to TOG in October Focus groups are being planned during 2009 to identify barriers to continued implementation Insufficient reporting process for Trust wide incidents related to Standard 15 Annual work plan and Terms of Reference for Nutrition Steering Group in development Food as Treatment Policy to be updated and agreed by the Nutrition Steering Group Page 67 Timescale Dates to be agreed Throughout 2009 December 2009

68 Current Gaps in the Assurance Framework The Protected Mealtimes Policy is in its final stages of development. Paediatric Care Plan is not yet available on the Document Management System Not all special diet plans are met issue with pharmacy supply of gluten free products and low protein products / diets Adapted cutlery/appliances for feeding are only available at Bristol General Hospital Insufficient ward based staff available to assist with feeding. Volunteers can help but need to be co-ordinated. Nutritional assessment information is not yet passed from ward to ward and needs to be addressed Chinese dietary requirements are not yet met Insufficient reporting processes for Trustwide incidents related to Standard 15 Summary of action being taken to address these Gaps Timescale The Modern Matrons and Food Policy Dietitian are currently developing a roll out plan During 2009 Core Care Plans for Nutrition Support in Paediatrics are being reviewed as they were written to go with STAMP. The Food Policy Dietitian is in the final stages of agreeing a supply chain for gluten-free and low protein products. Pharmacy / Dietetics and Hotel Services are working together on this issue. The latest meeting was 8 th October All these gaps will be addressed once funding has been agreed for a Nutrition Lead for Mealtimes Dietetic Assistant (Band 4). This post will have several functionalities: Carry out daily co-ordination of volunteers to support the patients most in need of assistance with feeding. Train the volunteers to have a responsibility for managing the use of adapted cutlery at the BRI Develop and monitor systems to enable the nutrition assessment information to be passed from ward to ward. The monitoring of Standard 15 has identified that some patients are not given assistance with feeding due to insufficient ward staff available. Evidence-based practice has demonstrated significant benefits to using volunteers to assist with feeding. A pilot project in UHB has demonstrated the need for a co-ordinator post specifically focused on patients that require assistance with feeding. November 2009 November 2009 Timescales to be agreed once funding date is known. A bid is being submitted as part of UHB s Business Planning process for a Band 4 post. Alternative supplier for Chinese food being sourced internal team to taste session. December 2009 Cases of incidents reported on Ulysses regarding nutritional issues will inform the Nutrition Steering Group of the key problem areas Trust wide. From October 2009 The Chief Nurse has agreed an accountability framework for the Nutrition Steering Group (Standard 15). October 2009 Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale Paediatric metabolic patients dietary requirements are not fully met by our current food provision services. Assistant Divisional Managers in Diagnostics & Therapies Division and Women s & Children s Division have been fully briefed about the specific requirements for a Diet Chef. Women s & Children s are meeting on November 9 th to identify the level of risk at which this area will appear on the Division s Risk Register Current very high risk From April 2010 there will be no ongoing monitoring of the Key Performance Indicators that relate to patient screening and patient feedback on nutritional care, numbers of patients requiring assistance with eating and the level of assistance received, observation of protected mealtimes. There will be Page 4 of 6 This risk is due to currently temporary funding only for our Band 3 Catering Ward Round Dietetic Assistant. This funding finishes at the end of March This will be presented and discussed at TOG, October This appears on Diagnostics & Therapies Division Risk Register. Page 68 High risk from April 2010

69 limited monitoring of food provision, choice of main entrée and correct meal received. Limited monitoring of patient satisfaction. Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period Catering Ward Rounds were presented to TOG in October 2009 Agreement reached on how the Nutrition Steering Group provides assurance and delivery of Standard 15 with Chief Nurse & Director of Governance (Accountability Framework). Induction for Nursing Staff includes a nutrition case study. Please comment on any other issues relevant to this Standard not covered above None Details of any non-compliant evidence items relevant to the current year 2009/10: (please reproduce the boxes below for each individual item ) Evidence item: Documentation- Trust Paperwork Nutrition Screening Reason for non-compliance judgement: Actions being taken: If an assessment of significant lapse was done please attach: Is it a significant lapse?: Summary statement on rationale / outcome of decision above: The first Catering Ward Rounds audit (Jan-July 2009) indicated that 53% of UHB wards were not carrying out nutritional screening of patients. The current (second round audit) has identified this figure is now at 40%. The Catering Ward Rounds Audit enables specific wards to be identified regarding their screening practices. Wards that are not screening receive immediate feedback from the Food Policy Manager and ward specific multidisciplinary actions plans are developed. Results of the first Catering Ward Rounds Audit were presented at TOG, October Results of ongoing Catering Ward Rounds are presented at the bimonthly Nutrition Steering Group. As part of the Business Planning process 09/10 a submission will be made for a Catering Ward Rounds Assistant post and a Co-ordinator of Volunteers for assistance with feeding. Case of incidents reported on Ulysses regarding nutritional issues will inform the Nutrition Steering Group of the key problems Trust-wide. Nutrition screening training has been added to Induction for Clinical Staff as a case study Yes see attached No The Trust is currently monitoring closely its nutrition screening rates and has comprehensive actions in place to bring about improvements targeted to wards that are performing poorly. Patients will always receive meals during their hospital stay but with the continuous improvement in screening rates, there will also be an increase in the Trust s ability to meet each patient s individual nutritional needs more appropriately. Details of any non-compliant evidence items relevant to the current year 2009/10: (please reproduce the boxes below for each individual item ) Page 5 of 6 Page 69

70 Evidence item: Reason for non-compliance judgement: Actions being taken: If an assessment of significant lapse was done please attach: Is it a significant lapse?: Summary statement on rationale / outcome of decision above: Documentation- Trust Paperwork Adapted Cutlery A suitable service for patients that require adapted cutlery is not available. This has been discussed with the Deputy Chief Nurse and recognised that appropriate procedures need to be put in place at ward level. Yes see attached No This problem has been identified to the Deputy Chief Nurse who will take this forward through the Trust s Nurse Management Structure. Details of any non-compliant evidence items relevant to the current year 2009/10: (please reproduce the boxes below for each individual item ) Evidence item: Documentation- Trust Paperwork Paediatric Metabolic Service Reason for non-compliance judgement: Actions being taken: If an assessment of significant lapse was done please attach: Is it a significant lapse?: Summary statement on rationale / outcome of decision above: Inadequate food provision for paediatric metabolic patients following the transfer of patients from Southmead during the summer of The Assistant Divisional managers in Diagnostics & Therapies Division and Women s & Children s have been fully briefed about the specific requirements for a Diet Chef. No. Women s and Children s are fully aware of the potential for a high risk situation when a child with an inborn error of metabolism is admitted and the need for a high intensity of input to manage individual cases. No The Paediatric Metabolic Service is a new service for University Hospitals Bristol since it s transfer from Southmead during the summer of The Business Case did not include provision for the therapeutic dietary management of patients with inborn errors of metabolism. Women s and Children s Division are fully aware of the risks of the current situation and have action plans in place. Details of any non-compliant evidence items relevant to the current year 2009/10: (please reproduce the boxes below for each individual item ) Evidence item: Documentation- Trust Paperwork Ketogenic Diets Reason for non-compliance judgement: Actions being taken: If an assessment of significant lapse was done please attach: Is it a significant lapse?: Summary statement on rationale / outcome of decision above: Women s & Children s food provision does not have the skills or facilities to provide ketogenic diets without using artificial nutrition via nasogastric tube or existing gastrostomy tubes. Women s & Children s Division are currently identifying clinical pathways and treatment options. No No Ketogenic diets are emerging in 2009 as treatment for epilepsy and some forms of autism. Each case requires individual assessment. The Women s & Children s Division are fully aware of the risks of the current situation and the need for a high intensity of input to manage individual cases. Page 6 of 6 Page 70

71 ASSESSMENT TOOL FOR A LAPSE IN COMPLIANCE WITH A CORE HEALTHCARE STANDARD Core Standard No Standard Exec Lead Description of Lapse 15b AM In 2008 revised Core Healthcare Standards requested that where required Trusts were to provide adapted cutlery to patients to encourage independent feeding. However, distribution and maintenance across a large clinical site has meant that a suitable service for patients requiring adapted cutlery is not available ASSESSMENT: Impact one Duration one [leave if isolated 0] Risk None 1 1 month 1 Rare 1 Minor mths 2 Unlikely 2 Moderate months Possible 3 3 Major months Likely 4 4 Catastrophic 5 12 months 5 Almost Certain 5 one Briefly explain rationale for assessment: Area Score Brief Rationale Impact 3 Patients who require adapted cutlery but do not receive the correct tool will struggle to use the usual hospital cutlery. Research indicates this reduces their overall calorie and protein intake and therefore increases their risk of malnutrition. Duration 0 possible 5 Without senior management action this situation will continue. Risk 5 This is high risk but has been identified by senior management as an area for immediate action. TOTAL Lapse Score: 13 Page 71

72 University Hospitals Bristol NHS Foundation Trust Declaration on Healthcare Standard C15 - Nutrition Additional assurance report requested by the Chief Nurse 1. Purpose The Chief Nurse has requested a detailed assurance report on this Standard for the following reasons: Concerns about nutritional screening compliance rates Recognition by the Chief Nurse of the urgent need to address the distribution and maintenance of adapted cutlery availability for patients across the Trust. 2. Key controls and assurances for Standard 15a & 15b Below is a summary of the key pieces of evidence providing assurance in respect of this Standard for the year 2009/10 to date: The Catering Ward Round s Audit provides evidence of nutrition screening rates and other key performance indicators that are key to the monitoring of Standard 15 and will continue until the end of March The Catering Ward Rounds Audit is presented in the form of a dashboard and clearly identifies areas of strength and weakness at ward level regarding nutritional and catering practices. This information is reported and acted on at different levels within the Trust. At individual ward level as soon as problems have been identified. Wardspecific action plans are then developed and reviewed. At Unit level via the monthly Food Groups (BHOC, BGH, St Michaels, BCH, BRI). At the bi-monthly Nutrition Steering Group which is a Trust wide group. The reporting arrangements for the Nutrition Steering Group have been recently agreed. From November 2009 this group will report to the Clinical Risk Assurance Committee for assurance purposes and to the Trust Operational Group for delivery of Standard 15. Clinical Incidents, PALS, Reports and Risk Register entries will be reviewed at the Nutrition Steering Group and actions agreed. Page 72

73 Induction training for nursing staff new to the Trust with additional educational sessions for current ward staff in the form of nutrition roadshows will occur to raise awareness and knowledge of the importance of nutritional screening. Improved attendance at Food Groups from all staffing groups at the BRI. For other units where attendance has historically been poor, significant approaches are being taken to improve attendance. Introduction of a nutrition case study to the Trust s induction programme for nursing staff. 3. Issues/concerns Below is a summary of current issues/concerns in relation to Standard 15, including relevant mitigating evidence which might direct the Committee towards a recommendation of compliance. The monitoring of Standard 15 has identified that some patients are not given assistance with feeding due to insufficient ward staff available. Evidence-based practice has demonstrated significant benefits to using volunteers to assist with feeding. A pilot project in UHB has demonstrated the need for a co-ordinator post specifically focused on patients that require assistance with feeding. A Band 3 Dietetics Assistant post currently carries out the Catering Ward Rounds Audit and produces the Dashboard. From April 2010 the funding for this post will end. Without this post the Trust is unable to monitor its progress with Standard 15 at the level required to enable targeted action plans at ward level to be produced. A bid is being developed through the Business Planning process within the Diagnostics and Therapies Division to support the above posts. 4. Summary The recommendation to the Audit and Assurance Committee is that Standard C11b be declared Compliant. Alison Moon Chief Nurse 9 th November 2009 Page 73

74 ASSESSMENT TOOL FOR A LAPSE IN COMPLIANCE WITH A CORE HEALTHCARE STANDARD Core Standard No Standard Exec Lead Description of Lapse 15b Healthcare Organisations have systems in place to ensure that patients individual nutritional, personal and clinical dietary requirements are met, including where necessary help with feeding and access to food 24 hours per day AM In order to identify the nutritional, personal and clinical dietary needs of all patients they should be screened for risk of disease related malnutrition within 24 hours of admission. The screening tool helps to identify barriers to good nutrition including assistance to eat and special diet provision. The Catering Ward Round Audit was developed this year to establish rates of nutrition screening across the Trust. In addition to measuring other criteria related to food service and provision the audit has highlighted inconsistent practice across the Trust. This is in part due to lack of screening tools for use in paediatrics until March However, 53% of wards were unable to meet acceptable standards for nutrition screening. (Jan -July 2009) ASSESSMENT: Impact one Duration one [leave if isolated 0] Risk None 1 1 month 1 Rare 1 Minor mths 2 Unlikely 2 Moderate months Possible 3 3 Major months Likely 4 4 Catastrophic 5 12 months 5 Almost Certain 5 one Page 74

75 Briefly explain rationale for assessment: Area Score Brief Rationale Impact 3 If patients are not screened in a timely fashion their special or therapeutic dietary needs are not identified, their risk of disease related malnutrition and its clinical consequences are not addressed, they are not referred correctly to AHP services and are at risk of pressure ulcer development, secondary infections and longer length of hospital stay. Duration 0 possible 5 Department of nutrition and dietetics are currently continuing to audit food service and provision to identify areas of poor practice to target resources to support wards to improve nutritional care at ward level. Risk 3 The risk of not being screened for nutritional risk is reducing due to the actions that have been put into place following the first Catering Ward Rounds Audit. TOTAL Lapse Score: 11 Page 75

76 Summary reports for all other Core Standards Page 76

77 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 1a Patient Safety Healthcare organisations protect patients through systems that identify and learn from all patient safety incidents and other reportable incidents, and make improvements in practice based on local and national experience and information derived from the analysis of incidents. Executive Lead J Sheffield Operational Lead N Henderson Group Clinical Risk Assurance Committee Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possible Estimated Risk to Compliance for remainder of 2009/10 Very Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The key indicator of compliance with this Standard is National Health Service Litigation Authority (NHSLA) Risk Standards for Acute Trusts. The Trust is currently compliant at Level 1 following an Assessment in September Relevant NHSLA Standards: Incident Reporting Being open with patients and families Supporting staff involved in incidents, complaints and claims Risk management training plan Investigation, analysis and improvement for incidents complaints and claims UH Bristol Trust has Level 1 accreditation currently for these NHSLA Standards. Detailed evidence spreadsheet (NHSLA format) is available from the Patient Safety Team and on Mildred Trust IT system Trust Patient Safety activity reflects best practice requirements including but not exclusively incident reporting and investigations. Clear structure of central corporate activity allied with activity in Clinical Divisions. Active committee function for patient safety. Network for activity with other healthcare providing organisations within Region. Network for development of staff with role in patient safety as part of primary clinical post. Introduction of range of technologies to improve patient safety e.g. online incident reporting, bar coding for patient identification. Gaps in Assurance Framework detailed below: Induction Only 2/3 of the Induction Standards achieved compliance at the last NHSLA Assessment. Blood transfusion This achieved compliance at the last NHSLA Assessment. Patient Falls This did not achieve compliance at the last NHSLA Assessment. No. of Internal No. of individual noncompliant Internal Page 1 of 3 28 No. of External 0 No. of individual noncompliant External 22 0 See below for details of non-compliant evidence items Page 77

78 Key Performance Indicators (measurables) NHS Litigation Authority Risk Management Assessment Acute Trusts NHS Litigation Authority Risk Management Assessment Maternity Services Healthcare Commission visit June 2008 review of 1a Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Annual Accreditation Level 1 (scale 0-3) for Acute Standards September 2009 Two Yearly Accreditation Level 3 (scale 0-3) for Maternity Standards February 2008 Determined by the Healthcare Commission Compliant additional monitoring required for patient falls June 2008 Current Gaps in the Assurance Framework Blood Transfusion competency training for all relevant clinical staff Induction Policy and Training Regular review of patient falls reported as incidents Appointment of Designated Patient Safety Leads in Divisions. Summary of action being taken to address these Gaps National Patient Safety Agency Alert deadline May Training workshops continue on the 23/03, 09/04 and 01/05 to take us to the deadline of May Attendance has been good but many areas that have accessed training still need to complete their competency assessments. Representatives have been sent from the majority of wards with the exception of: Medicine 23, 27, Phlebotomy and all wards at BGH Surgery 14, 15 and SAU W&C 32, 36, 37, ODB, Theatres, A&E, BMT, 72, CDS and St Michael s Theatres Specialised Services CICU, 18, 62 and 61 The Induction Policy covers 3 NHSLA Standards and was awarded compliance for 2 of these at the assessment in September However, the policy failed to contain all relevant information regarding the process for Induction and the management of those who do not attend specifically in relation to Local Induction for Temporary Staff. In order for it to be compliant in all 3 standards at future NHSLA Assessments it will need to include more detail on the processes for both Corporate and Local Induction of all types of staff. Falls Review Group agreed at their meeting in October 2008 that they would review data on a trust wide basis for all patient groups and since March 2009 this has become a regular item on the Groups Agenda. In September 2009 the Patient Falls Policy failed to achieve compliance with the Level 1 NHSLA Acute Standards Assessment. This was due to there being no process for managing falls from a height. A full review of the policy and procedures was planned for September 2009 to ensure they incorporate the regional work happening around falls and see if the Trust can be involved in the development and use of a Bristol Wide Falls Care Plan. Diagnostic and Therapies and Medicine Divisions are still covered by staff with full time clinical/managerial roles. Experience of remaining Divisions with designated Leads is that this helps with Patient Safety Initiatives and quality/timeliness of incident investigation. Timescale 50% of all relevant staff to be formally assessed by May % by May Currently not agreed. Awaiting formal feedback from the NHSLA Assessor due in October 2009 then an action plan can be set up. Assessment of procedures to begin in September Policy and Process to be amended during the next Policy Review in September Page 2 of 3 Page 78

