Philip Hall Joanne Hay Ajay Mehta Judith Rutherford Bindesh Shah. Ella Jaczynska Fiona McKenzie

Transcription

1 Title: Hounslow and Richmond Community Healthcare NHS Trust Board of Directors part I meeting (public) Date: Wednesday, 28 March 218 Time: 1.am 12.45pm Location: Conference rooms 1 & 2, Thames House, 18 Teddington High Street, Teddington TW11 8HU Membership of the Board Non-Executive Directors: Stephen Swords (Chairman) Philip Hall Joanne Hay Ajay Mehta Judith Rutherford Bindesh Shah Board Advisor: Executive Directors: In attendance: NHS Improvement NExT Director scheme Observers: Ginny Colwell* Patricia Wright, Chief Executive Monique Carayol, Director of Transformation* Stephen Hall, Director of Clinical Services (Richmond and South West London) David Hawkins, Director of Finance & Corporate Services Alison Heeralall, Director of Workforce* Donna Lamb, Director of Nursing and Non-Medical Professionals Dr Tony Snell, Interim Medical Director Anne Stratton, Director of Clinical Services (Hounslow and North West London) Swarnjit Singh, Trust Secretary Fiona Harcombe, Head of Communication* Ella Jaczynska Fiona McKenzie Paul Pegden Smith, Healthwatch Richmond Sue Charteris, Healthwatch Hounslow *non-voting Board members Enquiries: Swarnjit Singh, Trust Secretary Telephone swarnjit.singh@hrch.nhs.uk Issue date: 21 March 218 Page 1 of 2

2 Agenda: Part I Time Item Title Lead 1. 1 Welcome and apologies SS Declarations of interest If any member of the board has an interest in any of the items on the agenda, they must declare these at, and if necessary withdraw from the meeting. The register of interests is available at SS Patient story Richmond Rapid Response & DL / SH Rehabilitation service Minutes of the part 1 board meeting held on 31 SS January Chairman s report SS Chief Executive s report PW Governance / well-led Finance & Performance Committee, 16 March 218 BS Charitable Funds Committee, 15 March 218 AM Quality Governance Committee, 13 March 218 AM Audit & Risk Committee, 8 February 218 PH Quality Journey to Outstanding programme DL /19 Quality priorities consultation DL Patient & Public Engagement strategy DL Learning from deaths dashboard TS Information Governance Toolkit declaration DH People NHS staff survey outcome AH Gender pay gap reporting AH Other Any other business SS Questions received from the public SS Information items Board performance scorecard February 217 n/a Finance report February 217 n/a Board forward plan n/a Page 2 of 2

3 Meeting title Trust Board part I meeting Date: 28 March 218 Report title Patient Story Discharge to Assess from Kingston Hospital Agenda item: 3 Lead director Report author Executive summary Stephen Hall, Director of Clinical Services, Richmond and South West London (SWL) Jeanne Davey, Richmond Response and Rehabilitation Team (RRRT) Service Manager RRRT work across the borough of Richmond, providing three key roles: 1. Safe and timely hospital discharges 2. Prevention of hospital admission 3. Rehabilitation in the community As part of the safe and timely discharge from acute hospitals, we have introduced a pathway called, Better at Home or Discharge to Assess. This involves the patient being deemed medically optimised, screened for risk assessment, discharged home and assessed within the home environment. We have invited a patient who experienced this process to facilitate a discharge from A&E. This expedited the discharge without an unnecessary assessment in A&E. The patient was successfully discharged to the care of her brother, and reviewed at home the following day. The patient has received reablement care from the providers and regular reviews from RRRT occupational therapist. Purpose: Noting Recommendation(s) Board members are asked to note the report. BAF/TRR Report history Appendices P3 Engagement with patients, public and stakeholders. None None

4 Minutes of the Hounslow and Richmond Community Healthcare NHS Trust board s part I meeting held on Wednesday, 31 January 218 Present: Stephen Swords, Non-Executive Director (Chairman) Monique Carayol, Director of Transformation* Philip Hall, Non-Executive Director Stephen Hall, Director of Clinical Services (Richmond and SW London) Joanne Hay, Non-Executive Director Alison Heeralall, Director of Workforce* Christine Jordan, Acting Assistant Director, Quality & Clinical Excellence Ajay Mehta, Non-Executive Director Judith Rutherford, Non-Executive Director Bindesh Shah, Non-Executive Director Dr Tony Snell, Interim Medical Director Anne Stratton, Director of Clinical Services (Hounslow and NW London) Bridget Welch, Assistant Director, Finance Patricia Wright, Chief Executive (* non-voting attendees) In attendance: Swarnjit Singh, Trust Secretary Fiona Harcombe, Head of Communication and Engagement NHS Improvement NExT Director scheme participants: Ella Jaczynska Fiona McKenzie Observer: Paul Pegden Smith, Healthwatch Richmond Welcome and apologies Stephen Swords extended a warm welcome to attendees, particularly to Denise Carr, Chair of Richmond Mencap. Apologies for absence were noted for Ginny Colwell, Board Advisor, Donna Lamb, Director of Nursing & Non-Medical Professionals, David Hawkins, Director of Finance & Corporate Services and Sue Charteris, Healthwatch Hounslow. Declarations of interest There were none reported in addition to those already recorded in the publicly-available register. Patient story This item was deferred to the next meeting. Page 1 of 1

5 Annual report on patient stories The Assistant Director, Quality & Clinical Excellence, explained the report acknowledged the professionalism and compassion which patient stories had identified and this had been shared learning with staff in those services. In addition, themes had been identified to help improve patents experience of the services the trust provided: communication between different healthcare organisations; support for patients as they navigated through different providers of care; and, ensuring people were aware of the full range of services provided by the Trust. Board members raised the following points: Judith Rutherford welcomed the report and the themes identified to help share lessons. The Director of Clinical Services, SWL, provided assurance that the Trust would continue to fund the Parkinson s Nurse Care service post. In reply to query from Philip Hall, the Director of Transformation confirmed that the aim was to provide more routine reporting on locality working and transformation in both main local boroughs, in order to give assurance and evidence of a patient-centred approach Bindesh Shah suggested that, a You said, we did, style communication be issued widely to staff and other stakeholders on actions taken 4.3 The Board: i. agreed the actions set out to develop further the collection and sharing of patient stories across all services; ii. agreed that a You said, we did communication be issued; iii. agreed that confirmation be provided that the respective patients had been informed of the actions taken in response to them sharing their feedback with the Trust; and iv. sought assurance that information provided to patients and the public on the range of health and social care and third sector local bodies available met patients needs Minutes of the Board meeting held on 29 November 217 The following amendments were suggested: i. section 8.2 in the final sentence, insert the words were being monitored since the Patient-Led Assessment of the Care Environment inspection; and ii. section 1.2 in the final sentence of the first bullet point, insert the words based on good performance against the 12 week target following weeks The Board approved the amended minutes of the previous meeting as a correct record. Paul Pegden Smith confirmed that he had received briefing information sought from the Director of Finance. Page 2 of 1

6 5.4 The Board noted the updated action log Chairman s report The report was taken as read. Stephen Swords highlighted concerns observed during a visit to the Brentford District nursing service. He drew attention to the persistent pressures faced by the team, which also had a palliative caseload, as unviable in the long term and sought assurance on the actions being taken to support staff health and wellbeing. The Director of Clinical Services, NWL, confirmed that a number of actions were being taken including staff from the Princess Alice hospice supporting Trust teams; and, a specific piece of work to help understand the pressure on district nursing teams for which a workshop was being held with members of the Quality Governance Committee on 6 February. In reply to a question from Joanne Hay, the Director of Clinical Services, NWL, agreed that clinical supervision would help to support people when reviewing and discussing cases, on an individual and team basis. The Board noted the report. Chief Executive s report The report was taken as read. The Chief Executive highlighted: assurance that the Trust had no contracts with Carrillion Plc and there was no impact upon its services to patients following the support services business going into administration. the NHS would be 7 years old on 5 July 218 and the Trust was looking to hold its annual general meeting and open days around this date as part of the celebrations taking place nationally of the service s achievements. the considerable pressures across the service this winter and the excellent local working with partners in A&E Delivery Boards and at Kingston and West Middlesex University Hospitals as part of whole system integrated care. She thanked staff in the Trust s rapid response teams for their contribution to this work. the successful campaign to vaccinate frontline staff against winter flu which had met the 7% national target. She gave thanks, in particular, to Sheila Roberts, Immunisation Lead in the School Nurse and Child Health team, who was a real clinical champion in the campaign 7.2 In reply to a question from Judith Rutherford, the Director of Clinical Services, SWL, confirmed that no beds were closed at the Teddington Memorial Hospital s inpatient unit as a result of the recent norovirus outbreak and that one patient, with the norovirus, was being treated in a sideroom which was normal practice. Bindesh Shah welcomed the fact that Trust services were not impacted by the collapse of Carrillion and suggested the Finance & Performance Committee reviewed all of the Trust s outsourced contracts in order to provide assurance to the Board. Page 3 of 1

7 7.3 The Board received and noted the report. Board members agreed the Finance & Performance Committee review all outsourced contracts Workforce and Education Committee Joanne Hay, Committee Chair, drew attention to the following: Assurance that both Board Assurance Framework risks were being effectively-mitigated. While performance against the staff sickness indicator was red, this was within control limits. The increase was a reflection of seasonal factors and was being kept under review. Good work to implement e-rostering quickly across the organisation. Case studies to promote learning in areas of success across the sector. In reply to a question from Ajay Mehta, the Director of Workforce explained the collective executive responsibility for collaboratively ensuring that statutory and mandatory training data was accurate and timely. She provided assurance that the investment in in the WIRED2 would provide a better quality system going forward. The Director of Clinical Services, SWL, reported that the Finance & Performance Committee had reviewed a trajectory for statutory and mandatory training which showed the year end outcome as just under the 85% target. He provided assurance that action was being taken to achieve the target by 31 March. The Director of Workforce clarified to Ajay Mehta that the e-rostering had impacted on safer services through the better rostering of service teams and through reduced expenditure on agency staff, although there were other factors which contributed to the latter. The Board noted the report. Finance and Performance Committee Bindesh Shah, Committee Chair, took the report as read. He alerted Board members to the following: Financial outturn was very much on track and all staff involved in achieving that position were commended The 218/19 cost improvement programme target represented a significant challenge In terms of exception reports considered, the Committee had asked that the Board Advisor review the actions being taken to address falls. It would also continue to keep performance against sickness absence under close review, including a better understanding of the underlying factors and actions being taken It was important to have real metrics to help demonstrate the impact of significant organisational projects such as e-rostering 9.2 Judith Rutherford asked about the monitoring taking place to ensure services were safe and that staff were supported. The Director of Clinical Services, Page 4 of 1

8 NWL, outlined controls in place such as the safe staffing tool used to determine appropriate staff for shifts, the use of indicators e.g. falls and team leaders assessments of whether an individual services was safe. The Director of Clinical Services, SWL, reported staff had welcomed the provision of yoga and massage classes and confirmed the availability of a staff counselling service, if required, to also support staff health and wellbeing. In reply to a query from Paul Pegden Smith, Bindesh Shah reported that potential areas of investment were being considered for both short and oing term projects, particularly those which could assist staff recruitment and retention. The Board noted the report. Quality Governance Committee The report was taken as read. Ajay Mehta, Committee Chair, reported that a recruitment exercise was underway for a successor Freedom to Speak up Guardian and that the Committee would monitor the next steps and learning from the annual report of patient stories. Board members discussed the benefits provided by the different types of data available to better help map services to identified local priorities such as the Joint Strategic Needs Assessments carried out at borough level. The Medical Director highlighted the importance of locality working in providing this information through practice nurses, GPs, social services and third sector providers who knew the locality. He also drew attention to the need to present to the Quality Governance Committee on the outcome of Quality Impact Assessment of 218/19 cost improvement programme schemes to ensure there was no adverse impact upon the quality of services. The Board noted the report. Charitable Funds Committee Stephen Swords, Committee Chair, took the report as read. In discussion, Board members highlighted the benefits from the introduction of the red bag scheme such as an improved discharge experience and pathway for patients as well as reduced length of stay. The Board noted the report. Audit & Risk Committee The report was taken as read. Philp Hall, Committee Chair, reported that significant assurance was taken from all substantive agenda items with the exception of clinical audit. It was agreed to ask the Quality Governance Committee to monitor arrangements on a six-monthly basis to be assured on that effective processes were in in place and that learning from audits was being acted upon. The Medical Director concurred. He updated Board members regarding the appointment of a new Head of Clinical Audit who would take forward the programme of work and also reported that clinical audit training was being provided for 12 staff. Judith Rutherford asked that details for booking onto Page 5 of 1

9 the clinical audit training be shared with non-executive directors The Board noted the report and agreed that details of the clinical audit training programme be provided to non-executive directors. 217/18 Strategic objectives: quarter three delivery The Director of Transformation took the report as read. She highlighted the need for a commentary only update for indicators not due to be reported on in this quarter and the red-rating for the Journey to Outstanding programme which would be picked up under that agenda item. Philip Hall pointed out the need for the paper s commentary to explain the improved position in the community nursing redesign programme since September 217. The Board noted the report. Nursing establishment review The Director of Clinical Services, SWL, presented the report. It was a national requirement for NHS Trust Boards to be sighted every six months on compliance with safe staffing guidance. The report as considered at the March meeting of the Quality Governance Committee and assurance was provided to Board members that the Trust had met the safe staffing levels stipulated in the guidance, at all times. In addition, the Director of Clinical Services, SWL, highlighted good performance on key indicators for the inpatient unit: 92% of staff had received an annual appraisal; there was a % vacancy rate and 84% of staff had completed their annual statutory and mandatory training requirements. Judith Rutherford welcomed the encouraging outturn. The Board noted and received the report. Board members agreed that the Teddington Memorial Hospital inpatient unit met agreed safe staffing levels. Emergency Preparedness Resilience & Response (EPRR) assurance review 217 The report was taken as read and the Director of Clinical Services, NWL, highlighted the following points: The Trust was deemed to be substantially compliant following the very thorough, annual review by NHS England of the Trust s emergency preparedness arrangements Some minor changes to policies were being made and amber-rated areas of the assessment were being worked on for next year s assessment, including the consolidation of training for managers included in on-call arrangements 15.2 The Chief Executive observed that this process was designed very much around acute hospitals NHS Trusts. She provided assurance the Trust participated well with partner bodies in local emergency preparedness planning and that its risk was relatively low in comparison with acute hospitals. In reply to a question from Bindesh Shah, the Director of Clinical Page 6 of 1

10 Services, NWL, confirmed that business continuity plans were all reviewed externally in The Board of Directors approved the self-assessment rating and associated action plan (at appendix A) and noted the amendments to other documents which contribute towards the Trust s emergency preparedness and resilience. Journey to outstanding (J2O) programme The Acting Assistant Director, Quality, presented the report and drew Board members attention to the following: The updated report included actions from the self-assessment of core services Work was taking place with the medicines management and risk and incident teams and also infection prevention and control colleagues so that additional assurance could be provided on the robustness of information The Peer review programme would continue throughout February A workshop on community nursing was being held with non-executive members of the Quality Governance Committee on 6 February This month the J2O Delivery Board had focussed on the well-led domain and identified actions to help improve the Trust s rating from requires improvement to good During discussion, Board members highlighted these points: In reply to a question from Judith Rutherford on the common actions that could be implemented to help services, the Acting Assistant Director, Quality, advised that a standardised template for service team meetings had been produced The Director of Clinical Services, SWL, reported that, in addition, a suite of information was produced for a dashboard of quality indicators covering incidents, complaints, falls and clinical supervision The Medical Director raised a key concern in that the Trust needed to evidence a golden thread from board to ward and to also provide more assurance, at a governance level, of the matters considered by the Quality & Safety Committee The Chief Executive queried the data on page seven showing actions completed by service teams and its RAG rating The Acting Assistant Director, Quality, also confirmed that teams had been very self-critical in their peer reviews and were challenged to produce evidence which underpinned their self-assessment The Board: i. noted the progress to date in the Journey to Outstanding programme reporting pack; and ii. agreed that confirmation be provided of the data and RAG rating Page 7 of 1

11 contained on page 7 regarding actions completed by service teams Public sector equality duty report The Director of Workforce reminded Board members of the requirement contained in the Equality Act (21) for publicly-funded bodies to annually publish a report to evidence how they had advanced equality for staff and service users. She explained the report had been agreed by the Equality & Diversity, Workforce & Education Committees and was here for final approval, prior to publication on the Trust s web pages. During discussion, Board members raised the following: Bindesh Shah queried data in table 6 which showed no patients from a Hindu religious background and asked whether work had been carried out to look at the access to Trust services by different groups in the local community. The Director of Workforce confirmed the action plan contained a specific action to look at access to services and she would feed back this query to the Director of Nursing. The Chief Executive added that access to Trust services by different groups in the local population would also be discussed with local commissioners to help fully understand the situation Bindesh Shah also drew attention to the outcomes for black and minority ethnic (BME) applicants with less being successful at shortlisting and appointment stages The Chief Executive commented that the less successful outcomes for BME and disabled applicants during recruitment were well-known and that unconscious bias training had been provided for recruiting managers Bindesh Shah asked whether Healthwatch Hounslow had provided any feedback on the patient aspects of the report Ajay Mehta highlighted a need to collect and analyse data for all nine of the protected characteristics contained in the Equality Act (21) and that this was necessary particularly to understand patient outcomes and patients access to services and that any gaps in coverage should be accompanied with appropriate commentary. The Director of Workforce confirmed that collecting patient data was not an issue with SystmOne and that actions would include training for staff on collecting this personal data as well as working more closely with primary care services so that this information was contained in a patient s record at the outset Ajay Mehta suggested addressing the distribution of staff ethnicity across pay bands would benefit from holding an annual talent management exercise and suggested that the action plan needed to contain a RAG rating In reply to a query from Ajay Mehta regarding the effectiveness of the Equality & Diversity Committee, the Director of Workforce said that there was an action to review the committee s co-ordination and its identification of the good practice happening across the Trust. The Chief Executive commented that it was important for the Committee to Page 8 of 1

12 help drive this agenda and that, as part of the review of executive committees, it was important to embed equality and diversity considerations across the Trust The Director of Workforce also confirmed to Bindesh Shah that the Trust had no staff who self-reported as transgender The Board: i. agreed the annual public sector equality duty report for publication on the Trust s web pages; ii. agreed that data relating to patient s religious backgrounds be verified prior to publication; iii. agreed on the need for the action plan to have a specific action which looked at patient access and that this be fed back to the Director of Nursing; iv. agreed the report include commentary to explain the reasons for any gaps in monitoring and publishing patient diversity and also actions going forward to close this gap; v. agreed that feedback from Hounslow Healthwatch be sought; and vi. agreed delegated authority for the Trust Chairman, Bindesh Shah, Ajay Mehta and the Director of Workforce to agree the action plan prior to its publication Board forward plan The Chief Executive pointed out that there would be a number of reports for the May Board meeting and that draft reports would be brought to the March Board insofar as possible for instance the 217/18 Annual Report so that content was signed off as early as possible. The Board noted the report. Any other business There was none. Questions received from the public The following questions were received 1. Did HRCH Trust take any action (and if so what and when) between April 217 and September 217, to overturn the previous Trust Board decision not to conduct any level of DBS check on any administrative staff at the Trust in light of the publication on 24 April 217 of the NHS Employers Online DBS check eligibility tool* and the embedded scenario based role examples**? 2. On 1 December 217, Ms Heeralall wrote a letter to the CQC which explained that the Trust have identified the need for some changes to the roles requiring standard or no checks in light of new advice, which she explained was published in September 217***, and explained that the Trust is taking the necessary action to ensure that we comply with the new standards. What new DBS standards (or regulatory changes) were introduced or amended in the September 217 NHS Employers update, Page 9 of 1

13 requiring HRCH Trust to make changes to DBS check procedures for staff? 2.2 The Director of Workforce read out the following response: The Trust would take questions 1 and 2 together as follows: In respect of both questions, the Board is aware that the Trust has responded to these in part already, in respect of the questioner s query via a Freedom of Information request on the question of whether or not the Trust Board had at some date in the past made a decision not to conduct DBS checks on administrative staff at the Trust. We have previously confirmed that the Trust has no record of such a decision, and therefore there has been no Board decision on the point which has been overturned. In respect of the question about DBS process between April 217 to present, this is contained in the Trust response to the CQC on 1st December 217 which acknowledges the need for review and the action taken since. The relevant extract from our response to the CQC is as follows: This new guidance has been communicated to the Trust s recruitment team who have in turn reviewed their practice to include a secondary check of the type of DBS disclosure the recruiting manager has identified on TRAC. The new guidance has also been communicated at Executive level to inform and agree any actions required by the Trust to comply with the new DBS standards. A proposed list of roles, typically in place in the community setting, has been produced together with guidance as to the level of disclosure (if at all) required for each role. This list is in the process of being agreed as part of the policy review to assist both recruiting managers and the recruitment team, in conjunction with the NHS Employer s DBS Eligibility tool. We confirm that the Trust has been reviewing its policy on this, and is anticipating Trust approval in February 218. The Trust is happy to forward to the questioner a copy of the approved policy when this is ratified MEETING REVIEW The following comments were received: well-chaired very understandable and very thorough Page 1 of 1

