ASSURANCE REPORT NHS WALES SHARED SERVICES PARTNERSHIP COMMITTEE

Transcription

1 Reporting Committee Chaired by Lead Executive ASSURANCE REPORT NHS WALES SHARED SERVICES PARTNERSHIP COMMITTEE Shared Service Partnership Committee Mrs Margaret Foster, Chair Mr Neil Frow, Managing Director, NWSSP Author and contact details. Jacqui Maunder, Head of Corporate Services, Date of last meeting 19 th January 2016 Summary of key matters including achievements and progress considered by the Committee and any related decisions made. Development Deep Dive Session The deep dive session involved an informative presentation by the NWSSP Director of Workforce, Education and Development Services (WEDS) which included an update on the WEDS work programme as well as outlining the key achievements, opportunities and progress being made. Members welcomed the opportunity to discuss in greater detail the non medical education commissioning process and the Committee noted the significant investment being made to increase the commissioned numbers. Integrated Medium Term Plan (IMTP) Members received the draft Integrated Medium Term Plan (IMTP) , following review the Committee APPROVED the plan for the initial submission to Welsh Government at the end of January In approving the plan members emphasised the importance of further work being undertaken over the next few months to review additional opportunities to support Health Boards & Trusts and deliver efficiencies through increased collaborative working across Wales. The Committee also AGREED to consider re-investing the proposed 750k NWSSP dividend as part of this process. National Health Authority Information System (NHAIS) Exeter Primary Care System The Committee received an update report on the NHAIS transition project and Members noted the ongoing changes taking place within NHS England with regards to the NHAIS primary care system and the associated processes for GP medical record movements, GP patient registration, screening services data feeds and GP/Ophthalmic payments systems. The Managing Director outlined the potential implications of this change on NHS Wales as well as the work undertaken to date by the NHS Wales team who were developing an option appraisal to be 1

2 considered at the March NWSSP Committee meeting. The Committee acknowledged that there were still many questions that needed to be answered, including those surrounding the financial implications and timescales for transition to a new model, it was AGREED to review an options appraisal at the next NWSSP Committee meeting in March New Recruitment System Update The Committee received a report on the TRAC application management software which was being introduced to support the NHS Jobs recruitment process and to replace the existing Database of Recruitment Activity (DORA) system which was becoming outdated due to its limited functionality. Members noted that TRAC is already used by NHS London organisations as a core element of the recruitment streamlining project. The Managing Director advised that NWSSP had obtained useful feedback from a number of customer engagement sessions. The new system would help address a number of the concerns raised by providing improved functionality, efficiency as it linked directly into NHS Jobs, Electronic Staff Record (ESR) and the Disclosure and Barring Service (DBS), as well as increased visibility for management across the whole recruitment process including medical, non-medical and bank recruitment. Members noted that NWSSP had negotiated a specific deal for TRAC implementation across NHS Wales and the costs were being managed through internal NWSSP cost savings. A number of stakeholder engagement events were also being held across NHS Wales to raise awareness of the new system and to address any concerns that users may have. Feedback to date from system users had been extremely positive. Contract negotiations are at an advanced stage with implementation due to begin from March 2016 with a phased roll out commencing with Cardiff & Vale UHB. New Legal Services Framework The Committee ENDORSED a report which set out guidance on how organisations should access the new National Procurement Service (NPS) Legal Services Framework contract and the link with the internal NHS Wales NWSSP Legal & Risk Services who should normally be the first port of call in relation to legal services. The NPS Framework came into effect at the end of 2015 but can t be accessed by NHS Wales bodies until February 2016 when the current NHS framework contract expires. Chairman s Report The Chair advised that she and the Managing Director had attended a Hywel Dda UHB development meeting to update Board members on the IMTP progress and activities undertaken through NWSSP. Members noted that as part of the assurance process the Chair had also been invited to attend the January All Wales Chair Group to provide an update on the work of NWSSP. The Chair highlighted the importance of maintaining a regular dialogue with individual Health Boards and Trusts at different levels and asked all Committee Members if NWSSP Officers could be given a slot on an upcoming Local Partnership Meeting to obtain feedback on service provision and provide an update on NWSSP 2

3 activity. Managing Director s Report Members received an update on progress in relation to the following areas; E-learning platform Working collaboratively with Local Authorities and the wider public sector to provide access to the NHS Wales e learning platform and e learning content. ESR Enhance the development of the first phase of ESR functionality which will be available in the summer of Accounts Payable the development of an Accounts Payable helpdesk and User Improvement Groups at Health Board / Trust level. GP Return to Practice Scheme review options in partnership with the Wales Deanery and the BMA to extend the single lead employer status to cover GP Return to Practice scheme. Salary Sacrifice Schemes over 750 vehicles have been allocated which equates to an annual 450k saving. Further areas were to be reviewed for potential salary schemes. Lord Carter of Coles update on work supporting the initial recommendations applicable in the Welsh context. Finance and Performance The Committee received a report from the Director of Finance & Corporate Services summarising the latest financial position and performance indicators (KPIs). Members noted and welcomed the planned 2m distribution to stakeholders, which was 1m above the IMTP planned distribution level. Members, sought greater clarity on whether going forward it would deliver greater value to re-invest part of the distribution in areas such as the Project Management, supporting the delivery of various initiatives such as the Prudent Procurement initiative. The Committee agreed to receive a further update in March as part of the final IMTP sign off. Welsh Risk Pool The Director of Finance & Corporate Services updated the Committee on the current financial position with regard to the Welsh Risk Pool and the proposed actions being proposed to strengthen the related processes including learning lessons from claims. Members noted the forecast outturn was 75m, which was now likely to be the worst case position and that there would be no requirement for additional contribution from Health Boards under the risk sharing agreement. Further work was ongoing to understand the final outturn position and would be reported to the Directors of Finance meeting and Welsh Government. The Committee received and noted a number of reports for information, these included; o Committee s Forward Plan of Business o Accounts Payable Update o Audit Committee Highlight Report o WfIS Programme Board Minutes o NWSSP Response to the Green Paper Our Health, Our Health Service 3

4 Key risks and issues/matters of concern and any mitigating actions The Committee received an update on key risks and reviewed an updated Corporate Risk Register. The risks contained within the risk register included matters discussed within the business of the meeting. In particular the risks around the ongoing issues with the outsourcing of the NHAIS Exeter system in NHS England together with the challenges of meeting the Public Sector Payment Policy (PSPP) targets and the associated delays to invoice payments in some areas were discussed in detail. Matters requiring Board level consideration and/or approval The Board is asked to NOTE the work of the SSPC and ensure where appropriate that Officers support the related work streams. The APPROVED minutes of the Committee meeting held on 29 th November 2015 are attached for consideration of the Board Matters referred to other Committees N/A Date of next meeting 17 th March

5 PUBLIC TRUST BOARD MEETING CHAIRMANS URGENT ACTION MATTER REPORT Meeting Date: 17 th March 2016 Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Georgina Galletly, Board Secretary Steve Ham, Chief Executive Georgina Galletly, Board Secretary Not applicable Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Board are asked to consider and ENDORSE Chairs urgent action taken since the last Trust Board meeting as detailed within this report. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well This report supports the following Health & Care Standards: Governance Leadership and Accountability Staff and Resources Effective Care Timely Care

6 2 Chairman s Urgent Action 1. Introduction / Background 1.1. In accordance with Trust Standing Orders, there may, occasionally, be circumstances where decisions which would normally be made by the Board need to be taken between scheduled meetings and it is not practicable to call a meeting of the Board. In these circumstances, the Chair and Chief Executive, supported by the Board Secretary, as appropriate, may deal with the matter on behalf of the Board after first consulting with at least two other Independent Members. The Board Secretary must ensure that any such action is formally recorded and reported to the next meeting of the Board for consideration and ratification. Where issues are included in the Schedule of Expected Urgent Decisions and prior approval is sought from the Board, these issues will not be reported here Chair s action may not be taken where either the Chair or the Chief Executive has a personal or business interest in an urgent matter requiring decision. In this circumstance, the Vice-Chair or the Executive Director acting on behalf of the Chief Executive will take a decision on the urgent matter, as appropriate. 2. Timing: 2.1. This report details Chair s Urgent Action taken since the September 2015 Trust Board meeting. 3. Description: 4.1 The issues outlined in Appendix 1 have been dealt with by Chairs Urgent Action (not previously reported to the Board in the Expected Urgent Decisions report). 4. Financial Impact: 4.1. Please refer to Appendix 1 for information on the financial impact. 5. Quality, Equality, Safety and Patient Experience Impact: 5.1. This action is by exception and with prior approval from the Chair. The provision to permit this urgent action is to allow for quick decisions to be made where it is not practicable to call a Board meeting and to avoid delays that could affect service delivery and quality. 6. Considerations for Board / Committee: 6.1. The Board is asked to consider the issues considered under Chairs Urgent Action as detailed in Appendix Next Steps: 7.1 The Board is asked to CONSIDER and ENDORSE Chairs urgent action taken since the January Trust Board Meeting as outlined in Appendix 1. Page 2

7 3 Chairman s Urgent Action APPENDIX 1 The following issues have been dealt with by Chairs Urgent Action (not previously reported to the Board in the Expected Urgent Decisions report). 1. TRUST INFORMATION COMMUNICATION TECHNOLOGY INFRASTRUCTURE PROCUREMENT DECISIONS The Board were asked to approve the following Procurement decisions: Purchase of Servers and Desktop Infrastructure Purchase of Network Disaster Recovery & Resilience ICT Improvements Purchase of Personal Computer Desktop/Laptop and Associated Services Upgrade of Microsoft Licences Urgent action is being sought to allow the decisions to be progressed by the deadline of Friday 19 th February 2016 in order to enable expenditure to be incurred in the current financial year. The request was received via to the Independent Members and Executive Directors on the 16 th February 2016 under the Urgent Decisions framework within Standing Orders. Recommendation Approved: Professor Rosemary Kennedy, Chairman Mr Steve Ham, Interim Chief Executive Board Members supported the action and conveyed formal approval by return ; Mr Harry Ludgate, Independent Member Judge Ray Singh, Independent Member Mr Phil Roberts, Independent Member Mrs Janet Pickles, Independent Member Professor Susan Morgan, Executive Director of Nursing & Service Improvement Ms Sarah Morley, Executive Director of OD & Workforce No objections to approval received. Page 3

8 PUBLIC TRUST BOARD MEETING HIGHLIGHT REPORT FROM THE CHAIR OF THE QUALITY & SAFETY COMMITTEE Meeting Date: 17 March 2016 Author: Lisa Heydon-Mann, Quality & Safety Manager Sponsoring Executive Director: Professor Sue Morgan, Executive Director of Nursing & Service Improvement Report Presented by: Committee/Group who have received or considered this paper: Mrs Jan Pickles, Independent Member Nil. Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Trust Board are asked to NOTE the report of the Chair of the Quality & Safety Committee March This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well This report supports the following Health & Care Standards: Governance, Leadership and Accountability Staying Healthy Safe Care Effective Care Dignified Care Timely Care Individual Care Staff and Resources

9 2 Highlight Report Quality & Safety Committee 1. INTRODUCTION / BACKGROUND: 1.1. This paper had been prepared to provide the Board with details of the key issues considered by the Quality & Safety Committee at its meeting on the 3 rd March The Board is requested to NOTE the contents of the report and actions being taken. 2. TIMING 2.1 The Quality & Safety Committee met on 3 rd March 2016 as part of its normal cycle of meetings. 3. CONSIDERATIONS FOR BOARD / COMMITTEE 3.1. At the meeting, the Committee considered issues and can provide assurance to the Board on the issues delegated to them through the Trust Standing Orders relating to the following key items; 3.2. CONSIDERATION OF EXTERNAL/INDEPENDENT REPORTS/REVIEWS WBS Regulatory and Accreditation Update An update was provided against the regulatory inspections undertaken at the Welsh Blood Service during the period October 2015 December Actions plans are in place to address findings from the inspections and the service is on target to deliver against the action plans The Committee were advised of a serious adverse blood reaction and event which had been reported to the MHRA. A robust investigation has been undertaken and remedial actions implemented CONSIDERATION OF INTERNAL CONTROL ISSUES Nil for this meeting 3.4. ITEMS ENDORSED BY COMMITTEE FOR FURTHER CONSIDERATION BY FULL BOARD The Quality & Safety Committee terms of reference were approved by the Committee. The Trust Standing Orders will be updated to reflect the revised terms of reference Claims Management Policy and Claims Management Procedure were approved by the Committee Homecare Medicines and Delivery Service Policy were endorsed by the Committee for full approval at the Trust Board. The Committee expressed its concern relating to the lack of support from procurement to take forward the OJEU tender to implement this service which has subsequently delayed implementation. 3.5 TRUST RISK REGISTER The Committee were advised that progress is being made in the review of the Trust Risk Register, as agreed following the Board development session in As this was still in progress, the Trust Risk Register considered at the meeting was the approved January Page 2

10 3 Highlight Report Quality & Safety Committee 2016 version. One new risk that had been added to the register was highlighted and related to the further limitations on availability of car parking at Velindre Cancer Centre. The Planning & Performance Committee meeting had a detailed discussion on this issue at its meeting on 25 th February It is anticipated that the work to revise the Risk Register should conclude in May 2016 and will be presented to the Trust Board at that time. 3.6 OTHER ISSUES FOR BOARD CONSIDERATION Presentations were provided on the following areas: Patient Experience Kate Hammond, Patient Experience Co-ordinator, presented an overview of activities and processes used at the Velindre Cancer Centre to capture and respond to patient feedback. Welsh Blood Service Quality Systems Joan Jones, Head of Quality, provided an overview of the quality systems across the Welsh Blood Service, and highlighted future challenges facing the organisation. In particular, the requirement to develop an electronic quality management system and the streamlining of the current paper system Blood Health Strategy Joan Jones, Head of Quality, presented the Welsh Blood Service Blood Health Strategy describing the vision for Prudent Health Management Following the presentation the Committee identified an opportunity to review the current pathway for delivering blood transfusions to patients attending Velindre Cancer Centre with an aim of reducing the time it currently may take Patient and Donor Experience The Committee received feedback provided by patients and donors in the form of the Patient Experience Report and the Donor Experience Report. Overall patients were very positive about their experiences of treatment and care at Velindre Cancer Centre. The Committee were advised that the Welsh Blood Service were considering methods for improving the presentation of their donor feedback report Medical Education Standards Dr Louise Hanna updated the Committee on the changes to the medical education programme for junior doctors, and the new General Medical Council Standards for the quality of training which came into force January Discussions took place regarding the risks and challenges these Standards create for the organisation, and the requirement for ongoing assurance against delivery of those Standards to the Committee. A Governance framework for medical education will be developed by Dr Hanna which, it was agreed, would include reporting arrangements to the Quality & Safety Committee. The Trust risk register will be updated to reflect the risks relating to medical education. Page 3

11 4 Highlight Report Quality & Safety Committee Antimicrobial Stewardship The Committee were updated on the antimicrobial stewardship activities at Velindre Cancer Centre, and the impact of the weekly antimicrobial stewardship ward rounds. Excellent practice was noted Infection Prevention and Control Highlight Report The report continues to demonstrate positive results for infection control management and signification achievements in areas of Velindre cancer Centre whereby one ward had now achieved in excess of 783 days since the last event of Clostridium Difficile. Hand hygiene audits continue and results are being used to identify any trends in staff groups. MSSA and MRSA infections remain low Equality & Diversity Highlight Report It was highlighted that strategic equality objectives had been issued for consultation and would be submitted to the Board for approval Delivering Excellence The Progress Report Delivering Excellence December 2015 was discussed; Performance was reported as positive; work is on-going to ensure all targets are met. Infection control data and hand hygiene data was reported as positive. Hospital acquired pressure ulcers had increased and this was discussed at Executive Management Board. A deep dive review of these 4 cases had been commenced by the Head of Nursing. Performance measures being achieved at the Welsh Blood Service Influenza Vaccination Programme An update against the flu vaccination programme was provided. Year on year the Trust has increased the number of staff vaccinated, and it was noted that 625 of staff across the Trust have taken up an offer of vaccination so far in the 2015/16 vaccination programme (as of 21 st January 2016) It was also announced that the Flu Fighters Team had won an award for Best Flu Fighters Cymru and the Committee asked that their congratulations be extended to the team. 4 NEXT STEPS 4.1 The Trust Board is requested to NOTE the contents of the report and actions being taken. Page 4

12 PUBLIC TRUST BOARD MEETING TRUST RISK REGISTER Meeting Date: 17 th March 2016 Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Sian Lewis, Quality & Safety Coordinator Professor Sue Morgan, Executive Director of Nursing & Service Improvement Professor Sue Morgan, Executive Director of Nursing & Service Improvement Executive Management Board Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Committee are asked to DISCUSS the Trust risk register and the actions status of the Trust register. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well This report supports the following Health & Care Standards: Governance, Leadership and Accountability Safe Care Effective Care Staying Healthy Dignified Care Staff and Resources Individual Care Timely Care