79 Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale 957 Implementation of 'Toft Report' - Heparin Double checking of drugs - impact on standard anaesthetic practice. Waiting publication of NPSA Royal College National Introduction of high risk drug cupboards for all clinical areas. Progress on both actions Guidance. 888 Delays in logging of incidents details and data quality reported to Clinical Risk Assurance Committee and Trust Board on regular basis. Delayed implementation of online incident reporting to improve data quality (mandatory data fields) and timeliness for tracking and trending purposes. Pilot commenced Ward 24, BRI in September Pilot Ongoing Other current entries on the Assurance Framework Action Plan Implementation of work-streams associated with national Patient Safety First Project and South West Quality and Patient Safety Improvement Programme. Introduction of improved communication for safe transfer of patients (internally within Trust and externally to other health care providers) Linkage of Patient Safety activity with Lean Productive Ward implementation across Trust Timescale Regional event being held on 5/6/7 October 2009 to give further clarity. Details of any significant new controls or assurances added during this reporting period High Risk Incident Checklist implemented for Patient Safety Incidents to improve communication and early alerting of Divisional Patient Safety Leads. Introduction of risk assessment for all patients to determine measures to prevent the development of venous thrombo-embolism Surgical patients prioritised Standard Operating Procedure and Policy implemented in all theatres across the Trust on the use of SWABS. SUI reporting process reviewed and linked to CQUINS A range of risk management and patient safety policies where updated for September 2009 in preparation for the Level 1 NHSLA Acute Standards Assessment which took place on the 10 th /11 th September 2009 and which the Trust were awarded compliance for 42/50 standards. CQUIN Target for risk assessing 95% of all adult patients in relation to their risk for developing venous thromboembolism commenced from the 1 st October The Trust has implemented a policy, held launch events, nominated VTE Champions for each clinical division and the Trust Executive Group are the committee with accountability and responsibility for the delivery of the target. Please comment on any other issues relevant to this Standard not covered above Healthcare Commission random inspection of this Core Standard June UH Bristol Trust declaration as compliant was approved. Page 3 of 3 Page 79

80 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 1b Patient Safety Notices Healthcare organisations protect patients through systems that ensure that patient safety notices, alerts and other communications concerning patient safety which require action are acted upon within required timescales. Executive Lead J Sheffield Operational Lead M Gemmell Group Medical Equipment Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possible Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) There is a low risk to compliance due to the fact that we do not currently have a system that tests that implementation has taken place i.e. Divisional responses are taken on trust. The Trust is procuring the Ulysses package to track and monitor actions required. Recommended action : Compliant (Healthcare Commission Safely does it report.) No. of Internal No. of individual noncompliant Internal 6 No. of External 0 No. of individual noncompliant External 3 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) *Monitoring trends in clinical incidents involving medical equipment *Central Alerting System Reporting System- Responses Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Quarterly Majority Low/Near Miss categories. No change in trend. Oct 2009 Monthly Target Completion Date not always being me, e.g. Out of 14 NPSA alerts with outstanding actions, 9 have breached their completion dates. Oct 2009 Safety Alerts- Divisional Responses Annually Target Completion Date not always being met. Mar 2007 Page 1 of 2 Page 80

81 Current Gaps in the Assurance Framework Systems to ensure that implementation of safety alerts has taken place within divisions Summary of action being taken to address these Gaps Paper to be presented to Clinical Risk Assurance Committe relating to gaps in process for the management of NPSA Alerts. Safety Alert Management package to be implemented Timescale October 2009 Dec 2009 Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Nil Other current entries on the Assurance Framework Action Plan None Re-audit of divisional responses to Medical Device Agency Alerts Timescale Details of any significant new controls or assurances added during this reporting period Purchase of safety alert management package for Ulysses. Not yet implemented Surgery Head & Neck currently developing management of safety alerts using Workspace surveys with good effect Please comment on any other issues relevant to this Standard not covered above None Page 2 of 2 Page 81

82 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 3 National Institute for Clinical Excellence Interventional Procedures Healthcare organisations protect patients by following National Institute for Health and Clinical Excellence (NICE) interventional procedures guidance. Executive Lead J Sheffield Operational Lead J Osborne Group Clinical Effectiveness Committee (CEC) Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Very Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The Trust has established policies in place that address this Standard. A random Healthcare Commission inspection in 2008 confirmed the Trust s declaration of compliance for 2007/8. New NICE Interventional Procedure Guidance (IPGs) - both published and draft versions - are reviewed by the Clinical Effectiveness Committee monthly, with particular emphasis on procedures not recommended for use within the NHS. Applications to introduce any new procedures are formally reviewed by the Clinical Effectiveness Committee, irrespective of their status with NICE. Seven applications have been approved in the last year. One potential procedure was formally referred to NICE, who determined this to be a modification to an existing technique and outside of their remit. 289 Interventional Procedure Guidance have been issued by NICE to date. A summary dashboard is currently being constructed which will summarise Trust assurance status in relation to IPGs at a glance. No. of Internal No. of individual noncompliant Internal 8 No. of External 0 No. of individual noncompliant External 2 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Applications to introduce a new interventional procedure Page 1 of 2 Is this KPI Annual / quarterly / monthly / other? Monthly (as appropriate Most recent measurement of performance against KPIs Date if action being taken Two applications received and approved since the April 2009, as follows; Interstitial high dose rate brachytherapy for paediatric sarcomainsertion of a Pleurx pleural catheter Left atrial appendage occlusion using the Amplatzer Cardiac Plug Page 82 Oct 2009

83 Current Gaps in the Assurance Framework Auditing outcomes following the introduction of new interventional procedures Summary Dashboard Summary of action being taken to address these Gaps Whilst relevant clinicians review outcomes associated with new procedures, in some cases this audit activity is still not being registered with the Trust Clinical Audit Team. A new and regularly updated Progress Report against Clinical Audit Forward Plan, started in September 2009, will allow earlier identification of those procedures where lack of audit might constitute a risk. A summary dashboard of the (to date) 317 Interventional Procedure Guidance issued by NICE is now available from the Implementing NICE Guidance workspace on the Intranet. However, progress in fully completing the dashboard listing those procedures offered by the Trust has been slower than anticipated. Timescale March 2010 Winter Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period None Please comment on any other issues relevant to this Standard not covered above When NICE (exceptionally) determine that a procedure should NOT be used within the NHS, we immediately review the Trust s compliance. In all such cases (listed below) we fully comply with such recommendations. IP290 Photodynamic therapy for brain tumours IP296 Endoscopic mastectomy and endoscopic wide local excision for breast cancer IP301 Transmyocardial laser revascularisation for refractory angina pectoris IP302 Percutaneous laser revascularisation for refractory angina pectoris IP309 Percutaneous mitral valve leaflet repair for mitral regurgitation Page 2 of 2 Page 83

84 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 4a Infection Control and Prevention Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that the risk of healthcare acquired infection to patients is reduced, with particular emphasis on high standards of hygiene and cleanliness, achieving year on year reductions in Methicillin-Resistant Staphylococcus AUREUS (MRSA) Executive Lead A Moon Operational Lead C Perry Group Infection Control Committee Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Very low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) Due to the importance of infection control and prevention to both patient safety and confidence, the evidence for this Standard is extensive in both systems and controls, and assurance. The Trust Board receives monthly report including performance and compliance monitoring information. No. of Internal No. of individual noncompliant Internal 54 No. of External 1 No. of individual noncompliant External 7 0 See below for details of non-compliant evidence items Key Performance Indicators Is this KPI Annual / Most recent measurement of performance against KPIs Date if action being (measurables) quarterly / monthly / taken other? Number of MRSA bacteraemias Annual 8 cases against annual ceiling of 31 31/08/09 Number of hospital acquired C Annual 57 cases against an annual ceiling of /08/09 difficile infections Hand hygiene compliance (detailed) Monthly 97% August 09 Hand hygiene compliance (point of Bi-weekly 70% 23/08/09 care) Matrons environment and Bi-weekly 64% 23/08/09 cleanliness checklist Page 1 of 2 Page 84

85 Toilet and bathroom cleaning sign off Weekly 92% 30/08/09 Antibiotic compliance monitoring Weekly 53% 30/08/09 Protective clothing use Weekly 86% 30/08/09 Isolation practice Weekly 100% 30/08/09 Failure to isolate within 4 hours Weekly 0 incidents 30/08/09 Compliance to infection control training requirements Quarterly 64% against a target of 90% 30/08/09 Current Gaps in the Assurance Framework Mandatory training figures for August 2009 show a current compliance of 64% against a standard of 90%. Summary of action being taken to address these Gaps Central and local delivery of infection control update sessions agreed with support from Divisions. Timescale End of November 2009 Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale Blocked sewage pipe Bristol Heart Institute Remedial works and external expert support End of October 2009 with subsequent fly infestation Swine flu potential impact on ability to Surge capacity planning in place and monitoring via weekly operational meeting Ongoing with weekly review maintain services due to severe staff shortages Risk of contamination pharmacy aseptic units from building works Mitigating actions in place but remains high risk due to the type of products being manufactured and consequences if contamination occurs Ongoing with monitoring at infection control committee Risk that ground gained in 2007 to reach As above End of November % plus compliance with mandatory training will be lost in 2008 as staff come into 2 year updating requirement Intensive Care Unit has been closed with an outbreak of multi-resistant Acinetobacter baumannii. Environmental and air supply works required. Enhanced infection control and environmental monitoring. Business plan being prepared to address changes need to air supply and to install additional isolation capacity. Air cooling switched off and agreement to use isolation in Cardiac Intensive Care Unit for isolation in the interim March 2010 Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period None Please comment on any other issues relevant to this Standard not covered above Page 2 of 2 Page 85

86 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 4b Medical Devices/Equipment Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that all risks associated with the acquisition and use of medical devices are minimised. Executive Lead J Sheffield Operational Lead M Gemmell Group Medical Equipment Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possible Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) There is a low risk to compliance because we do not currently have an implemented system that covers all healthcare groups training needs i.e. no real system currently exists to ensure medical staffs training needs relating to medical devices are addressed. There have been no recorded clinical incidents suggesting that this gap in compliance has been a contributory factor to any patient safety incident in 2008/09. No. of Internal No. of individual noncompliant Internal 25 No. of External 0 No. of individual noncompliant External 11 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) *Monitoring trends in clinical incidents involving medical equipment Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Monthly Majority Low/Near Miss categories. No change in trend. Current Gaps in the Assurance Framework Implementation of system for medical staff delayed due to requirement to modify current system. Page 1 of 2 Summary of action being taken to address these Gaps IM&T to complete modification. Use of junior doctors clinical portal to improve communication. Page 86 Timescale November 2009 January 2010

87 Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period May There is now an electronic system in place; a web based form for medical staff to complete aimed at identifying training needs for high risk equipment. The form needs to be further refined to make it more user friendly. August 2009: Medical Device Training policy reviewed and includes a system to identify training needs for medical staff. September 2009: Medical Device Management Policy ratified September now applies to all reusable medical devices NHSLA Level 1 achieved September 2009, criteria relating to medical device training met. Please comment on any other issues relevant to this Standard not covered above Page 2 of 2 Page 87

88 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 4d Medicines Management Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that medicines are handled safely and securely. Executive Lead A Moon Operational Lead S Hepburn Group Medicines Governance Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The recommendation of the Medicines Governance Group is that the Trust is compliant with the Core Standard 4d to keep patients, staff and visitors safe by ensuring that medicines are handled safely and securely. Evidence to support this statement includes: 1. the Trust s medicine code (compliant to NHSLA level 1) which is supported by the Medicine Steering Group (main remit to ensure appropriate policies in place), Medicine Advisory Group (main remit to control the choice of medicines available) and Medicines governance group (MGG) (monitors that the policies are in use and reviews medication related incidents). 2. MHRA (the Medicines and Healthcare products Regulatory Agency) drug recalls are reviewed by a senior pharmacist and actioned when applicable 3. National Patient Safety Agency safety alerts involving medicines are reviewed and response co-ordinated by the MGG 4. Medication safety is included both on the clinical trustwide induction programme and safe prescribing for new medical staff Risk to compliance is Low, based on lack of Standard Operating Procedures (as opposed to policies) as detailed in Care Quality Commission s criteria for prescribing, administration, monitoring and controlled drugs. Likely to be compliant with evidence for one of the litmus tests (anticoagulation) but possible that the second litmus test (oral methotrexate) may be lacking. No. of Internal No. of individual noncompliant Internal 25 No. of External 0 No. of individual noncompliant External 11 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) % of catastrophic/major reported medicine related patient safety incidents vs total Is this KPI Annual / quarterly / monthly / other? Annual Page 1 of 2 version 2 (oct09) Page 88 Most recent measurement of performance against KPIs Date if action being taken Nil catastrophic/major actual impact medication related safety incidents reported Oct 2009

89 Compliance with medicines code prescribing policy Compliance with controlled drug storage and record keeping Annual Quarterly Audit of prescribing in St Michael s Central Delivery Suite. 12 criteria reviewed for 3 drug regimens. Of the resulting 36 measures audited only 3 were 100% compliant (all in maintenance Magnesium). The range for the rest was from 13% compliance (use of block capitals, prescriber identifiable) to 95.7% (pt DOB or hospital no. & signed) showing limited compliance with the prescribing policy. Main patient safety issues are only 50% of prescriptions were deemed legible and 70% included abbreviations 11/25 areas 100% compliant with 8 criteria. Copies of signatures and only storing cds in cupboard 2 weakest areas with 19/25 areas compliant. 1/25 stock level did not tally. 25/25 no exceptional usage June 2009 July 2009 Audit recommendations circulated within division Non-compliance feedback to nurse in charge at the time and to modern matrons Current Gaps in the Assurance Framework Limited audit of NPSA risk assessments to ensure compliance with controls Medication safety training provided on induction and e-learning packages available but limited records of staff attending/completing and follow up of nonattendors Compliance with medicine code administration policy audit overdue Summary of action being taken to address these Gaps Raised with Trust clinical audit committee. Needs to be included in Divisions audit timetable Addressed via the provision trust-wide of training records linked to ESR Currently identifying audit lead Timescale Confirm with trust clinical audit committee Confirm with patient safety lead Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale 807 lack of roof on Parenteral Service Risk in place since 20/11/06. Dialog with estates no agreed outcome. Likehood low but Not agreed Unit potential catastrophic as supply injectable chemotherapy and parenteral nutrition for NICU and BMT 944 clinical trial activity > capacity Funding identified and recruitment progressing but space an issue Not agreed Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period None Please comment on any other issues relevant to this Standard not covered above RCA carried out on Patient safety event (heparin 5000units per ml used to prepare an iv dose, inappropriate chart) Participating in Patient Safety First Campaign (SW region) and High 5 (international safety campaign) both with medicine management areas to improve safety around insulins, medicine reconciliation, anticoagulation, iv potassium, high dose opioids Page 2 of 2 version 2 (oct09) Page 89

90 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 4e Waste Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that the prevention, segregation, handling, transport and disposal of waste is properly managed so as to minimise the risks to the health and safety of staff, patients, the public and the safety of the environment. Executive Lead A Moon Operational Lead C Waldron Group Infection Control Committee (via Environmental Management Group) Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Very Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) Broad range of actions, processes and policies across clinical and non-clinical waste which demonstrate compliance, including: audits carried out by contractors, consignment records documenting how clinical waste has been managed, ongoing internal audit of clinical waste compliance, adverse incidents reported to Health & Safety Committee, Patient Environment Action Team (PEAT) score on waste handling conducted in Spring 2009 all excellent, and training of staff about waste management at induction. No. of Internal No. of individual noncompliant Internal 16 No. of External 0 No. of individual noncompliant External 6 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Clinical Waste Management contractor Key Performance Indictors used in Contract Review Meeting to assess compliance against standard Is this KPI Annual / quarterly / monthly / other? Quarterly Most recent measurement of performance against KPIs Date if action being taken All Key Performance Indicators met during period. In addition, Duty of Care re Clinical Waste Contract undertaken including Duty of Care visit of landfill site for alternative technology waste; Review of staff waste handbooks complete; Upstream Audit by contractor undertaken - positive response given June 2009 Page 1 of 2 Page 90

91 Current Gaps in the Assurance Framework None Summary of action being taken to address these Gaps Timescale Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period 2009 PEAT scores (excellent) External pre-acceptance audit (September 2009 report awaited) Please comment on any other issues relevant to this Standard not covered above None Page 2 of 2 Page 91

92 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 5a NICE Technology Appraisals Healthcare organisations ensure that they conform to National Institute for Health and Clinical Excellence (NICE) technology appraisals and, where it is available, take into account nationally agreed guidance when planning and delivering treatment and care. Executive Lead J Sheffield Operational Lead J Osborne Group Clinical Effectiveness Committee (CEC) Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) There is an updated (v3.1 Aug 2009) Trust policy in place to support the implementation of NICE Guidance, including Technology Appraisals. The Policy has passed NHSLA Level 1 inspection (Sep 2009). The Trust takes an active role within the cross-community Bristol North Somerset and South Gloucestershire NICE Commissioning College. The function of the College is to spread the implementation costs and facilitate service redesign that better enable PCTs and Acute Trusts to fully and speedily implement Technology Appraisal guidance. Clinical audit is an integral part of this process and audit forward plans are developed in consultation with Bristol North Somerset and South Gloucestershire NICE Commissioning College. The Trust has a well-developed and transparent approach to evaluating compliance with NICE Clinical Guidelines. NICE are currently updating Technology Appraisal guidance contained within Clinical Guidelines, which will therefore become increasingly relevant to this Standard. Most TA guidance relates to new drugs that Trusts can relatively easily offer to patients once NICE have approved them. However, where TA guidance relates to surgical procedures or has an impact on clinics, equipment or staffing, there can be delays in implementation as PCTs prefer to commission specialist services on an annual financial year basis, given that the lead time often necessary to realign such services. The estimated risk of compliance for the remainder of 2009/10 has therefore been recorded here as Low (and not Very Low ) because of potential delays in community-wide implementation of those few TAs where there are significant short-term commissioning consequences (see above). No. of Internal No. of individual noncompliant Internal 11 No. of External 0 No. of individual noncompliant External 12 0 See below for details of non-compliant evidence items Key Performance Indicators Is this KPI Annual / Most recent measurement of performance against KPIs Date if action being Page 1 of 3 Page 92

