BOARD OF DIRECTORS MEETING FRIDAY 10 JUNE 2016

Transcription

1 BOARD OF DIRECTORS MEETING FRIDAY 10 JUNE 2016 Please find attached the agenda for the next meeting of the Board of Directors. The meeting will take place in the QEQM Lecture Theatre, Queen Elizabeth The Queen Mother Hospital, St Peters Road, Margate, Kent, CT9 4AN, commencing at 13:00 1 Chairman s Welcome 2 Apologies for Absence 3 Declaration of Interests 4 Minutes of the previous meeting held on 8 April Matters arising from the public minutes of 8 April 2016 AGENDA 6 Patient Story Discussion BoD 41/16 Chief Nurse and Director of Quality 7 Dementia Village Discussion Presentation BoD 42/16 Director of Strategic Development and Capital Planning 8 Chief Executive s Report Discussion BoD 43/16 Chief Executive /17 Annual Objectives, to include Board Assurance Framework Discussion BoD 44/16 Chief Executive Alison Fox, Trust Secretary 10 Highest Mitigated Risks Discussion BoD 45/16 Chief Nurse and Director of Quality 11 Chair s Actions To Note BoD 46/16 Chair.

2 12 Board Committee Feedback: 12.1 Finance and Investment Committee 12.2 Quality Committee BoD 47/16 To Follow BoD 48/16 To Follow Board Committee Chairs 12.3 Strategic Workforce Committee 12.4 Integrated Audit and Governance Committee 12.5 Remuneration Committee 12.6 Nominations Committee Charitable Funds Committee, to include: Charity Annual Report and Accounts Charity Letter of Representation Charity Strategy Discussion Discussion Discussion Discussion Approval BoD 49/16 BoD 50/16 BoD 51/16 BoD 52/16 BoD 53/16 13 Integrated Performance Report Discussion BoD 54/16 Director of Finance and Performance Chief Nurse and Director of Quality Chief Operating Officer Director of HR 14 Trust Improvement Plans: Improvement Plan Discussion BoD 55/16 Chief Nurse and Director of Quality Emergency Recovery Plan Discussion BoD 56/16 Chief Operating Officer 15 Cultural Change Programme Update To Note BoD 57/16 Director of Human Resources 16 Sustainability and Transformation Plan Update 17 Communications and Engagement Strategy Discussion BoD 58/16 Director of Strategic Development and Capital Planning Discussion BoD 59/16 Director of Communications 18 Emergency Planning Update Audit Report Discussion BoD 60/16 Chief Operating Officer 19 Medical Revalidation Discussion BoD 61/16 Medical Director.

3 20 Feedback from Council of Governors, to include: Feedback from NEDs aligned to Governor Committees Discussion BoD 62/16 Chair and Non Executive Directors 21 Any Other Business 22 QUESTIONS FROM THE PUBLIC Date of next meeting in public: 9 September 2016, 9:30, QEQM Lecture Theatre.

4 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 UNCONFIRMED MINUTES OF THE SEVENTY-SECOND MEETING OF THE BOARD OF DIRECTORS FRIDAY 8 APRIL 2016, 2PM, BOARD ROOM, KENT AND CANTERBURY HOSPITAL PRESENT: Mrs N Cole Chair NC Mr R Earland Deputy Chair/Non-Executive Director RE Mr B Wilding Senior Independent Director BW Mrs G Gibb Non-Executive Director GG Mr S Adeusi Non-Executive Director SA Mr C Tomson Non-Executive Director CT Mr R Hoile Non-Executive Director RH Mr M Kershaw Chief Executive MK Mr N Gerrard Director of Finance and Performance Management NG Dr S Smith Chief Nurse and Director of Quality SSm Dr P Stevens Medical Director PS Ms J Ely Chief Operating Officer JE Ms L Shutler Director of Strategic Development and Capital Planning LS Sandra Le Blanc Director of Human Resources SLB IN ATTENDANCE: Sue Lewis Improvement Director SL Ms A Fox Trust Secretary AF William Harvey Hospital Ward Managers (Minute No 19./16 to 24/16): Maria Linden; Selina Moore; Lisa Johnson (forelaine Barclay); Carol Allan; Erin Toner; Kathryn Penticost Turnbull (KPT); Sharon Woods (SW); Julie Whittingham; and Sue Greenstreet Finbarr Murray Director of Estates and Facilities (Min No 11/16) FM MEMBERS OF THE PUBLIC AND STAFF OBSERVING: Sarah Andrews Junetta Whorwell Mr Edel Peggy Pryor Philip Bull Bess Browning Ruth Heron Andrew Scott MINUTE NO. 19/16 CHAIRMAN S WELCOME ACTION NC welcomed the Board and members of the public to the meeting and to the Ward Managers in attendance for the staff story item on the agenda. Those in the public gallery would have an opportunity to ask questions about the topics of the day at the end of the Board Meeting. Any other questions could be raised either through the website or direct correspondence. CHAIR S INITIALS Page 1 of 21

5 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 NC informed the members of the public a private Board meeting was held in the morning for matters of a confidential nature. She provided assurance that important decisions would be reported to the public prior to implementation. 20/16 APOLOGIES FOR ABSENCE Satish Mathur, Non Executive Director (Satish was in attendance for the morning private session). 21/16 DECLARATIONS OF INTEREST NC declared her interest in Healthex and EKMS and SLB declared her interest in EKMS. 22/16 MINUTES OF THE PREVIOUS MEETING HELD ON 5 FEBRUARY 2016 The minutes of the previous meeting were agreed as an accurate record. 23/16 MATTERS ARISING FROM THE PUBLIC MINUTES OF 5 FEBRUARY 2016 All actions were noted as closed or on the agenda. 24/16 STAFF STORY SSm introduced the item and Ward Managers in attendance. Ward Managers had attended the Board of Directors in April 2015 to share their concerns around how winter pressure wards were being operationalised. Following this session, a number of actions were put in place and these were listed in the report. Ward Managers had requested to attend the April 2016 Board meeting to describe their continued concerns around engagement with the planning process. During February and March 2016, Ward Managers had met with SSm and JE to discuss further actions to mitigate risk to maintain quality and safety. Maria Linden (ML), Ward Manager CDU, presented the report to the Board of Directors on behalf of the Ward Managers present. She expressed disappointment following the recent press article in the Ashford Herald about the intention of the report to the Board. She outlined some background and context to the current concerns around operational pressures: Cambridge M1 opened on 1 October 2015 as an escalation ward. Prior to this, beds were used in the ambulatory care unit. Although Ward Managers welcomed additional staffing investment for a Ward Manager Assistant, Cambridge M1 ward did not have a permanent staffing establishment. All medical wards shared the risk of staffing the shortfall and at present there appeared to be no end in sight. A roster was currently in place to cover Cambridge Ward to the end of May CHAIR S INITIALS Page 2 of 21

6 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 Whilst wards were permitted to backfill shifts, this was not always possible and, as an example, in March 2016 there were 42 unfilled shifts. Staff were anxious about the future of the extra beds and are concerned around sustaining patient safety. Ward Managers were not able to provide assurance that all elements of their roles could be fulfilled during this time. Training and management duties had fallen behind. Acuity of patients had increased. This was monitored daily. CDU was seeing 3-5 level 2 patients. Length of stay was 7-10 days, with patients transferring to the first available bed, not necessarily on a medical ward. Demand on medical beds did not match the current capacity. As of today s date, 28 medical patients were outliers in surgical beds. Kings D Ward (female) was being used as a swing ward as agreed with the service improvement team. This was a concern as the ward was initially intended to be open for six weeks. In light of the challenges conveyed above and in the report, Ward Managers asked the Board of Directors to consider: Proper involvement of and engagement between the Board and front line clinical staff. Directors to visit staff on wards to experience the pressures. Funding to be added every urgent care and long term condition ward budget to over establish by one registered and one unregistered member of staff in order to mitigate short staffing as a result of substantive moves to the Winter Pressures Ward. The Recruitment Panel to be removed or streamlined as this process is currently making recruitment challenging and adding to the pressure. A decision to be made about Cambridge M1 as a fully funded general medical ward with a permanent establishment of nursing and administrative staff. Board of Directors discussion: NC thanked all members of staff for taking the time to attend the Board of Directors meeting. GG welcomed the presentation from staff. She stated Non Executive Directors received a lot of assurance around the work of the improvement hubs. It was important to ensure communication channels were robust and appropriate for staff to raise concerns. Ward Managers explained there had been a short timeframe for involvement in the previous planning process. There had not been sufficient opportunity to express concerns, or to discuss and feedback from wards. Ward Managers were asking for this to change for the forthcoming year. JE responded that planning capacity and flow was a continuous issue and had recognised ward managers had not been sufficiently involved previously. CHAIR S INITIALS Page 3 of 21

7 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 Assurance was provided by JE that the meeting held with SSm, Ward Managers and herself in March 2016 was the start of continuous monthly meetings with teams going forward. Data for the plan for the forthcoming year was available and ready to be shared with staff. Last year there was a delay in agreeing health economy plans which had impacted significantly on the engagement process. RE concurred with the statement made by GG. He asked if there was anything more the organisation could do to ensure concerns were escalated more effectively. In addition, he asked the Ward Managers how effective the organisation was in providing real empowerment to staff. ML reported she had raised concerns to her Senior Matron who had taken this forward immediately. Ward Managers reported they found SSm to be supportive and approachable. They also provided assurance they provide feedback from meetings held with senior teams to their own staff who welcomed this approach. RE asked what the Ward Manager s anticipated outcome was following the open dialogue to the Board of Directors. Ward Managers felt that feedback in the past had been limited when raising a concern. They welcomed opening this line of communication. Ward Managers were uncertain of the continuing situation regarding operational pressures. Temporary Wards were becoming more permanent and asked for more clarification around mitigating actions and timeframes. RH referred to the recommendation in the report to remove or streamline the recruitment panel. LS explained the background to the recruitment panel put in place to help stem a rising pay and agency bill. The panel met for the first time in December The backlog had now been cleared and forms were now being processed quickly. LS agreed to facilitate an invitation to Ward Managers to attend the recruitment panel where they could experience the process put in place, the information considered by the panel and decisions made. The fundamental criteria assessed by the panel were whether the post was substantive in October 2015 (99% of applications received were) and whether or not the post would reduce agency expenditure. Ward Managers questioned why forms were still required if the post was substantive in October This was a particular area that could be streamlined. SSm referred to the recommendation that Directors visit staff on wards. SSm reported the Board s Quality Committee discussed a process for facilitating this. Ward Managers welcomed this and added that visibility was important for Board members to experience the pressures faced by staff first hand. NG recognised that working at unsustainable pressure resulted in low morale and CHAIR S INITIALS Page 4 of 21

8 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 asked what else the Trust could do to attract and retain nursing staff. Ward Managers had attended EU recruitment fairs where other Trusts were offering incentives such as IPads or monetary incentives such as a year s NMC registration or car parking payments for a year. Ward Managers added that employment into vacancies would offer security to staff and have a positive effect on future recruitment and retention. CT referred to the approach of you said, we did. The Trust needed to provide rationale for the actions it cannot follow through. CT referred to the roll out of the SAFER patient flow bundle and asked what the barriers were for this being used more effectively. Elisa Steele explained the SAFER bundle had not yet been rolled out in full. The S (Senior Review) had been rolled out. Work was on-going to re-focus and to identify wards for initial implementation. Barriers were the need for greater medical engagement. PS recognised the Trust needed to be more open with staff around the future sustainability of services. Actions being put in place would take time to embed. This could be better communicated through monthly meetings facilitated by JE. GG referred to the recommendation the report for additional funding to every urgent care and long term condition budget. No financials were included in the report to make a decision but she asked for a view from the Board as to how this would be taken forward. JE was currently working with Divisional Divisions to review the Trust s bed base. SSm would then work with ML to review staffing levels and address staffing shortfall through the Trust s business case process. GG asked for assurance that Board members had the capacity to undertake the necessary planning required. JE responded that work was focussed on planning for the new normal rather than winter planning. MK expressed his thanks to Ward Managers for attending and presenting their concerns so clearly. He would reflect on comments made around visibility and involvement of staff into the planning process. Going forward, more authority would be delegated down to departments. MK recognised the importance of regular informal visits to wards and there was more the Executive Directors and Non-Executive Directors could do. MK had recently participated in a CQC Visit to another Trust where patient safety visits had been well embedded. He would share learning. In terms of operational pressures, this was a significant challenge to the Trust and CHAIR S INITIALS Page 5 of 21

9 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 would take time to sustain. There were actions the Trust could take internally and externally with partners to improve the position and these were articulated within the organisation s improvement plans. The four main focus areas were streaming patients at the front door, roll out of the SAFER bundle, better site management and improving capacity outside of the hospital. MK welcomed the plea from Ward Managers to be more involved in planning processes and provided assurance this would be taken forward. Board of Directors decision/agreed actions: The Board of Directors formally recognised the concerns raised by Ward Managers and agreed the following actions would be taken: ACTION: The Board of Directors supported the approach being taken by JE to organise regular meetings with Ward Managers as part of the planning process. ACTION: Non-Executive Directors provided their support to Executive Directors to review the staffing levels on wards. An update would be reported at a later date. ACTION: LS agreed to facilitate attendance by the Ward Managers at Recruitment Panels. Consideration would be given to the proposal to further streamline forms required for submission to panels. ACTION: Increased visibility of Board Members both informally and formally would be facilitated. ACTION: SLB would explore more innovative ways to attract and retain nursing staff. JE JE/SSm LS SSm SLB 25/16 CHIEF EXECUTIVE S REPORT The Board of Directors noted the report. MK referred to an action from the last Board, and reported that the Director of Strategy and Business Development would be fulfilling the role of Programme Manager for the East Kent Strategy Board three days per week. Board of Directors discussion: As a Non-Executive Director, RE supported the importance of maintaining a balance between the priorities of quality and financial targets as referred to in the CEO report. Meeting financial targets should not compromise quality and patient care. RE asked SSm to clarify what percentage of the week the improvement hubs were manned and open: William Harvey Hospital: Thursdays 7am to 5pm/6pm; Queen Elizabeth The Queen Mother Hospital: Fridays. Kent and Canterbury Hospital: Roving location (within wards and departments). Dover Hospital: In the process of setting up hubs. Work for hubs was set at weekly Improvement Journey meetings chaired by SSm. Examples of recent areas of focus include: Duty of Candour; risk; and dementia café. RE felt the Sustainability Transformational Plan and the East Kent Strategy Board CHAIR S INITIALS Page 6 of 21

10 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 agendas were out of alignment in terms of timescales. He asked how this tension would be managed. MK explained the East Kent Strategy Board was the vehicle used to fulfil the requirements of the Sustainability and Transformational Plan. If there was misalignment, it was the way it was being described rather than reality. GG referred to paragraph 1.4 in the report delivering the recovery programme which referred to improved support from communities. She asked what had changed since the last Board, recognising the importance of influencing the work with our partners. MK reported there was specific work undertaken pre-easter with partners (through the Resilience Forum) to improve capacity in the community. He added although work was being taken forward, there still further work to do (coordinated with agencies) to alleviate pressures. RH asked where the key learning points from Operation Carbine would be reported. MK proposed, and the Board agreed, the outcome should be reported to the Board of Directors as part of the Trust s response to emergency planning. It was important there was a high level understanding at Board. Board of Directors decision/agreed actions: NOTED: The Board of Directors noted the report. ACTION: JE agreed to bring specific learning points from Operation Carbine to the next Board as part of the work plan for the year. The Board would be asked to agree the plan was fit for propose. DECISION: NC asked the Board of Directors to endorse the position taken by MK regarding the reaction MK received on his blog regarding LGBT History Month. The Board of Directors endorsed this position and expressed their disappointment. Noted JE Agreed 26/ /17 ANNUAL OBJECTIVES NC introduced the report which reflected discussions had by the Board in closed session when formulating the Trust s vision, mission and overarching objectives. The majority of the objectives had been turned into SMART and the document reflected one and three year objectives. The report was presented to the Board for approval. Board of Directors discussion: CT referred to the timescales on page four wondered if 2020 (rather than 2021) would be more palatable. NC clarified this objective referred to links to integration with European systems. The year 2021 was identified as it was felt this was not something the Trust needed to address immediately. CHAIR S INITIALS Page 7 of 21

11 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 CT reminded the Board of discussions regarding the benefits of the inclusion of research capability and links to universities, particularly in terms of recruitment and development. RH reported the improvements on page 5 of the report had been discussed by Quality Committee. The Committee had noted and accepted March 2017 as the timescale for delivery but noted the challenge to delivery. NG reminded the Board of Directors that the financial figures on page 5 of the report would be firmed up once the operational plan for 2016/17 had been agreed. BW felt the new style Board Assurance Framework was a positive improvement and, if used properly, could be an immensely powerful approach to risk and managing the Trust s business. A process for tracking actions needed to be established through Quality Committee. Following a question raised by BW, AF clarified that black indicted no assurance. BW recognised the development of the report was work in progress. SA commented that SMART objectives were a powerful tool. He asked how this would be cascaded and linked to performance. GG further asked how objectives would be shared with external partners. SLB responded annual objectives would be embedded into the new appraisal process introduced in the Trust on 1 April MK added once agreed by the Board of Directors, objectives would be cascaded through the communications team. Objectives would also be discussed as part of leadership sessions established with people managers and shared externally as part of the sustainability and transformational plan. MK agreed to take forward. JE reported she would share the objectives with Divisional Directors at a forthcoming Away Day. Board of Directors decision/agreed actions: The Board of Directors agreed the annual objectives subject to: ACTION: The Board of Directors noted financial figures could not be fully finalised pending sign off of the 2016/17 plan. NG to take forward. ACTION: Objectives would include reference to research capability and links to universities. MK to amend. ACTION: An updated report would be brought to the next Board of Directors meeting. The following additional actions would be taken forward: ACTION: The objectives would be embedded within the quality strategy and appraisal process. SSm to action. ACTION: The Communications Team would be asked to cascade the agreed objectives to staff. SLB to action. ACTION: Communication of the objectives externally would take place as part of the Sustainability and Transformational Plan. MK to take forward. NG MK MK SSm SLB MK CHAIR S INITIALS Page 8 of 21

12 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April /16 CHAIR S ACTIONS The Board of Directors noted the scope for the next External Board Governance Review. The tender process was now complete and Grant Thornton had been appointed, following a unanimous decision of the panel. NC further report she had approved as Chair the revision to the Trust s appraisal process. The monitoring of the implementation would be undertaken by the Strategic Workforce Committee. 28/16 PERFORMANCE REPORTS CORPORATE PERFORMANCE REPORTS CLINICAL QUALITY AND PATIENT SAFETY KEY NATIONAL PERFORMANCE TARGETS STRATEGIC WORKFORCE REPORT A new integrated report would be introduced in May 2016 reflecting April data. Corporate Performance Report GG asked to understand what the Trust had been doing differently since the last report to the Board of Directors and asked for this to be included in future reports going forward. JE responded significant work had been taken forward in emergency departments as part of the recovery plan. A specific area of focus was site management. A control centre had been established at William Harvey Hospital, next door to the emergency department. The Trust was considering a similar model at Queen Elizabeth The Queen Mother Hospital. Further work was being undertaken to improve leadership through senior reviews. Externally, the Trust was evaluating the impact of additional care packages as part of integrated working. Activity had increased by 10% in April compared to March. Building work was currently underway to improve the environment of the William Harvey Hospital Emergency Department. William Harvey Hospital Emergency Department was experiencing a particularly challenging period operationally. Site based improvement work was being taken forward with links to acute medical models and longer term solutions for each site. GG welcomed the explanation provided by JE which linked directly to financial position. She was pleased to hear the Trust was continuing with its original plan and flexing where necessary operationally. As reported earlier, the four main focus areas for emergency care were: streaming patients at the front door, roll out of the SAFER bundle, better site management and improved capacity outside of the hospital. SA felt a sense of resignation. Issues were being tackled for some time. The Finance and Investment Committee and Board of Directors were now well sighted CHAIR S INITIALS Page 9 of 21

13 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 on where the challenges lie. SA went on to refer to the number of initiatives put in place to tackle patient flow but commented there was not one project tackling delayed transfers of care. JE provided assurance this was being coordinated through East Kent Chief Operating Officers. CCGs were currently advertising for a programme manager. JE provided further assurance the recovery plan included and had links to external health economy plans. A single plan was in place but there were workforce and physical gaps which still need to be resolved. SL had worked closely with the Trust on the emergency department recovery plan. The national picture was deteriorating. However, the Trust needed to be careful when making comparisons to other Trusts. She urged the Trust to continually look inwards to identify and take forward improvements. SL was pleased the Trust had made the improvement plan more localised by site. This enabled Executives and Non Executives to easily identify blocks. Implementing SAFER bundle and staffing and recruitment were two examples. The Board of Directors recognised the importance of demonstrating quality and patient safety whilst delivering improvements required. RE added that the Board had a greater understanding of the actions required. There now needed to be greater understanding of the effectiveness of improvements. In terms of delivering the SAFER bundle, PS reported that work at Queen Elizabeth The Queen Mother was further ahead than William Harvey Hospital. JE added early ward rounds were taking place on this site. Over Easter, staff were allocated areas at QEQM and it was hoped this approach could be rolled out to William Harvey Hospital as part of the site based approach. Board of Directors decision/agreed actions (Corporate Performance Report): NOTED: The Board of Directors noted the report, areas of challenge and actions taken to date. ACTION: It was agreed public facing reports needed to clearly articulate the effectiveness of actions being taken and actions outstanding. The Board of Directors should also understand where outputs were not as expected. Links need to be made to the Corporate Risk Register and delivery of annual and strategic objectives. MK reminded the Board of Directors that the new Integrated Performance Report would be provided at Board level. The detailed performance would be discussed at Committee level. ACTION: It was agreed that reports from Board Committees would appear earlier on the Board agenda to demonstrate the level of scrutiny and challenge. Clinical quality and Patient Safety Report CHAIR S INITIALS Page 10 of 21

14 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 The Board of Directors received the report which had been subject to scrutiny by the Quality Committee on 6 April The report made comparisons to the previous year s performance and SSm drew the Board s attention to the following areas: Emergency Department challenges (as reported earlier in the meeting); patient flow (bed occupancy, outliers and delayed transfers of care). Although mortality rates were slightly higher than this time last year, the Trust reported above the national position. The performance heat map had identified specific areas of focus on wards. Issues were linked to staffing problems and work was ongoing with human resources and divisions to address this shift. These areas had impacted on the safety thermometer and focussed work was being taken forward. Positive performance included: Reduced number of serious incidents compared to the previous month. Reporting of incidents in general had increased compared to the national average. Below trajectory C.difficile. Increase in infection control mandatory training compliance. Improved pain management assessment. Reduction in deep pressure ulcers. Board of Directors discussion: RE and BW provided assurance to those in the public gallery that the report was subject to significant scrutiny at the Board s Quality Committee. RE referred to CDU and CSMs which often flag up on the performance heat map. He asked if there was anything to report in terms of medium to longer term improvements. SSm responded the key drivers were linked to staffing/resources. The immediate plan was to monitor through divisions and the longer term plans were linked to a review of the Trust s bed base. Links would also be made to cultural change. Key National Targets JE provided an update linked to the sustainability and transformational plan targets and Trust objectives for next year. JE was confident the six week diagnostic target would be maintained. One area of challenge was activity through endoscopy. This was a national resourcing issue. However, the Trust had recently recruited a gastroenterologist. The Trust was being asked to maintain a cancer trajectory of 85% by September The Kent and Medway Cancer Collaborative had observed the Trust s performance to be steady and consistent and on target to achieving trajectory by September. Delivering the two week wait performance was key to this. JE was committed to micromanaging this area. CHAIR S INITIALS Page 11 of 21

15 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 The Trust was non-compliant with the 18 week RTT due to demand, specifically in orthopaedics. This was subject to on-going discussions around activity with the CCG. Board of Directors discussion (Key National Performance Targets): ACTION: GG asked that future reports include more detail around timescales, action being taken. CT asked if there were any challenges to achieving the cancer trajectory of 85% by September 2016, given the complexities of the pathway. JE referred to challenges within endoscopy due to increased activity. Dermatology and breast had staffing issues. These areas were being managed with no major issues to report at this time. RH referred to page 7 of the report and asked for clarification around the perceived governance issues linked to loss of clinics and theatres. JE explained this was around ensuring appropriate supervision and competence. RE referred to page 8 of the report and the Trust s intention to remove fire breaks within annual jobs plans resulting in the number of weeks to increase to 42. JE/PS clarified 42 weeks took into consideration annual leave, study leave and bank holidays. The Trust had commissioned a piece of work to review job planning and productivity to ensure all consultants were fully utilised. RE had interpreted the A&E performance data to read that 50% of the breaches were within the Trust s own gift. MK explained the flow in and out of the emergency departments was complex. The emergency recovery plan reflected three out of the four focus areas to be internal. RE further referred to delays in receiving mental health assessments and asked for clarification around the impact on emergency care. PS explained that small numbers of patients could impact significantly on a department: ensuring appropriate waiting and treatment areas and staff resource. JE added that work was on-going with commissioners and mental health trusts to improve site liaison. Plans were in place to extend psychiatric liaison which would make a significant difference to East Kent mental health service. BW referred to A&E performance and asked why Kent and Canterbury Hospital had been included in data and what had impacted on performance. JE explained emergency care centre data was included in performance data. Performance had dipped and was in recovery at present. Strategic Workforce Report CHAIR S INITIALS Page 12 of 21

16 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 The report had been received at the Strategic Workforce Committee and SLB highlighted the following areas of risk: The number of staff who had never undertaken statutory mandatory training was subject to a focussed piece of work with divisions. Turnover of staff was not at the expected levels. It was noted the target would be changed following agreement of the annual objectives at today s meeting. Board of Directors discussion (Strategic Workforce Report): BW asked for clarity around the risk of the number of staff who had never completed mandatory training. SLB responded reports were produced for Divisions and work was on-going to illuminate staff absence and to understand this further. ACTION: The Board of Directors requested the Strategic Workforce Committee receive a report to understand where the challenges were around statutory mandatory training, actions being taken and anticipated outcomes. 29/16 TRUST IMPROVEMENT PLANS: IMPROVEMENT PLAN TURNAROUND PROGRAMME REPORT EMERGENCY RECOVERY PLAN Improvement Plan SSm confirmed there were no further updates to the report. SL referred to the areas reported as amber and the reasons provided. There would inevitably be some slippage with delivery. She would be prepared to undertake a review of delivery dates to ensure the Trust was focussing on the right areas. Board of Directors decision/agreed actions (Improvement Plan): NOTED: The Board of Directors noted the report. ACTION: The Board of Directors was in agreement with the review of delivery dates as proposed by SL. This would be taken forward with SSm. BW further proposed, and the Board agreed, the original dates remain visible as an audit trail together with reasons for the change. Noted SSm Turnaround Programme Report NG reported the Trust year end cash position was 3.8m. The deficit position as at today s date reported Monitor had revised its submission date for 2016/17 plans from Foundation Trusts from 11 April 2016 to 18 April This was driven by realistic offers not made between commissioners and providers and emerging issues around CQUIN payments. The Trust had held six meetings with CCG colleagues to look at the volume of CHAIR S INITIALS Page 13 of 21

17 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 activity to negotiate contracts for 2016/17. The Trust hoped to secure a firm position by Wednesday 13 April 2016 within the financial envelope of the draft plan submitted. It was likely a payment by results contract would be agreed and this would require decision by Board. If a contract cannot be agreed, formal arbitration was available. The Trust was required to deliver a savings target of over 30m for 2016/17. The Trust had expressed concern to NHS Improvement that this target was unrealistic. The Trust had also requested a review of the ceiling set by Monitor for agency spend. The ceiling was set at 20m and, following review of current spends, the Trust had requested this be set to a more realistic level of 23m. To achieve this, the Trust would need to see a month on month improvement across workforce spend. RE reported the Finance and Investment Committee had requested turnaround reports to Committee and Board move from process focussed reports to outcome and trajectory. The Finance and Investment Committee recognised the system pressures and the need to ensure a balance between financial turnaround and quality. NG added that turnaround performance would be integrated into the detailed finance report presented to Finance and Investment Committee and would include an element of well led. Following the introduction of the new integrated report from May 2016, CT asked for clarification as to where progress against CIPs would be reported. He stressed this needed to be more visible, particularly within public facing reports. NG responded this would be reported fully within the detailed finance report and all Board members would receive access. MK added a narrative would be included within the integrated report to Board. SA felt that the Trust needed to report more predictive forecasting and forward looking to enable more active management decisions to be made. NG agreed and provided assurance that going forward the Executive Team would be taking a more engaged, inclusive involvement in forward planning. Following a question raised by BW, NG confirmed the current plan does not take into account of non-recurrent measures. ACTION: NG agreed to update the Board of Directors with the outcome of the contract negotiations by following the meeting scheduled for 13 April NG Emergency Recovery Plan The Board of Directors agreed most questions had been raised and answered earlier in the meeting under minute number 28/16. JE added that a concentrated review of the plan was being undertaken. CHAIR S INITIALS Page 14 of 21

18 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 SL commented the narrative within the plan was concise and clearly explained what actions had not come to fruition and why. BW referred to the chart on the first page and was confused as to why some areas where reporting green when not all were on target. JE explained this reflected performance against the trajectory set at that time. BW referred to the overall compliance week ending 27 December 2015 to 13 March 2016 (top of page 9) and asked why performance had changed significantly. JE referred to earlier discussions regarding patient flow, higher attendances in March 2016 and gaps in bed capacity in February 2016 impacting on length of stay. MK reiterated the Trust recognised there was further work to be undertaken internally and this was reflected within the summary report. Board of Directors decision/agreed actions (Emergency Recovery Plan): NOTED: The Board of Directors noted the position to date and detailed discussions recorded under minute 28/16. Noted 30/ STAFF SURVEY RESULTS The Board of Directors received the 2015 Staff Survey Results. Board of Directors discussion: BW asked for reasons why the respecting each other programme had not demonstrated improvements (page 2 of the report). SLB was not sure why this had not impacted as planned as the Trust had put in concentrated effort in this area. Analysis of the results had been undertaken and SLB was aware of the areas of focus. Monitoring was reported through the Strategic Workforce Committee. MK recognised there had been significant work undertaken and results had not improved as much as they need to be, but there was improvement across some measures. GG referred to a helpful presentation at the Strategic Workforce Committee from Picker. Comparatives were provided and the Committee was provided with a real sense of what to expect and areas the Trust should be challenging. SLB stressed it would take time to move to an upper quartile position (approximately three/four years). CT added year on year improvements becomes harder over time. Board of Directors decision/agreed actions: NOTED: The Board of Directors noted the 2015 Staff Survey Results. DECISION: The Board of Directors agreed the priority areas for action: a Noted Agreed CHAIR S INITIALS Page 15 of 21

19 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 continuous focus on the respecting each other campaign; re-launch of the health and well-being group for the organisation; post implementation and evaluation and promotion of the Trust s new appraisal process; and a focus on capacity and capability of managers/leaders in the organisation. 31/16 HEALTH AND SAFETY KPI UPDATE The Board of Directors received the Health and Safety KPI update following a request at the February Board of Directors discussion: NC referred to discussions at the last Board to include near misses in future reports. LS/FM reported that these were not logged onto Datix and would take time to pull together. Work was needed to either identify an obvious place to record the data or create an entry field on Datix where these could be specifically registered. CT found the report to be helpful but felt a schedule needed to be set behind the timescales and it would be helpful to have a range of indictors. SLB felt it would be more helpful to have sharps as a separate number rather than included within accidents. FM agreed to pull out as a separate item. Although data was important, RE felt the Board of Directors needed to have more of a free forming discussion around health and safety (systemic risk/cultural risk). NC agreed and felt the top three accidents in terms of frequency and mitigation should be included. LS invited discussion around whether never events should be included in reports. The Board of Directors agreed this was adequately covered in the Medical Director s Report. Board of Directors decision/agreed actions: NOTED: The Board of Directors noted the report. ACTION: It was noted health and safety would be incorporated into the integrated performance report. A further report was requested for the next Board to see the evolution of the data. The following also to be included/considered: Inclusion of near misses; Top three accidents: frequency and mitigation; Extract sharps into a separate reporting line; A schedule to be set behind the timescales with a range of indictors. FM/LS 32/16 CORPORATE RISK REGISTER The Board of Directors received the latest risk register. SSm reminded the Board of Directors the next report would be set in the context of the new strategic objectives. CHAIR S INITIALS Page 16 of 21

20 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 The Trust had recruited to a risk manager position. Board of Directors discussion: BW reported the report had been subject to scrutiny at the Quality Committee on 6 April He was encouraged by the progress and development of the new format risk register and felt it had the potential to transform the business of the organisation. Board of Directors decision/agreed actions: ACTION: BW referred to actions which were past their due dates and asked for confirmation these had delivered to plan: CRR 15: Recruitment and Retention had no target risk and no action. SLB agreed to update with details of the inherent risk, actions taken and risks to delivery. CRR 5: Blood and blood product transfusion errors. SSm confirmed as complete. CRR12: Patients eyesight may be adversely affected by inadequate follow up arrangements. PS to find out if actions were complete. ACTION: MK proposed, and the Board of Directors agreed, that delivery of the emergency care programme board would be added to the risk register. ACTION: MK further proposed, and the Board of Directors agreed, that the storage and ownership of oncology records would be added to the risk register. This had been discussed at the Quality Committee on 6 April SLB SSm PS SSm SSm 33/16 MEDICAL DIRECTOR S REPORT PS reported that since submission of the report to Board, two legal challenges had been made against the junior doctors contract concerning diversity. The Trust would be conducting a piece of work to take forward a number of actions prior to making a decision as to whether to adopt the new contract. SL left the meeting. Board of Directors discussion: NC asked whether the Trust would be implementing the appointment of the Guardian of Safe Working regardless of whether the new contract was adopted. MK and PS would be discussing this with trainees initially. SLB reported advice had been received that the Trust would be able to implement local terms and conditions but there would be consequences in terms of funding for trainees. Local terms and conditions would also disadvantage trainees who were with the Trust for a short period. SLB also reported that no further negotiations were taking place between the BMA CHAIR S INITIALS Page 17 of 21

21 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 and NHS Employers. There was no other contract on offer other than the national contract. The Trust would be required submit weekly returns to the centre: numbers of junior doctors (currently 396); the number the trust had engaged with; the numbers of rotas that need redesigning (there were 142 on the system and 72% would need redesigning); and updates on the appointment of the Guardian of Safe Working. NC asked how many staff would be negatively impacted by the new contract. SLB advised it was difficult to say at present without undertaking a detailed review of rotas. The Trust had not undertaken as much work as it needed to at this point and this would be addressed. MK recognised the challenges faced by all Trusts nationally. He proposed to the Board of Directors the Trust continue with its preparatory work and continue discussions locally. Board of Directors decision/agreed actions: NOTED: The Board of Directors noted the report, specifically the position regarding the junior doctors contract. DECISION: The Board of Directors agreed the recommendation to continue preparatory work for the junior doctors contract. The Board of Directors formally acknowledged the impact. DECISION: The Board of Directors agreed the recommendation in the report to establish a Mortality Steering Group and a review of mortality Governance. The Board of Directors recognised the additional work required but also that it would provide additional opportunities for learning. Noted Agreed Agreed 34/16 BOARD COMMITTEE FEEDBACK Finance and Investment Committee The Board of Directors received the report from the 5 April 2016 Committee meeting and agreed salient points had been discussed earlier in the meeting. The Board of Directors noted the positive cash position at year end, in line with plan. The Committee heard that the implementation of the new PAS system was subject to risk around productivity. The Committee had requested a further update before implementation around mitigating actions and ownership of plans at divisional level. In addition, a description of the role of super user/sro. ACTION: SLB proposed the PAS Implementation be taken through management Board to understand the risk. SSm agreed to take forward. DECISION: The Board of Directors endorsed the recommendation to change the Committee name to Finance and Performance Committee. SSm Agreed Quality Committee CHAIR S INITIALS Page 18 of 21

22 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 The Board of Directors received and noted the report from the 6 April 2016 Committee meeting. RH reported the March 2016 meeting was cancelled. Strategic Workforce Committee The Board of Directors received and noted the report from the 19 February and 24 April 2016 meetings. CT drew the Board s attention to the following: A report on progress against job planning was received. The Committee had raised a concern regarding the lack of progress in some areas and expected to see improvement within the next report. Remuneration Committee The Board of Directors received and noted the report from the 22 March 2016 meeting. DECISION: The Board of Directors approved the amended Terms of Reference to remove the responsibility of succession planning. This was covered within the remit of the Nominations Committee. Agreed Nominations Committee The Board of Directors received and noted the report from the 22 March 2016 meeting. 35/16 COUNCIL OF GOVERNORS NC reported there had not been a full Council meeting since the February 2016 Board. The following Council of Governor Committees have met: Nom and Remuneration Committee 15 February 2016 RE was in attendance and reported the following: The Committee received the report following the Internal Assessment of Effectiveness of the Board. The Committee reviewed the NED appraisal Process. The Committee would be considering a core skills audit for governors. The Committee considered the term of office of RE and would be making a recommendation to full Council. Audit and governance Committee 18 February 2016 BW was in attendance and reported the following: The Committee considered alignment of Non-Executive Directors to Council of Governor Committees and hospital sites. The Committee would be receiving a presentation from KPMG at its next meeting to receive the outcome of the 2015/16 audit process. Joint Meeting with the Non-Executive Directors Communications Workshop 22 February 2016 Feedback from the workshop had been mixed. NC would discuss with MK/SLB how to take forward outcomes. CHAIR S INITIALS Page 19 of 21

23 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 Strategic Committee 1 April 2016 NG reported that SM was the Non-Executive in attendance. The main agenda item was the 2016/17 plan update. ACTION: Constitutionally, Governors should review financial plans before they were submitted. This needed to be addressed and AF was taking this forward. 36/16 ANY OTHER BUSINESS The Board of Directors received a Purdah Briefing from NHS Providers and noted the timetables and rules and regulations. ACTION: The briefing would be circulated to the Council of Governors. AF 37/16 QUESTIONS FROM THE PUBLIC Peggy Prior informed the Board of Directors she used to be the Secretary of CHEKK. She had seen on the Mountfield Plan a new site identified for the Kent and Canterbury Hospital and asked for an update on Trust plans. MK responded the Trust was in the process of developing the Sustainability and Transformational Plan due for submission in June At this point the Trust would have clarity over the model of care. Following submission, the Trust would be undertaking a more detailed piece of work with the public with the aim of going out to consultation at the end of the calendar year. At this point, the Trust would be clear about its proposals and options. MK stressed the Trust would be looking to ensure the future service provision was safe, effective, high quality and accessible to its East Kent population. Peggy Prior referred to the workforce challenges discussed earlier in the meeting and commented she had never seen an advert in the Royal College of Nursing Journal for EKHUFT staff. She referred to the 100 th Anniversity of the Royal College of Nursing and plans for an exhibition in Glasgow on 9 June 2016 and 23 June She proposed the Trust consider holding a stand to promote the organisation. ACTION: SLB agreed to take forward. SLB Mr Edel expressed his thanks to Maria Linden and her colleagues for raising their concerns at the meeting. He asked for clarification around the actions the Trust would be taking. JE/MK summarised the following actions were agreed: JE would be organising regular meetings with this group of staff as part of the planning process. Visibility of Board members on wards and departments, both informal and formal, would be taken forward. JE/SSm would be taking forward a piece of work to look at the workforce issues raised by the ward managers and investment required. Mr Edel referred to the form filling required as part of the Trust s vacancy panel process. He encouraged the Trust to test forms prior to implementation. CHAIR S INITIALS Page 20 of 21

24 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST Board of Directors 8 April 2016 MK reminded Mr Edel of the commitment to invite ward managers to join a recruitment panel. Mr Edel expressed difficulties with completing telephone surveys as part of the Friends and Family Test. ACTION: SSm agreed to follow this up. SSm Mr Edel was surprised Data Protection Regulations had not been mentioned under the Corporate Risk Register Item. The report indicated an unmitigated score of 20 and proposed the Trust appoint a Data Protection Officer. MK provided assurance the Trust had a robust information governance process in place within the Trust. JW referred to item 10 on the agenda Performance Reports. She asked if patients from Ashford had been disadvantaged following the closure of Celia Blakey. JE clarified the unit had not closed but had moved temporarily. Chemotheraphy was not being delivered there temporarily but the Chemotherapy Bus was providing a service for all patients. ACTION: JE agreed to produce an update for clarity and awareness of the current arrangements and future plans. JE Date of next meeting in public: 10 June 2016, 14:00, QEQM Lecture Theatre, QEQM Hospital Signature Date CHAIR S INITIALS Page 21 of 21

25 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST BOARD OF DIRECTORS MEETING 10 JUNE 2016 ACTION POINTS FROM THE PUBLIC MEETING OF THE BOARD OF DIRECTORS MEETING HELD ON 8 APRIL 2016 MINUTE NUMBER DATE OF MEETING ACTION DESCRIPTION LEAD DUE BY PROGRESS OUTSTANDING ACTIONS FROM PREVIOUS MEETINGS There were no issues outstanding from the previous meeting. ACTIONS FROM THE LAST MEETING HELD 24/ STAFF STORY Organise regular meetings with Ward Managers as part of the seasonal planning process. Executive Directors to review the staffing levels on wards. Facilitate attendance by the Ward Managers at Recruitment Panels. Consideration to further streamline forms required for submission to panels. Increased visibility of Board Members both informally and formally to be facilitated. Explore more innovative ways to attract and retain nursing staff. JE EMT LS SSm SLB There are regular meetings already on the sites and JE to use these meetings to share and discuss the bed models and winter plans starting 3 rd June. Paper discussed at EMT 25 May Closed to be incorporated into Recruitment and Retention Strategy 25/ CHIEF EXECUTIVE S REPORT Specific learning points from Operation Carbine to the next JE June 2016 Noted on work programme for June 1

26 MINUTE NUMBER DATE OF MEETING ACTION DESCRIPTION LEAD DUE BY PROGRESS Board as part of the emergency work plan for the year. Board 26/ /17 ANNUAL OBJECTIVES Financial figures to be finalised on agreement of the 2016/17 plan. Objectives to include reference to research capability and links to universities. An updated report would be brought to the next Board of Directors meeting. Objectives to be embedded within the quality strategy and appraisal process. The Communications Team to be asked to cascade the agreed objectives to staff. Communication of the objectives externally as part of the Sustainability and Transformational Plan. 28/ PERFORMANCE REPORTS Reports to clearly articulate the effectiveness of actions being taken, timescales and actions outstanding. Links need to be made to the Corporate Risk Register and delivery of annual and strategic objectives. Reports from Board Committees to appear earlier on the Board agenda. Strategic Workforce Committee to receive a report to understand where the challenges were around statutory mandatory training, actions being taken and anticipated outcomes. NG MK MK SSm SLB MK NG/JE/ SSm/ SLB NC SLB The plan is still under discussion with NHS Improvement. On Board agenda for 10 June Closed. All embedded. Closed. Communication/ awareness undertaken. Will be taken forward as the plan develops. Ongoing as the Integrated Performance Report is enhanced and developed. Closed. Agendas have been amended to reflect this change. Scheduled onto SWC Work programme twice per year (April and October 2016). 2

27 MINUTE DATE OF ACTION DESCRIPTION LEAD DUE BY PROGRESS NUMBER MEETING 29/ TRUST IMPROVEMENT PLAN Improvement Plan Review of delivery dates to be undertaken. Original dates toremain visible as an audit trail together with reasons for the change. SL/SSm Turnaround Programme Update to Board on the outcome of the contract negotiations by following the meeting scheduled for 13 April NG April 2016 Closed. Update also included in CEO Report for 10 June 2016 Board. 31/ HEALTH AND SAFETY KPI UPDATE Further report was requested for the next Board to see the evolution of the data. The following also to be included: Inclusion of near misses; Top three accidents: frequency and mitigation; Extract sharps into a separate reporting line; A schedule to be set behind the timescales with a range of indictors. 32/ CORPORATE RISK REGISTER CRR 15: Recruitment and Retention had no target risk and no action. Update with details of the inherent risk, actions taken and risks to delivery. CRR12: Patients eyesight may be adversely affected by inadequate follow up arrangements. To confirm if complete. Delivery of the emergency care programme board would be added to the risk register. Storage and ownership of oncology records would be added to the risk register. LS June 2016 SLB PS SSm SSm Health and Safety KPI Metrics included in Integrated Performance Report. Verbal update on top three incidents to be provided at the Board under the IPR item. Closed updated. Closed. Added to the risk register. Closed. Added to the risk register. 3

28 MINUTE DATE OF ACTION DESCRIPTION LEAD DUE BY PROGRESS NUMBER MEETING 34/ BOARD COMMITTEE FEEDBACK Finance and Investment Committee PAS Implementation be taken through management Board to understand the risk. 36/ ANY OTHER BUSINESS Purdah Briefing from NHS Providers to be circulated to Governors. 37/ QUESTIONS FROM THE PUBLIC Consider advertising for staffing the RCN Journal. LS AF SLB Scheduled for a Management Board meeting. Closed. Briefing circulated. Closed -.the Trust always carefully considers where to advertise a job vacancy, and what media, taking into account the cost, and the ability to provide a sufficiently wide pool of suitable candidates. Consider a stand at the RCN 100 th anniversary exhibition. SLB Closed a stand has been booked for September Explore difficulties with completing Friends and Family test telephone surveys. Circulate awareness of the current arrangements and future plans for Celia Blakey. SSm CB Reported to Envoy who coordinate the FFT for the Trust. 4

29 PATIENT STORY BoD 41/16 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS DATE: 10 JUNE 2016 SUBJECT: REPORT FROM: PURPOSE: PATIENT STORY CHIEF NURSE & DIRECTOR OF QUALITY Discussion Information CONTEXT / REVIEW HISTORY / STAKEHOLDER ENGAGEMENT The Board of Directors have been using patient stories to understand from the perspective of a patient and/or a carer about the experiences of using our services. Patient stories are a key feature of our ambition to revolutionise patient and customer experience. Capturing and triangulating intelligence pertaining to patient and carer experience from a variety of different sources will enable us to better understand the experiences of those who use our services. Patient stories provide a focus on how, through listening and learning from the patient voice, we can continually improve the quality of services and transform patient and carer experience. SUMMARY The Board of Directors receive a positive story followed by a story where something went less well every other month. This month s story is a poor patient experience and relates to a complaint received about the care of a person living with dementia. The story is presented by the daughter of the patient and concerns the admission of her mother to the Kent & Canterbury Hospital. The story describes a number of lapses in care, both physical and also in the way the patient and family were communicated with, which lacked compassion and care. The complaint investigation raised a number of serious concerns that warranted an internal review of the ward and its leadership. The ward was placed into Special Measures and required to attend three internal Quality Summits with the Chief Nurse and her Deputy. A ward action plan was developed and implemented with many positive changes to the way care was delivered. This resulted in the strengthening of the leadership team on the ward and subsequent improvements in the standards of care. This story describes the regrettable events, the learning and the journey of improvement that the ward went through. RECOMMENDATIONS: The Board of Directors are invited to discuss the key themes of this story and the actions in place for continuous improvement. 1

30 PATIENT STORY BoD 41/16 NEXT STEPS: Ensure sharing of the learning and prevention of recurrence. IMPACT ON TRUST S STRATEGIC OBJECTIVES: Patients: Help all patients take control of their own health. Provision: Provide the services people need and do it well. LINKS TO BOARD ASSURANCE FRAMEWORK: IDENTIFIED RISKS AND RISK MANAGEMENT ACTIONS: A number of management actions were taken to ensure the sustainability of the improvements and prevent recurrence. FINANCIAL AND RESOURCE IMPLICATIONS: The improvements in the environment across the Trust had financial implications. The Trust Dementia Appeal is raising funds to help improve the care of people with dementia. LEGAL IMPLICATIONS / IMPACT ON THE PUBLIC SECTOR EQUALITY DUTY: None noted. PROFESSIONAL ADVICE TAKEN ON ANY NOVEL OR CONTENTIOUS ISSUES: None. ACTION REQUIRED: (a) Discuss (b) To Note CONSEQUENCES OF NOT TAKING ACTION: If we do not learn from the feedback from patients and their families there is a risk that we do not continue to make improvements to patient experience and outcomes. 2

31 PATIENT STORY BoD 41/16 Board of Directors Patient Experience Story June 2016 Introduction This month s story was received from a complaint letter from the daughter of a patient living with dementia who was admitted to the Kent & Canterbury Hospital. The story describes a number of lapses of care, both physical and also in the way the patient and family were communicated with, which lacked compassion and care. The complaint investigation raised a number of serious concerns that warranted an internal review of the ward and its leadership. The ward was placed into Special Measures and required to attend three internal Quality Summits with the Chief Nurse and her Deputy. A ward action plan was developed and implemented with many positive changes to the way care was delivered. This resulted in the strengthening of the leadership team on the ward and subsequent improvements in the standards of care. This story describes the regrettable events, the learning and the journey of improvement that the ward went through. The Patient Story Mrs S, an 86 year old lady was admitted to Harbledown ward following one night stay in the Clinical Decision Unit at Kent and Canterbury Hospital (K&C). She was admitted with sepsis due to a urinary tract infection. She was a person living with dementia. Mrs S had a very attentive and caring daughter who wrote into the Trust following her mother s stay. She complained that: 1. Staff appeared unaware that Mrs S had dementia; 2. Staff did not provide assistance at mealtimes, although they were informed of her need to be assisted. Food and drink were left on her bedside table and it was physically impossible for Mrs S to reach the food and drink; 3. Mrs S became very dehydrated and was not offered drinks. The family explained that in her care home she enjoyed fizzy drinks and Forti-juice (an energy drink), and when they offered her these she drank a whole bottle of Forti-juice and four beakers of fizzy drink because she was so thirsty. The Sister said she would write this preference on the whiteboard above Mrs S head for others to be aware, but this was never done. The daughter also states that the fluid and food charts were either not completed, or had declined written on them. Even more concerning for the family was that they begun to check up on the staff. They placed a mark on one of the drinks and learned that the day when checking, that the fluid level had not altered. In addition they noted on the food chart that their mother had refused lunch. This had been recorded prior to lunch being served. Even more concerning was when the Housekeeper was asked why he did not serve Mrs S her meal, he said it was because the nurse said she had refused earlier so therefore he shouldn t bother. Such were the family s concerns, they begun a rota and vigil to be with their mother; 4. The family noticed that the toothbrush and toothpaste they had bought for their mother remained unopened and unused. The family cleaned their mother s mouth themselves and found it to be dry, caked with brown dirt and her lips were cracked and sore; 5. It took 5 days to obtain an air-flow pressure relieving bed, and the staff did not turn Mrs S either; 6. On the day that Mrs S was discharged the family noted that the flannel in her washbag was unused; 7. On another visit the oxygen she was being supplied was on, but was left over the back wall and not being delivered correctly to Mrs S; 3

32 PATIENT STORY BoD 41/16 8. During all of the visits the family were never approached by a member of staff to discuss or inform them how their mother was and how well she was responding to treatment. When staff were approached they appeared reluctant to speak or listen; 9. The bedside table was often littered with dirty tissues that remained the next day when the family visited; 10. The daughter was standing behind the curtain when the staff were administering nursing care for Mrs S and were talking about their personal lives and did not engage with Mrs S or offer her any encouraging words of comfort; 11. Mrs S was discharged with two grade 4 pressure ulcers back to her care home. These pressure ulcers were not reported on Datix and a referral to the Tissue Viability Team was not undertaken. Actions and Lessons Learned This complaint brought into sharp focus a number of serious basic care and safeguarding concerns and leadership inadequacies with the ward. Such were the seriousness of these concerns the Deputy Chief Nurse and Chief Nurse requested an independent review of the ward. The ward was immediately placed in Special Measures and the multidisciplinary ward team members attended a number of performance management meetings over the following weeks. The review was led by a new Matron. The review was carried out by the Tissue Viability Matron, Matron for Nutrition, Head of Adult Safeguarding, Matron for Dementia care, Consultant Nurse for Falls and Osteoporosis and the Infection Control Team. The CCG Head of Quality was closely involved following a complaint from the care home. Leadership This was a ward that lacked effective leadership. There was a high vacancy factor and staff were difficult to attract to the ward and to retain. The Matron begun to work on the ward undertaking observations of care and role-modeling and supporting the staff in the delivery of high standards of care. He met on a weekly basis with the Ward Sister and the Ward Sister s senior team. He also met every member of staff on a 1:1 basis to listen to their concerns. The Senior Matron also increased her presence and support to the ward. Professor Kim Manley undertook a cultural piece of work with the team that enabled them to refocus their purpose. They were given permission to be empowered to lead the care that the patients deserved on the ward and also helped them, via a 360 degree feedback process, to develop their accountability and leadership skills. This resulted in some staff taking responsibility for specific improvements in the way the ward managed its care. The leadership team agreed to change the focus of the Ward Manager role who is now more supervisory and able to role model the way with staff and ensure standards remain high. A new junior sister has been appointed to the ward and a ward manager s assistant role has been introduced. The Ward Establishment Review demonstrated that these were required. Funding for the three additional beds was also secured and the vacancies were advertised in order to reduce the need to rely on temporary staffing. The ward now has a new Matron and Ward Manager in place following this review. Both ensure greater visibility than before. The Matrons introduced regular ward rounds where they spoke with patients and their families to ensure any issues were addressed at the time. Pressure Area Care Standards The specialist nurses each undertook a detailed review of the care on the ward. This revealed a number of issues that were lacking. In safeguarding terms it was deemed that Mrs S had been neglected. She had not received basic care needs and suffered two category 4 deep pressure ulcers that had not been reported. A root cause analysis was undertaken and the following changes have now been implemented: 4

33 PATIENT STORY BoD 41/16 The correct pressure ulcer documentation from PAS (Patient Administration System) is now in place; Risk assessments of all patients are now carried out within 6 hours of admission to the ward. This was audited weekly; The handover sheet was redesigned so that pressure areas are discussed between shift changes every time; Medical staff now include discussion of pressure damage as part of their ward rounds; The team provided an increased presence of the Tissue Viability Team on the ward who also provided training and competence assessments of the staff; The staff now know how to obtain the correct equipment for the patients and the Medical Equipment Library is now operational. Nutrition and Hydration Care The review by the Matron for Nutrition revealed a large number of patients required assistance at mealtimes. A number of improvements have been implemented: Mealtime assistants have been recruited and volunteer on the ward; The visiting arrangements have been changed and families are encouraged to attend at mealtimes now. We know that even just sitting with a person at a mealtime encourages them to eat and drink as it becomes a more social event, especially if someone is living with dementia; The medical and therapy staff agreed that it was part of their role to offer and encourage people to eat and drink during their interactions with them and that this aspect of care is everyone s business; It transpired that the lunch club was not taking place as it should have been. This has been re-introduced with the Dementia Matron and the therapy staff actively committing to this as part of their routine work. This has been very successful, and indeed the Board of Directors have visited the ward during this time on one occasion; Refocusing on the ward routine at mealtimes in this way has enabled the nursing staff to concentrate on assisting those patients with the greatest need at mealtimes while the remainder enjoy a social time in the Day room. Infection Control There were no concerns that arose from the review that the team undertook. The dirty bedside table was indicative of the acceptance of poor standards of care on the ward that are now addressed. Falls The review of the management of falls on the ward did not flag any significant risks, but the Falls team have set up and run additional training for the staff and the link nurse role has been strengthened to ensure standards remain high. Safeguarding The Safeguarding concerns were very serious. The Head of Safeguarding worked very closely with our external partners to address these as an adult protection alert was raised. Training has been provided for staff in relation to safeguarding and mental capacity assessments. The lack of reporting of incidents, in this case the pressure ulcers revealed an unhealthy culture and unawareness of the implications and seriousness. This is now fully understood by the staff. Dementia Care The ward has undergone numerous improvements in relation to dementia care, some of which have been cited above. The ward has the Dementia Nurse Specialist based on the ward. The Day Room has been fitted out like a 1950s kitchen diner. It has a 5

34 PATIENT STORY BoD 41/16 Rempod, which is a portable screen of a scene from by-gone days for the patients to enjoy. Regular lunch clubs take place on the ward, knitting clubs and activities using all the adjuncts available for people living with dementia. This includes an old gramophone and music played for the days when the patients were young. Reminiscence pictures also deck the walls. A sing song is now a regular event. The Trust has in place a Dementia Strategy Steering Group with a Trust wide action plan in place. This includes the delivery of: Dementia training for all relevant staff; Dementia Champions in place; Guidance for managing patients who display challenging behaviour is in place to assist staff, supported by the Dementia Team and Adult Safeguarding Team; Strong links have been forged with local charitable organisations to improve the support for carers of patients with dementia. Signposting to this community support is provided by the dementia team. We have secured a regular space at the front entrance of both the William Harvey and QEQM sites for the Carers Support. We have introduced flexibility around visiting times, and also seeking feedback from carers to make improvements; Significant effort has been expended to improve early identification of those at risk of dementia using an early assessment form; Widespread use of the This Is Me document has improved understanding of individual s needs and reinforced a person-centred approach to care delivery; Ensuring the environment across the Trust meets the dementia friendly standards as set out by the Dementia Action Alliance. Improvements include colour-coded bays, improved signage, bathroom adaptations and day/night/clocks; The Trust has participated in the first phase of an NIHR funded Person Interaction Environment (PIE) research project to enable staff to develop both their skills and the environment to support people with dementia when they are admitted to hospital. This NIHR funded research is led by the Dementia Centre and Bradford & Leeds Universities and the Trust is both a collaborator and a site for the project; A dementia flag can now be entered on the Special Register, so that we know that the person is living with dementia is an inpatient; Staff are encouraged to sign up as Dementia Friends. Quality Summit The review resulted in an internal Quality Summit meeting chaired by the Chief Nurse. It was attended by all members of the multi-disciplinary team including the CCG Head of Quality, Patient Safety Team and those who undertook the review. Three meetings took place where the ward action plan was monitored and discussed. The ward was taken out of special measures 9 months after the complaint was investigated and now is being led by a new leadership team. Monitoring of all of the wards, including Harbledown, continues via the monthly heatmaps and feedback from patients, families and our external partners who link with the ward. The ward is currently undergoing refurbishment to improve the environment further. Summary This month s story describes a poor patient experience and relates to a complaint received about the care of a person living with dementia. The story is presented by the daughter of the patient and concerns the admission her mother to the Kent & Canterbury Hospital. 6

35 PATIENT STORY BoD 41/16 The lapses of care described in the story were investigated as part of the ward being placed in Special Measures. The story describes the improvements and changes that the ward implemented. It also describes and explains the wider learning and developments that we are implementing in particular in relation to dementia care across the Trust. This story describes as set unfortunate events, the learning and the journey of improvement undertaken. 7

36 BoD 42/16 A Dementia Village at Dover? June 2016

37 The Idea

38 We have an ageing population Over 65 s - 62% of total bed days in hospitals Length of stay increases with age 100% Distribution of death England % 80% % % 50% 40% 30% Number of over 80 s has doubled in the past two decades 20% 10% 0%

39 More people living with Dementia One in six people aged over 80 have dementia The financial cost of dementia to the UK is 26 billion per annum. Over 80 population in East Kent

40 Genesis of a new approach Trust research visit to Holland (September 2014) Participants Phillip Brighton - Consultant geriatrician Clinical Lead HCOOP Jonathon Hawkins - Consultant geriatrician and Medical Director UCLTC Kim Gardener - GP and EKHUFT Clinical Director of Primary Care John Ribchester - GP, executive partner, commissioning lead of Whitstable Joy Marshall - Matron for Dementia Heather Munro - Head Of Nursing, Surgical Division Andrea Reid - Therapies, Inpatient Team Lead Giselle Broomes - Divisional Director UCLTC Henry Quinn Strategic Development Places visited Hogewey GGzE Dementia village Mental Health Care Eindhoven and Kempen - Brainport Health Innovation Program ZorgSaam Zeeuws Vlaanderenorgsaam Guest House with Care Stimulated a lot of thought about a new approach for the UK

41 Hogewey dementia village, Holland Residential quarter for people with dementia Care Concept: Permit an everyday life which is as normal as possible The facilities are based around a village street lay out Local community, family & friends encouraged to use the facilities Identified seven separate social groups that are prevalent in Dutch society. Patients are placed in homes that reflect the preferences of these social groups: Urban Upper class Homely Cultural Christian Indonesian Handicraft Maximum of seven residents per house

42 Initial thinking on a new approach Hogewey Dementia Village Model High capital requirement Very difficult to fund in current UK healthcare environment Limited evidence base Financially sustainable Needs to be self sustaining and capable of attracting further investment funding Lower cost models of care in both the Dementia Village and the community Academic support Provide an evidence based model that can be rolled out further Robust evidence base on finances, outcomes and benefits Training Provide facilities and programmes to train healthcare professionals Community Support Hogewey does not support community providers of care and carers Provide access to expertise to help people living with dementia remain in, and return to, their community Integrate facility with local community

43 The Approach

44 The Dementia Village Enclosed, secure site Houses adapted to create 6 homes 4-5 occupants per home Guesthouse with Care Communal therapeutic garden New multi-purpose community building Training facilities Wide use of technology - Communications hub Job, training and volunteering opportunities

45 There is nothing new under the sun Medieval Britain Elderly, supported communities, embedded in the wider community are not new Residential care provided in almshouses and care institutions Almshouses St. Thomas s (Founded 1392) St. Batholomew s (Founded 1190) What is new is the higher demand and level of care required

46 European Funding: Interreg 2Seas The big issue is the capital required for the development Identified a European fund as a potential source Eleven applicants for healthcare projects One of only two approved for a full application Full application submitted at start of May Decision in late July Interreg provides 60% of project funding other 40% contribution comes from the partner EKHUFT s contribution Houses at Randolph Road Dedicated staff time Kent County Council also involved as an investment opportunity for the Public Estates Partnership

47 Interreg Funding Requirements Research project with partners from 2 seas area Requirement is to develop solutions to common problems that have Europe wide applicability and to inform policy making The Dementia Village is the core of the project requiring the highest level of funding Partners from the Netherlands, Belgium, France and the UK Some of the partners will also be developing facilities UK Respite care and training facility The Netherlands and Belgium Guesthouse with Care France Mobile dementia support unit Two partner universities: UK and the Netherlands Providing support for the research programme

48 What is new and innovative (I)? Dementia village based on existing housing stock Guesthouse with Care New model of respite & rehabilitation care for people living with dementia & the elderly Cross border centres of excellence in dementia care using telemedicine to promote virtual consultation/learning/research/innovation A hub & Spoke model for a training & development programmes High level of integration of telehealth and telecare technology Focus on urban regeneration New community facilities Jobs Investment Increased footfall of people/customers in the area Volunteer opportunities

49 What is new and innovative (II)? Internationally peer reviewed evidence base Demonstrating the cost saving of this new way of working leading to project roll out across Europe Partnering across borders to develop the care models and ensure Europe wide applicability Self financing and sustainable Demonstration of future investment opportunities Continuing beyond the project timeline

50 Summary of outputs Centre of excellence and rallying point for geriatric care in east Kent A better way of caring for people living with dementia Help in meeting demand pressures for hospital beds and services for the elderly A new cross border network for dementia research and training On-going source of healthcare professionals trained in care of the elderly & geriatric medicine Innovation engine Local community that is engaged with the elderly Excellent facilities that thrive beyond the lifetime of the project A new income stream for the Trust

51 CHIEF EXECUTIVE S REPORT BoD 43/16 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS DATE: 10 JUNE 2016 SUBJECT: REPORT FROM: PURPOSE: CHIEF EXECUTIVE S REPORT CHIEF EXECUTIVE Discussion CONTEXT / REVIEW HISTORY / STAKEHOLDER ENGAGEMENT The Chief Executive provides a monthly report to the Board of Directors providing key updates from within the organisation, Monitor, Department of Health and other key stakeholders. SUMMARY The monthly report from the Chief Executive provides the Board of Directors with key issues related to: Improvement Journey Financial recovery Leadership Events and Staff Engagement Emergency Department (ED) Recovery Plan Clinical Strategy Update Update on Junior Doctor Contract Negotiations Integrated Performance Report 2016/17 Contract Good News Stories Chief Executive Activity February 2016 to March 2016 RECOMMENDATIONS: The Board of Directors is asked to discuss and note the report. NEXT STEPS N/A IMPACT ON TRUST S STRATEGIC OBJECTIVES: Compliance with notifications from regulatory bodies and policy changes all contribute towards achievement of strategic objectives. Page 1 of 12

