Trust Board. Present:

Transcription

1 Trust Board Minutes of a meeting of the Board of Directors held at 9.30 am on Wednesday 28 th March 2018, in Room 3, Education Centre, Queen Elizabeth Hospital Present: Mrs JEA Hickey Chairman Mr A Beeby Medical Director Dr R Bonnington Non-Executive Director Mr S Bowron Non-Executive Director (Vice Chairman) Mrs C Coyne Director of Diagnostic and Screening Services Cllr M Gannon Non-Executive Director Mr P Hopkinson Non-Executive Director Mrs K Larkin-Bramley Non-Executive Director Ms A Lowery Deputy Director of Nursing, Midwifery and Quality Dr H Lloyd Director of Nursing, Midwifery and Quality Mrs N Kenny Associate Director Medicine Mr J Maddison Group Director of Finance and Informatics Mr ID Renwick Chief Executive Mr J Robinson Non-Executive Director Mr D Shilton Non-Executive Director Mrs S Watson Director of Strategy and Transformation In Attendance: Mrs D Atkinson Trust Secretary Mrs J Bilcliff Operational Director of Finance Mr M Laing Associate Director Community Services Mr N McDonaugh Associate Director Surgery Mrs J Williamson Membership Co-ordinator Presentation: Mrs S Burn Technical Instructor (for item 18/37) Mrs C Gilchrist Community Stroke Nurse (for item 18/37) Mr M Oxley Patient (for item 18/37) Mrs S Robinson Clinical Operations Manager (for item 18/37) Governors and Members of the Public: Mr R Brammer Public Governor Mr S Connolly Public Governor Mrs C Coulson Public Governor Reverend J Gill Public Governor Mrs G Henderson Public Governor Mr M Loome Public Governor Mrs J Todd Public Governor Ms T Lake Deputy Chief Finance Officer, NHS Sunderland CCG 2 x Members of the Public Apologies: Page 1 of 20

2 Agenda Discussion and Action Points Item 18/34 CHAIRMAN S BUSINESS: Action By Mrs JEA Hickey, Chairman, welcomed the Trust Governors to the meeting. She also welcomed Ms T Lake, Deputy Chief Finance Officer, NHS Sunderland CCG and two members of the public to the meeting. Mrs Hickey requested that Board members present report any revisions to their declared interests or any declaration of interest in the items on the agenda. She informed the meeting that prior to the Board meeting, Board members received a presentation to allow consideration of the Board s Self Assessments against the CQC Well Led Assessment process. She stated that overall the prompts were rated as either amber or green but that further evidence was being gathered, and stated that the final assessment will be brought to a future Board meeting once complete with an action plan. 18/35 MINUTES OF THE PREVIOUS MEETING: The minutes of the Board of Directors Meeting held on Wednesday 31 st January 2018 were approved as a correct record. 18/36 MATTERS ARISING FROM THE MINUTES: The Board Action Plan was updated accordingly to reflect matters arising from the minutes. 18/37 PATIENT S STORY Page 2 of 20 Mr M Laing, Associate Director Community Services, welcomed Mr M Oxley, patient, to the meeting. He also welcomed from the Community Stroke Team Mrs S Robinson, Clinical Operations Manager, Mrs C Gilchrist, Community Stroke Nurse, and Mrs S Burn, Technical Instructor. He informed the Board that the staff are members of the home team which includes nurses and therapists working together around the needs of the individual, and providing care for people closer to home. Mrs Gilchrist began the presentation by giving an overview of the Community Stroke Rehabilitation Team. She explained that

3 Agenda Item Page 3 of 20 Discussion and Action Points patients who are diagnosed with a stroke are contacted by the team within 24 hours to provide rehabilitation and advice to patients in their home environment. The team provide equipment as needed, therapy and set joint patient goals whilst facilitating safe and timely discharges from hospital. The team also review patients six months post-stroke. She explained that the Multidisciplinary Team has received 529 referrals since April 2017, either as inpatient referrals from the Stroke Unit at the QE or Ward 41 at the RVI, or through GPs, selfreferrals and out-patients. Mrs Gilchrist the significance of stroke as a health issue and gave a summary of the common signs and symptoms of a stroke. Mrs Gilchrist introduced Mr Oxley, and summarised his hospital stays at the RVI and then in Ward 4 here at the QE. Mr M Oxley, patient, gave an overview of his story. He reported that he woke up one morning and was unable to get out of bed. He stated that he was well looked after by the team on the ward but he found it very difficult to relax and focus on being discharged home. He also stated that it was difficult for him to understand what had happened. Mr Oxley commented that he managed to get into a wheelchair to initially enable him to move around, he was then moved into a frame and then to a tripod to mobilise. He added that the relevant aids have been installed in his home which has gave him everything that he needed to progress. He stated that he is now able to walk without a stick but he carries it with him for reassurance. Mr Oxley stated that the care he received in the hospital was spot on. However, it was not the best place to recover as he could not get any quiet time on the ward as there was a constant stream of things happening and people around. He also stated that there was no segregation of people age wise and some patients would be asleep during the day and therefore awake at night. Mrs JEA Hickey, Chairman, thanked Mr Oxley for sharing his journey. She stated that it is interesting to hear a patient s experience. She added that although a quiet room for patients cannot be promised, she understands the challenges involved. Mrs Hickey thanked Mr Oxley for his kind comments regarding the Action By

4 Agenda Item Discussion and Action Points nursing and care teams on the ward and in the community. Mr ID Renwick, Chief Executive, thanked Mr Oxley for attending the meeting and showing his inspirational determination following his stroke. He asked if Mr Oxley had received any psychological support to enable him to come to terms with his stroke. Mr Oxley stated that this has been mentioned but he is not sure if he would like to go down that road. He stated that this obviously affects different people in different ways and he feels more emotional now. He was very active before his stroke. Mrs JEA Hickey, Chairman, thanked Mrs Gilchrist and Mrs Burn for their presentation and Mr Oxley for sharing his experience. Action By 18/38 GUARDIAN OF SAFE WORKING REPORT: Dr J Hogg, Consultant Care of the Elderly and Guardian of Safe Working, presented her update report to the Board pertaining to the Junior Doctors contract. She drew attention to the paper, agenda item 7, which gave a routine update incorporating an annual overview. Dr Hogg reminded the Board that the contract came into force in December 2016 along with rules on the tighter limits on junior doctors hours and protection of educational opportunities. She reported that there has been one exception report outside of foundation programme and no exception reports from registrars. Dr Hogg stated that she is pleased with the submission times and these have improved significantly recently. The response times from clinical supervisors however, have not improved with a total of 32 exceptions not cleared by the end of two week period. She reported that there are currently 160 doctors in training, with the majority (64) SpR grade. She added that the Foundation Doctors total one third of the overall total, but are responsible for over 90% of exception reports. Dr Hogg reported that the number of fines has increased and this has reflected in some of the commentary from clinical supervisors. She added that it can be difficult to give Time Off In Lieu (TOIL) because of work pressures. Page 4 of 20

5 Agenda Item Discussion and Action Points She reported that following discussion at the Regional Guardians Meeting, it was agreed to create an annual report. However, for this year only it will include the extra time period (07/12/2016 to 31/12/2016) to allow the reports to align to the year end. Dr Hogg stated that exception reports made by F1 doctors who have been on contract for the full time period totalled 111. The remaining nine are from F2 doctors. She drew attention to the charts included in the paper, agenda item 7, which showed the number of F1 exception reports by speciality. She added that initially it was thought that exception reports would be made around on-call, however they are predominantly about ward pressures. Dr Hogg reported that fines for the time period show that the majority of fines are being paid by the Medical Business Unit. She reported that the summary and an audit of all reports has been carried out and the reasons analysed. She added that rich information has been gained from the free text box in the reporting system. Dr Hogg stated that for the exception reports from the bulk of F1 doctors, the volume of work was the biggest reason with low staffing stated as a separate reason. She added that winter pressures on Ward 8 were also cited with the volume of work having increased two-fold. She highlighted that there were no patient safety concerns raised and suggestions have been raised as to how work can be distributed differently. For example, is there room to be a bit more fluid around Christmas time for surgical juniors instead of medicine juniors. Mr ID Renwick, Chief Executive, noted that although the table shows total number of exceptions for the year, he queried if it had been found that they are evenly distributed throughout the year. He also queried if the exceptions are generally evenly spread or are there specific individuals who are raising the exceptions. Dr J Hogg stated that although the jobs are tracked, it is the individual who is the exception reporter. She reported that improvements have been made in gastro and the main reason is due to the introduction of the prescribing pharmacists. This has massively reduced pressure on the junior doctors. Action By Page 5 of 20

6 Agenda Item Discussion and Action Points Mr Renwick stated that this is a factual report that the Board can take assurance from but asked how the business units process the information. He stated that things can be readjusted where exception reports are being made, but the Board would look for assurance that the exception reports are making positive changes. Mr A Beeby, Medical Director, reported that the introduction of the Medical Workforce Group will bring together clinicians and managers across the Trust rather than just by individual business unit. Mr J Maddison, Group Director of Finance and Informatics, queried if any comparative analysis was available in relation to the consistency of themes of other Trusts. Dr J Hogg stated that she has taken the information to the Guardians Forum, however similar information was not shared by other Trusts. Mr J Maddison, Group Director of Finance and Informatics, asked if other Trusts anonymised data could be used. Dr J Hogg stated that there is information available through the HEE-NE Guardian. She hoped that information sharing would improve over time. Mrs N Kenny, Associate Director Medicine, reported that she is aware of issues and is currently looking at the actions. Cllr M Gannon, Non-Executive Director, left the meeting. Mrs JEA Hickey, Chairman, queried the continuing discrepancy between the Trust s data and what HEE-NE are reporting in relation to staff numbers. She asked if this was being followed up. Mr A Beeby, Medical Director, stated that this is a piece of work currently being led by Dr F Ahmad, Associate Medical Director for Postgraduate Medical Education, to confirm the numbers and positions they are in. Mrs JEA Hickey, Chairman, asked for assurance that the open cardiology exception reports are being looked into. Dr J Hogg stated that these exceptions are now greater than 60 days old. She has raised the issues with the trainee and has attempted to close the exception. She added that generally the supervisor should be having the conversation with the trainee. Action By Page 6 of 20

7 Agenda Item After further discussion, it was: Discussion and Action Points RESOLVED: to receive the report for assurance Action By 18/39 PERFORMANCE REPORT: Page 7 of 20 Mrs S Watson, Director of Strategy and Transformation, provided an update on the performance against national and local targets, giving assurance about the Trust s performance in the light of national requirements and local changes. She drew attention to the paper, agenda item 9, and stated that the Trust is experiencing ongoing difficulty in delivering the A&E targets. She added that the report was discussed in detail at the Finance and Performance Committee meeting the previous day. Mrs Watson reported that the Trust will not meet the A&E standards for March 2018 or the year as a whole, however the organisation is nonetheless one of the best performers in the country. She added that during the year, the Trust has rarely dropped below 20 th in the country and this will be taken into context to recognise the pressure the team has been experiencing. She added that the Trust s comparative performance had secured the Q3 STF payment and there were indications that a similar approach would be taken for Q4. Mrs Watson reported that action plan progress has been made in relation to the delivery of the mental health standards, but the Trust is not yet in a position to meet this national standard and teams are working to understand this in more detail. The action plan will be reviewed and redrafted to accommodate the discussions. She commented that the number of black breaches for ambulance waits has experienced a surge in the last quarter. This will be monitored by the Serious Incidents Panel. Black breaches reviewed to date have not identified any instances of patient harm. Mrs Watson concluded her report by stating that the workforce metrics in the report are disappointing, however a rise is sickness rates is always experienced at this time of year. This will continue to be monitored, along with the training and appraisal compliance. Mrs JEA Hickey, Chairman, commented that the report shows a lot of positive performance and the Trust continues to perform well in the referral to treatment (RTT) and cancer standards.