93 (measurables) quarterly / monthly / other? Technology Appraisal Guidance Reviewed monthly by CEC (TAs) issued relevant to the Trust, with implementation plans agreed with PCT partners via BNSSG NICE Commissioning College Forecast outturn of the NICE College budget. monthly There have been 12 new TAs issued during the first half of the year (TA ), of which 9 were relevant to UHBristol. The following TAs presented significant implementation challenges during this period; TA171 Multiple myeloma - lenalidamide TA174 Leukaemia (chronic lymphocytic, first line) - rituximab TA176 Colorectal cancer (first line) - cetuximabta166 Hearing impairment - cochlear implants The NICE College has a budget of c. 30M to fund NICE TAs (mostly drugs) during the year, of which c. 20M is allocated to UHBristol. Year to date Oct 2009 taken Based on activity April-July, the Trust is under spending by c.13%, equivalent to a forecast outturn of - 2.6M. The major factor in this is our less than anticipated use of TA155 (Lucentis). Current Gaps in the Assurance Framework Need to clarify accountability and expectations for auditing NICE guidance Implementation delays for those TAs where there is a significant service commissioning component. If such delays continue, there is potential for the issue to escalate from the current low risk Summary of action being taken to address these Gaps In April 2009 the NICE Commissioning College TAG Review Group issued guidance regarding expectations of Trusts for auditing NICE guidance. The Chair of the Trust s Clinical Audit Committee has since written to the Chair of the NICE College TAG Review Group seeking clarification on a number of points. This letter has been discussed by the TAG Review Group and a formal response is currently awaited. In principle however, we have agreed to focus on NICE TAG audits identified as priorities by the Review Group, and to provide copies of the relevant audit summary reports once these have received Divisional approval. Chair of Clinical Effectiveness Committee is also due to attend Clinical Audit Committee in November to discuss this and related matters. TA166 Hearing impairment - cochlear implants (Jan 2009) The paediatric service is provided at UHBristol and the adult service by North Bristol NHS Trust. The Trust presented a costed implementation plan for an enhanced paediatric service to the NICE College in good time, but the PCTs delayed agreement until there can be Bristol-wide agreement that addresses all patients. Scheduled for in-year approval at the November NICE College. TA160/161 Osteoporosis primary and secondary prevention (Oct 2008) Key to fully implementing this TA is adequate DEXA scanning provision across Bristol. UHBristol provides limited DEXA scanning from the BRI Rheumatology Dept and (direct access) via Radiology. There have considerable delays in agreeing a pan-bristol approach to increased DEXA provision, which is now been taken forward by specialist commissioning. Timescale Autumn 2009 Autumn 2009 Winter 2009? Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale Page 2 of 3 Page 93

94 None Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period The NICE College is tracking the budgetary forecast outturn as a means to identifying those TAs where implementation costs are less than anticipated as detailed in agreed implementation plans. The Implementing NICE Guidance Policy has been updated (v3.1) to be in line with NHSLA standards. The policy was passed by NHSLA at their September inspection visit. The Clinical Effectiveness Committee now reports quarterly to the Governance & Risk Management Committee, providing a summary of committee actions relating to NICE guidance implementation Please comment on any other issues relevant to this Standard not covered above Page 3 of 3 Page 94

95 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 5b - Clinical care and treatment are carried out under supervision and leadership Healthcare organisations ensure that clinical care and treatment are carried out under supervision and leadership Executive Lead J Sheffield Operational Lead P Hall Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) Following the average grading of C in Ophthalmology and Radiology in the NHSLA Supervision Score ( PMETB Survey), training and issues raised have been reviewed and addressed. A Specialty and Associate Specialist (SAS) Tutor has been appointed and an SAS Committee and Away Day programme established. No. of Internal No. of individual noncompliant Internal 47 No. of External 0 No. of individual noncompliant External 8 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) National Health Service Litigation Authority Supervision Score from PMETB Trainee Survey Page 1 of 2 Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Annual Programme Overall Grading Anaesthetics B Emergency Medicine A General Practice B Medicine B Obstetrics and Gynaecology A Ophthalmology C Paediatrics B Pathology B Page 95 October 2008 PGME Annual Report

96 Health Care Commission Staff Survey Number of staff undergoing Appraisal Psychiatry A Radiology C Surgery B Annual Board Report 2008 Annual See Standard 11c Current Gaps in the Assurance Framework None Summary of action being taken to address these Gaps Timescale Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period Specialty and Associate Specialist (SAS) Tutor appointed SAS Away Day programme implemented SAS Committee established Please comment on any other issues relevant to this Standard not covered above Page 2 of 2 Page 96

97 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 5c - Clinicians continually update skills and techniques relevant to their clinical work Healthcare organisations ensure that clinicians continuously update skills and techniques relevant to their clinical work. Executive Lead J Sheffield Operational Lead P Hall Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The Simulation Centre is now fully integrated within UH Bristol. All skills based training is situated under one common service to include PGME and Simulation Centre. The aim is to make access to simulation based training easier to all trainees and other multiprofessionals. Introduction of 360º Multi-Source Feedback for all consultants, Staff Grade and Associate Specialist Medical Staff to identify performance strengths of individuals. No. of Internal No. of individual noncompliant Internal 33 No. of External 0 No. of individual noncompliant External 6 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Is this KPI Annual / quarterly / monthly / other? Appraisal compliance See Standard 11c Professional Registration compliance See Standard 10a Statutory and Mandatory Training See Standard 11b Most recent measurement of performance against KPIs Date if action being taken Current Gaps in the Assurance Framework None Summary of action being taken to address these Gaps Timescale Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Page 1 of 2 Page 97

98 Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period Introduction of 360º Multi-Source Feedback Please comment on any other issues relevant to this Standard not covered above Page 2 of 2 Page 98

99 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 5d Clinical Audit (and other forms of service review) Healthcare organisations ensure that clinicians participate in regular clinical audit and reviews of clinical services. Executive Lead J Sheffield Operational Lead C Swonnell Group Clinical Audit Committee Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possible Estimated Risk to Compliance for remainder of 2009/10 Very Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) Clinical Audit: The Trust has well established systems for supporting and monitoring clinical audit activity. We participate in the vast majority of relevant national clinical audits, including all relevant national audits sponsored by the Healthcare Quality Improvement Partnership (previously the Healthcare Commission). The Trust received a runner-up award in the national Clinical Audit Programme of the Year national awards for 2008/9 (awarded April 2009). The Trust s failure to meet data submission requirements for the British Cardiovascular Society Intervention Audit for two successive years is a major disappointment, however the view of the Clinical Audit Committee is that the breach for 2008/9 was a technical one (see below) and not material in respect of compliance with Core Standard C5d. Other service review: The Trust participates in all relevant National Confidential Enquiry studies; mortality & morbidity meetings take place in Divisions; there is a programme of LEAN / service improvement activity; clinical guideline development activity; root cause analysis following patient safety incidents; a system for dealing with Serious Untoward Incidents; extensive Research & Development portfolio. Also recent agreement between R&D and Governance Team to establish system to improve governance of service evaluation activity. No. of Internal No. of individual noncompliant Internal 27 No. of External 0 No. of individual noncompliant External 6 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Proportion of clinical audit projects where a project report has been completed Number of stalled projects (i.e. with no evidence of progress across four Page 1 of 3 Is this KPI Annual / quarterly / monthly / other? Quarterly target = 100% Most recent measurement of performance against KPIs Date if action being taken 83% (April, 85%) September 2009 Quarterly 12 (April, also 12) September 2009 Page 99

100 previous quarters / reporting periods) Proportion of audit projects with multi-professional involvement There is registered clinical audit activity in all major clinical specialties Number of registered clinical audit projects Proportion of re-audits included in overall clinical audit Number of abandoned audit projects Quarterly target = 40% 38% (April, 40%) September 2009 Quarterly (in effect, September whenever CAC meets) 2009 Annual 432 in 2008/9 (451 in 2007/8) April 2009 Annual target = 25% Annual target = zero 24% in 2008/9 (24% in 2007/8) April in 2008/9 (27 in 2007/8) (indicator relates to a concern raised by Audit & Assurance Committee) April 2009 Current Gaps in the Assurance Framework Summary of action being taken to address these Gaps Timescale Clinical Audit: Poor Annual Health Check outcomes for British The Data Manager / Analyst for Cardiac Services continued to be on long-term sick Autumn 2009 Cardiovascular Society Intervention Audit 2007/8 leave through the early part of 2009/10, and has since left the Trust. This gap is and 2008/9. recorded on the Specialised Services Risk Register. Cover for absence has been 2007/8: Trust underachieved re. completeness of data - missed 90% target for completion of mandatory 'patient history' data field. 2008/9: Trust failed to submit small sub-set of data provided by the Trust s Clinical Audit Manager, supporting the Data Manager s team in Specialised Services. Specialised Services Division is currently developing plans to replace this function (F Jones will complete this work, despite recent appointment to BHOC). covering five indicators for patients undergoing primary angioplasty. The same data had been submitted as part of the MINAP national cardiac audited, however this remains a technical failure Note: not formally listed as a non-compliant evidence item as this was a technical breach and also relates to the financial year 2008/9. and has the potential to impact on the Trust s Annual Health Check outcome. Review of CQC cross-checking data has highlighted that the Trust is not currently submitting data to the National Joint Registry. CQC Engagement in Clinical Audit indicator. The detail of this indicator was updated by the CQC in August The Trust remains compliant with the indicator overall, however there are two aspects requiring attention. Clinical Audit Manager is in discussion with relevant Divisional leads. The Trust is currently submitting data to the National Hip Fracture Database and Surgical Site Infection data. It may also be possible to upload the relevant cases to the NJR. Action is required to ensure that the results of national clinical audits are reviewed at relevant Trust meetings, and that there is an audit trail to demonstrate this. This information will form part of future reporting to the Clinical Audit Committee. This has been a focus for Clinical Audit staff since April The Trust s National Audit Register is in the process of being redesigned to make it easier to record evidence of local review. The Trust will need to produce a formal Clinical Audit Strategy for An interim Strategy will also be required for 2009/10 this will be based on existing improvement plans for the year. December 2009 January 2010 November 2009 Need to clarify accountability and expectations for In April 2009 the NICE Commissioning College TAG Review Group issued guidance Autumn 2009 Page 2 of 3 Page 100

101 auditing NICE guidance Explore opportunities for engaging Trust membership in clinical audit Other service review Review of mortality and morbidity arrangements regarding expectations of Trusts for auditing NICE guidance. The Chair of the Trust s Clinical Audit Committee has since written to the Chair of the NICE College TAG Review Group seeking clarification on a number of points. This letter has been discussed by the TAG Review Group and a formal response is currently awaited. In principle however, we have agreed to focus on NICE TAG audits identified as priorities by the Review Group, and to provide copies of the relevant audit summary reports once these have received Divisional approval. Chair of Clinical Effectiveness Committee is also due to attend Clinical Audit Committee in November to discuss this and related matters. This aspiration remains outstanding from 2008/9. September - the Clinical Audit Manager has been tasked with taking this piece of work forward. The Medical Director is leading a review of this policy as part of the development of a new Quality Framework/Strategy. March 2010 To be agreed Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None currently (but see note re cardiac national datasets) Other current entries on the Assurance Framework Action Plan Review Clinical Audit Policy in light of new national guidance from the Healthcare Quality Improvement Partnership (published September 2009) Timescale November 2009 Details of any significant new controls or assurances added during this reporting period A UHBristol-led partnership has been awarded a contract by the Healthcare Quality Improvement Partnership to develop clinical audit policy and strategy documentation for NHS-wide use (published September 2009) A formal programme of Trust-wide audit projects has been developed for 2009/10 (overseen by the Chair of Clinical Audit Committee and the Trust s Clinical Audit Manager) The Trust s Clinical Audit Manager has devised a way of generating summary clinical audit projects reports from the corporate database for the first time, these reports provide key project results and outcomes in a format which can easily be digested by assurance committees. Clinical Audit Committee is now reporting to the Governance & Risk Management Committee following a recommendation from an internal audit of integrated governance arrangements. The Trust received a runner-up award in the national Clinical Audit Programme of the Year national awards for 2008/9 (awarded April 2009). Please comment on any other issues relevant to this Standard not covered above The Clinical Audit Manager is currently working to ensure that all clinical Divisions have appropriate arrangements in place to formally review and approve clinical audit summary reports before they are sent to the Governance & Risk Management Committee (and potentially onwards to commissioners in the future). The Audit Commission report Taking it on Trust has highlighted the need for greater Board-level engagement in clinical audit. The Healthcare Quality Improvement Partnership will also shortly be publishing clinical audit guidance for Trust Boards. The Chair of the Trust s Audit & Assurance Committee attended Clinical Audit Committee in September 2009 to advance a developing dialogue about the contribution of clinical audit to the management of key corporate risks. The Healthcare Quality Improvement Partnership will shortly be issuing a good practice guide for clinical audit, the results of which may inform the development of future KPIs. Page 3 of 3 Page 101

102 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 6 Discharge and Transfer of Care Healthcare organisations cooperate with each other and social care organisations to ensure that patients individual needs are properly managed and met. Executive Lead R Woolley Operational Lead S Clark Group Trust Operational Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) Good assurance of a compliant position. Evidence includes audit, patient information, Trust policies and links with external agencies, i.e. Bristol Intermediate and Long-Term Care Service Development Group (BILSDG). This Standard has been designated as Low risk as opposed to Very Low because the quarterly Partnership evaluation process indicates that the Bristol Intermediate Care Group is currently not producing significant impact on service delivery. This has the potential to impact on service delivery due to variable funding streams of health and social and community care. No. of Internal No. of individual noncompliant Internal 10 No. of External 0 No. of individual noncompliant External 2 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Acute delayed transfers of care below 1% The Provider shall issue the Patient's Discharge summary to the Patient's GP within 72 hours from 1st December 08 Minimum NHS Litigation Authority Level 1 compliance Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Monthly 0.94% August 2009 Will be monthly Measurement not available due to delay in implementing software to measure performance. Every 2 years NHSLA assessment undertaken in September 2009 Transfers of Care and Discharge compliant. September 2009 Page 1 of 2 Page 102

103 Current Gaps in the Assurance Framework Co-ordination of PALS, Complaints & other patient experience data in relation to discharge and transfer of care. Issue of discharge summaries to patient s GP within 72 hours. Summary of action being taken to address these Gaps A Joint Working Group has been established which links up feedback from PALS/Complaints/Legal/Health and Safety and Clinical Risk. It meets 6 monthly and reports into the Governance and Risk Management Committee. Reporting across PALS and Complaints has been brought together in an enhanced integrated quarterly report to the Governance and Risk Management Committee. Ulysses update now contains functionality to produce thematic reporting. Project plan to progress thematic reporting across further feedback mechanisms still to be finalised. Electronic System has been procured and software being prepared. Pilot will be undertaken on Wards 10 and 12. Timescale - March 2010 Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period None Please comment on any other issues relevant to this Standard not covered above Page 2 of 2 Page 103

104 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 7a&c Governance Healthcare organisations apply the principles of sound clinical and corporate governance and undertake systematic risk assessment and risk management. Executive Lead A Moon Operational Lead A Reader Group Governance and Risk Management Committee Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possible Estimated Risk to Compliance for remainder of 2009/10 Low- Possible pending Head of Internal Audit opinion on 2009/10 SIC after year end. Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The systems for both corporate and clinical governance have a good evidence base with a substantial amount of both internal and external assurance. An internal audit on integrated governance, April 2009, provided reasonable assurance with recommendations for some improvements which are due for completion by the end of the financial year. The Head of Internal Audit opinion for 2008/09 was given as significant assurance on the Trust s statement of Internal Control for 2008/09, with some recommendations for improvement in use of the Trust s assurance framework for 2009/10. During 2009/10 the existing corporate governance systems are being further developed and strengthened with a plan to mirror this within divisions in the future. An internal audit on risk management arrangements, August 2009, has informed this wider governance review. The Trust has been risk rated as green for governance by Monitor both in the Annual Risk Rating and in the Quarter /10 risk rating. The Trust was re-assessed under the NHSLA Acute General Standards for Level 1 in September 2009 and passed. No. of Internal No. of individual noncompliant Internal 28 No. of External 2 No. of individual noncompliant External 12 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Page 1 of 3 Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken National Health Service Litigation At least two yearly. Trust achieved Level 3 compliance with the Maternity February Page 104

105 Authority Standards and Assessment Standards under the NHSLA in 2007/2008. Pilot Assessment undertaken in November 2008 against new standards not achieved. Full Assessment at Level 3 planned for February The Trust was re-assessed under the NHSLA Acute General Standards for Level 1 and passed. On receipt of the full report, the Trust will consider the timeframe to achieve Level 2 compliance and interim NHSLA Assessment at Level 2 Monitor Governance Risk Ratings Quarterly The Trust has been risk rated as green for governance by Monitor both in the Annual Risk Rating and in the Quarter /10 risk rating. September 2009 August 2009 Current Gaps in the Assurance Framework Internal Audit Report Tendering of Contracts a number of recommendations relating to tendering receipt and security arrangements generally were highlighted Framework for Risks Associated with use of External Contracts/ Service Level Agreements 2006 needs assessment of compliance and review. Summary of action being taken to address these Gaps A follow up audit report was presented to Audit & Assurance Committee in June 2009 which reported that the recommendations relating to areas other than the Estates Department had been implemented. There were still a number of weaknesses in the operation of routine procedures for tendering and contracting which still existed within the Estates Department. These are being followed up by the Chief Operating Officer. The framework document requires updating and assessment of compliance. Work yet to commence on this. Timescale March January Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period The Trust has been risk rated as green for governance by Monitor both in the Annual Risk Rating and in the Quarter /10 risk rating. Please comment on any other issues relevant to this Standard not covered above Identification of a Governance Team link person and support / advisor to Divisions to be put on hold until new Director of Governance appointed Details of any non-compliant evidence items relevant to the current year 2009/10: (please reproduce the boxes below for each individual item ) Evidence item: No systematic electronic system to ensure that staff are aware of the policies they need to adhere to and any updates. This gap exists in all trusts but was highlighted in the Toft and Gritten Reports. Reason for non-compliance This issue was highlighted in the Toft and Gritten Reports. judgement: Page 2 of 3 Page 105

106 Actions being taken: If an assessment of significant lapse was done please attach: Is it a significant lapse?: An action plan has been developed in tandem with the procurement of a new electronic policy system for implementation in 2009/2010. This has been mitigated in part with the recently updated Document Control Policy which complied with NHSLA standards at Level 1. This project will become part of the Trust s Transformation Programme. Was one done? No No Page 3 of 3 Page 106

107 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 7b Openness and Honesty Healthcare Organisations actively support all employees to promote openness, honesty, probity, accountability, and the economic, efficient and effective use of services. Executive Lead S Aumayer Operational Lead R Ridsdale Group Strategic Development Trust Executive Group Risk Management Governance and Risk Management Committee Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The Trust actively supports all employees to promote openness, honesty, probity, accountability and the economic, efficient and effective use of resources. The Trust has in place robust policies and procedures on incident reporting, speaking out and complaints and has reaffirmed these messages through payslips. Estimated risk to compliance for remainder of 2009/2010 remains Low rather than Very Low because of no change to proportion of staff aware of how to raise concerns (staff attitude survey score). Activities within this assurance framework continue to be reviewed and monitored. There have been no material changes effecting compliance for this Standard. No. of Internal No. of individual noncompliant Internal 15 No. of External 0 No. of individual noncompliant External 9 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Increase proportion of staff reporting awareness of how to raise concerns by 5% by year end (measured by change in staff attitude survey score) Maintain compliance with Management of Health and Safety at Work regulations and all other related legislation Page 1 of 2 Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Annual Annual check reported in March (March 2009 with 2008 data) March 2009 Annual Progress report annually as part of ongoing 5 year plan Ongoing Page 107 Action Plan to TOG to include Loud & Clear and Patient Survey results