52 CHIEF EXECUTIVE S REPORT BoD 43/16 LINKS TO THE BOARD ASSURANCE FRAMEWORK: To enable the Trust to respond in a timely fashion with appropriate information which may affect the Trust s rating with Monitor and the CQC. IDENTIFIED RISKS AND RISK MANAGEMENT ACTIONS: None FINANCIAL AND RESOURCE IMPLICATIONS: None LEGAL IMPLICATIONS / IMPACT ON THE PUBLIC SECTOR EQUALITY DUTY: None. PROFESSIONAL ADVICE TAKEN ON ANY NOVEL OR CONTENTIOUS ISSUES: None BOARD ACTION REQUIRED: The Board of Directors is asked to discuss and note the report. CONSEQUENCES OF NOT TAKING ACTION: Failure of the Trust to respond in a timely fashion with appropriate information may affect the Trusts rating with Monitor and the CQC. Page 2 of 12

53 CHIEF EXECUTIVE S REPORT BoD 43/16 1 EXECUTIVE SUMMARY 1.1 Improvement Journey/CQC CHIEF EXECUTIVE S REPORT Progress continues to be made in implementing the Trust wide high level improvement plan (HLIP) and supporting clinical divisional plans overseen by the Improvement Plan Delivery Board. This Board is now jointly chaired by myself and Dr David Hargroves. In April an extraordinary IPDB was held with a focus on the Maternity Improvement Plan including recent recommendations made following a review requested by the Trust from the Royal College of Obstetricians and Gynaecologists. This was attended by representatives from NHS Improvement, NHS England and the CCGs. We were recently formally requested by NHS Improvement, for the purpose of Ministerial briefing, to undertake an evaluation of our Improvement Plan and submit an improvement trajectory. This included a self-assessment of our current position and forecast position in three months and six months time. The outputs of this review will continue to focus our improvement plans and via the weekly Improvement Plan Steering Group, preparation for our follow up visit. The Quality Innovation and Improvement (QII) Hubs on each site were established in April 2015 to support a shared approach to learning and to help develop and foster a multi-disciplinary culture of improvement and were commended in the July 2016 report. Due to changes of personnel in the teams and to ensure they are fit for purpose as we continue to progress our plans, the QII Hubs are currently undergoing further development and re launch in order to further improve engagement and ownership of our staff. In May, the Kent & Canterbury QII Hub was successfully re launched and is now open every Wednesday from (situated at the rear of the restaurant). The QEQM Hub (Ramsgate Road entrance) will be open from early June from in addition to the Hub meeting which all are welcome to attend from weekly. The William Harvey Hub will also be re launching on Thursday 2 nd June and outreaching to wards and departments. In addition Hubs are being developed at Buckland Hospital and Royal Victoria Hospital. Each Hub will have an assigned Executive Champion as requested by our teams. Monthly Improvement Visits continue coordinated by the Quality Improvement Team. Since February a total of 80 clinical areas have been visited across all sites. In addition we are encouraging teams to use the Improvement Visit tool as part of business as usual. Following the visits the Improvement Team have visited wards and departments to provide feedback and support further improvement. The visits have been well received and have provided an opportunity to gauge the temperature on the front line and assess staff awareness of local improvement plans and their role within them. There is much to celebrate but also recognition of areas where further work is required. The themes from the visits feed into our Fortnightly Focus a brief message that is shared and discussed amongst teams and supported by speakers and events on each site. During May there have been a range of events coordinated through the QII Hubs based around End of Life Care (to coincide with Dying Matters Week) and Medicines Management. During June there will be a focus on Equipment, Learning Disabilities and Adult Safeguarding (with a focus on the Mental Capacity Act and its practical application in our work). It should be noted that there is some slippage against the high level improvement plan this is being managed through the programme governance arrangements. Detail is provided within the CQC Agenda item led by the Chief Nurse, Executive Lead but we are confident of continuing to make positive progress. Page 3 of 12

54 CHIEF EXECUTIVE S REPORT BoD 43/ Financial Recovery The Trust ended 2015/16 with a reported 35.3m deficit, an increase of 27m over 2014/15 but in line with the expected position in July 2015 and in the September recovery plan. Compared to the prior year staffing costs increased by 16m (5.1%), clinical negligence insurance rose by 6m (60%), drugs costs by 2m (3.8%), and premises costs by 2m (11.8%). The Trust retained a positive cash balance of 3.8m at year end. The Trust has set s its local plan based on the agreed contract terms with CCGs and Specialist Commissioners which the Trust achieved on time. However, we are yet to agree a financial control total for 2016/17 as we are waiting final feedback following active discussions with NHS improvement. It is assumed that the Trust will receive 16m from the national Sustainability and Transformation Fund, although guidance is still awaited. At the end of April (month 1) the Trust is reporting a deficit of 2.8m, consistent with a c 10m deficit for the year although this will be finalised once agreements with NHSI are in place. Agency costs in April were disappointingly high, especially in Urgent Care, and further monitoring and controls are being put in place with the divisional teams. Confirmation of the ceiling on agency costs in 2016/17 is awaited. We need to add that this is now confirmed as 23m. The Trust is now implementing key improvements to productivity in theatres and outpatients as part of its 20m savings plan. Further work is being considered that would improve patient flow. Procurement, medicines and agency cost reductions are also critical elements of the programme. The central Programme Management Office has been scaled back with delivery resources focused into the divisions. CIPs savings of 0.5m were delivered against a plan of 0.6m. The Trust has so far developed 17.5m ( 12.5m risk adjusted) and is working on further plans to close the gap against the 20m target. Run-rate expenditure reduction plans of 0.95m - 1.5m per month in Q1 are being implemented targeting major spend drivers such as agency, waiting list initiatives and independent sector work. Decisions to reduce expenditure in these areas have taken into account the need to balance quality, operational impact and finance. April runrate expenditure shows a reduction of 1.7m compared to Mar and 0.6m against the average of last 6m which is a positive start to what will be an extremely challenging financial year. 1.3 Leadership Events and Staff Engagement The Executive Team hosted four leadership events in the first week of May. The events were designed to give EKHUFT s leaders an understanding of the Trust s vision, mission, values and four strategic priorities, and their role in engaging staff with these priorities of patients, people, provision and partnerships. 175 staff took part in these events, which included a formal presentation, Q&A session and interactive discussion. The events were followed up by team briefing materials and delegates took away key message wallet cards displaying the vision, mission, values and four strategic priorities. The events were the first in a series of leadership events and open staff forums that form part of the staff engagement framework. Open staff forums on the vision, mission, values and four strategic priorities are being held in June, and a series of You said, we did follow-up communications in response to the feedback gained at all these events is planned. Page 4 of 12

55 CHIEF EXECUTIVE S REPORT BoD 43/ Emergency Department (ED) Recovery Plan April performance against the 4 hour target was 84.02%, against an agreed trajectory of 85.22% (and an ultimate compliance target of 95%). April s performance level, was improved from the March position with a higher proportion of patients seen within 4 hours, has been impacted by an increase in the number of attendances to our departments with real spikes on some days. Improvements in Emergency Department performance are being pursued through the urgent care recovery plan and were reviewed by the Urgent Care Programme Board on 27/05/16. The pilot of team based working at QEQM Emergency Department was implemented in April There was an immediate positive impact with an improvement on the 60 minute standard from 31% to 48%. The hours of cover are being extended until in May as staffing allows. The senior clinical team at WHH Emergency Department have piloted an internationally recognised assessment process whereby self-presenting and ambulance patients are assessed by a senior doctor or nurse upon arrival in the Emergency Department. Patients will then be streamed to the appropriate pathway to ensure that timely and appropriate clinical care is provided and the sickest patients are seen and treated immediately. Following the successful pilot a formal project implementation group has been established to work through the implementation plan and the group are currently looking at the feasibility and resource implication of roll out. The Acute Medical Model at QEQM is now in its second month of implementation. The model has had an immediate positive impact on patient flow and it has been fully supported by the clinical teams on site. Weekly evaluation is being undertaken so learning is captured and shared. The model will be rolled out at the WHH with implementation planned by the end of June The SAFER model for improved patient flow and effective discharge has been implemented on Sandwich Bay and Minster Ward at QEQM and Cambridge L and Cambridge J at WHH. A SAFER Dashboard is being released on 30 th May to monitor progress and improvements. Operational Control Centres have been established on all three sites, with the major incident control centres now being formally co-located. These have quickly becoming established as information hubs for consultants, senior nurses and managers to provide and receive information regarding the status of a site. Programme Management for Emergency recovery is currently being strengthened through a review of the programme action plan, including those quality improvement measures and the terms of reference and this is essential to continue to support progress with this key priority. 1.5 Clinical Strategy Update Modelling work has progressed following the March clinical event and the April Board discussion and a further update is on the agenda. Further to the work previously undertaken to detail the acuity (how sick) the patients in our beds which demonstrated that around 300 beds could be released if appropriate care was available out of hospital, we are planning a multi-stakeholder 3 audit (1 day per site) in mid-june. This will support primary and community care develop services that will Page 5 of 12

56 CHIEF EXECUTIVE S REPORT BoD 43/16 enable patients to be cared for the in the most appropriate place which is a key part of our future strategy. East Kent Strategy Board: We are continuing to work closely with our CCGs and other healthcare partners in East Kent on the production of the Kent and Medway Sustainability and Transformational Plan (STP). The clinically-led task and finish groups are advising and informing the plan and a series of wider clinical workshops have been arranged for early July. A Patient and Public Engagement Group has also been established as part of the programme s governance. The chair of the group is a member of the East Kent Strategy Board. The detailed technical case for change is near completion and therefore a programme of wider public engagement is being planned. STP We received feedback from NHS England on the April submission and there was a subsequent meeting with Simon Stevens. We have been encouraged to move away from chapters however NHS England remain supportive of input from the East Kent Strategy Board as a key component of the submission. The 30 th June submission is now described as a way point after which there will be a further round of meetings with Simon Stevens/NHS England in July. Next steps the NHS England assurance framework: NHS England has advised the East Kent Strategy Board of the need to undertake an assurance process prior to beginning a public consultation associated with any proposed major service change. We are being encouraged by NHSE to engage with this process as soon as is possible to support us moving to public consultation by the end of the year. The timetable for this assurance process is tight and will be labourintensive. As EKHUFT is currently in special measures, NHS England s guidance requires us to submit any plans for reconfiguration to the NHSE regional team and then the NHSE Investment Committee. The process will follow a step-by-step progression which will commence with a Panel 1 (Strategic Sense Check) submission required by the 31 st May. This will be followed up by a conversation on the 2nd June. 1.6 Update on junior doctor contract negotiations The agreement between the BMA and DH (announced on 18 May 2016) on the future 31 March 2016 contract has been published on the ACAS website: On 27 May, NHS Employers published the terms and conditions agreement which has been agreed by the government, NHS Employers and the BMA, subject to securing the support of BMA junior doctor members in a referendum. The Department of Health has published an equalities statement, which considers the new proposals and their impact on junior doctors. Page 6 of 12

57 CHIEF EXECUTIVE S REPORT BoD 43/16 We have been asked by NHS Improvement to suspend the introduction of the new contract to enable BMA to have sufficient time to have a full and fair conversation with its members ahead of their referendum. We have been asked to facilitate this conversation by ensuring as many doctors can attend BMA regional events and we have done this. There is a agreement from all parties in the ACAS agreement that work to introduce the contract should now cease, with the exception of the appointment of the guardian of safe working hours. We have advertised this post on NHS jobs and will be progressing this as quickly as possible. NHS Employers suggested work to be done as part of normal business could continue and includes a focus on more preparation to facilitate effective engagement with doctors after the referendum result is known: financial modeling that could include the pay scenario outlined in the proposed terms and conditions normal annual / rolling review of current rotas which may also identify those rotas that would require amendment to comply with the proposed terms and conditions curriculum mapping to ensure that posts continue to deliver the required learning outcomes as defined in approved specialty curriculum. However this work can only be planned and cannot involve doctors in training, in the ways we would normally, until such time as the referendum has taken place. We will be meeting with Divisions shortly to discuss and agree actions now that terms and conditions have been published. Doctors commencing their rotations with the Trust in August will receive offers under the old contract, guidance is awaited from NHS Employers on the content of these offer letters. The revised timeline for implementation is attached as Appendix 1 to this report. An communication was sent out by the Medical Director to: make clear our pleasure in seeing clear potential for a negotiated settlement; as requested from the centre, meetings or discussions will be suspended; and our intention to continue to work with doctors in training to understand their concerns and to significantly improve the training experience for our medical workforce. To facilitate the latter, we have proposed regular meetings with doctors in training and we are organising open meetings on a quarterly basis to discuss issues that affect them and us in the way we work together to deliver excellent patient care. 1.7 Integrated Performance Report The Board of Directors will receive for the first time an Integrated Performance Report covering the areas of Finance, Performance and Quality and how these link together. The report goes some way to translate data from board to ward and links to our new strategic priorities. The Board of Directors is asked to provide feedback as this new report develops /17 CONTRACT 2016/17 contracting round has been unusually protracted due to delays nationally in the publication of both the PbR Tariffs and the NHS Standard Contract. The Trust has now reached agreement on the financial baselines for all its main contracts, namely, East Kent CCGs, West and North Kent CCGs, NHSE Specialised Services and NHSE Public Health Screening contracts. Baselines reflect growth (both Page 7 of 12

58 CHIEF EXECUTIVE S REPORT BoD 43/16 demographic and waiting list clearance), tariff inflation of 1.8% on PbR Tariffs and 1.1% on Local Tariffs and Commissioner QIPP schemes. East Kent Contract (including West and North Kent) This contract will now operate on a full PbR basis from 1 st April. The baseline agreed is 387.7m compared with 376.8m last year. Existing services that were previously not charged but are now being paid for include Cancer MDTs, Unbundled Echo s, Cardiology Stress Testing, Multi professional Outpatients, Telephone pre-operative assessments and patients transport reimbursements costs. There were also areas where commissioner funding intentions were agreed. NHSE Specialised Services Contract continues to operate under a full PbR basis. The 70% marginal rate levied on over performance last year has been removed so all over performance will be paid at 100%. The baseline for this year is 77.2m compared to 76.7m in 2015/16 and this includes a 1.5m QIPP scheme for High Cost Devices price savings for Commissioners. Commissioners have also adjusted CQUIN amount payable from 2.5% to 2% of contract value. On the upside, NHSE has agreed a funding uplift for max fax prosthesis, funding for paediatric insulin pumps and payment for specialist cancer MDT activity. 3 GOOD NEWS STORIES CHKS Top 40 Award East Kent Hospitals has been named as a CHKS Top Hospitals winner. The award is based on the evaluation of over 20 key performance indicators covering safety, clinical effectiveness, health outcomes, efficiency, patient experience and quality of care by CHKS - one of the leading providers of healthcare intelligence and quality improvement services in the UK. The Top Hospitals accolade is awarded to the 40 top performing CHKS client Trusts. K&C Hub re-launch The Quality Improvement and Innovation Hub at Kent & Canterbury Hospital has been re-launched. The Hub is a great way to meet colleagues from across the site and find out a great deal of useful information. New health records archiving facility opening The new Health Records Archiving and Scanning Bureau has been officially opened. Staff moved 600,000 records from the old warehouse in just under seven weeks while maintaining business as normal. Over 300,000 out-sourced healthcare records have now been repatriated into the non-current healthcare records library, bringing everything in house. Serco and EKHUFT win Hospital Caterers Association Award East Kent Hospitals, in partnership with Serco, is the inaugural winner of the Hospital Caterers Association 6Cs Award. The 6C s represent care, compassion, competence, communication, courage and commitment to patients,and the national award was presented to EKHUFT and Serco Page 8 of 12

59 CHIEF EXECUTIVE S REPORT BoD 43/16 for professional collaboration and partnership working between clinical, dietetic and catering colleagues. EKHUFT spinal injury research trial East Kent Hospitals has begun an innovative research trial into a robotic walking device for people with spinal injuries. The Trust is the only NHS organisation participating in the trial, which is taking place at the University of Kent at Canterbury. The robotic device lifts patients from a sitting position into a robot-supported standing position, allowing them to take part in a set of supported walking and stretching exercises, designed by specialist physiotherapists National Patient Safety Awards The team behind the TIPS (Teams Improving Patient Safety) programme has been shortlisted for the national 2016 Patient Safety Awards. TIPS is a great example of partnership working that benefits the patient it is a collaborative venture between EKHUFT, Health Education England Kent Surrey and Sussex, NHS Elect and University of Kent. It means teams of staff from many disciplines taking forward a patient safety project while learning about safety improvement methodology and tools. It began in June last year, and has already brought about real and practical changes in patient safety thanks to the hard work and dedication of the staff. HSJ Awards EKHUFT submission Sally Smith, Chief Nurse and Director of Quality, is busy submitting the Quality Improvement & Innovation Hubs teams for a national HSJ Award. These teams have done so much to help site teams share learning and innovations, and their work was highlighted as an area of excellence by the CQC in the last inspection. Centre of Excellence The urology surgical team at Kent and Canterbury Hospital has received a great accolade, having been chosen as one of five centres of excellence for robotic urological surgery training. Kent and Canterbury Hospital will be one of five high volume robotic training centres in the UK under a new scheme funded by The Urology Foundation. Again, Kent and Canterbury Hospital was selected based on its track record in surgical outcomes, expertise of the individual surgeons and in providing training to fellows or colleagues interested in acquiring robotic skills Nursing Times Award EKHUFT nomination Patients have nominated our stoma team for the 2016 Nursing Times Award for managing long Term Conditions. The Team have been nominated for working with patients, which has embraced patients to co-design the pathway for people living with a stoma. 4 CHIEF EXECUTIVE ACTIVITY APRIL 2016 AND MAY 2016 The following is an example of some of the meetings I as CEO have attended during April 2016 and May 2016 and their purpose: Various meetings with NHSI, including PRM s Page 9 of 12

60 CHIEF EXECUTIVE S REPORT BoD 43/16 Strategy Group Divisional Director s Interview Panel End of year reviews with Executive Directors Meeting with Ashford Borough Council Contract, Demand and Capacity meetings A variety of 1:1 s with a range of staff East Kent Strategy Board Meetings with MP s League of Friends East Kent Whole System meeting with NHSI/NHSE/CCGs Patient Safety Board Improvement Plan Delivery Board Maternity Meetings Trauma and Orthopaedic meetings Trust inductions Exec Away day A number of STP meetings SRG CRN KSS Partnership Board Meetings with CEO s from MTW and MFT IOD Programme Official Opening of Inca House Meetings with Kent County Council CQC Meetings Kent and Medway Footprint meeting Leadership events Vision and Mission Visited the Specialist Speech and Language Therapist Integrated Therapies Team Kent Provider s Meeting Surplus land meeting with the DoH Commitment to Excellence Conference Chairs and Chief Exec s meeting Cancer Boards. I attended the Council Of Governors meeting on 24 May where there was good engagement from Governors in relation to a number of the Trust s priorities for this year. Executive presentations on the Trust Performance, Staff Survey results and the 2016/17 Annual Plan provided Governors with an opportunity to ask questions of both the Executive s and Non-Executive Directors present. I have also attended the following Board Committees: Quality Committee IAGC Remuneration and Nominations Committee Joint FIC/QC/IAGC I chair the following Executive meetings on a regular basis as part of the Trust s governance structure that ensures upward reporting through Board Committees to Board. I will be reviewing the purpose of each group and assessing how they work before making a judgement about any changes that are necessary as we move into the next stage of the Trust s development. Executive Team Meetings (weekly) Management Board (monthly) Page 10 of 12

61 CHIEF EXECUTIVE S REPORT BoD 43/16 Trust Strategy Group (monthly) Turnaround Board (weekly) Key Metrics Reviews (monthly) Executive Performance Review Meetings (monthly) Matthew Kershaw Chief Executive Page 11 of 12

62 CHIEF EXECUTIVE S REPORT BoD 43/16 APPENDIX 1 JUNIOR DOCTORS CONTRACT REVISED IMPLEMENTATION TIMELINE July 2016 All guardians appointed 26 July 2016 Guardian conference 3 August 2016 New contract effective date October 2016 Transition to the new terms and conditions of service for: F1s (all specialties) F2 (when sharing a rota with F1s) ST3/4 in general practice ST3+ in obstetrics and gynaecology. February April 2017 April 2017 All grades in: Psychiatry Public health All pathology and lab based specialties Paediatrics All dental training programmes (excluding orthodontics) Any F2 and GP trainees who share a rota with trainees above in this category All grades in all surgical specialties (including orthodontics) Any F2 and GP trainees who share a rota with trainees above in this category August 2017 All remaining existing trainees All new entrants Page 12 of 12

63 2016/17 ANNUAL OBJECTIVES BoD 44/16 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS DATE: 10 JUNE 2016 SUBJECT: REPORT FROM: PURPOSE: 2016/17 ANNUAL OBJECTIVES CHIEF EXECUTIVE Discussion CONTEXT / REVIEW HISTORY / STAKEHOLDER ENGAGEMENT The Trust has determined a number of annual objectives for 2016 / 17 that enable the delivery of the strategic objectives and support the Trust in achieving its vision, mission and values. SUMMARY: At its away day in January, the Board of Directors discussed the main strategic priorities for the Trust, alongside its annual objectives and some of the key risks associated with achieving these objectives. The final objectives were agreed by the Board at the April meeting, subject to: Financial figures to be finalised, pending sign off of the 2016/17 plan. Include reference to research capability and links to universities. The Board of Directors requested a further updated report to the June Board of Directors. This report is the final version of the objectives as shared across the organisation. Since the April Board meeting, leadership events have been held and open forums are now being prepared. These forums plus many other mechanisms (included printed cards) will be used to cascade and embed the objectives within the organisation. In addition, the priorities will form the basis of exec director objectives and through them to the Divisions and wider organisation. The Trust Secretary has added a number of new risks (SRR9 SRR14) to the Board Assurance Framework from discussions held at Board or Committee level over the last month; in addition SRR8 has been escalated from the Corporate Risk Register to the Strategic Risk Register following discussion at Strategic Workforce Committee. The assigned Executive will be reviewing the detail and adding additional controls where appropriate for the full quarterly review planned for the September Board. However, as the BAF supports this report the Executive s wanted to ensure the most up to date position was presented. 4

64 2016/17 ANNUAL OBJECTIVES BoD 44/16 RECOMMENDATIONS: To note the final objectives and to support the wider and on-going communication of the priorities and to use these positively to help the Trust deliver for patients and staff. To note and discuss the BAF in relation to the risks to Trust s annual priorities. NEXT STEPS: To embed the final objectives across the organisation. IMPACT ON TRUST S STRATEGIC OBJECTIVES: Not applicable report is describing future strategic and annual objectives. LINKS TO BOARD ASSURANCE FRAMEWORK: The Board of Directors will receive periodically the Board Assurance Framework for monitoring delivery of the Trust s objectives, highlighting risks to delivery by exception. A copy is appended to this report. IDENTIFIED RISKS AND RISK MANAGEMENT ACTIONS: The Board of Directors will receive periodically the Board Assurance Framework for monitoring delivery of the Trust s objectives, highlighting risks to delivery by exception. A copy is appended to this report. FINANCIAL AND RESOURCE IMPLICATIONS: Costs have been included within annual planning. LEGAL IMPLICATIONS / IMPACT ON THE PUBLIC SECTOR EQUALITY DUTY: As the Trust develops detailed plans to meet the strategic objectives any legal implications will identified and addressed. PROFESSIONAL ADVICE TAKEN ON ANY NOVEL OR CONTENTIOUS ISSUES None ACTION REQUIRED: (a) Decision. CONSEQUENCES OF NOT TAKING ACTION: 4

65 The start of something special This month we are launching our new Trust vision and mission statements, and our strategic priorities for the year ahead. Our vision is: Great healthcare from great people Our vision is deliberately simple but sums up what we want to achieve for every patient every day. Our mission is: Together we care: improving health and lives Our mission statement explains why we exist what East Kent Hospitals is here to do. Our valuesare: Our values describe what s important to us and what we want it to feel like to work and be treated here.

66 The year ahead: our four strategic priorities We have four strategic priorities: Patients People Provision Partnerships The next slides give you more information about each priority. Our vision, mission, values and priorities build on the Shared Purpose Framework.

67 Priority one: patients We want to enable all our patients (and clients who are not ill) to take control of all aspects of their healthcare by This year, we need to: Deliver the CQC and emergency care improvement plans Deliver the improvement trajectories for the emergency care, RTT, cancer and diagnostic wait standards, by end of March 2017 Transform care for people with learning disabilities with local providers Deliver the following service quality improvements by March 2017: 20% reduction in harm from poor handover of care/transfer of care 30% reduction in preventable venous thromboembolism events 30% reduction in medication errors 30% reduction in catheter associated urinary tract infection 30% reduction in falls with harm reducing avoidable hip fractures to below 7, reducing the number of moderate and above harms to below 31 and ensure the falls rate in all our hospitals is below the national average. A 30% increase in completion of Falls Risk Assessments at the WHH. 30% reduction in category 2 pressure ulcers rate compared with last year, no more than 8 category 3 and 4 pressure ulcers. A 30% increase in completed pressure ulcer assessment in the ECC, EDs and CDUs. All patients diagnosed with sepsis get antibiotics within an hour of screening, aiming to reduce mortality by 20% by March Agree new pathways with commissioners for patients medically fit and not requiring an acute bed to reduce delays by 5% by December How are you doing? You can find out how your area is doing against key quality improvements through the ward dashboard.

68 This year we need to: Priority two: people We want to identify, recruit, educate and develop a talent pipeline of clinicians, healthcare professionals and broader teams of leaders, skilled at delivering integrated care and designing and implementing innovative solutions for performance improvement. Reduce the level of staff leaving by 2%, particularly in the first year of employment, by March 2017 Achieve a staff turnover rate of 10%, by March 2017 Roll out the Trust wide leadership and management development programme to another 200 staff, by September 2016 Continue with the implementation of the cultural change programme, incorporating divisional and corporate led plans into the programme, by June 2016 Continue to reduce agency and temporary staffing spend to 23m, as agreed with NHS Improvement, by March 2017 (plan to be confirmed) Improve staff engagement, as measured by the staff survey, by March 2017 Further drive recruitment and staff development by increasing our research capabilities and links with universities.

69 Priority three: provision We want to clearly identify what business we are in, what we want to be known for and what our core services are. We need to provide the right services and do it well. This year we need to: Agree core services, and a timetable to review and refresh these services, by September 2016 Be recognised as a provider of high quality care and as a system leader by NHS, social care and other public sector partners, by December 2017, and ensure staff and service achievements are recognised in press coverage Develop and grow a number of whole system leaders, joint appointments that cross the boundaries of the whole health care economy and are designed around the patient pathway Submit a financially sustainable plan for 2016/17 and the following four years that meets agreed control totals, by June 2016 Make a 20m recurrent saving by March 2017 and hit a year-end deficit plan of 12.5m by March 2017 (plan to be confirmed) Continue to progress improvements in 7 day services, focusing on the implementation of priority schemes agreed following further work internally and benchmarked with other similar organisations.

70 Priority four: partnerships We want to define and deliver sustainable services and patient pathways together with our health and social care partners, by This year we need to: Submit an agreed Sustainability and Transformation Plan by 30 June 2016 that defines an agreed financial improvement trajectory for the Trust, a comprehensive clinical productivity improvement programme and a sustainable clinical model for the Trust To submit by June 2016, with partners, a single Local Digital Roadmap which will outline how we will use technology to provide improved patient services Working with CCGs, begin commence formal consultation on a sustainable clinical configuration by December 2016 By working with the Vanguard, increase community provision to transfer the equivalent of 60 acute beds in patient activity, by March 2017 Deliver an estates strategy that supports the Trust s clinical configurations by March 2017 Continue to work with Maidstone & Tunbridge Wells NHS Trust on a joint pathology project, delivering a signed commercial agreement with external partners by June 2017.

71 What are we asking you? What do the four priorities and the year s objectives mean for your team? Any questions? If you have any questions about our vision and priorities, please tell us through the online survey at

72 Board Assurance Framework Report Date 02 Jun 2016 Risk Status Risk Area Open 1. Strategic Risk Register Page 1 of 11

73 Board Assurance Framework AO1: Patients. Help patients take control of their own health Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee Page 2 of 11

74 Board Assurance Framework AO1: Patients. Help patients take control of their own health Risk Ref SRR 2 Risk Title Cause & Effect Inherent Risk Score Adverse effects on Local services: Organisational Shape and Form Risk Owner: Sally Smith Delegated Risk Owner: Last Updated: 05 May 2016 Latest Review Date: 23 May 2016 Latest Review By: Sally Smith Latest Review Comments: CQC Re-Visit action has a new date in light of not receiving notice of the visit at present. Cause Failure to action and deliver our regulatory requirements that may result in being taken over by another organisation Effect - Loss of autonomy; - Impact on staff morale; - Reputational problems; - Decline in pace and development of service. I = 4 L = 4 Extreme (16) Risk Control 1st Line 2nd Line 3rd Line Assurance Level Financial Recovery Plan - Monitor Undertaking (12/16) Control Owner: Nick Gerrard Emergency Department Recovery Plan (agreed with partners and submitted to Monitor) 12/2015 Control Owner: Jane Ely Improvement Plan in place with supporting Divisional plans in place (01/2016) Control Owner: Sally Smith Director of Finance and Chief Executive review of document prior to submission. ED Plan updated by Urgent Care and Long Term Conditions Emma Kelly manages the updates to the Improvement Plan on at least a monthly basis. Plan circulated to Finance and Investment Committee members and thereafter all BoD members for input (12/16) - report to Executive Team on a weekly basis for information - UCLTC update on actions at Executive Performance Reviews - discussions at both Quality and Finance Committee in relation to impacts on safety, quality and finance - monthly BoD report showing progress against plans Improvement Board monitor progress (meets monthly) BoD receives exception and progress reports (bimonthly) Health Economy ED Recovery Meeting Monitor review of ED plan Improvement Director oversight of plan Emergency Care Improvement Programme working with the Trust (Sept 15). Monitor Progress Review meetings - provides challenge over progress of Trust in meeting deadlines Improvement Director - challenge to Trust CQC Inspection 07/15 - improved rating Internal Audit on data quality (11/15) Adequate Adequate Adequate Assurance Gap Monitor feedback expected Clear understanding of the ED pathway and how the plans start to resolve the key issues. Internal Audit on CQC (04/16) Internal Audit on Risk Management (04/16) Residual Risk Score I = 4 L = 3 Extreme (12) Action Required Progress Notes Target Risk Score Internal Audit to undertake a review of the CQC Improvement Plan Person Responsible: Sally Smith To be implemented by: 31 Mar 2017 CQC re-visit plan to provide timeline and actions to ensure organisation readiness for CQC insepction due around April 2016 Person Responsible: Sally Smith To be implemented by: 31 Oct Apr 2016 Sally Smith This action will be scoped in the 16/17 financial year. Dates are yet to be agreed. 25 Feb 2016 Alison Fox Intelligencesugges ts that the CQC revist will not take place until May / June Work on implementing the plan continues. The Hubs / staff have been involved in mock inspections (to be BAU). 11 Apr 2016 Alison Fox Report presented to BoD, however, as the Trust has not been provided with its inspection date the timeline presented was an example and the Board will receive a further timeline once a date is confirmed. 25 Feb 2016 Alison Fox Intelligence suggests that the CQC visit is likely to take place in May / June 2017; work is on-going to implement the improvements required. I = 4 L = 2 High (8) Reporting Committee Quality Committee Page 3 of 11

75 Board Assurance Framework AO1: Patients. Help patients take control of their own health Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Emergency Department Board workshop to provide a good understanding of the issues and plan to address performance. Person Responsible: Jane Ely To be implemented by: 11 Mar Mar 2016 Jane Ely Workshop completed with Board (Exec & Non-Exec) 11th March as planned. New Ed dashboard shared and the priority actions that would make a difference noted by all. Follow up action to review ED staffing at SWC and circulate to the Board. 29 Feb 2016 Alison Fox Planned for March 2016 BoD development session Reporting Committee Internal Audit to undertake review of the risk management systems and controls following output of Deloitte and PWC reviews Person Responsible: Helen Goodwin To be implemented by: 27 May Feb 2016 Alison Fox Reviewing workload to programme in this review. SRR 4 Estate Condition - Unable to source improvements in the Estate across the Trust to ensure long term quality of patient facilities Risk Owner: Liz Shutler Delegated Risk Owner: Last Updated: 05 May 2016 Latest Review Date: 26 Apr 2016 Latest Review By: Alison Fox Latest Review Comments: Scores revised following discussion with Liz Shutler Cause - Backlog of work ( 4-5 million); - The financial constraint on capital funding; - The sheer volume and extent of work required Effect resulting in poor patient and staff experience, potential breaches to health & safety standards and legislation, inefficiencies and difficulties in moving forward with providing services of the future. I = 3 L = 5 Extreme (15) Prioritisation exercise for capital spend has been completed to ensure resources are used in the most effective / efficient way Control Owner: Liz Shutler An assessment of the maintenance required has been undertaken to understand the overall position Control Owner: Liz Shutler Management Board receives reports from Director of Strategy and Capital Planning. Business cases are received on an adhoc basis - some of which require improvement to infrastructure Deputy Director of Estates and Director of Capital receive information from all areas of the Trust regarding maintenance and undertake a first pass at prioritisation. FIC receives quarterly reports on capital spend. FIC receive reports about Backlog maintenance showing the risks. Adequate Adequate I = 3 L = 3 High (9) Person Responsible: To be implemented by: Quality Committee Capital PLanning Group - review the prioritisation exercise Page 4 of 11

76 Board Assurance Framework AO1: Patients. Help patients take control of their own health Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee SRR 6 Ability to upgrade IT and take advantage of new technology Risk Owner: Liz Shutler Delegated Risk Owner: Andy Barker Last Updated: 05 May 2016 Latest Review Date: 11 May 2016 Latest Review By: Andy Barker Latest Review Comments: I have considered this risk and agree with its current status. Cause - Financial constraints on capital funding and the ability to invest in IT Effect - poor patient experience - poor staff experience - inefficient processes I = 3 L = 3 High (9) Continued investment in technology has been agreed at Strategic Investment Group as a priority Control Owner: Andy Barker Replacement programme has been agreed to the level required to maintain good performance. Control Owner: Andy Barker Director of IT manages the new and replacement programme on a day to day basis - Information Development Group manages delivery of replacement and new IT - Finance and Performance Committee receives reports on the capital programme as a whole. Limited I = 3 L = 2 Moderate (6) Maintain overview of investment in IT for both new and replacement programmes Person Responsible: Andy Barker To be implemented by: 29 Jul 2016 I = 3 L = 2 Moderate (6) Finance & Investment Committee SRR 9 Integration between quality and safety, finance, performance, activity and workforce management Risk Owner: Matthew Kershaw Delegated Risk Owner: Alison Fox Last Updated: 01 Jun 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause Due to a number of competing priorities which may have the potential to be discussed in isolation at the Board Committees, there is a risk that not all aspects (quality and safety, finance, performance, activity, workforce) will be considered. Effect This may lead to decisions or direction being given from one source to contradict or negatively impact on decisions or direction given in another. I = 4 L = 4 Extreme (16) Chair reports from each Committee to advise of key decisions / actions requested provided to each Board meetings to allow for triangulation Control Owner: Alison Fox Quality Impact Assessment on all CIP's that have a quality aspect Control Owner: Sally Smith Reports drafted by the NED Chair with support from the secretariat. (occurs monthly) Chief Nurse and Medical Director review the QIA's as they are received Review of Committee reports at Board on a bi-monthly basis. Management Board and Quality Committee receive updates on the number reviewed. Adequate Limited Ensure the NED's pull out areas where there is potential crossover. An audit of the process would provide assurance that the process is working well. I = 4 L = 3 Extreme (12) Integrated Performance Report which enables easy triangulation of information to support decision making. Person Responsible: Nick Gerrard To be implemented by: 10 Jun 2016 Full use of Integrated Performance Report to allow discussion of all aspects that may impact on a decision at Committee and Board level. Person Responsible: Alison Fox To be implemented by: 30 Sep 2016 I = 4 L = 2 High (8) Quality Committee AO2: People: Identify, recruit and develop talented staff Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee Page 5 of 11

77 Board Assurance Framework AO2: People: Identify, recruit and develop talented staff Risk Ref SRR 8 Risk Title Cause & Effect Inherent Risk Score Ability to attract, recruit and retain high calibre staff to the Trust Risk Owner: Sandra Le Blanc Delegated Risk Owner: Last Updated: 01 Jun 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause It is widely known that there is a national shortage of healthcare staff in specific occupational groups / specialities. It is a highly competitive recruitment market for these hard to fill roles, and the Trust being in special measures, cultural issues identified in the CQC inspection, and proximity to London has impacted on the ability to attract and retain high calibre staff. Effect Inappropriate levels of staff has the potential to impact negatively on patient outcomes and experience and adds to the Trust's financial and reputational risks. I = 4 L = 5 Extreme (20) Risk Control 1st Line 2nd Line 3rd Line Assurance Level Universities well engaged and the Trust recruits the majority of newly qualifies staff locally. Specific education and training programmes developed for Band 4 practitioner posts to cover EDs and operating theatre vacancies. Control Owner: Sally Smith Recruitment process revised and Job descriptions updated to incorporate Trust values and behaviours. Control Owner: Jacqui Siggers Staff able to access training and development to enable them to undertake their current role and meet their aspirations Control Owner: Jacqui Siggers Head of Strategic Resourcing to have in place clear recruitment process with template job descriptions that incorporate Trust values and behaviours Regular meetings with Canterbury ChristChurch University Strategic workforce committee Adequate Adequate Adequate Assurance Gap Residual Risk Score I = 3 L = 3 High (9) Action Required Progress Notes Target Risk Score The retention element of the recruitment and retention strategy to be updated and implemented as per the agreed timetable Person Responsible: Jacqui Siggers To be implemented by: 31 May 2016 I = 3 L = 3 High (9) Reporting Committee Strategic Workforce Committee Continued implementation of the Cultural Change Programme as part of the Trust's Improvement Journey - focusing on Leadership and Management Development, Staff Health and Wellbeing, 'Respecting Each Other' programme and New Appraisal PROcess Control Owner: Sandra Le Blanc Cultural change programme manager leading panorganisation and local implementation of programme with divisional leadership teams. Quarterly progress report to the BoD, Strategic Workforce Committee and to the Improvement Plan Delivery Board reporting against key milestones and outcomes, evaluating progress and making recommendations on changes Diagnostic phase supported by external consultancy. Staff survey published and benchmarked annually. Adequate Continued poor results of staff surveys and 2015 results place the Trust in the lowest quartile in comparison with other NHS Acute Trusts Publication of scheduled versus actual staffing levels on each ward, updated each shift to ensure visibility. Control Owner: Sally Smith Associate Chief Nurse responsible for receiving reports and checking staffing levels Strategic work force committee. Reporting to the BoD formally every 6-months. Day to day dashboards in place Substantial Acuity tools not consistent in all areas and specialty areas such as the EDs have not currently been comprehensively assessed Programme of overseas nurse recruitment established with 109 nurses recruited from Spain, Portugal, Greece, Italy, Malta, Romania and Croatia. Control Owner: Sally Smith Head of Strategic Resourcing and Acting Chief Nurse and Director of Quality leading programme with nominated leads at division level. Strategic Workforce Group with formal strategy in place Adequate Sustainability of model for overseas recruitment in the medium to long-term unclear Page 6 of 11

78 Board Assurance Framework AO2: People: Identify, recruit and develop talented staff Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level implementation of retention measures as detailed in the recruitment and retention strategy. Control Owner: Jacqui Siggers Limited Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee SRR 12 Executive and Divisional Capacity and Capability to deliver change at pace Risk Owner: Sandra Le Blanc Delegated Risk Owner: Last Updated: 01 Jun 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause Due to the large number of priorities that need to be delivered in 2016/17 including the sustainability and transformation plan, turnaround plan, cost improvement plans as well as business as usual, there is a risk that Executive Directors, Divisional and Corporate Leadership Teams may not have the capacity or capability to deliver the programme of changes which are required across the organisation. Effect Depending on which projects fail to be delivered this could impact on: - patient safety / care / experience - staff engagement / retention - meeting operational performance standards (RTT/A&E/Cancer) - meeting of regulatory requirements (CQC / NHSI) - I = 3 L = 4 High (12) The Executive Team is proactively reviewing succession plans and talent management for senior leadership roles and key posts in the organisation. All these posts are covered by substantive staff. Control Owner: Sandra Le Blanc Four Eyes Consultancy supporting Divisions to deliver the cost improvement programmes in outpatients and theatres Control Owner: Jane Ely Turnaround Director in place to support the Executive and Divisions in managing the turnaround process. Control Owner: Nick Gerrard Executive oversight, will review quarterly Weeklly reports through the Executive Team meetings / reports to Divisions Turnaround Director reports to the Chief Executive and meets weekly with members of the Executive / Divisions in workstream meetings. Nominations Committee - planned to review on a regular basis Review against the delivery of the Cost Improvement Programme at Finance and Performance Committee on a monthly basis. Monthly reports on progress to Finance and Performance Committee. Bi-monthly reports to Board of Directors on progress Adequate Adequate Adequate Fully populated succession plans to ensure short-term and long-term position is secure. Consistently meeting planned savings targets. Consistently delivering the phased savings. I = 3 L = 3 High (9) Working with the CEO to implement an Executive Team Development Programme Person Responsible: Sandra Le Blanc To be implemented by: 30 Jun 2017 Assessment and development of senior, middle and clinical and non clinical leaders against the EKHUFT leadership framework Person Responsible: Sandra Le Blanc To be implemented by: 31 Mar Jun 2016 Sandra Le Blanc The Trust is seeking an external partner to support with the implementation of the programme, and the tendering process is underway and is due to be completed shortly. 01 Jun 2016 Sandra Le Blanc The Trust is seeking an external partner to support with the implementation of the programme, and the tendering process is underway and is due to be completed shortly. I = 3 L = 2 Moderate (6) Strategic Workforce Committee Page 7 of 11

79 Board Assurance Framework AO3: Provision: Provide the services needed and do it well Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee SRR 5 Failure to achieve financial stability Risk Owner: Nick Gerrard Delegated Risk Owner: Last Updated: 01 Jun 2016 Latest Review Date: 25 Feb 2016 Latest Review By: Alison Fox Latest Review Comments: Reviewed current status of controls; adding to assurances (Trust Secretary) Cause due to: - failure to reduce the run rate - poor planning - poor recurrent CIP delivery - - poor cash management and - gaps in financial governance Effect resulting in - potential breaches to the Trust's Monitor licence, - adverse impact on the Trust's ability to deliver all of its services and in the longer term clinical strategy, - poor reputation and - failure to be a going concern I = 5 L = 5 Extreme (25) Turnaround Director in post (10/15) Control Owner: Nick Gerrard Clinical Workstreams in place to ensure quality of care Control Owner: Nick Gerrard Financial govenance in place Control Owner: Nick Gerrard Cost Improvement Plan targets in place with workstream in support Control Owner: Nick Gerrard Direct line management by Chief Executive Reports to Executive Team from workstream (weekly) Director of Finance oversees the governance Divisional Challenge meetings for Execs to challenge Feeds into Finance and Investment Committee Integrated Audit Committee reviewed controls through reporting from Internal and External Audit - executive review weekly - Turnaround report to FIC - Exception reports to BoD Feeds into BoD - Grant Thornton governance review (07/15) Monitor challenge at Progress Review meetings (6-8 weekly) Limited Adequate Adequate Adequate Feedback from Chief Exec sought on individuals performance against objectives Action plan development and requires full implementation I = 5 L = 4 Extreme (20) Implementation of finacial governance action plan Person Responsible: Nick Gerrard To be implemented by: 31 Mar 2016 CIP deep dive - Report to FIC on reasons for slippage on Theatres, Outpatients and Workforce Person Responsible: Nick Gerrard To be implemented by: 08 Mar Feb 2016 Alison Fox FIC to receive report on progress highlighting any areas for concern / risk to delivery. (to be scheduled). 25 Feb 2016 Alison Fox On FIC agenda in March Feb 2016 Alison Fox On FIC agenda for March 2016 I = 5 L = 3 Extreme (15) Finance & Investment Committee Financial Recovery Plan Control Owner: Nick Gerrard Divisions report progress into Financial Recovery Group on a monthly basis. - Exceptions reported into Finance and Investment Committee (monthly) - Board has final oversight (bi-monthly) Monitor reviewed draft plan and discusses the financial position at Progress Review meetings (6-8 weekly) Adequate Reporting shows slow improvement; Monitor still to provide feedback on 2 year plan SRR 11 Terms and conditions in relation to the interim working capital agreement Risk Owner: Nick Gerrard Delegated Risk Owner: Last Updated: 01 Jun 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause Due to the current performance of the Trust in relation to reduction of agency spend / off-framework use and the timeline in relation to delivery of a three year estates strategy there is a risk that some terms may not be met. Effect Resulting in the possibility that funding may be withdrawn. I = 4 L = 3 Extreme (12) Process in place to reduce agency spend. Control Owner: Sandra Le Blanc Dedicated project resource in place through the Service Improvement Team to deliver the reduction. Off-framework agency spend reviewed weekly through the Turnaround report at Exec Team Meeting. Divisions are challenged at Executive Performance Reviews and Key Metric Reviews. Strategic Workforce and Finance and Performance Committees review agency spend. Adequate Sustainable reduction needs to be seen before full assurance can be taken that this control is working. I = 4 L = 3 Extreme (12) Estates Strategy will be reviewed in light of the submission of the Sustainability and Transformation Plan (30 June 2016). Person Responsible: Liz Shutler To be implemented by: 29 Jul 2016 I = 4 L = 2 High (8) Finance & Investment Committee Page 8 of 11

80 Board Assurance Framework AO3: Provision: Provide the services needed and do it well Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee SRR 14 Ability to receive and retain the STP Fund Risk Owner: Matthew Kershaw Delegated Risk Owner: Alison Fox Last Updated: 02 Jun 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause Due to the number of performance metrics / trajectories that the Trust will need to meet on a quarterly basis there is a risk that the funding may be withdrawn. Effect Resulting in the Trust requiring additional working capital to support the cash position; the need to find additional efficiencies when the current CIP programme will be a stretch; impact on it's ability to deliver it's long-term strategy. I = 4 L = 4 Extreme (16) Trajectory for applicable standards agreed with the CCGs and NHSI. Control Owner: Jane Ely Annual financial plan in place including cost improvement programme. Control Owner: Nick Gerrard Divisional management of the standards through Governance and Business Boards Director of Finance manages the position routinely Compliance reports to Executive Performance Reviews Management Board Finance and Performance Committee Board of Directors Council of Governors Performance against plan monitored through: Turnaround Board (weekly at EMT) Executive Performance Reviews (monthly) Finance and Performance Committee (monthly) Board of Directors (bimonthly) External review from: CCG's through monthly performance reviews NHSI through 6 weekly progress review meetings Financial performance reviewed with NHSI at Progress Review Meetings Adequate Adequate Consistent performance against tracjetories Performance against plan - to be reviewed I = 4 L = 3 Extreme (12) Meeting the agreed plans in respect of: Annual financial plan Access standards Person Responsible: Jane Ely To be implemented by: 30 Sep 2016 I = 4 L = 2 High (8) Board of Directors Emergency Care Recovery Plan in place Control Owner: Jane Ely Divisional Management on a daily basis Performance monitored through: Emergency Care Board Executive Management Team (weekly) Finance and Performance Committee (monthly) Board of Directors (bimonthly) Improvement Director closely monitoring performance; Discussed with NHSI at Progress review meetings (6 weekly) Surge Resilience Group reviews Adequate Delivery of plan and trajectories met consistently. Page 9 of 11

81 Board Assurance Framework AO4: Partnership: Work with other people and other organisations to give patients the best care Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee SRR 1 Unable to deliver a clinical strategy that can be resourced Risk Owner: Liz Shutler Delegated Risk Owner: Last Updated: 05 May 2016 Latest Review Date: 25 Feb 2016 Latest Review By: Alison Fox Latest Review Comments: Reviewed controls and assurances 25/2/16 Cause - Four CCGs having differing agendas; - Lack of stakeholder agreement; - Lack of clear commissioning intentions; - Parliamentary timings may not be conjucive to timely implementation Effect - Patient care - Enforcement actions - Trust's Monitor licence. I = 5 L = 4 Extreme (20) Financial Recovery Plan Control Owner: Nick Gerrard Regular meetings with external partners / MP's and within the Trust Control Owner: Liz Shutler East Kent Strategy Board Control Owner: Liz Shutler Divisional / Executive Transformation Meetings (held biweekly) Awaiting engagement plan Trust Secretary hold all copies of agendas / minutes East Kent Strategy Board FIC and Board reporting from Turnaround Director In attendance are all Health economy partners Monitor receive monthly reports on the Trusts finances as well as the quarterly returns and discussions at PRM's. Monitor received first submission of Annual Plan 2016/17 02/2016 Adequate None Adequate Traction around clinical efficiencies - FIC requested an update on Theatre efficiencies / Outpatients and Workforce - scheduled for 03/2016 I = 5 L = 3 Extreme (15) Agree for approval by EKSB a timeline for delivery of STP Person Responsible: Liz Shutler To be implemented by: 11 Mar 2016 Presentations on Outpatients / Theatres and Workforce CIP schemes to FIC to facilitate understanding of slippage. Person Responsible: Nick Gerrard To be implemented by: 08 Mar 2016 Agreement of final consultation document by all partners Person Responsible: Liz Shutler To be implemented by: 31 Mar Feb 2016 Alison Fox Matthew Kershaw / Liz Shutler and Rachel Jones to produce this item for EKSB 25 Feb 2016 Alison Fox On FIC agenda for March 2016 I = 5 L = 2 Extreme (10) Finance & Investment Committee SRR 3 Loss of clinical specilaities and services that are Kent & Medway wide Risk Owner: Liz Shutler Delegated Risk Owner: Last Updated: 05 May 2016 Latest Review Date: 25 Feb 2016 Latest Review By: Alison Fox Latest Review Comments: Reviewed risk - actions due by end of March Added the delivery of a Sustainability & Transformation Plan to controls. Cause due to the Networks in place / competition and decisionmaking across the CCGs Effect result in a loss to the Trust of some of the services that may adversley impact on the local population's expereince of care I = 4 L = 3 Extreme (12) East Kent Strategy Board (Health Economy wide) that drives the delivery of an agreed set of options for service reconfiguration to be consulted on Control Owner: Liz Shutler Director of Strategy and Capital Planning has oversight of the progress made within the EKSB. Minutes from EKBS to BoD meetings (02/16) Adequate Monitor / NHS England approval of transformation programme (07/16) I = 4 L = 2 High (8) Delivery of a Sustainbability and Transformation Plan Person Responsible: Liz Shutler To be implemented by: 30 Jun 2016 Awareness of external factors that may indicate commissioning (both local and specialist) intends to tender out services that the Trust currently provides Person Responsible: Matthew Kershaw To be implemented by: 31 Mar Feb 2016 Alison Fox Worth through the East Kent Strategy Board to support this. Meetings are monthly 25 Feb 2016 Alison Fox Local meeting to take place in relation to vascular services (26/2/16) Discussions ongoing regarding pathology services I = 4 L = 2 High (8) Finance & Investment Committee One year operational plan to set the ground work for delivery of the five year plan. Person Responsible: Nick Gerrard To be implemented by: 31 Mar Feb 2016 Alison Fox Draft Annual Plan to be reviewed at BoD in March Page 10 of 11

82 Board Assurance Framework AO4: Partnership: Work with other people and other organisations to give patients the best care Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee SRR 7 IT purchases may not be aligned to / prioritised against the clinical strategy Risk Owner: Liz Shutler Delegated Risk Owner: Andy Barker Last Updated: 05 May 2016 Latest Review Date: 11 May 2016 Latest Review By: Andy Barker Latest Review Comments: Risk discussed with Liz and ok. Cause -Procurement processes not consistently followed - lack of clinical or professional involvement in process; - no consideration to deskilling of staff; - creation of supplier lock in with closed technology through legacy acquisitions. Effect - negative impact on patient experience - negative impact on staff motivation - cost of additional effort and resources / not VFM I = 3 L = 4 High (12) All technology purchases are reported to the Strategic Investment Group and scrutinised at the Information Development Group Control Owner: Andy Barker Director of IT who is aware of IT purchases to ensure that these follow the correct processes. Minutes and actions reported through to Finance and Performance Committee Evidence that IT purchases always follow that pathway I = 3 L = 3 High (9) Identify the policies and procedures that ensure purchases follow the correct route and make sure staff are aware of these. Person Responsible: Andy Barker To be implemented by: 29 Jul 2016 I = 3 L = 2 Moderate (6) Board of Directors SRR 10 Delivery of a timely Sustainability and Transformation Plan / Clinical Strategy which has some flexibility in it in relation to demand Risk Owner: Liz Shutler Delegated Risk Owner: Rachel Jones Last Updated: 01 Jun 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause Due to the number of assumptions within the draft analysis which are not under the control of the Trust (such as community bed reduction / activity levels), the requirement to produce an integrated Kent and Medway wide plan which will identify a number of models, and the need for staff and public / local interest group engagement, there is a risk the implementation will be delayed and not be flexible enough to meet demand. Effect Resulting in further pressure on the deliverability of safe services. I = 4 L = 4 Extreme (16) Clinical Engagement Forums to discuss options with staff (including a strategic planning event in May 2016) Control Owner: Liz Shutler East Kent Strategy Board in place which meets regularly to ensure deliver of an agreed plan by 30 June Control Owner: Liz Shutler Forums and events led by CEO, MD and DS&CP Trust Executive membership of the Board to influence the discussion. Feedback presented to the Board in private session (April 2016) Minutes and Board reporting on a bimonthly basis. Adequate Limited I = 4 L = 3 Extreme (12) Kent and Medway Plan agreed at East Kent Strategy Board for sign-off by Trust Board of Directors' Person Responsible: Liz Shutler To be implemented by: 30 Jun 2016 Public consultation on the options in relation to the East Kent elements of the plan Person Responsible: Liz Shutler To be implemented by: 30 Dec 2016 I = 4 L = 2 High (8) Finance & Investment Committee SRR 13 Pathology project contractual penalties and equipment failure Risk Owner: Nick Gerrard Delegated Risk Owner: Last Updated: 02 Jun 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause Due to significant delays in progressing the project previously there is a potential for external factors to impact on implementation, such as the sustainability and transformation plan or other providers wishing to be involved. Effect Resulting in delays in pathways reliant on pathology and additional impact on the Trust's finances. I = 2 L = 3 Moderate (6) Memorandum of Understanding in place - Robust governance structure in place to ensure project remains on track Control Owner: Nick Gerrard DoF has been appointed as Senior Responsible Officer Reporting from the Joint Project Board to the Board of Directors External legal advice on the MOU has been provided Adequate I = 2 L = 2 Low (4) Regular reporting at key milestones to Finance and Performance Committee to provide additional assurance to the Board. Person Responsible: Nick Gerrard To be implemented by: 30 Sep 2016 I = 2 L = 2 Low (4) Finance & Investment Committee Page 11 of 11

83 HIGHEST MITIGATED RISKS BoD 45/16 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS DATE: 10 JUNE 2016 SUBJECT: REPORT FROM: PURPOSE: HIGHES MITIGATED RISKS CHIEF NURSE AND DIRECTOR OF QUALITY Discussion CONTEXT / REVIEW HISTORY / STAKEHOLDER ENGAGEMENT This document provides the Board of Directors (BoD) with the highest ranked, mitigated risks on the Corporate Risk Register. New risks were reviewed at the Management Board on 25 May 2016 and added to the risk database. The top 10 risks were received by the Board of Directors at the meeting on 08 April 2016; the full register was reviewed by the Board at the January 2016 meeting and the strategic risks by the Board in December The top 10 risks were last reviewed by the Integrated Audit and Governance Committee on 19 April 2016 and the full register was reviewed on 20 July Quality risks were reviewed and discussed at the Quality Committee on 04 May 2016 and these were added to the register after discussion at Management Board. The quality risks are scheduled for presentation on 08 June at the Quality Committee. SUMMARY The corporate and strategic risks have been reformatted and re-scored following discussions with the Executive leads for each risk. These have included the risks identified from the newly drafted strategic risks. A new database Insight is being populated and a training programme for Divisions and the key corporate areas is being planned with the company. Recruitment into new Risk Manager post was completed during April and the post holder is now working across the Trust. The report contains the strategic and corporate risks where the residual risk remains red rated after mitigation. The following is a summary table in ranked order: ID Risk name Residual risk CRR8 Patients with mental health problems may be harmed because they do not receive timely mental health interventions 20 SRR5/CRR2 Failure to achieve financial stability and deliver financial plans 20 CRR7 Potential delayed treatment of patients requiring emergency acute general surgery intervention at the Kent and Canterbury Hospital site 15 SRR1 Unable to deliver a clinical strategy that can be resourced 15 CRR10 New European Data Protection Rules 12 CRR12 Patient's eyesight may be adversely affected by inadequate follow up arrangements 12 V1 1

84 HIGHEST MITIGATED RISKS BoD 45/16 CRR22 Failure to carry out timely Venous Thromobprophylaxis (VTE) risk assessments 12 SRR2 Adverse effects on Local services: Organisational Shape and Form 12 SRR9 CRR3 SRR11 Integration between quality and safety, finance, performance, activity and workforce management The Trust fails to plan for changing levels of demand appropriately Terms and conditions in relation to the interim working capital agreement SRR14 Ability to receive and retain the STP Fund 12 SRR10 CRR4 RECOMMENDATIONS: Delivery of a timely Sustainability and Transformation Plan / Clinical Strategy which has some flexibility in it in relation to demand Patients with sepsis are not recognised or treated in a timely way which may affect their outcome The Board is asked to review the highest mitigated risks on the corporate risk register NEXT STEPS: The Risk Group will review any new risks and the scoring of the existing risks. IMPACT ON TRUST S STRATEGIC OBJECTIVES: The quality risks align to all of the four annual objectives: People Patients Partnership Provision. LINKS TO BOARD ASSURANCE FRAMEWORK: There is an integral link to the Board Assurance Framework that runs through all the risks on the risk register. IDENTIFIED RISKS AND RISK MANAGEMENT ACTIONS: The attached risk register reflects the risks affecting the Trust and the mitigating actions in place. FINANCIAL IMPLICATIONS: Actions to mitigate certain risks have considerable impact on Trust expenditure; financial risks are now quantified in terms of single or cumulative costs. Failure to mitigate some risks will also result in financial loss or an inability to sustain projected income levels. V1 2

85 HIGHEST MITIGATED RISKS BoD 45/16 LEGAL IMPLICATIONS / IMPACT ON THE PUBLIC SECTOR EQUALITY DUTY: The Trust could face litigation if risks are not addressed effectively. The aim of the Public Sector Equality Duty is relevant to the report in terms of the provision of safe services across the nine protected characteristics. PROFESSIONAL ADVICE TAKEN ON ANY NOVEL OR CONTENTIOUS ISSUES Not applicable BOARD OF DIRECTORS ACTION REQUIRED: (a) to discuss and determine actions as appropriate CONSEQUENCES OF NOT TAKING ACTION: The Trust will continue to face unmitigated risks which may result in a worsening of the current position. V1 3

86 Board Assurance Framework (Inc Corporate Risk Register) Report Date 02 Jun 2016 Risk Status Risk Area Open 1. Strategic Risk Register, 2. Corporate Risk Register Page 1 of 12

87 Board Assurance Framework (Inc Corporate Risk Register) AO1: Patients. Help patients take control of their own health Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee CRR 4 Patients with sepsis are not recognised or treated in a timely way which may affect their outcome Risk Owner: Paul Stevens Delegated Risk Owner: Last Updated: 05 May 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause The opportunities and systems in place to recognise and manage patients presenting with or developing sepsis are not taken and/or the deteriorating patient is not recognised. Patients with cancer undergoing chemotherapy are susceptible to neutropenic sepsis. Previously fit and healthy adults may compensate clinically until they are critically ill. Effect Treatment is not administered in a timely way due to delayed recognition and and patients may suffer adverse outcomes. I = 5 L = 3 Extreme (15) Documentation in all EDs revised to record consistently patients vital signs and blood test results Control Owner: Paul Stevens All Point of Care testing equipment for blood gas analysis updated to include lactate measurements in EDs. Control Owner: Paul Stevens Clinical staff issued with aide-memoire on sepsis managment and compliance tested using CEM audit and local audit Control Owner: Paul Stevens Responsible lead identified in each ED. POCT coordinator in post Sepsis champions from all specialties at the monthly Sepsis meeting, including ED, Paediatrics, surgery and medicine. Programme led by Associate Medical Director of Patient Safety. Compliance reported to ED governance meetings in line with workplan Divisional Governance meetings held monthly in CSSD and reports submitted in line with workplan. Sepsis Committee reporting to PSB in line with workplan Deep dives undertaken by commissioners for each ED and reports submitted. All equipment subject to PPM and audit of accuracy Leading and participating in the Sepsis Collaborative across Kent, Surrey and Sussex coordinated by the AHSN. Review of mortality associated with patients with LD and patient under 59 years presented to commissioners and to Collaborative Substantial Substantial Substantial Not currently possible to use VitalPAC in the EDs to capture this information making collation of data more challenging. PPM scheduling Nationally coding of sepsis is inconsistent making outcome comparisons difficult I = 5 L = 2 Extreme (10) Trust requires a solution to electronic recording of vital signs across the whole Trust to ensure the deteriorating patient can be readily identified from the point of access. Person Responsible: Paul Stevens To be implemented by: 03 Apr 2017 I = 4 L = 2 High (8) Board of Directors Staff training in place on the recognition of patients with sepsis in line with national best practice, including primary care and Ambulance service Control Owner: Paul Stevens Sepsis lead and sepsis coordinator undertaking training to key clinical groups Reports to PSB in line with workplan Audit of compliance with CEM sepsis audit run over time in order to demonstrate and sustain changes to practice. Use of Yellow Alert in use by SECAmb and use audited. Adequate Results of audit showing improvement but not consistent across sites Page 2 of 12

88 Board Assurance Framework (Inc Corporate Risk Register) AO1: Patients. Help patients take control of their own health Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee CRR 7 Potential delayed treatment of patients requiring emergency acute general surgery intervention at the Kent and Canterbury Hospital site Risk Owner: Paul Stevens Delegated Risk Owner: Last Updated: 05 May 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause There is provision for specialist vascular and urology surgery on the Kent and Canterbury site only and the provision for the emergency pathway is restricted to an ECC model and not a full ED. This situation was widely shared with GP and SECAmb partners over 10 years ago. In the past general surgical intervention, when needed, was covered by vascular surgeons. With the introduction of Specialist Medical Training (Calman Report) the ability of surgeons to be deemed competent to perform procedures outside their registered speciality has decreased. Effect Patients requiring general surgical intervention are occasionally transferred to the K&CH site and require subsequent transfer to either the WHH or QEQMH after stabilisation. Some vascular surgeons do maintain core clinical competencies for general surgery but there is not a formal rota at the K&CH site and this can result in delays to treatment. Where the patient is considered I = 5 L = 3 Extreme (15) Clarity of the function of the K&CH site as not having the capability to manage general surgical emergencies communicated to external partners including SECAmb and GPs. Rapid assessment of patients and transfer out to the WHH and QEQMH or competent vascular surgical intervention at the K&CH, Fundamentally, the clinical strategy will mitigate the risk. Control Owner: Paul Stevens Senior vascular input into either patient stabilisation before transfer, or use surgical input on site. Incidents involving general surgical patient intervention reported onto Datix and reviewed as part of the quarterly report and to PSB. Adequate Full rota cannot be covered using an ad hoc mechanism and the skills required my not be fully up to date as the number of patients affected is small. There may be inpatients who develop a general surgical emergency after admission for a different reason. I = 5 L = 3 Extreme (15) Implementation of clinical strategy with a stable rota of general surgical cover across the Trust. Person Responsible: Liz Shutler To be implemented by: 31 Mar 2017 I = 5 L = 1 High (5) Quality Committee Page 3 of 12

