SouthKentCoastClinicalCommissioningGroup. GoverningBody. 09March :00. HytheImperialHotel,Prince'sParade,Hythe,CT216AE AGENDA

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1 SouthKentCoastClinicalCommissioningGroup GoverningBody GoverningBody 09March :00 HytheImperialHotel,Prince'sParade,Hythe,CT216AE AGENDA 1 OPENINGBUSINESS 1.01 Apologies,Announcements,DeclarationsofInterest Owner:DrDarrenCocker,ClinicalChair 1.02 QuestionsfromthePublic Owner:DrDarrenCocker,ClinicalChair 1.03 Minutesfromthelastmeetingheld13Janaury2016 Owner:DrDarrenCocker,ClinicalChair 1.3SKCGoverningBodyUnconfirmedminutesPart MattersArising/ActionLog Owner:DrDarrenCocker,ClinicalChair 1.4GBActionTablePart1Open AccountableOfficerandClinicalChairReport Owner:HazelCarpenter,AccountableOfficerandDrDarrenCocker,ClinicalChair 1.5SKC5YFVBriefingreportMarch STRATEGYANDPLANNING 2.01 ClinicalCabinetChairReport Owner:DrJoeChaudhuri 2.1ClinicalCabinetChairReportMar16 18

2 2.02 OneYearOperationalPlan(presentation) Owner:KarenBenbow,ChiefOperatingOfficer 2.2SKCAnnualOperatingPlan SKCAnnualRevenueBudget Owner:JonathanBates,ChiefFinanceOfficer 2.3SKCCCGAnnualRevenueBudget KentandMedwaySustainabilityandTransformationalPlanandEastKent Strategy Owner:HazelCarpenter,AccountableOfficer 2.4KentandMedwaySustainabilityandTransformat EastKentStrategyBoardFINALforHOSC 49 3 PATIENTANDPUBLICENGAGEMENT 3.01 PatientandPublicengagementReport Owner:CliveDavison,LayMemberforPatientandPublicEngagement 3.1NHSSouthKentCoastCommunicationsandEngage QuestionsandAnswersUpdatefromJanaury2016meeting Owner:CliveDavison,LayMemberforPatientandPublicEngagement 3.2GoverningBodyQuestionsfromthepublic-Jan 73 4 QUALITYANDPERFORMANCE 4.01 ChiefNurseReportMar2016andSafeguardingAdultsReport Owner:SharonGardner-Blatch,ChiefNurse 4.1ChiefNurseReportMarch Safeguarding_Adults_Annual_report_14_ IntegratedQualityandPerformanceReport Owner:SharonGardner-Blatch,ChiefNurse/ClaraWessinger,HeadofPerformance 4.2IntegratedQualityandPerformanceReportFebr BREAK15minutes 4.03 IntegratedCommissioningforLearningDisabilities Owner:SharonGardner-Blatch,ChiefNurseandSueGratton,ProjectManagerIntegrated Commissioning 4.3IntegratedCommissioningforLearningDisabili 170

3 5 FINANCEANDPERFORMANCE 5.01 FinanceMonth10Report Owner:JonathanBates,ChiefFinanceOfficer 5.1SKCCCGFinanceReportMonth BetterCareFundSection Owner:JonathanBates,ChiefFinanceOfficer 5.2BetterCareFundSection GOVERNANCE 6.01 DelegationofapprovalofdraftaccountstotheGovernanceandRisk Committee Owner:SueMartin,CompanySecretary 6.1SKCDelegatedAuthority HEALTHANDWELLBEINGBOARD 7.01 CountyHealthandWellbeingBoardminutes-18November Owner:DrDarrenCocker,ClinicalChair 7.1CountyHealthandWellbeingBoardMinutes LocalHealthandWellbeingBoardminutes-24November2015 Owner:DrJoeChaudhuri,GPClinicalMember 7.2SouthKentCoastHealthandWellbeingBoardMi CONSENTAGENDA 8.01 QualityandPerformanceCommitteeMinutes27Janaury Owner:DrDarrenCocker,ClinicalChair 8.02 ClinicalCabinetCommitteeMinutes-06Janaury2016and03February Owner:DrDarrenCocker,ClinicalChair 9 QuestionsfromthePublic Owner:DrDarrenCocker,ClinicalChair 10 DateofNextMeeting:Wednesday11May2016-TheGrandHotel, Folkestone 11 MEETINGCLOSE Attendees

4 Index 1.3SKCGoverningBodyUnconfirmedminutesPart1-13Jan GBActionTablePart1Open.pdf SKC5YFVBriefingreportMarch16.pdf ClinicalCabinetChairReportMar16.pdf SKCAnnualOperatingPlan pdf SKCCCGAnnualRevenueBudget pdf KentandMedwaySustainabilityandTransformationalPlan EastKentStrategyBoardFINALforHOSC.pdf NHSSouthKentCoastCommunicationsandEngagementRepo GoverningBodyQuestionsfromthepublic-January ChiefNurseReportMarch2016.pdf Safeguarding_Adults_Annual_report_14_15.pdf IntegratedQualityandPerformanceReportFebruary IntegratedCommissioningforLearningDisabilities.pdf SKCCCGFinanceReportMonth10.pdf BetterCareFundSection75.pdf SKCDelegatedAuthority.pdf CountyHealthandWellbeingBoardMinutes-18November SouthKentCoastHealthandWellbeingBoardMinutes24N Thefollowingavailabledocumentswerenotselected 8.1ConfirmedMinutesQualityandPerformanceCommittee pdf 8.2ClinicalCabinetConfirmedMinutes pdf 8.2.1ClinicalCabinetConfirmedMinutes pdf

5 Unconfirmed minutes NHS South Kent Coast Clinical Commissioning Group Governing Body - (Part 1 - Open Session) Meeting held 13 January 2016 The Ark, Dover, CT17 0DD Members: Dr Darren Cocker (DC) Clinical Chair Dr Joe Chaudhuri (JC) Clinical Member Governing Body Dr Ian Mckenzie (IM) Clinical Member Governing Body Dr Tuan Nguyen (TN) Clinical Member Governing Body Dr Jonathan Bryant (JBr) Clinical Member Governing Body Dr Stewart Coltart (SC) Secondary Care Doctor Alistair Smith (AS) Lay Member Governance Clive Davison (CD) Lay Member Patient Participation and Engagement Hazel Carpenter (HC) Accountable Officer Sharon Gardner-Blatch (SGB) Chief Nursing Officer Jonathan Bates (JBa) Chief Finance Officer In attendance: Sue Martin (AF) Head of Governance SKC CCG Karen Benbow (KB) Chief Operating Officer Julie Evans (JE) Governance Administrator (Minutes) Apologies: Dr Chee Mah (CM) Clinical Member Governing Body Dr Brighton Chireka (BCh) Clinical Member Governing Body Karen Benbow (KB) Chief Operating Officer (COO) SKC CCG Jess Mookherjee (JM) Public Health Consultant Item Action 01/16/001 Apologies, Announcements, Declarations of Interest The Chair welcomed members of the public to the South Kent Coast Clinical Commissioning Group (SKC CCG) Governing Body Meeting..1 Apologies: Apologies were received and noted above. Announcements: The Patient Transport Service Update was included in the agenda pack for information to the Governing Body and members of the public. Declarations of Interest (DOI): SKC Governing Body Unconfirmed Minutes of Formal Governing Version: 1.0 Document Ref: Body Meeting (Open Session) 13 January 2016 Chair : Dr Darren Cocker Date: 13/01/2016 Page 1 of 8 1.3SKCGoverningBodyUnconfi Page1of8 OverallPage6of204

6 No declarations of interest were noted. 01/16/002 Questions from the Public The Chair explained the process for putting questions to the Governing Body (GB). Pre-submitted questions would be answered first followed by questions from the floor, time permitting, at the end of the meeting. Pre-submitted questions had been received. Pre-submitted questions from the public had been received and would be addressed at the end of the meeting. 01/16/003 Minutes of the Last Meeting The minutes from the Governing Body meeting held on 11 November 2015 were amended under item 11/15/114, paragraph 7 with the addition performance at local level needed to be addressed. Subject to the amendment the minutes were signed and approved as an accurate record of the meeting. 01/16/004 Action Log / Matters Arising Updates were provided for the following actions: GB1-077 Action remained open GB1-089 Delays in relation to the Cancer pathways were being managed through the remedial action plan for delivering the 62 day treatment target. Action closed. GB1-092 Action closed. 01/16/005 Accountable Officer and Clinical Chair Report HC had met with the new Chief Executive for EKHUFT. East Kent Strategy Board HC discussed the clinical strategy for hospitals looking at transformation changes in the five year forward view, which could only be agreed following consultation with the public. The East Kent Strategy Board would lead on a whole system change. Over the coming months the board would be responsible for putting together the Sustainability and Transformational Plan for east Kent with sign off by Governing Bodies in June 2016 and consultation through to the Autumn. HOSC would advise on any consultation. A clinically led clinical forum would pull together strands of work from all 4 CCGs with input from the expert patient and public engagement group. Safety and quality pressures could see providers needing to take action within that time frame. Providers would need to be supported throughout that time frame to ensure services remained safe and of good quality. SKC Governing Body Unconfirmed Minutes of Formal Governing Version: 1.0 Document Ref: Body Meeting (Open Session) 13 January 2016 Chair : Dr Darren Cocker Date: 13/01/2016 Page 2 of 8 1.3SKCGoverningBodyUnconfi Page2of8 OverallPage7of204

7 Strategy and Planning 01/16/005 Clinical Cabinet Chair Report A summary of the discussions held at the November and December clinical cabinet meetings was provided to the Governing Body. Key highlights were: Lung Health Guided Consultation Programme for patients with COPD, which included respiratory specialist nurse advisers and a software tool An update on the Collaborative Orthopaedic Triage Service, patients were seen more quickly and the Clinical Cabinet agreed to continue with the service To look at a formal formulary for medicines, involving EKHUFT and other prescribing leads to ensure consensus on how to prescribe in a cost effective manner Decision: The Governing Body APPROVED the Clinical Cabinet Chair Report 01/16/006 East Kent Strategy Board Stakeholder Letter Discussed at item 01/16/005 01/16/007 The NHS over the next five years What is the vision for the SKC area? (Presentation) JBr gave a presentation looking at where SKC CCG was now and what the challenges over the next 5 years might be. Lack of integration for patients passing through the organisations with barriers between people and services was no longer sustainable. There was a need for an out of hours service with access to real time patient information across agencies to ensure timely decision making. Tiers of Care were being developed to align care pathways without duplications. Tier 1 would be GP led community care, Tier 2 would see an expert level of care nurse consultant or nurse led care for example rheumatology, and Tier 3 would be Consultant led care. Challenges were recognised such as workforce in primary and secondary care, lack of GPs, organisation boundaries and developing relationships with community and secondary care providers and an aging population, specifically in SKC area. Finance Money spent on prescribing was accelerating and unsustainable. Costs were high for patients taken out of the area for treatment Placements Needs of the populations were expanding The Year of Care would look at funding the cost of treatment with data SKC Governing Body Unconfirmed Minutes of Formal Governing Body Meeting (Open Session) 13 January 2016 Version: 1.0 Document Ref: Chair : Dr Darren Cocker Date: 13/01/2016 Page 3 of SKC Governing Body Unconfi Page 3 of 8 Overall Page 8 of 204

8 from all services involved in the care of that patient. Moving services across to primary care could involve a period of double funding during the transition period. GPs were communicating well regarding shared services. The medical interoperability gateway had progressed working on a patient consent basis allowing agencies to view patient information such as current medication and integrated intermediate care and would help to ensure only one assessment was carried out for patients for all of their health needs. iplato was being trialled allowing patients to access their information based around mobile phones, ie appointment reminders and options to cancel appointments. Mobile working would allow GPs to access patient notes. Update on local progress paramedics practitioners are well equipped and can help keep patients out of hospital Pilot at Romney Marsh linking the day centre with Martello Medical Practice using telemeds and video-conferencing SKC Allocation Presentation JB gave a presentation and discussed the allocation uplift of 2.83% or 7.5m, how the allocation would include specialist commissioning and primary care and the growth over the next 5 years. Across Kent savings of 25m were planned and only 2m had been achieved so far. Key actions were for Trusts to make savings, GP referrals to reduce and there would be no increase in GP prescribing budgets. Further savings were planned for placements, Continuing Health Care, London Trusts and CSU. Delivery of the East Kent Strategy for hospital change, ICO implementation and effective risk sharing would all need to be delivered much quicker than in the current year. The service model would be moved out of secondary care and into primary care through discussion, identifying issues and agreeing outcomes along with contract rounds, share allocation and system responsibility. 01/16/008 How should we engage the public? Including a review of strategic objective 9 we will engage effectively with members, the public and stakeholders to ensure they support the strategy of the CCG and that is meets their needs (Presentation) CD gave a presentation and discussed: Use of patient and focus groups How engagement on an east Kent level should always contribute to the CCG Further communication with voluntary services where health was not the primary concern, ie, Women s Institute SKC Governing Body Unconfirmed Minutes of Formal Governing Version: 1.0 Document Ref: Body Meeting (Open Session) 13 January 2016 Chair : Dr Darren Cocker Date: 13/01/2016 Page 4 of 8 1.3SKCGoverningBodyUnconfi Page4of8 OverallPage9of204

9 Whether there was a better way to involve patients and the public at the Governing Body meetings 01/16/009 The Planning guidance: What are we required to do? (Presentation) KB gave a presentation and a brief outline of the 5 year plan and operational plan. Funding would be attached from and further guidance was expected later in the month. There was a focus on psychological therapies, early intervention for psychosis and dementia diagnosis with services on an east Kent or local hub level. Good evidence had shown that moving budgets would induce change. Patient and Public Engagement 01/16/010 Public and Patient Engagement Report Communication and engagement progress highlights that had taken place with communities, stakeholders and voluntary and community sectors from the past month were discussed. The engagement phase of the stroke review had reached a significant point influencing the development of options for future models of care. Patient representatives positive input had helped with the mobilisation plans at Calais hospital. Action: CD and DC to discuss format of meetings to see if further interaction could be gained with the public CD / DC Decision: The Governing Body NOTED the Public and Patient Engagement Report Quality and Performance 01/16/011 Chief Nursing Officer Report The report informed the Governing Body about the key issues affecting its responsibilities for quality of commissioned services, safeguarding, making placements for residents with complex needs, reducing healthcare associated infections and delivering the Transforming Care requirements for residents of SKC. A summary of issues was provided regarding: Commissioned Services All commissioned services were facing challenges which were impacting on the quality of services and the ability to make significant and sustained quality improvements. Statutory Duties With significant safeguarding risks in the community it was vital to ensure safeguarding was embedded into all aspects of day to day SKC Governing Body Unconfirmed Minutes of Formal Governing Version: 1.0 Document Ref: Body Meeting (Open Session) 13 January 2016 Chair : Dr Darren Cocker Date: 13/01/2016 Page 5 of 8 1.3SKCGoverningBodyUnconfi Page5of8 OverallPage10of204

10 business. The CCG was not meeting is statutory requirements in full for Looked After Children and Unaccompanied Asylum Seeking Children, although significant work was underway to address the issue. Multiagency work was also progressing. Placements continued to be a significant challenge for the CCG to deliver on its objective to support people receiving care closer to home. Decision: The Governing Body APPROVED the Chief Nursing Officer Report 01/16/012 Safeguarding Annual Report The report provided an outline of how the CCG was meeting its statutory responsibilities for Safeguarding Children. Over the year, good progress had been made in strengthening processes. Evidence had been submitted to NHS England and the Kent Safeguarding Children Board in early 2015 and was able to demonstrate compliance in the majority of areas. Gaps in compliance had been identified and included in the Safeguarding Children work plan for , which would also be monitored via the Quality and Performance Committee. Action: Embed Safeguarding in the toolkit for hubs SGB 01/16/013 Integrated Quality and Performance Report (IQPR) The report informed the Governing Body of new or significant changes to concerns regarding provider s contractual obligations and national targets to provide high quality care to patients in SKC. Referral to Treatment (RTT) 18 week target The target of 92% had not been achieved and was currently at 88.9%. Key issues were clinical speciality workforce, winter pressures and delayed transfers of care. The junior doctors strike had some impact with cancellations of elective care. Spires St Savours had closed in September 2015 and all patients were re-allocated appointments with other providers, resulting in less capacity locally to take that planned care work. A & E 4 hour waiting time With the exception of one week in December 2015, no improvement had been seen and performance remained in the low to mid 80%. A national team, who work on the Safer Site program with those Trusts which struggle to meet targets, carried out an exercise across the three acute sites. EKHUFT was doing a lot of work internally, although it was not yet having an impact on achieving targets. Cancer Early discussions suggested a reduction in the number of SKC Governing Body Unconfirmed Minutes of Formal Governing Version: 1.0 Document Ref: Body Meeting (Open Session) 13 January 2016 Chair : Dr Darren Cocker Date: 13/01/2016 Page 6 of 8 1.3SKCGoverningBodyUnconfi Page6of8 OverallPage11of204

11 patients waiting longer than 62 days. The report was due in February 2016 on achievement on targets. Finance Decision: The Governing Body APPROVED the IQPR 01/16/014 Month 8 Finance Report Governance The CCG must meet statutory financial duties in 2015/16 and achieve statutory financial balance. Spend at Month 8 was in line with the plan, but the entire contingency had been used pro-rata, leaving no scope of any unexpected spend. The CCG would need to drive change at a quicker pace and continue to tackle problem areas such as prescribing, referrals and placements. Decision: The Governing Body APPROVED the Month 8 Finance Report 01/16/015 Governance and Risk Chair (GRC) Report The Governing Body was updated on recent items discussed the Governance and Risk Committee meeting held on 01 December Key recommendations were noted: The BAF would need to be updated ahead of the internal audit review. A future Governing Body development session should focus on the role of the committees and Governing Body as part of the Constitution update The Chief Finance Officer to recommend a footprint for tendering of External Audit Services Transparency should be included in contracts with Third Parties The process for managing single tenders should be updated. Decision: The Governing Body noted the recommendations from the GRC Report Health and Wellbeing Board 01/16/016 County Health and Wellbeing Board The Governing Body NOTED the minutes from the meeting held on 16 September /16/017 Local Health and Wellbeing Board The Governing Body NOTED the minutes from the meeting held SKC Governing Body Unconfirmed Minutes of Formal Governing Version: 1.0 Document Ref: Body Meeting (Open Session) 13 January 2016 Chair : Dr Darren Cocker Date: 13/01/2016 Page 7 of 8 1.3SKCGoverningBodyUnconfi Page7of8 OverallPage12of204

12 on 22 September /16/018 Consent Agenda.1 Quality and Performance Committee confirmed minutes (26/08/2015 and 30/09/2015).2 Clinical Cabinet confirmed minutes (02/09/2015).3 Governance and Risk Committee confirmed minutes (28/07/2015) Decision: The Governing Body noted the above minutes 01/16/019 Questions from Members of the Public There was an opportunity for questions to be asked by Members of the Public. Those questions noted are available via our website at: Date of the next Formal Governing Body Meeting: Wednesday 09 March 2016 SKC Governing Body Unconfirmed Minutes of Formal Governing Version: 1.0 Document Ref: Body Meeting (Open Session) 13 January 2016 Chair : Dr Darren Cocker Date: 13/01/2016 Page 8 of 8 1.3SKCGoverningBodyUnconfi Page8of8 OverallPage13of204

13 Governing Body Part 1 Open Action Number Date of Meeting minute number Item Action Target date Responsible Status Update GB /07/ /15/075 IQPR Quality Committee to discuss types of biopsies carried out and different Sep-15 SC open Sept15 - Remained open. SM will pick up with KB and SCr risks of infection GB /01/ /16/010 Patient and Public Engagement CD and DC to discuss format of meetings to see if further interaction could be gained with the public Mar-16 CD / DC Open GB /01/ /16/012 Chief Nursing Officer Report Embed Safeguarding in the toolkit for hubs Mar-16 SGB Open 1.4GBActionTablePart1Ope Page1of1

14 Report to: Date of Meeting: Title of Report: Author: Board Sponsor: Status: Appendices Governing Body Agenda 1.5 Meeting item: 9th March 2016 Mental Health Five Year Forward View - Briefing Andy Oldfield, Head of Mental Health Commissioning Hazel Carpenter, Accountable Officer Discuss 1. Purpose of the Paper The purpose of this paper is to brief the Governing Body on the recent publication of the above mental health strategy paper and to update on the current situation and progress being made locally against the main areas of the report. 2 Introduction In February 2016 the independent Mental Health Taskforce to the NHs England published its report The Five Year Forward View for Mental Health. The report outlines key issues and problems associated with mental health services in the UK currently and identifies areas where changes and service transformation/redesign need to take place. The report makes 58 recommendations in total many of which directly involve CCGs and commissioners, and much progress has already been made across east Kent to take forward work associated with the key areas of concern. 3. Summary of Issues In 2011, the Coalition government published a mental health strategy setting six objectives, including improvement in the outcomes, physical health and experience of care of people with mental health problems, and a reduction in avoidable harm and stigma. This report recognises that much work still needs to be done and builds on these objectives focusing on the four key areas of: Early intervention and prevention 24/7 access to mental health services including mental health liaison services in acute hospitals An integrated approach to mental and physical health (Parity of Esteem) The promotion of good mental health and preventing poor mental health at key moments in someone s life. 1.5 SKC 5YFV Briefing report M Page 1 of 3 Overall Page 15 of 204

15 East Kent CCGs are currently developing a mental health strategy that will reflect these areas and ensure that mental health is fully integrated within the wider Service Transformation Plans being developed. Across east Kent work is already underway to address many of the areas highlighted in the report including: Liaison Psychiatry a multi-agency working group including clinicians from mental health and acute hospital trusts is currently developing a revised model of service for east Kent which will ensure that people with mental health related problems receive the best possible care in an acute hospital setting, this work is due to be completed by end of March 2016 with the redesigned service in place by May 16. Early Intervention in Psychosis (EIP) Service East Kent commissioners are leading a Kent wide working group which is looking to develop the current EIP service in order to be able to deliver the new access and treatment standards required by April Acute mental health in-patient admissions Commissioners are in the advanced stages of working with Kent and Medway NHS Trust on demand and capacity for east Kent, and this includes reviewing the work done in 2012 to determine the optimum number of beds required. This work is being undertaken with Public Health to model demand to ensure we reduce the number of people who currently have to be admitted outside of Kent due to pressures on the system. The outcome of this work will be agreed in March SKC CCG are forecast to spend 36, on acute mental health admissions outside of Kent in 2015/16 The report confirmed that the government have identified the need to invest an additional 1billion in mental health by 2020/21 goes on to identify key issues that require action including: Out of area placements for acute care should be reduced and eliminated as quickly as possible. People experiencing a first episode of psychosis should have access to a NICE-approved care package within 2 weeks of referral. The NHS should expand proven community-based services for people of all ages with severe mental health problems who need support to live safely as close to home as possible. Reduce suicide by 10 per cent by 2020/21. By 2020/21, NHS England should support at least 30,000 more women each year to access evidence-based specialist mental health care during the perinatal period. By 2020/21, at least 280,000 people living with severe mental health problems should have their physical health needs met. Increase access to evidence-based psychological therapies to reach 25 per cent of need so that at least 600,000 more adults with anxiety and depression can access care (and 350,000 complete treatment) each year 1.5SKC5YFVBriefingreportM Page2of3 OverallPage16of204

16 by 2020/21. By 2020/21, at least 70,000 more children and young people should have access to high-quality mental health care when they need it. These areas and others included in the report s recommendations will form the basis of the mental health strategy for east Kent, and will require integrated working with physical health, social care, public health and housing/employment agencies to ensure collaborative and integrated working moving forward. The strategy and Service Transformation Plans will need to be developed by June Recommendations For information. 1.5SKC5YFVBriefingreportM Page3of3 OverallPage17of204

17 Report to: South Kent Coast Agenda 2.1 Governing Body item: Date of Meeting: 10 March 2016 Title of Report: Clinical cabinet Report Author: Dr Lynne Wright Clinical cabinet Chair Board Sponsor: Dr Joe Chaudhuri, Governing Body Clinical Member Status: Approve Appendices NA 1. Purpose of the Paper 1.1. We will do all we can to improve the health outcomes of the people that live in our area; prioritising, mental health, heart disease and cancer We will work with partners to help prevent ill health We will address the variation in quality of local healthcare services and the inequality of health outcomes that this can cause We will ensure that local health and care services are integrated and that patients experience "joined up" care We will ensure that services are provided locally wherever possible We will ensure that we are financially able to deliver excellent patient care We will ensure that the governance supports the functions of the CCG. 2 Introduction The paper summarises the discussions held at Clinical Cabinet during January 2016 and February 2016 meetings. A number of clinical areas were covered linking into the strategic objectives listed above. 3. Summary of Issues JANUARY 2016 It was decided that the Cancer Strategy needed to be reviewed and priorities made. To this end Public Health will advise us of the information required to help and we will request a discussion with EKHYFT Cancer Lead. This will be planned for March/April meeting. The issue of a centralised formulary was discussed again and it was agreed that Heather Lucas would continue to seek ways to better communication with GPs about this. HPRG recommendations on Endoscopy investigations for Dyspepsia were 2.1ClinicalCabinetChairRep Page1of3 OverallPage18of204

18 discussed and we will seek advice regarding the existing upper GiT referral forms and possible direct access to the procedure. HPRG recommendations for Hernia repair, tonsillectomy and electrical stimulation to upper limbs were all approved. The NHSE PMS review was discussed. The CCG practices involved were to be contacted and the Hubs to do a scoping exercise for the Elvington Project. It was felt that NHSE should provide us with an Equalities impact assessment prior to asking for our opinion as to whether the PMS schemes should continue It was noted that the Primary Care Transformation Fund criteria needed to be communicated to potential bidders and that the Clinical Cabinet would be the place for the bids to be assessed. Communication was received from Sean Crilly regarding the various East Kent Projects and how best to ensure progress. Poor communication with EKHUFT was seen as an obstacle and so was a lack of clinical consensus across the federation. It was agreed that updates on dermatology urology and ophthalmology should be given to the cabinet on a regular basis. Dr Tuan Nguyen was appointed clinical lead for Diabetes. It was made clear that the CC was to set the clinical strategic direction for the local area and to ensure clinical consensus regarding commissioning and procurement FEBRUARY 2016 The Chirag work plan was approved but no opinion on priorities was given Children s services were discussed at length: 1. Public Health paper was heard and it was agreed that a procurement update would be brought in June/ July. It was felt a positive paper and was welcomed. There was a call for additional assimilation of the School Nursing Service into the whole, a need for schools to be made aware of the service and that of the HV. This would help improve uptake by schools of the school nursing checks Paediatric Liaison Support was to be discontinued as there was duplication in work and EKHUFT should be providing an appropriate safeguarding service. Dawn Bisset head of quality was to ensure there was no risk to this service being decommissioned. Sharon Gardner-Blatch was nominated as SKC and Thanet CCG representative on the Section 75 Integrated Commissioning Board for Learning Disability. It was noted that with a limited number of professionals who fully understood LD provision that close scrutiny during the process was needed to ensure effective risk management. Dermatology Commissioning was discussed. It was felt that there were challenges to overcome to fully engage EKHUFT in the vision the CCG has for this area. Darren Cocker would meet with other clinical leads to discuss the issues and hopefully develop an East Kent wide plan for the service. The Over 74s Scheme involving GP practices was discussed. There was felt to be a need to look at specific costings at Hub level and to communicate this need to the 2.1ClinicalCabinetChairRep Page2of3 OverallPage19of204

19 Hub leads. With variation in how this resource will be spent the committee agreed to commitment to funding and to the principles of future allocation of funding, namely: Hib level, enablement of collaboration, integration transformation local provider development and support of the 5 year forward view. Health and Social Care Village beds were discussed and it was agreed that further work can be done to ensure more Hub linked beds and improved quality to aid the discharge to assess scheme rehabilitation in reach to beds and ensure Dover and Romney Marsh areas are recipients of some short term beds with Medical cover. 4. Recommendations The Governing Body is asked to note and approve this report 2.1 Clinical Cabinet Chair Rep Page 3 of 3 Overall Page 20 of 204

20 Annual Operating Plan 2016/17 Karen Benbow - Chief Operating Officer Governing Body - 9th March SKC Annual Operating Plan Page 1 of 19 Overall Page 21 of 204

21 Background This is the 3rd of 5 AOPs to deliver the CCG s 5 year strategy The AOP has been drafted to reflect changes in national policy, guidance and progress made during 2015/16 The AOP uses a Key Areas of Focus approach to link national policy and guidance with existing CCG projects 2.2SKCAnnualOperatingPlan Page2of19 OverallPage22of204

22 9 national Must Dos 1. Develop a high quality Sustainability and Transformation Plan (STP) with the partner organisations within the Kent and Medway STP footprint; 2. (Continue to) Maintain financial balance / contribute to efficiency savings; 3. (Continue to) Implement plans to address the sustainability and quality of general practice; 4. Recover and maintain the access standards for A&E and Ambulance pathways; 5. Recover and maintain the NHS Constitution standards for referral to treatment and improve upon the 2015/16 position; 6. Recover the NHS Constitution 62 day cancer waiting standard and maintain all other cancer waiting standards; 7. Achieve and maintain the two new mental health access standards; 8. (Continue to) Deliver plans to transform care for people with learning disabilities; 9. (Continue to) Implement plans to improve the quality and safety of services for our patients. 2.2SKCAnnualOperatingPlan Page3of19 OverallPage23of204

23 Key Areas of Focus for 2016/17 In order to show how the totality of CCG projects link with the 9 national must dos, we have grouped many of the CCG projects around six key focus areas: 1. Sustainability and Transformation 2. Finance and Activity 3. General Practice - Sustainability and Quality 4. Constitutional Targets / Access Standards 5. Learning Disability Pathways 6. Quality and Safety - Challenged Providers 2.2SKCAnnualOperatingPlan Page4of19 OverallPage24of204

24 1. Sustainability and Transformation What we plan to achieve in 2016/17 The development of a Sustainability and Transformation Plan by June 2016, setting out the case for an Integrated Care Organisation / Multi-speciality community provider in line with the Five Year Forward View Public Consultation on the STP in late summer / autumn 2016 How we plan to achieve this A detailed program plan has been developed and is overseen by an Integrated Executive Program Board co-chaired by KCC and the CCG 2.2SKCAnnualOperatingPlan Page5of19 OverallPage25of204

25 2. Finance and Activity What we plan to achieve in 2016/17 1% planned surplus, 1.5% contingency and 1% top slice (provisionally allocated for non-recurrent provider support) How we plan to achieve this Finance - capped contracts with main providers and a focus on key expenditure lines (prescribing and placements) Commissioning - continued Pathway Re-design (Managed Care) in key specialties to support the alignment of capacity to demand Performance - a focus on unwarranted variation using the NHS Right Care approach, the Atlas of Variation and the Joint Strategic Needs Assessment (to validate both existing projects and any proposed new projects) Quality - a continued focus on benchmarking providers and targeting outliers using quality levers (e.g. Audit, CQUINS, KPIs, Quality Visits) 2.2SKCAnnualOperatingPlan Page6of19 OverallPage26of204

26 3. Constitutional Targets / What we plan to achieve in 2016/17 Access Standards Recover and maintain the access standards for A&E and Ambulance pathways Recover and maintain the NHS Constitution standards for Referral to Treatment Recover the NHS Constitution 62 day cancer waiting standard, maintain all other cancer waiting standards Achieve and maintain the two new mental health access standards: More than 50 per cent of people experiencing a first episode of psychosis will commence treatment with a NICE approved care package within two weeks of referral 75 per cent of people with common mental health conditions referred to the Improved Access to Psychological Therapies (IAPT) programme will be treated within six weeks of referral, and 95 per cent in 18 weeks 2.2SKCAnnualOperatingPlan Page7of19 OverallPage27of204

27 3. Constitutional Targets / Access Standards (continued) How we plan to achieve this Commissioning: Implementation of collaborative projects with east Kent CCGs and providers to re-design elements of the urgent care, cancer, dementia, diagnostic and mental health pathways as well as the planned care pathways for: Cardiology Dermatology Diabetes Ophthalmology Orthopaedics Respiratory Disease Rheumatology Urology 2.2SKCAnnualOperatingPlan Page8of19 OverallPage28of204

28 3. Constitutional Targets / Access Standards (continued) How we plan to achieve this Commissioning: Continued implementation of the following Better Care Fund (BCF) initiatives that support achievement of the A&E access standards: Avoiding Unplanned Admissions Enhanced Service (Primary Care) Enhancing care for the over 75 s (Primary Care) Health Trainers Accident and Emergency Pilot Paramedic Practitioner Pilot Falls Work stream Care Homes Work stream Community Geriatrician Integrated Intermediate Care End of Life Care Work stream 2.2SKCAnnualOperatingPlan Page9of19 OverallPage29of204

29 3. Constitutional Targets / Access Standards (continued) How we plan to achieve this Finance - our finance and activity plans include the necessary activity and finance to achieve Constitutional Targets / Access Standards for 2016/17 (this approach is possible because acute activity is below the current years contracted plan). Funding for activity into the independent sector has also been identified to ensure that patient choice is supported Performance: Monitoring and reporting on Constitutional Targets / Access Standard achievement / trajectories through the year. Joint oversight with Commissioning and Quality colleagues of providers Recovery Action Plans and contractual performance management Quality: Assurance that, whilst under performance continues, challenged providers have mitigating actions in place with to minimise the risks to patients Joint oversight with Commissioning and Performance colleagues of providers Recovery Action Plans and contractual performance management 2.2SKCAnnualOperatingPlan Page10of19 OverallPage30of204

30 4. General Practice - Sustainability and Quality What we plan to achieve in 2016/17 To support the development of a range of healthcare services - traditionally beyond the immediate scope of an individual practice - within hubs based around the populations of Deal, Dover, Folkestone, Hythe & Lyminge and Romney Marsh How we plan to achieve this Commissioning: Hub / Provider Development for General Practice - provision of structured support to develop practices as hubs and as individual providers Enhanced Primary Care (BCF initiative) & Urgent Care Model - explore opportunities for patients to be seen by another GP within their local hub or another appropriate health care professional (e.g. pharmacist, paramedic practitioner, MIU nurse practitioner (out-reaching) or Rapid Response nurse) Integrated Out of Hours Service - procurement of an integrated OOH service including an east Kent NHS 111 hub and an advanced care navigation service capable of deploying/referring to clinical responders 2.2SKCAnnualOperatingPlan Page11of19 OverallPage31of204

31 4. General Practice - Sustainability and Quality (continued) Integrated Intermediate Care (BCF Initiative) - further integration of Intermediate Care Services provided by Kent County Council Social Care, health and the voluntary sector within South Kent Coast Integrated Primary Care Teams (BCF initiative) - further development of multidisciplinary/ agency teams at practice level (e.g. integrated nursing teams combining mental health, social care, voluntary agencies, health trainers, and other professionals) GP IT - deployment of additional tools to support clinicians and improve care for patients (e.g. clinicians, with patient consent, being able to share patient records with other clinicians; mobile working solutions to enable clinicians to update patient records away from base; video consultation for patients and care homes) Workforce Development - continued development of our primary care workforce (e.g. developing staff to transition into new roles (e.g. Health Care Assistants progressing into Associate Practitioner roles); increasing the number of Nurse Mentors and Training Practices; providing free educational events for Care Home and Domiciliary Care staff) 2.2SKCAnnualOperatingPlan Page12of19 OverallPage32of204

32 4. General Practice - Sustainability and Quality (continued) Vulnerable Practice Support - work jointly with NHS England to identify and support practices in difficulty Premises - development of a Primary Care Premises Strategy in agreement with hubs and practices, taking into account the emerging models of care and opportunities to share or co-locate facilities with other health and care services Primary Care Transformational Fund - use of this fund to improve estates and accelerate digital and technological developments in general practice Co-commissioning of Primary Care - engage with our member practices to develop and prepare them for the delegated responsibilities of primary care cocommissioning in 2017/18 2.2SKCAnnualOperatingPlan Page13of19 OverallPage33of204

33 4. General Practice - Sustainability and Quality (continued) Finance: Allocation of funding for additional capacity in Primary Care to improve outcomes for our older population Implement tools developed to enable benchmarking of spend against weighted budgets (to identify variation) Performance: Provision of practice profiles benchmarking referrals and activity for their practice population, based on locally developed weighted practice list data Development of a similar report for each hub with benchmarking within and between hubs Quality - direct and indirect support to practices (undertaking Quality Visits to practices who request assistance or who are identified as outliers via Performance colleagues primary care dashboard and supporting clinical leads peer review of unwarranted variation between practices) 2.2SKCAnnualOperatingPlan Page14of19 OverallPage34of204

34 5. Learning Disability Pathways What we plan to achieve in 2016/17 We will develop and implement Learning Disability pathways that ensure people wherever possible, are supported at home rather than in hospital. This will involve moving away from the traditional model of community beds and investing in more effective and comprehensive community support 2.2SKCAnnualOperatingPlan Page15of19 OverallPage35of204

35 5. Learning Disability Pathways (continued) How we plan to achieve this Commissioning: Continue to implement care and treatment reviews Maintain a register of all current learning disability and autistic spectrum disorder in-patient placements Discharge all current in-patients deemed to be inappropriately placed in hospital to more appropriate community based packages of support and accommodation Produce a Transforming Care Local Implementation Plan to outline service developments in line with the National Model of Care for people with learning disabilities or autistic spectrum conditions Finance - pooled funding arrangements between health and social care to support the integration of services and investigation of new models of contracting for support better patient pathways and improved outcomes Performance - monitoring and reporting on learning disabilities service providers and the development of more in-depth key performance indicators related to the quality of service 2.2SKCAnnualOperatingPlan Page16of19 OverallPage36of204

36 5. Learning Disability Pathways (continued) How we plan to achieve this Quality: Pro-active review of placements to ensure quality and safety is improved and maintained Development of a dashboard for Learning Disability Care Homes Engage with patient participation groups to understand patient experiences and improve the quality of service Work with commissioners to develop effective pathways that meet the needs of carers and patients Improve the quality of intelligence surrounding children services Transforming Care programme in place and progressing as per target - measuring outcomes for patients successfully relocated to community being developed 2.2SKCAnnualOperatingPlan Page17of19 OverallPage37of204

37 6. Quality and Safety - Challenged Providers What we plan to achieve in 2016/17 A continued pro-active focus on all challenged providers How we plan to achieve this Implementation of our Quality Strategy which provides a framework for identifying and quantifying quality and safety issues within challenged providers and developing a bespoke response to these providers. Elements of the strategy include: Intelligence gathering from multiple sources (e.g. quality visits, audits, contract management, patient feedback, serious incidents, CQC inspections) Formal review of the intelligence and an assessment of the risks to quality and patient safety (through a monthly Joint Clinical Round Table Meeting) Development of response / plan for each provider Monitoring and reporting progress of the plan through the CCG s Quality & Performance Committee 2.2SKCAnnualOperatingPlan Page18of19 OverallPage38of204

38 Next Steps Work is ongoing to revise the AOP in light of NHS England and colleagues feedback on the draft AOP submitted on 25 th January The deadline for submission of the AOP to NHS England is 4 th April 2.2SKCAnnualOperatingPlan Page19of19 OverallPage39of204

39 Report to: SKC Governing Body Agenda 2.3 item: Date of Meeting: 09 March 2016 Title of Report: South Kent Coast CCG Annual Revenue Budget 2015/2016 Author: Peter Hodgson, Financial Planning Accountant Board Sponsor: Jonathan Bates, Chief Finance Officer Status: Approval Appendices N/A 1. Purpose of the Paper To show the Governing Body the current financial plans for 2016/17 and gain their approval. This ties in to all of the CCG s strategic objectives. 2 Introduction The Governing Body has a statutory duty to set a budget before the start of the financial year. This paper sets out how the proposed budget for 2016/17 has been created. 3. Summary of Issues The CCG has received its allocation for 2016/17. The CCG has received allocation growth below the expected growth in demand. As a result it is important to have a firm grip on our financial position in the coming year. 4. Recommendations The board is asked to review and approve the planned revenue budget as set out in this paper. To note that some adjustments to the budget will be necessary to reflect completed contract negotiations. 2.3SKCCCGAnnualRevenueBud Page1of7 OverallPage40of204

40 South Kent Coast CCG Annual Revenue Budget 2016/2017 Introduction The CCG has been notified of its revenue allocation for 2016/17, 2017/18 and 2018/19 with indicative allocations for the following two years. NHS England has set out the key assumptions and service priorities. This report sets out the budget for the CCG for agreement by the Governing Body based on national guidance and the agreed strategy of the CCG. Background The changes to the CCGs resource limit from 2016/17 are shown below. The headline growth figure in 2016/17 is 2.8%. However some of this growth is due to NHS England including some non-recurrent funding within the baseline allocation. As such the allocation growth year on year is actually 2.22%. In addition 1% of the growth figure must now be held as an uncommitted Top Slice. The net funding increase is therefore below expected growth in demand and will put strain on resources. Overview of the Plan The CCG has prepared a balanced budget based on the information currently available. However there are several key points to note. 1. Contracts with key providers have not yet been agreed. 2. The CCG currently has a savings plan of 7.9m. Much of the planned saving is within contracts. Should the contracts not be signed for the planned amount then this will leave a significant gap in the finance plan. 3. The plan is based on a forecast at M9. Should the financial position in 2015/16 change then adjustments to the budget maybe required in 2016/17. A summary of the budget is shown in Appendix 1. The major changes from 2015/16 are set out below. 2.3SKCCCGAnnualRevenueBud Page2of7 OverallPage41of204