14 Action log, 31 January 218, part I Board meeting: Item Action(s) required Lead(s) Progress update Status Patient story 1. Implement a template to collect stories and subsequent learning DL Communciations have agreed to share a standard template to collect patient stories in a way which ensures story gathering is Open done in an objective and open way. This will be discussed at May QSC 2. Establish a central repository for patient stories 3. Issue a You said, we did communication 4. Confirm that respective patients whose stories featured at the Board had been informed of actions taken in response DL DL DL Use of the standard template would result in a central repository. We currently have Board patient stories and those from Always Events held centrally The Learn and Share newsletter already includes patient feedback; this will include Board patient stories from April 18. Completed Closed Closed Closed Chief Executive report Finance & Performance Committee to review all outsourced contracts DH To be considered at the Committee s May 218 meeting Open till May Audit & Risk Committee Provide details of the clinical audit programme to Non-Executive Directors TS/DL Completed - planners for clinical audit programmes for and children s and adult services were ed to Board members on 21 March Closed Journey to Outstanding programme Provide confirmation of the data and RAG rating contained on page 7 regarding actions completed by service teams DL Programmer reporting pack has been revised to reflect this action. Closed 1

15 Item Action(s) required Lead(s) Progress update Status Public sector equality duty report 1. Publish the report on the Trust s web pages, having verified data relating to patient s religious backgrounds and included commentary to explain the reasons for any gaps in patient diversity monitoring and also actions going forward to close this gap AH Completed Closed 2. Seek feedback from Sue Charteris of Hounslow Healthwatch SS Completed Closed 3. In the action plan, include a specific action which looked at patient access and feed this back to the Director of Nursing AH Completed, wording amended and fed back to Director of Nursing and Directors of Clinical Services to progress together. Closed 4. Delegated authority agreed for the Trust Chairman, Bindesh Shah, Ajay Mehta and the Director of Workforce to agree the action plan. SS, BS AM, AH, DL The revised action plan is due to be brought to the May Board meeting following consideration of proposed workforce actions at April s Workforce and Education Committee and patient actions at the May Quality Governance Committee meeting. The actions will also respond to areas identified for improvement in the assessment of patient and workforce performance with local stakeholders for the NHS Equality Delivery System. Open to May 218 2

16 Meeting title Trust Board part 1 meeting Date: 28 March 218 Report title Chairman s report Agenda item: 5 Lead director Report author Executive summary Stephen Swords, Chairman Swarnjit Singh, Board Secretary Treat Me Well I wanted to draw the attention of Board members to launch on 16 February 218 in Richmond of Mencap s Treat Me Well campaign which I attended. This was a launch of a campaign designed to transform how the NHS treats people with a learning disability through simple adjustments which can really impact positively on improving patient access and experience of healthcare services. Further details about this exciting and important campaign can be located via the link shown at the bottom of this page. In particular, examples of reasonable adjustments highlighted include the following: using more simple language or communication aids allowing extra time for appointments providing written information in an accessible format (such as easy read) I have invited Denise Carr, Chair of Richmond Mencap, to present at a future part I Board meeting on this campaign and learn more on how the Trust can rise to the challenge and meet the requirements set out for people with a learning disability who use our services and their wider access to healthcare. Purpose: Noting Recommendati on BAF/TRR Board members are asked to receive and note the report. None Report history Not applicable Appendices Link to Treat Me Well campaign document: IGITAL.pdf Page 1 of 1

17 Meeting title Trust Board part 1 meeting Date: 28 March 218 Report title Chief Executive s report Agenda item: 6 Lead director Patricia Wright, Chief Executive Report author Swarnjit Singh, Board Secretary Executive summary Board members are provided with a summary of national, regional and local developments. Purpose: To provide the Board with the Chief Executive s update on significant developments and key issues at a national, regional and local which impact upon community services. Recommendation Board members are asked to receive and note the report. BAF/TRR W1, W2, S1 Report history Not applicable Appendices None Page 1 of 4

18 1. National news A review of children and young people s mental health services 1.1 On 8 March 218, the Care Quality Commission published its independent review 1 of the system of services that support children and young people s mental health. It found that that many children and young people experiencing mental health problems did not receive the kind of care they deserved. This is an interesting report which has implications for the Trust s delivery of community services to children and young people we will seek to ensure that the Trust plays its part with local health and social care organisations to deliver a clear local offer of the care and support available to children and young people. Delayed transfers of care 1.2 On 14 March 218, NHS Improvement published a newly-developed improvement tool 2 to help NHS providers see where delayed transfers of care occurred in your system. It brings existing provider and local authority data together into an easy-to-use dashboard that shows where the biggest delays are and allows trusts to track the progress of any actions taken. The Trust will seek to utilise this helpful resource to ensure that there are no delayed patient transfers of care to other providers and to support transfers from the local acute trusts to Teddington Memorial Hospitals or patient s own homes. Meeting of NHS CEOs with Ian Dalton and Simon Stevens 1.3 NHS CEOs met with senior staff in NHSi and NHSE on 13 March 218 for briefings on the state of the NHS, progress with delivering the Five Year Forward View an update on improvement support available from NHSi and joint working between NHSi and NHSE. The Boards of both organisations will be considering proposals about how they can work more closely together at their meetings later this month. 2. Regional news 218 local elections purdah considerations for NHS providers 2.1 Purdah is the term used across central and local government to describe the period of time immediately before elections (or referendums) when specific restrictions on the activity of public servants are in place. The key consideration is to stop the announcement of activities by public bodies which could influence or be seen to influence the election outcome. For the purposes of the current local elections in England, purdah will start on 27 March and ends on 4 May 218. From a practical viewpoint, the Trust will adhere to the purdah guidance and not undertake any activity which could be seen as influencing the election outcome. In line with guidance, the Trust will, however, hold its Board meeting on 28 March and will ensure the agenda will be confined to matters which need a Board decision or oversight Page 2 of 4

19 Health Innovation Network (HIN) Board Round-up 2.2 On 28 February 218, the first Health Innovation Network Board meeting was held. It included an important update on the NHS England re-licensing process and the new national activities being undertaken by the HIN as well as an update on the creation of a more accessible version of the business plan, to be shared more widely. The meeting also featured presentations on digital and population health and improving public health in South London from Kevin Fenton, Director of Public Health in Southwark, as the Board gave thought to the development of a compelling vision for South London over the next five years. Requires improvement (RI) to Good 2.3 Ten members of the trust senior team attended a workshop on 5 March with NHSi (London) and CQC for an update on the regulatory regimen, including how to prepare for the Well-led assessment, and an opportunity to hear from trusts who had moved from RI to Good or Outstanding. The information from the day will be built into our local CQC preparation plans. 3. Local news Our people make a big difference every day 3.1 I am particularly proud to report that our amazing teams make a big difference to patients lives every day. Here s just one example: our Professional Education Lead and a nurse by background, provided support to an elderly pedestrian last week until the ambulance arrived. The lady had been in collision with a motorcycle opposite Thames House in Teddington. The Professional Education Lead and a Human Resources Advisor from the trust, had just stepped outside the office when they heard the accident happen. The member of staff kept the lady breathing and comforted her, while finding out important information for the ambulance crew. The other colleague directed traffic until the police arrived. She also comforted the motorcyclist and organised tea and coffee for the emergency services. Both members of staff exemplified the Trust s values of care, respect and communication that day. 3.2 This is the second time in a year that employees of the trust have kept people alive following motorcycle incidents in Teddington. In 217, following an accident outside Teddington Memorial Hospital, a Trust Nurse and Emergency Care Practitioner/Paramedic saved another patient s life following an accident. 3.3 These four fantastic people embody our values and would be worthy nominees for a quarterly Champion award. This recognition scheme is a tangible way of valuing our colleagues and the latest awards are due to be announced at the end of this month. NHS staff survey The Trust s outcome from the NHS staff survey in the autumn of 217 is the subject of a separate agenda item today. However, I am very pleased to Page 3 of 4

20 announce that The Trust was top of the national staff survey rankings for community trusts in a number of areas this year. I am particularly glad that the overall number of people who would recommend HRCH as a place to work increased to 68% from 64% last year. This compares well with the national average of 57% and is real recognition of the progress we have made so far on our journey to being an outstanding organisation. 3.5 I am also really encouraged by the fact that, despite the pressures on our Trust and the NHS as a whole, our people are working really hard to achieve great things every day, which is an indication of the professionalism of everyone we work with. While the vast majority of our results in this year s survey are overwhelmingly positive, the Trust will use all staff feedback to make further improvements to working conditions. Regulation 3.6 The Trust received its annual Provider Information Request (PIR) from CQC on 13 March 218. This triggers the inspection regimen for 218 and we expect to have an unannounced inspection of at least two of our core services and a Well-led review within the next four months. Page 4 of 4

21 Meeting title Trust Board part 1 meeting Date: 28 March 218 Report title Finance and Performance Committee Chair s report Agenda item: 7 Lead director Report author David Hawkins, Director of Finance and Corporate Services Swarnjit Singh, Trust Secretary Executive summary In line with governance arrangements, this report provides an update to trust board members of the key issues that arose at the 16 March 218 meeting of the Finance and Performance Committee: Areas of significant assurance: Finance report Board Assurance Framework risks Board scorecard Bribery Act provisions Areas of partial assurance: 218/19 Cost Improvement Programme The committee also discussed the following items: a commercial report a Chair s assurance report for the Performance Executive Committee meeting held on 2 February 218 quarter three reports for contract profitability and capital expenditure a draft 218/19 Board scorecard contractual exception reports Purpose: Noting Recommendation Board members are invited to note the report. BAF/TRR Report history Appendices S1, S2, S3 Not applicable None Page 1 of 4

22 Name of Committee Date of meeting 16 March 218 Finance and Performance Committee Summary of assurance The committee can report significant assurance to the trust board on the following areas: Item Assurance / action Lead Finance report The Committee reviewed and discussed the report for the position as at the end of month11. Key points to note included: The Month 11 position is slightly ahead of plan due to a combination of underachieved income overspends on non-pay and underspends on pay budgets. Non-pay budgets overspent mainly due to unfound cost improvement programme (CIP) savings, clinical contracts, depreciation and patients appliances. This full year forecast was that the Trust remained on track to deliver the planned yearend surplus of 2.178m plus the 21k Commissioning for Quality and Innovation (CQUIN) risk reserve but this was subject to delivering the full CIP programme and keeping control of finances for the remainder of the year. A Finance Use of Resources score of 1 was achieved. Better Payment Practice code performance (BPPC) was 98.4% for NHS and 95.5% for non-nhs bodies; Debtors due more than 9 days totalled 1,8k. The forecast and year to date positions assumed full receipt of income from the Sustainability & Transformation Fund (full year 92k). Agency staffing expenditure was lower than planned caps. The Committee noted the continued good financial performance, in particular the rating of 1 achieved under NHS Improvement s Single Operating Framework, the highest rating possible. Assistant Director, Finance Page 2 of 4

23 Item Assurance / action Lead Board Assurance Framework risks The Committee reviewed risk entries relating to the Trust s sustainability strategic objective. Committee members took assurance that risks were being effectively mitigated. They noted that the first risk entry in this section related to both an in-year need to achieve the agreed control total surplus with NHS Improvement and remained a longer term, three to five year risk for the Trust. Director of Committee members reviewed the risk entry relating to the inability to achieve interoperability across care partners/care providers. They agreed the risk score was too high for the consequences outlined should the risk manifest. Committee members also considered and fed back on entries for the 218/19 risk register and highlighted the need for integration to be included. Finance and Corporate Services Director of Clinical Services Board scorecard The Committee discussed the Board scorecard and exception reports for February 218. They noted and took assurance from the continued good performance against the vast majority of indicators. In relation to the two exception reports discussed for delayed transfers of care and staff sickness absence, the following points were highlighted: The Director of Clinical Services, SWL, outlined the individual reasons for the four delayed patient transfers of care and provided assurance that this was not an ongoing service issue The Director of Workforce explained the higher sickness absence outcome was partly due to seasonal factors, with the main reasons cited being cold and flu symptoms. She provided assurance that targeted work continued to take place with service areas to manage specific cases Directors of Clinical Services, Nursing and Workforce Bribery Act The Committee received a verbal report from the Director of Finance and Corporate Services who confirmed there were no cases to report this month. Director of Finance and Corporate Services Page 3 of 4

24 The committee is reporting partial assurance to the trust board on the following matter(s): Item Position / mitigation plan Lead 218/19 Cost Improvement Programme Committee members discussed progress in meeting its cost improvement programme targets. They noted the successful identification of all the 217/18 target of 5.4m and that two schemes required consideration and approval by a Quality Impact Assessment panel prior to implementation. In addition, Committee members noted the 218/19 target would be 4.7m (c. 7% of income) and took into account a projected increase in 217/18 non-recurrent expenditure and stranded costs in-year. Committee members were informed this target would be identified from a portfolio of schemes covering the following which was discussed in greater detail: A non-recurrent reduction in the run rate Non-pay zero-based budgeting Identified CIP contributions Financial adjustments A reduced contribution for the pay award Technical adjustments The Committee took partial assurance due the need to identify more savings in 218/19 from expenditure reductions. Committee meeting attendance, 16 March 218 Present: Bindesh Shah, Non-Executive Director (Committee Chair) Monique Carayol, Director of Transformation (items 1 and 11) Chris Giles, Assistant Director, Contracts and Performance Stephen Hall, Director of Clinical Services SWL Philip Hall, Non-Executive Director David Hawkins, Director of Finance and Corporate Services Joanne Hay, Non-Executive Director Alison Heeralall, Director of Workforce (items 5 and 6) Ella Jaczynska, NHS Improvement, NExT Non-Executive Director scheme Claire Peterzan, Assistant Director, Transformation (items 1 and 11) Swarnjit Singh, Trust Secretary Selina Tamrat, Programme Management Office (item 1) Bridget Welch, Assistant Director, Finance Apologies: none Director of Finance and Corporate Services Page 4 of 4

25 Meeting title Trust Board meeting - part 1 Date: 28 March 218 Report title Charitable Funds Committee s Chairman s assurance report Agenda item: 8 Lead director Report author Executive summary Director of Clinical Services, Hounslow Borough /NWL Louise Burkill, Personal Assistant to the Chief Executive and Chairman This report provides assurance to the board on the business transacted by the Charitable funds Committee meeting held on 15 March 218, in line with the trust s governance arrangements: Areas of assurance Finance Report There were no items on which the Committee took either partial or no assurance. In addition, the committee also discussed : 1. Reviewing the HRCH Charitable Funds Governance Framework 2. Holding a meeting with children s service leads to facilitate discussion on projects that the Charitable Fund could support 3. The process for approving applications of less than 3 was also clarified Purpose: Noting Recommendation Board members are asked to note the report BAF/TRR Report history Appendices S1 n/a none Page 1 of 2

26 Name of Committee Charitable funds Committee Dates of Meetings 14 December 217 Summary of assurance A. The Charitable funds committee can report assurance to the board on the following areas Agenda Item Assurance / action Lead 4 Financial Report The Committee received assurance that the finances reported for the period November 217 to January 218 were an accurate record, and that expenditure met the charitable fund purpose. BW B. There are no items where the executive committee is reporting partial assurance to the board. C. There are no items where the executive committee is reporting no assurance to the board. Applications for funds: There were no applications that had been approved outside of the committee: There were three application for funds that the committee considered: Agenda Item application Lead Item 5 Applications for funds 1. Family Nurse Partnership annual outing 6 -award approved 2. Autism Buckets for Children award approved 3. Chewable oral items for Children with Autism award approved Committee meeting attendance: Present: In attendance: Stephen Swords, Non-Executive Director (SS) (Committee Chairman) Ajay Mehta, Non-Executive Director, (AM) Anne Stratton Director of Clinical Services (AS) Bridget Welch Assistant Director of Finance (BW) Louise Burkill, Personal Assistant to Chief Executive and Chairman Page 2 of 2

27 Meeting title Trust Board part 1 meeting Date: 28 March 218 Report title Lead director Report author Quality Governance Committee Chair s report Donna Lamb, Director of Nursing and Non-Medical Professionals Swarnjit Singh, Trust Secretary Agenda item: 9 Executive summary In line with governance arrangements, this report provides an update to trust board members of the key issues that arose at the 13 March 218 meeting of the Quality Governance Committee: Areas of significant assurance: Quarter three Quality report Learning from deaths dashboard Quality Impact Assessment panel report Areas of partial assurance: Quality & Safety Committee Chair s report Infection Prevention and Control Committee Chair s assurance report Journey to Outstanding programme The committee also discussed reports on: Serious Incidents Safeguarding Committee Chair s assurance report Patient & Public Engagement strategy Trust risk register the committee s work plan draft 218/19 quality priorities In a separate part II meeting, the Committee reviewed Board Assurance Framework entries identified as risks to the Trust s quality strategic objective and a report on claims and litigation cases. Purpose: Noting Recommendation Board members are invited to note the report. BAF/TRR Q1, Q2, P3 Report history Not applicable Appendices None Page 1 of 5

28 Name of Committee Date of meetings 13 March 218 Quality Governance Committee (QGC) Summary of assurance The committee can report significant assurance to the trust board on the following areas: Item Assurance / action Lead Quarter three Quality report The Committee reviewed the quarter three quality report which provided information for key quality indicators on the quality dashboard including patient safety incidents, the top themes and trends for incidents, serious incidents, and Patient Advice & Liaison (PALs) activity summary. Committee members fed back on the new format for the report and welcomed the dashboard graphs and also welcomed the use of statistical process charts to illustrate variations in performance. They took assurance from the fact that all incidents were within control limits. Committee members suggested a clearer and more user-friendly style to be adopted such as having a graph per page and noted the dashboard would be reviewed so that the content and presentation aligned with the board performance scorecard. It also noted the dashboard would be updated to include the quarterly quality priorities. The Committee noted the quarter three quality report, fed back on the proposed new format and agreed the report be re-circulated with the inclusion of data for quality priorities. Director of Nursing Learning from deaths dashboard Quality Impact Assessment and In line with NHS Improvement s National Guidance on Learning from Deaths, published in March 217, the Committee reviewed a dashboard for quarter three. It noted and took assurance from the report as no reviews or investigations had been required as the national criteria was not met. The Committee considered a report of the Director of Finance who alongside the Medical Medical Director, Director of Clinical Services, SWL Director of Clinical Page 2 of 5

29 Item Assurance / action Lead Finance (QIA) Director and Directors of Nursing and panel report Transformation sat on the panel. It noted the QIA and Finance review panel which met on 8 February had agreed to: approve the procurement cost improvement plan scheme review in full the Specialist Adults, (MSK) cost improvement scheme at the next panel meeting review in full the community nursing cost improvement programme scheme at its next panel meeting. The Committee noted the panel had requested accelerated delivery of community nursing quality indicator dashboard to ensure progress on monitoring clinical efficiency and quality safety. This was being progressed as part of the community nursing transformation programme. The Director of Finance provided assurance that the procurement scheme approved was part of work being taken forward in collaboration with the NHS NW London sector to help generate savings. The Committee noted and was assured by the report. Services, South West London The committee is reporting partial assurance to the trust board on the following matters: Item Position / mitigation plan Lead Journey to Outstanding (J2O) Programme The Assistant Director, Quality, presented an updated on delivery of the programme. Committee members discussed the report in detail and were updated on developments since the report was despatched. The Director of Nursing provided assurance that the programme team and directors of clinical services were aware of current gaps and the actions being taken to address them. Committee members fed back the need for the report s front sheet to highlight clearly the key achievements, challenges and risks to delivery of Page 3 of 5 Acting Assistant Director, Quality