89 Board Assurance Framework (Inc Corporate Risk Register) AO1: Patients. Help patients take control of their own health Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee CRR 8 Patients with mental health problems may be harmed because they do not receive timely mental health interventions Risk Owner: Sally Smith Delegated Risk Owner: Last Updated: 05 May 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause KMPT have reduced the liaison Psychiatry cover to the Trust to to hours as they are not able to recruit into their current vacancies and they have relied on agency cover to maintain their rotas. There is a national shortage of in-patient mental health beds. Effect Patients with recognised mental health disorders may not be treated in a timely way. There are an increasing number of calls to security and to SafeAssist Acute to manage challenging and violent behaviour. Other patients and staff are put at risk of harm from violent episodes. Patients who require in-patient mental health care are managed in acute facilities which are not fit for this purpose. I = 4 L = 4 Extreme (16) Planned increase in cover arrangements for a 12 hour period across all 3 sites planned from May Control Owner: Jane Ely Single point of access for referrals for emergency and urgent patients from 01 April 2016 with a separate crisis team covering this area. Arrangements for other patients, including selfreferrals and existing patients set up through GPs and NHS111. Control Owner: Jane Ely Employment of dual qualified RN and RMNs in Emergency Departments. Control Owner: Jane Ely Plans being formulated to ensure 24 hour cover across the Trust by Mental Health Commissioner locally is leading the commissioning intentions up to this date. Control Owner: Jane Ely Advertising and restructuring of EDs in order to provide flexibility The UCLTC Divisional Detailed Action Plan containing specific actions to assist with this action completed with executive sign off 15th January 2016 Multi-agency Surge Resilience Group meeting monthly Surge Resilience meeting monthly and Liaison Psychiatry meetings quarterly Workforce committee in place. Six-monthly reviews of nurse staffing to the BoD using recognised activity and workforce tools. Regular reporting of staffing issues to shared CCG Quality and Performance Committees CQC will review arrangements at the next inspection in Limited Limited Actual times of cover yet to be agreed and there will be a lead time of 6 weeks while rotas are agreed with clinical staff Capacity may be an issue CQC inspections Limited May not be possible to recruit dual qualified personnel Limited May not be possible to recruit dual qualified personnel. The funding for mental health commissioning of additional staff may not be realised across the locality. I = 4 L = 3 Extreme (12) On-going work with local Commissioners and the mental Health Trust is underway, following a wider health economy improvement plan away day in December. A cogent and coherent action plan is required to ensure cover is provided in line with national timescale. Person Responsible: Jane Ely To be implemented by: 31 Mar 2017 I = 4 L = 2 High (8) Patient Safety Board Nominated consultant psychiatric cover for each site with Band 7 RMN and 5xBand 6 support to cover to hours. Control Owner: Jane Ely Clinical lead for transformation in post. Crisis team in place out of these hours but this covers mental health services across Kent and Medway for all community and inpatient services. Local meetings with KMPT and COO in place. Liaison Psychiatry meetings re-established from Feb-16. High level CQC plan identifies actions and monitoring required in collaboration with mental health providers and commissioners. CQC inspection programme Limited Existing cover, despite increased funding in 2015/16, only provides to hours. No additional local funding identified for 2016/17 within current commissioning intentions. Page 4 of 12

90 Board Assurance Framework (Inc Corporate Risk Register) AO1: Patients. Help patients take control of their own health Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee CRR 10 New European Data Protection Rules Risk Owner: Paul Stevens Delegated Risk Owner: Last Updated: 05 May 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause European Privacy Law will become part of UK statute in 2018 placing specific responsibilities on all organisations for the use of personal data; this will affect patients in the main, but staff records will be included within the regulations. Effect The Trust may not have the necessary infrastructure in place to deliver against the following key areas: 1. Obtaining individual consent for disclosure 2. Privacy Impact Assessments to enable the organisation to understand the risks to personal data and privacy. 3. The Trust will need to establish systems to ensure that protections of personal data are included in all areas of business. 4. The Trust will need to be transparent in reporting externally all breaches of security and confidentiality to regulators and the persons affected. 5. A process is required to give individuals the right to be forgotten. 6. There is a financial penalties, up to 4% of turnover is possible, equivalent to 20million, I = 5 L = 3 Extreme (15) The IG Manager is actively engaging nationally with peer and national leaders in order to assess accurately the impact of the proposed changes to legislation within the Trust. Control Owner: Paul Stevens The Trust is registered with the Office of the Information Commissioner and reports IG breaches locally and nationally Control Owner: Paul Stevens The Trust has an Information Governance function within the corporate team to support the changes required Control Owner: Paul Stevens Training booked for IG Manager on cyber security and data protection changes. Monitoring and investigating breaches and responding to individual concerns raised by patients and service users. IG Manager and administrative support in place Regular feedback to Information Governance Steering Group Information Governance Steering Group meeting monthly and participation in regional committees. Regular learning published in RiskWise Information Governance Steering Group meeting monthly with reports to IAGC. Internal audit reviews External audit of the Annual Governance Statement published in the Annual Report and Accounts. Internal audit of IG toolkit compliance as part of the internal audit function. Active participation in regional and national fora. Internal audit of IG Toolkit Adequate Substantial Adequate The scope of the new legislation is likely to exceed current internal capacity. I = 5 L = 2 Extreme (10) Comprehensive review of the IG function and succession planning arrangements to identify core gaps internally. Person Responsible: Paul Stevens To be implemented by: 31 Mar 2017 I = 4 L = 2 High (8) Board of Directors Page 5 of 12

91 Board Assurance Framework (Inc Corporate Risk Register) AO1: Patients. Help patients take control of their own health Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee CRR 12 Patient's eyesight may be adversely affected by inadequate follow up arrangements Risk Owner: Paul Stevens Delegated Risk Owner: Last Updated: 05 May 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause Due to historic PAS systems, the true patient follow up capacity gap has never been visible. Partial booking has given transparency to the issues facing patients requiring regular follow up. Ophthalmology specialties provide services in predicted high growth areas and these are expected to further increase with an aging demographic. Effect There are approximately 7,000 patients waiting for a follow up appointment outside of their required timeframe to be seen. Nearly 1,500 patients are being validated as they are not indicated at speciality level. Therefore nearly 5,500 patients have been escalated as requiring an appointment that is overdue and require urgent follow-up within the specialty. There is a lack of out-patient capacity to manage the backlog and maintain the current patient cohort. I = 4 L = 5 Extreme (20) Proposals for Virtual clinics have been described in the business case for follow up diabetic medical retina patients, with a conservative estimate of 3,000 patients who would benefit from this approach. Control Owner: Paul Stevens A pathway has been developed for the commissioners to enable the safe transfer of stable follow up glaucoma patients into the community Control Owner: Paul Stevens The service has been successful in bidding for government monies for an electronic patient record which can be shared from acute to community. This will facilitate patient flow with speed and reduce clinical risk. Control Owner: Paul Stevens Dedicated ophthalmology manager. Service meetings to review backlog position Divisional Governance Committee (Surgery) reviewing position. Position updated with Commissioners at Quality Committee Limited Limited Limited Ophthalmology is only able to implement limited solutions to address the capacity associated with the follow up waiting list and the rise in new referrals. Without a phased investment the status quo will remain and the risk to permanent sight impairment is high. I = 4 L = 3 Extreme (12) Implement the ophthalmology transformation strategy, which involves an increase in staff numbers and new equipment to support these staff. Person Responsible: Paul Stevens To be implemented by: 31 Mar 2017 Introduce an electronic patient record system in the form of Openeyes software, which will drive both efficiency increases and cost savings. The system can also be rolled out to, and integrated with, community services to support the flow of patients in and out of acute services. Person Responsible: Paul Stevens To be implemented by: 31 Mar 2016 I = 4 L = 2 High (8) Divisional Governance Boards CRR 22 Failure to carry out timely Venous Thromobprophylaxis (VTE) risk assessments Risk Owner: Dorothy Otite Delegated Risk Owner: Dorothy Otite Last Updated: 26 May 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause - The move from a paper to an electronic reporting system has resulted in issues with data accuracy and with data capture Effect - Non-compliance with NICE CG92 - Non-compliance with NICE Quality Standard (QS3) VTE in adults - Harm to patients - Reputational damage - Increased Complaints - Legal Claims - Financial Loss I = 4 L = 3 Extreme (12) Quarterly & Annual Performance reporting Nationally Control Owner: Dorothy Otite Oversight by Commissioners Control Owner: Dorothy Otite I = 4 L = 3 Extreme (12) Implement action plan devised in collaboration with the CCG quality leads to ensure the current reported rate of risk assessment improves and is sustained at the national level. Person Responsible: Dorothy Otite To be implemented by: 30 Sep 2016 I = 4 L = 2 High (8) Board of Directors Page 6 of 12

92 Board Assurance Framework (Inc Corporate Risk Register) AO1: Patients. Help patients take control of their own health Risk Ref SRR 2 Risk Title Cause & Effect Inherent Risk Score Adverse effects on Local services: Organisational Shape and Form Risk Owner: Sally Smith Delegated Risk Owner: Last Updated: 05 May 2016 Latest Review Date: 23 May 2016 Latest Review By: Sally Smith Latest Review Comments: CQC Re-Visit action has a new date in light of not receiving notice of the visit at present. Cause Failure to action and deliver our regulatory requirements that may result in being taken over by another organisation Effect - Loss of autonomy; - Impact on staff morale; - Reputational problems; - Decline in pace and development of service. I = 4 L = 4 Extreme (16) Risk Control 1st Line 2nd Line 3rd Line Assurance Level Financial Recovery Plan - Monitor Undertaking (12/16) Control Owner: Nick Gerrard Emergency Department Recovery Plan (agreed with partners and submitted to Monitor) 12/2015 Control Owner: Jane Ely Improvement Plan in place with supporting Divisional plans in place (01/2016) Control Owner: Sally Smith Director of Finance and Chief Executive review of document prior to submission. ED Plan updated by Urgent Care and Long Term Conditions Emma Kelly manages the updates to the Improvement Plan on at least a monthly basis. Plan circulated to Finance and Investment Committee members and thereafter all BoD members for input (12/16) - report to Executive Team on a weekly basis for information - UCLTC update on actions at Executive Performance Reviews - discussions at both Quality and Finance Committee in relation to impacts on safety, quality and finance - monthly BoD report showing progress against plans Improvement Board monitor progress (meets monthly) BoD receives exception and progress reports (bimonthly) Health Economy ED Recovery Meeting Monitor review of ED plan Improvement Director oversight of plan Emergency Care Improvement Programme working with the Trust (Sept 15). Monitor Progress Review meetings - provides challenge over progress of Trust in meeting deadlines Improvement Director - challenge to Trust CQC Inspection 07/15 - improved rating Internal Audit on data quality (11/15) Adequate Adequate Adequate Assurance Gap Monitor feedback expected Clear understanding of the ED pathway and how the plans start to resolve the key issues. Internal Audit on CQC (04/16) Internal Audit on Risk Management (04/16) Residual Risk Score I = 4 L = 3 Extreme (12) Action Required Progress Notes Target Risk Score Internal Audit to undertake a review of the CQC Improvement Plan Person Responsible: Sally Smith To be implemented by: 31 Mar 2017 CQC re-visit plan to provide timeline and actions to ensure organisation readiness for CQC insepction due around April 2016 Person Responsible: Sally Smith To be implemented by: 31 Oct Apr 2016 Sally Smith This action will be scoped in the 16/17 financial year. Dates are yet to be agreed. 25 Feb 2016 Alison Fox Intelligencesugges ts that the CQC revist will not take place until May / June Work on implementing the plan continues. The Hubs / staff have been involved in mock inspections (to be BAU). 11 Apr 2016 Alison Fox Report presented to BoD, however, as the Trust has not been provided with its inspection date the timeline presented was an example and the Board will receive a further timeline once a date is confirmed. 25 Feb 2016 Alison Fox Intelligence suggests that the CQC visit is likely to take place in May / June 2017; work is on-going to implement the improvements required. I = 4 L = 2 High (8) Reporting Committee Quality Committee Page 7 of 12

93 Board Assurance Framework (Inc Corporate Risk Register) AO1: Patients. Help patients take control of their own health Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Emergency Department Board workshop to provide a good understanding of the issues and plan to address performance. Person Responsible: Jane Ely To be implemented by: 11 Mar Mar 2016 Jane Ely Workshop completed with Board (Exec & Non-Exec) 11th March as planned. New Ed dashboard shared and the priority actions that would make a difference noted by all. Follow up action to review ED staffing at SWC and circulate to the Board. 29 Feb 2016 Alison Fox Planned for March 2016 BoD development session Reporting Committee Internal Audit to undertake review of the risk management systems and controls following output of Deloitte and PWC reviews Person Responsible: Helen Goodwin To be implemented by: 01 Jul Jun 2016 Helen Goodwin Grant Thornton currently undertaking a review of governance arrangements against NHS I Governance Framework. The report has yet to be received. 25 Feb 2016 Alison Fox Reviewing workload to programme in this review. Page 8 of 12

94 Board Assurance Framework (Inc Corporate Risk Register) AO1: Patients. Help patients take control of their own health Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee SRR 9 Integration between quality and safety, finance, performance, activity and workforce management Risk Owner: Matthew Kershaw Delegated Risk Owner: Alison Fox Last Updated: 01 Jun 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause Due to a number of competing priorities which may have the potential to be discussed in isolation at the Board Committees, there is a risk that not all aspects (quality and safety, finance, performance, activity, workforce) will be considered. Effect This may lead to decisions or direction being given from one source to contradict or negatively impact on decisions or direction given in another. I = 4 L = 4 Extreme (16) Chair reports from each Committee to advise of key decisions / actions requested provided to each Board meetings to allow for triangulation Control Owner: Alison Fox Quality Impact Assessment on all CIP's that have a quality aspect Control Owner: Sally Smith Reports drafted by the NED Chair with support from the secretariat. (occurs monthly) Chief Nurse and Medical Director review the QIA's as they are received Review of Committee reports at Board on a bi-monthly basis. Management Board and Quality Committee receive updates on the number reviewed. Adequate Limited Ensure the NED's pull out areas where there is potential crossover. An audit of the process would provide assurance that the process is working well. I = 4 L = 3 Extreme (12) Integrated Performance Report which enables easy triangulation of information to support decision making. Person Responsible: Nick Gerrard To be implemented by: 10 Jun 2016 Full use of Integrated Performance Report to allow discussion of all aspects that may impact on a decision at Committee and Board level. Person Responsible: Alison Fox To be implemented by: 30 Sep 2016 I = 4 L = 2 High (8) Quality Committee AO3: Provision: Provide the services needed and do it well Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee CRR 2 Failure to achieve financial stability and deliver financial plans Risk Owner: Nick Gerrard Delegated Risk Owner: Last Updated: 05 May 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause Due to : - poor planning - poor recurrent CIP delivery - poor cash management, and - gaps in financial governance Effect Resulting in: - potential breaches to the Trust's Monitor licence - adverse impact on the Trust's ability to deliver all of its services and, in the longer term, the clinical strategy, which further impacts on - the reputation of the organisation, and - the Trust being sustainable as a going concern in future as creditors lose confidence and there are reduced resources for investment. I = 5 L = 5 Extreme (25) Financial governance systems in place Control Owner: Nick Gerrard Financial recovery plan in place Control Owner: Nick Gerrard Divisional specific Cost Improvement Plan targets in place with PMO and workstream support Control Owner: Nick Gerrard Turnaround Director in post from October 2015 Control Owner: Nick Gerrard Director of Finance responsible for overseeing governance arrangements Monthly reporting by Divisions on progress against plan to the Financial Recovery Group Divisional challenge meetings in place for Executive Team to challenge progress against plan Direct line management by CEO Finance and Investment Committee Exception reporting to Finance and Investment Committee monthly with BoD oversight of final reports bimonthly - Weekly review of performance by Executive Team - Turnaround report to FIC monthly - Exception reporting to the BoD monthly Review of current governance arrangements undertaken in July 2015 by Grant Thornton Draft plan reviewed by Monitor and the financial position is reviewed at the PRMs (6-8 weekly) Progress Review Meetings with Monitor (6-8 weekly) to review progress Adequate Adequate Limited Adequate Action plan developed from review findings requires full implementation and on-going monitoring to ensure sustainability Reporting shows slow improvement. Monitor still to provide feedback on 2 year plan. I = 5 L = 4 Extreme (20) Implementation of financial governance action plan Person Responsible: Nick Gerrard To be implemented by: 31 Mar 2016 I = 5 L = 3 Extreme (15) Board of Directors Clinical workstreams in place to ensure the standards of care delivered are not adversely affected Control Owner: Sally Smith Reports to Executive Team (weekly) from workstream Report from Executive Team monthly to Finance and Investment Committee (FIC) and monthly reporting to BoD CQC quality inspection scheduled for date to be confirmed Limited Page 9 of 12

95 Board Assurance Framework (Inc Corporate Risk Register) AO3: Provision: Provide the services needed and do it well Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee CRR 3 The Trust fails to plan for changing levels of demand appropriately Risk Owner: Jane Ely Delegated Risk Owner: Last Updated: 05 May 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause There is a increased and unplanned local demand for emergency and elective services that the Trust is unable to meet with the resources and infrastructure available. Surge resilience plans do not meet unprecedented demand Effect Plans in place for activity and demand are not synchronised with actual activity performed and there is a resultant loss of income and the Trust carrying the risk in isolation. Engagement with commissioners and specialist commissioners is compromised making agreement about contracted activity difficult to manage. The Trust experiences increased costs associated with out-sourcing activity further compromising financial stability, patient safety and experience. The Trust is in breach of its licence to operate and is subject to close scrutiny by Monitor I = 4 L = 5 Extreme (20) The Trust is participating in the Emergency Care Improvement Programme (ECIP) Control Owner: Jane Ely Demand and capacity monitored in all areas outlined in the Operating Framework Control Owner: Jane Ely The CEO and COO are both active members of the SRG and have raised this lack of whole health economy capacity plans. Control Owner: Jane Ely Urgent Care Board Improvement leads meeting weekly Head of Nursing supporting EDs directly Reports from CSSD for Diagnostic compliance (DM01) Reports from UC&LTC on ED and ECC performance Reports from Surgical Division on referral to treatment performance Reports from Specialist Services on cancer compliance - all reported to executives Workstream leads working to deliver an ED improvement plan Weekly KPI meetings Reporting of core areas within the monthly Executive Performance Reviews. Exception reports to Management Board monthly Cancer compliance reviewed by Kent Cancer Board and RCA programme established for long cancer waits ECIP network of clinically led support with regular inspection and review Fortnightly meetings held across health economy Surge Resilience Group meetings Data quality review undertaken by KPMG in 2014 to cover all areas within the operating framework. Mandated indicators audited as part of the annual Quality Account Adequate Adequate Current assurances are not ensuring a consistent performance of 95% consistently across all sites I = 4 L = 3 Extreme (12) Review of clinical leadership in ED and effectiveness of current controls to be assessed by ECIP Person Responsible: Paul Stevens To be implemented by: 02 May 2016 I = 3 L = 3 High (9) Board of Directors SRR 5 Failure to achieve financial stability Risk Owner: Nick Gerrard Delegated Risk Owner: Last Updated: 01 Jun 2016 Latest Review Date: 25 Feb 2016 Latest Review By: Alison Fox Latest Review Comments: Reviewed current status of controls; adding to assurances (Trust Secretary) Cause due to: - failure to reduce the run rate - poor planning - poor recurrent CIP delivery - - poor cash management and - gaps in financial governance Effect resulting in - potential breaches to the Trust's Monitor licence, - adverse impact on the Trust's ability to deliver all of its services and in the longer term clinical strategy, - poor reputation and - failure to be a going concern I = 5 L = 5 Extreme (25) Turnaround Director in post (10/15) Control Owner: Nick Gerrard Clinical Workstreams in place to ensure quality of care Control Owner: Nick Gerrard Financial govenance in place Control Owner: Nick Gerrard Cost Improvement Plan targets in place with workstream in support Control Owner: Nick Gerrard Direct line management by Chief Executive Reports to Executive Team from workstream (weekly) Director of Finance oversees the governance Divisional Challenge meetings for Execs to challenge Feeds into Finance and Investment Committee Integrated Audit Committee reviewed controls through reporting from Internal and External Audit - executive review weekly - Turnaround report to FIC - Exception reports to BoD Feeds into BoD - Grant Thornton governance review (07/15) Monitor challenge at Progress Review meetings (6-8 weekly) Limited Adequate Adequate Adequate Feedback from Chief Exec sought on individuals performance against objectives Action plan development and requires full implementation I = 5 L = 4 Extreme (20) Implementation of finacial governance action plan Person Responsible: Nick Gerrard To be implemented by: 31 Mar 2016 CIP deep dive - Report to FIC on reasons for slippage on Theatres, Outpatients and Workforce Person Responsible: Nick Gerrard To be implemented by: 08 Mar Feb 2016 Alison Fox FIC to receive report on progress highlighting any areas for concern / risk to delivery. (to be scheduled). 25 Feb 2016 Alison Fox On FIC agenda in March Feb 2016 Alison Fox On FIC agenda for March 2016 I = 5 L = 3 Extreme (15) Finance & Investment Committee Financial Recovery Plan Control Owner: Nick Gerrard Divisions report progress into Financial Recovery Group on a monthly basis. - Exceptions reported into Finance and Investment Committee (monthly) - Board has final oversight (bi-monthly) Monitor reviewed draft plan and discusses the financial position at Progress Review meetings (6-8 weekly) Adequate Reporting shows slow improvement; Monitor still to provide feedback on 2 year plan Page 10 of 12

96 Board Assurance Framework (Inc Corporate Risk Register) AO3: Provision: Provide the services needed and do it well Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee SRR 11 Terms and conditions in relation to the interim working capital agreement Risk Owner: Nick Gerrard Delegated Risk Owner: Last Updated: 01 Jun 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause Due to the current performance of the Trust in relation to reduction of agency spend / off-framework use and the timeline in relation to delivery of a three year estates strategy there is a risk that some terms may not be met. Effect Resulting in the possibility that funding may be withdrawn. I = 4 L = 3 Extreme (12) Process in place to reduce agency spend. Control Owner: Sandra Le Blanc Dedicated project resource in place through the Service Improvement Team to deliver the reduction. Off-framework agency spend reviewed weekly through the Turnaround report at Exec Team Meeting. Divisions are challenged at Executive Performance Reviews and Key Metric Reviews. Strategic Workforce and Finance and Performance Committees review agency spend. Adequate Sustainable reduction needs to be seen before full assurance can be taken that this control is working. I = 4 L = 3 Extreme (12) Estates Strategy will be reviewed in light of the submission of the Sustainability and Transformation Plan (30 June 2016). Person Responsible: Liz Shutler To be implemented by: 29 Jul 2016 I = 4 L = 2 High (8) Finance & Investment Committee SRR 14 Ability to receive and retain the STP Fund Risk Owner: Matthew Kershaw Delegated Risk Owner: Alison Fox Last Updated: 02 Jun 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause Due to the number of performance metrics / trajectories that the Trust will need to meet on a quarterly basis there is a risk that the funding may be withdrawn. Effect Resulting in the Trust requiring additional working capital to support the cash position; the need to find additional efficiencies when the current CIP programme will be a stretch; impact on it's ability to deliver it's long-term strategy. I = 4 L = 4 Extreme (16) Trajectory for applicable standards agreed with the CCGs and NHSI. Control Owner: Jane Ely Annual financial plan in place including cost improvement programme. Control Owner: Nick Gerrard Divisional management of the standards through Governance and Business Boards Director of Finance manages the position routinely Compliance reports to Executive Performance Reviews Management Board Finance and Performance Committee Board of Directors Council of Governors Performance against plan monitored through: Turnaround Board (weekly at EMT) Executive Performance Reviews (monthly) Finance and Performance Committee (monthly) Board of Directors (bimonthly) External review from: CCG's through monthly performance reviews NHSI through 6 weekly progress review meetings Financial performance reviewed with NHSI at Progress Review Meetings Adequate Adequate Consistent performance against tracjetories Performance against plan - to be reviewed I = 4 L = 3 Extreme (12) Meeting the agreed plans in respect of: Annual financial plan Access standards Person Responsible: Jane Ely To be implemented by: 30 Sep 2016 I = 4 L = 2 High (8) Board of Directors Emergency Care Recovery Plan in place Control Owner: Jane Ely Divisional Management on a daily basis Performance monitored through: Emergency Care Board Executive Management Team (weekly) Finance and Performance Committee (monthly) Board of Directors (bimonthly) Improvement Director closely monitoring performance; Discussed with NHSI at Progress review meetings (6 weekly) Surge Resilience Group reviews Adequate Delivery of plan and trajectories met consistently. Page 11 of 12

97 Board Assurance Framework (Inc Corporate Risk Register) AO4: Partnership: Work with other people and other organisations to give patients the best care Risk Ref Risk Title Cause & Effect Inherent Risk Score Risk Control 1st Line 2nd Line 3rd Line Assurance Level Assurance Gap Residual Risk Score Action Required Progress Notes Target Risk Score Reporting Committee SRR 1 Unable to deliver a clinical strategy that can be resourced Risk Owner: Liz Shutler Delegated Risk Owner: Last Updated: 05 May 2016 Latest Review Date: 25 Feb 2016 Latest Review By: Alison Fox Latest Review Comments: Reviewed controls and assurances 25/2/16 Cause - Four CCGs having differing agendas; - Lack of stakeholder agreement; - Lack of clear commissioning intentions; - Parliamentary timings may not be conjucive to timely implementation Effect - Patient care - Enforcement actions - Trust's Monitor licence. I = 5 L = 4 Extreme (20) Financial Recovery Plan Control Owner: Nick Gerrard Regular meetings with external partners / MP's and within the Trust Control Owner: Liz Shutler East Kent Strategy Board Control Owner: Liz Shutler Divisional / Executive Transformation Meetings (held biweekly) Awaiting engagement plan Trust Secretary hold all copies of agendas / minutes East Kent Strategy Board FIC and Board reporting from Turnaround Director In attendance are all Health economy partners Monitor receive monthly reports on the Trusts finances as well as the quarterly returns and discussions at PRM's. Monitor received first submission of Annual Plan 2016/17 02/2016 Adequate None Adequate Traction around clinical efficiencies - FIC requested an update on Theatre efficiencies / Outpatients and Workforce - scheduled for 03/2016 I = 5 L = 3 Extreme (15) Agree for approval by EKSB a timeline for delivery of STP Person Responsible: Liz Shutler To be implemented by: 11 Mar 2016 Presentations on Outpatients / Theatres and Workforce CIP schemes to FIC to facilitate understanding of slippage. Person Responsible: Nick Gerrard To be implemented by: 08 Mar 2016 Agreement of final consultation document by all partners Person Responsible: Liz Shutler To be implemented by: 31 Mar Feb 2016 Alison Fox Matthew Kershaw / Liz Shutler and Rachel Jones to produce this item for EKSB 25 Feb 2016 Alison Fox On FIC agenda for March 2016 I = 5 L = 2 Extreme (10) Finance & Investment Committee SRR 10 Delivery of a timely Sustainability and Transformation Plan / Clinical Strategy which has some flexibility in it in relation to demand Risk Owner: Liz Shutler Delegated Risk Owner: Rachel Jones Last Updated: 01 Jun 2016 Latest Review Date: Latest Review By: Latest Review Comments: Cause Due to the number of assumptions within the draft analysis which are not under the control of the Trust (such as community bed reduction / activity levels), the requirement to produce an integrated Kent and Medway wide plan which will identify a number of models, and the need for staff and public / local interest group engagement, there is a risk the implementation will be delayed and not be flexible enough to meet demand. Effect Resulting in further pressure on the deliverability of safe services. I = 4 L = 4 Extreme (16) Clinical Engagement Forums to discuss options with staff (including a strategic planning event in May 2016) Control Owner: Liz Shutler East Kent Strategy Board in place which meets regularly to ensure deliver of an agreed plan by 30 June Control Owner: Liz Shutler Forums and events led by CEO, MD and DS&CP Trust Executive membership of the Board to influence the discussion. Feedback presented to the Board in private session (April 2016) Minutes and Board reporting on a bimonthly basis. Adequate Limited I = 4 L = 3 Extreme (12) Kent and Medway Plan agreed at East Kent Strategy Board for sign-off by Trust Board of Directors' Person Responsible: Liz Shutler To be implemented by: 30 Jun 2016 Public consultation on the options in relation to the East Kent elements of the plan Person Responsible: Liz Shutler To be implemented by: 30 Dec 2016 I = 4 L = 2 High (8) Finance & Investment Committee Page 12 of 12

98 CHAIR S ACTION BoD 46/16 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS DATE: 10 JUNE 2016 SUBJECT: REPORT FROM: PURPOSE: CHAIR S ACTIONS CHAIRMAN To Note CONTEXT / REVIEW HISTORY / STAKEHOLDER ENGAGEMENT This report summarises decisions taken by the Chair and Board outside of Board meeting cycle. SUMMARY: The following decisions have been taken by the Chair since the April Board of Directors meeting: The Chair and the CEO exercised their emergency powers to approve a lease agreement to purchase equipment for day to day use within the business of EKMS. The following decisions have been taken by the Board since the April Board of Directors meeting: As delegated at the April Board of Directors (closed session) the Joint Integrated Audit and Governance Committee / Finance and Performance Committee / Quality Committee approved the final text Annual Report and Accounts 2015/16. An electronic voting process was carried out to award the Waste Management Contract to SRCL for an initial period of 5 years with the option to extend for up to an additional 24 months. This was on recommendation from the Finance and Performance Committee. Thirteen Board members responded confirming their endorsement of this recommendation. The contract has been awarded. An electronic voting process was carried out to award the workforce services contract to NHS Professionals for an initial period of 2 years with the option to extend for up to a 2 further years as the most economically advantageous tenderer. This was on recommendation from the Finance and Performance Committee. Fourteen Board members responded confirming their endorsement of this recommendation. The contract has been awarded. RECOMMENDATIONS: To note the Chair s action. To formally note decisions taken by the Board. Page 1 of 2

99 CHAIR S ACTION BoD 46/16 NEXT STEPS: The Contracts have been awarded. The Lease agreement is in place. ACTION REQUIRED: (a) To note. CONSEQUENCES OF NOT TAKING ACTION: Delays with approval of important business decisions. Page 2 of 2

100 SWC CHAIR REPORT BoD 49/16 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS DATE: 10 JUNE 2016 REPORT FROM: PURPOSE: STRATEGIC WORKFORCE COMMITTEE CHAIR DISCUSSION PURPOSE OF THE COMMITTEE: The Committee is responsible for providing the Board with assurance on all aspects relating to the workforce, including strategy, delivery, governance, risk management. This report presented reflects Committee activity for both the April and May 2016 meetings. EXECUTIVE SUMMARY The report seeks to answer the following questions in relation to workforce: What went well over the period reported? What concerns were highlighted? Were the annual objectives for 2015/16 met? Looking forward, what are the annual objectives for 2016/17 and what are the risks to achieving these? The following went well over the reporting period: a. The Statutory Training Compliance Rate remains has risen to 87% - exceeding the Trust target of 85%; b. February 2016 has seen a slight reduction in the % of the Pay Bill that is made up of Temporary Staffing costs, from 9.7% to 9.3%; and c. The Workforce People Strategy was under development and Non-Executive Directors would be involved in the process. d. Cultural Change: Tender process for the Leadership and Development Programme to incorporate 200 key leaders was ongoing; communications and engagement had focused on the Trust s vision and values, mission and strategic priorities. The following concerns were highlighted at the April Committee Meeting a. The Trust appraisal rate has declined slightly in February 2016 and is now 84%, which is below the target rate of 90%. The Committee was assured that this was being addressed through the Executive Performance Reviews; b. February 2016 has seen a slight increase in the % of the Temporary Staff bill that is made up of Agency Staffing Spend, from 49.6% to 50.5%. c. Sickness absence appears to be on a slight upward trend across the Trust, and is higher in February 2016 than it was in February A good analysis of this was presented at the April Committee meeting which included; age, length of service and any seasonal variation and further analysis would be provided on the differences between short and long term sickness was provided to the May Committee meeting (see below). The Committee asked the Executive to: i. focus on reducing sickness in relation to staff in their first five years of 1

101 SWC CHAIR REPORT BoD 49/16 service; ii. look at innovative ways to manage sickness. d. There is a significant risk in regard to statutory training compliance, In February 2016, 897 staff were identified as not completing one or more of the statutory training courses required. This shows a slight reduction from the 911 staff in January 2016; and e. Cultural Change: whilst the staff engagement score in the staff survey was the highest in 5 years a number of other indicators were dropping and the Friends and Family Test had deteriorated in the last quarter. The Committee Committee has invited each Division to talk through their action plans to improve the position as part of their consolidated great place to work plans. Presentations were received at the May Committee meeting from the Clinical Support Services Division and Surgical Services Division. f. The divisional presentations gave the committee a level of assurance that serious attention is being paid to the need to listen to staff issues and that locally owned actions are being implemented. The improvement journey will take some time in certain areas. Presentations will be received at the June Meeting from Specialist Services Division and Urgent Care and Long Term Conditions Division. The following concerns were highlighted at the May Committee meeting: a. Sickness Absence: the age band with the highest level of sickness in their first year of service is the age bracket with 19% of the total sickness. Admin and Clerical have the highest sickness in the first year, with 30% of the total, but they are closely followed by Additional Clinical Services with 29%. The main reason for sickness during an employee s first year is Anxiety / Stress / Depression / other psychiatric causes with 18.6% of the total. Analysis of long-term and short-term sickness across the Trust shows the age-related results that would be expected, with short-term sickness episodes being most prevalent in the younger age bands and gradually the % of sickness taken in long-term absences increasing as age increases. The predominant reasons for short term sickness absence are as expected, namely, cold, cough, flu/influenza (22%) and gastro-intestinal problems (17%). Long-term absence is mainly due to anxiety/stress/depression (25%) followed by musculoskeletal problems (14%). b. The staff group with the highest percentage of leavers for the last 12 months is Admin and Clerical with 30%, followed by nursing and midwifery with 25%. Approximately 25% of leavers are aged under 30, with another expected peak as employees retire. The reasons for voluntary resignations (as recorded on the termination form) show other /not known as the biggest category (35.5%) followed by relocation (21.3) and work-life balance (15.2%). c. Appraisal Rates: The Trust appraisal rate has declined again in March 2016 and is now 82%, which is below the target rate of 90%. d. The turnover rate (Excluding Doctors in Training) for March 2016 is 11.4% - a slight decrease on last month s figure of 11.5%. e. There is a significant risk in regard to statutory training compliance. In March staff were identified as not completing one or more of the statutory training courses required. This shows a moderate reduction from the 897 staff in February f. A paper was received highlighting the Trust s health roster system was not used to its full potential. g. Workforce Planning: A paper was received at the May Committee meeting which brought together information on current workforce challenges and demographics with an update on the workforce plan submission for 16/17. Current risks for 16/17 are that the workforce plans developed by the Divisions do not deliver the workforce cost improvements that are required to meet their agreed targets. NHS Improvement were aware of the risks. 2

102 SWC CHAIR REPORT BoD 49/16 h. The Committee was made aware of the changes to the Government s apprenticeship policy and financial implications for the Trust. From April 2017, the Trust would be levied 0.5% of payroll ( 1.6m). The Government would add 2% to this levy. Funding could only be accessed through payment of training and assessment of apprenticeships. The Committee asked the executive to: Work to obtain more qualitative data in respect of leavers to avoid recording of other/unknown. Continue work linked to cultural change in terms of improved communications; improved staff support in the context of operational pressures and achieving standards. The Committee strongly supported the proper use of Health Rosters to support, recognising the significant benefits linked to better care and meeting standards. Continue to review and identify realistic workforce CIPs for delivery with links to the future clinical strategy. Continue to consider the impact of the changes to the Government s apprenticeship policy. The Committee will undertake ongoing monitoring. Progress was made against each of the objectives under review by the Strategic Workforce Committee, below is the high level achievement: a. Effective Workplace Culture (development and leadership) Fully achieved b. Culture Change programme Good achievement At the Board meeting in May 2016 it was agreed to downgrade the achievement in relation to 3a to reflect that, whilst there had been a good improvement, the main elements of the objective were implementation and process based. It was agreed that there was a great deal more to do by way of improvement in this area. The following annual objectives were discussed at the April Committee meeting, following approval at Board, in terms of the risks and will form a key part of the Committees work programme for 2016/17: a. Refresh and implement the recruitment and retention strategy to reduce the level of staff leaving by 2%, particularly in the first year of employment, by March b. Achieve a staff turnover rate of 10%, by March c. Roll out the Trust wide leadership and management development programme to another 200 staff, by September 2016 d. Continue with the implementation of the cultural change programme, incorporating divisional and corporate led plans into the programme, by June 2016 e. Continue to reduce agency and temporary staffing spend to 23m, as agreed with NHS Improvement, by March 2017 f. Improve the overall staff engagement score as measured by the staff survey, paying particular attention to those professional groups with lower levels of engagement, by March COUNCIL OF GOVERNORS ACTION: To note and discuss the report from the Strategic Workforce Committee. 3

103 INTERGRATED AUDIT AND GOVERNANCE COMMITTEE CHAIR REPORT BoD50/16 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS DATE: 10 JUNE 2016 REPORT FROM: PURPOSE: INTEGRATED AUDIT AND GOVERNANCE COMMITTEE CHAIR REPORT DISCUSSION PURPOSE OF THE COMMITTEE: The Integrated Audit and Governance Committee (IAGC) is the high level committee with overarching responsibility for risk. The role of the IAGC is to scrutinise and review the Trust s systems of governance, risk management, and internal control. It reports to the Board of Directors (herein shown as the Board) on its work in support of the Annual Report, Quality Report, Annual Governance Statement, specifically commenting on the fitness for purpose of the Board Assurance Framework, the completeness of risk management arrangements, and the robustness of the self-assessment against CQC regulations. This report is presented to the Council of Governors to assist them in their statutory duty holding non-executive directors to account for the performance of the Board. It is a standing agenda item in relation to risk, assurance and governance and reports on the April 2016 meeting. EXECUTIVE SUMMARY The report seeks to answer the following questions in relation to risk, governance and assurance: 1. What positive assurances were received? 2. What concerns in relation to assurance were identified? 3. Were any risks identified? 4. What other reports were discussed? 1. Positive assurance received in relation to: a. The Board Assurance Framework was presented for 2015/16 and it was felt that this was now providing the Board and its Committees with a clear view of the risks, mitigations and gaps against its Annual Objectives. Work was taking place to update it with the 2016/17 Annual Objectives; b. The Trust reported compliance with all the relevant requirements of the Information Governance Toolkit at level 2 (satisfactory) or above on 31 March The score was 75%; an increase of two percent on the previous year; c. Aseptic write-off: the newly appointed Director of Pharmacy provided assurance that recommendations from the Internal Audit report, external review by the Regional procurement specialists from the SE and SW of England and confirmed that improvement is being measured using the Carter metrics developed in the South West of England; d. Emergency Planning Audit: this was received by the Committee in the absence of a May Board of Directors meeting. The September 2015 audit showed that the Trust was non-compliant against the NHS England Page 1 of 2

104 INTERGRATED AUDIT AND GOVERNANCE COMMITTEE CHAIR REPORT BoD50/16 Emergency Preparedness Resilience and Response (EPRR) core standards. The revised audit showed good improvement and an achievement of significant compliance. 2. The following concerns were highlighted: a. Clinical Audit: there was concern in relation to the number of audits being carried forward by Divisions from 2015/16 to 2016/17. However, the Committee did receive positive assurance in relation to how the 2016/17 clinical audit programme would be delivered; b. Statutory Declaration to NHS Improvement, Compliance with Provider Licence, whilst the process for gathering the evidence to confirm compliance with the Provider Licence was robust the Trust remains in breach of its Licence. The evidence provided did give assurance that the Trust continued to improve its position. c. Internal Audit of Pharmaceutical Drug Processes: this audit was requested by Management following the identification of the aseptic write-off issues, it received an Amber/Red assurance. Point 1c above confirms that the Committee felt assured that the recommendations were being implemented. The Director of Pharmacy will be returning to the Committee later in the year to provide assurance that all the recommendations have been implemented and that these are delivering the required outcome. 3. Identified Risks: a. Information Governance mandatory training: 74% against a standard of 85%, however, 47% of those showing as non-compliant had undertaken the training but had accessed it in the wrong manner. 4. Other reports discussed: a. In year review of NHS Improvement Quarterly Return this showed that the Trust was predicting potential problems in performance accurately and advising NHSI in a timely way, in line with the Provider Licence requirements; b. Risk Register this risk register had improved significantly but additional work would make it more robust; c. Annual Report and Accounts, Quality Account and associated documents: these were reviewed and assurance received that they met the statutory requirements; d. Single Tender Waiver report: For the full year there has been a decrease in the quantity (an average decrease of 9.7%) but an increase in the value (0.66%) of STW s when compared to ; e. An update from KPMG on their audit work, in April 2016 there was little to report due to timing; f. Internal Audit reports on: i. Capital Procurement (Amber/Green) ii. Chief Executive and Chairman s expenses (Amber / Green) g. Local Counter Fraud reports, Anti-Fraud, Bribery and Corruption Policy was approved. BOARD ACTION: To note and discuss the report from the Integrated Audit and Governance Committee. Page 2 of 2

105 BoD REMUNERATION COMMITTEE CHAIR REPORT BoD 51/16 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS DATE: 10 JUNE 2016 REPORT FROM: PURPOSE: REMUNERATION COMMITTEE DISCUSSION PURPOSE OF THE COMMITTEE: The Remuneration Committee is a Committee of the Board and fulfils the role of the Remuneration Committee (for executive directors) described in the Trust s constitution and the NHS Foundation Trust Code of Governance. The purpose of the committee will be to decide on the appropriate remuneration, allowances and terms of and conditions of service for the chief executive and other executive directors including: (i) all aspects of salary (including performance related elements/ bonuses) (ii) provisions for other benefits, including pensions and cars (iii) arrangements for termination of employment and other contractual terms To recommend the level of remuneration for Executive Directors and monitor the level and structure of remuneration for very senior management. To agree and oversee, on behalf of the Board of Directors, performance management of the executive directors, including the chief executive. Any proposed changes to the terms of reference will be approved by the Board. EXECUTIVE SUMMARY The following summarises discussions held at the 17 May 2016 Committee meeting. The Committee agreed a proposal put forward by the Trust Chairman on how the Chief Executive s performance would be assessed by the Chairman and the Remuneration Committee. At the end of the year the Remunerations Committee will discuss the balance of performance across all objective areas leading to a final assessment which it will be able to articulate and justify publically. The Committee received performance objectives for each Executive Director and a report from the Chief Executive summarising his views on performance for discussion. The Committee agreed the process for determining performance objectives had been conducted in a balanced and fair way. A mid-year report will be received by the Remuneration Committee in November The conducted a review of executive director remuneration against benchmarking information available. The Chief Executive s performance and Executive Director objectives are based on the four main strategic priorities agreed by the Board: 1. Patients. Enable all our patients (and clients who are not ill) to take control of all aspects of their healthcare by There are 6 Annual Objectives in this category. Page 1 of 2

106 BoD REMUNERATION COMMITTEE CHAIR REPORT BoD 51/16 2. Partnerships. As a co-creator in the East Kent health economy, help define and deliver sustainable clinical services and associated pathways, providing clarity about who does what, by There are 6 Annual Objectives in this category. 3. People. Identify, recruit, educate and develop a talent pipeline of clinicians, healthcare professionals and broader teams of leaders, skilled at delivering integrated care and designing and implementing innovative solutions for performance improvement. There are 6 Annual Objectives in this category. 4. Provision. Clearly identify what business we are in, what we want to be known for and what our core services are. There are 9 Annual Objectives in this category. COUNCIL OF GOVERNORS ACTION: To note and discuss the report from the Remuneration Committee. Page 2 of 2

107 NOMINATIONS COMMITTEE CHAIR REPORT BoD 52/16 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS DATE: 10 JUNE 2016 REPORT FROM: PURPOSE: NOMINATIONS COMMITTEE DISCUSSION PURPOSE OF THE COMMITTEE: The Nominations Committee is a Committee of the Board and fulfils the role of the Nominations Committee for executive directors described in the Trust s constitution and the NHS Foundation Trust Code of Governance. The Trust chairman and other non-executive directors and chief executive (except in the case of the appointment of a chief executive) are responsible for deciding the appointment of executive directors. The appointment of a chief executive requires the approval of the Council of Governors. EXECUTIVE SUMMARY Internal Assessment, Action Plan and Board Development Plan A self-assessment review was undertaken by an independent HR consultant, and the report dated 30 December 2015 was shared with the Board of Directors and Monitor and the Council of Governors Nominations and Remuneration Committee. The resulting action plan was first considered in detail by the Nominations Committee in January In February 2016, the Board of Directors agreed the following areas of focus and the plan was updated: Strategic Marketing; Estates & Assets Management; Diversity, equality and strategy to support workforce planning. At its May meeting, the Committee received assurances that the Internal Board Assessment Action Plan had been updated to reflect: Personal Development Plans in place for Non Executive Directors; Grant Thornton s contract to undertake the Board Governance Review on the Well Led Framework. The Board Development Plan is continually reviewed and updated. The latest version received by the Committee incorporated development areas around: Board Readiness for CQC Re-inspection; Sustainability and Transformation Plan rollout; Estates and Asset Management; Statutory and Mandatory Training; and an appropriate level of media training/awareness. Board Governance Review Grant Thornton s External Governance Review was underway. All Interviews with the Board and Divisions were scheduled. On-site focus groups were being scheduled with Page 1 of 2

108 NOMINATIONS COMMITTEE CHAIR REPORT BoD 52/16 ward managers and other clinical staff. The final report would be shared with the Council of Governors. Succession Planning The HR Department had undertaken work to review all Executive Director positions and business critical posts to ensure that the organisation has staff with the right skills and potential, to move into key leadership roles. The Nominations Committee received the current position providing: Details of current post holders; collective Executive Team view on the talent pipeline and staff who can cover immediately; RAG rating on the level of risk to the organisation of not having the necessary skills in place to support business continuity and improving performance. Matthew Kershaw s approach to determining a Deputy CEO Position was discussed. The Council of Governors will be informed of the outcome of this process. Policy on Director s Fit and Proper Persons Test The amendment to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which took effect from 27 th November 2014 resulted in a new Directors Fit and Proper Persons test. This applies to all NHS organisations and includes Executive and Non-Executive Directors appointed to the Board. The Committee endorsed a policy which defined local principles. BOARD ACTION: To note and discuss the report from the Nominations Committee. Page 2 of 2

109 CHARITABLE FUNDS COMMITTEE CHAIR S SUMMARY BoD 53/16 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS MEETING DATE: 10 JUNE 2016 REPORT FROM: PURPOSE: CHARITABLE FUNDS COMMITTEE Approval PURPOSE OF THE COMMITTEE The purpose of the Committee is to maintain a detailed overview of the Charity s assets and resources in relation to the achievement of the agreed Charity Strategy, specifically:- Develop the strategy and objectives for the charity for consideration by the Board of Directors Oversee the implementation of an infrastructure appropriate to the efficient and effective running of the charity Oversee the development and delivery of the fundraising strategy Oversee the charity s expenditure Oversee the charity s investment plans Monitor the performance of all aspects of the charity s activities and ensure it adheres to the principles of good governance and all relevant legal requirements CHAIRMAN S SUMMARY OF MEETING 9 MAY Annual Accounts and Report 1.1 The report was discussed and key points regarding income and expenditure were highlighted. 1.2 The Committee were apprised of the changes required to presentation of accounts and notes due to the introduction of SORP FRS 102. No amendments were made to the previous year accounts. 1.3 The Committee discussed the requirement to consolidate the Charity accounts with the Trust accounts and the pressures this creates for both charity and Trust staff and audit. It was agreed to discuss this with auditors and the Trust for the Board to make a decision. 1.4 Auditors were on site from the 25 th April, but failed to complete the audit in time to provide their opinion for the Audit Committee (IAGC) held on the 19 th May. The draft accounts were sent to the IAGC with the approval of this Committee. 1.5 Overall the Committee agreed that the report was well presented and provided a good view to the public of the work and achievements of the Charity and agreed that this format should continue. It was noted that a short summary leaflet would be produced (unaudited) for distribution at the Trust AGM, the 1 of 3

110 CHARITABLE FUNDS COMMITTEE CHAIR S SUMMARY BoD 53/16 full report would be available on the website, but that no hard copies would be printed unless required by statutory mandate. 1.6 No areas of concern were identified and the Committee approved the Accounts and Report for presentation to the Board of Directors, which would be subject to any audit amendments. 2. Charity Strategy A revised Strategy format was presented to the Committee which provided a clear summary of objectives for the next three years. However it was agreed that progress should be reviewed annually to ensure this approach remained appropriate and achievable. 2.2 The format was well received by members and it was considered that this would enable the Charity to report on its achievement with more clarity in the future. 2.3 Key issues were to support the Trust with more funding, whilst ensuring that expenditures met Charity objectives especially given the Trusts financial pressures. 2.4 The Committee approved the Strategy for recommendation to the Board of Directors. 3 Staff Benefits and Awards 3.1 The Association of NHS Charities provided an alert to its members around further adverse publicity regarding staff benefits paid for from Charity Funds which was considered and debated by the Committee. 3.2 Funding for the 2016 Trust Awards was being sought and members were reminded that currently the Charity were paying for the Long Service Awards. Other staff benefits, such as the Christmas Ball were also discussed. 3.3 The Committee agreed to take this to the Trust for discussion as part of their commitment to the staff total rewards package. 3.4 After discussion with the Trust (outside of this meeting) the Committee members agreed to recommend to the Board of Directors a grant of 8k for the 2016 Trust Awards event. 4 Review of Policy on Fundraising on Trust Premises 4.1 The Trust Policy on Fundraising was presented for review and the Committee agreed that it covered the relevant guidance to staff to promote the East Kent Hospitals Charity whilst not being so restrictive as to alienate either staff or the Leagues of Friends. 4.2 The Policy would be taken to the Policy Compliance Group for approval. 2 of 3

111 CHARITABLE FUNDS COMMITTEE CHAIR S SUMMARY BoD 53/16 5 Prioritisation of Applications 5.1 The Committee had previously expressed concern over identifying best use of funds and how to ensure that the grants approved were in line with the Charity objectives. Using the Medical Devices Risk Assessment as a basis, the Charitable Funds Manager presented a Matrix to assist in rating applications. 5.2 Members agreed that this provided a good framework which would assist the Committee in making grant allocations. As a first draft this was approved but all members agreed that this should be a work in progress and refined and developed in the future. 5.3 The Matrix would be circulated to the Divisional Procurement Groups for dissemination to Fund Managers. 5.3 The Committee approved the adoption of the Prioritisation Matrix recommendation to the Board of Directors. 6 Application for Funding Maternity Bereavement Suite WHH 6.1 An application was presented to the Committee for the building of a suite on the Maternity Ward at the William Harvey for mothers who lose their babies at birth or immediately afterwards. The suite would provide privacy and a quiet area away from the main maternity wards so that they can spend time with their baby. 6.2 This suite was on a smaller scale, due to space, as the project at QEQM and both sites had the full support of staff and donations and fundraising had already been very successful. 6.3 The Committee fully supported the application and a grant of 61k was awarded. 7 Fundraising Update 7.1 The Committee were updated with ongoing events and activities. 7.2 Applications for the post of Community Fundraiser had been received and six candidates were selected for interview. A candidate had been appointed and subject to references would take up the post in early July. BOARD OF DIRECTORS ACTIONS REQUIRED: I. Approve the Charity Annual Accounts and Report. II. Sign the Letter of Representation to KPMG for the Charity. III. Approve the Charity Strategy for IV. Ratify the Grant of 8k for the 2016 Trust Awards V. Note the Report 3 of 3

112 Registered Charity Number Annual Report & Accounts 2015/16 Helping your local Hospitals

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114 Contents Registered Charity Number Chair of Charitable Funds Committee Foreword... Fundraising Introduction... The Role of the Charity... Fundraising Champions... Dementia Appeal... Making life better for patients in East Kent... Looking Forward - Our Plans for the Future... Financial Summary... Structure, Governance & Management... Objectives... Our funds... Statement of trustees responsibility... Independent Auditors Report... Statement of Financial Activities... Balance Sheet... Notes to the accounts

115 Chair of Charitable Funds Committee Foreword Gill Gibb Chair, Charitable Funds Committee More than ever, East Kent Hospitals Charity is grateful to all those people and organisations who are inspired to support the work of the East Kent Hospitals University NHS Foundation Trust, and whose efforts enable us to continually improve the quality of services we are able to provide for our patients and service users. As the new Chair of the Charitable Funds Committee I would like to offer a huge, heartfelt thank you to all those people who have contributed to our charitable work this year. From running a marathon, cycling long distances and baking delicious cakes, from singing to shaking a charity pot. This report highlights just a small number of the positive stories about the time and energy given by many to our charity. The results of our charitable efforts make very major contributions to the work of the Trust. We are particularly proud to be one of the first NHS Charities to be running a Major Appeal supporting Dementia Services. As more and more people are living with Dementia we would like your support so we can work together to make a positive difference to ensure the best possible facilities are provided to all those who use and visit our hospitals. Our very grateful thanks go to our partners, our supporters, our Friends organisations, our patients, our volunteers and our staff who all, in individual and unique ways support East Kent Hospitals Charity. Thank you. Gill Gibb Chair of the Charitable Funds Committee 4 East Kent Hospitals Charity Annual Report

116 Fundraising Introduction Welcome to our latest Annual Report which showcases the wonderful things that East Kent Hospitals Charity has been up to over the past year. In this report you will read about just a few of the stories we have covered this year, including the latest developments on our trust wide Dementia Appeal and new projects such as our initiative to introduce two maternity bereavement suites at the William Harvey, Ashford and QEQM, Margate. Rupert Williamson Head of Fundraising We would like to take this opportunity to thank everyone who has contributed to the charity over the past year, whether it is by holding a cake sale or jumping out of a plane every little helps! There are so many fantastic causes you can get behind within our hospitals and we are truly humbled to be working so closely with them on a day to day basis. We do hope you continue to support East Kent Hospitals Charity going forward and get involved with our appeals and events! Finally, Luke Underdown, Community Fundraising Manager, left the charity in March 2016 to take on a brand new venture. Luke Underdown Community Fundraising Manager Thank you for your support! Luke Underdown Rupert Williamson 5 East Kent Hospitals Charity Annual Report

117 The Role of the Charity The core mission of the Charity is to enhance the care and treatment of patients and visitors accessing NHS services provided by East Kent Hospitals University NHS Foundation Trust, by raising funds to support the purchase of equipment and facilities which are beyond the scope of government funding. We achieve this by involving NHS Clinicians and staff to identify and deliver projects that make a vital difference to patients by: Enhancing the quality of patient care Improving the environment for patients and visitors Supporting NHS staff development to enable them to provide excellent clinical and patient centered care Providing financial support for pioneering research that has the potential to impact on the treatment and well-being of patients The Trustees confirm that they have referred to the guidance provided by the Charity Commission with regard to the need for public benefit. They are confident that the activities which contribute to the above mission have a clear public benefit. The Trust provides clinical services within the scope of their NHS requirements and the Charity works hard to enhance these services to benefit the patients and visitors (and therefore the public). The Trustees are aware when making grants, of the distinction between the requirements of the NHS to provide their services and those grants made by the Charity to extend the scope of the service, either through new equipment, advanced technology and improving patient experience through the environment and/or additional activities and facilities which are not the responsibility of the NHS. We achieve our mission by involving NHS clinicians and staff to deliver projects that make a vital difference to patients Simon Rosenburg Resuscitation Officer, William Harvey Hospital 6 East Kent Hospitals Charity Annual Report

118 Fundraising Champions Support given by the local communities and individuals is very much appreciated by the wards and departments as well as the Trustees. This report can only cover a few of the heartwarming stories which have inspired people to give up their precious time to help raise funds. To all, we say thank you. Miranda Vernon goes Greek for SCBU at QEQM Cycling fanatics Alan & Tony ride 600 miles with team from the University of Kent to raise 1,644 Miranda Vernon wanted to give something back to the unit following the wonderful support she had when her daughter Mia was born prematurely at the beginning of Miranda decided to hold a Greek night in Broadstairs complete with music and delicious food, raising a total of 750 for the Unit! Fundraising fisherman Jim Walder reels in biggest total yet! Carp fisherman Jim Walder has raised an incredible 1,727 from his annual carp fish event held at Cackle Hill lakes in Biddenden. This is the third year Jim has run this event and has already started planning for 2016! This brings the grand total raised by Jim to 4,348! Alan Hollister and Tony Blofield wanted a challenge for the University of Kent s 50th anniversary, so decided to visit each of their universities campuses across Europe - by bike! The group started the 600 mile challenge in Tonbridge and ended in Canterbury after going via Fruges, Senlis, Paris, Brussels and Steenvoorde! The money raised will go to the Cathedral Day Unit at Kent and Canterbury Super fundraiser Jamie Spencer smashes target for Brabourne Ward at K&C Jamie approached the charity at the end of He wanted to give something back following the excellent care his brother-in-law has received on Brabourne Ward. Not wanting to do things by halves, he decided to set himself a series of challenges which included climbing Ben Nevis and organising a charity black tie ball. Thanks to his enthusiasm and fundraising resiliance, he manged to raise a fantastic 7,742! However, his fundraising hasn t stopped there, as he has now signed up to run in the Brighton Marathon 2016 for the ward! 7 East Kent Hospitals Charity Annual Report

119 Fundraising Champions Special mums Kayleigh and Jenna raise 3,712 for the Honey Bears nursery at Kent & Canterbury Hospital Kayleigh and Jenna wanted Fundraisers join forces to introduce stillbirth bereavement suites at the William Harvey and QEQM The Twinkling Stars (William Harvey) and Precious Memories (QEQM) have joined together to help raise almost 150,000 to introduce stillbirth bereavement suites at both hospitals. The campaign has raised just over 60,000 so far! to raise money for the Honey Bears nursery to give something back for the fanastic care their children have received. Their event at Faversham Cricket Club raised an amazing 3,712 and included a live band, an auction and a raffle. Isle of Thanet Gazette raise over 5,000 for Rainbow Ward to buy 5 chairbeds Another great outing for the Great Kent Bike Ride 2015 For the third year in a row, the charity has put on the Great Kent Bike Ride, with the 2015 event being the most successful one yet! Over 800 riders took part in a fun day out riding across the county taking on a 35, 60 or 100 mile route! Participants started at North Park in Ashford, before heading out to enjoy the views as they passed through Tenterden toward New Romney. The more challenging 100 mile route took a big loop through Lyminge and Canterbury. Overall the event raised an incredible 9,928 - our best total yet! The Gazette have successfully run a campaign which has enabled Rainbow Ward at QEQM to purchase 5 chair-beds, which go next to the patient beds, enabling carers and loved ones to stay over night with their children. Thanks to this campaign every patient bed now has a chair bed beside it. 8 East Kent Hospitals Charity Annual Report

120 Staff at the William Harvey raise 900 by holding two bric-a-brac sales Hilary Collins and Kelly-Anne Pullen from Folkestone Outpatients Department take on a 20 mile bike ride and raised 262! Staff from SCBU at the QEQM raise 850 by holding a cake sale! This year, East Kent Hospitals Charity launched the Dementia Appeal and have already had an overwhelming response raising almost 83,000 to date! Throughout 2015/16 support has come from many sources, including the wonderful staff in the Trust! At the end of 2015 the appeal launched the Challenge 500 campaign to encourage wards and departments to raise 500 for the Dementia Appeal. Thanks to staff coming up with some weird and wonderful ideas to raise money, across the Trust we managed to raise almost 8,000! An incredible achievement! Furthermore, we have seen a great deal of support come from the community with local businesses and organisations wanting to do their part to help the Appeal and have even been featured on the local BBC South East news and BBC Radio Kent. The Appeal has been launched to raise 500,000 to enhance our hospitals for people who are living with dementia. Plans include the refurbishment of day rooms, garden renovations and improvements to ward environments across the Trust. Do you fancy coming to one of our events or perhaps even volunteering? Want to organise your own fundraiser? Maybe you want to learn a bit more about dementia? We d love to hear from you! Simply get in touch by ing ekh.tr-fundraising@nhs.net or visit our website for more information. Alternatively, give us a call on (01227) East Kent Hospitals Charity Annual Report

121 The Great Kent Bike Ride 2015 was a wonderful day out in the Kent Countryside raising money for fantastic cause. It was great to combine raising money with my favourite hobby!