13 2 Trust Risk Register 1. Introduction / Background: The purpose of this report is to present to Board members the high level organisational risks contained on the Trust Risk Register and the management actions being taken to manage or mitigate these high level risks. The Board are requested to: 1. Review the Trust risks 2. Provide assurance that Trust risks are being managed/mitigated 3. Approve the content of the Trust risk register 2. Timing All divisions /departments have a register of risks which are updated and reviewed within the service division. The divisional senior management teams (SMTs) work with their supporting groups/ committees to ensure effective controls are in place for their risks to be managed at a tolerable level. The divisional SMT will determine whether the risk should be escalated onto the Trust risk register. As the Risk Register is being reviewed, following the Board development session, and the changes have yet to be considered by EMB, the January Risk Register is presented to the Board. 3. Description: The Executive Director of Nursing & Service Improvement, as the Executive lead on Risk Management, will invite lead Directors, or their nominated representatives, to present and lead a discussion on their areas of identified risk at each meeting in which the Risk Register is presented. Lead Directors are responsible for ensuring that risks are regularly updated and advise the Trust s Quality & Safety Department that the information contained in the Risk Register is accurate and kept up-to-date. It is the responsibility of lead Directors, or their nominated representatives, to ensure that any changes/updates to risk narrative arising from discussions at meetings are fedback to the Trust s Quality & Safety Department in a timely manner. The risk profile was placed on the corporate shared drive for Executive leads to update progress on actions. The closing date for submissions was the 5 th January Risks Updated January Insufficient numbers of SHO level medical staff to meet service and educational requirements 9296 Data Transfer Activities between NHSBT and WBS to support the transition to an All Wales Blood Service 7025 Delivery of the National Laboratory Information Management System Blood Transfusion and Welsh Transplantation and Immunogenetics Laboratory (WTAIL) Modules will be delayed outside of the original timescales. New risk identified January Car parking availability at VCC increases the potential risk of accidents and poor experience for patients, visitors and staff. Page 2

14 3 Trust Risk Register 4. Financial Impact: Financial risk will vary for each individual risk reported on the Trust Risk Register. 5. Quality, Equality, Safety and Patient Experience Impact. The high risk areas considered to have an impact on quality, equality, safety and patient experience are identified in the Trust Risk Register. The Trust Quality & Safety Manager is assisting Director Leads, together with the risk owner, as appropriate, in reviewing the risks currently on the Trust Risk Register. All risks will be reviewed for consideration at the next EMB meeting on the 9 th March 2016 with an improved register presented to the Trust Board in May Considerations for Board / Committee The Trust Risk Register is received and reviewed at Board, Board Committees, and the Executive Management Board meetings. The Executive Management Board identifies the assuring Committee for new risks. The role of Board and Committees is to scrutinise risks, comment and satisfy themselves on the adequacy of management actions and the control measures being implemented. 7. Next Steps The Board is asked to DISCUSS the Trust Risk Register and the actions status of the Trust register. As agreed with the Board, the narrative description of the risk was reviewed in February 2016 by each lead Director and will be discussed at the next Executive Management Board on 9 th March 2016 to ensure that the description accurately captures the risks. These discussions have already highlighted that a small number of risks can be proposed for de-escalation and management at Divisional level. Following agreement by EMB, Director Leads will review the formal risk assessments and revise the action and progress sections of the risk register as part of our agreed improvement programme. The aim is to present a revised Trust Risk Register to the May meeting of the Trust Board. Page 3

15 Trust Risk Register atus of Register xt Review Date Active -March 2016 Executive Management Board - March 2016 Datix Risk Ref Risk Summary Date Risk Identified & Initial Risk Rating Date & Rating when last assessed Action agreed at last risk assessment Progress Target Risk Rating & Target Date Exec Lead for Risk Assuring Com for Risk ) Lack of Physical space to accommodate the current requirements and future expansion at the Velindre Cancer Centre. a) Out Patients Department b) Pharmacy c) Office Accommodation d)lack of storage External audit completed for pharmacy concurring with above. Community Health Council audit have concurred with many of the above items and also raised issues in relation to external aspects of the site e.g. lack of patient car parking and pedestrian access around the site. Identified: Red 15 Date Assessed:- 20/10/2015 Due for review 20/03/2016 Red 15 1 Further development of the SOP for the Transformation of Cancer Services in South East Wales will be ongoing and will be generated under a different future risk assessment. 2. Accommodation Review of existing facilities to be completed, providing an outline SOP for submission to Welsh Government by end of financial year 2014/15, with a Business case justification for the following areas to allow access to funding to improve the following; Outpatient departments Pharmacy Mortuary 3. Continually review the ability to Increase the percentage of services undertaken in outreach clinics 4. Continually review capacity availability to ensure best use and maximisation through; Identification of appropriate and suitable clinical and non clinical areas on and off site Assessment of office areas to ensure compliance to workplace regulations. Management meetings and discussions with staff in identified areas, issued identified and documented. Managers should document and highlight issues around stress, ill health, occupational health assessments or exit interview feedback that can be directly attributed to lack of space or current working environment. Draft accommodation plan in development/updated. External Consultants appointed to develop SOP for Accommodation Improvements. Initial meetings have been held with relevant departmental managers. Project Structure now fully in place and business case being developed. Risk Assessment reviewed SG on 20/10/15 Accommodation SOP for existing VCC accommodation has been developed and is being reassessed by Senior Management prior to submission to Executive Board- Jan 2016 Yellow 6 31/03/16 Director VCC Planning & P'mance Committee Trust Board: EMB: P&P Com: Limited radiotherapy capacity and other pathway bottlenecks may impact on throughput and therefore the optimum quality of patient treatment intent as measured against UK standards Identified: Amber 12 Date Assessed:- 20/10/2015 Due for review: 20/04/2016 Amber 12 A plan for RT for next 5 years is being developed to identify future requirements to meet demand and deliver new RT technology. Implementation of the Site development plans. Interim plans for an increase in radiotherapy capacity are being developed in parallel to ensure continuity of service during the site development project Action Status 1.Development of a programme for radiotherapy strategic plan is underway with project team appointed to support the work programme. Initial meetings have taken place and plans in place for first draft of strategy to be available in early Waiting times are actively monitored and the number of patients affected is variable and recorded in the monthly breach reports. The position is monitored weekly. Ongoing work to develop a different way of capturing the patient experience as it is recognised that the waiting time target does reflect the on-the-day experience. 3. Following increase in demand department utilising agency staff to increase capacity and aim to meet demand. The continuation of agency is being discussed at Executive Management Board taking account of current financial plans. 4. Ongoing monitoring of linac uptime percentages and implications of breakdowns. 5. Business case for replacement of LA2 has been approved by Trust Board and Welsh Government. Project implementation plan in place. 6. Delivery and Support Unit Report (October 2014) identified a number of recommendations. A management group to monitor progress has been established to include the Chief Executive, Director of Cancer Services and Director of Planning. A workshop took place on the 30th October with internal and external stakeholders. 8. The longer term site development plans will include requirements to address linac capacity. 9. Risk assessment currently under review. Yellow Revised Chief Executive Planning & P'mance Committee Trust Board: EMB: P&P Com: Areas of VCC Estate are in breach of statutory standards, which may lead to prosecution and reputational damage; Asbestos- Non compliance with CAWR Duty holder, Asbestos management plan not in place. Unclear lines of accountability for management in hosted bodies. Identified: Amber 12 Date Assessed:- 20/10/2015 Due for review 20/04/2016 Amber 12 4.Action plan presented to EMB (Jan13) but requires further work before it can be approved. Asbestos - Establish a trust wide working group including hosted bodies. (complete) -Develop an action plan (complete) -Develop an asbestos policy (complete) -Develop an asbestos management plan by the end of August (complete) -Identified a nominated person and training booked 2nd August 2013 (complete) ISO identify all key actions required to retain accreditation at VCC (complete) -Review the resources requirement by July 5th 2013 (complete) All associated actions have been completed in relation to this risk mitigation. The issues will continue to be monitored. Both statutory compliance and asbestos management is being reported to the Estates Statutory Compliance Group. IS accreditation will be monitored through the sustainability and environmental group. SG Risk assessment reviewed 20/10/15. As previously reviewed on the 3/06/15 Actions pertaining to this RA have been completed. It is recommended that the following RA's are created and monitored at Divisional level and re-escalated when risks are not managed or controlled. 1. statutory compliance 2. asbestos management 3. environmental compliance 4. main access to VCC- this is covered by RA This is currently being explored. Yellow 6 31/01/16 Revised Director of Planning & Performance Planning & P'mance Committee Trust Board: EMB: P&P Com:

16 Trust Risk Register 8021 Trust wide assessment of the management and control of legionella across all Velindre buildings and locations. Management must have in place a robust system for maintaining the water systems free of legionella in accordance with legislation to ensure the safety of staff, visitors, patients, donors and service users across the Trust buildings. Identified 8/5/13 Red 20 Date Assessed 09/09/2015 Red Trust wide policy on management of legionella. 2. Monitoring compliance of the completion of divisional and local risk assessments will take place at the Trust Planning and Performance Committee and H&S Management Group. Due for review: 3. All Buildings or areas thereof to have an up to date risk assessment which 01/03/2016 should be discussed at their appropriate Divisional SMT or Q&S, H&S or risk Under review Management Committees. 4. Appropriate robust managed mechanisms for water monitoring and flushing of outlets to be co-ordinated, monitored audited and reviewed across the Trust. 1. Policy reviewed awaiting approval. 2. Legionella risk to be monitored at Planning and Performance Committee and H&S Management Group. 3.All buildings to have an up to date robust legionella risk assessment in place. 4. Senior Management, at Divisional Level, to provide annual assurance that water safety management is being pro-actively managed in accordance with the legionella risk assessment. SG reviewed 09/09/2015 no change. Yellow 5 31/12/15 Revised Director of Planning & Performance and Estates. Planning & P'mance Committee Trust Board: EMB: P&P Com: Insufficient numbers of SHO level medical staff to meet service and educational requirements Red Establishment of an All Wales Blood Service (AWBS) in 2016 Potential to deliver the service within the specified time and within budget and ensuring the Blood Establishment Authorisation of the WBS is maintained to allow storage and distribution of blood components from a site in Wrexham to BCUHB hospitals. 22/02/2013 Red Data Transfer Activities between NHSBT and WBS to support the transition to an All Wales Blood Service will not be completed on time 22/05/2015 Red 15 Date Assessed: 09/12/2015 Amber 12 Due for review: 31/10/2016 Date Assessed 08/09/2015 Red 15 Due for review 01/03/2016 Under review Date Assessed: 04/12/2015 Amber 10 Date for review 01/03/2016 Under review 1. Policy for principles for applications of leave for junior doctors. 2. Business continuity plan in place and any gaps in provision are activity monitored in line with the business continuity policy. 3. Temporary measure put in place for senior nurses to hold on-call bloods during 9-5 to allow attendance at clinic 4. In cases of emergency enactment of action down in terms of covering the service. For example, SPR to SHO, Consultant to SPR. Consultant to also cover TCT services when required. 5. Post take ward round 6. Weekly operational meetings re-established with Consultant, senior nurse and SHO's. 7. Regular meetings established with senior management, nursing and consultants to discuss any ongoing issues. 8. Three times daily handover meetings between medics and nursing to ensure workload is understood and to pre-empt any clinical problems. 9. Proactive management of rotas so that gaps are identified at an early stage 10. Wider workforce development discussions required in order to address future issues around medical workforce and in particular the use of medical trainees within the service. 11. Role of Consultant on-call needs reviewing with an option appraisal to increase the level of senior review for inpatients, in consideration with wider service implications. 12. Assessment Unit - Develop clinical model and define impact upon inpatient/day case services Establishing an All Wales Blood Service (AWBS). Potential failure to deliver an AWBS on time, within cost, meeting all Quality & Regulatory requirements. This is being actively managed through the programme and work streams An OCP needs to be developed to accommodate changes at Talbot Green and define how this will be communicated Technical IT work to review the data received. Currently identifying any areas of the specification which will need to be updated The Trust has successfully recruited one Staff Grade doctor that will work within the ward areas. This is a 9-5 post which will allow additional support during the busiest periods. An advertisement has been placed for an additional post in line with risk assessment. Feedback from the Deanery at their recent visit was more positive and the commitment to improving the experience of the trainees was noted. Feedback from the trainees, their attendance at clinics and training has improved. Unfortunately, the SHO's reduce in November as the trainee on rotation from Holme Tower commences maternity leave. Formal request to support the funding of additional GP trainee numbers in 2016 made to Director. 2/12/15 The Risk assessment has been updated with the progress identified above and approved by Medical Director. The situation continues to be monitored on a daily basis proactively managing 'gaps' in cover. Operational Implementation team in WBS established. BJC approved by Welsh Government. WG legal changes enacted. New governance arrangements for implementation now in place. November 2015 External Gateway review conducted with delivery confidence assessment of Amber / Green. Vehicle order for temperature controlled vehicles (base vehicle not conversion) placed as not to create increased delay. Estimated delivery times are likely to be post go live and mitigations are being explored, will not prevent go live. November nd data refresh now received from NHSBT and engagement now picking up with external supplier with regards to upload into eprogesa December rd iteration of data planned for 20/01/2016. Workshop for final go-live planning is planned for 08/02/2016 and 09/02/2016 with NHSBT colleagues. MAK to complete DM upload - minor delay in receipt - expected completion end of January yellow 4 30/11/16 Amber 10 04/12/2015 Revised 31/03/16 Amber 12 31/03/16 Clinical and Medical Directors WBS Director WBS Director Workforce & OD EMB Trust Board: WF&OD: Q&S Com Trust Board: Q&S EMB: Q&S Com Trust Board: Q&S EMB:

17 Trust Risk Register 7025 Delivery of the National Laboratory Information Management System Blood Transfusion and Welsh Transplantation and Immunogenetics Laboratory (WTAIL) Modules will be delayed outside of the original timescales 15/04/2015 Red 15 Date Assessed: 04/12/ Continued delay of delivery of Blood Transfusion module at an All Wales level could lead to significant reputational damage across the discipline and puts at risk a key benefit of an All Wales Blood Service. Red Lack of detailed Project Plan for delivery of WTAIL module presents business continuity and reputational damage for the service Due for review 01/03/2016 Under review WBS Chair Blood Transfusion and WTAIL Implementation Board. Amber 9 Governance in Health Board's reinstated. Programme Plan developed and internal resources identified to support local delivery. 31/03/16 Implementation Plan timetable agreed May Internal SME's and Programme resource identified in WBS. Initial software provided for WTAIL. BT system not locked down and awaiting supplier. WTAIL Phase 1 as a small slippage against plan due to timing of workshop and additional functions that need to be addressed. Review of current timescales planned for w/c 31 August Validation Analyst being recruited (new Validation Analyst commenced in post on 01/10/15) Oct 2015 WTAIL - Portfolio Project Manager has been appointed to support the WTAIL LIMS module and commenced in post on There has been a slippage against plan due to an unexpected delay in receiving the first iteration of the data migration. The data migration has now been received however some minor issues have been identified which are currently being reviewed with the supplier. This has impacted the timescales within the project plan as informal testing cannot progress until the issues has been resolved. Blood Transfusion - WBS validation fully involved with delivering the BT system. System testing is progressing albeit slowly with issues being identified. Further workshop planned for mid November DEC 2015 There has been a slippage against plan due to an unexpected delay in receiving the first iteration of the data migration. The data migration has now been received and the a majority of the identified issues have been resolved through correspondence with the supplier. It is anticipated that iteration 1 of the Project will be completed by the end of January The anticipated go-live date for Prometheus is April 2017, however the go-live date for Orpheus is still to be established. WBS Director IM&T Com IMT Q&S EMB: SaBTO recommendation for the implementation of NAT HEV Test for selected vulnerable recipients. 1. HEV Test for selected vulnerable recipients. 1a.Unable to implement Test to deadline 1b.Lack of staff resource to plan implementation 2. Legal Liability, transfusion of HEV via untested components to vulnerable groups as defined by WG Ministerial Agreement 3. Legal Liability, transfusion of HEV via untested components to unselected recipients 9675 Introduction of Nurse Revalidation from April 2016 The relatively short period of time between finalisation of the revalidation model and implementation from January 2016 presents potential risk. The Trust will need to ensure that appropriate processes are in place to support introduction of revalidation from the golive date of 1st January 2016, although it is anticipated that the first nurses and midwives to revalidate will be those due to renew their registration in April /08/2015 Red 15 13/07/2015 Red 16 Date Assessed 04/12/2015 Red 15 Due for review 01/03/2016 Under review Date Assessed: 17/11/15 Amber 12 Due for review 01/03/2016 Under review 1a. Procurement to tender for NAT HEV kits. 1b. Task & Finish Group established to resource the implementation requirement. 2.Test sufficient blood components to ensure continuity of supply to vulnerable groups & inform users of the WG instructions 3.The disease is self limiting, implementation as directed by Secretary of State under BSQR & WG instructions. Inform patients by use of patient safety leaflets & the WG instructions 1. Potential for the revalidation model proposed by the NMC to change (the model will be considered by the NMC Council in October 2015). 2. Lack of capacity within the Corporate Nursing Team and Head of Nursing functions within VCC and WBS to provide training for registrants and confirmers 3. Resources not identified to enable identification of an individual to lead on establishing and implementing the Trust s processes for revalidation 4. Individual registrants could be unprepared and consequently not meet the revalidation requirements; potential to impact on service delivery, patient care and organisational reputation. 5. Information contained in ESR (in relation to individual registrants expected revalidation date) may not be accurate 6. The Trust s role in supporting Revalidation processes in the Hosted Organisations needs to be affirmed. 1a. URS prepared & tender to be published 1b. SMT lead to set up T&F group 2. Ensure sufficient components are tested & supplied to users. Ensure users are aware of their responsibilities to transfuse selected components to vulnerable patients. Will only be detected if patient becomes seriously ill. 3. A better informed public will be more aware of the risk of transfusion transmitted HEV infection, although HEV disease is usually self limiting in the general immunocompetent population December 2015 Risk remains at 8 until the desk top audit of the manual process has been reviewed & considered by Medical Director & Head of QA&RC. Providing the reviewers are satisfied "in principle" with the temporary manual process until BECS can control HEV testing & labeling "On Line" then a full audit of the testing & labeling processes will be independently audited by QA systems auditor on 12th January Amber 8 31/03/16 1. The NMC agreed the revalidation model in October 2015, the first nurses to revalidate will in be Yellow 6 April A lead nurse for NMC revalidation took up post (3 days per week for 1 year initially) on 7th December This individual is in the process of implementing systems and processes to 01/09/2016 support nurses and confirmers to adhere to the NMC requirements for revalidation. Targeted support will initially be offered to the first cohort of nurses to go through the process (those due to revalidate between April 2016 and September 2016), and will be rolled out on a sequential basis. A number of individuals across the organisation have completed the NMC 'train the trainer' preparation. 3. Resources have been identified to support the appointment of a lead nurse for revalidation as detailed above. 4. The NMC has contacted individual nurses to confirm their revalidation date and to advise them what to do. In addition, the ESR system has been linked to the NMC register to enable revalidation dates to automatically update in ESR. Reminders are issued to individual registered nurses and line managers through ESR. Regular communications are being issued to emphasize that it is a professional and personal responsibility that registered nurses a revalidation-ready. Support, advice and training is being offered by the lead nurse for NMC revalidation.. 5.The lead nurse for NMC revalidation has been in contact with key individuals in hosted organisations. The same level of support, advice and training is being offered to registered nurses in nursing roles in hosted organsiations. An individual has been identified within the DISCHR team to lead implementation in this area, working closely with the Trust's lead nurse for NMC revalidation. Work is ongoing with the ESR team to identify registered nurses who are not currently employed in nursing roles and are therefore not routinely identified as nurses on ESR. Nurses falling into this category will be advised that they must make arrangements to meet to clinical practice component of the revalidation requirements if they wish to maintain their registration status. WBS Director Exec Director of Nursing & Service Imp Q&S Com Trust Board: Q&S EMB: WF&OD EMB: Trust Board: Q&S Com: WF&OD Com: Reduction in the limited Car Parking at VCC increases the potential risk of accidents and injuries to patients, visitors and staff. 04/11/2015 Red 16 Due for Review: 21/05/ Full review of car parking capacity and facilities. 2. Consider reintroducing permit process 3. Review staff and meetings held on VCC site with a view to reducing car throughput/car parking requirements 4 Undertake divisional travel survey in line with Velindre NHS Trust Travel plan. 1. IM's at Q&S Committee on 10th December 2015 requested Estates team undertake formal car parking appraisal of VCC and develop travel plan options. Yellow 6 Director VCC EMB: Business case being developed for dedicated resources to review, implement and manage Target Date permit system and parking on VCC site. 3. Development of capital business case is being considered for permit access car park barriers linked to staff identity/door access schemes. TBC at EMB on the 09/03/2016

18 PUBLIC TRUST BOARD MEETING ALL WALES HEALTH AND CARE STANDARDS AUDIT OF PATIENT EXPERIENCE (2015) Meeting Date: 17 th March 2016 Author: Ceri Hamilton, Senior Nurse Velindre Cancer Centre Jayne Elias, Assistant Director of Nursing and Service Improvement Sponsoring Executive Director: Professor Susan Morgan, Executive Director of Nursing and Service Improvement Report Presented by: Professor Susan Morgan, Executive Director of Nursing and Service Improvement Committee/Group who have received or Executive Management Board (9 th March considered this paper: 2016) Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Board are asked to endorse the findings of the 2015 All Wales Health and Care Standards audit of Patient Experience in Velindre Cancer Centre, prior to submission of the information to Welsh Government by 31 st March This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well This report supports the following Health & Care Standards: Standard 6.3 Listening and learning from feedback

19 2 All Wales Health & Care Standards Audit of Patient Experience Introduction / Background 1.1. The Health and Care Standards, introduced from April 2015, streamlined the expectations previously set out in the Doing Well Doing Better Standards for Health Services in Wales (2010) and the Fundamentals of Care Standards (2003) into a single quality standards framework for Wales In previous years Health Boards and NHS Trusts in Wales have undertaken a national audit using the twelve Fundamentals of Care Standards audit criteria, and have reported findings on an annual basis to the office of the Chief Nursing Officer for Wales To facilitate introduction of a new measurement and monitoring regime for the Health and Care Standards (2015) the 2015/16 business year was identified as a transition year. Health Boards and NHS Trusts in Wales were no longer required by Welsh Government to complete the full Fundamentals of Care audit, but were required to complete the Patient Feedback element of the audit during October and November 2015, and to submit the findings to Welsh Government by 31 st March Individual Executive Directors of Nursing and Boards were free to determine whether to also collect data in relation to the operational and staff feedback elements of the Fundamentals of Care audit tool; the full audit was undertaken in Velindre Cancer Centre during October and November 2015 as in previous years. 2. Timing: 2.1. This report details the findings of the Health and Care Standards audit of Patient Experience in Velindre NHS Trust for consideration by Velindre NHS Trust Board prior to submission to Welsh Government by 31 st March Results derived from the wider Fundamentals of Care audit (i.e. in relation to operational and staff feedback elements of the audit) will be collated and considered within Velindre Cancer Centre to enable relevant clinical areas to develop improvement action plans as appropriate. 3. Description: 3.1. The Health and Care Standards (2015) consist of seven overarching themes and twenty two health and care standards. When considered collectively they provide a description of how individual services provide high quality, safe and reliable person centred care. The standards have been mapped against the NHS Outcomes and Delivery Framework measures, and encompass the twelve standards of care previously set out in the Fundamentals of Care Standards (2003) Findings from the All Wales Health and Care Standards Audit of Patient Experience (2015) provide a snap shot view at a given point in time. They represent one of a number of quality assurance measures of care provided within Velindre Cancer Centre and therefore results should be considered in conjunction with other information relating to care standards and patient and carer feedback Work is ongoing within the Trust to revise the Trust s approach to listening and learning from patient and carer feedback to ensure consistency with the requirements of the recently updated National Framework for Assuring Service User Experience (WHC/2015/061). Currently a selection of patients and carers are asked each month for Page 2

20 3 All Wales Health & Care Standards Audit of Patient Experience 2015 feedback about the services they have received using a satisfaction questionnaire. Feedback from complaints and compliments is also captured and shared within the organisation. 4. Financial Impact: 4.1. Delivery of high quality, safe nursing care and the collation of patient and carer feedback generates expenditure however there are no specific or exceptional financial considerations to draw to the attention of the Board. 5. Quality, Equality, Safety and Patient Experience Impact: 5.1. Standard 6.3 of the Health and Care Standards (2015) require that people who receive care, and their families, must be empowered to describe their experiences to those who provided their care so there is a clear understanding of what is working well and what is not, and they must receive an open and honest response. Health services should be shaped by and meet the needs of the people served and demonstrate that they act on and learn from feedback Participating in the all Wales Health and Care Standards audit of patient experience is one of a suite of mechanisms to capture and report patient and carer feedback about the services received. Through actively seeking feedback the Trust enables patients and carers to share their views and experiences in relation to what went well, areas for improvement, and to have a voice in the quality of the care they receive. This approach also provides the Trust with a means of measuring and monitoring the quality of care provided, identifying key themes for improvement and to promote a culture of openness and transparency. 6. Considerations for Board: Audit methodology 6.1. The audit was conducted in six clinical areas within Velindre Cancer Centre: First Floor Ward Active Support Unit Chemotherapy Inpatient Unit Outpatients Department Rhosyn Day Unit Chemotherapy Day Unit 6.2. The audit team comprised Velindre Cancer Centre staff (independent of the clinical area subject to audit), and members of the Patient Liaison Group. The patient/carer aspects of the audit were undertaken by members of the Velindre Cancer Centre s Supportive Care Team and members of the Patient Liaison Group A random cohort of eligible patients and carers were approached to participate (n=71). Patients and carers were asked to rate how satisfied they were (always, usually, sometimes, never) in relation to eighteen specific questions Patients and carers were also asked to rate their overall experience on a scale of 1-10, where 1 was very poor and 10 excellent. Page 3

21 4 All Wales Health & Care Standards Audit of Patient Experience 2015 RAG Rating 6.5. A RAG rating (R=Red, A=Amber and G=Green), has been applied to each scored Standard to direct the immediacy of any improvement actions required. The RAG rating is as follows: Score RAG Rating Action 0-50% Red Immediate 51-84% Amber Review in 3 months % Green Review in 8 months Results 6.6. Overall respondents rated their experience within Velindre Cancer Centre highly. This is consistent with the pattern of feedback received on a monthly basis via the Trust s patient and care experience questionnaire All patients and carers rated their overall experience as 8/10 or above, as illustrated in Figure 1. Figure 1: Rating of overall experience using a 1-10 scale 6.8. Positive responses were received in response to 18 specific questions related to patient experience; patients and carers were asked to respond to each question in terms of always, usually, sometimes, never. Details of the questions and a summary of results for the 6 audited areas are provided in Table 1. Patients and carers also had facility to provide free text comments, and for completeness these are included as Appendix 1. Page 4

22 5 All Wales Health & Care Standards Audit of Patient Experience 2015 Table 1: Summary of Patient/Care Experience (all audited areas) 2015 Questions 2015 (n=71 ) 1 Throughout your stay/attendance, how often did you feel that you and those that care for you were given full information about your care in a way that you could understand? 2 Throughout your stay/attendance, how often did you feel that we kept you informed of any delays in appointment times? 3 Throughout your stay/attendance, how often did you feel that you were treated with dignity and respect? 4 Throughout your stay/attendance, how often did you feel that you were given the privacy that you needed? 5 Throughout your stay/attendance, how often did you feel that when you called us that we responded in a timely manner? 6 Throughout your stay/attendance, how often did you feel that the clinical area was kept clean, tidy & not cluttered? 7 Throughout your stay/attendance, how often did you feel that you were made to feel safe? 8 Throughout your stay/attendance, how often did you feel that you were given help to be as independent as you can and wish to be? 9 Throughout your stay, how often did you feel that you were able to get enough rest and sleep? 1 Throughout your stay, how often did you feel that you were made to feel 0 comfortable? 1 Throughout your stay/attendance, how often did you feel that you were, as 1 far as possible, kept free from pain? 1 Throughout your stay, how often did you feel that your personal hygiene 2 needs were met? 1 Throughout your stay, how often did you feel that you were given help with 3 feeding & drinking if you needed this? 1 Throughout your stay/attendance, how often did you feel that you were 4 provided with fresh drinking water and plenty of drinks when you need them? Throughout your stay, how often did you feel that you were provided with nutritious food and snacks? Throughout your stay, how often did you feel that you were given help, if required, to make sure that your mouth, teeth and gums were kept clean and healthy? Throughout your stay/attendance how often did you feel that if you needed help to use the toilet that we responded quickly and discreetly? Throughout your stay/attendance, how often did you feel that you were given help to look after your skin to prevent you from getting pressure sores? 2015 RAG 100% (Green) 92% (Green) 100% (Green) 100% (Green) 99% (Green) 100% (Green) 100% (Green) 100% (Green) 93% (Green) 100% (Green) 100% (Green) 100% (Green) 100% (Green) 100% (Green) 100% (Green) 100% (Green) 100% (Green) 100% (Green) 6.9. A 100% response of always or usually was not achieved in relation to three of the questions asked. Whilst the composite score for each of the three questions remained high at 92%, 99% and 93%, analysis of individual responses highlighted that some patients/carers had responded that they were sometimes or never satisfied with the services received. Table 2 provides detailed information. Page 5

23 6 All Wales Health & Care Standards Audit of Patient Experience 2015 Table 2: Sometimes or Never Responses 2015 Questions Sometimes Never 2 Throughout your stay/attendance, how often did you feel that we 3.92% 3.92% kept you informed of any delays in appointment times? 5 Throughout your stay/attendance, how often did you feel that when 1.75% 0 you called us that we responded in a timely manner? 9 Throughout your stay, how often did you feel that you were able to get enough rest and sleep? 5.88% Notwithstanding the very positive results overall, the service views all feedback as an opportunity to improve services provided, consequently the following is of note: Wall mounted screens will be used in the Out-patient Department to display delays; currently delays are displayed on hand written notices. Rhosyn and Chemotherapy day Units will continue with existing practice of informing patients of delays on a one to one basis. A Ward Sister currently working nights is undertaking an Improving Quality Together (IQT) silver project focused on rest and sleep with particular consideration of ward lighting and noise Although the audit methodology does not provide directly comparable data, Table 3 sets out the findings of the 2014 and 2015 audits to enable consideration of emerging trends. Table 3: Summary of Patient/Care Experience (all audited areas) 2014 & Questions 2014 (n= 52) 2015 (n=71) 1 Throughout your stay/attendance, how often did you feel that 100% 100% you and those that care for you were given full information about your care in a way that you could understand? 2 Throughout your stay/attendance, how often did you feel that we 96% 92% kept you informed of any delays in appointment times? 3 Throughout your stay/attendance, how often did you feel that 100% 100% you were treated with dignity and respect? 4 Throughout your stay/attendance, how often did you feel that 100% 100% you were given the privacy that you needed? 5 Throughout your stay/attendance, how often did you feel that 100% 99% when you called us that we responded in a timely manner? 6 Throughout your stay/attendance, how often did you feel that 100% 100% the clinical area was kept clean, tidy & not cluttered? 7 Throughout your stay/attendance, how often did you feel that 100% 100% you were made to feel safe? 8 Throughout your stay/attendance, how often did you feel that 100% 100% you were given help to be as independent as you can and wish to be? 9 Throughout your stay, how often did you feel that you were able 89% 93% to get enough rest and sleep? 10 Throughout your stay, how often did you feel that you were 100% 100% made to feel comfortable? 11 Throughout your stay/attendance, how often did you feel that 100% 100% you were, as far as possible, kept free from pain? 12 Throughout your stay, how often did you feel that your personal 97% 100% hygiene needs were met? 13 Throughout your stay, how often did you feel that you were 100% 100% given help with feeding & drinking if you needed this? Trend 1 5 areas were audited in 2014 and 6 areas were audited in 2015; the Active Support Unit was included in the audit for the first time in Page 6

24 7 All Wales Health & Care Standards Audit of Patient Experience Throughout your stay/attendance, how often did you feel that you were provided with fresh drinking water and plenty of drinks when you need them? 15 Throughout your stay, how often did you feel that you were provided with nutritious food and snacks? 16 Throughout your stay, how often did you feel that you were given help, if required, to make sure that your mouth, teeth and gums were kept clean and healthy? 17 Throughout your stay/attendance how often did you feel that if you needed help to use the toilet that we responded quickly and discreetly? 18 Throughout your stay/attendance, how often did you feel that you were given help to look after your skin to prevent you from getting pressure sores? 100% 100% 97% 100% 100% 100% 100% 100% 90% 100% 7. Next Steps: 7.1. Findings will be disseminated to front line nurses through Senior Nurses and Ward Sisters and to Welsh Government by 31 st March Page 7