8 Agenda Item Discussion and Action Points Mr S Bowron, Non-Executive Director, stated that further endorsement from the Finance and Performance Committee regarding the A&E performance is that although the Trust has not met the standard, it is still overall a very worthy performance. Following further discussion, it was: RESOLVED: to receive the report as assurance against the management of governance indicators in the Single Oversight Framework and local supporting measures of performance management Action By 18/40 NURSE STAFFING EXCEPTION REPORT: Dr H Lloyd, Director of Nursing, Midwifery and Quality, provided assurance to the Board that staffing establishments are being met on a shift-by-shift basis. The report included details of the number of actual staff on duty, compared with the planned staffing level, the reason for any gaps and the actions being taken to address these gaps. The report provides information for January and February She reported that overall the report is positive, with improvements being seen on previous months. Dr Lloyd stated that it is important to note the prolonged pressure in the organisation and the impact this has on staffing levels. The escalation areas have increased in number and have been open longer than originally anticipated. She added that staff have been amazing, particularly over the snow period. She stated that the Trust has been able to maintain good levels of staffing, showing a stable compliance with staffing levels. However, on some days it has been challenging and Ward 4 is currently a concern. The matron is working with the team to produce an action plan going forward. Dr Lloyd concluded her report by stating that the increasing number of patients in January and February has seen a reduction in the number of care hours per patient per day. However, the report provides good assurance and she thanked staff for their exceptional work. Mr D Shilton, Non-Executive Director, asked if non-ward based nurses are included in the overall figures. Page 8 of 20

9 Agenda Item Discussion and Action Points Dr H Lloyd, Director of Nursing, Midwifery and Quality, stated that they are where they are allocated shifts on a planned programme. The only cover that cannot be captured is if non-ward based nurses help out during unexpected busy periods. After further discussion, it was: RESOLVED: to receive the report for assurance Action By 18/41 HEALTHCARE ASSOCIATED INFECTIONS: Dr H Lloyd, Director of Nursing, Midwifery and Quality and Joint Director of Infection, Prevention and Control (DIPC), updated the Board on the current performance of HCAI in the Trust throughout 2017/18. She informed the Board that the Trust continues to perform well against the indicators, with the Trust now having been MRSA free for 761 days. She stated that the Trust has reported 28 post 72-hour CDI cases to date, with five cases having been successfully upheld at appeal to date. The Trust has also reported 40 cases to date against its annual pre-community 72-hour benchmark, which demonstrates a 29% improvement against the previous year and a 34% improvement against the benchmark. Dr Lloyd informed the Board that NHS Improvement has published all 2018/19 CDI objectives with the challenging objective for the Trust reduced by one case to 18 post 72-hour cases from 1 st April She stated this will also change in 2019/20 to post 48-hour not post 72-hour, which will make achieving the trajectory more challenging. She reported that the Trust continues to report one of the lowest post 48-hour MSSA in the region. Gram negative blood stream infections also continue to report low. Dr Lloyd concluded her update by informing the Board that the Trust has seen a significant 469% increase of identified positive flu cases. Mr J Robinson, Non-Executive Director, commented on the increase in flu cases relating to patients. He queried if any additional work is being carried out with staff who have experienced flu from treating people with flu, especially if they have not had the flu vaccination. Page 9 of 20

10 Agenda Item Discussion and Action Points Dr H Lloyd stated that she could investigate this with Mrs S Watson, Director of Strategy and Transformation. Mr Robinson added that it is important that the Trust knows to what extent staffing levels were reduced due to contracting flu and whether they had the vaccine or not. Mrs JEA Hickey, Chairman, stated that although patients can be formally confirmed as having flu, it is more difficult with staff as it is not always known if it is a confirmed flu. Mrs S Watson, Director of Strategy and Transformation, commented that this can be looked into and the data can be interpreted, but it may lack the detail needed to confirm. Dr R Bonnington, Non-Executive Director, asked if the Trust has changed the way in which patients are tested for flu. Mrs C Coyne, Director of Diagnostic and Screening Services, responded that the tests are different as the result is available within an hour, and this has therefore increased the number of people who have been swabbed. This has helped with patient flow and resulted in less beds being closed. After further discussion, it was: RESOLVED: to receive the report for assurance Action By 18/42 QUALITY AND SAFETY REPORT: Page 10 of 20 i) Quality Dashboard Dr H Lloyd, Director of Nursing, Midwifery and Quality, provided the Board with information on the Trust s Quality and Safety Performance for February She stated that it is pleasing to see the increase in incident reporting throughout the Trust. Dr Lloyd reported that patient experience on the whole remains very good and very static. There has been an increase in the number of needle stick injuries, but all other areas remain stable. Mrs C Coyne, Director of Diagnostic and Screening Services, confirmed that the increase in needle stick injuries has been traced to a specific department. She added that a confidential waste sack had been put in the wrong bin and

11 Agenda Item Discussion and Action Points the sharps had been put in. New bins have been bought to address and resolve this issue. After further discussion, it was: RESOLVED: to receive the report for assurance Action By ii) Quality and Safety Update Medicines Management Dr H Lloyd, Director of Nursing, Midwifery and Quality, provided the Board with a Quality and Safety update on omitted doses of medicines. Dr Lloyd drew attention to the paper, agenda item 11 ii, and reported that it is pleasing to know that the JAQ system, in conjunction with the Omnicell system, is now demonstrating improvements such as the reduction of omitted doses by 22%. She noted that there are clinically appropriate reasons for omitted doses e.g. a patient going to theatre. She stated that the accurate data from JAQ, along with partnership working between teams, robust medicines management by the pharmacy team and improved safety have all contributed to the reduction. Mrs JEA Hickey, Chairman, asked Dr Lloyd for her reflection on the Quality Summit held recently. Dr Lloyd commented that the Trust held its first Patient Safety Summit in March She stated that the event was well attended with an overall good feeling and vibe from those in attendance. Sir Robert Francis QC and Dr Umesh Prabhu, a paediatric consultant and former Medical Director at Wigan and Leigh NHS Trust, provided keynote speeches, and the Trust s Quality Team were on hand to run sessions. Dr Lloyd stated that the summit was exceptionally well received by all staff and a good response via social media was also achieved. Mr A Beeby, Medical Director, added that the event was a good positive day. 18/43 FINANCE AND ACTIVITY PERFORMANCE: Page 11 of 20 Mrs J Bilcliff, Operational Director of Finance, provided the Board with a summary performance against plan for activity, income and expenditure as at 28 th February 2018 (Month 11) for the Group

12 Agenda Item Discussion and Action Points (inclusive of Trust and QE Facilities, excluding Charitable Funds). She highlighted the key metrics in the paper, agenda item 12, reporting that the operational deficit is 1.637m for the period, a positive variance against plan of 0.799m. she noted that the second tranche of additional winter funding has now been received. Overall, the Trust is now forecasting a year-end out-turn 1m ahead of the original plan, which will allow access to additional STF funding via the for scheme. Mrs Bilcliff stated that CRP delivery at month 11 was 10.3m against the planned delivery of m, and although this is an adverse variance of 0.983m, it remains a positive position to have achieved at this level. She stated that the cash position has increased marginally to 7.665m. Mrs Bilcliff reported that the range of risks detailed in the report continue, the winter cash is no longer a risk and the Trust will end the year with a cash forecast of 5.5m, in line with the plan. Mr ID Renwick, Chief Executive, stated that it would be a struggle to find many organisations with such a solid performance and financial position. He added that the operational pressures are significant and against this the NHS is being asked to make savings at levels not achieved elsewhere. He added that the position to date is fantastic and all staff deserve thanks for their input and for going the extra mile, in particular during the snow period in February He stated that the Trust will ensure that those staff are appropriately thanked for their efforts. After further discussion, it was: RESOLVED: to note the reported financial performance for 2017/18 Action By 18/44 INFORMATION GOVERNANCE ANNUAL ASSURANCE REPORT: Page 12 of 20 Mr J Maddison, Group Director of Finance and Informatics, provided the Board with a statement of assurance on Information Governance issues across the Trust including the version 14.1 submission of the Information Governance Toolkit for 2017/18.