122 Making life better for patients in East Kent Our funds have helped patients in many different ways. This year East Kent Hospitals Charity awarded grants totalling 597,610 to improve the care and treatment of patients using East Kent s hospitals. Some of the key areas the Charity has supported are included below with examples of how the funds were used in achieving our aims and mission. Smiles for children visiting A&E Over the last year, East Kent Hospitals Charity has been able to continue to buy items such as stickers, bubbles and crayons to distract children whilst in A&E. Thanks to these purchases, we are able to make their time with us a little more enjoyable. Special Care Baby Unit at the William Harvey received GlideScope Video Laryngoscope - 7,525 Intubation of babies can be very difficult at times especially for babies who were born extremely premature or who have compromised airways. This equipment will enable clinicians to have a clear view of the airway and vocal cords and therefore assist them in the successful intubation of babies where existing methods were unsuccessful or required several attempts. GAU scanner purchased for Kennington Ward at the William Harvey - 48,000 Pacing bed for the Coronory Care Unit at QEQM - 22,105 This new bed will ensure patients that come in with a life threatening Bradycardia can be treated immediately by having a temporary wire fitted. This equipment will facilitate the opening of a new Gynaeocological assessment unit to provide a dedicated One Stop Clinic in an area that provides patient privacy for scans and assessments by dedicated Gynae staff away from the main A&E unit. This bed will enable the radiological equipment to be used with it and the patient is comfortable whilst the procedure is being performed as it has an adjustable backrest. 11 East Kent Hospitals Charity Annual Report

123 Making life better for patients in East Kent Mavi LED Phototherapy System x 6 for NeoNatal Unit William Harvey - 12,315 Neonatal jaundice occurs in 60% of term infants and 80% of preterm babies born in the UK. Early diagnosis and treatment is crucial to prevent long-term neurological harm. Jaundice is treated easily by exposing the baby to an LED or CFL light source (phototherapy) which changes the bilirubin molecules in the body to water soluble isomers which can then be excreted by the body. The new models have improved LED durability and provide higher light output which should reduce treatment time and hospital stay. Phototherapy Cabinets for Dermatology at Kent & Canterbury - 48,915 The two cabinets can be used by patients who cannot stand for long periods or support themselves and allows staff to adjust joules to deliver different amounts of treatment to specific areas of the body. This means that patients are treated more effectively as the whole treatment can be addressed with a single, rather than multiple, session in a shorter timespan than previously with a more efficient cooling system making the whole experience better for the patients. SMOTS Camera Sytem installed at the QEQM - 21,478 SMOTS is an audio visual camera system used with Simulation Based Learning (SBL). SBL can be used for any medical specialty where Doctors, nurses and other healthcare professionals observe colleagues interacting with each other and a simulated patient (mannequin). A variety of clinical scenarios (routine and rare life-threatening events) can be simulated in a training environment replicating a real clinical environment (eg ward, A&E, operating theatre). A group of candidates observe the scenario in a viewing room via real time images broadcast by the SMOTS system. The high definition camera records the scenario for video playback in a debrief session with a trained facilitator which leads to better quality of care, patient experience and patient safety. Outreach Clinic for ITU Patients - 5,000 Patients who have been treated in ITU can often have difficulty on discharge understanding what has happened to them and can be left feeling disorientated and anxious when discharged. The Outreach Clinic aims to support patients from across the Trust after discharge by explaining their conditions and what treatment they received during their stay in ITU. 12 East Kent Hospitals Charity Annual Report

124 Making life better for patients in East Kent Wall Mural for Paediatric Unit at Buckland Hospital - 4,500 This mural will provide a very child friendly environment for the children. The idea is to have a sea side theme. The plan is also to carry on this theme into the clinic rooms and along the corridor. Without this mural children would be coming into a very clinical environment with no distractions or child friendly surroundings. This will increase anxiety and may make treatment and rehabilitation more difficult and prolonged. Techotherm cooling system for Special Care Baby Unit at QEQM - 14,014 This system provides total body cooling for babies suffering from Hypoxic Ischaemic Encephalopathy after birth asphyxia. The system utilises an innovative servo controlled design with instant feedback, monitoring the infant s temperature every 2 seconds and making minute changes to the cooling fluid to ensure that the infants temperature remains stable. Use of this system reduces complications caused by brain damage and long term morbidity. MRI compatible Ventilator for William Harvey ITU - 28,900 Communication Skills Training Course for Cancer & Palliative Care Link Nurses - 1,350 This is a nationally recognised programme with the aim of improving communication with distressed patients and relatives. A Hospice approach to care is an important area for improvement in patient care in the Trust and these link nurses will be advocates to take this forward. Critically ill patients requiring ventilation who needed urgent MRI scans for diagnostic and prognostic purposes, had to wait for an anaesthetic machine from Theatres or be transferred to the Kent & Canterbury hospital until the purchase of this ventilator enabled patients to be scanned inside the scanning room in the ITU unit. This has vastly improved the treatment given to the patients and reduced the time and staffing levels previously required to undertake scans for ventilated patients. Better communication in end of life care is one of the 5 key priorities of care adopted nationally and by the Trust. 13 East Kent Hospitals Charity Annual Report

125 Looking forward - our plans for the future... The Trustees are aware of the financial pressures on the Trust and although encouraged by what the Charity has achieved in this year, the future plans are to provide a greater level of support to the Trust by increasing grants over the next three years. With a stronger and more focused Strategy the Charity aims to increase not only the total value of the grants given, but to ensure that the money is well spent and that the impact on the public identified in the application has been achieved. The revised Strategy will enable the Trustees to monitor more closely the achievements and performance of the Charity and the introduction of a prioritisation matrix for significant projects will assist in providing a basis for allocation of future grants to maximise impact. Key elements of the strategy are to maximise:- charitable income, charitable impact to EKHUFT and ensure good governance and best practice in all charitable activities To achieve these aims it is proposed to: seek to increase the level of income year on year through targeted fundraising, raising the profile of the Charity and optimising returns on investments work to maximise patient benefit by improving the grant making policy and increase the level of support to the Trust over the next three years. work to ensure that the Charity maintains the highest standards of governance and management whilst adhering to legislation and published best practice and is able to demonstrate value for money from the resources invested. In order to understand the success of the projects supported, a selection of applicants will be requested to report on the impact the grant has made providing analysis and documented evidence of the difference it made to the medical care, treatment and/or the comfort and experience to the patient. Significant projects identified for support in the coming year are:- Maternity Bereavement Unit at the William Harvey Hospital Maternity Bereavement Unit at the Queen Elizabeth The Queen Mother Hospital Dementia Appeal Garden at William Harvey Hospital Dementia Appeal Refurbishment of Harvey Ward patient room at Canterbury OPG machine Buckland Hospital in Dover Maternity services across the Trust additional Fetal monitors The Charity can only achieve these plans with your support. Please go to our website for more information about our work and to donate. www. ekhcharity.org.uk 14 East Kent Hospitals Charity Annual Report

126 Our Challenge 500 campaign as part of the Dementia Appeal has raised almost 8,000 across the trust through staff fundraising, enabling us to buy memory boxes for 28 wards and departments in Ashford, Canterbury & Margate! 15 East Kent Hospitals Charity Annual Report

127 Financial Summary Financial Review Summary The figures stated here provide an overview and are drawn from the full Annual Accounts at the back of this report. The Charity held net assets of 4.3m as at 31st March 2016 ( 4.7m in 2015) Income from all sources: 569k Voluntary contributions: 440k Expenditure totalled : 808k Grants to the Trust: 598k (Including Governace Costs 676k) Expenditure exceeded income by 252k The net assets of the Charity were reduced by 365k from the balance held at the end of the previous financial year. Where our income came from The Charity s main source of income comes from the generosity and efforts of the public who give voluntary donations as a thank you for the care they or their friends and family have received, through fundraising, in memory of loved ones and in bequests and legacies from their estates. Without this support the work of the Charity to provide additional facilities, support to patients, relatives and staff and enhance the services provided by the Trust would not be possible. Voluntary income detailed:- General donations 81k Give As You Earn (GAYE) 1k In Memory Of 29k Online Giving 22k Fundraising (public) 142k Gift Aid Claimed 2k Legacies 163k General donations were up by 59k from 218k last year to 277k this year indicating that support from the local community remains positive. Legacies were 367k lower than in 2015/16 showing an overall decrease in voluntary income of 308k. Income from investments and other sources totalled 111k which is 18k less than in the previous year. This is mainly due to the sale of the properties providing no further income from rent. Dividends continue to meet the target despite the market uncertainty. Increased cash holdings due to the sale of the properties have enabled the Trustees to invest in Short Term Deposits to maximise return. The plan is to increase the number of cash deposits to reduce risk and costs until funds are required to meet grant commitments. 16 East Kent Hospitals Charity Annual Report

128 Where we spent our funds The Charity spends the funds received in accordance with charity law, its grant making policy and respecting the wishes of the donors. Grants to the Trust made up 73% of the total expenditure and have increased from 512k in 2014/15 to 598k excluding support costs for 2015/16. Grants are approved to achieve a benefit to the public (the patients and visitors who use the services and facilities), which would not otherwise be possible within the constraints of the Trusts capital budgets. Trustees consider each application on merit and aim to support technogical advances in treatments by purchasing new and replacement medical equipment. Projects also include new furniture, refurbishment of patient rooms and gardens. The Charity provides specific suites and quiet rooms for both patients and their families for sensitive consultations and are away from busy wards. A summary of the grants given are listed below:- Medical equipment 462k Building and refurbishment 41k Patient education and welfare 29k Staff education & welfare 18k Research 48k New accounting rules for 2015/16 (FRS102) require the governance and administrative costs to be included in the value of the grant (charity activity) and therefore the accounts report the value of the grant plus apportional costs of 77k, showing grants to the Trust of 676k (see note 3). The Trustees review the costs on an annual basis to ensure that they reflect the requirements to administer the Charity in compliance with current legislation and effective day to day management of the funds. The Charity is a member of the Association of NHS Charities and uses their data to benchmark administration and fundraising costs. This comparision looks at NHS Charities of a similar size and geographical spread. Currently our expenditure is higher than that of other similar member Charities and the Trustees are reviewing the investment to try to improve the ratio. 17 East Kent Hospitals Charity Annual Report

129 Structure, Governance & Management The East Kent Hospitals Charity is a registered charity (number )*. The charity exists to raise and receive charity donations and covers the funds given to wards, departments and services provided by the East Kent Hospitals University NHS Foundation Trust. The following hospitals are the primary sites although outreach and other units and clinics are supported: William Harvey Hospital (WHH), Ashford Queen Elizabeth The Queen Mother Hospital (QEQM), Margate Kent & Canterbury Hospital (K&C), Canterbury Buckland Hospital (BHD), Dover Royal Victoria Hospital (RVH), Folkestone The objects of the Charity as stated in the governing document are:- The Trustees shall hold the trust fund upon trust to apply the income, and at their discretion, so far as may be permissible, the capital, for any charitable purpose relating to the National Health Service. At the balance sheet date, 31st March 2016, there were a total of 44 individual funds established under this Umbrella registration. Of those funds 20 are restricted, or special purpose funds and some of these are registered under the Umbrella as subsidiary charities governed by separate objects within the Charities Commission guidelines for fund expenditure. See page 26 The Charity has one small Endowment fund, which allows only the net income to be spent, whilst the capital remains invested. The remaining 23 funds are Unrestricted or Designated Funds created for donations received for use by hospitals, wards and departments to reflect donors wishes. These do not form a binding trust. The major funds within these categories are disclosed in Note 8 in the accounts. The total value of funds held at 31st March 2016 was 4.3m. The Umbrella registration allows for a single set of consolidated accounts for all the subsidiary charities and funds held under the umbrella. However, separate accounts for each fund are maintained to enable identification of transactions and balances. (*The charity was established in April 1999 by Declaration of Trust Deed as East Kent Hospitals NHS Trust Charitable Fund and amended by Trustee resolutions and supplemental deeds to incorporate name and structure changes.) The contact address is: East Kent Hospitals Charity 2nd Floor Trust Offices East Kent Hospitals University NHS Foundation Trust Kent and Canterbury Hospital Ethelbert Road Canterbury Kent. CT1 3NG. Telephone: East Kent Hospitals Charity Annual Report

130 The Trustees East Kent Hospitals University NHS Foundation Trust (the Trust) is the Corporate Trustee, empowered by the NHS Act The Board of Directors effectively adopts the role of Trustee as defined by the Charity Commission. Individual members of the Board are not trustees under Charity Law, but act as agents on behalf of the Corporate Trustee. The Council of Governors is responsible for the appointment of the Chairman and Non Executive Directors (NEDs) and approving the appointment of the Chief Executive. The council of Governors are elected and appointed to post. For further details visit None of the Trustees have received reimbursements or remuneration from the Charity for either their work or expenses incurred in this financial year whilst undertaking their responsibilities for the Charity. (2014/15 None) The following Trust Directors and Non-Executive Directors were/are members of the Charitable Funds Committee during the reported period and are considered to be the key management personnel for the charity : Matthew Kershaw Chief Executive Jan 16 - Present Chris Bown Interim Chief Executive April 16 - Jan 16 Dr Paul Stevens Medical Director June 13 - Present Nick Gerrard Director of Finance May 15 - Present Liz Shutler Director of Strategic Development Jan 04 - Present Meetings Attended: None Non- Executive Directors Meetings Attended: None Meetings Attended: Meetings Attended: Meetings Attended: Gill Gibb Chair of CFC Dec 15 - Present Valerie Owen Chair of CFC May 13 - Nov 15 Chris Corrigan Non-Executive Director Nov 11 - Dec 15 Satish Mathur Non-Executive Director Oct 15 - Present Barry Wilding Non-Executive Director Dec 15 - Present Meetings Attended: Meetings Attended: Meetings Attended: Meetings Attended: Appointed to CFC Dec East Kent Hospitals Charity Annual Report

131 Structure Administrative Structure Charitable Funds Committee Acting for the Corporate Trustee, the Charitable Funds Committee (CFC) was established as a separate committee in August 2008 to provide a dedicated team to manage the affairs of the Charity independently from the business of the Trust, whilst still linking closely with its strategy and planning. It is responsible for the management of the Charitable Fund under the Terms of Reference which are reviewed annually and updated where required to meet the changing needs of the Charity. The CFC meets routinely quarterly and additional meetings are held if required. All new members of the CFC attend an induction course for Charity Trustees within 6 months of appointment unless they have proven knowledge and experience as a Trustee. Delegated signatories are provided with guidelines and information regarding the Charity to ensure they understand their responsibilities The CFC review the Charity s affairs as outlined below: Performance and management of investments Financial matters relating to cash management Charity Policies and agreements with Trust Management of properties Review grant allocations to achieve objectives Approval of Grants over 25k as per the Scheme of Delegation Recommendation of grants over 100k to the Board of Directors Approve Strategy Agree administration, fundraising and audit budget The recommendations of the CFC are taken to the next available Board of Directors meeting for ratification. Members are required to disclose all relevant interests at the start of meetings and withdraw from decisions when a conflict of interest arises. 20 East Kent Hospitals Charity Annual Report

132 The Charity has 3.4 whole time equivalent (wte) staff employed by the Trust under Agenda for Change terms and condtions and recharged to the Charity as a pre set budget agreed annually and draws on professional services and advisors as required. Two wte staff are responsible for the daily administration of the funds including applications, all financial transactions and procedures, policies and financial reporting to the Fund Signatories (under a Scheme of Delegation) and the CFC including the production of the Annual Accounts and Report. They report to the Director of Finance via Assistance Director of Finance (Accounting) and the CFC. The remaining 1.4 wte are employed as Fundraisers to the Charity, responsible for the management of all aspects of fundraising for the Charity including supporting internal and external fundraisers, overseeing and arranging fundraising events, volunteers and the marketing and promotion of the Charity in all forms. They report to the Director of Strategic Development via Assistant Director of Strategic Development (Marketing) and the CFC. Advisors Investment Managers Shroder & Co Ltd T/as Cazenove Capital 12 Moorgate London EC2R 6DA Bankers Lloyds Banking Group 2 City Place Beehive Ring Road Gatwick RH6 0PA Agents and Valuations Cooke and Co Lettings Agents 147 Northdown Road Cliftonville CT9 2QY Auditor KPMG Limited Liability Partnership 15 Canada Square London Legal Advisors Clyde & Co St Boltolph Building 138 Houndsditch London EC3A 7AR Hempsons 40 Villiers Street London WC2N 6NJ Association of NHS Charities East Kent Hospitals Charity is an active member of the Association of NHS Charities. The Association seeks to support, and to be the voice of all NHS Charities in England and Wales. The principal aim of the Association is to promote the effective working of NHS Charities. Being a member offers our Charity a wide range of support, networking and information services as well as adopting best practice across the sector. To find out more please visit: 21 East Kent Hospitals Charity Annual Report

133 Objectives Grant making policy The Charity makes grants from its unrestricted and restricted funds. A Scheme of Delegation is maintained for the authorisation of grants and signatories are approved by the appropriate Finance Lead. Divisional Directors, senior medical staff and department managers are appointed as fund managers. The staff are made aware of the Trust s Standing Financial Instructions and Orders which are also applicable to the Charitable Funds. All signatories receive a monthly financial statement of all the charity s funds. Grants are made for specific purposes and projects under an application process. The applications are reviewed by the Charitable Funds Committee (CFC) to ensure that they meet the objectives of the Charity. The CFC score the applications for quality, value for money and patient benefit. Where any expenditure is considered inappropriate feedback is given to the the fund manager and applicant. No fund is permitted to operate in an overdrawn position and although an application may be approved this may be subject to the ward or department securing the fundraising to support all or part of the project. Risk statement During the year the Trustees continued to review the major risks to the Charity. The Charity uses the Trust procedures and processes. These systems undergo annual audit and risk reviews and action plans to mitigate the risks. The significant areas of risk have been identified as:- Fall in investment capital and returns Reduction in income levels Reconfiguration of NHS services The Trustees have mitigated these risks by:- Retaining expert investment managers Maintaining a diversified low risk portfolio Ensuring capital investments form no greater than 75% of the total assets of the Charity Review performance against benchmarks Utilise cash holdings in Short Term Deposits to maximise returns and diversify investment opportunities Reviewing the investment in Fundraising and analysing major and specific appeals and projects to identify effectiveness of approach and performance Working with the Trust to understand the changes in strategic approach to delivery of services. In the Trustees opinion all appropriate action has been taken to ensure the risks are mitigated. Investment Powers The investment powers are stated in the Declaration of Trust which provides for the following: to invest the trust fund and any part thereof in the purchase of or at interest upon the security of such stocks, funds, securities or other investments of whatsoever nature and where so ever situate as the trustees in their discretion think fit but so that the trustees: a) shall exercise such power with the care that a prudent person of business would in making investments for a person for whom he felt morally obliged to provide; b) shall not make any speculative or hazardous investment (and, for the avoidance of doubt, this power to invest does not extend to the laying outof money on the acquisition of futures and traded options); c) shall not have power under this clause to engage in trading ventures; and d) shall have regard to the need for diversification of investments in the circumstances of the Charity and to the suitability of proposed investments. 22 East Kent Hospitals Charity Annual Report

134 Investment Objective The investment objective is to seek to maximise the total return from the fund consistent with a relatively low degree of risk. The target is to achieve a 4% return annually providing an income of between k. Trustees have directed the investment managers to take an ethical approach to the portfolio and that no investments should be made in the shares of tobaccoproducing companies and will also avoid investment in companies that have more than 10% of their turnover in: Alcohol Manufacture Armaments Gambling Pornography The ethical restrictions are not considered to be so restrictive as to be likely to impact on long term performance. Investment Performance The Investment Managers were granted discretionary management powers under contract in January The total value of the investment portfolio at 31 March 2016 was 2.861K (excluding cash of 59k). The return did not reach target (4%) and underperformed from the cumulative benchmark. The return for the year was -0.4% against the benchmark of 1.2%. Income achieved dividends of 98k (gross). The CFC monitored and reviewed the performance of the Investment Managers on a quarterly basis to ensure the targets and management criteria was met. The investment managers are required to meet with the Trustees at least once in any one financial year, to explain any deviation from the anticipated rate of return in order that investment opportunities can be maximised. Investment managers are asked to explain exceptional losses and proposed recovery plans. Gross income from investments has increased from that achieved in the previous year by 9% and has remained within the objectives set by the Trustees. There is an annual review of the investment policy to ensure that returns are maximised at medium to low risk. Unless the donor has expressed a specific request regarding investment, the investment of funds is in accordance with the Trustees Investment Act East Kent Hospitals Charity Annual Report

135 Reserves Policy The Trustees recognise their obligation to ensure that income received by the Charity should be spent effectively and promptly in accordance with the funds objects. It is however considered prudent that a minimum reserve of 300k should be held to cover contingencies, particularly stock market fluctuations. This sum has been identified as being equal to one year s operational costs and estimated outstanding commitments. Charity Reserves as defined under SORP 2005 (1.48) are those funds which become available to the charity to be spent at the Trustees discretion in furtherance of the charity s objectives, excluding funds which are spent or committed or could only be realised through the disposal of fixed assets. These are therefore classified as free. Trust and can be transferrerd to general purpose funds at the discretion of the Trustees. Unrestricted Funds Funds which are expendable at the discretion of the Trustees, or designated in consideration of donors wishes. The Trustees have reviewed and revised their Reserves Policy and have determined that it is necessary to retain reserves over the longer term to: Reduce the impact of risks from the external environment should the levels of income reduce significantly Continue their programme of support to the Trust. Hold sufficient reserves to ensure the charity can cover its ongoing operational costs to process outstanding commitments. Meet the cost of closure or transfer of the charity s affairs s should the need ever arise At the 31st March 2016 the reserves were identified as below:- Total Unrestricted funds 596k Less property funds ( 48k) Less designated funds ( 310k) Freely available reserves 238k The level of reserves held at 31 March 2016 is slighly below the minimum requirements set in the policy by 62k. The majoirity of donations recieved are for specific wards and services and are held as designated to the Division or individual ward in recognition of the donors wishes. The Umbella General Purpose fund will no longer be invested in the portfolio, but will be retained as a cash only fund to provide the agreed minimum cash reserve. Definition of Funds Restricted Funds Funds which are subject to specific trusts e.g. terms of will Endowment Funds Funds which are to be held as capital and only the income generated can be expended. Designated Funds Funds held for specific wards or services or a particualar hospital in consideration of donors wishes. They do not form any binding 24 East Kent Hospitals Charity Annual Report

136 Our Funds Objects The East Kent Hospitals Charity is registered with the Charity Commission (England and Wales) as an umbrella charity under registration number Under the terms of the governing document, the Trustees can use the unrestricted funds to hold the trust fund upon trust to apply the income, and at their discretion, so far as may be permissible, the capital, for any charitable purpose relating to the NHS. The restricted funds have individual specified purposes that govern their use, in conjunction with the objects of the umbrella Charity. Some of these are registered with the Charity Commission as subsidiary charities of the Umbrella Charity. See Note 8.3 page 39. Fund Structure Where a donation is received under a legally binding trust, for example under the terms of a will, the funds are classified as restricted. Where the restriction is removed, either by the spending of original funds, or where no binding agreement is held, funds are re-classifi ed as unrestricted and placed into general purpose funds or a fund that achieves the donor s wishes. The Trustees periodically review balances held in designated funds to determine whether these funds are likely to be committed in the near future and the extent to which there is a continuing need identifi ed for any particular fund(s). In the event that the need no longer exists, those funds will be redirected to the appropriate Service (Divisional) General Fund. Further rationalisation is undertaken for individual funds that are not considered financially viable, or have the same objective as another fund. These funds will also be redirected to General Purposes or amalgamated with a similar fund. The dissolution of special purpose funds is managed under Clause I in the governing documents, without the need for referral to the Charity Commission. A continuing programme of rationalisation of funds is maintained to support the objectives of the Charity. Where funds have been received without forming a binding Trust they are designated to the appropriate Divisional Fund which is responsible for delivering the service and are classified as unrestricted. 25 East Kent Hospitals Charity Annual Report

137 Divisional Funds The following funds are held as general purpose funds for the wards and services managed under the clinical division and are classified as unrestricted. Urgent Care and Long Term Conditions incorporates the following specialties:- Respiratory, Diabetes, Rheumatology, General Medicine, A&E, Neurological Services, Cardiology, Gastroenterology Stroke, Health Care of Older People Surgical Services Anaesthetics, Critical Care, Pain Services General Surgery, Urology, Head and Neck, Trauma and Orthopaedics Specialist Services :- Cancer and Oncology, Haemophilia, Clinical Haematology, Renal, Dermatology, Womens Services and Childrens Services Clinical Support Services - Laboratory Medicine, Pharmacy, Radiology, Therapies, Outpatients Registered Restricted Funds The Charity holds funds for general purposes to benefit the specific NHS hospitals received through legacies and other binding agreements. Buckland Hospital Registration /5 Queen Elizabeth The Queen Mother Hospital Registration /6 Royal Victoria Hospital Registration /2 William Harvey Hospital Registration /4 Kent & Canterbury Hospital - Registration /7 Other Restricted funds are held for specific purposes and/or wards and departments with the NHS Trust:- Special Care Baby Unit William Harvey Hospital Registration /1 Heart Research Kent and Canterbury Hospital Registration /20 Colorectal Cancer Fund William Harvey hospital Registration /3 Renal Unit Fund Kent and Canterbury hospital Registration /43 Marlowe Ward Fund Kent and Canterbury hospital Registration /42 Chest Clinic Kent and Canterbury hospital Registration /18 Lesley Court Fund Kent and Canterbury hospital Registration /15 P Hall Legacy HCOOP Kent and Canterbury hospital Registration /12 26 East Kent Hospitals Charity Annual Report

138 Our Dementia specialist nurses across the trust have set up Memory Lane cafes for our patients who are living with dementia. This gives patients the opportunity to socialise, enjoy a cup of tea and perhaps even watch a film in a more familiar environment! 27 East Kent Hospitals Charity Annual Report

139 Statement of Trustees Responsibility The following pages show the financial accounts for the year ended 31st March Statement of Trustees rsponsibilitiesin respect of the Trustees annual report and the financial statements Under charity law, the trustees are responsible for preparing the Trustees Annual Report and the financial statements for each financial year which show a true and fair view of the state of affairs of the Charity and of the financial position at the end of the year. In preparing these financial statements, generally accepted accounting practice entails that the trustees: Select suitable accounting policies and then apply them consistently; Make judgments and estimates that are reasonable and prudent; State whether the recommendations of the Statement of Recommended Practice have been followed, subject to any material departures disclosed and explained in the financial statements; State whether the financial statements comply with the trust deed, subject to any material departures disclosed and explained in the financial statements; Prepare the financial statements on the going concern basis unless it is inappropriate to presume that the charity will continue its activities. The trustees are required to act in accordance with the trust deed of the charity, within the framework of trust law. They are responsible for keeping proper accounting records, sufficient to disclose at any time, with reasonable accuracy, the financial position of the charity at that time, and to enable the trustees to ensure that, where any statements of accounts are prepared by them under section 132(1) of the Charities Act 2011, those statements of accounts comply with the requirements of regulations under that provision. They have general responsibility for taking such steps as are reasonably open to them to safeguard the assets of the charity and to prevent and detect fraud and other irregularities. As far as the trustees are aware, there is no relevant audit information of which the charity s auditors are unaware and the trustees confirm that they have met the responsibilities set out above and complied with the requirements for preparing the accounts. The financial statements attached have been compiled from and are in accordance with the financial records maintained by the trustees. By Order of the Trustees Signed: Chairman: Date: Trustee: Date: 28 East Kent Hospitals Charity Annual Report

140 Independent Auditors Report Issued to the Trustees of East Kent Hospitals Charity We have audited the financial statements of East Kent Hospitals Charity for the year ended 31st March The financial reporting framework that has been applied in their preparation is applicable law and UK Accounting Standards (UK Generally Accepted Accounting Practice). This report is made solely to the charity s trustees as a body, in accordance with section 144 of the Charities Act 2011 (or its predecessors) and regulations made under section 154 of that Act. Our audit work has been undertaken so that we might state to the charity s trustees those matters we are required to state to them in an auditor s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the charity and its trustees as a body, for our audit work, for this report, or for the opinions we have formed. Respective responsibilities of trustees and auditor As explained more fully in the Statement of Trustees Responsibilities set out on page 28 the trustees are responsible for the preparation of financial statements which give a true and fair view. We have been appointed as auditor under section 144 of the Charities Act 2011 (or its predecessors) and report in accordance with regulations made under section 154 of that Act. Our responsibility is to audit, and express an opinion on, the financial statements in accordance with applicable law and International Standards on Auditing (UK and Ireland). Those standards require us to comply with the Auditing Practices Board s (APB s) Ethical Standards for Auditors. Scope of the audit of the financial statements A description of the scope of an audit of financial statements is provided on the Financial Reporting Council s website at auditscopeukprivate Opinion on financial statements In our opinion the financial statements: give a true and fair view of the state of the charity s affairs as at 31st March 2016 and of the Charity s incoming resources and application of resources for the year then ended; have been properly prepared in accordance with UK Generally Accepted Accounting Practice; and have been properly prepared in accordance with the requirements of the Charities Act Matters on which we are required to report by exception We have nothing to report in respect of the following matters where the Charities Act 2011 requires us to report to you if, in our opinion: the information given in the Trustees Annual Report is inconsistent in any material respect with the financial statements; or the charity has not kept sufficient accounting records; or the financial statements are not in agreement with the accounting records and returns; or we have not received all the information and explanations we require for our audit. Philip Johnston KPMG Limited LLP 15 Canada Square London E14 5GL 29 East Kent Hospitals Charity Annual Report

141 Statement of Financial Activities Statement of Financial Activities for the year ended 31 March / /15 Note Unrestricted Restricted Endowment Total Unrestricted Restricted Endowment Total Funds Funds Funds Funds Funds Funds Funds Funds Income from Donations and legacies Other trading activities Investment income Other incoming resources Total Expenditure 3 Raising funds 3.2 (25) (106) (1) (132) (19) (98) (1) (118) Charitable Activities 3.1 Purchase of medical equipment (144) (378) 0 (522) (277) (217) 0 (494) Building and refurbishment (24) (23) 0 (47) (14) (11) 0 (25) Patient Education and welfare (13) (19) 0 (32) (6) (8) 0 (14) Staff education and welfare (4) (16) 0 (20) 0 (16) 0 (16) Research 0 (55) 0 (55) (8) (28) 0 (36) Total expenditure on Charitable (185) (491) 0 (676) (305) (280) 0 (585) Activities Total expenditure (211) (596) (1) (808) (324) (378) (1) (703) Net gains/(losses) on investments 5 (67) (59) 0 (126) Net income/(expenditure) 4 (66) (298) (1) (365) (13) Net movement in funds (66) (298) (1) (365) (13) Fund balances brought forward 1,702 2, ,714 1,715 2, ,308 Fund balances carried forward 1,636 2, ,349 1,702 2, ,714 The accompanying notes form an integral part of these financial statements. 30 East Kent Hospitals Charity Annual Report

142 Balance Sheet Balance Sheet as at 31 March 2016 Fixed Assets 5 Note Restricted 2015/ /15 Total Restricted Unrestricted Endowment Unrestricted Endowment Total Funds Funds Funds Funds Funds Funds Funds Funds Investments - Cazenove portfolio 1,061 1, , , ,074 Properties Total Fixed Assets 1,109 1, ,909 1,559 2, ,874 Debtors due over one year Current Assets Debtors due within one year Cash held in investment portfolio Cash at bank and in hand , Total Current Assets 549 1, , Liabilities Creditors: Amounts falling due within one year 7 (35) (101) 0 (136) (22) (32) 0 (54) Total Net Current Assets/(Liabilities) , Total Net Assets 1,636 2, ,349 1,702 2, ,714 Funds of the Charity 8 Endowment Funds Restricted 8.2-2,688-2,688 2,986 2,986 Unrestricted 8.3 1, ,636 1,702 1,702 Total Funds 1,636 2, ,349 1,702 2, ,714 The accompanying notes form an integral part of these financial statements. Signed: Date: 31 East Kent Hospitals Charity Annual Report

143 Notes to the financial statements for the year ended 31 March 2016 Principal accounting policies 1.1 Basis of preparation The financial statements have been prepared under the historic cost convention, with the exception of investments which are included at market value. The financial statements have been prepared in accordance with applicable Accounting and Reporting by Charities: Statement of Recommended Practice (SORP) applicable to charities preparing their accounts in accordance with the Financial Reporting Standard applicable in the UK and Republic of Ireland (FRS 102) effective 1 January 2015 and the Charities Act The Trustees consider that there are no material uncertainties about the Charity s ability to continue as a going concern. and uncertainties affecting the current year s accounts. In future years, the key risks are a fall in investment and voluntary income. Arrangements are in place to mitigate those risks (see the risk management and reserves sections). 1.2 Reconciliation with previous generally accepted accounting practices In preparing these accounts, the Trustees have considered whether any restatement of comparatives was required to comply with FRS 102 and the Charities SORP FRS 102. No restatements were required although there has been a change in the analysis of governance and administration costs and inclusion of a cash flow statement. Governance and administration costs: previously these had been separately identified on the face of the statement of financial activity. These are now classified as a support cost and have therefore been apportioned between fundraising activities and charitable activities on a cost basis. The Trustees consider this is a more equitable treatment to avoid disadvantaging funds with high volume low value transactions. All funds attract administrative costs even without any expenditure as these have to be monitored, fund managers approached for future plans, investment transactions and overhead charges. The cost of the transaction does not necessarily reflect on the work involved to achieve that expenditure and therefore consistency is maintained by working with an activity cost based apportionment. See note 3. Support costs attributable to fundraising costs are apportioned on a similar basis, with the exception of salaries which are a significant cost, but do not attract the same level of support costs and these have therefore been adjusted to reflect work for general fundraising activities. The apportionment of support costs, including governance costs, is shown in note 3. There is no effect on the total expenditure for 2014/15 or 2015/16. Support Costs are identified as below:- Administration & governance costs 2015/16 Charges 15/16 CF manager 50% 19,060 Assistant Finance Director (Accounting) 15% 12,660 ADMIN - GOVERNANCE PAY COSTS 31,720 CF manager 50% & Assist (2 wte) 41,785 Supplies 0.4% 1,310 Payment clerks 0.34% 1,370 Cashiers 13% 1,910 Financial Systems team 5% 4,350 SUPPORT PAY COSTS 50,725 Total Pay costs 82,445 Total Pay costs 82,445 Non-pay & overheads 3,000 Systems non pay costs 5% 3,384 NON PAY SUPPORT COSTS 6,384 Audit (internal) 1% 1,000 Total Non Pay costs 7,384 Revised administrative costs 89,829 External audit 15/16 inc VAT 3,240 Total 93, Incoming Resources Donations, grants, legacies and gifts in kind All incoming resources are recognised once the charity has evidence of entitlement and it is probable (more likely than not) that the resources will be received and the monetary value can be measured with sufficient reliability. It is not the Charity s policy to defer income. Where there are terms or conditions attached to the incoming resource (particularly grants) then these must be met before the income is recognised as the entitlement will not be evidenced, or where there is uncertainty that the conditions can be met, then the income is not recognised in the year. It is not the Charity s policy to defer income even where a pre-condition for use is imposed. 32 East Kent Hospitals Charity Annual Report

144 Legacies are accounted for as incoming resource either on receipt or where the receipt of the legacy is probable. Receipt is probable when: Confirmation has been received from the representatives of the estate(s) that probate has been granted The executors have established that there are sufficient assets in the estate to pay the legacy and All conditions attached to the legacy have been fulfilled or are within the charity s control Where the amount of the legacy can be reliably estimated. Legacies which are subject to a life interest party are not recognised. Where a reliable estimate cannot be identified, then the legacy is shown as a contingent asset. Incoming resources from Capital Endowments are placed into an income fund when received. Income will be placed into funds in accordance with donors wishes, but without forming a binding trust, unless a signed document is received and approved by Trustees. Gifts in kind are valued at a reasonable estimate of their value to the Charity. Gifts donated for resale are included as income either when they are sold or at the estimated resale value after deduction of the cost to sell the goods. Intangible Income Intangible income, which comprises donated services or use of Trust property, is included in income at a valuation which is an estimate of the financial cost borne by the donor where such a cost is material, quantifiable and measurable. No income is recognised when there is no financial cost borne by a third party. 1.4 Resources expended All expenditure is accounted for on an accruals basis and has been classified under headings that aggregate all costs related to the category of expense shown in the Statement of Financial Activities. Expenditure is recognised when the following criteria are met: There is a present legal or constructive obligation to make a payment to a third party primarily to the Trust in furtherance of the charitable objectives It is more likely than not that a transfer of benefits (usually a cash payment) will be required in settlement The amount of the obligation can be measured or estimated reliably. The Trustees have control over the amount and timing of grant payments and are usually given with the condition that an item or service has been purchased. Conditions have to be met before the liability is recognised. Irrecoverable VAT is charged against the category of resources expended for which it was incurred. Allocation of support costs Support costs are those costs which do not relate directly to a single activity. These include some staff costs, costs of administration, internal and external audit costs and IT support. These costs include recharges of appropriate proportions of the staff costs and overheads from East Kent Hospitals University NHS Foundation Trust and the East Kent Finance Consortium and are apportioned on an average fund balance monthly across all funds. See note 1.2 and note 3. Fundraising costs The costs of generating funds are the costs associated with generating income for the charity. This will include the costs associated with investment managers, administration costs for management of investment properties and other promotional and fundraising events including any trading activities and for the salaries of the fundraisers as agreed with the Trust. Charitable activities Expenditures are given as grants made to third parties (including NHS bodies) in furtherance of the charitable objectives of the funds. They are accounted for on an accruals basis, in full, as liabilities of the Charity when approved by the Trustees and accepted by the beneficiaries. See note 3. Analysis of grants The Charity does not make grants to individuals. All grants are made to the Trust to provide for the care of NHS patients in furtherance of its charitable aims. The total cost of making grants, including support costs, is disclosed on the face of the statement of financial activities and further analysis in relation to activity is provided in note 3. Recognition of liabilities Liabilities are recognised as and when an obligation arises to transfer economic benefits as a result of past transactions or events. 1.5 Fixed assets Investments fixed assets Investments are a form of basic financial instrument. Investments held by the Trustees investment managers are initially recognised at their transaction value and are subsequently measured at their fair (market) value as at the balance sheet date as reported by the Investment Managers (Shroders T/as Cazenove). The statement of financial activities includes the net gains and losses arising on revaluation and disposals throughout the year. Quoted stocks and shares are included in the balance sheet at the current market value. The Trustees recognise that the main form of financial risk for the charity is the volatility in equity and other investment markets which are subject to global economic conditions and the investors responses to global incidents. To minimise risk the Trustees have identified that longer term investment produces a more stable return than short term investments and holds a mixed portfolio to alleviate any single area of instability. 33 East Kent Hospitals Charity Annual Report

145 Investment properties Property assets are not depreciated but are shown at market value. Valuations are generally carried out annually by an appropriate professional. Valuation gains and losses are recorded in the Statement of Financial Activities with the balance sheet reflecting the market value at 31st March Income and expenditure in respect of investment properties are reflected in the appropriate category in the Statement of Financial Activities. See notes 2 and 3.2. The Trustees have reduced their property holdings as the property market had improved in this year and to increase cash holdings to reduce costs and increase support to the Trust. 1.8 Prior Year Adjustments There has been no change to the accounts of the prior years although the comparison notes have been amended to meet the requirements of the new Statement of Recommended Practice (FRS 102) on all relevant financial statements and notes. 1.9 Pensions The Charity has no employees Irrecoverable VAT Any irrecoverable VAT is charged to the Statement of Financial Activities. 1.6 Realised gains and losses Realised gains and losses on investments are calculated as the difference between sales proceeds and opening market value (or date of purchase if later). Unrealised gains and losses are calculated as the difference between market value at the year end and opening market value (or date of purchase if later). Investment income and gains/losses are allocated monthly according to the average fund balance, to the appropriate fund and included within the Statement of Financial Activities. 1.7 Cash and cash equivalents Cash held in the bank and in hand is used to meet the day to day running costs of the charity as they fall due. Cash equivalents are short term liquid investments usually held for a period of 3 months notice interest bearing savings accounts. Cash held within the investment portfolio is identified in the balance sheet as reported by the investment managers. 34 East Kent Hospitals Charity Annual Report

146 2 Income from Unrestricted Restricted Endowment 2015/16 Total Unrestricted Restricted Endowment Total 2014/15 Donations from Individuals Donations from groups/orgs Corporate donations Legacies Total Donations and Legacies Other trading activities Investment Dividends from investment portfolio Bank Interest Rent from Investment properties Interest from Loan Total Investment income Other incoming resources- Staff Ball Tickets Total incoming resources Resources Expended Unrestricted Grant Funded Support Restricted Grant Funded Support Total Un restricted Grant Funded Support Restricted Grant Funded Support activity costs activity costs 2015/16 activity costs activity costs Charitable Activities (note 3.1) Purchase of medical equipment Building and refurbishment Patient Education and welfare Staff education and welfare Research Total Governance Costs (restated FRS 102) (78) (73) Raising funds (note 3.2) Fundraising events (inc Insurance) Fundraiser (FR) salaries FR general (database etc) Investment Management portfolio Investment Management Properties Total (Excl Endowment Fund) Governance Costs (UR & R restated FRS 102) (16) (19) Total Endowment - Gov costs (not 1 (1) 1 (1) apportioned to activities) Total (95) (93) Total 35 East Kent Hospitals Charity Annual Report

147 3.3 Cashflow as at 31 March 2016 Cash flows from operating activities: 15/16 14/ Net cash provided by (used in) operating activities (91) (188) Cash flows from investing activities: - Dividends, interest and rents from investments Proceeds from sale of investments Purchase of investments (458) (124) Charges applied to investments Net cash provided by (used in) investing activities Cash flows from financing activies: Repayments of borrowing Cash inflows from new borrowing Receipt of endowment Change in cash and cash equivalents in the reporting period 859 (13) Cash and cash equivalents at the beginning of the reporting period Cash and cash equivalents at the end of the reporting period Net income/(expenditure) for the reporting period (as per the statement of financial activities) (365) 406 Adjustments for: - (Gains)/losses on investments 81 (220) Dividends, interest and rents from investments (111) (119) Loss/(profit) on sale of fixed assets 45 0 (Increase)/decrease in debtors 177 (243) Increase/(decrease) in creditors 82 (12) Net cash provided by (used in) operating activities (91) (188) Analysis of cash and cash equivalents Cash in hand East Kent Hospitals Charity Annual Report

148 4 Net Movement in Funds Net resources of general donations and fundraising Restricted 2015/ /15 Total Restricted Unrestricted Endowment Unrestricted Endowment Total Funds Funds Funds Funds Funds Funds Funds Funds (21) (295) (1) (317) (118) 217 (1) 98 Net gain from fundraising-events 8 (7) (7) 0 4 Net loss from investment properties (1) 0 0 (1) Net gain from investment portfolio/bank Gains & Losses on investment assets (67) (59) 0 (126) Net movement in funds (66) (298) (1) (365) (13) Analysis of FIxed Asset Investments investments notes Alpha CIF Income Units 000's Investment properties 000's Total Fixed Assets 000's Common Investment Fund Market value at 1st April 2015 b/fwd 3, Less: Disposals at carrying value (564) (707) (1271) add: Acquisitions - less cash Net gain/loss on revaluation and sale (81) (45) (126) Charges applied to capital (26) 0 (26) Market value at 31 March , ,909 15/16 14/15 net gain/loss Uk Equities (55) Int equities (63) Other assets (16) Bonds (fixed assets) (79) Total 2, (213) Properties Property 1 Property 2 Property 3 sub total Property 4 Total b/fwd sold at cost of sales (5) (3) (5) (13) cash received (753) (Loss) / Gain (25) 4 (24) (45) 48 6 Analysis of Debtors 31 March March 2015 Unrestricted Restricted Total Unrestricted Restricted Total Funds Funds Funds Funds Funds Funds Amounts falling due within one year: Accrued income Legacies Amounts falling due over one year Loan for property maintenance Total debtors Debtors are monies due to the Charity which have been identified but not yet received. The Charity has a long term arrangement for upkeep of a property which is held in Trust in equal shares with the Margate Civic Society. The Charity pays for maintenance and insurance and charges against the estate at basic rate of interest on funds expended which will be recovered from the estate on distribution, which is subject to a life tenancy and interest. 37 East Kent Hospitals Charity Annual Report

149 7 Analysis of Creditors 2015/ /15 Amounts falling due within one year: Unrestricted Restricted Total Unrestricted Restricted Total Funds Funds Funds Funds Funds Funds 000 s 000 s 000 s 000 s 000 s 000 s Trade creditors (Trade Accruals) Audit (KMPG) 15/16 accs (Trade) East Kent Hospitals University NHS Foundation Trust Total creditors falling due within one year Creditors are amounts owed by the charity. They are measured at the amout that the charity expects to have to pay to settle the debt. 8 Details of Funds 8.1 Analysis of Funds Endowment Funds Balance Incoming Resources Gains & Balance 31st Mar 2015 Resources Expended Transfers Losses 31st Mar s 000 s 000 s 000 s 000 s 000 s KCH Longbotham 26 0 (1) Total 26 0 (1) Restricted Funds Balance Incoming Resources Gains & Balance 31st Mar 2015 Resources Expended Transfers Losses 31st Mar 2016 Name of fund 000 s 000 s 000 s 000 s 000 s 000 s QEQM General Purposes (99) 0 (15) 853 KCH Gen Purpose (243) 0 (16) 778 QEQM Coronary Care Unit - CCU (27) 0 (3) 129 BHD Gen Purpose (9) 0 (3) 127 KCH Heart Research (36) 0 (3) 127 RVH Gen Purpose (5) 0 (2) 110 WHH Gen Purpose (61) 0 (5) 104 KCH Renal Unit Fund 95 2 (5) 0 (2) 90 WHH Celia Blakey Unit 91 2 (3) 0 (2) 88 Others (109) 0 (8) 282 Total 2, (597) 0 (59) 2, East Kent Hospitals Charity Annual Report

150 8.3 Details of Material Funds Endowment Funds Name of fund Description of the nature and purpose of each fund KCH Longbotham Promoting any charitable purpose related to Kent & Canterbury Hospital services as Trustees see fit Restricted Funds Name of fund Description of the nature and purpose of each fund QEQM General Purpose KCH Gen Purpose QEQM Coronary Care Unit - CCU BHD Gen Purpose KCH Heart Research RVH Gen Purpose WHH Gen Purpose KCH Renal Unit Fund WHH Celia Blakey Unit Any Charitable purpose relating to NHS wholly or mainly for Queen Elizabeth Hospital Charitable purposes relating to NHS wholly or mainly for Kent & Canterbury Hospital Charitable purposes relating to Coronary Care Unit Any Charitable Purpose relating to NHS wholly or mainly for Buckland Hospital Charitable purposes relating to NHS to further Heart Research Any Charitable Purpose relating to NHS wholly or mainly for Royal Victoria Hospital Any Charitable Purpose relating to NHS wholly or mainly for William Harvey Hospital Charitable purposes relating to NHS & provision of additional equip & staff training for Renal Services Charitable purposes relating to NHS & provision of additional equip & staff training Designated Funds Name of fund Description of the nature and purpose of each fund QEQM Diabetes Fund QEQM Property Fund QEQM Coronary Care Fund QEQM Diabetes Fund EKHT Urgent & Long Term Care Services Fund EKHT Specialist Services Fund KCH Coronary Care Fund Any Charitable purpose relating to NHS & purchase of equipment & staff training Any Charitable purpose relating to NHS wholly or mainly for Queen Elizabeth Hospital Any Charitable purpose relating to NHS & purchase of equipment & staff training Any Charitable purpose relating to NHS & purchase of equipment & staff training Any Charitable purpose relating to NHS & purchase of equipment & staff training Any Charitable purpose relating to NHS & purchase of equipment & staff training Any Charitable purpose relating to NHS & purchase of equipment & staff training 39 East Kent Hospitals Charity Annual Report

151 9 Transfer of Funds The Trustees review all unrestricted and restricted funds to ensure that there is a need and can meet the restriction of those funds. In this financial year the Trustees transferred the funds of the designated Ladies Breast Care Support Group to the Mammography Breast Cancer Fund in the sum of 15k as the funds had the same purpose. There is a project being worked to expend the money in 2016/17. The balance of the Ophthalmic designated fund of 3k was transferred to the unrestricted Divisional Funds. 12 Contingent Assets The Charity has been made aware of an estate in which they are a 25% residual beneficiary but which is currently being held in Trust where the interest is paid to an individual beneficiary for her lifetime. The Trust is significant (estimated to be in the region of 439k at 31 March 2015), but this sum is subject to the markets and expertise of the investment manager. The Charity cannot at this time consider this as an assured income and has therefore not recognised the potential legacy of 100k for the Cancer Services in the accounts. The net proceeds from the sale of three investment properties (totaling 668k) was transferred from the unrestricted Property Fund to the Umbrella General Purpose Fund to provide additional resources to support the Trust. 10 Related party transactions During the year none of the Trustees or members of the key management staff or parties related to them has undertaken any material transactions with the East Kent Hospitals Charity. The Charity has made revenue and capital payments to the East Kent Hospitals University NHS Foundation Trust where the Trustees are also members of the Trust Board. 11 Charity Tax East Kent Hospitals Charity is considered to pass the tests set out in Paragraph 1 Schedule 6 Finance Act 2010 and therefore it meets the definition of a charitable trust for UK income tax purposes. Accordingly, the charity is potentially exempt from taxation in respect of income or capital gains received within categories covered by Part 10 Income Tax Act 2007 or Section 256 of the Taxation of Chargeable Gains Act 1992, to the extent that such income or gains are applied exclusively to charitable purposes. 40 East Kent Hospitals Charity Annual Report

152 Donation Form Full name: Home Address: Post Code: Telephone: Boost your donation by 25p of Gift Aid for every 1 you donate! Gift Aid is reclaimed by the charity from the tax you pay for the current tax year. Your address is needed to identify you as a current UK taxpayer. In order to Gift Aid your donation you must tick the box below: I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax in the current tax year than the amount of Gift Aid claimed on all my donations it is my responsibility to pay any difference. I want to Gift Aid my donation to East Kent Hospitals Charity I wish to donate the sum of to East Kent Hospitals Charity. I request that the donation be used for: (please tick) Wherever it is most needed Patients and staff at the The following specific purpose/department: (please specify) (please specify) Hospital Method of payment Credit Card Cheque Cash Other (e.g CAF voucher) Please make cheques payable to East Kent Hospitals Charity Cardholder Card No as appears on card Start Date/Issue No MM/YY Expiry Date MM/YY Three digit Security No Please send to: East Kent Hospitals Charity, 2nd Floor, Trust Offices, Kent & Canterbury Hospital, Ethelbert Road, Canterbury, Kent. CT1 3NG We would like to be able to contact you about future events and appeals. The charity will not pass on your details to any third party. If you do not want to receive this information, please tick the box 41 East Kent Hospitals Charity Annual Report

153 CHARITABLE FUNDS COMMITTEE CHAIR S SUMMARY BoD 53/16 Finance Directorate Kent & Canterbury Hospital Ethelbert Road Canterbury Kent CT1 3NG Registered Charity Number Mr Philip Johnstone KPMG LLP 12 th Floor 15 Canada Square Canary Wharf London E14 5GL Dear Mr Johnstone This representation letter is provided in connection with your audit of the financial statements of East Kent Hospitals Charity ( the Charity ), for the year ended 31 March 2016, for the purpose of expressing an opinion: i. as to whether these financial statements give a true and fair view of the state of the Charity s affairs as at 31 March 2016 and of its surplus or deficit for the financial year then ended; ii. whether the financial statements have been properly prepared in accordance with FRS 102; and iii. whether the financial statements have been prepared in accordance with the Charities Act These financial statements comprise the Balance Sheet, the Statement of Financial Activities, the Cash Flow Statement, and notes, comprising a summary of significant accounting policies and other explanatory notes. The Trustees confirm that the representations they make in this letter are in accordance with the definitions set out in the Appendix to this letter.

154 CHARITABLE FUNDS COMMITTEE CHAIR S SUMMARY BoD 53/16 The Trustees confirm that, to the best of their knowledge and belief, having made such inquiries as they considered necessary for the purpose of appropriately informing themselves. Financial statements 1. The Trustees have fulfilled their responsibilities, as set out in the terms of the audit engagement dated 12 August 2013, for the preparation of financial statements that: i. give a true and fair view of the state of the Charity s affairs as at the end of its financial year and of its surplus or deficit for that financial year; ii. have been properly prepared in accordance with FRS 102; and iii. have been prepared in accordance with the Charities Act The financial statements have been prepared on a going concern basis. 2. Measurement methods and significant assumptions used by the Trustees in making accounting estimates, including those measured at fair value, are reasonable. 3. All events subsequent to the date of the financial statements and for which FRS 21 Events after the balance sheet date requires adjustment or disclosure, have been adjusted or disclosed. 4. The effects of uncorrected misstatements are immaterial, both individually and in aggregate, to the financial statements as a whole. A list of the uncorrected misstatements is attached to this representation letter. Information provided 5. The Trustees have provided you with: access to all information of which it is aware, that is relevant to the preparation of the financial statements, such as records, documentation and other matters; additional information that you have requested from the Trustees for the purpose of the audit; and unrestricted access to persons within the Charity from whom you determined it necessary to obtain audit evidence. 6. All transactions have been recorded in the accounting records and are reflected in the financial statements. 7. The Trustees acknowledge their responsibility for such internal control as it determines necessary for the preparation of financial statements that are free from material misstatement, whether due to fraud or error. In particular, the Trustees acknowledge their responsibility for the design, implementation and maintenance of internal control to prevent and detect fraud and error.

155 CHARITABLE FUNDS COMMITTEE CHAIR S SUMMARY BoD 53/16 The Trustees have disclosed to you the results of their assessment of the risk that the financial statements may be materially misstated as a result of fraud. 8. There have been no instances of fraud or suspected fraud that the Trustees are aware of and which involves: a) The following: management; employees who have significant roles in internal control; or others where the fraud could have a material effect on the financial statements; and b) There have been no allegations of fraud, or suspected fraud, affecting the Charity s financial statements communicated by employees, former employees, analysts, regulators or others. 9. The Trustees have disclosed to you all known instances of non-compliance or suspected non-compliance with laws and regulations whose effects should be considered when preparing the financial statements. 10. The Trustees have disclosed to you and have appropriately accounted for and/or disclosed in the financial statements, in accordance with FRS 12 Provisions, Contingent Liabilities and Contingent Assets, all known actual or possible litigation and claims whose effects should be considered when preparing the financial statements. 11. The Trustees have disclosed to you the identity of the Charity s related parties and all the related party relationships and transactions of which it is aware. All related party relationships and transactions have been appropriately accounted for and disclosed in accordance with FRS 8 Related Party Disclosures. 12. The Trustees confirm that: a) The financial statements disclose all of the key risk factors, assumptions made and uncertainties surrounding the charity s ability to continue as a going concern as required to provide a true and fair view. b) Any uncertainties disclosed are not considered to be material and therefore do not cast significant doubt on the ability of the Charity to continue as a going concern. This letter was tabled and agreed at the meeting of the Integrated Audit and Governance Committee on 19 May Yours faithfully, Matthew Kershaw Chief Executive Nick Gerrard Director of Finance and Performance Management

156 CHARITABLE FUNDS COMMITTEE CHAIR S SUMMARY BoD 53/16 Appendix A to the Trustees Representation Letter of East Kent Hospitals Charity: Definitions Financial Statements A complete set of financial statements comprises: a Balance Sheet as at the end of the period; a Statement of Financial Activities for the period; a Cash Flow Statement for the period; and notes, comprising a summary of significant accounting policies and other explanatory information. Material Matters Certain representations in this letter are described as being limited to matters that are material. The ASB's Statement of Principles for Financial Reporting states that: Fraud An item of information is material to the financial statements if its misstatement or omission might reasonably be expected to influence the economic decisions of users of those financial statements, including their assessments of management's stewardship. Fraudulent financial reporting involves intentional misstatements including omissions of amounts or disclosures in financial statements to deceive financial statement users. Misappropriation of assets involves the theft of an entity s assets. It is often accompanied by false or misleading records or documents in order to conceal the fact that the assets are missing or have been pledged without proper authorisation. Error An error is an unintentional misstatement in financial statements, including the omission of an amount or a disclosure. Prior period errors are omissions from, and misstatements in, the entity s financial statements for one or more prior periods arising from a failure to use, or misuse of, reliable information that: a) was available when financial statements for those periods were authorised for issue; and b) could reasonably be expected to have been obtained and taken into account in the preparation and presentation of those financial statements. Such errors include the effects of mathematical mistakes, mistakes in applying accounting policies, oversights or misinterpretations of facts, and fraud.

157 CHARITABLE FUNDS COMMITTEE CHAIR S SUMMARY BoD 53/16 Management For the purposes of this letter, references to management should be read as management and, where appropriate, those charged with governance. Related parties A related party is a person or entity that is related to the entity that is preparing its financial statements (referred to in FRS 8 Related Party Disclosures as the reporting entity ). a) A person or a close member of that person s family is related to a reporting entity if that person: i. has control or joint control over the reporting entity; ii. has significant influence over the reporting entity; or iii. is a member of the key management personnel of the reporting entity or of a parent of the reporting entity. b) An entity is related to a reporting entity if any of the following conditions applies: i. The entity and the reporting entity are members of the same group (which means that each parent, subsidiary and fellow subsidiary is related to the others). ii. One entity is an associate or joint venture of the other entity (or an associate or joint venture of a member of a group of which the other entity is a member). iii. Both entities are joint ventures of the same third party. iv. One entity is a joint venture of a third entity and the other entity is an associate of the third entity. v. The entity is a retirement benefit scheme for the benefit of employees of either the reporting entity or an entity related to the reporting entity. If the reporting entity is itself such a scheme, the sponsoring employers are also related to the reporting entity. vi. The entity is controlled or jointly controlled by a person identified in (a). vii. A person identified in (a)(i) has significant influence over the entity or is a member of the key management personnel of the entity (or of a parent of the entity). Related party transaction The transfer of assets or liabilities or the performance of services by, to or for a related party irrespective of whether a price is charged.

158 CHARITABLE FUNDS COMMITTEE CHAIR S SUMMARY BoD 53/16 1 Introduction Charity Strategy East Kent Hospitals Charity is registered with the Charity Commission (Number ) and set up under NHS legislation. 1.2 The East Kent Hospitals University NHS Foundation Trust is the Corporate Trustee and holds assets belonging to the Charity. The directors of the Corporate Trustee act on behalf of the Corporate Trustee in the administration of the charitable funds. The Charity is independent of the Trust, but the Trustees always aim to work closely with the Trust and align activity with the strategic direction of the Trust. 2 The Strategy 2.1 This strategy identifies the key strategic aims and objectives for the period 1 st April st March The strategy aims to ensure the governance and management arrangements for East Kent Hospitals Charity (EKHC) continue to operate to an optimal standard by making best use of the resources available. 3 Vision Statement 3.1 The vision for the Charity is to meet the challenges of the current and ongoing healthcare needs of the people of East Kent by supporting the Trust; and 3.2 To promote the work of the Charity and establish strong partnerships across the communities served by the Trust. 4 Charity Purpose 4.1 The Charity s purpose is to support the services and facilities provided by the Trust. The grants given to the Trust must be able to demonstrate a public benefit. The public are the patients, relatives and visitors who use the Trust services and facilities, within the hospitals and in the community. 5 Charity aims 5.1 The Charity aims to support the prevention and improved treatment of illness in all its forms and to promote research and education in healthcare. The Charity will work in partnership with the Trust and other organisations and charities to achieve the greatest impact and promote great healthcare. 5.2 A Strengths, Weakness, Opportunities and Threats (SWOT) analysis has been completed and is at Appendix A. The Strategic Aims are set out in the next section. Page 1 of 6

159 CHARITABLE FUNDS COMMITTEE CHAIR S SUMMARY BoD 53/16 6 Strategic Aims The strategic aims are split into the three key areas maximising charitable income, maximising charitable impact to EKHUFT and ensuring good governance and best practice in all charitable activities This can be articulated as follows: 6.2 Maximising charitable Income Seek to increase the level of income year on year raised by the Charity by targeted fundraising, raising the profile of the Charity and optimising returns on investments. The Charity will aim to maximise use of assets whilst maintaining a minimum capital base of 1m. Deliver a major fundraising Appeal in support of Dementia Services across all the hospitals. Raise the awareness, visual presence and profile of the work of the Charity within and outside the Trust. Build relationships that foster a greater understanding of the Charity and its processes with NHS staff. 6.3 Maximising charitable impact to EKHUFT Work to maximise patient benefit through continually improving the grant making policy, processes and practices and therefore the impact as a Charity year upon year. To be respected throughout the hospitals for the professional service offered by the Charity and the efficient and effective fund management. With the increasing demands on the NHS to deliver more services, treatments and facilities the Committee have agreed to increase support to the Trust over the next three years. The level of this increased support, year on year, will be to some extent determined by the success of the aim to maximise income. In order for the Charity to be sustainable funds should not drop below 1m 6.4 Ensuring good governance and best practice in all charitable activities Work to ensure that our Charity maintains the highest standards of governance, management and service whilst adhering to the changing requirements of legislation and published best practice. Ensure that the Trustee receives all relevant information that enables them to make effective decisions. Ensure the Charity has access to the competencies and resources required to achieve our strategic aims. Ensure that we have an engaged team of staff (including voluntary resources) through training and support and the Charity is able to demonstrate value for money from the resources invested. Page 2 of 6

160 CHARITABLE FUNDS COMMITTEE CHAIR S SUMMARY BoD 53/ Key objectives to support Charity Aims 7.1 The key objectives to support the Charity Aims, together with responsible officer and timescales are detailed in the table below:- Strategic Aim Objective Responsible officer(s) Maximising income To achieve annual gross income exceeding Investment Investment Portfolio 80k (overall growth circa 4% per annum) Manager - Maximising income Reductions to investment portfolio Maximising income Cash management Maximising income general awareness to aim to increase general donations Maximising income Gift aid Maximising income application for external grants and sponsorship Maximising income - legacies Maximising income major appeals (Run by Charity Fundraising team) Maximising Income recruiting volunteer support Ensure that there are robust cash planning policies and procedures in place to allow any planned reductions to the portfolio to be managed to minimise risk of financial loss. Ensure that Cash is invested to maximise income whilst in bank accounts which have a low credit risk and are covered by the Financial Services Compensation scheme up to a maximum of 75,000 per banking institution (operating a separate banking license) Increased publicity will be obtained for the Charity by ensuring at least a 50% return on impact reports and publicity on all equipment funded by the charity, via the website, social media and proactive public relations. Ensure that all opportunities to collect relevant data to support gift aid claim are maximised Apply to a minimum of 5 grants making Trusts and organisations during each financial year. Report on the success or otherwise of these applications to each CFC Implement legacy awareness programme to internal and external potential legatees Manage the major appeal to ensure all opportunities for income generation are explored and appeal is delivered to agreed timescales Implement a recruitment campaign to engage volunteer resources to support charitable activities e.g. community fundraising and administration Cazenove Charitable Funds Manager Charitable Funds Manager Fundraising Manager Fundraising Manager Fundraising Manager Fundraising Manager Fundraising Manager Fundraising Manager Timescale Annual November th September 2016 and ongoing 1 October 2016 and ongoing 1 August 2016 and ongoing Annual To be agreed Ongoing Timescales to be agreed. Evidence of achievement Annual performance report Draft policy to November 2016 CF meeting Quarterly reports to CFC Evidence of increased activity on impact reports Increase gift aid income received Grant or commercial sponsorship received / report to CFC Evidence of engagement with potential legatees Appeal on target - 500k raised by 31 st March 2018 Volunteers recruited Page 3 of 6

161 CHARITABLE FUNDS COMMITTEE CHAIR S SUMMARY BoD 53/16 Maximising income minor fundraising projects (Run by volunteers) Maximising income valuing high level donors Maximising impact Grant making policies Maximising impact Fund Manager / education Maximising impact Grants to support fundraising activities Maximising impact celebrating charitable achievement Governance / best practice - updates Governance / best practice - policies Governance / best practice fund classification Governance / best practice - training For example - Maternity bereavement suite projects at QE & WHH Provide advice and support to ensure delivery of fundraising project to agreed timescale Implement initiative to encourage repeat donations by drafting correspondence from a representative of the Corporate Trustee advising how their donation was used and updating on current projects. Ensure there are robust processes in place to identify and prioritise grant applications Review current guidance to ensure this is still current and makes process clear for fund managers. Undertake workshops to support fund managers in the planning and application process. Ensure that all requests for fundraising support are accompanied by a robust business case to demonstrate the request is financially viable. At milestone stages throughout the activity, reports will be produced to demonstrate the effectiveness of the investment Ensure that the achievements of the charity are published and celebrated both within and outside the Trust Attend Association of NHS Charities events and local best practice groups to ensure update of new legislations and adoption of best practice. Ensure all CF policies and guidance documents are up to date, fit for purpose and published on sharepoint Review all funds currently classified as restricted and ensure these monies are expended in accordance with the restriction and governing document. For future donations ensure that the restricted classification is only used where appropriate Ensure new CFC members receive appropriate training on induction to the committee and ensure any developments in best practice or legislation are escalated to fund managers / committee members as appropriate Fundraising Manager Fundraising Manager Charitable Fund Manager Charitable Fund Manager / Fundraising Manager Charitable Funds Manager and Fundraising Manager & appropriate Fund Manager Fundraising Manager Charitable Fund Manager / Fundraising Manager / CFC Chair Charitable Fund Manager Charitable Fund Manager CFC Chair / Charitable Fund Manager Ongoing 1 September 2016 and ongoing May 2016 Revised Guidance to November CFC & workshops commence June 2016 Ongoing Projects completed on target Evidence of corresponde nce / repeat giving Prioritisation matrix produced Evidence of workshops / attendees & increased grant applications Business cases and CFC reports Monthly Trust news / website / social media / posters etc As available Evidence of attendance / meeting minutes / escalation As required ongoing ongoing Policies published on sharepoint CFC reporting of grants applied to restricted funds Updates and training evidenced Page 4 of 6

162 CHARITABLE FUNDS COMMITTEE CHAIR S SUMMARY BoD 53/ This document will remain live with progress against the objectives reported to all subsequent Charitable Fund Committee meetings to facilitate discussions on whether the objectives are still fit for purpose in achieving the charity s aims. 7.3 The Strategy will be reviewed by the Charitable Fund Committee at least annually Updated: 28 April 2016 Approved by CF Committee: May 2016 Joint Authors: Charity Fundraising Manager, Charitable Fund Manager, Assistant Director of Finance (Financial Accounting) Page 5 of 6

163 CHARITABLE FUNDS COMMITTEE CHAIR S SUMMARY BoD 53/16 Appendix A SWOT 2016 Major strengths, weaknesses, opportunities and threats in relation to EKHC Strengths Weaknesses General good will towards the NHS and NHS Brand Several unique selling points particularly with a unique major Appeal. Alignment of fundraising initiatives with business planning process Increasing Charity brand awareness Track-record in charitable contribution to Trust service developments Dedicated and motivated staff Poor legacy promotion Finite fundraising resources Reliance on community fundraising Multi-site marketing challenge. Focus on donor care Fundraising not always linked with specific projects. Opportunities Threats / Risks Bigger, better and more significant Scope to increase major giving, corporate and charitable trust income and; To increase legacies, payroll giving and sponsored events etc. Potential reputation benefits through aligning fundraising and marketing activities Raise the Trust media profile and specific public interest issues such as Dementia Appeal. Potential to increase links and use of volunteers for charity projects Encourage greater staff engagement in fundraising Media opportunities to feature staff and members of the public fundraising on the Trust s behalf; Generate a stronger emotional appeal for donors Crowded charitable fundraising marketplace especially close to the Trust Slowdown in charitable giving in line with national and regional economy Reduction in investment returns Reduction in general funds Overwhelming demand for Charity grants and unsustainable reduction in assets. Page 6 of 6

164 APRIL 2016 INTEGRATED PERFORMANCE REPORT

165 Chief Executive's Summary This is the first issue of the new integrated performance report and will present our performance in detail in each area but crucially will also show how they link together, how it translates from the board to the ward and also fits with the new priorities we have set for this year around patients, people, provision and partnerships. It will develop over time and therefore your thoughts on how this works for you will be gratefully received. With regard to the overall picture, it is positive that the caring and safety domains still demonstrate a strong and positive position with regard to a number of the headline measures such as mortality rates and infection control but it is also clear that there is work to do to maintain and improve those whilst also addressing areas where performance has been lower such as with Mixed Sex Accomodation, VTE reporting and complaints. This will continue to be an area of focus for us and fits within the priorities for this year and is included within the Improvement Journey work to help us achieve our immediate goal of getting out of Special Measures when the CQC reinspect us later in the year. There has been considerable work on the issues within the responsive and effective domains and there has been positive progress in terms of the new medical model at QEQM, the Operational Control Centre at WHH and SAFER roll out across the exemplar wards on each site. We have also done this during a time when activity has been higher than plan and last year and also with the additional challenge of industrial action so the progress is testament to the hard work of our staff working with our partners across the system. However, we have considerable more to do in areas such as 4 hour, cancer and RTT standards where we are not yet consistently achieving as we need to and this is a key element of our priorities this year. We have detailed plans set out to drive the necessary improvement and these will be monitored and managed through our established governance processes. The focus on how we work is covered in the well lead domain as are the financial targets we have for the year. The month one position is as we expected and therefore on track for our control total although we are awaiting final confirmation of the agreed position for the year from NHSI. This has and will continue to be challenging as it requires us to make difficult decisions and substantial improvements on staffing costs and productivity and this will only be possible by us all working together with our partners across the system. This requires us to be clear about the priorities we have, provide the necessary support and development to our staff and also make changes to the way we work today and set and implement a clinical strategy for the future. All of this is underpinned by the cultural change and leadership development work and focus on staff wellbeing which are also key elements of our priorities this year.