30 Item Position / mitigation plan Lead the programme in future reports. The Committee noted the report and received assurance that work was taking place to help achieve all necessary actions and strategic goals by 31 March 218. Infection Prevention and Control Committee (IPCC) Chair s assurance report and quarter three infection control and prevention report Quality & Safety Committee Chair s assurance report The Committee considered a report of the IPPC meeting held on 6 February 218 and the quarter three outcomes. They noted the following: The Trust was successful in exceeding its flu vaccination target of 7% of frontline staff Quarter three was a very busy time with norovirus outbreaks in both the community and at Teddington Memorial Hospital where two bays were temporarily closed as part of actions taken to swiftly contain an outbreak Errors in the WIRED recording system had been identified for level 2 training compliance data and this had been corrected. The provision of more face-toface training supported the required increase in uptake at level 2. From 1 May 218, the Trust s team would have a full complement of infection prevention and control staff A quarterly audit was taking place to provide assurance and evidence that frontline staff were meeting the standards required There were teams listed in the report for which no audit submissions had been received and this was being addressed The Committee noted the report and the actions being taken to address areas highlighted for improvement. The Committee reviewed a report for the Quality & Safety Committee meetings held on 7 February and 7 March 218. The Director of Nursing explained the report was drafted quickly as the meeting was held the same day as the despatch of meeting papers. Committee members discussed areas where Page 4 of 5 Lead Infection Prevention Control Nurse Director of Nursing

31 Item Position / mitigation plan Lead partial assurance was received: clinical audit The Trust was taking part in six national audits. When local audits were added, in Q3, a total of16 audits were completed and 2 audits were outstanding. Further clinical audit training was planned for April 218 NICE guidance process this had been updated and was now streamlined so guidance was screened and then went directly to relevant leads serious incident summary report it was agreed that additional work was needed to highlight the recommendations and lessons learnt Committee meeting attendance, 13 March 218 Present: Ajay Mehta, Non-Executive Director (Committee Chair) Remi Aderibigbe, Head of Quality and Patient Safety Ginny Colwell, Board Advisor David Hawkins, Director of Finance & Corporate Services Christine Jordan, Acting Assistant Director, Quality & Clinical Excellence Donna Lamb, Director of Nursing & Non-Medical Professionals Fiona McKenzie, NHS Improvement, NExT Non-Executive Director scheme Swarnjit Singh, Trust Secretary Anne Stratton, Director of Clinical Services, NWL Stephen Swords, Non-Executive Director Linda Woodward-Stammers, Lead Infection Prevention Control Nurse (item 5) Apologies: John Marshall, Healthwatch Hounslow (Observer) Dr Tony Snell, Interim Medical Director Sandra Wolper, Head of Pharmacy Page 5 of 5

32 Meeting title Trust Board part 1 meeting Date: 28 March 218 Report title Lead director Report author Audit and Risk Committee Chair s report David Hawkins, Director of Finance and Corporate Services Swarnjit Singh, Trust Secretary Agenda item: 1 Executive summary In line with governance arrangements, this report provides an update to trust board members of the key issues that arose at the 8 February 218 meeting of the Audit and Risk Committee: Areas of significant assurance: 217/18 external audit plan Corporate Governance Framework chapters for: o Standing orders o Standing financial instructions o Scheme of delegation Internal audit 217/18 progress report Counter fraud progress report There were no items on which the committee is reporting partial or no assurance to the Board of Directors. The Committee also noted verbal updates on arrangements for charging overseas patients for community services and noted there were no single tender waivers to report. The Committee also reviewed and agreed a minor amendment to its updated terms of reference and also reviewed its 218/19 work plan. Purpose: Noting Recommendation Board members are invited to note the report. BAF/TRR Report history Appendices All Board Assurance Framework entries Not applicable None Page 1 of 3

33 Name of Committee Audit and Risk Committee Date of meeting 8 February 218 Summary of assurance The committee can report significant assurance to the trust board on the following areas: Item Assurance / action Lead 217/18 external audit plan The Committee reviewed the external audit plan and noted the focus on revenue and receivables currently contained in financial statements and also key risks. Committee members took assurance from the stated declaration of auditor independence and that there was no proposed change in external audit fees. The Committee approved the external audit plan. Director of Finance and Corporate Services Corporate Governance Framework Internal audit Head of internal audit opinion and draft annual plan for 218/19 The Committee considered a report on revised elements of the Trust s corporate governance framework. They welcomed the work undertaken by the Trust Secretary and Assistant Director, Finance, in reviewing these documents. Committee members approved the updated scheme of delegation and reservation of powers, standing orders and standing financial instructions and agreed to recommend their approval at the March Board meeting. The Committee took significant assurance from the draft Head of Internal Audit Opinion s which would be updated at year-end. They noted this was a positive draft opinion which highlighted the fact that the Trust had an adequate and effective framework for risk management, governance and internal control. The Director of Finance and Corporate Services undertook to discuss the precise wording of the Opinon with the Head of Internal Audit outside of the meeting. Further assurance was derived from the Head of Internal Audit stating that, based on the work undertaken on the Trust s system on internal control, it was not considered that there were any issues that need to be flagged as significant control issues within the Annual Governance Statement in the 217/18 Annual Report & Director of Finance, Trust Secretary Director of Finance and Corporate Services Page 2 of 3

34 Item Assurance / action Lead Accounts. The Committee noted progress with the annual work plan and with the implementation of recommendations. The Committee also reviewed a draft 218/19 audit plan which would include quality areas, revisit disclosure and barring checks and conflicts of interest which had been an area of focus for NHS England. The Committee discussed the balance of the proposed plan and the scope of proposed audits. The Head of Internal Audit undertook to reflect on the comments when finalising the plan. Committee members were assured by internal audit fees being held at 216l17 s levels. Local Counter progress report and 218/19 work plan The Committee noted progress with the current year s work plan and welcomed the fraud prevention training delivered to Board members in December 217. The Committee Chair asked for more clarity in the work plan so that the Trust could better gauge the outputs it received for the number of working days committed to this area of work. Trust Secretary There are no matters on which the committee is reporting partial or no assurance to the trust board on agenda items covered at the meeting. Committee meeting attendance, 8 February 218 Present: Philip Hall, Non-Executive Director (Committee Chair) Judith Rutherford, Non-Executive Director Bindesh Shah, Non-Executive Director David Hawkins, Director of Finance and Corporate Services Swarnjit Singh, Trust Secretary Neil Hewitson, KPMG LLP Nick Atkinson, Head of Internal Audit, RSM LLP Tina Jones, Senior Counter Fraud Specialist, RSM LLP Apologies: Steve Lucas, KPMG LLP Page 3 of 3

35 Meeting title Trust Board part 1 meeting Date: 28 March 218 Report title Journey to Outstanding (J2O) programme reporting pack Agenda item: 11 Lead director Report author Executive summary Donna Lamb Director of Nursing and Non-Medical Professionals Christine Jordan, Assistant Director Quality and Clinical Excellence This report provides an update on the Journey to Outstanding in 4th quarter of year three and introduces the 217/218 programme reporting pack to the Board This month we can demonstrate that we have achieved good in each of the core service areas, adults, children, in-patients, urgent care and end of life in each of the domains, safe, effective, caring, responsive and well led. The work completed in the well led domain has now provided evidence that the core services have moved to good. The outstanding actions for the KPI are the completion of action plans at team levels and although there are a number still being worked on these have not affected the overall rating for the core service. Work continues at team level on the action plans. From the internal peer reviews we have identified areas of outstanding practice in at least one of the domains at team level. A programme of external peer reviews is being arranged for each of the core services to validate internal peer reviews. Purpose Recommendation Noting The board are asked to note the progress to date in the J2 Reporting Pack, in particular the: i. progress in the action plans for the core services ii. completion of KPIs for quarter one and two and the additional KPIs for quarter three and four iii. progress to strategic goal of all domains for all core services to be good by March 218 Page 1 of 4

36 BAF/TRR Q1 & Q2 Journey to Outstanding Report history Professional Executive Committee 2 March 218 J2O Delivery Board 15 March 218 Appendices Appendix 1 J2O PMO reporting pack Page 2 of 4

37 Journey to Outstanding programme 1. Background This report provides the Board with an update of progress (February 218) on the trust s journey to outstanding. The aim is that this report will provide the Board with the assurance of the actions being undertaken to move the trust to good across the five domains for the key services, that we are meeting the key performance indicators to demonstrate this and that by the end of 217/218 we are outstanding in one domain for each core service. 2. Key Issues There has been good engagement with all staff in the completion of the selfassessments. Where gaps have been identified between requires improvement and good, action plans have been developed and have been used to monitor progress against. There has been significant progress made, however all actions have not been completed. There has been support given to teams where there are still gaps. The teams where the actions that have not been completed in the action plan, do not impact on the overall rating for the core services. Work continues in these areas. Peer reviews have been completed for the majority of services, with a series of follow up visits to community nursing in progress. A peer review to a team in each of the core services with an external reviewer is being arranged. The external reviewers have been identified from Hounslow and Richmond CCGs, NHSI and a subject matter expert for end of life care. These reviews will help to validate our internal peer reviews. As the peer review is a key part of demonstrating we are an outstanding organisation alternative methods of carrying out this peer review have been sought. Digital technology has been identified which can instantly collate and produce reports, once a review has been performed. We are developing this with Carbon Lab and will start a pilot in April 218. Three Always Events are now in progress with measures being developed for testing. This has proved more challenging for End of Life care. The inpatient unit at Teddington Memorial Hospital had good engagement with its codesign. 3. Discussion The J2O team have started to verify evidence from core teams to triangulate what the action plans are telling us against other information we have. For example evidence from incident reporting and evidence of learning from these is shared. The ratings for infection prevention control (IPC) and medicines management are verified by the IPC and medicines management teams respectively. The J2O programme and project manager are working through these with the individual team leaders and the divisional mangers for support. Page 3 of 4

38 4. Conclusion and Recommendations This report demonstrates the progress of J2O to end February 218. This includes the progress against the KPIs for quarter one and two with the additional KPIs for quarter three and four. The progress in moving to good in all of the domains for the core services have been completed. The peer reviews have now been to the majority of teams to validate the selfassessments. We have shown that in some teams they have at least one domain that is outstanding. The board are asked to note the progress to date. Page 4 of 4

39 PMO Journey to Outstanding (J2O) Programme Year 3 217/218 Reporting Pack March 218 1

40 217/218 Journey to Outstanding (J2O) Programme Reporting Pack CONTENTS INTRODUCTION Contents Process: Methodology Being Used KPIs: Key progress to date BEING CQC READY KPI 7: Communication Programme to be developed 6 ACTION PLANS KPI 8: Number of teams completed all actions on action plan KPI 8: Progress towards good and core service level action plan KPI 9: Well Led Action Plan: progress Strategic Objective 1: Each core service good in all domains PEER REVIEWS KPI 1: Outcomes of Internal Peer Review KPI 11: External peer reviews Pg OUTSTANDING KPI 12: Identified domain will be outstanding for each core service Strategic Objective 2: Each core service minimum of outstanding in one domain OTHER Reducing Unwarranted Variation: Core Standards Always Events

41 217/18 Journey to Outstanding Process Process Having researched Outstanding organisations 3 distinct areas were highlighted and chosen to be monitored for the J2O programme for year three: a. monitoring against CQC domains, including peer reviews b. reduction in unwarranted variation c. staff and patient engagement. A) The monitoring process for each team: i. self assessment against the 5 Key Lines of Enquiry (KLOE s), Safe, Effective, Caring, Responsive and Well Led. ii. Forums were attended were shared learning took place. Quality assurance completed by Programme and Project manager visiting all services. iii. Gaps identified to inform service improvement plans iv. Internal peer review programme to test good v. External stakeholders to test outstanding for robust review and additional assurance. B) Reduction in unwarranted variation i. Development of Core Standards introduced to each team based on the CQC fundamental standards C) Staff and Patient Engagement i. Always Events will provide the methodology for patient involvement. ii. There are 4 Always Events through the year. 3

42 217/218 Journey to Outstanding (J2O) KPIs: Key Progress to Date KPI for Q1 and Q2 Key Progress to Date Expected Date 1. Develop 217/18 reporting pack Achieved July 217 Reporting pack in place 2. Complete self-assessment and Achieved Sept 217 gap analysis - All teams self-assessed S,E,C and R - Well Led completed via meridian link web survey - Gap analysis S,E,C,R: Aug 17 reporting pack. - Gap Analysis W/L: Sept 17 report pack 3. Quality improvement plans in place for all services 4. Identify which domain for each core service will aim to be outstanding by March Criteria and assessment process for assessment of outstanding to be developed 6. Programme of peer review during 217/18 to be developed In progress. - All teams and core services have quality improvement plans. Achieved - Information shared with AD s. - Decision made: responsive / caring In progress - Assessment process being developed - Outstanding criteria being developed - KPI rolled on to Q2 and 3 Achieved - Programme in place for manual peer review. - Capacity to deliver programme on J2O Risk Register. - Business Case being made for electronic app Sept 217 August 217 Sept 217 Sept 217 RAG Carried over to Q3/4 KPIs 4

43 217/218 Journey to Outstanding (J2O) KPIs: Key Progress to Date / Key Risks to Strategic Objective KPI for Q3 and Q4 Key Progress to Date Expected Date 7. Communication Programme to be In Progress Jan 18 developed re: Being CQC Ready - Comms programme developed. Plan with DL RAG 8. All teams to have all actions completed on their action plans 9. Well Led Action Plan to be completed In Progress - J2O Team updated monthly - Clear communication at all levels that action plans required completion end of March In Progress - Staff Led action plan finalised with relevant parties. Actions in progress, though engagement variable Feb 18 Mar All services to be peer reviewed internally In Progress - Internal peer reviews completed for year 17 / 18 programme. Feb Visits for External Peer Reviews to have been arranged and completed 12. Criteria and assessment process for assessment of outstanding to be developed In Progress External peer reviewers contacted, some dates booked, others being arranged. In Progress - To be tested via external peer review Feb 18 Mar 18 5

44 217/218 Journey to Outstanding (J2O) KPI 7: Communication Programme to be developed re: Being CQC Ready Outcome Actions Expected Date CQC Staff Drop-Ins February Dates ed to all HRCH staff and invites sent Jan 18 from J2O Calendar Poster developed and circulated to all HoS and This Week. Donna Lamb contacting CQC for more information to share with staff re: expectations Staff Briefing Sessions Rolling programme of briefing sessions by DL and CJ Jan 18 arranged. First one completed Learning the Language of CQC CQC key messages communicated via 12 days of Dec 18 Christmas daily s CQC Staff booklet updated and with printers. Jan 18 Being distributed via HoS meetings Unannounced Visits Leaflet re: what to do in development for dissemination Mar 18 once PIR request has been made RAG PIR Template Specific Support for District Nursing Circulated and shared with all executive leads. Question areas assigned to person for completion. Individual worksheets created and shared with operational leads Post in place for District Nursing to support with being CQC ready Mar 18 Jan 18 6

45 217/218 Journey to Outstanding (J2O) KPI 8: All Teams to have all actions completed on their action plan % Teams Completed Action Plans Teams Completed All Actions ( good in all areas ) Children 52 Adult 32 Children HV Haemoglobin LAC Services Health Visiting Team Paediatric Therapies (R) MSK & Pain Management Tissue Viability Diabetes Family Nurse Partnership Child Acute Nursing Service Audiology & New Born LAC Hounslow and Richmond Specialist School Nursing Richmond Neuro Rehab and ESD Night Nursing Specialist IV Inpatient 1 TMH Inpatient Urgent care EoLC 1 WIC undergoing services changes in line with national programme UCC: ongoing actions mainly focused on environment Note: outstanding work involving Co-ordinate My Care is believed to take this area to Outstanding J2O met with all Divisional managers individually to go through each team action plan J2O have created and shared divisional action plans including all team actions still to achieve J2O attended DMT meetings to push urgency of completing all actions, supported by DD s If actions not completed, outstanding issues will need to be placed on local risk registers as gaps 7

46 217/18 Journey to Outstanding KPI 8: Action Plans in place for improvement: outcome Core Service Action Plans: Areas were identified for improvement at Core Service Level as any KLOE rated as RI by 2%+ teams per core service Core services now rated as good, with evidence of completed actions at team level. Outstanding team actions to be completed will not affect final core service rating. Assurance: Focus on completing team action plans, resulting in no KLOE being rated as RI at core service level (2% or more of teams per KLOE) Operational level detail therefore removed from reporting pack.

47 217/18 Journey to Outstanding KPI 9: Well Led Action Plan to be completed J2O - Listening to Staff: Meridian Survey Completed Areas identified for improvement as any Meridian Survey Question (KLOE) rated as RI+Inad by 2 or more teams (approx. 4%) Survey results shared at Leaders Forum Leaders Forum identified key themes / actions Action Plan Developed and in place. Key Themes: Quality and Sustainability received coverage in relevant meetings at all levels All levels of management function effectively and interact with each other appropriately Staff actively engaged so their views are reflected in planning an deliver of services Candour, openness and honesty encouraged at all levels within the trust Audits regularly completed and action taken if required Board - Exec Leadership: Well Led Executive Programme in place, with specific KLOE s assigned Assurance Well Led Action Plan outstanding actions to be completed provided on following pages. Well Led now moved to good as outstanding actions are in progress and only require assurance 9

48 217/18 Journey to Outstanding WELL LED: actions to improve gaps across trust: Top 5 KLOEs from meridian survey Actions to achieve good in all areas RAG: progress against actions ASSURANCE: process in place to improve rating 1. KLOE Q&S IN RELEVANT MEETINGS: Do quality and sustainability both receive sufficient coverage in relevant meetings at all levels? (Well Led KLOE 6.3) CQC Descriptor of good Quality and sustainability receive coverage in relevant meetings at all levels. Key Themes from leaders forum feedback Increase awareness and understanding of business performance Increase staff experience of Q&S meetings Increase staff understanding of how board level decisions are made Involve / update staff in commissioning changes Make performance relevant to teams use of language Actions Update Whom 1.2 Governance issues to be covered at all team meetings using standard team agenda. Natalie and Claire to ensure that all team meetings are using this standard. 1.3 Divisional managers to regularly review use of team agendas to ensure ongoing use by: a) spot check on minutes b) Rolling attendance at team meetings. Feb 18: Contents of agenda reviewed and new template devised. Out for pilot with Team Managers. Feb 18: Minutes saved centrally on drive. Spot Checks occurring with divisional managers. Evidence of ward to floor escalation of issues when needed. ND & CM ND & CM RAG Assur ance

49 217/18 Journey to Outstanding WELL LED: actions to improve gaps across trust Actions to achieve good in all areas RAG: progress against actions ASSURANCE: process in place to improve rating 2. KLOE INTERACTION BETWEEN LEVELS OF MANAGEMENT Do all levels of governance and management function effectively and interact with each other appropriately? CQC Descriptor of good The Board and other levels of governance in the organisation function effectively and interact with each other appropriately. Key Themes from leaders forum feedback Getting the basics right Regular team meetings, 1to1 s Shadowing and training in place Staff info up to date Actions Update Whom 2.5 Team agenda items to be reviewed re: inclusion of: a) service improvement / quality initiatives b) Learning from incidents c) Question for exec / senior managers Feb 18: Team agenda reviewed by senior management and draft circulated to team leaders for feedback to ensure meets their needs. Feedback expected by end March. ND & CM RAG Ass uran ce (Well Led KLOE 4.2) 4. CANDOUR Are candour, openness and honesty encouraged at all levels within the trust? Candour, openness, honesty and transparency and challenges to poor practice are the norm. Authentic Visibility Open and proactive interaction with teams Service visits Shadowing clinical and corporate 4.1 All EXEC s to have inspirational posters available for sharing Nov 17: Proposed action by Fiona. Jan 18: J2O suggest peg this to the Well-Led KLOE that each exec is responsible for. To be picked up once new post in place, and also part of J2O comms strategy FT Comms / Execs (Well Led 3.5)

50 217/18 Journey to Outstanding WELL LED: actions to improve gaps across trust Top 5 KLOEs from meridian survey Actions to achieve good in all areas RAG: progress against actions ASSURANCE: process in place to improve rating 5. KLOE AUDITS Are audits regularly complete d and action taken if required? (Well Led KLOE 5.3) CQC Descript or of good Clinical and internal audit processes function well and have a positive impact in relation to quality governanc e, with clear evidence of action to resolve concerns. Key Themes from leaders forum feedback Staff Support Stability in audit department for consistent support Teams need support, training and clear expectations Audit Culture Change culture of audit so attractive, valued part of job Promote culture of audit What extent is clinical audit programme aligned to strategic objectives Actions Update Whom 5.5 Deputy Directors to have increased oversight of Audit Planners for services through DMT meetings. 5.7 Regular meetings to occur with QCE team to assure services are aligned with NICE guidance. Feb 18: to be part of new audit strategy going forwards. New audit lead starting on 16 th april. Currently trust are reviewing approach, to include clinical standards and outcomes. Nov 17: Preliminary meeting arranged for Nov 17 Jan 18: New Terms of Reference for monthly clinical audit & effectiveness sub committee have been drafted. To be sent to Interim medical director for agreement. Feb 18: First meeting to be arranged on return of TS. (14 th March) CM & ND Audits / QCE RAG Assur ance