41 Budget Preparation The budget is based on the forecast outturn for 2015/16. These figures have then been adjusted non-recurrent spend, growth, full year effects, cost pressures and savings. Expenditure Plans NHS England has mandated that all CCGs must deliver a minimum surplus of 1% in 2016/17. For South Kent Coast this surplus is 2.8m. As a result total CCG expenditure must not exceed 277.8m in 2016/17. The national requirement is for a 1% top slice and minimum 0.5% contingency. This budget meets these requirements. Summary Budget Applications '000 Recurrent Expenditure 2015/16 270,337 1 Placement & Prescribing Run Rate Adjustments 2,300 2 Population/Demand Growth 2,709 3 Tariff Growth 2,908 4 Loss of Non-recurrent Income 2,395 5 Non-recurrent Savings Rebuild Contingency (0.5%) 1,403 7 Rebuild Top Slice (1%) 2,778 8 Savings - 7,782 Expenditure 2016/17 277,839 Placement & Prescribing Run Rate Adjustments (line 1) This adjustment is to increase the base budget for 2016/17 so that it reflects 12 months of the forecast spend in March. These are the two areas of high growth in South Kent Coast and so it makes sense to rebase the budget based on activity we will see at the end of the year. 2.3SKCCCGAnnualRevenueBud Page3of7 OverallPage42of204

42 NR Savings (line 2) These are one off savings we have been able to make in 2015/16. We do not expect these savings to be achievable in 2016/17. They include the use of prior year balances. Population Demand Growth (line 3) We have used a population growth of 0.44% in South Kent Coast for these plans. This agrees to ONS data about the predicted growth in the CCG over the next year. We have also included increased growth for demand in placements of 3% and ambulance of 5%. Tariff Adjustment (line 4) The national guidance on the acute tariff deflator has been out to consultation. It has been set at an increase of 1.1% overall and this has been applied to contracts where appropriate. Within EKHUFT when the change in tariff is applied to the specific basket of activity that they carry out the inflator has an impact of 1.8%. This is reflected in our plans. Loss of Non-Recurrent Income (line 5) For 2016/17 some lines of spend have moved from being funded non-recurrently into our recurrent baseline. As a result we have had to use some of our growth to cover this expenditure including a nationally mandated increase in CAMHs transformational funding. The impact of this is shown below. While we have not been told to include any other non-recurrent funding from last year this could still change. Non-recurrent Funding 2015/16 '000 Funding Included in Baseline 2016/17 '000 ETO funding GP IT Allocation CAMHs Transformational Funding Total 1,450 1,612 Savings (line 8) The major driver for the savings plan has been the delivery of the CCG strategy. The savings identified in the budget are used to help offset growth in services and rebuild reserves. 2.3SKCCCGAnnualRevenueBud Page4of7 OverallPage43of204

43 The chart below shows the areas from which the savings are expected to come. The comments below relate to the savings shown in the pie chart above. The CCG is aiming to deliver 7.8m of net QIPP savings in 2016/ m of this is attributable to the contract with EKHUFT. This will include targeted reductions in outpatients, anticipating a fall in referrals, a reduction in low value follow-ups, reduced A&E attendances and non-elective admissions. The plan shows 0.5m of savings against other acute. This is because in 2015/16 we saw a large amount of growth which is not sustainable in the current financial climate. An action plan will be implemented to do this. We have also put 0.1m against SECAmb as we are currently trailing new ways of working with conveyancing and some of the EKHUFT QIPP is designed to reduce ambulance activity. The CCG is planning 1.4m of savings to be delivered from the KCHT contract. This will be delivered through finding efficiencies through service redesign and targeting existing inefficiency in the service. The first services to be redesigned will be community nursing and the integrated care team. The saving from Other Community in the pie chart is due to reinvestment of the reablement budget. The savings on KMPT are due to us offering a flat cash contract. However the CCG has increased mental health spend in other areas such as CAMHs and mental health prescribing. 2.3SKCCCGAnnualRevenueBud Page5of7 OverallPage44of204

44 The CCG aims to manage growth in CHC through improved management of existing placements and placing of new individuals by the SECSU team. The changes in community nursing should also lead to a reduction in placements. The budget shows a zero growth position on the medicines management budget as discussed within the CCG. Recommendations 1. To approve the planned revenue budget for the year 2016/17 as set out in this paper. 2. To note that some adjustments to the budget will be necessary to reflect completed contract negotiations. 3. To note that a paper showing a detailed budget with the adjustments will be brought to the Govering Body in May Jonathan Bates Chief Financial Officer March SKCCCGAnnualRevenueBud Page6of7 OverallPage45of204

45 Appendix 1 Budget by Board Line Summary Board Line Forecast 2015/16 Spend NR Contingency Support on Spend Reported Budget 2015/16 NR planned Support Final Budget 2015/16 Remove NR Resource NR spend FYE 2016/17 Run rate budget Change in Recurrent Resource Additional 2016/17 Opening NR Resource Budget Acute Local Acute Contracts 115,548, , ,850,109 2,619, ,230, , ,928, ,928,329 2,619,850 1,054,055 2,079,867 - (4,295,310) 114,386,791 Other Acute Contracts 13,941, ,428 12,976,218-12,976,218-12, ,428 13,954, ,954, , ,698 - (500,000) 13,798,331 High Cost Drugs 3,613, ,000 3,453,225-3,453, ,000 3,613, ,613,225-32, ,646,186 Ambulance Services 8,918,946-8,918,946-8,918, (9,000) 8,909, ,909, ,776 98,009 - (300,000) 9,234,731 Winter Pressures 1,395,000-1,395,000-1,395, ,395, ,395, ,395,000 Non-contract 3,484, ,000 3,274,897-3,274,897 (6,000) 225, ,000 3,704, ,704,889-33,532 66, ,804,587 Acute Total 146,901,893 2,033, ,868,395 2,619, ,248,545 (6,000) 238,367 2,024, ,505, ,505,410 2,619,850 1,799,936 2,435,740 - (5,095,310) 146,265,626 Community KCHT Contract 24,648, ,000 23,850,190-23,850,190 - (997,796) 798,000 23,650, ,650,394 (435,054) 101, ,369 - (1,383,975) 22,187,772 Other Community 2,642,951 (499,652) 3,142,603-3,142,603 (100,000) 887,239-3,929, ,929,842-9, (701,010) 3,238,263 Community Total 27,291, ,348 26,992,793-26,992,793 (100,000) (110,556) 798,000 27,580, ,580,237 (435,054) 110, ,369 - (2,084,985) 25,426,035 Continuing Health Care - Continuing Health Care 17,270,166 (150,000) 17,420,166-17,420, ,000 17,720, ,720,166 (237,951) 548, (250,000) 17,781,067 Mental Health Placements 4,841, ,407 4,678,738-4,678, ,407 4,841, ,841,145-21, ,862,215 Childrens Placements 833,309 60, , , , , ,309-3, ,936 Continuing Health Care Total 22,944,620 72,466 22,872,154-22,872, ,466 23,394, ,394,620 (237,951) 573, (250,000) 23,480,218 Mental Health IAPT 1,588,523 40,000 1,548,523-1,548, ,000 1,588, ,588,523-11, ,600,295 Other Mental Health 1,146,867 (97,000) 1,243,867-1,243,867 (487,000) 4,709 (97,000) 664, , ,846 2, ,110,347 Children Mental Health 2,255,279-2,255,279-2,255, ,255, ,255,279-20,573 24, ,300,660 Dementia 228, , , , , ,870 KMPT Contract 17,462,355-17,462,355-17,462, ,462, ,462, , , ,010 (351,381) 17,574,365 Out of Area Beds 34,000 (358,000) 392, , (358,000) 34, , ,000 2,324 - (112,010) - 424,314 Mental Health Total 22,715,024 (415,000) 23,130,024-23,130,024 (487,000) 4,709 (415,000) 22,232, ,232, , , ,894 - (351,381) 23,238,852 Primary Care Out Of Hours 1,670,054-1,670,054-1,670, ,670, ,670,054-7, ,677,322 Local Enhanced Service 1,118,561 16,123 1,102,438-1,102, ,123 1,118, ,118,561-4, ,123,429 Other Primary Care 492,407 (492,407) 984, , , ,814-4, ,100 Prescribing 36,092,302 1,200,000 34,892,302-34,892, ,763 2,100,000 37,654, ,654, ,654,340 Oxygen 464,505 27, , , , , , ,505 GP IT 512, , ,000 (512,000) , ,000 Primary Care Total 40,349, ,716 39,599,113-39,599,113 (512,000) 661,763 2,143,123 41,891, ,891, ,000 16, ,420,697 Other Patient Transport 1,745,539 38,000 1,707,539-1,707, ,000 1,745, ,745,539-7, ,753,231 Children's Commissioning 602,069 (43,140) 645, ,209 - (3,384) (43,140) 598, ,685-2, ,105 Prop Co Recharge 1,204,000-1,204,000-1,204, ,204, ,204, ,204,000 Better Care Fund 4,374,321-4,374,321-4,374, ,374, ,374, ,374,321 NHS , , , , , ,314 Other Total 8,405,243 (5,140) 8,410,383-8,410,383 - (3,384) (5,140) 8,401, ,401,859-10, ,411,971 Corporate Corporate 4,404,000 (149,000) 4,553,000-4,553,000 (149,000) - - 4,404,000 10,000-4,414, ,414,000 Corporate Total 4,404,000 (149,000) 4,553,000-4,553,000 (149,000) - - 4,404,000 10,000-4,414, ,414,000 Reserves Contingency - (2,585,888) 2,585,888-2,585,888 (4,259,198) (790,899) (5,067,947) (7,532,156) 7,360,476 2,811,448 2,639,768 (3,401,691) (2,708,523) (2,908,003) - 7,781,676 1,403,227 Top Slice (2,619,850) 2,619, ,619, ,490-2,778, ,778,340 Reserves Total - (2,585,888) 2,585,888 (2,619,850) 5,205,738 (4,259,198) (790,899) (5,067,947) (4,912,306) 7,518,966 2,811,448 5,418,108 (3,401,691) (2,708,523) (2,908,003) - 7,781,676 4,181,567 - TOTAL EXPENDITURE 273,011, ,011, ,011,750 (5,513,198) ,498,552 7,528,966 2,811, ,838, ,838,966 Resource Limit 275,823, ,823, ,823,198 (5,513,198) 270,310,000 7,523,972 2,811, ,645, ,645,420 TOTAL RESOURCE 275,823, ,823, ,823,198 (5,513,198) ,310,000 7,523,972 2,811, ,645, ,645,420 - SURPLUS / (DEFICIT) 2,811,448-2,811,448-2,811, ,811,448 (4,994) - 2,806, ,806,454 Funded Developments Funded Growth 2016 Tariff Adjustment Adjustments QIPP Final Budget for 2016/17 2.3SKCCCGAnnualRevenueBud Page7of7 OverallPage46of204

46 NHS England - South (South East) Wharf House Medway Wharf Road Tonbridge Kent TN9 1RE By Kent and Medway Simon Perks, Patricia Davies, Peter Green, Hazel Carpenter, Ian Ayres Felicity.cox1@nhs.net Tel February 2016 Dear Colleagues Kent and Medway: Sustainability and Transformation Plan Thank you for confirming your intended Sustainability and Transformation plan footprint for Kent and Medway. I know that system partners have worked hard to agree this; I now look forward to continuing our work with you over the coming months to realise the benefit of these discussions. Delivering the Forward View: NHS Planning Guidance 2016/17 sets out some initial expectations for Sustainable and Transformation Plans (STP), with a timescale for completion by June Further guidance is likely to be published shortly. In advance of that, I am writing to clarify some local expectations for this footprint, given the significant amount of work that needs to be done to meet that timetable. Fundamentally, the plan needs to address the 3 key gaps identified by the 5 Year Forward View in terms of health, quality and finance. I would like to see some early thinking and confirmation of how your plan will address these gaps. To support this, I would be grateful for clarity about the intended content and substance of the plan. I am expecting the STP to cover a range of key services or population groups, defining future need, identifying the gaps to close and scope for improvement, and indicating the model of care to be developed to implement this change. Work- streams might include but are not necessarily restricted to: - Prevention and self-care - Long term conditions, Frailty and End of Life - Maternity and Paediatrics - Mental Health and Learning Disabilities - Planned and Specialist Care - Urgent and Emergency Care Beyond that, I would like to understand the proposed approach to a number of other important components of the plan. These include: What process you intend to use to develop your STP, including development of a shared vision, to ensure that all partners including local authorities, independent and third sectors, and local populations are fully engaged? High quality care for all, now and for future generations 2.4KentandMedwaySustainabi Page1of2 OverallPage47of204

47 What delivery plans you expect to develop and on what geographical footprints? What additional underpinning plans you expect to develop to support the STP for example, workforce and OD, finance, information, estates and digital footprint. What governance arrangements you propose to put in place to ensure effective development of the plan in the short term and successful implementation in the medium and long term? How will this be co-ordinated across the multiple stakeholders? An indication of your leadership model which we need by Thursday 11 th February. What additional capacity and capability, if any, are you expecting to resource to secure delivery? I would therefore be grateful for a short paper in response to the points above by Friday 26 February. This will enable us to be clear about your thinking and approach at an early stage and ensure that we have a shared understanding of what is required and the implications for development and delivery of the plans. We will use this as a basis for discussion at March assurance meetings and in other relevant fora. Yours sincerely Felicity Cox Director of Commissioning Operations NHS England South (South East) High quality care for all, now and for future generations 2.4KentandMedwaySustainabi Page2of2 OverallPage48of204

48 East Kent Strategy Board HOSC Update 4 March EastKentStrategyBoard Page1of12 OverallPage49of204

49 Sustainability and Transformation Plan (STP) New planning guidance published on 22 December 2015 authored by the six national NHS bodies Clear list of national priorities and longer-term challenges for local systems We are asking every health and care system to create its own ambitious local blueprint for accelerating its implementation of the Forward View We are asking the NHS to spend the next six months delivering core access, quality and financial standards while planning properly for the next five years. Success also depends on having an open, engaging, and iterative process that harnesses the energies of clinicians, patients, carers, citizens, and local community partners including the independent and voluntary sectors and local government through health and well-being boards EastKentStrategyBoard Page2of12 OverallPage50of204

50 Sustainability and Transformation Plan Health service regulators require health economies to produce a five year sustainability and transformation plan to drive the Five Year Forward View and place based care. It involves five things: Local leaders working as a team A shared vision A coherent programme of activities Execution against the plan Learning and adapting EastKentStrategyBoard Page3of12 OverallPage51of204

51 Sustainability and Transformation Plan The plan will cover the population of Kent and Medway and will be submitted to NHS England at the end of June The planning process will have significant central money attached and the most compelling plans will secure the earliest additional funding (from April 2017). Further guidance has been issued and we are working with NHS England to ensure the plan will cover: Closing the health and well-being gap Driving transformation to close the care and quality gap Closing the financial and efficiency gap EastKentStrategyBoard Page4of12 OverallPage52of204

52 Sustainability and Transformation Plan Sustainability and transformation plans will cover a range of key services and population groups, defining future need, identifying gaps to close and scope for improvement. Model of care to implement these changes will be identified. Work-streams might include: Prevention and self-care Long term conditions, frailty and end of life care Maternity and paediatrics Mental health and learning disabilities Planned and specialist care Urgent and emergency care 2.4.1EastKentStrategyBoard Page5of12 OverallPage53of204

53 South east timetable Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16 Jul 16 Draft operating plan submission 25 January 8 February 3 February Feedback 22 February 2 March 11 April 2 nd Submission Commissioner only 21 March Feedback 4 April Final 2016/17 operational plans submitted 31 March Contracts signed Summer Final sustainability and transformation plans submitted Plan development Best practice sharing Ongoing dialogue Transformation footprints agreed; pre-submission support and challenge from national bodies Ambitious and advanced areas will be encouraged to work to a more rapid timescale and to share their learning with localities across the system STPs form integral part of ongoing conversation between national bodies and local areas National submission dates 2.4.1EastKentStrategyBoard South east submission dates Page6of12 OverallPage54of204

54 Developing the plan The East Kent Strategy Board will oversee the development of the sustainability and transformation plan for the east Kent population - this will be aligned with our partners in north Kent, west Kent, Medway and Swale Several key elements of work already underway in Kent and Medway, specifically reviews of vascular and stroke services The EKSB work to date and the development of the sustainability and transformation plan will now come together to meet the national timetable EastKentStrategyBoard Page7of12 OverallPage55of204

55 East Kent Strategy Board Update Through the autumn the Board has been focussing on: Forming a coalition of local health and social care leaders and developing a shared vision Understanding the map of current and planned reviews and initiatives in place across the economy Developing a robust Kent Integrated Data set (formerly Year of Care) which allows us to really understand flow across the health and social care system, and Working with colleagues across Kent and Medway to understand the impact in east Kent of the vascular and stroke reviews EastKentStrategyBoard Page8of12 OverallPage56of204

56 Work is well underway to set the strategic context Development of JSNA, joint H&WB strategies and commissioning plans Clinical working group Continuous dialogue with H&WBs, HOSC and local communities on local health priorities and needs Verbal presentation for HOSC Draft - East Kent Strategy Board February th Apr 1 st Draft STP to go to EKSB 12 th May 2 nd Draft STP to go to EKSB 9 th Jun Final STP to go to EKSB for sign off End June submission of final STP KEY East Kent Strategy Board Meeting HOSC meeting Jan 16 Feb 16 4 th 8 th 3 rd Mar Apr May Jun 16 Jul th Aug th Jan - Submit proposals for STP footprints and volunteers for mental health and small DGHs trials 22 nd Feb First submission of full draft 16/17 Operational Plans Aug 31 st Mar - submission - signed contracts Emerging clinical models and developing service options Action to be completed Developing the criteria for reviewing Developing and modelling the options and understanding their impact Evaluating the options and securing wide agreement from all key stakeholders Development of outline business case 4 th Apr - Submission of final 16/17 Operational Plans, aligned with contracts Clinical Senate Assurance Clinical Senate approval is required prior to NHS Panel Review NHS England s Assurance Process by the NHS Panel 2.4.1EastKentStrategyBoard Public engagement so public views can be fed into the process Preparation for consultation Page9of129 OverallPage57of204

57 Draft - East Kent Strategy Board February 2016 KEY East Kent Strategy Board Meeting HOSC meeting Sept 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Jun 17 July 17 Aug 17 Approvals and formal decision to consult by CCG Governing Bodies Formal consultation Independent analysis of process Formal decision by all CCG Governing Bodies Start implementation Aug 2.4.1EastKentStrategyBoard 1 Page10of12 0 OverallPage58of204

58 Future Timetable By Easter: o Governance arrangements and an agreed process in place o The east Kent Case for Change agreed o Key priorities for the gaps identified By end April: o Description of the emerging clinical models for the key priorities o Development of the evaluation criteria by which those models will be assessed o Ongoing engagement with key stakeholders, including HOSC and the public to feed into the process 2.4.1EastKentStrategyBoard Page11of12 OverallPage59of204

59 Future Timetable By end May: o A well developed draft sustainability and transformation plan with clear description of the models of care to meet key priorities o Clear ambitions, using a prioritised approach, for the future health and social care system in east Kent o Clarity on how we plan to meet the nine must dos in the planning guidance By end June: o We will submit our plan as part of our long-term ongoing work to improve health and care in east Kent EastKentStrategyBoard Page12of12 OverallPage60of204

60 Report to: SKC Governing Body Agenda item: Date of Meeting: 09 March Title of Report: Author: Board Sponsor: Status: Appendices Communications and Engagement report Sara Warner, South East Commissioning Support Unit Clive Davison, Lay Member for Patient and Public Engagement Approve 1. Purpose of the Paper This report highlights progress in the last month and highlights key engagement and communication that has taken place with our communities, stakeholders and the voluntary and community sectors. 2 Introduction NHS South Kent Coast CCG recognises that listening to and acting on what matters to local people is key to the delivery of our commissioning intensions and plans. Local engagement and communication with patients and people to jointly design and commission services will make services more responsive to local needs. It also helps us to gain a sense of shared responsibility and a better return on the money we invest in local services. 3. Summary of Issues Please note the efforts made to increase the partnership working with our wider partners in in Romney Marsh. That the Stroke review has been well received by the first JHOSC. The first patients are scheduled to go to France for elective treatment. A GP information leaflet and a patient information leaflet are being prepared. 4. Recommendations For noting 3.1NHSSouthKentCoastCommu Page1of12 OverallPage61of204

61 Communications and engagement progress report March Introduction NHS South Kent Coast Clinical Commissioning Group (CCG) aims to ensure the patient and community voice is embedded into its commissioning cycle so that it can become a valuable, high-performing and successful local NHS organisation. Our approach to communication and engagement is influenced by three main objectives: Listening to, and acting on, the views of our community by involving and engaging with as wide a range of the public as possible. Targeting services effectively to areas of particular need by using information and research about different communities needs. Increasing our reach into communities where evidence shows further engagement is needed. 2.0 Patient and public engagement Project aim To increase representation and engagement of community within NHS South Kent Coast CCG. Link to strategic goals Local We will address the variation in quality of local healthcare services and the inequality of health outcomes that this can cause. We will work with partners to help prevent ill health Kent Reduce ill-health by encouraging people to take greater responsibility for their own health and wellbeing. Activity National Preventing people from dying prematurely. Enhancing quality of life for people with long-term conditions. Helping people to recover from episodes of ill health or following injury. Activity meeting in Dover Kuldeep Dhillon, Senior Lead for Engagement attended the St Radigund s Community Information Day, Poulton Close, Dover on 16 February, This was a free community engagement event with over 20 organisations in attendance, many with market places/stalls. Some organisations attended including Headway, East Kent College, and Southern Housing Group. 3.1NHSSouthKentCoastCommu Page2of12 OverallPage62of204

62 The event proved beneficial in terms of cascading information about SKC s priorities, 111 NHS information cards, Health Network and Health Help Now app. However, attendance by children and families was considerably lower compared to the previous Dover engagement event held at Salem Baptist Church. The Roma Network Kuldeep Dhillon, Senior Lead Engagement made contact with the Roma Network having attended a recent engagement meeting at The Village Children s Centre, Denmark Street, Folkestone. A further stroke focus group taking place with members of the Roma Community on 25 February, 2016 as an integral part of the Kent and Medway Stroke Review. Royal Victoria Hospital Sue Baldwin and Steve James met with the Women s Institute (WI) in Folkestone to discuss the WI s petition for enhanced services at the Royal Victoria Hospital (RVH). The WI also invited a reporter from the Folkestone and Hythe Express to be present. The discussions between the CCG and the WI are ongoing and further meetings will take place in accordance with developments. Outcomes/ outputs Better engagement with active community groups within an area, reach better understanding and increase active participation in CCG campaigns such as increased self care. 2.1 Engagement and communications to support development of care in and around our towns and localities Project aim To work with our communities and partners to co-produce a plan for integrated working in and around our towns and localities, to be delivered by multispecialty community providers (MCPs) and through self-care, as part of our move towards developing an Link to strategic goals Integrated Care Organisation. Local We will ensure that local health and care services are integrated and that patients experience joined-up care We will ensure that services are provided locally wherever possible We will work with partners to help prevent ill health. Kent Reduce ill-health by encouraging people to take greater responsibility for their own health and wellbeing Better quality of life for people with long-term conditions by improving access to quality care and support. 3.1NHSSouthKentCoastCommu Page3of12 OverallPage63of204

63 National Enhancing quality of life for people with long-term conditions Helping people to recover from episodes of ill health or following injury Ensuring people have a positive experience of care. Activity and outputs February Folkestone Delivery Group The Folkestone Delivery Group took place on 5 February, 2016 at the Burlington Hotel. Key agenda items included: workstreams update from Sue Baldwin, integrated care and urgent care pathways update, children s services update Local Children s Partnership and EKHUFT strategy update. End of life: work has included pathway redesign, education and workforce issue and information and technology. The group was an east Kent collaboration between providers, CCGs, hospices and so on. The Just in Case boxes (JIC boxes), containing pain-relieving medication had been introduced. The JIC boxes were subject to strict governance procedures. GPs remain responsible for signing prescriptions. The group was discussing the potential of using Careflow (an IT platform for coordinating patient care currently used within EKHUFT) to manage palliative care. While the boxes can be re-issued, unused medication would be destroyed in accordance with current guidelines. Previous study had found that the potential waste was not excessive. Integrated Intermediate Care: Intermediate Care, Age Concern, Crossroads and Kent Enablement at Home services worked together to provide a cohesive service. The aim was to have an effective triage system for referrals, making best use of resources and avoiding duplication. Referrals for intermediate care were triaged on receipt at the Local Referral Unit. New Romney Town Council There is an ongoing dialogue between the CCG and New Romney Town Council on health matters affecting the Marsh community. The Town Council has campaigned for improved health services provision in the area, including 24-hour walk-in centre. The campaign is supported by the newly constituted 'Marsh Forum' which represents several Romney Marsh town and parish councils including, but not limited to Lydd Town Council, Burmarsh Parish Council and Brenzett Parish Council. 3.1NHSSouthKentCoastCommu Page4of12 OverallPage64of204

64 Sue Baldwin has already responded to some of the issues raised by the councils of Romney Marsh by providing an NHS England contact. And Sue has made contact with SECAmb in order for SECAmb to meet with representatives of New Romney Town Council. Dates of future Local Delivery Group meetings: Deal: The next meeting to take place on Thursday 10 March at St. Richard's Road Surgery. Meetings in 2016 all to be held on Thursdays at St. Richard's Road Surgery Romney Marsh: 31 March, 1pm to 3pm, Romney Marsh Day Centre. Dover: 14 April, 2016, 2 4 pm. Venue TBC. Folkestone: 26 May 2016, venue TBC am pm The Health Reference Group (HRG) met on 9 February 2016 Whitfield Offices, Dover. The Health Reference Group (HRG) met on 9 February, 2016, Whitfield Offices, Dover. HRG members contributed to the following: - Update on Calais and Calot Hospitals, ICO - operational development. Mental health: Talking therapies (IAPT) Referral Guide, text messaging and an update on medicines management. Mental health Jeanette Dean-Kimili updated members about the new Community Health Mental Health and Wellbeing Service that will start on 1 April 2016 which will seek to keep people well and support people with mental health needs on their recovery journey. Details of the robust procurement process, bid/criteria, IAPT providers was discussed. Other aspects included the mental health: IAPT referral guide steps 1, 2, 3 and 4. Update was provided about choice of qualified providers in East Kent: Dover Counselling Service, Thinkaction, Insight a national voluntary sector provider and the University Medical Centre. Integrated Care Organisation - Operational Development 3.1NHSSouthKentCoastCommu Page5of12 OverallPage65of204

65 Update Sue Baldwin provided a comprehensive update to members about the locality model, progress to date, integrated primary care, pathway changes, pharmacy and medicines management, end of life improvements, prevention and self-care. Medicines management Heather Lucas provided a detailed update to members about drives around medicine management, domiciliary providers, issues around G.P. recruitment, medications spend, over reliance on medication, prescribing budget, increasing number of pharmacies in G.P practices and the ordering of drugs, as well as important changes to the way repeat prescriptions were ordered in South Kent Coast. Messaging system Ray Berry updated members about Careflow: an internal messaging portal which is being used by health professionals across east Kent. The system would not hold patient records but will provide a secure network/tool for health professionals to use in the workplace e.g. updates about admissions/discharge. Further updates were provided about IPLATO text messaging reminder service creating a link with a patient mobile phone and their GP surgery. Update on mobilisation for French hospitals A number of representatives from the Health Reference Group have expressed interest in attending the Calot Institute an Orthopaedic Hospital. A further visit is intended to take place in the spring and members were awaiting a date of next proposed visit. Date of next Health Reference Group meeting Pre-meeting: HRG meeting: 12 April 3 pm 4 pm, Whitfield, Dover. 12 April 2016, 4 pm 6 pm Whitfield, Dover. Outcomes Patients and the public are actively involved in the work of the CCGs and able to inform and influence their local plans and the wider pieces of collaborative commissioning. This not only fulfils the NHS Constitutional rights and legislative duty around no decision about us without us, but also the CCGs ambitions: to work with its local partners and communities to keep our patients at the heart of everything we do. 3.1NHSSouthKentCoastCommu Page6of12 OverallPage66of204

66 Better local services are commissioned and procured as a result of patient involvement influencing the plans in all parts of the commissioning cycle: planning and development, service improvement and quality of care, procurement and contract delivery. 2.2 Engagement and communications supporting in-hospital care Project aim Link to strategic goals To review treatment for stroke focusing on the whole service but especially the quality of delivery in first 72 hours (hyper-acute phase) as part of a Kent and Medway review. Local We will address the variation in quality of local healthcare services and the inequality of health outcomes that this can cause. National Preventing people from dying prematurely Helping people to recover from episodes of ill health or following injury Ensuring people have a positive experience of care. Treating and caring for patients in a safe environment and protecting them from avoidable harm. Activity and outputs SKC CCG is part of a Kent and Medway-wide review of stroke services, which is looking at the care that people receive immediately after having a stroke (the hyper-acute / acute phase). The aim of the review is to deliver clinically sustainable, high quality, hyper-acute / acute stroke services for the next 10 to 15 years that are equally accessible to Kent and Medway residents 24 hours a day, seven days a week. All the clinical commissioning groups in Kent and Medway are part of this review. A comprehensive and robust programme of engagement has been carried out with patients and carers, members of the public, and community representatives including voluntary organisations. This culminated in deliberative events held in November and December when People s Panels came together to look at and critically evaluate the work conducted to date, including patient and public priorities and feedback from the clinical group. Deliberative events are a unique form of public engagement through which participants are recruited to explore an issue in greater detail than, for example, through focus groups. 3.1NHSSouthKentCoastCommu Page7of12 OverallPage67of204

67 Participants were presented with key information and evidence and required to scrutinise what they read and heard. And to ask questions of key people and specialists in the field, to give feedback and make suggestions directly to the people in charge of shaping the next stages of the review. Overall, across all the different forms of engagement for the stroke review, which included listening events, focus groups, a survey and the deliberative events (as well as earlier work carried out in west Kent), people were generally shocked and surprised to find that stroke services in Kent and Medway do not already provide a full seven-day service. And that performance against the national standards for stroke is variable and inconsistent, with improvements not always sustained. They recognised the importance of: A solution to the current significant workforce shortages in the specialist multi-disciplinary teams. Swift access to specialist high-quality care, seven days a week, across Kent and Medway inconsistent care due to the time of day or the location of the person having the stroke is not acceptable. Engaging staff throughout the process so they shape decisions about the future model of care. From the start, some people have suggested there should be fewer sites admitting stroke patients in the hyper-acute phase, and that travelling further is acceptable, depending on how far. The People s Panels at the deliberative events overwhelmingly recognised the need for a reduction in stroke units from the current seven. They voted 49 to 2 in favour. They also rejected the potential options of: one, two or three sites, and agreed that six sites would not deliver the required improvements. Their preference was for a four or five-site model. The Clinical Reference Group, which provides clinical guidance and assurance to the review process and its membership, represents all the K&M providers of acute stroke care, advised that models based on one, two sites for hyper-acute stroke care and the status quo should be rejected. They also recognised that while it would be desirable to have 24/7 hyper- acute care on all seven sites, this was unlikely to be recruitable. So further detailed work should be undertaken on three, 3.1NHSSouthKentCoastCommu Page8of12 OverallPage68of204

68 four and five site models. The Stroke Review Programme Board, which oversees the stroke review, accepted this advice. Work is now going on to evaluate three, four and five site models against key criteria including: Can they recruit and retain enough specialist staff to deliver a seven day service? What will the impact be on different populations? Are any groups likely to be disproportionately affected? Are all three models financially viable and sustainable? Do they support delivery of the national stroke standards for hyper acute and acute stroke care? Can they provide a model that can work towards SSNAP level A. Recommendations about changes to stroke services will be put forward by the Stroke Review Programme Board to clinical commissioning group Governing Bodies, which will take the final decisions. The Health Overview and Scrutiny Committee for Kent and Health and Adult Social Care Overview and Scrutiny Committee for Medway have formed a joint committee to review the plans and process used by the stroke review. It met for the first time in January when it approved the work carried out so far. It is expected to meet again in April. Outcomes Patients experience and insight is a strong component of the review of stroke services across Kent, informing development of options for an improved model of care. The next steps will be further public consultation depending on the options developed and the approval of the CCGs. 2.3 Engagement and communications to support public understanding of the role of the CCG and how to make best use of local services Project aim Link to strategic goals Activity/outputs To ensure that our population and stakeholders are able to access information about the CCG, its priorities and challenges, to support their understanding of its role and their willingness to engage; and are supported to use local health services in the most appropriate way. This work is an enabler which underpins delivery of the other projects outlined above. Mobilisation For French Hospitals The first patients are scheduled to go to France for elective treatment. A GP information leaflet and a patient information leaflet are being 3.1NHSSouthKentCoastCommu Page9of12 OverallPage69of204

69 prepared by Steve James based on earlier input from the HRG representatives. Mobilisation Patient Transport Service We are working with G4S, the new provider of the non-emergency Patient Transport Service for Kent, to assure their communications and engagement plans. A patient representative from east Kent is part of the steering group, overseeing this work. Community mental health and wellbeing service Following a joint procurement led by Kent County Council, Porchlight has been appointed the strategic partner for mental health support provided by voluntary organisations in Thanet. It will work with other voluntary organisations to co-ordinate the support available for people with mental health needs. We are liaising with Kent County Council which is overseeing the mobilisation and communications plans provided by Porchlight. It is very important that people with mental health needs and health professionals such as GPs are provided with the information they need about the new service. Wheelchair services Following a survey with users of NHS wheelchairs which gathered important intelligence about people s experience of the service, a Kent and Medway wide procurement of the NHS wheelchair service is getting underway. It is overseen by a Wheelchair Project Board, which will include patient representatives. The draft service specification is being shared widely with wheelchair users and their carers, user groups and clinicians, for their comments and input. The Board intends to ensure that users are consulted, included and engaged throughout the procurement process, which is likely to start formally in April The new service is expected to start in April Communication implementation for surge resilience We have a responsibility to have an effective surge resilience plan, which includes communications, to encourage people to use health services in the most appropriate way. A key part of this for us is Health Help Now, the mobile optimised website and apps for Kent and Medway. As of 19 February, the Health Help Now web app had been used 106,913 times by people using 80,860 devices (such as smartphones, 3.1NHSSouthKentCoastCommu Page10of12 OverallPage70of204

70 tablets or computers). Users stay on for two minutes on average. Forty per cent of users are aged 18 to 34, 23 per cent are 35 to 44, 17 per cent 45 to 54, 11 per cent 55 to 64, and nine per cent 65 plus. Two-thirds of usage is by women. The downloadable app, which launched on 9 December 2014, had been used 13,617 times and downloaded 8,358 times. People typically stay on for just over three minutes and look at nine screens. We along with the other CCGs in east Kent are funding some publicity for Health Help Now and other winter messaging to encourage people in east Kent to use NHS services appropriately. Before half term in February, people in Deal, Dover, Folkestone and Romney Marsh to be aware of Health Help Now. And also in February there was a strong call to action in the release to use the Health Help Now app and avoid A&E departments unless in an emergency. Other press releases have advised about mental health, pharmacies, self-care and the need to think about excessive alcohol consumption that may lead to injuries and illness. At the request of the Director on Call, separate tweets were sent out on 24 January, alerting people to avoid A&E if at all possible. There was a high rate of re-tweeting, distributing the message even further afield. Social media The CCG continues to use new technologies to better engage and communicate with patients and stakeholders. The CCG s Twitter now has 1,941 followers. Recent updates to the CCG public website include uploading and promotion of the 14/15 Annual Report via a homepage banner. Patient newsletter The latest four-page patient newsletter was distributed in January. The leading article from Dr Darren Cocker linked mental health and physical health, and the need for integrated care in the area. The newsletter also featured a local PPG member interview, and a stroke case study. There was also an article featuring a stroke patient and a longer article on the Kent and Medway stroke review. 3.1NHSSouthKentCoastCommu Page11of12 OverallPage71of204

71 Outcome People in the South Kent Coast area have the information they need to engage with the CCG and to take decisions about their use of NHS services. The CCG continues to address workforce issues 2.4 Opportunities for patients to get involved People who would like to influence CCG decisions can get involved through their patient participation group (PPG) at their GP practice; or by joining the CCG s Health Network; or attending governing body meetings.. For more information about the work of the CCG, visit or contact us by , social media and using our online surveys. 3.1NHSSouthKentCoastCommu Page12of12 OverallPage72of204

72 Governing Body Question from the Public - January 2016: Q1: Only 1% of mothers achieve the NHS recommended 6months of exclusively breastfeeding their children. The DoH has published statistics that show correlation between higher rates of breastfeeding and lower rates of inpatient admissions for infants under 1 year, thus the strain on NHS money and resources would be greatly reduced if more mothers were able to achieve this goal. What plans do you have for improving access, quality and awareness of breastfeeding support services in the area? A1: The CCG has formed a local children s partnership group, working with partners from public health, health visiting, local councils and early years district managers. The remit of the group is to identify, and agree priorities over the coming year. One of the agreed priorities is looking at how we can increase the breastfeeding rates. The group is in the process of mapping the current services, looking at where they are delivered and the quality of these services, when this has been completed we will be aware of where we need to make improvements working jointly with our partner agencies. This will include looking at access and ensuring that mothers receive the necessary support. Q2: As a breastfeeding peer supporter and breastfeeding mother myself, I know how imperative it is to get the best start. Through my own personal experiences and those told by others, I can identify a lack of knowledge and support in hospitals at the most crucial point in a breastfeeding journey, the beginning. The beginning. Will there be any funding available to ensure a breastfeeding specialist is available at each hospital? A2: The South Kent Coast Local Children s Partnership Group (LCPG) has listed breastfeeding as one of its five priorities to focus on this year; the group is aware the rates need to be improved and will be working with partners to improve these. The LCPG is aware that Shepway District Council will be supporting Breastfeeding week and will be ensuring all our clinicians are aware. The current commissioning arrangements for maternity services at East Kent Hospitals Foundation Trust will be reviewed in line with a wider piece of work to review what is currently provided, how this is performing and what gaps we need to address. As the LCPG develops, the intention is to meet with specific partners to address the priorities, in this case, it would include colleagues from the maternity teams to ensure they are actively encourage new mothers to breastfeed where possible. Q3: The current service for infants requiring a procedure to correct a lip or tongue tie is poor. I know of many parents who, facing very long waiting times, have shelled out upwards of 500 for private consultations and procedures. The implications of such a long waiting 3.2GoverningBodyQuestionsf Page1of4 OverallPage73of204

73 time can be detrimental to the health of the infant, whilst breastfeeding mothers are told to use formula to encourage weight gain. Can there be severe improvements made to the current service with shorter waiting times? A2: All four CCG s are aware of the issue with the current service being provided by the hospital trust and due to operational issues this has led to the increased waiting time. We are presently working with our provider to address these operational issues, with a plan on improving the current service provision to address the waiting time. Q4: Can we know the number and name of clinics that are operating out of Buckland Hospital; concern being expressed that patients are still having to travel out of the district. A4: A list of services currently provided at Buckland Hospital (and other local community health services) will be available shortly on the CCG website under the Your Health tab. The CCG continues to work with East Kent Hospitals NHS Foundation Trust to scope the opportunities for also providing the following services on the Buckland site. One stop out patients services One stop pre-assessment service Increased Ophthalmology services Ambulatory care i.e. Biologic Induction Service, IV treatments Hysteroscopy Virtual Fracture Clinics Minor Surgery i.e. dupuytrens contracture release, carpal tunnel release, possibly ganglion removal Cataract Surgery 24 hour Tape application 24 hour Blood Pressure Monitoring However, the ability to provide some of these services is dependent on the provision of appropriate and safe clinic environments which will form part of the scoping work. Q5: Dover Society would like an update in regard to Intermediate Care services and the protected existing land for community use on the Buckland site. The planning application is valid for 5 years and will that will elapse in 2 year s time. A5: The Trust continues to explore opportunities for the overall site and remains committed to see the land used for the regeneration purposes proposed in the local authorities Land Allocation Plans. Q6: Who are the members of the Group and who is their Chair now preparing the 'Transformation Footprint." to be submitted Jan 29 to NHS England - and when and how will this and then the subsequent "steps" (plans) over the next 6 months be made available to the public? 3.2GoverningBodyQuestionsf Page2of4 OverallPage74of204