166 Understanding the IPR 1 Headlines: Each domain has an aggregated score which is made up of a weighted score derived from their respective subdomain. There is an overall executive Trust summary followed by more specific commentaries for each of the five domains which are based on the recent Carter review and the way that the CQC organises its inspection into specific areas. 2 Domain Metrics: Each domain will have two pages; one showing overall aggregated scores split by sub-domain and another showing a selection of key metrics which help form the sub-domain aggregated metric scores. The first page indicates the sub-domain weighting % which is used to calculate the overall domain score. The second page illustrates key (but not all) metrics measured within that sub-domain. This is important as it explains why the sum of each metric doesn t total 100%. A list of all metrics used in the calculation is summarised in the Glossary pages.

167 Understanding the IPR 3 Key Metrics: This section provides the actual data that builds up into the domain, the actual performance in percentage or volume terms for any given metric. These metrics are explored in more detail in the next section, Strategic Themes. 4 Strategic Themes: The Strategic Theme pages house key metrics with additional analysis, showing trend over the last 12 months. They show the latest month RAG together with the last 12 months position status (ie improved or worsened % from the previous 12 months plus average metric score). In addition to this it includes a metric description and data assurance stars which reflects how assured the data is. Description for how the data assurance stars are formulated is explained in the Glossary. All RAGs are banded as Green, Amber and Red. The threshold for the green RAG point is indicated in the Glossary pages together with how much weight each metric holds towards the sub-domain.

168 Strategic Priorities

169 Contents Headlines Organisation Overview 7 Caring 8 Effective 10 Responsive 12 Safe 14 Effective 16 Well Led 18 Strategic Themes Patient Safety 20 Human Resources 32 Key Performance Indicators 35 Finance 43 Health & Safety 44 Use of Resources 46 Improvement Journey 49 Glossary Metric Descriptions 51

170 Headlines Caring Positives Falls reduced Falls rate below national average No avoidable deep ulcers FFT improved on March Challenges Mixed sex breaches, although high have reduced on last month A rise in the number of complaints A deterioration in meeting responses meeting the date agreed with client D J F M Apr Sally Smith Effective Clinical audit programme remains on plan WHO checklist is consistently delivering No cancelled operations on the day due to non-clinical reasons Bed occupancy remains high Reportable delayed discharges of care remain high D J F M Apr Jane Ely Responsive There has been some improvement against the 4hour A&E standard DM01 position is compliant Cancer two week wait and breast symptomatic did not meet the standard 6 patients waited over 52 week for an elective procedure D J F M Apr Jane Ely Safe HSMR below national Stable number of SIs reported cdiff on trajectory 0 MRSA infections reported in month VTE recording is being more closely managed with an action plan in place Elective crude mortality has risen in month Safety thermometer is slightly improved but still requires focus D J F M Apr Paul Stevens Well Led Improvement in nursing shift fill rates, both day and night No cash borrowing requirement in month Heads of Agreement for 2016/17 in place with CCGs and NHSE No health and safety notices New Board Integrated Performance Report Financial control total not yet agreed. Plan assumes 16.1m of STF, 20m CIPS and no readmissions fines Increasing pay costs driven by higher employee NI and staff pay awards continued high use of agency staff and breaches of framework and cap. 2.2m spent in April v 1.9m in March Staff turnover stable at 11% but increasing level of vacancies from 8% to 9% 2.8m deficit in month Increase in uncoded spells (0 to 2%) D J F M Apr Nick Gerrard

171 Caring OVERALL DOMAIN SCORE D J F M Apr Weight Initiatives D J F M Apr 10 % Patient Experience D J F M Apr 90 %

172 Caring Initiatives Dementia Diagnosed CQUIN Delivered % Dec Jan Feb Mar Apr Green Weight >= % Heart Failure CQUIN Delivered % >= % COPD CQUIN Delivered % >= % Patient Experience Diabetes CQUIN Delivered % >= % 75+ Frailty Pathway CQUIN Delivered % >= % Compliments to Complaints (#/1) >= % Overall Patient Experience % >= % Complaint Response in Timescales % >= 85 5 % FFT: Recommend (%) >= % FFT: Not Recommend (%) >= 1 11 %

173 Effective OVERALL DOMAIN SCORE D J F M Apr Weight Beds D J F M Apr 25 % Clinical Outcomes D J F M Apr 25 % Productivity D J F M Apr 25 %

174 Effective Dec Jan Feb Mar Apr Green Weight Beds Bed Occupancy (%) <= % IP - Discharges Before Midday (%) >= % DToCs (Average per Day) < % Clinical Outcomes Readmissions: EL dis. 30d (12M%) < % Readmissions: NEL dis. 30d (12M%) < % Clinical Audit Prog. Audit >= 3 5 % Audit of WHO Checklist % >= % Demand vs Capacity DNA Rate: New % < 7 0 % DNA Rate: Fup % < 7 0 % New:FUp Ratio (1:#) % Productivity LoS: Elective (Days) % LoS: Non-Elective (Days) % Theatres: Session Utilisation (%) >= % Theatres: On Time Start (% 30min) >= % Non-Clinical Cancellations (%) < % EME PPE Compliance % >= %

175 Responsive OVERALL DOMAIN SCORE D J F M Apr Weight A&E D J F M Apr 25 % Cancer D J F M Apr 25 % Diagnostics D J F M Apr 25 % RTT D J F M Apr 25 %

176 Responsive Dec Jan Feb Mar Apr Green Weight A&E ED - 4hr Compliance (%) >= % Cancer Cancer: 2ww (All) % >= % Cancer: 2ww (Breast) % >= 93 5 % Cancer: 31d (Diag - Treat) % >= % Cancer: 31d (2nd Treat - Surg) % >= 94 5 % Cancer: 31d (Drug) % >= 98 5 % Cancer: 62d (GP Ref) % >= % Cancer: 62d (Screening Ref) % >= 90 5 % Cancer: 62d (Con Upgrade) % >= 85 5 % Diagnostics DM01: Diagnostic Waits % >= % Audio: Complete Path. 18wks (%) >= 99 0 % Audio: Incomplete Path. 18wks (%) >= 99 0 % RTT RTT: Incompletes (%) >= % RTT: 52 Week Waits (Number) < 1 0 %

177 Safe OVERALL DOMAIN SCORE D J F M Apr Weight Incidents D J F M Apr 20 % Infection D J F M Apr 20 % Mortality D J F M Apr 50 % Observations D J F M Apr 10 %

178 Safe Dec Jan Feb Mar Apr Green Weight Incidents Mixed Sex Breaches % Serious Incidents (STEIS) % Harm Free Care: New Harms (%) >= % Clinical Incidents: Total % Falls (per 1,000 bed days) < = 5 20 % Pressure Ulcers Cat 2 (per 1,000) <= % Infection Cases of MRSA (per month) < 1 40 % Cases of C. Diff (Cumulative) <= Traj 40 % Mortality HSMR (Index) < % Crude Mortality EL (per 1,000) < % Crude Mortality NEL (per 1,000) < % RAMI (Index) < % Observations Cannula: Daily Check (%) >= % Catheter: Daily Check (%) >= % Central Line: Daily Check (%) >= % VTE: Risk Assessment % >= % Obs. On Time - 9pm-8am (%) >= % Obs. On Time - 8am-9pm (%) >= %

179 Well Led OVERALL DOMAIN SCORE D J F M Apr Weight Culture D J F M Apr 15 % Data Quality & Assurance D J F M Apr 10 % Finance D J F M Apr 25 % Health & Safety D J F M Apr 10 % Staffing D J F M Apr 25 % Training D J F M Apr 15 %

180 Well Led Dec Jan Feb Mar Apr Green Weight Culture Staff FFT - Work (%) >= % Staff FFT - Treatment (%) >= % Data Quality & Assurance Not Cached Up Clinics % < 4 25 % Valid NHS Number % >= % Uncoded Spells % < % Finance I&E m >= Plan 30 % Cash Balance m >= Plan 20 % Total Cost m >= Plan 20 % Forecast I&E m >= Plan 20 % Normalised Forecast m >= Plan 10 % Health & Safety RIDDOR Reports (Number) <= 3 20 % Formal Notices % Staffing Sickness (%) < % Staff Turnover (%) < % Vacancy (%) < % Shifts Filled - Day (%) >= % Shifts Filled - Night (%) >= % Agency % <= 10 0 % NHSP Use % of Agency > 90 0 % Training Appraisal Rate (%) >= % Mandatory Training (%) >= %

181 Mortality Apr HSMR (Index) Apr RAMI (Index) 89 (9.5%) 94 (5.3%) Strategic Theme: Patient Safety Hospital Standardised Mortality Ratios (HSMRs), via CHKS, compares the number of expected deaths with the number of actual deaths, in Hospital. The data is adjusted for factors statistically associated with hospital death rates and scores the number of secondary diagnoses according to severity (Charlson index). Risk Adjusted Mortality (via CHKS) computes the risk of death for hospital patients and compares to others with similar characteristics. Data including age, sex, length of stay, clinical grouping, ICD10 diagnoses, OPCS procedures and discharge method is constructed. Apr SHMI 103 (2.8%) Summary Hospital Mortality Indicator (SHMI) as reported via CHKS includes in hospital and out of hospital deaths within 30 days of discharge. Apr Crude Mortality EL (per 1,000) 0.3 (-28.9%) The number of deaths per 1,000 elective admissions. 20

182 Apr Crude Mortality NEL (per 1,000) 29 (-2.8%) Strategic Theme: Patient Safety The number of deaths per 1,000 non-elective admissions. Comments: While HSMR is higher in comparison over the last 12 months to the previous period, it still remains well below the national level and has shown over the last seven months that the rate is falling. This trend is consistent with RAMI. Both HSMR and RAMI, if using up to date data would be above plan for April however because the methodology uses HES data, it will always be atleast two months in arrears. April Crude Mortality NEL has reduced again for a second consecutive month and is below last years rate. The SHMI recorded on the National Health & Social Care Information Centre is 1.02, this is an improving position but hidden behind the overall indicator there remain concerns over sepsis-related mortality. At the front door, despite the overcrowding in our emergency departments, screening for sepsis has improved again with 69% of all patients with a EWS of 4 or more screened with a similar performance on all 3 sites. Mean time to receipt of intravenous antibiotics was 58 minutes despite the issues with the ED 4hr standard. 21

183 Apr Serious Incidents Serious Incidents (STEIS) 76 (-9.5%) Strategic Theme: Patient Safety Number of Serious Incidents. Uses validated data from STEIS. Apr Never Events (STEIS) 8 Monthly number of Never Events. Uses validated data from STEIS. Comments: Work continues to take place within divisions to improve the quality of the investigations and Duty of Candour actions to enable RCA completion within the 60 day deadline. The CCG have noted the quality of the RCAs have improved and the numbers of breaches have reduced. One case remains open that has been open for longer than a year but this is close to completion. The numbers of breached cases have dropped from 16 to 14 and work continues to ensure that the oldest cases will be closed first. One SI was downgraded. There were four new SIs relating to: the colonoscopy pathway and delays in the process; an abdominal aortic aneurysm treatment delay; pregnancy screening scans; a child with tuberculosis. Four serious incidents were required to be reported on STEIS in April. Six cases have been closed and three downgrades agreed in April; there remains 60 serious incidents open at the end of April. Over the last 12 months incident reporting has increased at all three main sites. 22

184 Strategic Theme: Patient Safety Infection Control Apr Cases of MRSA (per month) 2 (100.0%) Number of Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemia, as defined by NHS National Operating Framework (HQU01). Number of MRSA cases assigned to EKHUFT. Apr Cases of C. Diff (Cumulative) 4 (-85.7%) Number of Clostridium difficile infections (CDIs), as defined by NHS National Operating Framework, for patients aged 2 or more (HQU01) Apr E. Coli 124 (93.8%) The total number of E-Coli bacteraemia recorded Apr MSSA 35 (66.7%) The total number of MSSA bacteraemia recorded Comments: The Trust finished the last financial year in a very positive position with regard to infection control. We still have MRSA bacteraemia rates that are lower than national, which continues with 0 in April. We ended the year with the lowest number of C.difficile cases to date in any one financial year and April position is on trajectory. In April we have seen a drop in the total number of E-coli and MSSA bacteraemias. 23

185 Strategic Theme: Patient Safety Harm Free Care Apr Harm Free Care: New Harms (%) 98 (-0.3%) Percent of Inpatients deemed free from new, hospital acquired harm (ie free from: New pressure ulcers (categories 2 to 4); Injurious falls; New Urinary Tract Infection (UTI); New Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE) or Other VTE) Data source - Safety Thermometer. Apr Harm Free Care: All Harms (%) 92 (-0.9%) Percent of Inpatients deemed free from harm (ie free from old and new harm - Old and new pressure ulcers (categories 2 to 4); Injurious falls; Old and new Urinary Tract Infection (UTI); New Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE) or Other VTE) Data source - Safety Thermometer. Comments: Overall Harm Free Care relates to the Harms patients are admitted with as well as those they acquire in our care and remains below national average. However, Harm Free Care experienced in our care is higher than national average which means that our patients are receiving care that causes less harm than is reported nationally. There was a slight fall in April (97.8%) compared to March (98.2%). WHH maintained the same as last month at 97.9%, K&C reported a slight fall from 98.8% in March to 98.1% in April and QEQM also reported a slight fall from 98.0% in March to 97.4% in April. 24

186 Strategic Theme: Patient Safety Pressure Damage Apr Pressure Ulcers Cat 2 (per 1,000) 0.24 (-88.6%) Number of avoidable Category 2 hospital acquired pressure ulcers, per 1,000 bed days Data source - Datix. Apr Pressure Ulcers Cat 3/4 (per 1,000) 0.02 (-96.0%) Number of avoidable Category 3/4 hospital acquired pressure ulcers, per 1,000 bed days Data source - Datix. Comments: In April 16, a total of 34 acquired Category 2 pressure ulcers were reported and 11 were defined as avoidable due to learning in respect of aspects of the SKINS bundle. This is an increase from last month of 12 ulcers and 3 avoidable ulcers. Six of the eleven avoidable ulcers were located at the sacrum (1 at K & C, 2 at QEQM and 3 at WHH). As the 'Bottoms Up' campaign was commenced in November 2015 to reduce sacral ulcers, further time is required to fully drive through the campaign to full effect. The campaign is set to be relaunched at the Tissue Viability Link Nurse day in May and a stretch 30% reduction trajectory has been set. The TV team are also reviewing the data to identify specific areas of concern for targeted intervention. Extra tissue viability equipment has also been procured for each acute site during this April and the effect is currently being monitored. There were no confirmed category three of four acquired pressure ulcers in April 16. There were 7 unstageable/deep tissue injury reported of which 3 were avoidable. Two avoidables occurred on Bishopstone ward (sacrum and heels) and one at WHH, CM1 (sacrum). Individual learning points have been identified and are being addressed. These include, limiting time upright sitting; improving documentation and reassessing pressure ulcer risk on change in patient condition and stepping up prevention plan appropriately. 25

187 Strategic Theme: Patient Safety Falls Apr Falls (per 1,000 bed days) 5 (-91.9%) Total number of recorded falls, per 1,000 bed days. Assisted falls and rolls are excluded. Data source - Datix. Comments: National falls data indicates an average of 6.63/1000 bed days and a rate of falls with moderate or severe harm of 0.19/1000 bed days, our falls with moderate and severe harm rate was 0.18/1000 bed days in the National audit data. Total of 168 falls across all sites in April, at K&CH, 54 at QEQMH, 67 at WHH 3 falls resulted in fractures 1. 1 hip and clavicle fracture at QEQMH. A RCA has been held but the investigation team were unable to reach a decision about the fall being avoidable or unavoidable. The patient was medically fit for discharge and wanted to go home. He declined hip protectors and had capacity, was unsteady but wished to mobilise independently. His own decision was made on the balance of risk and independence fall at WHH resulted in finger fractures. This was deemed avoidable as the patient was moved late at night and the falls risk assessment was incomplete hip fracture at WHH was unavoidable as all measures were in place prior to and at the time of the fall. The Fallstop! Project has been delayed due to a staffing crisis in the Falls Prevention Team. However, the team are planning a secondment opportunity for an Associate Practitioner and therapist to start the programme in the summer at WHH within UCLTC where comparable rates with the other sites are highest. 26

188 Strategic Theme: Patient Safety Incidents Number of Total Clinical Incidents reported, recorded on Datix. Apr Clinical Incidents: Total 605 (12.0%) The number of blood transfusion errors sourced from Datix. Apr Blood Transfusion Errors 151 (-9.6%) Apr Medicines Mgmt. Incidents 1247 (1.9%) The number of medicine management issues sourced from Datix. Comments: In Apr-16, eight incidents have been graded as death and five as severe harm. In addition, 22 incidents have been escalated as a serious near miss, of which 16 are still under investigation. The number of moderate harm incidents reported during Apr-16 is higher than in previous months [Apr-16: 73 compared with Mar-16: 48 and Apr-15: 27]. In April, there were nine blood transfusion errors reported (13 in Mar-16 and 16 in Apr-15). Themes included two suspected allergic reactions to blood products, two wrong blood in tube incidents and two prescription/documentation errors (including traceability). Five incidents were graded no harm, three as low harm and one as moderate harm, in which the patient developed a high temperature, rigors and shortness of breath during transfusion of a second unit of a blood. The suspect unit has been returned to NHSBT for inspection. This incident is currently under investigation. There were 83 medication incidents reported as occurring in April (116 in Mar-16 and 90 in Apr-15). Over the last 12 months there has been a gradual increase in reporting of medication incidents at QEH. A downward trend is showing for WHH and K&CH. 27

189 Apr Friends & Family Test FFT: Response Rate (%) 34 (-19.6%) Strategic Theme: Patient Safety The percentage of patients who responded to the Friends & Family Test Apr FFT: Recommend (%) 96 (1.6%) Of those patients who responded to the Friends & Family Test and knew their opinion, would recommend the Trust Apr FFT: Not Recommend (%) 1.9 (-31.1%) Of those patients who responded to the Friends & Family Test and knew their opinion, would not recommend the Trust Comments: During April we received 9,280 responses in total. Overall 36% of eligible patients responded and 96% of them would recommend us to their friends and family and 1.6% would not. The total number of inpatients, including paediatrics who would recommend our services was 95% (93% in Mar-16). For A&E it was 79% (75% in Mar-16), maternity 95% (97% in Mar-16), outpatients 90% (91% in Mar-16) and day cases 94% (93% in Mar-16). The Trust star rating in February is 4.52 (4.48 in Mar-16). The response rate for inpatients was 36% (38% in Mar-16), A&E 24%, (26% in Mar-16), maternity 33% (37% in Mar-16). (Please note as per DH guidelines only the Birth experience is given a response rate, FFT questions at other stages in the patient's pathway are not calculated or required nationally). The response rate for outpatients was 24% (26% in Mar-16) and 31% for day cases (35% in Mar-16). All areas receive their individual reports to display each month, containing the feedback left by our patients which will assist staff in identifying areas for further improvement. This is monitored and actioned by the Divisional Governance Teams. 28

190 Apr Patient Experience 1 Overall Patient Experience % 90 (2.3%) Strategic Theme: Patient Safety This provides an overall inpatient experience percentage by weighting the responses to each question (eg. Did not eat or poor = 0, fair = 0.3, good = 0.6, very good = 1) Apr Care Explained? % 85 (13.7%) Was your care or treatment explained to you in a way you could understand by the medical/nursing/support staff? This measures the percentage of inpatients who answered 'yes always' or 'yes sometimes' in response to the inpatient survey. Apr Care that matters to you? % 93 Did you get the care that matters to you? Comments: Further work during June-16 will focus on improving response rates. Each ward reviews their real-time monitoring data regularly. This data is available via the ward dashboard and is updated frequently to ensure a valuable real time tool to capture patient experience and satisfaction feedback, to assist to identify any areas of concern and any areas of praise instantly and action can be demonstrated as needed. In Dec-15 the questions within the survey were updated to reflect the issues highlighted in the national inpatient survey to enable closer monitoring of improvement. Questions related to involvement in care decisons, staff availability to discuss concerns and privacy in discussing treatement have been substituted for questions on explanation of care / treatment and pain control as they are areas where we perform less well. This information is also shared as "heat maps" with other teams. From this actions are taken to address the themes which are considered with the Friends and Family Test feedback, and compliments and complaint information. This is monitored and actioned by the divisional governance teams. 29

191 Apr Patient Experience 2 Respect & Dignity? % 96 (0.0%) Strategic Theme: Patient Safety Overall, did you feel you were treated with respect and dignity while you were in hospital by the nursing staff? This measures the percentage of inpatients who answered 'yes always' or 'yes sometimes' in response to the inpatient survey. Apr Cleanliness? % 92 (-0.5%) In your opinion, how clean was the hospital room or ward that you were in? This measures the percentage of inpatients who answered 'very clean' or 'fairly clean' in response to the inpatient survey. Apr Hospital Food? % 71 (0.3%) How would you rate the hospital food? This measures the percentage of inpatients who answered 'very good' or 'good' in response to the inpatient survey. Comments: Cleanliness scored fractionally down this month but remains higher than the preceding 5 months. Cleaning audit scores remain high at 98% overall. Hospital food improved marginally from last month but remains RED if benchmarked against the PLACE scores. The Trust continues to work with SERCO to improve food standards and we have jointly won the Hospital Food Caterer of the Year Award. The Soft FM partnership board along with SERCO are going to look at potential alternative national metrics for food as it was felt 80% at Green was high compared to other sectors/providers. 30

192 Mixed Sex Apr Mixed Sex Breaches 375 (220.5%) Strategic Theme: Patient Safety Number of patients experiencing mixed sex accommodation due to non-clinical reasons. Comments: During Apr-16, 4 non-justifiable incidents of mixed sex accommodation breaches occurred between WHH ED and CDU. This information has been reported to NHS England via the Unify2 system. There were 14 mixed sex accomodation occurences in total, affecting 68 patients. This shows a reduction from last month when there were a total of 18 occurrences affecting 111 patients. The remaining incidents occurred at K&C on the Kingston stroke unit (1), at QEQM on the Fordwich stroke unit (7) and the CCU (2) which are justifiable mixes based on clinical need. During Mar-16 reporting of mixed sex occurrences improved at the WHH. The Divisional Head of Nursing has addressed the high number of breaches in the Observation Bay in CDU by designating two separate bays that separate men and women to care for both the short stay and observation bay patients together. 31

193 Gaps & Overtime Apr Vacancy (%) 8.8 (5.8%) Strategic Theme: Human Resources % Vacant positions against Whole Time Equivalent (WTE) Apr Staff Turnover (%) 11.2 (-15.0%) % Staff leaving & joining the Trust against Whole Time Equivalent (WTE). Metric excludes Dr's in training Apr Sickness (%) 3.7 (-2.2%) % of Full Time Equivalents (FTE) lost through absence (as a % of total FTEs). Data taken from HealthRoster: erostering for the current month (unvalidated) with previous months using the validated position from ESR. Calculated cumulatively/ytd. % of FTEs lost through absence (as a % of total FTEs). Apr Overtime % 8.8 % of Employee's that claim overtime Comments: The key findings of a detailed analysis of staff turnover and sickness absence will be presented to the Strategic Workforce Committee (SWC) on 20th May It has identified that the highest percentage of leavers are Admin and Clerical staff followed by Nursing and Midwifery staff. Turnover has remained at similar levels for the last few months. The highest reasons for voluntary resignation are other / unknown following by relocation and then work life balance. Further work will be undertaken on the reasons for leaving, and reported to the SWC. In terms of sickness absence, the analysis provides information on reasons for sickness absence in the first year of employment together with analysis on long and short-term absence. The predominant reason for short term absence is cold, cough, flu/influenza followed by gastro-intestinal problems. Long term absence is anxiety /stress / depression followed by musculoskeletal problems. The Head of Occupational Health will be reporting to a future meeting of the SWC on work being undertaken to support and improve employee health and well being. The Trust s vacancy rate is examined in detail at Executive Performance Reviews (EPRs) and SWC. We have seen a slight increase in vacancy due to adjustments made to budgets to reflect increases in establishments. 32

194 Apr Temporary Staff Employed vs Temporary Staff 92 (-0.4%) Strategic Theme: Human Resources Ratio showing mix of permanent vs temporary staff in post Apr Agency % 15.2 % of Employee's that are recruited through an agency Apr Apr NHSP Use % of Agency Agency Orders Placed % of Employee's recruited through an agency that are NHSP Total count of agency orders placed Comments: Reduction in agency spend is a key component of our cost improvement programme ( 4.1m). There is an agency programme programme, led by the Head of Human Resources supported by the Service Improvement Team. The Trust monitors and reports on a weekly basis, all agency shifts that breach the agency framework and NHSI pay caps by occupational group and division. Divisions are held to account for delivery of their agency CIPs through EPRs. The Trust has recently tendered for a new Bank partner. 33

195 Apr Workforce & Culture Mandatory Training (%) 84 (6.5%) Strategic Theme: Human Resources The percentage of staff that have completed mandatory training courses, this data is split out by training course. Apr Appraisal Rate (%) 80.3 (6.1%) Number of staff with appraisal in date as a % of total number of staff. Apr Time to Recruit 11 (5.2%) Average time taken to recruit to a new role Apr Staff FFT - Work (%) 52 (8.6%) Percentage of staff who would recommend the organisation as a place to work - data is quarterly and from the national submission. Comments: Statutory training has risen to 87% which remains below the target of 90%, however it does compare favourably to other NHS organisations. There remains a significant risk in regard to statutory training compliance. In February 2016, 897 staff were identified as not completing one or more of the statutory training courses required. Action plans have been implemented by the divisional leadership team, and we have since seen a moderate reduction. The Trust staff appraisal rate has declined as expected, as the majority of staff have their appraisals in April and May. I would anticipate this returning to compliant levels in June (reported in July). We have seen a slight reduction in Staff FFT. Each Division has developed a Great Place to Work plan that incorporates the feedback from the Staff FFT and the national NHS Staff Survey Results. The divisional plans will be presented to the SWC on 20th May Further work needs to be undertaken to reduce the time to recruit new staff, and this will be monitored at future SWC meetings. 34

196 Summary Performance The NHS Constitution sets out that a minimum of 95 per cent of patients attending an A&E department in England must be seen, treated, and then admitted or discharged in under 4 hours. This target was last revised by the Department of Health in When a decision to admit a patient from the emergency department is made, there is zero tolerance for waits of over 12 hours for admission to a ward. Due to the Trust being unable to achieve compliance against the 4 Hour Standard, it has developed an urgent care recovery plan aimed at improving performance across the Trust. It has been mandated through the Sustainability & Transformational Plans that the Trust will achieve performance levels which demonstrate consistent improvement over the course of , with overall compliance in excess of 90%.

197 April performance against the 4 hour target was 84.02%, against a trajectory of 85.22% and a compliance target of 95%. April s performance level is improved compared to the February and March positions, with a higher proportion of patients seen within 4 hours. Analysis of the breach reasons shows a reduction in the proportion of breaches due to delays to be seen by a first clinician, (32% of all breach reasons, compared to 43% in March). This improvement in patients being seen by a clinical decision maker more promptly is also shown by the increased proportion of patients seen within 60 minutes, a sign of reduced overall waiting times for patients compared to recent months. There was a single 12 hour trolley wait breach in the month. In April, the William Harvey Hospital (WHH) in Ashford showed a clear mid-month step change in performance, with the last 14 days of the month showing overall performance of 85% against the 4 hour compliance standard, contrasting against 71% for the first fortnight of the month. There was no notable change in the volumes of attendances to the site over this period of time, but it is noted that the last week of April saw fewer extended waits to be seen, and an increased proportion of patients first seen within 60 minutes (improved to 49% within 60 minutes compared to 31% in the first fortnight). Improvements in Emergency Department performance are being pursued through the urgent care recovery plan, which has gone through a detailed review to identify areas which will improve performance the most. The 4 key areas and actions are as follows; Priority 1- Improvements in ED Team Based Working This pilot has been developed by the senior clinical team at QEQMH. Senior medical, nursing and support staff are allocated into teams who are responsible for specific areas of the Emergency Department with clinical responsibility for managing patients in those areas through their pathways. Implemented in April The pilot is being run between the hours of There was an immediate positive impact with an improvement on the 60 minute standard from 31% to 48%, which resulted in more patients being seen by a clinician within 60 minutes of arrival in the department. 4hr compliance overall sees a 5% compliance increase for non-admitted patients during pilot hours moving from 81% to 86%. The hours of cover are being extended until in May as staffing allows, however there are currently 4 speciality doctor vacancies which are being covered by locum doctors whilst recruitment is completed and this may impact on the department s ability to provide the service consistently. Nine new speciality doctors have accepted posts and will be arriving in the next 3 6 months. Consultant Recruitment The Emergency Department is funded for 10 Emergency Medicine Consultants on each site. In 2015/16 there were 6 substantive consultants in post. There is a national shortage of Emergency Medicine Consultant and Specialist Registrars in training. An internal consultant development programme was implemented in 2015/16 to enable speciality doctors to be supported by a dedicated clinical supervisor and teaching programme, linked to the College of Emergency Medicine examination programme. The programme has been successful with 3 speciality doctors expected to be able to apply for substantive consultant posts within 1-2 years. Over the past year there have also been an additional 3 consultants have been recruited, with two of the applicants coming into post in September 2016.

198 Early Senior Intervention (ESI) project The senior clinical team at WHH have piloted an internationally recognised assessment process whereby self-presenting and ambulance patients are assessed by a senior doctor or nurse upon arrival in the Emergency Department. Patients will then be streamed to the appropriate pathway to ensure that timely and appropriate clinical care is provided and the sickest patients are seen and treated immediately. The ESO project has been accepted by the TIPs programmes (Teams Improving Patient Safety). Full roll out may require additional nursing staff to support the model and this has been included in the nursing workforce review which was completed in April 16. Priority 2 - Re-launch of Acute Medical Model at QEQM. The Acute Medical Model was implemented as Phase 1 on 2 April The model has had an immediate positive impact on patient flow and has been fully supported by the clinical teams on site. The model is being evaluated on a weekly basis and managed through a project structure to ensure that the learning is captured and will be shared. Due to the model s success, plans are in place to roll out the model to WHH with the project group being established in May and implementation by the end of June Aims of model: Strong MDT approach to managing patients pathway Direct referrals to specialist teams within MDT board round/careflow electronic referrals Reduced LOS both short stay & specialist patients as indicated earlier in pathway Improved flow across emergency floor / improved patient experience Increasing use of emergency ambulatory care / improved management for primary care referrals Further developments/consideration Priority 3 - Implementation of SAFER 7 day working Recruit Acute Medical staffing team Inclusion of Frailty team within model SAFER has been implemented on Sandwich Bay and Minster Ward at QEQMH and Cambridge L and Cambridge J at WHH. The processes are becoming embedded with morning MDT ward rounds established. A discharge website is being developed to include information and policies relating to simple and complex discharges, SAFER tools and patient leaflets. Next steps include drop in training sessions for MDT staff around discharge, SAFER principles and patient flow. Developing a SAFER dashboard to monitor progress and improvements. Identify a consultant champion for each ward area and improve senior clinical engagement

199 Priority 4 - Site Management Arrangements Operational Control Centres (OCC s) Meeting Structures Communication Systems OCC s have been established on all three sites, with the major incident control centres now being formally co-located. The OCC s have quickly becoming established as information hubs for consultants, senior nurses and managers to provide and receive information. Trustwide video conferenced SITREP meetings have been standardised with meetings being held at and Additional meetings may be requested according to site escalation status. Chaired by the Head of Clinical Operations, the site based meetings focussing on the provision of safe and effective emergency and elective patient flow, staffing issues and risk are held twice daily. The above meetings are also supported by a SITREP telephone call to escalate emerging risks to the Head of Clinical Operations or Divisional Director for UCLTC. QEQMH is piloting the use of mobile telephones using wi-fi to improve the network coverage. Trajectory Confidence April performance against the 4 hour target was 84.02%, against a trajectory of 85.22%. The new Acute Medical Model and Team Based Working models all had a positive impact on performance. The improvements gave confidence that the projects which have been developed and implemented by the clinical teams would provide the sustained improvement to patient experience, quality and flow. The formalised meeting structure, improved discipline and information flows that the OCC s have delivered have also had a positive impact on performance, particularly at QEQMH where the meeting structure has been developed and become established. The QEQMH communication and meeting model is being rolled out to all sites. The on-going risk to delivery of the trajectory is: The number of DTOC s (delayed transfers of care) and access to short term external capacity in the community. A high % of breaches of the 4 hour emergency access standard relate to patient flow and bed availability. High numbers of patients attending ED in the evenings who could be managed by primary care, in particular paediatric attendances.

200 Key Performance Indicators % May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 Green 62 day Treatments 70.31% 72.43% 64.84% 68.83% 69.76% 70.45% 70.89% 79.11% 71.68% 79.86% 74.53% 69.64% >=85% 100 day breaches <0 Demand: 2ww Refs 2,555 3,020 3,195 2,535 2,835 2,748 2,785 2,550 2,725 2,839 2,908 3,050 2ww Compliance 94.24% 92.11% 90.32% 89.96% 95.05% 95.62% 94.52% 93.87% 93.28% 94.10% 93.59% 89.00% >=93% Symptomatic Breast 93.08% 87.50% 85.45% 80.52% 93.46% 94.12% 93.55% 92.22% 94.06% 88.03% 93.02% 85.00% >=93% 31 Day First Treatment 91.84% 96.09% 90.64% 94.02% 93.17% 96.43% 97.48% 98.00% 94.82% 97.07% 98.14% 96.40% >=96% 31 Day Subsequent Surgery 87.80% 92.31% 91.89% 92.86% 92.11% 94.44% 96.97% 94.44% 94.59% 97.50% 96.72% 90.48% >=94% 31 Day Subsequent Drug % % % % % % 98.53% 98.44% 86.17% % % 98.25% >=98% 62 Day Screening 94.44% % 96.15% 88.24% 86.27% 84.21% 86.36% 85.00% 93.75% 95.65% 92.59% 92.31% >=90% 62 Day Upgrades % % 25.00% 33.33% 91.67% 66.67% 77.78% 70.00% 50.00% 86.67% 70.37% 95.00% >=85% Sustainability & Transformational Funding Trajectory % Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Green STF Trajectory 74.20% 76.40% 77.60% 77.40% 82.70% 85.40% 85.00% 85.50% 85.20% 85.10% 85.40% 85.20% Sept Performance 69.64% Sept

201 Summary Performance The Trust s main priority within cancer services is to ensure our patients receive treatment within the appropriate timeframe. The national target which has been consistently difficult for the Trust to maintain is the 62-day referral to treatment, which is made up of three key components: following an urgent referral from their GP, patients should be seen by a clinician within 14 days. If the diagnosis is cancer, a decision to treat should be made as soon as possible, and treatment should begin within 31 days of agreeing this treatment. Over the patient s total pathway, treatment should be initiated within 62 days of the GP making the original urgent referral. There is a zero tolerance of patient waiting greater than 100 days for treatment, and Lead Clinicians now review each of these cases to identify causes and risk of harm to the patient. Where potential harm is identified, a full root cause analysis will be conducted and shared with our Clinical Commissioning Groups and internal governance boards. Due to non-compliance of this 62-day standard over the past year, it is this target for which the Trust has developed an improvement trajectory as part of the Sustainability and Transformation Fund. The Trust has developed an internal plan to return to compliance, including revising capacity in outpatient clinics, re-launching multi-disciplinary team meetings and agreeing timed pathways and operation procedures. The Trust expects to deliver a compliant 62-day pathway by September April performance against this standard is 69.64%, with 42 patients waiting 100+ days for their first treatment. The Trust delivered a total of treatments, and 46 of those patients breached the 62 day timeframe. The Trust aggregate position is 4.56% behind the submitted recovery trajectory, and saw 6 more breaches than anticipated. The breaches are generally caused by either capacity shortfalls or delays in agreed pathways. Priority 1 Provide a named Executive Director responsible for delivering the national cancer waiting time standards. The Trusts named Executive is Jane Ely (Chief Operating Officer). Priority 2 Deliver 62 day cancer wait performance reports for each individual cancer tumour pathway to the Trust Board. The Trust Board receives a cancer briefing report submitted as part of the Chief Operating Officer's report on the Key Performance Standards. This report refers to monthly and quarterly performance for all the cancer standards (2WW, 31days and 62days) for each tumour site. As required the detail includes actions being taken to improve performance and on-going work with CCGs etc. In addition, the cancer tumour performance is discussed in detail at the bi-monthly Cancer Board attended by Executive members, Cancer Lead Clinicians, managers and the wider cancer MDT. Priority 3 Provide and adhere to a cancer operational policy which is approved by the Trust Board. This should include the approach to auditing data quality and accuracy, the Trust approach to ensure MDT coordinators are effectively supported, and have sufficient dedicated capacity to fulfil the function effectively. The Operational Policy for Cancer is in its first version and has not yet been circulated to Cancer Board Members for ratification at the June Cancer Board. This document is a lengthy policy that includes information around the Access Policy, roles and responsibilities of key members of the Cancer and Leadership team along with the escalation policy. Detailed information around data quality, targets and Cancer standards are addressed. Written guidance on internal processes for MDT working is available within the document (including guidance around achieving the effective MDT). Cancer reporting mechanisms including the Cancer Dashboard is also evident within the document. A review of the MDT Coordinators

202 has taken place with a new management structure within the team. MDT coordination and Tracking roles have been separated to ensure PTL is validated on time and MDT work is safe, timely and effective. Due to high levels of sickness and turnaround within the team we have over-established the team with MDM coordinators. We are also going out to advert for an apprentice role within the tracking team. The team have all been re-trained and have met their competencies, led by the Macmillan Project manager. Priority 4 Maintain and publish a timed pathway, which is agreed with the local commissioners and any other Providers involved in the pathway, taking advice from the Clinical Network for the following cancer sites: lung, colorectal, prostate and breast. These should specify the point within the 62 day pathway by which key activities such as OP assessment, key diagnostics, inter-provider transfer and TCI dates need to be completed. Assurance will be provided by regional tripartite groups. East Kent Hospitals University NHS Trust hosts the Kent and Medway Cancer Collaborative - which was previously the Kent and Medway Cancer Network. The collaborative continues to ensure that there are Kent and Medway wide (includes the Cancer Centre) Tumour site specific groups (TSSGs). The TSSGs review the cancer pathways on an annual basis and review the referral proforma, diagnostic tests and other milestones. These pathways are agreed with the SCN (and thus the CCGs). The Trust now has a live cancer dashboard to enable clinical and operational staff to view the cancer PTL as well as understand issues around tumour specific pathways. A list of key events to ensure teams can predict future delays and overcome these before they become an issue is developed within the Cancer Dashboard. As well as the PTL the dashboard will aim to have COSD data added so this is open and transparent. Priority 5 Maintain a valid cancer specific PTL and carry out a weekly review for all cancer tumour pathways to track patients and review data for accuracy and performance. The Trust to identify individual patient deviation from the published pathway standards and agree corrective action. Weekly PTL meetings have always taken place. We have revised the timetables with a new agreed escalation policy. The purpose of the meeting will be to ensure that the operational managers, clinical nurse specialist, Cancer data manager and MDM coordinator meet to discuss each tumour site and review the PTL. Breaches and other issues will be discussed in the weekly operational cancer performance meeting. These meetings have been superseded by the new Key Performance Indicator meetings, chaired by the Chief Operating Officer and Divisional Directors with the purpose of identifying and resolving pathway bottlenecks and key issues preventing achieving performance. Priority 6 Carry out root cause breach analysis for each pathway not meeting current standards, reviewing the last ten patient breaches and near misses (defined as patients who came within 48 hours of breaching). These should be reviewed in the weekly PTL meetings. Work has been undertaken with the Patient Safety Board and Governance leads. Each Monday a breach report with a summarised RCA section is sent to the MDT lead for their review. A Clinical Incident reporting form (DATIX) is also completed on the electronic reporting system. This is then reviewed within the Governance team for the Division concerned. The MDT Lead completes the RCA summary and finalises the electronic DATIX form deciding if a full Route Cause Analysis is required. This is then processed through the Trusts Governance procedures, led by the Governance team. Themes from the DATIX forms and Breach Reports are presented to the Patient Safety Board on a monthly basis and the Cancer Board Bi-monthly. Priority 7 Carry out capacity and demand analysis for key elements of the pathway not meeting the standard (1st OP appointment; treatment by modality). There should also be an assessment of sustainable list size at this point. It has been agreed for all tumour sites that the pathway timelines and key milestones are to be ratified within the specialty and at the cancer board - in line with revised NICE guidance. Following this we are to use the IST capacity and demand tool to calculate the capacity need to deliver the standard. We will ask to complete this in collaboration with the CCGs as the increase in cancer referrals is significant. Diagnostic capacity and first appointment capacity planning is already commenced.

203 Priority 8 Set out an Improvement Plan for each pathway not meeting the standard, based on breach analysis, and capacity and demand modelling, describing a timetabled recovery trajectory for the relevant pathway to achieve the national standard. This should be agreed by local commissioners and any other providers involved in the pathway, taking advice from the local Cancer Clinical Network. Regional tripartite groups will carry out escalation reviews in the event of non-delivery of an agreed Improvement Plan. The Trust has met with the CCGs and agreed to work collaboratively to ensure improvement against the 62 day standard. A recovery trajectory and action plan has been submitted and is reviewed monthly with the CCGs. Urology's trajectory has improved significantly and is no longer the Trusts main concern for delivery of the 62 day standard. The Urology department have made significant improvements to their pathway and a focus has been to ensure this improvement plan is shared with other specialties facing bottlenecks around their pathways. Sharing good practice has been encouraged. Colorectal remains a high risk for the Trust, mainly due to delays in Endoscopy booking which has been recognised at National level. Each tumour site has produced an action plan that will be reviewed weekly at KPI meetings. The Cancer Dashboard will highlight capacity, demand modelling and predictions for future issues therefore making a significant improvement in performance.

204 Summary Performance The DM01 is a national monthly report of performance against the 6 week standard for 15 key diagnostic tests. These include Radiology (MRI, CT and Ultrasound), Audiology, Echocardiography, Neurophysiology and Cystoscopy. Around 13/14 thousand tests per month are measured against the 6 week standard. The Division support the pathways for all patients on an 18 week and Cancer pathway.

205 29 patients waited over the 6 weeks standards in April 16 breakdown below Computed Tomography - 9 Non-obstetric ultrasound - 9 Audiology - 1 Colonoscopy - 5 Gastroscopy - 5 Risks and Issues to sustainable performance Aging equipment and downtime, rebooking enabling patient choice is a risk mitigated by daily conference call across the Trust with full overview and management of slot availability and use of alternative sites. Increasing demand in modalities of CT MRI and Ultrasound Recruitment to key Consultant, Radiographer, Ultra sonographer and Nursing posts, with locums vacancies of Consultants in Radiology, Endoscopy and Neurophysiology Reduction to current workforce and outsourcing availability would dramatically reduce the ability to deliver and sustain the DMO1 position it would further compromise the RTT and cancer standards National public drives in screening can drive capacity and demand issues particularly in Endoscopy. The volume of cancer related to endoscopy referrals this month is at unprecedented levels for the Trust and we are reporting serious incident in relation to the demand and impact this could have on waiting times. What actions are we taking to mitigate and improve performance? Management and servicing of equipment managed closely. Serviced regularly to maximise use and work flow. Daily overview and mapping of demand to capacity bi-weekly overview by senior team to ensure on track and mitigate any issues in month Additional lists being undertaken to include both extended days during the week and Saturday lists. Consultant workforce recruiting to 4 vacancies and reviewing the speciality Interest of posts including Breast. Interview May 16 and July 16 - NHS Locums in place to mitigate in interim. Developing Business case to convert locums to substantive whilst ensuring full productivity and maximise DPA time of all consultants Neurophysiology- Consultant vacancy - The Consultant is employed by EKHUFT on a sessional basis to carry out the diagnostic reporting until the post is recruited to. This allows us to continue to achieve compliance. The vacancy is being actively recruited to. Additional outsourcing of reporting and using I.S. for MRI and Ultrasound (as required) to support delivery. Full Review of demand by speciality and by Division and Direct Access flows this is actively being shared with Divisions and CCGs Working with Cardiology to review their pathways and booking processes and enable Nurse led booking of requests and reduce bulk ordering of tests. Endoscopy we will continue to manage with daily overview of all available capacity. We continue to offer Direct access and straight to diagnostic approaches.

206 Summary Performance The NHS Constitution gives all patients the legal right to start their non-emergency NHS consultant-led treatment within a maximum of 18 weeks from referral; unless they choose to wait longer or it is clinically appropriate that they wait longer. To measure compliance against this constitutional right EKHUFT is monitored against the Percentage of Patients on incomplete RTT pathways (yet to start treatment) waiting no more than 18 weeks from Referral, the Threshold for national compliance has been set at 92%. There is a zero tolerance for any patient waiting over 52 weeks for treatment to commence. All breaches undergo a full root cause analysis, the results are shared with our Clinical Commissioning Groups and themes and lessons learnt are cascaded through our divisional governance structure.

207 Throughout the last year the Trust has been unable to deliver performance against the national standard as the number of patients waiting for treatment significantly exceeded our capability to see and treat within 18 weeks of referral. The Trust has developed internal activity plans which address the imbalance, and delivery of these activity levels alongside primary care commitments to reduce demand will enable the Trust to successfully deliver the Trajectory over the course of the financial year, this has formed the basis of our Sustainability and Transformation Fund Improvement Trajectory. The Trust intends to deliver compliance against the national standard by September In April performance against the 2016/17 standard was 88.2% and six patients had waited for treatment for more than 52 weeks as at the end of the month. Unplanned losses in capacity due to the four junior doctor strike days, plus significant localised medical sickness and vacancies have meant we have been unable to deliver the business plan in month one. The Trust continues to receive primary care demand at an unmanageable rate which if left unchecked will render the trajectory unachievable. The Trust has developed four key priorities which address all of the issues detailed above and we will continue to work with our local commissioners to achieve the sustainability and transformational trajectories and comply with our NHS constitutional duty. Priority 1 - Improve Pathway Management Development of New Interactive Patient Tracking List We have developed a new Interactive Patient Tracking System which will enable our Operational Teams to access to live data, ensuring all patients waiting for Treatment are being actively monitored and managed, it is anticipated that this will significantly reduce the risk of patients waiting in excess of 52 weeks for Treatment. The software is now in beta testing phase and it is expected to be in operational use before the end of June Documented Timed Referral to Treatment Patient Pathways Each specialty to map 18 week compliant pathways to enable us to unblock delays, monitor and hold ourselves to account to achievement of the RTT standard. Maxillo Facial and Colorectal and are due to be completed and presented by the end of May 2016, Full Implementation plan for the mapping of all specialities will be completed by end of June Reinstate Patient Tracking List (PTL) meetings - Each divisional team has reintroduced a PTL meeting used to provide robust monitoring at patient level on weekly basis, this will greatly reduce the risk to patients waiting over 35 weeks for treatment to commence. All PTL meetings have been established Priority 2 - Achieve the Outpatient Milestones Demand Management The health system acknowledges the Trust does not have the operational capacity to deal with the current demand, as such our local Clinical Commissioning Groups (CCGs) have committed to reducing referrals to East Kent in 2016/17.

208 The CCGs have confirmed they have identified alternative providers to deliver Orthopaedic pathways in 2016/17, and the Trust is working with Primary Care colleagues to ensure this commences before the end of quarter one as planned. Referrals into the Trust over performed the plan by 12.5% in April; this level of demand will render the recovery plan unachievable and has been escalated to the Chief Executive and will be tabled for discussion at the next CCG Performance Meeting. The Trust has identified an alternative provider who will accept tertiary referrals for complex adult ear procedures. The Trust is now working with CCG to confirm funding approval and timescales. Secure Additional Required Sessions In 2016/17 the Trust will need to provide significant additional outpatient and theatre sessions to meet demand and achieve the required improvement against the RTT standard. All operational teams have been asked to secure additional capacity for the first two quarters of the year. Risk around continued support from nursing staff to accommodate additional capacity Improve Slot Utilisation The Trust has developed operational datasets to locate and identify and fill unused slots, a baseline has been produced and the effectiveness in reducing waste will be reported shortly. Bring forward the Decision to Treat Date Identifying patients who have passed the optimal point in patient pathway and securing decision or treatment capacity Weekly validation, monitored at the weekly Patient treatment tracker meeting Decision making tree to be developed to support patient management Endoscopy delays are extending the colorectal pathway, to mitigate this joint clinical colorectal and gastroenterology meetings established in May Agrred actions are logged and taken forward with the respective operational teams. Priority 3 - Deliver the Efficiency Programme Deliver Theatre Booking Magic Numbers In collaboration with Medical Productivity & Clinical Service Redesign Specialists, Four Eyes Insight, the Trust has identified an efficiency opportunity of 5,000 operative procedures per annum. The Trust has developed key monitoring documentation and enhanced the booking procedures required to achieve the required Theatre efficiency target. It is expected the first results of these will be realised in June Programme The Trust has established a programme of work to reduce the number of Theatre sessions that are cancelled and not re-established. The Trust has developed future focused reports and established meetings to review underutilised and empty theatre sessions. Early indications support a step change reduction in empty sessions.

209 Priority 4 Deliver recurrent demand substantively Live view of current demand Monitoring referrals on a weekly basis to identify outpatient and admitted capacity required to respond Real time response Developing a process to empower staff to address changes in demand, this will reduce delays in responding to unplanned or unexpected changes to patient flow. Agree a waiting list initiative authorisation process, to include weekly demand monitoring and risk management within in the established PTL meetings. Substantive planning identifying demand within core capacity to deliver within financial constraints Job planning clinical teams to deliver flexible sessions to achieve cross covering of clinical commitment during leave in outpatient and theatres. Explore moving cataracts from QEQM and WHH to Dover procedure theatre to release theatre capacity June 2016 Identified Ophthalmology sessions to transfer to extended days to release theatre capacity and provide cross cover July 2016 CCG have committed to providing Independent Sector capacity to transfer patients from the trust admitted waiting list, no timescales have been received from the CCG at present and as such the Trust should consider the continued use of the Independent Sector outsourcing to avoid whole system failure of the RTT Trajectory. Closing the loop on business planning and accountability Developing operational procedures and monitoring tools to ensure delivery of the Business Plan Develop, train and embed consultant session tracker models to ensure we achieve our substantive internal activity. Deliver business planning action plans at speciality level to be monitored weekly at the RTT meeting. Clear objective setting, monitoring and accountability at monthly meetings.

210 Finance Apr I&E m -2.8 (-22.7%) Strategic Theme: Finance The graph shows the Income and Expenditure result for each month - the year to date is shown in the arrow. The year to date plan = 2.6m adjusted for "extra" CIPs. Apr Cash Balance m 7.9 (105.4%) Closing Bank Balance. The graph shows the cash balance at the end of each month - the latest cash balance is shown in the arrow. Apr Total Cost m (-4.5%) Total costs (Total Expenditure + Non-Operating Expenses) or "Run Rate". The graph shows the Total Costs (including nonoperating expenses) for each month - the year to date is shown in the arrow. Apr Forecast I&E m (-67.4%) This shows the latest forecast year end Income & Expenditure position as at 31st March The latest plan is yet to be agreed. 43

211 Strategic Theme: Finance Apr Normalised Forecast m (-63.9%) This shows the Normalised Income & Expenditure Forecast as at 31st March Comments: The Trust ended 2015/16 with a reported 35.3m deficit, an increase of 27m over 2014/15. Compared to the prior year staffing costs increased by 16m (5.1%), clinical negligence insurance rose by 6m (60%), drugs costs by 2m (3.8%), and premises costs by 2m (11.8%). The Trust retained a positive cash balance of 3.8m at year end. The Trust is yet to agree a financial control total for 2016/17 and is in active discussion with NHS improvement. It is assumed that the Trust will receive 16m (non-recurrent) from the national Sustainability and Transformation Fund, although guidance is still awaited. The Major part of the Trust s activity is now on PbR contracts. At the end of April the Trust is reporting a deficit of 2.8m, consistent with a c 10m deficit for the year, and an improvement on the February and March deficits of 4.4m and 3.6m respectively. Agency costs are were disappointingly high, especially in Urgent Care, and further monitoring and controls are being put in place with the divisional teams. It is estimated that the impact of the two day junior doctor strike cost the Trust 0.3m in lost income. The Trust maintained a positive cash balance in month. 44

212 Apr Strategic Direction 1 Representation at H&S 444 (581.4%) Strategic Theme: Health & Safety % of Clinical Divisions representation at the site Health & Safety Committee's Apr RIDDOR Reports (Number) 23 (666.7%) RIDDOR reports sent to HSE each month Apr Formal Notices 0 Formal notices from HSE (Improvement Notices, Prohibition Notices) Comments: H&S Divisional representation has increased positively this month, reflecting the work being done to support Divisions, in identifying named leads The Trust had no RIDDORs to report this month for the second month running The Trust has had no formal notices from the HSE for the last 12 months. Additional metrics as agreed by Board continue to be developed. Lost Time Accidents (LTA), a field is being entered onto Datix in May with communication being sent to staff in June. Between June and September we will monitor how this fields is being embedded. Risk Registers, this is being developed as part of the new risk governance systems being led by Helen Goodwin and due for roll out in Q2. Finally, numbers attending H&S training will be included in next month s report. 44

213 Strategic Direction 2 Apr Accidents 543 (1162.8%) Strategic Theme: Health & Safety Accidents excluding sharps (needles etc) but including manual handling Apr Fire Incidents 128 (1728.6%) Fire alarm activations (including false alarms) Apr Violence & Aggression 432 (819.1%) Violence, aggression and verbal abuse Apr Sharps 133 (682.4%) Incidents with sharps (e.g. needle stick) Comments: Accidents remains the same as last month at 42 which is the lowest point for the last 12 month period Violence & Aggression is slightly up this month at 30 but remains well below our highest point of 53 incidents, in August last year. As agreed accidents involving Sharps has a separated entry in the IPR. The number of incidents for April remains consistent with the average over the last year. 45

214 Pay Independent Apr Payroll Pay m (2.6%) Strategic Theme: Use of Resources Payroll Pay (Permanent+Overtime+Bank). The graph shows the total pay per month for a rolling 12 months - the current year to date is shown in the arrow. Apr Agency Spend m -2.5 (1.7%) Agency and Medical/StaffFlow Locum spend by month YTD. Apr Additional sessions k -328 (-28.4%) Additional sessions (Waiting List Payments) The graph shows the additional sessions (waiting list payments) pay per month for a rolling 12 months Apr Independent Sector k -569 (-11.6%) Independent Sector (Cost of Secondary Commissioning of mandatory services) The graph shows the Independent Sector (cost of secondary commissioning of mandatory services) cost per month for a rolling 12 months Comments: Total pay spend (permanent, overtime, WLI, bank, locum and agency) in April was 28.6m against 27.7m in March. This increase was driven by higher employer NI, the A4C pay award, and payments relating to Easter bank holidays. Agency, Stafflow and locum spend was 2.2m in April against 1.9m in March. This was predominantly in UCLTC. The ceiling set for 2016/17 is 20.1m although a request has been submitted to raise this to 23m Additional sessions in month were 0.3m, similar to the monthly average in 2015/16 when April was the lowest month. ( 7.2m 2015/16). Use of the Independent Sector in April was 0.6m, marginally down on March and lower than the monthly average in 2015/16 of 0.75m (2015/16 9.1m - 3m H&SCV beds, 2.5m Spencer Wing, 3.6m other IS) 46

215 Apr CIPS Balance Sheet 0.0 (NaN) Strategic Theme: Use of Resources Cost Improvement Programmes (CIPs) graph: ytd v plan plus forecast. Metric shows variance difference to plan %. Apr Cash borrowings 0.0 (NaN) Cash borrowings. The graph shows the total year to date cash borrowings - the latest cash borrowing total is shown in the arrow. Apr Capital position m -0.4 (-79.1%) Capital spend. The graph shows the capital spend for each month - the year to date is shown in the arrow. The year to date plan = 14.27m (Annual Plan). Comments: The CIP target for 2015/16 is 20m. In April the Trust is reporting delivery of 0.5m against a 0.6m target. Cash borrowings were 0 in April as planned. Discussions are continuing with NHSI in the profile over the rest of the year. Capital expenditure is on target against its annual plan. There have been no amendments to the programme 47

216 Apr Productivity Clinical Productivity: Theatres 0.0 Strategic Theme: Use of Resources Clinical Productivity graph: theatre sessions v plan. Apr Clinical Productivity: Outpatient 0.0 Clinical Productivity graph: outpatient sessions v plan Comments: The work with Four Eyes has now gone live with the key focus on securing reductions in additional sessions and use of IS. The theatres programme has contributed 32k in April. The outpatients programme is yet to contribute. 48

217 Strategic Theme: Improvement Journey Dec Jan Feb Mar Apr MD02 - Emergency Pathway ED - 4hr Compliance (%) MD03 - Maternity Capacity Midwife:Birth Ratio (%) MD06 - Pathway Flow IP - Discharges Before Midday (%) DToCs (Average per Day) MD07 - Medicines Management Pharm: Fridges Locked (%) Pharm: Fridge Temps (%) Pharm: Drug Trolleys Locked (%) Pharm: Resus. Trolley Check (%) Pharm: Drug Cupboards Locked (%) MD08 - Staffing Levels Vacancy (%) Shifts Filled - Day (%) Shifts Filled - Night (%) MD09 - Workforce Culture Sickness (%) Appraisal Rate (%) Staff Turnover (%) Corporate Induction (%) Staff FFT - Work (%) Staff FFT - Treatment (%) MD11 - Clinical Audit Clinical Audit Prog. Audit Clinical Audit Review

218 MD12 - Environment Cleanliness Audits (%) MD13 - Equipment EME Planned Maintenance (%) MD17 - Incident Reporting Clinical Incidents: Total MD18 - Policies & Procedures Policies in Date (%) MD19 - Major Incident Planning Major Incident Training (%) MD22 - Agency Staffing Unplanned Agency Expense Clinical Time Worked (%) Temp Staff (WTE) Employed vs Temporary Staff MD26 - Complaints Process Complaint Response in Timescales % MD30 - Medicines Management Medicines Mgmt. Incidents

219 Domain Metric Name Metric Description Green Weight A&E ED - 4hr Compliance (%) % of A&E attendances who were in department less than 4 hours - from arrival at A&E to admission/transfer/discharge. Beds Bed Occupancy (%) This metric looks at the number of beds the Trust has utilised over the month. This is calculated as funded beds / (number of patients per day X average length of episode stay). The metric now excludes all Maternity, Intensive Treatment Unit (ITU) and Paediatric beds and activity. >= % <= % DToCs (Average per Day) The average number of delayed transfers of care < % Extra Beds Number of extra 'unfunded' beds available 0 % IP - Discharges Before Midday (%) % of Inpatients discharged before midday >= % Outliers Number of Bed Outliers in the Trust, where the intended use of the bed is used for another service 0 % Cancer Cancer: 2ww (All) % Two week wait (urgent referral) services (including cancer), as stated by The NHS Operating Framework. % of patients seen within two weeks of an urgent GP referral for suspected cancer (CB_B6) Cancer: 2ww (Breast) % Cancer: 31d (2nd Treat - Surg) % Cancer: 31d (Diag - Treat) % Cancer: 31d (Drug) % Cancer: 62d (Con Upgrade) % Cancer: 62d (GP Ref) % Cancer: 62d (Screening Ref) % Glossary Two week wait (urgent referral) services (including cancer), as stated by The NHS Operating Framework. % of patients seen within two weeks of an urgent referral for breast symptoms where cancer was not initially suspected (CB_B7). Cancer 31 day waits, as stated by NHS Operating Framework. % of patients receiving subsequent treatment for cancer within 31-days, where that treatment is a Surgery (CB_B9). Cancer 31 day waits, as stated by NHS Operating Framework. % of patients receiving first definitive treatment within one month (31-days) of a cancer diagnosis (measured from date of decision to treat ) (CB_B8) Cancer 31 day waits, as stated by NHS Operating Framework. % of patients receiving subsequent treatment for cancer within 31-days, where that treatment is an Anti-Cancer Drug Regimen (CB_B10). Cancer 62 day waits, as stated by NHS Operating Framework. % of patients receiving first definitive treatment for cancer within 62-days of a consultant decision to upgrade their priority status. Cancer 62 day waits, as stated by NHS Operating Framework. % of patients receiving first definitive treatment for cancer within two months (62 days) of an urgent GP referral for suspected cancer. Cancer 62 day waits, as stated by NHS Operating Framework. % of patients receiving first definitive treatment for cancer within 62-days of referral from an NHS Cancer Screening Service. >= % >= 93 5 % >= 94 5 % >= % >= 98 5 % >= 85 5 % >= % >= 90 5 % Clinical Outcomes Audit of WHO Checklist % An observational audit takes place to audit the World Health Organisation (WHO) checklist >= % Cleanliness Audits (%) Cleaning Schedule Audits >= 98 5 % Clinical Audit Prog. Audit Agreed Clinical Audit programme meets national programme requirements >= 3 5 % Clinical Audit Review Review of the Clinical Audit Programme >= 3 5 % 51