108 Monitor outcome of Compound Indicators testing of Counter Fraud Annual Work Plan Annual Annual check reported in October 2008 for 2007/8 had outcome of Level 2 (adequate) Compound Indicator Declaration for 2009 submitted April 2009 October 2008 Report due Autumn 2009 Current Gaps in the Assurance Framework None Summary of action being taken to address these Gaps Timescale Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan Action - Logging of return of signed contracts to be included in quarterly controls assurance (see above) Timescale Details of any significant new controls or assurances added during this reporting period Logging of return of signed contracts for all staff included on Local Orientation Checklist as more efficient method of reporting Please comment on any other issues relevant to this Standard not covered above In order to comply more completely with the revised elements within the Standard, a detailed review of the KPIs will be conducted in Quarter 4 (January-March 2009) for effect in Quarter 1 (April-June 2009). Ongoing Page 2 of 2 Page 108

109 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 7e Equality Healthcare organisations challenge discrimination, promote equality and respect human rights. Executive Lead S Aumayer Operational Lead R Ridsdale Group Equality Diversity Steering Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Moderate Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The Trust has systems and assurances in place to challenge discrimination, promote equality and respect human rights. There is currently insufficient assurance of compliance with equalities legislation, however, training in completion of Equality Impact Assessments provided to 93 managers in June All policies/procedures currently under revision include Equality Impact Assessment Screening Forms as standard. Moderate risk to compliance due to continuing low numbers of completed Equality Impact Assessments and lack of emphasis on Equality and Diversity as part of Trust communications processes. The estimated risk has been amended from Low to Moderate because of insufficient increase in numbers of completed Equality Impact Assessments since the last declaration, and emphasis on their importance in CQC Assessment Criteria. It is considered that this does not effect overall compliance for this standard. No. of Internal No. of individual noncompliant Internal 34 No. of External 0 No. of individual noncompliant External 12 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Monitor Single Equality Scheme and report to Board on six monthly basis Ensure new equality and diversity online training shows a 5% increase bi-monthly throughout Is this KPI Annual / quarterly / monthly / other? Six-monthly Bi-monthly Most recent measurement of performance against KPIs Date if action being taken Report and Action Plan from Equality & Diversity Steering Group to Trust Board in March and September Outstanding actions listed below. Mandatory nature of training agreed by TOG in November 2008 and Equality & Diversity Steering Group in December Progress report due end of February Incomplete reporting through 2008/2009. Further report due March 2010 Ongoing More robust reporting system in place for 2009/2010 Page 1 of 2 Page 109

110 Current Gaps in the Assurance Framework Equality Impact Assessments (EIAs) need to be in place for all Trust services, policies and functions. Lack of emphasis on Equality & Diversity as part of Trust communications processes Summary of action being taken to address these Gaps 1. Training provided to owners of services, policies and functions. 2. HR policies due for revision in 2009 will include EIAs as part of the revision process Timescale June 2009 & ongoing Ongoing through 2009 Greater Trust-wide drive to embed Equality & Diversity in all Trust activities and areas. Ongoing from October 2009 Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale Compliance with Equalities Legislation entered as risk on Corporate Risk Register External training provided in June All Divisions required to map services, functions, policies to prioritise completion of assessment, including consultation and involvement with external partnerships. Conduct training needs analysis to ensure all Equality & Diversity training requirements are met. In addition, funding is being sought from Charitable Trustees to support the activity. Ongoing Other current entries on the Assurance Framework Action Plan Single Equality Scheme Action 1 Increase resources for translating and interpreting requests. Scope how existing employees interpretation levels can be captured 2 Implement recommendations from Maternity & Newborn Services Review to train midwives to provide more contraceptive advice 3 Map areas where recording the sexual orientation of patients will be undertaken & introduce monitoring & evaluation systems 4 Scope men s health services across areas. Identify specific issues and make recommendations to Divisional & Trust Boards 5 Scope and review barriers to employment of young people (under 18) and develop guidance for recruiting managers 6 Scope and review Diabetes provision, particularly among young Somalians. 7 Review percentage of staff, by equality strands, undertaking research in Divisions. Explore opportunities for research areas relating to Single Equality Scheme Timescale December 2009 (revised) Training halted for capacity reasons To be confirmed December 2009 onwards December 2009 Halted. No funding for link worker November 2009 Details of any significant new controls or assurances added during this reporting period Training in completion of Equality Impact Assessments provided to managers June 2009 Developing relationship with Bristol City Council Multi Faith Forum Equality & Diversity policies & procedures of suppliers required as part of Procurement pre-qualification assessment Please comment on any other issues relevant to this Standard not covered above None Page 2 of 2 Page 110

111 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 8a Raising Concerns Healthcare organisations support their staff through having access to processes which permit them to raise, in confidence and without prejudicing their position, concerns over any aspect of service delivery, treatment or management that the consider to have a detrimental effect on patient care or on the delivery of services. Executive Lead S Aumayer Operational Lead R Ridsdale Group Strategic Development Trust Executive Group Risk Management Governance and Risk Management Committee Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The Trust has policies, controls and assurances in place to ensure that staff can raise concerns. Employment Contracts contain reference to the Trust s Speaking Out Policy and an awareness raising exercise was carried out in February Issues arising from the annual NHS Staff Survey are monitored. The Tackling Bullying & Harassment at Work Policy underlines the Trust s support for members of staff raising concerns, and an awareness raising leaflet was distributed to all staff in June Estimated risk to compliance for remainder of 2009/2010 remains Low rather than Very Low because of no change to proportion of staff aware of how to raise concerns (staff attitude survey score). Activities within this assurance framework continue to be reviewed and monitored. There have been no material changes effecting compliance for this standard. No. of Internal No. of individual noncompliant Internal 14 No. of External 0 No. of individual noncompliant External 16 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Percentage reporting awareness of how to raise concerns increased by 5% by year end (measure is change in annual staff attitude survey) Ensure all policies in place to provide staff support Page 1 of 2 Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Annual Annual check reported in March (March 2009 with 2008 data) No change reported. Two-yearly review of policies Review of HR policies started January 2009 Page 111 March 2009 ongoing through 2009 Action Plan to TOG to include Loud & Clear and Patient Survey results

112 Monitor outcome of Compound Indicators testing of Counter Fraud Annual Work Plan Annual Annual check reported in October 2008 for 2007/8 had outcome of Level 2 (adequate) Compound Indicator Declaration for 2009 submitted April 2009 Annual Report due Autumn 2009 Current Gaps in the Assurance Framework None Summary of action being taken to address these Gaps Timescale Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan Use feedback from NHS Staff Survey to highlight issues about staff feeling able to raise concerns. Timescale Ongoing Details of any significant new controls or assurances added during this reporting period Awareness raising exercise around Child Protection and Protection of Vulnerable Adults conducted September 2009 (leaflets with payslips) Stop Bullying leaflet to all staff with payslips June 2009 Please comment on any other issues relevant to this Standard not covered above Page 2 of 2 Page 112

113 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 8b Organisational/Personal Development Healthcare organisations support their staff through organisational and personal development programmes which recognise the contribution and value of staff, and address, where appropriate, under-representation of minority groups. Executive Lead S Aumayer Operational Lead S Bennett Group Teaching and Learning Strategy Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Moderate Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The Trust is committed in its Teaching and Learning Strategy to supporting personal development of staff and the overall development of the organisation. The NHS Staff Survey for 2008 showed that UH Bristol is above average for acute trusts in questions relating to appraisal, support from managers and agreed personal development plans. The estimated risk has been amended from Low to Moderate because of insufficient improvement in monitoring of training accessed by minority groups. It is considered that there have been no material changes effecting overall compliance for this Standard. No. of Internal No. of individual noncompliant Internal 22 No. of External 0 No. of individual noncompliant External 14 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Achieve a 5% increase in compliance with new equality and diversity on-line training every two months throughout 2008/9 Appraisal and Personal Development Plan compliance rate to have increased to 80% by end of November 2008 Increase % of all staff receiving jobrelevant training, learning or Page 1 of 2 Is this KPI Annual / quarterly / monthly / other? Bi-monthly target throughout financial year 2008/9 Most recent measurement of performance against KPIs Date if action being taken Mandatory nature of training agreed by TOG in November 2008 and Equality and Diversity Steering Group in December Progress report due end of February 2009 Incomplete reporting through 2008/2009. Being monitored monthly 72% reported to Trust Board on 2nd December % achieved Trust-wide April September 2009, except for May (78.7%). 86.4% achieved September 2009 Annual staff attitude survey Annual check reported in March (March 2009 with 2008 data) Page 113 Ongoing Ongoing March 2009 More robust reporting system in place for 2009/2010

114 development in previous 12 months by 2% Current Gaps in the Assurance Framework Reporting/monitoring of training accessed by minority groups 2008 Survey results show increase of 4%, from 78% to 82% Summary of action being taken to address these Gaps Reporting system under review. Monitoring to be undertaken on completion of system review and implementation. Any under-representation to be addressed by action plan following appropriate period of monitoring. Timescale Autumn 2009 Spring 2010 Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan Work on addressing disability is ongoing through the Disability Staff Forum and Training & Development initiatives. Timescale Ongoing Details of any significant new controls or assurances added during this reporting period None Please comment on any other issues relevant to this Standard not covered above Equal Opportunities questionnaire for corporate management development devised December 2008 for use from January To be used for Corporate Induction from April Attendance at Induction recorded on Oracle Learning Management. Reporting system under review. In order to comply more completely with revised elements within the Standard, a detailed review of the KPIs will be conducted in Quarter 4 (January March 2009) for effect in Quarter 1 (April June 2009). Ongoing Page 2 of 2 Page 114

115 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 10a Recruitment and Employment Checks Healthcare organisations undertake all appropriate employment checks and ensure that all employed or contracted professionally qualified staff are registered with the appropriate bodies. Executive Lead S Aumayer Operational Lead D Tunnell Group Strategic Development Trust Executive Group Risk Management Governance and Risk Management Committee Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The Trust undertakes all appropriate employment checks on staff. In addition to the NHS Employment Check standards, the Trust has documentation and systems in place to cover recruitment and criminal records checks. There is also a robust controls system in place to check and report on professional registration and any Critical Employment Incidents in respect of these areas. Detailed assurances were provided for the year end 2008/09 declaration in response to concerns raised by the Governance & Risk Management Committee in respect of the negative audit report. The estimated risk has been amended from Very Low to Low because of a sustained low risk to consistency in the application of the controls around Employment Check Standards. In response, schedules have been established to undertake local audits of recruitment processes and files, and the provision of ongoing training for staff involved in recruitment. It is anticipated that these schedules will enhance the levels of assurance for this Standard, otherwise there have been no material changes. No. of Internal No. of individual noncompliant Internal 28 No. of External 0 No. of individual noncompliant External 7 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Compliance with new NHS Employment Check Standards for recruitment Page 1 of 2 Is this KPI Annual / quarterly / monthly / other? Ongoing (every application & interview as appropriate) Most recent measurement of performance against KPIs Date if action being taken Personal file checklist states appropriate checks carried out & copies of all documentation included in personal file Ongoing Professional registration is at 100% Monthly Compliance at an average of 98.8% for March June Ongoing A dip in April was caused by NMC website problems. Effectiveness of local reviews, audits and training Quarterly Feedback from local audits and training sessions Ongoing Page 115

116 Current Gaps in the Assurance Framework Compliance with new Employment Check Standards including qualification checks - audit requested and undertaken. Audit report graded 3 (limited assurance) due to inconsistency in the application of the controls. Summary of action being taken to address these Gaps Action Plan in place to address and rectify points raised. Timescale Ongoing Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period Internal Audit report on Pre-Employment checks graded 3 (limited assurance) received March Insufficient Assurance on this control. A schedule of local audits, reviews and training in place since June 2009 to address the limited assurance. These cover all Trust recruitment functions. Roll out of Vetting & Barring Scheme commencing Oct 2009 in line with National implementation. Please comment on any other issues relevant to this Standard not covered above Review of KPIs to be conducted in Quarter 4 (January March 2009) for effect in Quarter 1 (April June 2009). Reviewed Sept 2009 Page 2 of 2 Page 116

117 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 10b Codes of Professional Practice Healthcare organisations require that all employed professionals abide by relevant published codes of professional practice. Executive Lead S Aumayer Operational Lead R Ridsdale Group Strategic Development Trust Executive Group Risk Management Governance and Risk Management Committee Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The Trust has policies and systems in place to ensure professional staff abide by relevant codes of professional practice. This Standard was inspected and assessed as compliant by the Healthcare Commission in June Activities within this assurance framework continue to be reviewed and monitored. There have been no material changes effecting compliance for this Standard. The estimated risk has been amended from Very Low to Low because of the sustained low risk associated with employment contracts outstanding over 8 weeks. This is being addressed by an ongoing drive to reduce numbers, supported by a revised process. No. of Internal No. of individual noncompliant Internal 18 No. of External 0 No. of individual noncompliant External 5 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Professional registration is at 100% Monthly Compliance at an average of 98.8% for March June A dip in April was caused by NMC website problems. All employment contracts are issued within a maximum of 8 weeks Increase Appraisal compliance to 80% by end November 2008 Monthly Not compliant during the period October December 2008, although numbers reduced from 71 to 9. Action plan has resulted in number of contracts outstanding over 8 weeks for permanent staff being reduced to 5 by early September 2009 Being monitored monthly 72% reported to Trust Board on 2nd December % achieved Trust-wide April September 2009, except for May (78.7%). 86.4% achieved September 2009 Ongoing Ongoing Ongoing Page 1 of 2 Page 117

118 Current Gaps in the Assurance Framework None Summary of action being taken to address these Gaps Timescale Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale Employment contracts outstanding over 8 weeks (Low) Sustained low risk Drive to reduce numbers ongoing. Significant reduction in backlog in reporting period. New process for issuing contracts agreed January 2009 & being rolled out February 2009 New process has succeeded in reducing numbers as detailed above Ongoing Other current entries on the Assurance Framework Action Plan Appraisal - updates to TOG every month Review of relevant evidence following inspection and updating of Ulysses by end of February 2009 Review of existing data and controls, especially for breeches to codes of professional conduct ongoing monthly Timescale Ongoing Ongoing Ongoing Details of any significant new controls or assurances added during this reporting period None Please comment on any other issues relevant to this Standard not covered above Standard assessed as compliant by Healthcare Standards random inspection in June 2008 (reported September 2008) Page 2 of 2 Page 118

119 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 11a Recruitment Training Healthcare organisations ensure that staff concerned with all aspects of the provision of healthcare are appropriately recruited, trained and qualified for the work they undertake. Executive Lead S Aumayer Operational Lead D Tunnell Group Strategic Development Trust Executive Group Risk Management Governance and Risk Management Committee Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) In addition to NHS Employment Check Standards, the Trust has systems in place to ensure that all staff are recruited appropriately, trained and qualified for the work they undertake. These are supported by the Trust s Recruitment Policy and attendant guidance and checked through the monthly controls report for appropriate professional registration. Detailed assurances were provided for the declaration for Standard 10a in year end 2008/09 in response to concerns raised by the Governance & Risk Management Committee in respect of the negative audit report. The estimated risk has been amended from Very Low to Low because of a sustained low risk to consistency in the application of the controls around Employment Check Standards. In response, schedules have been established to undertake local audits of recruitment processes and files, and the provision of ongoing training for staff involved in recruitment. It is anticipated that these schedules will enhance the levels of assurance for this Standard, otherwise there have been no material changes. No. of Internal No. of individual noncompliant Internal 27 No. of External 0 No. of individual noncompliant External 13 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Increase % of staff receiving jobrelated training, learning or development in previous 12 months by 2% Employment contracts are issued within a maximum of 8 weeks Page 1 of 2 Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Annual - staff survey Annual check reported in March (March 2009 with 2008 data) 2008 Survey results show increase of 4%, from 78% to 82% Monthly Not compliant during the period October December 2008, although numbers reduced from 71 to 9. Action plan has resulted in number of contracts outstanding over 8 weeks for permanent staff being reduced to 5 by Page 119 March 2009 Ongoing

120 Compliance with new NHS Employment Check Standards for recruitment Ongoing (every application & interview as appropriate) early September Personal file checklist states appropriate checks carried out & copies of all documentation included in personal file Ongoing Effectiveness of local reviews, audits and training Quarterly Feedback from local audits and training sessions Ongoing Professional registration is at 100% Monthly Compliance at an average of 99.7% for October December 2008 Ongoing Current Gaps in the Assurance Framework Compliance with new Employment Check Standards including qualification checks - audit requested and undertaken. Audit report graded 3 (limited assurance) due to inconsistency in the application of the controls. Summary of action being taken to address these Gaps Action plan in place to address and rectify points raised Timescale Ongoing Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale Employment contracts outstanding over 8 weeks (Low) Sustained low risk. Drive to reduce numbers ongoing. Significant reduction in backlog in reporting period. New process for issuing contracts agreed January 2009 & being rolled out February 2009 New process has succeeded in reducing numbers as detailed above. Ongoing Other current entries on the Assurance Framework Action Plan Training compliance monitored and reported to TOG monthly Timescale Ongoing Details of any significant new controls or assurances added during this reporting period Internal Audit report on Pre-Employment checks graded 3 (limited assurance) received March Insufficient Assurance on this control. A schedule of local audits, reviews and training in place since June 2009 to address the limited assurance. These cover all Trust recruitment functions. Roll out of Vetting & Barring Scheme commencing Oct 2009 in line with National implementation. Please comment on any other issues relevant to this Standard not covered above In order to comply more completely with revised elements with the Standard, a detailed review of the KPIs will be conducted in Quarter 4 (January March 2009) for effect in Quarter 1 (April June 2009). Reviewed Sept 2009 Page 2 of 2 Page 120

121 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 11c Professional Development Healthcare organisations ensure that staff concerned with all aspects of the provision of healthcare participate in further professional and occupational development commensurate with their work throughout their working lives. Executive Lead S Aumayer Operational Lead S Bennett Group Governance and Risk Management Committee Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) Staff participate in professional development and role development throughout the course of their employment with the Trust. The Postgraduate Medical Education & Training Board and the Severn Institute report on aspects of professional development for doctors training. The Trust s Appraisal Policy and practice includes personal development which is supported by the Trust s Training Plan. Activities associated with this Standard continue to be reviewed and monitored. There have been no material changes effecting compliance. The estimated risk has been amended from Very Low to Low because of concern over the ability to produce sound evidence to substantiate comparable development opportunities being provided to all staff. No. of Internal No. of individual noncompliant Internal 15 No. of External 0 No. of individual noncompliant External 4 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Increase % of staff receiving jobrelevant training, learning or development in previous 12 months by 2% Increase Appraisal compliance to 80% by end of Nov 2008 Is this KPI Annual / quarterly / monthly / other? Annual - staff attitude survey Most recent measurement of performance against KPIs Date if action being taken Annual check reported in March (March 2009 with 2008 data) 2008 Survey results show increase of 4%, from 78% to 82% Being monitored monthly 72% reported to Trust Board on 2nd December % achieved Trust-wide April September 2009, except for May (78.7%). 86.4% achieved September 2009 March 2009 Ongoing Page 1 of 2 Page 121