74 A6: There is a geographical Sustainability and Transformation Plan (STP) footprint that the CCG submits to NHS England on 29 January The development of the STP is being progressed by the East Kent Strategy Board. Recommendations will be submitted to the public meeting of the 4 EK CCG Governing Bodies for approval. Q7: The CCG announced on the 22 December 2015 that it had signed a 90m contract for hospital transportation with G4S. On the same day a coroner found G4S guilty of negligence when a patient was killed by falling out of his wheelchair in the ambulance due to the ambulance staff not securing the wheelchair. An inquest jury found that the driver and staff of the security firm had not received sufficient training to move patients safely between the homes, hospitals and clinics. Was the CCG aware of this before they signed the contract? A7: In May 2011 a patient tragically died following an incident in a G4S ambulance. Whilst we can confirm that the staff involved had received all mandatory training required at the time, an inquest jury in its narrative verdict found that staff were not sufficiently trained. There was no finding of negligence. G4S took immediate action to replace the wheelchair ratchet mechanism across its fleet, provided suitable additional training on all equipment and installed an additional team to conduct a complete review on all training policies and procedures. A full Health and Safety Executive (HSE) investigation took place, with no further action being required. The incident was formally closed by the HSE on 21 st June G4S's ambulance fleet for Kent and Medway will use the most up to date protection for wheelchair passengers, equipped for best practice rather than minimum standards, and includes 100 brand new ambulances for the start of the new contract. Q8: Are there any penalty clauses in the G4S contract? A8: Common to all standard NHS contracts there are a number of safeguards in place to ensure that patients are protected and penalties for failure to deliver the service required. The tender included a number of qualitative assurances processes that ensures we are confident that G4S are the best placed provider to deliver the quality service required. The performance of G4S will be monitored on a regular basis. Q9: Is the CCG aware of the pitfalls by agreeing to introduce the CIS Paperlite System, whereby the patient no longer has a hard copy of any information the various agencies will write about them. This system is open to abuse to the detriment of the patient. 3.2GoverningBodyQuestionsf Page3of4 OverallPage75of204

75 What steps are the CCG going to introduce to ensure that patients are kept fully informed in relation to information held about them by the various agencies responsible for their care? A9: The CIS system is an information system used by Kent Community NHS Trust. The information system was not commissioned by the CCG. Any information sharing across agencies requires patient consent unless to ensure appropriate treatment during a medical emergency. Q10: GPs want patients to make use more use of pharmacists. Can the CCG ensure pharmacy assistants also consult the pharmacist before selling over the counter medicines to patients? A10: NHS England is currently responsible for commissioning pharmacy services. Any concerns in relation to the quality of services provided by pharmacists should be directed to NHSE 3.2GoverningBodyQuestionsf Page4of4 OverallPage76of204

76 Report to: South Kent Coast Agenda 4.1 CCG Governing item: Date of Meeting: 9 th March 2016 Title of Report: Chief Nursing Officer Report Author: Sharon Gardner-Blatch Board Sponsor: Sharon Gardner-Blatch Status: Discussion of progress with key quality concerns across commissioned providers and confirmation that the Governing Body is assured by management response Appendices Appendix 1: Adults Safeguarding Annual Report 2014/15 1. Purpose of the Paper This paper provides the Governing Body with an assurance report across the Chief of Nursing and Quality executive portfolio relating to key statutory duties of the CCG Quality of commissioned services, Safeguarding, Placements, Infection Control and Winterbourne View 2 Introduction The issues in this report have all been presented at the Quality and Operational Leadership Team Committee for scrutiny and to seek assurance on behalf of the Governing Body that appropriate actions were underway to address any quality of commissioned service issues and assurances were gained that CCG requirements were being met. 3. Summary of Issues Commissioned Services The Governing Body is requested to note the existing challenges across all of our commissioned providers which are impacting on quality of services and our ability to make significant and sustained quality improvements in organisational silos and advise how they would wish to consider the opportunities transformation and integrated care offer to drive improvement and how this may impact our strategic objectives. Statutory Duties Significant safeguarding risks exist in our communities and whilst our systems and processes are strengthened there is considerable work to be achieved to ensure we are ensuring safeguarding is embedded into all aspects of our day to day business. The CCG is not meeting its statutory requirements in full for Looked after children and UASC health assessments. Significant work is underway to address this but the solutions are not entirely within the gift of the CCG and multi agency work is being progressed by our Accountable Officer. 4.1ChiefNurseReportMarch2 Page1of6 OverallPage77of204

77 4. Recommendations The Governing Body is requested to note the contents of the report, discuss any concerns regarding strategic objectives and if they consider there is a lack of assurance on robust management action, direct any further actions they require to be assured and to ensure delivery of the strategic objectives. approve the Adults Safeguarding Annual Report 2014/5 for publication on the CCG s website 4.1ChiefNurseReportMarch2 Page2of6 OverallPage78of204

78 1.0 Introduction This paper provides an assurance report to the Governing Body across the Chief of Nursing and Quality s portfolio. It informs the Governing Body about the current levels of assurance on the quality of services provided by the NHS Trusts commissioned by South Kent Coast CCG and the decisions reached by the Quality, Performance and Delivery Committee (QPD) following it s scrutiny of the latest quality and safeguarding information and action the CCG is taking to drive up quality of its commissioned services. It further reports on the CCG s delivery, as a statutory NHS organisation, of its safeguarding duties, health funded placements and infection control duties. 2.0 Commissioned Providers Quality of Services 2.1 East Kent Hospitals United Foundation NHS Trust (EKHUFT) The Trust is judged as requires improvement by the CQC and Monitor has placed them in Special Measures. The Quality Surveillance Group of commissioners in Kent and Medway has continued to require enhanced surveillance of the Trust Whilst there is system recognition of improvements made since the 2014 CQC inspection there is a new executive team leading the organization and significant cultural change needed to achieve sustainable improved quality across all services at this time of significant operational and financial challenge. The CCG is not currently assured regarding the Trust s adult and children s safeguarding arrangements; therefore work is ongoing with safeguarding leads to address this urgently. The CCG are continuing their work with the Trust to gain assurance for specific services and key areas of risk to quality; maternity services and learning, AE services, avoidable harm from venous thromboembolism, infection control, management of NG feeding tubes and the management of diagnostic tests and follow up results. 2.2 Kent Community Health Foundation NHS Trust (KCHFT) The Trust is judged as good by the CQC. The Quality surveillance group has noted the Trust is under enhanced surveillance in East Kent. The CCG is assured with the improving standards of quality and patient safety and have now closed the CPN. The Clinical leadership is scrutinized through patient outcomes and safety issues. The Trust has started delivering Clinical leadership training in order ensures progress is maintained. Work continues to review service models to reflect the national framework for community nursing. 4.1ChiefNurseReportMarch2 Page3of6 OverallPage79of204

79 Services provided by the Trust which supports effective system wide child safeguarding arrangements are not sufficiently robust. A CPN has been issued for the Paediatric Liaison Service in response to the recovery plan not been effective. The children s commissioning teams are taking East Kent wide work forward to improve the service and safeguarding. 2.3 Kent and Medway Partnership NHS Trust (KMPT) The CQC has rated this Trust as requires improvement and requiring actions in three main areas; internal actions to improve quality and manage risk in some services, capital investment to improve facilities for patients and whole system actions to ensure access to services and meet mental health needs of the resident population in Kent. The Quality Surveillance Group has routine surveillance in place for this provider. The CCG continues to monitor the Trusts CQC improvement action plan to ensure improvement to patient care and safety is maintained. The CCG has met with NHSE and agreed a way forward for the Trust to provide assurance for the management of outstanding Serious Incidents. The Clinical Chair is formally writing the Trust Board with the proposal and the CCG is requesting the themes and duty of candor are addressed. The CCG continues to monitor the 2.4 South East Coast Ambulance Foundation NHS Trust (SECAmb) The CQC have rated this provider good. The NHS Mandate has made the ambulance response times in relation to R3 a must do for 16/17. Previous performance target pressures led to the R3 pilot being introduced. The R3 incidences previously reported have been investigated and the CCG can gain positive assurance from the investigation that new governance processes are robust. The Trust Board and Commissioners will be fully sighted on any future developments. Swale CCG as the Host Commissioner has requested additional assurance from the Trust for workforce related issues. Swale CCG is leading an audit to understand the ambulance handover delays and associated risks for Hospitals in East Kent. Conclusion The CCG is commissioning from a number of providers who all have challenges across at least one of their services. It is essential that the quality surveillance and remedial action is owned by all members of the CCG and embedded into all aspects of CCG business. 4.1ChiefNurseReportMarch2 Page4of6 OverallPage80of204

80 The CCG is employs a range of methods to gain assurance across our commissioned services in addition to the monthly contract performance and quality meetings. All issues are risk assessed based on the information scrutinized by the CCG to identify the best method of gaining assurance including; site visits, observations, deep dive reviews, attendance at provider committees working with other CCGs and partners CCG Statutory Duties 3.1 CCG Safeguarding Arrangements The committee received the Adult Safeguarding Annual Report (2014/15) and approved the CCG s Self-Assessment Framework which will be submitted to the Kent & Medway Safeguarding Adults Board in March. The areas of noncompliance are the requirement for delivery of Governing Body training, safe recruitment training for HR staff and improving links with partners to support improved public awareness of how to report concerns about possible abuse or neglect. An action plan is in place to address these areas by July. Work is underway to support GPs and primary care staff in identifying and supporting victims of domestic abuse. There is pilot work being carried out across all of the CCGs to embed Mental Capacity Act and Deprivation of Liberty Safeguards in primary care with this work being evaluated in April. 3.2 Unaccompanied Asylum seeking Children (UASC) and Looked After Children. There continue to be significant issues with meeting the needs of this group of vulnerable children arising from the volume of children arriving in Kent. The Chief Nursing Officer for Ashford and Canterbury is providing strategic CNO leadership to the UASC agenda in support of the Accountable Officer for SKC CCG. Concerns have been escalated to the QSG and an SI has been declared in respect of the risks within the system from a health perspective and the specific mitigations in place. NHSE through the Kent CCGs have funded the UASC Project to deliver 3 work streams to address the identified gaps in service provision for LAC/UASC. The CCGs have issued contract query notices to both KCHFT and EKHUFT regarding the services they are commissioned to provide on behalf of the CCGs for delivering Looked after children health assessments and statutory requirements. Remedial action plans are in place and being monitored to ensure improvements. The Governing Body should note that at present we are not meeting the required standards this has been recorded on the risk register. 4.1ChiefNurseReportMarch2 Page5of6 OverallPage81of204

81 3.3 Child Death Review Team Within the CCG there were 5 reported deaths of these 3 were unexpected and are in the process of being fully investigated. In all Sudden Unexplained Death in Infancy (SUDI) in Kent co-sleeping was a factor. The CCG is supporting the Safer Sleeping Campaign. 3.4 Winterbourne The CCG continues to deliver relocation for people who have been identified as being inappropriately placed. 3.5 Placements The CCG is meeting all national timescales for managing referrals for CHC assessment and decision on eligibility. Whilst referral numbers remain high the numbers of referrals which are found to be eligible by the multi-disciplinary team remains much lower. There are low numbers of appeals and all are resolved locally and no requests have been received to have an independent review by NHS England. Arrangements for quality monitoring of placements and providers of placements continues to be strengthened. The CCG chairs a multi-agency Care Home Group which looks at information held by a number of organisations to inform us on emerging/ known risks and agree actions which will be taken to improve services. Conclusion The CCG continues to develop its internal working arrangements to ensure all of its staff teams and clinical leads are provided with the information needed and supported to ensure that quality can be central to all aspects of our CCG business. 4.1ChiefNurseReportMarch2 Page6of6 OverallPage82of204

82 Safeguarding Adult Annual Report April March 2015 South Kent Coast Clinical Commissioning Group By Sallyann Baxter - Designated Nurse Adult Safeguarding January 2015 Safeguarding means protecting an adult s right to live in safety, free from abuse and neglect. It is about people and organisations working together to prevent and stop both the risks and experience of abuse or neglect, while at the time making sure that the adult s wellbeing is promoted including, where appropriate, having regard to their views, wishes, feelings and beliefs in deciding on any action. Care Act (2014) Safeguarding_Adults_Annu Page1of35 OverallPage83of204

83 Contents Page 1. Introduction 3 2. National Context 4 3. Local Context 8 4. Governance and Accountability Arrangements National Legislation and Guidance Summary of Progress and Key Achievements in adult safeguarding 2014/ Kent and Medway Safeguarding Adult Board (KMSAB) Safeguarding Adult Reviews Self-Neglect Domestic Homicide Reviews Thanet CCG Safeguarding Assurance Supporting Safeguarding Standards in Primary Care Thanet CCG Key Providers Summary 2014/ Conclusions Safeguarding Adult Priorities for 2016/ Appendices Safeguarding_Adults_Annu Page2of35 OverallPage84of204

84 1. Introduction 1.1 This report provides South Kent Coast Clinical Commissioning Group (SKCCCG) Governing Body with an overview of safeguarding across health services during This report reviews the work from 1 April 2014 until 31 March 2015, giving assurance that SKCCCG has discharged its statutory responsibility to safeguard the welfare of adults at risk across the health services that it commissions. 1.2 Clinical Commissioning Groups (CCGs) are statutorily responsible for ensuring that the organisations from which they commission services provide a safe system that safeguards children and adults at risk of abuse or neglect. This includes specific responsibilities as statutory agencies who have responsibilities as panel members for Domestic Homicide Reviews. Local authorities have the same responsibilities in relation to the public health services that they commission. 1.3 Prior to the authorisation of CCGs in Kent and Medway on the 1 April 2013, a hosted model for safeguarding children and adults, as well as the LAC statutory functions, as set out in the NHS Accountability and Assurance Framework (2013)1, was established. This model allowed for the eight CCGs in Kent and Medway to share a joint team of designated professionals (nurses) hosted by Medway CCG. 1.4 Each CCG is a statutory organisation with safeguarding accountabilities which are discharged at a Governing Body level through the Chief Nurse (CNO). Safeguarding accountability is via the designated professionals to the CNOs. 1.5 The Safeguarding Partnership Board undertook a review of working arrangements and with agreement from the Governing Bodies made the decision to disaggregate the hosted team. From 1 January 2015, designated professionals for safeguarding children and adults have been directly employed by their respective CCGs. 1.6 The South Kent Coast Safeguarding Team consists of 0.5WTE Designated Nurse for Safeguarding Children and 0.5W TE Designated Nurse for Safeguarding Adults. In the 1 Safeguarding Vulnerable People in the Reformed NHS: Accountability and Assurance Framework (2013) NHS Commissioning Board Safeguarding_Adults_Annu Page 3 of 35 Overall Page 85 of 204

85 wider team t h e r e is a designated nurse for LAC and Specialist Nurse for Child Death both hosted by Swale CCG. 1.7 The Designated Nurse for Adult Safeguarding retired in July 2015 and a new Designated Nurse was appointed in August This report was written by the new Designated Nurse for Adult Safeguarding with input and support from the other Designated Professionals in Kent who were part of the hosted model during the time period the report covers. This annual report will focus on safeguarding adults across South Kent Coast CCG. 2. National Context 2.1 A number of key documents published in have influenced the adult safeguarding agenda. They include: 2.2 Safeguarding Adults a joint statement (2014) Annual Joint Statement on Safeguarding issued by the national member organisations of the core statutory bodies tasked with the implementation of new legislation that put safeguarding adults on a statutory footing. It outlined key priorities for adult safeguarding in the light of the Care Bill. This highlighted the need for closer links between Safeguarding Adult Boards and Health and Wellbeing Boards and that all agencies are committed to adult safeguarding through strong leadership, governance, risk assessment and training. This was endorsed by the Local Government Association, Associations of Directors of Adult Social Services, Association of Chief Police Officers, the NHS Confederation and NHS Clinical Commissioners. 2.3 Positive and Proactive Care: reducing the need for restrictive interventions (DH April 2014) afeguarding%20adults%20joint%20statement%20-% pdf 3 _RP_web_accessible.pdf Safeguarding_Adults_Annu Page4of35 OverallPage86of204

86 2.3.1 In 2012 the Department of Health published Transforming Care: A national response to Winterbourne View Hospital which outlined the actions to be taken to avoid any repeat of the abuse and illegal practices witnessed at Winterbourne View Hospital. A subsequent Care Quality Commission (CQC) inspection of nearly 150 learning disability in-patient services found providers were often uncertain about the use of restrictive interventions, with some services having an over-reliance on the use of restraint rather than on preventative approaches to challenging behaviour. The purpose of the guidance is to provide a framework to support the development of service cultures and ways of delivering care and support which better meet people s needs and which enhance their quality of life. It provides guidance on the delivery of services together with key actions that will ensure that people s quality of life is enhanced and that their needs are better met, which will reduce the need for restrictive interventions and promote recovery. The learning from this has informed our key performance indicators within Schedule Care Act (2014) Safeguarding Provisions The Care Act 2014 statutory guidance was published on 24th October Sections of the Care Act provide the statutory framework for protecting adults from abuse and neglect. These new safeguarding provisions include: New duty for local authorities to carry out enquiries (or cause others to) where it suspects an adult is at risk of abuse or neglect; Local Safeguarding Adults Boards to carry out safeguarding adults reviews into cases where someone who experienced abuse or neglect died or was seriously harmed and there are concerns about how authorities acted, to ensure lessons are learned; New ability for Safeguarding Adults Boards to require information sharing from other partners to support reviews or other functions; Abolition of the existing power (under section 47 of the National Assistance Act 1948) for local authorities to remove people from their homes and 4 Act_Book.pdf Safeguarding_Adults_Annu Page5of35 OverallPage87of204

87 Requirement for all areas to establish a Safeguarding Adults Board to bring together the local authority, NHS and police to coordinate activity to protect adults from abuse and neglect In addition to providing a fundamental reform of the adult social care and support system, the Care Act also created a legal framework for key organisations and individuals with responsibilities for adult safeguarding to agree how they must work together and what roles they must play to keep adults at risk safe. The safeguarding duties have a legal effect in relation to NHS by ensuring that NHS partners engage the person in a conversation about how best to respond to their safeguarding situation in a way that enhances involvement, choice and control as well as improving quality of life, wellbeing and safety; that agencies must have safeguarding policies and procedures; that NHS partners in the exercise of our functions relevant to care and support includes those to protect adults in preventing abuse and neglect; ensure that we have the mechanisms in place that enable early identification and assessment of risk through timely information sharing and targeted multiagency intervention and we should encourage an open culture around safeguarding. 2.5 NICE guidelines (50) Domestic violence and abuse: multiagency working (DH February 2015) All healthcare professionals should ensure people have a high quality experience of the NHS. The guidelines can help: Commissioners and providers of NHS services to meet the quality requirements of the DH's Operating framework for 2012/13. It can also help them to deliver against domain 1 of the NHS outcomes framework (preventing people from dying prematurely); Local health and wellbeing boards to deliver on their requirements within Healthy lives, healthy people (2010); and Safeguarding_Adults_Annu Page6of35 OverallPage88of204

88 Local authorities, NHS services and local organisations determine how to improve health outcomes and reduce health inequalities during the joint strategic needs assessment process. The NICE guidelines include tools to help organisations put this into practice. 2.6 Prevent Training and Competencies Framework (NHS England February 2015) The purpose of this document is to encourage a consistent and proportionate ap-proach to raising awareness of Prevent as part of the wider safeguarding agenda. The Prevent Training and Competencies Framework has been developed to provide clarity on the level of training required for healthcare workers; it identifies staff groups that require basic Prevent awareness and those who have to attend Workshops to Raise Awareness of Prevent (WRAP). This will support NHS provider organisations and organisations providing services on behalf of the NHS to meet contractual obligations in relation to safeguarding as set out in the NHS Standard Contract. As a result the Designated Nurse is a WRAP trainer and is delivering training sessions to CCG members. 2.7 Adult Safeguarding Improvement Tool (March 2015) The Improvement Tool, based on the Adult Safeguarding Standards, was refreshed in March Developed by the sector, the document sets out key areas of focus which have been used in numerous peer reviews and challenges and as a means of selfassessment. The characteristics of a well-performing and ambitious partnership are described, particularly in relation to the three key partners in safeguarding adults; the council, NHS and Police. The CCG will be working with partners on the KMSAB Self-assessment review document in light of this tool Safeguarding_Adults_Annu Page7of35 OverallPage89of204

89 2.8 Draft Safeguarding Adults: roles and competences for health care staff Intercollegiate document (NHS England 2015) All staff that come into contact with adults have a responsibility to safeguard and promote their welfare and should be aware of the actions to take if they have concerns about safeguarding issues. The guidance provides a clear framework which identifies the competences required for all health care staff. Levels 1-3 relate to the many different occupational roles that work within health, while level 4 and 5 are related to specific safeguarding roles. The framework also outlines specific details for Chief Executives, Chief Officers for CCGs, Board Members including Executives, Non -Executives and Lay members. The document is out for consultation and the final document will be published in January Local Context 3.1 NHS South Kent Coast CCG sits within the area covered by Dover and Shepway District Councils and is part of the Local Authority of Kent County Council. The area includes Dover, Folkestone, Hythe, Deal and surrounding rural areas. South Kent Coast Clinical Commissioning Group (SKCCCG) covers patients from 30 practices with a registered practice population of approximately 221, The Health and Social Care Act (2012) places a statutory duty on health services to reduce inequalities in health. Demonstrating this intention is also a requirement of CCGs for the purposes of authorisation by NHS England. According to the 2015 PHE Health profiles, the health of people in Shepway is varied compared with the England average. Deprivation is lower than average; however, about 21.8% (4,100) children live in poverty. Life expectancy for both men and women is similar to the England average. Priorities in Dover include improving life expectancy by preventing suicide, heart disease and reducing smoking prevalence, improving teenage pregnancy rates, and improving physical activity in children and adults. This average masks high levels of early death from the three big killers - cancer, circulatory disease and respiratory or lung disease in the three wards (2015 boundary wards) with the poorest health outcomes - East Folkstone, Folkestone Central, Folkestone Harbour Safeguarding_Adults_Annu Page8of35 OverallPage90of204

90 3.3 Older people: South Kent Coast CCG has a smaller proportion of people aged under 40 than Kent, but a larger proportion aged 55 and above. Walmer has the highest number of residents aged 65 and above (2442) of the wards in this CCG whilst Eastry has the least (303). Overall in South Kent Coast CCG, there are people in this age band. Hythe Central (429) and Walmer (408) have the highest number of residents aged 85 and above. In South Kent Coast CCG there are 6450 residents aged 85 and above. Large increases are observed in the 65 and above age band, with an additional 5,096 people expected between 2015 and Carers: In 2011, 151,777 people or 10.4% of Kent s total population provided unpaid care. This proportion is higher than the regional average of 8.9% and the national average of 10.2%. Out of the Kent local authority districts, Shepway and Dover have the second and third highest proportion of unpaid carers with 11.4% and 11.3% or and 12,654 residents respectively 9. Shepway and Dover also have the third and fourth highest proportion of carers, with Thanet being the highest, who provide care for 50 or more hours per week. 3.5 Care homes: There are a large number of care homes for older people in South Kent Coast area, and these are generally around the coastline (Nursing =19 ; Residential = 50; Learning Disability = 93 and Mental health = 4 ). Kent Social Care Accommodation Strategy - Better Homes: Greater Choice (July 2014) 10 identified that there is a need to develop nursing provision with the independent sector across the district of Dover. They also identified a need to develop services in Sandwich where there is a high population of older people. Shepway has the highest proportion of residential care homes for people with a learning disability. There are a number of services for people with learning and physical disabilities on the Romney Marsh but fewer older persons services which will need addressing. 3.6 Domestic Abuse: In 2014 the Chief Medical Officer (CMO) identified that Domestic violence is a major public health issue worldwide, and may account for up to 7% of the overall burden of disease in women, largely as a result of its impact on mental illness. During 2013/14 A to- 8 data/assets/pdf_file/0003/46128/overview-south-kent-coast-ccg.pdf 9 Kent Joint Strategic Needs Assessment - Kent Carers JSNA Chapter Summary Update ( ) 10 / Safeguarding_Adults_Annu Page9of35 OverallPage91of204

91 tal of 25,365 incidents of domestic abuse incidents were reported to Kent Police, an increase of 8.4% from the previous year. The number of reported domestic abuse incidents has increased in the Dover district from 13 to 15 per 1,000 population between 2012/13 and 2013/14. MARACs ( Multi-agency Risk Assessment Conferences ) are designed for victims and families assessed at high risk of significant harm or murder. In MARAC meetings, agencies share information and agree to an action plan to support victims. Dover and Shepway had the second and third lowest number of cases that were referred to MARAC in the 12 months up to August 2015 (93 and 91 respectively) This is compared to Thanet which has the highest number of referrals of 256. Dover and Shepway s One Stop Shop (OSS), offering free advice, information and support from a range of agencies under one roof each week, to help victims of domestic abuse, visitor rate also increased by 6.2% and 10.9% respectively in 2014/15.This increase in visitor numbers has also been echoed by other OSSs around Kent. 4. Governance and Accountability Arrangements 4.1 Safeguarding accountability sits within the portfolio of the Chief Nurse, who provides strategic direction on safeguarding, including Looked after Children, and has direct or delegated representation on the Kent and Medway Safeguarding Adult Board. 4.2 Governance is achieved for South Kent Coast CCG via the Quality and Operational Leadership Meeting which is established in accordance with South Kent Coast Clinical Commissioning Group s Constitution, Standing Orders and Scheme of Delegation. 4.3 Clinical Commissioning Groups need to secure the expertise of a designated doctor and nurses for safeguarding adult to provide strategic and clinical leadership and advice, not only for themselves but also for the local authority. The role of these designated professionals is to assist the CCGs in fulfilling their responsibilities as commissioners of services to safeguard children. South Kent Coast CCG has a Designated Nurse for Safeguarding Adults which is shared with South Kent CCG. The CNOS are currently discussing plans for an agreement for a Designated Doctor and this is being reviewed in All CCG staff are expected to undertake safeguarding adult training appropriate to their role and this will be reviewed in line with the Draft Safeguarding Adults: roles and competences for health care staff Intercollegiate document (NHS England 2015). In addition to e Safeguarding_Adults_Annu Page10of35 OverallPage92of204

92 learning, the designated nurses are providing face-to-face sessions to CCG staff and training is planned to the governing body in early National legislation and guidance 5.1 The Care Act (2014) The Care Act states that safeguarding duties apply to an adult who: has needs for care and support (whether or not the local authority is meeting any of those needs); and is experiencing, or at risk of, abuse or neglect; and as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse and neglect. Abuse or neglect can take many forms. The Care Act lists the following types of abuse and neglect: Physical abuse Domestic Violence Sexual abuse Psychological abuse Financial or material abuse Modern slavery Discriminatory abuse Organisational abuse Neglect and acts of omission and Self-neglect These are reflected in the revised Kent and Medway Safeguarding Adult s Multi Agency Policy, Protocols and Guidance published in March The Care Act 2014 consolidates provisions from over a dozen different Acts into a single, framework for care and support. It is a fundamental reform of the way the law works. It places the wellbeing, needs and goals of people at the centre of the legislation to create care and sup Safeguarding_Adults_Annu Page11of35 OverallPage93of204

93 port which fits around the individual and works for them. The Act also provides a new framework for adult safeguarding. It sets out the first ever statutory framework for adult safeguarding, which stipulates local authorities responsibilities, and those with whom they work, to protect adults at risk of abuse or neglect. These provisions require the local authority to carry out enquiries into suspected cases of abuse or neglect and to establish Safeguarding Adults Boards in their area. 5.2 Roles and Competencies of healthcare staff in safeguarding adult Safeguarding competences are a set of abilities that enable staff to work effectively in order to help recognise and prevent abuse and neglect, as well as supporting people who are at risk of abuse or neglect or are actually experiencing it. There are a combination of skills, knowledge, attitudes and values that are required for safe and effective practice. The draft Safeguarding Adults: roles and competences for health care staff Intercollegiate document (NHS England 2015) provides the framework to give the detail to the competences and roles within adult safeguarding Different staff groups require different levels of competence depending on their role and degree of contact with individuals, the nature of their work and their level of responsibility. It is recognised that some individual s roles may require a higher level as determined by the personal development planning e.g. a receptionist on a ward may need a higher level. The framework identifies five levels of competence and gives examples of groups that fall within each of these. The levels are as follows: Level 1: The minimum level of competence required of all staff working in a health care organisation; Level 2: All staff that have regular contact with patients, their families or carers, or the public. This is the minimum level of competence for all professionally qualified healthcare staff; Level 3: All staff who regularly contributes to supporting adults at risk of harm or abuse and/or their families / carers. This includes through the multiagency safeguarding procedures, and assessing, planning, intervening and evaluating the needs of an adult that there are safeguarding concerns about.; Safeguarding_Adults_Annu Page12of35 OverallPage94of204

94 Level 4: Named Safeguarding Professionals (Adults); and Level 5: Designated Professionals (Adults) In addition, the framework also provides specific detail for Chief Executives, Chairs, Chief Officers of CCGs, Board members including Executives, Non-Executives and Lay Members on their statutory responsibilities in relation to adult safeguarding. 6. Summary of Progress and Key Achievements in adult safeguarding 2014/ The NHS Kent and Medway Annual Safeguarding Report 2013/14 set out priorities for the year and the Designated Professionals as part of the hosted model worked on these. Below is a summary of how those priorities have been implemented: a) Ensure achievement against actions required from NHS England following their assurance process Completed - Action plans submitted and assurance given to NHSE b) Implement Service Level Agreements, Job Plans and JDs for all designated doctors across Kent and Medway, securing this statutory provision In progress to be completed during 2016 c) Area Teams ( NHSE ) are responsible for recruitment to Named GP, to ensure collaborative working In progress NHS England are planning to set up an SLA to discharge this responsibility via the CCGs. d) Review policies, strategies and guidance in line with recent key national documents, national and legislation In Progress - Updated Safeguarding Policy to reflect updated national guidance will be completed by January e) Transfer the Child Death Function into a CCG Complete - hosted by Swale CCG. f) Deliver training for CCG employed staff and Governing Bodies In progress All CCG staff undertake safeguarding adult training via e-learning. It was identified as part of the assurance to NHSE that face to face sessions should Safeguarding_Adults_Annu Page13of35 OverallPage95of204

95 be provided to CCG staff and the governing body. 2015/16. These will be completed during g) Consolidate Designated Nurse s alignment to CCGs and chief nurses Complete - As part of disaggregation of hosted team and Designated Nurses being employed directly by CCGs. h) Build on work already completed to develop robust arrangements and relationships Ongoing A memorandum of understanding is in place with the Designated Nurses who meet monthly. Chief Nurses also meet regularly. i) Attendance and influence at KMSAB sub-groups Ongoing full attendance at all KSCB sub-groups is achieved by all CCGs being represented as outlined in the safeguarding MOU j) Implement Safeguarding Work plans for all CCGs 14/15 Complete The safeguarding adult work plan for South Kent Coast CCG has been developed and is monitored through the Quality and Operational Leadership meeting. k) Continue to develop robust arrangements and relationships with provider organisations including standardisation of data collation and safeguarding representation at local operational meetings Complete safeguarding metrics have been agreed and are incorporated into all provider contracts. This will be further developed during 2015/ Key Achievements between April 2014 and December 2015 Development of robust networks and relationships with designated nurses across all 8 CCGs to ensure robust arrangements and application of thresholds to protect adults. with the collaboration achieved through a Memorandum of Understanding (MOU); Agreement of adult safeguarding metrics to be used to monitor and measure standards across commissioned providers; Safeguarding_Adults_Annu Page14of35 OverallPage96of204

96 Continued provision of advice and support to GP staff and other primary care professionals; KMSAB self-assessment action plan submitted in January 2015; and Continued adult safeguarding input at key CCG meetings, KMSAB Board and subgroups. 7. Kent and Medway Safeguarding Adult Board (KMSAB) 7.1 The Care Act 2014 statutory guidance was published on 24th October Sections of the Care Act provide the statutory framework for protecting adults from abuse and neglect. These new safeguarding provisions included the requirement to establish a Safeguarding Adults Board to bring together the local authority, NHS and police to coordinate activity to protect adults from abuse and neglect. The KMSAB has senior representatives from all main agencies and organisations. The KMSAB has sub-groups which are formed to tackle the various area of concern on a more targeted and thematic basis. Health providers across Kent are members of all sub-groups and the designated nurses for safeguarding adult are active members who give the strategic health expertise and oversight of the whole health economy. Subgroups include: Policy, Protocols and Guidance; Quality Assurance Working Group; and Learning and Development 7.2 In March 2015, KMSAB agreed a draft strategy and annual plan which sets out what it intends to achieve and how it s success will be measured. The principles of the KMSABs following six strategic priorities for 2015/16 should be reflected in any commissioning decisions the CCG make. The six principles have been taken from the Statement of Government Policy on Adult Safeguarding (DH 2013) 12 : 12 v_policy.pdf Safeguarding_Adults_Annu Page15of35 OverallPage97of204

97 No. Principle Priority 1 Empowerment The Board will continue working towards supporting people to manage risk in their own lives, with professionals supporting their decision making at each stage of Kent and Medway s safeguarding adult s procedures. 2 Protection The Board will continue working towards ensuring safeguarding adults procedures that serve to respond to abuse or neglect and that decisions are made in line with the Mental Capacity Act. 3 Proportionality The Board will continue working towards ensuring that safeguarding adults policies, procedures and guidance are used in appropriate circumstances to inform a proportional response to the concerns being raised. 4 Prevention The Board will continue working towards gaining assurance from all partner agencies that prevention is a core element in the delivery, commissioning and development of services. This includes providing appropriate information and training to their respective workforces on how to recognise and respond to abuse and neglect. 5 Partnership The Board will continue to develop joint working practices between and across organisations that promote coordinated, timely and effective responses for the individual at risk. The partnership aims to foster a one team approach that places the welfare of individuals before the needs of the system. 6 Accountability The Board will continue to work to ensure that the roles of all agencies and staff (and their lines of accountability) are clear and explicit. Agencies across the partnership will recognise their responsibilities to each other, act upon them and accept collective responsibility for safeguarding arrangements. 8. Safeguarding Adult Reviews 8.1 Since April 2014 KMSAB now has a statutory duty to carry out Safeguarding Adult Reviews (SAR) formally known as Serious Case Reviews. The purpose of SARs is described very clearly in the statutory guidance as to promote effective learning and improvement action to Safeguarding_Adults_Annu Page16of35 OverallPage98of204

98 prevent future deaths or serious harm occurring again. The aim is that lessons can be learned from the case and for those lessons to be applied to future cases to prevent similar harm re-occurring. KMSAB have produced guidance on what cases would require the need for a SAR and details on how to refer a case for a SAR One SAR (Mary Smith) was commissioned by KMSAB during 2014/15. The Review Panel identified the following lessons that should be learned from this review: 1. Agencies must adopt a flexible and creative approach to engaging with vulnerable adults using all possible means, including contact with family and other agencies; 2. There is a need for agencies to ensure that the policies, protocols and guidance produced by Kent &Medway Safeguarding Adults Board are consistently put into practice; 3. Agencies need to be constantly reviewing whether the service users would benefit from services provided by other agencies. If they believe that to be the case, they must make appropriate referrals;and 4. Agencies must continually be aware that self-reporting by service users may need to be corroborated before it is acted upon. A separate report regarding this SAR was presented to QOLT in November Self-Neglect 9.1 The Kent and Medway Multi-Agency Policy and Procedures to Support People who Self- Neglect were published by the KMSAB in September 2014 and revised in April The policy and procedures will support practitioners in supporting an adult at risk who is believed to be self-neglecting. An individual may be considered as self-neglecting and therefore maybe at risk of harm where they are: Either unable, or unwilling to provide adequate care for themselves; Not engaging with a network of support; Unable to or unwilling to obtain necessary care to meet their needs; 13 data/assets/pdf_file/0019/8155/procedure-for-safeguarding-adultreviews.pdf 14 data/assets/pdf_file/0012/16140/self-neglect-policy-and-procedures.pdf Safeguarding_Adults_Annu Page17of35 OverallPage99of204

99 Unable to make reasonable, informed or mentally capacitated decisions due to mental disorder (including hoarding behaviours), illness or an acquired brain injury; Unable to protect themselves adequately against potential exploitation or abuse;and Refusing essential support without which their health and safety needs cannot be met and the individual lacks the insight to recognise this. 9.3 Public authorities, as defined in the Human Rights Act 1998, must act in accordance with the requirements of public law. In relation to adults perceived to be at risk because of selfneglect, public law does not impose specific obligations on public bodies to take particular action. Instead, authorities are expected to act within the powers granted to them. They must act fairly, proportionately, rationally and in line with the principles of the Care Act 2014, the Mental Capacity Act (2005) and consideration should be given to the application of the Mental Health Act (1983) where appropriate. This is achieved through: promoting a person-centred approach which supports the right of the individual to be treated with respect and dignity, and to be in control of, and as far as possible, to lead an independent life; aiding recognition of situations of self-neglect; increasing knowledge and awareness of the different powers and duties provided by legislation and their relevance to the particular situation and individuals needs, this includes the extent and limitations of the duty of care of professionals; promoting adherence to a standard of reasonable care whilst carrying out duties required within a professional role, in order to avoid foreseeable harm; promoting a proportionate approach to risk assessment and management; clarifying different agency and practitioner responsibilities and in so doing, promoting transparency, accountability, evidence of decision-making processes, actions taken;and promoting an appropriate level of intervention through a multi-agency approach Safeguarding_Adults_Annu Page18of35 OverallPage100of204

100 10. Domestic Homicide Reviews 10.1 Domestic abuse is defined as: any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality The NICE guidance Domestic violence and abuse: how health services, social care and the organisations they work with can respond effectively (DH 2015) makes a number of recommendations, including developing an integrated commissioning strategy through local strategic partnerships and commissioning integrated care pathways. The Kent and Medway Domestic Abuse Strategy Group, a multi- agency group, is responsible for setting the strategy, and is accountable to the Community Safety Partnerships. The Kent and Medway Domestic Abuse Strategy ( ) and Delivery Plan is available on the Kent and Medway Domestic Abuse website Domestic Homicide Review (DHRs) were established on a statutory basis under section 9 of the Domestic Violence, Crime and Victims Act (2004). This provision came into force on 13 th April Revised guidance has been issued, applicable from August A DHR is a review of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect perpetrated by: (a) a person to whom he/she was related or with whom he/she was or had been in an intimate personal relationship, or (b) a member of the same household as himself/herself, held with a view to identifying the lessons to be learnt from the death. An intimate personal relationship includes relationships between adults who are or have been intimate partners or family members, regardless of gender or sexuality Safeguarding_Adults_Annu Page19of35 OverallPage101of204

101 10.4 A number of DHRs have been undertaken in Kent and lessons disseminated. The Designated Nurse will produce a report in January 2016 to bring together the recommendations for both local DHRs and the Mary Smith SAR, focusing on sharing the lessons learnt within primary care. 11. South Kent Coast CCG Safeguarding Assurance 11.1 Following disaggregation of the hosted safeguarding team, the designated nurse became a member of the Quality and Safety Team. This has allowed closer relationships in quality, safety and safeguarding assurance. Soft intelligence, data collection and scrutiny are shared within the team and have added to a collective picture of assurance and risk assessment. These processes will be further developed in 2015/16 with the development of a commissioning toolkit which includes Safeguarding to ensure that safeguarding is considered at all parts of the commissioning cycle. The effectiveness of the safeguarding is assured and regulated by a number of mechanisms. These include: Provider internal assurance processes and Board accountability KMSAB Self-Assessment submission External regulation and inspection - CQC and Monitor Locally developed peer review and assurance processes Effective commissioning, procurement and contract monitoring The South Kent Coast CCG KMSAB return was submitted in January 2015 and was mainly compliant. Two areas were partially compliant and these included training for CCG staff and Governing lay members The Designated Nurse works closely with Kent County Council, Safeguarding Adult Coordinator and partners in seeking assurance for the quality of care for care home residents. This includes attendance at Thanet Care Home Working Group, KCC safeguarding liaison meetings, Section 42 safeguarding enquiry meetings and joint visits with the Clinical Nurses Specialist Older People (Care Homes Team) Safeguarding_Adults_Annu Page20of35 OverallPage102of204

102 11.4 All provider services, including every General Practice, are required to comply with the Care Quality Commission Essential Standards for Quality and Safety which include Regulation 13 Safeguarding service users from abuse and improper treatment NHS South Kent Coast CCG manages each provider organisation via formal contract meetings. In addition, the Designated Nurses attend Provider Quality and Performance Meetings where relevant to raise safeguarding issues and meet with Safeguarding leads to seek further assurance. 12. Supporting Safeguarding Standards in Primary Care 12.1 Although not directly responsible for commissioning primary care services during 2014/15, CCGs have a duty to support improvements in the quality of primary medical care. The Designated Nurses have supported this through providing relevant information through the GP Bulletins e.g. local and national guidance and information and CQC have produced their own guidance for primary care in readiness for inspection 17. In 2016, the designated nurses will be delivering a development program for staff that require level 3 competence in primary care staff who take the role of safeguarding leads The General Medical Council ( GMC ) has provided guidance to all GPs outlining GP s individual responsibilities in achieving and maintaining their professional competencies. As independent GP contract holders, monitoring of compliance with these professional standards is a function of NHS England through the GP revalidation process In meeting requirements of registration with the CQC, a number of South Kent Coast GP Practices have already been subject to inspections. Following these visits reports are made publicly available and allow the public to see if GP practices and other primary medical services are meeting the essential standards. The Designated Nurses will work with NHSE, the CCG Membership Development team and the primary care safeguarding leads to review any themes from inspections Safeguarding_Adults_Annu Page21of35 OverallPage103of204