220 Clinical Outcomes FNoF (36h) (%) % Fragility hip fractures operated on within 36 hours (Time to Surgery within 36 hours from arrival in an emergency department, or time of diagnosis if an Inpatient, to the start of anaesthesia). Data taken from the National Hip Fracture Database. Reporting one month in arrears to ensure upload completeness to the National Hip Fracture Database. Pharm: Drug Cupboards Locked (%) Pharm: Drug Trolleys Locked (%) >= 85 5 % Data taken from Medicines Storage & Waste Audit - percentage of drug cupboards locked >= 90 5 % Data taken from Medicines Storage & Waste Audit - percentage of drug trolley's locked >= 90 5 % Pharm: Fridge Temps (%) Data taken from Medicines Storage & Waste Audit - percentage of wards recording temperature of fridges each day >= % Pharm: Fridges Locked (%) Data taken from Medicines Storage & Waste Audit - percentage of fridges locked >=95 5 % Pharm: Resus. Trolley Check (%) ppci (Balloon w/in 150m) (%) PROMs EQ-5D Index: Groin Hernia PROMs EQ-5D Index: Hip Replacement PROMs EQ-5D Index: Knee Replacement Readmissions: EL dis. 30d (12M%) Readmissions: NEL dis. 30d (12M%) Stroke Brain Scans (24h) (%) Data taken from Medicines Storage & Waste Audit - percentage of resus trolley's checked >= 90 5 % % Achievement of Call to Balloon Time within 150 mins of ppci. >= 75 5 % PROMs measures health gain in patients undergoing hip replacement, knee replacement, varicose vein and groin hernia surgery in England, based on responses to questionnaires before and after surgery. PROMs measures health gain in patients undergoing hip replacement, knee replacement, varicose vein and groin hernia surgery in England, based on responses to questionnaires before and after surgery. PROMs measures health gain in patients undergoing hip replacement, knee replacement, varicose vein and groin hernia surgery in England, based on responses to questionnaires before and after surgery. Percentage of patients that have been discharged from an elective admission and been readmitted as a non-elective admission within thirty days. This is acccording to an external methodology, which has been signed off by the Contract & Procurement Team. This is a rolling twelve month figure. Percentage of patients that have been discharged from a non-elective admission and been readmitted as a nonelective admission within thirty days. This is acccording to an external methodology, which has been signed off by the Contract & Procurement Team. This is a rolling twelve month figure. 0 % 0 % 0 % < % < % % stroke patients receiving a brain CT scan within 24 hours. >= % Culture Policies in Date (%) All documents that are marked as policies are in date on the SharePoint system >= % Data Quality & Assurance Staff FFT - Treatment (%) Staff FFT - Work (%) Not Cached Up Clinics % Percentage of staff who would recommend the organisation for treatment - data is quarterly and from the national submission. Percentage of staff who would recommend the organisation as a place to work - data is quarterly and from the national submission. Outpatients bookings that either have no outcome coded (i.e. attended, DNA or cancelled) or there is a conflict (e.g. patient discharged but no discharge date) as a % of all outpatient bookings. >= % >= % < 4 25 % 52

221 Data Quality & Assurance Demand vs Capacity Uncoded Spells % Inpatient spells that either have no HRG code or a U-coded HRG as a % of total spells (included uncoded spells). < % Valid Ethnic Category Code % Valid GP Code % Valid NHS Number % DNA Rate: Fup % DNA Rate: New % Patient contacts where Ethnicity is not blank as a % of all patient contacts. Includes all Outpatients, Inpatients and A&E contacts. Patient contacts where GP code is not blank or G or G (or is blank/g /g and NHS number status is 7) as a % of all patient contacts. Includes all OP, IP and A&E contacts Patient contacts where NHS number is not blank (or NHS number is blank and NHS Number Status is equal to 7) as a % of all patient contacts. Includes all Outpatients, Inpatients and A&E contacts. Follow up appointments where the patient did not attend (appointment type=2, appointment status=3) as a % of all follow up appointments. New appointments where the patient did not attend (appointment type=1, appointment status=3) as a % of all new appointments. >= % >= % >= % < 7 0 % < 7 0 % New:FUp Ratio (1:#) Ratio of attended follow up appointments compared to attended new appointments 0 % Diagnostics Audio: Complete Path. 18wks (%) Audio: Incomplete Path. 18wks (%) AD01 = % of Patients waiting under 18wks on a completed Audiology pathway >= 99 0 % AD02 = % of Patients waiting under 18wks on an incomplete Audiology pathway >= 99 0 % DM01: Diagnostic Waits % The percentage of patients waiting less than 6 weeks for diagnostic testing. The Diagnostics Waiting Times and Activity Data Set provides definitions to support the national data collections on diagnostic tests, a key element towards monitoring waits from referral to treatment. Organisations responsible for the diagnostic test activity, report the diagnostic test waiting times and the number of tests completed.the diagnostic investigations are grouped into categories of Imaging, Physiological Measurement and Endoscopy and covers 15 key diagnostic tests. Finance Cash Balance m Closing Bank Balance. The graph shows the cash balance at the end of each month - the latest cash balance is shown in the arrow. Forecast I&E m I&E m This shows the latest forecast year end Income & Expenditure position as at 31st March The latest plan is yet to be agreed. The graph shows the Income and Expenditure result for each month - the year to date is shown in the arrow. The year to date plan = 2.6m adjusted for "extra" CIPs. >= % >= Plan 20 % >= Plan 20 % >= Plan 30 % Normalised Forecast m This shows the Normalised Income & Expenditure Forecast as at 31st March >= Plan 10 % Total Cost m Total costs (Total Expenditure + Non-Operating Expenses) or "Run Rate". The graph shows the Total Costs (including non-operating expenses) for each month - the year to date is shown in the arrow. >= Plan 20 % Health & Safety Accidents Accidents excluding sharps (needles etc) but including manual handling <= % Fire Incidents Fire alarm activations (including false alarms) <= 5 10 % Formal Notices Formal notices from HSE (Improvement Notices, Prohibition Notices) 1 15 % Representation at H&S % of Clinical Divisions representation at the site Health & Safety Committee's >= % 53

222 Health & Safety RIDDOR Reports (Number) RIDDOR reports sent to HSE each month <= 3 20 % Sharps Incidents with sharps (e.g. needle stick) <= 10 5 % Violence & Aggression Violence, aggression and verbal abuse <= % Incidents All Pressure Damage: Cat 2 Number of all (old and new) Category 2 pressure ulcers. Data source - Datix. Blood Transfusion Errors The number of blood transfusion errors sourced from Datix. 0 % 0 % Clinical Incidents: Total Number of Total Clinical Incidents reported, recorded on Datix. 0 % Falls (per 1,000 bed days) Falls: Total Harm Free Care: All Harms (%) Harm Free Care: New Harms (%) Medicines Mgmt. Incidents Total number of recorded falls, per 1,000 bed days. Assisted falls and rolls are excluded. Data source - Datix. Total number of recorded falls. Assisted falls and rolls are excluded. Data source - Datix. Percent of Inpatients deemed free from harm (ie free from old and new harm - Old and new pressure ulcers (categories 2 to 4); Injurious falls; Old and new Urinary Tract Infection (UTI); New Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE) or Other VTE) Data source - Safety Thermometer. Percent of Inpatients deemed free from new, hospital acquired harm (ie free from: New pressure ulcers (categories 2 to 4); Injurious falls; New Urinary Tract Infection (UTI); New Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE) or Other VTE) Data source - Safety Thermometer. < = 5 20 % < 3 0 % >= % >= % The number of medicine management issues sourced from Datix. 0 % Mixed Sex Breaches Number of patients experiencing mixed sex accommodation due to non-clinical reasons % Never Events (STEIS) Monthly number of Never Events. Uses validated data from STEIS. < 1 20 % Number of Cardiac Arrests Number of actual cardiac arrests, not calls 0 % Pressure Ulcers Cat 2 (per 1,000) Pressure Ulcers Cat 3/4 (per 1,000) Number of avoidable Category 2 hospital acquired pressure ulcers, per 1,000 bed days Data source - Datix. Number of avoidable Category 3/4 hospital acquired pressure ulcers, per 1,000 bed days Data source - Datix. <= % < 1 10 % Serious Incidents (STEIS) Number of Serious Incidents. Uses validated data from STEIS. 0 % Infection Bare Below Elbows Audit The % of ward staff compliant with hand hygiene standards. Data source - SharePoint >= 95 0 % Blood Culture Training Blood Culture Training compliance >= 85 0 % C Diff (per 100,000 bed days) Number of Clostridium difficile infections (CDIs), as defined by NHS National Operating Framework, for patients aged 2 or more (HQU01), recorded at greater than 72h post admission per 100,000 bed days < 1 0 % 54

223 Infection Cases of C. Diff (Cumulative) Cases of C.Diff (Cumulative) Cases of MRSA (per month) Commode Audit E Coli (per 100,000 population) Number of Clostridium difficile infections (CDIs), as defined by NHS National Operating Framework, for patients aged 2 or more (HQU01) Number of Clostridium difficile infections (CDIs), as defined by NHS National Operating Framework, for patients aged 2 or more (HQU01) Number of Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemia, as defined by NHS National Operating Framework (HQU01). Number of MRSA cases assigned to EKHUFT. The % of ward staff compliant with hand hygiene standards. Data source - SharePoint <= Traj 40 % <= Traj 0 % < 1 40 % >= 95 0 % The total number of E-Coli bacteraemia per 100,000 population. < 44 0 % E. Coli The total number of E-Coli bacteraemia recorded < % Hand Hygiene Audit Hand Hygiene Competences Infection Control Training MRSA (per 100,000 bed days) The % of ward staff compliant with hand hygiene standards. Data source - SharePoint >= 95 0 % Hand Hygiene Training compliance for those with competences >= 85 0 % Percentage of staff compliant with the Infection Prevention Control Mandatory Training - staff within six weeks of joining and are non-compliant are excluded Number of Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemia, as defined by NHS National Operating Framework (HQU01). Number of MRSA cases assigned to EKHUFT, cases per 100,000 bed days >= 85 0 % < 1 0 % MSSA The total number of MSSA bacteraemia recorded < 1 10 % Initiatives MSSA (per 100,000 population) MSSA - 48hr (per 100,000 bed days) 75+ Frailty Pathway CQUIN Delivered % COPD CQUIN Delivered % Dementia Diagnosed CQUIN Delivered % Diabetes CQUIN Delivered % Heart Failure CQUIN Delivered % The total number of MSSA bacteraemia per 100,000 population. < 12 0 % The total number of Trust assigned (post 48h) MSSA bacteraemia per 100,000 bed days. < 1 0 % Metric for the measurement of achievement against delivering CQUIN plan by month. CQUIN to develop integrated care pathway Metric for the measurement of achievement against delivering CQUIN plan by month. CQUIN to develop integrated care pathway and improve referral rates to the Stop Smoking Service and to the Community Respiratory Team Metric for the measurement of achievement against delivering CQUIN plan by month. CQUIN to monitor the diagnosis for Dementia. Green = on target for case finding, assessment and referral to reach 90% for each indicator for 3 consecutive months, AND staff training on target for improvement, AND on target to provide support to carers Metric for the measurement of achievement against delivering CQUIN plan by month. CQUIN to develop integrated care pathway Metric for the measurement of achievement against delivering CQUIN plan by month. CQUIN to develop integrated care pathway and sustain EQ HF measures >= % >= % >= % >= % >= % 55

224 Mortality Crude Mortality EL (per 1,000) Crude Mortality NEL (per 1,000) HSMR (Index) RAMI (Index) SHMI The number of deaths per 1,000 elective admissions. < % The number of deaths per 1,000 non-elective admissions. < % Hospital Standardised Mortality Ratios (HSMRs), via CHKS, compares the number of expected deaths with the number of actual deaths, in Hospital. The data is adjusted for factors statistically associated with hospital death rates and scores the number of secondary diagnoses according to severity (Charlson index). Risk Adjusted Mortality (via CHKS) computes the risk of death for hospital patients and compares to others with similar characteristics. Data including age, sex, length of stay, clinical grouping, ICD10 diagnoses, OPCS procedures and discharge method is constructed. Summary Hospital Mortality Indicator (SHMI) as reported via CHKS includes in hospital and out of hospital deaths within 30 days of discharge. Observations Cannula: Daily Check (%) The % of cannulas checked daily. Daily checks are calculated on the assumption that a patient's indwelling device should be checked at least once a day. Data source - VitalPAC Catheter: Daily Check (%) Central Line: Daily Check (%) Obs. On Time - 8am-9pm (%) Obs. On Time - 9pm-8am (%) VTE: Risk Assessment % The % of catheters which were checked daily. Daily checks are calculated on the assumption that a patient's indwelling device should be checked at least once a day. Data source - VitalPAC The % of central lines checked daily. Daily checks are calculated on the assumption that a patient's indwelling device should be checked at least once a day. Data source - VitalPAC < % < % < % >= % >= % >= % Number of patient observations taken on time >= % Number of patient observations taken on time >= % Adults who have had a Venous Thromboembolism (VTE) Risk Assessment at any point during their Admission. Low-Risk Cohort counted as compliant. Patient Experience Care Explained? % Was your care or treatment explained to you in a way you could understand by the medical/nursing/support staff? This measures the percentage of inpatients who answered 'yes always' or 'yes sometimes' in response to the inpatient survey. Care that matters to you? % Cleanliness? % Complaint Response in Timescales % Compliments to Complaints (#/1) >= % >= 98 4 % Did you get the care that matters to you? >= 98 4 % In your opinion, how clean was the hospital room or ward that you were in? This measures the percentage of inpatients who answered 'very clean' or 'fairly clean' in response to the inpatient survey. >= 95 5 % Audit due to commence in January - Percentage of controlled drugs signed off by two nurses >= 85 5 % Number of compliments per complaint >= % 56

225 Patient Experience FFT: Not Recommend (%) Of those patients who responded to the Friends & Family Test and knew their opinion, would not recommend the Trust >= 1 11 % FFT: Recommend (%) Of those patients who responded to the Friends & Family Test and knew their opinion, would recommend the Trust >= % FFT: Response Rate (%) The percentage of patients who responded to the Friends & Family Test >= % Hospital Food? % Number of Complaints Number of Compliments Overall Patient Experience % Respect & Dignity? % How would you rate the hospital food? This measures the percentage of inpatients who answered 'very good' or 'good' in response to the inpatient survey. The number of complaints recorded per ward. Data source - Datix. The number of compliments recorded per ward. Data source - Patient Experience Team (Kayleigh McIntyre). This provides an overall inpatient experience percentage by weighting the responses to each question (eg. Did not eat or poor = 0, fair = 0.3, good = 0.6, very good = 1) Overall, did you feel you were treated with respect and dignity while you were in hospital by the nursing staff? This measures the percentage of inpatients who answered 'yes always' or 'yes sometimes' in response to the inpatient survey. >= 85 5 % 0 % 0 % >= % >= 98 2 % Returning Complaints Number of complaints returned 4 % Productivity BADS British Association of Day Surgery (BADS) Efficiency Score calculated on actual v predicted overnight bed use allowing comparison between procedure, specialty and case mix. >= % edn Communication % of patients discharged with an Electronic Discharge Notification (edn). >= 99 5 % EME PPE Compliance % EME PPE % Compliance >= % Health Records Availability: Pt Care(%) LoS: Elective (Days) Healthcare records availability for patient care(%) (Incl short notice clinics) Complete, Source: Walk the floor Audits >=98 5 % Calculated mean of lengths of stay >0 with no trim point for admitted elective patients. M.Sakel (NuroRehab) excluded for EL. LoS: Non-Elective (Days) Calculated mean of lengths of stay >0 with no trim point for non-admitted elective patients. 0 % 0 % Non-Clinical Cancellations (%) Non-Clinical Canx Breaches (%) Pharmacy TTAs Dispensed (%) Theatres: On Time Start (% 30min) Cancelled theatre procedures on the day of surgery for non-clinical cancellations as a % of the total non-clinical cancellations. Cancelled theatre procedures on the day of surgery for non-clinical cancellations that were not rebooked within 28days as a % of total admitted patients. The percentage of Discharge Prescriptions (known as TTAs, TTOs or EDNS) dispensed by Pharmacy before the time required on the ward < % < 5 10 % >= 80 0 % The % of cases that start within 30 minutes of their planned start time. >= % 57

226 Productivity RTT Theatres: Session Utilisation (%) RTT: 52 Week Waits (Number) RTT: Incompletes (%) % of allocated time in theatre used, including turn around time between cases, excluding early starts and over runs. >= % Zero tolerance of any referral to treatment waits of more than 52 weeks, with intervention, as stated in NHS Operating Framework % of Referral to Treatment (RTT) pathways within 18 weeks for completed admitted pathways, completed nonadmitted pathways and incomplete pathways, as stated by NHS Operating Framework. CB_B3 - the percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the period. < 1 0 % >= % Staffing Agency % % of Employee's that are recruited through an agency <= 10 0 % Agency & Locum Spend Total agency spend including NHSP spend 0 % Agency Orders Placed Total count of agency orders placed <= % Clinical Time Worked (%) % of clinical time worked as a % of total rostered hours. >= 74 2 % Employed vs Temporary Staff Midwife:Birth Ratio (%) Ratio showing mix of permanent vs temporary staff in post >= % The number of births compared to the number of whole time equivilant midwives per month (total midwive staff in post divided by twelve). Midwives totals are calculated by the Finance Department using Midwife Led Unit (MLU), Maternity and Community Midwives budget codes. < 28 2 % NHSP Use % of Agency % of Employee's recruited through an agency that are NHSP > 90 0 % Overtime % % of Employee's that claim overtime <= 10 0 % Overtime (WTE) Count of employee's claiming overtime <= 60 1 % Roster Effectiveness (%) The time ward staff attribute to clinical duties as a % of the ward duty roster. Data source - eroster. Shifts Filled - Day (%) Percentage of RCN and HCA shifts filled on wards during the day (split by RCN & HCA) >= % Shifts Filled - Night (%) Percentage of RCN and HCA shifts filled on wards at night (split by RCN & HCA) >= % Sickness (%) % of Full Time Equivalents (FTE) lost through absence (as a % of total FTEs). Data taken from HealthRoster: erostering for the current month (unvalidated) with previous months using the validated position from ESR. Calculated cumulatively/ytd. % of FTEs lost through absence (as a % of total FTEs). Stability Index (excl JDs) % Whole Time Equivalent (WTE) staff in post as at current month, and WTE staff in post as 12 months prior. Calculate WTE staff in post with 12 months+ Trust service / WTE staff in post 12 month prior (no exclusions) * 100 for percentage. exclude Junior medical staff, any staff with grade codes beginning MN or MT Stability Index (incl JDs) % Whole Time Equivalent (WTE) staff in post as at current month, and WTE staff in post as 12 months prior. Calculate WTE staff in post with 12 months+ Trust service / WTE staff in post 12 month prior (no exclusions) * 100 for percentage 15 % < % Staff Turnover (%) % Staff leaving & joining the Trust against Whole Time Equivalent (WTE). Metric excludes Dr's in training < % 0 % 0 % 58

227 Staffing Staffing Level Difficulties Any incident related to Staffing Levels Difficulties 1 % Temp Staff (WTE) Count of Temporary Staff in post < % Time to Recruit Average time taken to recruit to a new role <= 11 0 % Total Staff In Post (FundEst) Count of total funded establishment staff 1 % Total Staff In Post (SiP) Count of total staff in post 1 % Unplanned Agency Expense Total expediture on agency staff as a % of total monthly budget. < % Vacancy (%) % Vacant positions against Whole Time Equivalent (WTE) < % Training Appraisal Rate (%) Number of staff with appraisal in date as a % of total number of staff. >= % Corporate Induction (%) % of people who have undertaken a Corporate Induction >= 95 0 % EME Planned Maintenance (%) Major Incident Training (%) Planned maintenance of EME managed medical equipment >= 95 0 % % of people who have undertaken Major Incident Training >= 95 0 % Mandatory Training (%) The percentage of staff that have completed mandatory training courses, this data is split out by training course. >= % Use of Resources Additional sessions k Additional sessions (Waiting List Payments) The graph shows the additional sessions (waiting list payments) pay per month for a rolling 12 months 0 0 % Agency Spend m Agency and Medical/StaffFlow Locum spend by month YTD. 0 0 % Capital position m Cash borrowings Capital spend. The graph shows the capital spend for each month - the year to date is shown in the arrow. The year to date plan = 14.27m (Annual Plan). Cash borrowings. The graph shows the total year to date cash borrowings - the latest cash borrowing total is shown in the arrow. 0 0 % 0 0 % CIPS Essex P23 CIPS graph: ytd v plan plus forecast. Metric shows variance difference to plan %. 0 0 % Clinical Productivity: Outpatient Clinical Productivity: Theatres Independent Sector k Payroll Pay m Clinical Productivity graph: outpatient sessions v plan 0 % Clinical Productivity graph: theatre sessions v plan. 0 % Independent Sector (Cost of Secondary Commissioning of mandatory services) The graph shows the Independent Sector (cost of secondary commissioning of mandatory services) cost per month for a rolling 12 months Payroll Pay (Permanent+Overtime+Bank). The graph shows the total pay per month for a rolling 12 months - the current year to date is shown in the arrow. 0 0 % 0 0 % 59

228 Data Assurance Stars Not captured on an electronic system, no assurance process, data is not robust Data is either not captured on an electronic system or via a manual feeder sheet, does not follow an assured process, or not validated/reconciled Data captured on electronic system with direct feed, data has an assured process, data is validated/reconciled 60

229 Patient Safety Heatmap Harm Free Care: New Harms (%) All Pressure Damage: Cat 2 Falls: Total Number of Cardiac Arrests ACC - KCH A&E DEPARTMENT BIR - BIRCHINGTON WARD BIS - BISHOPSTONE WARD CATD - CATHEDRAL DAY UNIT 1 CCU - CCU CDU - CLINICAL DECISION UNIT 3 CJ2 - CAMBRIDGE J CK - CAMBRIDGE K CL - CAMBRIDGE L REHABILITATION CLKE - CLARKE WARD CM1 - CAMBRIDGE M1 SHORT STAY CM2 - CAMBRIDGE M CSF - CHEERFUL SPARROWS FEMALE CSM - CHEERFUL SPARROWS MALE DEAL - DEAL WARD DSC - DAY SURGERY CENTRE 1 DSSC - DAY SURGERY 2 1 EKCC - EK CARDIAC CATHETER SUITE 1 FF - FOLKESTONE FRD - FORDWICH WARD STROKE UNIT HARB - HARBLEDOWN WARD HARV - HARVEY WARD INV - INVICTA WARD ITU - WHH ITU KA2 - KINGS A KB - KINGS B KBRA - BRABOURNE (KCH) KC - KINGS C KC2 - KINGS C KCDU - EMERGENCY CARE CENTRE Number of Complaints Number of Compliments Care that matters to you? % Care Explained? % Respect & Dignity? % FFT: Response Rate (%) FFT: Recommend (%) FFT: Not Recommend (%) Employed vs Temporary Staff Apdx.

230 Harm Free Care: New Harms (%) All Pressure Damage: Cat 2 Falls: Total Number of Cardiac Arrests KDF - KINGS D FEMALE KDM - KINGS D MALE KEN - KENNINGTON WARD KEND - ENDOSCOPY (KCH) 1 KENT - KENT WARD KHOM - KCH HOME WARD 0 0 KIN - KINGSGATE WARD KING - KINGSTON WARD KITU - KCH ITU KNRU - EAST KENT NEURO REHAB UNIT KXRY - X-RAY (KCH) 1 MARL - MARLOWE WARD MTMC - MOUNT/MCMASTER WARD MW - MINSTER WARD OPTH - OPHTHALMOLOGY SUITE 1 2 OXF - OXFORD PAD - PADUA QAE - QEH A&E DEPARTMENT QCCU - QEH CCU QCDU - QEH CDU QHOM - QEH HOME WARD QITU - QEH ITU QSCB - QEH SPECIAL CARE BABY UNIT QX - QUEX WARD RAI - RAINBOW WARD RST1 - RICHARD STEVENS 1 STROKE UNIT RW - ROTARY WARD SAN - SANDWICH BAY WARD SAU - ST AUGUSTINES, THE REHAB. WARD SB - SEA BATHING WARD SBU - SEABATHING UNIT SCBU - THOMAS HOBBES NEONATAL UNIT Number of Complaints Number of Compliments Care that matters to you? % Care Explained? % Respect & Dignity? % FFT: Response Rate (%) FFT: Recommend (%) FFT: Not Recommend (%) Employed vs Temporary Staff Apdx.

231 Harm Free Care: New Harms (%) All Pressure Damage: Cat 2 Falls: Total Number of Cardiac Arrests SEAU - SURGICAL EMERGENCY ASSESS WHH STM - ST MARGARETS WARD TAY - TAYLOR WARD TREB - TREBLE WARD WAE - WHH A&E DEPARTMENT WCDM - WHH CDU MIXED WCDU - ***** DO NOT USE ***** WDL - DISCHARGE LOUNGE WHH 1 WHOM - WHH HOME WARD Number of Complaints Number of Compliments Care that matters to you? % Care Explained? % Respect & Dignity? % FFT: Response Rate (%) FFT: Recommend (%) FFT: Not Recommend (%) Employed vs Temporary Staff Apdx.

232 Clinical Human Resources Heatmap Finance & Perform HR & Corporate Qual Safety & Ops Specialist Strat Dev & Cap Plan Surgical Urgent & Long Term Kent Pathology Partnership Agency % Appraisal Rate (%) Employed vs Temporary Staff Mandatory Training (%) NHSP Use % of Agency Sickness (%) Stability Index (excl JDs) % Stability Index (incl JDs) % Staff Turnover (%) Vacancy (%) Apdx.

233 CQC UPDATE BoD 55/16 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS DATE: 10 JUNE 2016 SUBJECT: REPORT FROM: PURPOSE: IMPROVEMENT PLAN UPDATE CHIEF NURSE & DIRECTOR OF QUALITY DISCUSSION CONTEXT / REVIEW HISTORY / STAKEHOLDER ENGAGEMENT The Trust was put into special measures in August 2014 following a CQC inspection in March 2014 which rated the Trust overall as inadequate. The Trust underwent a re-inspection w/c July 13 th The Trust received the reports from this inspection and has been rated overall as Requires Improvement. The Trust has submitted to the CQC a new high level improvement plan in response, with 30 Must Do Areas. Divisional Action Plans with additional key findings are complete and were submitted to Monitor and the CQC for approval in January The priority is for the Trust to come out of Special Measures at our next inspection. The Trust is assuming an inspection will take place 6 months after the November 15 Quality Summit week beginning 16 th May 2016 or thereafter; we are yet to receive the customary 12 weeks notice of a future inspection date. SUMMARY: The Trust submitted an action plan to the CQC on the 14 th December 2015 and governance arrangements for the plan were re-established. In addition to the internal governance arrangements (via the Improvement Plan Delivery Board), progress against delivery of the plan is critiqued at the monthly Performance Review Meetings (PRM) with NHS Improvement (NHSI), previously Monitor. Matthew Kershaw, Chief Executive (CEO), and Dr David Hargroves, clinical chair of the Improvement Plan Delivery Board (IPDB) have agreed to alternate the chairing responsibilities of the group as of the April IPDB. The Executive lead remains the Chief Nurse & Director of Quality. To facilitate improvements through the Quality Improvement & Innovation Hubs (QII Hubs) and site based teams, 1.1 wte Quality Improvement Facilitators are in post. Additionally a fixed term appointment has been made to a dedicated Communications Lead and Programme Administrator (the latter being vacant since November 16) with an anticipated start date of July/August 2016 for both. Key objectives of the programme remain: o To come out of Special Measures; o To embed continuous and sustainable improvements to the organisation; o To prepare for re-inspection; 1

234 CQC UPDATE BoD 55/16 o o o To have no Inadequate ratings at the next inspection; To obtain a rating of good for the safe and well-led domains; To sustain a rating of good for caring with an ambitious objective to aim for a rating of outstanding for the caring domain. The April 2016 Improvement Plan Delivery Board (IPDB) met on Friday 15 th April 2016 and was chaired by the CEO. Bethan Haskins, Chief Nurse for Ashford and Canterbury CCGs and Sharon Gardner- Blatch, Chief Nurse for Thanet and South Kent Coast CCGs, were invited to represent the 4 CCGs. They were in attendance for the first time. The minutes were ratified of the Friday 18 th March 2016 IPDB and open actions closed or updated. An extraordinary IPDB maternity session followed with representatives from Public Health England and the area Medical Director James Thallon in attendance. Since this meeting the Maternity team have ensured that the recommendations of the recent Royal College of Obstetricians and Gynaecologists (RCOG) report has been developed and embedded into the improvement plan. A separate meeting has also taken place to review the details within the local plan with the Chief Nurse, Deputy Chief Nurse and Improvement Director. The May 2016 IPDB met on Friday 20 th May Although the minutes of this meeting are not yet available the following outlines the improvement work in progress and discussions that have taken place at both meetings. Update upon programme activities: Fortnightly detailed performance reviews with divisions regarding progress and pace of improvements to plan; Divisional reporting dashboards delivered and updated; Monthly IPDB to hold all action owners to account for the delivery of their plans; The development of organisational IPDB KPIs which have been amalgamated into revised Integrated Performance Report/Balanced Scorecard. These were presented at the May IPDB on 20 th May 16; Monthly improvement visits & feedback via the QI Facilitators to clinical areas to support staff in preparation for re inspection are regularly taking place. Approximately 80 areas have been visited across all sites since February 16; Weekly Improvement Plan CQC Steering Group meetings to engage staff and work alongside the Quality Improvement and Innovation Hubs (QIIHs) continue; A new team has been formed at the Kent & Canterbury site QIIHs with multidisciplinary representation. The Hub held a listening event in April and re launched officially on the 18 th May 2016; The QEQM Hub has been relocated with improved facilities and plans are being agreed regarding the Hub opening times and hosting arrangements to ensure increased staff uptake; The WHH Hub is having a re-launch on 2 nd June 2016 with the aim of getting a wider cohort of staff involved in leading alongside the nurse leads; QIIHs models are being agreed for RVF and BHD; A Fortnightly Focus communications strategy with a supporting programme of speakers through the QII Hubs is published; A programme of work was submitted to the April Board of Directors outlining preparation for the next inspection. Following the April IPDB, it was recommended by the Improvement Director that a 2

235 CQC UPDATE BoD 55/16 review be undertaken of the final due dates for each scheme in the High Level Improvement Plan prior to the submission of the April NHS Choices Report due on the 11 th May This review was completed and some minor amendments were approved where external delays had impacted on timescale delivery. The May NHS Choices submission (based on April 16 reporting month) presented deterioration to the position with 3 blue actions, 8 green, 10 amber and 9 red. There had been no schemes with a red RAG previously but this in part was due to the ambitious timescales set when the plan was submitted. The red schemes are as below: Maternity Capacity (MD03) red rated due to slippage in undertaking demand and capacity work relating to implementation of new electronic E3 system. Safe Management of Medicines (MD07) red rated due to slippage in ensuring safe storage solutions are in place for IV fluids. An environmental audit has been undertaken and solutions are being embedded. Practice will then be audited. Clinical Audit (MD11) red rated as some actions are incomplete post January 2016 initial deadline. 16/17 Programme is in place and external review of audit function has been undertaken. Equipment (MD13) red rated due to slippage in submitting a business case for investment for increasing the establishment to the EME team to ensure standards around planned maintenance can be met. Paediatric Staffing in ED (MD14) red rated due to slippage in having 24/7 paediatric nursing cover. Will be in place by May at QEQM and June at WHH. Governance & Leadership (MD16) red rated due to outstanding action around review of new arrangements and staff understanding. Pharmacy Staffing (MD23) red rated due to slippage in producing final workforce development plan and strategy. Now in draft. Patient Complaints (MD26) red rated due to slippage against timescales and risk regarding 30 day response compliance. Escalation Wards/St Augustines (MD29) red rated due to slippage in agreeing care model and assurance regarding staffing. Plans in place and the building works have commenced. These were reviewed at the PRM and discussed in detail. The following remain risks: Recruitment and retention (MD08) Amber rated due to recruitment challenges; Temporary and agency staff (MD22) Amber rated due to some slippage; Urgent & Emergency Care (MD02) and Access and Operations (MD06) Amber rated due to slippage in the ED Recovery Plan; Workforce Culture (MD09) Amber rated due to some slippage in programme; 7 Day services (MD25) Amber rated due to some slippage in programme; Maternity (MD04) Amber rated due to some slippage in programme; Mental Health (MD05) Amber rated due to some delay in agreeing mid-long term commissioning model (now complete) and internal processes; Policy Compliance (MD18) Amber rated due to risks to achievement by June 16 and infrastructure support required; Adult Safeguarding (MD20) Amber rated due to delays caused by training data accessibility. Plans in place to resolve by June 16. 3

236 CQC UPDATE BoD 55/16 All of the above areas were discussed at the IPDB on the 20 th May A forecast position is being discussed based on the outstanding actions with intention to ensure that tasks are completed by the end of August 16 where due dates have been breached. RECOMMENDATIONS: The Board of Directors is invited to discuss the progress to date and seek any further assurances that may be required. NEXT STEPS: Monitoring of the actions will take place through the Improvement Programme Governance Structure (monthly Improvement Plan Delivery Board and weekly Improvement Plan Steering Group Meetings). At a divisional level monitoring will take place via the Monthly CQC Improvement Plan Review Meetings. The divisions have local structures in place for managing plans and disseminating to staff. IMPACT ON TRUST S STRATEGIC OBJECTIVES: Patients. Enable all our patients (and clients who are not ill) to take control of all aspects of their healthcare by Partnerships. To define and deliver sustainable services and patient pathways together with our health and social care partners, by People. Identify, recruit, educate and develop a talent pipeline of clinicians, healthcare professionals and broader teams of leaders, skilled at delivering integrated care and designing and implementing innovative solutions for performance improvement. Provision. Clearly identify what business we are in, what we want to be known for and what our core services are. LINKS TO BOARD ASSURANCE FRAMEWORK: IDENTIFIED RISKS AND RISK MANAGEMENT ACTIONS: Identified risks include: - necessary improvements to the emergency pathway - the patient safety culture on the shop floor - safe staffing levels in all areas - maintaining staff engagement - poor financial position delaying the programme Management Actions are: 1. The CQC Improvement Steering Group continues to meet weekly to engage staff and work alongside the Quality Improvement and Innovation Hubs; 4

237 CQC UPDATE BoD 55/16 2. The Improvement Plan Delivery Board will continue to meet monthly to ensure delivery of the regulatory requirements cited by the CQC and to ensure all of the recommendations in the reports are delivered; 3. A divisional reporting process is in place in relation to the local divisional improvement plans and mechanisms have been agreed for implementation and communication with front line staff. 4. Preparation for the next inspection has begun and a programme of monthly Improvement Visits has commenced to assess progress and effectiveness of communication of the plan on the ground. FINANCIAL AND RESOURCE IMPLICATIONS: Improvement initiatives that are successfully delivered and embedded into daily operations support the more effective and efficient use of resources. Additional junior project management support has been identified to backfill some of the current post holder s substantive duties. This will go to the next vacancy pane. An appointment has been made to a fixed term Communications role to support the programme - any delay to the start date may need to be mitigated by temporary staffing as this poses a significant risk at present. This is being discussed with the incoming Director of Communications. LEGAL IMPLICATIONS / IMPACT ON THE PUBLIC SECTOR EQUALITY DUTY: The Trust is currently in breach of its Licence with Monitor by virtue of being placed in Special Measures. PROFESSIONAL ADVICE TAKEN ON ANY NOVEL OR CONTENTIOUS ISSUES None. ACTION REQUIRED: (a) To discuss and note CONSEQUENCES OF NOT TAKING ACTION: The Trust may remain in Special Measures and in breach of its Licence. 5

238 Special Measures Improvement Plan Update East Kent Hospitals University NHS Foundation Trust Date of Report: 11th May 2016 Date of Reporting Period: April 2016 KEY Delivered On Track to deliver Some issues narrative disclosure Not on track to deliver 1

239 East Kent Hospitals University NHS Foundation Trust Our improvement plan & our progress Background & Summary The Trust was put into special measures on the 29 th August 2014 following a CQC inspection with reports that identified two of the three main sites as inadequate and the Trust rated overall as inadequate. The sites rated as inadequate were the Kent and Canterbury Hospital and the William Harvey Hospital. The Trust was also rated inadequate in the safety and well-led domains. On the 16 th November 2015, the CQC presented the findings of their subsequent inspection in the Trust which took place in July The reports identified improvement since the last inspection. The overall Trust rating went from inadequate to requires improvement. The trust was rated requires improvement for the domains of safe, responsive and well-led. The domain of caring was rated as good. The Trust was rated as inadequate for effective services. The three acute sites (William Harvey Hospital, Kent & Canterbury Hospital and Queen Elizabeth Queen Mother Hospital) were all rated as requires improvement with the Buckland Hospital and Royal Victoria Hospital, Folkestone, rated as good. The Trust has been given a variety of recommendations that can be themed below: Trust leadership and governance arrangements sustaining of changes made since the last report; Staff engagement and organisational culture to address the gap between frontline staff and senior managers; Safe staffing to delivery timely patient care; Staff training and development, specifically around mandatory training; Demand and capacity pressures on patient experience, specifically within the emergency pathway and onward flow through the hospital and maternity services; Following national best practice and policy consistently, specifically in relation to end of life care ensuring there is a suitable pathway, documentation and education in place; Support services are in place to ensure 7 day services can be delivered in priority areas including pharmacy and radiology; Mental health provision and timely specialist response for our patients; Caring for children and young people outside dedicated paediatric areas; Estate and equipment maintenance and replacement programme concerns; Key national and local audits are undertaken and action plans implemented to improve care; Incident reporting processes are robustly followed and learning from incidents and complaints is shared with all teams to improve services Clinical Strategy - in place and communicated with all members of staff. The published CQC report can be found on the CQC website: : The Trust agreed an implementation plan to deal with 30 must do actions within the High Level Improvement Plan. These can be grouped into 12 thematic work streams. Each clinical division also has a local plan containing actions surrounding all of the detailed key findings, with timeframes and corresponding key performance indicators. We recognised all of the recommendations and are addressing them to improve the quality of services. Who is responsible? This document provides a summary of Trust progress against our published High Level Improvement Plan - which provides further detail. A decision was made that despite evidence of improvement, the Trust should remain in special measures to ensure that required changes made are sustained. The new Improvement Plan builds on the previous plan to continue the Trust Our Improvement actions to Journey address and the 47 get recommendations to good. have been agreed by the Trust Board. Our Oversight Interim and Chief improvement Executive, Chris arrangements Bown, is have ultimately been responsible put in place for to support implementing changes actions required. in this The document. Improvement Other Plan key staff is overseen are Dr Sally by a Smith, monthly Chief Improvement Nurse and Plan Director Delivery of Quality Board, and chaired Dr Paul by Stevens, Dr David Medical Hargroves, Director, Clinical as Lead. they provide The Delivery the executive Board is leadership accountable for to quality, the Board patient of Directors. safety and Operationally patient experience. progress is reviewed via a fortnightly Improvement Plan Steering Committee with The accountable Improvement named Director leads assigned for each site to East and division. Kent Hospitals A Quality University Innovation NHS and Foundation Improvement Trust Hub is Sue is in Lewis place who on each will be hospital acting site on behalf and is of used Monitor as a and vehicle in concert to drive with change the relevant and communicate Regional Team of progress. Monitor to A ensure Programme delivery Office of the has improvements ben established and with oversee Programme the implementation Management of support the action and plan a Quality overleaf. Improvement Should you Facilitator require any working further with information front line divisional this role teams. please contact specialmeasures@monitor.gov.uk This report outlines a monthly basis the progress that is being made in implementing the organisational improvement plans our Trust Improvement Journey. Ultimately, our success in implementing the recommendations of the Improvement Plan will be assessed by the Chief Inspector of Hospitals, upon re-inspection of our Trust. Who is responsible? If you have any questions about how we re doing, contact our Trust Secretary, Alison Fox on (ext ) or by at alison.fox4@nhs.net Our actions to address the recommendations have been agreed by the Trust Board and shared with our staff. Our Chief Executive, Matthew Kershaw, is ultimately responsible for implementing actions in this document. Other key staff are the Chief Nurse, Director of Quality and the Medical Director, who provide the executive leadership for quality, patient safety and patient experience. The Improvement Director assigned to East Kent Hospitals University NHS Foundation Trust is Susan Lewis, who will be acting on behalf of Monitor and in concert with the relevant Regional Team of Monitor to oversee the implementation of the action plan overleaf and ensure delivery of the improvements. Should you require any further information on this role please contact specialmeasures@monitor.gov.uk If you have any questions about how we re doing, contact our Trust Secretary, Alison Fox on (ext ) or by at alison.fox4@nhs.net 2

240 East Kent Hospitals University NHS Foundation Trust - Our improvement plan & our progress How we will communicate our progress to you We will update this progress report every month while we are in special measures. Our High Level Improvement Plan will also be available through the Trust internet site (link to be added when live). Chair / Chief Executive Approval (on behalf of the Board): Chair Name: Nikki Cole Signature: Date: 11 May 16 Chief Executive Name: Matthew Kershaw Signature: Date: 11 May 16 3

241 East Kent Hospitals University NHS Foundation Trust Summary of progress against improvement plan CQC Key Question Agreed timescale for implementation Progress (i.e. successes/outcomes) against original timescale What has been achieved? Comments / Current main concerns Safe MD07 - There are robust systems to monitor the safe management of medicines and IV fluids according to national guidelines. December 2015 March 2016 The monthly audit tool has been strengthened. Average monthly performance continues to be 80-90% with medicine trolley locking 98%. An environmental audit of current IV storage facilities has been undertaken. Audit has shown most areas only require minor works aside from critical care, theatres and renal OPD. Decision to be made at Heads of Nursing meeting in May Readjustment of stock levels for IV fluids has taken place. Red: Slippage on implementing findings re IV storage audit and monitoring compliance. Status of previous reporting month (March 16) Amber (MD07) External assurance will be required by the CCGs MD30 The Medicine Management Policy is adhered with and there are systems in place to ensure that prescribing practices across site for critical drugs are uniform. December February 2016 Noradrenaline standardised prescribing policy agreed and has been rolled out to all areas. Compliance monitoring in place. Audit on track for completion in June 16 according to plan. Green: On track Status of previous reporting month (March 16) Green. MD08 - There are sufficient numbers of suitably qualified, skilled and experienced staff available to deliver patient care in a timely manner. December 2015 On-going (with monthly review) Over 138 RNs have been recruited since July 15. In March 16, Trust is carrying a 12.3% vacancy factor in nursing. Workforce and recruitment and retention plans are in place. Safe staffing reports for nursing are reported every month to the Board. Work has been initiated to look at 'retention' rates for hard to recruit staff (Recruitment Strategy 15-18) including working with agencies relating to further overseas recruitment. Further overseas recruitment in progress this month. A more in depth induction programme is being devised for overseas doctors to support retention. Some slippage regarding 'on boarding' and exit interview strategy. Exit interview process re launched in October 15. Revised vacancy trajectories to be approved at May 16 Strategic Workforce Committee and presented at Improvement Plan Delivery Board. External assurance will be required by the CCGs Amber: Delays given recruitment and retention challenges (although plans in progress as part of Recruitment Strategy 15-18). Concerns remain around the ability to recruit sufficient Consultant staff in the Emergency Departments, Pharmacy and Therapy staff due to national supply. Ability to recruit overseas nurses a risk due to changes in ELTS (English Language qualification). Status of previous reporting month (March 16) - Amber MD19 - The major incident policy is up to date and staff are aware of their roles and responsibilities. Staff are confident in its application having received sufficient training and 'drills' in appropriate areas. December September 2016 The Trust has enlisted the help of Maidstone & Tunbridge Wells NHS Trust Emergency Planning Team. In December 2015 a major incident test took place. On 22 nd March a full table top exercise was conducted led by external partners. Training DVD has been re launched staff trained since April 15. Emergency Planning Annual Report presented to the Trust Board. External assessment undertaken by CSU on behalf of NHSE compliant in most areas. Further work to do on training trajectories. External assurance provided South East CSU on behalf of NHSE Green: On Track Status of previous reporting month (March 16) - Green 4

242 CQC Key Question Agreed timescale for implementation Progress (i.e. successes/outcomes) against original timescale What has been achieved? Comments / Current main concerns MD20 - Staff training is focused on the principles of the MCA (2005) and how to assess capacity. Trust policies relating to adult safeguarding are updated regularly and are easily accessible. There is evidence that staff consider mental capacity in the planning and delivering care. Capacity assessments are considered carefully and are proportionate to patients needs. Best interests decisions are timely and issue specific. December 2015 June 2016 The Policy was approved in December The content of the Mental Capacity Act (MCA) and Deprivation of Liberty (DoLs) training has been reviewed and TNA refreshed. Agreement that refresher should be every 3 years (not 2 years) in line with UK Core Skills Training Framework. Need for trajectory to be refreshed to take account of this. The Safeguarding intranet and internet has been refreshed with much clearer signposting for staff on accessing the correct information. The Trust has met with Brighton University and will be the lead organisation for the Kent, Surrey and Sussex Learning Disability Mortality Project (LeDeR). Training has been delivered in the QII Hubs on MCA and DoLS and will continue across all sites on a rolling programme. An Ask 5 questions audit is being rolled out to assess staff understanding of both areas. Collaboration with Learning and Development has identified the cohort of staff requiring extended training and will be used to report training compliance clinical staff have received training this year (L1 and L2). Amber: some slippage against milestones. Some risks around availability of training data by level but plan in place to resolve by June 16 as per plan. Status of previous reporting month (March 2016) - Green The CCG Contract Quality Metrics require reporting of training numbers by level. To be in place by June MD21 - There is a Trust specific Children's Safeguarding Policy (which is consistent with the Kent & Medway Multiagency policy). December March 2016 The Trust specific Policy was approved at the Policy Compliance Group in March and is being disseminated to staff. Board Seminar on Safeguarding to be held. The Kent & Medway Children s Safeguarding Board require assurance and receive this via the Board s work. Blue: Compete Status of previous reporting month (March 2016) - Blue MD22 - All temporary/agency staff (all disciplines) should have the appropriate competencies for the clinical environment they are placed within and receive appropriate induction. December 2015 August 2016 Following review of current medical locum induction processes a template has been issued to Divisions to be developed locally and implemented from 1st April. Induction checklists for nursing have been compiled and shared with wards to use for local inductions from the end of March. A process have been agreed with NHSP and Stafflow to record the completion of local induction and report monthly, this data to be included in Divisional reporting and monitoring. The bank contract is currently out to retender and the requirement for agency checklists to be stored and available for reporting is included (from June 16). External assurance is being requested by the CCGs Amber: Slippage in programme but plan in place. Additional target of compliance with induction process to be agreed and achieved by August Status of previous reporting month (March 2016) - Amber 5

243 CQC Key Question Agreed timescale for implementation Progress (i.e. successes/outcomes) against original timescale What has been achieved? Comments / Current main concerns MD23 - The pharmacy department is appropriately staffed and skilled to support the timely and safe discharge of patients. December March 2016 Recruitment and retention plans are in place, but at present the pharmacy department is carrying a 27% vacancy factor for qualified staff and a 14% vacancy factor for unqualified (March 16). The Department have taken part in the Safer Start initiative during January and have tested out prioritising those being discharged to reduce delays. Red: Delays due difficulties in recruiting and retaining Pharmacy staff. National/regional shortages of Pharmacists. Workforce development plans including retention strategies developed to address this. Slippage against original timeframes. The workforce development plan has been completed and submitted to CSSD Board in March, along with the pharmacy business plan which describes in detail the strategic plan for development of pharmacy in line with the recommendations of the Carter Report. To be finalised in May An initial assessment using the TDA Trust development tool for Medicines Optimisation has been completed. A proposal has been made about level of service by ward (with associated KPIs) to be discussed at Improvement Plan Delivery Board. Status of previous reporting month (March 2016) - Amber MD28 - Fine bore naso-gastric tubes are inserted and checked in accordance with NHS England's patient safety alerts; the Trust NG Policy is in line with this guidance. December 2015 Trust NG policy implemented. Governance procedures in place to ensure compliance against standards. There is an article in Risk Wise (Trust wide Risk publication) this month to reinforce the learning. An external review of the safety of the system for NG tube insertion was independently reviewed by a Patient Safety Consultant; there were no issues identified. Blue: Completed Status of previous reporting month (March 2016) - Blue NHS England undertook an external review of Trust use of the Central Alert System (CAS) on Friday 19 th February 16. This does not impact on completion of this action but will provide assurance regarding Trust use of the CAS. 6

244 CQC Key Question Agreed timescale for implementation Progress (i.e. successes/outcomes) against original timescale What has been achieved? Comments / Current main concerns Effective MD11 - There is participation in relevant local and national audits, including clinical audits and other monitoring activities such as reviews of services, benchmarking, peer review and service accreditation. Accurate and up-to-date information about effectiveness is shared internally and externally and is understood by staff. It is used to improve care and treatment and people s outcomes. Clear action plans developed and managed through the Trust governance framework. MD12 - The environment and facilities in which patients are cared for must be safe, well maintained, fit for purpose and meet current best practice standards. December January 2016 December On-going but with key milestones achieved and evidenced by June 2016 An Internal Audit of divisional engagement and governance started on the 20 February First draft received and to be ratified in May The clinical audit forward programme for 2016 / 17 was approved by the Clinical Audit and Effectiveness Committee in March and is due to be reviewed by the Integrated Audit Governance Committee in April. Prior to submission of the forward programme, all programme were approved by the divisional medical directors. As part of the approval certain conditions aimed at improving completion rates were applied to the programme & these conditions will be communicated to the clinical specialities shortly. The forward programme is divided into "Must do", Carried over & New audit topics with priority given to the "Must do" topics. The programme will be reviewed by each division at six months to ensure the "Must do" topics are on track. The clinical audit website is to be re launched in April. The Board Audit Committee has requested a report on progress of this scheme. Internal audit assurance is at the planning stage with an anticipated start in March investment programme agreed. Consultation has closed regarding availability of estates team. Team now available 7am-10pm with increased availability. This will also increase capacity for planned maintenance. Work on going to develop Estates Web Portal for reporting jobs and monitoring progress. To be complete by June Estates checklist has been piloted and revised version now rolled out. A project to establish a procurement run stock system is being developed, this will seek to ensure that jobs raised by staff can be completed in a timely manner and not delayed by the lack of parts. Plan to go live in May 16. The Trust has run two fire evacuation exercises with Kent Fire and Rescue to test the robustness of procedures and safety. Work to WHH ED is nearing completion and work has commenced in St Augustine's Ward, QEQM. Red: Slippage against original timescales agreed. Review of job planned activities by June Status of previous reporting month (March 2016) - Amber Green: 1617 investment programme agreed. Further investment to be agreed for subsequent years based on priority areas. Status of previous reporting month (March 2016) - Green HSE are working with the Trust at present to ensure compliance to essential standards. 7

245 CQC Key Question Agreed timescale for implementation Progress (i.e. successes/outcomes) against original timescale What has been achieved? Comments / Current main concerns MD13 - There is sufficient equipment in place to enable the safe delivery of care and treatment, equipment is regularly maintained and fit for purpose to reduce the risk to patients and staff. December 2015 Start February 2016 End A programme of equipment maintenance is in place and will continue going forward. The equipment library is working effectively. The Medical Devices Group manages the equipment requirements across the Trust ensuring there is sufficient equipment in place for safe delivery of care and to manage the risk. Some slippage against the business case to ensure team can achieve 95% compliance level for high risk equipment. Sign off to happen in June and then mobilisation of approved option. Current performance is 83% for EME equipment and 94% for high risk equipment. New electronic system is in place where departments can review equipment and date of last service. To be communicated to all leads. Red: Slippage against original timescales agreed. Business Case to go to SIC in June 16 and decision to be made regarding midlong term resourcing of the team. Scheme to go Green at this stage. Status of previous reporting month (March 2016) Amber. No external assurance is being sought at present. MD27 - Operating Theatres on all sites comply with HTM 05-01, particularly in relation to risk assessment, the environment and staff training. December March 2016 (with interim measurable milestones to demonstrate trajectory of improvement). Compliant. All operating theatres are compliant with HTM and undergo an annual verification. The General manager for surgery works closely with estates to coordinate a cycle of closures and repairs annually Blue: complete Status of previous reporting month (March 2016) - Green External assurance is provided via the Trusts external Authorised Engineer. 8

246 CQC Key Question Agreed timescale for implementation Progress (i.e. successes/outcomes) against original timescale What has been achieved? Comments / Current main concerns MD29 - All escalation wards/clinical areas are appropriately staffed and equipped to safely care for the cohort of patients intended. December March 2016 Recruitment is in progress and each of the escalation areas has been risk assessed. Where possible the escalation beds are closed when not required according to the demand in the Trust. The Trust has approved funding for substantive staff in areas that are consistently opened. These posts are being recruited into currently. A paper presenting the care model options for St Augustine's is in progress - for agreement in May 16. Capital works have commenced on St Augustine s ward. Confirmation has been made to recruit to unfunded beds on Cheerful Sparrows Ward. Red: Slippage against original timescales. Estates works to be completed by July 16. Model of care outstanding and to be agreed. Status of previous reporting month (March 2016) - Amber Caring MD24 - Patients' pain scores should be regularly and clearly documented and there should be interventions - pharmaceutical and alternative therapies. There are clear tools for use with patients with dementia and learning disability. December August 2016 (with interim measurable milestones to demonstrate trajectory of improvement). Pain scores are collected via Vital Pac and there is an audit process in place. A review of pain interventions available and access to specialist advice is underway. A tool has been developed for patients with dementia and also learning disability. Consultation and communication has been undertaken with patients and staff and the tool has been made available on PAS as a clinical form. In addition to the above, an audit of pain management scores across the Trust and patient s experience of pain and an associated action plan will be in place by August Green: on track. Extension agreed to end date of plan to August 16 to represent milestones. Status of previous reporting month (March 2016) - Green Pain assessment documentation will also be made universal (August 2016). No external assurance or support being sought. MD26 - Patients' complaints are responded to as per national standards. Ensure there is a clear process for learning across the Trust. December On-going but with key milestones achieved and evidenced by April There is still significant work to do to improve the response time within 30 days. A trajectory for improvement will be discussed and agreed by the Complaints and Patient/Carer Feedback Group. Q3 compliance of complaints responded to within 30 days is 33%. Surgical Services have a very effective 'Outcomes with Learning' newsletter for staff related to complaints. This format is being shared with the other divisions. The Terms of Reference for the Steering Group have been revised now incorporating other forms of patient feedback. Complaints training is being considered as part of the 1617 action plan for the Group. An Away Day was with the Patient Experience Team w/c 29th March and additional investment made in the RSO role. Trajectory for improvement agreed. Training to be delivered in June 16. No external assurance or support being sought. Red: some slippage against timescales agreed. Status of previous reporting month (March 2016) - Amber 9

247 CQC Key Question Agreed timescale for implementation Progress (i.e. successes/outcomes) against original timescale What has been achieved? Comments / Current main concerns Responsive MD06 - Effective processes are in place on each site (and between sites) to manage flow - senior on site leadership supported by accountable leads. Information supports escalation and decision making. Patients are cared for in the most appropriate place and care is coordinated. December 2015 On-going (key milestones set out in column K and detailed in interrelated Emergency Care Recovery Plan). Clinical Site Operational Leads in place on each site and substantive model agreed for implementation. Baseline bed model agreed and to be agreed in May 16. Access target trajectories agreed with CCGs as part of 1617 contract. The Emergency Pathway Improvement Plan is being implemented. ECIP are working with the Trust to make the necessary improvements in patient flow, safety and quality across the Trust. The Site Management Standard Operating Procedure draft to be circulated for the end of February. The Safer Care Bundle has been launched across all sites. Information has been improved to support predicted admission and discharges from each site and a revised dashboard is now in place. The Clinical site Operational Leads have tested processes and the learning will be used to replicate better practice. Slippage identified in relation to mapping of social care beds (external partner led) and review of bed base across Trust. Amber: Slippage against some milestones in ED Recovery Plan. (Programme risks include insufficient pathway 3 bed capacity out of hospital. This is being taken forward via the SRG. Safer Care Bundle to be further embedded - job planning will support maintenance). Status of previous reporting month (March 2016) - Amber ECIP Support is in place and multi partner support via the SRG MD25 - Inpatient areas are supported by 7 day services (radiology, therapies and pharmacy) to enable effective use of capacity and enable flow. December 2015 Start On-going but with key milestones achieved and evidenced by April Clinical Divisions are assessing which services are currently 7 days and which services may benefit from 7 day working. This forms part of workforce plans. Also ensuring that teams are aware of how to access out of hours services and is clearly documented. Diagnostic audit has been undertaken and action plan to be developed. Discussion within contract negotiations with commissioners around short, medium and long term plan. Amber: Some slippage. Workforce plans being scoped where there is a service need and commissioner support. Status of previous reporting month (March 2016) - Amber No external support or assurance requested. Well led MD09 - There is a positive workforce culture demonstrated by content staff who are supported and empowered to lead improvement, are aware of the Trust vision and their role within it and provide excellent patient care. Leaders at all levels have the skills to support and embed cultural change. December 2015 Start On-going (key milestones set out in column K and detailed in Cultural Programme Plan). Following the Staff Survey results the Trust priorities have been agreed. These are to continue the 'Respecting each Other' programme around bullying and harassment, a focus on health and wellbeing of staff, quality of appraisals and leadership and management development capacity and capability. Work has commenced. Re launch of Respecting each Other' video and further workshops planned. Health and Wellbeing Group has been established. New appraisal process to be launched on 1st April with conversation around Trust Values and Behaviours. Proposal agreed for leadership development and assessment. Tender closes May 16. HR BPs working on 'Great Place to Work' action plans. There is slippage against timescales for the OD Strategy. Communications Plan work to be finalised in April. External consultancy support has been utilised for OD Strategy. Monitor are requesting further assurance around the next steps and embedding of the cultural values. Amber: Minor slippage against milestones. Status of previous reporting month (March 2016) - Amber 10

248 CQC Key Question Agreed timescale for implementation Progress (i.e. successes/outcomes) against original timescale What has been achieved? Comments / Current main concerns MD10 - The clinical strategy plan is delivered to timescale and communicated and implemented successfully led by clinical champions. December December 2016 (interim milestones within HLIP). Next milestone development of models of care (April 16). STP due end of June 16. The Clinical Forum meetings have continued and have focussed on developing out of hospital models. This has been supported by provider organisations who are both providing and triangulating in hospital data to better understand the type of activity that will be managed out of hospital future models of care. We continue to work closely, via the East Kent Strategy Board and aligned clinical meetings, to design of sustainable model of health and social care for east Kent. The national request for health economies to produce a 5 year Sustainability and Transformation Plan by June 2016 has also been aligned with the work on strategy. The Trust held a significant clinical engagement event on 1st to 3rd March to consider how acute care will be developed in the future and a range of meetings have taken place with staff who responded to a call for ideas for future ways of working. The output of these sessions was reviewed by the Trust Board in April and further work is being progressed for presentation back in June 16. Green: On Track Status of previous reporting month (March 2016) - Green External collaboration is central to this item and is in place. MD16 The Trust governance arrangements are clear and transparent December March 2016 (with interim measurable milestones) The outputs of the external governance reviews have been implemented. An evaluation of the new governance arrangements is outstanding as is a review of staff understanding of the arrangements. External support commissioned by Trust from Grant Thornton regarding board governance. Red: Slippage against original timescales. Status of previous reporting month (March 2016) - Amber MD17 - The Trust incident reporting process is robustly followed by all departments - with focus on ED departments at WHH, QEQM and Maternity services. Ensure that incidents are acted on in a timely manner and that staff receive feedback December 2015 Start September 2016 Incident reporting is high across the Trust when benchmarked against peers. Forums are in place where incidents are reviewed and action plans monitored. The next national report from the NRLS is awaited in order to confirm national benchmarking for reporting. Datix V14 testing was completed in April and fully rolled out across the Trust with a few minor issues which were resolved without issue. External support is not required. Green: On Track Status of previous reporting month (March 2016) - Green MD18 - Trust wide policies are procedures are up to date and in line with best practice. Policies and procedures are clearly written and easily accessible by staff. December 2015 Start June 16 (but trajectory for improvement set based on programme plan) Policy group has been set up and meets regularly to ensure policies are up to date and are in line with best practice. There is a manual process for identification if any policy documentation which will be out of date within 2 months. A system has been purchased to provide assurance that staff have accessed and read policies relevant to their role. In order for this to work effectively, the system must be configured and a member of staff must be nominated to work on this project. MicroGuide app functionality to be explored for clinical guidelines. External support is not required. Amber: Some risk regarding slippage to milestones to enable June 16 achievement. Resourcing to be agreed in month to mitigate risk. Status of previous reporting month (March 2016) - Green 11

249 East Kent Hospitals University NHS Foundation Trust Summary of progress against improvement plan Specific service (i.e. cutting across CQC Key Questions) Agreed timescale for implementation Progress (i.e. successes/outcomes) against original timescale What has been achieved? Comments / Current main concerns End of Life MD01 - A suitable End of Life Pathway will be in place and staff will be competent in its consistent application. Contribution to local and national audits to evidence compliance. December 2015 Start June 2016 (with interim measurable milestones to demonstrate trajectory of improvement). The End of Life Board meets bi monthly chaired by the Divisional Head of Nursing, Specialist Services. Revised documentation which is trust specific and nationally compliant is now complete and available. Multidisciplinary staff awareness of the inclusive responsibility of end of life knowledge and expertise is progressing through specific training on end of life conversations local clinical area based Link Nurses. The Link Nurse contract has been agreed and nurses identified for most areas. Green: On Track Status of previous reporting month (March 2016) - Green. The EKHUFT section of the Interagency Policy was completed for the end of March. A report following the EoL Carers Experience Questionnaire was presented to the EoL Board in April 16. The Link Nurse Contract has been agreed. The EoL Facilitator will start in June Macmillan have in addition confirmed two band 7 posts for a two year period to support the Trust's implementation programme. Draft recommendations for training were discussed on the 14th April at the EoL Board. Revised proposal to be presented at the May EoL Board. To be implemented from June. Final Multi-Agency Policy sign off delay - CCG led. Tier 4 (EKHUFT) section complete. Urgent & Emergency Care MD02 - The Trust has an effective and safe emergency and urgent care pathway. Care is delivered in the most appropriate environment, working alongside local partners, with multi-agency leadership. On-going (key milestones set out in column K and detailed in Emergency Care Recovery Plan). The Emergency Pathway Improvement Plan is being implemented. ECIP are working with the Trust to make the necessary improvements in patient flow, safety and quality across the Trust. The ED Recovery Plan has been updated to reflected the HLIP and vice versa (February 2016). Work has commenced on defining the ECC model with a due date of June A workforce model for mid grade doctors is being written. The building work in ED Minors has been completed meaning there is more space and an appropriate paediatric waiting area. Funding has been agreed for continuation of IDT and H&S Care Village beds until July 16. The ED Escalation Policy/SOP has been approved and being rolled out. There is some slippage against programme schemes and risks. Continued risks regarding the ability to recruit to medical vacancies although 9 senior grade/consultant offers have recently been made. Revised trajectory agreed by SRG around 4 hour performance % achieved for April. Improvement in clinician see first assessment times in under an hour in month. Amber: Some slippage against the ED Recovery Plan. Status of previous reporting month (March 2016)- Amber ECIP Support is in place 12

