Thursday 23 June 2016 at 9.45 am (Staff Representatives pre-meeting at 9.00am) in Seminar Room 1, 2 nd Floor, Cochrane Building, UHW

Transcription

1 front page LPF Cardiff and Vale University Health Board Local Partnership Forum Meeting Thursday 23 June 2016 at 9.45 am (Staff Representatives pre-meeting at 9.00am) in Seminar Room 1, 2 nd Floor, Cochrane Building, UHW 1 of 121

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3 agenda LPF LOCAL PARTNERSHIP FORUM 9.45am on Thursday 23 June 2016 in Seminar Room 1, 2 nd Floor, Cochrane Building, UHW AGENDA PART 1: ITEMS FOR ACTION 1 Welcome and Introductions Verbal Chair 2 Apologies for Absence Verbal Chair 3 Declarations of Interest Verbal Chair 4 Minutes of the Local Partnership Forum meeting held on Chair 4 May Action Log Review Chair 6 Staff Engagement: PCIC Clinical Diagnostics and Therapeutics Presentation - Heads of Workforce and OD 7 Partnership and Recognition Agreement including Head of Workforce Revised Local Partnership Forum Terms of Reference Governance 8 Car Parking and Traffic Flow on the UHW Site Verbal Director of Planning 9 The Tobacco Challenge Implementing The UHB s No Director of Public Smoking Policy Health 10 Workforce Report Head of Workforce Governance 11 Finance Report Director of Finance 12 Reports from the Nurse Director a. Patient Experience and Concerns Report b. Serious Patient Safety Incident Report Director of Nursing 13 Emergency Services the voice of the staff Verbal Chief Executive 14 Staff Benefits Group Terms of Reference Director of Corporate Governance PART 2: ITEMS TO BE RECORDED AS RECEIVED AND NOTED FOR INFORMATION BY THE FORUM Papers are available on the Health Board website 1 Emergency Services Independent Review Update 2 Performance Report 3 Unconfirmed Minutes of the Employment Policy Sub 2 of 121

4 agenda LPF Group Meeting held on 11 May Any Other Business previously agreed with the co-chairs 5 Review of Meeting Oral Chair 6 The next meeting will be held on: Tuesday 9 August 2016, 10.00am in Seminar Room 2, Cochrane Building (N.B. the room will be available for a Staff Representatives Pre-Meeting 1 hour prior to the meeting) 3 of 121

5 1.4 Minutes of the Local Partnership Forum meeting held on 4 May 2016 LOCAL PARTNERSHIP FORUM Minutes of a Meeting held on Wednesday 4 May 2016 at 10am in the Board Room, Executive Headquarters, UHW Present: Raj Chana Mike Jones Maria Battle Fiona Salter Ceri Dolan Dorothy Debrah Zoe Morgan Pauline Williams Peter Hewin Joe Monks David Gogherty Jonathan Pritchard Jane Williams Peter Cockburn Peter Welsh Chris Lewis Claire Radley Stuart Egan Abigail Harris Joanne Brandon Judith Hill Adam Cairns Sharon Hopkins Apologies: Julia Davies Ruth Walker Graham Shortland Fiona Jenkins Paul Harrison Nigel Gibbs Julie Cassley Dawn Ward Andrew Crook Secretariat: Rachel Pressley Executive Director of Workforce and OD Chair of Staff Representatives/UNISON UHB Chair (part of meeting) RCN RCN BDA CSP RCN BAOT/UNISON UNISON UNITE Head of Workforce and OD, Specialist Services (part of meeting) Head of Workforce and OD, Planning and Dental (part of meeting) Head of Commercial Services, Planning (part of meeting) Director of Corporate Governance Deputy Director of Finance Assistant Director of OD Independent Member Trade Union Executive Director of Strategy and Planning Director of Communication and Engagement Deputy Director of Nursing Chief Executive Director of Public Health UNISON Executive Director of Nursing Medical Director Executive Director of Therapies and Health Sciences SCP UNITE Assistant Director of Workforce BAOT/UNISON Head of Workforce Governance Workforce Governance Manager 4 of 121

6 1.4 Minutes of the Local Partnership Forum meeting held on 4 May 2016 LPF 16/021 WELCOME AND INTRODUCTIONS Ms Chana welcomed everyone to the meeting and introductions were made. LPF 16/022 APOLOGIES FOR ABSENCE Apologies for Absence were NOTED. LPF 16/023 DECLARATIONS OF INTEREST There were no declarations of interest in respect of agenda items. LPF 16/024 MINUTES OF THE PREVIOUS MEETING The minutes of the meeting held on 10 February 2016 were RECEIVED and APPROVED as an accurate record subject to the following amendment: Miss Fiona Salter asked if initials could be used to avoid confusion between herself and Ms Catherine Salter. LPF 16/025 ACTION LOG REVIEW The updated Action Log was RECEIVED and NOTED. (Mrs Harris and Ms Brandon entered the meeting) LPF 16/026 STAFF ENGAGEMENT - SPECIALIST SERVICES CLINICAL BOARD The Local Partnership Forum RECEIVED a presentation on staff engagement within Specialist Services Clinical Board from the Head of Workforce and OD. Mr Pritchard tabled a copy of the Clinical Board Staff Engagement Action Plan. Key points raised during the presentation included: The make-up of the Clinical Board, noting that workforce costs accounted for the majority of the budget Staff feedback had been provided through the 2013 staff survey. It was noted that strengths and weaknesses had been identified and incorporated into the action plan. It was important that staff had confidence that their feedback was being acted upon. 5 of 121

7 1.4 Minutes of the Local Partnership Forum meeting held on 4 May 2016 Achievements included challenging unacceptable behaviours at all levels and changes in recruitment through the introduction of values and behaviours based interview questions. The work conducted in Suite 19 and improvements in employee relations were also noted. Planned initiatives included a pilot of entry questionnaires in areas with low retention levels to assess the views of new staff when they had been in post for 3 months, and the introduction of smaller teams in Critical Care It was noted that there was no Lead Staff Representative within the Clinical Board at present but that one would be appointed by the staff representative body soon. Mr Jones noted that Suite 19 had previously been a very bad place to work, but that this had been turned around at pace. He stated that this had been a brilliant piece of work which had involved partnership working between the Clinical Board, staff and the Executive Director of Nursing. Miss Battle added that issues around Suite 19 had also been raised through the Safety Valve. She had visited it the previous day and had found it to have marvellous care and atmosphere. Mrs Dolan congratulated Mr Pritchard on reducing the number of disciplinary cases. She noted that the Capability Policy had been used to good effect instead, and that staff had been moved to more appropriate areas rather than inappropriately disciplined on occasions. Ms Chana noted that there had also been a pulse survey in 2015 and asked if the feedback received through that had also been built into the action plan. Mr Pritchard confirmed that this was the case. (Miss Battle left the meeting) LPF 16/027 STAFF ENGAGEMENT PLANNING SERVICES BOARD The Local Partnership Forum RECEIVED a presentation on staff engagement within the Planning Services Board from the Commercial Services Manager and the Lead Staff Representative. Key points raised during the presentation included: The diverse nature of the workforce, while noting that 75% of staff employed in the Board are in Bands 1 and 2. Engagement has been historically low and communication is an issue. Key issues had been identified through surveys and focus groups. High sickness levels and employee relations activity have also been considered. 6 of 121

8 1.4 Minutes of the Local Partnership Forum meeting held on 4 May 2016 An action plan has been developed since the last survey - this includes items such as improved communication and visibility, KPIs, and the establishment of an engagement group and other task and finish groups. The issue of respect was a recurring theme, particularly in relation to the way Planning staff are perceived by other Clinical Boards. Work was taking place to improve PADR and statutory/mandatory training compliance rates and incorporate the values and behaviours into recruitment and all other aspects of the service. Mr Hewin commented on the band weighting of the Board, noting that in Scotland work had taken place to remove Band 1 from the structure through up-skilling and redesign. He suggested that this was something that could be done incrementally on a local level and would potentially help with the respect issue. Mrs J Williams advised that this issue had already been raised by Mr Monks at the Service Board. It was noted that all Band 1 staff are paid the National Living Wage which is the equivalent of half way up the Band 2 scale. Miss F Salter stated that while she supported the idea of phasing out Band 1 posts, she had some concerns about the effect this could have on potential staff seeking entry level posts because they do not have the skills and experience required for Band 2 roles. Mrs J Williams advised that work was taking place to promote participation and improve opportunity to take part in the planned 2016 staff survey. Ms Chana asked what improved respect from other areas would look like. Mrs J Williams advised that a number of ideas had been put forward including greater understanding of the role and the individuals working in an area. Mr Cockburn suggested that as he was relatively new in post he would prefer to spend more time evaluating and understanding the evidence before developing a detailed action plan to address staff concerns. LPF 16/028 VALUES AND BEHAVIOURS The Local Partnership Forum RECEIVED and NOTED a verbal report from the Assistant Director of OD. Dr Radley reminded the forum that the UHB had had clear values for some time, but that it had not yet articulated what this meant in terms of the behaviours which were expected or were not expected as a consequence. A company called April Strategy had been appointed to support the UHB with this. Part of the process would include building capacity and expertise so that the work could continue internally under the brand Values into Action. The work would take place in 3 phases: 7 of 121

9 1.4 Minutes of the Local Partnership Forum meeting held on 4 May Laying the foundations, including establishing a baseline. This would include establishing what other pieces of work had been undertaken which were relevant to this and working with the Concerns team. 2. An articulation of what behaviours we do and do not expect to this. This would include collating feedback from thousands of staff, patients, carers and visitors under the title In Your Shoes. 3. Identifying how to integrate these behaviours into workforce processes. The work would be launched on 11 July, with the listening exercises taking place during the weeks beginning 19 and 26 September. The expected outcomes were improved patient experience and a behavioural shift. Mr Hewin stated that while he understood capacity could be an issue, he was surprised that the UHB did not have the capability to undertake this piece of work without external support. Dr Radley explained that part of the package offered by April Strategy was a methodology which had not previously been available to the UHB but which could be used continually to listen to staff and patients because of the training they also provided. Mr Hewin also expressed concern that staff could become confused between this work and the All-Wales Common Principles launched recently. Dr Radley advised that care was being taken to ensure that the two were made complimentary to avoid such confusion. LPF 16/029 NHS WALES STAFF SURVEY 2016 The Local Partnership Forum RECEIVED and NOTED the report of the Assistant Director of OD, outlining plans for the 2016 national Staff Survey. Dr Radley asked the Local Partnership Forum to note the following additional points: The NHS Centre for Equality and Human Rights would be Equality Impact Assessing the survey Delays in signing off the procurement process meant that the proposed start date of June 2016 had slipped. The survey would now take place either between July and September, or for 4-6 weeks commencing in September. The UHB had been asked to express a preference. Dr Radley was particularly keen that it did not coincide with the values and behaviours work due to take place. Mr Jones advised that Mr Gibbs had already asked staff representative colleagues for their views on the timing of the survey. He understood that Mr Gibbs had received a number of responses and would feedback through the agreed channels, but the general view seemed to be that commencing in September was the preferred option. 8 of 121

10 1.4 Minutes of the Local Partnership Forum meeting held on 4 May 2016 LPF 16/030 FRAMEWORK FOR WORKING WITH THE THIRD SECTOR The Local Partnership Forum RECEIVED and NOTED the report of the Executive Director of Public Health, outlining the UHB Framework for working with the third sector. Dr Hopkins advised that the third sector was increasingly becoming a partner of the UHB. Following a survey and engagement event a framework and action plan had previously been developed and had subsequently been refreshed against Shaping Our Future Wellbeing. Dr Hopkins added that if anyone was engaging with the third sector and would like some support they were welcome to get in touch. LPF 16/031 WORKFORCE REPORT The Local Partnership Forum RECEIVED and NOTED the report of the Executive Director of Workforce, outlining the UHB key financial and workforce indicators for March 2016 (February 2016 for sickness). Ms Chana advised that vacancies, turnover and sickness absence had improved, while PADR compliance, statutory and mandatory training compliance, pay bill spend and variable pay rate had moved in a negative direction. New sickness targets for 2016/17 had been agreed with the Clinical Boards and were set out in the report. Sickness and PADRs remained Welsh Government Tier 1 targets. Ms Chana reminded members of the Forum of the importance of remaining up to date with statutory and mandatory training requirements. She acknowledged that there were some problems with the All-Wales system such as the inability to re-do the training until the expiry date had passed, and its failure to speak directly to ESR. Both issues had been flagged with NWIS through the Statutory and Mandatory Training Steering group. LPF 16/032 FINANCE REPORT The Local Partnership Forum RECEIVED and NOTED the report of the Deputy Director of Finance, outlining the UHBs financial position for the period ended 29 February 2016 (month 11). Mr Lewis advised that the UHB financial position for month 11 was a year to date deficit of 10.3m and a full year forecast deficit of 9.9m. As part of receiving additional allocations from Welsh Government in month 9 the UHB had been tasked to deliver a year end position below a 10m deficit. The 9 of 121

11 1.4 Minutes of the Local Partnership Forum meeting held on 4 May 2016 draft month 12 position was below 10m which meant that the UHB had achieved its control target set by Welsh Government. In addition, the UHB was successful in securing 10m additional funding for acute service and winter pressures, the net effect is that, subject to audit, the UHB is reporting a very small surplus for 2015/16. Mr Lewis explained that this was largely due to the UHB performing well against Welsh Government targets, particularly RTT. However, Mr Lewis pointed out that 25m of the monies for 2015/16 was non-recurrent, which meant that the UHB was starting 2016/17 with a 25m deficit. LPF 16/033 PATIENT EXPERIENCE AND CONCERNS The Local Partnership Forum RECEIVED and NOTED the report of the Executive Director of Nursing, presented by the Deputy Director of Nursing, outlining patient experience and concerns. Mrs Hill advised that patients continued to report good experience and satisfaction in many areas, though there was some dissatisfaction, particularly around delayed discharge. In terms of concerns, Mrs Hill reported that the majority were resolved informally, and performance against the 2 day target was good, but more work was needed against the 30 day target. LPF 16/034 SERIOUS PATIENT SAFETY INCIDENT REPORT The Local Partnership Forum RECEIVED and NOTED the report of the Executive Director of Nursing, presented by the Deputy Director of Nursing, outlining serious patient safety incidents. Mrs Hill reminded the forum that the purpose of this report was to learn lessons, not to apportion blame. She advised that 27 new serious incidents had been reported to Welsh Government, some of which were very significant for the individuals concerned. She emphasised the importance of working to ensure that these mistakes were not replicated. LPF 16/035 EMERGENCY SERVICES Ms Chana advised the Local Partnership Forum that all 46 recommendations were now being reported as amber or green. The recommendations were being signed by the Clinical Board on completion as they would continue to own them. There was a need to ensure communication with colleagues continued. Mr Cairns asked staff representative members of the Forum if they had any issues they wanted to raise. Both Miss F Salter and Mr Jones indicated that 10 of 121

12 1.4 Minutes of the Local Partnership Forum meeting held on 4 May 2016 no specific issues had been raised with them, though Mr Jones acknowledged that staffing levels was an ongoing concern and was likely to remain so. LPF 16/36 LEADERSHIP The Local Partnership Forum RECEIVED a presentation from the Chief Executive. Mr Cairns reminded the Forum that the UHB mission was Caring for People, Keeping People Well and that a strategy had been developed to enable this. He acknowledged the good work being undertaking by the workforce in a context of competing priorities. He noted that it was easy to spend time on the urgent at the expense of the important and talked about Eisenhower s matrix which encouraged people to do, decide, delegate or delete. Mr Cairns described 3 features of healthcare which patients do not ask for: avoidable harm; avoidable waste; and unwarranted variation. He advised that if these were resolved as much as 35-40% of total capacity could be recovered which would lead to better outcomes and lower costs, and would in turn enable us to do more for more people. The Forum was advised that 2016 was a BIG year this meant that there were three Bold Improvement Goals: Big 1 reorganised in-patient medical beds by October 2016 Big 2 the perfect locality described by October 2016 and ready for implementation by April 2017 Big 3 tackling unwarranted variation. To achieve this, plans were in place to bring together experts to blend into a new healthcare academy for Cardiff a CAVacademy. This would be built on the success of the LIPS programme and would include aspects such as continuous service improvement, organisational development, training, talent management etc to lift the skills base of our people. Alongside this was a recognition that one cause of health inequality was whether or not the individual was in employment. A collaboration called HEART (Health Enterprise Alliance for Regional Transformation) was being set up between the UHB, Cardiff University and Cardiff and the Vale Councils to combine capacity and capability and bring about a significant revolution in health and wellbeing, as well as an engine for economic development. To finish, Mr Cairns described some of the achievements over the last year including RTT and Cancer care, and he thanked everyone for the contribution they had made to these. The Forum discussed the presentation and the following points were noted: 11 of 121

13 1.4 Minutes of the Local Partnership Forum meeting held on 4 May 2016 It was good to hear how well the UHB was doing The proposals contained in BIG 1 were similar to changes made locally in one of the Community Mental Health Teams. This showed alignment between the bottom-up and the top-down ideas currently being implemented. The achievements of the last year were due to the efforts of the whole organisation and it was important to acknowledge this. Miss F Salter expressed concern about the idea of another restructure or significant change within Medicine and asked for caution and sensitivity in the communication of any plans. Mr Cairns asked for the Forum s help and support in driving and implementing the changes discussed. LPF 16/037 STAFF BENEFITS The Local Partnership Forum RECEIVED the report of the Director of Corporate Governance, outlining plans for the Staff Benefits Group to report to the Local Partnership Forum. The Forum SUPPORTED this suggestion, and asked for a more formal report along with revised Terms of Reference to be brought to the next meeting. ACTION: Mr Welsh LPF 16/038 NURSE REVALIDATION The Local Partnership Forum RECEIVED and NOTED the report of the Executive Director of Nursing outlining progress against the implementation of the NMC Revalidation process. LPF 16/039 PERFORMANCE REPORT The Local Partnership Forum RECEIVED and NOTED the Performance Report outlining performance against the Welsh Government Delivery Framework and other priority targets up to December LPF 16/040 NHS WALES POLICIES FOR ADOPTION The Local Partnership Forum RECEIVED and NOTED the report of the Executive Director of Workforce and OD summarising key changes to three NHS Wales Policies. The Grievance Policy, Secondment Policy and Reservist Policy had been reviewed on a national basis and would now be adopted by the People, Planning and Performance Committee on behalf of the UHB. 12 of 121

14 1.4 Minutes of the Local Partnership Forum meeting held on 4 May 2016 LPF 16/041 ANY OTHER BUSINESS There was no other business for consideration by the Forum. LPF 16/042 REVIEW OF THE MEETING The Local Partnership Forum reviewed the meeting and asked Mr Egan to bring the three presentations received to the attention of the Board. ACTION: Mr Egan LPF 16/043 ARRANGEMENTS FOR THE NEXT MEETING The next meeting of the Local Partnership Forum would be held on Thursday 23 June 2016 at 10.30am in Seminar Room 1, 2 nd Floor, Cochrane Building, UHW. The room would be available from 9.30am for a staff representative pre-meeting. 13 of 121

15 1.5 Action Log Review Local Partnership Forum Action Log MINUTE DATE SUBJECT AGREED ACTION ACTIONED TO LPF 4 May 2016 Staff Benefits Group Formal report along with revised Mr Welsh 16/037 Terms of Reference to be brought to the next meeting. STATUS On agenda LPF 16/042 4 May 2016 Review of the Meeting The three presentations received to be brought to the attention of the Board. Mr Egan Complete 14 of 121

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17 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference PARTNERSHIP AND RECOGNITION AGREEMENT Executive Lead: Director of Workforce and OD Author: Head of Workforce Governance, Caring for People, Keeping People Well : elements of the Health Board s Strategy Financial impact not applicable This report underpins the Values Quality, Safety, Patient Experience impact The implementation of these the Partnership and Recognition Agreement will positively impact on the delivery of clinical services through the raising of standards Healthcare Standard Number 7 CRAF Reference Number Equality Impact Assessment Completed: no RECOMMENDATION The Local Partnership Forum is asked to: COMMENT on and RECOMMEND the approval of the Partnership And Recognition Agreement SITUATION This paper summarises for the Local Partnership Forum details of the revised Partnership and Recognition Agreement, including the Local Partnership Forum Terms of Reference BACKGROUND As part of the establishment of the Local Partnership Forum in 2009, the preexisting Partnership & Recognition Agreements in the former Trust and Local Health Boards were reviewed and updated to create the current Health Board Partnership & Recognition Agreement. This Agreement reflects the open and participative working style within the Health Board and reinforces the principles of partnership working, the scope of recognition and the position of work place representatives. The Agreement includes and incorporates the Terms of Reference of the Local Partnership Forum and outlines the negotiation and consultation framework within the Health Board. The Agreement has now been reviewed again and will be presented to the Board for approval in July of 121