122 Current Gaps in the Assurance Framework None Summary of action being taken to address these Gaps Timescale Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan Ongoing rollout of KSF and application in Personal Development Plans. KSF Lead appointed September Project Plan being developed for end November Timescale Ongoing Details of any significant new controls or assurances added during this reporting period Development of career pathway for Nursing Assistants through Assistant Practitioner Programme Five non-clinical NVQs available to staff through City of Bristol College Please comment on any other issues relevant to this Standard not covered above In order to comply more completely with revised elements within the Standard, a detailed review of the KPIs will be conducted in Quarter 4 (January March 2009) for effect in Quarter 1 (April June 2009). Ongoing Page 2 of 2 Page 122

123 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 12 Research Healthcare organisations which either lead or participate in research have systems in place to ensure that the principles and requirements of the research governance framework are consistently applied. Executive Lead J Sheffield Operational Lead D Benton Group Governance and Risk Management Committee Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Very Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The Trust has research governance systems in place to ensure that all research can be recorded and approved by the Research and Development Department. All research is approved in accordance with the Research Governance Framework for Health and Social Care (External Assurance) and the Medicines for Human Use Clinical Trials Regulations (where relevant External Assurance). Internal assurances are in place for finance review and legal review of research contracts prior to Research and Development Department Approval. A risk-based monitoring programme is in place for research sponsored by University Hospitals Bristol and University of Bristol, and for hosted research. A Research & Development committee will be established by the end of January 2010; this has been agreed by the Trust Executive Group. Training for researchers in Good Clinical Practice has been made mandatory (every 3 years) and the course content and delivery have been modified to identify whether learning objectives are met by attendees. No. of Internal No. of individual noncompliant Internal 19 No. of External 0 No. of individual noncompliant External 7 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Provision of International Conference of Harmonisation Good Clinical Practice courses to UH Bristol research staff in year Page 1 of 3 Is this KPI Most recent measurement of performance against KPIs Date if action being taken Usually Course Date Trust Othe Total April to Sept 09 quarterly, but r 6 monthly PI Update figure (April April to Good Practice in Clinical September) Research May quoted in this 41 Page 123

124 Grant applications supported by the R&D office in year Number of projects approved in year Number of projects sponsored in year Number of projects monitored in year report. ICH GCP 14 July Totals 79 Usually 17 April to Sept 09 quarterly, but 6 monthly figure (April to September) quoted in this report. Usually 111 April to Sept 09 quarterly, but 6 monthly figure (April to September) quoted in this report. Usually 16 April to Sept 09 quarterly, but 6 monthly figure (April to September) quoted in this report. Usually 23 projects monitored April to Sept 09 quarterly, but 4 set-up support visits 6 monthly figure (April to September) quoted in this report. Current Gaps in the Assurance Summary of action being taken to address these Gaps Timescale Framework Monitoring of source data and entered data Monitoring Standard Operating Procedures to be updated. To be addressed by the newly May 2010 not currently done created R&D committee Key performance indicators not defined To be addressed by the newly created R&D committee. May 2010 R&D Committee not established To be established End of Jan 2010 Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Page 2 of 3 Page 124

125 Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period Redesign and delivery of Good Clinical Practice training, with more objective measurement of effectiveness Please comment on any other issues relevant to this Standard not covered above Page 3 of 3 Page 125

126 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 13a Treating Patients with Dignity and Respect Healthcare organisations have systems in place to ensure that staff treat patients, their relatives and carers with dignity and respect. Executive Lead A Moon Operational Lead H Morgan Group Trust Privacy and Dignity Steering Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possible Estimated Risk to Compliance for remainder of 2009/10 Very Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) A significant work programme is virtually complete across the Trust, including bathroom and toilet upgrades and upgrades to nightingale style wards along side early reviews of critical care, day case and emergency departments support a declaration of compliance. An overall improvement from the Patient Environment Action Team assessment in 2008, together with the latest Inpatient Survey results also supports this declaration. No. of Internal No. of individual noncompliant Internal 18 No. of External 0 No. of individual noncompliant External 3 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Page 1 of 2 Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken National Inpatient Survey results. Annual 70% given enough privacy when discussing condition/treatment 87% given enough privacy when being examined/treated 73% given enough privacy when examined/treated in ED 30% shared sleeping area with the opposite sex when first admitted (improved from 2007) 22% shared sleeping area when moved to another ward (improved from 2007) 79% overall were treated with respect and Dignity (national 79%) Page survey

127 PEAT assessment scores for Privacy and dignity NHS South West Mixed Sex Accommodation Standards 41% definitely found someone to talk to about worries and fears (national 41%) Annual Bristol Royal Infirmary - Good Bristol General Hospital Excellent St Michaels Hospital Excellent Bristol Eye Hospital Good Bristol Haematology and Oncology Centre Excellent Bristol Royal Hospital for Children - Good Works programme to ensure single sex accommodation within mixed wards programme virtually completed Bathroom and toilet upgrade programme to ensure single sex facilities Breech protocol and recording mechanisms implemented 2009 assessment 2009 Current Gaps in the Assurance Framework Aspects of poor practice identified via monthly reports from Patient Affairs and Mortuary staff relating to last offices and care of property Summary of action being taken to address these Gaps Timescale Reviewing Last Offices and property policies (via End of Life Steering Group) - ongoing October 2009 Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period Funding secured from the SHA A significant works programme is almost completed to ensure ward areas comply with standards. Pictorial signage now in place across the Trust, indicating male/female facilities Same-sex accommodation patient leaflet available Breech protocol now in place, with agreed reporting mechanisms. Discussions held with disposable curtain supplier to develop do not disturb printing on curtains Equipment screens installed in ED, to maximise patient privacy and dignity Please comment on any other issues relevant to this Standard not covered above An action plan relating to the work of the Privacy and Dignity Group is currently under review. Leadership and implementation through Head of Nursing Specialised Services Page 2 of 2 Page 127

128 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 13b Consent Healthcare organisations have systems in place to ensure that appropriate consent is obtained when required, for all contacts with patients and for the use of any confidential patient information. Executive Lead J Sheffield Operational Lead N Henderson Group Clinical Risk Assurance Committee Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possible Estimated Risk to Compliance for remainder of 2009/10 Very Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The key indicator of compliance with this Standard is National Health Service Litigation Authority (NHSLA) Risk Standards for Acute Trusts. The Trust is currently compliant at Level 1 following an Assessment in September Relevant NHSLA Standards: Consent this achieved compliance at the last NHSLA Assessment. Patient information this did not achieve compliance at the last NHSLA Assessment. Complaints - this achieved compliance at the last NHSLA Assessment. Claims - this achieved compliance at the last NHSLA Assessment. Detailed evidence spreadsheet (NHSLA format) is available from the Patient Safety Team and on Mildred Trust IT system No. of Internal No. of individual noncompliant Internal 3 No. of External 0 No. of individual noncompliant External 3 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Compliance with NHS Litigation Authority Risk Management Standard for patient consent Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Annual Currently accredited at Level 1 (scale 0-3). September Current Gaps in the Assurance Framework None Summary of action being taken to address these Gaps Timescale Page 1 of 2 Page 128

129 Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale 881 Appropriate delegation of consent to clinical staff. Low returns of completed competency assessments for junior medical staff. August Introduction of electronic monitoring tool and competency assessment with August induction of medical staff to improve compliance. This replaces manual paper system 2. Induction of all relevant trainee medical staff (surgical primarily) highlights need for appropriate delegation monthly reporting on compliance levels to Clinical Risk Assurance Committee ongoing next due January CRAC approval of policy amendments and notification of Consultant Medical Staff. 5. CRAC approval of delegated consent for specific procedures to commence. Established ENT nurse consent approved. Review April 09 Commenced 2004 Commenced 2007 Feb 2009 March 2009 Other current entries on the Assurance Framework Action Plan Case notes audit for 2010 to include staff identification by grade to ensure policy requirements on delegation of consent are followed obtaining patient consent as per Trust Policy Timescale By June 2010 Details of any significant new controls or assurances added during this reporting period Review of delegation of consent by trainee medical staff has lead to Trust Policy change and notification of relevant staff. Introduction of CRAC approval of delegation of consent should ensure staff are adequately prepared for the role and patients receive improved information as part of consent provision. Notification of change in process for permission of delegation of consent to trainee medical staff and nursing staff. Trust Clinical Risk Assurance Committee to approve departments and procedures for delegation of consent. Letter to Consultant Medical Staff. Trust Clinical Risk Assurance Committee to approve amendments to Policy. Consent breaches of policy are reported as clinical incidents. Please comment on any other issues relevant to this Standard not covered above Actions to address risk 881 are not demonstrating an improvement in returns of completed competency assessments. Agreed by CRAC in January 2009 (See CRAC/GRMC Patient Safety 1/4rly report Jan 2009) that they would implement a Trust Policy revision to prohibit delegation of consent. Risk 881 remains open at present but will close once CRAC are sufficiently assured that all the necessary notifications and changes have taken place to ensure employees are aware of the procedure not to delegate consent. Page 2 of 2 Page 129

130 University Hospitals Bristol NHS Foundation Trust Autumn Healthcare Standards Declaration 2009/10 Core Standard 14 Complaints a. Healthcare organisations have systems in place to ensure that patients, their relatives and carers have suitable and accessible information about, and clear access to, procedures to register formal complaints and feedback on the quality of services b. Healthcare organisations have systems in place to ensure that patients, their relatives and carers are not discriminated against when complaints are made c. Healthcare organisations have systems in place to ensure that patients, their relatives and carers are assured that organisations act appropriately on any concerns and, where appropriate, make changes to ensure improvements in service delivery Executive Lead A Moon Operational Lead S Harrison- Boyle Group Governance and Risk Management Committee Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for Very Low Unlikely Very Low remainder of 2009/10 Declaration Summary Statement 2009/10 (Autumn) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) Recent assurances in respect of C14 a, b and c include: Updated Complaints Policy in line with the Trust Document Control Policy, based on the new Complaints process introduced in April 2009 and acceptable to the NHS Litigation Authority at Level 1 (September 2009 review) Website development including new patient information complaints leaflets (including audio format and textphone) Updated leaflet for staff outlining their role in handling complaints based on the new complaints process A variety of complaints training provided to all grades of staff New posters in all departments on how to make a complaint with Complaints and PALS departmental access information Restructuring of the Complaints and PALS service completed to achieve aims of the new Complaints process, linking the 2 departments with cross departmental staffing and reportage to acknowledge the similarity of process across departments. Electronic data collection system (Ulysses Safeguard) improved to ensure accuracy of data collection In respect of Standard 14b (Complaints & Discrimination), patients are now surveyed to assess the possibility of individuals suffering discrimination while being cared for at the Trust as a result of making a complaint previously. This survey takes place annually and will next be repeated in December A Health Records audit was carried out in April 2009 to determine whether any complainant letters had been incorrectly filed in medical notes. The results of the audit were presented to the Governance & Risk Management Committee in August 2009 No. of Internal 30 No. of External 3 Page 1 of 3 Page 130

131 No. of individual noncompliant Internal 0 No. of individual noncompliant External 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) 0% complaints responded to outside of time frame are without the complainants agreement 95% of complainants are satisfied with the response to their complaint. Recent 3 months Most recent measurement of performance Date if action being taken Quarterly 10% resolved outside of the Local Resolution Plan timescale September - figures relating to complaints dealt with by the new process 2009 Quarterly 4.5% figures relating to complaints dealt with by the new process July 2009 Current Gaps in the Assurance Framework Follow up actions from survey respondents who felt their care is being compromised as a result of their making a complaint Need to establish an improved system to share learning from complaints across the organisation Summary of action being taken to address these Gaps Survey of complainants completed in January 2009, presented to Governance and Risk Management Committee in February Respondents who identified themselves and raised specific issues are to be followed up individually. Follow up audit of medical notes carried out to determine if any complaint correspondence has been filed in health records, April One set of notes included complaints letter. Letter removed and issue raised Trust wide via use of Newsbeat article October 2009 The Trust is developing systems for sharing learning from Complaints, including the Joint Review Group. This will be strengthened during the year by plans to create trust wide access to intranet web Complaints and PALS webpage. Reporting developed to provide qualitative and quantitative data to some Divisions by unit and Matron areas (roll-out to all Divisions in progress). Timescale October 2009 November 2009 Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan Develop an improved system for assurance on completion of action plans in divisions. Discussions with Divisions occurring with a view to commencement November 1 st Following initial monitoring of compensation costs, need to implement a comprehensive system to capture data. Data collected in specific areas. Development of Ulysses to collate all information still in progress Monthly, consistently presented reporting of Complaints and PALS enquires into Divisions. New template for reports being rolled out to all Divisions Progressing towards reporting themes across all patient feedback mechanisms and disseminating learning Trust wide. Themes created and added to Electronic data collection system. Timescale November 2009 December 2009 December 2009 December 2009 Page 2 of 3 Page 131

132 Details of any significant new controls or assurances added during this reporting period Training for existing Divisional Complaints Co-ordinators, Associate Divisional Managers, Matrons and Ward Managers now includes new complaints legislation introduced on 1 st April 2009; at the request of Divisions, senior staff are being trained complaints letter-writing skills and the response requirements of the new system (style and timing). Trust-wide training introduced for Bands 1-5 on Treating People Well. Complaints / PALS training added to Trust Induction training for all new staff. Complaints information contained within the Governance Training sessions aimed at all staff, with specifically targeted sessions for Junior Doctors and Healthcare Assistants. New complaints signage posters implemented in all wards and departments remain in situ with accurate information post introduction of new Complaints System Survey of complainants to seek assurance that their care is not being compromised as a result of their making a complaint completed January 2009 and to be repeated December 2009 Formal complaints and PALS enquiries recording on Ulysses now all real time and being logged under same categories. Informal complaints received by divisions being recorded monthly. Dissatisfied complainants being recorded on Ulysses. System altered to include this information September Further alterations necessary to be made by Ulysses Staff complaints leaflet finalised February 2009 and launched March Reviewed and set to Trust format October 2009 Refined combined report of Complaints and PALS to Governance & Risk Management Committee. Report altered to include data applicable to new Complaints Process introduced April From October 2009 Complaints & PALS will be reported to the Involving People Committee Please comment on any other issues relevant to this Standard not covered above Continued development of electronic data collection system. Users provided with a forum to discuss issues within their area and across Governance boundaries. September 2009 Page 3 of 3 Page 132

133 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 16 Patient Information Healthcare organisations make information available to patients and the public on their services, provide patients with suitable and accessible information on the care and treatment they receive and, where appropriate, inform patients on what to expect during treatment, care and after care. Executive Lead A Moon Operational Lead C Swonnell Group Involving People Committee Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Very Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The Trust has a robust and comprehensive system in place to govern the process of producing written patient information. Since the April Declaration, significant progress has been made to reduce the Patient Information Service s historic backlog of leaflet editing requests. The Trust also has effective systems in place to provide patients and visitors with access to appropriate translating and interpreting services. No. of Internal No. of individual noncompliant Internal 29 No. of External 2 No. of individual noncompliant External 6 1 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Proportion of patient leaflets showing as "current" on the Document Management Service s awaiting action from Patient Information Service Page 1 of 3 Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Monthly Currently 90% (last report 87%; 89%; target is 80%+) September 2009 Monthly 100 (200 last report; 230 and 300 previously) The size of the backlog is steadily improving as a result of efficiency measures introduced by the Patient Information Service towards the end of the financial year. Reducing the backlog of enquiries and associated turnaround times will Page 133 September 2009

134 Typical turnaround time for nonurgent editing requests for patient information leaflets Quarterly remain a key focus in 2009/10 Approximately four weeks (target is two weeks we still need to make significant improvements) September 2009 Current Gaps in the Assurance Framework Need to improve British Sign Language interpreting capacity Patient Information Policy failed NHSLA Level 1 review Summary of action being taken to address these Gaps Update September 2009: The Trust is actively working with a local representative from the Association of Sign Language Interpreters (ASLI) to improve the number of freelance interpreters on our approved register. The policy was updated prior to the review, however initial feedback indicated that the NHSLA was more focussed on procedural detail than had been anticipated. Policy will be updated again once we are in receipt of detailed feedback from NHSLA. Timescale Ongoing December 2009 (pending NHSLA feedback) Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None at present. Other current entries on the Assurance Framework Action Plan Rebranding of patient information leaflets: approximately 65% of the Trust s 1300 patient information leaflets have now been systematically re-branded as University Hospitals Bristol (rather than UBHT). Further changes to the standard leaflet template are likely to be introduced pending the outcome of wider Trust work on Vision and Values. Plans to identify high-usage patient information leaflets and make these available as audio files via Trust internet site. The first audio leaflet was made available via the Document Management Service in January 2009, however plans to roll-out up to 20 key leaflets have been delayed due to technical issues recently resolved. The Department of Health has recently published an Information Standard. This is an NHS information kite mark which is awarded to information providers, rather than specific pieces of information. An initial assessment will be made during the Autumn to determine likely resource implications of aspiring to this Standard (both in terms of the workload of the Patient Information Service and the annual cost of being part of this scheme) Timescale To be advised. December 2009 December 2009 Details of any significant new controls or assurances added during this reporting period 2009 PEAT scores for Patient Information were Good/Excellent Following consultation with Human Resources, the Trust has introduced a more robust system for obtaining assurances around the use of freelance British Sign Language interpreters. Please comment on any other issues relevant to this Standard not covered above Maternity Services has agreed to pilot an alternative provider of telephone interpreting (The Big Word) with a view to reducing costs and improving patient access to interpreting services. Pilot anticipated during autumn/winter 2009/10. Details of any non-compliant evidence items relevant to the current year 2009/10: (please reproduce the boxes below for each individual item ) Evidence item: Access to patient information leaflets and resources via the internet Reason for non-compliance Page 2 of 3 Identified gap need to develop and improve on-line access to patient information Page 134

135 judgement: Actions being taken: Part of Patient Information Co-ordinator s work plan for 2009/10 If an assessment of significant lapse was done please attach: Is it a significant lapse?: Summary statement on rationale / outcome of decision above: No No An identified gap / area of improvement for the future. Details of any non-compliant evidence items relevant to the current year 2009/10: (please reproduce the boxes below for each individual item ) Evidence item: Patient Information Service backlog Reason for non-compliance judgement: Actions being taken: If an assessment of significant lapse was done please attach: Is it a significant lapse?: Summary statement on rationale / outcome of decision above: Significant recent improvement (see KPI above). Target to remove historic backlog by end of Challenge for the future will then be to maintain this position without the use of temporary staffing. Income identified from the National Research Ethics Service has enabled the Trust to bring in an additional 9 hours of substantive administration support. Short-term Bank support is also being funded via income received from the Healthcare Quality Improvement Partnership. No No Significant recent improvement with a route through to removing the backlog of work. Details of any non-compliant evidence items relevant to the current year 2009/10: (please reproduce the boxes below for each individual item ) Evidence item: Patient Information Policy failed NHS Litigation Authority review Reason for non-compliance judgement: Actions being taken: If an assessment of significant lapse was done please attach: Is it a significant lapse?: Summary statement on rationale / outcome of decision above: Current policy lacks procedural detail regarding the production, editing and archiving of patient information leaflets. Policy will be updated once we are in receipt of detailed NHSLA feedback. No No The NHSLA was satisfied that the Trust was able to describe all of the necessary procedures however they are not detailed in the policy. Page 3 of 3 Page 135

136 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 17 Patient and Public Involvement The views of patients, their carers and others are sought and taken into account in designing, planning, delivering and improving healthcare services. Executive Lead A Moon Operational Lead C Swonnell Group Involving People Committee Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Very Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The Trust is able to demonstrate: a varied programme of survey-based patient involvement activity; continuing public engagement in major corporate service redesign; developing relations with traditionally seldom heard community groups; extensive examples of ongoing patient involvement at Divisional level; and positive outcomes from National Patient Surveys. A Patient & Public Involvement Plan is in place for 2009/10, pending the development of a medium-term Patient Experience Strategy for The Trust continues to use its Membership as a significant vehicle for developing involvement. Engagement events have been held for members, and respective Involvement and Quality sub-groups of the Governors Council have been established. No. of Internal No. of individual noncompliant Internal 28 No. of External 0 No. of individual noncompliant External 3 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Key metrics on patient involvement and experience will be developed as part of Quality Accounts. This will be included in the planned Quality Metrics away day with the clinical Divisions on 25 th November. The proposed ward (and clinic)-based patient feedback system will be key to delivering reliable metrics. Current Gaps in the Assurance Framework Expectation that all Trusts will develop systems for gathering routine ward-based patient feedback Page 1 of 2 Summary of action being taken to address these Gaps September 2009 the Trust has identified (through procurement) two potential suppliers of an electronic patient feedback system. The option of an in-house IT system has been ruled out. The electronic system will complement a new system of exit cards. Page 136 Timescale Electronic system to be in place by 1 st April 2010.