13 Agenda Item Discussion and Action Points He stated that the report also covers the Senior Information Risk Owner (SIRO) Information Governance Annual Report 2017/18, including a number of areas and themes in relation to what the Trust has been doing and our performance against those themes. The work is reviewed at operational level throughout the year and monthly by the Information Governance Group, reporting into the Finance and Performance Committee. He added that the work is monitored and overseen by Mr D Rigg, Information Governance Manager. Mr Maddison stated that Mr Rigg has made a great difference to the Trust with his knowledge and professionalism. Mr Maddison highlighted the main areas of the report, including the major project and work associated with General Data Protection Regulation (GDPR). He added that the Trust needs to be compliant by 25 th May 2018, and the project group is making good progress to ensure this takes place. He reported that in relation to the IG Toolkit, it is proposed that the Trust submits as level 2 satisfactory. He stated that there is currently one area that is not in the required position. This relates to training and the complications of getting staff the time and headroom for them to carry out their training. Mr Maddison reported that from April 2018 the new Data Security and Protection Toolkit (DSP Toolkit) will replace the Information Governance Toolkit (IG Toolkit). This will form part of a new framework for assuring that organisations are implementing the ten security data standards and meeting their statutory obligations on data protection and data security. In addition to the annual submission there will also be greater scrutiny for NHS Trusts as evidence will now form part of CQC well led inspections focusing on cyber security. He added that it must also be noted by the Board that all Trusts must submit an action plan to NHS Digital to comply with Cyber Essentials Plus by the 30 th June This must then lead onto full implementation of the Cyber Security standard by June Mr Maddison informed the Board that two serious Level 2 incidents were reported to the Information Commissioner s Office in 2017/18 (to date). In each case a full investigation was completed and actions were taken to mitigate the risk of recurrence. The Trust received no penalties. Action By Page 13 of 20

14 Agenda Item Discussion and Action Points He reported that a good response service continues with regard to Data Protection Act Subject Access Requests and Freedom of Information Requests. He added that it is to be noted that the Trust will lose around 40k of income due to the charge for processing Subject Access Requests for Medical Records being no longer applicable from the 25 th May Mr Maddison stated that the workplan for 2018/19 includes information flow mapping work across the organisation and the necessity to ensure the flow of information is mapped in and out of the Trust. This work needs to be completed in the next year and needs to be resourced appropriately. He concluded his report by asking the Board to note the content of the report and to approve the submission of Level 2 subject to the caveat of IG training. Mrs JEA Hickey, Chairman, stated that the IG Toolkit was discussed at Finance and Performance Committee the previous day. She added that the Committee is happy to support recommendation at level 2. She also stated that under the leadership obligations, NHS Digital have requested that a named Non-Executive is given responsibility for Data Protection and Cyber Security compliance. She commented that the Trust s position is that the Non-Executive Directors challenge and gain assurance from the reports that are presented to the Finance and Performance Committee. There appears to be a trend towards having a Non-Executive Director assigned to pieces of work, but unless you have someone with specialist skills then assurance routes are already in place. Mrs Hickey stated that she feels it is not appropriate to have one Non- Executive Director to take on this responsibility. Mrs Hickey added that all Board members are receiving the relevant training and this will be incorporated into the forward plan. She added that the paper does not reflect the work already undertaken in relation to an overall business continuity plan. She asked for more detailed comments to be included regarding the level of work and the lessons learned from the cyber-attack. After further discussion, it was: Action By RESOLVED: i) to note the report and the key areas of work around Information Governance and the requirements of the General Data Protection Page 14 of 20

15 Agenda Item ii) Discussion and Action Points Regulation across the Trust to approve the submission of the Information Governance Toolkit at a Level 2 compliance rating as required by NHS Digital Action By 18/45 ASSURANCE FROM BOARD COMMITTEES: i) Quality Governance Committee Mr D Shilton, Non-Executive Director and Chairman of the Quality Governance Committee, highlighted the summary report from the committee meeting held on 21 st February 2018 He highlighted that the report contains a lot of positive assurance from a number of areas, and gave a verbal update from the meeting held on 21 st March Mr Shilton reported that the CQC mental health inspection update remains as amber, however an update was provided to the committee. He reported that discussion took place regarding the quality dashboard and this is reported as green, along with the falls audit. ii) Finance and Performance Committee Mrs JEA Hickey, Chairman and Finance and Performance Committee Chairman, highlighted the summary points from the committee meeting held on 27 th February 2018, and gave a verbal update from the meeting held on 27 th March She reported that the committee had undertaken discussion on two items for approval. The first item was the budget for 2018/19 and the second item was the business case for mental health. Mrs Hickey stated that the committee received the Information Governance Annual Report and received an assurance report from Mr N Black, Deputy Director of Informatics, on wider issues from IT and Informatics. She added that a number of ambers were noted, particularly around IG training and preparation for GDPR. Action plans were in place. She concluded her report by stating that the standard items for the committee on financial performance were Page 15 of 20

16 Agenda Item Discussion and Action Points discussed. It was agreed that finance and activity, given the forecasting for the year-end, should be rated green, and that the finance and sustainability programme should be rated amber due to the recognised performance against a challenging agenda. Other performance ratings remained as amber. Action By iii) Audit Committee Mrs K Larkin-Bramley, Non-Executive Director and Chairman of the Audit Committee, highlighted the summary report from the committee meeting held on 8 th March She reported that the assurance on internal audit work is good but with outstanding actions. She noted, however, that some good progress has recently been made in reducing the number of outstanding actions. Mrs Larkin-Bramley stated that one item has been issued with a limited assurance. This is on Trust mobile devices and an action plan is now in place. She reported that reasonable assurance was provided from the audit of the accounts payable system however it was identified that the Trust is currently not paying all invoices in accordance with Trust policies as a result of a change to the Oracle System facilitated by North East Shared Services. Mrs J Bilcliff, Operational Director of Finance, added that this issue is being addressed as part of the audit and if considered a material issue it will be disclosed appropriately. iv) HR Committee Mr J Robinson, Non-Executive Director and Chairman of the Human Resources Committee, highlighted the summary report from the committee meeting held on 6 th February He highlighted the assurance levels reported in the paper, agenda item 14. Mr Robinson reported that the Committee discussed the people strategy, in particular diversity and inclusion. He stated that current progress is good however further monitoring is needed and therefore this has been rated as amber. Page 16 of 20

17 Agenda Item Discussion and Action Points He stated that workforce metrics remain amber; however a fair amount of work has been undertaken on appraisals and core training. Mr Robinson reported that a detailed discussion took place to ensure that Gender Pay Gap Reporting is fully understood. He stated that the data published shows that the Trust does have a gap that needs to be addressed, however this is not dissimilar to other organisations. He stated that the Committee reviewed a video led by Mr ID Renwick, Chief Executive, about the Trust s vision and values which is being used to refresh and remind staff about the living the values of the Trust. The Board Assurance Framework and Workforce Risks remain as amber and this will be reviewed again at the next meeting. Mr Robinson concluded his update by reporting that the Committee approved the Volunteer Services Policy and received good assurance on the Trust s in-house NVQ and apprenticeship provision. Mrs S Watson, Director of Strategy and Transformation, explained that the Trust has a legal requirement to publish the Gender Pay Gap Reporting by 31 st March She added that a small number of Trusts have published their data to date, and although the reports are slightly varied, there are similar gaps. A copy of the Trust s reporting was circulated to Board members for information. She added that there is no standard definition of what needs to be submitted. The Trust looked at the baseline reporting and took legal advice, however not everyone has adopted the same interpretation. Mrs Watson reported that the data is required to be reported at group level and this has been carried out. She added that the biggest issue to arise is that of the bonus element, and although the Trust does not generally apply bonuses this area has been largely driven by Clinical Excellence Awards scheme. She stated that a work plan has been developed and this will be reviewed by the HR Committee over the next few months. Action By Page 17 of 20

18 Agenda Item Discussion and Action Points Action By 18/46 MAJOR INCIDENT PLANNING ANNUAL REPORT TO INCLUDE EPRR ASSURANCE REPORT: Mrs C Coyne, Director of Diagnostic and Screening Services, provided the Board with an update on the changes within the NHS for Emergency Preparedness, Resilience and Response (EPRR) and the programme of work currently being addressed by the Trust s EPRR Group. She highlighted that Mr J Robinson, Non-Executive Director, has joined the EPRR Group along with Mrs S Robinson, Clinical Operations Manager, Community Services. Mrs Coyne reported that as part of the national EPRR assurance process for 2017/18, the Trust was required to self-assess against the EPRR core standards. This was submitted in August 2017 and identified that the Trust is fully compliant with 60 of the standards and partially compliant with six of the standards. The partially compliant standards relate specifically to training exercises with staff and the demonstration of competencies for the on-call team. Mrs Coyne stated that this will increase over the next few months as part of a high level work plan which will be monitored by the EPRR Committee. Mrs Coyne reported that the Trust continues to support other contaminants with wet decontamination using the inflatable tent and the tent is tested regularly. Whilst still fully functional the age and condition of the inflatable tent will needed to be considered in line with the existing risk management process for EPRR and this is reflected in the risk register. She stated that a number of business continuity plans have been tested over the last 12 months. In particular, tests and actions relating to the cyber-attack where the Trust took part in a health economy debrief in June From this an internal action plan was produced, which includes the programme of regular patching of all systems with planned downtime for critical systems e.g. Medway. She reported that the Trust also took part in a mass casualty 'Recovery' exercise undertaken in September Mrs JEA Hickey, Chairman, commented that the ongoing work is reassuring that the Trust and others are supporting vulnerable people. Page 18 of 20

19 Agenda Item Discussion and Action Points Mrs C Coyne, Director of Diagnostic and Screening Services, stated that the procedures were tested again recently when a large fire broke out near to the hospital. There was an impact on the hospital and vulnerable patients and a lot of work took place with the local authority, where further issues were raised. Mrs JEA Hickey, Chairman, stated liaison with the local authority is positive moving forward. Mrs C Coyne, Director of Diagnostic and Screening Services, commented that the relationship works well across the board. She added that the local authority should be informed by the police of any incidents in the area, however the recent fire in Low Fell highlighted that they were not informed. This needs updating on the Trust s action card and will be adapted accordingly. Mr J Robinson, Non-Executive Director, commented that although he has only attended a few of the EPRR Committee meetings so far, he is impressed with the energy from people who have experience of dealing with issues and taking part in exercises. He added that recently patients in Ward 4 and Ward 6 were moved in the middle of the night, and while this was not written in any particular plan, staff used their initiative to do this safely and effectively. After further discussion, it was: RESOLVED: to receive the report for information Action By 18/47 QUESTIONS FROM GOVERNORS IN ATTENDANCE: Page 19 of 20 Mr M Loome, public governor, raised a query regarding agenda item 8. He asked if the indicator for the 62 day wait for cancer treatment was lower for any particular reason. Mrs S Watson, Director of Strategy and Transformation, stated that this is due to the number of patients being small numbers. From this the Trust experiences fluctuations each month. She reported that the Trust has advised NHS Improvement, and commented that the standards are maintained at a quarterly level. Mr M Loome, public governor, also queried the quality dashboard, agenda item 11. He asked if with regard to the medication errors, these occurred in a particular area. Dr H Lloyd, Director of Nursing, Midwifery and Quality, stated that there are no particular causes for concern. She advised that the