250 Specific service (i.e. cutting across CQC Key Questions) Agreed timescale for implementation Progress (i.e. successes/outcomes) against original timescale What has been achieved? Comments / Current main concerns Children & Young People MD15 - Ensure that appropriately trained paediatric staff are provided in all areas of the hospital where children are treated to ensure they receive a safe level of care and treatment. December March 2016 (with interim measurable milestones to demonstrate trajectory of improvement). Recruitment and retention plans are in place to ensure appropriately trained staff are in place. Green: On Track Status of previous reporting month (March 2016)- Green MD14 - There are sufficient numbers of paediatric trained staff within Emergency and Urgent Care Pathway. December March 2016 (with interim measurable milestones to demonstrate trajectory of improvement Recruitment of paediatric nurses in the ED is almost complete to enable 24/7 cover. From May 16 there will be 24/7 paediatric RN cover at the QEQM and from June 16 for the WHH site. Red: Slippage against original timescale given. Vacancies filled from May and June 16 when status will go blue. Status of previous reporting month (March 2016 Green) Maternity Services MD04 - The Trust offers safe, effective, caring, responsive and well-led maternity services December September 2016 The MBRRACE-UK report has been published and shows the Trust to have a 10% lower average mortality rate for its comparator group. The RCOG final report has been received and an action plan will be signed off in May The deadline for embedding the new maternity dashboard slipped due to the new E3 electronic reporting system. The April dashboard has been completed and this will be populated monthly going forward from mid May. Work underway on bereavement suite at QEQM. Environmental constraints mean problematic to improve facilities for partners but written information to be reviewed. CTG machines received and replacement programme in place. Maternity Vision Strategy shared for comment with staff and 'Great Place to Work' workshops set up for staff involvement. Amber: Some slippage against milestones. Agreement from Improvement Director that scheme should be split with implementation of RCOG separate RAG after plan sign off. Status of previous reporting month (March 2016) - Amber MD03 The Trust has sufficient capacity for women in labour on a day to day basis April 2016 (with interim measurable milestones to demonstrate trajectory of improvement). The final version of Birth Rate Plus has been received. The Trust assesses staff requirements on a shift basis and addresses any shortfalls that occur with temporary staffing. A live database is in place for recruitment. A database has also been put in place to record the number of diverts and closures to the unit and a revised policy circulated for comment for sign off by end of May The review of demand and capacity and development of live tools (based on bookings) remains outstanding - this has been impacted by the implementation of the new E3 electronic system. The demand and capacity analysis will be undertaken in May with findings presented in June. There have been 11 diverts in place since December 15. Red: Slippage against original timescale given for demand and capacity work. To be completed by June. Status of previous reporting month (March 2016) -Amber 13

251 Specific service (i.e. cutting across CQC Key Questions) Agreed timescale for implementation Progress (i.e. successes/outcomes) against original timescale What has been achieved? Comments / Current main concerns Mental Health MD05 - Patients receive timely mental health assessment and have appropriate facilities whilst waiting. December May 2016 In December 2015, a HLIP partnership engagement session took place where the accountable officers for the local CCGs agreed to support an action plan regarding the level of psychiatric liaison support required as part of the emergency pathway. An interim solution was agreed until the end of March SRG have approved an options appraisal for model of care. From end of May 16, KMPT will provide 8-8pm cover on all three sites 7 days per week. A third consultant will also be employed. Changes to the physical environment in the WHH ED will be complete by June Internal escalation policy in draft - to be agreed in May 16. Consideration to be given of additional training required by staff. Amber: Some minor slippage. Status of previous reporting month (March 2016) - Amber KMPT (MH provider) and all CCG Accountable Officers 14

252 Other (e.g. concerns arising after CQC re-inspection; awaiting CQC report from re-inspection etc.) No other concerns noted. Other comments for reporting period (April 2016): A regular programme of Improvement Visits has been established and the template embedded in operational process. The fourth Improvement Visit (May 2016) is about to commence. A Communications Plan has been launched a themed fortnightly message is cascaded to staff and supported by training and a programme of speakers in the Quality Innovation and Improvement Hubs. The pace of progress has continued since the plan was signed off and continues to progress - as part of our organisational Improvement Journey. 15

253 EMERGENCY RECOVERY PLAN BoD 56/16 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS DATE: 10 JUNE 2016 SUBJECT: REPORT FROM: PURPOSE: EMERGENCY RECOVERY PLAN REPORT CHIEF OPERATING OFFICER Discussion CONTEXT / REVIEW HISTORY / STAKEHOLDER ENGAGEMENT This paper provides an update to the Board on the progress being made against Emergency Recovery Plan and should be read in conjunction with the Key National Performance Targets report. SUMMARY: This paper outlines performance trends against the 4 hour standard over the last 12 weeks and identifies the progress made against the Trust Emergency Recovery Plan. The Trust and the system is currently not achieving the agreed trajectories in respect of performance against the 4 hour standard although signs of improvement have started to emerge over the last couple of weeks. The Trust achieved 84% for April, with variances in performance across the three main acute sites. Performance for week ending 20 th May was 82.2% for the month and 83.2%. ED Attendances for May are 8.8% above plan. The governance and programme management arrangements of the ERP have been revised with a new programme manager in place from 14 th April and new site based site management and clinical leadership forums have been established to drive forward priority site based improvement initiatives related to the 4 key improvement priorities. The Trust s CEO and the wide System s resilience group has identified 4 key areas of high impact focus within the Acute part of the system to ensure consistent achievement of improvement on our trajectory. (a) Improvement in ED. (b) Implementation of the Patient SAFER Bundle (c) Development of the Acute Medical Model (d) Improvements to Site Management Arrangements The attached paper sets out performance of the last 12 weeks together with an update on the progress being made against the 4 identified high impact priorities. There continues to be high ambulance attendances and also a high number of unwell children attending in the evenings and weekends. The junior Doctor strikes have also had an impact in that patient attendances on these day remain at normal levels, with higher attendances the day after. 1

254 EMERGENCY RECOVERY PLAN BoD 56/16 URGENT CARE RECOVERY PLAN The plan has undergone a detailed review in order to internally challenge and identify the high impact changes which will improve performance. The programme governance and management has also been completely refreshed to include a dedicated senior site meeting which will be used to drive the key projects for the site at pace and ensure that all professional groups are represented at the meeting. The four key actions that the site based meetings will focus on are: Improvements in ED Acute Medical Model SAFER Site management arrangements Summary Performance April performance against the 4 hour target was 84.02%, against a trajectory of 85.22% and a compliance target of 95%. April s performance level is improved compared to the February and March positions, with a higher proportion of patients seen within 4 hours. Analysis of the breach reasons shows a reduction in the proportion of breaches due to delays to be seen by a first clinician, (32% of all breach reasons, compared to 43% in March). This improvement in patients being seen by a clinical decision maker more promptly is also shown by the increased proportion of patients seen within 60 minutes, a sign of reduced overall waiting times for patients compared to recent months. In April, the William Harvey Hospital (WHH) in Ashford showed a clear mid-month step change in performance, with the last 14 days of the month showing overall performance of 85% against the 4 hour compliance standard, contrasting against 71% for the first fortnight of the month. There was no notable change in the volumes of attendances to the site over this period of time, but it is noted that the last week of April saw fewer extended waits to be seen, and an increased proportion of patients first seen within 60 minutes (improved to 49% within 60 minutes compared to 31% in the first fortnight). 2

255 EMERGENCY RECOVERY PLAN BoD 56/16 Improvements in Emergency Department performance are being pursued through the urgent care recovery plan, which has gone through a detailed review to identify areas which will improve performance the most. The 4 key areas and actions are as follows; Priority 1- Improvements in ED Team Based Working This pilot has been developed by the senior clinical team at QEQMH. Senior medical, nursing and support staff are allocated into teams who are responsible for specific areas of the Emergency Department with clinical responsibility for managing patients in those areas through their pathways. Implemented in April The pilot is being run between the hours of There was an immediate positive impact with an improvement on the 60 minute standard from 31% to 48%, which resulted in more patients being seen by a clinician within 60 minutes of arrival in the department. 4hr compliance overall sees a 5% compliance increase for non-admitted patients during pilot hours moving from 81% to 86%. The hours of cover are being extended until in May as staffing allows, however there are currently 4 speciality doctor vacancies which are being covered by locum doctors whilst recruitment is completed and this may impact on the department s ability to provide the service consistently. Nine new speciality doctors have accepted posts and will be arriving in the next 3 6 months. Consultant Recruitment The Emergency Department is funded for 10 Emergency Medicine Consultants on each site. In 2015/16 there were 6 substantive consultants in post. There is a national shortage of Emergency Medicine Consultant and Specialist Registrars in training. An internal consultant development programme was implemented in 2015/16 to enable speciality doctors to be supported by a dedicated clinical supervisor and teaching programme, linked to the College of Emergency Medicine examination programme. The programme has been successful with 3 speciality doctors expected to be able to apply for substantive consultant posts within 1-2 years. Over the past year there have also been an additional 3 consultants have been recruited, with two of the applicants coming into post in September Early Senior Intervention (ESI) project The senior clinical team at WHH have piloted an internationally recognised assessment process whereby self-presenting and ambulance patients are assessed by a senior doctor or nurse upon arrival in the Emergency Department. Patients will then be streamed to the appropriate pathway to ensure that timely and appropriate clinical care is provided and the sickest patients are seen and treated immediately. The ESO project has been accepted by the TIPs programmes (Teams Improving Patient Safety). Full roll out may require additional nursing staff to support the model and this has been included in the nursing workforce review which was completed in April 16. Priority 2 - Re-launch of Acute Medical Model at QEQM. The Acute Medical Model was implemented as Phase 1 on 2 April The model 3

256 EMERGENCY RECOVERY PLAN BoD 56/16 has had an immediate positive impact on patient flow and has been fully supported by the clinical teams on site. The model is being evaluated on a weekly basis and managed through a project structure to ensure that the learning is captured and will be shared. Due to the model s success, plans are in place to roll out the model to WHH with the project group being established in May and implementation by the end of June Aims of model: Strong MDT approach to managing patients pathway Direct referrals to specialist teams within MDT board round/careflow electronic referrals Reduced LOS both short stay & specialist patients as indicated earlier in pathway Improved flow across emergency floor / improved patient experience Increasing use of emergency ambulatory care / improved management for primary care referrals Further developments/consideration 7 day working Recruit Acute Medical staffing team Inclusion of Frailty team within model Priority 3 - Implementation of SAFER SAFER has been implemented on Sandwich Bay and Minster Ward at QEQMH and Cambridge L and Cambridge J at WHH. The processes are becoming embedded with morning MDT ward rounds established. A discharge website is being developed to include information and policies relating to simple and complex discharges, SAFER tools and patient leaflets. Next steps include drop in training sessions for MDT staff around discharge, SAFER principles and patient flow. Developing a SAFER dashboard to monitor progress and improvements. Identify a consultant champion for each ward area and improve senior clinical engagement Priority 4 - Site Management Arrangements Operational Control Centres (OCC s) OCC s have been established on all three sites, with the major incident control centres now being formally co-located. The OCC s have quickly becoming established as information hubs for consultants, senior nurses and managers to provide and receive information. Meeting Structures Trustwide video conferenced SITREP meetings have been standardised with meetings being held at and Additional meetings may be requested according to site escalation status. Chaired by the Head of Clinical Operations, the site based meetings focussing on the provision of safe and effective emergency and elective patient flow, staffing issues and risk are held twice daily. The above meetings are also supported by a SITREP telephone call to escalate emerging risks to the Head of Clinical Operations or Divisional Director for UCLTC. Communication Systems QEQMH is piloting the use of mobile telephones using wi-fi to improve the network coverage. 4

257 EMERGENCY RECOVERY PLAN BoD 56/16 Trajectory Confidence April performance against the 4 hour target was 84.02%, against a trajectory of 85.22%. The new Acute Medical Model and Team Based Working models all had a positive impact on performance. The improvements gave confidence that the projects which have been developed and implemented by the clinical teams would provide the sustained improvement to patient experience, quality and flow. The formalised meeting structure, improved discipline and information flows that the OCC s have delivered have also had a positive impact on performance, particularly at QEQMH where the meeting structure has been developed and become established. The QEQMH communication and meeting model is being rolled out to all sites. The ongoing risk to delivery of the trajectory is: o the number of DTOC s (delayed transfers of care) and access to short term external capacity in the community. A high % of breaches of the 4 hour emergency access standard relate to patient flow and bed availability. o High numbers of patients attending ED in the evenings who could be managed by primary care, in particular paediatric attendances. JUNIOR DOCTORS STRIKE The priority for the strike days was to provide safe service delivery during and after the two day strike (EKHUFT had implemented this as a critical incident where all unplanned (emergency / urgent) care was maintained and the majority of planned (elective) care was cancelled in order to release individuals to support the most critical areas: Emergency department activity, Emergency surgery activity Emergency cardiac / respiratory resuscitations Emergency Paediatric activity Emergency Obstetric activity Day 1 26 th April: 90.1% attendances (39% minors / 61% majors) - Previous Tuesday 86.5% attendances (42% minors / 58% majors) Day 2 27 th April: 95.9% attendances (39% minors / 61% majors) - Previous Wednesday 89.8% attendances (44% minors / 56% majors) Strike, followed by Bank Holiday weekend: 28 th /29 th /30 th 93.2%/90.4%/93% - 544/529/559 attendances The surge was not felt until Tuesday 3 rd May 85.4% attendances (43% minors) Attendances have remained high 5 th and 6 th May 607 and 604 attendances Weekend attendances are now as high as week days 7/5 579, 8/5-580 Over the two days of strike 1600 out patient appointments and 80 elective operations have had to be rescheduled (at increased cost). After Action Review : Overall the two days were well planned and all emergency service where delivered efficiently. This was at the cost of elective activity (which is an unrealistic situation) Future planning for an indefinite strike could have even greater impact due to the 5

258 EMERGENCY RECOVERY PLAN BoD 56/16 prolonged nature of such as strike and the need to rest staff for following days and nights. Acute actions: Task and finish group to be set up to review how the success of the two days can be replicated via a Consultant of the Week (hot week) rota. Consultants to continue two way contact with control centres. Business continuity plans to be revised to include lessons learnt on releasing the appropriate surgeons to support ED, SEAU, and the wards. This to include the needs of therapists etc. Business continuity plans to be revised by all teams to apply lessons learnt, and consider the actions required for an indefinite strike. RECOMMENDATIONS: The Board is asked to note the content of this report and seek further assurance if required. The Emergency Recovery Plan has also been reviewed by the Finance and Performance Committee. NEXT STEPS: Progress to continue to be monitored through the Urgent Care Programme Board. IMPACT ON TRUST S STRATEGIC OBJECTIVES: Patients: Help all patients take control of their own health. People: Identify, recruit, educate and develop talented staff. Provision: Provide the services people need and do it well. Partnership: Work with other people and other organisations to give patients the best care. LINKS TO BOARD ASSURANCE FRAMEWORK: These standards form part of the reporting mechanism to Board of Directors. IDENTIFIED RISKS AND RISK MANAGEMENT ACTIONS: All these standards are being closely monitored and mitigating actions are being taken where appropriate (in collaboration with the whole health economy) FINANCIAL AND RESOURCE IMPLICATIONS: There is a financial penalty for not achieving these targets when in a PbR contract the current managed contract does not hold this financial risk. 6

259 EMERGENCY RECOVERY PLAN BoD 56/16 LEGAL IMPLICATIONS / IMPACT ON THE PUBLIC SECTOR EQUALITY DUTY: None PROFESSIONAL ADVICE TAKEN ON ANY NOVEL OR CONTENTIOUS ISSUES N/A ACTION REQUIRED: (a) To note and discuss the content of the report CONSEQUENCES OF NOT TAKING ACTION: Potential risk of failing the required standards which has an impact on our Monitor rating and Trust reputation. 7

260 EAST KENT URGENT CARE RECOVERY PLAN SUMMARY EKHUFT Performance Trajectory PROGRAMME STATUS 2015 / 16 Emergency Department 100% Monthly Performance Trajectory Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 89.3% 88.4% 88.0% 87.0% 89.3% 89.3% 90.9% 91.4% 93.3% 85.2% 90.0% 90.2% Monthly Performance Achieved 89.3% 88.4% 88.0% 87.0% 89.4% 87.8% 84.01% Avg Quarterly Perf. Trajectory 89% 89% 92% 88.52% Avg Quarterly Perf. Achieved 88.6% 88.0% ECC 80% Alternate Pathways 60% Systems Resilience Group: Five Key Actions (ECIP Concordant) Communications & Engagement Quality Improvement Workforce 40% 20% 0% Estates SAFER Discharge Site Management & Leadership Information & Reporting No KEY ACTION Improve medical and nursing leadership in ED to improve all aspects of ED process and patient safety at all sites Implement the SAFER patient flow bundle across all medical wards PROGRESS SINCE LAST REPORT Development and Site Management Proposal Paper to be submitted to Trust Board in March. QEQM Head of implementation of an Clinical Operations post to be substantively recruited to, with WHH and K&C to follow. effective clinically and operationally led site management mode to improve and sustain effective operational delivery Agree and develop an effective acute medical model UCLTC Division currently implementing a Site-based leadership approach SAFER Patient Flow Bundle has been introduced across the UCLTC wards at QEQM, and implementation has been commenced at WHH, as of 22nd February. SAFER project Teams to be revised to reflect a Site-based MDT approach, linking with ED Recovery, Site management and development of the acute medical model. QEQM Working Group commenced 4/2/16 and 'Aspirational Model' agreed. Short Term actions identified to enable implementation of 'Phase 1'. Implementation of the Acute Medical Model to be supported jointly by the Service Improvement & Innovation Team and Strategic Development PROECT OWNER Ajay Bhargava / Karina Greenan/ Elisa Steele Elisa Steele / Karina Greenan Jane Ely / Mark Angus Jonathan Hawkins / Lesley White WHEN Ongoing Ongoing Ongoing Ongoing 5 Realigning the Whole Systems Integration Workshop to be held on 14th March to plan future vision for Discharge commissioning intentions for to Assess, Integrated Discharge Team and capacity plans discharge to assess EK COO's 31st July 2016 PROJECT No 01 - Jane Ely RA GC PROJECT TITLE PROJECT INDICATOR em ro PROJECT DESCRIPTION Emergency Department 73% Reinvigorate department ownership of urgent care patient flow and motivate all staff to improve the quality of performance, through clear clinical leadership EXECUTIVE LEAD / SPONSOR Jane Ely PROJECT MANAGERS ED Leads & Senior Matrons START DATE END DATE PROJECT BRAG RATING 01/06/15 31/03/ No PROJECT Key Actions completed since the Last report MANAGEMENT ACTION WHO WHEN 02 - Paul Stevens 03 - Sally Smith Alternate Pathways SAFER Discharge 83% 95% Establish clearly a defined and documented Acute Medical Model of Care which includes rapid access to patient pathways within Ambulatory Care, Acute Medical Units, Surgical Emergency Assessment Units, Gynaecology Assessment Units and Hot Frailty Clinics Ensure robust Discharge Planning is established throughout the Trust, based on the principles of SAFER Discharge. Optimise the role of the Integrated Discharge Team and re-enhance the nursing role (including Matrons), including Registered Practitioner-led Discharge Paul Stevens Sally Smith Acute Physicians & Nurse Consultants Clinical Site Leads & Senior Matrons 01/06/15 31/03/ /06/15 31/03/ Jane Ely Site Management & Leadership 79% Establish Senior Site-based leadership teams to promote a site-based culture of improvement. Ensure provision of Senior Clinical Leadership 24/7 Jane Ely General Managers & Senior Site Matrons 01/08/15 30/09/ Nick Gerrard Information & Reporting 84% Agree A&E impact Metrics. Optimise use of technology to enable rapid access to accurate information relating to patient flow. Circulate Breach Analysis data to inform learning and improvement Nick Gerrard Michael Straight 01/06/15 31/03/ Current Issues / Risks 06 - Liz Shutler Estates 100% Ensure the Emergency Departments are fit for purpose and sufficiently supported by Estates Liz Shutler Gary Lupton 01/06/15 31/03/ No PROJECT ISSUE or RISK MITIGATION ACTION WHO WHEN 07 - Sandra Le Blanc 08 - Sally Smith & David Hargroves Workforce 74% Quality Improvement 85% Agree and Implement the Recruitment Strategy for the Emergency floor and inpatient wards areas to enable timely patient flow and stability of workforce. Utilise opportunities to enhance workforce flexibility through introduction of new roles (where able) and new ways of working Ensure robust structure and governance is established to keep projects to agreed timescales and highlight/resolve potential issues early. Monitor risks and performance against the Plan Sandra Leblanc Carolyn Apps 01/06/15 31/03/ Workforce Jane Ely Sarah Maycock 17/08/15 31/08/ SAFER Discharge Medical Staff vacancies, high reliance on agency staff - agency cap risk impact on availability. Nursing recruitment progress being limited by 12% turnover rate in urgent care 9 Senior Middle Grade/Consultants offered - awawitint confrimation of acceptance. Workforce recruitment plan in place and agreed trajectories. Review of ED medical and nursing rota aligned with attendanc trends being undertaken by Head of Nursing and Clinical Lead for ED. Insufficient PW3 bed capacity and Direction of Choice Policy submmitted to WSOG for approval, Capacity and limited flexibility within external facility Demand review to bbe commissioned by EK COOs providers bed base. Jonathan Hawkins / Karina Greenan 31st March 2016 Jane Ely 14/01/16 East Kent Whole System Urgent Kent Plan Summary 03/06/2016 Page 1

261 09 - Sandra LeBlanc Communications & Engagement 80% Ensure staff across the Trust are fully aware of the Urgent Care Programme (Recovery Plan) and the role they have in achieving success Sandra Le Blanc Sarah Maycock 21/08/15 31/03/ SAFER Discharge Operational Issues relating to the new equipment provider is causing a number of delays to patient discharge Urgent Task and Finish Group to meet week commencing 11/1 to agree actions to resolve the issues. Mary Tunbridge 15/01/16 Redesign of the ECC Model and patient flow 10 - TBC ECC 90% Paul Stevens (TBC) Anne Neal SAFER Discharge Fast Track Process Issues Urgent Task and Finish Group to meet week commencing 11/1 to agree actions to resolve the issues. Mark Angus 15/01/16 Totals KEY R A G B BRAG RATING: PROJECT SUMMARY < 50% of Actions on Target. Combination of no progress and slippage > 50% of Actions are on Target, but some slippage &/or risk in timescales > 85% of Actions are on Target, minimal slippage &/or risk ALL Actions completed. Project Plan closed East Kent Whole System Urgent Kent Plan Summary 03/06/2016 Page 2

262 URGENT CARE PROGRAMME: RECOVERY ACTION PLAN 01 - Jane Ely Reference - 4hr A&E Access target Aim is to achieve 95% (NB: 93% by March 2016) Emergency Department Organistion - Improved performance against the 60 min KEY PERFORMANCE METRICS. Aim is to achieve 60% by June 2016 Reinvigorate department ownership of urgent care patient flow and motivate THIS PROJECT WILL ENABLE THE ACHIEVEMENT OF: Service Type all staff to improve the quality of performance, through clear clinical - Improved performance against the 15 min Aim is to achieve 85% leadership Quantity Blue items - also shown again in the SRG plan Percentage % 23.8% 3.2% 19.0% 54.0% Original BRAG STATUS Site Item No Summary of Action DRIVER SITE / KF39 13 / KF / MD02 21 / MD02 22 / KF19 ED Consultant Rota's to enable 7 day working, to 22.00hrs (Revised to 5 day cover only until 8 wte appointed on each site) NEW ACTION: Pilot of a 'go to' doctor to improve one hour and four hour standard in all areas of ED (Triage, Paeds, Resus, Majors), assuming a 'RAT' type model Clear definition of when an ED/ECC is unsafe and requires senior nursing and senior consultant attendance Ensure See & Treat is functioning during Core Hours Clinical triage of patients to be undertaken within 15 minutes of patients arrival. Adherence will be monitored via the ED Dashboard RAT to be established and embedded during Core Hours. Process must be in place to monitor compliance. ECIST TRUST TRUST ECIST CQC CQC ALL QEQM ALL ALL ALL ALL Review ED patient flow against staffing numbers, to ensure good skill mix of staffing experience and numbers on duty. Medical and nursing rotas to be reviewed to re-align staffing to peaks in activity. ECIST ALL EKHUFT / SECAMB to review current EK handover policy against Mid Essex handover policy and recommend any improvements/amendments with particular reference to patient safety and privacy and TRUST WHH dignity (may need to reflect environmental/estates differences between the different sites). Oncological emergencies to be seen within 4 hours in ED. AOM's are currently undertaking an audit regarding emergency care pathway for oncology patients. CQC ALL Ensure that a pathway from ED to accessing gynaecology related admissions is robust and in line with local and national guidance. CQC ALL Minimal delays for MH patients receiving assessment. Work with KPMT to ensure there is timely intervention by the MH team and patients are seen in the correct environment at the right time CQC ALL Project Manager Ajay Bhargava Wayne Kisson Paul Stevens; Sally Smith; Jane Ely Ajay Bhargava / Peter Orsman / Mike Walker Karina Greenan / Ajay Bhargava Karina Greenan / Ajay Bhargava Ajay Bhargava / Karina Greenan Karina Greenan / Peter Orsman Elizabeth Mount Hussein Rfidah Helen Bland Elizabeth Mount Hussein Rfidah Helen Bland Lesley White Start Date Original End Date Revised End Date Overdue/ Mtg action Some Risk Work in Progress Action Complete Complete Date K Q W 01/06/ /03/2016 G N B B 26/01/ /03/2016 G N B N 21/10/ /11/2015 R B R R 01/06/ /10/2015 R B R B 31/10/ /01/2016 R G B A 31/10/ /01/2016 R N R R 01/06/ /10/ /03/2016 A N G A 31/10/ /02/2016 A N N A 30/04/ /04/2016 G G G G Liz to update 30/04/ /04/2016 G G G G 31/10/ /04/2016 R A A A Comments Consultant cover until 22.00hrs Monday to Friday. 8hrs cover at weekends. - WWH and Job Plans being reviwed as 5 day rota not being followed Full 7 day cover cannot be provided until recruitment completed close as we will not be in a position to provide a seven day rota until at least eight consultants per site PDSA for a week - WK to confirm date of pilot. - Doctor in Charge of WHH ED Implemented mid-march Embedding process and extending to 09:00-21:00 in May. KG advised a mtg to discuss - Meeting to be confirmed meeting 5 April at 12 noon. ED consultants and matrons. David Hargroves to be invited ED DNA meeting. LW to escalate to JH KG advised availability of ENPs to effectively manage S&T compromising the ability of the EDs to consistently provide this service accepting service cannot be provided 24/7 due to ENP resources. Plan to provide 10:00-20:00 service 7/ Dashboard demonstrates performance at 95.8% Trustwide (91% K&C, 96% QE, 97% WHH), 95% nationally. Data quality check linked to ambulance handover KG advised availability of depts to effectively manage RAT due to crowding and staffing remains an issue - Space issue will improve once Paediatric Unit at WHH is finished at the end of March. Other speciality assessment pathways need to be reviewed to align with RAT model RAT not applicable to K&C. QEQMH and WHH will RAT as staffing allows. Close? KG completed nursing review Mel B completing demand and capacity model for staffing ED. Modelling to be completed 7 April 2016 Meeting with SECAMB now being set up asap MS/PK liaising re meeting for LW and JE to both attend 7 Day direct access for all Gynae emergencies at WHH Liz Mount to update - gynae assess issue by EPU KG advised she believes this is an issue which should be classified as red change to red EAST KENT HOSPITALS UNIVERSITY FOUNDATION TRUST 03/06/2016 Page 3

263 URGENT CARE PROGRAMME: RECOVERY ACTION PLAN 01 - Jane Ely Reference - 4hr A&E Access target Aim is to achieve 95% (NB: 93% by March 2016) Emergency Department Organistion - Improved performance against the 60 min KEY PERFORMANCE METRICS. Aim is to achieve 60% by June 2016 Reinvigorate department ownership of urgent care patient flow and motivate THIS PROJECT WILL ENABLE THE ACHIEVEMENT OF: Service Type all staff to improve the quality of performance, through clear clinical - Improved performance against the 15 min Aim is to achieve 85% leadership Quantity Blue items - also shown again in the SRG plan Percentage % 23.8% 3.2% 19.0% 54.0% Original BRAG STATUS Site Item No Summary of Action DRIVER SITE 23 / MD05 24 / MD05 25 / MD05 26 / MD05 27 / MD05 28 / MD05 29 / MD05 32 / KF01 34 / KF42 36 / KF63 Action plan to be agreed between KMPT and the Commissioners for the model of psychiatric Liason service in order to provide access to mental health assessment in all emergency areas of EKHUFT to meet their requirements to be agreed as part of KMPT and EKHUFT CQC improvement plans, Patients receive timely mental health assessment and have appropriate facilities whilst waiting. Design solutions with Stakeholders (clarity over provision of service and how to reduce delays in transferring patient following assessment) Evaluate current plan for ED investment 16/17 for Mental Health support to ED. Include new roles across all three sites Relevant to Mental Health: undertake a workforce review that evaluates the establishment, skill mix and development of new roles as part of the Trust workforce strategy. (e.g. Associate Practitioner role to undertake assessments and provide expert care) Review the environment where mental health clients are cared for in ED and CDU and implement findings where feasible Ensure documentation around presentation of mental health patients is clear and concise and offers the ability to audit attendance effectively. Expand training of current staff to ensure they have an understanding of mental health presentations a) work with KMPT lead clinicians to develop training programme for ED and ECC staff Review Operational Procedures (July 15) in relation to overcrowding - ensuring that there are identified trigger points and a process for escalation (in line with locally agreed Surge Management Policy and MAJAX plans). All sites to see a reduction in reattendance figures. All clinical staff to be trained in phlebotomy. Training records and % staff trained. Waits for phlebotomy measured. CQC CQC ALL ALL Project Manager Lesley White / Mark Angus Lesley White / Mark Angus Start Date Original End Date Revised End Date Overdue/ Mtg action Some Risk Work in Progress Action Complete Complete Date K Q W 31/10/ /01/2016 R R R R 31/10/ /01/2016 R R R R as above CQC ALL KPMT/CCG 31/10/ /01/2016 R R R R CQC ALL KPMT/CCG 31/10/ /01/2016 R R R R CQC ALL KPMT/CCG 31/10/ /02/2016 G B B G CQC CQC CQC CQC CQC ALL ALL WHH ALL QEQM KPMT/EKH UFT KPMT/EKH UFT Jonathan Hawkins Lesley White Karina Greenan 31/10/ /03/2016 G G G G 31/10/ /03/2016 G G G G 31/10/ /07/2016 G N N G 31/10/ /07/2016 G G G G 31/10/ /03/2016 G N G N Comments LW/MA met with Mental Health Trust and made clear current situation not acceptable. They are not in a position to support all 3 sites. They requested 2 site model ie seen at K&C - transferred to WHH/QE. Options appraisal to be completed by 31/ Working group taking forward. SH-T to feedback on design of liaison service. LW to further discuss K&C walk-ins and medical patients with SH-T ongoing concerns regarding length of time patients are being delayed in ED awaiting mental health assessment. KMPT have proposed a 12 hour service across three sites. Proposal not agreed. Links to workforce number as above Links to workforce number as above Rooms to be made available at all sites. CHECK to be made on compliance KG advised that there are MH assessment compliant rooms on all sites WHH room has been refurnished. Issue with door frame can be addressed if essential, however the room does have two doors SH-T to review paperwork - link to service review no Referral psych. Evidence of Training Programme required Sharon HT to update Feb 16 MA dealing. LW advised there is a basis to work on. Need guidance with consistency. Exec team have asked for something that builds on guidance from the College. AJ, KG, LW, Rees, Syed to draft something next week policy has been agreed at Management Board. Final amendments to be included by LW reattenders monitored monthly. Frequent attenders are discussed with consultants in ED with a plan to organise case conferences with GP or other professionals to reduce. Review K&C. Add re-attenders to dashboard IPS required for clarity on roles in ED.Info system will improve and labelling will speed up and this should be rolled out in March. Support needed to enable this asap. SH-T advised shouldn't be an issue if pilot goes ahead KG advised PDN in post at QEQM. Skills analysis being undertaken and training plan developed and deliverd. Basis nursing interventions will be part of ED induction for all staff all staff will be trained by the end of May. New appointments will have training as part of their induction EAST KENT HOSPITALS UNIVERSITY FOUNDATION TRUST 03/06/2016 Page 4

264 URGENT CARE PROGRAMME: RECOVERY ACTION PLAN 01 - Jane Ely Reference - 4hr A&E Access target Aim is to achieve 95% (NB: 93% by March 2016) Emergency Department Organistion - Improved performance against the 60 min KEY PERFORMANCE METRICS. Aim is to achieve 60% by June 2016 Reinvigorate department ownership of urgent care patient flow and motivate THIS PROJECT WILL ENABLE THE ACHIEVEMENT OF: Service Type all staff to improve the quality of performance, through clear clinical - Improved performance against the 15 min Aim is to achieve 85% leadership Quantity Blue items - also shown again in the SRG plan Percentage % 23.8% 3.2% 19.0% 54.0% Original BRAG STATUS Site Item No Summary of Action DRIVER SITE 39 Review Senior Nurse Leadership roles and responsbilities and accountabilities within Urgent Care Project Manager Start Date Original End Date Revised End Date Overdue/ Mtg action Some Risk Work in Progress Action Complete Complete Date K Q W Comments ECIP ALL Sally Smith 10/02/2016 TBC 30/05/2016 G G G G ongoing as part of restructure of teams. Move date to end of May. 40 Establish monthly senior ops meetings with SECAmb G G G meeting date agreed. ToR and agenda agreed. PROPOSED ACTIONS FOR ARCHIVING EAST KENT HOSPITALS UNIVERSITY FOUNDATION TRUST 03/06/2016 Page 5

265 Reference - 4hr A&E Access target Aim is to achieve 95% (NB: 93% by March 2016) Organistion 02 - Paul Stevens Alternate Pathways - Increased no: of patients treated in: Hot Ambulatory Care & Hot Specialty Clinics Service Type Establish clearly a defined and documented Acute Medical Model of Care which includes rapid access to patient pathways within Ambulatory Care, Acute Medical Units, Surgical Emergency Assessment Units, Gynaecology Assessment Units and Hot Frailty Clinics KEY PERFORMANCE METRICS. THIS PROJECT WILL ENABLE THE ACHIEVEMENT OF: Quantity Blue items - also shown again in the SRG plan 'Acute Medical Model' Percentage % 4.9% 12.2% 34.1% 48.8% Original BRAG STATUS Site Item No Summary of Action DRIVER SITE Develop a longer term startegy (supported by a Business Case as required) to enable full implementation Review WHH Acute Medical Model of Care to include: Primary Care triage, Specialist 'pullining' of patients, twice daily MDT Board Rounds, maximum LOS of 72hrs across Emergency Floor Undertake Establishment review to determine Medical & Nursing staff required to support Phase 1 implementation TRUST ECIST ECIST QEQMH WHH WHH Project Manager Lesley White Lesley White / Jonathan Hawkins Lesley White / Jonathan Hawkins Start Date Original End Date Revised End Date Overdue/ Mtg action Some Risk Work in Progress Action Complete Completion Date K Q W Comments 01/02/ /09/2016 G N G N 02/02/ /08/2016 G N N G 02/02/ /03/ /05/2016 G N N G until model goes live and review of the model completed it is not possible to confirm whether additional resources are required LW - Aim to set up AMU project group before end Mar meeting to be implemented mid-april when Dr Balogun back from leave As QE item 2 - MB to advise WHH staff to take forward staffing will be considered as part of the WHH project plan. The project group for WHH will be set up in April and therefore the date of is not appropriate. Amend to to allow the project plan to be developed Undertake a Capacity & Demand review to ensure the WHH Acute Medical Model is 'right sized'. Should include both Emergency Floor and Speciality wards within UCLTC Frailty Ambulatory Pathway to be implemented and fully aligned with the Acute Medical Model ECIST ECIST WHH ALL Lesley White / Jonathan Hawkins Phil Brighton / Juliet Apps 02/02/ /04/2016 G N N G 01/10/ /11/2015 A A G A As QE item as above Hot Frailty Clinics have been worked up for all acute Sites, but implementation delayed as a result of Job Planning. Hot Frailty to be fully implemented as part of Acute Medical Model (Quick Wins being identified as part of weekly meetings) Test acute frailty unit within the AMU at WHH - being discussed at meeting on with project plan at end of March green stagus for QEQMH as will be inlucded in the model from 18 April. Amber for other sites as a frailty area is being considered for ECC new model due to be delivered in July WHH option being developed by Dr Hawkins and will be included in the new model. 11 / MD02 11 Implement new model for Virtual Fracture Clinics across Trust Virtual fracture clinics being designed for all sites (by April 2016). EXECUTIVE TOP 10 ACTION Establish an SEAU and revised surgical flow on the QEQM site TRUST TRUST WHH / QEQM QEQMH Julia Blackwood Chris Hudson 01/06/ /09/ /04/2016 G G G G 21/10/ /11/2015 A N A N Delays associated with Consultant input (QEQM) and nursing recruitment means likely delay in fully establishing the model of care until April The project is also dependent also on CCG funding (decision awaited) MA to discuss with CH MA/DC to chase update from Chris Hudson Surgery to update SH updated - not currently able to fully implement due to lack of suitable space. As of we are implementing hot clinics Monday-Friday on the SAU then from till 6 the SEAU nurse will work within A&E implementing the model until suitable accomodation can be found Looking at working in a more integrated way. KG and HM to work together to refresh project by end March QEQMH new medical model has taken priority over area. Opportunities to colocate to be considered after acute medical model established in 3/12 SEAU - commenced ground work on a two trolley area in conjunction with ULTC. Hot clinics being established to support to commence operationally / MDO2 / KF60 Establishment of a surgical assessemnt unit. Escalation of overcrowding potential before it happens through use of IT 14 / MDO2 CQC QEQMH Develop policies and pathways for EPU and GAU admissions from ED. Work with ED to develop appropriate pathways. CQC ALL Chris Hudson SPECIALIS T 31/10/ /03/2016 A N A N 31/10/ /03/2016 A N A A Update required as per 11 above no update Changed to Amber. MB to link with Mike Forsyth to ensure consistency of cover at WHH and QEQM. (WHH to be early pregnancy advisory to send to K&C and add to policy - To be picked up in ECC work TH to update EAST KENT HOSPITALS UNIVERSITY FOUNDATION TRUST 03/06/2016 Page 6

266 Reference - 4hr A&E Access target Aim is to achieve 95% (NB: 93% by March 2016) Organistion 02 - Paul Stevens Alternate Pathways - Increased no: of patients treated in: Hot Ambulatory Care & Hot Specialty Clinics Service Type Establish clearly a defined and documented Acute Medical Model of Care which includes rapid access to patient pathways within Ambulatory Care, Acute Medical Units, Surgical Emergency Assessment Units, Gynaecology Assessment Units and Hot Frailty Clinics KEY PERFORMANCE METRICS. THIS PROJECT WILL ENABLE THE ACHIEVEMENT OF: Quantity Blue items - also shown again in the SRG plan 'Acute Medical Model' Percentage % 4.9% 12.2% 34.1% 48.8% Original BRAG STATUS Site Item No Summary of Action DRIVER SITE 16 / KF20 CDU LoS to be < 24 hrs for any individual patient. CDU articulates the number of patients it has requiring longer stay bed at bed meetings twice daily. Ward staff to be proactive in 'pulling' patients into empty longer stay beds with CDU practicing a more 'push' mentality CQC ALL Project Manager Jonathan Hawkins Start Date Original End Date Revised End Date Overdue/ Mtg action Some Risk Work in Progress Action Complete Completion Date K Q W Comments 31/10/ /03/2016 G G G G KG and JW to work on bringing 'pulling of patients onto wards' in at the site based bed meeting. DC to link with PB for bed form and KG will take forward link to implementation of OCC 17 / KF28 Ambulatory pathways for first fits to be developed, shared and consistently implemented within the EDs and ECC CQC ALL Jonathan Hawkins 31/10/ /06/2016 G G G G under development with Juliet Apps and Nick Moran. May update - There is a pilate underway at WHH during May Juliet Apps to update Implement Community Medicines Management Scheme (Thanet Medicines Concordance Team) - Screening & Referral process within CDU Review QEQM Acute Medical Model of Care to include: Primary Care triage, Specialist 'pullining' of patients, twice daily MDT Board Rounds, maximum LOS of 72hrs across Emergency Floor Undertake Establishment review to determine Medical & Nursing staff required to support Phase 1 implementation SAFER Start ECIST ECIST QEQM Mel Blinston 26/01/ /03/2016 G N G N QEQM QEQM Identify 'Quick Wins' and 'Must Do's to enable short term improvements with patient flow (use PDSA Cycles to test change & monitor impact) TRUST QEQMH Lesley White / Jonathan Hawkins Lesley White / Jonathan Hawkins Lesley White 02/02/ /08/2016 B N B N 02/20/ /03/2016 B N B N 01/02/ /03/2016 B N B N Rebecca Morgan taking forward. DC to request update Mel B to update on progress with project QEQM AWorking Group established (Chaired by Lesley White, facilitated by Sarah Maycock working group meeting weekly. Planning pilot on Pharm and radiology and careflow joining for electronic referrals. This will focus on current CDU at QEQM with slightly changed Acute Medical Model. LW to set up weekly group at WHH in April pilot going live 18 April Draft Medical Rota's to be produced by Mel Blinston. Draft Nursing Rotas to be developed by Ian Setchfield and Louise Harmes. Rota prepped for medical - gaps will be filled in ad hoc. Nursing review - Helen O'Keefe met with Louise. Funding awaited as above MB to try PDSA's for specialty referrals by careflow, the diagnostic dashboard for wards and CDU and develop a PDSA metrics dashboard. Consider having an acute model dashboard Mel B taking forward Careflow as part of project 5 Undertake a Pilot of the QEQM Acute Medical Model (Phase 1) and review the Outcomes / Benefits ECIST QEQM PROPOSED ACTIONS FOR ARCHIVING Lobo Sunil / Ian Setchfield 02/02/ /04/2016 B N B N April 18th go live. EAST KENT HOSPITALS UNIVERSITY FOUNDATION TRUST 03/06/2016 Page 7

267 Project Reference / Number 03 - Sally Smith - 5 Discharges by 10am (UCLTC) Project Name SAFER Discharge - 50% Discharges by 3pm (UCLTC) Project Description Ensure robust Discharge Planning is established throughout the Trust, based on the principles of SAFER Discharge. Optimise the role of the Integrated Discharge Team and re-enhance the nursing role (including Matrons), including Registered Practitioner-led Discharge KEY PERFORMANCE METRICS. THIS PROJECT WILL ENABLE THE ACHIEVEMENT OF: - Alignment of Admissions & Discharges per Site (All Specialties) Quantity Blue items - also shown again in the SRG plan Percentage % 5.2% 32.8% 62.1% Original BRAG STATUS Site Item No Summary of Action DRIVER SITE Project Manager Start Date Original End Date Revised End Date Overdue/ Mtg action Some Risk Work in Progress Action Complete Completion Date K Q W Comments 15 SAFER CARE BUNDLE (LEADS: Elisa Steele (UCLTC) and Chris Bernthal) DISCHARGE PLANNING (LEAD: Sarah Maycock) Direction of Choice Policy has been approved by EK COO's - for implementation throughout NHS funded beds (Acute & Community). Formal launch of the Choice Policy to be included as part of the 'SAFER Launch at WHH' week commencing TRUST ALL Sarah Maycock 26/01/216 31/03/2016 G B B B Direction of Choice Policy approved by EK COO's and circulated across EKHUFT, KCHFT and HSCV Beds. KCC included as part of circulation. May update - The Choice Policy has been approved & distributed Trustwide and also approved & circulated across the Community Hospitals & H&SCV Beds, to support patient flow throughout the EK health economy. Awareness raising is underway at a Divisional level and the development of easy to follow guides for the Choice Policy (among other things) is underway / MDO6 Lack of S&LT resource leading to delays need for a process of prioritisation and staffing SAFER Start ALL TBC 26/01/ /04/2016 G G G G COMPLEX DISCHARGE & INTEGRATED DISCHARGE TEAM (LEAD: Sarah Maycock) MULTI-AGENCY IMPROVEMENT (LEAD: EK COOs ) Up to date mapping of current provision of social care (NH or RH) in each CCG area with note of relevant changes to provision (KCC by January 2016). CQC KCC Janice Duff 31/10/ /01/2016 R R R R external/jane Ely 35 / MDO6 36 / MDO6 37 / MDO6 38 / KF68 Joint KCC and EKHUFT review of social care delays to discharge with memorandum of understanding that no patient should wait in hospital for assessment (February 2016). Agree joint approach to communication with regard to joint patient / pubic / provider engagement events regarding delayed discharges, (March 2016). Ensure that contracting and commissioning is based on actual capacity (Timescale as per contract negotiations timelines). Trust to work with partners to ensure appropriate patients only are retained on the acute site bed capacity - resulting in many patients being moved during stay. CQC ALL Jane Ely / Janice Duff 31/10/ /02/2016 R R R R CQC ALL EK COO's 31/10/ /03/2016 G G G G CQC ALL EK COO's 31/10/ /07/2016 G G G G CQC ALL EK COO's 31/10/ /06/2016 G G G G external/jane Ely external/jane Ely external/jane Ely external/jane Ely Lack of pathway 3 capacity, particularly at QEQM SAFER Start All patients must be reviewed by a senior decision (consultant/middle grade) every morning Monday to Friday ECIST ALL All medical wards should hold a daily MDT board round in the morning - Monday to Friday ECIST ALL EK COO's 26/01/ /03/2016 G G G G ALL Jonathan Hawkins & Elisa Steele, Karina Greenan Elisa Steele/Karin a Greenan 01/06/ /09/ /03/2016 B B B B 02/02/ /03/2016 B B B B Interim job plan changes implemented across UC&LTC division to enable consultants to attend wards 1 hour per day to undertake senior review of all patients and attendance where possible at ward MDM SAFER board rounds. Permanent Job plan changes to be implemented by June 2016 (check with LW) MDM board rounds in place across all UC&LTC wards - Medical attendance inconsistent on some wards 4 New Action New Action All patients within inpatient wards to have consultant and MDT owned EDDs within 12 hours of admission. ECIP ALL Full SAFER Patient Flow Bundle being implemented on two wards and WHH (Camb L and Camb J) and two wards at QEQM (Sandwich and Minster) - with ECIP support. Four Eyes Efficiency Project Linked to Embedded of SAFER to run alongside UC&LTC division SAFER roll out plan CQC Trust ALL ALL Jonathan Hawkins & Elisa Steele Elisa Steele/Karin a Greenan Sarah Maycock 01/06/ /08/ /10/2015 B B B B 01/09/ /10/ /09/2016 G B B B 01/09/ /10/ /09/2016 G G G G All patients have a post take review wtihin 12 hours (in hours) and within 14 hours overnight QEQM project implemented. There is now a SAFER dashboard which allows progress to be carefully monitored. An action plan is in place for delivering at QEQM and is being established for WHH EAST KENT HOSPITALS UNIVERSITY FOUNDATION TRUST 03/06/2016 Page 8

268 Project Reference / Number 03 - Sally Smith - 5 Discharges by 10am (UCLTC) Project Name SAFER Discharge - 50% Discharges by 3pm (UCLTC) Project Description Ensure robust Discharge Planning is established throughout the Trust, based on the principles of SAFER Discharge. Optimise the role of the Integrated Discharge Team and re-enhance the nursing role (including Matrons), including Registered Practitioner-led Discharge KEY PERFORMANCE METRICS. THIS PROJECT WILL ENABLE THE ACHIEVEMENT OF: - Alignment of Admissions & Discharges per Site (All Specialties) Quantity Blue items - also shown again in the SRG plan Percentage % 5.2% 32.8% 62.1% Original BRAG STATUS Site Item No Summary of Action DRIVER SITE 14 Agree the longer term plan for K&C regarding provision of a Discharge Lounge (temporary provision only) Project Manager Start Date Original End Date Revised End Date Overdue/ Mtg action Some Risk Work in Progress Action Complete Completion Date K Q W Comments TRUST K&C Elisa Steele 20/11/ /03/2016 G G N N St Lawrence Ward open as discharge lounge Jan 16. May 16 - Recruitment requirements have been submitted to the 20/05/16 Vacancy Panel. If approved the posts will then be recruited and opening date agreed New Action New Action New Action Project established to review St Augustines Ward at QEQM model with a view to developing a therapy led rehab ward. Implementation of Emergency Physician of the week rota (free from all elective activity) - phased approach Ward Training on Supportive Discharge including Directory of Services PROPOSED ACTIONS FOR ARCHIVING TRUST QEQM Sally Moore 01/04/ /06/2016 G N G N TRUST TRUST WHH/QE QM ALL Jonathan Hawkins / Lesley White Chris Bernthal/Cr ystal McCleod 01/05/ /10/2016 G N G G 01/05/ /06/2016 G G G G LW to confirm on-going funding Training and awareness sessions being organised. EAST KENT HOSPITALS UNIVERSITY FOUNDATION TRUST 03/06/2016 Page 9

269 Reference - 4hr A&E Access target Aim is to achieve 95% (NB: 93% by March 2016) Organistion 04 - Jane Ely Site Management & Leadership Service Type Establish Senior Site-based leadership teams to promote a site-based culture of improvement. Ensure provision of Senior Clinical Leadership 24/7 KEY PERFORMANCE METRICS. THIS PROJECT WILL ENABLE THE ACHIEVEMENT OF: Quantity Blue items - also shown again in the SRG plan Percentage % 14.7% 5.9% 14.7% 64.7% Original BRAG STATUS Site Item No Summary of Action DRIVER SITE 3 5 New Action New action New Action New Action New Action 8 / MD06 Re-location of control centres at QEQM and WHH to larger more suitable facilities TRUST ALL Prepare formal consultation document and business case for implementation of a full 24/7 clinical site management model Review and update Trust Internal Capacity and Demand Escalation Policy Re-launch and pilot SHREWD v2 at QEQM Evaluate Pilot of new Site Management Models and agree final model for implementation Appoint substantive Heads of Clinical Operations for WHH and QEQM Finalise final Site Management RESPONSE based standard operating procedure for all site meetings Review of patient pathways, divisional and specialty accountability for the emergency pathway action plan (Timescales as per Plan). PROPOSED ACTIONS FOR ARCHIVING TRUST ALL Project Manager Paula Brogan/And y Schofield Paula Brogan/And y Schofield Start Date Original End Date Revised End Date Overdue/ Mtg action Some Risk Work in Progress Action Complete Completion Date K Q W Comments /12/2015 G B G B /02/2015 R G G G TRUST ALL Mark Angus 01/06/ /06/2016 G G G G TRUST QEQM Mark Angus 01/06/ /07/2016 G N G N TRUST ALL Jane Ely 01/04/ /04/2016 B B B B TRUST WHH/QE QM Jane Ely 01/05/ /06/2016 G G G G TRUST ALL Mark Angus 01/05/ /06/2016 G G G G CQC ALL Paula Brogan/And y Schofield 31/10/ /03/2016 R R R R Date for WHH OCC to move into the Red Room needs to be confirmed by the UCLTC Division complted 1 April K&C Winter 2016 Paper being circulated to UCPB members. MA and JE to confirm funding arrangements. Final site management model agreed National advert to be placed May 16 Draft SOP developed to be finalised following input from ECIP Acute medical model at QEQMH to go live 18 April managed via site meetings EAST KENT HOSPITALS UNIVERSITY FOUNDATION TRUST 03/06/2016 Page 10

270 Reference 05 - Nick Gerrard - Daily Breach Analysis Reports Aim to achieve 100% circulation by 11am (Mon - Fri) Organistion Information & Reporting Service Type Agree A&E impact Metrics. Optimise use of technology to enable rapid access to accurate information relating to patient flow. Circulate Breach Analysis data to inform learning and improvement KEY PERFORMANCE METRICS. THIS PROJECT WILL ENABLE THE ACHIEVEMENT OF: Quantity Percentage % 10.5% 5.3% 26.3% 57.9% Original BRAG STATUS Site Item No Summary of Action DRIVER SITE Introduce Electonic Bed Management across the Trust 1 ECIST ALL Project Manager Debbie Lowes Start Date Original End Date Revised End Date Overdue/ Mtg action Some Risk Work in Progress Action Complete Completion Date K Q W Comments /09/2016 G G G G I.T Project Team currently developing Electronic Bed Management option - Interim solution being devleoped by Richard Ewins usinng Bed Base PTL report. Inerim solution going live in Decemember JH meeting to resolve on LW linking with EC-IP for support. May 16 update - The implementation of the new PAS which is currently due to go live 5th September The process of re-planning is underway and it is extremely likely that this date will change due to problems with the Ordercomms functionality. 4 5 Implement the electronic cascards to support accurate tracking through ED TRUST ALL Implement the use of Electronic Tool for Bed Managers to use to generate 'live' bed states, linking in with the OCC Dashboard / SHREWD and the Site-Based Operational Control Centres TRUST ALL Pat Cook / Ajay Bhargava Richard Ewins /12/2015 G G G G /10/2015 R R R R Pilot at Buckland raised various issues through testing stages. Implementation date now 30 December Detail from Ros Andrews - Project Manager End date QEQM Minors only 1/2/16. No date scheduled for majors as yet. Other dates dependent on approval from Nurse in charge at sites to ensure staff can be trained for go live dates on schedule for delivery WHH testing Bed Management App w/c 19th October - bed base PTL being developed by Richard Ewins. To go live 22/ MA reported this is now ready. PB/AS to ensure Bed Managers are able to use the technology MA to meet RE, PB, AS and MN to take forward Have system. Plan to pilot at K&C or QEQMH 7 10 / MD23 11 Contact Michael Straight to undertake a review of the current process for recording ambulance arrivals on the ED system and the impact on the 4 hour wait target. Establish EDN KPIs (TTAs available upon discharge) and monitor. New action : Reportable DTOC bed days to be compiled. IDT team leaders/social care etc team to understand process and guidance and send to JE, MA, RE. Review of DTOC reporting process?? PROPOSED ACTIONS FOR ARCHIVING TRUST CQC WHH ALL Lesley White / Louise Hughes Jonathan Hawkins /02/2016 A A A A staff have ben advised that all ambulances but be booked in within 15 minutes. Mel B drafting protocol to confirm processes /03/2016 G G G G : MA to work with Info team to resolve. TRUST ALL G G G G Claire Casarotto completing with JE/MA. Progress MA. EAST KENT HOSPITALS UNIVERSITY FOUNDATION TRUST 03/06/2016 Page 11

271 Reference - 4hr A&E Access target Aim is to achieve 95% (NB: 93% by March 2016) Organistion 06 - Liz Shutler Estates - Increased no: of patients treated in: Hot Ambulatory Care & Hot Specialty Clinics Service Type Ensure the Emergency Departments are fit for purpose and sufficiently supported by Estates KEY PERFORMANCE METRICS. THIS PROJECT WILL ENABLE THE ACHIEVEMENT OF: Quantity 1 9 Percentage % 10.0% 90.0% Original BRAG STATUS Site Item No Summary of Action DRIVER SITE 4 / KF35 5 / KF36 Reception area is fit for purpose and maintains patients privacy and dignity, Review of estates actions that can be undertaken to improve reception area. MH crisis room was not safe - only one exit and room not ligature proof. PROPOSED ACTIONS FOR ARCHIVING Project Manager Start Date Original End Date Revised End Date Overdue/ Mtg action Some Risk Work in Progress Action Complete Completion Date K Q W Comments CQC WHH Keith Bourn 31/03/16 N N B CQC WHH Keith Bourn 31/03/16 B B Any corrective work has been undertaken/strategies in place to protect patient dignity as far as possible. MH crisis room was not safe - only one exit and room not ligature proof PO advised proposed WHH room not safe to use. JE advised to use this room temporarily and for PO to address this with the builders. LW to further discuss with PO room appropriate. Door opening can be changed if essential EAST KENT HOSPITALS UNIVERSITY FOUNDATION TRUST 03/06/2016 Page 12

272 07 - Sandra Le Blanc Reference - 4hr A&E Access target Aim is to achieve 95% (NB: 93% by March 2016) Workforce Organistion - Improved performance against the 60 minute 'first assessment by Dr' Aim is to achieve 60% by June 2016 Service Type Agree and Implement the Recruitment Strategy for the Emergency floor and inpatient wards areas to enable timely patient flow and stability of workforce. Utilise opportunities to enhance workforce flexibility through introduction of new roles (where able) and new ways of working KEY PERFORMANCE METRICS. THIS PROJECT WILL ENABLE THE ACHIEVEMENT OF: Reduce Medical Staff and Nursing Staff Vacancies in ED and Urgent Care as per agreed trajectory See Trajectory TAB Quantity Percentage % 13.0% 13.0% 30.4% 43.5% Original BRAG STATUS Site Item No Summary of Action DRIVER SITE Recruit into the 20 specialty doctor posts in ED at QEQMH and WHH Longer term vision - fewer middle grades and more consultants on the rota Redesign 7/7 middle grade rota to provide prospective cover and enhanced cover across the evenings and weekends. On-going plan to recruit 10 ED consultants for WHH and 10 ED consultants for QEQMH Critical mass 8 will allow 7/7 working Recruit to current Divisional vacancies and additional posts WHH - nursing vacancies QEQMH - nursing vacancy Develop Band 7 and Matron roles in ED and ECC to include leadership and team building. ECIST ECIST TRUST TRUST TRUST TRUST ALL ALL WHH / QEQM WHH / QEQM WHH / QEQM ALL Project Manager Ajay Bhargava / Lesley White Ajay Bhargava / Lesley White Ajay Bhargava / Lesley White Ajay Bhargava / Lesley White Karina Greenan Karina Greenan Start Date Original End Date Revised End Date Overdue/ Mtg action Some Risk Work in Progress Action Complete Completion Date K Q W Comments /11/2015 Ongoing A N R R Regular (monthly) interview panels are in place with skype and UK recruitment ongoing CA - no update.negotiations with 5. 1 A&E decline - anticipating one other. LW to take control - further discuss with AB/CA and link with resourcing to move forward. Some interviews to take place next week and some in Feb. (Only 17 trainees in Emergency Med to qualify next year). LW to send PS advert Nine posts accepted; three offers being negotiated Plan to implement the 14 person rota is the immediate focus for safe service delivery. This rota may have a mixture of SAS and senior core trainee level doctors working within the same rota. This will enable the core trainee level doctors to be developed into SAS or go on to senior training opportunities. Associate Practitioner roles are being considered for /03/2016 G N G G development in 16/17 and will be included in the workforce plan Physicians Assistant posts being considered with Christchurch; CA in discussion. Aim to progress via nursing review additional consultants recruited April 2016 now 10 in post 14 person rota developed. LW aware of gaps, cannot fully implement until action 1b is completed. 22/12 Meeting taking place on the 24/12 to review outcome of rota review. MA to speak /11/2015 R N B B to Kashiv CA advised Overseas negotiations is not a fast process. Nine on pipeline 1 confirmed. Query - agency workers for Margate - same doctors weekly so no scope to rotate at Margate Rota aim to be implemented. ED workforce plan developed and approved. 8 consultants per site approved by Strategy Workforce Committee to be recruited over the next 6-12 months. Update LW : A critical mass of 8 consultants per site is considered to be the number at which /11/2015 A N A A a 7 day consultant rota could be implemented. 1 Consultant appointed in December interviews arranged for January recruited; 2 further interviews in April. 1 spec doctor sitting Fellowship exam Workforce projections agreed - Projection indicates full establishement by June /12 progress to be tracked weekly through EPR revised KPI dashboard. UPDATE KG /11/2015 G N G G situation the same Situation has improved. More overseas nurses recruited to be included in data Nursing vacancies - ongoing recruitment. Overseas recruitment 2016/2017 planned. KG reviewing role of the ED Co-ordinator (Band 7) to minimise the impact of the OSM role becoming more clincially focussed. Risk to delivery as no formal plan in place or made avaialble. 22/12 - Plan to be presented to recovery group on 12/1 by KG KG reported Linda Holt introduced 360 degree feedback to staff. Sally Smith waiting for feedback. KG meeting with matrons tomorrow to support in band 7 and matron roles and submit /11/2015 R R R R asap LW to link in with KG Linda Holt course - no report received. Closed due to time elaped. Band 7 nurses to complete leadership course as part of objectives - ongoing. Roles and responsibilities for all ED nursing grades to be clarified by HoNs by WHH to have team days Support from ECIP. EAST KENT HOSPITALS UNIVERSITY FOUNDATION TRUST 03/06/2016 Page 13

273 7 8 / MD14 9 / MD23 10 / KF27 11 / KF50 Consultant Job Planning COMPLETION dates TBC, to include allocated time to undertake morning Board Rounds TRUST ALL Recruitment to defined establishment within Emergency Departments for RN(Child) to provide 24/7 cover Review of pharmacy workforce undertaken & action plan developed including workforce development plan.workforce metrics to include % vacancy rate, % turnover, % training compliance and staff satisfaction. Consistent nursing numbers per shift negating the need for staff to move between majors and minors. Increase in staffing numbers allowing for appropriate training and education to be managed Paediatric specific areas are identified within the EDs. Staffing of a minimum of 1 RN (child) for any 24 hr per. RN (child) will provide expert advice when necessary. Out to advert in collaboration with paed services for a Paedicatric Nurse Consultant PROPOSED ACTIONS FOR ARCHIVING CQC ALL Jonathan Hawkins Karina Greenan /03/2016 A G G G Job planning process agreed with LMC. UCLTC Division's ED and HCOOP in cohort 1; workshop arranged for 3 November /01 Completed Ongoing 2016/17. 50% by end of March aiming for end of May /07/2016 G G G G Paediatric nurses recruited. Start dates to be confirmed. CQC ALL Will Wilson /03/2016 G G G G CQC CQC ALL ALL Karina Greenan Karina Greenan /03/2016 G G G G /08/2016 G G G G Not UCLTC will be included in nursing review due as per 8/MD14. Fully recruited. EAST KENT HOSPITALS UNIVERSITY FOUNDATION TRUST 03/06/2016 Page 14