25 8 All Wales Health & Care Standards Audit of Patient Experience 2015 Appendix 1: Patient Comments In-Patient Active Support Unit Staff all friendly and compassionate about their patients, always find time to sit there and talk about any concerns I might have. I have been coming for the last 12 years and I am still here because of the care I have received from them. No need to change something that is not broken. Only they do need more money to carry on their terrific job Staff have been friendly helpful and reliable. I felt involved with my treatment everyday Undivided attention from staff is great I would pay 1000 a day for this treatment if I had it!!! I would like to say about the commitment of the staff and that they convey caring always. They care for your particular needs and I can tell they are different towards everyone. There is a calmness that is instilled in patients despite the nature of the disease. First thing in the morning a cheerful N/A came on duty and was so helpful. As I didn't know I was staying Julie made sure I had something decent to wear and sorted out all my hygiene needs. Particularly impressed with cleanliness and tidiness of the ward. Says he will leave with better skin and pressure area integrity than when he came in. It has been enjoyable, there is no morbid atmosphere. Staff have been excellent. In-Patient First Floor Ward Nothing I can fault. Everyone is wonderful, been here before and all lovely I ve had a good experience of being at Velindre. thank you I have had a positive experience all staff are kind in every way All the staff seem to go the extra mile on this ward It has been good and staff have been very patient with me Clean staff friendly but professional. Good food Immaculate ward environment - very clean and tidy at all times. Nursing staff are all kind and professional food choice and quality good Staff are so friendly, from the time the night sister rang me to say they had a bed available for me and reassured me that I would be looked after, made me feel safe and secure, which has been throughout my stay at this hospital My all round care was faultless and excellent In-Patient Chemotherapy Inpatient Unit Since I had problems with cannulation the staff have made every possible effort to resolve it successfully. I ve also been having reflexology which has helped me to relax. I m happy with all the care given Friendly staff I always feel that the staff keep me in the picture and do everything to make sure that the chemo experience is a hassle free as possible. The information given in the morning and yellow card are both good Everything has been good, can t fault it Chemo pager system is excellent. Feel safe and looked after. Nice environment Outstanding, nurses very helpful and nice General atmosphere great and nursing staff attitude great everything is efficient and people take time to give explanations Well organised and staff very polite Feeling very safe within the hospital car parking is problematic - not enough spaces Overall good car parking, not enough parking spaces. one car taking up 2 spaces Rhosyn Day Unit Excellent only experienced in this hospital All been good staff are excellent Page 8

26 9 All Wales Health & Care Standards Audit of Patient Experience 2015 Nurses have more time to spend with you, you have continuing care and know the staff Really good how staff re-organise and re-schedule when things go wrong and put fears at rest All staff are welcoming and friendly Excellent staff All staff are very helpful and cheerful, makes worrying experience bearable thank you The staff are wonderful Pharmacy hopeless, give the wrong tablets and dose and have to queue up after treatment to get your tablets!! Beds not always comfortable, TV s on arms not good for your neck, TV s only have 3 channels, mobile signal very poor Information overload, signposting of info services rather than giving lots of booklets and sheets The car park could change Chemotherapy Day Unit The care is amazing and will do anything for you The staff are AMAZING!!! Always happy to help and with a smile on their faces!! Pleasantly surprised how easy going, but efficient everything is going Support from the staff is wonderful The staff are fantastic I feel all the staff have been exceptional, both their manner and expertise. Nothing is too much bother and any requests or questions are dealt with promptly. They make you feel they are here to make you as relaxed and comfortable as possible. The staff are so happy and cheerful made me so at ease Outpatient Department Staff always pleasant, smiles and makes me feel better. Only now starting a second session of treatment overall excellent A good first appointment Nurses are always very pleasant Radiotherapy department were very flexible regarding appointment times to fit around carers. Great staff always friendly and helpful Everyone was very nice and kind, the doctors and nurses were very good and helpful and caring in everything they did Always treated with respect. Nurses excellent during chemotherapy sessions Staff very friendly and extremely helpful I think the staff are wonderful The x-ray department is excellent - no waiting. The pharmacy waiting times could be improved X-ray service is excellent and no waiting. The intercom system for calling patients area is not very clear Nice and friendly staff would like to be informed about delays Staff very friendly and considerate could have a louder intercom system when calling patients Doctors and staff all very good. Better waiting area, very warm, excellent staff, and appointment time options. Improve time keeping to improve the service. You could change the word anonymised on this form Being cared for by the same staff on each visit makes you feel less stressed. Sometimes Page 9

27 10 All Wales Health & Care Standards Audit of Patient Experience 2015 seating is difficult, chairs were too low for me when I was having trouble with mobility. Higher chairs would be great for those who need them. Collection of medicine from pharmacy could be improved, always made to feel comfortable by the staff The general attitude and friendliness of all staff has always been of the highest standard and made me feel confident and positive throughout. Also the professionalism of all staff was outstanding. The calling system is not used and it could be difficult to hear staff who just call your name without using the calling system. Page 10

28 PUBLIC TRUST BOARD MEETING NURSE STAFFING LEVELS (WALES) BILL Meeting Date: 17 th March 2016 Author: Jayne Elias Assistant Director of Nursing and Service Improvement Sponsoring Executive Director: Professor Susan Morgan, Executive Director of Nursing and Service Improvement Report Presented by: Professor Susan Morgan, Executive Director of Nursing and Service Committee/Group who have received or considered this paper: Trust Resolution to: (please tick) Improvement Executive Management Board (9 th 2016) Approve: Endorse: Discuss: Note: Recommendation: March The Board are asked to NOTE the progress of the Nurse Staffing Levels (Wales) Bill through the National Assembly for Wales s legislative processes, and to consider implications for Velindre NHS Trust. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well This report supports the following Health & Care Standards: Standard 7.1 Workforce

29 2 Nurse Staffing Levels (Wales) Bill 1. Introduction / Background 1.1. The Nursing Staffing Levels (Wales) Bill, introduced by Kirsty Williams AM as a Members Bill, was given leave to proceed by the Assembly on 5 th March Originally entitled Safe Nurse Staffing Levels (Wales) Bill the short title of the Bill was amended during stage 2 proceedings to the Nursing Staffing Levels (Wales) Bill The Bill s stated purpose is to require health service bodies to make provision for safe nurse staffing levels, and to ensure that nurses are deployed in sufficient numbers to: Enable the provision of safe nursing care to patients at all times; Improve working conditions for nursing and other staff; and Strengthen accountability for the safety, quality and efficacy of workforce planning and management. 2. Timing: 2.1. The Nursing Staffing Levels (Wales) Bill is currently at Post-Stage 4 and is awaiting Royal Assent. The final text of the Bill was approved by the National Assembly for Wales on 10 th February Description: 3.1. When enacted the Nursing Staffing Levels (Wales) Bill will place statutory duties on Local Health Boards and NHS Trusts in Wales In relation to NHS Trusts in Wales, the Bill requires: That where an NHS Trust in Wales provides nursing services it must provide those services to such an extent as it considers necessary to meet all reasonable requirements. When an NHS Trust in Wales is considering the extent of provision of nursing services, the Trust must have regard to the importance of providing sufficient nurses to allow the nurses time to care for patients sensitively, and when securing the provision of nursing services, ensuring that there are sufficient nurses to allow the nurses time to care for patients sensitively. NHS Trust in Wales must (among other things) undertake workforce planning (including planning the recruitment, retention, education and training of nurses) as part of the process of providing sufficient nurses to allow the nurses time to care for patients sensitively The term nurse means a registered nurse; provision of care by an individual performing duties delegated and supervised by the registered nurse is referenced in the Bill. 4. Financial Impact: 4.1. The financial impact of implementing the Nursing Staffing Levels (Wales) Act within the Trust has not been calculated. However workforce planning activity for nursing is underway and is articulated through the organisations Integrated Medium Term Plan. Page 2

30 3 Nurse Staffing Levels (Wales) Bill 5. Quality, Equality, Safety and Patient Experience Impact: 5.1. Standard 7.1 of the Health and Care Standards (2015) require that health services should ensure there are enough staff with the right knowledge and skills available at the right time to meet need There is a strong evidence base that links nurse staffing levels with patient experience and outcomes. 6. Considerations for Board: 6.1. A detailed paper is included as appendix 1. Key points of note include: Sections 25B and 25C of the Nurse Staffing Levels (Wales) Bill will introduce a duty to calculate and take steps to maintain nurse staffing levels in: (a) Adult acute medical inpatient wards (b) Adult acute surgical inpatient wards, and (c) Such other situations as the Welsh Ministers may by regulations specify. In such situations Health Boards and Trusts in Wales must designate a person to calculate the number of nurses required to meet all reasonable requirements of the patients being cared for, take all reasonable steps to maintain this staffing level, and make arrangements to inform patients of the required staffing levels. The calculation must be formulated using a combination of professional judgement and evidence based workforce planning tools, and must take into account different periods of time and conditions on the ward. Welsh Ministers will be required to issue guidance about the duties incumbent in sections 25B and 25C, for which Local Health Boards and NHS Trusts in Wales must have regard Each Local Health Board and NHS Trust to which the duty in section 25B applies will be required to submit a nurse staffing level report on a three year cycle to Welsh Government. Welsh Government will subsequently produce a summary report for consideration by the National Assembly for Wales. 7. Next Steps: 7.1. The Board are asked to note the progress of the Nurse Staffing Levels (Wales) Bill through the National Assembly for Wales s legislative processes, and to consider implications for Velindre NHS Trust. Page 3

31 Nurse Staffing Levels (Wales) Bill i ACCOMPANYING DOCUMENTS Explanatory Notes and an Explanatory Memorandum are printed separately. Nurse Staffing Levels (Wales) Bill [AS PASSED] 1 Nurse staffing levels 2 Commencement 3 Short title CONTENTS

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33 Nurse Staffing Levels (Wales) Bill 1 Nurse Staffing Levels (Wales) Bill [AS PASSED] An Act of the National Assembly for Wales to make provision about Local Health Boards and NHS Trusts in Wales establishing nurse staffing levels. Having been passed by the National Assembly for Wales and having received the assent of Her Majesty, it is enacted as follows: 1 Nurse staffing levels (1) In Part 2 of the National Health Service (Wales) Act 2006 (c.42) (health service bodies), in Chapter 4 (miscellaneous), before section 26 insert Nursing services 25A Duty to have regard to providing sufficient nurses (1) Subsection (2) applies where a Local Health Board is considering the extent of provision of nursing services for its area necessary to meet all reasonable requirements. (2) The Local Health Board must have regard to the importance of (a) (b) providing sufficient nurses to allow the nurses time to care for patients sensitively, and where securing the provision of nursing services, ensuring that there are sufficient nurses to allow the nurses time to care for patients sensitively. (3) Where an NHS Trust in Wales provides nursing services it must provide those services to such extent as it considers necessary to meet all reasonable requirements; and subsection (4) applies where an NHS Trust in Wales is considering the extent of provision of nursing services. (4) The NHS Trust must have regard to the importance of (a) (b) providing sufficient nurses to allow the nurses time to care for patients sensitively, and where securing the provision of nursing services, ensuring that there are sufficient nurses to allow the nurses time to care for patients sensitively. (5) For the purposes of having regard to the importance of providing sufficient nurses to allow the nurses time to care for patients sensitively, a Local Health Board or NHS Trust in Wales must (among other things) undertake workforce planning (including planning the recruitment, retention, education and training of nurses).

34 Nurse Staffing Levels (Wales) Bill 2 (6) In this section, and in sections 25B to 25E, references to (a) (b) (c) a nurse providing care for patients include the provision of care by a person other than a nurse acting under the supervision of, or discharging duties delegated to the person by, a nurse; a nurse mean a registered nurse; an NHS Trust in Wales mean an NHS trust all or most of whose hospitals, establishments and facilities are situated in Wales. Nurse staffing levels 25B 25C Duty to calculate and take steps to maintain nurse staffing levels (1) Where a Local Health Board or NHS Trust in Wales provides nursing services in a situation to which this section applies, it must (a) (b) (c) designate a person or a description of person to calculate the number of nurses appropriate to provide care to patients that meets all reasonable requirements in that situation (the nurse staffing level ), take all reasonable steps to maintain the nurse staffing level, and make arrangements for the purpose of informing patients of the nurse staffing level. (2) A person designated by virtue of subsection (1)(a) ( a designated person ) must calculate the nurse staffing level in accordance with section 25C. (3) This section applies to the following situations (a) (b) (c) adult acute medical inpatient wards, adult acute surgical inpatient wards, and such other situations as the Welsh Ministers may by regulations specify. Nurse staffing levels: method of calculation (1) When calculating a nurse staffing level, a designated person must (a) (b) exercise professional judgement, and take into account each of the following (i) (ii) the average ratio of nurses to patients appropriate to provide care to patients that meets all reasonable requirements, estimated for a specified period using evidence-based workforce planning tools; the extent to which patients well-being is known to be particularly sensitive to the provision of care by a nurse.

35 Nurse Staffing Levels (Wales) Bill 3 25D (2) A designated person may calculate different nurse staffing levels (a) (b) in relation to different periods of time; depending on the conditions in which care is provided by a nurse. Nurse staffing levels: guidance (1) The Welsh Ministers must issue guidance about the duties under sections 25B and 25C and Local Health Boards and any NHS Trust to which those sections apply must have regard to the guidance. (2) The guidance may set out, in particular, that when calculating a nurse staffing level a designated person should exercise professional judgement by taking the following into account (a) (b) (c) (d) (e) the qualifications, competencies, skills and experience of the nurses providing care to patients; the conditions in which care by a nurse is provided; the potential impact on care by a nurse of (i) (ii) the physical condition and layout of the ward or other situation in which the care is provided; the turnover of patients receiving the care; services or care provided to patients by other health professionals or other staff (for example, health care support workers), and their qualifications, competencies, skills and experience; the extent to which the nurses providing care are required to undertake supervisory or administrative functions. (3) The guidance may also make provision about workforce planning that Local Health Boards and NHS Trusts may undertake in order to enable them to comply with their duties under sections 25B and 25C. (4) Before issuing guidance the Welsh Ministers must consult (a) (b) (c) (d) Local Health Boards and any NHS Trust that is under a duty to have regard to the guidance, such organisations as appear to them to represent the interests of any (i) (ii) providers of care homes, or providers of independent hospitals in Wales, likely to be affected by the guidance, such organisations as appear to them to represent the interests of any other persons likely to be affected by the guidance, and such other persons likely to be affected by the guidance as they consider appropriate.

36 Nurse Staffing Levels (Wales) Bill 4 (5) For the purposes of subsection (4) care home means premises at which a care home service within the meaning given by paragraph 1 of Schedule 1 to the Regulation and Inspection of Social Care (Wales) Act 2016 (anaw 2) is provided, and independent hospital has the meaning given in section 2 of the Care Standards Act 2000 (c.14). 25E Nurse staffing levels: reports (1) Each Local Health Board and any NHS Trust to which the duty in section 25B applies must submit a nurse staffing levels report (whether or not as part of a wider report) in accordance with this section. (2) A nurse staffing levels report must set out, in respect of the period to which the report relates (the reporting period ) (a) (b) (c) the extent to which nurse staffing levels have been maintained; the impact the Board or Trust considers that not maintaining nurse staffing levels has had on care provided to patients by nurses, for example by reference to complaints about care provided to patients by nurses made in accordance with the Complaints Regulations or by reference to an increase in incidents of harm caused by (i) (ii) (iii) errors in administering medication to patients; patients falling; patients developing hospital-acquired pressure ulcers; any actions taken in response to not maintaining nurse staffing levels. (3) Each nurse staffing levels report must be submitted to the Welsh Ministers no later than 30 days after the last day of the reporting period. (4) The Welsh Ministers must, after the expiry of each reporting period (a) (b) prepare and publish a document summarising the content of the nurse staffing levels reports submitted in respect of that reporting period, and lay each report submitted to them in that period before the National Assembly for Wales. (5) For the purposes of this section the reporting period is (a) (b) in the case of the initial reporting period, the period of three years beginning with the commencement of this section, and in the case of all subsequent reporting periods, the period of three years beginning with the day after the last day of the preceding reporting period.

37 Nurse Staffing Levels (Wales) Bill 5 (6) In subsection (2)(b) Complaints Regulations means regulations made under (a) section 113 of the Health and Social Care (Community Health and Standards) Act 2003 (c.43); (b) the NHS Redress (Wales) Measure 2008 (nawm 1). (2) In section 203(6) of the National Health Service (Wales) Act 2006 (c.42) (subordinate legislation: affirmative resolution) after containing insert regulations under section 25B(3)(c) or. (3) In section 207 of the National Health Service (Wales) Act 2006 (c.42) (index of defined expressions) after the entry in the table for NHS trust order insert nurse staffing level in the first column and insert section 25B(1)(a) next to it in the second column. 2 Commencement (1) This Act comes into force on the day on which this Act receives Royal Assent except for section 1 which comes into force on such day as the Welsh Ministers may appoint by order made by statutory instrument. (2) An order under subsection (1) may (a) (b) 3 Short title appoint different days for different purposes; make transitional, transitory or saving provision in connection with the coming into force of a provision of this Act. The short title of this Act is the Nurse Staffing Levels (Wales) Act 2016.