20 Agenda Item Discussion and Action Points issues are discussed in detail at the Medicines Management Group meetings. Action By 18/48 DATE AND TIME OF NEXT MEETING: RESOLVED: that the next meeting of the Board of Directors will be held at 9.30am on Wednesday 25 th April 2018 in Room 3, Education Centre, Queen Elizabeth Hospital 18/49 EXCLUSION OF THE PRESS AND PUBLIC: RESOLVED: to exclude the press and public from the remainder of the meeting due to the confidential nature of the business to be discussed Page 20 of 20

21 Actions from Board of Directors Meetings Part I Date of Meeting Minute Reference Action Lead Complete 28/03/ /34 To present the final CQC Well-Led self-assessment and associated action plan. SW

22 Trust Board Report Cover Sheet Agenda Item: 7 Date of Meeting: Wednesday 25 th April 2018 Report Title: Purpose of Report: Declaration of Board Members Interests and Fit and Proper Persons Declaration In accordance with section 20 of Schedule 1 of the Health & Social Care (Community Health and Standards) Act 2003 NHS Foundation Trusts are required to maintain a register of Directors and Governors interests. This requirement is also enshrined in section 10 of the Trust s Constitution. Also included is the Fit and Proper Persons Test required by the Health Act 2012 and subsequently the Trust s Standard Licence Conditions. The register for Gateshead Health NHS Foundation Trust is held at Trust Headquarters and is available to the public through the Trust Secretary. This availability is published in the annual report and on the Trust s web site. The declared interests for 2017/18 for the Chairman and Board members are attached as appendix I and The Fit and Proper Persons Declaration as appendix 2. Trust Goals that the report relates to: (Including reference to any specific risk) Recommendations: (Action required by Board of Directors) Financial Implications: Decision: Discussion: Assurance: Information: Goal 2 All the services we deliver will be good or outstanding when assessed against being safe, effective, caring, responsive, and well-led. The Board is asked to: i) Approve and record in the Board minutes the declared interests and Fit and Proper Persons Declaration as shown in appendices I and 2. ii) Note that the next full routine review of the declaration of Board members interests will take place in April None

23 Risk Management Implications: Human Resource Implications: Trust Diversity & Inclusion Objective that the report relates to: (including reference to any specific implications and actions) Author: Presented by: None None None Mrs D Atkinson, Trust Secretary Mrs D Atkinson, Trust Secretary

24 Appendix 1 Gateshead Health NHS Foundation Trust Register of Board Member Interests 2016/2017 Name Position Interest Interest of Spouse Category Mr Andrew Beeby Medical Director Director of Medicolegal reporting firm (Private company). Rebecca Beeby Director of same company) A Dr Ruth Bonnington Non- Executive Director Mr Shaun Bowron Non- Executive Director General Practitioner in Gateshead Non Executive Director of QE Facilities None A A Mrs Claire Coyne Cllr Martin Gannon Mrs Julia Hickey Executive Director Non- Executive Director Director North East Transformation System Ltd Newcastle Airport Local Authority Holding Company Limited Leader of Gateshead Council Chairman Trustee and Audit Chair of NHS Confederation and None None None None A A F D Mr Paul Hopkinson Non- Executive Director Mrs Nichola Kenny Associate Director Management Committee Member of SVP which manages two local approved premises Partner PL Law LLP Trustee FACT Fighting All Cancers Together Charity Secretary, Jackie in the Community None B D D Mr Michael Laing Associate Director Director North East Transformation A System Ltd Christ s Hospital Sherburn None D

25 Name Position Interest Interest of Spouse Category Mrs Kathryn Larkin-Bramley Non- Executive Director Non-Executive Director of Karbon Homes Ltd (from 1 April 17) A Trustee Childrens Cancer Fund (RVI) D Lecturer New College Durham Governor Johnston School Lay Member North East Clinical Excellence Awards End to End Financial Solutions Ltd No NHS work F F F A Mrs Hilary Lloyd Director None Mr Nicholas McDonaugh Associate Director None None Mr John Maddison Director None None Mr Ian Renwick Chief Executive Director NETS Ltd None Patron, Just Visiting CIC Independent Board Member Tyne & Wear Archives Museum (TWAM) A E E Mr John Robinson Non- Executive Director Mr David Shilton Non- Executive Director Governor and Vice Chair, Gateshead College None Director Meadow Lodge Care Ltd Director Holistic Care Provision Ltd None F A A Mrs Susan Watson Director Member Meadow Lodge Homecare Services LLP Trustee - Friends of Friarage Hospital None B D Key to Interests Declared: A B C Directorships, including Non-Executive Directorships held in private companies or PLCs (with the exeption of dormant companies). Ownership or part ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the NHS Majority or controlling shareholdings in organisations likely or possibly seeking to do business with the NHS

26 D E F A position of authority in a charity or voluntary body in the field of health and social care Any connection with a voluntary or other body contracting the NHS service To the extent not covered in the declarations above, any connections with an organisation, entity or company considering entering into or having entered into a financial arrangement with the Trust but not limited to, lenders or banks.

27 Appendix 2 All Members of the Board of Directors have signed the following declaration and an annual search of insolvency, bankruptcy and disqualified director s registers has also taken place. Fit and Proper Person Declaration 1. It is a condition of employment that those holding director and director-equivalent posts provide confirmation in writing, on appointment and thereafter on demand, of their fitness to hold such posts. Your post has been designated as being such a post. Fitness to hold such a post is determined in a number of ways, including (but not exclusively) by the Trust s provider licence, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2008 ( the Regulated Activities Regulations ) and the Trust s constitution. 2. By signing the declaration below, you are confirming that you do not fall within the definition of an unfit person or any other criteria set out below, and that you are not aware of any pending proceedings or matters which may call such a declaration into question. Provider licence 3. Condition G4(2) of Gateshead Health NHS Foundation Trust s Provider Licence ( the Licence ) provides that the Licensee shall not appoint as a director any person who is an unfit person, except with the approval in writing of Monitor. 4. Licence Condition G4(3) requires the Licensee to ensure that its contracts of service with its directors contain a provision permitting summary termination in the event of a director being or becoming an unfit person. The Licence also requires the Licensee to enforce that provision promptly upon discovering any director to be an unfit person, except with the approval in writing of Monitor. 5. An unfit person is defined at condition G4(5) of the Licence as: (a) an individual: (i) (ii) (iii) (iv) who has been adjudged bankrupt or whose estate has been sequestrated and (in either case) has not been discharged; or who has made a composition or arrangement with, or granted a trust deed for, his creditors and has not been discharged in respect of it; or who within the preceding five years has been convicted in the British Islands of any offence and a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on him; or who is subject to an unexpired disqualification order made under the Company Directors Disqualification Act 1986; or

28 (b) a body corporate, or a body corporate with a parent body corporate: (i) (ii) (iii) (iv) (v) (vi) where one or more of the Directors of the body corporate or of its parent body corporate is an unfit person under the provisions of sub-paragraph (a) of this paragraph, or in relation to which a voluntary arrangement is proposed under section 1 of the Insolvency Act 1986, or which has a receiver (including an administrative receiver within the meaning of section 29(2) of the 1986 Act) appointed for the whole or any material part of its assets or undertaking, or which has an administrator appointed to manage its affairs, business and property in accordance with Schedule B1 to the 1986 Act, or which passes any resolution for winding up, or which becomes subject to an order of a Court for winding up. Regulated Activities Regulations 6. Regulation 5 of the Regulated Activities Regulations states that the Trust must not appoint or have in place an individual as a director, or performing the functions of or equivalent or similar to the functions of, such a director, if they do not satisfy all the requirements set out in paragraph 3 of that Regulation. 7. The requirements of paragraph 3 of Regulation 5 of the Regulated Activities Regulations are that: (a) (b) (c) (d) (e) the individual is of good character; the individual has the qualifications, competence, skills and experience which are necessary for the relevant office or position or the work for which they are employed; the individual is able by reason of their health, after reasonable adjustments are made, of properly performing tasks which are intrinsic to the office or position for which they are appointed or to the work for which they are employed; the individual has not been responsible for, privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity or providing a service elsewhere which, if provided in England, would be a regulated activity; and none of the grounds of unfitness specified in Part 1 of Schedule 4 apply to the individual. 8. The grounds of unfitness specified in Part 1 of Schedule 4 to the Regulated Activities Regulations are: (a) (b) the person is an undischarged bankrupt or a person whose estate has had sequestration awarded in respect of it and who has not been discharged; the person is the subject of a bankruptcy restrictions order or an interim bankruptcy restrictions order or an order to like effect made in Scotland or Northern Ireland;

29 (c) (d) (e) (f) the person is a person to whom a moratorium period under a debt relief order applies under Part VIIA (debt relief orders) of the Insolvency Act 1986; the person has made a composition or arrangement with, or granted a trust deed for, creditors and not been discharged in respect of it; the person is included in the children s barred list or the adults barred list maintained under section 2 of the Safeguarding Vulnerable Groups Act 2006, or in any corresponding list maintained under an equivalent enactment in force in Scotland or Northern Ireland; the person is prohibited from holding the relevant office or position, or in the case of an individual for carrying on the regulated activity, by or under any enactment. Trust s Constitution 9. The Trust s constitution places a number of restrictions on an individual s ability to become or continue as a director. A person may not become or continue as a director of the Trust if: (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) they have been adjudged bankrupt or their estate has been sequestrated and in either case they have not been discharged; they have made a composition or arrangement with, or granted a Trust deed for their creditors and have not been discharged in respect of it; they have within the preceding five years been convicted in the British islands of any offence, and a sentence of imprisonment (whether suspended or not) for a period of three months or more (without the option of a fine) was imposed on them; in the case of a Non-Executive Director they are no longer a Member of the Public or Patient Constituency. they are a person whose tenure of office as a Chairman or as a Member or Director of a Health Service body has been terminated on the grounds that his/her appointment is not in the interests of public service, for non-attendance at meetings, or for non-disclosure of a pecuniary/non-pecuniary interest; they have within the preceding two years been dismissed, from any paid employment for misconduct with a Health Service body; they are an Executive Director of the Trust, or a Governor, Non-Executive Director, Chairman, Chief Executive officer of another Trust; they are incapable by reason of mental disorder, illness or injury of managing and administering their property and affairs; they bring the Board of Directors or any of its Member organisations into disrepute; they have failed to comply with the required standard of behaviour as per the Trust policy for withholding treatment from violent and abusive patients; they have had their name removed, by a direction under section 46 of the 1977 Act from any list prepared under Part II of that Act, and has not subsequently had their name included in such a list;