51 Strategic Objective 1 all core services rated as good in all domains (Q4: by Mar ) Safe Effective Caring Responsive Well-led (new info) Overall Children Good Good Good Good Good Good Adult Good Good Good Good Good Good Inpatient Good Good Good Good Good Good Urgent care Good Good Good Good Good Good EoLC Good Good Good Good Good Good Overall Good Good Good Good Good Good Although a core service may be rated as good (see explanation on right), there may be specific domains for specific teams that are rated as requires improvement Each individual team scored themselves against all KLOE s (self-assessed) For any gaps (areas that require improvement), actions were identified. Once actions achieved, this specific KLOE for the specific team is then rerated as good. Scores also adjusted following results of peer reviews if RI, and improved once actions to address these gaps are completed. Scores for all teams within each Core Service are amalgamated using: Good = 9% of all KLOE responses across all teams in core service being rated as good or outstanding RI = less than 9% Well Led 8% + = good See outcomes of peer review for individual team information 13

52 217/18 Journey to Outstanding KPI 1: All service to be peer reviewed internally Core Service Team SAFE EFFECTIVE CARING RESPONSIVE WELL LED OVERALL Date Inpatient TMH Good Good Good Good Good Good April Sept 17 Urgent Care WIC Good Good Good RI RI Good Sept 217 UCC Good Good Good Good Good Good Oct 217 Children Audiology Good Outstnd Good Outstnd Outstnd Outstnd Aug 217 Child Comm Nursing (H) Paed Thrpy (R) Paed Thrpy (H) Child Dvlpmt Services (H) Child Dvlpmt Services (R) Health Visiting Children s CHC Good Good Good Good Good Good Nov 217 RI Good Good Good Good Good Nov 217 RI Good Good Good Good Good Nov 217 Good Good Good Good RI Good Nov 217 Good Good Good Good RI Good Nov 217 Good Good Good Good RI Good Dec 217 Good Good Good Good Good Good Dec 217

53 217/18 Journey to Outstanding KPI 1: All service to be peer reviewed internally Core Service Team SAFE EFFECTIVE CARING RESPONSIVE WELL LED OVERALL Date Adults DN (all) RI RI RI RI RI RI June 217 DN (all) table top RI RI Good Good RI RI Feb 18 DN teams Awaiting feedback Feb 18 H CRS RI Good Good Good RI Good Jan 18 CNRT Good Good Good Good Good Good Jan 18 RRRT Good Good No ptnt seen Good Good Good Jan 18 ICRS Good Good Good Good Outstanding Good Feb 18 CLDT Good Good Good Good Good Good Jan 18 Dietetics Good Good No ptnt seen Good Good Good Jan 18 Respiratory Good Good Good Good Outstanding Good Feb 18 Diabetes R Good Good Outstanding Good Good Good Feb 18 Wheelchair Good Good Outstanding Good Good Good Feb 18 Falls &Bone Good Outstanding Good Good Outstanding Good Feb 18

54 217/18 Journey to Outstanding KPI 1: All service to be peer reviewed internally Service Paed Therapy (Richmond) Paed Therapy (Hounslow) Peer Review Rating Actions RI Policies & Procedures Risk Assessments Risk Register Incident reporting IPC Risk Assessment Paper notes Admin support IPC CRS Supervision Staff competencies Datix Paper notes District Nursing Stat and Mand Recruitment Skill mix Capacity & Demand Record Keeping Current Rating Actions achieved rated as good Actions achieved rated as good Actions achieved rated as good Actions in progress, remains requires improvement but is a safe service Note: For those services rated as requires improvement in SAFE from peer reviews, more detail given here to demonstrate that services are SAFE. Actions exist to improve only. 16

55 217/18 Journey to Outstanding KPI 11: Visits for External Peer Reviews to have been arranged & completed Service Date Reviewer UCC: Cancelled by NHS I to be re-arranged AD QCE & NHSI TMH Inpatients 28 th march J2O & CCG RRRT 21 st March J2O & CCG ICRS 23 rd April J2O & CCG Health Visiting 17 th April J2O & CCG EoLC Being arranged with CLCH lead TBC 17

56 217/18 Journey to Outstanding KPI 12: Criteria and assessment process for outstanding to be developed CORE SERVICE Team Objectives Adults Community Nursing RESPONSIVE Unplanned (H) (ICRS and CRS) RESPONSIVE Unplanned (R) (RRT and Neuro) EFFECTIVE Planned (H&R) EFFECTIVE Children RESPONSIVE Inpatient EFFECTIVE Urgent Care EoLC RESPONSIVE CARING Notes: Aug 17: From the data-set, % of all questions for all teams within each domain which rate themselves as Outstanding, good or RI was shared with Assistant Directors. This provided a decision making tool as to which domain was the most suitable for progression to outstanding. See Aug 17 Reporting Pack for full data. Dec 17: All teams have team objectives. J2O Team reviewing these objectives to ensure that outstanding domain is aligned with current quality improvement work being undertaken. Jan 18: domains cross referenced against Team Objectives. Suggested changes checked against new structure for ease of management. 18

57 Strategic Objective 2: all core services have minimum of one domain outstanding (Q4: by March 218-5) Focusing on achieving good in all areas, and validated by peer review. Team engagement high. Agreement with action plans, feel it is achievable and working towards improvement Specific teams identified for work to begin towards Outstanding As evidenced by Peer Reviews, some teams achieving outstanding in at least one domain. 19

58 217/18 Journey to Outstanding: Reduction in Unwarranted variation: Core Standards Core Standards in development to be trust wide and link with generic and service specific competencies This to be reflected in appraisal Christine Jordan, Donna Lamb and Linda Thomas had first meeting to agree core standards, under which competencies will sit for the whole organisation 2

59 217/18 Journey to Outstanding Always Events Set-up and Oversight of Always Events EOL April to June 217. Patients and Staff interviewed Community Nursing including dementia TMH 13 th Sept Dementia Always event completed Always event held on 19 th Sept but more patients and staff required to be involved to give richer feedback Co-designing and Testing an Always Events July 217 Co-design Event: 6 th July 25 th Sept Dementia event, was extended to capture additional patient feedback. Co-design event occurred 9 th March. Event held on 22 nd Sept was extended to capture additional patient feedback. Co-design event occurred February Reliably Implementing an Always Events planning implementation workshop (Feb 21 st ). Training arranged for mid-march, with follow up workshop Developing actions Developing actions Sustaining and Spreading Always Events 21

60 Meeting title Trust Board part 1 meeting Date: 28 March 218 Report title 218/19 Quality priorities outcome of consultation Agenda item: 12 Lead director Report author Executive summary Donna Lamb, Director of Nursing and Non-medical professionals Christine Jordan, Assistant Director (Interim) Quality & Clinical Excellence The report summarises the responses received to the consultation on the quality priorities for 218/19 and proposes three quality priorities with measures. The report asks the trust board (as recommended by the Quality Governance Committee {QGC}) to approve the recommended priorities as described in the report. Purpose: Approval Recommendation: The board is asked to: To note the consultation results; To agree the recommendation from the QGC to the Trust Board as to the quality priorities for the HRCH Quality Accounts for 218/19 BAF/TRR Report history Appendices Q1/2 Quality March 218 Quality Governance Committee March 218 Executive Committee Appendix 1 summary of consultation findings Page 1 of 6

61 Quality Priorities outcome of consultation 1. Introduction Under each of the following categories, Patient Safety; Clinical Effectiveness; and Patient Experience, ten suggested quality priorities were put forward for consultation approved by the Quality and Safety Committee in January 217. HRCH is obliged to have at least one priority for each of the three domains of quality but can choose to have up to five priorities in total. The period of consultation was from 22 January to 23 February 218. The consultation included: HRCH Staff o 133 responses to online survey Public o 124 responses to online survey Healthwatch o Richmond suggested measures for reporting on the priorities, Hounslow nil response, however may have shared online survey to its members HRCH Patient & Public Engagement Forum o One collective response following a full discussion with 2 members of the public at the forum on 17 January 218 Quality & Safety Committee o One collective response Quality Governance Committee o One collective response Hounslow Clinical Commissioning Group o discussed at its Clinical Quality Group meeting on 2 February 218 suggested response from Assistant Director for Quality Improvement and Clinical Assurance Richmond Clinical Executive Committee o Raised but not discussed at its Clinical Quality Review Group Committee on 13 February nil response received 2. Responses The responses have been collated and are at appendix A 3. Conclusions On this occasion the priorities of the majority of those who have been consulted has been the same. The response from staff and the public has been triangulated with feedback from commissioners and information held internally about priorities. The requirement to be able to demonstrate a thread of quality improvement has also been taken into account. The proposed quality priorities for 218/19 and the rationale for the proposal have been discussed and agreed at the Quality & Safety Committee on the 7 March 218, Executive Committee on 12 March 218 and QGC on 16 March 218. Page 2 of 6

62 3.1 Patient safety: Improve the management of the deteriorating patient through effective sharing of information The trust strategic goal for quality is to ensure services are safe today and every day. In 216/17 the trust focussed on implementing the National/Paediatric Early Warning Score (NEWS/PEWS) to support early identification of a deteriorating patient in relevant services. A key part of safe care for a deteriorating patient is to ensure referrals are made in a timely way and that the referrer gives the right information. We will therefore introduce SBAR (Situation, Background, Assessment, Recommendation) in the relevant services as a framework for sharing information which leads to safe, timely and effective care. Measures: The % of staff in the agreed cohort who have completed training on the use of SBAR (training data) The % of patients for whom SBAR was used when transferred from TMH inpatient unit to the acute hospital (audit of patient records) The % of patients with a grade 3 or 4 pressure ulcer who received a clinically appropriate referral to the tissue viability service (audit of patient records) The % of referrals from community matrons to the acute hospital where SBAR has been used (audit of patient records) 3.2 Clinical effectiveness: Strengthen the application of evidence-based guidance and research Whilst the public felt strongly that the community nursing redesign should be a priority, it was considered that focusing on the application of evidence-based practice and research would have a broader impact on clinical effectiveness across the trust rather than in one service. National guidance is from the National Institute for Health and Care Excellence (NICE), from professional bodies and from research and development. This can be relevant to many services, including our community nursing service in areas such as wound care. As an organisation which is aiming to deliver outstanding care in all services we propose that we take this opportunity to focus on using national best practice guidance to ensure patients have the best clinical outcomes from our care. Measures: The % of applicable NICE guidance where there is evidence that the guidance/standard has been systematically reviewed and implemented in the relevant service The % of services where NICE guidance is applicable who can demonstrate actions have been implemented to be compliant. The number of patients who have been enrolled in a research study Page 3 of 6

63 3.3 Patient experience Promote patient-centred care through better understanding of what matters to our patients Taking into consideration the feedback from the public and staff about the importance of using stories we have revised our priority so that we can encompass the use of patient stories to support patient-centred care. Hearing the voice of patients through stories is key to understanding what matters to them and this is an integral part of the co-design of an Always Event. We will therefore continue the work started on the Always Events programme in 217/18 so that we can demonstrate the impact of this on patient care and experience. Measures The % of contacts which meet the Always Event in end of life care (audit of patient records) The % of contacts which meet the Always Event in the inpatient unit (audit of patient records) The % of contacts which meet the Always Event in dementia care (audit of patient records) 4. Measures The measures for the agreed priorities will be worked through in consultation with clinicians and managers to confirm baseline and targets. 5. Recommendations The board is asked to: To note the consultation results; To agree the recommendation from the QGC to the Trust Board as to the quality priorities for the HRCH Quality Accounts for 218/19 Page 4 of 6

64 Appendix A Patient safety Proposed Quality Priorities To ensure all incidents are investigated in a timely way HRCH staff Public PPE Forum 23.74% 29.84% No Improving analysis and learning from incidents 33.9% 15.32% No QSC QGC CCGs Recommendation of author No specific feedback received Early detection of the deteriorating patient 43.17% 58.84% Strong positive response Yes HCCG Yes Clinical effectiveness Community nursing Service redesign 37.59% 7.54% Medium response Incidents attributable to other organisations 27.82% 11.61% Medium response Clinical outcomes No No No specific feedback received HCCG 2.3% 9.82% Yes Yes Clinical Audit 14.29% 8.4% No Patient engagement Page 5 of 6

65 Patient experience Proposed Quality Priorities and involvement through Always Events Customer service in community nursing service Patient led improvement through use of patient stories HRCH staff Public PPE Forum QSC QGC CCGs Recommendation of author 25.19% 29.41% Strong No Yes positive No HCCG response specific feedback 39.69% 53.92% No received 35.11% 16.67% Yes Page 6 of 6

66 Meeting title Trust Board part 1 meeting Date: 28 March 218 Report title Lead director Report author Executive summary Patient and public engagement Agenda item: 13 strategy Donna Lamb, Director of Nursing and Non-medical Professionals Donna Lamb, Director of Nursing and Non-medical Professionals The trust had identified that its approach to and processes for effective and meaningful patient engagement required review. A period of planning and consulting with local people and patient representative groups was undertaken to understand what mattered to them about how the trust engaged with patients and the public. This information has been used along with a mapping of existing engagement to develop a model of engagement and a strategy to take this forward over the next three years. The strategy was shared with Hounslow and Richmond clinical commissioning groups. Feedback was received from Hounslow and those comments have been incorporated into this document. The strategy was also shared with Richmond and Hounslow Healthwatch. Richmond Healthwatch fed back comments which have been incorporated into this version and they noted that the trust s vision to go beyond the statutory duty to engage and to embed engagement in its strategic objectives where there are clear synergies and benefits (5.1) is compelling and genuine. Purpose Recommendation BAF/TRR Report history Appendices Approval The board are asked to: Note the content of this draft strategy including the mapping Approve the strategy and the next steps (p1) Request that the Quality Governance Committee oversee the objectives and action plan P3 Nil Appendix A Patient and public engagement mapping Appendix B - The ladder of engagement and participation Appendix C Proposed patient and public engagement model Page 1 of 18

67 Patient and Public Engagement Strategy Author: Donna Lamb Director of Nursing and Non-medical Professionals Approved by: TBC Lead Director Donna Lamb Director of Nursing and Non-medical Professionals Version.3 Date: 2 March 218 Page 2 of 18

68 Contents Section Title Page Number 1. Vision 6 2. Context 6 3. Analysis 8 4. Alignment 1 5. Next Steps Risks 12 Appendix 1 Mapping of patient and public engagement Appendix 2 Self-assessment against framework of engagement Appendix 3 Model of engagement Page 3 of 18

69 1. Introduction Hounslow & Richmond Community Healthcare NHS Trust (HRCH) provides community health services for around 515, people predominantly living in the London boroughs of Hounslow and Richmond and a wider population across southwest London. The trust employs over 1, staff, who work across a wide range of health centres, hospitals, GP surgeries, children s centres, local council facilities and in community settings including in people s homes. We help people to stay well, manage their own health with the right support and avoid unnecessary trips to, or long stays in, hospital. Reports about NHS care, in particular the Francis Inquiry, have made a call for real patient and public involvement in all that is done and a cultural change across the NHS to ensure greater openness, transparency and a duty of candour to patients. The duty to involve patients in the development of services and in their individual care and treatment is also central to the NHS Constitution, which describes the rights of patients and public to the provision of NHS services. The trust s engagement framework Engaging for Outstanding Care represents our commitment to engage as effectively as possible with our local community and we are part of local Sustainability and Transformation Partnerships (STPs) across NW London and SW London to improve health and care through more joined-up working. Patient and public engagement (PPE) is an approach that puts the people at the heart of care to improve service quality. It can be considered to be made up of four key groups of activities: Involving people in decisions about their own care and treatment Engaging people in on-going service delivery Engaging people in making changes to services or re-designing care pathways Engaging people in organisational decision-making We consider patient and public to include: patients and service users; carers, relatives and friends of patients; people living in the areas we serve; communities; patient groups and voluntary sector organisations. We can engage people as individuals or as a group. We can inform people, involve people or work in partnership this is all about engaging people. Whilst the Trust has a statutory duty to involve patients and the public in its work, our commitment goes beyond this duty and is embedded in our strategic objectives. We know that engaging with patients can lead to better decision making and better outcomes and that there are many ways in which we can and do put this into practice. These include how we involve patients and carers in decisions about care to how we work together with patients and the wider community in developing and planning our services. However, we also know there is still more we can do to ensure the voices of patients, carers and public stakeholders are at the centre of our everyday business and this strategy sets out our vision and plans to do this. Page 4 of 18

70 2. Vision Our patients and service users are at the centre of all that we do. Our vision is to put patients at the heart of our services. We believe a truly patient-centred approach focused on listening, understanding and responding to the needs of the whole individual is essential to the delivery of the best possible quality of care. A quality service is one that recognises the needs and circumstances of each patient, carer and ensures that services are accessible, appropriate and effective for all. The trust s vision to provide care and services that we and our families would want to use is driven by a commitment to outstanding engagement. Empowering and engaging patients, their families and carers and the public underpins our road map towards our journey to outstanding. We want: Patients, services users and carers to be actively involved in decisions about their care and treatment and understand what to do if they are not satisfied People from all backgrounds and communities to have equal access to information and involvement in our services Patients and communities to feel involved and able to influence changes to our services Patients, service users and carers to understand who to talk to, what our plans are for services and how they can be influenced Children and young people having more input and a voice in their care to help shape services. To better understand the population we serve so that we can target resources to those patients and patient groups who will benefit the most. 3. Context People have a right in law to be involved in their care, as set out in the Care Quality Commission (CQC) fundamental standard of person-centred care, a standard below which care should never fall. This national standard describes the action that care providers must take to ensure that each person receives appropriate care and treatment based on an assessment of their needs and preferences. The CQC report that enabling people to be more in control of their own care leads to better and often more cost effective outcomes. Being involved is an essential characteristic of person-centred care and critical to the move to successful integrated health and care services as set out in the NHS Five Year Forward View and the Care Act. Reports about NHS care, in particular the Francis Inquiry, have made a call for real patient and public involvement in all that is done and a cultural change across the NHS to ensure greater openness, transparency and a duty of candour to patients. Page 5 of 18

71 The duty to involve patients in the development of services and in their individual care and treatment is also central to the NHS Constitution (21), which describes the rights of patients and public to the provision of NHS services. The Equality Act (21) also requires organisations to engage with patients, service users and organisations that represent people with protected characteristics. The launch of the NHS Five Year Forward View (FYFV), published in October 214, has put a greater emphasis on the role of engagement with all partners in healthcare. The FYFV places a duty on those providing health services to make arrangements to involve users of services in decision making - whether directly or through representatives. The trust needs to be able to demonstrate it is well-led against both the CQC s Key Lines of Enquiry and the NHSI Well-Led Framework. This requires the trust to be able to evidence that people who use services, the public, staff and external partners are engaged and involved to support high-quality sustainable services. Summary of key drivers: External drivers Implications Political Strong patient focus Need to be able to meet expectations around PPE Changing commissioning Need to be able to evidence strong patient engagement in co-design of clinical pathways landscape Competitive marketplace Need to be able to demonstrate HRCH is the provider of choice Well-led Framework Need to be able to evidence compliance with Social and economic Technological Legal Value for money Changing role of patients and the public in healthcare Demographic profile of population Increasing use of new media and digital health Various legislation (as above) including compliance with CQC fundamental standards Quality accounts CQC KLOE and NHSI WL framework Need to be able to demonstrate impact of PPE Need to be able to demonstrate clear decision making with patients about their care and treatment Need to be able to demonstrate an approach to engagement which aligns with demographic profile as reported in trust Public Sector Equality Duty report. Need to demonstrate opportunities for this are optimised but that patients with protected characteristics are enabled and supported to be part of this Need to be able to demonstrate compliance with statutory requirements Must be agreed with the public and published Page 6 of 18