18 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference ASSESSMENT The main revisions to the Partnership and Recognition Agreement are as follows: An updated restatement of the UHB s commitment to partnership working from the Chair, Chief Executive and Chair of Staff Representatives. A refinement and reinforcement of the principles of partnership working A statement in relation to the responsibilities of the UHB, Staff Representatives and Managers to ensure effective partnership working The general principles and purpose of the Local Partnership Forum as set out in the Terms of Reference remain unchanged. The main changes to the Local Partnership Forum Terms of Reference (Appendix 1) are practical in nature and include: Inclusion of the Staff Benefits Group as a sub-group of the Local Partnership Forum The list of management representatives has been updated to reflect the current Executive structure and to include the Director of Corporate Governance, Director of Communications and Engagement and Head of Workforce Governance It has been made explicit that members of the Forum are expected to attend regularly and that this will be reviewed by the join chairs Greater clarity has been provided around quoracy arrangements - this now consists of 6 management and 6 staff representatives. Members of the Forum who are unable to attend may send a suitable deputies who will contribute to the meeting being quorate. The requirement to elect officers annually has been removed as this is undertaken by the staff representative body outside of the Local Partnership Forum The Workforce Governance Manager is named as secretary for the Local Partnership Forum In addition, the Welsh Partnership Forum Time Off And Facilities For Trade Union Representatives Key Principles Framework has been added to the Partnership and Recognition Agreement as Appendix 2. The UHB Time Off and Facilities for Accredited Staff Representatives Policy will be rescinded on approval of the Partnership and Recognition Agreement. Wide consultation has taken place to ensure that the Partnership and Recognition Agreement meets the needs of our stakeholders and the Health Board. The consultation undertaken in relation to the policy was as follows:- The Chair of Staff Representatives was heavily involved in the review process The document was added to the Policy Consultation pages on the intranet between 17 February and 18 March 2016 and a link was sent to Executive Directors, Clinical Board Teams, senior Staff Representatives, members of 16 of 121

19 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference the Workforce and OD function, the Equality Manager and other policy stakeholders The Agreement was shared with the Employment Policy Sub Group on 11 May 2016 Where appropriate comments were taken on board and incorporated within the draft document. The primary source for dissemination of this policy within the UHB will be via the intranet and clinical portal. It will also be made available to the wider community and our partners via the UHB internet site. 17 of 121

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21 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 1 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy PARTNERSHIP & RECOGNITION AGREEMENT 18 of 121

22 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 2 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy CARDIFF AND VALE UNIVERSITY LOCAL HEALTH BOARD PARTNERSHIP & RECOGNITION AGREEMENT The Cardiff and Vale University Local Health Board (the UHB) is committed to working in partnership with recognised Trade Unions and Professional Staff Organisations. The UHB will negotiate and discuss strategic issues with staff representatives and involve them in the decision making process to shape the Health Board s services. Representatives and managers are required to work collaboratively for the benefit of staff, patients, visitors, relatives and the Health Board. Maria Battle Chair Adam Cairns Chief Executive Mike Jones Chair of Staff Representatives 19 of 121

23 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 3 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy PARTNERSHIP & RECOGNITION AGREEMENT BETWEENTHE HEALTH BOARD & TRADE UNIONS & PROFESSIONAL ORGANISATIONS WHICH REPRESENT STAFF CONTENTS 1. Introduction PAGE 2. Principles 3. Definitions 4. Duties, Responsibilities and Commitment 5. Recognition 6. Scope of Recognition 7. Work Place Representatives 8. Information 9. Negotiation / Consultation Machinery 10. Review Appendix 1 Local Partnership Forum Terms of Reference Appendix 2 - Welsh Partnership Forum Time Off and Facilities for Trade Union Representatives Key Principles Framework 20 of 121

24 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 4 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy 1. Introduction The Health Board is committed to the partnership agenda with its employees to ensure that they can be involved in the decisions that affect them and the services they provide for patients The Health Board objective of delivering the highest quality services possible can only be achieved by a workforce that is sufficiently skilled, committed and feels valued. This agreement is intended to help further embed partnership working within the culture and practice of the organisation at all levels. The Health Board will ensure that managers are committed to an open and participative working style by being honest, open and fair in their relationships with staff. Managers will demonstrate this through their own behaviour and the behaviour they expect from their staff. 2. Principles of Partnership Working To deliver partnership working successfully, it is important to develop good formal and informal working relations that build trust and share responsibility, whilst respecting difference. It is a principle of the UHB that all our staff and their representatives are involved at every level in matters affecting their jobs and working lives. This involvement should be at the earliest opportunity, prior to decisions being made. To facilitate effective partnership working, all parties will commit to adopt the following principles in their dealings with one another: Building trust and mutual respect for each other s roles and responsibilities; Openness, honesty and transparency Top level commitment A positive and constructive approach Commitment to work and learn from each other Early discussion on emerging issues and maintaining dialogue on policy and priorities Commitment to ensuring high quality outcomes for service users Making the best of available resources Ensuring a no surprises culture is maintained. Working together on a basis of co-operation, openness and mutual trust is acknowledged by both the UHB and Trade Unions to be the best way to 21 of 121

25 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 5 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy enhance the ability of the UHB to adapt to changing circumstances and financial constraints and to ensure the future success of the Health Board in the delivery of high quality patient services. The UHB s approach to partnership working is underpinned by our agreed values and behaviours: We care about the people we serve and the people we work with We trust and respect one another We take personal responsibility We treat people with kindness We act with integrity Treat people as you would like to be treated and always with compassion Look for feedback from others on how you are doing and strive for better ways of doing things Be enthusiastic and take responsibility for what you do. Thank people, celebrate success and when things go wrong ask what can I learn? Never let structures get in the way of doing the right thing. 3. Definitions 3.1. The UHB and Unions agree that the pursuit of the common objectives, aims and values outlined in the introduction to this agreement shall be by negotiation, consultation and the exchange of information which are defined as follows: Negotiation conferring with another with a view to reaching a compromise or agreement. This is with the understanding that if this cannot be reached after a reasonable period of time, management will make a decision to move things forward. Consultation a process of dialogue that leads to a decision (Audit Commission). This will ensure the early involvement of Unions on key issues affecting the Health Board with a meaningful opportunity to influence decisions. Information Ensuring that everyone is fully and promptly informed on all relevant matters. 22 of 121

26 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 6 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy 3.2. The issues to be relayed, consulted upon or negotiated under this agreement concern the Health Board s staff, and will therefore be between the Health Board s management and those accredited representatives of the staff belonging to the organisation listed in 5.1 who are themselves employed by the Health Board. 4. Duties, Responsibilities and Commitment The following outlines the agreed responsibilities and commitment of the UHB, Staff Representatives and Managers in ensuring effective partnership working: 4.1. The UHB will be responsible for: Developing and implementing an effective two-way communication process across the Health Board. Developing a culture where managers involve staff at all times, and as soon as possible, in decision making and where staff feel able to contribute and be confident that their contribution is valued Developing and implementing a structure and process which requires managers at all levels to involve staff in day to day service decisions and formulation of service plans Developing and implementing a structure that provides Staff Representatives and Managers to input into the formulation of UHB services plans and decisions. Appraise and discuss in partnership with Staff Representatives, the financial performance of the UHB on a regular basis Ensuring all levels of management are familiar with agreements and arrangements relating to partnership working / staff involvement including the facilities agreement Working in partnership to manage change more effectively and achieve long term goals Encouraging staff to join a recognised Trade Union, staff organisation or professional organisation. Unions have an important role in representing staff both individually and collectively. As members of a Trade Union participating in the Health Board s 23 of 121

27 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 7 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy joint negotiation / consultation machinery, staff are able to influence plans and decisions relating to employment Recognising and acknowledging the Unions right and responsibility to represent the interests of their members and to work for improved conditions of employment for the employees covered by this agreement. Ensure Staff Representatives are afforded reasonable paid time off to undertake their duties and activities 4.3 Staff Representatives will be responsible for: Recognising and acknowledging that it is the responsibility of the Health Board s management to determine the most effective way of planning, organising and managing the activities of the Health Board according to the objectives set by the Health Board. Accepting that management has a responsibility to keep employees directly informed on matters concerning the activities of the Health Board, but this does not obviate the requirement under this agreement to negotiate or consult through the recognised machinery on matters covered by this agreement. Ensuring that their representatives are at all times committed to an open and participative working style. Staff and their representatives will demonstrate this through their own behaviour and the behaviour that they expect from colleagues. Ensuring their time and resources are used appropriately and cost effectively Ensuring that decisions reached in partnership will be supported through implementation Communicating effectively with their members to ensure that they fully represent their views Support the correct, appropriate and efficient application of Health Board policies Agree to maintain confidentiality regarding sensitive issues 24 of 121

28 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 8 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy Demonstrating joint commitment to the success of the organisation with a positive and constructive approach Ensuring that representatives are elected and accredited in accordance with Trade Union constitutions Provision of appropriate training for representatives and members either separately or jointly in partnership 4.3 Managers will be responsible for: Communicating and engaging with staff on a regular basis and keep them informed of developments across the organisation Encourage staff and their representatives to be involved at the earliest stages of any new developments Ensure that staff representatives are released to support the engagement and partnership work of the Health Board Ensure that the views of the staff are passed up the organisation, as well as communicating the views of the Executives and the Health Board Encourage and support staff to challenge and question systems of work Staff involvement taking place throughout the organisation, irrespective of boundaries of profession, service and functional structure Staff have the opportunity to express their opinions and be actively involved in issues affecting them Ensure that Trade Union representatives have access to all relevant information, other than confidential information about patients or staff, to support involvement in decisions that affect working lives and the delivery of healthcare Recognising that staff, and their representatives, must have a degree of protected time away from their place of work to enable them to attend and contribute to the staff involvement process. To achieve this, managers will ensure employees are treated fairly for their Trade Union involvement and careers are not prejudiced 25 of 121

29 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 9 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy 5. Recognition 5.1. The Health Board agrees to recognise for negotiation, meaningful discussion and debate on key issues and individual representation all Unions nationally recognised and who have members within the Health Board. British Association of Occupational Therapists British Dental Association British Dietetic Association British Medical Association British Orthoptic Society Chartered Society of Physiotherapy Federation of Clinical Scientists GMB Hospital Consultants and Specialists Association Royal College of Midwives Royal College of Nursing Society of Chiropodists and Podiatrists Society of Radiographers Union of Construction and Allied Trades & Technicians UNISON UNITE BAOT BDA BDA BMA BOS CSP FCS GMB HCSA RCM RCN SOCP SOR UCATT UNISON UNITE 5.2. Any Union listed which ceases to have any members employed by the Health Board will cease to be recognised under this Agreement. 6. Scope of Recognition 6.1. This agreement will cover major issues of Health Board policy including: Organisational culture Organisational change Employment security Employment practices (e.g. family friendly, best practice, equal opportunities, health and safety at work, etc) Lifelong learning 6.2. In addition this agreement will cover such other matters agreed as being of common interest, for example: 26 of 121

30 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 10 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy Terms and Conditions of employment Allocation of work and duties of employment Matters of Discipline / Grievance Facilities and time off for Union Officials Machinery for consultation and negotiation and any procedures relating to the above and other relevant matters. Union membership or non-membership 6.3. This agreement commits management and Trade Unions to working together to develop and implement an annual staff involvement action plan to encompass the delivery of: A charter of staff rights and responsibilities A programme of joint development for staff involvement and partnership working Staff involvement in service planning An annual staff survey on working life within the organisation and a joint action plan to respond to its outcomes An annual joint audit of progress with the results published in the Health Board s Annual Report 7. Work Place Representatives 7.1. In order to ensure appropriate representation of Union members and their interests, the Unions will make arrangements from among their members, who are employees of the Health Board, for such numbers of representatives as are appropriate to provide adequate representation. The election of representatives and officials shall be determined by the individual Unions in accordance with their Rules. The names of representatives, the constituencies they represent or function they carry out, and their term of office, will be notified in writing to the Director of Workforce & OD, who will be notified of any changes in the Union representatives or officials On receipt of details or amendments, the Director of Workforce & OD will formally accredit the nomination, ensure the provision of facilities to accredited representatives and inform the appropriate manager(s) The Health Board will provide time off and facilities in accordance with current legislation, and the relevant Code of Practice. Details of time off and facilities are outlined in the Time Off and Facilities for Accredited Representatives document which forms part of this Agreement. 27 of 121

31 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 11 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy 7.4. The Health Board recognises the value of work place representatives and will ensure that representatives suffer no detriment in relation to career progression as a result of their role It is acknowledged that there will be circumstances where it is beneficial for Full Time Officers to be involved. Full Time Officers may therefore be involved at the request of the local representatives, following prior notification to management and in accordance with any constitutional arrangements agreed for any joint forum The Health Board also recognises the role and contribution of Union Learning Representatives in accordance with the provisions of the Employment Act Information 8.1. The Health Board will provide timely information required for collective bargaining purposes, in accordance with current legislation and Code of Practice The Health Board will also seek to ensure that its Communication Policy and practices ensure that all staff are able to be informed of the Health Board s plans, objectives and progress The Unions will supply to the Health Board, upon request, a copy of their rules, either free or at a reasonable charge. 9. Negotiation / Consultation Machinery 9.1. The NHS Terms and Conditions handbook requires that Joint Consultation arrangements should be set up in agreement with employee representatives. Agreement should be reached on a number of issues, including: Size and composition of the committee Organisation of committee meetings Subjects to discuss Facilities for committee members; and Arrangements for reporting back 9.2. Detailed arrangements for the working of the Health Board s Local Partnership Forum are outlined in the Terms of Reference for that 28 of 121

32 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 12 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy committee and form part of this agreement, and are attached as Appendix Review This agreement may be amended at any time following agreement by both parties The operation of the agreement will be reviewed after a period of 3 years from its commencement. 29 of 121

33 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 13 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy APPENDIX 1 Local Partnership Forum Terms of Reference and Operating Arrangements 30 of 121

34 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 14 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy 1. INTRODUCTION 1.1 The Cardiff and Vale University Health Board Local Partnership Forum (LPF) is the formal mechanism where the Health Board and trade unions* work together to improve health services for the people of Cardiff and the Vale of Glamorgan and for others accessing services provided by the Health Board. It is the forum where key stakeholders will engage with each other to inform, debate and seek to agree local priorities on workforce and health service issues. 1.2 Cardiff and Vale University Health Board (the UHB) will engage staff organisations in the key discussions at the UHB Board, UHB Partnership Forum and Locality/Clinical Board level. 1.3 The UHB LPF will provide the formal mechanism for consultation, negotiation and communication between the Unions and management. The TUC principles of partnership will apply the principles are attached at Annex 1. * all references to Trade unions include Trade Unions, Professional Staff Organisations and Staff Associations General Principles 1.4 The Partnership Forum accepts that partnerships help the workforce and management work through challenges and to grow and strengthen their organisations. Relationships are built on trust and confidence and demonstrate a real commitment to work together. The principles of true partnership working between Trades Union and Management are as follows: TU s and management show joint commitment to the success of the organisation with a positive and constructive approach they recognise the legitimacy of other partners and their interests and treat all parties with trust and mutual respect they demonstrate commitment to security for workers and flexible ways of working they share success rewards must be felt to be fair 31 of 121

35 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 15 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy they practice open and transparent communication sharing information widely with openness, honesty and transparency they must bring effective representation of the views and interests of the workforce they must demonstrate a commitment to work with and learn from each other. All members must: be prepared to engage with and contribute fully to the Forum s activities and in a manner that upholds the standards of good governance set for the NHS in Wales comply with their terms and conditions of appointment equip themselves to fulfil the breadth of their responsibilities by participating in appropriate personal and organisational development programmes, and promote the work of the LPF within the professional discipline he/she represents. A Code of Conduct is attached as Annex PURPOSE 2.1 The purpose of the UHB Local Partnership Forum is to: establish a regular and formal dialogue between the UHB Executive and the Trade Unions on matters relating to workforce and health service issues enable Employers and Trade Unions to put forward issues affecting the workforce provide opportunities for Trade Unions and Managers to input into UHB service development plans at an early stage consider the implications on staff of service reviews and identify and seek to agree new ways of working 32 of 121

36 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 16 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy consider the implications for staff of NHS reorganisation at a national or local level and to work in partnership to achieve the mutually successful implementation appraise and discuss in partnership the financial performance of the organisation on a regular basis appraise and discuss in partnership the UHB service and activity and its implications provide opportunities to identify and seek to agree quality issues, including clinical governance, particularly where such issues have implications for staff communicate to the partners the key decisions taken by the Health Board and senior management consider national developments in NHS Wales Workforce Strategy and the implications for the UHB including matters of service re-profiling negotiate on matters subject to local determination ensure Trade Union representatives are afforded reasonable paid time off to undertake trade union duties develop in partnership appropriate facilities arrangements using Agenda for Change Facilities Agreement as a minimum standard. In addition the Health Board will establish Clinical Board Partnership Forums to establish ongoing dialogue, communication and consultation on service and operational management issues specific to Clinical Board areas. Each Clinical Board will have a Lead Staff Representative who will jointly chair the Clinical Board Partnership Forum. Each Clinical Board Partnership Forum will report to the Health Board Local Partnership Forum. 3. DELEGATED POWERS AND AUTHORITY 3.1 The Partnership Forum may establish sub committees or task and finish groups to carry out on its behalf specific aspects of Forum. Three sub-groups have been established, namely the Employment Policies sub-group (EPSG), the Workforce Partnership Group (WPG) and the Staff Benefit s Group. 33 of 121

37 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 17 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy Employment Policies Sub Group Local Employment Policies will continue to be developed in partnership. For each policy a nominated Management and Staff representative will jointly develop the policies, seeking views/comments from management and staff colleagues. Each Policy will be subject to an Equalities Impact Assessment. The proposed policies will be submitted to the Health Board Partnership Forum for consideration with final approval being made by the Health Board s People, Performance and Planning (PPP) Committee. The EPSG will approve all employment and other related Human Resources (HR), Workforce and Organisational Development (OD) procedures and other written control documents Workforce Partnership Group The Workforce Partnership Group (WPG) has been created to provide a forum for the Health Board and Trade Unions to work together on issues of service development, engagement and communication specifically as they affect the workforce The purpose of the WPG is to provide a focused opportunity to establish a regular and formal dialogue between the Director of Workforce and OD and the Trade Unions on matters relating specifically to workforce issues Staff Benefits Group Cardiff and Vale University Health Board is one of the major employers in Wales with over 15,000 staff. Given the size of the organisation this provides a great opportunity to ensure all staff has exclusive access to a comprehensive range of specially selected products and services. As an employee of the Health Board this will provide money saving discounts and extra value for money on special and everyday purchases. 34 of 121

38 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 18 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy The Health Board has established a Staff Benefits Group to explore and maximise benefits for staff, and advising the Local Partnership Forum (LPF). 4. MEMBERSHIP Members 4.1 All members of the LPF are full and equal members and share responsibility for the decisions of the LPF. The Health Board shall agree the overall size and composition of the LPF in consultation with those Trades Unions it recognises. The UHB s Trade Union Independent Member will be expected to attend the LPF in an ex-officio capacity. As a minimum, the membership of the LPF shall comprise: Chair Joint chairmanship by the Executive Director of Workforce and OD and Chair of Staff Representatives Members Management Representatives Chief Executive Executive Director of Finance Medical Director Executive Director of Nursing Executive Director of Planning Executive Director of Therapies and Health Sciences Chief Operating Officer Executive Director of Workforce and OD (Chair) Director of Corporate Governance Director of Communications and Engagement Assistant Director of Organisation Development Assistant Director of Workforce Head of Workforce Governance Staff Representatives The Health Board recognises those Trade Unions listed in Annex 3 for the representation of members who are employed by the organisation. It will be the prerogative of the staff representatives to decide on the formula to achieve the maximum number of representatives. This can be reviewed locally as required. 35 of 121

39 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 19 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy Standing Invitation Independent Member (Trades Unions) 4.2 Staff representatives must be employed by the organisation and accredited by their respective organisations. If a representative ceases to be employed by the Health Board or ceases to be a member of a nominating organisation then he/she will automatically cease to be a member of the LPF. Full Time Officers of the Trade Unions may attend meetings subject to prior notification and agreement. 4.3 Members of the Forum who are unable to attend a meeting may send a suitable deputy who will contribute to the meeting being quorate. 4.4 Consistent attendance and commitment to participate in discussions is essential. Where a member of the Forum does not attend within a year (except for reasons of sickness, preplanned annual leave, maternity leave, etc.), the Joint Chairs will write to the member and bring the response to the next meeting for further consideration and possible removal from the Forum. In attendance 4.5 By invitation The LPF Joint Chairs may invite: any others from within or outside the organisation to attend all or part of a meeting to assist it with its discussions on any particular matter Chairs 4.5 The Director of Workforce and OD and Staff Representatives Chair will co-chair the LPF. The Chairs shall work in partnership with each other and, as appropriate, with the Chairs of the Health Board s other advisory groups. Supported by the Workforce Governance Manager, Chairs shall ensure that key and appropriate issues are discussed by the Forum in a timely manner with all the necessary information and advice being made available to members to inform the debate and ultimate resolutions. Vice Chairs will be identified. 36 of 121

40 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 20 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy Secretariat 4.8 The Workforce Governance Manager will act as Secretary and will be responsible for the maintenance of the constitution of the membership, the circulation of agenda and minutes and notification of meetings. 4.9 Consistent attendance and commitment to participate in discussions is essential. Where a member of the Forum does not attend within a year (except for reasons of sickness, pre-planned annual leave, maternity leave, etc.), the joint Chairs will write to the member and bring the response to the next meeting for further consideration and possible removal from the Forum. 5. COMMITTEE MEETINGS Quorum 5.1 There should be 6 management representatives and 6 staff representatives for the meeting to be quorate. 5.2 If the meeting is not quorate no decisions can be made but information may be exchanged and recommendations can be endorsed at the next meeting (when quorate). Frequency of Meetings 5.3 Meetings will be held bi monthly but this may be changed to reflect the need of either staff or management representatives. 5.4 Where joint chairs agree extraordinary meetings may be scheduled with 7 calendar days notice. Management of Meetings 5.6 The business of the meeting shall be restricted to matters pertaining to Health Board Wide strategic issues. Local operational issues should be raised at the Clinical Board Partnership Forums and will not be considered unless it is agreed that such issues have Health Board wide implications. The agenda and papers shall be sent out no later than 7 days prior to the following meeting. Items for the agenda and supporting papers 37 of 121