103 12.4 There is not currently a Named GP in place in East Kent. This is being progressed by NHSE and CCGs in 2015/ Quality Improvement Nurse for MCA & DoLS in Primary Care Project Funding of 160,000 to support the implementation of the MCA & DOLS programme of work was given to the eight Kent CCGs. The project is hosted by North Kent CCGs and the four Designated Adult Safeguarding Nurses for Kent make up the project board Part of the spend for the project will be directed specifically at increasing the awareness and understanding of the Mental Capacity Act and the Deprivation of Liberty within Primary Care by means of a time limited Quality Improvement Project Nurse post. The post holder will support the CCG s Designated Nurses for Adult Safeguarding in delivering an improvement agenda with a clear focus on the knowledge, understanding and use of the Mental Capacity Act and Deprivation of Liberty Safeguards within Primary Care in GP settings. The aim of the role is to improve implementation of the MCA in Primary Care by providing outreach advice, bespoke training and support to practices. Networking across the eight CCGs has commenced to highlight project and support available. There has already been some interest generated in the project to date. Progress made to date: Audit tool / assurance framework first draft; 1 GP practice identified in South Kent Coast; and Planned attendance at MCA / DoLs PLT event in Thanet in February South Kent Coast CCG Key Providers Summary 2014/15 Summary of Safeguarding Assurance in relation to Providers Kent Community Health Foundation Trust ( KCHFT ) 13.1 Kent Community Health NHS Trust was formed on 1 April 2011 from the merger of Eastern and Coastal Kent Community Services NHS Trust and West Kent Community Health. The organisation became a Foundation Trust on the 1st March Safeguarding_Adults_Annu Page22of35 OverallPage104of204

104 13.2 The Executive Lead with the responsibility for safeguarding in Kent Community Health Foundation Trust is the Director of Nursing and Quality, who is also a standing member of the KMSAB. KCHFT actively participates at the KMSAB sub-groups KCHFT provides the health support at the Central Referral Unit (CRU) for the Kent Health economy to improve information sharing and decision making in relation to preventive and reactive safeguarding work to protect children, young people and adults at risk. Safeguarding assurance within KCHFT is provided by the Head of Safeguarding and the team, which includes named doctors and nurses. This is the only provider organisation locally that has it s own MCA lead KCHFT hold a bi-monthly safeguarding committee and a Designated Nurse for Adult Safeguarding attends this on behalf of all Designated Nurses in Kent KCHFT has submitted their KMSAB Self Assessment tool. They have self-assessed that they are compliant in all areas They are very close to compliance with all safeguarding adult training KPIs, however they are still establishing data collection methods for domestic abuse and PREVENT staff training figures. They are conducting a MCA compliance audit and have a dedicated action plan in response to the NICE guidelines (50) Domestic violence and abuse: multiagency working. This will be monitored through their Safeguarding Assurance Committee. East Kent Hospitals NHS Foundation Trust ( EKHUFT ) 13.7 EKHUFT has an executive Lead for Safeguarding is in place with a Named Nurse and Safeguarding Advisors including 0.8WTE based in QEQM The Executive Lead with the responsibility for safeguarding in EKHUFT is the Director of Nursing and Quality, who is also a standing member of the KMSAB. EKHFT actively participates at the KMSAB sub-groups. Safeguarding Committee was reported to be in place during 2014/15 but this is now on hold and being re-launched in The Designated Nurse will be attending EKHUFT was subject to a CQC Inspection in July 2015 and QEQM was found to be requiring improvement in some areas including effectiveness urgent care services. CQC Safeguarding_Adults_Annu Page23of35 OverallPage105of204

105 felt there were processes were in place for the identification and management of adults and children at risk from abuse. Staff understood their responsibilities and were aware of safeguarding policies and procedures. However, they identified that staff compliance with safeguarding training was 77%. Following a Thanet Quality Lead Deep Dive Report identified that staff did not always know what action to take about safeguarding vulnerable people from abuse or understand Mental Capacity Act (Deprivation of Liberty Safeguards). The Designated Nurses are working with the management team to address these gaps in addition to improving their response to victims of domestic abuse EKHUFT has arrangements in place to safeguard adults and has submitted their KMSAB Self-Assessment tool. They have self-assessed that they are compliant in all but three areas which will addressed in early Kent & Medway NHS and Social Care Partnership Trust (KMPT) The trust provides adult mental health services and is commissioned by the CCGs across Kent The named nurses for safeguarding adult are active in Kent and Medway in ensuring that practitioners recognise domestic abuse and attend all of the MARAC (Multiagency Risk assessment Conference) meetings in Kent The Executive Lead for Safeguarding is the Director of Nursing and Governance who sits on the Trust board. There is a Head of Safeguarding who is also the Prevent Lead with 1 WTE Named Nurse for East Kent KMPT plays a full role within the Safeguarding Boards and subgroups and the Executive Lead for Safeguarding holds a seat on the Safeguarding Board and the Head of Safeguarding Deputises when required They are currently working on their CQC improvement plan following an inspection in March In particular CQC found that safeguarding incidents were not being consistently reported, or they had not received feedback on safeguarding cases. They also found that he use of the Mental Health Act (MHA), Mental Capacity Act (MCA) and Depravation of Liberty safeguards (DoLs) was inconsistent across the trust with poor practice identified in several areas Safeguarding_Adults_Annu Page24of35 OverallPage106of204

106 13.16 KMPT has arrangements in place to safeguard adults and has submitted their KMSAB Self-Assessment tool. They have self-assessed that they are compliant in all but two areas. South East Coast Ambulance Service (SECAmb)/ NHS Swale CCG leads the contract for service provision by South East Coast Ambulance Service. The NHS 111 service for Kent is provided from two call centres, one in Ashford and one in Dorking. The 111 service in Dorking is provided by Care UK and the contract is managed by SECAmb A safeguarding quality review has been undertaken on behalf of NHS Swale CCG by the designated nurses for safeguarding Adults and Children on the 111 service. Time was spent in visiting both 111 sites and with meeting key individuals at 111 and SECAmb. The organisations commitment to safeguarding was evident throughout the process and where issues were identified; there was an acknowledgement that further work was needed. The Designated nurses for Safeguarding were assured that SECAmb and 111 have satisfactory arrangements in place to meet statutory and national requirements for safeguarding, with the proviso that additional work is required in a number of areas. It is expected that progress will be reported back as part of the three times a year reporting at the Clinical Quality Review Group (CQRG) meetings and at meetings with the Designated nurses for Safeguarding SECAmb have submitted their KMSAB self-assessment and are not compliant in eight areas. The outstanding areas which require additional work have now been completed including specific reference within safeguarding procedures and supervision for safeguarding staff There are a number of other smaller providers and a full review will be undertaken in 2015/ Safeguarding metrics for children and adults have been agreed and inserted into the 2015/2016 contracts. This includes compliance with Safeguarding training. Designated Professionals work with the Head of Quality and the Quality team to review provider performance by attending Provider Quality Meetings and raising issues related to gaps in safeguarding assurance. In addition, further assurance is received through meetings with Providers and attending Safeguarding Assurance Committees where these are in place There have also been a number of updates in National Guidance and Policy and Procedures from NHS England. Designated Professionals are now embedded within the CCG and a Safeguarding_Adults_Annu Page25of35 OverallPage107of204

107 full review of all providers safeguarding assurance evidence will take place in 2015/16 to identify any gaps in safeguarding assurance. The safeguarding metrics will be adjusted according to align with the NHSE a guidance and will be fed in to the CCG Quality and Performance reports and shared through Designated Professional Networks and KMSAB where relevant The CCGs are required to have effective systems for responding to abuse and neglect of adults and evidence the outcome measures used to give assurance that the systems and processes in place are effective Currently there are no national safeguarding outcome measures that focus on people who have been supported by adult safeguarding services. This means that local authorities, who are statutorily the lead for safeguarding, do not know if adults at risk are satisfied with the safeguarding service or what difference it makes. They are also not able to make comparisons between councils as there is no national benchmark for adult safeguarding. The Health and Social Care Information Centre (HSCIC) has been exploring a new measure for inclusion in the Adult Social Care Outcome Framework (ASCOF) Kent County Council and multi-agency partners, including the CCGs, are implementing the Making Safeguarding Personal agenda to ensure that adults at risk are engaged in the safeguarding process and that outcomes of an enquiry are person focused. The Designated nurses have supported the revised Kent Adult Social Care Safeguarding Adults form to ensure that the person s views and engagement are taken into consideration throughout the process The CCGs recognise that defining and measuring outcomes is important and has to go beyond process-led approaches but is sometimes a difficult part of safeguarding adults work. In the absence of a national framework, the designated nurses use the following framework in all clinical work with NHS providers, care homes and other multi-agency partners to ensure that outcomes for patients and residents are person focused. This framework is based on the six key principles in The Statement of Government Policy on Adult Safeguarding (2013) Safeguarding_Adults_Annu Page26of35 OverallPage108of204

108 14. Conclusions 14.1 Thanet has significant issues including very high levels of deprivation particularly in Margate Central and Cliftonville West but also in other parts of the District. There are also a range of issues including higher rates of Domestic Abuse and a high numbers of care homes which have an impact on safeguarding adults. Strong multi-agency working and building on existing relationships and good practice in particular through KMSAB is key to success Designated Professionals have a key role to play in providing leadership including working with providers and supporting safeguarding adult leads/named professionals to raise standards. In particular all health providers need to ensure that front line staff are able to respond effectively to safeguard adults and understand their role. The volume of change including new legislation and guidance is a challenge and it is essential that all staff receive the training they need but also that the training is effective and up to date and takes in to account lessons from DHR/SARs nationally and locally South Kent Coast CCG has made significant progress around safeguarding adults and was able to demonstrate through the NHS England Assurance process and the KMSAB selfassessment on how they are meeting statutory requirements. In addition, there is further work to be done by the CCG in ensuring that making safeguarding personal and adult safeguarding is considered through all parts of the commissioning cycle. 15. Safeguarding Adult Priorities for 2016/17 a) Review policies, strategies and guidance in line with recent key national documents, national and local SAR/DHR/Case Reviews; b) Build on work already completed to develop robust arrangements and relationships with providers and partner agencies; c) Assist in the recruitment to the named GP within East Kent CCGs and develop measures to ensure collaborative working; d) Continued attendance and influence at KMSAB sub-groups; e) To work with Designated Professionals, CCG colleagues and SECSU to develop standardised assurance and data collation in relation to adult safeguarding; f) Support MCA Development Nurse working with primary care; Safeguarding_Adults_Annu Page27of35 OverallPage109of204

109 g) To ensure that national developments / lessons learnt from DHR/SARs are disseminated to local health providers and Primary Care colleagues; h) Develop an adult safeguarding commissioning toolkit as part of the Quality Strategy; i) Improve compliance for safeguarding training by delivering face-to-face training to CCG staff and Governing body members to supplement e-learning and ensure everyone is aware of their role in safeguarding adults; j) Develop program to support primary care who require level 3 competencies; k) Develop missing persons alerting procedures; and l) Support MCA/DOLs project locally in primary care Safeguarding_Adults_Annu Page28of35 OverallPage110of204

110 16. Appendices Appendix 1 - South Kent Coast CCG Safeguarding Adult Workplan 2015/ Safeguarding_Adults_Annu Page29of35 OverallPage111of204

111 1.1 CCG Compliance with statutory safeguarding responsibilities / Assurance to NHSE and SAB Appendix 1 - South Kent Coast CCG Safeguarding Adult Workplan: 2015/2016 Area Actions By When? Progress Review the SAB self-assessment and ensure that gaps are included in the July 2015 Safeguarding workplan 1.2 Review NHSE Assurance return and ensure that gaps are included in the Safeguarding workplan 1.3 Ensure that the CCG Safeguarding Declaration is updated on the website October Review the updated NHSE Safeguarding Accountability framework against January CCG policies and identify and address any gaps Raise awareness of Safeguarding within the CCG and ensure safeguarding has a high profile at all levels of the organisation 1.7 Update on progress of statutory requirements to CCG Quality Committee/ NHSE and KMSAB 1.8 Support the CCG to develop an effective mechanism to ensure the voice of vulnerable adults are heard when commissioning services 1.9 Ensure that any priority safeguarding gaps are included on the CCG Risk Register 2.1 Serious Adult Reviews / Contribute to Statutory Safeguarding Adult Reviews to ensure that health National reports/ Safe- requirements are completed Completed. The KMSAB QAWG reviewing all returns at next meeting July 15. New Framework and submission to KMSAB will be December July 2015 Completed September Submitted to NHSE May 15 (Awaiting response) January 2016 Quarterly Ongoing Ongoing Ongoing Add MCA and Prevent - Completed December 2015 This has been reviewed. Actions: CCG Safeguarding Policy and Commissioning Toolkits to be agreed by January Governing body require training and website requires updating. None at present Safeguarding_Adults_Annu Page30of35 OverallPage112of204

112 2.2 guarding Guidance Ensure that the combined health action plan for Safeguarding Adult Reviews is completed to address recommendations - monitor and update SAB/ CCG at Quality committee As required 2.4 Ensure that any learning from Serious Adult Reviews is disseminated to Ongoing CCG/ providers and actions followed up 2.5 Interpret new / updated legislation and guidance and communicate any impact Ongoing on commissioners and providers particularly The Care Act 2014: Coun- ter-terrorism Act and Prevent Duty Guidance; The Mental Capacity Act 2005 and Deprivation of Liberty Safeguards Review National Serious Adult Reviews and other reports and provide professional Ongoing responses 2.7 Update CCG/ Providers on updated NICE Guidance Ongoing None ongoing at present. Nothing this quarter. 3.1 Policies and Procedures Update CCG Safeguarding Policy and ensure that it complies with legislation December Ensure that the Safeguarding Policy is disseminated to all staff members January and available on the Intranet and CCG website Develop an allegations against staff policy and ensure that all staff are December aware of the Named Person in the organisation for allegations Work with SAB and other Designated Nurses to seek assurance that all providers have updated their safeguarding policies to comply with national legislation and guidance & assurance and accountability 4.2 Undertake a review of safeguarding training, including training strategy to establish compliance, staff awareness and help determine future training needs December 2015 October 2015 In progress In progress In progress Completed Safeguarding_Adults_Annu Page31of35 OverallPage113of204

113 4.3 Deliver face to face sessions to CCG staff annually in conjunction with Designated nurse for Children to provide assurance to the CCG of staff understanding of roles and responsibilities within the commissioning cycle 4.4 Work with HR and colleagues to review induction process for all staff to ensure that all new staff complete E learning within 2 weeks 4.5 Deliver face to face session to governing body members to include CCG statutory responsibilities 4.6 Work with the SAB and providers to ensure that single agency training by health providers is quality assured 4.7 Seek assurance from providers of the compliance of training undertaken and evidence that the training provides staff with the level of competence required. 5.1 CCG Annual Report for Review Previous Annual Reports for Safeguarding Adult and identify any Safeguarding Adult outstanding actions 5.2 Complete Annual report for 2015/16 summarising progress in safeguarding Adult by the CCG and providers and identifying priorities 5.3 Ensure Annual report for 2015/16 is presented to the Quality Committee and governing body January 2016 Oct 2015 December 2015 December 2015 Ongoing July 15 January 2016 February 2016 SKC CCG Mandatory Training SG data.pdf Training will be planned with children s service to address gaps. NHS E learning disseminated to Induction lead to ensure 100% compliance 15/16. See 4.3. Training Standards for Level 1 and 2 now agreed by KMSAB August Providers will need to produce evidence of its use as part of their training strategy. Provider quality reports. September Completed Completed Safeguarding_Adults_Annu Page32of35 OverallPage114of204

114 6.1 GPs and Safeguarding With NHSE, review GP training compliance and awareness of safeguarding including PREVENT, MCA and DoLS and DA. 6.2 With NHSE, undertake a review of all GP practices to ensure that they have a Safeguarding lead 7.1 Commissioning Services Obtain a list of all current contracts and undertake a safeguarding review and work with Providers against statutory requirements 7.2 Review safeguarding metrics and provide input in to quality committees, Quality Heads of meeting, Roundtable, Risk Registers 7.3 Attend Provider Quality and Performance meetings when safeguarding is on the agenda 7.4 Develop, in partnership with other members of the Quality team, a Quality and Safeguarding Assurance Framework for future procurement and contract reviews ( to include core statutory requirements ) 7.5 Ensure that all providers have completed SAB SAF return and work with SAB and other Designated Nurses to quality assure these 7.6 Ensure that there is a provider evidence folder to include: SAF Copy of Safeguarding and other relevant policies, Safeguarding training compliance on safeguarding metrics Safeguarding declaration on Website is up to date, Job Descriptions and Structure charts Safeguarding supervision policy Audit schedule 7.7 Liaise with other Designated Nurses to ensure that there is attendance at provider safeguarding committees 7.8 Designated Nurse to provide Quarterly Safeguarding updates to Quality Committee to provide assurance and identify gaps in safeguarding provision 7.9 Ensure that Statutory Designated Nurse functions are met and that the CCG has effective arrangements in place with SAB January 2016 January 2016 October 2015 October 2015 Ongoing January 2016 December 2015 October 2015 October 2015 Ongoing Quarterly Quarterly In progress Completed Completed October Safeguarding_Adults_Annu Page33of35 OverallPage115of204

115 8.1 Links with Kent Safeguarding Adult Board ( SAB ) Work with Designated Nurses to ensure that there is representation on all groups in line and a communication strategy in line with the MOU to feed in to the group. Take part in MOU review. 8.3 Work with Local Health and other partners to identify current safeguarding issues and priorities, contribute to multi-agency response and raise awareness 8.4 Work with other Designated Nurses on response to Child Sexual Exploitation including setting up PREVENT and MCA 9.1 Partnership working and Contribute to CSE workshops for Designated and Named Professionals other Local safeguarding issues including: KCC AP Co Coordinators including LD and ASD; Care homes & forums; Mental Health issues and MHA/ MCA interface; DA; PREVENT; Link with Designated nurse for Safeguarding children and CSE; MCA / BIA Agenda; October 2015 Ongoing Ongoing Ongoing Completed October Ensure that the CCG is represented on the Domestic Abuse Forum and Community Safety Partnerships locally and update as relevant 9.3 Ensure that local intelligence and issues are fed in to the CCG commissioning priorities, Health and Wellbeing Board, SAB and other appropriate fo- September 2015 Ongoing Now attending: Dover CSP PREVENT subgroup Folkestone and Thanet DA Forums Safeguarding_Adults_Annu Page34of35 OverallPage116of204

116 rums 9.4 Work with SAB and Designated Professionals to take forward Prevent agenda, identifying prevalence and issues in Kent and raise awareness. Set up IT network to support provider Prevent returns. 9.5 Work with Designated Nurses to ensure that all providers and GPs are aware of reporting requirements for Domestic Abuse and Domestic Homicide Reviews December 2015 June 2016 Designated Nurses attend Kent PREVENT Delivery Board Safeguarding_Adults_Annu Page35of35 OverallPage117of204

117 Report to: Governing Body Date of Meeting: 09 March 2016 Agenda item: 4.2 Title of Report: Author: Board Sponsor: Status: Appendices: IQPR Clara Wessinger, Head of Performance, Dawn Bisset, Head of Quality Karen Benbow, Chief Operating Officer and Sharon Gardner - Blatch, Chief Nurse Approve IQPR 1. Purpose of the Paper To update the committee on South Kent Coast s position with regard to quality and performance targets and action going forward to improve areas of non-compliance. 2. Introduction This paper identifies new or significant changes to concerns regarding providers contractual obligations and national targets to provide high quality care to patients in South Kent Coast. Issues where assurance has now been gained regarding quality of care are now presented to the Committee for Closure. 3. Summary of Issues This report provides an overview of SKC CCG Integrated Quality and Performance Report based on the NHS Outcomes Framework. The contents include a brief summary of SKC performance and quality over all services, as well as a detailed NHS Outcomes Framework report for each provider containing high level quality and performance indicators. Areas of underperformance and quality issues are described in greater detail including mitigation and ongoing actions for each provider in the triangulation pages. Issues where assurance has now been gained regarding quality of care are now presented to the Committee for Closure. EKHUFT A&E - Continued underperformance toward trajectory Cancer Improvements shown in Q3, 62 day standard continues to fail target. RTT Target not met 4.2IntegratedQualityandPer Page1of52 OverallPage118of204

118 KCHFT The CPN for Community Nursing Workforce is being closed. The CCG will continue to monitor the service provided to our residents. The clinical leadership for the nursing staff is scrutinised through patient outcomes and quality and safety issues. CIS update - Activity has improved in LTC, bringing the provider as a whole close to planned activity levels in December. Individual services remain consistently below plan. KMPT The CQC Action plan continues to progress. The three tier assurance system within the Trust is now embedded and the Trust are now providing their Third level of assurance for their actions due in December. The CCGs assurance visits commence in March SECAmb NK CCGS are leading on an audit to understand the handover process and delays and associated risk to quality for all Hospitals in East Kent. The report is not yet ready to be shared. 4. Recommendations Report to be noted 4.2IntegratedQualityandPer Page2of52 OverallPage119of204

119 NHS South Kent Coast Clinical Commissioning Group Integrated Quality and Performance Report February Integrated Quality and Per Page 1 of 50 Page 3 of 52 Overall Page 120 of 204

120 CONTENTS Page Executive Summary 3 South Kent Coast Clinical Commissioning Group 4 Providers Overview 9 East Kent Hospitals University NHS Foundation Trust 10 Kent Community Health NHS Foundation Trust 24 Kent and Medway NHS and Social Care Partnership Trust 28 Sussex Partnership NHS Foundation Trust 34 South East Coast Ambulance Service NHS Foundation Trust 36 IC24 42 NSL 44 Independent, Tertiary and Out of Area Providers 46 Care Homes: Nursing 49 Appendix I: Process to Identify and Address Provider Underperformance IntegratedQualityandPer Page 2 of 50 Page4of52 OverallPage121of204

121 EXECUTIVE SUMMARY Introduction This paper identifies new or significant changes to concerns regarding providers contractual obligations and national targets to provide high quality care to patients in South Kent Coast. Issues where assurance has now been gained regarding quality of care are now presented to the Committee for Closure. The quality and performance escalation processes are included in appendix 1 to aid any discussions on the escalation of issues within the report. Key Performance Matters A number of key national targets have been failed and these are identified as issues within the report: * 18 week referral to treatment (page 14) * A&E waiting times (page 15) * Cancer waiting times (page 13) * Ambulance waiting times (page 46) It is recommended that these remain open to be reported again next month. KCHFT * Activity reporting (page 31) * Serious Incident reporting (page 32) * Collaborative working with KCHFT and domiciliary partners (page 32) KMPT *CQN issued for out of area bed use and psychiatric liasion services (page 36 and 37) * CQC report (page 38) SECAmb *waiting times (page 47) SPFT * Lack of reporting following change in information system (page 44) IC24 *Swale CCG have identified concerns regarding capacity (page 51) Nursing Homes *4 homes have been inspected by CQC and reprted as 'requiring improvement' (page 61) Key Quality Matters. The following issues have been raised within the report: Serious Incidents (page 7) EKHUFT * MRSA Screening (page 23) * Governance Reporting (page 23) * Induction and Training Issues (page 23) * Safeguarding in A/E (page 23) * WHH A/E Deep Dive (page 24) 4.2IntegratedQualityandPer Page 3 of 50 Page5of52 OverallPage122of204

122 Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory SOUTH KENT COAST CLINICAL COMMISSIONING GROUP (SKCCCG) Outcome 1 - Preventing People from Dying Prematurely Indicator Actual YTD Trend Outcome 2 - Enhancing Quality of Life for People with Long Term Conditions Indicator Actual YTD Trend Outcome 3 - Helping People to Recover from Episodes of Ill Health, or Following Injury Indicator Actual YTD Trend H 2 week wait Dec 93% 94.1% 93.4% P Mental health 12-Jul 2 P Completed Admitted (Unadjusted) - Within 18 Weeks Dec 70.8% 77.4% H 2 week wait breast symptomatic Dec 93% 90.9% 91.7% Treating People out of Hospital (SKC) P Completed Non admitted - Within 18 Weeks Dec 91.5% 92.6% H 31 day diagnosis to treatment Dec 96% 99.0% 94.9% P Readmission to Acute following Step- Down Dec 100% 97% P Incomplete - Within 18 Weeks Dec 92% 89.8% 89.8% H 31 day subsequent drug treatment Dec 98% 90.0% 98.9% P Readmission to community hospital following discharge Dec 0 0 P Incomplete Week Waiters Dec H 31 day subsequent radiotherapy Dec 94% 100.0% 97.7% P Admissions avoided (ICT,LTC) Dec 2 2 P Incomplete with Decision to Admit - Within 18 Weeks Dec 80.0% 82.8% H 31 day subsequent surgery Dec 94% 100.0% 93.1% P Delayed Transfer of Care Dec 0.00% 0.00% P New RTT Period - Within 18 Weeks Dec 0.0% 0.0% H 62 day referral to first treatment Dec 85% 86.0% 70.0% Mental Health LTD (SKC all providers) P Audiology assessments in 18 weeks Dec 99% 100.0% 100.0% H 62 day screening referral to first treatment Cancer (SKC all providers) Out of Area Placements (SKC) Referral to Treatment in 18 weeks (SKC all providers) Dec 90% 83.3% 80.6% H IAPT access Nov 15% 30% 28% A&E/IP * (EKHUFT all CCGs) **(SKC all providers) H 62 day consultant upgrade Dec 100.0% 68.8% H IAPT Recovery rate Nov 50% 39% 41% N A&E activity * Dec 16, ,469 Diagnostics (SKC all providers) H IAPT 6 we eks RTT Nov 75% 39% 41% N A&E seen within 4 hrs * Dec 95% 87.9% 87.9% P Diagnostic waiting times over 6 weeks Dec 99.0% 99.8% 99.7% H IAPT 18 we eks RTT Nov 95% 100% 100% N A&E admissions * Dec 34.1% 33.5% P Diagnostic activity Dec 4,560 41,903 PC GP Register Dementia Diagnosis Rate Jan 65.8% 63.4% Hi Admissions short stay % ** Nov 58% 50% N Elective operations cancelled with non Increased health gain - Q H clinical reason Hip replacement 2013/14 N Number not treated w/in 28 day of last Increased health gain- Q3 1 3 H minute elective cancellation Knee replacement 2013/14 Mortality (SKC all providers) H Increased health gain - Groin hernia 2013/14 H Summary Hospital Mortality Indicator Inc health gain - Em. admis. children 1.02 H (SHMI) lower resp tract infs * 2014/15 H hsmr tba H Em. Admis. acute conds that shouldn't req hosp admission * 2014/15 H Health related quality of life - Under 75 mortality from liver disease H LTC 2014/15 H Emergency admission from alcohol related liver disease 2014/ H Health-related quality of life - Carers 2014/15 H Under 75 mortality from cancer People feeling supported to manage their condition 2014/15 H Under 75 mortality from respiratory Unplanned admission <19 asthma, H disease diabetes and epilepsy * 2014/15 H Under 75 mortality from cardiovascular Unplanned admission ambulatory H disease care adult * 2014/15 H Pot yrs of life lost from causes considered amenable to healthcare ,124 Cancelled operations (EKHUFT all CCGs) Patient Reported Outcomes (SKC all providers) , Hi Admissions long stay % ** Nov 36% 37% P Red 1 <8 min Jan 75% 66.2% 65.9% P Red 2 <8 min Jan 75% 58.7% 66.6% P Category A (R1 & R2) <19 min Jan 95% 92.8% 92.3% P Met on arrival in ED by member of stroke thrombolysis team P % patients CT Scanned < 1 Hr of onset/arrival to site (WHH) P Direct admission to a Stroke Unit < 4 hrs admission (WHH) P Brain Imaging within 12 hours of admission P Patient spending 90% of their time on a stroke unit P Patients seen by a consultant < 24 hours of admission P Swallow screen within 4 hours of admission to stroke unit P High risk patients seen TIA fast track clinic < 24 hrs of referral Proportion of eligible patients on P CPA DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) s=ssnap Q = QOF hi=hisbi PC= Primary Care Web Tool Ambulance Waiting Times (SKC) Stroke (EKHUFT Level - ALLCCGs) Nov 95% 49.3% 60.9% Nov TBC 52.8% 58.1% Nov 80% 88.2% 84.9% Nov 95% 100.0% 99.4% Nov 90% 90.9% 88.9% Nov 90% 87.8% 85.1% Nov 95% 91.9% 91.3% Nov 95% 100.0% 82.4% Mental Health Care Planning Approach (SKC) Feb 95% 66% 4.2IntegratedQualityandPer Page 4 of 50 Page6of52 OverallPage123of204

123 Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory SOUTH KENT COAST CLINICAL COMMISSIONING GROUP (SKCCCG) Outcome 4 - Ensuring that People Have a Positive Experience of Care Indicator Actual YTD Trend Outcome 5 - Treating and Caring for People in a Safe Environment: Protecting Them from Avoidable Harm Indicator Actual YTD Trend Indicator Activity and Referrals Actual YTD Trend Complaints/Compliments (SKC) Health Care Associated Infections (HCAI) (SKC) K Complaints Dec N/A 3 46 PH MRSA Bacteraemia Dec Friends and Family Test: Patients (EKHUFT, KMPT, KCHFT, SECAMB all CCGs) PH C. Difficile Dec N A&E: Would Recommend Dec-15 87% 82% 81% PH MSSA Dec N/A 4 34 N Inpatients: Would Recommend Dec-15 96% 97% 94% PH E-Coli Dec N/A N Outpatients: Would Recommend Dec-15 92% 92% 90% Quality of Care (Providers all CCGs) Ordinary Elective Spells - G&A (% variance vs plan) Day case Elective Spells - G&A (% variance vs plan) Non-elective spells - G&A (% variance vs plan) All 1st OP Attendances - G&A (% variance vs plan) Activity (variance against plan) Dec -2% 5% Dec 19% 18% Dec 10% 2% Dec 15% 13% GP referrals (whole systems Programme plan) N Maternity: Would Recommend Dec-15 96% 98% 96% C Care Quality Commission Dec N/A See Provider Pages General Surgery Dec -5% -2.9% 12.2% N Mental Health: Would Recommend Dec-15 88% 91% 86% Preventing avoidable harm (Providers all CCGs) Urology Dec -5% 16.2% 9.7% N Community: Would Recommend Dec-15 95% 98% 97% N VTE Risk Assessment (EKHUFT) Sep 95% 94.3% 94.9% Trauma & Orthopaedics Dec -5% 16.1% 2.5% N Ambulance: Would Recommend Dec-15 93% 92% 98% H Friends and Family Test: Staff (EKHUFT, KCHFT, KMPT, SPFT, SECAMB all CCGs) Safety Thermometer: Harm Free Care (EKHUFT, KCHFT & KMPT) N Would Recommend Work Q2 62% 56% 56% K Serious Incidents Reported Dec N/A 6 46 Dec 95% 94.2% 94.5% Ophthalmology Dec -5% -2.4% 20.0% Incident Reporting (SKC all providers) Dermatology Dec -5% 10.6% 8.7% N Would Recommend Care Q2 79% 75% 76% Mixed Sex Accommodation (SKC all providers) N Mixed Sex Accommodation Breaches Dec DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) PH = Public Health England K = STEIS 4.2IntegratedQualityandPer Page 5 of 50 Page7of52 OverallPage124of204

124 SKC CCG QUALITY/PERFORMANCE CONCERN TRIANGULATION DESCRIPTION OF CONCERN: DATE CONCERN INDENTIFIED: C. difficile Infection (CDI) Apr-15 BACKGROUND: The CCG has a trajectory with a maximum of 44 cases of CDI in 2015/16. Cases are identified as either pre-72 hour (allocated to SKC CCG) or post-72 hour (allocated to EKHUFT or other acute providers). Pre 72-hour cases refer to specimens from all sources including: GP's, care homes, community hospitals and acute hospital outpatient, day cases, pre-admission or during the first 48 hours of admission. All pre 72-hour cases require a RCA form to be completed by the GP responsible for specimen to share learning and identify trends/themes. CURRENT POSITION: * Increase in toxin positive CDI cases in Q3: * There have been a total of 12 cases in Q3. * Last year the total for this period was 5 cases. * 8 of these cases are attributed to the CCG. * 6 cases were associated with recent admission to EKHUFT. * Only two completed RCAs have been returned thus making any further analysis of root causes difficult. * A total of 12/22 RCA forms have been returned during Q1 Q3 with the return rate having slowed significantly in recent months. South Kent Coast CCG NHS # ACTION PLAN: HCAI spotlight report being presented to SKC CCG QPD Committee in February 2016 where the Committee will be asked to give an opinion on: Suggestions for improving the return rate of RCAs. The principle of incentivising practices to return RCAs as part of the antimicrobial incentive scheme. Additional ways in which the CCG can support members to accurately identify and manage potentially transmissible infections. RISK RATING: (Refer to Appendix I) DCS ID Month Reported Practice Surgery Practice Town Infections Breakdown Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Total C. difficile Out of Area Acute CCG Total Trajectory Locality Origin of Specimen Recent Admission Details Apr Buckland MC Dover Dover GP 18/7 post-discharge Received Apr The New Surgery Lyminge Shepway AH on admission 19/7 post-discharge Received Apr Sandgate Road Folkestone Shepway GP 9/52 post-discharge Ma y Ba lmora l Surgery Dea l Deal AH 2/7 post-transfer from Deal hospital Received May The s urgery Folkes tone Shepway GP Received not counted* May The New Surgery Lyminge Shepway GP May Church La ne Surgery New Romney Shepway GP May Oa kla nds HC Hythe Shepway AH Received May Ceda rs Surgery Dea l Deal AH Jun The s urgery Lyminge Shepway GP 5/7 post-discharge Received MEDIUM EXPECTED RESOLUTION DATE: Mar-16 PLACED ON RISK REGISTER: R0122 (risk score 12) RCA Received Previous positive specimens Jun The Surgery Lyminge Shepway GP 9/52 post-discharge Received 20/04/ Jul The Park Farm Surgery Folkestone Shepway GP 6/52 Post Discharge Received Aug Peter Street Surgery Dover Dover AH Received Aug The Surgery Lyminge Shepway GP Sept Folkestone East Fmaily Practice Folkestone Shepway St Matin's Hospital Received Oct Oa k Ha ll Surgery New Romney Shepway Acute Oct Ba lmora l Surgery Dea l Deal Acute Oct Lydden Surgery lydden Dover GP 2/52 post discharge Oct Oa kla nds HC Hythe Shepway GP 6/52 post discharge Oct Oa kla nds HC Hythe Shepway GP 5/12 post discharge Oct The White Hous e Folkes tone Shepway GP N/A Nov Peter Street Surgery Dover Dover GP 3/52 Post Discharge Received 27/09/ Nov The White Hous e Folkes tone Shepway Acute 5/52 Post discharge Dec Oa kla nds HC Hythe Shepway GP N/a Dec The New Surgery Folkes tone Shepway GP 3/52 Post Discharge Received Notes: AH = Acute Hospital RH/NH = Residential/Nursing Home * Specimen not included in trajectory CH = Community Hospital PRE-72 HOUR CDI CASES April March 2016 GP = GP 4.2IntegratedQualityandPer Page 6 of 50 Page8of52 OverallPage125of204

125 SOUTH KENT COAST CCG: QUALITY AND PERFORMANCE ISSUE LOG Issue Reference Date identified Description of Issue Current Position SKCCCG2015/003 Aug-15 Looked After Children: CCG Statutory Duties There is a risk of CCG not fulfilling its The CCG has access to a designated Nurse for LAC through the hosted safeguarding team although this statutory duties in relation to Looked After Children (LAC) as the CCG is not able to resource is across the whole of Kent. Safeguarding nurse for LAC has given EKHUFT a template for data for monitor provision of services adequately due to the lack of performance quarterly reporting. A new service spec being written with KPIs. The expertise of a second Designated information available from providers. As a result LAC are not receiving required Nurse for LAC has been secured. Safeguarding Partnership Board in place. EKHUFT continues to perform services due to inadequate provision of statutory health assessments which may poorly against statutory timescales. Q1 data shows 29.7% of Initial health assessments were completed lead to harm to LAC and resulting in reputational damage for the CCG. within statutory timeframe of 28 days of the start of care episode. EKHUFT continue to misunderstand the statutory timescales around completion. For KCHFT Q1 performance report does not provide any detail on the Review health Assessments undertaken by the nursing team apart from number of RHA completed and number of DNA's. Risk Status (as per escalation process) Actions HIGH 1. A Contract Performance meeting took place on 6th November 2015 following a Contract Performance Notice being issued to EKHUFT in August EKHUFT to write a recovery plan to address the issues raised by the CCG's. 2. West Kent CCG are monitoring a Service Improvement Development Plan (SDIP) with KCHFT to improve the service against the Statutory Guidance. Last meeting held in October 2015 had many of the actions closed and a few actions outstanding but progress is being made. Risk Register R0078 (risk score 16) Timescale for Completion Mar-16 SKCCCG2015/004 Aug-15 Looked After Children: Unaccompanied Asylum Seeking Children Assessment and Currently Kent has c. 958 UASC under 18, with 274 arriving within the last seven weeks. The majority of screening services for unaccompanied asylum seeking young men placed at new arrivals continue to come from Eritrea, Afghanistan and Syria. In order to cope with the Millbank Assessment Centre do not have capacity to meet demand. The CCG is unprecedented numbers of young people KCC have opened two additional reception centres, Appledore in failing in it's statutory obligation by being unable to carry out initial assessment Swattenden and Ladesfield in Whitstable. within the 28 day timeframe. There is also a Public Health risk to the delayed While additional funding is available for Initial Health Assessments, no additional resources are being made assessment and screening of these young people. available to the LAC nursing team to undertake any additional work with this cohort or additional capacity to carry out review health assessments in a year's time. NHS England whole system meeting in September reported: * All 3 reception centres now have GP support * Increasing capacity to deliver initial Health Assessments following national call for Paediatricians * Mass vaccination sessions have been carried out in Ladesfield Reception Centre and planning for sessions in Appledore and Millbank. * Support from NHSE on dental, ophthalmology, audiology. Meeting held with CAMHs taken place and work agreed to address emotional and mental health needs. HIGH KCC continues to request a dispersal system set up by the Home Office and the Director of Children's services has written to all local authorities in England to request that they accept a number of UASC on permanent case transfer, so far only 42 UASC have been accepted. SKC CCG has agreed to meet the additional costs that are outside of existing contracts to ensure that all costs are consolidated and discussions are being held with NHS England around additional funding to cover some of these costs. Briefing sent to GP's in November to provide an update on current situation R0098 (risk score 20) Mar-16 SKCCCG2015/006 Sep-15 Safeguarding The CCG is not assured regarding providers compliance with their A gap analysis has been undertaken by the Designated Nurses for EKHUFT, KCHFT and KMPT against the statutory duties related to Safeguarding Adults, Safeguarding Children, Mental Schedule 4 Safeguarding Metrics for 2014/15. These are part of the contract and include core statutory Capacity Act (MCA) and Deprivation of Liberties (DoLs). requirements. The gap analysis has been sent to Safeguarding Leads in organisations requesting further assurance on gaps. These were followed up in the relevant provider quality and performance contract meetings in January 16. HIGH KMPT / KCHFT - the majority of areas have been addressed with either further evidence or assurance that this will be put in place. Designated Nurses will follow up outstanding gaps and update the committee at the meeting in March through the IQPR. There remain a number of gaps for EKHUFT in terms of safeguarding adults. Written assurance and an action plan has been requested from EKHUFT by 1st March R0082/R0098 (risk score 12) Mar-16 SKCCCG2015/007 Oct-15 Serious Incidents NHS England have requested that all outstanding Serious For SKC CCG, 26 SI's across all providers need to be closed in order to meet NHSE request to close STEIS 1 Incidents prior to 20th May 2015 need to be closed by CCGs/Area Teams by 31st & 2. A large propostion of these SI's are from KMPT and SKC Head of Quality attended a meeting with Dec 2015 in order for STEIS 1 & 2 to be closed. NHSE on 19th October looking at the quality of some of the RCA's submitted by KMPT and how best to progress with the closure of these SI's given the deadline. NHSE have reviewed a sample of RCA's and agree with the CCG's assessment. A closure proposal was agreed at the meeting held on 5th Jan 2016 with NHSE, CCG's and KMPT Medical Director and Patient Safety Manager. The proposal needs to be agreed by all East Kent CCGs. It will be presented to all East Kent CCG Quality Committees in February 2016 for approval. HIGH SI & Quality Officer to get an update from providers regarding timeline of when outstanding SI's will be submitted to the CCG and to keep NHSE informed of progress. R0129 Mar-16 SKCCCG2015/008 Nov-15 Off framework agencies In November Monitor published new rules on spending in Monitor are enforcing a 5% agency cap next year. The current target is 4.7% which is considered to be a relation to agency staff. Monitors new rules mean that any payments in excess of cautious estimate. EKHUFT Plan submitted to Monitor in October 2015 re: NICU, chemotherapy, ITU WHH their new price caps will be scrutinised by them and excessive use and failure to make rapid improvements to workforce management may lead to regulatory action. EKHUFT, KCHFT and KMPT all use off framework agencies to fill staffing and medical and surgical wards at the WHH and QEQM. The Trust has not heard back from Monitor re: this yet. There is a requirement to stop all off framework agency use. The Tust has to report all off framework agency use. The Trust has experienced challenges due to tactics employed by the off slots which charge a much higher rate. There are also concerns whether there are framework agencies to get business such as sending nurses that have not been booked; the Trust has processes in place with these agencies to undertake the required level of preemployment checks. tackled such issues directly wit the agencies concered. The Trust is currently looking at the induction process for temporary staff. This is less of a concern for the on framework agencies as the Trust has been assured of the quality of staff supplied. HIGH There has not been the expected reduction in agency use. Of the expected 50 newly qualified nurses only 27 took up posts in EKHUFT. This was the first all degree cohort and many of these nurses opted to return home or take up posts in tertiary centres rather than stay locally. Head of Quality to monitor EKHUFT weekly off framework agency data submission to Monitor. NO May-16 SKCCCG2015/009 Nov-15 Discharge to Assess (DTA) Pathway There is a gap in assurance around the DTA Pathway 1 is provided by the Hilton. Pathways 2 & 3 are provided by KCHFT. Concerns that pathway 2 is pathway; no service specification and no quality data/kpi's being reported. not working. Remains a gap in performance data. Being evaluated in Feb/March. MEDIUM Ashford and Canterbury CCG's are leading on this. NO Mar IntegratedQualityandPer Page 7 of 50 Page9of52 OverallPage126of204