72 4. Analysis The populations of Hounslow and Richmond are significantly different. Hounslow is the fifth fastest growing population in the country. It is a young population with 52% of people under the age of 35. The population is 34% Asian, 7% black and 51% white (211 census). This compares to Richmond where 7% are Asian, 2% black and 86% white. Richmond also has the highest proportion of patients over the age of 85 in London. When the trust has moved to locality working i.e. working with defined population groups of approximately 5, in partnership with primary care, there will be greater scope for engagement tailored to the specific needs of population groups. The current proposed model of engagement allows for broad and inclusive forum-type engagement alongside smaller, focussed engagement groups which are service or condition specific. 4.1 Mapping of engagement The term patient and public engagement (or involvement) is a process of working together with patients, carers and other stakeholders (e.g. relatives, carers of patients, patient representative groups and advocates) to design and develop services and the Trusts future plans. There are generally considered to be different levels of patient engagement: Involving people in decisions about their own care and treatment Engaging people in on-going service delivery and in making changes to services or re-designing care pathways Engaging people in organisational decision-making The mapping (appendix 1) shows the trust s engagement activity at each level. This document is a snapshot in time and will not be exhaustive but it clearly demonstrates the commitment to involving patients and the public in their care, in decisions/planning/design of care and treatment but also in education and awareness raising. As a community provider this plays an important part in community and public health as well as self-care. 4.2 The principles of engagement and why this is important. This has been discussed at a series of events held in community venues. People have been open and receptive to change but the principles of engagement are agreed as being: The time people give to our trust is valuable Include outreach in the model Use existing networks Use less paper and more digital options Be clear about the purpose of the engagement and share the outcome People who have attended the forum have identified why engagement is important: Page 7 of 18

73 The public being ambassadors for our services Need to understand how services overlap To feedback patient experience and to use this to influence at the point of service delivery For the public to know what they can do, what they can report on and how they can become involved The value of good patient engagement is not underestimated by the trust. It is an important factor in developing the culture of the trust, the quality of care provided, outcomes for patients and patient experience. 4.3 Framework for patient and public engagement The chart at appendix 2 is a self-assessment against a suggested framework for patient involvement and engagement, the ladder of engagement and participation taken from Transforming Participation in Health and Care, NHS England, September 213. This is a useful framework to map our progress to becoming an organisation which works in partnership with communities and patients to ensure that concerns and aspirations are consistently understood and considered and each aspect of a decision, including the development of alternatives and the identification of the preferred solution. The trust has made some positive movement over the last nine months as a result of the engagement work undertaken and the evidence from the mapping exercise. The trust will review its position annually and agree where it wants to be at each level of activity i.e. assurance, patient involvement in individual care and treatment, service delivery, development and transformation, patient involvement in monitoring the quality of services and strategy future planning. 4.4 Model of engagement The trust had a Patient and Public Involvement (PPI) Committee for several years. The average attendance was approximately six people although the distribution list for papers was large. The committee was run as a formal committee with an agenda and papers. The approach was often one way; with the trust staff giving information to the committee through papers although there had been some more successful workshopstyle meetings. The people who attended were committed and supportive of the organisation but were not representative of the population the trust serves particularly in terms of age and ethnicity. The purpose of the re-designed model was to: Increase the number and representative nature of the membership Adopt a forum style group with more opportunities for discussion Page 8 of 18

74 Move the trust towards the involve level in service delivery, development and transformation, patient involvement in monitoring the quality of services and strategy future planning. (see appendix 2) Our proposed model of engagement has been shared at a community event and was well-received (appendix 3). We propose to facilitate larger forums which have a consultative workshop type approach. These will be supported by a range of satellite options which may be virtual and can be developed using a task and finish model. This model is supported by a register of people who have expressed an interest in being involved in patient and public engagement. 5. Alignment Following a discussion paper at Executive Committee in March 217, the trust acknowledged that its strategic commitment to improving engagement with patients and the public was not clear and that the operational model was not inclusive or representative enough. The executive committee agreed two main actions: A revision of the 217/18 strategic objectives to include under people to actively engage with patients, public and carers to improve the care we provide at every level. The goal to deliver this objective is P3. Improve engagement with the people we serve. A re-design of the PPI committee and to implement Always Events. The lead director was agreed as the Director of Nursing and Non-medical Professionals. 5.1 Strategic objectives The trust s strategic objectives and goals for 217/18 were revised; our strategic objective people now includes: - We will actively engage with patients, public and carers to improve the care we provide at every level And our goal is to: - Improve engagement with the people we serve However strong patient and public engagement supports the other three strategic goals: Quality: Feedback from patients and the public is a key indicator of the quality and safety of services. Good engagement supports the delivery of services which are patient-centred and which are inclusive of people with protected characteristics. Page 9 of 18

75 Whole systems solutions: Engagement with patients and the public leads to the design and delivery of care which is based on the needs of patients and supports working across traditional organisational boundaries, working in care systems which are based on a patient pathway. Sustainability: Part of being sustainable means to identify opportunities to do things differently in order that care is provided efficiently and effectively. Good patient and public engagement supports the trust being a viable contender in a competitive market. Part of the STP principles is that they will work with local people at a local level, through health and care partnerships. 6. Next steps Engaging people is everybody s responsibility, regardless of the role they have in the trust. The vast majority of the staff in the organisation speak with patients every day and receive important feedback on how services are operating. Everyone is responsible for encouraging people to be engaged in decisions about their care and treatment, through providing information and responding to concerns and everyone should seek people s views about services, respond to patient feedback and actively involve people to find solutions to meet expectations, where possible. For this strategy to be useful, we will develop annual objectives which link to our vision and our analysis and which are SMART (Specific, Measurable, Achievably, Relevant, Time-bound). In 218/19 the priority areas will be: Implement the proposed model of engagement so that the people we engage with are confident that we listen and make changes as a result of their contributions. Further developing relationships with partner organisations patient and public engagement groups to ensure there is an escalation or sharing of issues raised through engagement forums. Demonstrate improved patient experience as a result of the implementation of the fourth (of four) Always Events, co-designed in 217/18. Demonstrate improved understanding of the population we serve through better analysis of patient engagement, particularly considering those with a protected characteristics 7. Risks Page 1 of 18

76 Risk If we are unable to deliver this strategy then we will have lost an opportunity to improve outcomes for patients If there are not sufficient resources to deliver this strategy then the trust will not be able to demonstrate it has met either its vision or its strategic objectives If we are not able to demonstrate that we engage with patients and the public as part of a well-led assessment then we will not be a provider of choice Initial risk Mitigation rating 12 Dedicated patient experience and engagement manager Action plan to deliver strategy Executive lead Board oversight of delivery of strategic objectives Always Events programme monitored through strategic objective review 12 Dedicated patient experience and engagement manager Quarterly patient experience and engagement report Action plan to deliver strategy Executive lead Board oversight of delivery of strategic objectives 12 Self-assessment completed; requires Board review and actions to address gaps Exec and Board development programme J2O programme Residual risk rating Page 11 of 18

77 Appendix 1 Mapping of patient and public engagement Strategic level How we involve patients and the public in broader discussions about trust and local strategy Healthwatch representation at Trust Board and Quality Governance Committee Public and Patient Engagement Forum Complaints Scrutiny Panel meeting with participation from Healthwatch representative Member of the PPRIG which includes patient representatives. Member of Hounslow CCG patient and public engagement committee. Patient Stories to the Board. Patient participation group as part of RCHiP Attendance at community events (patient experience team): -HRCH AGM -HRCH Community Health Fair Condition/service specific How we involve patients and the public in the review, planning and decision making about specific services Implementation of Always Events through co-design methodology Development of patient pathways through OBC work in: Diabetes Respiratory care Presentations to service specific groups: Implementation of self-management folder for patients receiving care from RRRT end of life care presentation to the Home Support-Provider Forum Presentation at Woodville day centre and Crossroads office in Teddington (Continence) Interactive presentations on bladder and bowel care management in people with Parkinson disease (Continence) Presentation to Homelink Carers Group (dementia) Primary Care Business Support Manager attended each PPGs across Hounslow to Page 12 of 18 Individual patient level How we involve patients in their care and decisions about their care Being Open meetings following a complaint or concern MDT meetings with patients, family and carers Safeguarding case conferences Care planning Medication reviews

78 -Richmond Carers event -Hounslow Carers Rights day -Richmond CCG and Richmond Healthwatch event -Hounslow community network conference Outreach work to community groups (patient experience team): Asian elders group -Hounslow Pensioners forum -Richmond Carers -Nepalese Community Group promote and explain what the primary care service is doing in their practices. OT and SLT attend the CAMHs Parent Group Children s therapy services attended an Open Day held by the SEN Advisory Teachers for parents to drop in Actions taken as a result of patient feedback: designed and started using a leavers pack (Cardiac Rehab) community nurses received training from expert carer as a result of a patient story Attendance at specific community events: Health Fair and Transforming Care Event in Hounslow (Learning disabilities) Dementia Awareness week ran stalls at 5 locations across the Trust for staff and public. Presentation to EMAG group - ethnic minority group to raise awareness of dementia Information stall at Richmond carers conference (dementia) Woodville dementia awareness week Falls & Bone Health service engage through Age UK, Bluebird Care and Winter Warmth scheme at social services Training for specific patient/carer groups: Medicine training provided to foster carers in Hounslow (Pharmacy) Dementia friends training sessions for the Page 13 of 18

79 public and staff Positive Dementia Care Conference at Stoop over 1 people attended across the whole day. Staff and carers Dementia training at Homelink for 15 of their staff Dementia Friends session for Richmond police cadets Service specific engagement groups: Children s hearing services working groups (audiology) Hear to inform group for developing materials (audiology) Hounslow & Richmond dementia steering groups Involved service users in designing the new integrated service, The Wheelchair Hub including selecting a name and a logo. Gained feedback on redesign of service and determine the demand for weekend rehabilitation appointments within the service. (CRS) Interview process re-designed the process and includes service users in interviewing for new members of staff (LD). FNP annual review attended by six young parents FNP celebration event attended by service users, along with children s commissioner and FNP regional lead for London. Children s continence forum (Children s Community Nursing service) Page 14 of 18

80 FNP clients feedback experiences of mental health services at FNP advisory board. Clinical service manager (Children s therapy services) attends the Hounslow Parent Forum Meetings with the DCO, Designated Clinical Officer and Head of SEN & Disability Page 15 of 18

81 Appendix 2 The ladder of engagement and participation. (Transforming Participation in Health and Care, NHS England, September 213). The chart below is a self-assessment against a suggested framework for patient involvement and engagement. The left hand column is a list of trust activity where the patient and public voice needs to be present. The top row of the diagram is the involvement continuum, which describes the type or intensity of patient and public engagement activity. The ladder of engagement and participation* January 217 Assurance Inform Consult Involve Collaboration as equal partners Patient involvement in individual care and treatment Service delivery, development and transformation Patient involvement in monitoring the quality of services Strategy future planning *The ladder of engagement and participation (Transforming Participation in Health and Care, NHS England, September 213). Inform Providing communities and individuals with balanced and objective information to assist them in understanding problems, alternatives, opportunities, solutions. For example, websites, newsletters and press releases. Consult Obtaining community and individual feedback on analysis, alternatives and / or decisions. For example, surveys, door knocking, citizens panels and focus groups. Involve Working directly with communities and patients to ensure that concerns and aspirations are consistently understood and considered. For example, partnership boards, reference groups and service users participating in policy groups. Collaboration Working in partnership with communities and patients in each aspect of the decision, including the development of alternatives and the identification of the preferred solution. Page 12 of 18

82 The ladder of engagement and participation* December 217 Assurance Inform Consult Involve Collaboration as equal partners Patient involvement in individual care and treatment Service delivery, development and transformation Patient involvement in monitoring the quality of services Strategy future planning Page 13 of 18

83 Appendix 3 Proposed model of engagement Page 14 of 18

84 Meeting title Trust Board part I meeting Date: 28 March 218 Report title Learning from deaths dashboard Agenda item: 14 Lead director Report authors Executive summary Tony Snell - Interim Medical Director Chris Giles, Assistant Director for Contracts and Performance, and David Griffiths, Information Analyst This is the second Trust Learning from Deaths Dashboard under the new Trust Learning from Deaths Policy. NHSI s National Guidance on Learning from Deaths, published in March 217 which states, community trusts should ensure their governance arrangements and processes include, facilitate and give due focus to the review, investigation and reporting of deaths, including those deaths that are determined more likely than not to have resulted from problems in care. Trust should also ensure that they share and act upon any learning derived from these processes. The Trust will report separately for adults dying in the Teddington War Memorial Hospital and the community as well as for Learning Difficulties, through the LeDeR process, managed by the CCGs. The following are the definitions used for inclusion in the reporting dashboards: Adults Services All deaths of patients in our inpatient care or who have been recently discharged within 3 days are to be screened once the service becomes aware of the death. All deaths occurring while services were being provided in the carrying on of a regulated activity or have, or may have, resulted from the carrying on of a regulated activity (e.g. wrong dose of medication given) are to be screened once the service becomes aware of the death. (These deaths would be reportable to CQC) In addition to the mandatory list above the Trust intends taking a pragmatic approach to identifying other groups that would require review. This list is not exhaustive and may be added to at any time and does not exclude other examples or events. Front line clinicians and managers need to identify any case that might warrant review and where learning would be beneficial; Cases on the adult caseload: Where there is any concern that management could have been better compared to what we would expect for a relation of our own. Where the GP, pharmacist or any other relevant health professional requests a review Where patient family or friend raise issues or concerns Where individual members of clinical team wish for a review to take place The Trust has determined that it will record the total number of deaths Page 1 of 2

85 across the service that were currently on the services caseload, where we are informed of the death. These deaths may be entirely unrelated to the services the Trust provide, e.g. road traffic accident, deaths from unrelated causes, e.g. stroke in a wound management patient, etc. On reviewing this data in twelve months time, the Trust will determine the workload resource associated with screening and reviewing these cases and what, if any, learning would be achieved by doing so. two dashboards have been provided; The first Whole Trust dashboard displays deaths of patients that appear on the organisation total caseload. Month (and deaths) Quarter (and deaths) December (172) Q2 (464) January (282) Q3 (282) The second dashboard displays Inpatients Only activity for Teddington War Memorial Hospital. Month (and deaths) Quarter (and deaths) December (1) Q2 () January () Q3 (4) No reviews or investigations have taken place as the criteria were not met. Purpose: Recommendation(s) For review The Board is asked to: i. receive and discuss the mortality dashboard; ii. no conclusions, trends or learning can be identified at this time as numbers are very small; iii. we await the report from the CCG regarding the learning disability deaths. iv. approve publishing this report on the Trust website as required by NHSE BAF/TRR Q1/Q2 Report history Appendices Quarterly report to Quality and Safety and Quality Governance Committees Appendix 1: Learning from deaths dashboard Page 2 of 2

86 Hounslow & Richmond Community Healthcare NHS Trust (HRCH Trustwide): Learning from Deaths Dashboard - January Description: The suggested dashboard is a tool to aid the systematic recording of deaths and learning from care provided by NHS Trusts. Trusts are encouraged to use this to record relevant incidents of mortality, number of deaths reviewed and cases from which lessons can be learnt to improve care. Summary of total number of deaths and total number of cases reviewed under the Structured Judgement Review Methodology Total Number of Deaths, Deaths Reviewed and Deaths Deemed Avoidable (does not include patients with identified learning disabilities) Total Number of Deaths in Scope Total Deaths Reviewed Total Number of deaths considered to have been potentially avoidable (RCP<=3) This Month Last Month This Month Last Month This Month Last Month This Quarter (QTD) Last Quarter This Quarter (QTD) Last Quarter This Quarter (QTD) Last Quarter This Year (YTD) Last Year This Year (YTD) Last Year This Year (YTD) Last Year Time Series: Start date Q1 End date Q Mortality over time, total deaths reviewed and deaths considered to have been potentially avoidable (Note: Changes in recording or review practice may make comparison over time invalid) Q Q2 Q3 Q4 Q Q2 Total deaths Deaths reviewed Total Deaths Reviewed by RCP Methodology Score Score 1 Score 2 Score 3 Score 4 Score 5 Score 6 Definitely avoidable Strong evidence of avoidability Probably avoidable (more than 5:5) Probably avoidable but not very likely Slight evidence of avoidability Definitely not avoidable This Month - This Month - This Month - This Month - This Month - This Month - This Quarter (QTD) - This Quarter (QTD) - This Quarter (QTD) - This Quarter (QTD) - This Quarter (QTD) - This Quarter (QTD) - This Year (YTD) - This Year (YTD) - This Year (YTD) - This Year (YTD) - This Year (YTD) - This Year (YTD) - Summary of total number of learning disability deaths and total number reviewed under the LeDeR methodology Total Number of Deaths, Deaths Reviewed and Deaths Deemed Avoidable for patients with identified learning disabilities Total Number of Deaths in scope Total Deaths Reviewed Through the LeDeR Methodology (or equivalent) This Month Last Month This Month Last Month This Month Last Month 1 1 This Quarter (QTD) Last Quarter This Quarter (QTD) Last Quarter This Quarter (QTD) Total Number of deaths considered to have been potentially avoidable Last Quarter 1 2 This Year (YTD) Last Year This Year (YTD) Last Year This Year (YTD) Last Year 5 11 Time Series: Start date Q1 End date Q Mortality over time, total deaths reviewed and deaths considered to have been potentially avoidable (Note: Changes in recording or review practice may make comparison over time invalid) Q Q2 Q3 Q4 Q Total deaths Deaths reviewed

87 Hounslow & Richmond Community Healthcare NHS Trust (TMH Inpatients Only): Learning from Deaths Dashboard - January Description: The suggested dashboard is a tool to aid the systematic recording of deaths and learning from care provided by NHS Trusts. Trusts are encouraged to use this to record relevant incidents of mortality, number of deaths reviewed and cases from which lessons can be learnt to improve care. Summary of total number of deaths and total number of cases reviewed under the Structured Judgement Review Methodology Total Number of Deaths, Deaths Reviewed and Deaths Deemed Avoidable (does not include patients with identified learning disabilities) Total Number of Deaths in Scope Total Deaths Reviewed Total Number of deaths considered to have been potentially avoidable (RCP<=3) This Month Last Month This Month Last Month This Month Last Month 1 This Quarter (QTD) Last Quarter This Quarter (QTD) Last Quarter This Quarter (QTD) Last Quarter 4 This Year (YTD) Last Year This Year (YTD) Last Year This Year (YTD) Last Year 6 15 Time Series: Start date Q1 End date Q Mortality over time, total deaths reviewed and deaths considered to have been potentially avoidable (Note: Changes in recording or review practice may make comparison over time invalid) Q Q2 Q3 Q4 Q Q2 Total deaths Deaths reviewed Total Deaths Reviewed by RCP Methodology Score Score 1 Score 2 Score 3 Score 4 Score 5 Score 6 Definitely avoidable Strong evidence of avoidability Probably avoidable (more than 5:5) Probably avoidable but not very likely Slight evidence of avoidability Definitely not avoidable This Month - This Month - This Month - This Month - This Month - This Month - This Quarter (QTD) - This Quarter (QTD) - This Quarter (QTD) - This Quarter (QTD) - This Quarter (QTD) - This Quarter (QTD) - This Year (YTD) - This Year (YTD) - This Year (YTD) - This Year (YTD) - This Year (YTD) - This Year (YTD) - Summary of total number of learning disability deaths and total number reviewed under the LeDeR methodology Total Number of Deaths, Deaths Reviewed and Deaths Deemed Avoidable for patients with identified learning disabilities Total Number of Deaths in scope Total Deaths Reviewed Through the LeDeR Methodology (or equivalent) This Month Last Month This Month Last Month This Month Last Month This Quarter (QTD) Last Quarter This Quarter (QTD) Last Quarter This Quarter (QTD) Total Number of deaths considered to have been potentially avoidable Last Quarter This Year (YTD) Last Year This Year (YTD) Last Year This Year (YTD) Last Year Time Series: Start date Q1 End date Q Mortality over time, total deaths reviewed and deaths considered to have been potentially avoidable (Note: Changes in recording or review practice may make comparison over time invalid) Q Q2 Q3 Q4 Q Total deaths Deaths reviewed

88 Meeting title Trust Board part 1 meeting Date: 28 March 218 Report title 217/18 Information Governance Toolkit Submission Agenda item: 15 Lead director Report author Executive summary David Hawkins, Director of Finance and Corporate Services David Hawkins, Director of Finance and Corporate Services Background The NHS Information Governance Toolkit (IGT) is a selfassessment strategic framework consisting of a range of linked initiatives (standards) which all NHS organisations are required to complete and submit to NHS Digital on an annual basis. The toolkit evaluates the adequacy of risk management and control within the trust and assesses progress against these initiatives. Where the trust has indicated that the necessary policies, procedures and measures are in place to meet these criteria, current supporting evidence is required to be maintained. An integral part of the IGT assessment is the annual submission of the Statement of Compliance (SoC), which provides assurance to NHS Digital that the trust has robust and effective infrastructure and systems in place for handling information securely and confidentially. This annual statement is necessary to obtain and maintain connection to the NHS secure infrastructure (N3) and national services. To show the required level of assurance, a minimum attainment of Level 2 compliance against all requirements within the IGT is required. This also requires staff to undertake annual information governance mandatory training, with the requirement that at least 95% must have completed within the financial year to achieve the necessary standard. As part of our assurance HRCH requested our internal auditors, RSM Risk Assurance Services LLP, to undertake a review of our available evidence via a sample audit of ten IG Toolkit requirements. The draft report is attached for information to the Board showing that our self-assessment of evidence is robust. The latest training figures of 16 th March also shows that 96.44% of HRCH staff had successfully completed their IG training. A final review of the IG Toolkit evidence is underway to Page 1 of 2

89 ensure all other categories reach a minimum of level 2 compliance, before submitting our self-assessment by 31 st March. Purpose: Noting Recommendation(s) The Board is asked to: i. note the assessment of the internal audit report for IG Toolkit evidence for 217/18; and ii. take assurance from this and the latest training numbers that HRCH will successfully achieve Level 2 compliance. BAF/TRR S1 Sustainability Report history Executive Committee meeting 12/3/18 Appendices RSM Risk Assurance Services LLP Information Governance Toolkit draft internal audit report Page 2 of 2

90 HOUNSLOW AND RICHMOND COMMUNITY HEALTHCARE NHS TRUST Information Governance Toolkit (Version 14.1) DRAFT Internal Audit Report: 6.17/18 5 March 218 This report is solely for the use of the persons to whom it is addressed. To the fullest extent permitted by law, RSM Risk Assurance Services LLP will accept no responsibility or liability in respect of this report to any other party.