38 PUBLIC TRUST BOARD MEETING HIGHLIGHT REPORT FROM THE CHAIR OF THE WORKFORCE AND ORGANISATIONAL DEVELOPMENT COMMITTEE Meeting Date: 17 th March 2016 Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Trust Resolution to: (please tick) Sarah Morley, Executive Director of OD and Workforce Sarah Morley, Executive Director of OD and Workforce Harry Ludgate, Independent Member, Chair of the Workforce and OD Committee Workforce and Organisational Development Committee 11 February 2016 Approve: Endorse: Discuss: Note: Recommendation: The Board is requested to NOTE the contents of the report and actions being taken. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well This report supports the following Health & Care Standards: Governance, Leadership and Accountability Safe Care Effective Care Staying Healthy Dignified Care Staff and Resources

39 2 Highlight Report WF&OD Committee 1. INTRODUCTION / BACKGROUND: This paper had been prepared to provide the Board with details of the key issues considered by the Workforce & Organisational Development Committee at its meeting on the 11 th February TIMING The Workforce & Organisational Development Committee met on 11 th February 2016 as part of its normal cycle of meetings. 3. CONSIDERATIONS FOR BOARD / COMMITTEE At the meeting, the Committee considered issues and can provide assurance to the Board on the issues delegated to them through the Trust Standing Orders relating to the following key items; The following key items were discussed; 3.1 POLICIES Preceptorship Policy Not approved 3.2 BUILDING EXCELLLENCE OD STRATEGY The Senior OD Business Partner delivered a presentation to the Committee outlining the progress made in early implementation of the Trust s OD Strategy, and the further plans for embedding the Strategy over the coming months. The Committee discussed some of the opportunities and challenges inherent in embedding the four organisational Values, and reiterated the long-term strategic nature of this work. The Committee commended the momentum being maintained and expressed their continued support for this ongoing work and requested that an overview of the activity remain a standing Agenda item at future Workforce and OD Committee meetings. 3.3 HEALTH AND WELLBEING FRAMEWORK The Committee received a formal update on progress to date on key areas of the Trust Health and Wellbeing Framework. A number of Health and Wellbeing activities have commenced across the Trust including Dry January (abstain from drinking alcohol throughout January), Couch to 5K programme, and Yoga at WBS. Moving forward, it is the intention to try and evaluate the success of such initiatives. The Health and wellbeing Twitter account has also been illustrated by the Live Well Work Well Velindre NHS Trust logo. Progress has been made in developing a Health and Wellbeing steering group. The first formal meeting of this group will take place in March. Membership of the group includes members of the Workforce team and clinical representatives. Links have also been made with Public Health and it is hoped that they will also be able to support the group. 3.4 TRANSFORMING CANCER SERVICES WORKFORCE PLANNING The Workforce Transformation & Planning Manager discussed the managers information resource, Building the Workforce Plan, which had been developed as part of the Transforming Page 2

40 3 Highlight Report WF&OD Committee Cancer Services Programme of work. The document provides managers with information on what strategic workforce planning is and why it is important to develop one as part of this work. The guide also outlined an indicative timeline for a number of engagement sessions that will take place during Spring/early Summer which will inform the development of the long term aspects of the strategic workforce plan. The Committee recognised the guide as a useful resource for managers and discussed the desire for resources such as this to be made more widely available across the Trust. 3.5 ALL WALES BLOOD SERVICE WORKFORCE AND ORGANISATIONAL CHANGE WORKSTREAM The Committee received an update on the progress being made by the workstream noting that the key points continue to be the recruitment of the North Wales Stock Holding Unit and the progression of the Donor Contact Centre meetings have been undertaken with management, Workforce and transferring NHSBT employees during January and February Representatives from WBS Nursing also attended the meetings with nurses from NHSBT. It was reported that that staff are keen to progress with the transfer and whilst had lots of questions did not raise any issues relating to pre or post transfer. 3.6 NCC-C STAFF TUPE TRANSFER UPDATE An update was provided on the progress to date on the TUPE transfer arrangements to the Royal College of Obstetrics and Gynaecology (RCOG). It was reported that the RCOG continue to provide monthly updates and have meetings scheduled to meet with transferring employees and TU representatives on the 24 th /25 th February WORKFORCE PERFORMANCE REPORT The Assistant Director of Workforce (Interim) spoke about the increase in sickness levels and the need to go back to basics around managing people particularly around hotspots and short term sickness. The Senior Workforce Business Partners will be attending SMTs to present the areas of concern. The Director of OD & Workforce shared that Business Intelligence can give an immediate view of sickness in a team. Managers need to input the information into the self service system SMT s need to be talking to their managers to highlight the benefit from this function. The Chair noted that we are not where we need to be with mandatory and statutory training. However, the Assistant Director of Workforce (Interim) shared that the introduction of the Pay Progression policy will pick this up along with PADRs as needing to be completed to progress through pay scales and the importance of personal accountability around these targets. 3.8 WORKFORCE AND OD KEY ISSUES The Director of OD and Workforce presented the highlight report to inform the Committee of key areas of importance and significance and in particular workforce issues outlined in the IMTP. The Committee was provided an update on the early work that had commenced on the workforce elements of the TCS. The Committee noted the contents of the report. 3.9 UNDERSTANDING SICKNESS ABSENCE IN VELINDRE NHS TRUST The Senior Workforce & OD Business Partner (VCC) provided a detailed presentation to the committee on the current Trust wide sickness absence data, causes for absence, management of sickness absence and resources available to managers and staff when dealing with absence. It Page 3

41 4 Highlight Report WF&OD Committee was highlighted that whilst the WOD Team have been providing extensive support to managers, there are still a number of areas that require additional support when managing the sickness absence of their staff. Both Senior Workforce & OD Business Partners will be presenting to the SMT on the current sickness absence picture and proposed actions. 4. NEXT STEPS The Trust Board is requested to NOTE the contents of the report and actions being taken. Page 4

42 PUBLIC TRUST BOARD MEETING WORKFORCE & ORGANISATIONAL DEVELOPMENT UPDATE REPORT Meeting Date: 17 th March 2016 Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Workforce & OD Team Sarah Morley Executive Director of OD and Workforce Sarah Morley Executive Director of OD and Workforce N/A Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Board is requested to NOTE the contents of the report and actions being taken. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well This report supports the following Health & Care Standards: Governance, Leadership and Accountability Safe Care Effective Care Staying Healthy Dignified Care Staff and Resources

43 2 Workforce & OD Update Report 1. Introduction / Background: The report reflects the specific workforce priorities required to ensure that staff are supported to excel. 2. Timing This report covers the period January 2016 to March Description: This report provides an update on the Workforce and OD elements of the Trust s Three Year IMTP Delivering Excellence and current workforce and OD issues of importance or significance. A Productive, Healthy Workforce: ESR Self-Service Implementation is continuing to progress across the Trust and considerable progress has been made across WBS and areas across VCC that have faced some implementation issues. Throughout January and February NWSSP Internal Audit has been undertaking a Trust wide review of the implementation of ESR Self Service. It is anticipated that formal feedback will be received during March PADR Working Group The PADR Working Group is nearing the end of its 12 month tenure, and due to conclude its work in June The Group s most recent activities have been to: 1. Draft and refine revised PADR paperwork which, once approved, will be used as the core documentation to support and record PADR discussions along with Revalidation and Pay Progression decisions. 2. Provide a first review of a revised PADR Policy document prior to wider consultation. Health and Wellbeing update The implementation and progress of the Trust Health and Wellbeing Framework continues across the Trust. A number of Health and Wellbeing activities have been undertaken across the Trust including Dry January (abstain from drinking alcohol throughout January) which has been widely embraced across departments. The Couch to 5K programme was formally launched in January with a number of staff across VCC, WBS and Corporate Headquarters running at least once a week. It is expected that at the end of the programme staff will be able to run 5k. The Health and wellbeing Twitter account has also been illustrated by the Live Well Work Well Velindre NHS Trust logo. Regular informational tweets are being posted to share not just Velindre information but also sharing work and services that are available from local health boards, Public Health and other public sector organisations. The Health and Wellbeing Steering group is scheduled to meet on March 8 th. The aim of the group is to bring together both clinical and no clinical employees to discuss initiatives that can be made available to all Velindre staff with an aim to improve their health and wellbeing. It is Page 2

44 3 Workforce & OD Update Report anticipated that the group are looking to set up an events which will be run across the three main sites and cover a selection of topics yet to be agreed. Salary Sacrifice Car Lease Scheme The launch of the car lease scheme will commence during February and March. Road shows will be undertaken across WBS (29 th February 2016), Trust Headquarters (2 nd March 2016) and VCC (7 th March 2016). Experienced NWSSP colleagues will be available at the road shows to offer information and advice about the scheme. During the road shows staff will be made aware of the implications to their pensions should they wish to participate in this scheme, this is also illustrated in the brochures. Employee Excellence Awards Through agreement by the EMB Velindre NHS Trust will be launching its first Employee Excellence Awards in The award event will take place in July 2016 in conjunction with the 60 th Anniversary of Velindre Cancer Centre. Eleven categories have been agreed by the Trust and are as follows: CEO and Chairs Award - an individual from any level within the organisation who has demonstrated a work ethic in line with the Trust Values and Behaviours. Leadership an individual from any level within the organisation who has made a significant difference through their leadership. This includes encouraging, supporting and inspiring others. This person may not directly manage staff. Improving Patient Experience an individual or team who have made significant improvement to the patient/client/carer experience. Improving Donor Experience an individual or team who have made significant improvement to the donor experience. Equality, Diversity and Human Rights an individual who has recognised the individual needs of patients/donors/colleagues and taken action to value diversity and promote equality and human rights. Quality, Sustainability and Efficiency This category reflects our aspiration and ongoing drive for service improvement, reducing waste and delays throughout the organisation. Individuals or teams recognised in this category will have generated effective ideas for improving efficiency; and/or have implemented changes that maintain/improve safety/quality of patient care/service delivery whilst improving efficiency and value for money. Health and Wellbeing An individual or team who can demonstrate notable practice in relation to health promotion activities in the organisation and/or community. Or an individual who has made significant changes to their life style in order to improve their health and has gone beyond their work role in order to promote the wellbeing and a healthy working environment for their colleagues. Partnership Working - any individual or team who can demonstrate outstanding commitment to partnership working, internally or external to the organisation. Page 3

45 4 Workforce & OD Update Report Team of the Year for the team who have made an outstanding contribution to the delivery of the organisations objectives. Going The Extra Mile an individual or team who has contributed in such a way as to have gone the extra mile and brought that extra special something to patients, dononrs, colleagues or the organisation. Education, Research and Innovation This category reflects the importance that we place on education, research and innovation. It aims to recognise an individual or team who delivers or responds to the broad range of activities that help create the culture of education, research and innovation we need to continuously improve what we do. The Scheme will be formally launched to all Trust employees in March Building Excellence: Velindre NHS Trust s Organisational Development Strategy Implementation of the Building Excellence Strategy is being maintained; with a detailed report being submitted to the March Trust Board meeting to assure progress being made. Recent actions have included: Welsh Language Commissioner approval of the Welsh translations of our organisational Values. Publication of a comprehensive set of behaviours which support the organisational values. NB: all behaviours have been established using feedback from staff from across the Trust. Distribution of a third Staff Newsletter, focusing on translating the Values into behaviours. Establishing a staff communications and engagement plan, and obtaining quotes for display and promotional materials. Creation of bilingual poster and desk pyramid Values display material. Creation of a BE intranet page and Twitter account which promotes, explains and provides supporting resources. Promoting the Values with WBS Blood Collection Teams on their Spring 2016 Team Training Days. A meeting is planned with the WBS Working Better Together project lead to explore methods of Building Excellence supporting long-term embedding of the WBT project principles. Electronic Rostering Work is continuing to engage with the Divisions to develop the appropriate user specifications to prepare for the procurement process for an Electronic Rostering system to be deployed in departments across the Trust. A Transformed, Modernised Workforce delivered through; Donor Contact Centre The WBS faces a significant modernisation agenda in order to support the establishment of the All Wales Blood Service whilst ensuring that existing donors receive an improved service and new donors are continuously recruited in order to maintain blood stock levels. Future blood collection activity is estimated to increase by approximately 25% with the introduction of North Wales and in readiness for the service change, WBS has recognised the importance of improved telephony and donor contact services to support the recruitment and retention of donors. Page 4

46 5 Workforce & OD Update Report The WBS has approved the proposals to redesign both the Donor Relationship Management and Donor Records functions to enable the formation of a new and enhanced Donor Contact Centre at Talbot Green HQ. Donor data and activity levels across South Wales and NHSBT have been analysed alongside workshops with management, staff and their representatives and formal consultation in relation to these proposals commenced on 14 th December Staff and their representatives have been provided with the opportunity to take part in engagement sessions and informal drop-in clinics throughout the month of December. Formal one-to-one meetings with staff and trade union colleagues commenced on 12 th January 2016 and the formal consultation period ended on 22 nd January Consultation was carried out in line with the NHS All Wales Organisational Change Policy (OCP) supporting the principles of ensuring the WBS retains the valuable knowledge, skills and experience of its existing workforce. Three existing staff have been appointed to new supervisory roles and will undertake further training and development to provide them with the necessary skills and support to carry out the role effectively. WBS are currently in the process of interviewing new Donor Contact Centre Advisors and have 11 part-time posts available. There is a commitment to appointing Welsh Language Advisors and the recruitment campaign has been successful to date with over 120 applicants for these positions. In line with IMTP objectives, in order to support this new service model, the WBS is aiming to achieve a fully flexible workforce, balancing this against the health and well-being of staff and work-life balance policies. New starters will take up post week commencing 11 th April 2016 in order to commence training for go live on 3 rd May The new workforce will be multi-skilled and new technology incorporated into the roles in order to increase resilience and improve the donor communication experience. N-CCC The Royal College of Obstetricians & Gynaecologists (RCOG) have undertaken a series of one to one meetings with NCC-C employees who will be transferring on 1 st April Monthly newsletters continue to provide updates and provide answers to questions raised as part of the pre-transfer engagement meetings have been held on the 24 th /25 th February 2016 will all transferring staff, TU representatives and RCOG HR Lead. The meetings are aimed at addressing any pre and post transfer issues. The main theme that has come from the meetings has been around the amount of meetings that transferring staff will have to attend in London post transfer and the proposed new structure that RCOG will be consulting on in September The Assistant Director of Workforce will ensure that the actions detailed in the Due Diligence action plan are undertaken and completed in a timely manner. Andrea Jones, UNITE Representative will also be attending future meetings on behalf of the UNITE members. Transforming Cancer Services GE Healthcare Finnamore, along with members from the Workforce and Finance teams, undertook a number of workforce modelling sessions with managers throughout January. The outputs from this work informed a number of refinements to the model and will be mapped against the activity data and activity projections to provide a strategic level, costed assessment of the future workforce requirements to inform the business cases. A number of workforce modelling assumptions have been added to the TCS Programme Assumptions and Decisions Log. A cross cutting event will be developed by GEHCF whereby service managers will be able to cross check the outputs of the model and compare to each other s areas. The model, assumptions, potential Page 5

47 6 Workforce & OD Update Report outputs and costings modelling were presented to representatives of the Trust and the scenarios for the model were identified. An information resource for managers. Building the Workforce Plan, has been developed and shared. The guide was presented to the Workforce & OD Committee in February and explains what strategic workforce planning is and why one is required as part of the TCS Programme. An indicative timescale for a number of engagement events was included within the resource and work has commenced to plan for and schedule the first event which is anticipated to take place after Easter. A stakeholder analysis will be undertaken with the members of the Workforce, Training & Education Workstream during March, which will identify the key players in the development of the strategic workforce plan and for the purposes of engagement. A staff side representative has been identified and will be joining the Worksteam. Workforce have met with workforce colleagues from Aneurin Bevan Health Board and Clatterbridge Cancer Centre to make links regarding their work to date on developing workforce plans for transformation and the Workforce Director from Clatterbridge Cancer Centre is keen that further meetings are scheduled so that sharing of learning and experience can take place. The Assistant Director of Workforce and Modernisation and the Workforce Transformation and Planning Manager will also be meeting with Dr Deirdre Kelly-Patterson from the University of West London who leads study on strategic workforce planning. Work has commenced on the analysis of the current workforce information for the Cancer Centre and meetings have been arranged with managers throughout March to gather profession specific qualitative workforce information that will enrich that analysis. This work forms the initial stages of the strategic workforce plan, will act as a baseline for benefits measures and will start to identify workforce drivers for transformation and workforce risks. A Skilled and Flexible Workforce facilitated by; Leadership Development An inviting applications to three, internal and external, leadership development opportunities was distributed throughout the Corporate, WBS and VCC Divisions on 17 th February. The second cohort of the Velindre NHS Trust Leadership Development Programme are concluding their course, with final Action Learning Sets and Coaching sessions taking place during March, and their final workshop day scheduled in April The application criteria for the third Velindre NHS Trust Leadership Development Programme was submitted to the February meeting of the Trust s EMB for approval, and introduces a more robust application and shortlisting process which supports implementation of Values and Service Improvement alongside alignment with IMTP priorities and Talent Management. Funding for this programme is being confirmed prior to supplier contracting and confirmation of course dates. The Velindre NHS Trust Building Excellence Alumni was approved by EMB earlier this year and will be implemented by 31 st March NHS Wales Staff Surveys Confirmation has been received that NHS Wales will be implementing a Medical Engagement Scale survey in March Velindre NHS Trust has confirmed the range of medical specialities employed, contact has been made with Dr Stephen Field (WBS) and the VCC BMA Page 6