126 SERIOUS INCIDENTS: SKC CCG December 2015 CCG STEIS Ref Date Logged Time to report Incident Date Date incident identified SKC 2015/ Dec Dec-15 4-Dec-15 KMPT Client's flat Psychiatry Provider Site of Incident Clincal Area Category Never Event Due Date Pending review (a category must be selected before incident is closed) SKC 2015/ Dec Nov Dec-15 EKHUFT K&CH - Gastroenterology Medicine Treatment delay meeting SI criteria SKC 2015/ Dec Nov Dec-15 SECAMB Beach at Walmer, Kent Other Sub-optimal care of the deteriorating patient meeting SI criteria SKC 2015/ Dec Dec Dec-15 KMPT Woodchurch Ward, Thanet Mental Health Unit Psychiatry Slips/trips/falls meeting SI criteria SKC 2015/ Dec Oct Dec-15 EKHUFT QEQM Accident and Emergency Pressure ulcer meeting SI criteria SKC 2015/ Dec Oct Dec-15 EKHUFT Breakdown of Serious Incidents for SKC CCG patients logged in December 2015 William Harvey Hospital - ophthalmology DATA SOURCE: STEIS & CCG Treatment delay meeting SI criteria Not a Never Event Not a Never Event Not a Never Event Not a Never Event Not a Never Event Not a Never Event 4-Mar-16 8-Mar Mar Mar Mar Mar-16 SI Reporting Breach Rate by Provider: November 2015 On-Going SI's: by Provider: Investigation Completion Breach Rate Provider SI's reported in October SI's reported within 2 days Breach rate for SI's reported in October Provider Total number of ongoing SI's SI's with provider awaiting completion of investigation SI's with CCG awaiting closure SI's back with provider awaiting further information SI's which meet deadline Total SI's breaching deadline Breach rate SECAMB 1 1 0% EKHUFT % KMPT % KCHFT % EKHUFT 3 3 0% KMPT % Total % CHYPS % Spires % SKC CCG % SECAMB % Pilgrims % Total % SKC CCG: Number of SI's reported Year on Year Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar IntegratedQualityandPer Page10of52 OverallPage127of204

127 Providers Overview SECAMB/ NHS111 Outcome 1: Preventing People from Dying Prematurely NHS OUTCOMES FRAMEWORK EKHUFT KCHFT KMPT SPFT IC24 NSL Spires Spencer Marie Stopes Includes: Mortality, Smoking Cessation, follow-up after discharge, etc. 6 / / / / 6 Includes: Readmission rates, Admission avoidance, Patient reported outcomes, delayed transfers of care, etc. Outcome 2: Enhancing the Quality of Life for People with Long Term Conditions 3 / / 1 3 / 5 5 / 5 4 / 8 Outcome 3: Helping People to Recover from Episodes of Ill Health or Following Injury Includes: Activity, Waiting times, Care planning, etc. 6.5 / / / 6 5 / 5 2 / 6 Outcome 4: Ensuring that People have a Positive Experience of Care Includes: Complaints, Friends & Family Test Score, Mixed Sex Accommodation Breaches, etc. 4 / / / / 2 2 / 3 2 / 2 1 / 1 3 / 3 2 / 2 Outcome 5: Treating and Caring for People in a Safe Environment and Protecting them from Avoidable Harm Includes: Care Quality Commission, Serious Incidents, Health Care Acquired Infections (HCAI), Safety Thermometer, etc. 5.5 / / / / / 9 4 / 6 6 / 6 5 / 5 5 / 5 Based on proportion of indicators compliant with internal or national targets. G=80% R=50% 4.2IntegratedQualityandPer Page 9 of 50 Page11of52 OverallPage128of204

128 Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST (EKHUFT) Outcome 1 - Preventing People from Dying Prematurely Indicator Actual YTD Trend Outcome 2 - Enhancing Quality of Life for People with Long Term Conditions Indicator Actual YTD Trend Outcome 3 - Helping People to Recover from Episodes of Ill Health, or Following Injury Indicator Actual YTD Trend Mortality Indicators P Term neonatal deaths < 7 days 0 P Readmissions 7 Days (%) Oct 2.00% 3.99% 4.05% P Completed Admitted (Unadjusted) - Within 18 Weeks P Maternal Mortality 0 P Readmissions 30 Days (%) Oct 8.32% 7.39% 8.20% P Completed Non admitted - Within 18 Weeks Cancer (SKC) Dec 68.6% 75.3% Dec 90.9% 92.1% P Delayed Transfers of Care (average) Oct P Incomplete - Within 18 Weeks Dec 92% 89.4% 89.4% H 2 week wait Dec 93% 94.0% 93.4% P Incomplete Week Waiters Dec H 2 week wait breast symptomatic Dec 93% 92.3% 92.4% Dementia (National CQUIN) (EKHUFT All CCGs) P Incomplete with Decision to Admit - Within 18 Weeks Dec 79.9% 82.9% H 31 day diagnosis to treatment Dec 96% 98.8% 94.7% N Percentage of cases identified Nov 90% 99.2% 99.2% P New RTT Period - Within 18 Weeks Dec 0.0% 0.0% H 31 day subsequent drug treatment Dec 98% 93.3% 99.3% N Percentage of cases with diagnostic assessment Treating People out of Hospital (EKHUFT All CCGs) Nov 90% 93.7% 92.9% Referral to Treatment in 18 weeks (SKC) H 31 day subsequent radiotherapy Dec 94% P Assessments in 18 weeks Dec 99% 100.0% 100.0% Audiology (SKC) H 31 day subsequent surgery Dec 94% 100.0% 92.4% A&E/IP (Trust) H 62 day referral to first treatment Dec 90% 91.8% 73.0% N A&E activity Dec 16, ,469 H 62 day screening referral to first treatment Dec 90% 83.3% 82.0% N A&E seen within 4 hrs Dec 95% 87.9% 87.9% H 62 day consultant upgrade Dec 100.0% 70.0% N A&E admissions Dec 34.1% 33.5% Diagnostics (SKC) Hi Admissions short stay % (SKC) Nov 58% 50% P Diagnostic waiting times over 6 weeks Dec 99.0% 99.9% 99.8% Hi Admissions long stay % (SKC) Nov 36% 37% Elective operations cancelled with N non clinical reason Number not treated w/in 28 day of N last minute elective cancellation Cancelled operations (EKHUFT All CCGs) Q P Met on arrival in ED by member of stroke thrombolysis team Q3 1 3 P % patients CT Scanned < 1 Hr of onset/arrival to site (WHH) P Direct admission to a Stroke Unit < 4 hrs admission (WHH) P Brain Imaging within 12 hours of admission P Patient spending 90% of their time on a stroke unit P Patients seen by a consultant < 24 hours of admission P Swallow screen within 4 hours of admission to stroke unit P High risk patients seen TIA fast track clinic < 24 hrs of referral DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) K = KMCS Hi = HISBI Stroke (EKHUFT All CCGs unless otherwise specified) Nov 95% 49.3% 60.9% Nov TBC 52.8% 58.1% Nov 80% 88.2% 84.9% Nov 95% 100.0% 99.4% Nov 90% 90.9% 88.9% Nov 90% 87.8% 85.1% Nov 95% 91.9% 91.3% Nov 95% 100.0% 82.4% 4.2IntegratedQualityandPer Page 10 of 50 Page12of52 OverallPage129of204

129 Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST (EKHUFT) Outcome 4 - Ensuring that People Have a Positive Experience of Care Indicator Actual YTD Trend Outcome 5 - Treating and Caring for People in a Safe Environment: Protecting Them from Avoidable Harm Indicator Actual YTD Trend Summary Key themes relating to concerns regarding the performance and quality of care provided by EKHUFT include: N A&E: Would Recommend Dec-15 87% 82% 81% C Safe Nov-15 N/A N Inpatients: Would Recommend Dec-15 96% 97% 94% C Effective Nov-15 N/A N Outpatients: Would Recommend Dec-15 92% 92% 90% C Caring Nov-15 N/A N Maternity: Would Recommend Dec-15 96% 98% 96% C Responsive to People's Needs Nov-15 N/A N Would Recommend Work Q2 62% 53% 53% C Well-Led Nov-15 N/A N Would Recommend Care Q2 79% 76% 76% P MRSA Bacteraemia Dec P C. Difficile Dec P Adult Inpatient Experience Dec 80% 91% 89% P MSSA (post 48 hours) Dec N/A 2 16 P E-Coli (post 48 hours) Dec N/A 9 52 P Compliments Dec N/A P Training Dec 95% 87% 87% P Formal Complaints Dec N/A P Informal Concerns Dec N/A N VTE Risk Assessments Sep 95% 94% 95% P PALS Contacts Dec N/A P Compliance Against First Response Met (%) Dec 85% 88% 94% H Harm Free Care Dec 93% 92% 93% P Referred to Trust by PHSO Dec N/A 3 24 H New Pressure Ulcers Dec N/A 4 47 P Cases Open with PHSO Dec N/A H Falls with Harm Dec N/A 2 48 N MSA Breaches Dec H Cleanliness % 94.44% 94.44% K H Food % 82.79% 82.79% K H Privacy, Dignity and Well-Being % 77.16% 77.16% K H Condition, Appearance and Maintenance Friends and Family Test: Patients (EKHUFT All CCGs) Friends and Family Test: Staff (EKHUFT All CCGs) Inpatient Survey (EKHUFT All CCGs) Complaints/Compliments (EKHUFT All CCGs) Mixed Sex Accommodation (MSA) (EKHUFT All CCGs) Patient-Led Assessment of the Care Environment (PLACE) (EKHUFT All CCGs) % 89.72% 89.72% H NEW VTE Dec N/A 6 41 K Serious Incidents Reported - EKHUFT Total Serious Incidents Reported - SKC CCG Total Never Events Reported - EKHUFT Total Never Events Reported - SKC CCG Total Care Quality Commission (EKHUFT All CCGs) Requires Improvement Inadequate Requires Improvement Dec N/A 9 60 Dec N/A 3 14 Dec Dec H Dementia % 72.19% 72.19% CA Compliance with Deadlines Dec 100% 75% 87% Good Requires Improvement Health Care Associated Infections (HCAI) (EKHUFT All CCGs) Venous Thromboembolism (VTE) Risk Assessments (EKHUFT All CCGs) Patient Safety Thermometer (EKHUFT All CCGs) Incident Reporting (EKHUFT All CCGs) Central Alerts System (CAS) (EKHUFT All CCGs) Workforce (EKHUFT All CCGs) P % Hours Filled Planned v Actual Dec N/A 95% 95% 18 Weeks A&E Cancer Care Quality Commission (CQC)/Monitor Maternity Services Pressure Ulcers Falls Safeguarding Adults Assurance Safeguarding Children Assurance Health & Social Care Village Beds Pleural Procedures Tongue Tie Service Tuberculosis Medway NICU Looked After Children (LAC) Late Stage Termination of Pregnancy MRSA Screening Health Education Kent, Surrey and Sussex Ophthalmology Outpatients Backlog Maternal Death Review Venous Thromboembolism (VTE) Infection Prevention and Control Off Framework Agencies Paediatric DNA Policy Serious Incidents VitalPAC Blood Culture Training Misplaced Naso-Gastric Tube DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) K = SECSU Hi = HISBI CA = Central Alerts System 4.2IntegratedQualityandPer Page 11 of 50 Page13of52 OverallPage130of204

130 EKHUFT QUALITY/PERFORMANCE CONCERN TRIANGULATION DESCRIPTION OF CONCERN: DATE CONCERN INDENTIFIED: Cancer Sep-14 BACKGROUND: Failure of cancer constitution targets. CURRENT POSITION: Cancer performance has shown improvement in Q3, with all 2 week wait targets met, and significant improvement in 31 day first treatment. EKHUFT has shown improvement toward 62 target though have not met the trajecory to meet the target in December. EKHUFT have submitted a revised trajectory to meet the 62 day target by March Analysis of breaches beyond 104 days shows that the majority of breach reasons focus on delays in diagnostics. Updates to action plan suggest that diagnostic delays due to innapropriate use of cancer flags should show an impact from January. ACTION PLAN: Plan included agreement for practices to provide cancer referral patients with a leaflet regarding the 2ww referral process and ensure patients are available to be seen in 2 weeks. Feedback from patients indicate that this is not rutinely offered. Progress in Decmber: Urology have made significant improvements to their diagnostic pathway and resolved bottlenecks around their pathways which is now enabling patient to receive diagnosis within 31 days. Diagnostics delays have been linked to incorrect use of cancer flaggs. The trust will manage incorrect useage at clinician level. The capacity issue of the Davici Robot, which has affected both 62 day and 31 day standards, has now been resolved. Diagnostic capacity and demand issue within Endoscopy causing delays to Lower GI and Upper GI pathways. RISK RATING: (Refer to Appendix I) reason for breach Capacity 11% Diagnostics 47% DNA 4% Late referral 13% Pt. choice 2% Pt. unfit 9% Other 15% HIGH EXPECTED RESOLUTION DATE: Mar-16 PLACED ON RISK REGISTER: R0102 (risk score 16) 4.2IntegratedQualityandPer Page 12 of 50 Page14of52 OverallPage131of204

131 EKHUFT QUALITY/PERFORMANCE CONCERN TRIANGULATION DESCRIPTION OF CONCERN: DATE CONCERN INDENTIFIED: 18 Week Referral to Treatment Jul-14 BACKGROUND: EKHUFT have agreed a planned trajectory to reach a sustainable admitted waiting list position and a backlog position which will enable the Trust to achieve and maintain the incomplete 92% target CURRENT POSITION: Fell below target in November and December, following successfully meeting trajectory plan to reach target in October. Revised trajectory indicates the trust will not maintain the target in year. Revised trajectory as follows: ACTION PLAN: 4.2IntegratedQualityandPer Page 13 of 50 Page15of52 OverallPage132of204

132 EKHUFT QUALITY/PERFORMANCE CONCERN TRIANGULATION T&O - - Implement new pathway for repeat injection patients for 2 CCGs. - Difficulties with independent sector experienced, dating of patients has been delayed due to contractual difficulties. General Surgery - Extra outpatient capacity to be set up for January - Extra theatre capacity for Upper GI - increased incidences of cholecystitis Gastroenterology - Substantive UK recruitment ongoing all through 2015/16 with one part time appointment. - Nurse Consultant appointed to support IBD OPD activity -Two locums have been appointed for short term assignments arriving in January and February Dermatology - New Speciality doctor has commenced in post Monday 4th January and following induction and phased return to work after a long illness will create capacity for 2-3 procedure lists per week (12-18 patients per week). - The preferred option would be to secure additional evening / weekend lists from existing workforce and a programme for January-March is being put together. Maxillio facial - Dermatology and Maxillofacial to determine continuation or further rise in cons to cons referrals and plan capacity accordingly. - extra weekend lists in January-capacity found for 14 Gynae -data validation has improved position to 92.75% Neurology - Long term locums used to fill vacancy gap whilst recruitment progresses (interviews Mid Jan) Underway. -Referral & Triage Criteria developed with Consultants to reduce the number of inappropriate referrals. Two months use has reduced referrals by 20%. -Slots dedicated to 2 ww referrals to ensure no breaches for Brain cancer. RISK RATING: (Refer to Appendix I) HIGH EXPECTED RESOLUTION DATE: Apr-16 PLACED ON RISK REGISTER: R0004 (risk score 16) 4.2IntegratedQualityandPer Page 14 of 50 Page16of52 OverallPage133of204

133 EKHUFT QUALITY/PERFORMANCE CONCERN TRIANGULATION DESCRIPTION OF CONCERN: DATE CONCERN INDENTIFIED: A & E Mar-14 BACKGROUND: lack of compliance with 4 hour A&E target CURRENT POSITION: Monthly Performance validated (December 15) % EKHUFT have not yet reached a sustainable position. EKHUFT have developed a comprehensive A&E dashboard including clinician and specialist response targets, workforce and discharge planning. ACTION PLAN: Safer Start workshop feedback has been received highlighting the following: positive impact on bed occupancy at QEQM positive relationships with radiology and pharmacy departements proatvive working with therapy team Issues to be addressed: EKHUFT Site management and communication blocks identified lack of understanding of pathways in some areas Issues to be addressed CCGs: GP medical referral process into Ambulatory Care and CDU needs to be reviewed Issues identified with new equipment provider RISK RATING: (Refer to Appendix I) HIGH EXPECTED RESOLUTION DATE: Apr-16 PLACED ON RISK REGISTER: R0030/R0035 (risk score 6) 4.2IntegratedQualityandPer Page 15 of 50 Page17of52 OverallPage134of204

134 EKHUFT: QUALITY AND PERFORMANCE ISSUE LOG Issue Reference Date identified Description of Issue Current Position Risk Status (as per escalation process) Actions Risk Register Timescale for Completion EKHUFT2014/008 EKHUFT2014/008T May-14 Care Quality Commission (CQC Inspection) Following the trust being placed in special measures due to an overall 'inadequate' rating from the March 2014 CQC inspection. In response the trust developed a detailed action plan based on the findings identified in the CQC report. The findings of the re-inspection in July 2015 has resulted in an overall rating of 'requires improvement'. The inspection identified significant improvements in safety and wellled (from 'inadequate' to 'requires improvement') whilst effective has moved from 'requires improvement' to 'inadequate'. The CQC report notes an improved culture at the trust and references some outstanding practice. The trust has a well-developed approach to the management of learning from complaints and care is rated as 'good' across the whole trust. EKHUFT2016/003 Nov-15 Off framework agencies In November Monitor published new rules on spending in relation to agency staff. Monitors new rules mean that any payments in excess of their new price caps will be scruitinised by them and excessive use and failure to make rapid improvements to workforce management may lead to regulatory action. EKHUFT use off framework agencies to fill staffing slots which charge a much higher rate. There are also concerns whether there are processes in place with these agencies to undertake the required level of pre-employment checks. A Quality Summit was held on 16th November. The CQC report notes some important quality and safety areas for improvement including: Ensuring there are sufficient numbers of suitably qualified, skilled, and experienced staff available to deliver safe patient care; The development of robust systems to monitor the safe management of medicines ; Ensuring suitable arrangements for patients with mental health issues whilst awaiting assessment; Replacing the Liverpool Care Pathway; Improving the emergency pathway, escalation when areas become under pressure and the escalation wards; The need for sufficient, well maintained equipment Following helpful CQC comments, the trust is working with its health and social care partners to improve the overall emergency pathway across all of its acute hospitals, in particular the busy Emergency Department at WHH. Monitor are enforcing a 5% agency cap next year. The current target is 4.7% which is considered to be a cautious estimate. EKHUFT Plan submitted to Monitor in October 2015 re: NICU, chemotherapy, ITU WHH and medical and surgical wards at the WHH and QEQM. The Trust has not heard back from Monitor re: this yet. There is a requirement to stop all off framework agency use. The Tust has to report all off framework agency use. The Trust has experienced challenges due to tactics employed by the off framework agencies to get business such as sending nurses that have not been booked; the Trust has tackled such issues directly wit the agencies concered. The Trust is currently looking at the induction process for temporary staff. This is less of a concern for the on framework agencies as the Trust has been assured of the quality of staff supplied. HIGH HIGH The trusts finalised High Level Improvement Plan and governance arrangements were sent to Monitor and the CQC on 14th December More detailed action plans are being developed within teams to support delivery of the high level actions. The CQC Improvement Steering Group continues to meet fortnightly to engage staff and work alongside the Quality Improvement and Innovation Hubs Quality visit conducted by Thanet CCG quality team to ensure that issues highlighted in the CQC report are being addressed. Thanet CCG quality team is conducting a gap analysis of the High Level Improvement Plan and will be used as a monitoring tool to ensure more detailed action plans address areas where further assurance is required. There has not been the expected reduction in agency use. Of the expected 50 newly qualified nurses only 27 took up posts in EKHUFT. This was the first all degree cohort and many of these nurses opted to return home or take up posts in tertiary centres rather than stay locally. Head of Quality to monitor EKHUFT weekly off framework agency data submission to Monitor. R0101/R0110 (risk score 9) NO Mar-17 May-16 EKHUFT2014/014 EKHUFT2014/014T Sep-14 Venous Thromboembolism VTE assessment and prescription of VTE SKC CCG Head of Quality undertook a Quality Visit on 23rd November prophylaxis is aimed at preventing an avoidable cause of mortality and The outcome of the visit was: morbidity following hospitalisation. The CCG is not assured of the Trust s position for reducing harm from The national standard is for every patient to have a documented VTE hospital associated VTE or managing patients affected by lower limb risk assessment within 8 hours of admission. immobilisation. Trusts are expected to achieve at least 95% of patients being admitted The summary of the visit is cross referenced, in the table below, to having a signed and dated VTE risk assessment. Schedule 4 with the gaps and actions requested identified. The monthly data provided by EKHUFT to UNIFY2 is showing the trust The Trust are to provide a detailed plan to demonstrate how and when as a national outlier in terms of compliance with VTE Risk Assessments they will complete the agreed actions. for patients, with data showing around 80% compliance whilst the A/E and Fracture clinics are not consistently following CME guidance majority of trusts are achieving >95%. lack of lower limb immobilisation. In addition the VTE Risk Assessment data (1 day snapshot) submitted via the Patient Safety Thermometer is showing that not all patients are being given appropriate prophylaxis treatment. HIGH The recommendations from the Quality Visit were that the Trust need to provide: A ratified policy for lower limb immobilisation. PGDs for staff working in areas where there are no medical colleagues or nurse prescribers. There needs to be a clear pathway for who should prescribe, provide and pay for the prophylaxis after the initial attendance. The trust have developed and implemented a protocol and a patient information leaflet. Overall, CCGs are not assured as provider is not compling with standards and action plan is insufficient. Action plans and progress to be reported to East Kent Contract meeting in February NO Mar-16 EKHUFT2015/004 EKHUFT2015/004T Mar-15 Pleural Procedures Thanet CCG have identified low compliance with an One of the four Never Events reported by EKHUFT in 2013 related to a internal audit following submission of a Serious Incident for closure. pleural procedure at the wrong side which contributed to a patient death. Following this, new safety procedures have been introduced by EKHUFT. Discussed at the QIG in October. Ongoing monitoring and improvements will be part of the new NHSE programme NatSSIPs (National Safety Standards for Invasive procedures). A Patient Safety Alert has been raised. Every invasive procedure has to have a policy and have an audit trail. Pleural Safety checklist was introduced 2 years ago however still not embedded and using in only 38% of cases. HIGH Pleural procedures audit compliance has been received from EKHUFT however CCG's still not assured. HoQ to chase up with Helen Goodwin to see action plan. NO Mar IntegratedQualityandPer Page 16 of 50 Page18of52 OverallPage135of204

135 EKHUFT: QUALITY AND PERFORMANCE ISSUE LOG Issue Reference Date identified Description of Issue Current Position Risk Status (as per escalation process) Actions Risk Register Timescale for Completion EKHUFT2015/013 EKHUFT2015/011T Aug-15 Looked After Children (LAC) EKHUFT's performance against the Contract Query Notice issued 25th August EKHUFT to identify what statutory target to ensure 85% of initial health assessments completed remedial steps are being taken to drastically improve its performance within 28 days of a child or young person becoming looked after is against the statutory requirement. currently only at 3% overall. EKHUFT achieved a very small percentage of assessments within the time frame for South Kent Coast and Thanet CCGs but no assessments were completed within the time frame for Ashford and Canterbury & Coastal CCGs. The 28 day time frame is a statutory requirement set out by the Government as outlined in the Promoting the health and wellbeing of looked after children statutory guidance HIGH A Contract Performance meeting took place on 6th November EKHUFT to write a recovery plan to address the issues raised by the CCG's. R0078/R0093 (risk score 16) Feb-16 EKHUFT2015/018 EKHUFT2015/016T Sep-15 Governance reporting Following QEQM A&E Deep Dive, partial It is recognised that there is a clear governance structure in place for assurance received around governance. quality although further assurance is required around data entry and incidents in relation to missed x-rays. CCG's have requested monthly governance report but are yet to receive this. HIGH Still awaiting update from EKHUFT on each of the actions and progress report. Been escalated to the Acting Deputy Chief Nurse and on agenda for Quality and performance meeting in January. NO Feb-16 EKHUFT2015/019 EKHUFT2015/017T Sep-15 Induction & Training Following QEQM A&E Deep Dive, partial The deep dive found evidence of cultural change within the Emergency assurance received around the induction of new members of staff Care department and recognised the gaps within the medical workforce. However, further assurance has been requested around the training and induction programme for new members of staff. A copy of the induction and training for new members has been requested from EKHUFT but CCGs are yet to receive this. HIGH Still awaiting update from EKHUFT on each of the actions and progress report. This has been escalated to A&E, Senior Matron via Deputy Chief Nurse at EKHUFT. On agenda for quality and performance meeting in January. NO Feb-16 EKHUFT2015/025 EKHUFT2015/023T Oct-15 Serious Incidents: Lack of assurance around the monitoring of actions Internal work being undertaken by EKHUFT to provide assurance that and learnings learning is taking place HIGH Monitoring of SI action plans needs to be embedded into the agenda for IQIT Meeting. To be included in the agenda for the January meeting. If not then it will be escalated to the quality and performance meeting. NO Feb-16 EKHUFT2015/027 EKHUFT2015/025T EKHUFT2015/031 EKHUFT2015/029T Oct-15 Competencies around agency staff and access to systems to review Concerns have been raised around management of deteriorating patients patient records related to agency staff, for example not being trained to use VitalPAC. Nov-15 Blood Culture Training PSB Minutes for October documented that there are Concerns escalated re regular Locums in A&E s inability to access Mandatory Training so currently unable to take blood cultures.". The IPC Report for September 2015 highlights that this isn t just an issue for regular locums as for A&E across the trust as only 7% of doctors are up to date with Blood Culture Training. Action being taken. Substantive locum to have the training. At QEQM work has been undertaken to improve the situation. HIGH HIGH This issue was raised at the contractual Quality and performance meeting in October and is being followed up by the deputy CNO at EKHUFT. It is on the agenda again for the quality and performance meeting in January. Head of Quality to raise at the next IQIT meeting and will be added into the WHH A&E Deep Dive exercise. Action plan to be shared at the IQIT. In the meantime monitor updates via IPC and PSB minutes/reports. NO NO Feb-16 Feb-16 EKHUFT2015/23T Dec-15 Misplaced naso-gastric feeding tube A Never Event occurred in July 2015 at KCH involving a Swale CCG resident which involved a nasogastric feeding tube being incorrectly placed into the lung. Given that National guidance has been issued and the trust has declared compliance with the best practice this event should not have The incident is currently under investigation. In order to gain assurance that current practice meets national guidance, East Kent CCG's and NHS England conducted a nasgastric tube assurance visit which recommended that EKHUFT commissions an urgent external review looking into the safety of the continued use of CORTRAK Enteral Access Sysstem (EAS) for happened. This has also been highlighted in the CQC inspection report. placement of fine bore nasogastric feeding tubes. Nurses remained nervous of continuing to use the system because of concerns about the consequences of signing to confirm correct placement. The Patient Safety Board believe there is a bigger risk of withdrawing from Cortrack and reverting to the previous system. EKHUFT are in the process of revising its policy which has been submitted to the Patient Safety Board in November. HIGH EKHUFT to feedback results of a review of Cortrack to demonstrate that its benefits were in the best interest of the patient. CCG to monitor the nasogastric assurance report action plan at quality meetings. Further updates to be monitored via IQIT. NO Feb IntegratedQualityandPer Page 17 of 50 Page19of52 OverallPage136of204

136 EKHUFT: QUALITY AND PERFORMANCE ISSUE LOG Issue Reference Date identified Description of Issue Current Position Risk Status (as per escalation process) Actions Risk Register Timescale for Completion EKHUFT2015/24T Dec-15 Health Education Kent, Surrey and Sussex Following a review of the trust's core medical training at KCH by HEKSS in July 2015, HEKSS insisted that changes were made to the Emergency Care Centre (ECC) model by 1st Dec 2015 and the implementation of a new emergency model of care for KCH by August Failure by the trust to undertake this would result in the removal of medical trainees from the KCH site. Main issues identified by HEKSS include: * Patients presented at ECC with either a medical or surgical problem can require a general surgery opinion but General Surgeons are not available at KCH leaving juniors feeling vulnerable * At nights and weekends the ECC takes trainees' time away from patient care in the rest of the hospital * Junior's perception that the ECC is an A&E without the benefit of A&E doctors present * Paediatric and obstetric services are not avaiable 24/7 at KCH which leaves juniors feeling vulnerable * Juniors are being asked to 'act up' without adequate supervision from consultants. Interim arrangements have been put into place as of 1st December 2015: * provide consultant physician presence 12 hours a day 7 days a week; * provide senior surgical review for patients presenting as acute general surgical emergencies Monday to Friday with network surgical advice out of hours; and * minimise the risk of non-medical patients being taken to K&CH. However, this arrangement is reliant on the use of locum staff and overtime to provide the senior clinical input required by HEKSS. In order to ensure medical trainees in the ECC only assess patients with medical problems, the trust is working with SECAMB and Commissioners to cease the referral of all patients with abdominal pains, alcohol intoxication and patients with a primary mental health problem to the ECC at K&CH. In total this equates to less than 3000 attendances a year. Instead, these patients will be taken to either the William Harvey Hospital, Ashford (WHH) or to Queen Elizabeth the Queen Mother Hospital, Margate (QEQMH). HIGH The interim arangements are not sustainable and the trust is working with commissioners to develop a more robust approach by the end of June The trust continues to keep the Kent Health Overview and Scrutiny Committee informed of progress. NO Aug-16 EKHUFT2015/026 EKHUFT2015/024T Oct-15 Maternity: Reading and interpretation of CTGs. Following up on EKHUFT have confirmed they are moving from the K2 training and to the Serious incidents: STEIS and 2015/7970 there is a need to RCOG Training. It will take 1 year before EKHUFT are fully compliant with understand the CTG training package. It has been identified at the the training. Other trusts are using K2 not RCOG training. GROW training EKHUFT quality meeting that the trust needs to undertake further work has commenced in the Community and then will be rolled-out in the acute in this area. The current training has been found to be unsatisfactory setting. EKHUFT is 57% compliant with the revised 1 day CTG training and all staff need to be retrained. As the new training takes 3 days it which is to be completed every 2 years with a shortened CTG refresher will take up to a year to get all staff fully trained. yearly. At the moment, 16% of midwifes in process of completing training and 13% of doctors, this will be updated monthly. HIGH To follow-up compliance with GROW training following SI and to continue to monitor RCOG Training at the IQIT Meeting. GROW training part of TIPS programme which is reported monthly. NO Feb-16 EKHUFT2015/029 EKHUFT2015/027T Oct-15 Maternity Service Issues QEQM: Issues have been identified around 3 There is only 1 theatre at QEQM for sections therefore if there is more areas: 1. Theatres 2. Consent for partners to stay overnight 3. One than one case then there is a significant distance to travel to another matron across 2 sites. theatre. MEDIUM Head of Quality to follow up with the Deputy CNO at Ashford CCG to check that the theatre issue is being included in the ROCG review. The theatres issue is being picked up as part of the CQC exercise and the Thanet Head of Quality will follow up with EKHUFT regarding the policy about partners staying overnight. NO Feb-16 EKHUFT2014/005 EKHUFT2014/005T Feb-14 Maternity Service Outcomes The Trust Maternity dashboard Concerns remain regarding staffing levels and high numbers of serious demonstrates a number of indicators that have been below expected incidents. standards for some months. The CCG is aware from patient and local The Regional Chief Nurse (NHSE) has held an intelligence sharing stakeholder feedback of dissatisfaction with the maternity services conference call with CCGs regarding the maternity serious incidents at provided. There have been a number of serious incidents reported by EKHUFT. EKHUFT in relation to maternity services. The concerns identified by Joint NHSE and RCOG Review taking place 25th-26th November the CCG were supported by the findings of the CQC inspection in Report will be available 6 weeks after the review. March Concerns regarding service provision have been received Maternity Improvement Plan has been shared with the CCGs. Low morale at SKC CCG from a GP in Shepway. of staff. Issues regarding the emergency bell in the Birthing Centre (Kingsgate MLU). A new Head of Midwifery has been appointed. MBRRACE learning and action plan have not yet been received by the CCGs. Maternity midwifery ratio has been shared by EKHUFT which shows bands 3&4 6.4% and Band %. There is a plan to recruit band 2's and have bespoke modules run by Christchurch university so that they can be promoted to band 3 (maternity support worker). MEDIUM An update on the risks was presented at QSG in February It was felt that the concerns now meet the threshold for NHS England to call a risk summit. When the RCOG report (due February) there will be a system wide intelligence sharing call to agree how this will be taken forward which the Chief Nursing Officers (CNOs) will join for the CCGs. NO May-16 EKHUFT2015/033 EKHUFT2015/031T Nov-15 Maternity: Datix Backlog EKHUFT Specialist Services Division Quality & Governance Board Minutes 21/09/2015 identifies a risk of noncompliance with Serious Incident Framework timescales for reporting, investigating and completion of actions. Within the same report it identifies that within midwifery there are a total of 391 outstanding Datix incidents; 331 awaiting review and 60 awaiting approval. MEDIUM To seek assurances at the IQIT Meeting regarding plans to clear the outstanding incidents. NO Feb IntegratedQualityandPer Page 18 of 50 Page20of52 OverallPage137of204

137 EKHUFT: QUALITY AND PERFORMANCE ISSUE LOG Issue Reference Date identified Description of Issue Current Position Risk Status (as per escalation process) Actions Risk Register Timescale for Completion EKHUFT2014/016 EKHUFT2014/016T Oct-14 Safeguarding Adults Assurance It has been identified by the CCG There remain a number of gaps for EKHUFT in terms of safeguarding Designated Nurse for Safeguarding Adults that there has been a lack of adults. The Designated Nurse attended the EKHUFT contract meeting in safeguarding assurance received from EKHUFT against their January 2016 to outline this and request further assurance. Following the contractual requirements. meeting, we were not assured in relation to safeguarding adult arrangements in the following areas: There is no adult safeguarding training strategy; There is a draft Safeguarding Supervision Policy but not ratified as yet; No data regarding staff who receive safeguarding clinical supervision; All adult safeguarding training levels 1-6. No training data supplied in terms of clinical areas or localities; MCA training - no training data supplied; MCA audit. Mention of MCA audit in 9 month report but require full audit proposals and plan; No information about safeguarding alerts upheld that implicate EKHFT; Number of IMCA referrals for Serious Medical Treatment data given to EKHFT from Advocacy service does not separate SMT for EKHFT patients; Domestic abuse included within new policy. However no evidence of action plan submitted about EKHFT work on NICE (50) guidelines; Domestic abuse training no training data; and Prevent strategy no training data. MEDIUM The Designated Nurses for Thanet and South Kent Coast and Canterbury and Ashford will be progressing this with the provider. Written assurance and an action plan has been requested by 1st March R0082/R0098 (risk score 12) Mar-16 EKHUFT2015/001 EKHUFT2015/001T Jan-15 Safeguarding Children Assurance It has been identified by the CCG There remain a number of gaps for EKHUFT in terms of safeguarding Designated Nurse for Safeguarding Children that there has been a lack children. The Designated Nurse for Safeguarding Children attended the of safeguarding assurance received from EKHUFT against their EKHUFT quality meeting in January 2016 to outline this and request contractual requirements. further assurance. Following the meeting the CCG were not assured in full in relation to safeguarding arrangements. MEDIUM An updated gap analysis has been completed by the CCG Desginated Nurses which demonstrates the areas where further assurance is required and the Designated Nurses for Thanet and South Kent Coast and Canterbury and Ashford will be progressing this with the provider. Written assurance and an action plan has been requested from the provider by 1st March 2016 and it will be reviewed again at the EKHUFT Quality Meeting in March 2016 and an update provider to the CCG Commitee in March NO Mar-16 EKHUFT2015/009 EKHUFT2015/007T May-15 Infection Prevention and Control Risk that a lack of specialist Staffing shortages continue within the IPC Team and reflect the National Infection Prevention and Control (IPC) staff at EKHUFT is impacting on shortage of specialist. Currently there are 2 x Band 8a and 2 x Band 7 provision of assurance around various aspects of HCAI management vacancies at EKHUFT and consequently the pressure on the team is e.g. training, patient assessment, notification of alert organisms etc. significant. The Director of Infection Prevention and Control is to step meaning Thanet and SKC residents would be more likely to contract down from January EKHUFT are reviewing priorities in light of winter HCAIs. approaching. Proposal to reduce specialist involvement in RCA's and to push back IPC audits to divisions being presented to Divisional Heads of Nursing for discussion. EKHUFT stopping RCA's regarding E-Coli Bacteraemia within 30 days of surgery due to staffing levels. EKHUFT completing an antimicrobial review with geriatricians. They will produce a prescribing formulary for the elderly so high risk antibiotics are avoided wherever possible. MEDIUM This will be monitored via the HCAI Assurance Panel and will also be raised at the Quality and Performance meeting to discuss how to minimise risk. R0111/R0126 (risk score 12) Feb IntegratedQualityandPer Page 19 of 50 Page21of52 OverallPage138of204

138 EKHUFT: QUALITY AND PERFORMANCE ISSUE LOG Issue Reference Date identified Description of Issue Current Position Risk Status (as per escalation process) Actions Risk Register Timescale for Completion EKHUFT2015/002 EKHUFT2015/002T Feb-15 Health and Social Care Village Beds In 2012 EKHUFT introduced the A copy of the contract and KPI's for the Health and Social Care Village Beds Health & Social Care Village Model. Where by they contracted beds in has been received from EKHUFT. EKHUFT representatives attend the CCG Nursing Homes using Reablement Funding. Currently EKHUFT has 20 Care Homes meetings. CQC reports for AMI Court, The Knoll and beds at Halden Heights (Ashford CCG), 13 beds at Saltwood Care Home Saltwood Care Home all require improvement. Issues relating to H&S risk (SKC CCG), 7 beds at AMI Lodge, Deal (SKC CCG) and 20 beds at AMI assessments and staffing (EKHUFT had discussed with the manager). The Lodge (Thanet CCG). The beds are used for step-down care and Specialist Nurse for Older People visited AMI Court on 27th August 2015 to include dedicated Non-Weight Bearing (NWB) bed base. review some care plans and discuss their action plan following their CQC report and gained assurance regarding the quality of care. Quality visit reports have been requested by CCGs but to date no quality visit reports have been received from EKHUFT. A quality visits schedule has been provided. EKHUFT have provided partial assurance regarding the quality assurance work they are undertaking with Ami Lodge/Court and the other HSCV providers. Discussed at the QIG in October where EKHUFT have confirmed that they are managing HSCVB as if they are a ward. Quality visit reports have been received by the CCG with varying degrees of assurance. Action plan and quality exception report received following peer review visit to AMI Lodge. MEDIUM Further concerns identified in January 2016 following a safeguarding alert. A patient had been admitted to AMI Court on the discharge to assess patient and then deteriorated and was re-admitted to EKHUFT. Concern identified regarding the monitoring of the patient and there is an ongoing theme regarding AMI Court and complex patients. The AMI Court management did not attend the Safeguarding Meeting. KCC to feedback to AMI Court the concerns regarding management and leadership. KCC has no derestriction over the beds and cannot apply sanctions as EKHUFT contract. NO Feb-16 EKHUFT2015/016 EKHUFT2015/014T Sep-15 MRSA Screening Concerns that patients are not being screened as per MRSA screening policy states to screen patients at first attendance to the the MRSA Screening policy. Viking Day Unit this was not undertaken and the senior nurse at the PIR stated that they do not do this on any patient (this was also picked up at one of last weeks PIRs in SKC). Three out of four recent MRSA bacteraemia cases (SKC and Thanet) relate to failure to screen as per policy. Meeting held in November 2015 to review the quality metrics for 2016/17 and increase emphasis on MRSA Screening. Discussed at the HCAI panel in December. KPI's have been reviewed and feedback provided. MEDIUM Monthly audits being conducted on wards across the 3 sites. KPI's around outcomes to be added. NO Feb-16 EKHUFT2015/020 EKHUFT2015/018T Sep-15 Safeguarding Adults and Children in Emergency Care It was identified CCG leads for Safeguarding met with the Safeguarding team at EKHUFT as part of the QEQM A&E deep dive that there is a lack of evidence of which only provided partial assurance. Queries relating to Safeguarding safeguarding training and DoLs in emergency care. The CCG has also children which include training and induction of A and E staff including requested benchmarking information around AP alerts with other A & locums and agency staff and also the system for ensuring staff know E departments. whether there are safety concerns through the patient alert system e.g. if a child was known to have safeguarding concerns, the process that would alert the staff member to contact the safeguarding team. At the meeting verbal assurances were given that the system is robust, that all staff receive a local induction and all agency staff would have received basic safeguarding training. A follow up meeting with Penny Jedrezewski, Named Nurse provided verbal assurance that the alert process had been audited and gaps were identified. The Trust had taken action to raise awareness including s, screen savers. Further assurance to be provided when a re-audit is undertaken and of the Trust induction procedures. Safeguarding training compliance information has been provided but this is not compliant and doesn t break down the information at the levels required. MEDIUM CCG Designated Nurse for Safeguarding Adults to follow up with Safeguarding leads to follow up and liaise with domestic abuse training. Training data broken down by level still not been submitted by provider as no system in place to enable breakdown. Awaiting EKHUFT to provide data. NO Feb-16 EKHUFT2015/021 EKHUFT2015/019T Sep-15 WHH A&E Deep Dive Following concerns around delays and SKC, Ashford and Canterbury & Coastal CCG's are embarking on an A&E deteriorating patients. deep dive at William Harvey Hospital. The process will be a minimum 12 week process similar to that used for the QEQM A&E deep dive. A table top exercise has been completed by SKC CCG. Terms of Reference (ToR) and Project Plan have been agreed. Review will include looking at vulnerable patients. There will be peer reviews alongside the quality visits. Gap analysis is also being conducted. MEDIUM A number of quality visits have already been completed, more visits to follow. NO Mar IntegratedQualityandPer Page 20 of 50 Page22of52 OverallPage139of204