91 CONTENTS 1 Executive summary Detailed findings and Action Plan... 5 APPENDIX A: SCOPE... 6 For further information contact... 7 Debrief held Draft report issued 6 March 218 Responses received Internal Audit team Nick Atkinson, Head of Internal Audit David May, Client Manager Oliver Bowden, Internal Auditor Final report issued Client sponsor David Hawkins, Director of Finance, Contracts, Procurement and Performance Distribution Avril Duncan, Director of IT Noel Davey, IG Manager As a practising member firm of the Institute of Chartered Accountants in England and Wales (ICAEW), we are subject to its ethical and other professional requirements which are detailed at The matters raised in this report are only those which came to our attention during the course of our review and are not necessarily a comprehensive statement of all the weaknesses that exist or all improvements that might be made. Recommendations for improvements should be assessed by you for their full impact before they are implemented. This report, or our work, should not be taken as a substitute for management s responsibilities for the application of sound commercial practices. We emphasise that the responsibility for a sound system of internal controls rests with management and our work should not be relied upon to identify all strengths and weaknesses that may exist. Neither should our work be relied upon to identify all circumstances of fraud and irregularity should there be any. This report is solely for the use of the persons to whom it is addressed and for the purposes set out herein. This report should not therefore be regarded as suitable to be used or relied on by any other party wishing to acquire any rights from RSM Risk Assurance Services LLP for any purpose or in any context. Any third party which obtains access to this report or a copy and chooses to rely on it (or any part of it) will do so at its own risk. To the fullest extent permitted by law, RSM Risk Assurance Services LLP will accept no responsibility or liability in respect of this report to any other party and shall not be liable for any loss, damage or expense of whatsoever nature which is caused by any person s reliance on representations in this report. This report is released to you on the basis that it shall not be copied, referred to or disclosed, in whole or in part (save as otherwise permitted by agreed written terms), without our prior written consent. We have no responsibility to update this report for events and circumstances occurring after the date of this report. RSM Risk Assurance Services LLP is a limited liability partnership registered in England and Wales no. OC at 6th floor, 25 Farringdon Street, London EC4A 4AB Hounslow and Richmond Community Healthcare NHS Trust Information Governance Toolkit 14.1 (6.17/18) 1

92 1 EXECUTIVE SUMMARY 1.1 Background An audit of the Information Governance Toolkit (IGT) Version 14.1 was undertaken as part of the approved internal audit periodic plan for 217/18. During the audit we reviewed a sample of ten Information Governance (IG) Toolkit requirements based on the current scores submitted by the Trust. It should be noted that these scores can be updated prior to the March 218 submission. The NHS Information Governance Toolkit is a self-assessment strategic framework consisting of a range of linked initiatives (standards) which all NHS organisations are required to complete and submit to NHS Digital on an annual basis. The toolkit evaluates the adequacy of risk management and control within the Trust and assesses progress against these initiatives. Based on the results, the Trust would be assigned an attainment rating, ranging from to 3 (3 being the highest and fully compliant with all criteria). Where the Trust has indicated that the necessary policies, procedures and measures are in place to meet these criteria, current supporting evidence is required to be maintained. An integral part of the IGT assessment is the annual submission of the Statement of Compliance (SoC), which provides assurance to NHS Digital that the Trust has robust and effective infrastructure and systems in place for handling information securely and confidentially. This annual statement is necessary to obtain and maintain connection to the NHS secure infrastructure (N3) and national services. To show the required level of assurance, a minimum attainment of Level 2 compliance against all requirements within the IGT is required. As part of this audit we have reviewed the evidence maintained to show compliance with a sample of ten requirements which are detailed in the table below under Section 1.3 Key Findings. The sample was selected in collaboration with the Trust to cover both strategic and operational governance controls. The IGT requirement initiatives considered as part of this review relate to the following control areas: Information Governance Management ( ) Confidentiality and Data Protection Assurance (14.1-2, , , ) Information Security Assurance ( , , ) Clinical Information Assurance (14.1-4) Secondary Use Assurance (Not in sample) Corporate Information Assurance ( ) 1.2 Conclusion The Trust submitted a Baseline/Performance report on the 3th of October 217. We reviewed ten requirements, and based on the evidence at the time of the audit we were able to confirm that the scores stated by the Trust were in line with the evidence uploaded to the Toolkit. Out of the ten requirements we found that one was at the highest level (level 3) and the other nine were at level 2, which is the level required by the NHS. For the nine requirements which were at attainment level two, target scores of level two were set within the toolkit. We reviewed the Trust s improvement plan and noted separate plans in place for each responsible owner. On review of the plans we found these were detailed in showing evidence that was required as well as the status of completion. Hounslow and Richmond Community Healthcare NHS Trust Information Governance Toolkit 14.1 (6.17/18) 2

93 We reviewed the Trust s procedures for managing and monitoring IG Toolkit improvement planning and found it to be a robust process. From reviewing meeting agendas, we ascertained that the IG toolkit is reported on and discussed within the Information Governance Sub-Committee meetings. Please note that IGT requirements and scoring criteria represent a high level self-assessment of performance within the organisation. Our review is based upon the evidence provided to us to substantiate the scores submitted in relation to these high-level requirements and criteria. Our assessment of scores is based on the reasonableness of the scores in these circumstances and do not, therefore, imply assurance that detailed controls are adequate to meet business needs. It is possible, therefore, that more detailed audits of specific areas contained within the IGT may uncover control weaknesses that subsequently appear to contradict the opinions herein. 1.3 Key findings The following table highlights the Trust s scoring when compared to our scoring through the independent assessment. No management actions were required to be raised during this review. Assessment and Recommendations Req No. Description Trust Self- Assessed Score (as at 22 nd February 218) Trust Target Score for March 218 Submission Evidence Supports a Minimum Assessment Level RSM Assessment of Trusts current score There is an adequate Information Governance Management Framework to support the current and evolving Information Governance agenda The Information Governance agenda is supported by adequate confidentiality and data protection skills, knowledge and experience which meet the organisation s assessed needs The organisation ensures that arrangements are in place to support and promote information sharing for coordinated and integrated care, and staff are provided with clear guidance on sharing information for care in an effective, secure and safe manner Patients, service users and the public understand how personal information is used and shared for both direct and nondirect care, and are fully informed of their rights in relation to such use There are appropriate procedures for recognising and responding to individuals requests for access to their personal data Agree Agree Agree Agree Agree Hounslow and Richmond Community Healthcare NHS Trust Information Governance Toolkit 14.1 (6.17/18) 3

94 Req No Description There are documented information security incident / event reporting and management procedures that are accessible to all staff Monitoring and enforcement processes are in place to ensure NHS national application Smartcard users comply with the terms and conditions of use Policy and procedures ensure that mobile computing and teleworking are secure The Information Governance agenda is supported by adequate information quality and records management skills, knowledge and experience Documented and publicly available procedures are in place to ensure compliance with the Freedom of Information Act 2 Trust Self- Assessed Score (as at 22 nd February 218) Trust Target Score for March 218 Submission Evidence Supports a Minimum Assessment Level RSM Assessment of Trusts current score Agree Agree Agree Agree Agree Assessment Explanation Agree Understated Overstated Unsubstantiated From the evidence available we are able to agree the score recorded as a reasonable assessment of current performance. From the evidence provided it is our assessment the organisation is performing at a Level higher than recorded. From the evidence provided it is our assessment the organisation is performing at a lower Level than recorded. The organisation has not provided enough evidence to confirm the score recorded. Where scores differ based on the evidence uploaded to the IGT, management actions have been agreed to address the shortfall. Hounslow and Richmond Community Healthcare NHS Trust Information Governance Toolkit 14.1 (6.17/18) 4

95 2 DETAILED FINDINGS AND ACTION PLAN During the course of the audit and the review of the requirements selected we found there were no exceptions identified. Hounslow and Richmond Community Healthcare NHS Trust Information Governance Toolkit 14.1 (6.17/18) 5

96 APPENDIX A: SCOPE Scope of the Review The internal audit assignment has been scoped to provide assurance on how the Trust manages the following risk: Objective of the area under review The objective of our review is to provide an opinion on the validity of a sample of IG Toolkit scores based on the evidence available at the time of audit fieldwork. Risks relevant to the scope of the review Non-compliance with the IG Toolkit requirements. When planning the audit, the following areas for consideration and limitations were agreed: Areas for Consideration: The validity of the toolkit return based upon a review of a sample of toolkit requirements; Compliance with 2-stage reporting requirements; and The robustness of the IG Toolkit improvement plans, monitoring and reporting of these (where applicable). Limitations to the Scope of the Audit Assignment: This is a sample review of the version 14.1 scores only. Therefore, not all requirements will be examined as part of this review The evidence must be clearly referenced to the requirement it supports and provided at the start of the audit, otherwise we may not be able to complete any testing or provide an opinion As a compliance review, detailed testing will not be undertaken. The operational level of the section under review will not be assessed neither will the design of the controls Staff surveys will not be completed to assess awareness and workplace practices Our work does not provide any guarantee against material error, loss or fraud or provide an absolute assurance that material error, loss or fraud does not exist. Hounslow and Richmond Community Healthcare NHS Trust Information Governance Toolkit 14.1 (6.17/18) 6

97 FOR FURTHER INFORMATION CONTACT Nick Atkinson, Head of Internal Audit RSM Risk Assurance Services LLP Direct Line: +44 () Mobile: +44 () David May, Audit Manager RSM Risk Assurance Services LLP Phone: +44 () Mobile: +44 () Hounslow and Richmond Community Healthcare NHS Trust Information Governance Toolkit 14.1 (6.17/18) 7

98 Meeting title Trust Board part I meeting Date: 28 March 218 Report title 217 Staff survey results and action planning Agenda item: 16 Lead director Alison Heeralall, Director of Workforce Report author Executive summary Lisa Waugh, Staff Engagement and Wellbeing Manager Attached are the Trust results from the National Staff Survey conducted between October and November 217 (Appendix A). The results were published nationally on 6 March 218 and the Trust published internal and external media highlighting these on the same day (Appendix B). We achieved a high response rate of 62% (community trust average 49%), which provides rich data to understand staff views whilst working at HRCH and to inform improvements. The survey comprises 32 key findings grouped into 9 themes. It is noteworthy that the Trust has improved 21 of its key finding scores since 216 and scored top nationally in five areas. The report went to Executive Committee on 12 th March. Executives agreed the overall results were positive and showed incremental improvement in a number of areas. It was agreed that actions need to be more targeted and solutions focussed on where the specific services, staff groups or bands raised concern with staff focus groups to ensure the right actions are deployed to achieve a step change. It was also recommended to look at results where the trust had a low percentage albeit faring better than the national average. The results are now being circulated to heads of service and teams to share and discuss the results and create targeted actions. Feedback will be used to inform actions to be incorporated into the Trust Staff Engagement Plan 218/19 and aligned to trust strategic priorities where relevant. Purpose: Review Recommendation(s) The Board is asked to: i. note the results and key headlines; 1

99 ii. iii. provide feedback on the areas identified; and give feedback on any other areas of focus which will then be used to inform actions to be incorporated into the Trust Staff Engagement Plan 218/19 and aligned to strategic and/or local service priorities and actions. BAF/TRR Report history People P1/P2a n/a Appendices A: 217 staff survey results published nationally B: Internal trust communications and external press release issued

100 1. Background Attached are the Trust results from the national staff survey conducted in Autumn 217 (Appendix A). All NHS organisations use the same staff survey and are required to use an approved survey provider, which in our case is Quality Health who issue the survey to our staff and independently collate the results. The results were published nationally on 6 March 218 and the Trust published internal and external media highlighting these on the same day (Appendix B). The trust achieved a high response rate of 685 staff equalling 62% of the organisation (compared to 49% community trust average), but fundamentally this helps provide as rich data as possible to understand staff views whilst working at HRCH and to inform improvements. 2. Key points There is good evidence to show the correlation between an engaged workforce and high quality patient care, and new evidence to show that staff engagement is associated with low rates of staff sickness and therefore lower spending on bank and agency staff (Kings Fund, March 218). The Staff Engagement score in the staff survey measures the following: willingness of staff to recommend the Trust as a place to work and/ or receive treatment; the extent to which staff feel motivated and engaged with their work; and staff feeling able to contribute towards improvements at work. The Trust has improved its position for overall Staff Engagement, scoring 3.95 (on a scale of 1 to 5, 5 being the most engaged) compared to 3.9 in 216 and 3.88 in 215 and 3.78 national average for community trusts which has remained static). It is also worth noting that the Trust scored the best (top) results of all community Trusts nationally in the following areas: number of people agreeing their role makes a difference to patients and service users (93%) employee satisfaction with the quality of work and care they are able to deliver (4.7/5) motivation at work (4.7/5), a further improvement since last year satisfaction with resources and support (equal to the best score for community trusts at 3.47/5) feeling unwell due to work-related stress in the past 12 months (the lowest score for community trusts at 35%, compared with the highest score of 45%) Change since 216: The survey comprises 32 key findings and the trust has improved 22 of the key findings scores since the 216 survey, and 9 areas have reduced scores. There has 3

101 been a significant improvement (more than 5%) in the staff recommendation of the organisation as a place to work or receive treatment (3.83 to 3.93 out of 5). Our areas for focus and improvement from last year were: % of staff witnessing potentially harmful errors, near misses of incidents in the last month (24% in 216 compared to 2% nationally). This has improved by 3% and is now down to 2%, better than the average of 21%. % of staff who received an appraisal in the last 12 months. This has significantly improved by 5% to 9% from 85% in 216. % staff experiencing discrimination, violence, bullying and harassment, from the public and staff in the last 12 months. o Discrimination has remained the same since last year at 1%. o Staff experiencing physical violence has reduced from 2% to 1% o Bullying, harassment and abuse has also reduced slightly from 24% to 23%. However, the percentage of staff / colleagues reporting most recent experience of harassment, bullying or abuse has reduced from 58% to 51% which needs addressing. % staff reporting good communication between senior management and staff has improved from 35% last year, to 38% in 217. We are still above the national average of 36% but the best score for community trusts is 45% and we should continue our focus to improve this. Comparisons with other community trusts: The trust is better than average in 19 of the 32 key findings, and only below average in 4 key findings (the rest were average). For the second year in a row, the trust was higher than the national average for community trust in all of the key findings under the themes of Job satisfaction and Patient Care and Experience. 3. Initial improvement areas identified The key findings where the survey has highlighted we are below the average for community trusts are: Staff believing that the organisation provides equal opportunities for career progression or promotion (83% compared to 88% average) Percentage of staff / colleagues reporting most recent experience of harassment, bullying or abuse (51% compared to 53% average). Percentage of staff experiencing discrimination at work in the last 12 months (1% compared to 9% average) Percentage of staff working extra unpaid hours (65% compared to 64% average) From analysis of directorates, professional groups and staff banding, groups of staff identified for specific focus groups are: 4

102 Health and wellbeing and operational support directorate (low directorate for overall engagement) Urgent care (low directorate for overall engagement) Bands 2, 3, & 4 less satisfied than other bands this tends to be administrative staff. In addition, Band 8b are less satisfied than other pay bands Health and safety committee to lead on improving reporting of harassment, bullying and abuse across whole organisation and tackling factors that may support patient/carer on staff and staff on staff harassment, bullying and abuse Equality and diversity committee to consider the analysis presented at the 14 March committee to inform updates to the equality and diversity action plan including focusing on staff who report they are disadvantaged because they have a disability or are from a BAME group In addition to the targeted areas, every team will receive their survey results along with a poster and card to discuss and formalise the changes they will make as a team to address some of the issues raised in their team s survey results 4. Conclusions and recommendations The Board is asked to note the results and provide feedback on the initial areas identified and any other areas of focus which will then be used to inform actions to be incorporated into the trust staff engagement plan 218/19 and aligned to strategic and/or local service priorities and actions. 5

103 Staff Survey 217 results I am really pleased that HRCH tops the national staff survey rankings for community trusts in a number of areas this year. I m particularly pleased that the overall number of people who would recommend HRCH as a place to work increased to 68% from 64% last year. This compares well with the national average of 57% and is real recognition of the progress we have made so far on our Journey to Outstanding. I m also really encouraged by the fact that, despite the pressures on our people and the NHS as a whole, our people are working really hard to achieve great things every day, which is an indication of the professionalism of everyone we work with at HRCH. We received the best community trust results in the following areas: number of people agreeing their role makes a difference to patients and service users (93%) employee satisfaction with the quality of work and care they are able to deliver (4.7/5) motivation at work (4.7/5), a further improvement since last year satisfaction with resources and support (equal to the best score for community trusts at 3.47/5) feeling unwell due to work-related stress in the past 12 months (the lowest score for community trusts at 35%, compared with the highest score of 45%) We had 685 responses as part of the latest NHS staff survey with an impressive 62% of people responding to tell us about working conditions at HRCH, considerably higher than the community trust average of 49.1%. The results from our annual staff surveys are incredibly important to us as we get to hear about our colleagues views on working conditions and identify areas in which we can make improvements for our staff and patients. This year s results show we have continued to improve in 21 key areas and many of our scores are well above the national average for NHS organisations. We also improved in our areas of focus for last year: The number of people receiving an appraisal in the past 12 months increased from 85% to 9% in 217 Fewer employees experienced bullying and harassment, although the figure stayed the same for staff experiencing discrimination from patients and colleagues, so this will continue to be a focus for 218/19 The overall number of people who would recommend HRCH as a place to work increased to 68% from 64% last year (average 57%) While the vast majority of our results in this year s survey are overwhelmingly positive, we will use all your feedback to make further improvements to working conditions. Areas of focus for improvement during 218/19 will be: employees believing the trust provides equal opportunities for career progression or promotion percentage of employees working unpaid extra hours percentage of colleagues reporting their most recent experience of harassment, bullying, abuse or discrimination at work

104 We would like to work with teams on specific action plans as a result of the survey results and will be asking teams for at least one thing they will be changing. To get specific results for your team to discuss at a team meeting or for further support, please lisa.waugh@hrch.nhs.uk. We are also considering setting up some focus groups to talk through the survey results and discuss how to improve in areas with specific issues. Watch this space for more information. This year s staff survey prize winners randomly chosen by our external survey company were: Christine Lawler Registered Nurse, Outpatients, TMH Shelley Garrett Occupational Therapist, Community Neuro-Rehab Team Tania Parker Ward Clerk, TMH Inpatients I want to thank everyone who completed the survey and gave us such valuable feedback to enable our trust board to further improve HRCH for our staff and our patients. Finally, thank you to everyone who braved the Beast from the East last week to keep our patients safe and well in the community. Patricia Wright Chief Executive

105 Press release EMBARGOED to.1 hours Tuesday 6 March 218 HRCH gets top scores in national staff survey Almost seven out of ten employees would recommend Hounslow and Richmond Community Healthcare NHS Trust as a place to work, according to the NHS staff survey. The overall percentage increased to 68% from 64% last year. The national average is 57%. In addition, the trust has the top score in the country for employees agreeing their role makes a difference to patients and service users (93%). Hounslow and Richmond Community Healthcare has the best community trust results for: employee satisfaction with the quality of work and care they are able to deliver (4.7/5) employee motivation at work (4.7/5), a further improvement since last year employee satisfaction with resources and support (3.47/5) employees feeling unwell due to work related stress in the past 12 months the lowest score in the country at 35%, compared with the highest score of 45%) The trust improved its scores in 21 key areas including: number of staff receiving an appraisal in the past 12 months (up to 9% from 85% in 217) fewer staff experiencing bullying and harassment from patients and colleagues Areas to improve further during 218/19 will be: employees believing the trust provides equal opportunities for career progression or promotion working unpaid extra hours reporting harassment, bullying, abuse or discrimination at work Patricia Wright, chief executive, said: The results from the staff survey are incredibly important to us as we get to hear about our colleagues views on working conditions at the trust. I am pleased that 685 of our staff responded to the survey, which is 62% of our workforce. This is a brilliant response and considerably higher than the 49.1% national average for NHS community trusts. Most of our results are overwhelmingly positive, but our trust board recognises there are areas in which we can improve to benefit not only our people, but the patients they care for. We will work closely with teams to tackle areas in which we could do better and want to thank all our employees for completing the survey and providing such valuable feedback. ends Notes to editors The NHS Staff Survey is the largest survey of staff opinion in the UK and one of the largest staff surveys in the world. Each year NHS employees are encouraged to share

106 their views on the range of their experience at work including on development opportunities, health and wellbeing, staff engagement and involvement, and feeling able to raise concerns. Hounslow and Richmond Community Healthcare NHS Trust provides the majority of communitybased health services in the London boroughs of Hounslow and Richmond-upon-Thames. We employ more than 1,2 staff, including district nurses, health visitors, therapists, podiatrists and dietitians. For more information please contact Fiona Harcombe, head of communications and engagement, on or communications@hrch.nhs.uk.