30 (l) (m) (n) (o) they have been placed on the Registers of schedule 1 Offenders pursuant to the Sex Offenders Act 1977 and/or the Children & Young Person Act 1933; they fail to abide by the Constitution they are under 16 years of age; they have failed to undertake the required training for Directors I acknowledge the extracts from the provider licence, Regulated Activities Regulations and the Trust s constitution above. I confirm that I do not fit within the definition of an unfit person as listed above and that there are no other grounds under which I would be ineligible to continue in post. I undertake to notify the Trust immediately if I no longer satisfy the criteria to be a fit and proper person or other grounds under which I would be ineligible to continue in post come to my attention. Name: Signed: Position: Date:

31 Trust Board Report Cover Sheet Agenda Item: 8 Date of Meeting: Wednesday 25 th April 2018 Report Title: Purpose of Report: Trust Goals that the report relates to: (Including reference to any specific risk) Trust Performance Report To provide an overview on performance against national and local targets, ensuring the Board receives assurance about the Trust s performance in light of national requirements and local changes. Decision: Discussion: Assurance: Information: Goal 3 In all locations and settings of delivery, our patients will experience excellent, timely and seamless care that meets their individual needs. Goal 6 We will have an engaged and motivated workforce living the values and behaviours of the organisation, and who are responsive and adaptive to the changing needs of our environment. Recommendations: (Action required by Board of Directors) Financial Implications: Goal 7 We will deliver value for money and help ensure the local health and care system is sustainable and well led. The Board is asked to note the overall continuing good performance of the Trust - but with specific action required by Executive Team and Associate Directors in relation to the workforce metrics, as discussed at the HR Committee, and the operational metrics for A&E, Mental Health and Cancer 2ww as discussed at the Finance and Performance Committee. Identifies non-achievement of the A&E operational performance element of the STF for Q4 in 2017/18. Submissions of mitigations and Gateshead performance in relation to the national position will be made to NHSI. Sickness absence has peaked over recent months which is a cost to the organisation; albeit absences are being managed appropriately. Risk Management Implications: The Trust is not meeting the Single Oversight Framework (SOF) requirement on dementia assessment and referral. The delivery of 1

32 the Medicine Business Unit s action plan continues to work to recovery for May. The Trust s internal performance escalation framework is being used and NHSI have been informed. The Trust did not meet the SOF A&E standard in March. April performance is much improved to date, but remains a risk. A potential support need by NHSI based on March performance remains in place throughout April. Gateshead continues to outperform the national average and remain as one of the top quartile providers against this access standard. The Trust did not meet the cancer 2ww standards in March. There is no impact on the Trust via the SOF as it is no longer part of NHSI performance framework. The Trust s internal performance escalation framework is being used to manage recovery. Completion of core training has improved over the last month which is positive however as yet we have not reached the anticipated levels, thus there is a small risk that some staff are not up-to-date with essential training. Human Resource Implications: Trust Diversity & Inclusion Objective that the report relates to: (including reference to any specific implications and actions) Author: Presented by: It remains a priority for the Trust to ensure our staff have a quality appraisal discussion every 12 months, are up-to-date with core training, and are supported with their health and well-being; key strands of the Trust s Vision, Values and underpinning People Strategy. Objective 1 All patients receive high quality care through streamlined accessible services with a focus on improving knowledge and capacity to support communication barriers. Objective 2 The Trust promotes a culture of inclusion where employees have the opportunity to work in a supportive and positive environment and find a healthy balance between working life and personal commitments. Steven Lawson, Head of Performance Susan Watson, Director Strategy and Transformation 2

33 1. Single Oversight Framework: The scorecard below reflects the Trust performance against the operational metrics described in the Single Oversight Framework and if there are any potential support needs. As at 31 st March 2018, the Trust is reporting two areas of potential support need under the operational performance theme of the SOF, relating to the dementia assessment and referral data and A&E access standard. 3

34 2. Performance dashboard access/outcome standards not included in the Single Oversight Framework 4

35 3. Workforce metrics 5

36 Trust Board Report Cover Sheet Agenda Item: 9 Date of Meeting: Wednesday 25 th April 2018 Report Title: Purpose of Report: Trust Goals that the report relates to: (Including reference to any specific risk) Nursing Staffing Exception Report Provide assurance to the Board that staffing establishments are being met month by month Decision: Discussion: Assurance: Information: Goal 2 All the services we deliver will be good or outstanding when assessed against being safe, effective, caring, responsive, and well-led. Goal 3 In all locations and settings of delivery, our patients will experience excellent, timely and seamless care that meets their individual needs. Goal 5 All our services will be effective: we will reduce unwarranted variation, ensure our practice is consistent with recognised best practice 7 days a week, and improve outcomes for patients. Recommendations: (Action required by Board of Directors) Financial Implications: Risk Management Implications: Human Resource Implications: Diversity and Inclusion Implications: The Board are asked to receive the report for assurance Costs associated with nurse bank to provide cover for vacancies maternity and sickness Areas of potential risk have been mitigated against through the implementation of robust staffing plans and ongoing monitoring of staffing levels across the organisation Nurse recruitment continues to be a challenge; however the Trust is being proactive and innovative in terms of recruitment solutions Objective 3 Leaders within the Trust are informed and knowledgeable about the impact of business decisions on a diverse workforce and the differing needs of the communities we serve 1

37 Author: Presented by: Avril Lowery, Deputy Director of Nursing, Midwifery & Quality Gareth Armstrong, Chief Matron Surgery Hilary Lloyd, Director of Nursing, Midwifery & Quality 2

38 Gateshead Health NHS Foundation Trust Nursing and Midwifery Staffing Exception Report March Introduction This report is to provide assurance to the Board that staffing establishments are being met on a shift-to-shift basis. The Board will receive monthly updates on workforce information, including the number of actual staff on duty during the previous month, compared to the planned staffing level, the reasons for any gaps and the actions being taken to address these. Following the Lord Carter Cole report, it was recommended that all trusts start to report on care hours per patient per day (CHPPD) this is to provide a single consistent way of recording and reporting deployment of staff working on inpatient wards/units. It is calculated by adding the hours of registered nurses to the hours of support workers and dividing the total by every 24 hours of inpatient admissions. This report provides information for March Staffing The actual ward staffing against the budgeted establishments for March are presented in Table 1: Whole Trust wards staffing and Table 2: Ward by ward staffing in this report. In addition the Trust has published this information on our website for the public, and provided a link from NHS Choices to this information. Table 1: Whole Trust wards staffing March 2018 Day Day Night Night Average fill rate - care staff (%) Average fill rate - registered nurses/midwives (%) Average fill rate - registered nurses/midwives (%) Average fill rate - care staff (%) 89.2% 127.2% 95.1% 107.2% The Trust is required to present information on funded establishments (planned) against actual nurses on duty. Appendix 1 Illustrates the Trusts staffing fill rates over the past 12 months by Qualified days, Nursing Assistant days, Qualified nights and Nursing Assistant nights. 3

39 Table 2: Ward by Ward staffing March 2018 Day Night Care Hours Per Patient Per Day (CHPPD) Ward Cragside Court Average fill rate - registered nurses/midwives (%) Average fill rate - care staff (%) Average fill rate - registered nurses/midwive s (%) Average fill rate - care staff (%) Cumulative patient count over the month Registered midwives / nurses Care Staff Overall 92.7% 106.0% 80.8% 119.4% Critical Care 72.6% 98.9% 93.4% 93.7% EAU 98.2% 138.8% 81.2% 107.1% ICAR 96.5% 112.1% 98.8% 129.3% Maternity 108.5% 124.9% 85.4% 74.2% Paediatrics 75.0% 66.3% 122.3% NA SCBU 142.9% 115.9% 106.9% 97.3% St Bedes 100.3% 73.3% 82.1% 111.3% Sunniside 87.7% 83.8% 80.4% 116.5% Ward % 132.2% 103.8% 102.6% Ward % 164.8% 103.2% 110.4% Ward % 122.6% 102.7% 71.2%

40 Day Night Care Hours Per Patient Per Day (CHPPD) Ward Average fill rate - nurses/midwives (%) Average fill rate - care staff (%) Average fill rate - nurses/midwives (%) Average fill rate - care staff (%) Cumulative patient count over the month Registered midwives / nurses Care Staff Overall Ward % 110.8% 128.7% 108.8% Ward % 132.0% 102.6% 94.8% Ward % 202.3% 102.6% 109.1% Ward % 144.7% 94.5% 151.5% Ward % 196.1% 101.6% 99.9% Ward % 163.5% 99.8% 109.9% Ward % 80.0% 95.3% 97.2% Ward % 116.8% 102.0% 97.3% Ward % 120.9% 116.0% 105.0% Ward % 316.5% 85.8% 133.0% Ward % 111.7% 80.2% 125.6% Ward % 165.3% 103.0% 104.6%

41 3. Exceptions: The Board will be advised of those wards where staffing capacity and capability frequently falls short of what is planned, the reasons why, any impact on quality and the actions taken to address gaps in staffing. In terms of exception reporting, we will report to the Board if the safe planned staffing drops below 75% or above 125%. The exceptions to report are as below: March 2018 Qualified Nurse Days % Critical Care 72.6% SCBU 142.9% Ward % Ward % Ward % Ward % Ward % Nursing Assistant Days % EAU 138.8% Paediatrics 66.3% St Bedes 73.3% Ward % Ward % Ward % Ward % Ward % Ward % Ward % Ward % Ward % Qualified Nurse Nights % Ward % Nursing Assistant Nights % ICAR 129.3% Maternity 74.2% Ward % Ward % Ward % Ward % 6