139 EKHUFT: QUALITY AND PERFORMANCE ISSUE LOG Issue Reference Date identified Description of Issue Current Position Risk Status (as per escalation process) Actions Risk Register Timescale for Completion EKHUFT2015/022 EKHUFT2015/020T EKHUFT2015/032 EKHUFT2015/030T Sep-15 Nov-15 Cancer Waiting Times 2 week wait breast symptomatic not hit target This is one of two areas the Trust has a CPN. Breast and dermatology have for 8 months. EKHUFT has pointed to patient cancellation of booked high breach rates. A number of SI's have been reported around delays in appointments. Gap in understanding from a quality perspective. A diagnosis. Meetings to discuss CPN has been issued to EKHUFT. Ophthalmology outpatients backlog There are concerns around the Outpatients raised issue as the waits were long and they were concerned fact that there were patients with delayed/missed follow up in patients had been discharged incorrectly. All have been validated and all Ophthalmology. This relates to the 'switching off' of the auto function were correct as having been treated still being managed or RIP/moved. and was in all specialities. There is not thought to be any clinical harm at present. MEDIUM MEDIUM Thanet QIL to conduct an analysis to gain a more in-depth understanding of the issue and facilitate development of action plan to support local Cancer Strategy and recovery activity. EKHUFT have provided some assurance. Business case has been approved for more staff which will be implemented from April. NO NO Mar-16 Feb-16 EKHUFT2015/030 EKHUFT2015/028T Oct-15 Lack of space for Majors at A&E People with chest pains presenting in A&E are being made to wait in chairs at A&E, QEQM. Lack of clear escalation plan in A&E, situation dependent on who is on shift. EKHUFT2016/001 Feb-16 Tongue Tie Service A complaint has been receieved in SKC CCG about the service and there was a public question from the SKC Governing Body. East Kent Children's Team and SECSU provided an update regarding the service on 10/02/2016: There is a service in WHH-currently for babies 0-12 weeks. There was no provision in Thanet. QEQM following Consultant retirement-secsu had requested service be reinstated but has yet to receive assurance that this has happened. Thanet babies were being sent to London for treatment. Currently the CSU do not have any access to performance figures for the service at any site so reports of long waits cannot be corroborated. MEDIUM Escaltion plan is part of the A&E recovery plan NO Feb-16 MEDIUM The East Kent Children s Team will support SECSU with arranging a meeting with EKHUFT to seek assurance on current service in QEQM. East Kent Children's Team will request performance information for that meeting inc waiting times. Head of East Kent Children s Commissioning Support will escalate concerns to quality leads to ensure it is on the radar. Head of East Kent Children s Commissioning Support will then feed back to you all parties on progress. NO Apr-16 EKHUFT2016/002 Feb-16 Medway NICU At the Maternity Patient Safety Forum on 29th January 2016 CCGs became aware that the NICU in Medway has been closed several times in recent weeks. A SI was delcared due to the closure of the cots and the impact of closure of Maternity units. Sometimes due to capacity other time due to staffing. This has had significant impact on the maternity services and the maternity departments have had to transfer pregnant women. This has affected all maternity departments. EKHUFT recently had to transfer a baby to Portsmouth. The Maternity services in Kent agreed they do not always inform each other when closed, they do not use the network to advise of closures. MEDIUM Work is being dome to see if Maternity services can be reported on SHREWD. In the meantime all maternity services have agreed to formally escalate maternity and SCBU closures through the internal escalation processes in the hospitals for reporting to the health system. NO Apr-16 EKHUFT2015/10 EKHUFT2015/008T Jun-15 Tuberculosis (TB) Late diagnosis of patient in QEQM who is a care Following discussion at CCG Quality Team Away Day 17th September 2015 worker in residential home in Thanet. There now appears to be 3 three actions were identified: 1. Delayed diagnosis - review SI action plan cases of TB within EKHUFT raising concerns around the whole system to assess if there are systems in place to prevent reoccurrence of delayed management of TB. diagnosis. 2. Immunisation - discuss with Sally Smith what assurance has EKHUFT got that there are systems in place. 3. NICE Guidance re: TB Management - review NICE guidance and follow up with CCG finance re: contingency budget. National data shows that SKC and Thanet CCGS have low levels of TB (data 2 yrs old). EKHUFT policy for BCG vaccination has been updated to follow national guidance. E3 (new maternity system replacing Euroking) will provide an electronic notification regarding vaccinations. The trust is conducting a review on Euroking to ensure that no baby eligible for vaccination has been missed. Head of Quality has received information from Public Health which shows that Thanet is not a high reporter. LOW Head of Quality to check policy re: BCG vaccination and then issue can be closed. A further TB cases associated with QEQM is the subject of a meeting in February There was exposure on ITU and on CSM ward for a good few weeks hence concerns. NO Mar-16 EKHUFT2014/009 May-14 Pressure Ulcers Concerns regarding hospital acquired avoidable It was reported at the contractual Quality Meeting on 23rd April 2015 that pressure ulcers were first highlighted in May 2014 following a number pressure ulcer rates have improved ahead of improvement trajectory of Serious Incidents (SI's). The concern has remained open being levels. monitored through the EKHUFT contractual Quality Meeting. LOW The Kent and Medway Patient Safety Collaborative for Pressure Ulcers met in April 2015 and have agreed Term of Reference, Pressure Ulcer definitions and reporting criteria. Serious Incidents (SI) do not demonstrate lessons learnt. SKC Head of Quality to take to IQIT in December for discussion and then escalate if necessary to contractual Quality Meeting. The CCG are going to seek additional assurance around pressure ulcer prevention training and documentation. Work has been taken over by regional team. EKHUFT Acting Deputy Chief Nurse to share presentation from EKHUFT CNO to CCG's. NO Feb IntegratedQualityandPer Page 21 of 50 Page23of52 OverallPage140of204

140 EKHUFT: QUALITY AND PERFORMANCE ISSUE LOG Issue Reference Date identified Description of Issue Current Position Risk Status (as per escalation process) Actions Risk Register Timescale for Completion EKHUFT2014/013 EKHUFT2014/013T Aug-14 Falls There have been increasing concerns regarding the reporting of EKHUFT commenced reporting all falls resulting in a fracture of a major falls by EKHUFT, in particular falls which result in a fracture. A review long bone on STEIS from 1st January SKC have identified a theme of of Serious Incidents (SI's) related to slips, trips and falls has shown that EKHUFT reporting falls due to co-morbities and failure to risk assess; links no SI's had been reported in to cultural concerns within EKHUFT. EKHUFT have been requested to present themes and trends related to Falls SI's at both the contractual Quality Meeting and to the IQIT. The National Inpatient Falls Audit results are now available in which KCH were in the top 5, QEQM is in the top 30 and WHH in the bottom quartile out of the c.170 hospitals. The 'Falls Stop' campaign, focusing on audit, improvement and evaluation was rolled out trust wide in November 2015 as part of the trust's high level action plan for the national audit as well as enabling monitoring of the falls policy and NICE quality standards. LOW National falls audit is being discussed and reviewed. With analysis a trust wide action plan will be developed. Trust to report benchmarking against other organisations. the focus will be on the falls stop programme which looks at patients at risk. EKHUFT are confident that issues around the availability of walking aids will be improved given that a new provider of equipment and investment by EKHUFT in a new ordering system are in place. A process is in place to monitor impact. To be reported back to the quality committee in March. NO Mar-16 EKHUFT2015/015 EKHUFT2015/013T Sep-15 Late Stage Termination of Pregnancy Concerns had been identified Raw data has been received regarding the number of late stage that EKHUFT maybe undertaking late stage termination of pregnancy terminations undertaken by EKHUFT. Analysis of data undertaken to when they were not commissioned to do so. It has been confirmed identify pregnancy rate and conversion for therapeutic and elective that EKHUFT are commissioned to provide late stage termination of terminations. Definition is of what is considered 'late termination of pregnancy for foetal abnormalities. 2 issues to explore: 1) Is there a pregnancy' has been discussed and has been identified as anything over higher frequency of abnormalities within Thanet and Deal areas and 2) 22 weeks. Is maternity screening taking place later in these areas? LOW Awaiting EKHUFT Head of Midwifery to supply a review of how appropriate and timely the screening is against national guidance and benchmarking. To be fed back through the IQIT. NO Feb-16 EKHUFT2015/017 EKHUFT2015/015T Sep-15 Paediatric DNA Policy A Serious Incident from KCHFT reported to Thanet CCG highlighted gaps in Paediatric DNA policy at EKHUFT. LOW Head of Quality to follow up with EKHUFT via IQIT. NO Feb-16 EKHUFT2015/024 Sep-15 Maternal Death Review Patient Safety Collaborative undertaking Policy and framework is in the process of being revised. Templates have LOW First exercise completed around incidents which could contribute to maternal death. NO Feb-16 EKHUFT2015/022T review to understand the gaps in the process. been sent out to providers to complete. EKHUFT not present at the meeting. Providers to work up individual action plans following the meeting. It has been noted that EKHUFT have not supplied their action plans around both the old and new EMBRACE reports. The new EMBRACE report was published in November EKHUFT2015/032 EKHUFT2015/030T Dec-15 NICU transportation and retrieval services Serious incident reported raised concerns around delays in transfer times. LOW Raised at IQIT. EKHUFT agreed that they will report all cot closures via maternity review forum. NO Mar-16 EKHUFT2015/033 EKHUFT2015/031T Dec-15 Oxygen policy The minutes from the PSB meeting noted a number of Consultant physician at QEQM has provided details of oxygen reported problems including clinical incidents which had resulted in patient incidents. harm. LOW HoQ to review and assess if further assurance is required. NO Feb-16 EKHUFT2015/034 Dec-15 Workforce: Lack of accommodation for agency staff EKHUFT are using staff provided by London agencies but there is not LOW Head of Quality to follow up in IQIT. NO Feb-16 EKHUFT2015/032T enough accommodation for these staff. EKHUFT2015/035 Dec-15 Workforce: Overseas recruitment of nursing staff New overseas recruits receive 1 week induction by EKHUFT although there LOW Head of Quality to follow up in IQIT. NO Feb-16 EKHUFT2015/033T are concerns that there is limited on-going support for these staff to help them settle in and stay. EKHUFT2016/003 Feb-16 Legionnaires Disease PHE notified HSE who visited and scrutinised EKHUFT Legionella control CLOSED EKHUFT shll keep enhanced surveillance of the system in place for a period of time to NO CLOSED A case was notified to PHE by Kings College Hospital as a possible case prograame, examined records of water termperatures, etc and were ensure the water system remains "in control". acquired in EKHUFT. satisfied that all was in order. PHE locally were involved from the very beginning and have been kept infomed about the local water sampling undertaken and results obtained. EKHUFT2015/007 Apr-15 Harbledown Ward During the months of October and November a At the IQIG Meeting in October 2015 EKHUFT Acting Deputy CNO outlined number of claims and concerns were brought to the attention of the the positive improvements on Harbledown ward which were shared at the Directorate Management Team at EKHUFT. These were by way of recent Quality Summit. An interim ward manager is in post, supported by Datix reporting, Adult Protection Alerts and a general feeling of the new Matron and Senior Matron. Band 6s and Band 5s are rotating to concern regarding ward issues. The issues raised were those of poor other areas for experience. A lot of work has been completed on the high pressure ulcer management, inadequate documentation completion impact interventions e.g. heel offloading, nutrition, EDN and dementia CLOSED QILs have reviewed heatmap - assurance gained. Will continue to monitor ward. NO Feb-16 and raised complaints. care. A staff room is now available. All patients recommended the ward in the August FFT. Inpatient surveys are completed and reviewed regularly. 4.2IntegratedQualityandPer Page 22 of 50 Page24of52 OverallPage141of204

141 EKHUFT: QUALITY AND PERFORMANCE ISSUE LOG Issue Reference Date identified Description of Issue Current Position Risk Status (as per escalation process) Actions Risk Register Timescale for Completion EKHUFT2015/023 EKHUFT2015/021T Sep-15 Closure of NICU cots at Medway due to restructuring. EKHUFT had raised concerns that this had not been communicated to them however it transpires that relevant people had been notified but not through the official route. Concerns around communication between maternity wards and NICU, transportation and retrieval service were discussed at QIG in October and Maternity Forum. CLOSED It has been identified through a SI that a pilot is taking place at Regional Level. Medway NICU cots are now open. NO CLOSED EKHUFT2015/11 EKHUFT2015/009T Jul-15 QEQM Falls and Pressure Ulcer Rates High falls and pressure ulcer For Seabathing ward EKHUFT have advised that quality issues have been rates at Bishopstone and Seabathing wards. identified following the Heatmap for July identifying a reduction in FFT scores. Lots of actions in train around Seabathing ward including movement of staff, action plan, consultation with consultants. Things are improving so a quality summit is no longer deemed necessary. The ward is being closely monitored. Verbal assurance have been received via the IQIT Meeting. To be a standing item on IQIT Meeting agenda. Head of Quality to conduct a quality visit to gain further assurance. Heatmap data shows improvement although still flagging red. Culture remains an issue. CLOSED There has been a reduction in falls and Pressuer Ulcers and therefore this issue to be closed. NO CLOSED 4.2IntegratedQualityandPer Page 23 of 50 Page25of52 OverallPage142of204

142 Data Source Latest Data KENT COMMUNITY HEALTH NHS FOUNDATION TRUST (KCHFT) INDICATOR KCHFT LONG TERM CONDITIONS (LTC) LTC: CARDIAC LTC: RESPIRATORY INTERMEDIATE CARE TEAM (ICT) VICTORIA HOSPITAL, DEAL DEAL MINOR INJURIES UNIT (MIU) FOLKESTONE WALK IN CENTRE (WIC) YTD Target YTD Actual Trend YTD Target YTD Actual Trend YTD Target YTD Actual Trend YTD Target YTD Actual Trend YTD Target YTD Actual Trend YTD Target YTD Actual Trend YTD Target YTD Actual Trend YTD Target YTD Actual Trend Service Level TRUST SKC CCG SKC CCG SKC CCG SKC CCG SKC CCG SKC CCG SKC CCG Outcome 1 Preventing People from Dying Prematurely Outcome 2 - Enhancing Quality of Life for People with Long Term Conditions P Admissions Avoided Dec N/A 2,073 N/A 2,641 P SECAMB Conveyances Avoided Dec N/A 162 P SECAMB Admissions Avoided Dec N/A 54 P Re-admissions to Acute Following Step-Down Dec N/A 97.2% P Re-admissions to Community Hospital Dec N/A 0 P Delayed Transfers of Care Dec 3.5% 0.0% N Dementia: Percentage of Cases Identified Nov 90% 54% N Dementia: Percentage of Cases with Diagnostic Assessment Nov 90% 100% Outcome 3 - Helping People to Recover from Episodes of Ill Health, or Following Injury P Activity Dec 111,424 78,902 1,241 1,574 2,790 2,101 62,650 47, N/A 7,402 N/A 15,289 P Referrals Dec P Waiting Times (See Within 4 Hours) Dec 95% 0% 95% 0% P Use of Step-Up Beds Dec N/A 0% P Median Length of Stay Dec 21 0 P Occupancy Dec 87% 0% P Percentage Referred onto Acute (A&E) Dec N/A 0% N/A 0% P Percentage Referred onto Acute (In/Outpatient) Dec N/A 0% N/A 0% Outcome 4 - Ensuring that People Have a Positive Experience of Care P Complaints Dec N/A 8 N/A 2 N/A 1 N/A 0 N/A 2 P Patient Experience (%) Dec 90% 92% 90% 98% 90% 91% 90% 97% 90% 96% P Friends and Family Test Score: Patients Dec 95% 97% 95% 96% 95% 84% 95% 96% 95% 98% 95% 97% P Friends and Family Test: Staff: Recommend Work Q2 62% 13800% P Friends and Family Test: Staff: Recommend Care Q2 79% 500% E MSA Breaches Dec 0 0 H PLACE: Cleanliness % 97.38% 97.57% 97.05% H PLACE: Food % 90.67% 88.49% 93.59% H PLACE: Privacy, Dignity and Wellbeing % 81.63% 86.03% 83.62% H PLACE: Condition, Appearance and Maintenance % 88.87% 90.11% 93.97% H PLACE: Dementia % 57.75% 74.51% 50.87% Outcome 5 - Treating and Caring for People in a Safe Environment: Protecting Them from Avoidable Harm P Care Quality Commission: Safe Sep-14 Good P Care Quality Commission: Effective Sep-14 Requires Improvement P Care Quality Commission: Caring Sep-14 Good P Care Quality Commission: Responsive Sep-14 Good P Care Quality Commission: Well-Led Sep-14 Good P Compliance with CAS Alerts Dec 100% 100% P Serious Incidents Dec N/A 2 N/A 1 N/A 0 N/A 0 N/A 0 P Patient Incidents Dec N/A 68 N/A 36 N/A 31 N/A 2 N/A 0 P Harm Free Care Dec 95% 94.7% 95% 98% 95% 100% 95% 99% P C.difficile Dec N/A 0 P MRSA Dec 0 0 P Mandatory Training (All) Dec 85% 94% 85% 91% 85% 92% 85% 99% 85% 95% P Infection Prevention & Control Training Dec 85% 90% 85% 89% 85% 84% 85% 100% 85% 600% P Safeguarding Children Training Dec 85% 89% 85% 87% 85% 87% 85% 100% 85% 0% P Safeguarding Adults Training Dec 85% 86% 85% 84% 85% 76% 85% 73% 85% 0% P Appraisals Dec 85% 79% 85% 80% 85% 96% 85% 90% 85% 100% P Long Term Sickness Dec 3.73% 4.42% 3.73% 1.47% 3.73% 2.74% 3.73% 4.28% 3.73% 0.77% P Short Term Sickness Dec 1.32% 2.49% 1.32% 1.94% 1.32% 1.57% 1.32% 2.42% 1.32% 0.91% P Turnover Dec 10% 15% 10% 13% 10% 20% 10% 26% 10% 15% P Vacancy Rate Dec 5% 7% 5% 18% 5% 18% 5% 16% 5% 0% P Average Shift Fill Rate - Safer Staffing Dec 100% % 4.2IntegratedQualityandPer Page 24 of 50 Page26of52 OverallPage143of204

143 Data Source Latest Data Data Source Latest Data KENT COMMUNITY HEALTH NHS FOUNDATION TRUST (KCHFT) INDICATOR PODIATRY PODIATRY: ORTHOTICS MUSCULOSKELETAL PHYSIOTHERAPY (MSK) CHRONIC PAIN SERVICE ORTHOPAEDICS LYMPHOEDEMA CONTINENCE EPILEPSY YTD Target YTD Actual Trend YTD Target YTD Actual Trend YTD Target YTD Actual Trend YTD Target YTD Actual Trend YTD Target YTD Actual Trend YTD Target YTD Actual Trend YTD Target YTD Actual Trend YTD Target YTD Actual Trend Service Level EAST KENT EAST KENT EAST KENT KENT KENT KENT KENT KENT Outcome 1 Preventing People from Dying Prematurely Outcome 2 - Enhancing Quality of Life for People with Long Term Conditions Outcome 3 - Helping People to Recover from Episodes of Ill Health, or Following Injury P Activity Dec 21,061 15,021 1, ,581 2,220 3,103 4,119 8, , P Referrals Dec N/A 2540 N/A 5,253 N/A 1,336 N/A 4527 N/A 86 N/A 731 N/A 82 P Waiting Times (% Seen within 18 Weeks) Dec 95% 90% 95% 100% 95% 100% Outcome 4 - Ensuring that People Have a Positive Experience of Care P Complaints Dec N/A 7 N/A 1 N/A 2 N/A 0 N/A 1 N/A 2 N/A 0 P Patient Experience (%) Dec 90% 92% 90% 99% 90% 97% 90% 98% 90% 98% 90% 92% P Friends and Family Test Score Dec 95% 95% 95% 98% 95% 94% 95% 97% 95% 100% 95% 100% Outcome 5 - Treating and Caring for People in a Safe Environment: Protecting Them from Avoidable Harm P Serious Incidents Dec N/A 0 N/A 0 N/A 0 N/A 0 N/A 0 N/A 0 N/A 0 P Patient Incidents Dec N/A 5 N/A 1 N/A 2 N/A 0 N/A 0 N/A 2 N/A 0 P Mandatory Training (All) Dec 85% 97% 85% 96% 85% 97% 85% 97% 85% 97% 85% 96% 85% 99% P Infection Prevention & Control Training Dec 85% 97% 85% 94% 85% 96% 85% 90% 85% 95% 85% 0% P Safeguarding Children Training Dec 85% 93% 85% 94% 85% 93% 85% 86% 85% 86% 85% 0% P Safeguarding Adults Training Dec 85% 91% 85% 94% 85% 100% 85% 83% 85% 90% 85% 0% P Appraisals Dec 85% 85% 85% 100% 85% 100% 85% 93% 85% 90% 85% 82% 85% 100% P Long Term Sickness Dec 3.73% 1.14% 3.73% 0.00% 3.73% 0.37% 3.73% 0.00% 3.73% 4.37% 3.73% 1.55% 3.73% 0.00% P Short Term Sickness Dec 1.32% 1.28% 1.32% 1.70% 1.32% 1.70% 1.32% 1.41% 1.32% 3.57% 1.32% 1.17% 1.32% 3.05% P Turnover Dec 10% 22% 10% 7% 10% 31% 10% 21% 10% 0% 10% 29% 10% 0% P Vacancy Rate Dec 5% 15% 5% 20% 5% 15% 5% 19% 5% 7% 5% 11% 5% -17% INDICATOR YTD Target DIABETES WHEELCHAIR SERVICE DIETETICS AND NUTRITION CARDIAC REHABILIATION PULMONARY REHABILIATION LEARNING DISABILITIES YTD YTD YTD Actual Target YTD Actual Trend YTD Target YTD Actual Trend YTD Actual Trend YTD Actual Trend Target YTD Actual Trend Trend YTD YTD Target Target CHILDREN'S COMMUNITY NURSING YTD YTD Actual Trend Target Service Level KENT KENT KENT KENT KENT KENT KENT Outcome 1 Preventing People from Dying Prematurely Outcome 2 - Enhancing Quality of Life for People with Long Term Conditions Outcome 3 - Helping People to Recover from Episodes of Ill Health, or Following Injury P Activity Dec 3,505 3,362 5,097 3,749 5,655 5,029 4,235 2,368 6,645 6,051 3,819 5,541 P Referrals Dec N/A 755 N/A 587 N/A 456 N/A #N/A P Waiting Times (% Items Delivered within 7 Days) Dec Outcome 4 - Ensuring that People Have a Positive Experience of Care P Complaints Dec N/A 0 N/A 2 N/A 1 N/A 0 N/A 0 N/A 0 N/A 0 P Patient Experience (%) Dec 90% 96% 90% 99% 90% 99% 90% 99% 90% 99% 90% 93% 90% 98% P Friends and Family Test Score Dec 95% 100% 95% 99% 95% 99% 95% 100% 95% 100% 95% 99% 95% 95% Outcome 5 - Treating and Caring for People in a Safe Environment: Protecting Them from Avoidable Harm P Serious Incidents Dec N/A 0 N/A 0 N/A 0 N/A 0 N/A 0 N/A 0 N/A 0 P Patient Incidents Dec N/A 0 N/A 1 N/A 7 N/A 2 N/A 1 N/A 2 N/A 0 P Mandatory Training (All) Dec 85% 99% 85% 99% 85% 97% 85% 100% 85% 98% 85% 97% 85% 96% P Infection Prevention & Control Training Dec 85% 100% 85% 100% 85% 89% 85% 7100% 85% 100% 85% 93% 85% 28600% P Safeguarding Children Training Dec 85% 96% 85% 97% 85% 87% 85% 4400% 85% 100% 85% 90% 85% 900% P Safeguarding Adults Training Dec 85% 90% 85% 92% 85% 83% 85% 0% 85% 87% 85% 89% 85% 0% P Appraisals Dec 85% 100% 85% 100% 85% 97% 85% 98% 85% 100% 85% 93% 85% 88% P Long Term Sickness Dec 3.73% 0.00% 3.73% 1.39% 3.73% 0.53% 3.73% 1.54% 3.73% 0.00% 3.73% 1.06% 3.73% 1.56% P Short Term Sickness Dec 1.32% 0.97% 1.32% 1.19% 1.32% 1.42% 1.32% 1.63% 1.32% 1.05% 1.32% 1.75% 1.32% 1.79% P Turnover Dec 10% 6% 10% 25% 10% 16% 10% 7% 10% 11% 10% 13% 10% 17% P Vacancy Rate Dec 5% 2% 5% 8% 5% 7% 5% -3% 5% 5% 5% 11% 5% 15% 4.2IntegratedQualityandPer Page 25 of 50 Page27of52 OverallPage144of204

144 KCHFT QUALITY/PERFORMANCE CONCERN TRIANGULATION DESCRIPTION OF CONCERN: DATE CONCERN INDENTIFIED: Workforce: Long Term Conditions Service - Community Nursing Feb-14 BACKGROUND: Workforce Staffing levels (sickness and vacancy rates) and recruitment and retention continue to cause concern. There is a risk patients are not receiving holistic assessments. Soft intelligence indicates staff are delivering task based care. Despite assurances from management that staffing levels are improving, intelligence suggests the service has been in crisis and this is impacting on the care that is being provided. GPs have expressed concerns about the competency and conduct of agency staff. CURRENT POSITION: The Contract Performance Notice (CPN) issued on 9th February 2015 has now been closed. The CPN was raised as a result of the following concerns; 1. The lack of deployed clinical staff, due to vacancies, turnover and maternity leave, which has led to gaps in the staff establishment required to deliver a safe community nursing service. 2. A lack of clinical and operational leadership which impacts on the delivery of a safe community nursing service. 3. Concerns about the competence of staff to deliver a safe community nursing service. South Kent Coast CCG acknowledges that the action plan associated with the query notice has been completed but it should be noted that although the CPN has been closed the CCG will continue to monitor the service in terms of activity, staffing and quality via the Contract Performance meetings. ACTION PLAN: To continue to monitor through the contractual Quality and Performance Meetings. Head of Quality to undertake further Quality Visit booked for 19th February 2016 (Romney Marsh Team). Work to develop Service Operating Procedures (SOPs) is being taken forward as part of the 2016/17 contract negotiations. The next meeting is on 12th February RISK RATING: (Refer to Appendix I) HIGH EXPECTED RESOLUTION DATE: Mar-16 PLACED ON RISK REGISTER: R0107 (risk score 16) 4.2IntegratedQualityandPer Page 26 of 50 Page28of52 OverallPage145of204

145 KCHFT (SKC CCG): QUALITY AND PERFORMANCE ISSUE LOG Issue Reference Date identified Description of Issue Current Position KCHFT2014/004 Oct-14 Paediatric Safeguarding Liaison Service It has been identified by The service commissioned is not the service that is currently being delivered by the provider. No EKHUFT that there is currently a 3 month backlog in the Paediatric performance monitoring has been taking place. Head of East Kent Children's Commissioning is Safeguarding Liaison Service which is provided to them by KCHFT. leading the working group. The original service specification cannot be found. Meeting held in December made it clear that KCHFT is providing a paediatric liaison service and not a safeguarding service to EKHUFT. The backlog is on the trust's risk register and reviewed on a regular basis - the backlog in Deal/Shepway is now cleared and the backlog at Dover is in progress. Still awaiting data from KCHFT to confirm how many children are included in the backlog. Risk Status (as per escalation process) HIGH Actions Initially the plan was to review pathways and processes between EKHUFT and KCHFT. Report submitted to CLT which highlighted significant gaps in the service and it was recommended to CCGs to decommission the service. CCG to monitor trusts risk register to ensure backlog has been cleared in full. Head of Safeguarding has requested further assurance. Risk Register NO Timescale for Completion Feb-16 KCHFT2014/005 Sep-15 Looked After Children (LAC) There is a risk that, despite national CCGs received a report on the issue which included the risks and actions needed. Letter sent to requirements, Health Histories for care leavers are not being KCHFT requesting an action plan to address the issue and costings to provide the service. The CCGs completed by KCHFT causing CCG to miss statutory targets and are aware that there are year olds who require health histories. Costings and action plan has resulting in both financial implications for the CCG, as additional been agreed by the CCGs with KCHFT. A form of words has been sent to KCC for them to send out to capacity is needed to clear a backlog and reputational damage for the the 18/19 year olds to gain consent for their health history to be written. Final number of this age CCG. group will not be known until the consent forms have been returned. Light touch health history template has been written and agreed to be used with all 17, 18 and 19 year olds. Agreement has been reached that KCHFT will now embed as normal business the starting of health histories as children and young people become looked after. KCHFT2015/015 Oct-14 Safeguarding Assurance KCHFT has consistently failed to achieve their There has been a willingness to meet and share safeguarding data. The majority of services are now targets in relation to safeguarding training since April 2014 and this above 85%, there are a few services that are below the target and work continues within the services was an area highlighted in the CQC Inspection in September to achieve the 85%. It was noted that in the breakdown report the % is impacted when there are small staff numbers. KCHFT2015/016 Jul-15 Flu Vaccinations It has been included in the 2015/16 contract that It was raised with the provider at the Local Operational Meeting in June and has been raised with the KCHFT will deliver vaccines to all housebound patients not on their Chief Operating Officer (COO). The risk has been identified on the CCG risk register. caseload. KCHFT2015/009 Jul-15 Central Referral Unit (CRU) KCHFT provide 1.6 WTE (2) nurses to The contracting arrangements for the CRU are unclear. West Kent CCG are reviewing the metrics for triage incoming referrals in the multi-agency CRU for safeguarding the contract. referrals. HIGH MEDIUM MEDIUM LOW KCHFT report having staff in place to start this work but no start date has been confirmed. CCGs have requested a work plan to better understand the timeframe. Designated Nurses for Safeguarding to continue to monitor through KCHFT Local Operational Meetings. To be followed up in the Quality and Performance meeting in December West Kent Designated Nurse for Safeguarding Adults is reviewing the contracting arrangements and looking at KPI's. Designated Nurse for Safeguarding Children to follow up with West Kent CCG Designated Nurse to get update. KCHFT are conducting an internal review of datix to ensure that serious incidents are being reported correctly. Awaiting report. KCHFT2015/011 Sep-15 Serious Incident Reporting Following the updated Serious Incident The lack of assurance around this issue was discussed with KCHFT in the SKC CCG Quality and Framework issued in March 2015 there are concerns that the revised Performance Meeting due to the absence of a trigger list following the new national SI framework. definitions and guidance has resulted in low reporting of Serious Incidents. LOW KCHFT2015/012 Sep-15 Collaborative working with KCHFT and domiciliary partners It is unclear how KCHFT would address any issues with other domiciliary providers LOW KCHFT Head of Service to look at policy and feedback to CCG. To follow-up at the contractual Quality and Performance Meeting in December KCHFT2015/013 Oct-15 Social Services ability to admit to a hospital bed as a place of safety (coming out of SI review) KCHFT2015/014 Nov-15 Cannulation by KCHFT Community Children Nurses on EKHUFT Ward Community children's nurses have been attending the wards to cannulate children as the ward staff KCHFT Community Children's Nurses have been attending the wards to can't do it. There has been another issue with the needle that EKHUFT are using for children too. cannulate children as the ward staff cant do it; ward staff have not had the right training and do not have the right equipment. KCHFT2015/015 Nov-15 Paediatric Continence Services/Provision Following the It has been agreed that this is a service which is commissioned by NHS England. Whilst this is being commissioning of school nursing services by KCC they have been resolved the School Nurses are continuing to provide the service. advised not to provide continence products, support and training as it is not part of the service specification. It is a precedent. R0118 (risk score 15) R0082 (risk score 12) R0119 (risk score 15) NO NO NO Feb-16 Jan-16 Feb-16 Feb-16 Feb-16 Feb-16 LOW Head of Quality to follow up with Social Services NO Feb-16 LOW LOW Head of Quality to discuss further with provider to understand the issue around whether ward staff training gaps or correct equipment available. KCHFT have been requested to raise this directly with EKHUFT provider to provider. Head of East Kent Children's Commissioning to follow-up. Paper is being submitted to the Quality and Performance meeting in December to discuss how KCHFT intend to hand this over. NO NO Feb-16 Feb-16 KCHFT2015/016 Nov-15 Pulmonary Rehabilitation Pulmonary rehabilitation issues due to commissioning of service. Waiting list is increasing there are quality issues for patients. LOW Awaiting details from Commissioners regarding the specific quality concerns. NO Feb IntegratedQualityandPer Page 27 of 50 Page29of52 OverallPage146of204

146 Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory KENT AND MEDWAY NHS AND SOCIAL CARE PARTNERSHIP TRUST (KMPT) Outcome 1 - Preventing People from Dying Prematurely Indicator Actual YTD Trend Outcome 2 - Enhancing Quality of Life for People with Long Term Conditions Indicator Actual YTD Trend Outcome 3 - Helping People to Recover from Episodes of Ill Health, or Following Injury Indicator Actual YTD Trend Mortality (SKC) Treating People out of Hospital (SKC) Activity (SKC) P 7 day follow-up after discharge (on CPA) Sep 95% 89% 96% P Readmission w/in 28 days Nov 5% 0.0% 10.0% P IP Admissions Nov P 7 day follow-up after discharge (All) Mar 95% 89% 90% P Delayed transfers of care Sep 7.5% 32% 33% P IP Discharges Nov crisis resolution home treatment team gatekeeping Nov 95% 100% 100% P EIS referrals Nov 7 60 P Number of Suicides (suspected) while in KMPT Care Dec N/A 3 25 P CMHT referrals Nov P Number of patient safety incident related deaths reported to NPSA Patient Safety Incidents (KMPT all CCGs) Improving Physical Health (KMPT all CCGs) Dec N/A 1 18 P People on CPA in accommodation Nov 75% 84% 87% P Referrals not accepted Nov P People on CPA in employment Nov 10% 3.0% 3.0% P CMHT caseload Nov 1400 P Physical health checks in-patients Dec 95% 94% 94% Dementia Waiting times (SKC) P Physical health checks community Q3 80% 36% 36% P KMPT Dementia Diagnosis Rate 0% P 4 Week wait for assessment adult Nov 85% 99% 88% Improving Access to Psychological Therapy (IAPT) (SKC) H IAPT Recovery rate Nov 50% 37% 42% P P 4 Week wait for assessment OP Nov 85% 97% 81% P 18 Week wait for treatment adult Nov 90% 100% 98% P 18 Week wait for treatment OP Nov 90% 100% 95% Proportion of patients in eligible clusters on CPA Nov 95% 32% 32% H IAPT % entered treatment Nov 54% P Discharged on CPA Nov 100% 37% 48% IAPT % 18 week RTT Nov 95% 67% 72% P CPA Care plan up to date Nov 95% 74% DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) K = SECSU Quality of care (SKC) P Risk assessment up to date Nov 95% 76% 4.2IntegratedQualityandPer Page 28 of 50 Page30of52 OverallPage147of204

147 Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory KENT AND MEDWAY NHS AND SOCIAL CARE PARTNERSHIP TRUST (KMPT) Outcome 4 - Ensuring that People Have a Positive Experience of Care Indicator Actual YTD Trend Outcome 5 - Treating and Caring for People in a Safe Environment: Protecting Them from Avoidable Harm Indicator Actual YTD Trend Summary Key themes relating to concerns regarding the performance and quality of care provided by KMPT include: Friends and Family Test: Patients (KMPT all CCGs) Care Quality Commission (KMPT all CCGs) N Would Recommend Dec-15 88% 91% 86% C Safe Jul-15 N/A Requires Improvement Friends and Family Test: Staff (KMPT all CCGs) C Effective Jul-15 N/A Requires Improvement N Would Recommend Work Q2 62% 52% 53% C Caring Jul-15 N/A Good N Would Recommend Care Q2 79% 62% 62% C Responsive Jul-15 N/A Requires Improvement Complaints/Compliments (KMPT all CCGs) C Well-Led Jul-15 N/A Requires Improvement P Compliments Dec N/A Health Care Associated Infections (HCAI) (KMPT all CCGs) P Complaints (including MP Enquiries) Dec N/A P MRSA Bacteraemia Dec Mixed Sex Accommodation (MSA) (KMPT all CCGs) P C. Difficile Dec N MSA Breaches Dec P Hand Hygiene Training Dec 85% 90% 90% P Wrong Gender Bathroom Incidents Dec Patient Safety Thermometer (KMPT all CCGs) Care Planning & Coordination (KMPT all CCGs) H Harm Free Care Nov 95% 98% 98% % of service users in PbR clusters 4, 8 & 10 who have P designated care co-ordinator % of service users in PbR clusters 4,8 & 10 receiving a P comprehensive assessment Q3 95% 76% 76% H NEW VTE Nov N/A 0 7 Q3 95% 81% 81% H New Pressure Ulcers Nov N/A 0 2 P % of service users using a Recovery Star Q3 TBA 8% 8% H Falls with Harm Nov N/A 2 18 Acute Inpatient Beds Application of Care Programme Approach Workforce Dementia Liaison Psychiatry Serious Incident Investigation Lack pf Physical Health Care Increased Reporting of Suicides CQC Report Post 72 Hour C. difficile at St Martins Hospital Section 136 Suite Medical Oversight P P P Acute inpatients (all age) experiencing one or more incidents of control & restraining Acute inpatients (all age) experiencing one or more incidents of seclusion All inpatients who have nutritional assessment in total Restraint & Seclusion (KMPT all CCGs) Nutritional Assessments (KMPT all CCGs) Patient-Led Assessment of the Care Environment (PLACE) (KMPT all CCGs) Incident Reporting (KMPT all CCGs/SKC CCG (see below)) Q3 N/A K Serious Incidents Reported - KMPT Total Dec N/A Q3 N/A K Serious Incidents Reported - SKC CCG Total Dec N/A 2 23 K Never Events Reported - KMPT Total Dec Dec 95% 80% 80% K Never Events Reported - SKC CCG Total Dec Central Alerts System (CAS) (KMPT all CCGs) H Cleanliness % 99.32% 99.32% CA Compliance with Deadlines Dec 100% 100% 84% H Food % 90.27% 90.27% Safeguarding (KMPT all CCGs) H Privacy, Dignity and Well-Being % 91.49% 91.49% P Level 1 - Children Training Dec 85% 98% 98% H Condition, Appearance and Maintenance % 93.95% 93.95% P Level 2 - Adults Training Dec 85% 89% 89% H Dementia % 90.02% 90.02% Workforce (KMPT SKC CCG) P Vacancy Rate Dec <15% 16% 12% P Sickness Dec 3.90% 3.42% 4.25% P Turnover Dec 14% 6% 3% DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) K = STEIS CA = Central Alerts System 4.2IntegratedQualityandPer Page 29 of 50 Page31of52 OverallPage148of204

148 KMPT QUALITY/PERFORMANCE CONCERN TRIANGULATION DESCRIPTION OF CONCERN: DATE CONCERN INDENTIFIED: Acute Inpatient Beds Risk Share Oct-15 BACKGROUND: Increasing use of out of area beds in east Kent CURRENT POSITION: CQN issued in October 2015 regarding use of out of area beds. KMPT will be required to provide a plan identifying: trajectory to improve efficiency of inpatient bed stock in Kent and Medway and reduce the numbers of East Kent patients placed out of area; implement an agreed plan to reduce the length of stay for EK patients in acute beds and manage staff vacancy levels and prioritise staff workload to support the reduction in use of acute out of area beds. Out of area and PICU placements are reviewed on a daily basis by KMPT and patients repatriated as soon as possible. ACTION PLAN: Action plan agreed including management of bed stock and Scoping of in-year additional capacity options, reduction of length of stay, remodelling of complex care panel, twice weekly conference calls with CCGs, and community capacity review. Issues identified from the twice weekly conference calls have been escalated to Director level and include: * no cover for case managers at times of absence; * referral process for funding and placements needs to be clarified and strengthened to all staff in acute and community service lines; * discharge planning processes are being reviewed; * case note deep-dive audit for top ten frequent users of in-patient beds to be undertaken. RISK RATING: (Refer to Appendix I) EXPECTED RESOLUTION DATE: to be determined in action plan PLACED ON RISK REGISTER: 4.2IntegratedQualityandPer Page 30 of 50 Page32of52 OverallPage149of204