137 The Trust Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan Timescale Patient Experience Strategy for to be developed. December 2009 Need to develop a planned programme of involvement and experience activity. April 2010 Details of any significant new controls or assurances added during this reporting period The Involving People Committee has been reconstituted (meetings in June and October 2009), including representation from the Bristol Local Involvement Network via the former Chair of the Trust s Patient & Public Involvement Forum. Results of 2008 National Inpatient Survey published UHBristol placed amongst mid-performing Trust. Local analysis of data has revealed key drivers of patient satisfaction which will form cornerstones of the planned Patient Experience Strategy. Divisional action plans submitted to Board, September A ward-based patient experience survey is currently being piloted in Maternity Services and on Ward 6 (Thoracics) the data from this survey is being reported to NHS Bristol under the terms of CQUIN13 (reporting to commence at the end of Q2, i.e. 30 th September 2009) Administration of National Patient Surveys (Picker) has been outsourced to Quality Health more cost effective; addresses gaps re. translating and interpreting for these surveys; makes better use of Patient Involvement Facilitator s analytical skills. Please comment on any other issues relevant to this Standard not covered above Page 2 of 2 Page 137

138 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 20a - Safe and Secure Environment Healthcare services are provided in environments which promote effective care and optimise health outcomes by being a safe and secure environment which protects patients, staff, visitors and their property, and the physical assets of the organisation. Executive Lead S Aumayer Operational Lead M Fewkes Group Health and Safety Committee Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The Trust has structures in place to ensure that it provides a safe and secure environment for people who are cared for, work in, or enter the Trust premises and it audited annually for compliance in areas concerning Health & Safety by external bodies. Concerns raised following an HSE investigation have prompted a report and action plan for the Governance & Risk Management Committee (attached to April 2009 declaration). This issue was resolved in conjunction with the Medical Director Activities within this assurance framework continue to be reviewed and monitored. There have been no material changes effecting compliance for this standard. The estimated risk is Low rather than Very Low because of the nature of the age of the buildings within the trust estate this being the subject of a significant re-development plan. No. of Internal No. of individual noncompliant Internal 58 No. of External 0 No. of individual noncompliant External 21 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Compliance with Estates Return and Information Collection Compliance with Annual NHS Fire certificate Compliance with Disability Discrimination Act Compliance with Patient Environment Action Team (PEAT) Page 1 of 2 Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Annual Declared compliant by NHS Estates April 2009 Annual Compliant & re-certified January 2009 Response based Responses linked to PALS information and complaints ad hoc Annual and ad hoc visits Improved performance in three categories for No deterioration in any categories Page

139 audits Compliance with Counter Fraud Security Management Service requirements Compliance with national targets - smoke free policy implementation Annual Audit compliance Submission completed Early 2009 January 2009 Ongoing On target for early 2009 audit compliance ongoing Current Gaps in the Assurance Framework Compliance with training standard see 11b Summary of action being taken to address these Gaps Fire safety and health and safety training compliance has reduced e learning training to be encouraged as part of the recovery plan Lead trainers to also meet with Head of Health & Safety services regarding this issue Timescale Ongoing Ongoing Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period None Please comment on any other issues relevant to this Standard not covered above Page 2 of 2 Page 139

140 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 20b Privacy and Dignity Environment Healthcare services are providing in environments which promote effective care and optimise health outcomes by being supportive of patient privacy and confidentiality Executive Lead A Moon Operational Lead H Morgan Group Privacy and Dignity Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possible Estimated Risk to Compliance for remainder of 2009/10 Very low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) A significant work programme is virtually complete across the Trust, including bathroom and toilet upgrades and upgrades to nightingale style wards along side early reviews of critical care, day case and emergency departments support a declaration of compliance. An overall improvement from the Patient Environment Action Team assessment in 2008, together with the latest Inpatient Survey results also supports this declaration. No. of Internal No. of individual noncompliant Internal 17 No. of External 0 No. of individual noncompliant External 3 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) National Inpatient 2008 Survey results indicators PEAT assessment environment scores Page 1 of 2 Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Annual 30% shared sleeping area with the opposite sex when first admitted (improved from 2007) 22% shared sleeping area when moved to another ward (improved from 2007) Annual Bristol Royal Infirmary - Acceptable Bristol General Hospital Good St Michaels Hospital Acceptable Bristol Eye Hospital Good Bristol Haematology and Oncology Centre Good Bristol Royal Hospital for Children - Good Page assessment

141 NHS South West Mixed Sex Accommodation Standards Works programme to ensure single sex accommodation within mixed wards programme virtually completed Bathroom and toilet upgrade programme to ensure single sex facilities Breech protocol and recording mechanisms implemented 2009 Current Gaps in the Assurance Framework None Summary of action being taken to address these Gaps Timescale Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period Funding secured from the SHA A significant works programme is almost completed to ensure ward areas comply with standards. Pictorial signage now in place across the Trust, indicating male/female facilities Breech protocol now in place, with agreed reporting mechanisms. Equipment screens installed in ED, to maximise patient privacy and dignity Please comment on any other issues relevant to this Standard not covered above An action plan relating to the work of the Privacy and Dignity Group is currently under review. Leadership and implementation through Head of Nursing Specialised Services Page 2 of 2 Page 141

142 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 21a Environment Healthcare services are provided in environments which promote effective care and optimise health outcomes by being well designed. Executive Lead I Scott Operational Lead B Pepper Group Trust Operational Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Very Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) In arriving at a recommendation of compliance, the context is of an estate significantly older than average, with a strategic investment plan to transform the age profile over the period 2006 to 2012 and beyond. In May 2009, the Bristol Heart Institute was opened with a state-of-the-art patient environment. This has triggered a further programme of ward decants and moves which are facilitating ward upgrades, toilet and bathroom improvements and the closure of some wards in the BRI Old Building. PEAT assessments have gradually improved year on year and the investment in replacing and upgrading buildings is a key feature of the capital programme. A programme of work which, alongside operational changes, will assure compliance with single sex ward guidance is largely completed at this time, with the exception of the refurbishment and conversion of wards 5a, b and c. Progress has occurred on a great number of fronts since the last assessment of compliance that one could only conclude that the extent of compliance has markedly improved. No. of Internal No. of individual noncompliant Internal 25 No. of External 0 No. of individual noncompliant External 4 1 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Risk Assessed Backlog Maintenance Level Maintenance Revenue Investment benchmarking Page 1 of 3 Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Annual 9.912m. (2006/07); 9.573m. (2007/08); 1.4m. (2008/9); 1.4m. (2009/10). Reported through TOG and TEG. Finance plan shows 2.0m. proposed for 2010/11. Annual / sq. m. - very low - Reported through TEG. Benchmark has deteriorated from 14/16 in peer group to 16/16. However capital investment in improvements has a mitigating effect. Page 142 Oct 2009 Oct 2009 Year programme being implemented

143 Hard and Soft Facilities Management FM benchmarking Energy benchmarking Annual Other: one-off measurement as part of programme Cost and value comparisons being undertaken. Overall review of roles in hand. Carbon Trust Programme benchmark shows Trust performance as better than Good Practice. Trust Board approved 5-year programme of improvement and reduction measures April 2009 March PEAT scores Annual Of the eighteen assessments over six hospitals: 50% showed Excellent, 39% Good, 11% Acceptable, 0% Poor, 0% Unacceptable. Annual Statement of Fire Safety Annual No Enforcement Action by Fire and Rescue Authority. Programme of Annual Audits being progressed. Annual report to Governance and Risk Committee Feb 2009 Oct 2009 Oct 2009 Oct 2009 Oct 2009 Current Gaps in the Assurance Summary of action being taken to address these Gaps Timescale Framework Poor patient environment in Bristol BHOC Refresh project currently on site. Funded jointly by Trust Capital and Charitable October 2009 July 2010 Haematology and Oncology Centre funding. Poor sanitary facilities Bathrooms, toilets and washbasins project (two-year ongoing programme) Ongoing in BRI and BHOC until March Lack of car parking for visitors Valet parking assessed. Feasibility study for multi storey car park complete. Discussions with commercial car park operators have taken place to ascertain whether a multi-storey would be commercially viable. Joint Trust Board Governors Meeting discussed access to the BRI. Follow-on working group convened for November / 2010 to source solutions. Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale Risks to business continuity due to Risks continually reviewed and priorities adjusted accordingly. Ongoing mismatch between Risk Adjusted backlog and actual investment Risks as above specific to Bristol General Hospital Original closure date for BGH was September Now unlikely before end of 2011, more likely Risks surrounding reliability of lift installations, structural integrity of balconies and Current issue until closure (2011 / 2012). Age profile of estate generates risks of poor patient environment Fire Safety Compliance with current single sex guidance lifespan of boilers is uncertain. Redevelopment programme and planned closure of Old Building Bristol Royal Infirmary and Bristol General Hospital progressing. Annual programme of Patient Environment Works ( 250K.) All Hospitals risk assessed and audited annually. Remedial actions identified are programmed and implemented from the fire safety capital budget. Specific actions bid for funding to PCT Mar 2009 was successful. Partitions erected in each of the 5 wards in King Edward Building Review of operational practice and physical configuration undertaken and implemented end June Single sex bays and separate bathroom facilities created in ward 16 MAU. Bristol Heart Institute opened May Patient environment programme being implemented. Annual programme. Actions April June 2009 Subsequently operational policy review will determine action. Page 2 of 3 Page 143

144 Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period Legionella Risks - replacement of hot water pipework throughout St Michael's Hospital Isolation facilities - Ward 26A converted for isolation purposes; Additional cubicles added to King Edward ward refurbishments; Ward 16 MAU has sex segregated bays each with a new isolation cubicle Reliability of pneumatic tubes system - comprehensive repair, replacement and upgrade of the entire system, funded from capital Please comment on any other issues relevant to this Standard not covered above Risks continually reviewed and priorities adjusted accordingly. Details of any non-compliant evidence items relevant to the current year 2009/10: (please reproduce the boxes below for each individual item ) Evidence item: At the time of completing this assessment, compliance with the new definitions regarding single sex wards is technically noncompliant. Reason for non-compliance Re-definition of single sex wards requirements no longer excludes assessment areas. judgement: Page 3 of 3 Page 144

145 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 21b Environment Cleanliness Healthcare services are well maintained with cleanliness levels in clinical and non-clinical areas that meet the national specification for clean NHS premises Executive Lead A Moon Operational Lead D Ponsford Group Infection Control Committee Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possible Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) A focus on improving cleanliness has continued throughout the year. There is a wealth of evidence on systems and controls, and positive assurance on improved Standards. The estimated risk to compliance for the remainder of 2009/10 is recorded as Low rather than Very Low as a result of the Trust s recent decision to set a more challenging Green status target for monthly cleanliness audits, i.e. 95%, instead of the previous 90%. No. of Internal No. of individual noncompliant Internal 5 No. of External 0 No. of individual noncompliant External 6 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Page 1 of 4 Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Monthly Cleaning Audit Scores Monthly Presented in detail to the Board. Concerns have been expressed on gaps in audit due to capacity constraints in audit post. Request therefore for prioritisation of clinical seriously high and high risk areas. Trust Score for Feb was 90% Oct 2009 Auditing continues to be prioritised in very high and high risk clinical areas. Positive improvement of random audit completion in significant and low risk category areas thereby reducing gaps in audit process. Toilet and Bathroom Cleaning Checklist on Clostridium difficile dashboard Weekly 88% Achieved 84% Achieved Page 145 March 2009 Feb 2009 Sept 2009

146 Weekly analysis to Infection Control and Senior Management on deep cleans by ward and date Side room cleaning sign off sheet Monthly Hand Hygiene Compliance Patient Environment Action Team Annual Inspection Results and analysis of cleaning scores prior to submission. Weekly 100% compliance against requests March 2009 Internal monitoring Monthly 97% 91% Annual Historical Performance 2009 PEAT B R I ENVIR ONME NT FOOD PRIVACY ENVIR & ONME DIGNITY NT FOOD ACCEP TABLE GOOD GOOD PRIVACY & DIGNITY ACCEP TABLE GOOD GOOD B R C H GOOD GOOD GOOD GOOD GOOD GOOD S t. M s B G H B E H B H O C ACCEP TABLE GOOD GOOD GOOD GOOD ACCEP TABLE EXCEL LENT GOOD GOOD EXCEL LENT EXCEL LENT EXCELLE NT GOOD ACCEP TABLE GOOD GOOD GOOD ACCEP TABLE EXCELLE NT EXCELLE NT EXCELLE NT GOOD EXCELLENT GOOD Feb Sept Cleaning Data Analysis: BRCH: 90.63% St Ms: 84.35% BEH: 94.57% BHOC: 94.29% BGH: 95.49% BRI: 97.2% Trust Cleaning Performance: 92.61% PEAT 2009 Site Environment Food Privacy and Dignity BRI Acceptable Excellent Good BRCH Good Excellent Good SMH Acceptable Excellent Excellent BGH Good Excellent Excellent BEH Good Excellent Excellent Feb./March 2009 Feb/March Page 2 of 4 Page 146

147 BHOC Good Excellent Excellent 2009 Cleaning Data Analysis: Running Totals for the BRI: 85% (Feb: 85%) BHI: 97.4% ( Not opened) BRCH: (Feb: 88%) St Ms: (Feb:85%) BGH: ( Feb: 88%) BEH: 93.29% (Feb: 92%) BHOC: 96.56% (Feb: 95%) Sept 2009 Trust Cleaning Performance: Sept % (Feb 09: 89.57%) Sept 2009 Evaluation of Comparative Indicators Annually Indicators: Clostridium difficile rate of infection As expected Clostridium difficile trend As expected MRSA rate of infection As expected MRSA trend As expected 2009 Constructions: PEAT cleanliness Patient experience hospital and ward Current Gaps in the Assurance Framework Monthly cleanliness audits have gaps in the audits in low risk areas due to lack of audit capacity Summary of action being taken to address these Gaps Increased auditing has been implemented since November 08. Audits in low risk category areas have commenced at 2 sites with roll out to all sites planned for April 09. Priority has been transferred to monthly auditing in wards/departments as directed by IC teams. Sept 09 Auditing resource continues to be prioritised to very high and high risk clinical areas. Plans in development stage to roll out enhanced level of audit in a number of sites. Staff training and development required. Facilities currently reviewing benefits of an electronic recording audit system which may release more time to audit. Timescale Feb 2010 April 2010 Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Page 3 of 4 Page 147

148 Other current entries on the Assurance Framework Action Plan Timescale Development of plan for a bed store and area for proactive hydrogen peroxide cleaning October 2009 Development plans delayed as single sex and toilet and bathroom upgrade programme prioritised and implemented. Options being considered at Trust Space Committee Details of any significant new controls or assurances added during this reporting period Enhanced assurance in relation to on site induction training of agency HSA staff Enhanced evidence to support orientation training of agency HAS staff Evidence to support practical skills training and monitor of competency checks Bed Space Cleaning tag introduced when cleaning process complete July 09. In process of being rolled out across all sites. Please comment on any other issues relevant to this Standard not covered above Risks continually reviewed and priorities adjusted accordingly. Sept Trust Board raised the bar achievement of 95% is required to achieve Green status. Action plans being progressed on a site by site basis to aim for achievement of new 95% target. As a result there is evidence of a move to amber status yet an improvement overall percentage position in Sept 2009 of the Trust wide score which is 94% (90% March 09) Page 4 of 4 Page 148

149 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 22a&c External Partnerships Healthcare organisations promote, protect and demonstrably improve the health of the community served, and narrow health inequalities by cooperating with each other and with local authorities and other organizations and making an appropriate and effective contribution to local partnership arrangements including local strategic partnerships and crime and disorder reduction partnerships. Executive Lead R Woolley Operational Lead S Clark Group Trust Executive Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) A 4-monthly checklist evaluation is undertaken to ensure compliance with the Trust s Partnership Evaluation Framework and therefore with this standard. There is good assurance of compliance of the standard because each Partnerships Working is evaluated against key indicators to ensure public money is judiciously used to bring significant benefits, assess whether partnerships add value to the organisation and to ensure an accountability process within the Trust to service users. The process also demonstrates an assurance that the Trust cooperates and effectively contributes to local partnership arrangements including local strategic partnerships. A quarterly evaluation report is presented to the Trust Executive Group. The estimated risk to compliance for the remainder of the year is recorded as Low as opposed to Very Low due to a minimum two year slippage time for completion of the South Bristol Community Hospital which has a potential risk to transferring services e.g. Community Dental Services. No. of Internal No. of individual noncompliant Internal 4 No. of External 0 No. of individual noncompliant External 2 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) 4 monthly evaluation of Partnerships to ensure robust relationships, effectiveness and value for money Page 1 of 2 Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken 4 monthly Significant slippage in the South Bristol Community Hospital project and completion of building work anticipated to be December 2011 at the earliest. Page 149 September 2009 Divisions to assess the impact and contingency plans to