48 7 Workforce & OD Update Report Representative (Dr Owen Tilsley) to advise of the likely survey implementation timescales and ask their support in encouraging medical colleagues to complete the survey. The full NHS Wales Staff Survey 2016 is being planned for national rollout in June A small Velindre NHS Trust implementation team has been established to include IT, Communications, Informatics, Workforce and Staff Side colleagues. Procurement to appoint the national survey supplier is currently in progress, and further information will become available over coming weeks/months. Work Experience: Foundation Programme Doctors taster weeks have been planned with 4 intakes in 2016 with a maximum 3 doctors per taster. An Open Day has been arranged in November 2016 to encourage FP doctors and Core Medical Trainees to choose Oncology as a career. In addition, structured medical work experience with 2 intakes organised for 2016 with 3 students per intake and ad hoc departmental work experience requests have been arranged in conjunction with the identified departments. LIFT placements continue with one placement currently within the Education and Development Department at Velindre Cancer Centre. There is a potential porter placement in the new year. Due to the minimal administration support currently available within the Education and Development team, the promotion and co-ordination of LIFT placements will be fully restored once the Workforce and OD restructure has been fully implemented. IT Training: Access to IT training facilities within Velindre is limited therefore, the IT Trainer has now become mobile, with the use of several laptops and WIFI, IT training can now take place within available rooms throughout the Trust. Due to a high demand for Excel training at all levels, the IT Trainer has successfully delivered 4 classes via the mobile IT facilities in February with more planned for the remainder of the year. With the IT Training Suite at WBS back in operation in May 2016, the offer of ECDL qualification will be promoted together with tailored IT learning. HCSW Framework: Velindre NHS Trust has signed up to the HCSW Framework which will be implemented on 1 st April The purpose of this Framework is to provide a governance mechanism to inform the skills and career development of the HCSW workforce in NHS Wales. This resource is relevant to all HCSWs in Nursing and AHP s. It will support current and future role development by standardising the scope of these roles, and through the development of learning pathways it will provide the underpinning knowledge and skills to practice safely. This Framework will support HCSW careers and increase the professionalization of this core workforce, building on the high quality services already delivered by individuals by this workforce. A HCSW coordinator has been appointed until end of March 2016 to take this forward with the Welsh Blood Service and Velindre Cancer Centre with an aim to extend the role once the funding has been agreed. Page 7

49 8 Workforce & OD Update Report Sickness Absence Training and Pay Progression To support the implementation of the new All Wales Sickness Absence policy, to date eight awareness/training sessions have been delivered to approx 100 managers/supervisors. The majority of the training sessions have been delivered in partnership with TU colleagues. Additional sessions are currently being scheduled for January & February. In addition, the sessions have also covered the implementation of the All Wales Pay Progression policy which has been developed to support the application of amendments to the Career and Pay Progression sections of the National Pay and Terms and Conditions which apply to Agenda for Change staff. The Pay Progression Policy needs to work closely with the Appraisal Process and therefore sets out some best practice principles for appraisal that the Trust should embed in their local processes. It has been agreed by EMB that core objectives for all staff will be implemented to support the PADR process and embed the Trust Values. The core objectives are: All Employees 100% compliance with your essential statutory training requirements as set out in the NHS Core Skills Training Framework Engagement with your own PADR in the past 12 months Sustained and meaningful commitment to personal objectives in line with the organisations IMTP and Organisational Values Manager/ Supervisor 100% compliance with your essential statutory training requirements as set out in the NHS Core Skills Training Framework 100% compliance for your team s essential statutory training requirements Engagement with your own PADR in the past 12 months 100% Completion for each member of your team with their PADR Sustained and meaningful commitment to personal objectives in line with the organisations IMTP and Organisational Values Demonstrable commitment to engage staff with the creation and delivery of IMTP objectives and align team activities / behaviours to Organisational Values It is important that all employees have an opportunity to contribute to the development of the services that they work within. Therefore, to ensure that all employees are aware of their departmental agreed objectives outlined in the Trust IMTP, there should be a clear link between the IMTP and employee and team objectives. To support the embedding of the Trust Values all employees should be able to demonstrate their understanding and commitment to work within the agreed framework. Managers will need to meet with their staff for the Pay Progression/PADR discussions before the employees incremental dates. As such, it has been agreed (All Wales) that the role out of the policy to be undertaken in three stages: Band st April 2016 Bands 5 & 6 1 st October 2016 Remaining Bands 1 st April 2017 Page 8

50 9 Workforce & OD Update Report ESR data is currently being made available to managers so that they are able to schedule PADR meetings in line with employee s incremental dates. 4. Financial Impact: The paper has outlined initiatives (Pay Progression, Benefits Realisation of ESR, Electronic Rostering) to support the development of a productive and efficient workforce which will have a positive financial impact. 5. Quality, Equality, Safety and Patient Experience Impact. The four key outcomes of the Trust OD Strategy is: Values Driven culture; Excellent patient and donor experience; World class performance and productivity, and; Organisational flexibility and resilience. The interventions identified through the strategy will impact in these areas across the whole organisation. 6. Considerations for Board / Committee The Board is requested to NOTE the contents of the report and actions being taken. 7. Next Steps Work will continue as per agreed timescales for the different programmes of work. Page 9

51 PUBLIC TRUST BOARD MEETING UPHOLDING PROFESSIONAL STANDARDS Meeting Date: 17 th March 2016 Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Julie Stokes, Assistant Director of Workforce (Interim) Sarah Morley, Director of OD & Workforce Sarah Morley, Director of OD & Workforce None identified Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Board is asked to NOTE the contents of this paper. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well This report supports the following Health & Care Standards: Governance, Leadership and Accountability Safe Care Effective Care Staying Healthy Dignified Care Staff and Resources

52 2 Upholding Professional Standards 1. Introduction / Background: On 26 th August 2015 Welsh Government issued circular M&D (W) 3/2015, which advised Health Boards and Trust across Wales of the implementation of a new disciplinary procedure for medical and dental staff, Upholding Professional Standards in Wales. 2. Timing The Upholding Professional Standards in Wales procedure came into effect from the 1 st September Description: This procedure sets out the approach for addressing concerns about capability, performance and conduct for all practitioners (doctors and dentists) employed by Local Health Boards or other NHS organisations in Wales. It replaces all existing procedures in operation within the Local Health Boards and NHS Trusts in NHS Wales or successor bodies with effect from 1 September The new procedure replaces all previous disciplinary procedures enshrined in WHC (90)22 and DGM (95)44, as implemented by any NHS organisation or LHB policy document. The procedure also replaces the provisions in WHC (82)17 for Special Professional Panels (the Three Wise Men ) as implemented by NHS Wales organisations. The right of appeal to the Secretary of State, held by certain practitioners under paragraph 190 of their terms and conditions of service, is also abolished from the effective date of this procedure. The procedure applies to all practitioners, which covers all practitioners employed by Velindre NHS Trust including those in training and on temporary, locum or honorary contracts and comprises of five parts: (I) Action when a concern arises; (II) Restriction of practice and exclusion from work; (III) Handling concerns about a practitioner s health; (IV) The Standard Procedure; (V) Extended Procedure. The role of the Welsh Government (WG) in monitoring the effective implementation of this procedure will be coordinated through the Workforce and OD Division and any others as appropriate. Detailed arrangements for practical operation of this procedure will be notified to employers in NHS Wales directly by the Workforce and OD Division. Velindre NHS Trust will ensure that this procedure is operated in a way that does not discriminate on the grounds of any protected characteristic as defined in the Equality Act Financial Impact: To minimise both individual s time and financial expenditure on professional legal services, where possible, Velindre NHS Trust will seek to address capability and/or performance concerns through training or other local remedial action. It will continue to support practitioners in their professional development in particular, through appraisal, GMC/GDC guidance and other relevant local or Welsh Government processes. Page 2

53 3 Upholding Professional Standards 5. Quality, Equality, Safety and Patient Experience Impact. It is essential that the Trust addresses and if required investigates any concerns raised about the conduct of Trust employed practitioners or those that may hold an honorary contract with the Trust. The Trust, in their response to performance concerns, will ensure that due account is taken of the potential relevance of the practitioner s health, system failure and the working environment. The application of this procedure will be considered in conjunction with the relevant organisation s incident reporting or investigation systems. The fundamental aim of the procedure is to remove and or minimise any direct or indirect impact that the highlighted concern may have on the patient s experience, safety or the quality of care delivered. 6. Considerations for Board The Board is asked to note that as set out within the procedure there are a number of roles that are required to be undertaken by the Chairman and Independent members/nonexecutive Directors. When a formal investigation is initiated, the Chairman of the Velindre NHS Trust must nominate an Independent Member/non-executive Director as "the Designated Board Member" to oversee the operation of the procedure and to ensure that momentum is maintained. The Designated Board Member's responsibilities specifically include:- o Routinely monitoring the grounds for a practitioner s continued exclusion from work, having regard to the requirements of this procedure; o To consider representations from the practitioner about his or her exclusion and any inappropriate application of the procedure; o Preparing a report for the Board giving an account of progress where any exclusion has lasted more than six months. Where a practitioner chooses to register an appeal against a decision under the Standard Procedure the appeal panel will consist of three members. The members of the appeal panel must not have had any previous direct involvement in the matters that are the subject of the appeal. These members will be: o An Independent Member/non-executive Director of the employing organisation o A senior clinician/manager nominated by the LHB/Trust appropriate to the matter under consideration o A medically qualified member (or dentally qualified if appropriate) nominated by LNC and employed by the organisation (who may be a clinical academic) 7. Next Steps Velindre NHS Trust will seek to ensure that all those that are required to participate and undertake a role within this procedure will have been appropriately trained, including in particular those undertaking investigations and sitting on any relevant panels (which will include equality training). Training sessions are currently being scheduled and will be delivered by NWSSP Legal & Risk team. The National Clinical Assessment Service (NCAS) has a scheduled workshop titled Understanding and Using the Upholding Professional Standards in Wales Procedure on the 27 th April 2016.This workshop has been designed specifically for clinical and workforce leads who deal first hand with performance concerns using this new framework or are involved in supporting the process. Page 3

54 PUBLIC TRUST BOARD MEETING BUILDING EXCELLENCE ORGANISATIONAL DEVELOPMENT STRATEGY IMPLEMENTATION UPDATE Meeting Date: Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: 17 th March 2016 Sarah Patmore Senior OD Business Partner Sarah Morley Executive Director of OD & Workforce Sarah Morley Executive Director of OD & Workforce Presentation Update to Workforce and OD Committee Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: The Trust Board are asked to NOTE the progress outlined in this Recommendation: paper. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well This report supports the following Health & Care Standards: Governance, Leadership and Accountability Safe Care Effective Care Staying Healthy Dignified Care Staff and Resources

55 2 Building Excellence OD Strategy Implementation Update 1. Introduction / Background: Velindre NHS Trust approved the Building Excellence Organisational Development Strategy in December This paper provides an update as to the implementation progress made thus far, and outlines the plans for continued implementation over the coming months. 2. Timing Building Excellence constitutes a long term strategy to support Velindre NHS Trust in achieving its organisational ambitions. As such, implementation of the Strategy will commence in 2016, with communications, engagement, discussions, recommendations, and underpinning actions commencing in this first year, it is essential to underpin strategic implementation with a long term and sustainable approach. A project management approach will be used to support implementation in 2016, with the aim of creating sustainable conditions which can be continuously maintained and developed over the coming 3-5 years. 3. Description: Our Organisational Development (OD) Strategy, Building Excellence outlines how over the next 3-5 years the Trust will develop a culture that enables each of us to be great and achieve the delivery of ambitious and exciting service change plans. Through conversations with staff we know we need a values driven culture where world class services are delivered by a workforce that understands the difference it makes to the donor and patient experience. The Trust will deliver this through its resilience and flexibility, and a culture that encourages ambition and improvement and is agile and responsive to change. 4. Financial Impact: Backfill monies from the part-time secondment of the Senior OD Business Partner will be used to fund a fixed-term Project Manager post which will be responsible for ensuring the successful delivery of the Building Excellence OD Strategy projects to ensure they produce the required products, to the required standard of quality and within the specified constraints of time and cost. There will be necessary expenditure related to purchase of communications and engagement display and promotional items. The cost of these items is being confirmed, but it is expected that expenditure will be met from within the current Workforce budget. 5. Quality, Safety and Patient Experience Impact: With patient/donor care central to everything we do, the Trust, through its Integrated Medium Term Plan (IMTP) has articulated a future that involves significant change to the scope and expectations of service delivery. With change comes the opportunity to modernise and redesign services and the workforce, and further strengthen collaborative relationships with patients and stakeholder organisations. Through the application of the prudent healthcare principles across the Trust, moving forward we will continue to excel in the delivery of care and clinical services that are uniquely ours, while understanding how to use the skills of our staff and available resources most effectively to continue to improve. Building Excellence provides the building blocks to enable Velindre NHS Trust to deliver against this ambitious change agenda and through the delivery of transformed clinical services, improve the lives of the population it serves. Page 2

56 3 Building Excellence OD Strategy Implementation Update 6. Considerations for Board / Committee The Building Excellence Strategy makes the following implementation commitments: Progress made against these commitments thus far is as follows: Establishing a Project Approach: a. A Job Description for a Band 7 Project Manager has been through the necessary workforce processes and recruitment has commenced. Baseline for Outputs/Outcomes: b. A database of existing resources has been established to enable monitoring and measurement of strategy impact. This is a significant ongoing piece of work to enable the Trust to measure the impact of different interventions. Appendix 1 Identify a Strategic Lead for each Activity & Establish Topic Think Tanks: c. Terms of Reference to inform and guide the work of the OD Strategy Activities Topic Think Tanks have been created. These will be used to recruit Strategic Leads for each Think Tank. Appendix 2 Communications & Engagement Initiatives: d. We have received Welsh Language Commissioner approval of the Welsh translations of our organisational Values. Appendix 3 e. Publication of a comprehensive set of behaviours which support the organisational values. NB: all behaviours have been established using feedback from staff from across the Trust. Appendix 4 Page 3

57 4 Building Excellence OD Strategy Implementation Update f. Distribution of three Staff Newsletters, focussing on: i. Building Excellence Research results ii. Introduction of the approved Trust Values iii. Translating the Values into behaviours /sitesplus/972/page/66585 g. Establishing a staff communications and engagement plan, and obtaining procurement quotes for purchase of display and promotional materials. Appendix 5 h. Creation of bilingual poster design and desk pyramid Values display material. i. Creation of a dedicated Building Excellence account, intranet page and Twitter account which provides the opportunity to communicate, promote, inform and provide access to supporting resources. /sitesplus/972/page/66585 Building.Excellence@wales.nhs.uk /sitesplus/972/page/66585 j. Promoting the Trust Values at every New Staff Induction Welcome Day. /sitesplus/972/page/62645 k. Promoting the offer to speak to any team/meeting/group throughout the Trust to introduce the Values. Talks so far have included: i. Trust Leadership Development Programme ii. VCC Pharmacy iii. WBS Staff Forum, North Wales staff, WBT Training Team and Blood Collection Teams (via Spring 2016 Team Training Days) Page 4