149 KMPT QUALITY/PERFORMANCE CONCERN TRIANGULATION DESCRIPTION OF CONCERN: Liaison Psychiatry DATE CONCERN INDENTIFIED: BACKGROUND: Failure to agree plans for improved Psychiatric liaison Service CURRENT POSITION: KMPT has been issued a CQN in October 2015 with a requirement to develop an agreed improvement plan for Psychiatric Liaison Service across East Kent. ACTION PLAN: A proposal has been put forward by CCGs for additional investment in all ages psychiatric liaison service development. CCGs are to be informed of allocation and 50% of funds to be released by October Further assurance are required by NHS England regarding the scope of plans to deliver 24 hr services and to meet CAMHS transition requirements before the final 50% of funding is released. Funding is non-recurrent and sustainability of delivery will need to be addressed. Plans in place include funding of additional psychiatric liaison clinical post and further development of CAMHS transition pathway. RISK RATING: (Refer to Appendix I) EXPECTED RESOLUTION DATE: PLACED ON RISK REGISTER: 4.2IntegratedQualityandPer Page 31 of 50 Page33of52 OverallPage150of204

150 KMPT QUALITY/PERFORMANCE CONCERN TRIANGULATION DESCRIPTION OF CONCERN: DATE CONCERN INDENTIFIED: Serious Incident Investigation Nov-14 BACKGROUND: KMPT are currently submitting management investigations not root cause analysis investigations which are being rejected by the CCG. Due to this KMPT have a high number of open SI's. understanding of Root Cause Analysis (RCA) investigations and their inability to identify root causes. Concerns include KMPT's CURRENT POSITION: KMPT are continuing to submit inadequate RCA investigations and there is a lack of executive sign-off. This was escalated at SKC CCG Quality and Performance Committee in April Concerns escalated to QSG and NHSE where the standard of RCAs is recognised as poor. KMPT have been supplied with a list of outstanding RCAs. SKC CCG Head of Quality attended a meeting with NHSE on 19th October looking at the quality of some of the RCA's submitted by KMPT and how best to progress with the closure of these SI's given the deadline. NHSE will be attended the Pan-Kent SI meeting which will need to be refocused. NHSE have confirmed that the CCG is correct in it's approach that the RCAs should stand along. Telecom held with KMPT to discuss the ongoing issues with the RCAs on 20th October NHSE have reviewed a sample of RCAs and agree with the CCGs assessment about the poor quality of the reports and the lack of information contained within them and the fact that there is not a consistent template in use. SKC CCG Head of Quality attended KMPT Learning Review Meeting on 25th November Ashford and Canterbury CCG Quality Lead to provide SI training to KMPT Meeting held on 5th January 2016 with NHSE, CCGs and KMPT Medical Director and Patient Safety Manager to address the ongoing issues with the RCA investigations and reports and how actions are implemented. ACTION PLAN: Following the meeting on 5th January 2016 NHSE suggested a closure proposal that had been used with other providers/ccgs: STEIS 1 open SI ( Pre May 2015): Provider to review all open SI investigations: Identify which cases can be reinvestigated and complete. Identify cases that can t be reinvestigated and briefly explain why and undertake the following assurance process. Identify all root causes, contributory factors. Map these to current operations. Identify where actions/ interventions/ developments etc. have taken place that now mitigate and reduce the risk of harm to patients. Provide assurance that these interventions have been effective - have there been further incidences with the same themes Trust wide since this reported incident. Request closure based the above evidence. Where the incident cannot be reinvestigated and no action has been taken, the KMPT Trust Board to confirm in writing that they are prepared to close the SI and understand the risk to the patients remains and that this theme will be considered with every occurring incident to identify where lessons can be learned. STEIS 3 ( Post May 2015) All open SI cases will be reviewed by KMPT in the light of the detailed feedback from the CCG and resubmit the SI for closure. NHSE expect the number of STEIS 1 and 2 cases that KMPT will not be able to review in any way to be very small. The proposal needs to be agreed with all East Kent CCGS. The proposal is going to all East Kent CCG quality committees in February RISK RATING: (Refer to Appendix I) HIGH EXPECTED RESOLUTION DATE: Feb-16 PLACED ON RISK REGISTER: R IntegratedQualityandPer Page 32 of 50 Page34of52 OverallPage151of204

151 KMPT: QUALITY AND PERFORMANCE ISSUE LOG Date Issue Reference identified Description of Issue Current Position Risk Status (as per escalation process) Actions Risk Register Timescale for Completion KMPT2014/004 Jan-14 Workforce Staffing shortages within the South Kent Coast CCG area continue to Staffing levels and the impact on service delivery continue to be monitored through the Local Operational Meeting (LOM) impact on patient care and continuity. Current workforce reporting and metrics and contractual Quality and Performance meeting. The workforce reporting still does not provide the assurance the CCG are not yet agreed for the 15/16 contract. The current metrics provided do not requires. SECSU have benchmark KMPT vacancy and sickness rates with other Trusts and this is inline with other provide adequate assurance that existing workforce is appropriate. organisations. Significant issues have bee identified in the Crisis Teams. KCC are rolling out a new model which may impact CMHTs as some Social Workers are being moved out of CMHTs into hubs. KCC Project on the agenda for the East Kent Mental Health SIG on 2nd September KMPT is involved with the patient safety collaborative (mental health) and has shared the VTE project with other mental health organisations. KMPT Resuscitation Manager has represented KMPT at the All Party Parliamentary Thrombosis Group held at the House of Commons where VTE within mental health settings was discussed. NICE guidance is being reviewed to take into account VTE risks due to anti-psychotic medication. As an invaluable resource, for support and to ensure best practice KMPT Resuscitation Manager is in contact with the Kings Thrombosis Centre and attends the Kent Thrombosis Network meetings. These meetings are also attended by the VTE lead nurses/consultants for the acute hospital organisations in the south. Ensuring that collaborative practice between the acute and the mental health settings continues. HIGH Local workforce issues being addressed through Local Operational Meeting. Reporting of workforce data being monitored and developed via the contractual Quality and Performance meeting. More comprehensive workforce data provided but still lacking the supporting narrative. No themes or trends identified from data provided, suggesting that the issue is more around management and culture rather than staffing shortages. NO Mar-16 KMPT2015/011 Nov-15 Lack of Physical Health Care There have been 3 Serious Incidents (SI's) in SKC CCG which have resulted in patient death due to inadequate management of physical health conditions. 1 patient had VTE and no risk assessment had been completed. Another patient had ischaemic bowel disease and MEWS was being monitored every 30 minutes but this was not escalated and the patient transferred appropriately. Issue discussed at KMPT Q&P meeting in November Physical health monitoring is below target. The Trust is now employing Physical Health nurses on the wards but many patients refuse a physical health check within the first 72 hours, but all receive checks in due course. Minimum checks made in the first 72 hours include: blood pressure, urine, VTE and temperature. CQC have issued new guidance and the Trust is reviewing how this corresponds with what is currently being done. The Trust also plans to carry out an audit program and will share the findings with the CCG s. The areas of Physical Health continue to be challenging to meet the 72 hour timeframe for these assessments to be completed. There are a variety of reasons for these delays, such as patients refusing the physical health check within the timeframe or the documentation being recorded in the wrong place by the clerking doctors. The corporate nursing department continues to monitor the physical health check figures on a monthly basis using the nursing metrics. To analyse the results and increase compliance the service managers are required to write a narrative for any breaches in the timeframe. Analysis indicates that physical health checks are being completed during an inpatient stay despite sometimes falling outside of the 72 hour target. Thanet CCG is seeing an improvement from 77.8% in Sept 2015 to 92.6% in Dec HIGH Physical Health Checks audit reports and new protocols to be shared with CCGs. Consideration to be given to issuing a Contract Performance Notice (CPN). HoQ to meet with AD for community services line to discuss in further detail (date to be confirmed) NO Mar-16 KMPT2015/007 Jul-15 Medical Oversight KMPT Consultants are providing medication which requires Lack of clarity regarding who is responsible for the medical oversight. KMPT Consultants can refer patients for routine workups but often signpost patients via their medical oversight e.g. blood tests, ECGs, etc. GP. KMPT2015/008 Jul-15 Increased Reporting of Suicides in SKC CCG There has been an increase in the CNO requested at the April 2015 contractual Quality and Performance Meeting that KMPT provide assurance of learning and number of SI's related regarding suicides of patients under the care of KMPT. actions taken from recurrent themes as well their strategy for reducing suicides. Dr Mike Kingham, Chair of the POSH (Prevention of Suicide) group provided a POSH presentation to SKC Quality and Performance Meeting in August The presentation did not include any analysis of recurrent themes around suicides. MEDIUM To monitor in the Local Operational Meetings. KMPT Consultant to summarise NICE guidance and share with CCG. This will be raised again at the SKC LOM in January MEDIUM KMPT Patient Safety Manager is undertaking a piece of work around themed analysis. This has been requested twice. To follow-up at contractual Quality and Performance Meeting in January NO NO Mar-16 Mar-16 KMPT2015/009 Aug-15 CQC Inspection The Care Quality Commission (CQC) conducted an inspection of Response from CCGs to the first version of the action plan requested development of a comprehensive integrated action KMPT services in March The overall rating was 'Requires Improvement'. plan. The Quality Improvement Plan was submitted to CQC on 7th September. KMPT have provided an updated action The key themes were as follows: plan however CCGs still have concerns. A meeting with CCG Accountable Officers, TDA and Monitor is to be held to review All services were rated as either good or outstanding for caring for their the action plan. SKC CCG quality team have conducted a comprehensive gap analysis which has been discussed with KMPT. patients Local leadership is strong and staff report feeling well supported by local managers/leaders Morale is reported as high in specialist services but not so in more generic community and ward based services Most services were rated as requires improvement for safety, however the rationale for this varies across different services There is inconsistency of care from one unit to another, and across community teams Governance processes appear to be in place in most services Quality of care planning is inconsistent, with specialist services rated higher for quality and focus of care planning KMPT2015/010 Oct-15 Pre 72 hr C. difficile case at St Martins hospital has raised concerns that there is KMPT presented the RCA at the HCAI Assurance Panel in November The RCA has identified multiple concerns no system in place for EKHUFT to notify the KMPT specialist lead regarding systems and processes e.g. multiple admissions to KMPT and acute trusts. Serious Incident RCA due to be submitted to CCG on 31/12/15. has been sent from CCG CNO to directors of nursing at EKHUFT, KMPT and Darrent Valley requesting that this is seen as a multi-system process around the lack of physical and mental health assessment at time of transfers in and out. KMPT2015/006 Jun-15 Section 136 Suite KMPT have submitted a briefing to the CCG identifying the A briefing paper was submitted to the contractual Quality and Performance Meeting in July KMPT liaising with CCGs need to reduce the Section 136 suite provision from 5 to 4 bed for a period of regarding the work programme and impact being monitored. On 25th August, KMPT advised that there are delays with the time in order to achieve the standards expected by the CQC and ensure the completion of the refurbishment work in Dartford S136 suite. This means that the conclusion to the work has now shifted to places of safety are fit for purpose and safe for patients and staff. the 14th September The refurbishment work on Section 136 Suite in Canterbury started on 7th October. Section 136s will be diverted to Maidstone and Dartford (4 Places) during the works which is estimated to last 9 weeks. MEDIUM Routine monthly audits are being conducted and as a third line of assurance the CCGs are being invited to participate in a programme of site visits from the central team who are adopting a CQC style approach. The Trust wide medicines management plan is being shared with the CCGs. The gap analysis and supporting queries is being shared with KMPT with agreement on how gaps are going to be addressed. Monitoring plan developed for East Kent to ensure gaps are closed. NO Mar-16 MEDIUM Awaiting RCA from Serious Investigation. NO Mar-16 CLOSED It was verbally reported at the KMPT Q&P Meeting in January 2016 that Canterbury will re-open week commencing 1st February 2016 and that will be refurbishments complete. NO Mar IntegratedQualityandPer Page 33 of 50 Page35of52 OverallPage152of204

152 Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark (Kent ave.) SUSSEX PARTNERSHIP FOUNDATION TRUST (SPFT) Outcome 1 - Preventing People from Dying Prematurely Indicator Actual YTD Trend Outcome 2 - Enhancing Quality of Life for People with Long Term Conditions Indicator Actual YTD Trend Outcome 3 - Helping People to Recover from Episodes of Ill Health, or Following Injury Indicator Actual YTD/ Avg Trend P Total number on all caseloads (at end of month) Dec 920 1,030 P Total number of external referrals received Dec P Assessment waiting list Dec reduction P Treatment waiting list Dec reduction P <6 weeks wait for assessment Dec increase 65.0% 69.55% P <10 weeks wait for treatment Dec increase 66% 68.68% P Out of Hours emergency referrals < 24 hr Dec 100% % P % Inappropriate (based on external referrals received) DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) K = SECSU Activity (SKC) Waiting times (SKC) Signposted to Other Services (SKC) Dec 23% 27% 20% Quality of contact (SKC) P % Face to face contacts Dec 87% 88% 82% Outcome 4 - Ensuring that People Have a Positive Experience of Care Indicator Actual YTD Trend Outcome 5 - Treating and Caring for People in a Safe Environment: Protecting Them from Avoidable Harm Indicator Actual YTD Trend Summary Key themes relating to concerns regarding the performance and quality of care provided by SPFT include: Friends and Family Test: Patients (SPFT all CCGs) N Would Recommend Dec-15 88% 86% 85% C Safe Jan-15 N/A Friends and Family Test: Staff (SPFT all CCGs) C Effective Jan-15 N/A N Would Recommend Work Q2 62% 57% 58% C Caring Jan-15 N/A N Would Recommend Care Q2 79% 69% 70% C Responsive Jan-15 N/A Complaints/Compliments (SPFT Kent and Medway CCGs) P Complaints Dec N/A 6 59 Care Quality Commission (SPFT all CCGs) C Well-Led Jan-15 N/A Incident Reporting (SPFT Kent and Medway CCGs) Requires Improvement Requires Improvement Outstanding Requires Improvement Good P Serious Incidents Reported Dec N/A 0 13 Central Alerts System (CAS) (SPFT all CCGs) Please note :- Quality Assurance CQC Report NRLS Data/Under Reporting Risk Assessment Process Home Treatment Service SPFT has recently changed their system, resulting in some July data currently being absent. Therefore year to date figures are subject to change. Additionally, in the latest data SPFT state that electronic contacts are being under reported. CA Compliance with Deadlines Dec 100% 100% 99% NHS West Kent CCG are the host for the SPFT Contract. DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) CA = Central Alerts System 4.2IntegratedQualityandPer Page 34 of 50 Page36of52 OverallPage153of204

153 SPFT: QUALITY AND PERFORMANCE ISSUE LOG Issue Reference Date identified Description of Issue Current Position Risk Status (as per escalation process) Actions Risk Register Timescale for Completion SPFT2016/001 Jan-16 NRLS data Under-reporting on incidents compared to other trusts Lack of assurance around incidents being reported onto NRLS. Trust unable to look within other divisions. SPFT2014/001 Mar-15 Quality Assurance Lack of quality data. Quality data is not There have been improvements as CCG's are now receiving monthly quality reports. being submitted at contractual Quality and Performance There still continues to be a gap in CQUINS as the Quarter 1 and Quarter 2 evidence has Meeting. not been presented at the contractual Quality and Performance Meetings. Contract is being extended to next year. SPFT2015/004T Sep-15 Risk Assessment process There are concerns around 2nd The gap between the 2nd and 3rd appointment is not meeting target. Although the and 3rd appointment breaches by SPFT. numbers involved are not high, an action plan is needed as to how SPFT are managing and resolving this issue. Partial assurance has been provided and gaps have been reduced. SPFT have supplied an action plan and process. SPFT2015/004 Jun-15 CQC Inspection The Care Quality Commission (CQC) NHS West Kent CCG are the lead for the SPFT contract. The Quality Summit was held undertook a routine inspection of Sussex Partnership on 22nd May 2015 and West Kent CCG attended. The summit involved the whole of Foundation Trust (SPFT) week commencing 12th January the SPFT services across 3 counties, Kent CAMHS service was only a small part of this 2015; visiting CAMHS services on 8th and 9th January report. The report was published on 27th May The inspection A meeting was convened by West Kent CCG jointly with Kent CCG s and SPFT, in July team did not review CAMHS within East Kent but reviewed 2015, to review the CQC report and Oxford Peer Review Report and latest Healthwatch teams in West and North Kent and Medway. The findings of report to create an action plan that is relevant to East Kent CCGs. the CQC support the concerns previously identified by SKC CCG. The CQC gave SPFT an overall rating of 'Requires Improvement'. Key Findings: People were waiting too long for assessments to happen. There were not always adequate risk assessments and an inconsistent approach to physical health monitoring, particularly for young people on psychotropic medication. In some areas staffing levels did not always ensure that people in need of these services received a timely response. Outcome measures for children and young people were not routinely used to monitor the effectiveness of care treatment. However, in the caring domain the services were rated as outstanding and good for well-led. HIGH Thanet Head of Quality to follow up with Director of Nursing to further e NO Mar-16 HIGH SPFT Director of Ops met with Thanet Head of Quality to discuss gaps in process and accountabilty around quality in SPFT. Director of Nursing at SPFT to meet Thanet Head of Quality to discuss further. To be monitored through SPFT Performance and Quality meeting NO Mar-16 MEDIUM Action plan to be sent to CCG on a monthly basis. NO Mar-16 MEDIUM An integrated action plan for Kent and Medway Services has been developed focusing on the following areas: * Demand and capacity measuring across the service and ongoing demand. * Recruitment in hard to recruit areas including appropriate incentives * Process for managing young people on the waiting list with safety risk plans * Review and train referrers in triage process/criteria and information required for referral * Signposting and contact for families re: referrals To be monitored through contractual Quality and Performance Meetings. NO Mar-16 SPFT2015/005 Nov-15 Home Treatment in SKC A Root Cause Analysis (RCA) There is limited quality data available for SPFT services in general. LOW SKC CCG Head of Quality arranging Quality Visit to the Home Investigation from a Serious Incident has identified concerns Treatment Service. December Quality Visit had to be cancelled with the Home Treatment Service including de-escalation of currently liaising with the provider to re-schedule. young people from Section 136 Suite and skills and competence within the Home Treatment Service workforce. NO Mar IntegratedQualityandPer Page 35 of 50 Page37of52 OverallPage154of204

154 Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory SOUTH EAST COAST AMBULANCE SERVICE NHS FOUNDATION TRUST (SECAMB) Outcome 1 - Preventing People from Dying Prematurely Indicator Actual YTD Trend Outcome 2 - Enhancing Quality of Life for People with Long Term Conditions Indicator Actual YTD Trend Outcome 3 - Helping People to Recover from Episodes of Ill Health, or Following Injury Indicator Actual YTD Trend Quality Indicators: Clinical Outcomes (SECAMB all CCGs) (SKC) Activity (SKC) N Cardiac Arrest: Return of spontaneous circulation (ROSC) ALL PATIENTS Aug 28.1% 27.6% 27.0% Ambulance conveyances requested by GP Nov 787 P Hear and Treat Jan ,449 N N N Cardiac Arrest: Return of spontaneous circulation (ROSC) UTSTEIN COMPARATOR Cardiac Arrest: patients discharged from hospital alive ALL PATIENTS Cardiac Arrest: patients discharged from hospital alive UTSTEIN COMPARATOR Aug 54.1% 50.0% 45.7% Ambulance conveyances requested by care homes Mar 159 Q4-232 P See and Treat Jan 1,262 1,418 12,625 Aug 8.3% 8.6% 8.5% Handover (All CCGs) P See and Convey - HCP Jan ,203 Aug 28.7% 25.0% 22.5% KCH Recorded Pat H/O Jan 77% 77% P See and Convey Jan 1,598 1,515 14,289 N STEMI: angioplasty within 150 minutes Aug 85.7% 100.0% 94.0% QEQM Recorded Pat H/O Jan 79% 78% P Total Activity Jan 3,598 3,621 33,581 N STEMI: appropriate care bundle Aug 75.7% 65.6% 66.8% WHH Recorded Pat H/O Jan 85% 83% P % non-conveyance Jan 49.4% 47.9% Stroke: arriving at a hyperacute stroke unit N within 60 minutes Stroke: assessed face to face and N appropriate care bundle Aug 58.2% 67.1% 65.4% Aug 97.3% 96.2% 96.3% P Red 1 <8 min Jan 75% 66.2% 65.9% P Red 2 <8 min Jan 75% 58.7% 66.6% P Category A (R1 & R2) <19 min Jan 95% 92.8% 92.3% P Percentage of calls answered within 60 seconds P Percentage of patients advised to attend A&E DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) K = SECSU Waiting Times (SKC) 111 KPIs (All CCGs) Jan 95% 74.7% 84.2% P Percentage of answered calls triaged Jan 60% 87.9% 87.7% Jan 5% 6.6% 6.8% 4.2IntegratedQualityandPer Page 36 of 50 Page38of52 OverallPage155of204

155 Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory SOUTH EAST COAST AMBULANCE SERVICE NHS FOUNDATION TRUST (SECAMB) Outcome 4 - Ensuring that People Have a Positive Experience of Care Indicator Actual YTD Trend Outcome 5 - Treating and Caring for People in a Safe Environment: Protecting Them from Avoidable Harm Indicator Actual YTD Trend Summary Key themes relating to concerns regarding the performance and quality of care provided by SECAMB include: Friends and Family Test: Patients (SECAMB all CCGs) Care Quality Commission (SECAMB all CCGs) N Would Recommend (See & Treat) Dec-15 93% 92% 98% C Safe Oct-14 N/A Met Standard Friends and Family Test: Staff (SECAMB all CCGs) C Effective Oct-14 N/A Met Standard N Would Recommend Work Q2 62% 43% 47% C Caring Oct-14 N/A Met Standard N Would Recommend Care Q2 79% 86% 84% C Responsive to People's Needs Oct-14 N/A Met Standard Complaints/Compliments (SECAMB all CCGs) C Well-Led Oct-14 N/A Met Standard P Compliments Nov N/A Infection Prevention and Control (IPC) (SECAMB all CCGs) P Formal Complaints Nov N/A P IPC Training Dec 95% 88% 88% P Informal Complaints Nov N/A Incident Reporting (SECAMB all CCGs/SKC CCG) P Health Care Professional Complaints Nov N/A K Serious Incidents Reported - SECAMB 999 Total Dec N/A 7 34 P 111 Service Complaints: Kent Nov N/A 5 74 K Serious Incidents Reported - SECAMB 111 Total Dec N/A 1 5 K Serious Incidents Reported - SKC CCG Total Dec N/A 1 2 K Never Events Reported - SECAMB 999 Total Dec K Never Events Reported - SECAMB 111 Total Dec K Never Events Reported - SKC CCG Total Dec Central Alerts System (CAS) (SECAMB all CCGs) CA Compliance with Deadlines Dec 100% 100% 87% Safeguarding (SECAMB all CCGs) Statutory and Mandatory Training Compliance (Including Safeguarding) SECAMB R3 Calls Private Contractors Governance Processes Handover Response Times Fire Co-Responders High Acuity Patient Transport Services NHS Swale CCG are the host for the SECAMB Contract (including 111 Service). P Safeguarding Training Dec 95% 86% 86% Workforce (SECAMB all CCGs) P SECAMB Sickness Rate Dec 4.50% 5.70% 4.97% P SEAMB Appraisal Rate Dec N/A 57.70% 57.70% P SECAMB Vacancy Rate Dec N/A 17.38% 15.55% DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) K = STEIS CA = Central Alerts System 4.2IntegratedQualityandPer Page 37 of 50 Page39of52 OverallPage156of204

156 SECAMB QUALITY/PERFORMANCE CONCERN TRIANGULATION DESCRIPTION OF CONCERN: DATE CONCERN INDENTIFIED: Red 3 Feb-15 BACKGROUND: Concerns came to light following declaration of a serious incident involving a Red 3 (R3) call (which is a classification not previously recognised). Investigation highlighted changes to the national allocation standards to allow additional time for 999 clinicians to reclassify calls from 111. SECAmb implemented a project to change standard operating procedures to re-triage Red 2 dispositions sent form NHS 111 service to ambulance 999 service. These R2 patients were relabelled Red 3 and allowed an extra 10 minutes for clinical triage before ambulance was despatched. The project was not approved by CCGs or documented through SECAMB board papers. The R3 /G5 partition pilot may have been instigated with good intentions, but due to lack of due diligence, good governance and board leadership it was allowed to proceed without effective risk management. Despite executive directors acknowledging that many of the processes involved in the project were inadequate, there was a distinct lack of accountability. project management and communication issues: There was no formal project initiation process nor a clear evidence based project plan. There was no stakeholder engagement, no financial planning, and no formal approval by all the executives or board. There was no timely data collection and evaluation, with no risk assessment and limited risk management. Communication with the commissioners was poor and no written agreement was sought to deviate from nationally agreed standard operating plans. Timeline R3 Partition Process 4.2IntegratedQualityandPer Page 38 of 50 Page40of52 OverallPage157of204

157 SECAMB QUALITY/PERFORMANCE CONCERN TRIANGULATION CURRENT POSITION: * 2 of the 7 SIs showed that the partition project contributed to adverse clinical outcome. A further 2 incidents were identified at a later date * R3 SI investigation is ongoing, and further detail has been sought from SECAMB * Subsequent drop in constitution target performance coincides with suspension of partition project. SECAMB has remained below standard since returning to national process. * SECAMB anticipates R1 will be met by year end, but R2 is unlikely to be met. * NHSE have published a report on recommendations in November * Mitigating actions have been taken. NHS Swale CCG are receiving assurance of mitigating actions. * Monitor holding SECAMB in breech of governance procedures and putting measure in place to address safety concerns ACTION PLAN: SECAMB actions SECAMB governance system to be simplified and not circumvented patients and carers to be involved at all levels or organisation including consultations Improved transparency improved leadership supporting quality and clinical governance Improved Mandate and Impact Assessment process requiring project responsibilities and governance structures to be defined before a mandate to proceed with the next stage of the project is given Investigations into serious clinical incidents need to be objective and include families from the outset Improved internal organisation within SECAmb, improved communication between corporate/operational/clinical governance structures must be implemented Organised engagement with patients and the public for timely stakeholder involvement needs to be formalised and actioned CCG actions Commissioners not providers should decide what they want provided The CCG should identify within their contract how the Trust can approach any potential change to operating standards New governance process has been signed off and is being implemented and is being further reviewed in view of disaggregation of commissioning arrangement for 999 service In relation to quality, the 3 lead CCGs are working collaboratively to ensure a unified approach and no duplication of work for the Trust In Kent and Medway, there is a combined SECAmb team, so all decisions/issues have oversight by quality, commissioning and contracting. Further review of arrangements in Surrey/Sussex CCG clarifying for Trust threshold for raising proposals to Contract Quality Review Group. Trust has invited CCG into their internal quality meeting to gain assurance. A table top day planned on 6th Nov to bottom out how CCGs ensure quality Outcome * SKC input into contract monitoring and quality review has been strengthened * Potential outcome for improved services through reinvestment * quality review ongoing with Swale CCG - limited SKC input * Developing input in contract negotiations Areas for Improvement: Improve input into quality and contract negotiations Improve feedback from assurance process with Swale CCG (table top exercise findings and assurance details to be shared) Recommendation: Consideration of means to strengthen SKC input with provider RISK RATING: EXPECTED RESOLUTION DATE: TBA following further investigation PLACED ON RISK REGISTER: in progress 4.2IntegratedQualityandPer Page 39 of 50 Page41of52 OverallPage158of204

158 SECAMB: QUALITY AND PERFORMANCE ISSUE LOG Issue Reference SECAMB2015/005 (SKC) SECAMB2015/003T Date identified Description of Issue Current Position Apr-15 Private Contractors A Serious Incident was reported on 12th March * The investigation has been completed which reported the most fundamental underlying SECAMB received intelligence regarding the storage of medicines by a Private factors contributing to this incident appear to be poor corporate governance arrangements. Ambulance Provider (UKSAS) at a Hotel in Folkestone used as their base * The key outcomes from the investigation include: together with concerns over the controls and standards they provided within * Secam have ceased to use the hotel as a base the Kent area. The Trust liaised with Kent Police s Controlled Drug Liaison * Police have taken appropriate legal action/proceedings against the relevant parties and Officer (CDLO) and on Friday 6th March 2015 Kent Police together with Seam staff have been cautioned. conducted an unannounced check of the hotel in accordance with the Misuse of * The rectification plan by Seam is being tightly managed. Drugs Regulations 2001 to ascertain the safe storage and custody of controlled * The Counter Fraud are looking into an external review of relevant parties. drugs. * Seam have since undertaken a desktop review of its PAP governance arrangements which is to be submitted to the Trust Executive Team. North Kent SI Group agreed to close as this SI on 22 October 2015 is being picked up through contractual measures at the PAP crew governance meeting on 5 November The trust had committed to providing a governance paper due 5th November 2015 in relation to the ongoing assurance monitoring of private ambulance providers. Following the Quality and Safety team s attendance at the trusts internal clinical assurance committee the paper presented was not a governance paper but one of recommendations to be achieved if internal governance was to be achieved. Risk Status (as per escalation process) HIGH Actions To be followed up at CQRG meeting in January - awaiting minutes for update. Risk Register NO Timescale for Completion Mar-16 SECAMB2016/002 Jan-16 Quality of care whilst waiting post handover Following handover at QEQM, a patient did not receive oxygen whilst waiting to be treated. HIGH Swale CCG to follow up with SECAMB and provide feedback. NO Mar-16 SECAMB2016/003 Jan-16 Pain Relief Whilst a patient was waiting to be seen, a patient did not receive any pain relief. HIGH Swale CCG to follow up with SECAMB and provide feedback. NO Mar-16 SECAMB2014/002 Oct-14 Statutory and Mandatory Training Compliance (including Safeguarding) A paper was presented to the CQRG in November 2015 due to the concerns regarding SECAMB 999 service provision have failed to achieve training compliance targets Statutory and Mandatory Training Compliance. Despite the figures as at October still being since April below target they are showing improvement and North Kent CCGs reported confidence regarding the figures provided at the SECAMB Performance Meeting in January MEDIUM December data showing improvement but Swale CCG continue to have concerns as still lack assurance around processes. NO Mar-16 SECAMB2015/006 (SKC) SECAMB2015/004T SECAMB2015/007 (SKC) SECAMB2015/005T Sep-15 Oct-15 Governance process Lack of accountability and reporting following a number of Meetings are currently being remapped and aligned. SKC Head of Quality participated in a changes to meetings at SECAMB. Minutes are not being received in a consistent tele-conference around CCG attendance at SECAMB meetings. A monthly tele-conference and timely manner. with North Kent Quality Lead has been agreed. Handover Handover delays above the national target remain a significant Following the trust issuing a contract performance notice against the CCGS in relation to problem for Seam and directly affect not only the quality and experience of care this, the three counties are looking at local solutions. Within Kent and Medway, the Head delivery for the patients in stacked queues at acute trusts, but potentially put of Quality and Safety for North Kent Localities will be conducting a mapping exercise in patients at risk who may be stacked in the clinical queue waiting for an conjunction with identified CCG leads in the acute trusts. The mapping exercise is to ambulance response due to crews being unavailable. Although Sussex is the determine how the handover process works in the different trusts, how key performance significant outlier in relation to performance, Kent and Medway s position is indicators are recorded, at what stage medical responsibility is owned by the acute trust deteriorating, which is of significant concern as winter pressures approach. and how the clinical quality and patient safety requirements of patients are managed whilst in the stack. Terms of Reference for the audit of handover process between SECAMB and local acute providers have been developed and shared with relevant parties. MEDIUM New governance process in place, waiting for copies to be sent to CCGs NO Mar-16 MEDIUM Handover audits have been completed at QEQM, the report has been received and some amendments required. Remaining audits in progress. NO Mar-16 SECAMB2015/009 (SKC) SECAMB2015/007T Nov-15 Response Times A Contract Performance Notice (CPN) was issued on 10th In order that clinical quality outcomes can be assessed, the trust should review 10% of all September 2015 because the Trust did not achieve the 75% standard for Red 1 Red 1 and Red 2 responses that breach the Cat A19 KPI target. Each incident reviewed minute response for the first quarter of the contract. Red 1 Performance should be RAG rated following review by a senior clinician to establish whether the time has continued to bebelow standard in July and August. In addition, it was noted delay in response either exacerbated the patient's condition or could have been that both Red 2 and A19 have also slipped recently, although they remain above detrimental to the quality of clinical care the patient received. SECAMB did not produce the standard for the year to date. any data for the September CQRG. SECAMB2016/001 Jan-16 High Acuity Patient Transport Services (PTS) SECAMB are being requested to There is a need for greater flexibility between SECAMB and NSL regarding the use 999 vehicles for high acuity patients requiring transportation instead of NSL. transportation of this patient group. SECAMB are having to use 999 vehicles to transport patients which affects their capacity for 999 calls. MEDIUM MEDIUM This is a standing item on the CQRG agenda and will be discussed at the November meeting. North Kent Quality and Safety team will continue to work with the trust to explore quality impact from non-achievement of performance data and triangulate any intelligence in relation to poor patient experience. In the short-term EKHUFT are being requested to make telephoning bookings for this patient group rather than use the electronic booking system to ensure appropriate information sharing. SECAMB will work with G4S to review PTS specification and understanding. SKC Head of Quality hosting a meeting between providers on 24th February 2016 to address the current concerns. NO NO Mar-16 Mar IntegratedQualityandPer Page 40 of 50 Page42of52 OverallPage159of204

159 SECAMB: QUALITY AND PERFORMANCE ISSUE LOG Issue Reference SECAMB2015/008 (SKC) SECAMB2015/006T Date identified Nov-15 Description of Issue Current Position Fire Co-Responders There is a national drive for collaboration by Emergency The project initially went live in Surrey on 28th September, with a plan to go live in Kent on Services in order to increase efficiency and improve services to the public; this is 1st October. Despite ongoing project work of over two years SECAMB failed to include likely to become a legal requirements in the near future. As such SECAMB have commissioners in the discussions in relation to the project. Due to lack of commissioner been working in close collaboration with the Fire and Rescue Service (FRS) to awareness in relation to the project, the go-live in Kent was postponed until both implement a first responder service. Due to the demand profile of the fire commissioners and quality leads had assurance that the project was safe and had gone service, fire resources are located in more rural areas in comparison to the through proper governance. Following a meeting on 2nd October, it was agreed that R1 ambulance service. In addition in the last 10 years their demand has decreased calls could go live with immediate effect. by 40%, which gives the FRS increased capacity to respond to new demand in collaborative working. It is widely evidenced the early defibrillation in cardiac arrest situation increases survival rates and as such the fire service in the Surrey and Kent localities have been equipped with defibrillators and given training for acute trauma and basic life support. The training programme has been observed by the quality and safety team, it appears robust with rigorous processes for ensuring competencies are maintained. Risk Status (as per escalation process) MEDIUM Actions There are further concerns in relation to FRS responding to R2 calls, in particular the appropriateness of some responses and what exclusions should be put in place, such as maternity calls, the volume of work this could entail and how clinical quality, patient safety and patient experience will be maintained and monitored. The quality and safety team in North Kent will be working with the trust to address patient safety concerns and how the system will be monitored by attending a weekly project meeting. Further work is taking place with the Kent collaborative in order to ensure standardisation of the project across localities and that any learning will be fed into the national data feed in order to inform national changes to 'blue light' collaboration. Risk Register NO Timescale for Completion Mar IntegratedQualityandPer Page 41 of 50 Page43of52 OverallPage160of204

160 Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory INTEGRATED CARE 24 (IC24) Outcome 1 - Preventing People from Dying Prematurely Indicator Actual YTD Trend Outcome 2 - Enhancing Quality of Life for People with Long Term Conditions Indicator Actual YTD Trend Outcome 3 - Helping People to Recover from Episodes of Ill Health, or Following Injury Indicator Actual YTD Trend % Calls Answered Within 60 Secs of end of Intro mess (no longer than 30 seconds) Nov 95% 83.2% 83.1% Appointment Punctuality - 30 mins of appointment time Nov 95% 96.4% 96.0% K Advice Oct 1,040 8,364 % Calls Abandoned Nov 5% 1.4% 3.3% Provision of interpreter Nov 95% n/a n/a K Base Oct 829 6,969 Start definitive clinical assessment for patients with urgent needs within 20 minutes of the Start of definitive clinical assessment for patients with non - urgent needs within 60 minutes of the Emergency face to face booked Within 1 hour. To be reported monthly. Urgent 2 hr disposition - Definitive clinical assessment for patients within 2 hr disposition Less urgent 6 hr disp - Start of definitive clinical asst within 6 hr disposition 24 hr disposition - Start of definitive clinical asst for patients within 24 hr disposition (Provider level) (Provider level) Nov 95% 100.0% 76.9% Details of all OOH consultations sent to GP Nov 95% 99.9% 100.0% K DN Message Oct 205 1,959 Nov 95% 100.0% 100.0% 111 Referrals accepted Nov 100% 100.0% 100.0% K Visit Oct 310 2,521 Nov 95% n/a n/a K Walkin Oct 139 1,013 Nov 95% 94.8% 93.2% K Routine Aug 0 9 Nov 95% 98.7% 98.5% K Urgent Aug 0 11 Nov 95% n/a n/a K % urgent Aug % % DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) K = SECSU Activity (SKC) Outcome 4 - Ensuring that People Have a Positive Experience of Care Indicator Actual YTD Trend Outcome 5 - Treating and Caring for People in a Safe Environment: Protecting Them from Avoidable Harm Indicator Actual YTD Trend Summary IC24 has not been inspected by the Care Quality Commission to date. Ashford & Canterbury CCGs are the host for the IC24 Contract. P Complaints Dec N/A 5 29 C Safe N/A N/A C Effective N/A N/A P Patient Satisfaction Dec 85% 98% 95% C Caring N/A N/A P Response Rate Dec 3% 3% 3% C Responsive to People's Needs N/A N/A P % of patients contacted within the allocated DX time Complaints/Compliments (IC24 - East Kent CCGs) Patient Satisfaction (IC24 - East Kent CCGs) GP Speak to Service (IC24 - East Kent CCGs) Dec 95% 69% 82% Care Quality Commission (IC24 - All CCGs) C Well-Led N/A N/A Incident Reporting (IC24 - East Kent CCGs) Not Inspected Not Inspected Not Inspected Not Inspected Not Inspected P Serious Incidents Dec N/A 0 3 P Never Events Dec Training (IC24 - East Kent CCGs) P Information Governance Dec 85% 96% 97% P Safeguarding Adults Level 1 Dec 85% 98% 98% P Safeguarding Children Level 1 Oct 85% 96% 96% Performance: The Out of Hours Service for East Kent CCGs is provided by IC24 for a total contract value of 4.73m. The South Kent Coast CCG share of this is 1.41m. The contract has a 5% activity threshold above and below plan to which a marginal rate of 30 per unit of activity is applied beyond these limits. Key themes relating to concerns regarding the performance and quality of care provided by IC24 include: Quality Assurance Concerns Regarding Capacity Raised by SECAMB 111 Service/Swale CCG Management of Patients with Chest Pain Safeguarding Assurance Workforce (IC24 - East Kent CCGs) P P At least 95% of planned hours for clinical staff will be filled on a monthly basis At least 90% of planned medical shifts will be provided by Doctors on the Kent Performers List Dec 95% 97% 99% Dec 90% 100% 100% DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) K = SECSU 4.2IntegratedQualityandPer Page 42 of 50 Page44of52 OverallPage161of204

161 IC24: QUALITY AND PERFORMANCE ISSUE LOG Issue Reference Date identified Description of Issue Current Position Risk Status (as per escalation process) Actions Risk Register Timescale for Completion IC242015/001 Apr-15 Quality Assurance The CCGs have not received any IC24 attended the contractual Quality Meetings in April and quality reports for IC24 since January Ashford May Subsequent to the meetings the CCGs received and Canterbury CCGs host the East Kent contract for reports from the provider however, the CCGs do not have IC24. It was agreed in January 2015 that the East and assurance from the report and are in discussion to agree a West Kent Quality Meetings would be joint moving more comprehensive report format. Ashford and Canterbury forward. IC24 are restructuring their quality and CCGs continue to work through the reporting and assurance governance teams and reporting is being changed. issues with IC24. IC24 have requested quarterly reporting in Currently there is a gap in reporting. order to enable better theming in locality. Move to a joint quality/performance meeting, quarterly report will be tabled. This arrangement to be reviewed in 6 months as not first choice for commissioners. HIGH Revised KPI scorecard is now being received but quality reporting still outstanding. Next meeting contractual Quality and Performance Meeting on 20/11/2015. If quality report is not received Ashford and Canterbury CCGs will be raising a Contract Performance Notice (CPN). NO Mar-16 IC242015/002 Oct-15 Concerns Regarding Capacity Raised by SECAMB 111 Issue taken forward at IC24 contractual Quality and Service/Swale CCG Swale CCG attended a meeting with Performance Meeting on 6th October The limited data Surrey and Sussex week commencing 21st September available suggests that the issue is having greater impact in 2015 where system issues were raised by SECAMB 111 Surrey and Sussex. However, the GP Speak to Service in Kent is regarding Out of Hours (OOH): impacting and they are consistently not achieving the KPI for OOH (predominantly IC24) for a long time have been 95% of patients contacted within the allocated DX time going red on DOS- i.e. close doors. Therefore 111 cannot send to IC24. Patient then gets diverted to ED or have been writing escalation plan with IC stating they are getting on average 400 call backs Can t determine the area / locality as no data. Data for some weekends in report from SECAMB. 111 had to employ specific admin staff to deal with call backs. Swale CCG can demonstrate the pattern regarding closing doors. 111 is not being penalised for Service Level Agreement (SLA) in view of this as long as clinical queue is being managed. Other CCGs want to put IC24 into remedial action plan. West Kent CCG not supportive. Sussex / Surry will be meeting IC24 with remedial action plan on 30th September Medway requesting they are put into remedial action plan from a quality perspective. Ashford and Canterbury CCGs view is that it is more contractual issue with a quality component but either way it will affect whole system during times of pressure if not resolved. MEDIUM A conference call was held on 12/11/2015 led by North Kent CCGs. Concerns regarding the format of the conference call have been escalated to the CCG Chief Nursing Officers (CNO). The issues discussed primarily related to commissioning rather than quality of service provision. SKC CCG Head of Quality to follow-up performance issues with SKC CCG Head of Performance. NO Mar-16 IC242015/003 Oct-15 Management of Patients with Chest Pain A GP working for IC24 has highlighted concerns regarding the management of patients with chest pains following an incident in Dover. A patient presented to MIU (Buckland) with chest pain and was inappropriately referred to IC24. Commissioners have confirmed that there are no agreed pathways. LOW SKC CCG Head of Quality to seek assurance regarding the policies and pathways in place within IC24 and MIU's at KCHFT and EKHUFT for patients presenting with chest pain. Quality Visits have been undertaken to the MIU's at Buckland, Deal and Folkestone in December The reports are currently with the providers for accuracy checking. NO Mar-16 IC242015/004 Nov-15 Safeguarding Assurance Based on the information supplied by IC24 the CCG's are still to have sight of the Safeguarding policies and have not received any safeguarding data. There are concerns that safeguarding referrals are sent to CCG's rather than the Local Authorities. A policy has been received by the CCG which is robust and clarifies the process regarding referrals of safeguarding alerts. However there is still partial assurance as still not received Safeguarding data around training compliance. LOW CCG's awaiting further Safeguarding data NO Mar IntegratedQualityandPer Page 43 of 50 Page45of52 OverallPage162of204