41 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 21 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy should be notified to the LPF Secretary as early as possible, and in the event at least three weeks in advance of the meeting. 6. REPORTING AND ASSURANCE ARRANGEMENTS 6.1 The LPF shall: report each of its meetings formally to the Board via submission of its minutes; bring to the Board s specific attention any significant matter under consideration by the Forum; 7. REVIEW 7.1 These terms of reference and operating arrangements shall be reviewed as directed by Welsh Government following recommendation by the NHS Wales Partnership Forum or as and when required by the Health Board. 38 of 121

42 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 22 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy Annex 1 Six TUC Principles of Partnership Working a shared commitment to the success of the organisation a focus on the quality of working life recognition of the legitimate roles of the employer and the trade union a commitment by the employer to employment security openness on both sides and a willingness by the employer to share information and discuss the future plans for the organisation adding value a shared understanding that the partnership is delivering measurable improvements for the employer, the union and employees 39 of 121

43 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 23 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy Annex 2 Code of Conduct A code of conduct for meetings sets ground rules for all participants: - Respect the meeting start time and arrive punctually Attend the meeting well-prepared, willing to contribute and with a positive attitude Listen actively. Allow others to explain or clarify when necessary Observe the requirement that only one person speaks at a time Avoid put downs of views or points made by colleagues Respect a colleague s point of view Avoid using negative behaviours e.g. sarcasm, point-scoring, personalisation Try not to react negatively to criticism or take as a personal slight Put forward criticism in a positive way Be mindful that decisions have to be made and it is not possible to accommodate all individual views No side-meetings to take place Respect the Chair Failure to adhere to the Code of Conduct may result in the suspension or removal of the member Be mindful of other agenda items when delivering to ensure that the meeting runs on time. 40 of 121

44 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 24 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy Annex 3 List of Recognised Trade Unions British Association of Occupational Therapists British Dental Association British Dietetic Association British Medical Association British Orthoptic Society Chartered Society of Physiotherapy Federation of Clinical Scientists GMB Hospital Consultants and Specialists Association Royal College of Midwives Royal College of Nursing Society of Chiropodists and Podiatrists Society of Radiographers Union of Construction and Allied Trades & Technicians UNISON UNITE 41 of 121

45 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 25 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy Appendix 2 WELSH PARTNERSHIP FORUM TIME OFF AND FACILITIES FOR TRADE UNION REPRESENTATIVES Introduction KEY PRINCIPLES FRAMEWORK November The Welsh Partnership Forum is committed to the principles of partnership working and staff involvement. Partnership underpins and facilitates the development of sound and effective employee relations throughout the NHS. It also recognises that the participation of trade union representatives in the partnership process can contribute to delivering improved services to patients and users. 2. The Welsh Partnership Forum recognises the importance of ensuring that the representatives of trade unions recognised for purposes of collective bargaining at local level are released appropriately to participate in local partnership arrangements. The principles of partnership working are set out in the annex to this document. 3. It is for employers and representatives of locally recognised trade unions to agree in partnership local arrangements and procedures on time off and facilities that are appropriate to meet local circumstances. Local arrangements are expected to be consistent with the principles set out below. TIME OFF FOR ACCREDITED TRADE UNION REPRESENTATIVES Accredited Representatives 4. Local arrangements should apply to accredited representatives of trade unions recognised by local NHS organisations. Accreditation will only be given to employees of the organisation who have been duly elected or appointed in accordance with the rules of the respective trade unions. 5. Accredited representatives of trade unions will: 42 of 121

46 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 26 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy Abide by the rules of their trade union and the policies and procedures of the employing organisation. Represent their members on matters that are of concern to the employing organisation and/or its employees. 6. It will be for the relevant trade unions to discuss and agree with the local employer an appropriate number of representatives. Local discussions should have regard to the size and location of the unions membership and the expected workload associated with the role. The unions would be required to issue written credentials and notify the human resources department of the number and location of work groups for which each representative will be responsible. 7. Subject to the needs of the service and adequate notification, accredited representatives should be permitted paid time off, including time to prepare for meetings and disseminate information and outcomes to members, during working hours to carry out duties that are concerned with any aspect of:- Negotiation and/or consultation on matters relating to terms and conditions of employment or agreed partnership processes examples include: terms and conditions of employment; engagement or termination of employment; allocation of work; matters of discipline; grievances and disputes; union membership or non-membership; facilities for trade union representatives; machinery for negotiation or consultation or other procedures. Meetings with members; Meetings with other lay officials or full time officers; Appearing on behalf of members before internal or external bodies; All joint policy implementation and partnership working; Environmental issues linked to the Green workplaces projects; Other matters relating to employee relations and partnership working. 8. The expectation is that it is good practice that staff representatives should indicate the general nature of the business for which time off is required, where they can be contacted if required. Requests should 43 of 121

47 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 27 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy be made as far in advance as possible as is reasonable in the circumstances. Wherever possible, the representatives should indicate the anticipated period of absence. The expectation is that requests for paid time off for trade union representatives will not be unreasonably refused. Training 9. Accredited trade union representatives should be given adequate time off to allow them to attend trade union approved training courses or events. Time off should not be regarded as automatic, as employers have responsibilities to take account of the needs of service delivery. However, the expectation is that requests for paid time off to attend training courses should not be unreasonably refused as long as locally agreed processes are followed. 10. The expectation is that requests for release for training should be made with reasonable notice to the appropriate manager. Any training course should be relevant to their duties approved by their trade union. Local representatives should provide details of the course to local management. Payment Arrangements 11. Where time with pay has been approved, the payment due will equate to the earnings the employee would otherwise have received had/she been at work. 12. Where meetings called by management are held on matters covered by paragraphs 7 where staff representatives have to attend outside their normal working hours, equivalent time off will be granted or appropriate payment should be made by local agreement. 13. There should be local agreement on when travelling and subsistence expenses will be reimbursed to accredited representatives who are undertaking approved work in relation to the partnership process and/or joint policy implementations (as listed in paragraph7). Trades Union Activities 14. It is the responsibility of the recognised local trade unions to ensure that the time and resources provided in this context are used appropriately. 44 of 121

48 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 28 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy 15. NHS organisations are encouraged to support partnership working, by giving reasonable time off, during working hours to enable trade union members or representatives for:- executive committee meetings or annual conference or regional union meetings; voting in properly conducted ballots on industrial relations; voting in union elections; meetings to discuss urgent matters relating to the workplace; recruitment and organisation of members. 16. Local arrangements should specify the circumstances when time off may be refused for either representatives or members. These may include:- unreasonable notice periods on behalf of the representatives; activities which do not fall within the any of the categories in paragraphs 7, 10 and 15; activities are not authorised by the union; service needs; 17. Locally, it may be agreed that it is appropriate in the interests of partnership working and good industrial relations for trade union representatives to be released from work for regular defined periods each week. Trade Union Learning Representatives 18. Trade Union Learning representatives are accredited by their unions to support organisations in identifying training needs and ensuring staff access to training. Learning representatives also have the right to reasonable paid time off for undertaking these duties and for relevant training. Health and Safety Representatives 19. The Safety Representatives and Safety Committee Regulations 1977 provides a legal entitlement for trade union appointed safety representatives to have paid time from their normal work to carry out their functions and undergo training. 45 of 121

49 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 29 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy FACILITIES FOR TRADES UNION REPRESENTATIVES 20. The local partnership should agree the facilities that are provided to representatives of recognised trade unions. It is recommended that local employers provide the following facilities:- Access to appropriate private accommodation, with storage facilities for documentation, appropriate administrative facilities and access to meeting rooms. Access to internal and external telephones with due regard given for the need for privacy and confidentiality. Access to appropriate internal & external mail systems. Appropriate access to the employer s intranet and systems. Access to appropriate computer facilities Access to sufficient notice boards at all major locations for the display of trade union literature and information. Access for staff representatives to all joint documents relating to the local partnership process. Based on the geographical nature of the organisation consideration may need to be given to access to suitable transport facilities. Backfilling of posts where practical. The extent to which practical would inevitably be dependent on such factors as the numbers of representatives needing time off and the work areas that would need to be covered and the needs of the service. 46 of 121

50 1.7 Partnership and Recognition Agreement including Revised Local Partnership Forum Terms of Reference Document Title: Partnership and Recognition Agreement Reference Number: Version Number: Approved By: 30 of 30 Approval Date: dd mmm yyyy Next Review Date: dd mmm yyyy Date of Publication: dd mmm yyyy Annex Principles and Best Practice of Partnership Working [Taken from: Partnership Agreement. An agreement between Department of Health, NHS Employers and NHS Trade Unions. To deliver partnership working successfully it is important to develop good formal and informal working relations that build trust and share responsibility, whilst respecting difference. To facilitate this, all parties commit to adopt the following principles in their dealings with each other: Building trust and a mutual respect for each other s roles and responsibilities; Openness, honesty and transparency in communications; Top level commitment; A positive and constructive approach; Commitment to work with and learn from each other; Early discussion of emerging issues and maintaining dialogue on policy and priorities; Commitment to ensuring high quality outcomes; Where appropriate, confidentiality and agreed external positions; Making the best use of resources; Ensuring a no surprise culture. 47 of 121

51 1.9 The Tobacco Challenge Implementing The UHB s No Smoking Policy THE TOBACCO CHALLENGE IMPLEMENTING THE UHB S NO SMOKING POLICY Executive Lead : Executive Director of Public Health Author : Principal Health Promotion Specialist Caring for People, Keeping People Well : This report underpins the Health board s key priorities Helping you stay as healthy and independent as possible Financial impact : n/a Quality, Safety, Patient Experience impact : Smoking impacts on the health and safety of patients, staff and visitors via the dangers of passive (second hand smoke) and risk of fire. Overall, a patient s experience of the health board is enhanced by no visible evidence of smoking (cigarette butt litter and smokers on site) and promotes the health promoting hospital Health and Care Standard Number CRAF Reference Number Equality Impact Assessment Completed: Yes - however, this has recently been re-drafted (June 2016) and awaiting final approval RECOMMENDATION The Local Partnership Forum is asked to: SUPPORT the actions recommended in Appendix A (Tobacco 20 Challenge Action Plan) SITUATION Since October 2014 over 6,000 smokers have been challenged at the University of Hospital Wales (UHW) by the health board s No Smoking Enforcement Officer. 63% of those approached are visitors and 28% patients (the highest 2 groupings). This is outlined in Figures 1 and 2. Figure 1: Total Number of Smokers approached, October 2014-April 2016, Cardiff and Vale of Glamorgan UHB 1 48 of 121

52 1.9 The Tobacco Challenge Implementing The UHB s No Smoking Policy 800 Total number of smokers approached Source: Cardiff and Vale UHB Figure 2: Total Number of Smokers approached, by grouping, October 2014-April 2016, Cardiff and Vale of Glamorgan UHB Patient Staff Visitor Starbucks Staff Student Concourse Staff Contractor Resident Taxi Driver Source: Cardiff and Vale UHB Although numbers approached have reduced in recent months, smoking incidence across all hospital sites remains an ongoing concern despite a well publicised and recently re-launched, No Smoking Policy - with complaints from both staff and visitors related to smoking received to the Patient Experience Team weekly. In March 2016, on No Smoking Day, the health board launched the Tobacco 20 Challenge. Based on the current 20% smoking prevalence rate for Cardiff and Vale of Glamorgan and the Welsh Government s 20% rate challenge to be achieved by 2016 which the health board has achieved the Tobacco 2 49 of 121

53 1.9 The Tobacco Challenge Implementing The UHB s No Smoking Policy 20 campaign aimed to raise awareness of the No Smoking Policy specifically to staff, who are recognized as crucial in the successful implementation of the Policy. Various social media tools were used to promote the campaign with staff being asked to pledge support by suggesting actions around a 20 theme ie to challenge 20 smokers in a week or to refer 20 patients to the Smoking Cessation Service. The actual launch was supported by members of the UHB s Executive Team who participated in a televised news interview for the Made in Cardiff TV programme which was broadcast that day, a no smoking patrol and a litter sweep outside the Concourse area. Although staff are crucial in implementing the policy, it is recognised that the highest proportion of smokers on hospital sites are visitors, therefore, raising awareness and gaining support from the wider public is vital in gaining adherence to the UHB s No Smoking Policy. Engaging with the public requires a wider awareness campaign utilising all available communication methods backed up by robust internal smoking cessation pathways such as ensuring all patients on admittance/booking are asked if they smoke, systemized recording if yes, and are routinely referred to the Smoking Cessation Service. Whilst Welsh Government proposed plans to ban smoking on hospital grounds in the Public Health White Paper which was recently halted but is now planned to be discussed again in the National Assembly during October the UHB must commit to a sustained programme of no smoking actions if it is to provide a smoke free environment with reduced smoking incidence across all sites. BACKGROUND The UHB agreed the No Smoking and Smoke Free Environment Policy in October 2013 following an 18 month comprehensive preparation and consultation process including staff, patients, visitors and contractors. Since then, supported by a comprehensive action plan, a series of actions have been implemented with varying degrees of engagement and success, to include: 3 50 of 121

54 1.9 The Tobacco Challenge Implementing The UHB s No Smoking Policy Establishment of the UHB Tobacco Control Delivery Board ( Smoke Free UHB Steering Group) Agreement that the Tier 1 Smoking Cessation target remains a priority for the UHB and targets issued to Clinical Boards with outcomes measured quarterly and reported to UHB performance meetings Manager s Guidance Briefings published and disseminated Staff Guidance Briefings published and disseminated Use of social media (FaceBook and Twitter) to help promote the no smoking message TV interview for Made in Cardiff news bulletin Payslip messages Supported patrols around UHW grounds to help in developing skills to approach smokers Employment of a No Smoking Enforcement Officer, 1 WTE Referral pathway (to Smoking Cessation Services) approved (for smokers approached ) Medicines Management Pathway (for prescribing of nicotine replacement therapy products) approved Electronic referral (via the Clinical Workstation/COM/PMS system and Clinical Outcomes Form (COF) ) Approaching smokers training offered for all staff 2 training sessions implemented Brief Intervention for Smoking Cessation Training for all staff Smoking Cessation Support for all staff (provided by the UHB s Smoking Cessation Service and Stop Smoking Wales (SSW) including a dedicated Smoking Cessation Group run by SSW) Audio messaging at main entrances including the purchase of new flame activated messages No Smoking messages on all patient letters and envelopes Significant signage improvements Production and installation of the Dragodil wallscape on UHW exterior Attendance and presentations at Resident s Associations relating to the impact of no smoking at UHW - for neighbours living in close proximity to UHW Removal of litter bins containing integral cigarette ash trays and wall mounted cigarette ash bins Additional contracted litter picks by Cardiff County Council (UHW) Commissioning of Local Authority Enforcement Officers to issue penalties for litter (to include cigarette butts) UHW and UHL Despite implementing the above, smoking incidence specifically the UHW site remains an on-going challenge requiring continual monitoring and engagement of 121

55 Number of treated smokers Local Partnership Forum 23 June The Tobacco Challenge Implementing The UHB s No Smoking Policy All health boards across Wales have implemented a No Smoking Policy however, all experience similar issues in terms of enforcement. To date, only one other Aneurin Bevan have employed a dedicated Enforcement Officer, although several are considering this approach. ASSESSMENT Evidence shows that referral of smokers (by increased staff engagement) to support services will impact on smoking incidence. Smoking status is not routinely recorded currently and identification of smokers is important in planning their support whilst they are in hospital. This is required in order for referral to smoking cessation services and pharmacological support prescribing. Referral targets set for UHB Clinical Boards to smoking cessation support remains low, and Welsh Government s Tier 1 Smoking Cessation target of 5% of smokers setting a firm quit date, remains at less than 1.5% (Cardiff and Vale of Glamorgan UHB) for (Figures 3 and 4) and quarterly, at less than 0.5%. To achieve this target increased referral (Figure 5) from all Directorates will need to be implemented as part of systematised, routine practice Figure 3: Total Number of Treated Smokers Cardiff and Vale of Glamorgan, by smoking cessation service, Number of smokers treated annually across Cardiff and the Vale of Glamorgan by smoking cessation services Tier 1 Target, 4088 Tier 1 Target, 3827* SSW UHB Tier 1 Target Year *Amended Tier 1 target (based on population estimates and Welsh Health Survey Smoking Prevalence rates 2014/2014) Source: Cardiff and Vale UHB/SSW 5 52 of 121

56 Percentage of smoking population Local Partnership Forum 23 June The Tobacco Challenge Implementing The UHB s No Smoking Policy Figure 4: Percentage of Treated Smokers Cardiff and Vale of Glamorgan, by smoking cessation service, Percentage of the smoking population (aged 16+) that have become treated smokers and set a firm quit date 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% Year Cardiff Vale Cardiff and Vale Wales Tier 1 Target Source: Cardiff and Vale UHB Figure 5: Total Number of Referrals by Cardiff and Vale UHB Clinical Boards, Quarter 2 (July September) 2014 and 2015 Cardiff & Vale Clinical boards, Q2 (July-Sept) referrals, 2014 and 2015 Referrals July-Sept Referrals July- Sept 2015 Average no. of referrals expected each quarter Specialist Services Source: Cardiff and Vale UHB Clinical Mental Health Diagnostics & Therapeutics Dental Services Children & Women's Primary, Community Intermediate Care Medicine Surgical Services The UHB s Optimising Outcomes Policy (OOPS) aimed at increasing referrals of elective surgery patients (who smoke or have a BMI greater than 40) to smoking cessation support and Dietetic services, has not increased the number of clients accessing smoking cessation despite the evidence base of improving outcomes of quitting smoking and losing weight prior to surgery. Supporting staff to implement this requires internal awareness raising and dissemination of resources to publicise and implement this process. Whilst staff approached smoking on hospital sites accounts for less than 9% of all smokers challenged, it remains a concern that staff continue to breach the No Smoking Policy and are not routinely disciplined by the UHB s formal process. Increased support to line managers is planned in order to ensure adherence to the Policy. Visitors are the greatest challenge in terms of enforcing the No Smoking Policy, not least of all as these are different people entering the hospital on an hourly basis therefore not repeat offenders. Furthermore, they are often 6 53 of 121

57 1.9 The Tobacco Challenge Implementing The UHB s No Smoking Policy travelling from outside the Cardiff and Vale of Glamorgan area and therefore may not have received information prior to their visit. For those visiting patients already in hospital, a clearer message in admission information needs to be communicated so that visitors are made aware prior to their journey that smoking is not permitted. Evidence from Behavioural Insights shows that people are likely to follow the norm which is usually the greatest proportion of adherence to the rules or the majority - this can be applied to smoking behaviour by stating that 80% of the population don t smoke or that smokers are 7 times more likely to quit with smoking cessation support. Additionally, behavioural insights shows us that people are less likely to undertake risky behaviour in areas or locations where it is understood (by the majority) not to be acceptable in applying this to smoking behaviour, smoking in children s play areas or near children would aim to reduce smoking incidence. In the same way, smoking near patient areas could be applied. Advising visitors that they will be challenged would also reflect this work since non-adherence to a policy represents the minority of visitors to our hospital sites. Enforcing a No Smoking Policy requires full engagement of staff. It requires a consistent approach based on routine systems and practices of work. Furthermore, it requires continual monitoring and reinforcement. Ultimately, full adherence will only be achieved by either (or both) legislation or cultural change. It is recognized that different approaches to enforcement may be required with different target groups such as staff, patients and visitors. Actions have been proposed as part of a comprehensive Communication Plan, which is available on request of 121

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59 1.10 Workforce Report Cardiff and Vale UHB Key Financial and Workforce Indicators Executive Lead : Director of Workforce & OD Author : Workforce Information and Planning Manager, ext Caring for People, Keeping People Well : These workforce metrics form key performance indicators for the UHB and each Clinical Board in order to enable assessment against our vision to be a great place to work and learn in line with the SOFW strategy. Financial impact: Managing the staff profile, paybill and turnover impacts on the ability of the UHB to meet its financial targets and attain recurring sustainability. Maximising attendance can reduce direct, premium and variable cost element of the pay bill. This report highlights the level of spend on workforce, particularly the high level of variable pay spend. Quality, Safety, Patient Experience impact: Workforce information and metrics provide key data to support the organisation s goal of providing high quality, safe services to our patients. High levels of sickness and temporary staffing may have an adverse impact on patient experience, safety and quality if not appropriately managed. Non-compliance to compulsory training and an annual performance appraisal and development review may adversely impact safety and quality in care as well as lack of productivity and appropriate performance management. Health and Care Standard Number 7 CRAF Reference Number 6.1, 6.2 Equality Impact Assessment Completed: Not Applicable RECOMMENDATION The Local Partnership Forum is asked to: Note the sickness targets Note the May position for staffing, pay bill, and workforce KPIs (March position for sickness absence). Note the content of the monthly Workforce KPI report. SITUATION / BACKGROUND Since January 2015, the Local Partnership Forum has received a new style monthly report on Key Financial and Workforce Indicators which: Provides an overarching Health Board position on seven KPIs of which six have current agreed targets for 2016/17 (a further two KPIs were added from July 2015 on Recruitment Decision to Hire and Time to Hire ); Includes summary narrative on the key enablers being delivered by the WOD function to help improvement of these KPIs as well as key points on operational implementation against these targets by Clinical Boards; and Has league tables indicating Clinical Board positions against the targets. 55 of 121