274 Reference - 4hr A&E Access target Aim is to achieve 95% (NB: 93% by March 2016) Organistion 08 - Sally Smith & David Hargroves Quality Improvement Service Type Ensure robust structure and governance is established to keep projects to agreed timescales and highlight/resolve potential issues early. Monitor risks and performance against the Plan KEY PERFORMANCE METRICS. THIS PROJECT WILL ENABLE THE ACHIEVEMENT OF: Quantity Percentage % 4.3% 10.6% 31.9% 53.2% Original BRAG STATUS Site Item No Summary of Action DRIVER SITE 2 / KF11 Major incident training for paediatrics is current. All staff who need training to have had training. CQC ALL Project Manager Jonathan Hawkins Start Date Original End Date Revised End Date Overdue/ Mtg action Some Risk Work in Progress Action Complete Completion Date K Q W Comments /03/2016 N N N Need to check action for accuracy closed - we do not have separate paediatric majax training 3 / KF12 Evidence based clinical guidelines/guidance current. Staff to be aware of staff how to access on Sharepoint. Clinical lead to review current guidance and ensure it is maintained and relevant. CQC ALL Jonathan Hawkins /03/2016 A A A A Guidance published don shareporint - need to confirm appropriate sign off has take place. May 16 - Issues relating to Sharepoint access and search impacts on effective delivery Dr Hawkins has raised concern that staff are finding it difficult to use the search aspect of Sharepoint. Raised with Helen Goodwin at EPR 5 / KF14 8 / KF16 9 / KF18 Pain relief is administerd at time of assessment of patient, then reviewed for effectiveness 30 mins thereafter. Awareness of DoLs in ED environment and confidence of staff in appropriately applying it. DoLs training to be implemented to current staff and maintained for new starters Privacy and dignity in ED to be maintained at the highest possible levels. Staff speaking courteously to patients and respecting their wishes. CQC CQC CQC ALL ALL ALL Jonathan Hawkins Karina Greenan Lesley White /03/2016 G G G G /03/2016 A A A A /01/2016 R R R R Not 100% compliant at present audit programme has been reviewed with analgesia as a standard ongoing audit Training completed for Nursing Staff - Medical staff training to be confirmed remains an issue due to crowding. May 16 - New model introduced at QEQM 10 / KF29 / KF43 All staff to received LD and dementia training. CQC ALL Karina Greenan /03/2016 A A A A Senior matrons to invite the LD lead and specialist nurse for dementia to their team meetings. Bespoke training in dementia management in emergency department - train the trainer - rolling out KG and ES to check with PDN to confirm progress 13 / KF34 15 / KF38 19 / KF48 20 / KF49 21 / KF51 22 / KF52 23 / KF56 24 / KF57 25 / KF64 26 / KF72 Improved face to face communication with teams to avoid mixed messages. Monthly staff meetings with accress to the senior divisional team All staff to be trained in appropriate risk assessments pertaining to paeds Implementation of effective communciation strategy around the Clinical Strategy. All incidents to reported by staff involved consistently. Feedback to staff following and incident to be the norm. Cleanliness of the department to be maintained at or above standard levels. Mechanisms to be in place and followed to check FP10 use. Access to up to date evidence based guidance. All PGDs to be in date. Head of workforce development team to update PGDs. New guidleines and policy to be brought to divisional meetings and cascaded through the team Divisional lead clinician for emergency care to oversee completion of outstanding audits and to ensure compliance with new audits Ensure all staff are aware of the Consent Policy relating to children (such as within X-ray dept) and compliance is audited. Staff to be aware of the requirement for Duty of Candour. Team leaders in process of competing Trust RCA training and consolidated learning. Sharing of need for duty of candor being shared with their teams. CQC CQC CQC CQC CQC CQC CQC CQC CQC CQC ALL ALL ALL ALL ALL ALL QE ALL QE QE Lesley White Karina Greenan Lesley White Karina Greenan Karina Greenan Karina Greenan Karina Greenan Jonathan Hawkins Lesley White Lesley White /03/2016 R G G G /03/2016 A A A A monthly ED staff meetings in place. Dates in Divisional triumvirate diaries. HoN attends site based ward manager meeting Not currently 100% safeguarding paediatric nurses to update by 30 May /06/2016 B B B B CS away days/ecc plan - part of this plan? /03/2016 B B B B /01/2016 B B B B /12/2015 G G G G /03/2016 G N G N KG and ES to update Increased incident reporting. Themes and treds readily identified. Propt appropriate closure of incidents. Action plans around themes and trends to be monitored for compliance and effectiveness evidence numbers being reported by ED nursing staff Need evidence of compliance ED matrons audit - monthly with SERCO,amager Need evidence of compliance ED matrons audit in place since incident /06/2016 A A A A audit plan reviewed and updated /03/2016 G N G N KG and ES to advise /03/2016 G N B N all clincal staff provided with Duty of Candour policy. Include in staff meetings and minutes as evidence 28 / KF75 29 / KF76 Medical store room to be non accessible to patients and items safely stored. Access to medicines and CDs to be in line with Trust safe storage of drugs policy. All registered staff to be held to account for non compliance with standards required. Matrons to audit same CQC CQC QE QE Lesley White Karina Greenan /02/2016 G N B N KG and ES to advise /01/2016 A N A N KG and ES to advise May 16 - This will be undertaken via audits EAST KENT HOSPITALS UNIVERSITY FOUNDATION TRUST 03/06/2016 Page 15

275 Reference - 4hr A&E Access target Aim is to achieve 95% (NB: 93% by March 2016) Organistion 08 - Sally Smith & David Hargroves Quality Improvement Service Type Ensure robust structure and governance is established to keep projects to agreed timescales and highlight/resolve potential issues early. Monitor risks and performance against the Plan KEY PERFORMANCE METRICS. THIS PROJECT WILL ENABLE THE ACHIEVEMENT OF: Quantity Percentage % 4.3% 10.6% 31.9% 53.2% Original BRAG STATUS Site Item No Summary of Action DRIVER SITE 33 / KF81 34 / KF86 35 / KF87 36 / KF89 37 / KF90 38 / KF93 40 / KF / KF168 Junior doctors to be aware who Chief Exec and Medical Director are. Site lead and PME to highlight key members of the organisation to staff Management of confidential records across acute medical wards. 1. Review of medical records management, to include storage, organisation, maintenance to uniform standards.. 2. Ensure confidentiality is maintained in the use of computerised records. Infection control practice on wards (bare below elbows, compliance with isolation procedures etc) Maintenance of resus equipment - clarity over ward staff responsibilities, checking at the weekends, following up actions and learning from monthly audits by resus officer. Sharp bins not being closed properly after use.to be added to daily handover sheet to monitor compliance link to MD17 Documentation and notes - often disorganised and no procedure for maintaining records to a uniform standard. Nursing documentation sometimes missing. Occassions where risk identified (eg falls) but no care plan. Nursing staffing numbers not always visibly displayed on wards as required (planned and actual) Use of whiteboards above patients beds - good practice on some wards not consistently used across all areas. PROPOSED ACTIONS FOR ARCHIVING: Governance CQC CQC QE WHH Project Manager Jonathan Hawkins Elisa Steele / Jonathan Hawkins Start Date Original End Date Revised End Date Overdue/ Mtg action Some Risk Work in Progress Action Complete Completion Date K Q W Comments /03/2016 G N G N included in induction/trust news/meetings with juniors /03/2016 G N N G ongoing visual monitoring by matrons CQC WHH Elisa Steele /02/2016 G N N G ongoing visual monitoring my matrons/site leads CQC WHH Elisa Steele /03/2016 G N N G check Fernando and Resus team CQC WHH Elisa Steele /03/2016 G N N G monitoring ongoing by matrons CQC WHH Elisa Steele /03/2016 G N N G CQC WHH Elisa Steele /03/2016 G N N G ongoing monitoring CQC WHH Elisa Steele /03/2016 G N N G ongoing monitoring ward issue? LW to confirm whether there is an annual notes audit in place in the organisation. ED notes have not been reported as an issue EAST KENT HOSPITALS UNIVERSITY FOUNDATION TRUST 03/06/2016 Page 16

276 Reference - 4hr A&E Access target Aim is to achieve 95% (NB: 93% by March 2016) Organistion 09 - Sandra Le Blanc Communication & Engagement Service Type Ensure staff across the Trust are fully aware of the Urgent Care Programme (Recovery Plan) and the role they have in achieving success KEY PERFORMANCE METRICS. THIS PROJECT WILL ENABLE THE ACHIEVEMENT OF: Quantity Percentage % 20.0% 6.7% 73.3% Original BRAG STATUS Site Item No Summary of Action DRIVER SITE 15 Review public information screen messages and locations to include both positive messages around performance and alternatives to A&E PROPOSED ACTIONS FOR ARCHIVING TRUST ALL Project Manager Gemma Shillito/Yas min Khan Start Date Original End Date Revised End Date Overdue/ Mtg action Some Risk Work in Progress Action Complete Completion Date K Q W Comments R G G G New action added to include public & patient audience Trust-wide project in place around outpatient, A&E and ward screens Reviewed - GS advised will be in place in next few weeks. Moved to Red status GS update: Change status to red. in progress but not complete yet. EAST KENT HOSPITALS UNIVERSITY FOUNDATION TRUST 03/06/2016 Page 17

277 Reference - 4hr A&E Access target Aim is to achieve 95% (NB: 93% by March 2016) Organistion 10 - Paul Stevens? Emergency Care Centre Service Type Redesign the model of care to ensure it is fir for purpose and is aligned to Deanery requirements KEY PERFORMANCE METRICS. THIS PROJECT WILL ENABLE THE ACHIEVEMENT OF: Quantity Percentage % 0.0% 10.0% 80.0% 10.0% Original BRAG STATUS Site Item No Summary of Action DRIVER SITE Project Manager Start Date Original End Date Revised End Date Overdue/ Mtg action Some Risk Work in Progress Action Complete Completion Date K Q W Comments 1 Establish programme structure and governance Deanery K&CH AN 01/12/ /01/2016 B B N N 2 Design 'Front Door' model of care Deanery K&CH AN 08/01/ /03/2016 G G N N Nurse streaming agreed rota being drawn up 3 Design Primary Care Urgent Care Centre Deanery K&CH AN 08/01/ /03/2016 G G N agreed GPs being approached for rota. Plan B being drawn up N Design Acute Medical Unit model Establish clear pathways and protocols for Urology and Vascular patients and any patient requiring a general surgical opinion Establish pathway including assessment and onward referral for patients with a primary mental health condition Understand the impact of any changes on WHH & QEQM A&E departments, in-patient beds and workforce requirements Develop clear criteria for primary care and SECAMB Deanery Deanery Deanery K&CH K&CH K&CH AN AN AN 08/01/ /03/2016 G G N N aim to use QEQm model but will need to consider staffing for frailty and ambulatory. Completed and agreed. Ongoing evaluation of implementation 15/02/ /04/2016 G G N N required 15/02/ /04/2016 G G N N Completed and agreed AN Patient flows being analysed 7 Deanery K&CH 30/06/2016 G G N N 08/01/ Deanery K&CH AN Dec-15 29/02/2016 A A N Criteria agreed, SeCAMB go live 9/5/16 N 9 Clarify infrastructure requirements Deanery K&CH AN Mar-16 30/04/2016 G G N N estate chnages agreed detailed plans being drawn up 10 Develop a comprehensive communication plan Deanery K&CH AN Dec-15 30/06/2016 G G N N Communication to commence as per plan 4/5/16 M

278 Emergency Care Recovery Plan KPI Dashboard Economy-Wide Metrics Week End: 28 Feb 06 Mar 13 Mar 20 Mar 27 Mar 03 Apr 10 Apr 17 Apr 24 Apr 01 May 08 May 15 May Overall Compliance ED - 4hr Compliance (%) Actuals: Trajectory: Improve Leadership in ED ED - Total Attendances Actuals: 4,135 4,155 4,274 4,385 4,285 4,122 3,805 3,835 3,980 3,856 4,226 4,339 ED - Major Attendances Actuals: 1,669 1,706 1,793 1,786 1,831 1,822 1,622 1,685 1,759 1,704 1,954 1,994 ED - Minor Attendances Actuals: 2,466 2,449 2,481 2,599 2,454 2,300 2,183 2,150 2,221 2,152 2,272 2,345 ED - Total Breaches Actuals: , ED - Major Breaches Actuals: ED - Minor Breaches Actuals: ED - 4hr Major Compliance (%) Actuals: ED - 4hr Minor Compliance (%) Actuals: ED - Ambulance Triage < 15 mins (%) Actuals: ED - Clinician Seen - 1st Assess. < 1hr (%) Actuals: Trajectory: ED - Decision to Admit < 2 hrs (%) Actuals: ED - Seen by Specialist Ref. < 30 mins (%) Actuals: ED - Clinically Complete mins (%) Actuals: ED - Unplanned Reattends (%) Actuals: HR - ED Senior Medical Vacancies (WTE) Actuals: Trajectory: HR - UC Band 5 Nursing Vacancies (WTE) Actuals: Trajectory: HR - ED Nurse Band 5 Vacancies (WTE) Actuals: Trajectory: SAFER Flow Bundle IP - Stranded Patient Metric ( > 7 Days LoS) Actuals: IP - LoS - Medical - exc. 0 day (Avg) Actuals: IP - LoS - Surgical - exc. 0 day (Avg) Actuals: IP - Discharges before 10am (%) Actuals: IP - Discharges before Midday (%) Actuals: IP - Discharges before 3pm (%) Actuals: IDT - Dis. Home with Support (Total) Actuals: IDT - Awaiting an external SAFE bed (Snp) Actuals: Trajectory: IP - Discharge Lounge (%) Actuals: IDT - DToC - Occupied Bed Days (Total) IDT - DToC - Total Patients (Avg) Actuals: Actuals: Trajectory: Trajectory: IDT - DToC - Health Patients (Avg) Actuals: IDT- Medically Optimised (Snp) Actuals: Trajectory: ALL - Medically Optimised (Avg) Actuals: Effective Medical Model IP - NEL Medical Discharges < 24h (%) Actuals: IP - NEL Medical Discharges < 72h (%) Actuals: IP - Admissions via Ambulatory Care (%) Actuals: Effective Site Management IP - Midnight (%) Actuals: IP - Escalcation Midnight (Avg) Actuals:

279 Emergency Care Recovery Plan KPI Dashboard Buckland Hospital Week End: 28 Feb 06 Mar 13 Mar 20 Mar 27 Mar 03 Apr 10 Apr 17 Apr 24 Apr 01 May 08 May 15 May Overall Compliance ED - 4hr Compliance (%) Actuals: Improve Leadership in ED ED - Total Attendances Actuals: ED - Major Attendances Actuals: ED - Minor Attendances Actuals: ED - Total Breaches Actuals: ED - Major Breaches Actuals: ED - Minor Breaches Actuals: ED - 4hr Major Compliance (%) Actuals: ED - 4hr Minor Compliance (%) Actuals:

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281 Emergency Care Recovery Plan KPI Dashboard Kent & Canterbury Hospital Week End: 28 Feb 06 Mar 13 Mar 20 Mar 27 Mar 03 Apr 10 Apr 17 Apr 24 Apr 01 May 08 May 15 May Overall Compliance ED - 4hr Compliance (%) Actuals: Improve Leadership in ED ED - Total Attendances Actuals: ED - Major Attendances Actuals: ED - Minor Attendances Actuals: ED - Total Breaches Actuals: ED - Major Breaches Actuals: ED - Minor Breaches Actuals: ED - 4hr Major Compliance (%) Actuals: ED - 4hr Minor Compliance (%) Actuals: ED - Ambulance Triage < 15 mins (%) Actuals: ED - Clinician Seen - 1st Assess. < 1hr (%) Actuals: ED - Decision to Admit < 2 hrs (%) Actuals: 0.00 ED - Seen by Specialist Ref. < 30 mins (%) Actuals: ED - Clinically Complete mins (%) Actuals: ED - Unplanned Reattends (%) Actuals: HR - ED Senior Medical Vacancies (WTE) Actuals: HR - UC Band 5 Nursing Vacancies (WTE) Actuals: HR - ED Nurse Band 5 Vacancies (WTE) Actuals: SAFER Flow Bundle IP - Stranded Patient Metric ( > 7 Days LoS) Actuals: IP - LoS - Medical - exc. 0 day (Avg) Actuals: IP - LoS - Surgical - exc. 0 day (Avg) Actuals: IP - Discharges before 10am (%) Actuals: IP - Discharges before Midday (%) Actuals: IP - Discharges before 3pm (%) Actuals: IDT - Dis. Home with Support (Total) Actuals:

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283 Emergency Care Recovery Plan KPI Dashboard Queen Elizabeth Queen Mother Hospital Week End: 28 Feb 06 Mar 13 Mar 20 Mar 27 Mar 03 Apr 10 Apr 17 Apr 24 Apr 01 May 08 May 15 May Overall Compliance ED - 4hr Compliance (%) Actuals: Improve Leadership in ED ED - Total Attendances Actuals: 1,498 1,368 1,473 1,495 1,518 1,421 1,327 1,292 1,338 1,303 1,474 1,470 ED - Major Attendances Actuals: ED - Minor Attendances Actuals: 1, ED - Total Breaches Actuals: ED - Major Breaches Actuals: ED - Minor Breaches Actuals: ED - 4hr Major Compliance (%) Actuals: ED - 4hr Minor Compliance (%) Actuals: ED - Ambulance Triage < 15 mins (%) Actuals: ED - Clinician Seen - 1st Assess. < 1hr (%) Actuals: ED - Decision to Admit < 2 hrs (%) Actuals: ED - Seen by Specialist Ref. < 30 mins (%) Actuals: ED - Clinically Complete mins (%) Actuals: ED - Unplanned Reattends (%) Actuals: HR - ED Senior Medical Vacancies (WTE) Actuals: HR - UC Band 5 Nursing Vacancies (WTE) Actuals: HR - ED Nurse Band 5 Vacancies (WTE) Actuals: SAFER Flow Bundle IP - Stranded Patient Metric ( > 7 Days LoS) Actuals: IP - LoS - Medical - exc. 0 day (Avg) Actuals: IP - LoS - Surgical - exc. 0 day (Avg) Actuals: IP - Discharges before 10am (%) Actuals: IP - Discharges before Midday (%) Actuals: IP - Discharges before 3pm (%) Actuals: IDT - Dis. Home with Support (Total) Actuals: IDT - Awaiting an external SAFE bed (Snp) Actuals:

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285 Emergency Care Recovery Plan KPI Dashboard William Harvey Hospital Week End: 28 Feb 06 Mar 13 Mar 20 Mar 27 Mar 03 Apr 10 Apr 17 Apr 24 Apr 01 May 08 May 15 May Overall Compliance ED - 4hr Compliance (%) Actuals: Improve Leadership in ED ED - Total Attendances Actuals: 1,487 1,520 1,542 1,599 1,596 1,497 1,440 1,469 1,498 1,471 1,556 1,620 ED - Major Attendances Actuals: ED - Minor Attendances Actuals: 980 1,041 1,015 1,105 1, , ,010 ED - Total Breaches Actuals: ED - Major Breaches Actuals: ED - Minor Breaches Actuals: ED - 4hr Major Compliance (%) Actuals: ED - 4hr Minor Compliance (%) Actuals: ED - Ambulance Triage < 15 mins (%) Actuals: ED - Clinician Seen - 1st Assess. < 1hr (%) Actuals: ED - Decision to Admit < 2 hrs (%) Actuals: ED - Seen by Specialist Ref. < 30 mins (%) Actuals: ED - Clinically Complete mins (%) Actuals: ED - Unplanned Reattends (%) Actuals: HR - ED Senior Medical Vacancies (WTE) Actuals: HR - UC Band 5 Nursing Vacancies (WTE) Actuals: HR - ED Nurse Band 5 Vacancies (WTE) Actuals: SAFER Flow Bundle IP - Stranded Patient Metric ( > 7 Days LoS) Actuals: IP - LoS - Medical - exc. 0 day (Avg) Actuals: IP - LoS - Surgical - exc. 0 day (Avg) Actuals: IP - Discharges before 10am (%) Actuals: IP - Discharges before Midday (%) Actuals: IP - Discharges before 3pm (%) Actuals: IDT - Dis. Home with Support (Total) Actuals: IDT - Awaiting an external SAFE bed (Snp) Actuals:

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287 CULTURAL CHANGE PROGRAMME UPDATE BoD 57/16 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS DATE: 10 JUNE 2016 SUBJECT: REPORT FROM: PURPOSE: CULTURAL CHANGE PROGRAMME UPDATE DIRECTOR OF HUMAN RESOURCES INFORMATION CONTEXT / REVIEW HISTORY / STAKEHOLDER ENGAGEMENT The Cultural Change Programme was established early 2015 in response to feedback from staff and the CQC. A detailed action plan was developed for 2015 and agreed by the Board and Monitor. Progress of this plan has been reported on a monthly basis to the Strategic Workforce Committee (SWC) and also to the Improvement Plan Delivery Board (IPDB). SUMMARY: This report provides an update on EKHUFT s Culture Change Programme. It gives a brief background to the programme, summarises work completed and the progress made against the agreed measures. It then goes on to detail current work, against the Trust s cultural change priorities, and suggests next steps. RECOMMENDATIONS: The Board is asked to note the progress made against the agreed measures and next steps. NEXT STEPS: Updates will be provided on a monthly basis to the SWC and also periodically to the IPDB. IMPACT ON TRUST S STRATEGIC OBJECTIVES: The Cultural Change Programme will support the Trust in meeting its People strategic priority. LINKS TO BOARD ASSURANCE FRAMEWORK: IDENTIFIED RISKS AND RISK MANAGEMENT ACTIONS: Included on HR risk register 1

288 CULTURAL CHANGE PROGRAMME UPDATE BoD 57/16 FINANCIAL AND RESOURCE IMPLICATIONS: These have been considered and allocated to the cultural change programme LEGAL IMPLICATIONS / IMPACT ON THE PUBLIC SECTOR EQUALITY DUTY: N/A PROFESSIONAL ADVICE TAKEN ON ANY NOVEL OR CONTENTIOUS ISSUES N/A ACTION REQUIRED: To note CONSEQUENCES OF NOT TAKING ACTION: Trust s rating with NHS Improvement & the CQC may be affected 2

289 CULTURAL CHANGE PROGRAMME UPDATE BoD 57/16 1. Introduction This report provides an update on EKHUFT s Culture Change Programme. It gives a brief background to the programme, summarises work completed and the progress made against the agreed measures. It then goes on to detail current work, against the Trust s cultural change priorities, and suggests next steps. 2. Background The Culture Change Programme (CCP) was established at the beginning of 2015 in response to staff feedback, reinforced by the findings of the Trust s CQC inspection carried out in March 2014, and 2014 staff survey results published in March Three clear priorities emerged from this combined feedback leadership & management, communications & engagement and bullying & harassment which informed the work of the CCP throughout The CCP is owned and led by the executive team, is an integral part of the Trust s improvement journey and reports into the Improvement Plan Delivery Board. 3. Summary of work completed The CCP has worked to a detailed action plan for each of the three priority areas. The action plan was shared and agreed with NHS Improvement (Monitor) and progress against the plan and agreed measures has been reported on a monthly basis to the Strategic Workforce Committee (SWC). The following summarises work completed in 2015: 3.1 Leadership & Management Executive team development included MBTI, the creation of a Code of Conduct and creating a shared story A cultural change leadership programme took place for the divisional management teams and their corporate group colleagues. This programme, facilitated by Hay Group, provided this cohort of twenty, with the space and time to agree priorities and ways of working to lead the cultural change in their areas. The programme comprised 5.5 days in total over six months and also provided diagnostics, and a one-to-one session for each delegate, to gain feedback on their leadership style and the climate they create. Participants highlighted the impact the programme had on relationships across the divisions and between the divisions and corporate groups. Many felt the programme supported them to understand their role in delivering culture change and helped them to be able to have more effective conversations and problem solve together. The participants valued the time to think collectively about their purpose and roles. A one-day getting started programme was developed in-house for all middle managers. The day provides an opportunity for people managers to consider their role in achieving the cultural change, the importance of communicating with and engaging their teams, their preferences around leadership styles and how they can look after themselves in challenging times. The programme has been attended by Band 8 and Band 7 managers and is currently being delivered to Band 6 people managers. Each manager is asked to make 2-3 commitments as part of the day; key actions to implement once they are back at work. Evaluation, carried out a few weeks later, has been very positive. Participants value the time that they have be given to discuss topics and problem solve with other colleagues across the Trust. Many are reporting that they are communicating more with their teams and looking after themselves better, since attending the programme. 3

290 CULTURAL CHANGE PROGRAMME UPDATE BoD 57/ Communications & Engagement Communications focused on leadership visibility, the strengthened set of values, and on EKHUFT s improvement journey. There have also been a number of other significant interventions: Three key forums were established consultant s, administrator s, people manager s to deliver important messages, encourage networking and gain feedback. These forums continue to run and attendance is good. The new format team brief, Let s talk, was piloted within the UC&LTC division. Its aim is to increase the effectiveness of two-way communication, encouraging managers to hold face-to-face meetings with their team and discuss important topics. The process has been rolled out to the majority of areas across the Trust. To ensure immediate face-to-face communication and engagement with new staff, the Learning & Development team developed a Welcome Day for all new starters. These have been held on a fortnightly basis, providing a welcome to EKHUFT from the CEO, an introduction to a great place to work, and essential getting started information. The days began at the beginning of June 2015 and are receiving very positive feedback. 3.3 Bullying & Harassment During its first year the Trust s Respecting each other anti-bullying campaign focused on raising awareness and implementing support mechanisms: A Respecting each other video was produced and used across the Trust in forums and team meetings A confidential help-line was established solely for those staff who feel bullied Workplace contacts were trained to support staff and signpost a way forward The Trust s bullying & harassment policy was reviewed and a manager s toolkit developed 4. Outcomes of the programme to date 4.1 Agreed Measures In July 2015 the SWC approved the following to measure the Cultural Change Programme: Outcomes of engagement: Lower rates of sickness absence Lower turnover rates Higher rates of advocacy Key measure of engagement Overall engagement score in NHS annual staff survey Additional measures: Quarterly Staff Friends and Family test (FFT) 4

291 CULTURAL CHANGE PROGRAMME UPDATE BoD 57/ Progress against the agreed measures Outcomes of engagement The data shows that as yet the programme is not significantly impacting sickness absence or turnover rates. These are expected to decline as overall staff engagement increases. Advocacy rates gradually increased last year with 53% of staff recommending EKHUFT as a place to work and 76% recommending it as a place to be treated. These scores dropped over the last quarter (covered in below) Key measure of engagement The overall engagement sore in the NHS annual staff survey increased to 3.66 in This is the highest engagement score that the Trust has achieved over the last five years (see graph below). The overall engagement score is calculated as an average of the 3 average scores on staff advocacy, staff involvement and staff motivation. Although our score is still significantly below the national average (3.78), our increase of 0.15, from 2014 to 2015, is significantly more than the national increase of Additional measures The most recent staff FFT, run over the first two weeks of March, has shown a drop in advocacy rates as EKHUFT as a place to work and be treated. The percentage of staff that would recommend the Trust as a place to work has fallen to 49% and those that would recommend it as a place to be treated has dropped to 74%. A breakdown of the results showed the following: 5

292 CULTURAL CHANGE PROGRAMME UPDATE BoD 57/16 Recommend as a place to work % Q2 2015/16 (Sept 2015) Recommend as a place to get treatment % Recommen d as a place to work % Q4 2015/6 (March 2016) Recommend as a place to get treatment % Clinical Support Services (CSS) Corporate Specialist Services (SpS) Strategic Dev &CP (SD&CP) Surgical Services (SS) UC&LTC In order to identify any hot spots within the divisions and corporate groups, further analysis was undertaken and RAG rated reports produced for each of the divisions (appendix 1). The results of this FFT deep dive were presented to the SWC in April, along with examples of the actions that divisions are taking to address the issues. The next FFT will be run during June. It is also useful to consider the broader picture that the 2015 staff survey results paint. Although EKHUFT still sits in the bottom 20%, it has improved in 42 of the 60 comparator questions over the year There has been significant positive improvement in a number of areas including senior managers acting on staff feedback (up by 13%), effective communication between senior management and staff (up by 12%) and immediate managers taking an interest in staff health and wellbeing (up by 11%). Picker carried out a high-level analysis of our data, which they presented to the SWC at the end of March. The analysis compared EKHUFT with other acute Trusts which have been on a similar journey over the last few years. They established that all of the Trusts had a tipping point where their problem scores decreased by an average of more than 3% in a single year. Each of these Trusts then went on to make significant progress, improving their position in the staff survey rankings. From EKHUFT s problem scores decreased by an average of 3.46% - hence our tipping point year. To build further on this progress the Board, at its April 2016 meeting, agreed four priorities for action in Trust-wide priorities The four agreed priorities are: 1. A continuing focus on the Respecting Each Other campaign including working with Health & Safety on the broader aspects of violence and aggression 2. Re-launch of the health and well-being group for the organisation with a focus on providing useful interventions to support staff in feeling well, using recent NICE guidance as a road map for action 3. Launch, promotion and post implementation evaluation of Trust s new appraisal process 4. A focus on capacity and capability of managers / leaders in the organisation 6

293 CULTURAL CHANGE PROGRAMME UPDATE BoD 57/16 6. Progress against the priorities A CCP action plan has been developed for 2016 and is provided as appendix 2. The following summarises the work that is taking place against each of the priorities: 6.1 Respecting each other Anniversary road shows were held in early May and included the launch of the refreshed anti-bullying video and also drop-in sessions held by the Employee Relations team. Workshops for managers and staff, particularly in hot spot areas began in early June, focusing on what bullying is and is not. 6.2 Health & wellbeing group The purpose of this steering group, a sub-committee of SWC, is to empower the EKHUFT workforce to improve their health and wellbeing through planned programmes, promotions and activities. The group is also responsible for monitoring compliance with NICE guidance on health and well-being as well as ensuring actions are taken to meet relevant national and local CQUINs. A first meeting of the group, which will be chaired by the Director of HR, has taken place to agree terms of reference and membership as well as areas for action in 2016/17. A draft action plan has been developed and work is underway. A focus on internal communications and engagement of staff in this agenda will be the key to the success of this work stream in 2016/ New appraisal process The lead up to the launch of the new appraisal process included refresher training, drop-in sessions and telephone/ hot-line support. The process launched on 1 April 2016 as planned and initial feedback has been very positive, focusing on how effective the process is in facilitating a very constructive and valuable conversation. It involves new paperwork which incorporates preparation, objective setting and a personal development plan. The process also incorporates the Trust s values and related behaviours, focusing attention on the how as well as the what. The Appraisal Project group will continue to meet on a bi-monthly basis and are planning a post-implementation survey, quality checks on paperwork and staff experience and a review of the appraiser hierarchy. 6.4 Leadership capacity and capability The staff survey results suggested a continuing need to establish a consistent leadership style and approach across EKHUFT. Leaders need to understand what good looks like and recognise where their key strengths and development areas lie against the agreed standards. This need was reinforced by NHS Improvement s feedback, which suggested the Trust needs to undertake and embed robust assessment and development of its leaders, to determine capacity and capability. As part of the Trust s undertakings, a proposal on assessing competence and capability of the top 200 leaders in the organisation was agreed by the Executive team and a tendering process carried out. Bids have been received and scored, and supplier presentations held. A decision on an external partner to support this work is imminent. In order that the Trust-wide priorities and also more specific issues are addressed, the HR Business Partners are currently engaging with their divisions and corporate areas to create Great Place to Work action plans. These plans will take into account staff survey results, CQC actions and workforce plan challenges. Two of the 7

294 CULTURAL CHANGE PROGRAMME UPDATE BoD 57/16 HRBPs have presented their divisional plans to the SWC in May; the two remaining divisional plans will be presented at the SWC meeting in June. Along with a continuing focus on the CCP priorities, there is a commitment to progress the wider people agenda in the following ways. 7. Next steps 7.1 Medical Engagement Scale (MES) survey By running this survey, specifically developed to assess medical engagement, EKHUFT will be able to develop a tailored action plan with the aim of increasing medical engagement. This is vital given the importance of clinical leadership and engagement in the development and implementation of the Trust s future clinical strategy. The survey will be carried out in June and once results have been presented in July, an action plan will be developed and implemented. 7.2 Talent Management and Succession Planning Work has begun with the Executive team to implement talent management and succession planning processes. The Head of HR has facilitated discussions to identify immediate and longer term successors to senior leadership and business critical roles. There are plans to broaden this work by piloting in one division in the first instance. Lessons learned will be considered and enhancements incorporated before the process is rolled out further. 7.3 Development of staff engagement pulse survey In order to gain more regular and specific engagement feedback, work has started to develop an on-line pulse survey which can be used with smaller staff populations within the Trust. This will provide the opportunity to monitor engagement levels and tailor interventions to meet particular needs in a much more timely way than is possible at present. 7.4 People Strategy The Board has agreed the development of a People Strategy incorporating all HR areas, including leadership, staff engagement and health and wellbeing. The development of this strategy will mean that any existing projects and work streams will be incorporated into one coherent people plan. The People Strategy will be presented to the Management Board in July and the Board of Directors in September. 8. Conclusion This update demonstrates that the commitment to cultural change at EKHUFT is beginning to pay off, as evidenced by the 2015 staff survey results. It is important that a continued focus is maintained to ensure that the Trust builds on the progress made to make EKHUFT a Great Place to Work over the coming years. 8

295 CULTURAL CHANGE PROGRAMME UPDATE BoD 57/16 Division Clinical Support Services Kent and Canterbury Recommend as a place to work % change since last quarter (%) Recommend as a place to get treatment % Speciality CSS Divisional Management Outpatients Pathology EKHUFT Pharmacy Radiological Sciences Therapies CQPS Corporate SD&CP Specialist Services Surgical Services Finance & Performance Management Human Resources PGME/Library Research & Development Trust Board Facilities * * * Hospital Management- K&C * 38 IT 75 * 88 Procurement * * * Strategic Development Directorate Strategic Estates * * * Cancer, Clinical Haematology & Haemophilia Child Health Dermatology Renal Directorate SpS Divisional Management Women s Health Anaesthetics General Surgery * * * Head & Neck SS Divisional Management T&O * * *

296 CULTURAL CHANGE PROGRAMME UPDATE BoD 57/16 UCLTC Vascular, Inter Radiology & Urology A&E Acute HCOOP Speciality Medicine UCLTC Divisional Management

297 CULTURAL CHANGE PROGRAMME UPDATE BoD 57/16 change since last quarter (%) Division Speciality QEQM Recommend as a place to work % Change since last quarter (%) 33 CSS Divisional Management * * 3 Outpatients 61-6 Clinical -4 Pathology EKHUFT 48 7 Support 7 Pharmacy 17 0 Services 7 Radiological Sciences Therapies CQPS Finance & Performance Management * * -2 Corporate Human Resources * * 6 PGME/Library Research & Development * * 10 Trust Board * * * Facilities * * -29 Hospital Management- QEQM 13-5 * IT * * SD&CP * Procurement * * 10 Strategic Development Directorate * * * Strategic Estates * * -8 Cancer, Clinical Haematology & Haemophilia Child Health 61 3 Specialist -19 Dermatology * * Services -11 Renal Directorate * * SpS Divisional -33 Management * * -11 Women s Health Anaesthetics 54-5 * General Surgery Head & Neck SS Divisional Surgical 3 Management Services * T&O 50 9

298 CULTURAL CHANGE PROGRAMME UPDATE BoD 57/16 3 Vascular, Inter Radiology & Urology * * 7 A&E Acute HCOOP UCLTC -10 Speciality Medicine 29-4 UCLTC Divisional -9 Management 67 6

299 CULTURAL CHANGE PROGRAMME UPDATE BoD 57/16 Recommend as a place to get treatment % Change since last quarter (%) Division Recommend as a place to work % CSS Divisional Management * * * 89 2 Outpatients 67 Clinical 70 5 Pathology EKHUFT 31 Support 50 8 Pharmacy 15 Services 68-4 Radiological Sciences Therapies CQPS 42 * * Finance & Performance Management 55 * * Corporate Human Resources PGME/Library 100 * * Research & Development * * * Trust Board * * * Facilities Hospital Management- K&C 10 * * IT 50 SD&CP * * Procurement 69 * * Strategic Development Directorate * * * Strategic Estates * 50-4 Cancer, Clinical Haematology & Haemophilia Child Health 64 Specialist * * Dermatology * Services * * Renal Directorate 80 SpS Divisional * * Management * Women s Health Anaesthetics General Surgery Head & Neck 38 SS Divisional Surgical Management 71 Services 81 3 T&O 68 William Harvey

300 CULTURAL CHANGE PROGRAMME UPDATE BoD 57/16 * * Vascular, Inter Radiology & Urology * 81-7 A&E Acute HCOOP 71 UCLTC 63-7 Speciality Medicine 36 UCLTC Divisional Management 57

301 CULTURAL CHANGE PROGRAMME UPDATE BoD 57/16 ey Hospital Change since last quarter (%) Recommend as a place to get treatment % Change since last quarter (%) * * * * * * * * * * * 83 * * * * * * * * * * * * *

302 CULTURAL CHANGE PROGRAMME UPDATE BoD 57/16 * * *

303 CULTURAL CHANGE PROGRAMME UPDATE Cultural Change Action Plan - May 2016 BoD 57/16 1. Leadership & Management HLIP Ref Plan Ref. Action Planned MD09 - There is a positive workforce culture demonstrated by content staff who are supported and empowered to lead improvement, are aware of the Trust vision and their role within it and provide excellent patient care. Leaders at all levels have the skills to support and embed cultural change Date Starting Target Completion Date By whom RAG rating Action taken to date- March Actions carried over from 2015 Longer term Senior Leadership engagement strategy to be developed May-15 Jul-15 SLB/LS May 15- communications review underway, Jul 15- review still continuing, clinical strategy 1. Monthly Pulse Surveys as 1.24 Oct 15- communications review due to complete Nov 15, Clinical strategy as 1.24 Dec 15- Comms review complete, actions being implemented subject to funding approval, clincial strategy as 1.24 Mar 16- New director of comms to work on engagement plan when in post and SLB, JS & JW currently working on a People Strategy and plan Develop and deliver exec leadership programme May-15 Dec-15 HG May 15- leadership programme started Dec 15- programme still on-going Mar 16- new exec programme to be developed as part of leadership assessment and development programme. Currently out to tender. May 16- please see 1.12 for further action plan updates Develop and deliver 1 day 'Getting Started' management development programmes for middle managers (Bands 6-8) Strengthen the clinical leadership development programme in light of the medical engagement issues at the Trust Ensure time is protected from operational duties for Key Clinical Leaders to attend May-15 Dec-15 JW May 15- Programme started being rolled out to band 8 across the Trusts. Jul 15-90% 8+ managers attended course, due to be rolled out to Band 7 Sept-Dec. Oct 15- Band 7s programme now increased to Jan 16, final band 8 numbers 92%. Dec 15- Band 7 due to finish Feb 16, band 6 due to start Feb 16-Sept 16. Mar 16- Band 6 currently in progress, due to finish September 16 May 16- please see 1.11 for further action plan updates Key Measures 2. Monthly updates on the CQC dashboard over: Staff Turnover Mar-15 Jun-15 PS/SS/ SLB Jul 15- review underway in light of clinical engagement stragedy ( & 1.25) but not yet complete Oct 15- review still incomplete Dec 15- review still incomplete Mar 16- no change May 16- leadership assesment and development programme (action 1.12) will cover key clinical leadership roles Staff sickness Apr-15 Jun-15 Jul 15- see Oct 15- see Dec 15- see Mar 16- see 2015 Annual appraisals (quality & quantity) 1.51 May 16- as above (1.05) Review Trust reward & recognition schemes Sep-15 Oct-15 RE Oct 15- project group established as part of embedding behaviours, led by Louise Goldup Dec 15- new scheme review complete and pilot due to commence Jan 16 Mar 16- Pilot taken place in Feb 16, following feedback Trustwide launch due to commence May 16- launch restricted to those teams that have requested recognition cards 3. Quarterly FFT survey results 1.07 Launch Trust-wide recognition scheme Nov-15 Nov-15 RE Oct 15- as above Dec 15- as above Mar 16- as above May 16- as above 4. Annual NHS Staff Survey 1.08 Embed values into employee life-cycle e.g. recruitment, induction, appraisal) 1.1 Leadership Development Jun-15 Sep-15 JW Jun 15- Steering group to take on project work in 3 key areas- appraisals, recruitment, trustwide recognition scheme. Jul 15- all PMs for project groups identified, due to attend first meeting Aug. Oct 15- projects now up and running, due to complete by April 16 Dec 15- all projects still on-going Mar 16- new appraisal launched, values and behaviours covered at induction. Recruitment project on-going. May 16- recruitment project still ongoing Cascade further people management development days to band 6 Feb-16 Sep-16 JW/CBy May 16- Band 6 managers currently attending 1 day course- around 75% booked on Leadership assessment and development (incl. exec programme) Apr-16 Mar-17 JW/JS May 16- RFT sent 20th April, bids received 6th May, supplier presentations and decision th May. Planning to commence in June Leadership capability framework May-16 Jun-16 JW May 16- first draft now developed and feedback sought 5. Project activities feedback/evaluation 2. Communications & Engagement CQC KF ref Plan Ref. Action Planned Date Starting Target Completion Date By whom RAG rating Action taken to date- Feb 2015 Key Measures MD09 - There is a positive workforce culture demonstrated by content staff who are supported and empowered to lead improvement, are aware of the Trust vision and their role within it and provide excellent Behavioural framework/trust Values developed Engage staff throughout the Trust with the values and behavioural framework through communication campaign, focusing work on engaging people managers Apr-15 On-going HG Feb 15- Produced a great place to work wheel with staff to show what they feel makes a 1. Monthly Pulse Surveys great place to work. May 15-6 month plan agreed to cascade values/behavioural framework to Trust. Exec team leading cascade. Oct 15- How we show care leaflet produced and used for training in People Manager days, given out at welcome day, available at staff information points. Dec 15- Planning for 'Top 100' leadership event to focus on vision and values being held Feb Mar 16- Top 100 event rebranded to a larger scale engagement plan for leaders to commence May 16. May 16- please see action 2.21 for further reference

304 within it and provide excellent patient care. Leaders at all levels have the skills to support and embed cultural change Ensure Board plans and progress are effectively communicated and 2.02 staff have opportunity to contribute, e.g. annual plan, annual report Apr-15 On-going GS Apr 15- initial annual plan not available in April, has been put the agenda of the comms plan for July 15 Oct 15- On-going comms around transformation programme, e.g. CEO forum and key points from annual review in Oct's Our Improvement Journey Dec 15- Comms plan for Transformation programme is being finalised. Mar 16- Comms on Trust strategic objectives and priorities underway. May 16- progress update- leadership events held in May across the Trust, followed up with briefing materials. Staff open forums on Topic followed up in June. Chair will start a quarterly blog in June. 2. Monthly updates on the CQC dashboard over: Introduce a revised team brief communication tool systematically throughout Trust, incorporating communication training for people managers Develop use of social media (particularly Yammer) and mobile technology (including BYOD) to communicate with hard to reach staff Mar-15 Mar-15 Jan-16 VC Jan-16 GS Feb 15- Planning underway for piloting new style team brief in UCLTC staff involvement in planning and implementation being sought. Mar 15- Team Brief Pilot meetings underway for UCLTC division. May 15- first phase of pilot complete. Evaluation underway before full roll out Oct 15- Following pilot feedback new web app developed. Trialled in pilot area throughout Nov. 27th Nov Let's Talks rolls out to next area as part of full roll out. Dec 15- SD&CP went live in December. Cascade continuing though planned completion now Mar 16. Mar 16- Cascade still taking place, due to complete May 16 May 16- CSS, FRM, CQPS & Corporate services still to complete. Jul 15- assessment of Yammer redendered tool indequate- currently exploring further options. Oct 15- marketplace been developed on staff zone in place of yammer. Facebook is being used increasingly by staff, pending comms review, we will explore options further with this. Mar 16- no change May 16- no change, but strategy expected in July. Staff Turnover Staff sickness 2.05 Develop measurement mechanism for communication reach and Jun-15 On-going GS Oct 15- printed communication audit taken place and acted upon appropriately. Dec 15- Annual appraisals (quality & quantity) effectiveness so problem areas can be identified and sorted quickly Lets talk montioring highlights areas where team brief not taking place, this data reported to HRBPs on weekly basis. Mar 16- Staff FFT also used to measure communication reach. May 16- no change 2.1 Medical Engagement 3. Quarterly FFT survey results 2.11 Medical Engagement Scale Survey Jun-16 Aug-16 UKMES 4. Annual NHS Staff Survey 2.12 EKHUFT Medical Forum Apr-16 Mar-17 PS/MK 5. Project activities feedback/evaluation 2.13 MES Survey action plan Sep-16 Mar-17 PS/MK 2.2 Develop forms of 2 way communication and engagement between senior management and frontline staff 2.21 CEO Leadership Events May-16 Sep-16 GS/MK May 16- first leadership events held 2.22 CEO Staff Events Jun-16 Nov-16 GS/MK 2.23 Exec Team Walk the floor May-16 On-going MK May 16- MK organising this for Exec team, now up and running You said, we did' monthly feedback through Lets Talk Jun-16 On going GS 2.25 Regular onion Jul-16 On-going GS 2.5 Staff Engagement 2.51 Staff Survey Analysis Mar-16 Apr-16 JW/KD 2.52 Quartley Staff FFT & analysis Mar-16 Mar-17 KD 2.53 Divisonal GPTW action plans Apr-16 Mar-17 HRBPs Mar 16- Staff FFT survey and additional qu's on communications complete. Apr 16- Q4 analysis complete. May 16- action plans developed through staff focus groups. Plans and progress reported to SWC on a regular basis Quarterly pulse surveys to staff to measure engagement Jun-16 On-going KD 2.55 Admin Forums Mar-16 Mar-17 LP/KD 2.6 On-going measurement of communication effectiveness Develop a communication contract to outline Trust/Staff expectations 2.61 and responsibilities Jul-16 Sep-16 GS/CT 2.62 Measuring the reduction of use in the Trust Sep-16 Mar-17 GS 3. Bullying & Harassment CQC KF ref Plan Ref. Action Planned MD09 - There is a positive workforce culture 3 Development of the Respecting Each Other Programme Date Starting Target Completion Date By whom RAG rating Action taken to date- Feb 2015 Key Measures

305 workforce culture demonstrated by content staff who are supported and empowered to lead improvement, are aware of the Trust vision and their role within it and provide excellent patient care. Leaders at all levels have the skills to support and embed cultural change Increase the scope of REO to include bullying and harrassment from 3.01 patients Jun-16 Dec-16 CB/GS 1. Quarterly pulse surveys 3.1 Respecting Each Other' Anti-bullying activities 2. Monthly updates on the CQC dashboard over: 3.11 Continue to advertise the Respect programme throughout the Trust Apr-16 on-going April 16- REO roadshows planned for April/May across the Trust to Staff Turnover 3.12 Recruit further workplace contacts to include underrepresented groups Apr-16 Sep-16 CB April 16- sent to consultants to target recruitment Staff sickness 3.13 Develop the use of the Trust's intranet/respect webpages to publicise support available to staff Apr-16 Jun-16 CB May 16- Desktop app on all trust desktops for direct link to REO webpage, to be publicised with launch of video. Annual appraisals (quality & quantity) 3.14 Relaunch Respect Video with new CEO Mar-16 May-16 GS April 16- Video edited with MK speech and new quotes. Due to be launched May '16 3. Quarterly FFT survey results (Q1 2015/16) Target B&H 'Hotspot' areas identified from 2015 staff survey with 3.15 specific interventions Arrange specific support for people managers about how to deal with 3.16 B&H in their teams Jun-16 Mar-17 HRBPs 3.17 Launch Meetings code of conduct and etiquette May-16 Jun Keeping workplace contacts/mediators up to date with relevant training/information May 16- first workshops scheduled for June 16. Will roll out to further areas in coming months. Apr-16 Mar-17 ML April 16- ER team have started drop-in sessions for people managers acroos 5 trust sites CB, JW, GS May 16- KD to check Meeting code of conduct template complete & send to PMs Apr-16 on-going CB May 16- WPC/M supervision session planned for June 4. Annual NHS Staff Survey 5. Project activities feedback/evaluation: Forums Listening Events 3.19 Empower staff to increase resilence and awareness May-16 Jun-16 CB/KD Training days 3.2 Review & Implement key HR policies/templates 3.21 Review Corporate HR templates to rebrand to 'We Care' tone. May-16 Jul-16 CB April 16- CBe to take forward to JW. Key Claire Berry Executive Team Gemma Shillito HR Business Partners Matthew Kershaw Lesley Palin Jane Waters Kerry Diamond Martin Luff Comms Team Paul Stevens Jacqui Siggers Sandra Le Blanc UK Medical Engagement Survey CB ET GS HRBPs MK LP JW KD ML CT PS JS SLB UKMES

306 SUSTAINABILITY AND TRANSFORMATION PLAN BoD 58/16 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS DATE: 10 JUNE 2016 SUBJECT: REPORT FROM: PURPOSE: SUSTAINABILITY AND TRANSFORMATION PLAN UPDATE DIRECTOR OF STRATEGY AND CAPITAL PLANNING Discussion CONTEXT / REVIEW HISTORY / STAKEHOLDER ENGAGEMENT The purpose of this paper is to provide information and support a discussion on the development of the Kent & Medway Sustainability and Transformation Plan. SUMMARY This document details the arrangements for developing the Kent and Medway Sustainability and Transformation Plan (STP). RECOMMENDATIONS None NEXT STEPS: (a) Consider and discuss the contents of the paper IMPACT ON TRUST S STRATEGIC OBJECTIVES: Patients: Help all patients take control of their own health. People: Identify, recruit, educate and develop talented staff. Provision: Provide the services people need and do it well. Partnership: Work with other people and other organisations to give patients the best care. LINKS TO BOARD ASSURANCE FRAMEWORK: IDENTIFIED RISKS AND RISK MANAGEMENT ACTIONS: None FINANCIAL AND RESOURCE IMPLICATIONS: None 1

307 SUSTAINABILITY AND TRANSFORMATION PLAN BoD 58/16 LEGAL IMPLICATIONS / IMPACT ON THE PUBLIC SECTOR EQUALITY DUTY: None PROFESSIONAL ADVICE TAKEN ON ANY NOVEL OR CONTENTIOUS ISSUES None ACTION REQUIRED: The Board is asked to: Consider and discuss the contents of the paper and endorse the approach being taken. CONSEQUENCES OF NOT TAKING ACTION: None 2

308 SUSTAINABILITY AND TRANSFORMATION PLAN BoD 58/16 Introduction SUSTAINABILITY AND TRANSFORMATION PLAN Update for the Trust s Board of Directors May 2016 In December 2015, the NHS shared planning guidance outlined a new approach to help ensure that health and care services are built around the needs of local populations. In order to achieve this, every health and care system in England has been tasked with producing a multi-year Sustainability and Transformation Plan (STP), showing how local services will evolve and become sustainable over the next five years. The ultimate aim is to deliver the Five Year Forward View vision of better health, better patient care and improved NHS efficiency. 44 STP geographic footprints have been identified and the health and care organisations within these geographic footprints are working together to develop STPs which will help drive long-term, sustainable transformation in patient experience and health outcomes. Our geographic footprint covers Kent & Medway and the principle objectives are to; develop a Kent and Medway STP that delivers the best possible health and social care for the local population, within available resources, and meets the requirements of national planning guidance; bring together local plans to present these at a Kent and Medway level (including supporting local health and social care systems to develop a consistent structure for the production of local plans); ensure links and consistency with Better Care Fund plans and the newly formed Sustainability and Transformation Fund (STF); agree those projects and initiatives / strategies that need to be progressed at a Kent and Medway level (and ensure there is consistency on those areas that are being progressed locally); and establish a planning arrangement to ensure the successful delivery of the Kent and Medway initiatives / strategies. Developing the submission The East Kent Strategy Board is coordinating the input into developing the STP for the east Kent health economy and has nominated two members, Dr Sarah Phillips (GP chair of the East Kent Strategy Board) and Matthew Kershaw (Chief Executive Officer of EKHUFT) to represent them at the Kent & Medway STP Steering Group. Initially the approach was to submit a single Kent & Medway plan with a series of chapters aligned to local health economies. However, the NHS England feedback on the first STP submission in April encouraged us to review that approach for the submission due at the end of June. NHS England remains supportive of input from the East Kent Strategy Board as a key component of the submission and we have proceeded on that basis. There are regular meetings taking place across Kent & Medway to develop the content for the submission which is currently in draft form. The East Kent Strategy Board will consider this document at the next meeting on 9 th June. The next deadline for submission is 30th June, after which there will be a further round of meetings with NHS England in July. 3

309 COMMUNICATIONS AND ENGAGEMENT STRATEGY BoD 59/16 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS DATE: 10 JUNE 2016 SUBJECT: REPORT FROM: PURPOSE: COMMUNICATIONS AND ENGAGEMENT STRATEGY DIRECTOR OF COMMUNICATIONS AND ENGAGEMENT Discussion CONTEXT / REVIEW HISTORY This report provides the Board of Directors with a summary of the current position in relation to the Trust s Communication and Engagement Strategy. The contents of this report was presented to the Council of Governors on 24 May 2016 as a follow up from the workshop held with Governors and Board members on 22 February. SUMMARY: The report presented to the Council of Governors asked for agreement to the involvement of Governors in the development of the Strategy through their Communications and Membership Committee The attached report provides an overview of progress on communications and engagement and plans for developing the strategy. RECOMMENDATIONS: To discuss and note the report. NEXT STEPS: During June, July and August a complete review of the Trust s communications channels and engagement activity will be carried out. The review will include: Evaluating the effectiveness of all channels and activity Benchmarking against other Trusts and national best practice Development of key performance indicators Progress against an action plan to deliver the strategy will be produced on a monthly basis. This will include immediate improvements where appropriate and recommendations for the longer-term. The completed strategy will be brought to the Board in September. Page 1 of 6

310 COMMUNICATIONS AND ENGAGEMENT STRATEGY BoD 59/16 IMPACT ON TRUST S STRATEGIC OBJECTIVES: Patients: Help all patients take control of their own health. People: Identify, recruit, educate and develop talented staff. Provision: Provide the services people need and do it well. Partnership: Work with other people and other organisations to give patients the best care. LINKS TO THE BOARD ASSURANCE FRAMEWORK: IDENTIFIED RISKS AND RISK MANAGEMENT ACTIONS: Risks and risk management actions will be identified in the monthly action plan to the Board. FINANCIAL AND RESOURCE IMPLICATIONS: The development of the strategy will identify any costs associated with delivery. LEGAL IMPLICATIONS/IMPACT ON THE PUBLIC SECTOR EQUALITY DUTY: The strategy will be developed in line with the equality duty. PROFESSIONAL ADVICE TAKEN ON ANY NOVEL OR CONTENTIOUS ISSUES: National best practice will be used as the strategy is developed. ACTION REQUIRED To discuss and note the report. CONSEQUENCES OF NOT TAKING ACTION: The strategy is essential to supporting the strategic objectives of the Trust. Page 2 of 6

311 COMMUNICATIONS AND ENGAGEMENT STRATEGY BoD 59/16 1 BACKGROUND COMMUNICATIONS AND ENGAGEMENT STRATEGY 1.1 The Trust is making good progress in improving engagement and communication with colleagues as part of the culture strategy. This has included increased face to face activity as well as encouraging ideas from the front-line. Some of this work has already been recognised by the CQC, for example the innovation hubs. 1.2 The Board and new Chief Executive are developing valuable working relationships with key stakeholders, including commissioners and MPs. The Chief Executive has also met and is developing relationships with the local newspaper editors. 1.3 The Trust s communications function was reviewed and a new Director of Communications and Engagement appointed joined us on 31 May The communications team has been restructured and includes a post dedicated to public and patient engagement. Vacancies are currently being recruited to. During the summer the team will focus on the delivery of the communications and engagement strategy to support the Trust s priorities, including improvement, culture change and the clinical strategy. The development of the strategy will involve engagement with patients, staff, governors and members, and other stakeholders. 2 CHALLENGES 2.1 The latest CQC inspection identified a number of areas where performance had improved but also some areas that still needed work, for example cross directorate learning, communication with people with dementia and learning disabilities and patient information accessible to children or in alternative languages. 2.2 Although staff engagement had improved there were still pockets which needed to be improved. The staff survey results remain low in comparison with other trusts, in particular in areas such as staff bullying and harassment. Staff retention and recruitment remains a challenge for all NHS trusts. 2.3 The CQC recognised the work to engage stakeholders but called for a renewed emphasis on public engagement. 2.4 The Trust s digital communications and internal communications (Trust news, Chief Executive s blog) are clear and engaging, however some of the Trust s communications are dated, for example the magazine and use of noticeboards, and their effectiveness needs to be reviewed. 2.5 We need to work with our local media so they are well briefed so that stories are well informed and balanced and stakeholders are aware of emerging media coverage. 3 OPPORTUNITIES 3.1 The Board has approved a clear strategic direction, focussing on Patients, People, Provision and Partnerships, with annual objectives. The communications and engagement strategy will support this with clear Page 3 of 6

312 COMMUNICATIONS AND ENGAGEMENT STRATEGY BoD 59/16 objectives and performance measures which will be reported to the Board of Directors and shared with the Council of Governors. 3.2 The Trust has been recognised as caring by the CQC and the brand We Care is a useful platform to build on, which will support recruitment and retention and help us to engage with staff and patients. 3.3 There are IT solutions that can support effective communications, although some of these would be subject to capital investment (e.g. electronic message boards in place of noticeboards). Other sources of income will need to be explored. 3.4 The Trust s clinical strategy will involve patient and public engagement, shared across the whole system, and will be supported by the Trust and CCG communications and engagement teams. 4 TRUST PROGRESS ON COMMUNICATION AND ENGAGEMENT 4.1 Over the past 12 months there has been a particular focus on improving internal communications, including: The introduction of an executive team blog, including a weekly blog from the Chief Executive. A new team briefing process in 5 divisions, this continues to be rolled out The development of a staff engagement framework, with channels and feedback routes that are Trust-wide, by division and by site improvement teams Engagement and internal communications on the new Trust vision, mission and values An annual internal communications audit 4.2 An annual survey, run in quarter 4 in 2014/15 and 2015/16 shows an improvement in staff perception of internal communications over the year: I feel well informed about what is going on at the Trust 63% (up 5%) I have a way to put forward my views and ideas about the Trust 52% (up 2%) I have a way to put forward my views and ideas about my area of work 67% (up 3%) I have access to the necessary information to communicate Trust messages to my team with confidence 68% (up 10%). 4.3 The 2015 (latest) staff survey results had the best staff engagement score for five years and the internal communication metrics were the most improved scores overall. 5 ROLLING OUT OUR STRATEGY, VISION AND VALUES 5.1 During May there was a major focus on supporting our people managers with the communications aspect of their role, including sessions to support them to share our strategic direction, vision and values so that staff engagement is embedded at a local level. 5.2 These are the leaders that colleagues have the closest affinity and relationships with and are important influencers in our trust. Themes that emerged from the sessions included: Page 4 of 6

313 COMMUNICATIONS AND ENGAGEMENT STRATEGY BoD 59/16 Giving managers the tools and messages to be able to communicate consistently with teams Providing the skills/coaching/training to be able to do this Having the time to do this effectively Supporting colleagues to challenge people where they see the values are not being upheld 6 GOVERNORS AND BOARD COMMUNICATIONS WORKSHOP 6.1 A Governor and Board development session was held on 22 February to discuss setting the communications approach for the Trust, how we should talk with each other, with the public and patients and with our partners and colleagues. 6.2 The session was valuable in identifying who we need to communicate with, how we communicate currently and the key topics. 6.3 Everyone agreed that communication should be open and honest; clear and simple. 6.4 Other attributes were also identified as important and the principles for the way the trust should communicate shared similar themes: In all we do and all we say we will be clear and honest With clarity and honesty we will communicate our constructive messages to all our audiences Positively open and proactive: in line with our values We will communicate in ways that are clear, open, honest and appropriate Support trust values with clear, honest and timely communications Positively open and proactive communication which is informative 7 SUPPORTING GOVERNORS TO COMMUNICATE AND ENGAGE 7.1 Governors are passionate about communications and engagement and are strong advocates for their constituents. This insight will help us to develop the strategy which will also have a strong focus on how we support Governors to continue to communicate and engage with their constituents. 7.2 An immediate priority is ensuring Governors are briefed in advance of announcements, and breaking stories in the media, and have appropriate support to respond to them and the enquiries they generate. 8 NEXT STEPS 8.1 The feedback from the workshop, emerging improvement plans (for example the culture strategy action plan), feedback from staff, stakeholders and regulators will inform the Trust s communications and engagement strategy. 8.2 The communication and engagement strategy will also be developed using: insight into the trust s audiences and how they receive information/are engaged evaluation of current communication and engagement methods and feedback Page 5 of 6

314 COMMUNICATIONS AND ENGAGEMENT STRATEGY BoD 59/16 situation analysis best practice in NHS communications And will include: Communication and engagement objectives aligned to the Trust s priorities and values, with key performance indicators Key messages Channels and tools Responsibilities at different levels/areas of the Trust Agreed metrics for measuring the effectiveness of communications and engagement which will be reported to the Board of Directors 9 TIMESCALES 9.1 During June, July and August a complete review of the Trust s communications channels and engagement activity will be carried out. 9.2 The review will include: Evaluating the effectiveness of all channels and activity Benchmarking against other Trusts and national best practice Development of key performance indicators Progress against an action plan to deliver the strategy will be produced on a monthly basis. This will include immediate improvements where appropriate and recommendations for the longer-term. The completed strategy will be brought to the Board in September. Page 6 of 6

315 EMERGENCY PLANNING AUDIT REPORT BoD 60/16 EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST REPORT TO: BOARD OF DIRECTORS DATE: 10 JUNE 2016 SUBJECT: REPORT FROM: PURPOSE: EMERGENCY PLANNING UPDATE AUDIT REPORT CHIEF OPERATING OFFICER Discussion CONTEXT / REVIEW HISTORY / STAKEHOLDER ENGAGEMENT Introduction The East Kent Hospitals University NHS Foundation Trust (EKHUFT) has a duty to provide safe healthcare services. The Trust needs to plan to provide an effective response to the interruption or emergency while ensuring minimum disruption to its normal business. The Trust s duties are underpinned by the Civil Contingencies Act (CCA) 2004 which defines the trust as a Category 1 responder with legal duties in planning and responding to emergencies. NHS England has set out the Emergency Preparedness Resilience and Response (EPRR) core standards which complement our statutory duties under the CCA 2004, the Trust is audited annually against these core standards by the South East Commissioning Support Unit (SECSU) on behalf of the CCGs, the last audit of the Trust was September The outcome of this was non-compliance. SUMMARY: Specific actions have been taken to resolve the areas of non-compliance. The Trust predicted that it would only reach partial compliance by the next assessment which was carried out in March The results of the re-audit demonstrated significant improvements and progress since the initial audit in September The Trust has made substantial changes to their emergency planning function and is now currently sharing an emergency planning lead with Maidstone and Tunbridge Wells Trust. Recruitment into additional emergency planning roles is planned and needs to be taken forward to ensure that EKHUFT is able to continue to deliver improvements. The overall result was one of significant compliance. Much of the improvement is down to the integration of emergency planning into the culture and the investment in physical resources This report is presented as planned to the June 2016 Trust Board. It is noted that the elements essential to maintaining and improving the Trust performance in the future are: maintaining its current level of CBRN training to increase staff trained and ensure it is able to respond effectively, and further work is required if emergency preparedness is to become fully embedded into the trusts culture. The established resilience groups should be maintained; and the planned recruitment take place as soon as possible as it can take up to 6 1

316 EMERGENCY PLANNING AUDIT REPORT BoD 60/16 months for an emergency planner to be recruited and brought up to speed with necessary processes, procedures and working relationships. The draft report from Exercise Carbine has been received. This will be reviewed by the Resilience Forum to identify key learning outcomes to incorporate into the EPRR work plan. RECOMMENDATIONS: The Board is asked to note the improvement in the audit and note the steps that are required to maintain the good progress. NEXT STEPS: Revise the EPRR work plan to ensure and maintain compliance with national core standards. The revision can be completed once the national guidance for 2016/17 has been received. This will include the key actions from the table top exercise Exercise CARBINE. IMPACT ON TRUST S STRATEGIC OBJECTIVES: Patients Enable all our patients (and clients who are not ill) to take control of all aspects of their healthcare Partnerships To define and deliver sustainable services and patient pathways together with our health and social care partners People Identify, recruit, educate and develop a talent pipeline of clinicians, healthcare professional and broader teams of leaders, skilled at delivering integrated care and designing and implementing innovative solutions for performance improvement Provision Clearly identify what business we are in, what we want to be known for, our core services LINKS TO BOARD ASSURANCE FRAMEWORK: IDENTIFIED RISKS AND RISK MANAGEMENT ACTIONS: maintaining the training programme / ensuring staff are released; and FINANCIAL AND RESOURCE IMPLICATIONS: The Trust must maintain current funding levels for emergency planning and resilience. LEGAL IMPLICATIONS / IMPACT ON THE PUBLIC SECTOR EQUALITY DUTY: Failure to improve the situation may result in contractual penalties and action by the Secretary of State. In addition prosecution under the Civil Contingencies Act 2004 is possible. 2

317 EMERGENCY PLANNING AUDIT REPORT BoD 60/16 PROFESSIONAL ADVICE TAKEN ON ANY NOVEL OR CONTENTIOUS ISSUES ACTION REQUIRED: East Kent Hospitals University NHS FT has a duty under the Civil Contingencies Act 2004 to prepare and test arrangements for all types of hazard incident and disruptive challenge. The Board is requested to note the improvement and request the Emergency planning team (now working in collaboration with Maidstone and Tunbridge Wells NHS Trust ) to present to the Board in September in advance of the 2016/17 assessment. CONSEQUENCES OF NOT TAKING ACTION: Failure to improve the situation may result in contractual penalties and action by the Secretary of State. In addition prosecution under the Civil Contingencies Act 2004 is possible. 3

318 EAST KENT HOSPITALS UNIVERSITY FOUNDATION NHS TRUST EPRR Assurance Re-audit Report March 2016