150 and compliance with the Trust s Partnership Framework be developed. Current Gaps in the Assurance Framework Slippage in the South Bristol Community Hospital project Bristol Intermediate Care Partnership is in need of considerable development and is currently not producing significant impact on service delivery The Bristol Intermediate Care partnership is in need of considerable development and is currently not producing significant impact on service delivery. It has major potential to impact on service delivery yet remains hampered by the variable funding streams of health and social community care. Summary of action being taken to address these Gaps Divisions to assess the impact and contingency plans to be developed. Regular evaluation through the Partnership Framework September 2009 Timescale Building work anticipated to be December 2011 at the earliest. Quarterly reviews next one due December Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period None Please comment on any other issues relevant to this Standard not covered above Page 2 of 2 Page 150

151 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 23 NSF and Clinical Priorities Healthcare organisations have systematic and managed disease prevention and health promotion programmes which meet the requirements of the national service frameworks and national plans with particular regard to reducing obesity through action on nutrition and exercise, smoking, substance misuse and sexually transmitted infections. Executive Lead Jonathan Sheffield Operational Lead P Hall Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possi ble Estimated Risk to Compliance for remainder of 2009/10 Very Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The Trust hosts the Bristol and Weston Bowel Cancer Screening Centre as part of the National Bowel Screening Programme and the Avon Breast Screening Unit has improved its performance to above average. The Trust is working with Bristol PCT Public Health in partnership with North Somerset and South Gloucester PCTs, North Bristol and Weston NHS Trusts, and the Avon & Wiltshire Mental Health Partnership to improve the delivery of health promotion to staff and patients. No. of Internal No. of individual noncompliant Internal 142 No. of External 0 No. of individual noncompliant External 13 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) National Health Promotion in Hospitals Audit of 100 adult medical and surgical in-patients during January 2009 Page 1 of 2 Is this KPI Annual / quarterly / monthly / other? Annual Most recent measurement of performance against KPIs Date if action being taken A. Patients assessed for smoking: Standard 100%; Trust 79%. Patients delivered health promotion: Standard 35% Trust 22% B. Patients assessed fro alcohol use: Standard 95%; Trust 66%. Patients delivered health promotion: Standard 50%; Trust 33% C. Patients assessed for obesity: Standard 45%; Trust 46%. Patients delivered health promotion: Standard 45%; Trust 8% Page 151 September 2009 No action plan in place but some issues being addressed through other initiatives

152 Current Gaps in the Assurance Framework None D. Patients assessed for physical activity: Standard 35%; Trust 1%. Patients delivered health promotion: Standard 45%; Trust 0% Summary of action being taken to address these Gaps Timescale Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale None Other current entries on the Assurance Framework Action Plan Avon Breast Screening is meeting the minimum standard for round length. (99% within 36 months.) We are also currently meeting the waiting times targets for screen to assessment (date of first offered appointment 96% within 3 weeks) and screen to results (97% within 2 weeks.). Timescale Oct Oct 2009 Details of any significant new controls or assurances added during this reporting period Trust Health & Wellbeing Group re-established Nutritional Screening tool and audit implemented Please comment on any other issues relevant to this Standard not covered above The evidence given under standard C22b (Public Health) has been amalgamated within this standard as C22b is designated to be for Primary Care Trusts only Page 2 of 2 Page 152

153 University Hospitals Bristol NHS Foundation Trust Mid-Year Healthcare Standards Declaration 2009/10 Core Standard 24 Major Incident Planning Healthcare organisations protect the public by having a planned, prepared and, where possible, practised response to incidents and emergency situations, which could affect the provision of normal services. Executive Lead I Scott Operational Lead C Sandmann Group Trust Operational Group Declaration 2007/8 Compliant Key for estimated risk: High Almost Certain Declaration 2008/9 Compliant Moderate Likely Recommended Declaration 2009/10 Compliant Low Possible Estimated Risk to Compliance for remainder of 2009/10 Very Low Very Low Unlikely Declaration Summary Statement 2009/10 (Mid-Year) (a brief statement in support of the recommended declaration position, e.g. perhaps making reference to any particularly significant controls or assurances listed on the Assurance Framework) The Emergency Planning Officer was appointed in September The outstanding work to complete the review and rewrite of the major incident plan has been completed and has been accepted by the Trust Board. The plan will be released on the 19 th October The pandemic flu plan is complete and has been accepted by the Trust Board. Business continuity planning is now being overseen by the Business Continuity Planning Group that reports to the Board via the Civil Contingencies Committee No. of Internal No. of individual noncompliant Internal 37 No. of External 0 No. of individual noncompliant External 2 0 See below for details of non-compliant evidence items Key Performance Indicators (measurables) Contingency / major incident plans current Business Continuity Plans in place for all areas identified Is this KPI Annual / quarterly / monthly / other? Most recent measurement of performance against KPIs Date if action being taken Capacity modelling undertaken. Winter Plan development completed and being monitored. Pandemic flu Plan reviewed and updated. Major Incident Plan has been reviewed and rewritten 16/10/09 Business Continuity Plans in place for all areas. Page 1 of 2 Page 153

154 Current Gaps in the Assurance Framework None Summary of action being taken to address these Gaps Timescale Residual Seriously High or High Risks Summary of action being taken to address these Risks? Timescale Major Incident Plan being due a refresh Interim mitigating actions being identified to manage risk prior to full refresh in Q4.(complete) Accepted by the Trust Board August 2009 Other current entries on the Assurance Framework Action Plan None Timescale Details of any significant new controls or assurances added during this reporting period Pandemic Flu Plan completed and submitted to PCT and SHA for initial review. Final self assessment completed 13/02/09 and presented to the SHA. Plan has been presented to and accepted by the Board. Plan has been included on the Web page Emergency planning web page now operational Winter plan refreshed (complete) - Winter plan will then be reviewed and lessons learned identified (February) Business continuity plans are finalised in all areas. This is a process of continual update and review across all Trust Divisions. Emergency Planning Liaison Officer appointed Please comment on any other issues relevant to this Standard not covered above None Page 2 of 2 Page 154

155 Dr Graham Rich Chief Executive University Hospital Bristol NHS Foundation Trust Marlborough Street Bristol BS1 3NU Care Quality Commission 4 th Floor Colston Colston Avenue Bristol BS1 4UA Telephone: Fax: November 2009 Dear Graham Re: Health Care Standard 11b Mandatory Training Thank you for your letter of 6 November 2009 requesting guidance regarding the expected levels of completion of mandatory training required in order to declare compliance with Standard 11b - Mandatory Training. The Commission's position is that it is not for us to determine a set level of completion of mandatory training which would equate to compliance with this standard but is for each trust board to determine this level. This is because our current method of assessment is of the trust board's assurance of compliance with the standard and, as you rightly state, this level may vary due to sickness, maternity leave, turnover etc. The Commission would, however, expect the trust to be able to identify why the level that has been set for compliance with this standard is satisfactory. In respect of the measurement of completion rates in order to assess compliance, again it is for you and the trust board to determine how best you can gain assurance of compliance with the standard, but this may more clearly be determined by measuring the completion rate for each individual element of your mandatory training program. Page 155

156 I hope that this information is useful to you and look forward to working with you in the future. Yours sincerely Catherine Campbell Assessor - South West Region. Page 156

157 6 th November 2009 Trust Headquarters Marlborough Street Bristol BS1 3NU Tel: By Catherine Campbell Account Manager Care Quality Commission Dear Catherine Healthcare Standard 11b Mandatory Training As you will be aware, we are now in the process of considering our mid-year healthcare standards declaration for 2009/10. One standard of particular debate for us is 11b as it appears that there is no guidance as to what percentage of employees having completed training constitutes compliance. We have reviewed the inspection guide for this standard to help in our deliberations and it is not specific on this point. Additionally, there is no guidance as to whether the same levels are required for every category of training in order to be compliant. Clearly, 100% completeness is not possible due to sickness, maternity leave, turnover, etc but there is no guidance as to what is acceptable. Can you please therefore advise by return:- i) The expected level of completion of mandatory training in order to declare compliance. ii) Whether this level of completion is required for all individual element of mandatory and statutory training (e.g. Fire safety, manual handling etc). iii) How compliance should be measured, be it by average completion rate for all elements, or individually for each element. We also think that this advice would be of benefit to the whole NHS, and so should be published, as it appears that organisations are declaring compliance with 11b with widely varying levels of completion of mandatory training. We believe that our compliance rates are good and improving, but want to be clear that our compliance statement is in line with a clearly laid out set of requirements as for most other standards. Page 157

158 I look forward to hearing from you. Yours sincerely Dr Graham Rich Chief Executive Page 158

159 Trust Board Meeting Date: 30 November 2009 Agenda Item Title of Report Recommendations Independent Safeguarding Authority Vetting and Barring Independent Safeguarding Authority Vetting and Barring Overview For Information Only Actions Required Which Corporate Objective(s) are supported by this paper? Is this on the Trust s risk register? For Information Only 0910/OD05 To ensure that the Trust continues to meet the requirements set out by Monitor, the regulator for Foundation Trusts No. Which Healthcare Commission standard does this report provide evidence for? 10a Recruitment and Employment Checks Financial Implications Revenue N/A Capital N/A Prepared by: Name & Title Presented by: Name & Title D Tunnel Head of Recruitment Steve Aumayer Director of Workforce and OD Previous Meetings Please insert the date the paper was presented under to the relevant group Exec Team Audit & Assurance Committee Governance Risk and Risk Management Finance Committee Trust Executive Group Other Meeting (Please state) Action to update Board Initial Briefing March 2009 Page 159

160 UNIVERSITY HOSPITALS BRISTOL NHS FOUNDATION TRUST Implementation of the Independent Safeguarding Authority (ISA) and New Vetting and Barring Scheme (VBS) Introduction The purpose of this paper is to brief the Board on the introduction of the Independent Safeguarding Authority (ISA) Vetting and Barring Scheme (VBS), which commenced roll out nationally from 12 October 2009, with full implementation from July Background The Safeguarding Vulnerable Groups Act was created in response to recommendations made in the Bichard Inquiry, arising from the Soham murders in One of the recommendations from the Inquiry was the need for a single agency to vet all individuals who want to work, or volunteer to work, with children or vulnerable adults and to bar unsuitable people from doing so. (See appendix 1 for the definition of children and vulnerable adults). The full requirements of registering with the scheme will be phased in over a period of 5 years. The introduction of the VBS builds on current legislation around pre and post employment checks To provide a more robust system for preventing those who seek to harm children, or vulnerable adults, from gaining access to them through work or volunteering. The scheme places a new duty to share information. Employers, social services and professional regulators will have to notify the ISA of all relevant information so individuals who pose a threat to vulnerable groups can be identified and barred from working with these groups. With effect from 12 October 2009, the VBS replaced the current Government lists under the Protection of Children s Act (PoCA), Protection of Vulnerable Adults Act (PoVA) and List 99; there will be two main registers under the new system, one to cover working with children and one to cover working with vulnerable adults. Scope The new VBS covers paid workers, volunteers, contractors, the self-employed and overseas workers. With effect from 12 October 2009, anyone included on the new barred lists by the ISA will be barred from a far wider range of regulated positions and activities than previously. For the NHS this will mean that the scheme will be extended to people working or volunteering with vulnerable adults. Regulated and Controlled Activities Work with vulnerable groups is divided into two categories: Regulated Activity This is any activity which involved contact with children or vulnerable adults, and can be paid or voluntary work. Examples of regulated activities: Any activity of specified nature which involves contact with children or vulnerable adults frequently, intensively and/or overnight. Any activity allowing contact with children or vulnerable adults that is in a specified place frequently or intensively. Fostering and childcare. Any activity that involved people in certain defined positions of responsibility. Page 160

161 Specified nature: Teaching, training, instruction, care or supervision of children or vulnerable adults. Advice or guidance for children, advice, guidance or assistance for vulnerable adults. Any form of treatment or therapy provided to a child or vulnerable adult. Driving a vehicle which is being used only for the purpose of conveying children or vulnerable adults (including ambulance services). Activity which involves, on a regular basis, the day to day management or supervision of a person carrying out the activity above is also a regulated activity. Specified place: Childcare premises including nurseries. Residential home for children in care. Children s hospitals. Children s detention centres. Adult care homes. In a specified place even if an individual is not carrying out specified activity (for example, treatment of care), they are engaged in regulated activity if they are carrying out any form of work which gives them an opportunity to have access to vulnerable groups i.e. staff such as catering, cleaning, administration, maintenance and contract workers. These will therefore need to be considered. Controlled Activity Examples of controlled activity: Frequent or intensive support work in general health settings, the NHS and further education settings. People working for specified organisations with frequent access to sensitive records about children and vulnerable adults. Support work in adult social care settings. People who are barred from regulated activity will not necessarily be barred from undertaking work within controlled activity. Difference between ISA checks and Criminal Records Bureau (CRB) checks The new scheme does not remove the need to carry out a Disclosure check. Being registered with the ISA does not guarantee an individual had no criminal record through the Criminal Records Bureau. The ISA and the CRB offer employers different, but complementary safeguards when recruiting people to work with vulnerable groups. The ISA is a specialist body concerned with protecting vulnerable groups from harm, with independent experts making barring decisions. The CRB works on the full range of criminal records information, which goes much wider than the ISA s specialist area. Checking an individual s ISA registration status is essential to ensure that we are not appointing a person who poses a known risk to children and/or vulnerable adults and to meet the legal requirements placed on employers by the Safeguarding Vulnerable Groups Act. CRB checks should be used in parallel to ensure that the Trust is not at risk of employing someone who has committee a criminal offence which may make them unsuitable to do the actual job. Implications of UH Bristol With effect from November 2010: Page 161

162 Regulated Activity Employers duties and responsibilities It will be a criminal offence for an employer to knowingly appoint or continue to employ anyone in regulated activity who is barred from working with vulnerable adults or children. It will be a criminal offence for an employer to take on a person in a regulated activity if they fail to check that person s status. Controlled Activity Employers duties and responsibilities It will be an offence for an employer to take on an individual in a controlled activity if they fail to check the person s status. An employer can permit a barred person to work in a controlled activity as long as safeguards are put in place. With effect from 12 October 2009, access to the new lists will be available on request as part of an enhanced CRB check Standard CRB checks will no longer be available for those working or volunteering with children or vulnerable adults in regulated activity. This level of check will, however, still be available for all other positions covered under the Rehabilitation of Offenders Act 1974 (Exceptions) Order Registering with the ISA Legally the responsibility to register with ISA lies with the individual, however it is unlikely that people will automatically do this and therefore onus will be on the employers to prompt registration. With effect from July 2010, employers and voluntary organisations working with children and vulnerable adults cannot recruit workers who are not ISA-registered before they take up the appointment. What happens if an individual s ISA status changes during employment? With effect from July 2010, once the Trust has carried out an on-line ISA check and registered interest in that individual, it will be able to check an individual s ISA status online. The Trust will also be able to express an interest in a person s ISA registration status and will be notified should any employee s ISA status subsequently change whilst they are in their employment. It is essential for the Trust to remember that when an individual leaves their employment, it will have to de-register their interest otherwise they will continue to be notified of that person s status. Implications for Employees Employees duties and responsibilities A person must apply for registration if wanting to work or volunteer in regulated or controlled activity. A barred individual must not apply to work or work in any regulated activity. It will be a criminal offence for a barred person to take part in a regulated activity for any length of time. Registering onto the ISA scheme From July 2010, those people who are applying to work or volunteer with children or vulnerable adults in regulated activity will have to apply to the vetting service via the Criminal Records Bureau (CRB). They can apply for registration through their existing employer, or if applying for a job, through their prospective employer. This can be done through the Trust, as it is a CRB registered body. Once registered the employee/volunteer receives a personal ISA Registration Number. With effect from November 2010, it will be a criminal offence for anyone to seek work or to undertake work in regulated activity with vulnerable adults or children if they are barred from doing so. Five Year Phasing-In Programme Page 162

163 From 12 October 2009 Wider range of regulated activities to be introduced. Two new barred lists come into place one to cover working with children, one to cover working with vulnerable adults. Replace Protection of Children Act (PoCA), Protection of Vulnerable Adults (PoVA), List 99. All new recruits and staff changing jobs within regulated activity will require an enhanced CR check, which included checks against the 2 new barred lists. Employers have a duty to refer relevant conduct information. Criminal offence for barred person to seek or engage in regulated activity. Criminal offence for employer to knowingly allow a barred person to engage in regulated activity. From 26 July 2010 Individuals applying for posts in regulated activity will be able to start registering with the Independent Safeguarding Authority, through a registered body, i.e. through UH Bristol. Registration is a one-off event, a unique registration number is issued to the individual and it is portable between employers. Existing staff changing posts internally in regulated activity will also be able to start registering with the Independent Safeguarding Authority. UH Bristol will be able to start checking those registered individuals through the Independent Safeguarding Authority online system, and registering an interest in them for continuous monitoring purposes against their registration status. From 1 November 2010 Registration with the Independent Safeguarding Authority becomes mandatory for individuals applying for posts in regulated activity, and existing staff changing posts internally in regulated activity. Criminal offence for an employer to allow an individual to engage in regulated activity without first checking the individual is registered with the Independent Safeguarding Authority. Employers start to invite existing staff working within regulated activity to register with the Independent Safeguarding Authority. This is phased in over 4 years, commencing with those staff who have never had a CRB check. The final phase will cover registration for those working in controlled activity. Page 163

164 Appendix 1 Definitions from Safeguarding Vulnerable groups Act 2006 (Section 59/60) A Child means a person who has attained the age of 18. A Vulnerable Adult means a person has attained the age of 18 and: a) He is in residential accommodation. b) He is in sheltered housing. c) He receives domiciliary care. d) He receives any form of health care. e) He is detained in lawful custody. f) He is by virtue of an order of a court under supervision by a person exercising function for the purposes of Part 1 of the Criminal Justice and Court services Act 2000 (c.43). g) He receives a welfare service of a prescribed description. h) He receives any service or participates in any activity provided specifically for person who fall without subsection (9). i) Payments are made to him (or to another on his behalf) in pursuance of arrangements under section 57 of the Health and Social Care Act 2001 (c.15) or j) He requires assistance in the conduct of his own affairs. Page 164