42 Registered Nurses In March Ward 4, 21, 22 and 25 had low fill rates for registered nurses days due to vacancies sickness and maternity leave. Fill rates continue to be high on Ward 6 due to the establishment not being adjusted to reflect the increased bed base. Critical Care has low fill rates in March for Qualified Nurse days due to vacancies, qualified nurses on secondment and maternity leave. Safe staffing levels were maintained due to reduced bed occupancy and acuity during this period. Ward 14 has had high fill rates for registered nurses on nights as a result of an extended period of escalation. SCBU have high fill rates for registered midwives on days due to newly qualified staff requiring supervisory practice within the clinical area. In all the areas where qualified fill rates were low risk assessments were undertaken on a daily basis by the SNOOH and matron for these ward areas to ensure patient safety was maintained. The non-ward based nursing teams have continued to support the wards to achieve safe staffing levels. The Matron s continue to closely monitor staffing across all wards and take action to ensure safe staffing levels are maintained. Nursing Assistants A number of wards continue to have elevated fill rates for Nursing Assistants days and nights in March due to back filling for qualified vacancies, maternity leave, long term sickness absence and additional bed capacity due to winter pressures. ICAR, Wards 11, 22, 23, 24 and 25 have rostered additional Nursing Assistants to provide enhanced care and maintain patient safety. Maternity and ward 12 and have had a low fill rate for nursing assistants on nights due to short term sickness and absence in March. Paediatrics continues to have low fill rates for Nursing Assistant days in March due to short term sickness absence. To address this and in order to maintain safe staffing the Nursing Assistants work flexibly across the Children s Short Stay Unit, Children s Outpatients and Day Unit. In addition to this the team utilise the skills and expertise of the ED Nursing team and the Nursery Nurse in times of pressure. 4. Monitoring Nurse Staffing via Datix The Trust has in place a process for reporting and monitoring any concerns regarding nurse staffing levels. This is via the Datix incident reporting system. A report is generated on a monthly basis and discussed at the Nursing and Midwifery Professional Forum. This report helps identify areas where nurse staffing may have fallen below planned levels and what actions were taken to manage the situation. It is also helpful in identifying trends and organisational learning. There were 7 incidents reported in March. 7

43 5. Governance Actual staff on duty on a shift to shift basis compared to planned staffing is displayed on the time to care boards alongside key quality and outcome metrics i.e. safety thermometer ; infection control measures. These time to care boards are located in an area clearly visible to the public. The Trust nurse bank has over 1000 nurses on the system to provide temporary cover at short notice. The Trust only uses its own nurse bank staff to fill unfilled shifts, all staff on the bank are supported with induction and training. Recruitment of Registered Nurses remains challenging and the Trust continues to actively recruit both Qualified and Nursing Assistants on a monthly basis. Rotational appointments continue to be offered to newly qualified staff to give them the opportunity to work across a variety of areas to enhance their learning and development as well as help retain our nurses. Further work is being developed and implemented in relation to improving nurse retention rates. 6. Conclusion This paper provides an exception report for nursing and midwifery staffing in March Recommendations The Board is asked to receive this report for assurance. Avril Lowery Deputy Director of Nursing, Midwifery and Quality Gareth Armstrong, Chief Matron Surgery 8

44 Appendix 1 Fill rates by shift type 150% 125% 100% 75% 50% 25% 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Care Hours Per Patient Day Percentage fill rates - Unqualified (Days + Nights) with Care Hours Per Patient Day (Unqualified) April 17 -March 18 All inpatient areas CHPPD Unqualified Unqualified fill rates (Day+Night) Fill Rate

45 Appendix 1 Fill rates by shift type 150.0% 125.0% 100.0% 75.0% 50.0% 25.0% 0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month CHPPD Days Qualified CHPPD Days Unqualified CHPPD Nights Qualified CHPPD Nights Unqualified Days Qualified fill rate Days Unqualified fill rate Nights Qualified fill rate Nights Unqualified fill rate Fill rate Care Hours Per Patient Day Fill rates (all shift types) April 17 -March 18 All inpatient areas

46 Appendix 1 Fill rates by shift type Days Qualified fill rate Days Unqualified fill rate Nights Qualified fill rate Nights Unqualified fill rate Fill rates (all shift types) April March 2018 All inpatient areas CHPPD Days Qualified CHPPD Days Unqualified CHPPD Nights Qualified CHPPD Nights Unqualified Apr % 133.9% 95.17% 107.8% May % 135.3% 94.49% 104.7% Jun % 131.2% 97.43% 105.0% Jul % 132.8% 96.29% 108.0% Aug % 129.0% 92.47% 111.2% Sep % 128.5% 94.00% 111.2% Oct % 133.6% 95.13% 106.0% Nov % 130.6% 97.72% 111.5% Dec % 127.1% 96.63% 103.9% Jan % 135.9% % 107.8% Feb % 130.6% 95.67% 113.6% Mar % 127.2% 95.1% 107.2%

47 Trust Board Report Cover Sheet Agenda Item: 10 Date of Meeting: Wednesday 25 th April 2018 Report Title: Purpose of Report: Trust Goals that the report relates to: (Including reference to any specific risk) Healthcare Associated Infection (HCAI) Performance Report To update and advise the Trust Board on the current performance of HCAI mandatory reporting for Gateshead Health NHS Foundation Trust throughout the period. Decision: Discussion: Assurance: Information: Goal 1 Working with partners, we will manage and improve the health of the population of Gateshead, promoting wellbeing and preventing the occurrence and progression of ill-health wherever possible. Goal 2 All the services we deliver will be good or outstanding when assessed against being safe, effective, caring, responsive, and well-led. Goal 3 In all locations and settings of delivery, our patients will experience excellent, timely and seamless care that meets their individual needs. Recommendations: (Action required by Board of Directors) Financial Implications: Risk Management Implications: Human Resource Implications: To note the Trust performance on mandatory Healthcare Associated Infection reporting and other infection prevention activity as required. Yes - Healthcare associated infection (HCAI) and treatment is costly across the whole healthcare economy, delays discharge and increases length of hospital stay. Financial sanctions may also be applied by NHS England and Commissioners. Yes - HCAI has implications for the whole healthcare economy. The expertise, advice and support of the IPC team are crucial in ensuring that the risk and spread of infection is minimised. Yes organisational culture and behaviours, engagement, responsibility and ownership required across the whole healthcare economy. 1

48 Trust Diversity & Inclusion Objective that the report relates to: (including reference to any specific implications and actions) Author: Objective 1 All patients receive high quality care through streamlined accessible services with a focus on improving knowledge and capacity to support communication barriers. Philip Pugh, Head of Infection Prevention and Control Presented by: Hilary Lloyd - Director of Nursing, Midwifery & Quality Joint Director of Infection Prevention and Control (DIPC) 2

49 1.0 SUMMARY The Trust has reported post 48hr MRSA BSI zero rate per 100K bed days for 793 days to Q4and has successfully achieved a zero tolerance approach towards MRSA BSI and patient safety meeting the national aspiration. The Trust reported 3 pre 48hr/community MRSA BSI attributed to the Newcastle Gateshead Clinical Commissioning Group and remained the lowest reporting Trust in the North East. NHS Improvement (NHSI) published updated guidance regarding the continued aspiration of zero tolerance of MRSA BSI. From April 2018 formal Post Infection Reviews (PIR) must only be undertaken for organisations with the highest rates of infection (>1.7 per 100k bed days) and PIRs will become a local process. The Trust is not listed as one that must carry out a formal PIR but implement locally. The Trust has reported 31 post 72hr CDI cases to date. 6 cases have been successfully upheld at appeal representing 25 cases against the trust quality premium. One case is awaiting an RCA decision and one case remains to be appealed. The Trust also reports 41 cases to date against its annual pre 72hr/community cumulative data and benchmark, demonstrating a 29% improvement against 2016/17 data and an overall 32% improvement against the benchmark of 61 cases. Overall the NE region has seen a 20% increase of post 72hr CDI cases. Comparatively 6 of 8 Trusts including GHFT have demonstrated an increase in post 72hr CDI cases to Q4 against 2016/17 and also exceeded their annual objective. The Trust continues to report one of the lowest post 48hr Meticillin sensitive Staphylococcus aureus (MSSA) BSI in the North East region reporting 8 post 48hr MSSA cases with a rate of 4.6 per 100k bed days and 39 pre/community 48hr MSSA BSI cases. GHFT continues to report one of the lowest MSSA BSI rates across the NE region. With regard to Gram negative blood stream infections (GNBSI) reporting for 2017/18 period has been voluntary and does not have any comparative data: Escherichia coli (E.coli): Gateshead Health remains one of the lowest reporting trusts reporting 40 post 48hr E. coli GNBSI cases with a rate of 23.2 per 100k bed days and 199 pre 48hr/community GNBSI cases. Pseudomonas aeruginosa: The Trust reports 6 post 48hr cases with a rate of 3.5 per 100k bed days and 14 pre 48hr/community P. aeruginosa GNBSI cases to date. Klebsiella spp: The Trust reports 11 post 48hr cases with a rate of 6.4 per 100k bed days and 43 pre 48hr/community Klebsiella GNBSI cases. The Trust has seen a significant 478% increase in identified positive cases against 2016/17 with a substantial increase in influenza B cases. To date the Trust reports 567 confirmed positive cases of influenza of which 348 identified as influenza A. 219 identified as influenza B. Public Health England reports that influenza activity continues to circulate, although decreases are noted across most indicators. The Trust has experienced 6 PII to date linked to the significant increase in the number of confirmed influenza hospitalisations in addition to a small number of areas affected by Norovirus. 3

50 2.0 MANDATORY HCAI SURVEILLANCE 2.1 Meticillin Resistant Staphylococcus aureus (MRSA) Blood Stream Infections (BSI) All positive pre/community 48 hour MRSA BSI cases are allocated to the Newcastle and Gateshead Clinical Commissioning Group (CCG) as per national guidance. Until 31 st March 2018 each positive MRSA BSI case was reviewed and apportioned to its respective Trust or CCG following a Post Infection Review (PIR) in line with national guidance. NHS Improvement (NHSI) have published updated guidance regarding the continued aspiration of zero tolerance of MRSA BSI. This update describes the detailed requirements for the reporting and review of MRSA BSI, part of the Single Oversight Framework, from April 2018 and it includes lists of the Trusts and CCGs that will need to carry out formal PIR s. From April 2018 this requirement will be modified so that formal reviews must only be undertaken for organisations with the highest rates of infection (>1.7 per 100k bed days) and PIRs will become a local process rather than be administered through the Public Health England data Capture site (DCS). Recording of an MRSA BSI will still take place on the DCS to ensure the full mandatory dataset is recorded. North East Foundation Trusts identified in the document and will be expected to report through a formal PIR process are: City Hospital Sunderland FT South Tees Hospitals FT County Durham & Darlington FT As Gateshead Health FT currently has a zero rate per 100k bed days, the Trust is not listed as one that must carry out a formal PIR but implement locally. The Trust has successfully reported zero (0) post 48hr cases of MRSA BSI for 793 days to end of Q4 and three (3) pre/community 48hr cases as identified in table 1. Table 1 Q1 Q2 Q3 Q4 Acute Trust Data Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Post 48hr MRSA BSI Cumulative YTD /17 data = 0/ Q1 Q2 Q3 Q4 Community Data Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Pre/community 48hr MRSA BSI Cumulative YTD /17 data = 0/ Chart 1 (ordered by secondary care) demonstrates the total number of attributed MRSA BSI data per Foundation Trust/CCG across the North East. The NE region has seen a 31% increase of pre 48hr cases against 2016/17 and an overall 50% reduction of post 48hr cases. Gateshead Health FT continues to remain one of the lowest reporting Foundation Trusts and has successfully achieved a zero tolerance 4