60 1.10 Workforce Report The latest report (May 2016) is attached. These workforce metrics enable assessment against our vision to be a great place to work and learn. This summary highlights current progress, challenges and direction of travel against KPIs. ASSESSMENT 8. Recruitment Decision to Hire & 9. Recruitment Time to Hire The provision of data for these key performance indicators has been interrupted as a consequence of NWSSP implementing Trac (a new recruitment management system) during March. It is anticipated that data will be available for the next report. KPIs 2 5 & 7 are moving in a positive direction: 2. Turnover The UHB position of 7.49% is within the target tolerance and has fallen by comparison with April. The UHB-wide exit interview process is now in place to enable better analysis of turnover. Clinical Boards hold responsibility for retention and recruitment plans at a local level. 3. Sickness Absence The March 12-month cumulative figure of 5.09% is the best performance position for the UHB for five years and two months (since January 2011), and was 0.09% above the year-end target of 5.00%. There has now been a month-on-month reduction for fourteen months in a row. The result is a 1.6 million direct cost reduction since the commencement of the agile method sickness reduction plan in January 2015 by returning staff to work and keeping staff at work well and engaged. CDT, Children & Women s, Dental, Medicine and Planning sickness rates met the targets as set by the uhb to be achieved by March 2016, and PCIC, and Specialist and Surgical Services got to within 0.50% of reaching their targets. 4. PADR The current position of 58.01% is 1.36% higher than the rate for April. The reported compliance rates include both PADR (required to be completed every 12 months) and consultant and staff grade medical appraisals, which are considered 'achieved' if undertaken within a 15-month timeframe since the last appraisal. 5. Statutory and mandatory training the uhb compliance rate rose in May 2016 to 54.67%, by comparison to 51.56% in April. The May rate is however manufactured; the compliance rates for the Fire e-learning module were not available for May, so those for April have been used to calculate an overall compliance rate. 7. Variable Pay Rate There is no target for the variable pay rate as this is used as another indicator to cross-check with pay spend, vacancy rate and turnover. The UHB is currently using 8.24% of its total pay bill on variable pay. The rate has fallen by 0.09% by comparison with April. The highest users continue to be Medicine and Surgical Services for a number of on-going 56 of 121

61 1.10 Workforce Report reasons indicated. Weekly CBN meetings include review of off-contract nurse agency usage in order to switch off from using premium rate agency. KPIs 1, 4a & 6 are moving in a negative direction: 1. Vacancies The overall UHB position of 4.34% is within the target. Surgical Services, Mental Health, Planning, Dental and PCIC are above target. Overall nursing vacancy rate is 4.99%. The May 2016 vacancy rate at Band 5 has fallen to 9.46% (180 WTE vacancies), down 0.69% (13 WTE vacancies) from April The band 5 nursing turnover rate for May 2016 has risen to 11.60% from 11.59%. Aside from increased recruitment activity presently taking place Clinical Boards most take action to improve retention of qualified nurses. For the fifth month in succession there were more new starters than leavers. The Nurse Workforce Sustainability Plan continues to be implemented through the NPG. The plan includes actions to mitigate risks of shortage in the short, medium and long term (overseas recruitment, retention initiatives, improved temporary staffing fill, eradicating off-contract agency, reducing agency use, enhancing use of technology e.g. Rosterpro). 4a. Consultant and staff grade medical appraisal compliance has fallen from 79.21% at August 2015 to 74.10% in May Pay Bill Spend The amount of overspend on the pay rose compared to the previous month with an overall UHB monthly overspend of 405k in May. Both the contracted WTE and the worked WTE position fell for May. Clinical Boards have been advised to closely monitor and review locally agreed workforce and service plans against temporary versus long-term activity and demand. Sickness Targets Clinical Boards and Planning have been allocated graduated sickness targets for dependent upon their performance (at December 2015). The rationale for application of reductions is as follows: - The areas with sickness rates between 4% and the uhb rate (5.28%) have a 0.75% reduction applied. 1% reduction has been applied to the CBs where the rate is above 5.28% (Medicine, Mental Health, Planning and PCIC). The areas with sickness at around 3 4% have had a reduction of 0.5% applied, and the areas with low sickness have had 0.25% applied. 57 of 121

62 1.10 Workforce Report If all of the targets are met the uhb will achieve a reduction in cumulative sickness rate to 4.5% at March March 2017 Target Cardiff and Vale University uhb 4.50% Children & Women 3.99% CD&T 3.17% Corporate 3.11% Dental 3.68% Medicine 5.38% Mental Health 5.83% Planning 6.51% PCIC 4.90% Specialist Services 4.49% Surgical Services 4.28% Staff Engagement Values and Behaviours A project is underway to identify the behaviours associated with our UHB values, called Our Values into Action. The work is supported by a comprehensive communications plan and a project team (drawn from within existing capacity). The project will be launched officially on 4 th July 2016 and will include: a survey with patients and staff to understand experience related to our values; a graffiti board for people to express their views and experiences; and listening exercises involving patients, carers and staff. Our own staff will be trained to facilitate these sessions. All this data will be used to identify the behaviours we expect to see across the UHB. These will then be incorporated in to our recruitment, PADR and other workforce processes. To date, the Executive team have been engaged to establish their role in and expectations of the project. All-Wales Staff Survey The staff survey will commence on 15 th August 2016 and run for 10 weeks, closing on 17 th October. The survey contract is being managed by Welsh Government and has been awarded to Quality Health who have experience of running the NHS England staff survey. A random sample of 50% of our staff will be selected to take part in the survey, although the sampling methodology has yet to be confirmed. The survey questions will largely replicate the 2013 survey, including the engagement index. This will enable us to track any changes since of 121

63 1.10 Workforce Report Workforce Key Performance Indicators May 2016 Key Performance Indicator Outturn YTD Monthly Actual Comparison with Previous Month target Notes 1. Vacancy Rate (WTE) 4.72% 4.92% 4.34% 0.15% 5.00% YTD is 12-month average 2. Turnover Rate (WTE) 8.53% 7.49% 7.49% 0.77% 7.0% - 9.0% Excludes junior medical staff in training 3. Sickness Absence Rate 5.71% 5.09% 4.85% 0.05% 4.50% YTD is 12-month cumulative rate 4. PADR Rate 57.02% 58.01% 58.01% 1.36% 85.00% 5. Statutory and Mandatory Training Rate 34.88% 54.67% 54.67% 3.11% 85.00% Data eariler than Jan-15 is not presently available 6. Pay Bill Over/Underspend 3.70% 0.64% 0.87% 0.22% Underspend YTD is April-14 to current month, value shown is the amount of over/underspend as a % of budget 7. Variable Pay Rate 8.95% 8.24% 8.14% 0.09% No target YTD is April-14 to current month, value shown is variable pay as a % of pay bill Key Messages: Enablers (WOD) Nurse Recruitment: The May 2016 nurse vacancy rate at Band 5 was 9.46% (180 vacancies), downby 1.27% from May Turnover has increased in the same period by 2.03% to 11.60%. There has been a net increase of 29 wte more in post, and 24 wte fewer vacancies than a year ago. Nurse Workforce Sustainability Plan being implemented to further progress this improved position. Medical Recruitment: As at end of May 2016, there are 42.4 WTE hardto-fill vacancies which represents 3.1% of the M&D workforce. Employee Assistance Programme: There were 108 instances of usage during this month, representing an annualised usage rate of 9.1% of 14,248 employees. During the month there were no calls to the Managerial Adviceline. 15 of the callers were referred for counselling. 1 caller from this month had not been matched to a counsellor by the end of the month. Employee Wellbeing Service: 33 people self-referred to Employee Wellbeing in May Anxiety was the most common reasons for referral, with 67% citing it as a problem. 95 sessions were attended in total, of which 60 were ongoing sessions, 22 resource appointments and 13 counselling assessments. 16 of the 22 people who attended a 1-hour resource appointments were discharged, and 13 were discharged following ongoing sessions. A workshop on Understanding Stress was delivered in the Cochrane Building on May 27th. An Equality Monitoring form has been designed. Work has begun on website development. Operational Implementation (Clinical Boards) PCIC: Appointed a Workforce Planning Manager, Band 8a, 12 months Fixed term/secondment to support the delivery of the Primary Care Workforce Plan and to support the sustainability of GMS PCIC: Appointed an Assistant Head of Workforce and OD, Band 7, permanent post to support the Head of Workforce and OD. PCIC: Employee Engagement Group have met to discuss and agree employee engagement priorities PCIC: Band 5 nurse interviews have taken place and 7 offers made to various District Nursing posts Mental Health: Pay Progression Policy briefing sessions and PADR Coaching Sessions are being arranged for managers to show them how to use the toolkit. These sessions are also being used to assist in understanding why the PADR compliance rate is so low and how this impacts pay progression. Mental Health: The Clinical Board held a successful staff recognition awards in December 2015 with positive feedback from staff. A further event is to be arranged. Mental Health: Statutory and mandatory training compliance improvement plans are being developed. Mental Health: Recruitment/pre-employment events for a number of posts in nursing/ HCSW are being held throughout the Clinical Board. Mental Health: Implementation of a Staff Newsletter, Summer edition to be launched shortly. Mental Health: External degree students are undertaking placements and visits within the Clinical Board to gain experience and observe the service. This is being co-ordinated to maximise any future recruitment. CD&T: Managers within CD&T have been asked for their thoughts and opinions with regards to the introduction of an Employee Engagement group. CD&T: Training is being arranged for line managers within the Board on the main employment policies. CD&T: Managers within the Clinical Board have been reminded to ensure their staff complete exit questionnaires when staff leave the UHB or move to another department. Page 1 of 9 59 of 121

64 1.10 Workforce Report Statutory and Mandatory training: The Mandatory Training Steering Group (MTSG) has met twice and agreed the Terms of Reference and gathered data from the members in relation to content for the action plan, which is currently being collated. It has been agreed that meetings will initially be held monthly in order to gain momentum for increasing compliance and this will be reviewed in the Autumn. The group will report to the Health System Management Board (HSMB) and People, Performance and Planning Committee. The action plan previously developed to improve Mandatory Training compliance under the themes of i) data quality, transparency and access, ii) provision of smarter and more accessible training, and iii) strong communication and performance management will be merged with the Mandatory Training Steering Group Action Plan and project managed by LED with input from members of the MTSG. Detailed reports of attendance are available for managers on the shared network drive (updated monthly) alongside the PADR data. Clinical Boards can request extended access and would need to contact LED in the first instance. Following completion of the tutor led Mandatory May Programme a total of 622 staff attended the Fire Safety Sessions and an average of 469 staff attended the remaining modules. The feedback from the evaluation forms has been circulated to the individual speakers, these are extremely positive with staff asking for more sessions to be delivered using this method. This will be discussed at the next Mandatory Training Steering Group. Medical Engagement Scale (MES): The MES survey is now live. The link to the on-line questionnaires have been ed directly to the medical staff and selected managers. To date the response rate for the medical questionnaire is 14.8% and the manager questionnaire is 45.9%. Communications have gone out on the intranet, twitter and facebook and the deadline is Friday 20 th May The outcomes for the UHB and all-wales will be available during July/August and it is likely they will be presented at the Clinical Leadership Conference in September. PADR: Dates are available for PADR training, which is aimed at new starters or new reviewers. Enhanced reviewer training and objective writing workshops are being advertised. The new internet PADR/ Pay Progression toolkit has been launched this week, which provides a wealth of information and guidance for all staff. CD&T: As part of the CD&T Clinical Board engagement plan, a bi-monthly lunch with the board have been arranged, whereby staff within the Board are randomly selected to meet with the members of the board to ask any questions they may have, raise concerns or provide suggestions for improvement. CD&T: A Welsh Language action plan is being put into place, with managers being asked to provide details of Welsh speakers. Lanyards will be issued to staff who can speak Welsh and posters distributed in patient facing areas. Regularly used patient leaflets have also been sent to the Welsh Language Officer for translation. Medicine: Recruitment for the Director of Nursing and Director of Operations post is continuing. Closing date for the Director of Operations is the 13th June. A secondment opportunity has been advertised for the Director of Nursing. Medicine: Workforce planning in EU is underway with a workshop to establish short and medium terms plans arranged for the 20th June. Medicine: Focused recruitment of Band 5 registered Nurses is still continuing via overseas recruitment and locally through a rolling advert on NHS Jobs. Medicine: Work to develop a workforce plan across the diabetes pathway has commenced with workshops planned from early summer to autumn. Medicine: Pauline Williams will commence as Lead Staff Representative for Medicine from the beginning of June the Board welcomes Pauline and looks forward to an excellent partnership arrangement. Medicine: The Medicine Clinical Board has commenced Appraise and Support Meetings for Hotspot areas within the clinical board to support ward/work areas with their workforce performance, this will include supporting managers in their sickness management, PADR completion, Statutory and Mandatory training rates and assisting in addressing ways of reducing bank usage. These meeting will be support by workforce and finance. Planning: Work has begun on a verification exercise of PADRs undertaken in Operational Services. The departmental compliance data is not reflected in the ESR reports from LED. Once the data has been collected, a meeting will take place with LED to look at where the issues are. Planning: A rolling programme of focused recruitment into Band 1 and 2 Operational Services posts has begun. Thirty posts will be recruited into and any other eligible candidates will be placed on a list or will be offered the option of being placed on a bank. Planning: As part of its Engagement strategy, the Planning Clinical Board is compiling a Board Newsletter to be sent to other Clinical Boards, raising the profile of the services provided by the Board. Planning: A newsletter aimed at Operational Services staff has been drafted and will be circulated in the near future. Surgery: Focused recruitment of Band 5 registered Nurses and Band 5 experienced Theatre Practitioners is still continuing via overseas recruitment and locally through a rolling advert on NHS Jobs. Surgery: A pulse survey was conducted in HSDU/SSU and feedback has been given to HSDU staff. A draft action plan has been devised to address the concerns raised. The Lead union representative and the representatives from the department will be heavily involved in this culture change. Surgery: Partnership working is going from strength to strength and our Lead Union representative is continuing to work closely with managers and staff. Surgery: An event was held on 8th June celebrating the work and achievements of our Page 2 of 9 60 of 121

65 1.10 Workforce Report 1. Vacancy Rate (Monthly WTE) WTE May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 CDT % 4.35% 4.39% 4.03% 3.29% 2.80% 3.06% 4.33% 3.68% 3.28% 2.69% 2.07% 1.48% Over 5.0% Specialist Services % 4.64% 4.51% 2.65% 2.99% 3.15% 3.46% 4.11% 2.88% 1.76% 1.78% 1.18% 2.05% Under 5.0% Children & Women % 2.49% 2.07% 3.41% 1.54% 2.20% 1.43% 1.86% 1.14% 0.70% 1.32% 2.24% 2.63% Corporate % 2.50% 2.59% 4.54% 3.10% 3.46% 3.48% 2.49% 1.15% 0.68% 1.66% 3.92% 2.97% Medicine % 10.79% 6.50% 7.96% 6.17% 6.22% 6.88% 7.54% 7.07% 6.14% 5.77% 4.83% 4.92% Surgical Services % 5.23% 5.30% 5.31% 4.84% 4.54% 4.75% 4.41% 4.17% 3.50% 3.99% 3.96% 5.20% Mental Health % 4.25% 4.38% 6.09% 7.50% 6.49% 5.41% 5.66% 4.72% 4.47% 4.86% 6.44% 6.08% Planning % 7.83% 7.55% 7.49% 8.59% 8.90% 9.61% 9.26% 8.19% 8.42% 7.95% 7.73% 6.46% Dental % 7.07% 6.77% 14.11% 5.82% 7.79% 7.65% 7.77% 7.73% 7.38% 5.87% 2.44% 6.72% PCIC % 7.41% 12.81% 12.10% 12.89% 12.76% 12.52% 10.33% 8.59% 8.40% 10.03% 12.58% 11.80% uhb % 5.58% 5.26% 5.79% 5.13% 5.12% 5.16% 5.34% 4.54% 4.02% 4.13% 4.19% 4.34% Note: This data is sourced from ESR and whilst the WTE staffing numbers are accurate (Payroll-managed), department managers and Finance staff are required to maintain the accuracy of the recorded establishment data. The WTE staffing numbers and % rates for PCIC, CDT, Medicine and Children & Women's are adjusted to reflect posts that are hosted within CDT, Medicine and Children & Women's for professional accountability purposes where the service delivery is within PCIC. The PCIC vacancy figure increased by WTE in July 2015 due to investment in Primary Care by WG to expand Community Resource Teams. 2. Turnover Rate (12-Month WTE, excluding junior medical staff) Average WTE May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Planning % 7.30% 7.14% 7.17% 7.52% 7.80% 7.41% 7.70% 6.91% 7.47% 7.04% 6.71% 6.68% Under 7%, Over 9% Children & Women % 8.43% 8.24% 8.12% 8.63% 8.76% 8.00% 8.13% 8.24% 7.19% 7.12% 7.57% 6.68% 7.0% - 9.0% Mental Health % 9.36% 8.96% 8.76% 10.26% 9.95% 9.84% 9.93% 9.45% 9.39% 9.30% 8.45% 6.72% Surgical Services % 8.27% 8.36% 8.18% 7.56% 8.07% 7.37% 7.25% 7.22% 7.42% 7.31% 7.55% 6.74% Medicine % 8.57% 8.80% 8.84% 9.08% 8.82% 9.29% 9.18% 9.20% 9.00% 8.37% 8.37% 7.00% Specialist Services % 8.29% 8.00% 7.81% 8.07% 8.52% 8.60% 8.82% 8.47% 7.70% 8.73% 8.89% 7.55% CDT % 8.95% 9.05% 8.54% 8.28% 7.75% 8.01% 8.03% 8.25% 8.46% 8.10% 8.21% 8.15% Dental % 8.39% 6.58% 8.74% 8.43% 8.06% 7.71% 8.02% 7.96% 7.60% 8.06% 8.04% 8.92% Corporate % 6.55% 7.37% 8.13% 8.46% 8.71% 9.16% 8.14% 8.80% 8.56% 8.30% 9.54% 9.49% PCIC % 5.80% 6.53% 7.85% 8.05% 8.43% 9.27% 9.21% 8.84% 8.94% 10.16% 11.21% 10.27% uhb % 8.24% 8.21% 8.23% 8.43% 8.47% 8.41% 8.41% 8.31% 8.62% 8.12% 8.26% 7.49% Note: Turnover data in respect of junior medical staff in training has been excluded from these calculations, so the average WTE numbers also exclude this staff group. There are other areas (notably Dental) that are training centres where student turnover may skew the turnover rates. 103 staff attached to the Diabetic Retinopathy Screening Service, which was part of the PCIC Clinical Board, TUPE transferred to NWSSP with effect from 31st March Consequently all of the staffing numbers, both leavers and average staffing numbers, related to DRSS have now been excluded from turnover calculations. uhb Staffing Position Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 since Mar- 16 Worked WTE Contracted WTE Note: Currently an improvement would be a reduction in the worked WTE, as this is a calculated value and includes staff overtime and bank use; and an increase in contracted WTE, as this would demonstrate that vacancies are being filled. As can be seen above the uhb is delivering an increase in contracted WTE, but the worked WTE remains higher than during 2015 and has increased month-on -month. Page 3 of 9 61 of 121

66 1.10 Workforce Report 3. Sickness Rate (12- Month Cumulative) WTE Target Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 CDT % 4.05% 4.02% 3.98% 3.92% 3.87% 3.86% 3.80% 3.76% 3.75% 3.67% 3.61% 3.64% 3.63% > 0.5% Off Target Children & Women % 5.24% 5.15% 5.10% 5.09% 5.05% 5.01% 4.96% 4.88% 4.85% 4.74% 4.68% 4.67% 4.68% < 0.5% Off Target Corporate % 3.37% 3.35% 3.26% 3.22% 3.18% 3.15% 3.13% 3.11% 3.12% 3.17% 3.27% 3.32% 3.30% Below / On Target Dental % 4.93% 4.84% 4.74% 4.68% 4.63% 4.61% 4.50% 4.26% 4.17% 4.18% 4.09% 4.10% 4.02% Medicine % 7.29% 7.18% 7.13% 7.12% 7.10% 7.07% 6.91% 6.71% 6.55% 6.38% 6.18% 6.10% 5.97% Mental Health % 6.44% 6.46% 6.56% 6.66% 6.70% 6.80% 6.88% 6.89% 6.86% 6.83% 6.90% 6.82% 6.70% PCIC % 6.50% 6.62% 6.54% 6.50% 6.48% 6.29% 6.18% 6.19% 6.14% 5.90% 5.69% 5.57% 5.46% Planning % 8.18% 8.21% 8.22% 8.22% 8.12% 7.90% 7.76% 7.67% 7.63% 7.51% 7.30% 7.14% 7.08% Specialist Services % 5.46% 5.42% 5.41% 5.39% 5.38% 5.37% 5.33% 5.36% 5.28% 5.24% 5.21% 5.16% 5.16% Surgical Services % 5.49% 5.45% 5.41% 5.33% 5.33% 5.25% 5.18% 5.09% 5.04% 5.03% 4.93% 4.85% 4.76% uhb % 5.71% 5.67% 5.64% 5.62% 5.59% 5.54% 5.48% 5.41% 5.36% 5.28% 5.19% 5.14% 5.09% 6.50% uhb Sickness Performance Against Target Position Rate Av. WTE Lost per Calendar Day Av. Calendar Days Lost per WTE Actual Direct Cost 6.00% 5.50% 5.00% Start Jan-15 Current Mar-16 Progress achieved to date Target Mar % m 5.09% m -0.66% m 5.00% m (projected) 4.50% 4.00% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 5.0% Target 4.96% 4.52% 4.57% 4.74% 4.83% 4.99% 5.35% 5.21% 5.42% 5.44% 5.12% 4.83% Actual 5.67% 5.23% 5.26% 5.44% 5.54% 5.70% 6.06% 5.92% 6.13% 6.14% 5.83% 5.53% Actual 5.21% 4.98% 5.09% 5.15% 4.95% 4.91% 5.20% 5.21% 5.19% 5.21% 5.12% 4.85% 5.0% Target Actual Actual Note: Sickness data is the most up-to-date currently available. The April rates will be produced during the week of 20th June The target lines are based on the sickness trend, reduced by the necessary reduction to deliver 5% sickness. The Direct costs of sickness shown are the actual and target of the amount of salary paid to staff who are absent from work due to sickness. This takes no account of the replacement costs (Bank, overtime etc.) Page 4 of 9 62 of 121