107 Meeting title Trust Board part 1 meeting Date: 28 March 218 Report title Gender pay gap Agenda item: 17 Lead director Report author Executive summary Alison Heeralall, Director of Workforce Ian Hughes, Head of Workforce Information and Systems As part of the Equality Act 21 (Specific Duties and Public Authorities) Regulations 217, the trust is required to report on gender pay gap information as a snapshot of the pay period including 31 March 217. The appended report was approved by the Executive Committee on 12 March with final sign off by the Chief Executive before publication on the Trust website by 31 March 218. Purpose Noting Recommendation(s) Trust board members are asked to note the report to be published on our webpages. BAF/TRR People P1/P2a Report history Gender pay gap report executive committee 12 March 218 Appendices Appendix 1 Final gender pay gap report

108 Gender Pay Gap Report: Snap Shot Introduction Since the Equality Act 21 (Specific Duties) Regulations 211 (SDR) came into force on 1 September 211, there has been a duty for public bodies with 15 or more employees to publish information on the diversity of their workforce. Although the SDR did not require mandatory Gender Pay Gap (GPG) reporting, the Government Equalities Office (GEO) and the Equality and Human Rights Commission (EHRC) provided guidance that made it clear that employers should consider including GPG information in the data they already publish. It was evident that not all employers did this, so the government made GPG reporting mandatory by amending the SDR so that all public sector employers with more than 25 employees have to measure and publish their gender pay gaps from onward. For the first year, the data will be a snapshot of the pay period including 31 March 217 1, which needs to be uploaded to the Government website and published on the Trust website by 31 March 218. The results must remain on the organisation's website for three years. Subsequent Gender Pay Gap reports will be amalgamated into the Public Sector Equality Duty (PSED) reports from 218 onwards. The legal requirement for employers is to: Calculate the hourly rate of ordinary pay relating to the pay period in which the snapshot day falls. Calculate the difference between the mean hourly rate of ordinary pay of male and female employees, and the difference between the median hourly rate of ordinary pay of male and female employees. Calculate the difference between the mean (and median) bonus pay paid to male and female employees. Calculate the proportions of male and female employees who were paid a bonus. Calculate the proportions of male and female employees in the lower, lower middle, upper middle and upper quartile pay bands by number of employees rather than rate of pay. Further guidance around the Gender Pay Report can be found on the NHS Employers website below, which has links to advice from Capsticks and ACAS which we have referred to in compiling this report: The majority of salaries at HRCH are determined through a job evaluation scheme called Agenda for Change (AFC); this accounts for 97.9% of the workforce. Job evaluation measures the job and not the post holder. It makes no reference to gender of existing or potential job holders. 1 The relevant pay period means the pay period within which the snapshot date falls, which for monthly-paid staff would be the month in which the date is included. Page 1 of 5

109 Pay is predominately based on salary and/or service prior to or upon joining the Trust. Pay on promotion and progression in pay scale is based on the relevant national terms and conditions of service. The data is derived from the specifically designed report in the Business Intelligence (BI) reporting element of the Electronic Staff Record (ESR) and records the following number of staff in each group. 2. Gender Pay Gap Analysis The data below represents the gender pay gap snapshot data for the Trust 2. Table 1 Split of female and male staff counted in the gender pay gap report Payscale/ Band Female Male Total Females as a % Males as a % Band % 25.% Band % 11.74% Band % 7.95% Band % 7.7% Band % 11.32% Band % 17.7% Band 8a % 22.% Band 8b % 26.67% Band 8c % 33.33% Band 8d %.% Medical/ Other % 24.% Total % 13.2% 2 The figures are accurate at the time of reporting based on an extract from a nationally agreed ESR BI reporting template. Further advice will be available in 218/19 in terms of which groups to include in the figures. Page 2 of 5

110 Table 2 Overall Mean & Median Hourly Rates Gender Mean Hourly Rate Median Hourly Rate Male Female Difference Pay Gap % 5.51% 3.34% The overall mean and median pay rates include all staff on Agenda for Change, Medical and Dental, Very Senior Manager (VSM) 3 and non-executive director s (NEDs) remuneration pay scales 4. The Trust mean hourly rate for men is higher than women by 1.3 per hour or 5.51%. The median hourly rate, shows less of a gap by.58 or 3.34%. Table 3 Average hourly rate by Agenda for Change and Medical/Other payscales Payscale Band Average Female Average Male Diff Diff % AFC Band % AFC Band % AFC Band % AFC Band % AFC Band % AFC Band % AFC Band 8a % AFC Band 8b % AFC Band 8c % AFC Band 8d N/A N/A Medical/ Other % The table above splits the overall Trust figure into Agenda for Change and Medical/ Other pay bands/ scales. The table shows that for staff on Agenda for Change pay scales, female workers have for each pay band a higher average hourly pay rate than male counterparts. The Medical/ Other category includes doctors of all grades, VSM staff and NEDs. This category is the only one that shows on average males being paid a higher hourly rate than females. It should be noted that this data is based on 6 male staff 3 VSM pay rates apply to staff governed by NHS Improvement s Guidance on Pay for very senior managers in NHS trusts and foundation trusts. 4 Non-Executive Director (NED) remuneration scales are set nationally Page 3 of 5

111 and 19 females., The combination of a few male staff in the category, prescribed salary scales for particular VSM Director roles with relative high hourly rates and differences in years of service led to a higher average than their female counterparts. The 19 females in the Medical/ Other category contained more consultant medical staff but the majority of these staff have fewer years service as a consultant and the consultant s pay scale increments are based on years service in accordance with medical and dental terms and conditions. It should be noted that two female workers in this group had the highest hourly rate in the Trust. The 6 males in higher hourly rate roles also have a significant influence on the overall Trust mean hourly rate (Table 2) constituting 3.82% of the male workforce; whereas 19 females only constitute 1.81% of the total female workforce. Table 4 - Median hourly rate by Agenda for Change and Medical/Other payscales Payscale Band Median Female Median Male Diff Diff % AFC Band % AFC Band % AFC Band % AFC Band % AFC Band % AFC Band % AFC Band 8a % AFC Band 8b % AFC Band 8c % AFC Band 8d N/A N/A N/A Medical/ Other % As with the mean table the median table shows that for staff on Agenda for Change pay scales the female median is higher than the male median except for the Medical/ Other category has a higher median for males than females. The reason for this is the same as for the mean. Table 5 Number and % of male and females in each quartile of hourly rate Quartile Female Male Female % Male % % 13.95% % 9.93% % 11.59% % 16.61% Page 4 of 5

112 Table 5 was produced by listing the hourly rates in order and splitting the table into quartiles by number of employees Quartile 1 includes those staff with the lowest hourly rate while Quartile 4 includes those staff with the highest hourly rates. Bonus Payments In the current reporting year one bonus payment (Clinical Excellence Award) was paid as part of Medical and Dental remuneration package to a male doctor. The Clinical Excellence Award is an historical award which predates the current organisation. This means that.64% of males received a bonus and % of females. There is no difference between the mean or median bonus paid to males and females as the bonus relates to only one member of staff. Conclusion The Trust employs a predominantly female workforce and follows national pay guidance across all grades of staff regardless of gender. Across all Agenda for Change pay scales, females are paid more than their male counterparts on average. In the category Medical/Other males are paid more than females. This difference is influenced by the salary scales for particular VSM Director roles and years of service for Medical staff rather than gender difference. Actions The Gender Pay Gap report has been shared with the Trust s Executive Committee, Trust Board, Trust Equality and Diversity Committee and recognised trade unions via our Joint Negotiating and Consultative Committee (JNCC) The information generated by the Gender Pay Gap review will be monitored closely by the Trust Equality and Diversity Committee to ensure that there is no evidence of gender discrimination developing The Trust will publish gender pay gap information annually and monitor its situation internally and in relation to other NHS Trust benchmarks. Page 5 of 5

113 Meeting title Trust Board part I meeting Date: Report title February 218 Quality & Performance Scorecard and Exception Reports Agenda item: 2 Lead director Report authors Executive summary David Hawkins, Director of Finance, Contracts, Procurement and Performance Chris Giles, Assistant Director, Contracts and Performance, David Murrell, Performance Manager, and Sandeep Walia, Performance Analyst The Quality and Performance scorecard illustrates the Trust s performance against Key Performance Indicators, which are broken down into Trust and Divisional levels. Indicators are organised under the five CQC Domains: Safe, Effective, Caring, Responsive and Well-Led. NHS Improvement indicators are labelled with an N in the KPI code whilst internal ones are labelled with an I. Scorecard for February 218 Percentage of indicators RAG rated Green has increased from 87.% in January to 89.4% in February. The number of Amber RAG Rated has decreased from 1.9% in January to 6.4% in February. There were two breaches reported for this month: Staff sickness (Well-Led). Exception reports for these have been provided. W7(N) Staff sickness: Currently at 3.8% in January, a decrease of.2% from previous month (4.%). R6(N) Percentage Of Delayed Transfers Of Care: Currently at 7.5% in February, an increase of.7% from previous month (7.5%). KPI s in Amber are for the following:- S14(N) - Percentage of Harm free care (Safety Thermometer): 94.1% of patients surveyed were harm free for February, a decrease of.9% from previous month. Pressure ulcers have decreased at 4.5% and falls have increased to 1.4%. UTI s has increased to.5%. E3(I) - Clinical Supervision (% of staff in last 3 months): Currently at 82.8%. A decrease of 1.6% from previous month. W9(I) Vacancy Rate: 1.6% in February, RAG, previous month was also Rag Rated Amber at 1.7% (January). Page 1 of 4

114 Key areas to draw to the Committee s attention this month: Safe: S6(N) - Proportion of reported safety incidents that are harmful: Performance against this indicator has decreased to 32% in February from 34% in January. S1(N) Number of new serious incidents in the month: There was 1 new serious incident reported this month compared to in January. S11(I) Number of Open Serious incidents requiring investigation in month: No of open SI s have been on the increase this financial year with a small drop in September, and as at February 16 are currently open compared to previous month 15. S15(N)- Percentage of new Harms (Safety Thermometer): Increased from previous month 1.6% (January) to 2.1% (February). Caring: C1(N)- Inpatient Friends and Family Test (FFT) - % Recommend/ % Not Recommend: 1% would recommend; an increase from 93.8% in January. Not recommend has decreased to.% from previous month (January 6.3%). C3(N)- Community FFT - % recommend / Not Recommend %: 97.3% would recommend reported for February, a decrease of.8% from 98.1% in January. Not recommend remained the same at.3% from previous month. C4(N) Trust Composite FFT - % Recommend / % Not Recommend: 95.4% reported for February, a decrease of 1.7% from 97.1% in January. Not recommended increased to 1.5% from previous month.8% (January) C5(N) Staff FFT % recommend the trust as a place to receive care & treatment (Quarterly) & % not recommend the trust as a place to receive care & treatment (Quarterly): Recommend for Q3 is 67.5% a decrease of 18.9% from previous Quarter 86.4% (Q2). Not recommended increased to 12.1% from previous month 4.6% (Q2). C6(I)- Patient Survey- % patients who felt their privacy and dignity were respected: 1% reported for February, an increase from 99.3% in December. C7(I)- Patient survey- % patients who felt they received their care in a way that was right for them: 1% reported for February. An increase from previous month (95.4% January). Page 2 of 4

115 C8(I)- Percentage of Richmond Response and Rehabilitation Team (RRRT) service users very satisfied /satisfied 9.9% of service users satisfied with the service in February. An increase from 84.6% in January. C1(N)- Formal Complaints Received: Complaints received increased at 3 in February. C11(N)- Formal Compliments Received: 24 in February (compared to 49 in January). Effective: E1(I)- Percentage Of Staff Appraised: Currently RAG rated Green at 91.9%, a slight increase from 84.9% in January. A significant improvement from previous months. E2(I)- Percentage of Staff - Statutory & Mandatory Training: Currently RAG rated Green at 89.3%, an increase from 85.4% in January. E3(I) Clinical Supervision (% of staff in the last 3 months): Currently Rag Rated Amber at 82.8%. A decrease of 1.6% from previous month (January at 84.4%), Rag Rated Amber also. E5(I)- Patient Outcomes - Richmond Response & Rehabilitation Team (RRRT): 78% in February, RAG rated Green. A decrease of 1% from January (88%). Responsive: R1(N)- A&E: maximum waiting time of four hours from arrival to admission/ transfer/ discharge: 99.2% (RAG rated Green) for February. R1(I)- Percentage of services meeting contractual waiting times targets: 91% in February Rag rated Green an increase of 1% compared to previous month January (81%). Well-Led: W1(N)- Inpatient Friends & Family Test (FFT) response rate: Currently RAG rated Green at 8%. An increase of 18% from January (62%). W5(N)- Staff FFT response rate (Quarterly): 62.% response rate for Q3, compared to Q2 (3.7%) W6(N)- Staff FFT - % recommend / not recommend the trust as a place to work (Quarterly): 65.8% in Quarter 3 recommend the trust. % has decreased against previous Quarter (Q2, 66.4%). % for not recommend has decreased compared to previous quarter (Q2, 15.4%). Page 3 of 4

116 W8(N)- Staff turnover: 17.1% in February, RAG Rated Green, similar to previous two months December and January (17.1%). W1(N)- Temporary costs and overtime as a percentage of total pay bill: 13.5% for February, RAG rated Green. A slight increase of 1.% from previous month 12.5% (December). W11(N)- Percentage of BME staff in Bands 7-9 and VSM compared with the percentage of BME staff in the overall workforce: 27.8% in February, a decrease of 1.4% from previous month 29.2% in January. Of the 329 AFC Band 7 & above staff 83 are BME. Kindly note a correction made to previous month January. W12(N)- Temporary staff spend on agency staff (Variance against cap): Current month at -35.% compared to previous month at -34.% (January). This KPI has remained around the -3 mark since August. Purpose: Information Recommendation(s) Board members are invited to note the report. BAF/TRR Report history Appendices Q1/Q2, P1/2a Performance Executive Committee and Finance and Performance Committee meetings in March 218 February 218 Quality & Performance Scorecard Page 4 of 4

117 Quality and Performance Scorecard 217/18 Reporting Period: Feb 218 (Q4)

118 Contents Section 1 Performance Summary 3 Section 2 Areas of Concern 4-5 Section 3 Trust Performance Indicators 6 Safe Domain 6-7 Caring Domain 8-9 Effective Domain 1 Responsive Domain 11 Well-Led Domain 12 Section 4 Division Level Scorecards 13 Urgent Care Services 13 Integrated Response & Reablement Community Nursing Specialist Services Health & Well Being Services 2-21 Children s Specialist Services Children s Universal Services Operational Support Services 26 Corporate Services 27 Section 5 Safe Staffing Reports 28 TMH Inpatient Safe Staffing Levels 28 2

119 Section 1: Performance Summary The Quality and Performance Scorecard Indicators are broken down into the Care Quality Commission key domains: Safe, Effective, Caring, Responsive and Well-Led. The scorecard presents the indicators at an overall Trust Level and at a Divisional level. The selection of indicators presented are based on NHS improvement guidance and the Trust's priorities. February 218 Performance Domain Red Amber Green Not RAG Rated Reported Quarterly Unable to Report Total % Red % Amber % Green Safe % 14.3% 85.7% Caring %.% 1.% Effective % 2.% 8.% Responsive %.% 9.% Well-Led % 14.3% 71.4% Safe Staffing 9 9.%.% 1.% Total % 6.4% 89.4% Performance against Targets The Trust remains within target (Green RAG rated) for the majority of indicators (89.4%). 4.3% 6.4% Red Amber Green 89.4% Performance over the previous 13 months Monthly Performance Number of Indicators RAG Rated Number Green RAG Rated Green RAG Rated Number Amber RAG Rated Amber RAG Rated Number Red RAG Rated Red RAG Rated Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb % 8.4% 81.3% 82.2% 93.3% 88.2% 93.9% 83.% 88.2% 87.% 89.1% 81.6% 87.% 89.4% % 8.7% 12.5% 15.6% 4.4% 9.8% 6.1% 14.9% 5.9% 6.5% 8.7% 8.2% 1.9% 6.4% % 1.9% 6.3% 2.2% 2.2% 2.%.% 2.1% 5.9% 6.5% 2.2% 1.2% 2.2% 4.3% 1% 8% 6% 4% Rolling Twelve Month Performance Comparison 2.2% 2.2% 2.%.% 2.1% 2.2% 4.3% 1.9% 6.3% 4.4% 6.1% 5.9% 6.5% 9.8% 15.2% 15.6% 14.9% 5.9% 8.7% 6.5% 12.5% 8.7% 93.3% 93.9% 88.2% 8.4% 8.4% 81.3% 82.2% 83.% 88.2% 87.% 89.1% 1.2% 8.2% 81.6% 2.2% 1.9% 87.% In February 18 the percentage of indicators RAG rated Green has increased from the previous month 87.% to 89.4%. The percentage of indicators RAG rated Red has increased and is now at 4.3%. The proportion of indicators RAG rated Amber has decreased to 6.4% (from 1.9%). 2% % Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Green RAG Rated Amber RAG Rated Red RAG Rated 3

120 Section 2: Areas of Concern In February 218 there are two indicators which are RAG rated Red. Please see below for details of the indicators by reporting domain. Well-Led Domain Indicator: Gap to target / current performance: Staff Sickness Staff Sickness Staff Sickness compliance was below target for February. The following divisions breached target for February and RAG rated Red: Community Nursing: 5.6% Urgent Care: 4.3% Integrated Response And Reablement 5.1% Health & Wellbeing (not including Operational support): 7.4% Universal Children's: 3.8% Target Current Month YTD Trend 3.8% 3.5% 3% q R A Reason for performance gap: The sickness rate has reduced from 3.8% January 218 to 3.7% February, this is above last February s sick absence rate which was 3.32%. The main cause of the high rate of absence is due to colds and flu which remains high at 19.2% compared to 22.8% January 218, 13.2% December 1.8% November 217 and 6.8% October 217. The second highest cause is unknown. All the above listed areas are not only above target but have increased since last month, apart from H & W. However, overall this remains within the SPC limits. Taking into account seasonal trends, it is anticipated that the Trust will remain over the Trust target during the winter. The sickness rate has been below the Trust target of 3.2 % for a significant proportion of the year but has been elevated in the last 4 months. This is in line with expected seasonal fluctuations and reflects a similar position to last year s sickness absence rate for the Trust. Taking into account seasonal trends, it is anticipated that the Trust will remain over the Trust target during the winter period. The latest February 217 figures for Community Provider Trusts show we are below the national figure of 4.99% (Feb 17) The current year metrics are set consistently through each month, where it is expected that sickness will increase through the winter months, and it would be more sensible to flex the performance measure through the course of the year without increasing the accumulative measure for the year or base absence on a monthly year to date figure with a flat target. Description of Action Start Date End Date Status Outcome HR Advisors continue to support managers to manage their staff sickness absence attending service meetings and one to one meetings with Divisional leads. HRAs track sickness breaches to ensure that appropriate actions are taken, including RTW interviews. Sickness absence is also reviewed as part of the Clinical Performance Review Meetings to provide assurance that individual departments and services are effectively managing sickness absence in their areas. Senior managers to check the tracked information regarding absence management to assure themselves that the process is being followed robustly Feb-18 Mar-18 Monthly Bradford scores distributed and absences tracked for action Number of cases at informal stage with one at first formal stage Action Plan Managers to ensure reasons for absence are recorded via the RTW interview and uploaded to e-roster to ensure better monitoring and appropriate support identified. HRAs to review in monthly sickness meetings Mar-18 May-18 Not yet commenced Potential reduction in unknown causes for absence A rolling 12 month sickness absence statistic will be introduced to measure the 3.2% target against, which will iron out seasonal fluctuations. Apr-18 Apr-18 Completed This has been submitted to NHSi on the operating plan. This starts at 2.65% in April and increases to 4.% in Dec, with monthly variations to reflect the trend. Author: Ian Hughes/ Jane Smith/ Linda Thomas Sickness absence policy reviewed and prepared for consultation with JNCC Feb-18 Apr-18 In progress Reviewed policy drafted and ready to review at JNCC 4