51 approach towards MRSA BSI and patient safety meeting the national aspiration. Chart 1 8 Comparison of NE Region Apportioned Pre/Community and Post 48hr MRSA BSI Reports by Trust/CCG 2017/18 Attributed MRSA BSI GHFT North FT Sth Tees FT Sth Tyne FT CHS FT Co DD FT NUTH FT NT & H NHS Trust/CCG Trust Apportioned CCG Apportioned Chart 2 The chart is ordered by secondary care post 48hr cases Chart 2 demonstrates the rate of MRSA BSI acquisition per 100k bed days per Foundation Trust/CCG across the North East. Gateshead Health FT continues to remain the lowest reporting Foundation Trusts with a zero rate of post 48hr MRSA BSI to end of Q Rate of post 48hr MRSA BSI per 100k bed days 2017/18 Rate per 100k bed days GHFT Sth Tees FT North FT CHS FT Co DD FT NUTH FT Sth Tyne FT NT & H Foundation Trust 5

52 2.2 Post 72hr Clostridium difficile Infection (CDI). Table 2 The Trust CDI objective for 2017/18 is nineteen (19) post 72hr cases. All positive pre/community 72 hour CDI cases are allocated to the CCG. The pre 72hr/community CDI data is based against a benchmark of sixty one (61) pre 72hr cases. The Trust has reported thirty one (31) post 72hr CDI cases to date with each case being unique to the patient with no evidence of cross infection. Six cases (6) have been successfully upheld at appeal representing twenty five cases (25) against the Trust quality premium. One (1) case is awaiting an RCA decision and one (1) case remains to be appealed. Table 2 indicates the total number of Trust pre 72hr/community and post 72hr CDI toxin positive cases and current CDI status to Q4 against 2016/17 data as a comparison. Acute Trust Data Q1 (5) Q2 (5) Q3 (4) Q4 (5) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Monthly post 72hr CDI Cumulative YTD (objective 19) 31 Actual following appeal by month Cumulative YTD following appeal /17: objective =19: Actual= 20/ /17 Actual per month following appeal Q1 Q2 Q3 Q4 Community Data Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Monthly no. of pre/community 72hr CDI Cumulative YTD /17: monthly data /17 year end total 58 Chart 3 demonstrates the Trust cumulative position against its annual post 72hr cumulative objective to Q4. Chart 3 40 Post 72hr CDI Cumulative Objective to date 2017/18 CDI Reports Q1 Q2 Quarter Q3 Q4 CDI Cumu Obj YTD CDI following appeals CDI Cumu Obj 2017/18 6

53 Chart 4 Chart 4 demonstrates the Pre 72hr/Community CDI position reporting forty one (41) cases to date against its annual pre 72hr/community cumulative data and benchmark, demonstrating a 29% improvement against 2016/17 data and an overall 32% improvement against the benchmark of 61 cases to Q Pre/Community 72hr CDI data 2017/18 61 CDI Reports Q1 Q2 Quarter Q3 Q4 Pre 72hr CDI Cumu data 2017/18 CDI Cumu data to date Chart 5 Chart 5 provides a comparison of the total count of post 72 hour CDI attributed to each Trust in the North East region to Q4 against the same period for 2016/17. Overall the NE region has seen a 20% increase of post 72hr CDI cases. Comparatively six (6) of eight (8) Trusts including GHFT have demonstrated an increase in post 72hr CDI cases to Q4 against 2016/17 and also exceeded their annual objective as shown in Chart 6. No of Post 72hr CDI cases Comparison of Total Number of Trust Post 72hr CDI cases for 2017/18 against 2016/ Sth Tyn CDD CHS GHFT NT&H Nth HC Sth Tees NUTH Foundation Trust / /17. 7

54 Chart 6 provides a comparison of the total count of post 72 hour CDI attributed to each Trust in the North East region against each Trust cumulative objective to Q4. To date six (6) of eight (8) FT s in the NE region including Gateshead Health FT exceeded their annual objective as opposed to during 2016/17 where three (3) of eight (8)Trusts exceeded their annual objective. Chart Comparison of NE Foundations Trusts CDI objective against actual apportioned cases 2017/18 No of Post 72hr CDI cases Sth Tyn FT NT&H FT GHFT CoD&D FT North HC FT CHS FT STees FT NUTH FT NE Foundation Trust Objective 2017/18 cases over objective 2.3 Meticillin Sensitive Staphylococcus aureus (MSSA) Blood Stream Infections (BSI) Reporting of MSSA BSI is a mandatory requirement and collated nationally by PHE for all Trusts however there are no established national improvement objectives to benchmark against. In terms of improving patient safety and continuous development a 10% internal performance improvement has been applied for 2017/18. Table 3 indicates the number of pre 48hr/community and post 48hr MSSA BSI attributable to the CCG and Trust against 2016/17 and reports eight (8) post 48hr cases to Q4 exceeding 2016/17 by 1 case. In addition the Trust reports forty (40) pre 48hr/community cases exceeding 2016/17 by seven (7) cases. 8

55 Table 3 Acute Trust Data Q1 Q2 Q3 Q4 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Monthly post 48hr MSSA BSI YTD /17 Actual = Community Data Q1 Q2 Q3 Q4 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Monthly pre 48hr/community MSSA BSI Chart 6 YTD /17 Actual = Chart 6 (ordered by post 48hr secondary care) provides a comparison of the total number of reported pre 48hr/community and post 48hr MSSA BSI by Foundation Trust in the NE region to Q4. Comparison of Pre/Community and Post 48hr MSSA BSI No. of pre & post 48hr MSSA BSI per trust Sth Tyne GH FT North H FT CD&D FT NT&H FT CHS FT STH FT NUTH FT NE Region Post 48hr MSSA Pre/community 48hr MSSA The chart is ordered by post 48hr cases Chart 7 demonstrates the rate of MSSA BSI acquisition per 100k bed days per Foundation Trust/CCG across the North East. Gateshead Health FT continues to remain one of the lowest reporting Foundation Trusts with a rate of 4.6 per 100k bed days post 48hr MSSA BSI. 9

56 Chart 7 Rate of Post 48hrs MSSA BSI per 100k bed days 2017/ Rate per 100k bed days GHFT North FT Sth Tyne FT Co DD FT Sth Tees FT CHS FT NT & H NUTH Ft Foundation Trust 3.0 GRAM-NEGATIVE BLOOD STREAM INFECTIONS (GNBSI) - ENGLAND ONLY A national ambition to reduce healthcare associated GNBSI by 50% by March 2021 was introduced from April The GNBSI targeted are E. coli, Klebsiella species and Pseudomonas aeruginosa with a specific focus on reducing Escherichia coli (E. coli) BSI nationally by 10% for 2017/18 and 2018/19 across the whole health care economy. This ambition presents a huge challenge for secondary care providers however presents an even greater challenge for the primary and social care economy. The following data representing E. coli, Klebsiella species and Pseudomonas aeruginosa clearly demonstrates that the largest proportion of these BSI occur within the primary and social care environment. 3.1 Escherichia coli BSI (E. coli) The Trust aims for an annual 10% performance improvement in line with the current national ambition reporting forty (40) post 48hr demonstrating an increase of 14% (5 cases) and one hundred and ninety nine (199) pre 48hr/community E.coli BSI cases to Q4 demonstrating an increase of 35%. These are as indicated in table 4 and Chart 8. 10

57 Table 4 Q1 Q2 Q3 Q4 Acute Trust Data Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar post 48hr E-coli BSI YTD /17 Actual = Community Data Q1 Q2 Q3 Q4 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar pre/community 48hr E-coli BSI YTD /17 Actual = Chart Annual count of pre/community and post 48hr E. coli BSI Combined No of E.coli reports / / / / / / /18 Financial Year Pre/community 48hr Post 48hr Linear (Pre/community 48hr ) Linear (Post 48hr). Chart 9 demonstrates the total count of Trust E. coli BSI data (Pre 48hr/community and post 48hr 2017/18) in comparison to other Trusts across the NE region representing actual patient infections and demonstrating Gateshead Health as one of the lowest reporting trusts within an increasing national trend. 11

58 Chart Comparison of Pre/community and Post 48hr E.coli BSI reports per NE Trust 2017/18 No. of E.coli BSI Sth Tyne FT GH FT Nth T& H FT Co D&D FT CHS FT Nth HC FT ST H FT NUT FT NE Region Post 48hr Pre/community 48hr The chart is ordered by post 48hr cases Chart 10 Chart 10 demonstrates a comparison of the total North East region FT E. coli BSI rate per 100k bed days to date for both pre/community and post 48hr reports clearly identifying primary care as a challenging area. North East Foundation Trust rate of E.coli BSI per 100k bed days 2017/18 Rate per 100k bed days CDDFT STFT NTHFT GHFT NoFT CHSFT STHFT NUTH Foundation Trust Post 48hr rate The chart is ordered by post 48hr cases 12

59 3.2 Pseudomonas aeruginosa BSI Pseudomonas aeruginosa is a common opportunistic Gram-negative pathogen often found in soil and ground water. It rarely affects healthy individuals however can cause a wide range of infections, particularly in those with a weakened immune system. In hospitals, the organism can contaminate devices that are left inside the body, such as respiratory equipment and urinary catheters. P. aeruginosa is also resistant to many commonly-used antibiotics. The Trust reports six (6) post 48hr and fourteen (14) pre/community 48hr P. aeruginosa BSI cases to date as indicated in table 5. Reporting for 2017/18 period has been voluntary and does not have any comparative data. Table 5 Q1 Q2 Q3 Q4 Voluntary Acute Trust Data Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Number of post 48hr P. aeruginosa BSI YTD 6 Q1 Q2 Q3 Q4 Voluntary Community Data Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Number of Pre 48hr P. aeruginosa BSI YTD 14 Chart 11 (ordered by secondary care) demonstrates the current annual rates per 100k bed days to date of all reported P. aeruginosa BSI with Gateshead Health reporting a post 48hr rate of 3.5 per 100k bed days. Chart North East Foundation Trusts rate of Pseudomonas aeruginosa BSI 2017/18 Rate per 100k bed days CDDFT STyFT NTHFT NoFT GHFT NUTH CHSFT STHFT Foundation Trust Post 48hr rate Pre/community 48hr rate 3.3 Klebsiella species BSI The chart is ordered by post 48hr cases Klebsiella species are a type of gram negative rod shaped-bacteria that are found ubiquitously in the environment and also in the human intestinal tract and are commonly associated with a range of healthcare-associated infections. In healthcare settings, Klebsiella infections are seen in vulnerable, 13