67 1.10 Workforce Report 4. PADR and Medical Appraisal Rate (12- Month Cumulative) Headcount May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Dental % 49.25% 61.34% 70.24% 81.16% 73.07% 71.71% 73.51% 73.45% 69.74% 66.85% 65.98% 75.01% Under 75% PCIC % 79.44% 77.30% 72.12% 74.62% 66.48% 66.09% 68.09% 63.37% 59.92% 62.40% 69.11% 69.56% 75% - 85% Specialist Services % 61.01% 59.95% 60.04% 58.25% 56.53% 55.53% 56.36% 58.13% 60.43% 64.66% 66.29% 67.47% Over 85% Surgical Services % 44.38% 44.44% 46.10% 47.06% 47.60% 52.75% 56.10% 54.35% 51.30% 52.81% 57.67% 59.84% Children & Women % 49.83% 50.75% 52.18% 55.05% 57.63% 58.88% 52.83% 56.36% 54.37% 53.22% 57.34% 59.24% CDT % 58.48% 64.14% 65.53% 67.71% 67.67% 67.13% 65.59% 62.36% 57.70% 55.36% 56.38% 55.98% Medicine % 43.48% 42.61% 43.44% 46.16% 48.34% 50.95% 54.68% 56.33% 54.17% 55.17% 54.68% 55.50% Corporate % 55.26% 56.49% 57.14% 60.03% 58.80% 55.12% 56.28% 55.85% 52.24% 49.87% 50.87% 55.41% Mental Health % 54.10% 55.36% 59.67% 65.41% 65.21% 67.08% 65.71% 66.57% 62.09% 60.24% 56.12% 52.94% Planning % 48.18% 50.88% 51.22% 54.04% 54.02% 53.17% 54.12% 48.75% 45.39% 42.46% 36.71% 41.74% uhb % 53.44% 54.99% 56.24% 58.70% 58.29% 59.09% 59.20% 58.66% 55.96% 55.66% 56.66% 58.01% 4a. Medical Appraisal Rate Headcount May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Corporate % 66.67% 66.67% % % % 50.00% % % % % % % Under 75% PCIC % 91.67% % % % 92.31% 92.31% 92.31% 91.67% 90.91% 90.00% 90.91% 90.91% 75% - 85% CDT % 91.18% 91.18% 94.12% 90.14% 90.14% 88.89% 88.73% 90.14% 87.50% 87.50% 84.93% 86.49% Over 85% Medicine % 74.05% 74.40% 75.61% 76.86% 75.41% 77.24% 77.60% 76.98% 78.57% 78.57% 77.95% 78.13% Surgical Services % 78.48% 78.67% 77.93% 78.22% 77.33% 78.22% 77.33% 77.63% 79.65% 76.65% 76.65% 76.65% Specialist Services % 75.17% 74.48% 74.15% 73.79% 74.31% 70.95% 70.86% 72.30% 74.00% 70.78% 72.26% 72.37% Mental Health % 83.33% 85.07% 88.24% 85.29% 82.35% 84.06% 77.78% 76.71% 79.45% 73.61% 72.22% 71.83% Children & Women % 75.78% 77.95% 78.05% 71.76% 69.92% 72.52% 73.08% 73.13% 73.13% 69.57% 65.96% 65.99% Dental % 68.00% 72.92% 72.92% 72.92% 68.09% 70.21% 70.21% 67.35% 67.35% 69.39% 65.31% 61.22% Planning uhb % 77.72% 78.66% 79.21% 77.89% 76.61% 76.99% 76.44% 76.51% 77.58% 75.18% 74.21% 74.10% Note: The compliance rates in matrix 4 above include both PADR (required to be completed every 12 months) and consultant and staff grade medical appraisals, which are considered 'achieved' if undertaken within a 15- month timeframe since the last appraisal. Matrix 4a shows consultant and staff grade medical & dental staf appriasal only. It is worth noting that whilst the overall PADR/Appraisal rate is increasing month on month, the consultant and staff grade medical appraisal compliance has fallen from 79.21% at August to 74.21% in April. Page 5 of 9 63 of 121

68 1.10 Workforce Report 5. Statutory and Mandatory Training Rate (12- Month Cumulative) Headcount May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 CDT % 45.13% 49.31% 51.02% 53.87% 55.76% 55.91% 57.15% 58.20% 62.22% 60.13% 62.23% 65.75% Under 75% Corporate % 41.09% 43.74% 46.49% 46.84% 49.77% 51.36% 51.74% 54.76% 58.47% 58.36% 60.72% 63.47% 75% - 85% Dental % 37.99% 37.74% 39.88% 42.45% 44.30% 44.42% 45.09% 45.75% 48.21% 54.59% 57.36% 59.54% Over 85% Specialist Services % 40.72% 40.90% 39.72% 44.13% 46.03% 46.58% 47.20% 47.47% 48.65% 49.07% 50.94% 53.86% Planning % 35.34% 35.45% 36.42% 36.30% 36.47% 37.76% 38.94% 42.78% 46.08% 47.16% 52.51% 53.74% PCIC % 40.40% 42.42% 42.44% 44.46% 46.29% 45.71% 47.63% 49.17% 50.78% 40.77% 50.27% 52.72% Children & Women % 37.54% 39.29% 40.54% 42.59% 43.78% 43.71% 43.06% 45.76% 43.24% 46.84% 48.38% 52.53% Surgical Services % 37.89% 37.99% 38.01% 42.13% 44.47% 45.83% 47.85% 47.35% 48.01% 46.84% 47.38% 50.02% Mental Health % 40.86% 42.13% 42.66% 43.32% 44.43% 44.56% 44.56% 45.25% 46.53% 46.33% 46.38% 49.27% Medicine % 34.90% 35.42% 33.01% 37.08% 38.75% 39.27% 39.91% 41.24% 42.66% 42.71% 44.53% 48.45% uhb % 39.37% 40.76% 41.15% 43.71% 45.37% 45.87% 46.67% 48.01% 49.51% 49.14% 51.56% 54.67% Statutory and Mandatory Training Rate (12- Month Cumulative) by Topic Headcount May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Equality % 71.21% 71.52% 71.46% 70.51% 77.05% 71.04% 70.67% 69.97% 70.15% 67.87% 63.74% 70.97% Under 75% Fire % 49.26% 51.70% 52.92% 47.79% ** ** ** 53.19% 53.70% 51.76% 53.85% ** 75% - 85% Health & Safety % 68.32% 68.65% 69.11% 68.23% 68.77% 70.16% 70.04% 69.72% 70.37% 68.59% 70.24% 72.64% Over 85% Information Governance % 10.96% 12.58% 18.69% 21.58% 24.26% 24.36% 29.44% 32.10% 35.38% 37.70% 42.56% 49.23% IPC % 69.38% 69.55% 69.11% 69.30% 69.84% 71.15% 71.06% 70.63% 71.33% 69.42% 70.96% 73.41% Manual Handling % 32.52% 34.25% 23.95% 47.51% 50.10% 51.42% 52.10% 52.49% 53.74% 52.80% 57.21% 59.00% Resuscitation % 0.86% 3.02% 5.30% 6.60% 8.57% 10.20% 11.52% 13.38% 16.35% 17.79% 21.27% 23.76% Safeguarding Adults % 19.65% 22.12% 24.98% 26.47% 26.78% 29.10% 30.14% 31.74% 34.34% 35.21% 38.98% 42.59% Safeguarding Children % 51.48% 51.54% 46.17% 46.29% 46.66% 48.10% 47.44% 48.37% 49.23% 48.50% 50.94% 52.36% Violence & Aggression % 20.10% 22.64% 29.77% 32.80% 34.07% 35.63% 36.77% 38.52% 40.52% 41.80% 45.85% 48.33% Resuscitation data is shown only for staff who have undertaken the Resuscitation training module available through the NHS Wales e-learning system. Data for those staff who have attended classroom training in Resuscitation is not presently recorded in ESR. All staff other than junior medical staff in training are expected to maintain up-to-date training compliance. ** Due to technical issues with Learning@NHS Wales data on Fire Safety was not available for reporting. Consequently the April data for Fire Safety has been used to calculate the Clinical Board and uhb overall compliance rates for May. Page 6 of 9 64 of 121

69 1.10 Workforce Report 6. Pay Bill Over/Underspend (Year-to-Date from April) Budget May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 April-16 to Date ( ) Planning 25,715, % -3.89% -2.82% -3.18% -3.03% -3.48% -4.10% -4.55% -4.49% -5.04% -4.73% -1.87% -2.38% - 105,816 Specialist Services 72,651, % 1.85% 1.45% 1.32% 1.24% 1.41% 1.28% 1.21% 1.22% 1.14% 1.05% -2.08% -2.15% - 281,240 Mental Health 45,910, % -1.24% -0.87% -0.84% -0.85% -0.85% -0.84% -0.84% -0.84% -0.79% -0.66% -1.39% -1.31% - 107,578 PCIC 26,225, % -1.80% -1.71% -1.38% -1.68% -1.78% -2.22% -2.23% -1.45% -1.64% -1.47% -1.37% -1.08% - 50,507 Dental 15,281, % -1.70% -2.05% -2.22% -1.60% -1.46% -1.52% -1.54% -1.42% -1.41% -1.04% -1.31% -0.88% - 24,767 Corporate 26,579, % -0.18% -0.49% -0.58% -0.54% -0.81% -0.88% -1.05% -1.26% -0.96% -1.00% -0.42% -0.26% - 12,910 CDT 72,684, % -0.81% -0.82% -0.77% -0.83% -0.53% -0.46% -0.23% -0.23% -0.19% 0.05% 0.97% 1.00% 133,468 Surgical Services 82,045, % 0.53% 0.35% 0.99% 0.87% 1.29% 1.45% 1.18% 1.28% 1.46% 2.02% 1.34% 1.46% 220,149 Medicine 67,214, % 2.43% 2.94% 3.42% 3.70% 3.93% 4.24% 4.10% 4.33% 4.30% 4.31% 1.72% 2.75% 357,568 Children & Women 67,384, % 1.51% 0.40% 0.72% 1.03% 1.56% 1.97% 1.60% 1.74% 1.78% 1.89% 3.08% 3.57% 443,735 uhb 508,109, % 0.30% 0.20% 0.39% 0.45% 0.64% 0.69% 0.58% 0.69% 0.70% 0.96% 0.42% 0.64% 598,459 Note: The pay budget for May 2016 was 46,603,852 and the pay bill was 47,008,577. This represents an overspend of 404,724. For the financial year the 12-month pay budget is 508,109,807. Over Budget Under Budget 7. Variable Pay Rate (Year-to-Date from April) Budget May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Dental 15,281, % 1.47% 1.53% 1.42% 1.28% 1.25% 1.28% 1.26% 1.28% 1.27% 1.44% 0.69% 1.10% No Target Corporate 26,579, % 1.96% 2.16% 2.20% 2.28% 2.37% 2.39% 2.49% 2.52% 2.48% 2.57% 1.66% 2.16% CDT 72,684, % 5.42% 5.66% 5.67% 5.66% 5.74% 5.69% 5.71% 5.69% 5.71% 5.95% 5.55% 5.21% Planning 25,715, % 4.74% 4.59% 4.50% 4.43% 4.44% 4.53% 4.57% 4.56% 4.60% 4.75% 5.92% 5.30% PCIC 26,225, % 5.13% 5.22% 5.33% 5.40% 5.53% 5.62% 5.72% 5.60% 5.39% 5.65% 6.10% 6.18% Specialist Services 72,651, % 8.67% 8.62% 8.47% 8.39% 8.45% 8.47% 8.41% 8.53% 8.48% 8.59% 6.48% 6.95% Children & Women 67,384, % 3.90% 4.07% 4.37% 4.50% 4.53% 4.59% 4.65% 4.81% 4.86% 5.16% 6.54% 7.01% Mental Health 45,910, % 6.00% 6.42% 6.54% 6.60% 6.78% 6.84% 6.98% 7.12% 7.14% 7.34% 7.22% 7.11% Surgical Services 82,045, % 7.96% 8.24% 8.46% 8.58% 8.59% 8.61% 8.55% 8.55% 8.52% 8.73% 8.43% 8.60% Medicine 67,214, % 13.23% 13.50% 13.79% 14.16% 14.21% 14.24% 14.52% 15.16% 15.51% 16.08% 19.70% 18.46% uhb 508,109, % 7.02% 7.18% 7.30% 7.40% 7.45% 7.48% 7.53% 7.68% 7.72% 7.97% 8.33% 8.24% Note: The matrix above shows variable pay represented as a percentage of total pay bill. The level of spend on variable pay has risen mont on month since April 2015 and remains higher than for much of the last financial year. The proportion of the paybill attributable to bank and agency for April 2016 (5.99%) represents a 3-year high. The the trend for the percentage of overtime continues upwards. Medicine: Variable pay remains high for a number of on-going reasons. Whilst additional capacity has closed which was staffed via a large proportion of agency staff, there has been some backdated costs. The large number of substantive vacancies on-going across the Clinical Board has meant further variable pay to cover these shifts. This has been completed both at a registered and unregistered level. It should also be noted that an additional HCSW is required 24/7 on A6 South in the acute stroke admissions unit. This is predominantly covered through temporary staff at present. Specialling remains in a number of areas in particular for confused/wandering as well as increased acuity on wards B7 and A7. Specialling for risk of falls on East 8 and East 6 amongst other wards remains significant coupled with sickness cover across a number of areas including East 7, West 1 and A4. Within the Emergency Unit agency nursing expenditure remains to cover maternity leave and vacant shifts. Medical agency expenditure to cover middle grade and consultant gaps within the Emergency Unit also remain and will continue in the medium term. Medical sickness and cover of gaps across the Clinical Board has resulted in significant additional agency expenditure. There are at least 10 vacant posts at junior doctor level in Internal Medicine, coupled with staff on restricted duties, maternity leave and sickness. Page 7 of 9 65 of 121

70 1.10 Workforce Report uhb Cumulative Sickness Rates 2010 to Date Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar % 4.94% 4.93% 4.93% 4.90% 4.93% 4.90% 4.91% 5.00% 5.07% 5.10% 5.16% % 5.17% 5.20% 5.22% 5.26% 5.31% 5.35% 5.39% 5.35% 5.36% 5.43% 5.47% % 5.54% 5.51% 5.51% 5.50% 5.49% 5.50% 5.52% 5.57% 5.56% 5.55% 5.55% % 5.53% 5.50% 5.49% 5.50% 5.53% 5.54% 5.55% 5.55% 5.54% 5.58% 5.62% % 5.66% 5.69% 5.70% 5.72% 5.74% 5.76% 5.74% 5.74% 5.75% 5.74% 5.71% % 5.64% 5.62% 5.59% 5.54% 5.48% 5.41% 5.36% 5.28% 5.19% 5.14% 5.09% Change Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar % -0.01% 0.00% -0.03% 0.03% -0.03% 0.01% 0.09% 0.07% 0.03% 0.06% % -0.01% 0.03% 0.02% 0.04% 0.05% 0.03% 0.04% -0.04% 0.01% 0.07% 0.03% % 0.05% -0.03% 0.00% -0.01% -0.01% 0.00% 0.02% 0.05% -0.01% -0.01% -0.01% % -0.03% -0.03% -0.01% 0.00% 0.04% 0.01% 0.01% 0.00% -0.01% 0.04% 0.04% % 0.00% 0.03% 0.01% 0.02% 0.01% 0.02% -0.02% 0.00% 0.01% -0.01% -0.04% % -0.03% -0.02% -0.03% -0.05% -0.06% -0.07% -0.05% -0.08% -0.09% -0.05% -0.05% 5.80% Cardiff and Vale uhb 12-Month Cumulative Sickness 5.80% Cardiff & Vale uhb 12-Month Cumulative Sickness April 2010 to March % 5.60% 5.40% 5.40% 5.20% 5.20% 5.00% 5.00% 4.80% 4.80% Month Cumulative Sickness 66 of 121

71 1.10 Workforce Report Sickness Hotspot Monitoring May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 CD&T Phlebotomy 9.88% 8.54% 10.49% 11.73% 11.69% 11.93% 12.21% 5.79% 7.52% 6.84% 10.25% 9.72% 9.30% < last month & < last year PCIC Cardiff North-West District Nursing Team 3.36% 5.29% 6.51% 4.93% 6.22% 10.13% 10.94% 8.01% 7.58% 7.37% 4.83% < last month or < last year Ely District Nursing Team 8.02% 5.18% 4.81% 2.21% 0.27% 8.47% 4.20% 3.89% 5.70% 7.68% 4.21% 1.20% 7.44% > last month & > last year North Cardiff District Nursing Team 0.00% 4.87% 5.07% 4.67% 6.02% 11.88% 14.32% 7.34% 2.95% 5.07% 0.00% 0.79% 8.02% Radyr District Nursing Team 5.97% 0.94% 1.21% 9.07% 9.23% 8.12% 9.23% 7.14% 6.51% 1.22% 2.15% 5.71% 0.77% Riverside District Nursing Team 15.48% 16.81% 13.65% 4.62% 7.58% 9.31% 1.67% 2.01% 3.36% 7.46% 10.37% 10.13% 11.00% Whitchurch District Nursing Team 0.32% 9.82% 13.95% 4.26% 8.53% 11.24% 13.44% 11.88% 14.37% 11.77% 5.99% 1.06% 1.80% Planning Ward Based Teams UHW 9.23% 6.47% 7.92% 7.53% 6.70% 7.10% 7.18% 6.55% 8.06% 7.33% 7.29% 6.47% 5.69% Source: ESR Self-Service Note: In April 2015 Cardiff North-West District Nursing Team was divided in to separate Ely, North Cardiff, Radyr and Whitchurch teams. These, together with Riverside District Nursing Team, have been identified as the key sickness hotspot area for PCIC. For comparative purposes until Apriol 2016 a combined sickness rate for the 4 areas will be used. May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Children & Women's Band 5/6 Antenatal 4.98% 4.37% 4.30% 4.62% 5.01% 3.05% 2.66% 3.99% 6.44% 11.15% 7.67% 7.90% 9.67% Medicine Stroke Rehabilitation Unit 3.51% 6.29% 7.02% 7.53% 6.59% 6.83% 3.20% 4.28% 3.70% 7.29% 11.44% 9.18% 9.68% Ward East 7 Llandough 1.67% 5.62% 12.16% 16.09% 13.10% 10.16% 8.18% 5.89% 12.39% 9.53% 12.85% 13.62% 9.62% Mental Health Ward East 10 Llandough 13.74% 15.15% 14.74% 16.35% 5.03% 3.76% 3.57% 3.87% 5.02% 4.59% 3.66% 3.63% 2.76% St Barrucs 4.45% 2.90% 5.18% 6.09% 1.67% 1.71% 0.37% 0.89% 1.65% 2.95% 2.73% 0.14% 1.40% Specialist Services Ward B5 UHW 9.57% 10.04% 8.99% 11.41% 11.74% 8.19% 4.95% 6.89% 9.39% 6.51% 9.62% 9.93% 15.97% Surgical Services SSSU Recovery & Anaesthetics 19.32% 14.00% 17.11% 27.00% 18.06% 13.41% 18.34% 13.76% 7.62% 10.20% 8.48% 6.27% 5.89% SSSU Theatre 11.73% 13.74% 10.02% 2.88% 10.69% 12.61% 10.61% 7.29% 9.79% 6.73% 5.94% 9.62% 5.52% Source: Rosterpro 2nd Sickness Improvement Cycle: - Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 CD&T Medical Records UHL 3.83% 6.24% 7.63% 8.46% 9.97% 8.11% 6.12% 4.28% 6.05% 6.78% 5.01% < last month & < last year PCIC Prison Services 2.60% 0.50% 1.24% 3.68% 0.58% 1.29% 3.16% 3.28% 1.94% 1.81% 5.74% < last month or < last year Planning Ward Based Teams UHL 9.32% 9.13% 12.45% 12.56% 9.77% 6.08% 7.55% 4.91% 9.85% 12.91% 16.81% > last month & > last year Source: ESR Self-Service Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Children & Women's Gwdihw Ward 2.82% 2.39% 3.81% 2.40% 2.81% 2.56% 2.66% 2.60% 4.17% 4.66% 3.63% Medicine Hamadryad Centre, SRC 11.60% 9.90% 6.59% 6.83% 3.20% 4.28% 11.94% 10.19% 8.20% 7.70% 7.03% Mental Health Ward East 18 Llandough 7.27% 18.73% 15.00% 12.19% 9.25% 8.79% 13.48% 19.11% 13.68% 16.09% 11.99% West 3 Whitchurch 11.37% 10.64% 10.67% 6.76% 8.19% 14.19% 11.02% 4.58% 5.23% 4.82% 3.85% Specialist Services T4, Neurosciences UHW 8.78% 8.59% 6.74% 7.98% 5.07% 9.79% 10.31% 9.58% 11.05% 4.73% 8.24% Source: Rosterpro Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Surgical Services Breast Centre Admin, UHL 8.54% 6.28% 15.95% 1.63% 5.27% 0.00% 1.83% 0.00% 0.00% Source: ESR Page 9 of 9 67 of 121