58 5 Building Excellence OD Strategy Implementation Update 7. Next Steps Getting the ground work correct is important to ensure that implementation momentum is maintained. While the following actions are being planned over the coming months, the work is ongoing to ensure engagement and that the strategy has a profile across the Trust. Establishing a Project Approach: a. Appointment of the Band 7 Project Manager on a 9-12 month fixed term contract. b. Discussions with the WBS Working Better Together project lead to explore ways that the Building Excellence project can support long-term embedding of the WBT project principles. Baseline for Outputs/Outcomes: c. As reports are published (in line with the timescales outlined in 6b above) they will be collected and analysed to create a growing database of baseline ( ) data and comparison (2016 onwards) data. Identify a Strategic Lead for each Activity & Establish Topic Think Tanks: d. Gain commitment from identified Strategic Leads and support establishment of Topic Think Tanks using a project management approach coordinated by the fixed-term OD Project Manager post. Plan and Programme the Interventions: e. Continue to develop and implement initiatives in support of Building Excellence principles on an ongoing basis, for example the Velindre NHS Trust Leadership Development Programme. f. Embed use of the approved Values and behaviours through: i. Undertaking an audit of each Trust site to identify the type and quantity of Values-related display material required. ii. Making the Values core elements of revised PADR documentation and processes. iii. Linking the Values to IQT & Leadership Development programme Service Improvement projects. iv. Establish a Values-based Recruitment approach for the Trust, to include: Inclusion in standard Job Description & job advert wording. Creation of advice for Interview Panel members re questions about Values & Behaviours Revision of Interview and selection paperwork Communications & Engagement Initiatives: g. Establish a timetable of interactive, flexible and portable communication methodologies which travel between Trust sites on a regular basis, and link to a Senior Leadership Listening Tour. h. Continue to promote the Trust s Values and associated behaviours via face-to-face workshops embedded within team meetings and relevant training days. Annual Monitoring Report: i. Use the resources database (described in 6b above) and data collected (described in 7c above) to create an annual monitoring report each December. Page 5

59 6 Building Excellence OD Strategy Implementation Update Appendix 1 Baseline for Outputs and Outcomes The baseline assessment for the OD Strategy involves the measurement of the Outputs and Outcomes as described in the OD model outlined within the Building Excellence Strategy. The model describes outputs as areas that add measurable value to the organisation and are the result of effective processes, activities and OD interventions. Outcomes are the top level of our model, where the Trust seeks to measure the quality of our outputs and the resulting impact at organisational level from our inputs and activities. OUTPUTS Leadership & Management Capability Clear evidence of link between leadership and people management and patient outcomes. Existing Measurement & Monitoring Resources: 1. Governance & Accountability Board Member Self-Assessment Annual Legal Services & Governance Manager 2. Healthcare Standards Governance, Leadership and Annual Quality & Safety Team Accountability 3. In-house leadership and management training evaluation data Annual Workforce Team 4. Investors in People Reaccreditation Report Tri-Annual Workforce Team 5. Leadership & management training activity Quarterly Workforce Team 6. Staff Survey and Pulse Survey responses relating to Line Annual Workforce Team Management, Senior Management and Leadership 7. Trust Board Annual Effectiveness Self-Assessment Annual Legal Services & Governance Manager Proposed Additional Measurement & Monitoring Resources: a. 360 Appraisal Group Report Data Quality & Continuous Improvement Developing frontline staff to improve and create a culture that promotes innovation. Existing Measurement & Monitoring Resources: 1. Annual Claims Report Annual Legal Services & Governance Manager 2. Annual Complaints Report Annual Complaints Manager 3. Annual Quality Statement Annual Quality & Safety Team 4. Complaints & Claims Highlight report Quarterly Quality & Safety Team 5. Divisional Progress Reports Safe & Reliable Services Monthly Planning & Performance Team 6. Healthcare Standards Theme 2: Safe Care & Theme 3: Annual Quality & Safety Team Effective Care 7. Improving Quality Together Silver Project Database Quarterly Divisional Service Page 6

60 7 Building Excellence OD Strategy Implementation Update Improvement Teams 8. Improving Quality Together training activity Quarterly Workforce Team 9. Putting Things Right Data Capture Form Report Annual Complaints Manager Diversity & Inclusiveness Diverse teams increase ability to anticipate customer s needs with innovation and creativity. Existing Measurement & Monitoring Resources: 1. Corporate Health Standard Bi-Annual Workforce Team 2. Equality Monitoring Activity Report Annual Workforce Team 3. Equality Monitoring report Annual Workforce Team 4. Health Care Standards : 4.1 Dignified Care & 6.2 Peoples Rights Annual Quality & Safety Team 5. NHS Wales Communication and Sensory Loss Action Plan Annual Workforce Team 6. Quality and Safety Committee Equality Reports Monthly Workforce Team 7. Staff Survey & Pulse Survey results Annual Workforce Team 8. Stonewall Diversity Index Annual Workforce Team 9. Strategic Equality Objectives Annual Workforce Team 10. Welsh Language Scheme Annual Report Annual Communications Team Proposed Additional Measurement & Monitoring Resources: a. Working Longer Review Metrics Staff Engagement & Wellbeing High levels of engagement tend to have lower levels of patient mortality. Existing Measurement & Monitoring Resources: 1. Corporate Health Standard Bi-Annual Workforce Team 2. Divisional Progress Reports Quality Improvement Monthly Planning & Performance Team 3. Employee Assistance Programme & Occupational Health Service Quarterly Workforce Team Usage Report 4. Health & Wellbeing Framework Annual Report Annual Workforce Team 5. Healthcare Standards Standard 7.1: Workforce Annual Quality & Safety Team 6. Investors in People Reaccreditation Report Tri-Annual Workforce Team 7. PADR activity data Monthly Workforce Team 8. Sickness Absence data Monthly Workforce Team 9. Staff Survey & Pulse Survey Engagement Index Annual Workforce Team Proposed Additional Measurement & Monitoring Resources: a. Service Improvement Activity Report Collaborative & Partnership Working Strong collaborative partnerships go hand in hand with high performance. Existing Measurement & Monitoring Resources: 1. Corporate Progress Report Research & Development Monthly Planning & Performance Team 2. Minutes of Partnership Forum Meetings Monthly Workforce Team 3. Number of Trade Union Representatives Annual Workforce Team Page 7

61 8 Building Excellence OD Strategy Implementation Update 4. Register of Declarations of Interest Annual Legal Services & Governance Manager 5. Register of Gifts & Hospitality Annual Legal Services & Governance Manager 6. Report of Gifts, Hospitality and Declarations of Interest Bi-Monthly Legal Services & Governance Manager 7. Transforming Cancer Services Project Progress Reports TBC TCS Team 8. Trust Talk Newsletter Bi-Monthly Communications Team 9. Velindre NHS Trust Annual Report Annual Communications Team 10. WBS Progress Report Equitable & Timely Access to Services Monthly Planning & Performance Team OUTCOMES Values Driven Organisational Culture Populate your organisation with people who share your values and type of environment you want to create. Existing Measurement & Monitoring Resources: 1. Counter-fraud Progress Report Monthly Quality & Safety Committee 2. Investors in People Reaccreditation Report Tri-Annual Workforce Team 3. PADR activity data Monthly Workforce Team 4. Standards of Behaviour Policy Register of Declarations Annual Legal Services & Governance Manager 5. Use of the Raising Concerns (Whistleblowing) Policy Annual Legal Services & Governance Manager Proposed Additional Measurement & Monitoring Resources: a. Cultural Survey b. Values-based Recruitment Implementation Report Excellent Patient and Donor Experience It is the sum of all interactions, shaped by an organisation s culture, that influence patient/donor perceptions across a continuum of care. Existing Measurement & Monitoring Resources: 1. WBS Progress Reports TBC WBS TBC 2. Divisional Progress Reports First Class Patient/Donor Experience Monthly Planning & Performance Team 3. Healthcare Standards Theme 4: Dignified Care & Theme 6: Annual Quality & Safety Team Individual Care 4. VCC Patient Experience Plan Annual VCC Patient Experience Manager 5. VCC Patient Experience Report Monthly VCC Patient Experience Manager Page 8

62 9 Building Excellence OD Strategy Implementation Update World Class Performance & Delivery Those who built the best organisations were ambitious first for the cause of the company, for the work, not for themselves. Existing Measurement & Monitoring Resources: 1. Divisional Progress Reports Areas to Celebrate Monthly Planning & Performance Team 2. Divisional Progress Reports At A Glance Summary Table Monthly Planning & Performance Team Organisational Flexibility & Resilience Truly great companies always focus on what they can do next. The hidden secret is to realise that it is a constantly dynamic process. Existing Measurement & Monitoring Resources: 1. Building Excellence OD Strategy Annual Report Annual Workforce Team 2. Divisional Business Continuity Plans Annual Divisional Directors 3. Divisional Sustainability Plans Annual Divisional Directors 4. Prudent Healthcare Annual Report Annual TBC 5. Service Improvement Small Grants Scheme Report Annual Service Improvement Steering Group 6. Timetable of Board Development Sessions Bi-Annual Board Secretary 7. Wellbeing of Future Generations Act Annual Report Annual Board Secretary Proposed Additional Measurement & Monitoring Resources: a. Change Readiness Index b. Internal Talent Pipeline Usage Report Page 9

63 10 Building Excellence OD Strategy Implementation Update Appendix 2 Terms of Reference BUILDING EXCELLENCE OD STRATEGY COMMUNICATIONS TOPIC THINK TANK Name of Group: Building Excellence OD Strategy - Communications Topic Think Tank Summary of Role: To act as an expert reference group on the topic of Communications and generate ideas and recommendations for the Trust to implement which would positively impact communications for: i. all staff groups throughout the Trust, and ii. our external stakeholders. Remit: 1. To review internal and external good practice, academic research and industry-specific recommendations in order to ascertain what excellent internal and external communications means in practice. Example Sources: o o 85% of respondents to Straight Talking: the role of the business leader as communicator survey are keen to be kept informed of their employers plans for the organisations future. Employees receive 70% of information through informal channels, but employees who are kept informed are more likely to be motivated, engaged and deliver added value (CHA ). Wise leaders engage in communication with as many people as possible and display a high degree of commitment to communication...communication is critical to bringing dreams to life (The Wise Leader Harvard Business Review, 2011). 2. To clearly define what excellent communications looks like in relation to Velindre NHS Trust s internal and external communications needs. 3. To make recommendations to the Velindre NHS Trust Workforce Committee about initiatives which should be implemented which will have a positive impact on internal and external communications. 4. To write a brief final report (using a template) which outlines the Think Tank s recommendations. Reporting to: Communicates with: Monitoring of: Velindre NHS Trust Workforce Committee Internal and external experts and stakeholders as required TBC Sub Committees: None Page 10

64 11 Building Excellence OD Strategy Implementation Update Chaired by: TBC Membership: TBC Meeting Frequency: 6 meetings to take place by 30 th November 2016 Documentation Required/Submitted From: Documentation Building Excellence OD Strategy Research to Support the OD Strategy Submitted From Senior OD Business Partner Outputs (i.e. minutes of meeting submitted to other committee meetings) Contact: (secretary to meeting) 1. Action Log & Ideas Log submitted to Building Excellence Project Manager after each meeting 2. Final recommendations submitted to Senior OD Business Partner and Workforce Committee in time for submission at 6 th December 2016 meeting Date ToR Last Revised Next Review Date OD Project Manager February 2016 N/A Page 11

65 12 Building Excellence OD Strategy Implementation Update Appendix 3 Page 12

66 13 Building Excellence OD Strategy Implementation Update Appendix 4 TRANSLATING VELINDRE NHS TRUST S ORGANISATIONAL VALUES INTO BEHAVIOURS These four Values were approved in 2015 following analysis of significant feedback from staff who worked for all Divisions, professions and staff groups in the Trust. They describe the aspects of Velindre NHS Trust which we already have, and must respect and protect; and also what we must become in order to achieve our organisational ambitions in a modern NHS. Is it clear to you what each of these Values means in practice? To help us understand the reality of them in our day-to-day roles we ve worked with a wide range of staff from across the organisation to create this list of behaviours which clearly describe how we should...and shouldn t be behaving if we are to be true to our organisational Values. Being ACCOUNTABLE means... We will: 1. Complete all assigned tasks on time and with minimal supervision 2. Fulfil all commitments made to peers, co-workers, supervisors, and customers 3. Admit mistakes, misjudgements, or errors; immediately inform others when unable to meet a commitment 4. Take personal responsibility for seeing efforts through to completion and/or tough decisions, etc 5. Accept full responsibility for our contribution as a team member 6. Display honesty and truthfulness 7. Follow through and meet personal commitments to others on time 8. Take our responsibilities seriously and consistently 9. Present ourselves with professionalism and credibility 10. Express concern for doing things better and producing quality work 11. Acknowledge responsibility for failures and mistakes 12. Set and maintains high performance standards for self and others that support the Trust s strategic plan 13. Manage our time well in order to complete tasks on time and with high quality 14. Assume responsibility for results of own actions and their impact on the work group/department 15. Complete assignments without the need for prompting from our supervisor or others 16. Successfully complete most tasks independently but ask for additional support, as appropriate, when faced with unfamiliar tasks or situations It does not mean that we can: 1. Use our position to delay decisions 2. Ignore the contributions of colleagues 3. Disempower colleagues Page 13

67 14 Building Excellence OD Strategy Implementation Update We will: 1. Take calculated risks to achieve goals 2. Challenge ourselves and others to consistently improve and achieve stretch goals 3. Push forward with important initiatives in the face of uncertainty 4. Move ahead without always requiring a consensus 5. Make recommendations that challenge the status-quo 6. Step forward with a position of principle even when there is ambiguity regarding the facts 7. Give people the feedback they need even in difficult situations 8. Support others who take calculated risks to achieve Velindre NHS Trust goals Being BOLD means Take responsibility and stays focused on problems until an effective solution can be found 10. Make decisions through weighing up the cost-benefit and risk implications 11. Take decisions as necessary on the basis of the information available 12. Make decisions without unnecessarily referring to others 13. Involve and consult with internal and external stakeholders early in decisions that impact them 14. Identify potential barriers to decision making and initiates action to move a situation forward 15. Be aware of the Trust s decision making processes and how to use them 16. Propose options for solutions to presented problems 17. Demonstrate resilience against challenges and obstacles We will not: 1. Be impulsive or rash 2. Ignore the facts 3. Pass responsibility for decisions inappropriately to others 4. Make decisions without discussing them with those they will affect, or without clear rationale or consideration of their impact 5. Take an unimaginative or narrow approach to solving problems Page 14

68 15 Building Excellence OD Strategy Implementation Update We will: 1. Be dedicated to meeting the expectations and requirements of internal colleagues and external donors/patients 2. Take pride in delivering a high quality service 3. Treat all people, both colleagues and service users, with dignity and respect 4. Avoid making statements that may offend or hurt others Being CARING means Consistently communicate even the most difficult messages in a sensitive and supportive manner without compromising on the meaning of the message 6. Consider and respects different opinions, styles, and ways of working 7. Ask questions to identify the needs or expectations of others 8. Consider the impact on colleagues, donors and patients when carrying out our own job 9. Work to remove barriers that get in the way of providing a high quality service 10. Seek feedback from others to assess satisfaction with service being provided 11. Continuously monitor service delivery and act promptly to resolve any problems 12. Endeavour to respond to phone calls and s promptly; update voice messages and notification when we re going to be absent from the workplace for more than one half day, advising alternative contact where possible 13. Be punctual and fully prepared for meetings It does not mean we that we are allowed to: 1. Not deliver the task 2. Avoid difficult decisions Page 15

69 16 Building Excellence OD Strategy Implementation Update We will: 1. Be adaptable and able work effectively with a variety of situations, individuals and groups. 2. Demonstrate flexibility and agility, and not be unduly delayed or stopped by the unexpected 3. Open to new ideas and listen to other people s points of view 4. Demonstrate willingness to change our ideas or perceptions based on new information or contrary evidence 5. Remain focused on strategic priorities when faced with competing demands 6. Make pragmatic reasonable adjustments to ensure maximum effectiveness and motivation of ourselves and others 7. Change our overall plan, goal or project to fit the situation 8. Create and support dynamism by ensuring our processes and procedures don t block quick turnaround and flexibility Being DYNAMIC means Weigh up costs and benefits impartially 10. Think laterally, creatively and collaboratively to resolve problems 11. Be willing to investigate options in depth, even when they are the ideas of others 12. Adjust schedules, tasks, and priorities when necessary 13. Anticipate and change strategy before the current method proves to be ineffective 14. Proactively identify and take action to achieve standards of excellence 15. Look for ways to improve services, add value and contribute new ideas 16. Plan ahead for upcoming problems or opportunities and takes appropriate action 17. Recognise and act upon opportunities 18. Exhibit a strong sense of urgency about solving problems and accomplishing work 19. Respond flexibly to changing circumstances 20. Demonstrate openness to changing work priorities and deadlines 21. Use change as an opportunity to improve ways of working, encouraging others buy-in It does not mean that we can: 1. Ignore our colleagues views 2. Be unrealistic in our goals 3. Be unaware of the impact of change on others 4. Be resistant to change and trying new things 5. Rush change or change for change sake 6. Do it all ourselves Page 16

70 17 Building Excellence OD Strategy Implementation Update Appendix 5 Contents Organisational Development Strategy Communications and Engagement Plan 1 SITUATION ANALYSIS RATIONALE AIM AND OBJECTIVES APPROACH TO COMMUNICATIONS STAKEHOLDER GROUPS AND COMMUNICATIONS NEEDS SWOT ANALYSIS KEY MESSAGES KEY COMMUNICATIONS CHANNELS AND TOOLS ACTIVITY PLAN Page 17