60 Table 6 immunocompromised and unwell patients who have other co-morbidities and who are receiving treatment for other conditions. Reporting for 2017/18 period has been voluntary and does not have any comparative data. The Trust reports eleven (11) post 48hr and forty three (43) pre 48hr/community Klebsiella BSI cases to date as indicated in table 6. Q1 Q2 Q3 Q4 Voluntary Acute Trust Data Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Number of post 48hr Klebsiella spp. BSI YTD 11 Q1 Q2 Q3 Q4 Voluntary Community Data Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Number of Pre 48hr Klebsiella spp. BSI YTD 43 Chart 12 (ordered by post 48hr secondary care cases) demonstrates the current rate of all reported Klebsiella spp. BSI with Gateshead Health as one of the lowest post 48hr rates at 6.4 per 100k bed days. Chart NE Foundation Trusts Rate of Klebsiella spp BSI 2017/18 Rate per 100k bed days GHFT CDDFT NoFT STFT CHSFT STHFT NTHFT NUTH Foundation Trust Post 48hr rate Pre/community 48hr rate The chart is ordered by post 48hr cases 14

61 4.0 Influenza Activity Chart 13 Influenza is a highly infectious, acute viral respiratory tract infection which has a usual incubation period of one to three days. Annual surveillance of Influenza activity has been implemented in the Trust since week 40. The Trust has seen a significant 478% increase in identified positive cases against 2016/17 with a substantial increase in identified influenza B cases. To date the Trust reports five hundred and sixty seven (567) confirmed positive cases of which three hundred and forty eight (348) were identified as influenza A and two hundred and nineteen cases (219), influenza B. Public Health England reported that influenza activity continues to circulate, although decreases are noted across most indicators. The Infection Prevention and Control Team and Consultant Clinical Microbiologists have been providing consistent advice and guidance with regard to patient and bed management on a daily basis. All hospitalised influenza cases and close contacts identified as inpatients have and continue to be treated in line with national guidance and all infection prevention and control precautions are being implemented to ensure patient and staff safety remains a top priority. Chart 13 demonstrates the current confirmed positive influenza cases against the previous two years Influenza data demonstrating that influenza activity increased significantly from week 51. This is similar to the national trend as reported by Public Health England in chart Gateshead FT confirmed Influenza Case Surveillance 567 cases (348 Flu A 219 Flu B) 102 Influenza reports Wk 40 Wk 41 Wk 42 Wk 43 Wk 44 Wk 45 Wk 46 Wk 47 Wk 48 Wk 49 Wk 50 Wk 51 Wk 52 Wk 01 Wk 02 Wk 03 Wk 04 Wk 05 Wk 06 Wk 07 Wk 08 Wk 09 Wk 10 Wk 11 Wk 12 Wk 13 Wk 14 Wk 15 Wk 16 Wk 17 Wk 18 Wk 19 Wk 20 Wk /16 Total 2016/17 Total 2017/18 Total 15

62 Chart 14 provided by PHE demonstrates the weekly rate and trend across England of hospitalised influenza cases to date per 100k population. Chart PERIODS OF INCREASED INCIDENCE (PII) AND OUTBREAKS Table 7 An outbreak is the occurrence of two or more actual or potentially related infections within a ward/department/area of practice within the Trust. This is also referred to as a Period of Increased Incidence (PII) for clusters of known/unknown infections. The Trust has experienced six (6) PII to Q4 however has seen a significant increase in the number of confirmed influenza hospitalisations as described above in addition to a small number of areas affected by Norovirus. Table 7 indicates the number of PII by month to Q4 against 2016/17. Outbreaks & Periods of Q1 Q2 Q3 Q4 Increased Incidence (PII) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2017/ YTD /17 Actual =

63 Chart Period of Increased incidence/outbreaks reported No. of reported PII / / / / /18 Year Mr Philip Pugh Head of Infection Prevention and Control 17

64 Trust Board Report Cover Sheet Agenda Item: 11 Date of Meeting: Report Title: Purpose of Report: Trust Goals that the report relates to: (Including reference to any specific risk) Wednesday 25th April Quarterly Mortality Report To present the Quarterly Mortality report and proposed framework Decision: Discussion: Assurance: Information: Goal 3 In all locations and settings of delivery, our patients will experience excellent, timely and seamless care that meets their individual needs. Goal 4 All our services will have a high safety culture in which openness, fairness, accountability and learning from high levels of incident reporting and mortality reviews is the norm. Recommendations: (Action required by Board of Directors) Financial Implications: Risk Management Implications: Human Resource Implications: Trust Diversity & Inclusion Objective that the report relates to: (including reference to any specific implications and actions) Goal 5 All our services will be effective: we will reduce unwarranted variation, ensure our practice is consistent with recognised best practice 7 days a week, and improve outcomes for patients. To receive the report for assurance Learning from deaths and reducing risk has the potential to reduce the volume of financial claims received by the Trust. Monitoring, review and learning from deaths is essential to ensure the Trust can identify areas of risk and reduce potential risk. No Objective 1 All patients receive high quality care through streamlined accessible services with a focus on improving knowledge and capacity to support communication barriers.

65 Author: Presented by: Andrew Ward, Senior Information Analyst Quality and Patient Safety Mr Andy Beeby, Medical Director

66 Quarterly Mortality Report Document Map: 1 Introduction 2 National summary/update 3 Trust based analysis and trending of data 4 Acting on mortality & morbidity surveillance 5 Trust Mortality Database and Learning From Death 6 Conclusion 7 Recommendation 1. Introduction: The purpose of this paper is to update the board upon on going work in relation to mortality within Gateshead Health NHS Foundation Trust. Within the paper is an update on the Summary Hospital-level Mortality Indicator (SHMI) which is the national mortality ratio score developed for use across the NHS and the Hospital Mortality Standardised Ratio (HSMR) provided by Healthcare Evaluation Data (HED). This paper also contains an update regarding Learning from Deaths as set out in the Learning from Deaths Guidance published by the National Quality Board in March The National Picture: The latest SHMI update was published on the 22 nd March 2018 covering the period from October 2016 to September The Trust remains with the SHMI Banding of As Expected with a SHMI score of 1.00 Time period SHMI Score SHMI banding October 2016 to September As Expected July 2016 to June As Expected April 2016 to March As expected January 2016 to December As expected October 2015 to September As expected July 2015 to June As expected April 2015 to March As expected January 2015 to December As expected October 2014 to September As expected July 2014 to June As expected April 2014 to March As expected January 2014 to December As expected October 2013 to September As expected

67 The table below is supporting information displayed on the NHS choices indicator website that is used to support the SHMI statistic. The latest information is displayed alongside the figures for the previous SHMI calculation to enable comparison. Supporting information Current Period Jul-16 to Jun-16 Previous Period Jul-16 to Jun-17 Number of deaths observed Number of deaths expected by SHMI calculation Percentage of deaths with palliative care coding by specialty and or diagnosis % (282 out of 1,494 deaths) 16.68% (251 out of 1,505 deaths) Percentage of deaths in hospital 71.22% 71.36% Percentage of deaths outside of hospital 28.78% 28.64%

68 Comparing to local Trusts, Gateshead Health NHS Foundation Trust has the third lowest SHMI of North East Trusts for this period.

69 3. Trust based data analysis: The chart below illustrates the Trusts monthly trend in HSMR from January 2016 to January The HSMR is a risk based assessment using a basket of 56 conditions which account for approximately 80% of all deaths nationally. The Trust mortality rate using this indicator shows that the monthly HSMR has remained within the expected range since September To add further context the below information displays the HSMR achieved at neighbouring Trust s for the last 12 months available between January 2017 and December The Trust HSMR is for this period, when compared to peers the Trust is fifth of the eight trusts within the local peer group and showing more deaths than expected.

70 Four Trusts (South Tyneside, Sunderland, South Tees, and Gateshead) have a high HSMR with more deaths than expected; the remaining Trusts have deaths within the expected range. South Tyneside is a frequent outlier due to the inclusion of activity from the St Benedict s Hospice. Analysing the Trusts HSMR identifies four clinical classification system groups with a high HSMR and showing significantly more deaths than expected. These also feature within Section 4 Mortality Surveillance. Cancer of the Bronchus: Lung (40 deaths: 21.6 expected) Acute Bronchitis (27 deaths; 16.8 expected) Peripheral and Visceral Atherosclerosis (26 deaths; expected) Non-Hodgkin s lymphoma (6 deaths; 1.24 expected) The volume of in hospital deaths by month is provided in the chart below for the period between March 2016 and March The number of in-hospital deaths remained relatively low during the summer months with an increase observed over the winter period. In recent months the volume of deaths has reduced to typical levels observed for the time of year. Inpatient deaths by day of admission Data from HED shows that the HSMR higher for deaths associated with weekday admissions however both weekday and weekend admissions had deaths within the expected range.

71 4. Acting on mortality & morbidity surveillance CQC Alert Request for Information The Trust has received a letter from the CQC following an Alert for Peripheral and Visceral Atherosclerosis. The alert was picked up following monitoring of the CQC insights report and work was undertaken as outlined in the mortality report last month and the following actions identified regarding the clinical coding. Education for coders re. Vascular coding. Education for clinicians relating to documentation of vascular conditions. A business intelligence report to be developed to keep track of K55 Vascular disorders of intestine and I73.9 Peripheral vascular disease. Liaising with consultants in a proactive manner regarding the coding for patients with peripheral and visceral atherosclerosis. The Trust is reviewing 28 patients identified with the clinical classification of Peripheral and Visceral Diagnosis and coordinating a response to the CQC letter. Referencing the Trusts mortality database indicates all but two patients had a Hogan score of 1 (definitely not preventable); one case is awaiting and Root Cause Analysis / Complaint investigation; and one patient had a Hogan score of 3 Possibly preventable (less than 50:50) CuSum Alerts The CuSum is a statistical process control (SPC) technique which provides focus on the outcome trend of a series of consecutive procedures. It is designed to allow prompt detection of changes in performance reflected by persistent deviation to an acceptable and expected rate of adverse outcomes.