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73 1.11 Finance Report FINANCE REPORT FOR THE PERIOD ENDED 31 st MARCH 2016 Executive Lead : Executive Director of Finance Author : Deputy Director of Finance Caring for People, Keeping People Well: This report details performance against the financial plan supporting the IMTP to develop service priorities, maximize patient outcomes whilst maintaining the sustainability of services. Financial impact: This report sets out the UHB financial position to month 12 which is a 0.068m surplus. Quality, Safety, Patient Experience impact: This report details financial performance against the approved plan which supports improvements in quality, safety and patient / carer experience. Health and Care Standard Number 1 CRAF Reference Number 6.7 Equality Impact Assessment Completed: Not Applicable RECOMMENDATION The Local Partnership Forum is asked to: NOTE the provisional year end surplus of 0.068m against plan at month 12; NOTE that the final position is still provisional as it is subject to external audit review; NOTE that the UHB received 20.9m net additional cash support from Welsh Government and finished the year with a cash balance of 2.696m; NOTE that the UHB met its statutory duty to remain within its Capital Resource Limit. SITUATION This report details the financial position of the UHB for the period ended 31 st March The Health Board approved its three year Integrated Medium Term Plan (IMTP) containing the Financial Plan over the period 2015/16 to 2017/18 at its 31 st March 2015 meeting. The plan received ministerial approval after demonstrating service improvements in a number of key performance areas. This report sets out financial performance for the twelve months of the year. BACKGROUND To mitigate the combined impact of an underlying deficit, cost pressures and service change investments above allocation increase levels, the first year of the UHB plan starting in 2015/16 targets required the delivery of 28.8m of financial savings which is equivalent to 3.5% of relevant expenditure. Despite this ambitious savings plan, the current UHB Financial Plan does not deliver a breakeven position over 2015/16 to 2017/18. The residual deficit in the approved plan was 13.2m for 2015/16. Options to secure financial sustainability continue to be discussed with Welsh Government. ASSESSMENT 68 of 121

74 1.11 Finance Report Month 12 Cumulative Financial Position The UHB managed to end the year below its 10m control total set by Welsh Government. In addition, it was successful in securing 10m additional funding at the year end to recognise the significant acute service and winter pressures experienced by the UHB in 2015/16. The net effect of this is that the UHB successfully remained within its 2015/16 resource limit with the 2015/16 year end outturn confirmed subject to External Audit as a surplus of 0.068m. It is important to note however that this was only achieved following and confirmation of 25.2m additional in year financial support abated by the non recovery of 4.3m income that the UHB expected to collect for provider services from the population growth funding. The non recurrent income will lead to an underlying deficit carried forward into 2016/17. A summary of the tear end financial position is shown below. Table 1: Summary Financial Position for the period ended 31 March 2016 Annual YTD YTD YTD Budget Budget Actual Variance m m m m Income Revenue Allocation ( ) ( ) ( ) Income from other NHS Bodies ( ) ( ) ( ) Education Training and Research (45.816) (45.816) (45.761) Other Income (61.293) (61.293) (59.696) Non resource Limit Income (24.548) (24.548) (24.548) Total Income m (1, ) (1, ) (1, ) Expenditure Pay Budgets Contractor Services Cross Border Flows Other Non Pay Budgets (8.773) Total Expenditure m 1, , , (1.870) Total (surplus) m (0.068) (0.068) The surplus of 0.068m at month 12 is made up of: 7.551m adverse variance against the UHBs original 28.8m savings target m adverse operational variance m planned deficit net additional resources (funding received in months 9 & 12 less anticipated income) The year end and monthly financial position is shown in table of 121

75 1.11 Finance Report Table 2: Movement in the Financial Position for Month 12 Month 8 Month 9 Month 10 Month 11 Month 12 Movement m m m m m m Savings variance Operational variance (1.099) Variance from plan (0.120) Planned deficit Total Variance Less additional resources (7.770) (8.634) (9.496) (20.860) (11.364) Total Deficit (0.068) (10.383) The UHB developed savings schemes to deliver m of savings in year leaving a 4.069m gap to the target approved by the Board and identified in the IMTP. This gap and other non-recurrent savings remains the main concern surrounding the delivery of the savings plan identified in the IMTP as it has a recurrent impact into 2016/17. The UHB delivered m savings in year leaving an adverse variance of 3.481m against developed schemes and 7.550m against the Health Boards original savings target. The year end operational variance is a small adverse variance of 0.032m. The surplus is due to the cost controls and recovery actions implemented by Clinical Boards in the later part of the year and expenditure slippage against in year investment resources provided by Welsh Government. However, a number of key pressures emerged in year particularly in nursing within the Medicine Clinical Board ( 2.4m), laboratory medicine ( 1.1m), financial pressures in critical care ( 0.8m) and haematology ( 0.7m), continuing healthcare costs ( 2.1m) and capacity pressures in SAU/SSSU ( 0.7m). The reported month 12 position is subject to External Audit scrutiny and this will be carried out by the Wales Audit Office. At this point in time the Health Board does not know of any risks that could materially affect the reported year end position. The reported position is however, provisional at this stage until this work has been completed. Financial Performance of Clinical Boards Financial performance for 2015/16 by Clinical Board is shown in Table of 121

76 1.11 Finance Report Table 3: Financial Performance for the period ended 31st March 2016 Clinical Board Income Budgets The adverse variance reported against miscellaneous income increased from 1.459m to 1.802m in month primarily due to a deterioration in income arising from the Compensation Recovery Unit (CRU) where an adverse variance of 1.060m has been recorded in year. A large part of this variance is deemed to be recurrent. Pay Budgets M11 Budget Variance m M12 Budget Variance m Pay budgets were 5.365m overspent for the year. The main overspends are on medical and dental and nursing pay budgets. An analysis of spend on pay for the year is set out in Table 4. Table 4: Analysis of Fixed and Variable Pay to Month 12 *2014/15 Staff Flow costs included in external locum line In Month Budget Variance m %age Variance Surgery % Medicine % Clinical Diagnostics & Therapeutics (0.412) 0.60% Specialist Services % Mental Health % Children & Women % Primary, Community & Integrated Care (0.017) 0.24% Dental % Operational Services & Estates (0.082) (0.168) -0.15% Corporate Executives (0.136) (0.229) (0.093) -0.66% Central and Reserves (6.467) (8.968) (2.501) -7.79% Total (0.120) 1.02% Additional Resources (9.497) (20.860) (11.363) Planned Deficit - Central & Reserves Total (0.068) (10.382) -0.01% 2014/15 M 1-8 M 9 M 10 M 11 M 12 Total 2015/16 Year Average Average 2015/16 Average m m m m m m '000 m Basic Enhancements Maternity Protection Total Fixed Pay Agency Nursing Bank Internal locum External locum On Call Overtime Staff Flow WLI's & extra sessions Total Variable Pay Total Pay Pay Budget Budget Variance of 121

77 1.11 Finance Report The month 12 pay overspend is predominantly in Medicine ( 3.1m). Overspends are also reported against Specialist Services ( 0.8m), Surgery ( 1.8m) and Children and Women ( 1.4m). The variances are primarily driven by operational pressures in nursing and medical budgets. The trend analysis of worked Whole Time Equivalents (WTE) is shown in Table 5. Table 5: Worked Whole Time Equivalents Mar-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Change In Month Staff Group WTE WTE WTE WTE WTE WTE WTE WTE A & C & Senior Managers 1,923 1,951 1,977 1,988 1,972 1,982 1, Medical & Dental 1,259 1,296 1,300 1,297 1,289 1,293 1,290-3 Registered Nursing 3,621 3,738 3,709 3,727 3,723 3,710 3, Other Clinical Staff 4,337 4,450 4,459 4,512 4,534 4,546 4, Other Staff 1,104 1,110 1,105 1,111 1,107 1,120 1, Total Worked WTE 12,243 12,545 12,550 12,635 12,626 12,651 12, Total Contracted WTE 12,069 12,216 12,262 12,311 12,372 12,457 12, Both worked WTE and contracted numbers increased in month. Non-pay Budgets The 7.235m underspend against non-pay budgets at Month 12 is primarily due to the additional Welsh Government resources which were confirmed in year. Financial Risks The UHB s provisional year end position is subject to External Audit scrutiny and review. At this point in time the UHB does not expect any risks to materially affect the reported year end position. Balance Sheet Appendix 1 sets out the balance sheet for the period ended 31 st March The carrying value of property, plant & equipment has increased since the start of the year due to the impact of indexation and the significant spend on capital projects in year. During the year receivables outstanding fell by circa 13m largely as a result of a circa 14m reduction in amounts owed by the Welsh Risk Pool. Trade and other payables increased by approximately 23m in the year in part due to a delay in the UHBs energy supplier issuing invoices. Cash Flow Forecast The cash flow forecast is contained in Appendix 2. The UHB ended the year with a figure for cash and bank of 2.696m which is higher than previous years, but not considered to be significantly in advance of need, given the UHBs monthly cash requirements. 72 of 121

78 1.11 Finance Report Public Sector Payment Compliance The cumulative compliance rate improved to 93.0% at the end of March. Whilst the final position remains short of the target, it is in line with expectations following the implementation of UHB plans to manage cash towards year end. The confirmation of Welsh Government cash assistance in February allowed the clearance of backlog invoices which should in turn help the UHB s performance going into 2016/17. Capital Resource Limit (CRL) Progress against the CRL for the period to the end of March 2016 is detailed in Appendix 3 and summarised in Table 6. Table 6: Progress against Capital Resource Limit m Capital Resource Limit issued March Actual net expenditure against CRL at month Variance against planned Capital Expenditure (0.063) The UHB successfully remained within its 2015/16 Capital Resource Limit (CRL) of m. Net capital expenditure was 0.063m (0.15%) below the approved capital resource limit. Where there was 2015/16 slippage on Centrally Funded Schemes support will be re-provided from discretionary funds in 2016/ of 121

79 1.11 Finance Report BALANCE SHEET AS AT 31 MARCH 2016 Appendix 1 Opening Balance Closing Balance 1st April st Mar 2016 Non-Current Assets '000 '000 Property, plant and equipment 592, ,018 Intangible assets 1,398 1,659 Trade and other receivables 17,974 8,992 Other financial assets Non-Current Assets sub total 612, ,669 Current Assets Inventories 15,315 15,108 Trade and other receivables 117, ,233 Other financial assets 0 0 Cash and cash equivalents 562 2,696 Non-current assets classified as held for sale 2,200 1,593 Current Assets sub total 135, ,630 TOTAL ASSETS 747, ,299 Current Liabilities Trade and other payables 127, ,029 Other financial liabilities 0 0 Provisions 87,535 76,767 Current Liabilities sub total 214, ,796 NET ASSETS LESS CURRENT LIABILITIES 532, ,503 Non-Current Liabilities Trade and other payables 11,823 10,958 Other financial liabilities 0 0 Provisions 19,904 10,191 Non-Current Liabilities sub total 31,727 21,149 TOTAL ASSETS EMPLOYED 500, ,354 FINANCED BY: Taxpayers' Equity General Fund 396, ,709 Revaluation Reserve 104, ,645 Total Taxpayers' Equity 500, , of 121

80 1.11 Finance Report CASH FLOW FORECAST AS AT 31 MARCH 2016 Appendix 2 April May June July Aug Sept Oct Nov Dec Jan Feb Mar Total '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000,000,000 RECEIPTS WG Revenue Funding - Cash Limit (excluding NCL) 72,547 62,647 77,081 80,431 58,815 61,515 68,575 57,840 70,196 63, ,265 12, ,388 WG Revenue Funding - Non Cash Limited (NCL) 1,860 1,860 1,860 1,860 2,300 1,930 2,300 1,820 2,350 2,000 3, ,849 WG Revenue Funding - Other (e.g. invoices) 2,727 2,611 3,093 2,676 4,036 3,748 5,109 2,354 4,844 2,601 2,871 6,696 43,366 WG Capital Funding - Cash Limit 5,500 3,500 4,000 3,750 4,300 4, ,500 1,050 7,572 1,515 40,627 Sale of Assets Income from other Welsh NHS Organisations 29,227 33,730 32,325 38,359 22,676 35,898 35,177 26,893 37,005 25,483 31,931 39, ,109 Other - (Specify in narrative) 6,981 4,255 6,106 7,676 4,508 7,174 6,434 5,701 4,962 6,684 6,318 5,275 72,074 TOTAL RECEIPTS 118, , , ,752 96, , ,135 95, , , ,557 65,087 1,375,413 PAYMENTS Primary Care Services : General Medical Services 4,012 5,845 7,978 4,091 3,879 5,763 3,974 3,776 6,136 4,009 3,793 6,230 59,486 Primary Care Services : Pharmacy Services ,220 Primary Care Services : Prescribed Drugs & Appliances 7,121 8,050 7,295 16, ,099 15, , ,625 7,864 94,212 Primary Care Services : General Dental Services 1,701 1,863 1,897 1,896 1,759 1,906 1,865 1,779 1,775 1,750 2,002 1,617 21,810 Non Cash Limited Payments 2,032 2,361 2,256 2,191 2,508 2,388 2,256 2,414 2,305 2,228 2,378 2,113 27,430 Salaries and Wages 42,863 42,725 42,928 43,296 43,209 42,519 43,488 43,777 43,909 44,339 44,108 44, ,043 Non Pay Expenditure 38,100 39,261 46,724 44,012 34,599 39,303 40,631 36,611 42,769 37,891 31,344 60, ,520 Capital Payment 5,250 4,869 3,492 5, ,703 2,324 2,250 2,873 1,466 2,961 6,721 40,786 Other items (Specify in narrative) 8,427 9,678 11,551 15,272 2,755 10,321 14,753 2,704 15,944 2,842 9,538 9, ,772 TOTAL PAYMENTS 109, , , ,478 89, , ,725 93, ,576 95, , ,876 1,373,279 Net cash inflow/outflow 9,194 (6,173) 216 2,274 7,330 1,831 (6,590) 1,879 (8,719) 6,190 69,491 (74,789) Balance b/f 562 9,756 3,583 3,799 6,073 13,403 15,234 8,644 10,523 1,804 7,994 77,485 Balance c/f 9,756 3,583 3,799 6,073 13,403 15,234 8,644 10,523 1,804 7,994 77,485 2, of 121

81 1.11 Finance Report Board Meeting 31 st March 2016 Agenda Item PROGRESS AGAINST CRL AS AT 31 MARCH 2016 Appendix 3 Approved CRL issued March 2016 '000s 41,027 Year To Date Forecast Performance against CRL Plan Actual Var. Plan F'cast Var. '000 '000 '000 '000 '000 '000 All Wales Capital Programme: CRI Remedial Works Adult Acute Mental Health Unit (Llandough) 19,392 19, ,392 19, Children's Hospital Phase 2 2,667 2,636 (31) 2,667 2,636 (31) Rookwood Essential Maintenance JAG Accreditation Funding UHW Neurovascular (454) (454) Children's Hospital Priority Equipment 1,185 1,165 (20) 1,185 1,165 (20) Modernising Pharmacy - Hydrogen Peroxide Decontamination Hatch 132 System 15 (117) (117) Rookwood Replacement Neonatal Upgrading 2,055 1,982 (73) 2,055 1,982 (73) CRI Substance Misuse (38) (38) Endoscopy Works HTTF -Remote Access for Radiology HTTF - Bring Your Own Device Replacement Medical Equipment (6) (6) Asbestos- Management UHW (27) (27) Asbestos - Management UHL Critical Care (1) (1) Cardiology - Portable Echo Machine (8) (8) Lymphodema Equipment Sub Total 30,594 30,092 (502) 30,594 30,092 (502) Discretionary: I.T , , Equipment 2,841 3, ,841 3, Statutory Compliance 2,295 2, ,295 2, Estates 5,761 4,576 (1,185) 5,761 4,576 (1,185) Sub Total 11,404 11, ,404 11, Donations: Noah's ark and C&V Charitable Fund Sub Total Asset Disposals: 0 Equipment Sub Total CHARGE AGAINST CRL 41,027 40,964 (63) 41,027 40,964 (63) PERFORMANCE AGAINST CRL (Under)/Over '000s (63) (63) 76 of 121

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83 1.12 Reports from the Nurse Director PATIENT EXPERIENCE AND CONCERNS REPORT Executive Lead: Executive Nurse Director Author: Lead Nurse Patient Experience and Acting Assistant Director Patient Experience Financial impact None Quality, Safety, Patient Experience impact The work outlined within this paper reflects the significant activity taking place to improve patient experience leading to improved quality and care outcomes for patients. Health and Care Standards Number: 6.3 and 7.3 CRAF Reference Number: 2.7,4.2, 5.1, 5.1.5, 5.6, 5.7 Equality Impact Assessment Completed: Not Applicable RECOMMENDATION The Local Partnership Forum is asked to: CONSIDER the report. SITUATION This report provides the Local Partnership Forum with details of the work around Patient Experience feedback and Concerns. It describes the ongoing work regarding patient feedback gained both proactively and reactively, through the implementation of the Framework for Assuring Service User Experience. Within the framework there are four quadrants identifying different methods of ascertaining feedback; Real time surveys Retrospective Proactive /Reactive Balancing The report also describes an overview of our compliance to performance times. BACKGROUND The UHB welcomes the opportunity to listen to patients through a variety of mechanisms. This paper highlights patient feedback gained from patient surveys and concerns. ASSESSMENT Quadrant 1: Real Time Surveys Real time surveys continue to be administered in a planned manner. Alternate months, inpatients receive either the 2 minutes of your time or the National survey, with the National survey administered each month in departmental settings. 77 of 121

84 1.12 Reports from the Nurse Director Table1 demonstrates the number of real time surveys, routinely completed each month. They include both the National and 2 minute of your time surveys. From April 2015 until March 2016 in excess of 8500 real times surveys were completed across all Clinical Boards and Outpatient Departments within the Health Board. During February and March an additional 361 surveys were received in Acute Adult Mental Health Services and Paediatrics. 2 minutes of your time The 2 minutes of your time survey seeks to gain inpatient views of the identified determinants of good care, with the following questions asked; ` During February 75% of our patients did feel that hospital meals were appetizing / tasty. Operational Services are notified and continue to follow up with the individual wards if there are numerous negative, qualitative comments received. Within the 2 minutes survey some patients take the opportunity to provide free text comments, which are routinely themed. 129 positive comments were received in February focusing upon the high levels of satisfaction with our staff and the treatment the patients received. One comment to illustrate this is: 78 of 121

85 1.12 Reports from the Nurse Director I have honestly never stayed at a hospital/ward with such amazing, caring wonderful doctors and nurses. All staff from food, cleaning have all been an individual pleasure to meet. I came in a week ago with a bleed on the brain, I had surgery, lumber puncture and through all my nurses have been second to none. I will actually miss these angels. We received 82 comments in the section suggestions and complaints. One comment illustrating this is: I came into hospital as I was feeling very unwell but the nurses and doctors were very helpful when I needed their support. However, I would never want to stay again due to the noise. I have been in for nearly a week and had so little sleep due to patient screaming and swearing all night. During the last few months there has been an increase in qualitative patient feedback relating to noise. The Patient Experience Team is reviewing the potential of an awareness raising campaign to advocate the importance of noise reduction where able, particularly during night time hours. The National Survey The survey results continue to demonstrate that the majority of patients surveyed are happy with the care they receive. The National Survey asks patients/relatives or carers, to rate their overall experience of care across a 0-10 range, 0 being very bad and 10 very good. Patients who have indicated satisfaction at 8, 9 or 10 are shown below in Table 2. Table 2 The National Survey concludes with two questions: Was there anything particularly good about your experience that you would like to tell us? During February and March 769 National surveys were completed, with overwhelmingly positivity regarding the care provided by our staff. A few examples of what patients told us are; 79 of 121

86 1.12 Reports from the Nurse Director The nurses and care staff on the ward are fabulous, always trying to make time to explain things properly and attend to needs as quickly as they can. Absolutely amazing. Excellent team at the X-ray Department. I was a little frightened at first, the team picked up how I felt and got the x-ray over and done in seconds. These comments highlight examples of positive communication and truly understanding the patient s needs. The second question asks: Was there anything that we could change to improve your experience? 221 comments were received in relation to this question, during February and March. One example; There is a serious problem with flies on this ward due to dead pigeons on the outside roof which are attracting flies and coming in onto the ward. The ward was contacted immediately, as more than one patient had provided similar feedback; fortunately this issue had already been addressed. Acute Adult Mental Heath Qualitative Feedback Forty four areas are surveys across both inpatient and outpatient Acute Adult Mental Health Services. The surveys completed are either a survey for Adult Mental Health Inpatient or Adult Mental Health Community Areas. When asked Any further comments? The following qualitative comments were noted; Always felt staff were very friendly and always treated with respect and not made to feel stupid no matter what you needed to talk about. Sick of hospitals, want to go home. 80 of 121

87 1.12 Reports from the Nurse Director Paediatric Surveys Within the Women and Children Clinical Board, three specific surveys are undertaken monthly, including, a survey for children 4-9 years, years and a parents survey. The younger children have an opportunity to express themselves by drawing a picture and incorporating their own qualitative feedback, with examples illustrated below; The play room is good (aged 4 years) Everyone is nice (aged 8 years). With positive qualitative comments from parents including; I found that all staff were absolutely wonderful. They have cared for my daughter brilliantly and helped myself and my husband through mixed emotions we ve had during our stay. During February car parking was an adverse theme noted within Women and Children which was shared with appropriate colleagues. Mental Health Services Older People Surveys within Mental Health Services for Older People, were not completed during February and March as the patients are within our care for a long period of time. However, from April 2016 monthly surveys will be undertaken as requested by the Chief Nurse. 81 of 121