121 Responsive Indicator: Gap to target / current performance: Percentage of Delayed Transfers of care Target Current Month YTD Trend Percentage of Delayed Transfers of care 7.5% 4.4% 7.5% p R G Percentage Of Delayed Transfers Of Care compliance was below target for February Patients all delayed by 58 days against an Occupancy of patient was delayed for 29 days from 11/1/18 because the family did not want him to go home and felt that he should go into interim placement. The patient did not have capacity to make this decision so there had to be a best interest meeting. The family also delayed getting financial information to the social worker which in turn delayed discharge. A family meeting was held and choice letters were issued before the patient was moved on 1 patient was delayed for 17 days From 2/1/18. He was a patient who had been visiting family in Richmond and had a fall. KHT advised the family to move the patients GP from Lewisham to Richmond to facilitate an admission to TMH. When the patient got to us, he wanted to go home to his own flat therefore, he was transferred to an inpatient facility closer to where he lived 1 patient was delayed for 28 days waiting on a CHC decision and placement in a nursing home 1 patient was delayed for 12 days waiting for funding and sourcing of a residential home placement Reason for performance gap: Description of Action Start Date End Date Status Outcome Action Plan Introduction of an additional red/green board round to discuss complex patients and set/complete actions to facilitate discharge and problem solve Jan-18 Ongoing Green Red/Green rounds to continue and to be audited Review of expected length of stay for each pathway - Rehabilitation, Frailty, CHC and EOLC against national benchmarking data to ensure that we have our expectations set at the correct level Feb-18 ongoing Amber Review of the use of the choice letters and discharge policy with senior members of the Inpatient team so that all of the senior team are confident in using the policy when needed. Feb-18 ongoing Amber Standing agenda item on band 6/7 meeting agenda Author: Anna Howard-McNulty/ Gareth Roblin/ Tom Penman 5

122 Section 3: Trust Performance Indicators Safe Domain People are protected from abuse and avoidable harm. Safe Current Month Quarter-to-date Year-to-date KPI Code KPI Description Target Actual Trend Target Actual Target Actual Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar S1 (N) S2 (N) S3 (N) S5 (N) Incidence of Clostridium difficile 1 Incidence of MRSA Year End Monthly Trend - 217/18 tu G G G G G G G G G G G G G G tu G G G G G G G G G G G G G G Never Events occurring in month tu G G G G G G G G G G G G G G S4 (N) Medication errors causing serious harm Overdue Central Alerting System (CAS) Alerts tu G G G G G G G G G G G G G G tu G G G G G G G G G G G G G G 13-Month Trend S6 (N) Proportion of reported safety incidents that are harmful N/A 32% q N/A 33% N/A 33% N/A 24% 36% 32% 33% 26% 36% 33% 34% 39% 34% 32% S9 (N) Consistency of reporting to National Reporting and Learning System (NRLS) ** N/A 3 q N/A 9 N/A 36 N/A S1 (N) Number of new Serious Incidents in month N/A 1 p N/A 1 N/A 12 N/A S11 (I) Number of open Serious Incidents requiring investigation in month N/A 16 p N/A 31 N/A 125 N/A Notes: ** Number of reports submitted to NRLS. Incident reports should be submitted to the NRLS at least monthly. TBC - Awaiting guidance on targets from NHS Improvement. 6

123 Safe Domain (Continued) People are protected from abuse and avoidable harm. Safe Current Month Quarter-to-date Year-to-date Year End Monthly Trend - 217/18 KPI Code KPI Description Target Actual Trend Target Actual Target Actual Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 13-Month Trend S12 (N) S13 (I) S14 (N) Proportion of patients risk assessed for Venous Thromboembolism (VTE) Inpatient Falls per 1, Occupied Bed Days *** (Quarterly) Percentage of Harm free care (Safety Thermometer) 95% 1% tu 95% 1% 95% 1% 95% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% G G G G G G G G G G G G G G N/A 1.4 p R R % 94.5% 94.3% 94.6% 95.1% 93.4% 93.4% 93.3% 94.8% 93.8% 95.2% 94.2% 95.% 94.1% 95% q 95% 95% 95% A A A A G A A A A A G A G A S14.1 (I) Pressure Ulcers 4.5% q 4.6% 4.7% 4.8% 4.% 5.5% 5.3% 5.1% 4.1% 5.4% 3.9% 4.7% 4.7% 4.5% S14.2 (I) Falls with harm 1.4% p.7% 1.2%.6% 1.2%.8% 1.3% 1.4% 2.1% 1.1% 1.1% 1.6%.% 1.4% N/A N/A N/A N/A Urinary Tract Infections (UTIs) in patients S14.3 (I).5% p.4%.5%.%.5% 1.%.2%.7%.8%.%.5%.5%.3%.5% with a catheter S14.4 (I) New Venous Thromboembolisms (VTEs).% tu.%.1%.%.%.%.% 1.2%.2%.%.%.%.%.% S15 (N) Percentage of new Harms (Safety Thermometer) TBC 2.1% p TBC 1.8% TBC 1.9% TBC 1.5% 1.7% 1.6% 2.6% 1.7% 2.% 2.1% 2.3% 1.6% 1.6% 2.1% Safe (Indicators reported in arrears) Current Month Quarter-to-date Year-to-date Year End Q4 216/17 Monthly Trend - 217/18 13-Month KPI Code KPI Description Target Actual Trend Target Actual Target Actual Target Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Trend S16 (I) Avoidable pressure ulcers - Numbers and percentage (Reported 3 month in arrears) ^ *** N/A N/A N/A 19% tu tu N/A 16% N/A N/A N/A N/A % 12.9% % 15% 11% 21% 4% 8% 24% 12% 4% 3% 19% 31% N/A G G G G G Notes: TBC - Awaiting guidance on targets from NHS Improvement. *** Indicator is based on quite small numbers and therefore varies significantly on a monthly basis, so quarterly target instead of monthly. ^ Trajectory in year target from current position to Year End target. 7

124 Caring Domain Involving people in their care and treating them with compassion, kindness, dignity and respect. Caring Current Month Quarter-to-date Year-to-date Year End Monthly Trend - 217/18 KPI Code KPI Description Target Actual Trend Target Actual Target Actual Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar C1 (N) 1% 96.4% 95.6% 86.7% 96.% 1.% 1.% 88.9% 94.7% 1% 93.3% 1% 93.8% 1% Inpatient Friends & Family Test (FFT) - % recommend * 9% p 9% 9% 9% G G G A G G G A G G G G G G Inpatient FFT - % not recommend N/A.% q N/A 3.6% N/A 1.6% N/A 6.7%.%.%.%.%.%.% 6.7%.% 6.3%.% 13-Month Trend C2 (N) A&E FFT (Walk-In Centre (WIC) and Urgent Care Centre (UCC)) - % recommend * A&E FFT (Walk-In Centre (WIC) and Urgent Care Centre (UCC)) - % not recommend 93.8% 95.1% 94.% 93.6% 96.7% 95.9% 92.5% 94.4% 93.3% 91.2% 92.% 93.6% 96.3% 93.8% 9% q 9% 9% 9% G G G G G G G G G G G G G G N/A 2.3% p N/A 1.7% N/A 2.1% N/A 1.9%.9% 1.9% 3.6% 1.2% 1.9% 2.6% 4.% 2.7% 1.1% 2.3% C3 (N) 97.3% 97.7% 96.1% 9.8% 96.2% 97.6% 94.8% 97.1% 97.1% 97.% 98.3% 95.4% 98.1% 97.3% Community FFT - % recommend * 9% q 9% 9% 9% G G G G G G G G G G G G G G Community FFT - % not recommend N/A.3% tu N/A.3% N/A 1.1% N/A 2.3%.5% 1.1% 5.6%.3%.5% 1.4%.4%.5%.3%.3% C4 (N) C5 (N) C6 (I) C7 (I) C8 (I) Trust Composite FFT - % recommend * Trust Composite FFT - % not recommend Staff FFT - % recommend the trust as a place to receive care & treatment (Quarterly)^** Staff FFT - % not recommend the trust as a place to receive care & treatment (Quarterly)^** Patient Survey: % patients who felt their privacy and dignity were respected * Patient Survey: % of patients who felt they received their care in a way that was right for them * Percentage of Richmond Response and Rehabilitation Team (RRRT) service users very satisfied /satisfied ** Percentage of Richmond Response and Rehabilitation Team (RRRT) service users very dissatisfied /dissatisfied ** 95.4% 96.3% 95.1% 92.% 96.5% 96.9% 94.% 95.7% 95.3% 93.6% 95.2% 94.7% 97.1% 95.4% 9% q 9% 9% 9% G G G G G G G G G G G G G G N/A 1.5% p N/A 1.1% N/A 1.6% N/A 2.2%.7% 1.4% 4.4%.7% 1.1% 2.1% 2.2% 1.5%.8% 1.5% 67.5% 67.5% 75.8% 84.9% 86.4% 67.5% 67% q 67% 67% 67% G G G G G G N/A 12.1% p N/A 12.1% N/A 8.5% N/A 2.9% 4.6% 12.1% 95% 95% 1% 99.4% 96.4% 91.7% 94.2% 98.7% 98.1% 94.7% 97.6% 1% 95.7% 96.% 99.3% 1% p 95% 95% 95% G G G A A G G A G G G G G G 1% 96.1% 94.7% 9.5% 92.3% 95.2% 98.% 93.6% 93.1% 1% 98.9% 95.7% 95.4% 1% p 95% 95% 95% G G A A A G G A A G G G G G 9.9% 87.5% 95.2% 1.% 1.% 96.3% 1% 87.5% 1% 91.7% 96.% 1% 84.6% 9.9% 9% G p 9% A 9% G 9% G G G G A G G G G A G N/A % tu N/A % N/A.5% N/A % % 4% % % % % % % % % Notes: * Internal Trust target (No National NHS target currently available). ** Contractual target. Better Care Fund Indicator. ^** Staff FFT Not Available Until Feb 218 (National Figures To Be Published End Of Jan-18) 8

125 Caring Domain (Continued) Involving people in their care and treating them with compassion, kindness, dignity and respect. Caring Current Month Quarter-to-date Year-to-date Year End Monthly Trend - 217/18 KPI Code KPI Description Target Actual Trend Target Actual Target Actual Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar C9 (N) Mixed Sex Accommodation Breaches tu G G G G G G G G G G G G G G 13-Month Trend C1 (N) Formal complaints received N/A 3 p N/A 5 N/A 38 N/A C11 (I) Formal compliments received N/A 24 q N/A 73 N/A 367 N/A

126 Effective Domain People s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. Effective Current Month Quarter-to-date Year-to-date Year End Monthly Trend - 217/18 KPI Code KPI Description Target Actual Trend Target Actual Target Actual Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 91.9% 88.4% 86.3% 85.1% 86.4% 86.1% 86.7% 85.5% 86.6% 85.9% 86.4% 84.% 84.9% 91.9% E1 (I) Percentage of Staff Appraised 9% p 9% 9% 9% G A A A A A A A A A A A A G 89.3% 87.3% 85.3% 81.4% 87.3% 87.6% 89.6% 88.5% 88.5% 76.4% 8.4% 81.3% 85.4% 89.3% E2 (I) Percentage of Staff - Statutory & Mandatory Training 85% p 85% 85% 85% G G G A G G G G G R A A G G 82.8% 83.6% 81.1% 69.5% 78.7% 74.8% 96.9% 72.3% 75.5% 89.3% 88.1% 78.4% 84.4% 82.8% E3 (I) Clinical Supervision (% of staff in last 3 months) *^ ^^ 9% q 9% 9% 9% A A A R R R G R R A A R A A E4 (I) E5 (I) Patient Outcomes - Inpatient Unit - % with improved functional outcome score on discharge (Quarterly) ***^^ Patient Outcomes - Richmond Response & Rehabilitation Team (RRRT) - % leaving with no service or reduced service ** N/A 57% q 8% 72% 8% 71% 83% 74% 7% 1% 75% 81% 85% 93% 84% 57% 8% 8% A A A G G 78% 84% 87% 79% 88% 92% 85% 96% 81% 85% 84% 88% 88% 78% 75% G q 75% G 75% G 75% G G G G G G G G G G G 1% 1% 97% 1% 1% 1% 1% 1% 1% 1% 1% 33% 1% 1% E6 (I) Proportion of all completed audits with an action plan 8% tu 8% 8% 8% G G G G G G G G G G G R G G 13-Month Trend Notes: * Internal Trust target (No National NHS target currently available). *^^ Statutory and Mandatory Training excludes Waste Manangement from Aug-17 as requested, previous months includes both indicators (Apr-Jun), apart from July-17 where Risk Management and Waste Training were excluded. ** Contractual target ***^^ Indicator is based on quite small numbers and therefore varies significantly on a monthly basis, so quarterly target instead of annual. Current process being reviewed and underway to revise figures with the service. *^ ^^ Target for Clinical Supervision has now been revised in June-17 from 85% to 9% 1

127 Responsive Domain Organising services so that they are tailored to peoples needs. Responsive Current Month Quarter-to-date Year-to-date Year End Monthly Trend - 217/18 KPI Code KPI Description Target Actual Trend Target Actual Target Actual Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar R1 (N) R2 (N) R3 (N) 95% 99.2% q 95% 99.3% 95% 99.4% 95% 99.2% 99.5% 99.6% 99.3% 99.9% 99.5% 99.7% 99.% 99.5% 99.4% 99.2% G G G G G G G G G G G G G G 95% 1% tu 95% 1% 95% 1% 95% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% G G G G G G G G G G G G G G 92% 1% tu 92% 1% 92% 1% 92% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% G G G G G G G G G G G G G G R4 (N) RTT over 52 week waiters tu G G G G G G G G G G G G G G R5 (N) R6 (N) R7 (I) Activity against plan variance YTD - Hounslow CCG * 1% % tu 1% % 1% % 1% % % % % % % % % % % % G G G G G G G G G G G G G G 7.5% 7.5% p 7.5% 7.1% 7.5% 4.4% 7.5% 1.5% 3.2%.% 2.8% 3.2% 6.2% 9.2% 1.% 5.6% 6.8% 7.5% R G G G G G G G G R G G G R N/A N/A q N/A N/A -5 or above -.4% -5 or -1.6%.7%.9% 1.9% 2.%.% -1.%.4% -1.1% -1.3% -1.6% G above G G G G G G G G G G G 18.5% -5 or 4.1% 15.8% 15.2% 15.4% 15.1% 13.3% 17.1% 22.3% 18.9% 21.6% 21.4% G above G G G G G G G G G G G R9 (I) DNA Rate * 6% 3.6% q 6% 3.7% 6% 3.6% 6% 3.8% 3.7% 3.5% 3.4% 3.6% 3.7% 3.8% 3.6% 3.6% 3.9% 3.6% G G G G G G G G G G G G G G R1 (I) A&E: maximum waiting time of four hours from arrival to admission/ transfer/ discharge RTT waiting times for non-admitted pathways: percentage within 18 weeks RTT waiting times incomplete pathways: percentage within 18 weeks Diagnostic waiting times: patients waiting over 6 weeks for a diagnostic test Percentage of Delayed Transfers of care R8 (I) Activity against Plan Variance YTD - Richmond CCG * Percentage of services meeting contractual waiting times targets *^ N/A N/A q N/A N/A -5 or above 84% 91% p 83% 86% 8% 9% 85% 89% 98% 98% 91% 88% 86% 86% 9% 88% 81% 91% G G G G G G G G G G G G A G 13-Month Trend Notes: * Internal Trust target. ^ Trajectory in year target from current position to Year End target. 11

128 Well-Led Domain Leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture. Well-Led Current Month Quarter-to-date Year-to-date Year End Monthly Trend - 217/18 KPI Code KPI Description Target Actual Trend Target Actual Target Actual Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar W1 (N) W2 (N) Inpatient Friends & Family Test (FFT) response rate A&E FFT (Walk-In Centre (WIC) and Urgent Care Centre (UCC) response rate 8% 68% 77% 87% 96% 1% 57% 1% 95% 85% 63% 46% 62% 8% 3% p 3% 3% 3% G G G G G G G G G G G G G G 5% 7.1% q 5% 7.3% 5% 5.9% 5% 6.5% 6.% 5.% 5.8% 6.6% 5.7% 6.9% 4.7% 2.9% 7.5% 7.1% G G G G G G G G G G A R G G 13-Month Trend W3 (N) Community FFT response rate TBC 2.3% q TBC 2.6% TBC 2.5% TBC 3.9% 2.3% 3.% 2.% 3.1% 2.7% 2.1% 1.7% 2.% 3.1% 2.3% W4 (N) Trust Composite FFT response rate TBC 3.7% q TBC 4.1% TBC 3.61% TBC 4.9% 3.5% 3.6% 3.3% 4.2% 3.7% 3.7% 2.4% 2.4% 4.6% 3.7% W5 (N) Staff FFT response rate (Quarterly)^** TBC 62.% p TBC 62.% TBC 34.9% TBC 14.3% 3.7% 62.% W6 (N) Staff FFT - % recommend the trust as a place to work (Quarterly)^** Staff FFT - % not recommend the trust as a place to work (Quarterly) ^** 61% N/A 65.8% q 61% 65.8% 61% 66.% G G G 11.8% q N/A 11.8% N/A 12.3% 61% N/A 65.7% G 66.4% 7.6% 15.4% G 65.8% G 11.8% Current Month Quarter-to-date Year-to-date Year End Monthly Trend - 217/18 Target Actual Trend Target Actual Target Actual Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 13-Month Trend W7 (N) Staff Sickness 3.2% 3.7% q 3.2% 3.7% 3.2% 3.5% 3.2% 2.7% 3.4% 3.1% 3.2% 3.4% 3.8% 3.9% 3.7% 4.% 3.8% 3.7% R R A G A G G A R R R R R R W8 (N) Staff Turnover**^ 17.5% 17.1% tu 17.5% 17.1% 17.5% 17.4% 17.3% 17.8% 19.3% 18.7% 16.9% 17.7% 17.1% 16.8% 16.6% 17.1% 17.1% 17.1% G G G G G G G G G G G G G G W9 (I) W1 (N) W11 (N) Vacancy rate**^ Temporary costs and overtime as a percentage of total paybill (Reported a month in arrears) *^ Percentage of BME staff in Bands 7-9 and VSM compared with the percentage of BME staff in the overall workforce 1.% 1.6% q 1.% 1.6% 1.% 11.3% 1% 12.9% 11.9% 12.% 11.3% 11.2% 1.8% 1.1% 11.5% 11.4% 1.7% 1.6% A A G G G G G G G G A A A A 21% N/A 13.5% 13.5% 13.7% 14.2% 16.1% 14.8% 14.4% 12.5% 12.1% 13.7% 13.9% 12.5% 13.5% p 25% 21% 21% N/A G G G G G G G G G G G G G 27.8% q N/A 27.8% N/A 27.7% N/A 27.9% 27.1% 28.2% 28.5% 24.5% 25.9% 25.9% 21.7% 28.% 44.4% 27.8% W12 (N) Temporary staff spend on agency staff* ^^ (Variance against cap) +% or below -34.% +% or -34.% +% or -3.5% +% or -27.7% -38.8% -13.2% -31.% -33.% -33.% -34.% -33.% -34.% -35.% q N/A G below G below G below G G G G G G G G G G Notes: 118% * Internal Trust target (No National NHS target currently available). ^ Trajectory in year target from current position to Year End target. ^^Cumlative figures for April-17 and May-17 **^Vacancy and Turnover has a reducing target over the financial year. The reports use the current month s target to measure data against. ^** Staff FFT Not Available Until Feb 218 (National Figures To Be Published End Of Jan-18) 12