71 18 Building Excellence OD Strategy Implementation Update 1 Situation Analysis 1.1 Rationale This communications plan has been developed to support the introduction of the Velindre NHS Trust Building Excellence Organisational Development Strategy, embed the Trust values within the organisation, and to enable a shared understanding of Strategy s key messages. 1.2 Aim and Objectives The initial aim is to incrementally launch and maintain awareness of the new Velindre NHS Trust values. The objectives are: To create clear and effective communications activities to increase awareness of the Organisational Development Strategy and new values; To illustrate how our staff are already living our values in the workplace; To influence the knowledge, attitudes and behaviours of our staff; To ensure stakeholders understand that a process of staff engagement has taken place to shape our values and wider Organisational Development Strategy. A longer term aim is to launch and maintain awareness of the Strategy s principles; and furthermore to promote engagement with developing practical activities to embed the Strategy within Velindre NHS Trust. 1.3 Approach to Communications Give every member of staff the opportunity to learn about the Strategy and Values; Be open about important messages that need communicating to our staff and other stakeholders; Engage with discussion and debate about the Strategy and Values; Offer staff the chance to feedback through a variety of methods; Be proactive in our approach and tell people information before we are asked for it. 1.4 Stakeholder Groups and Communications Needs Stakeholder group Trust Board Members / Senior Managers Communications Needs regular detailed information support input to OD Strategy development/implementation Staff awareness information support enabling feedback Trade union representatives awareness enabling feedback Patients, families and awareness Page 18

72 19 Building Excellence OD Strategy Implementation Update carers Stakeholder group Communications Needs Welsh Government awareness information Media information on request 1.5 SWOT Analysis Strengths Helpful to achieving the project s aim Widespread staff involvement in developing values and behaviours Staff desire to deliver excellent services Good reputation of the Trust/divisions Sponsorship of senior leaders 2016 NHS Wales Staff Survey Weaknesses Harmful to achieving the project s aim Small communications team Competing priorities / workload of staff Divisional differences Poor Intranets Some staff without regular Intranet/ access Opportunities More joined-up approach to working throughout the Trust Better communication amongst staff Values-based recruitment Staff Recognition Award project Better engagement within the Trust Implementation of the NHS Wales Pay Progression Policy Threats Cynicism from staff Perceived waste of money/time Negative attitude towards Trust and divisions 1.5 Key Messages The Building Excellence Strategy will guide how we work and develop together as a Trust; Staff input has shaped the new organisational values; Considering the new values in all the work we do will enhance the professionalism and consistency of the care and services we provide to donors and patients; We welcome and listen to stakeholder feedback. Page 19

73 20 Building Excellence OD Strategy Implementation Update 1.6 Key Communications Channels and Tools Stakeholder group Key channels Key tools Trust Board members / Senior managers Trust Board meetings Executive Management Board meetings Intranet Verbal updates Written updates Posters OD Strategy Newsletter TrustTalk Newsletter Staff Information cascade / Briefings Intranet Engagement events Social Media Project updates Posters OD Strategy Newsletter TrustTalk Newsletter Promotional Materials Verbal discussion Welsh Government Meetings with CEO / Chair Social Media Trade union representatives Partnership Meetings Patients, families and carers Awareness raising Social Media Verbal updates Sharing OD Strategy newsletter Sharing OD Strategy Newsletter Meeting papers Verbal updates Posters Info screen updates Media Phone Press enquiry responses Page 20

74 21 Building Excellence OD Strategy Implementation Update 2 Activity Plan To implement the communications plan, the following actions need to be taken: Action By When By Whom Progress Establish Intranet page December 2015 SP / JHM December 2015 page published Building Excellence dedicated address set up bulletins December 2015 Ongoing Comms Team / SP November address established Building Excellence Newsletter (already published in September, December) February April June Comms Team / SP / HW December 2015 theme of February newsletter confirmed as The Principles TrustTalk newsletter articles (already included in Oct and Dec 2015 editions) February April June Comms Team / SP December 2015 theme of February article confirmed as The Principles Large Poster Boards for meeting rooms / staff areas February 2015 Comms team / MH / SP December Poster design approved & printing options being sought Social media (adopt redundant Trust TED Twitter account to post Building Excellence and Ed & Dev material for staff) Jan 2015 SP / JHM / Comms Team December 2015 Twitter account reactivated Verbal Team Briefings (offer made to all departments within the Trust) Ongoing SP / HW / RP / KE December sessions undertaken, offer to be reiterated throughout organisation Interactive promotional Materials -Big Letters -Desk pyramids March 2015 SP / MH / Comms Team December 2015 Letter quote obtained & verbally approved. Space to paint the letters in BE branding being sought. Pyramid quote obtained and forwarded - awaiting discussion/approval Board Staff Engagement Sessions (Listening Tour) - Proposal to Feb 2016 Trust Board - First session by April 2016 Ongoing timetable for 2016/17 SP / HW / SM Board Report on OD Model Activities Ongoing SP / HW Page 21

75 PUBLIC TRUST BOARD MEETING HIGHLIGHT REPORT FROM THE CHAIR OF THE PLANNING & PERFORMANCE COMMITTEE Meeting Date: 17 th March 2016 Author: William Oliver, Associate Director of Planning and Performance Sponsoring Executive Director: Carl James, Director of Planning, Performance & Estates Report Presented by: Mr Phil Roberts, Independent Member and Chair of the Planning & Performance Committee Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Board is asked to NOTE the report from the Planning and Performance Committee held on 25th February 2016 This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well This report supports the following Health & Care Standards: Governance, Leadership and Accountability Safe Care Effective Care Staying Healthy Dignified Care Staff and Resources Individual Care Timely Care

76 2 Highlight Report Planning & Performance Committee 1. INTRODUCTION / BACKGROUND: 1.1. This paper has been prepared to provide the Board with details of the key issues considered by the Planning & Performance Committee at its meeting on the 25 th February TIMING 2.1. The Planning & Performance Committee met on 25 th February 2016 as part of its normal cycle of meetings. 3. CONSIDERATIONS FOR BOARD / COMMITTEE 3.1. At the meeting, the Committee considered issues and can provide assurance to the Board on the issues delegated to them through the Trust Standing Orders relating to the following key items; 3.2. CONSIDERATION OF EXTERNAL/INDEPENDENT REPORTS/REVIEWS No external / independent reports or reviews were considered by the committee at this meeting CONSIDERATION OF INTERNAL CONTROL ISSUES Platelet Strategy update - an update of the timeline was provided. This was noted by the committee having been endorsed at a previous meeting Radiotherapy Strategy update - Radiotherapy capacity issues were discussed and it was requested that a presentation providing additional detail on progress to date be given to the next committee meeting Malthus update a presentation was provided to the committee on the modelling work undertaken using Malthus to review Radiotherapy demand and projected requirements. This was noted by the committee DSU action plan it was reported that further meetings have been held and actions are ongoing. It was agreed that an update be provided as part of at the next committee meeting WBS All Wales Laboratory Information Management System (LIMS) programme update an update was provided to the committee highlighting progress and key risks. These were noted as ongoing resource availability and unknown final go live timescales. These risks were being mitigated via communication with NWIS. This was noted by the committee Performance report - Radiotherapy and Chemotherapy were noted as areas with capacity pressures. The performance report (content and format) were discussed and it was agreed that the committee needed to focus on measures and areas that had not seen improvement in performance. Both areas are to be reported upon and discussed in detail at the next committee meeting. The Committee discussed the measure in the report for new bone marrow donors, as the target has not been met for 12 months. It was agreed that a narrative would be included in the report to provide clarity on performance, as there has been a change in policy which has had an impact on new donor numbers. Page 2

77 3 Highlight Report Planning & Performance Committee It was agreed that a Project Initiation Document (PID) will be developed and considered by the Trust planning group, setting out new proposals for the performance reports including timescales for their development along with a review of the performance management framework across the Trust. It was agreed that measures included in the performance report must align with the risk register. Feedback on the performance report from a recent meeting with the Cardiff and Vale Community Health Council was given to the committee. This had noted the potential to more positively, comprehensively and clearly tell the story of Velindre NHS Trust and both divisions Performance benchmarking - A presentation was received by the committee setting out the proposed approach for benchmarking. It was reported that a project plan is being developed for this and for the agreement of the specification of benchmarking data (initially for Velindre Cancer Centre). The committee supported this approach Blood Health Strategy - a presentation on the proposed Blood Health Strategy was received by the committee. It was noted by the committee and agreed that this would be taken forward by the Welsh Blood Service (WBS) ITEMS ENDORSED BY COMMITTEE FOR FURTHER CONSIDERATION BY FULL BOARD The latest draft version of the Integrated Medium Term Plan (IMTP) including updates and amendments made was noted and endorsed by the committee TRUST RISK REGISTER The committee discussed the current car parking situation at the Velindre Cancer Centre. This risk was noted as multi-factorial in nature and it was agreed for Executive Directors and the Director of the Cancer Centre to discuss this outside the meeting to ensure measures are in place to mitigate / avoid potential accidents or legal issues The committee agreed that a risk should be added to the register regarding the financial uplift assumption of 4.5% ( 1.356m) within the IMTP and the risk to delivery if this is not granted OTHER ISSUES FOR BOARD CONSIDERATION None 3.7. OTHER ISSUES FOR THE BOARD TO NOTE FOR INFORMATION Linked to the above risk, the committee asked what the potential options were if financial uplift is not received. It was noted that work is in progress to assess implication of not receiving the uplift requirement. 4. NEXT STEPS 4.1. The Trust Board is requested to NOTE the contents of the report and actions being taken. Page 3

78 PUBLIC TRUST BOARD MEETING HIGHLIGHT REPORT FROM THE CHAIR OF THE TRANSFORMING CANCER SERVICES IN SOUTH EAST WALES PROGRAMME MANAGEMENT COMMITTEE Meeting Date: 17 th March 2016 Author: Phil Hodson, Assistant Director of Planning and Performance / Interim TCS Programme Manager Sponsoring Executive Director: Carl James, Director of Planning, Performance & Estates / TCS Programme Director Report Presented by: Paul Griffiths, Independent Member, Velindre Committee/Group who have received or considered this paper Trust Resolution to: (please tick) NHS Trust Transforming Cancer Services in South East Wales Programme Management Committee Approve: Endorse: Discuss: Note: Recommendation: To NOTE the contents of the report and to APPROVE the development of a Velindre NHS Trust Cancer Strategy (Agenda item 6.6). This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well This report supports the following Health & Care Standards: Governance, Leadership and Accountability Safe Care Effective Care Staying Healthy Dignified Care Staff and Resources Individual Care Timely Care

79 2 Highlight Report TCS Programme Management Committee 1. INTRODUCTION / BACKGROUND: This paper had been prepared to provide the Board with details of the key issues considered by the Transforming Cancer Services Programme Management Committee (PMC) at its meeting on the 24 th February TIMING The Transforming Cancer Services Committee met on the 24 th February 2016 as part of its normal cycle of meetings. 3. CONSIDERATIONS FOR BOARD / COMMITTEE At the meeting, the Committee considered issues and can provide assurance to the Board on the issues delegated to them through the Trust Standing Orders relating to the following key items; I. CONSIDERATION OF EXTERNAL/INDEPENDENT REPORTS/REVIEWS None. II. CONSIDERATION OF INTERNAL CONTROL ISSUES None. III. ITEMS ENDORSED BY COMMITTEE FOR FURTHER CONSIDERATION BY FULL BOARD The Trust Board are asked to approve the development of a Velindre NHS Trust Cancer Strategy (attached). IV. TRUST RISK REGISTER The Transforming Cancer Services Programme Risk Register was discussed with a number of risks considered at length. The Committee were informed that the following risks had been closed since the last PMC meeting. Ref TCS- 05 CLOSED TCS- 06 REDUCED to Risk Score 6 Risk Delay in providing temporary office accommodation for the Core Leadership Team: Temporary office accommodation now provided. Delay in providing permanent office accommodation for the Core Leadership Team: Planning permission secured and an agreed handover date of the 31 st March Page 2

80 3 Highlight Report TCS Programme Management Committee The Committee were informed that the following risks remained critical on the Programme Risk Register since the last PMC meeting. Ref TCS-07 INCREASED to Risk Score 20 TCS-09 INCREASED to Risk Score 15 P03-24 INCREASED to Risk Score 16 TCS-25 INCREASED to Risk Score 20 TCS-2 INCREASED to Risk Score Risk Inability to recruit specialist financial advisors within required timeframes. The delay in appointing specialist finance advisors presents a risk to the development of the Business Cases which support the Programme. Trust Response: The Programme Director has written to the Welsh Government setting out the Trusts concerns and the potential Programme delays that this may cause. Delay in completing the healthcare planning phase of the clinical model development. The delay in completing this phase of the work presents a risk to the development of the Business Cases which support the Programme. Trust Response: The Trust met with its technical advisory team met on the 27 th February and agreed a process and Programme for completing the healthcare planning work. Deadlines for submitting the PBC and OBC are not achieved. Trust yet to receive confirmed dates from Welsh Government for the publication of a Project Agreement. Trust Response: The Programme Director has written to the Welsh Government setting out the Trusts concerns and the potential programme delays that this may cause. Delay to overall Programme. Caused by: o A delay in the Trust receiving confirmed dates from Welsh Government for the publication of a Project Agreement. o A delay in Welsh Government appointing specialist finance advisors to support the Programme. o A delay in completing the healthcare planning phase of the clinical model development. Trust Response: The Programme Director has written to the Welsh Government setting out the Trusts concerns and the potential programme delays that this may cause. In parallel the Trust met with its technical advisory team met on the 26 th February to re-profile the Programme in light of the delays and assumed timescales for resolution of these delays. Finally, the Trust met with its technical advisory team met on the 27 th February and agreed a process and Programme for completing the healthcare planning work. Delay to Infrastructure Project. Caused by: o A delay in the Trust receiving confirmed dates from Welsh Page 3

81 4 Highlight Report TCS Programme Management Committee 20 Government for the publication of a Project Agreement. o A delay in Welsh Government appointing specialist finance advisors to support the Programme. o A delay in completing the healthcare planning phase of the clinical model development. Trust Response: The Programme Director has written to the Welsh Government setting out the Trusts concerns and the potential programme delays that this may cause. In parallel the Trust met with its technical advisory team met on the 26 th February to re-profile the Programme in light of the delays and assumed timescales for resolution of these delays. Finally, the Trust met with its technical advisory team met on the 27 th February and agreed a process and Programme for completing the healthcare planning work. Following the meeting of the Committee it was agreed that the above risks should be escalated to the Trust Risk Register. V. OTHER ISSUES FOR BOARD CONSIDERATION None. VI. OTHER ISSUES FOR THE BOARD TO NOTE FOR INFORMATION The Board is asked to note the following information. a. Review of Terms of Reference of the TCS Programme Clinical Reference Group: The committee received a progress report and a list of clinical recommendations from TCS Programme Clinical Reference Group. The committee noted the report and recommendations but requested that there be an independent clinical review of these recommendations. Dr. Crosby agreed to issue draft terms of reference and a proposed membership for an independent Clinical Reference Group at the next meeting of the committee. b. Programme Level Planning Assumptions: The committee received a report which identified the current planning assumptions for the TCS Programme. It was agreed that this report would be refined for the next committee meeting with a view to submitting for approval at a future Trust Board meeting. c. Recruitment Update: The committee received verbal confirmation that the Trust had been successful in recruiting to the post of Programme Manager. The planned start date for the Programme Manager is the 9 th May Phil Hodson will continue to act as Programme Manager on an interim basis. d. Programme Budget Update: The committee received a financial report which provided assurance that the Programme remained within budget. 4. NEXT STEPS The Trust Board is requested to NOTE the contents of the report and actions being taken and to APPROVE the development of a Velindre NHS Trust Cancer Strategy included at agenda item 6.6. Page 4

82 PUBLIC TRUST BOARD MEETING FINANCIAL REPORT MONTH 10 JANUARY 2016 Meeting Date: 17 th March 2016 Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Trust Resolution to: (please tick) Tony Virgo, Deputy Director of Finance Mark Osland, Interim Executive Director of Finance Mark Osland, Interim Executive Director of Finance Planning and Performance Committee Executive Management Board Approve: Endorse: Discuss: Note: Recommendation: The Trust Board are asked to DISCUSS and NOTE the January Finance Report This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well This report supports the following Health & Care Standards: Governance, Leadership and Accountability Safe Care Effective Care Staying Healthy Dignified Care Staff and Resources Individual Care Timely Care Page 1

83 VELINDRE NHS TRUST FINANCE REPORT MONTH 10 - JANUARY 2016 CONTENTS 1. Executive Summary 2. Divisional Performance 3. Summary of Hosted Organisations 4. Appendix 1 Summarised Financial Statement 5. Appendix 2 Summary of Budget Movements 6. Appendix 3 Performance Against Savings Plans 7. Appendix 4 Summary of Capital Programmes 1