88 1.12 Reports from the Nurse Director So have we made a difference? You said Lack of changing facilities in Paediatric OPD for children with additional needs We did Changing places toilet now available in the Paediatric Outpatients Department Patient anxious about their mobility when discharged raised this with a Volunteer Discussed with appropriate staff and a referral was made to the Physiotherapy Department Belongings not put away properly because wardrobe was broken The ward is due allocation of new wardrobes to rectify this issue Quadrant 2: Retrospective Quadrant 2: Retrospective Clinical Boards are working with the Patient Experience team to ascertain patient feedback from retrospective studies. For each study, assistance provided by the team can include all or some of the following processes, depending on the requirements of the Clinical Board. Survey design Sampling, survey pack production and data collection Database design, data input, analysis and report production Study co-ordination The Patient Experience Team have been asked to assist with survey design in the following areas Patient-reported health status for stroke survivors and people living with a neurological condition. Neurological Patient Experience Survey District Nurse Survey MECHF Cardiff and Vale UHB Travel Survey Cardiff and Vale Proms Study WAST and EU Survey Perinatal Mental Health Team Pilot Study 82 of 121

89 1.12 Reports from the Nurse Director A report has also been completed in relation to the Perinatal Mental Health Team pilot study reported previously. This will be provided to the team lead for further discussion during May. These examples illustrate survey diversity being undertaken, complementing the real time feedback. Quadrant 3: Proactive / Reactive A range of opportunities should be made available for users, families and carers to provide feedback at any time. This can include paper as well as online. How are we doing cards are an example of this. This simple method provides an opportunity for people to share their experiences. The UHB internet site currently hosts three different types of surveys, with a link for the surveys on the facing page. Hits to the Patient Survey page are showing a general upwards trajectory; During February a proactive young Carers Survey was undertaken. This survey was an accumulation of work undertaken between health, the councils, social services and YMCA. The young carers advised the best way to hear their voice was through a questionnaire. A questionnaire was then designed using their words, by their steering group. Focus groups were also undertaken by Cardiff University, and once finalized results will be reported upon in a future Board report. A proactive staff survey was also undertaken during February, focusing primarily upon how the Cardiff and Vale workforce play a role in delivering services for un-paid, informal or family carers. It was available in paper copies and online, with 228 surveys completed. Key results; 95% of respondents were able to identify young carers 14% had received training on carers during the last 3 years 93% of respondents incorrectly identified someone who is paid via a direct payment as a carer. This result does reflect a general confusion in society regarding paid and unpaid carers. 83 of 121

90 1.12 Reports from the Nurse Director 92% of those responsible for hospital discharge involved carers in the discharge process. This was a positive result as often within the 2 Minutes of your time feedback discharge is a question that scores slightly lower. Once available, both reports will help inform the Carers Framework and agenda moving forward. At the end of January a three month pilot was also commenced to ascertain the experience of patients brought into either the Emergency Unit at University Hospital of Wales or the Medical Emergency Assessment Unit at University Hospital Llandough by welsh Ambulance. This survey was codesigned between The Health Board and WAST. Health Board volunteers undertake the survey; assisting to alleviate bias. The pilot is due to be completed at the end of May 2016 and the report will be collated and shared following analysis. Quadrant 4: Balancing Within this quadrant the narrative feedback adds balance to survey-based feedback. Sources additional to patient /carer stories include concerns and compliments and third party surveys for example the Community Health Council. Patient stories continue to be heard in many forums and meetings. A recent parent story undertaken by Hywel Dda Health Board was shared with colleagues at the Health Board as the young child had received care at the University Hospital Wales. Learning from the story will be shared with relevant teams with an edited version shared through Quality, Safety and Patient experience and staff forums. The Patient Experience team also recently captured a digital story regarding a gentleman who had rapidly developed influenza and was admitted into our care. The story was shared with Medicine Clinical Board, the Welsh Ambulance Service, Primary Care, and Public Health Colleagues. It is available to view on the link below; \\cav-vstor10\photolib_users$\videofiles\misc\my Flu Story.wmv These examples highlight the diversity, power and shared learning opportunities from patient stories. CONCERNS For the period of 1 April 2015 to 31 March 2016 the UHB received 2299 concerns. It is interesting to note that the preferred methods of raising concerns are by e mail and telephone. 84 of 121

91 1.12 Reports from the Nurse Director Complaints by Method of complaint 762 From Incident Form 26 Letter by post or e mail 742 In person 31 Telephone 738 Totals: % of these concerns were processed informally over the year-the month by month trajectory has seen an increase in informal concerns resolution Each Clinical board has been advised of tier Key performance indicators and targets for the next year. The primary subjects are Communication, clinical diagnosis and treatment, waiting times and cancellations. By Sub subject we can identify that 23% of the concerns we receive are about medical treatment. Communication issues remain a significant concern and this includes a lack of communication. Waiting times and cancellations are a major source of concern for our patients and relatives. The increasing trend is for claims to be identified where there has been an omission to follow up patients either at all or in a timely manner which has resulted in harm to a patient. Acknowledgement times Some 99% of all concerns are acknowledged within 2 working days of receipt this has increased from 98% in the previous report. The Concerns Team 85 of 121

92 1.12 Reports from the Nurse Director continues to contact complainants to clarify the issues to be investigated. This has supported the appropriate use of early resolution where possible. Performance for the Clinical boards is detailed over the year UHB wide the response rate to informal concerns in 2 working days is 77% Informal Concerns performance Clinical Board Number of Informal % responded to in 2 Concerns working days Children and Women % Dental 19 74% Clinical Diagnostics and % Therapies Medicine % Mental Health 3 67% Primary and 82 78% Intermediate Care Specialist % Surgery % Other 43 - During April 2015 to March 2016 only 0.7% of the informal concerns were converted to formal. The response times to 30 working days remains an area of concern. Clinical Boards are challenged at the Executive Performance reviews and performance is discussed at the Concerns, claims and Compliments panel. Performance over the year Clinical Board Number of formal Concerns Children and Women % Dental 31 61% Clinical Diagnostics and 60 68% Therapies Medicine % Mental Health % Primary and 47 50% Intermediate Care Specialist % Surgery % Other 56 - % responded to in 30 working days 86 of 121

93 1.12 Reports from the Nurse Director Some examples of You said we did Patient very anxious as she had tried various numbers but could not get through to the dept to cancel an apt as she had caught an infection. Patient rang concerned as she felt that her treatment was being compromised due to the change and lack of staff at the Centre. Patient had a letter to say she was on the waiting list for surgery but when she rang to enquire about a date she was told she was not on she was worried and anxious. Patient rang concerned that he had not received an appointment even though his GP had referred him in early January and feels his symptoms are getting worse. Patient s mother rang enquiring whether there would be a bed available when her son came in for surgery the next day. She is very anxious as it has been cancelled at short notice once before. Patient sent in pictures of illegally parked cars at the hospital. Contacted dept and explained frustration on patient getting through - arranged new appointment. Contacted PCIC who met with patient, who had been given various wrong information and reassured her that staff are fully qualified to carry out her treatment. Manager to speak with members of staff involved. Patient reassured that she was on the list and advised of the timescale for surgery. Patient was contacted by the Clinical board and given a date for his surgery. Spoke to Ward who said that they could not confirm at this time but to give the mother their number and ask her to ring between 6:00 and 7:00am in the morning where they would have a better view - relayed this to mother happy and a bed was available Contacted Estates and patient given an update on current situation. The patient was happy that action was being taken to address the problem Actions in response to the themes from concerns and other intelligence. Waiting times for admission and Out patients appointment The FAB (Fully Automated Booking ) Process should help to reduce the number of missed follow ups and achieve maximum utilization of the out patients capacity. Cancellations: Fully automated booking (FAB) is currently being rolled out to increase the number of agreed appointment dates with patients. In terms of inpatient cancellations significant work continues as part of the (Newton) theatre improvement project. This allows us to more accurately identify cancellation reasons and improve processes. Particularly over this winter period (to date) there has been a significant reduction in the no bed cancellations - compared to previous years. Improvements in surgical pre-operative pathways are key to reducing cancellations. The Surgical Clinical Board is undertaking work to improve pre-assessment processes as a result. Waiting Times: 87 of 121

94 1.12 Reports from the Nurse Director The Health Board has placed particular emphasis on improving access to elective care this year. A quarterly cohort performance improvement approach to RTT has resulted in the volumes of patients waiting > than 36 weeks for their treatment reducing for the third quarter in a row in quarter 3. The Health Board has moved from having the highest >36 week breach volume in Wales in January 2015, to the lowest in December Plans are in place to continue this improvement for the remainder of 2015/16 and into 2016/17. Update The year end position on RTT is improving and we would expect to see a sustained decrease in concerns raised regarding waiting times. The advent of PACU has meant a decrease in cancelations of patients requiring critical care facilities post operatively being cancelled due to a lack of a critical care bed. Some patients are contacting the concerns department when they cannot park and have been unable to attend OPA. Staffs are also reporting that patients are raising informal concerns on arrival at the clinics. Staff have been reminded that patients can complete verbal concerns forms in order to capture the totality of the problem. Concerns have liaised with the records team to enable improved data capture. The Board is aware of the problems with traffic congestion on the UHW site and several potential solutions are being considered as a matter of priority. Some immediate remedial action has been taken e.g. the allocation of protected spaces outside the maternity area which enables community midwives to park whilst the building work continues. The drop off zone for patients in maternity has also been maintained. Ombudsman 21 cases i.e. 1% of the concerns received in this reported 2105/16 year were referred to the Ombudsman Premature prior to response being issued 3 Ombudsman not investigating 5 Voluntary settlement 2 Investigation on going 7 Final report Not upheld 1 Final report Partially upheld 3 Final report fully upheld 0 In July 2015 the Concerns Team accepted Responsibility for processing all AM/MP concerns from the Chief Executive s office 88 of 121

95 1.12 Reports from the Nurse Director 177 Concerns have been received from AM/MP s in total since 1 July 2015 to 30 April have been responded to 72 in 5 days or under 30 in over 5 days but fewer than 20 days 57 in 20 to 30 days 9 in total exceeded 30 working days-2 were RCA Investigations, one was delayed and the others had commenced pre July and were already delayed on receipt in concerns Communication is a source of concern and the highest number is regarding a lack of communication. Waiting times and cancellations are a major source of concern All AM/MP concerns are subject to weekly review by the Executive team who monitor themes and trends as well as individual cases. Redress The Regulations require that when undertaking an investigation consideration is given to the possibility of a qualifying liability in tort. A qualifying liability in tort may be present if harm has arisen and it meets the necessary criteria which are based on legal definitions. Where it is considered that there is or may be a qualifying liability which would attract financial compensation of 25,000 or less, then the Redress arrangements should be engaged and a decision made whether or not an offer of redress should be made. 89 of 121

96 1.12 Reports from the Nurse Director Redress can be financial, an apology or remedial treatment. Often it is a combination of these elements. Following the agreed IMTP additional funding agreed in 2014/15 the additional monies enabled the introduction of redress lead posts. The Redress posts have had a significant impact on the timeliness of reviewing cases, increased personal contact with claimants and a reduced conversion rate to formal claims. The developing relationships with claimant s solicitors and the engagement with the redress leads has been noticeable. Actions taken since the redress lead posts were introduced From 1 September WTE redress leads were appointed and a meeting is held on a weekly basis with the head of concerns and claims and the claims managers to review all active cases It has been agreed with the Legal services shared partnership that the pilot of the half a day session per week with the solicitors being available in the concerns department to provide legal advice on complex cases will continue. This model has been adopted by several other health boards. Personal contact is encouraged with complainants. A redress fact sheet and template letters have been developed. This is a means of explaining the legal terminology in an understandable format to people in the concerns process. Background From 1 September April 2016 From Concerns Redress Received Settled Active Settlement Amount ,974 ** ** Figure includes settlement / expert reports / solicitor s fees etc From Concerns Claims Received Settled Active Settlement Amount Most conversion cases are pre redress introduction or claim has different issues raised. From Serious Incident Redress 90 of 121

97 1.12 Reports from the Nurse Director Received Settled Active Settlement Amount Current Position Numbers With independent expert for review 8 To be forwarded to independent expert 16 Independent expert received 7 Currently under Offer 9 Within the department we aim to settle cases at the first opportunity and training has been provided for the team to identify the cases that can be settled in the first response. All cases can be presented at the Tuesday morning meeting chaired by the head of concerns and Claims where we decide Has breach been identified? Has causation been established? Is this agreed by the Clinical Board? Is further information required from Clinical Board or claimant? If further information is required-if yes questions are agreed? Can quantum be assessed? Is an expert report required-internal or external? Is further legal advice required? If yes- refer to Thursday workshop with solicitors or request the further information and review at the following Tuesday Meeting. On occasions Clinicians can be asked to attend the Tuesday ort Thursday meeting The weekly focus on cases ensures that we maintain actions and there are not any unreasonable significant delays in the process. The timely process limits costs and reduces the likelihood of conversion to a formal claim because of delays. On reviewing the redress offers made since 2011 they broadly mirror the claims 91 of 121

98 1.12 Reports from the Nurse Director Number of Claims It is pleasing to note that to date there have not been any conversions to claims in 2016 In cases were converted to formal claims this was the point at which 92 of 121

99 1.12 Reports from the Nurse Director Number of Claims Claims 106 new clinical negligence claims and 72 new personal injury claims have been received in the past year. The graphs below demonstrate the Clinical Negligence and Personal Injury case loads since April 2011 Due to the variance in the workload between personal injury and Clinical negligence the claims managers have changed their workload and cover a mixture of both types of cases and have aligned with the Clinical The graphs below measure the news cases since April of 121

100 1.12 Reports from the Nurse Director The primary categories in new claims have been related to Clinical Treatment within Clinical Negligence Claims and Needle stick injuries within Personal Injury claims. The clinical negligence claims in the significant categories range from delay to diagnose ectopic pregnancy to cauda equina the only trend identified was an increase in pressure area damage new claims across the specialities Examples of actions arising from Closed Cases Number of Claims The primary category for Clinical Negligence Claims is a delay to diagnose and a failure to treat. An example of lesson learnt generated from one of the closed cases included a review of the arrangements for the reporting of abnormal x-ray results. Consequently, a policy was produced that was endorsed for implementation by the Quality and Safety Committee. The main thrust of the policy defines the respective roles and responsibilities for notification and subsequent actioning of abnormal x-ray reports by the referring Consultant Team. The implementation of the protocol has strengthened our clinical reporting systems by ensuring that abnormal x-ray reports are appropriately actioned irrespective of whether patients have been discharged from hospital care. Furthermore, a system of flagging up abnormal radiological results has been introduced to ensure that treating clinicians can review future care plans and implement treatment where necessary. 94 of 121

101 1.12 Reports from the Nurse Director Key acute areas such as the Emergency Unit have identified cases for learning opportunities and junior staff receive specific training in their teaching programmes related to for example assessment and identification of Achilles tendon rupture and clinical skills necessary to exclude one. There were a total of 8 new needle stick injury claims and the graph below show reason that these needle stick injuries have occurred. All claims were reported and investigated at the time and given the short life of this type of claim, recommendations to avoid future incidents are given at the time of investigation. Needle stick Injuries How? Number of claims Exposed Needle in waste bag 3 Unknowingly picked up whilst 2 cleaning Unknowingly picked up in waste 1 outside Sharp object left in cupboard/tray 2 Total 8 The primary reason for closed claims is for Personal Injury Claims is Equipment, these case are very diverse, with failure or broken equipment being identified. There are planned maintenance in place for specific equipment. However, all staff are encouraged to report faulty equipment through the appropriate routes. Managers should ensure that where tasks require the use of equipment that appropriate checks and risk assessments are undertaken to ensure equipment is used appropriately and repaired when necessary. The second category for Personal Injury Claims is Violence and Aggression and the injuries that arise from this, there is a range of causative factor but often the environment is a contributing factor. The new facilities at Hafan y Coed will provide a safer environment for patients and for staff looking after these patients. With improved security for access and monitoring on the wards and improved facilities to aid rehabilitation. A representative from Legal and Risk Services recently visited the Unit and was reassured by the environment that they viewed. In order to enhance the knowledge that our legal advisor have of our services, particularly when advising us on claims that involve Violence and Aggression and Manual Handling. An invitation for representatives from the personal injury team at Legal and Risk Services has been given to attend our training which will give them a greater understanding of these techniques and practical information which will be of assistance when they advise us in claims. 95 of 121

102 1.12 Reports from the Nurse Director Compliments 716 compliments were logged by the Concerns team from 1 April 2015 to 31 March This is an increase from the previous year where 581 compliments were logged. The Concerns team log all complimentary letters, phone calls and s. Where possible the information is shared with the clinical staff. All clinical staff and wards/areas mentioned in the correspondence receive a letter from Ruth Walker. All people who e mail compliments receive a response on the same day. Medicine has the highest number of compliments Emergency Medicine (previously Unscheduled Care until 1/4/14) 92 Clinical Gerontology (Active from 19/9/13) 76 Haematology, Immunology and Genetics 68 Obstetrics and Gynaecology 58 Internal Medicine (Active from 01/04/14) 50 Primary Care 38 Peri-Operative Directorate (Surgery Support Services prior to 1/7/15) 37 Therapy Services 37 Trauma and Orthopaedics 33 Not Known 28 ENT, Ophthalmology and Urology (Active from 01/11/14) of 121

103 1.12 Reports from the Nurse Director General Surgery and Wound Healing (Active from 01/11/14) 24 Cardiothoracic and Critical Care 21 Neurosciences 21 South East Cardiff Locality 14 Acute Child Health 13 Adult Mental Health 11 Highest numbers of recorded compliments Complement cards, e mails and letters remain the most popular methods of sharing positive feedback. Study Day On the 23 March 2016 a study day was held for staff and 140 people attended. The feedback was very positive. Some of the feedback included Reminding us to look at issues from a patient s perspective. Increased confidence in where to seek advice. All of the presentations were useful. Consent, due to interests of this topic recently by members of staff at ward level. 97 of 121

104 1.12 Reports from the Nurse Director I enjoyed the case scenarios with the solicitor and also enjoyed the inquest talk. All very informative and interesting. Reinforcing importance of accurate record keeping. Understanding the context of how concerns are addressed. Examples of cases help to put into context. The whole day has been useful. Each speaker was excellent and their session valuable. Good overview of the legal context that governs the way we work. Differences in the law. UHB has no insurance - money comes out of patient services funds. Each session (topic) had something useful to take away for consideration - time to sit back and reflect on current practices and procedures. Information around open candour and openness of the trust. The topics covered are all essential to the day to day management of the service I work for and my current understanding of the legal position is not as good as it should be. Excellent refresher. Really enjoyed the introduction from Ruth walker and the first two sessions. Consent - understanding with regards to the right to patient consent. Complaints - refresher on how important it is to be transparent and involve the complainant at the early stages. All presentations interesting and informative. The whole day was very informative, interactive and engaging. A further study day is planned for September 2016 in conjunction with the patient Safety Team. Conclusion Through the development of a patient experience framework we will progress the collaborative working of the patient experience team to optimize all opportunities to collate and action patient experience feedback. The information will be viewed collectively with intelligence from observational visits, inspections, concerns, compliments and bespoke survey work to truly understand what it feels like to be a patient using our services. We will engage with staff to ensure that the patient experience framework and philosophy is embedded in our day to day behavior. This will be in addition to influencing a consideration of how we will measure patient experience from the outset of any service changes to ensure that we are truly listening and acting upon the wealth of information that is shared with the Health Board. 98 of 121

105 1.12 Reports from the Nurse Director SERIOUS PATIENT SAFETY INCIDENT REPORTING Executive Lead : Chief Nurse/Executive Nurse Director Author Patient Safety Manager, Caring for People, Keeping People Well : This report underpins the Health Board s Sustainability elements of the Health Board s Strategy. Financial impact : There are significant potential financial implications associated with this work in relation to clinical negligence claims. Quality, Safety, Patient Experience impact : The work outlined within this paper reflects the significant activity taking place to improve patient safety and experience leading to improved quality and care outcomes for patients. Health and Care Standard Number: 2.1, 3.1, 3.3 CRAF Reference Number: 5.1, 5.1.5, 5.6, 5.7 Equality Impact Assessment Completed: Not Applicable RECOMMENDATION The Local Partnership Forum is asked to: CONSIDER the Serious Patient Safety Incident report. SITUATION This report provides the Local Partnership Forum with an update on the number and themes of new Serious Incidents (SI) and No Surprises/Sensitive Issues (NS) reported to Welsh Government since the last meeting. BACKGROUND The Health Board is required to report Serious Incidents (SI) relating to patient safety and No Surprises (NS), through an agreed internal process, to Welsh Government as outlined within guidance issued in July This guidance was updated in November 2013 to reflect the revised regulations relating to Putting Things Right. For ease of reference, a Serious Incident (SI) is defined as an event that occurred during NHS funded healthcare (including in the community setting) which resulted in unexpected or avoidable death or severe harm of one or more patients, staff or members of the public; was a Never Event, threatens to prevent an organisation s ability to continue to deliver healthcare services, allegations of physical/sexual abuse or adverse media attention about an organisation. 99 of 121