165 Trust Board Meeting Agenda Item 11b Date: 30 th November 2009 Title of Report Recommendations (please outline the purpose of the report and the key issues for consideration/decision) Actions Required Financial Report To inform the Trust Board of the Trust s financial position and report on related financial matters that require the Board s attention To receive the report and comment on any issues of concern Which Corporate Objective(s) are supported by this paper Is this on the Trust s risk register? If yes please give details. If not, why not? Eg. Risk Score is below 15 Which healthcare commission standard does this report provide evidence for? Financial Implications Revenue 0 Capital 0 Prepared by: Name & Title Presented by: Name & Title Paul Mapson, Finance Director Paul Tanner, Head of Finance Paul Mapson, Finance Director Previous Meetings xec Team Audit & Assurance Committee Governance Risk and Risk Management Finance Committee Trust Executive Group Other Meeting Please state 23rd November Page 165

166 Trust Board 30 th November2009 Agenda Item 4b TRUST BOARD 30 th November 2009 PAPER: Financial Report for the seven months to 31 st October 2009 PURPOSE: FORMAT: THE TRUST BOARD IS ASKED TO NOTE: To inform the Trust Board of the Trust s financial position and report on related financial matters that require the Board s attention. Monthly report with revisions to reflect financial reporting requirements for NHS Foundation Trusts. The October 2009 Financial Position Page 166

167 Financial Overview 1. The summary income and expenditure statement shows a deficit of 4.348m for the seven months to 31 st October The Annual Plan projections anticipate a deficit position at this stage in the year as a consequence of the inclusion of the charge for fixed asset impairments. The cumulative position is 0.501m better than the proportion of the Annual Plan EBITDA 1 surplus for the period. The estimated impact of the Modern Equivalent Value (MEA) revaluation of asset values has been included this month together with a proportion of the likely further reduction in the value of land and buildings to 31 st March For clarity the position is shown below with and without the MEA impact: Income and Expenditure for the 7 months to 31 st October Without MEA Revaluation 000 With MEA Revaluation 000 EBITDA 22,616 22,616 Fixed Assets impairments - (10,903) Depreciation (11,361) (10,402) Interest receivable Interest payable (275) (275) PDC Dividend (6,300) (5,472) Net Surplus/(Deficit) 4,768 (4,348) Financial Risk Rating The main Budget changes in October include the following:- 000 NICE funding to Divisions 1,573 Research & Development CLRN funding to Divisions 1,085 Discharge Service to Divisions 146 European Working Time Directive 112 Neurosciences Review to Trust HQ 63 CRB checks to Trust HQ Overall Financial Position Taking the MEA impact out of the equation the position to October is still a cause for concern. In particular the Clinical Divisions position needs to be understood with the additional funding improving the year to date position but hiding a still serious run-rate i.e. 1 Earnings Before Interest Taxation Depreciation and Amortisation Page 1 167

168 Financial Overview 000 Clinical Divisions Overspend to Month 06 (4,038) Funding for Discharge Ambulance Service 146 Impact of Research and Development funding 506 (3,386) Gross deterioration in the month (804) Overspend to Month 07 (4,190) This shows the underlying overspend in the month was still 804k which is of real continuing concern. The position on the key pay spending headings is shown in Appendix 1. This shows the actual spend by month by Division and at the Trust total level for key pay elements including bank, agency, waiting list payments and overtime payments. The Trust totals indicate that high levels of spend on these elements continue with minor reductions in bank, waiting list spend and overtime spend this month but an increase in agency spend. There is as yet no indication of a trend indicating a slowing down in the rate of spend on these key areas. The overall position on CRES shows an underachievement to date of 2.312m compared with an underachievement last month of 2.303m. However the month 7 position includes 506k relating to CLRN additional funding treated as non recurring CRES. Therefore the true comparison to last month is deterioration in the year to date position against plan of 515k. This is due to a further re-assessment CRES schemes and is particularly evident in the Surgery, Head and Neck, Women s and Children s and Specialised Services Divisions. The forecast year end under-achievement at month 07 is 3.319m compared to a forecast year end underachievement at month 06 of 4.146m. This is due mainly to the inclusion of 1.085m CLRN additional funding treated as non recurring CRES. If the impact of the CLRN funding is excluded the year end forecast compared to last month has worsened by 258k As reported last month if the financial plan is to be achieved there must be both a higher level of CRES achievement and a significant reduction in pay costs for the remainder of the year. 4. Divisional Position In total, Clinical Divisional budgets are overspent by 4.190m for the first seven months of the year. Pay and non pay budgets are overspent by 3.342m and 2.811m respectively. The surplus of 1.963m on income budgets partially offsets the expenditure overspendings. The Surgery, Head and Neck Division reports an adverse variance of 2.041m after seven months. There has been an adverse movement in the month of 190k when compared with the reported position to 30 th September ( 1,851k adverse). Pay budgets show a cumulative overspending of 1.733m. Non pay budgets show a cumulative overspending of 97k (September = 255k) with the Division having benefitted from the receipt of additional funding, backdated to the start of the year, for Research & Development ( 75k) and Emergency Response Service ( 58k). Income from Activities budgets show a cumulative underachievement to date of 141k (September = 72k adverse). The net overspending for the Division of Women s and Children s Services totals 1.405m for the seven months to 31 st October (September = 1,464k adverse). The improvement in Page 168 2

169 Financial Overview financial performance this month is mainly due to the addition of Research & Development funding of 110k and excess income overachievement of 150k. This results in a net improvement of 60k after allowing for the forecast trajectory of an overspend on all other headings of 200k in the month. The Diagnostic and Therapies Division reports a cumulative overspending of 35k after 7 months an improvement in the month of 31k. The Division is working to secure a breakeven position by the year end. The Division of Medicine has overspent by 276k over the seven month period to 31 st October an increase of 27k in the month. The Division has benefitted from additional income ( 265k) resulting from higher SLA performance. The Division continues to require a significant level of bank and agency nursing staff to cover for vacancies, sickness absence and to support additional beds. A number of non pay headings also continue to overspend as a result of the higher activity levels e.g. drugs and medical supplies. The Division of Specialised Services reports an adverse variance on its income and expenditure position of 433k (September 408k). The overspending on pay budgets in broadly unchanged in the month but this is masked by the receipt of Research & Development funding of 82k in the month. Non pay budgets have underspent in the month by 190k with gains reported against medical and surgical equipment ( 109k), Research & Development funding ( 128k) and the introduction of divisional reserves ( 172k). There were offsetting overspendings on other headings most notably haematology drugs ( 68k), blood products ( 63k) and CRES ( 47k). Income budgets report an adverse movement in the month of 213k of which 188k relates to SLA income. 5. Forecast Outturn The forecast out-turn excluding the MEA revaluation is unchanged. However the MEA impact has now been revised. This is still under further review due to the floor areas requiring more validation. 6. The income over-performance position for Bristol, North Somerset and South Gloucestershire PCTs needs to be understood. The position as at Month 6 (September) can be presented as follows: SLA Variances (All 000s) South Glos PCT North Somerset PCT Bristol PCT Total BNSSG PCTs Over-performance at Month 5 1, (78) 1,692 Unidentified savings in SLA (694) (682) (325) (1,701) A&E/Emergencies (143) (472) 29 (586) Residual Over(Under)performance 259 (480) (374) (595) Planned GP Referrals to week 31 3,748 5,964 26,118 35,830 Actual GP Referrals to week 31 4,924 6,045 26,709 37,678 Memo GP Referrals to wk /09 4,726 6,184 26,971 37,881 Page 169 3

170 Financial Overview This demonstrates that of the 1.7m over-performance to date 2.3m is due to unidentified savings in the SLA and emergency activity. In total there is, therefore, a residual underperformance of 0.6m. The GP referrals analysis also shows that actuals to date are 5.2% higher than plan, with referrals from GPs in South Gloucestershire 31% higher than plan. 7. Public Dividend Capital Funding The Trust s financial plan includes the receipt of 9m of Public Dividend Capital from the Department of Health to fund schemes in the capital programme (e.g. Bristol Heart Institute). The Trust resubmitted its application for funding in September in accordance with a revised timetable. The Trust had expected to be notified of its approved additional PDC in October. Work continues with the DoH Funding Team to finalise the Trust s PDC for 2009/10. Page 170 4

171 University Hospitals NHS Foundation Trust Agenda Item 5.1 Appendix 1 Analysis of pay spend month on month 2009/10 Division April May June July August September October Women's and Children's '000 '000 '000 '000 '000 '000 '000 Pay budget 5,134 5,207 5,065 5,147 5,170 5,316 5,154 Bank Agency Waiting List initiative Overtime Other pay 4,992 5,038 5,143 5,148 5,160 5,147 4,944 Total Pay expenditure 5,222 5,298 5,350 5,420 5,387 5,381 5,149 Variance Fav / (Adverse) (88) (91) (285) (273) (217) (65) 5 Medicine Pay budget 3,168 3,393 3,391 3,341 3,364 3,381 3,351 Bank Agency Waiting List initiative Overtime Other pay 2,814 3,125 2,965 2,939 2,999 3,091 3,007 Total Pay expenditure 3,168 3,523 3,320 3,360 3,396 3,532 3,365 Surgery Head and Neck Specialised Services Variance Fav / (Adverse) - (130) 71 (19) (32) (151) (14) Pay budget 5,210 5,302 5,173 4,683 5,199 5,219 5,200 Bank Agency Waiting List initiative Overtime Other pay 4,728 4,859 4,897 4,738 4,951 5,016 4,889 Total Pay expenditure 5,242 5,326 5,424 5,290 5,443 5,589 5,405 Variance Fav / (Adverse) (32) (24) (251) (607) (244) (370) (205) Pay budget 2,385 2,775 2,554 2,665 2,632 2,702 2,718 Bank Agency 22 (7) Waiting List initiative Overtime Other pay 2,447 2,624 2,610 2,544 2,583 2,612 2,552 Total Pay expenditure 2,559 2,711 2,737 2,699 2,768 2,788 2,720 Variance Fav / (Adverse) (174) 64 (183) (34) (136) (86) (2) Page 171

172 University Hospitals NHS Foundation Trust Agenda Item 5.1 Appendix 1 Analysis of pay spend month on month 2009/10 Division April May June July August September October Diagnostic & Therapies '000 '000 '000 '000 '000 '000 '000 Pay budget 2,749 2,813 2,864 2,857 2,934 2,969 3,207 Bank Agency Waiting List initiative Overtime Other pay 2,649 2,653 2,772 2,687 2,769 2,805 2,980 Total Pay expenditure 2,747 2,732 2,858 2,824 2,913 2,963 3,125 Facilities & Estates Variance Fav / (Adverse) Pay budget 1,261 1,427 1,373 1,604 1,390 1,612 1,390 Bank Agency Waiting List initiative Overtime Other pay 1,118 1,218 1,210 1,398 1,232 1,430 1,172 Total Pay expenditure 1,320 1,452 1,421 1,642 1,474 1,658 1,390 Variance Fav / (Adverse) (59) (25) (48) (38) (84) (46) - Trust Services Pay budget 2,124 2,233 2,304 2,075 2,133 2,304 1,648 Bank Agency Waiting List initiative Overtime Other pay 2,053 2,075 2,178 2,090 1,949 2,379 1,583 Total Pay expenditure 2,134 2,168 2,241 2,151 2,033 2,435 1,653 Variance Fav / (Adverse) (10) (76) 100 (131) (5) Trust totals Pay budget 22,031 23,150 22,724 22,372 22,822 23,503 22,668 Bank , , Agency Waiting List initiative Overtime Other pay 20,801 21,592 21,775 21,544 21,643 22,480 21,127 Total Pay expenditure 22,392 23,210 23,351 23,386 23,414 24,346 22,807 Variance Fav / (Adverse) (361) (60) (627) (1,014) (592) (843) (139) Page 172

173 UNIVERSITY HOSPITALS BRISTOL NHS FOUNDATION TRUST Finance Report October Summary Income Report Approved Budget / Plan 2009/10 Service Plan Position as at 31st October Actual Variance Fav / (Adv) Variance to 30th Sept Fav / (Adv) Forecast Outturn '000 '000 '000 '000 '000 '000 Income from Activities 360,667 Primary Care Trusts 208, ,463 1,882 2, ,939 - Dept of Health (95) - 6,789 Territorial Bodies 3,978 5,113 1, Non NHS Income 2,097 Private Patients 1,253 1,155 (98) (67) 2, Overseas Patients (Non Recip) (55) Road Traffic Act Other Non NHS Income (215) (186) ,124 Sub Total Income from Activities 214, ,491 2,667 2, ,280 Other Operating Income 2,058 Patient Transport Services 1,201 1, ,058 48,752 Education / Training / Research 27,288 27, , Charity / Other Contribution ,236 Transfer from Donation Reserve ,236 63,774 Other 37,793 38, , ,338 Sub Total Other Operating Income 67,443 68, , ,462 Totals 282, ,546 3,279 3, ,672 Page 173

174 Executive Summary Key Issue RAG Executive Summary Table SLA Income and Activity G Contract income is 0.37m higher than planned in October and now stands at 4.54m over target for the year to date. The majority of the over-performance is within BNSSG and the South West Specialised Commissioning Group. The main risk to contract income is that PCTs may refuse to pay for any over-performance, instead stating that the Trust must operate within the agreed contract value. INC 1 Income and Expenditure A A Accident & emergency attendances for April September at 57,138 are 1,954 attendances higher than planned. Non elective activity at 8,361 spells is 2.1% less than planned, with a year on year reduction of 2.4%. Emergency activity at 17,579 spells is 3.6% higher than planned, with a year on year increase of 5.7%. Overall elective activity is greater than planned to date - day cases by 291 spells partially offset by in patient activity being 159 spells less than planned for the period. New outpatient activity and follow up out-patient activity are also greater than plan by 9,191 and 6,001 attendances respectively. An income analysis by commissioner is shown at Table INC 2. Information on clinical activity by Division, specialty and patient type is given at Table INC 3. The overall position for the seven months to 31 st October is a deficit of 4.348m. This is 501k (2.3%) better than the planned EBITDA surplus to date contained within the Annual Plan. The reported position for the period includes the estimated impact of the Modern Equivalent Asset revaluation together with a proportion of the impact of the forecast further downward revaluation of building values for March This has given rise to the reporting of a technical deficit for the year to date. INC 2 INC 3 I&E 1 Total income receivable to 31 st October is shown as m this is 3.279m greater than plan to date. Expenditure at m is higher than planned by 8.286m. CRES The 2009/10 CRES programme totals m. Actual savings are 2.312m (or 27%) behind target after 7 R months. The forecast for the year using a weighted achievement methodology, which adjusts forecasts for the likelihood of successful delivery given progress and current status, indicates total CRES of m. This is of concern as it is 3.854m less than the target CRES. The balance of the 2008/09 programme, which was not achieved recurrently in 2008/09, totals 2.892m. The required level of recurring savings to date has been achieved and Divisions forecast full achievement for the year. I&E 2 I&E 3 I&E 4a 4b 4c - 4d Page 174

175 Executive Summary Balance Sheet G The cash balance on 31 st October was m, of which m is attributable to Skills for Health under segmental reporting. The year-end cash balance is forecast to be m, an increase on the Annual Plan forecast given the likely slippage on the capital programme in 2009/10 and the projected impact of the Modern Equivalent Asset valuation. Invoiced debtors have decreased by 6.206m in the month to m. Within this total are debtors for Skills for Health services of 2.355m (a reduction of 6.019m in the month). Creditors and accrual account balances total m although m relates to deferred income (including m for Skills for Health). Invoiced Creditors - payment performance for April October of Non NHS invoices and NHS invoices within 30 days was 91% and 84% respectively. BS 1 BS 2 BS 3 BS 4 BS5 Capital G Capital expenditure to 31 st October totals m, this is 1.484m less than the plan to date of m. The Trust, along with other Foundation Trusts, has had to resubmit its application for 2009/10 Public Dividend capital funding. The Trust had expected to be notified of its approved additional PDC in October. Work continues with the DoH Funding Team to finalise the Trust s PDC for 2009/10. Projected expenditure for the year is 25-30m. This is up to 15m less than planned primarily because of slippage on the BRI Redevelopment schemes, BHOC Refresh and Operational Capital schemes. Capital 1 Capital 2 Capital 3 KPIs G The Trust's overall financial risk rating using the results to 31 st October has been calculated to be 4 (actual score 4.05). The Trust s ratings under the Prudential Borrowing Code are satisfactory with all ratios well within the Monitor thresholds. Private Patient Cap G Private patient income to 31 st October was 1.155m. This equates to 0.53% of patient related income and is well below the Trust s Private Patient Cap of 1.1%. Page 175

176 UNIVERSITY HOSPITALS BRISTOL NHS FOUNDATION TRUST Finance Report October Risk Matrix Description of Risk Risk if no action taken Risk Score Financial Value 'm CRES Targets High 5.0 Action to be taken to mitigate risk CRES Group established. Monthly Divisional reviews to ensure targets are met. Lead Risk Score Residual Risk Financial Value 'm IS High 4.0 Progress / Completion Monthly reviews. Non recurring action if necessary. Fixed asset revaluation to Modern Equivalent Asset basis (August Review) Fixed asset impairments re Bristol Heart Institute and other major schemes High 10.0 High 4.2 Provision in Financial 1m. Discuss findings with District Valuer - September 2009 Provision in Financial 5.5m. Discuss findings with District Valuer - September 2009 PM High 3.7 PM High 4.2 Meetings held with District Valuer to finalise valuations. Process and initial findings discussed and agreed with External Auditor. SLA Performance Fines Medium 6.6 Infection Control plan implemented IS Low - Regular review of performance. Maintain capacity to assist with delivery of 4 hour A&E maximum waits. Medium 2.0 Capacity plans developed by Divisions. Likely to be offset by additional income. IS High 1.0 PCT Income challenges Medium 2.0 Maintain reviews of data, minmise risk of bad debts PM Medium 1.0 Limited by SLA ceiling on in year challenges. Fixed asset revaluation to Modern Equivalent Asset basis (March 2010 Review) Medium 9.6 Discuss with District Valuer PM Medium 8.9 District Valuer advises on potential reduction of 14% on value of buildings to March Energy costs Low 0.5 Carbon footprint / energy consumption awareness within Trust IS Low 0.1 Monitoring of energy contract prices (currently falling). File: Item 5.1 Nov 2009 Risk Matrix : Risk Matrix Page : 1 of 1 Page 176

177 Management Letter University Hospitals Bristol NHS Foundation Trust September 2009 Page 177