106 1.12 Reports from the Nurse Director No Surprises reporting requires Health Boards/Trusts to report sensitive issues to Welsh Government. Such issues may include incidents or events which could lead to adverse media attention, temporary capacity issues or incidents where it is initially unclear whether a serious incident has occurred. Patient safety incidents reported through the UHB Risk Management System (DATIX) are uploaded anonymously to the National Reporting and Learning System (NRLS). The UHB usually reports in the region of 15,000 patient safety related incidents to the NRLS annually, the vast majority of which fall within the near miss, no harm and low harm categories. This is set in the context of approximately 1.8 million patient contacts which represents less than 1% of patient related activity occurring within the UHB. In order to protect patient / family confidentiality in this report, the detail of each individual Serious Incident is discussed and taken forward within the relevant Clinical Board as appropriate and summary information is provided within this report only. When appropriate, the outcome of any internal review is shared with the patient and/or their family and with HM Coroner or other external body when the UHB is required to do so. ASSESSMENT In March and April 2016, the UHB has reported 43 new Serious Incidents to Welsh Government. 5 new No Surprises incidents have also been reported by the UHB during this period. All reported Serious Incidents are subject to internal investigation and are monitored at the weekly Serious Incidents and Concerns meeting led by the Executive Nurse Director. In summary, the new Serious Incidents and No Surprises reported by the UHB are as follows: Serious Incidents Clinical Board Number Description Clinical Diagnostics and Therapeutics 1 A coagulation test has been performed as a secondary test to determine Lupus anticoagulant requirements. Concern has been raised regarding the volume of positive results. The test results are under review and further tests have Executive and Corporate Services ceased until a review is completed. 1 Incidents where the Procedural Response to the Unexpected Death in Childhood (PRUDiC) process has been activated. 100 of 121

107 1.12 Reports from the Nurse Director Medicine Falls where the patients sustained significant injury, such as fractured neck of femur. The patients are all at various stages of recovery. A patient unexpectedly collapsed and died on transfer from UHW to UHL. The patient was being transferred for ongoing rehabilitative care. Grade 3-4 healthcare acquired pressure damage. Delays in undertaking diagnostic or surveillance procedure in Gastroenterology. A patient has unexpectedly died in the Emergency Department. There was a reported delay in administering medication for acute alcohol withdrawal symptoms in the patient. A patient has been found to have sustained a fracture but the cause of the fracture is unknown. A patient absconded from UHL and was subsequently involved in an accident with a bus. No major injuries were sustained. A patient has had an unintended radiological examination due to a breach in Ionising Radiation (Medical Examination) Regulations. This has also been reported to Healthcare Inspectorate Wales as required. A patient died who had Clostridium difficile recorded on part 2 of their death certificate as a contributory factor. A patient required cardiopulmonary resuscitation following wrong route administration of adrenaline for anaphylactic shock. The patient survived. 101 of 121

108 1.12 Reports from the Nurse Director Mental Health 6 Primary Care and Intermediate Care Specialist Falls where the patients sustained significant injury, such as fractured neck of femur. The patients are all at various stages of recovery. Unexpected deaths of patients known to Mental Health services. 2 of the deaths are likely to conclude as suicide by the Coroner; the cause of death in the remaining 3 patients is yet to be determined. A former client known to Addiction Services has been arrested on suspicion of murder. The victim was also known to Addiction Services. Unexpected death of a patient known to community services. The cause of the patient s death is currently unknown. Grade 3-4 healthcare acquired pressure damage, possibly contributed to by failure of a pressure relieving device. A patient died who had MRSA recorded on their death certificate as a contributory factor. Falls where two patients sustained a significant injury, such as fractured neck of femur. In a third fall, a patient died having sustained a significant head injury in a fall from his bed. It is reported that the raised bed rail collapsed when the patient pulled on it to roll over in bed. The matter has been reported to the Health and Safety Executive and MHRA. Early indications suggest that the bed rail may not have been fully secured in the raised position. A Coroner s inquest is due to be held in June A patient unexpectedly died following problematic ventilation after insertion of a tracheostomy tube. 102 of 121

109 1.12 Reports from the Nurse Director Surgery Total 43 Two patients died who had MRSA recorded on their death certificates as a contributory factor. Accidental retention of a throat swab occurred in surgery which has been reported and managed as a Never Event. A patient has had an unintended radiological examination due to a breach in Ionising Radiation (Medical Examination) Regulations. This has also been reported to Healthcare Inspectorate Wales as required. A patient sustained a burn to their skin requiring review by a specialist team at Morriston Hospital. It is thought possible that the burn may have been caused by chlorhexidine skin cleansing solution. A patient has undergone an inappropriate surgical procedure for her diagnosis. No Surprises Clinical Board Number Description Medicine 1 One ward was temporarily disrupted due to an outbreak of diarrhoea. Specialist 1 One ward was temporarily disrupted due to an outbreak of diarrhoea and vomiting. 1 A patient who required specialist treatment in an NHS England hospital experienced funding difficulties which have since been resolved by Welsh Health Specialised Services Committee (WHSSC). Surgery 1 One ward was temporarily disrupted due to an outbreak of diarrhoea and vomiting. Pan - UHB 1 A No Surprises incident was reported when the UHB experienced a significant diarrhoea and vomiting outbreak across the UHB. Total of 121

110 1.12 Reports from the Nurse Director Welsh Government Serious Incident Closure Process The UHB is required to submit a closure form to Welsh Government on conclusion of a Serious Incident investigation process. This provides assurance on the measures that have been taken to avoid a similar incident in a similar set of circumstances. Closure forms are subject to review within Clinical Boards quality and safety mechanisms, prior to sign off by the Director of Nursing. The submitted closure forms are reviewed by Welsh Government who may proceed to request additional information or close the incident. The UHB has continued to make good progress with submission of closure forms to Welsh Government. In March and April 2016, Welsh Government closed 29 Serious Incidents having been provided with assurance on the actions taken by the UHB. The learning identified from the incidents closed by Welsh Government included: Review of governance arrangements including communication and standard operating procedures in use by the All Wales Lymphoma Panel Review of standard operating procedures in Toxicology Training and competence assessment for staff in Toxicology to the revised standard operating procedures Transport arrangements for patients requiring transfer to Whitchurch Hospital for ECT were reviewed but the issue has resolved with the opening of the new unit at Hafan Y Coed on the University Hospital of Llandough site Training on sepsis identification and management has been undertaken on the Medical Assessment Unit at University Hospital of Llandough A working group has been established to improve healthcare with patients with Learning Disabilities A sepsis working group has been established Review of pressure area management, including devices to support pressure relief has been undertaken in Critical Care Staff have been reminded of the correct procedures to follow after a patient has suffered an injurious fall, particularly to remind them about neurological observations and use of the Hoverjack hoist Review of procedures for patients undergoing tracheostomy insertion who also require Critical Care intervention Importance of nurse in charge attending ward rounds has been highlighted with arrangements to ensure necessary communication between medical and nursing staff reinforced if nursing staff cannot attend the round Procedures to access prescribed medicines out of hours where they are not kept on ward areas has been highlighted to staff Review of booking procedures for endoscopy surveillance procedures 104 of 121

111 1.12 Reports from the Nurse Director The Directorate of Gastroenterology, Hepatology and Endoscopy have implemented a robust mechanism to review and manage investigation results during periods of leave of absence for medical and secretarial staff A software patch was implemented to strengthen the Laboratory Information Management System to reduce the risk of sending results to non-uhb locations Review of standard operating procedures for labeling of intravenous infusions in Critical Care to reduce risk of accidental disconnection. Training provided to update staff on the revised procedures. Her Majesty s Coroner Regulation 28 reports Her Majesty s Coroner has not issued any Regulation 28 reports relating to inquests of patients who had been under the care of the UHB since the last report provided to Board in March of 121

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113 1.14 Staff Benefits Group Terms of Reference Staff Benefits Group Executive Lead : Director of Corporate Governance Author : Director of Corporate Governance Caring for People, Keeping People Well : Financial impact : N/A Quality, Safety, Patient Experience impact : Our Values Health and Care Standard Number: CRAF Reference Number: Equality Impact Assessment Completed: Not applicable RECOMMENDATION The Local Partnership Forum is asked to : APPROVE the Terms of Reference for the Staff Benefits Group. NOTE areas being prioritised for Staff Benefits SITUATION Throughout the N.H.S in the U.K there are a number of NHS Staff Benefit Schemes, providing a range of free benefits for staff from private and public organisations. At the current time these are received by various offices and locations across the Health Board. The purpose of this paper to set arrangements for the coordination and authorisation of staff benefit s scheme for the Health Board BACKGROUND Prior to the establishment of the Health Board, the previous organisations supported the use of a Staff Benefits Booklet. This detailed a comprehensive range of suppliers and services offering discounts varying from 10 25% off retail prices. However, this booklet is no longer available. A range of ad-hoc offers continue to be received but are not coordinated or widely communicated to staff. In recent months, there have been a series of meeting held with interested parties to consider how, to manage staff benefit schemes within the Health Board. In order to make further progress a further meeting was held early 2016 involving the following 106 of 121

114 1.14 Staff Benefits Group Terms of Reference Chair of Staff Side Independent member (Staff side) Director of Corporate Governance Head of Communications, and Web Page Manager Assistant Director of Human Resources- Head of Workforce Governance Senior Manager Procurement Following discussions it was agreed to set up a group to consider staff benefits. ASSESSMENT The Health Board has established a Staff Benefits Group in late 2015 to explore and maximize benefits for staff making recommendations to the Local Partnership Forum (LPF) The benefits for staff will include: Salary sacrifice schemes including bikes, cars home electronics and a lot more Travel and Holiday discounts Health and wellbeing schemes e.g. discounted corporate and public gyms and sports facilities Discounted tickets for sports events National NHS discount schemes Enhancing a range of internal staff benefits e.g. use of Health Board facilities for wellbeing Staff Lottery, long service awards and promoting retire and return. Terms of Reference Purpose To consider opportunities for staff working in Cardiff and Vale University Health Board to receive a range of benefits provided from internal and external sources. 107 of 121

115 1.14 Staff Benefits Group Terms of Reference Membership Director of Corporate Governance-Chair Director of Staff Side Head of Staff Side Head of WOD Governance Head of Procurement / Senior Representatives Communications Representatives Fundraising Representatives Sustainable Travel Manager Assistant Finance Director Accountability Reports to Local Partnership Forum (LPF) Roles and Responsibility The Group will explore and make recommendations to the LPF (regarding opportunities for staff to benefit from exclusive deals. These will include: Eating in/out Education and Childcare Entertainment Financial Services Health and Beauty Home and Garden Hotels and Travel Motoring and Servicing Retails Sports and Recreation Utilities Weddings Fostering and Adoption Salary Sacrifice Scheme for a range of products Staff Lottery Staff Wellbeing The Group has met on 3 occasions and the current potential benefits being explored are: Salary Sacrifice Scheme including vehicles, white goods furniture and other house and technology equipment. 108 of 121

116 1.14 Staff Benefits Group Terms of Reference Consideration to extending long service awards to recognize 40 years service within the current policy and potential funding service Mobile phone contracts Partnership working with Peugeot (Lookers) offering significant discounts on sales and services. Developing a staff handbook. 109 of 121

117 2.1 Emergency Services Independent Review Update EMERGENCY SERVICES INDEPENDENT REVIEW UPDATE Executive Lead: Chief Operating Officer Author: Director of Workforce and Organisational Development Caring for People, Keeping People Well: The Emergency Services independent review was commissioned by the Health Board in response to concerns raised about patient care and employee engagement within the directorate. Follow through of recommendations from the review report are integral to the Health Board s strategy on achieving optimal patient experience and embedding the values amongst the workforce. The delivery of services within the ES is recognised as a key part of this strategy. Financial impact: TBC through implementation of recommendations Quality, Safety, Patient Experience impact: Delivery of the report recommendations will enable benefits to be realised that will positively impact quality, safety and experience for patients, service users as well as the workforce within the Emergency Services. Health and Care Standard Number 3.1 CRAF Reference Number Equality Impact Assessment Completed: Not Applicable RECOMMENDATION The Local Partnership Forum is asked to: NOTE the update on implementation of recommendations from the Emergency Services independent report. SITUATION This report provides an update on the implementation of the recommendations from the Emergency Services (ES) independent report published on 2 nd July In summary, all of the 46 recommendations are either complete or on track for completion. The sub-groups, Improvement Group and Steering Committee which make up the programme infrastructure continue to meet regularly with a monthly quality assurance session to ensure that implementation is in line with the principles set from the start as well as highlighting any blockers to smooth and timely delivery of 121

118 2.1 Emergency Services Independent Review Update As a reminder, the ES Improvement Plan is in two parts to aid delivery: Part A of the Improvement Plan consists of recommendations that can be delivered within the sphere of influence of the sub-groups and monitored through the Improvement Group. Part B of the Improvement Plan consists of recommendations that can be better delivered through the Steering Committee where the impact of actions are specific to a group of staff or an individual or the actions impact upon the whole organisation. BACKGROUND To implement the comprehensive set of recommendations in the independent report, the programme structure remains in place with the sole purpose of following through on all recommendations and to provide the Health Board with assurance that sufficient action has been taken to enable the desired improvements. The four independent facilitators continue to track progress and ensure activity is in line with the design principles of: keeping process and progress transparent; engaging and involving staff; working in line with UHB values; and robust tracking of impact of deliverables. ASSESSMENT The ES Steering Committee meets monthly and continues to ensure robust oversight, monitoring and control of the effective implementation of the recommendations. Final meetings are scheduled for June and July 2016 at which point the aim to complete the majority of the recommendations by that point should have been achieved. The following table summarises the delivery status of the 46 recommendations as at the last meeting on 27 April 2016: Completion status Plan Part A Plan Part B Total RED (to commence) n/a n/a 0 AMBER (on track) R14, R27, R28, R30, R42, R11, R15, R25, R29, R26, R21, R17 GREEN (completed) R16, R2, R10, R7, R39, R20, R22, R43, R19, R23 R1, R18, R38, R6, R13, R5, R3, R32, R24 R40, R45, R4, R46, R31, R33, R34, R35, R36, R44, R12, R37, R9, of 121

119 2.1 Emergency Services Independent Review Update All recommendations are either on track or completed. There are no longer any that are deemed Red. Recommendations are due for completion by end of June with a few, as appropriate, which may continue into business-as-usual activity due to their nature e.g. organisational development and culture change. Further completed recommendations from ES Improvement Plan Part A (update from the previous Board report) Recommendation R19: We recommend that the Lead Nurse and Clinical Director should immediately review and improve the risk register. They should lead the development of clinical audit processes that is linked to the risks identified, with the overall aim of reducing risk through quality improvements that are evidenced based. R23: We recommend that training should be provided to staff so that they understand escalation processes and how to effectively report harm/errors. Assurance Risk register reviewed and cross referenced with health and care standards for Wales and draft QSE committee agenda. Two half day workshops took place for risk assessment training/ incident reporting and to develop the risk register. Copies have also been made available to a wider section of frontline staff to enable them to comment in line with UHB Policy. Based on this, the risk register has been revised and circulated. Two hour risk assessment workshop delivered in March. Evaluation and recommendations were collated where a process has been agreed by consultant and clinical governance lead. This process will include training in existing induction and junior doctor training and middle grades. Further completed recommendations from ES Improvement Plan Part B (update from the previous Board report) Recommendation Assurance R35: We recommend that given the significant levels of stress related absence identified in the directorate, that this is investigated further by occupational health and systems/support are put in place to address any findings. R36: We recommend that the organisation implement a systematic and robust process for understanding the reasons why people leave the organization, or departments to move elsewhere within the organisation. This should be more than a purely questionnaire type approach and should include random selection of individuals for more in depth interviews by appropriately trained staff (e.g. the organisational psychologist). Investigations took place to find primary reasons for stress related absence by occupational health. Processes are now in place to support staff experiencing significant levels of stress. Exit questionnaires have been issued to all members of staff who resign from the Directorate followed by an exit interview with an organisational psychologist. Information to be collated and analysed on a quarterly basis to identify what actions can be put in place to reduce turnover of 121

120 2.1 Emergency Services Independent Review Update Recommendation R44: It is recommended that the Executive undertake discussions to establish a more open and constructive style of engagement with the Director of RCN Wales, which enables both sides to be confident that issues will be managed by both parties in an appropriate way and at the correct level of escalation. R12: We recommend that the Health Board invests in the Organisational Development programme for Emergency Services to assist the management team and the wider staff group to affect sustained cultural change within ES. R37: It is recommended that a series of interventions are undertaken, by an appropriately trained individual to develop a mutual level of trust and openness within the Emergency Services staff group as a whole. This should include a shared understanding of different roles and responsibilities and the development of an agreed set of ground rules including behavioural values to which all staff should be held accountable to enact. Assurance Communication channels exist between Health Board Executives and Director of RCN Wales. The meeting between the UHB and RCN Chairs on 23 rd March 2016 confirmed that in future, issues can be are managed through routine meetings given the better relations now in place. An Organisational Development programme has been invested in and is in place. Implementation forms part of business-as-usual activity and is led by the Clinical Board Director with close support by the recently new Head of Workforce and OD. This recommendation forms a vital part of the OD programme which is in place and being implemented (see above). R9: We recommend that role modelling of the values and behaviours espoused by the Health Board must be the norm and senior leaders must be observant to and challenge inappropriate behaviours of managers and staff in real time. Senior leaders and managers must be prepared to take allegations seriously and fully investigate in a prompt way, regardless of where the allegation comes from. This recommendation forms a vital part of the OD programme which is in place and being implemented (see above). ES colleagues will also be involved in the Health Board s overall values and behaviours programme which has just commenced implementation of its first phase. Communications and engagement Communications continue to be shared regarding progress. Communication with ES staff consists of newsletters, Facebook group chats and use of the notice board in ES following feedback from a collective ES sub-group meeting that took place in February. A communications plan is in place and remains under review by the Improvement Group to ensure effectiveness of messaging. There is continued union involvement throughout the groups, including the RCN and Unison. Updates about this programme of work remains a standing item on the agendas of the QSE Committee and the LPF; feedback to date has been largely positive from both representatives of 121

121 2.2 Performance Report PERFORMANCE REPORT Executive Lead : Director of Public Health Authors : Members of the Performance and Information Department Caring for People, Keeping People Well: This report underpins the integrity value of the Health Board s Strategy, providing transparency on our progress in delivering our duties to our resident population and patients and clients who rely on us to provide clinically and cost effective care. Financial impact: The achievement of the efficiency and productivity targets will deliver savings to support the financial position Quality, Safety, Patient Experience impact : The performance report outlines performance over the domains of quality and safety and patient experience, and outlines areas and actions for improvement Health and Care Standard 1 Governance Leadership and Accountability CRAF Reference Number 46/10 Failure to deliver integrated finance, workforce and service delivery Equality Impact Assessment Completed: Not Applicable RECOMMENDATION The Local Partnership Forum is asked to: NOTE the UHB s current performance and the actions being taken to improve performance SITUATION The full Performance Report sets out the UHB s performance against Welsh Government (WG) Delivery Framework and other priority targets up to April 2016 and provides more detail on actions being taken to improve performance in areas of concern. The full report can be accessed via the Board papers from 26 May 2016 on the UHB internet BACKGROUND The UHB is compliant with 25 of its 59 performance measures (February = 21/59, December =22/59, October = 20/59,) and is making satisfactory progress towards delivering a further 14 (February = 15, December = 19, October = 14, September = 13). The indicators that have improved to Green since the last report are: #4 The annual mortality rate for admissions with severe sepsis into the Critical Care Department in the University Hospital of Wales reduced from c. 32% to c.29%s 114 of 121

122 2.2 Performance Report #10 The proportion of % patients aged over 65 who were discharged from hospital and referred to a care home and not their usual place of residence fell to 2.6% from 2.9% 12 months ago. #16 The proportion of patients receiving a nutritional assessment, having the nutrition score completed and appropriate action taken within 24 hours of admission increased to 95% in March from 94% in February. #26 The percentage of patients assessed by Local Primary care Mental Health Support Services within 28 days of receipt of referral & their therapy starting within 28 days of their assessment, in accordance with Part 1 of the Mental Health Measure Local Primary care Mental Health Support Services, improved to 82.8% and 92.8% respectively. #44 The proportion of Cardiff and Vale of Glamorgan residents who are CO validated as successfully quitting at 4 weeks increased to 51% at the end of the 3 rd quarter, from 38% at then end of the second quarter. The indicator where sufficient improvement has been observed to take them from Red to Amber in the period since the last performance report was: #50 The proportion of patients receiving clinical handover from the Ambulance service to the UHB s clinical services within 15 minutes and 60 minutes to 56% and 93% respectively in April from 45% and 80% in February. The indicators where performance deteriorated since the last report are: #53 The number of patients whose pathway of care has been delayed has increased to 94, 73 of whom are receiving the non mental health care and 21 whom are receiving mental health care. #59 Despite marked improvements having been observed the UHB s annual sickness rate for 2015/15 was 5.14% against the internal target of 5%. Consequently there are now 20 measures where performance is either below the expected standard or progress has not been made sufficiently quickly to ensure delivery by the requisite timescale. This is summarised in the table below: Policy Objective Green Amber Red Score Improving our patients experience of care Improving the health and well being & reducing inequity of our population Making effective use of our staff and resources / / / of 121

123 2.2 Performance Report Total /59 ASSESSMENT Section 2 provides commentary on the following areas of performance which have been prioritised by the Board or which have deteriorated in the period and the actions being taken to drive improvement. These are: Emergency Department and ambulance response and handover times GP Out of Hours services Delayed Transfers of Care Stroke Mental Health Measures Cancer Elective access including dementia and diagnostic waiting times Healthcare Associated Infections Hand hygiene Cleaning standards Staff Appraisal 116 of 121

124 2.2 Performance Report Board Meeting 26 th May 2016 Performance Report 117 of 121