162 Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory Data Source Latest Data Benchmark/ Target/Trajectory NSL Outcome 1 - Preventing People from Dying Prematurely Outcome 2 - Enhancing Quality of Life for People with Long Term Conditions Outcome 3 - Helping People to Recover from Episodes of Ill Health, or Following Injury Indicator Actual YTD Trend Indicator Actual YTD Trend Indicator Actual YTD Trend (Service) (SKC) P Patients arrive prior to appointment Dec 98.0% 74.7% 75.4% P Core service activity Dec 2,484 22,462 P Return journey collected within 60 mins Dec 95.0% 88.9% 87.7% P OOH activity Dec 5 36 P Discharges/ xfres booked on the day collected 2 hrs Dec 98.0% 80.7% 81.0% P Unplanned Activity Dec 520 4,365 P Journeys aborted by provider Dec 0.0% 2.1% 2.6% P Bariatric Dec P Journeys up to 10 mls no more than 90 mins in vehicle Dec 95.0% 99.7% 99.7% P HDU Dec P Journeys mls no more than 90 mins in vehicle Dec 80.0% 97.5% 97.8% P 1 person crew Dec ,902 P Journeys mls no more than 150 mins in vehicle Dec 95.0% 99.2% 99.2% P 2 person crew Dec ,047 P Stretcher Dec all data above based on service wide performance. P Walker Dec 1,376 1,291 3,974 P Wheelchair Dec ,724 DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) Outcome 4 - Ensuring that People Have a Positive Experience of Care Outcome 5 - Treating and Caring for People in a Safe Environment: Protecting Them from Avoidable Harm Indicator Actual YTD Trend Indicator Actual YTD Trend Friends and Family Test (NSL: All Kent & Medway CCGs) Care Quality Commission (NSL: All Kent & Medway CCGs) P % Would Recommend to Friends & Family Dec 90% 99% 98% C Safe Jul-14 N/A P Number of Responses Dec N/A C Effective Jul-14 N/A Complaints/Compliments (NSL: All Kent & Medway CCGs) C Caring Jul-14 N/A P Compliments Dec N/A 1 16 C Responsive to People's Needs Jul-14 N/A P Complaints Dec N/A C Well-Led Jul-14 N/A Incident Reporting (NSL: All Kent & Medway CCGs) Met Standard Not Met Standard Not Met Standard Met Standard Met Standard P Total Incidents Reported May N/A P Serious Incidents Reported - NSL Total May N/A 0 0 Safeguarding (NSL: All Kent & Medway CCGs) P Safeguarding Alerts Reported by NSL Dec N/A Workforce (NSL: All Kent & Medway CCGs) P % Staff Absence Oct N/A 5.90% 5.66% Summary The Care Quality Commission (CQC) originally inspected NSL in November NSL failed to meet standards in relation to staffing and providing care, treatment and support that meets people's needs. NSL were re-inspected in March 2014 (report published July 2014) and it was found that whilst improvements had been made NSL was still not meeting the required standards. NHS West Kent CCG is the Lead Commissioner for this contract and is working with NSL to seek assurance of improvement. The CQC are taking action against this provider. Key themes relating to concerns regarding the performance and quality of care provided by NSL include: Quality Assurance Safeguarding Infection Prevention and Control Serious Incident Management and Reporting Transporting Patients with Mental Health Problems Mobilisation Phase of Contract DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) 4.2IntegratedQualityandPer Page 44 of 50 Page46of52 OverallPage163of204

163 Issue Reference Date identified Description of Issue NSL: QUALITY AND PERFORMANCE ISSUE LOG Current Position NSL2014/001 Jan-14 Quality Assurance Concerns about the quality of NSL NSL are continuing to provide quality report which are providing to support the contractual Services were confirmed in a CQC Report published in requirements and provide assurance. January 2014 following an inspection in November NSL failed to make the improvements required by the CQC in a follow-up inspection in March CQC Action Plans are in place for Outcome 4: Care and welfare of people who use the service, Outcome 12: People should be cared for by staff who are properly qualified and able to do the job and Outcome 14: Supporting workers. Risk Status (as per escalation process) HIGH Actions Summary of Complaints: NSL to link performance into the quality report going forward, showing a breakdown between East and West Kent. West Kent CCG are continuing to support NSL to develop their quality reporting. To continue to monitor through NSL contractual Quality and Performance Meeting. Risk Register NO Timescale for Completion Mar-16 NSL2015/001 Jun-15 Safeguarding It has been identified within NSL that there is a lack pf policy and reporting against the quality metrics for Safeguarding. NSL2015/002 Jun-15 Infection Prevention and Control It has been identified Update from SECSU on 12th January awaiting update on the infection control policy. Last that there is a lack of assurance including a policy for update was that NSL were putting the policy back through their sign off process after receiving Infection Prevention and Control within NSL. Updated from SECSU on 12th January the policy for Safeguarding has now been agreed. MEDIUM Awaiting copies of the minutes of the contractual Quality and Performance Meeting. comments from West Kent CCG Infection Prevention and Control Specialist. NSL view though was that the policy is now CCG approved. MEDIUM To follow up at contractual Quality and Performance Meeting in February NO NO Mar-16 Mar-16 NSL2015/003 Jun-15 Serious Incident Management and Reporting It has been Updated from SECSU on 12th January the policy for Serious Incidents has now been identified that there is a lack of policy and reporting of agreed. Serious Incidents within NSL. NSL2016/001 Jan-16 Transporting patients with Mental Health problems There are concerns around the appropriateness of patients being transferred by NSL with mental health problems. NSL is discussing with EKHUFT and other providers on a case by case basis MEDIUM MEDIUM Awaiting copies of the minutes of the contractual Quality and Performance Meeting. HoQ SKC leading meeting with NSL, SECAMB and other providers to discuss and define mental health and process/flow chart. NO NO Mar-16 Mar-16 NSL2016/002 Jan-16 Mobilisation Phase of Contract NSL have raised lots of concerns and do not have assurance around mobilisation phase of contract to G4S. NSL2016/001 Jan-16 High Acuity Patient Transport Services (PTS) Following an There is a need for greater flexibility between SECAMB and NSL regarding the transportation of incident whereby a mental health patient fell out of a NSL this patient group. SECAMB are having to use 999 vehicles to transport patients which affects vehicle concerns have been identified regarding the their capacity for 999 calls. transportation of this patient group including inadequate booking information from EKHUFT. SECAMB are being requested to use 999 vehicles for high acuity patients requiring transportation instead of NSL. MEDIUM Briefing at next NSL contract meeting NO Mar-16 CLOSED NSL have reported no further problems and so issue can be closed. NO Mar-16 NSL2015/005 Nov-15 Reprocurement of Patient Transport Services (PTS) On NSL have briefed commissioners and have shared their internal briefing for their staff. The 11th November 2015 NSL announced that they have contract has been awarded to G4S. NSL Exit Plan Meeting held on 7th January withdrawn from the bidding process for the three new Kent PTS contracts and will be withdrawing from the Care Services market as contracts expire over the next two years. NSL2015/004 01/08/2015 DNA CPR Policy Issues with understanding of the DNA The have been incidents where patients have not been transferred with DNACPR Form. The (closed Sept- CPR policy by other organisations e.g. acute, care homes. issues relates to EKHUFT where forms have not been signed by two doctors (junior doctors are 15) Further incident reported in January 2016 relating to signinng the forms and not getting them countersigned) and Care Homes where forms are being Reopened QEQM and end of life care transfer from hospice. lost or there has been a myth that the forms expire. Jan-2016 CLOSED CLOSED Meeting to take forward mobilisation of the G4S contract scheduled week commencing 18th January New contract commences on 1st July To continue to monitor through NSL Quality and Performance Meetings. The issue was EKHUFT has been resolved. NSL met with EKHUFT Lead Nurse. NSL Policy well aligned with EKHUFT. The issues with care homes are being addressed on an individual basis and will be raised at the CCG Care Home Meetings in February NO NO Jul-16 Feb IntegratedQualityandPer Page 45 of 50 Page47of52 OverallPage164of204

164 Data Source Latest Data Target Actual YTD Trend Latest Data Target Actual YTD Trend Latest Data Target Actual YTD Trend Latest Data Target Actual YTD Trend Latest Data Target Actual YTD Trend Latest Data Target Actual YTD Trend Latest Data Target Actual YTD Trend Data Source Latest Data Target Actual YTD Latest Data Target Actual YTD Latest Data Target Actual YTD Latest Data Target Actual YTD Latest Data Target Actual YTD Trend Latest Data Target Actual YTD Trend Latest Data Target Actual YTD Trend INDEPENDENT, TERTIARY AND OUT OF AREA PROVIDERS Indicator Concordia: Out Patients: Dermatology Spencer Private Hospitals BMI - The Chaucer Hospital Benenden Hospital Trend Trend Trend Trend Horder Healthcare Marie Stopes Pilgrims Hospice Outcome 1 - Preventing People from Dying Prematurely Outcome 2 - Enhancing Quality of Life for People with Long Term Conditions In Month Expenditure Jun Jun 35,831 35,639 Jun 65,804 76,593 Jun 23,925 25,765 Jun Jun Jun Year End Forecast Jun 433,380 Jun 795,914 Jun 289,377 Jun Jun Jun Month Variance to plan with QIPP Jun Jun 10,789 Jun 1,840 Jun Jun Jun N Friends & Family Test: % Recommend Dec-15 96% 100% 98% Dec-15 96% 100% 98% Dec-15 96% 98% 99% N Mixed Sex Accommodation Outcome 3 - Helping People to Recover from Episodes of Ill Health, or Following Injury (Provider - SKC CCG) Outcome 4 - Ensuring that People Have a Positive Experience of Care (Provider - All CCGs) Outcome 5 - Treating and Caring for People in a Safe Environment: Protecting Them from Avoidable Harm (Provider - All CCGs) C CQC: Safe Feb-14 N/A Met Standard Oct-15 N/A Good Mar-14 N/A Met Standard Apr-14 N/A Met Standard Mar-14 N/A Met Standard Feb-14 N/A Met Standard Mar-15 N/A Not Sufficient Evidence C CQC: Effective Feb-14 N/A Action Needed Oct-15 N/A Mar-14 N/A Met Standard Apr-14 N/A Met Standard Mar-14 N/A Met Standard Feb-14 N/A Met Standard Mar-15 N/A to Rate C CQC: Caring Feb-14 N/A Met Standard Oct-15 N/A Good Mar-14 N/A Met Standard Apr-14 N/A Met Standard Mar-14 N/A Met Standard Feb-14 N/A Met Standard Mar-15 N/A C CQC: Responsive to People's Needs Feb-14 N/A Met Standard Oct-15 N/A Good Mar-14 N/A Met Standard Apr-14 N/A Met Standard Mar-14 N/A Met Standard Feb-14 N/A Met Standard Mar-15 N/A Good Met Standard Met Standard Met Standard C CQC: Well-Led Feb-14 N/A Oct-15 N/A Mar-14 N/A Apr-14 N/A Mar-14 N/A Feb-14 N/A Mar-15 N/A Met Standard Met Standard Good H Harm Free Care Dec 95% 100% 100% N VTE Risk Assessments Sep 95% 100% 100% Sep 95% 100% 100% DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) Good Good Good Good Indicator South London and Maudsley NHS Foundation Trust Guy's and St Thomas' NHS Foundation Trust King's College Hospital NHS Foundation Trust Queen Victoria Hospital NHS Foundation Trust Royal National Orthopaedic Hospital NHS Trust University College London Hospitals NHS Foundation Trust Kent Institute of Medicines and Surgery (KIMS) Hospital Outcome 1 - Preventing People from Dying Prematurely Outcome 2 - Enhancing Quality of Life for People with Long Term Conditions Outcome 3 - Helping People to Recover from Episodes of Ill Health, or Following Injury (Provider - SKC CCG) In Month Expenditure Jun 286, ,609 Jun 161, ,497 Jun 64,989 48,299 Jun 23,370 35,010 Jun 38,599 45,837 Year End Forecast Jun 3,200,549 Jun 1,903,824 Jun 595,180 Jun 335,157 Jun 444,169 variance to plan with QIPP Jun 56,183 Jun - Jun - 16,690 Jun 11,640 Jun 7,238 Outcome 4 - Ensuring that People Have a Positive Experience of Care (Provider - All CCGs) N Friends & Family Test: % Recommend Dec-15 88% 82% 83% Dec-15 96% 96% 95% Dec-15 96% 95% 94% Dec-15 96% 99% 99% Dec-15 96% 97% 96% Dec-15 96% 96% 97% Dec-15 96% 87% 95% N Mixed Sex Accommodation Dec Dec Dec Dec Dec Dec Dec Outcome 5 - Treating and Caring for People in a Safe Environment: Protecting Them from Avoidable Harm (Provider - All CCGs) Met Standard C CQC: Safe Apr-15 N/A Sep/Dec-13 N/A Oct-12 N/A Oct-13 N/A Aug-14 N/A Aug-13 N/A Action Needed Met Standard Met Standard Met Standard Met Standard Outstanding C CQC: Effective Apr-15 N/A Sep/Dec-13 N/A Oct-12 N/A Oct-13 N/A Aug-14 N/A Aug-13 N/A Action Needed Met Standard Met Standard Met Standard Met Standard Not Inspected Outstanding Action Needed C CQC: Caring Apr-15 N/A Sep/Dec-13 N/A Oct-12 N/A Oct-13 N/A Aug-14 N/A Aug-13 N/A Met Standard Met Standard Met Standard Met Standard Met Standard Action Needed C CQC: Responsive to People's Needs Apr-15 N/A Sep/Dec-13 N/A Oct-12 N/A Oct-13 N/A Aug-14 N/A Aug-13 N/A Met Standard Met Standard Met Standard Action Needed C CQC: Well-Led Apr-15 N/A Sep/Dec-13 N/A Oct-12 N/A Oct-13 N/A Aug-14 N/A Aug-13 N/A Met Standard Met Standard Met Standard Met Standard Met Standard Action Needed H Harm Free Care Dec 95% 94% 94% Dec 95% 97% 97% Sep 95% 95% 93% Dec 95% 96% 96% Dec 95% 98% 96% Dec 95% 96% 96% Dec 95% 96% 100% N VTE Risk Assessments Sep 95% 97% 97% Sep 95% 93% 97% Sep 95% 98% 96% Sep 95% 100% 99% Sep 95% 94% 95% Sep 95% 100% 100% DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) Not Inspected Not Inspected Not Inspected Not Inspected 4.2IntegratedQualityandPer Page 46 of 50 Page48of52 OverallPage165of204

165 INDEPENDENT, TERTIARY AND OUT OF AREA PROVIDERS: QUALITY AND PERFORMANCE ISSUE LOG Issue Reference Date identified Description of Issue SLAM2015/001 Jul-15 South London and Maudsley NHS Foundation Trust (SLAM) The Care Quality Commission (CQC) undertook an unannounced inspection of Fitzmary 2 ward which is a national psychosis inpatient ward within the grounds of The Bethlem Royal Hospital in March This service is provided by South London and Maudsley NHS Foundation Trust and provides 23 bed, mixed gender ward that offers assessments and treatments for adults suffering from treatment resistant psychosis who have had treatment elsewhere where progress has proven difficult. The CQC identified a number of areas where action is required by the provider. Current Position Although the majority of patients said they were happy with the service and the staff were kind and caring there are a number of concerns identified: Care plans not always reviewed on time and no evidence of patient involvement, Daily planning meetings and weekly community meetings not held regularly, Patients not protected against risk of abuse. Some staff not aware of who the SG lead is for the trust, did not understand SG procedures and referrals not made to appropriate authority. Some incidents not been reported appropriately. Ashford and Canterbury CCG's are the leads on the SLAM contract for EK CCG's. At short notice, Ashford and Canterbury CCG's were invited to a SLAM contract meeting on 10th July to discuss the CQC report. Following this meeting Ashford and Canterbury CCG's have raised a Contract Query Notice (CQN) on 15th July for the action plan. Letter received from SLAM on 20th August in response to CQN addressing key areas and providing the CQC action plan, latest quality dashboard and Board Assurance Framework paper which provide at corporate level actions that the Trust is taking and the risks which include the CQC actions. Risk Status (as per escalation process) HIGH Actions Ashford and Canterbury CCG's reviewing action plan. SKC Head of Quality to follow up with Head of East Kent Mental Health Commissioning and Ashford and Canterbury CCG Quality Lead as to whether patients that were delayed are now authorised to receive assessment and treatment from National Psychosis Service. Risk Register NO Timescale for Completion Mar-16 CON2015/001 Sep-15 Concordia Outpatient: Dermatology Use of locum doctors Serious Incident in progress re delay in treatment/escalation. Discovered that Concordia have been using locum doctors when should have been employing specialist consultants. Commissioners have significant concerns with this provider including their poor relationship with EKHUFT. Most GP are sending through Dermatology referrals using 2 week wait pathway. Issue appears to be related to the contract being open to misinterpretation, this is being addressed by commissioning. HIGH The serious incident RCA was submitted to QPD after which there will be a response from commissioning on how to move forward. NO Mar-16 KIMS2015/001 Sep-15 Kent Institute of Medicine and Surgery (KIMS) Hospital Safeguarding Policy KIMS have been awarded the contract for elective services starting 1st September. A Safeguarding Policy for adults is in place but there is the requirement to have a separate Safeguarding policy for children. This has been requested by the CCG. EKHUFT are already using this provider without having assurance. HIGH CCG will be meeting on a quarterly basis for contract monitoring and this issue will be raised. Safeguarding lead to follow up to seek assurance. Head of Quality to follow up with SECSU. NO Mar-16 HOR2016/001 Jan-16 Horder Healthcare Quality metrics (orthopedics) issues with quality metrics relating to patient safety, SI medical errors, falls and patient satisfaction. HIGH West Kent CCG attend meetings and will feedback. NO Mar-16 EKMS2015/001 Dec-15 East Kent Medical Services (EKMS): Spencer As per the service spec, the provider is entitled to exclude certain groups of patients for reasons of clinical HIGH This issue has been escalated to exec and will be reviewed in the next NO Mar-16 Private Hospitals safety; complexity of support healthcare facilities normally required which are not available, or security contract round. Thanet CCG quality team was made aware that reasons. These include: East Kent Medical Services are not accepting ASA IV - a patient with severe systematic disease that is a constant threat to life referrals by GPs of patients who have or had a ASA V A moribund patient who is not expected to survive without the operation mental health diagnosis. This was raised at the ASA VI A declared brain-dead patient whose organs are being removed for donor purposes (subject to EKMS Performance and Quality meeting in amendment see 4.4 above) December where it was confirmed that they do All paediatric surgery not accept patients with a mental health Biopsies of lesions which could result in further treatment for malignancies diagnosis. There are concerns that EKMS is not Patients with a known history of violence providing an equitable service and is potentially Patients who are receiving active psychiatric treatment under a Section of the Mental Health Act excluding a cohort of CCG residents. Patients being detained by Her Majesty s Prison Service where security issues are deemed not to be appropriate Other exclusions as jointly agreed However, there are concerns that this referral criteria is being mis-interpreted by the provider. PH2015/005 Nov-15 Pilgrim's Hospice Anomalies in Data Reporting The CNO at Pilgrim's Hospice has reported that she has been reviewing the validity of data which has resulted Variances have in discrepancies between Quarter 1 and Quarter 2. Data for Q3 has been shared at P&Q meeting on 19th been noted between the Quarter 1 and Quarter 2 January 2016 which showed improvements but CCG has requested that only validated is shown. HoQ has quality reports. requested that the dashboard is supported with narrative. MEDIUM Head of Quality to receive and review governance reports and review. To share reports with other EK CCG quality teams. NO Mar-16 PH2015/003 Aug-15 Pilgrim's Hospice Thanet Head of Quality has met with Pilgrims Chief Nurse at Pilgrims to seek assurance. The new Tissue Acquired Pressure Ulcers At the July Viability Nurse in post has reviewed these cases as a matter of urgency. Assurance has been received that Performance and Quality Meeting it was noted pressure ulcers are being appropriately diagnosed and reported following new awareness and education. that there has been a high level of acquired Prior to this staff were inappropriately reporting wounds as pressure ulcers. Tissue Viability Nurse attended pressure ulcers reported across all 3 sites of Quality and Performance meeting in January to discuss progress and action plan. Pilgrim's Hospice. LOW Head of Quality to arrange meeting with TVN to discuss quarterly reporting and review 3 months data for pressure ulcers across all 3 sites. NO Mar IntegratedQualityandPer Page 47 of 50 Page49of52 OverallPage166of204

166 INDEPENDENT, TERTIARY AND OUT OF AREA PROVIDERS: QUALITY AND PERFORMANCE ISSUE LOG Issue Reference Date identified Description of Issue Current Position PH2015/006 Nov-15 Pilgrim's Hospice The CNO at Pilgrim's Hospice has reported that the Pressure Ulcers are not validated Grade 3 and therefore Grade 3 Acquired Pressure Ulcers Pilgrim's they have not reported them on STEIS. TVN is attending all 3 sites to review all patients who have been Hospice have not been reporting Grade 3 assessed as having either inherited or acquired pressure ulcers of grade 3 or 4 to ensure the patients are being Acquired Pressure Ulcers on STEIS. correctly categorised. A monthly validation process is conducted to ascertain what is 'avoidable' and 'unavoidable'. PH2015/002 Apr-15 Pilgrim's Hospice There were concerns around whether there is anyone within Pilgrims to provide the training to ensure Safeguarding Assurance there are low levels in safeguarding training compliance. Training compliance is improving as there were problems with KCC uptake of safeguarding training. cancelling the training which was picked up later in the year. Q3 data continues to show non-compliance: mandatory safeguarding training 74%, MCA level 2 and DoLS 55% vs target of 85%. Thanet Head of Quality and CCG Designated Nurse for Safeguarding Adults has met with the lead trainer at Pilgrims. there are also concerns around low levels of AP alerts as only 2 have been reported across all sites. Risk Status (as per escalation process) LOW Actions Head of Quality to discuss with TVN to ensure that Thanet CCG is being sited on any grade 3 or 4 pressure ulcers. Risk Register NO Timescale for Completion Mar-16 LOW Pilgrims to benchmark against other hospices NO May IntegratedQualityandPer Page 48 of 50 Page50of52 OverallPage167of204

167 Data Source Latest Data Actual Latest Data Actual Latest Data Actual Latest Data Actual Latest Data Actual Latest Data Actual Latest Data Actual Latest Data Actual Latest Data Actual Latest Data Actual Data Source Latest Data Actual Latest Data Actual Latest Data Actual Latest Data Actual Latest Data Actual Latest Data Actual Latest Data Actual Latest Data Actual Latest Data Actual Latest Data Actual SOUTH KENT COAST CARE HOMES: NURSING Indicator AMI COURT APPLECROFT CARE HOME BALGOWAN HURSING HOME BETHANY HOUSE CARE HOME BETHANY LODGE CREEDY HOUSE HAWKINGE HOUSE HYTHE NURSING HOME KEARSNEY MANOR NURSING HOME MARTHA HOUSE Provider: Raj & Knoll Ltd Applecroft Care Home Ltd Premium Healthcare Ltd Bethany House Care Home Bethany Lodge Outcome 1 - Preventing People from Dying Prematurely First Choice Residential Home Hawkinge House Ltd Premium Healthcare Ltd Sisters of the Christian Retreat Martha Trust Outcome 2 - Enhancing Quality of Life for People with Long Term Conditions K Number of CHC Placements (SKC CCG patients) May May-15 4 May-15 2 May-15 3 May-15 6 May-15 2 May May-15 3 May May-15 6 Outcome 3 - Helping People to Recover from Episodes of Ill Health, or Following Injury K K K K A&E Attendance Emergency Admissions Short Stay Admissions Long Stay Admissions Outcome 4 - Ensuring that People Have a Positive Experience of Care NC User overall rating (No. of reviews) Jul-15 N/A Jul-15 N/A Jul-15 (39) Jul-15 N/A Jul-15 N/A Jul-15 N/A Jul-15 (4) Jul-15 (16) Jul-15 N/A Jul-15 N/A Outcome 5 - Treating and Caring for People in a Safe Environment: Protecting Them from Avoidable Harm C CQC: Overall Rating Apr-15 C CQC: Safe Apr-15 C CQC: Effective Apr-15 Requires Improvement Requires Improvement Requires Improvement Jan-15 Requires Improvement Oct-14 Good Oct-14 Oct-14 Good Oct-14 Oct-14 Good Oct-14 Requires Improvement Requires Improvement Requires Improvement Aug-14 Met Standard Oct-14 Good Jun-14 Met Standard Oct-15 Oct-14 Good Oct-15 Oct-14 Good Oct-15 C CQC: Caring Apr-15 Good Oct-14 Oustanding Oct-14 Good Oct-14 Good Oct-15 C CQC: Responsive to People's Needs Apr-15 C CQC: Well-Led Apr-15 Requires Improvement Requires Improvement Oct-14 Good Oct-14 Oct-14 Good Oct-14 Requires Improvement Requires Improvement Oct-14 Good Oct-15 Oct-14 Good Oct-15 DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) K = SECSU G = Kent County Council (KCC) NC = NHS Choices Requires Improvement Requires Improvement Requires Improvement Requires Improvement Requires Improvement Requires Improvement Apr-14 Met Standard May-15 May-15 May-15 May-15 May-15 May-15 Requires Improvement Requires Improvement Requires Improvement Good Requires Improvement Requires Improvement Indicator MELVYN & JAN JOHN SALTWOOD CARE CENTRE SONIA LODGE (previously Fassaroe ) ST ANSELM'S NURSING HOME ST MARGARET'S NURSING HOME ST STEPHENS NURSING HOME TEMPLE EWELL NURSING HOME THE KNOLL NURSING HOME WELLS HOUSE WELLS LODGE NURSING HOME Provider: Melvyn & Jan John Saltwood Care Centre Ltd Foxley Lodge Care Ltd St Anselm's Nursing Home Simicare Ltd Charing Rose Ltd Charing Cross Investments Ltd Raj & Knoll Ltd Wells Care Ltd Outcome 1 - Preventing People from Dying Prematurely Wells Care Ltd Outcome 2 - Enhancing Quality of Life for People with Long Term Conditions K Number of CHC Placements (SKC CCG patients) May-15 1 May-15 7 May-15 0 May May-15 3 May-15 3 May-15 5 May-15 3 May-15 3 May-15 5 K A&E Attendance K Emergency Admissions K Short Stay Admissions K Long Stay Admissions NC User overall rating (No. of reviews) Jul-15 N/A Jul-15 (46) Jul-15 (1) Jul-15 N/A Jul-15 N/A Jul-15 N/A Jul-15 N/A Jul-15 (2) Jul-15 (8) Jul-15 (6) C CQC: Overall Rating Jan-14 Met Standard Oct-15 C CQC: Safe Oct-15 C CQC: Effective Oct-15 C CQC: Caring Oct-15 C CQC: Responsive to People's Needs Oct-15 C CQC: Well-Led Oct-15 Requires Improvement Requires Improvement Requires Improvement Requires Improvement Requires Improvement Requires Improvement Outcome 3 - Helping People to Recover from Episodes of Ill Health, or Following Injury Feb-14 Met Standard Sep-15 Outcome 4 - Ensuring that People Have a Positive Experience of Care Outcome 5 - Treating and Caring for People in a Safe Environment: Protecting Them from Avoidable Harm Requires Improvement Jan-14 Met Standard Oct-15 Sep-15 Good Oct-15 Sep-15 Requires Improvement Oct-15 Requires Improvement Requires Improvement Requires Improvement Sep-15 Sep-15 Sep-15 Sep-15 Good Oct-15 Good Sep-15 Sep-15 Good Oct-15 Good Sep-15 Sep-15 Requires Improvement Oct-15 Requires Improvement Sep-15 Requires Improvement Requires Improvement Requires Improvement Requires Improvement Requires Improvement Requires Improvement DATA SOURCE KEY: C = Care Quality Commission P = Provider N = NHS England H = Health and Social Care Information Centre (HSCIC) K = SECSU G = Kent County Council (KCC) NC = NHS Choices Apr-15 Apr-15 Apr-15 Apr-15 Apr-15 Apr-15 Requires Improvement Requires Improvement Requires Improvement Good Requires Improvement Requires Improvement Jul-14 Met Standard May-14 Met Standard 4.2IntegratedQualityandPer Page 49 of 50 Page51of52 OverallPage168of204

168 Continuance or Deterioration APPENDIX I Process to Identify and Address Quality Issues Assurance Quality & Performance Review Meeting EKHUFT Quality & Performance Review Meeting KCHT Quality & Performance Review Meeting KMPT Quality & Performance Review Meeting SPFT Other providers and sources of info e.g. locality meetings, CQC, Patient groups Specific Concern Raised with CCG (e.g. Serious Incident) QUALITY REPORT TO CCG QUALITY AND PERFORMANCE COMMITTEE Chief of Clinical Quality informed Quality Risk Identified and Actions Taken Low Risk Patients are safe but delivery of the service may not always ensure best outcomes/patient experience Medium Risk Patients are safe but quality of service is impacting on their health outcomes PATIENTS SAFE BUT ESCALATED GOVERNANCE REQUIRED Increased reporting (weekly/daily as required) Escalated to Single Performance Conversation Contractual levers (see underperformance diagram) Site visits Alert CQC/NTDA to inform their discussions with providers High Risk Evidence of current risk to patient safety due to service delivery and/or persistent long term impact on health outcomes is likely IMMEDIATE PATIENT SAFETY RISK Escalated Governance AND immediate notification where appropriate of Governing Body/NHS England Area Team/CQC/NTDA/partner CCGs, other regulators No No Resolution? Resolution? Yes Yes Resolution Continue to monitor through regular assurance EKHUFT: East Kent Hospital University Foundation Trust KCHT: Kent Community Health Trust KMPT: Kent & Medway NHS & Social Care Partnership Trust SPFT: Sussex Partnership NHS Foundation Trust CQC: Care Quality Commission NTDA: NHS Trust Development Authority 4.2IntegratedQualityandPer Page 50 of 50 Page52of52 OverallPage169of204

169 Report to: Governing Body Agenda 4.3 item: Date of Meeting: 9 th March 2016 Title of Report: Integrated Commissioning Learning Disability Author: Sue Gratton Board Sponsor: Sharon Gardner-Blatch, Chief Nurse Status: Approve Appendices NA 1. Purpose of the Paper This paper seeks the approval of the Governing Body for SKC CCG to enter into a Section 75 Agreement along with the other Kent CCGs with Kent County Council for the provision of an integrated commissioning arrangement for learning disability to serve all partners to the Agreement. 2 Introduction The Clinical Cabinet has previously considered and agreed reports through which have proposed the establishment of an integrated commissioning arrangement to provide a single point of expertise and specialist knowledge, this will support the commissioning system in Kent to deliver: The Transforming Care Programme of change to ensure people with learning disabilities and / or autism who present with challenges or mental health problems are supported in the community wherever possible and are only admitted to in-patient care when clinically appropriate; Integrated specialist care through multiagency community learning disability teams working to the agreed integrated pathway under a single form of agreement; Person centred care through enabling packages of good quality care at an affordable cost, promoting the use of personal budgets wherever possible; Easy access through reasonable adjustments to the full range of health and social care for people with learning disabilities; A strong partnership with the Kent Learning Disability Partnership Board and its network of Delivery and District Partnership Groups to ensure people with learning disabilities and their carers are fully engaged in the planning and development of services; A smooth transition into adulthood with an emphasis on early support to promote independence and good health in adulthood through partnership working with Children s colleagues. The commissioning team will be managed by KCC on behalf of the partners and the 4.3IntegratedCommissioningf Page1of4 OverallPage170of204

170 partnership arrangements are set in out a Section 75 Agreement, the key issues of which are set out below. 3. Summary of Issues The Section 75 Agreement will provide for an integrated commissioning arrangement between the partners and covers the following issues: The partners to the Agreement will be the 7 Kent CCGs and Kent County Council. A new Section 75 Integrated Commissioning Board for Learning Disability has been established. SKC CCG is represented by Sharon Gardner-Blatch. The Board will meet quarterly. It has met once already to agree its Terms of Reference and its annual forward plan. A new governance framework has been agreed by the S75 Board (see attached). Any key decisions will be referred back to the Partners own governance processes with a recommendation from the S75 Board. The governance framework includes the Transforming Care Partnership, which NHSE requires to be a Kent and Medway partnership and will be consistent with the Sustainability and Transformation planning footprint. The commissioning team will be managed by KCC and will include a member of staff, Jimmy Kerrigan, who will be employed by SKC CCG and seconded to KCC. The team will work to deliver the agreed annual joint commissioning plan, which will set out the key aims and objectives and projects for the year. There will be provision for a pooled budget. This will be approached in phases and can only be extended with the agreement of the Partner organisations. The first phase allows for the following items: - The cost of the integrated commissioning team (NB CCGs will share the cost of the health element of the team only, as already happens); - Development costs of the new alliance agreement and the integrated performance framework shared across all Partners; - Management and administration of the S75 arrangements (eg finance support) shared across all Partners; - Dowry payments to be brought in under Transforming Care from April 2016 for anyone discharged from hospital after April who had been in hospital for more than 5 years on the 1 st April these will be CCG specific and linked to named patients. There are two SKC patients who will qualify for dowry payments which means the cost of the care package will be transferred through the pooled budget to KCC. - Cost of Care and Treatment Reviews, introduced through Transforming Care to ensure people detained in hospital or at risk of being admitted to hospital are regularly reviewed by a panel of experts, the cost of these reviews has now been passed to CCGs where they are the responsible commissioner. The cost of CTRs in the pooled budget will be specific to CCG. All of the above elements will be part of the operational pooled budget for 4.3IntegratedCommissioningf Page2of4 OverallPage171of204

171 In addition there will be a notional pooled budget to show the commitment of the Partners to contribute from April 2017 toward the cost of the new alliance contract for integrated community services provided by KCC, KCHFT and KMPT. During a new alliance contracting agreement will be developed. Currently money flows in 10 different contracts across the county to KCHFT and KMPT for the provision of integrated community LD services. The successful delivery of these depends on the collaboration of the three providers, KCC, KCHFT and KMPT. Whilst KCC has agreed to work to the new integrated pathway of care they are not part of the contracting arrangements. The new Alliance Agreement will aim to replace the fragmented contracting arrangements with one form of contract binding the providers to work collaboratively together with the integrated commissioning team. This will introduce a new contracting culture of collaboration, shared ownership and shared problem solving to deliver integrated care to people with a learning disability. This will build upon and cement the history of good partnership working on the ground by the teams. They will continue to work closely with all parts of the health and social care system to ensure people with learning disabilities get good access to care across the system from primary care to specialist tertiary care. There will be an integrated performance framework to measure the service outcomes, this is already in development and will be further improved in preparation for the new Alliance Agreement. The Alliance Agreement, with approval of the Partners, will be introduced from April 2017 and will be managed by KCC through the new integrated commissioning arrangement. 4. Recommendations It is recommended that the Governing Body agree that the SKC CCG should enter into a Section 75 Agreement with the other Kent CCGs and KCC. Hazel Carpenter, the Accountable Officer should be delegated to sign off the S75 Agreement once the content has been approved by the Company Secretary and the operation of the pooled budget approved by the Chief Finance Officer. 4.3IntegratedCommissioningf Page3of4 OverallPage172of204

172 Proposed governance framework for integrated commissioning for learning disability Kent Health and Wellbeing Board Kent LD Partnership Board Kent and Medway Strategic Transformation Executive (See Appendix 4) (Strategic SRO) Delivery Groups District Partnership Groups KCC Governance Kent S75 Integrated Commissioning Board for Learning Disability CCG Governance Kent & Medway Transforming Care Working Group Providers Alliance Group Integrated Commissioning Team (work streams from annual joint commissioning plan - e.g. SAF) (Bi) monthly meeting with CCG Clinical & Commissioning Leads ASC Implementation Groups Kent C&YP Emotional Wellbeing & Mental Health Procurement Board Public Health LD Working Group Kent Good Health Delivery Group V2 February 2016 amended by Monique Verlaan 4.3IntegratedCommissioningf Page4of4 OverallPage173of204

173 Report to: SKC Governing Body Date of Meeting: 9 March 2016 Agenda item: 5.1 Title of Report: Finance Report to 30 January 2016 (Month 10) Author: Board Sponsor: Status: Appendices: Jonathan Bates, Chief Finance Officer Jonathan Bates, Chief Finance Officer Discuss / Approve / Note Appendix 1 Finance Board Report M10 Appendix 2 Referals in Key MOU specialties to Month Purpose of the Paper The CCG must meet statutory financial duties in 2015/2016, and achieve Statutory Financial Balance 2. Introduction To ensure that we, NHS South Kent Coast CCG, can afford to deliver excellent clinical care and achieve statutory financial targets. 3. Summary of Issues Delivery of financial targets for 2015/16 is on track. However contingencies have been fully utilised. Primary care referrals continue to be at levels higher than previous years, and the targets set in the Memorandum of Understanding with EKHUFT will not be achieved. A key focus this month is on agreeing contracts with major providers at affordable levels. 5.1SKCCCGFinanceReportMon Page1of14 OverallPage174of204

174 4. Recommendations The Governing Body is asked to:- Note the contents of this report. 5.1SKCCCGFinanceReportMon Page2of14 OverallPage175of204

175 South Kent Coast CCG Finance Report to 31 January 2016 (Month 10) 1 Summary Delivery of financial targets for 2015/16 is on track. However contingencies have been fully utilised. Primary care referrals continue to be at levels higher than previous years, and the targets set in the Memorandum of Understanding with EKHUFT will not be achieved. A key focus this month is on agreeing contracts with major providers at affordable levels. Actions 2. Tackle the key areas where spend and activity continues to grow: - Prescribing. - Referrals. - Placements, particularly CHC. The CCG must present a balanced budget in 2016/17, which will require significant input from members to achieve. 2016/17 and Beyond The growth in funding allocation reflects a growing population, and includes an amount to cover specific policy pressures (predominantly relating to pensions and seven day service delivery). NHSE have now confirmed that the baseline allocation includes monies for GPIT and Transformational (CAMHS) funding. This causes an additional cost pressure for the CCG. The CCG is working with providers to agree affordable contracts. The CGG is actively involved in the project to drive strategic change in east Kent, and staff are in post to start the work. The aim is to develop comprehensive, integrated local health and social care services tailored to SKC CCG Finance Report Mon Page 3 of 14 Overall Page 176 of 204

176 communities, supported by a high quality financially sustainable acute hospital sector, and access to safe specialist services. 3. Acute 3i. EKHUFT EKHUFT have now shared their forecast outturn position for year-end spend and are predicting a year-end underspend of 167,000 for South Kent Coast CCG. SECSU is currently forecasting a year end underspend of 587,000. The gap between CSU and Trust positions is due to an unlikely level of growth being assumed by the Trust in the last quarter. Referrals continue to be above the levels of prior years as shown in the graph below. The bars reflect referrals in the current year (2015/16). Appendix 2 shows a breakdown by key MOU specialty. Referrals are all above prior year levels. The CSU are undertaking a piece of work to understand how referral figures are recorded by EKHUFT, and to ensure accuracy of data. QIPP (additional to that rolled into the block agreement) is unlikely to be delivered as activity is now starting to reduce wait times. Elective T&O activity has doubled in October 2015 as EKHUFT outsource to the new KIMS hospital. High levels of growth have been seen in emergency admissions under the A&E specialty. This may reflect a change in admission practice by new consultants. The CSU are investigating SKCCCGFinanceReportMon Page4of14 OverallPage177of204

177 3ii. Tertiary Providers There has been a clear directive from NHSE that local interpretation of Specialist Rules are not to be grounds for dispute of invoices, and that the provider view is prime, provided that the view has been consistent since 12/13. This means that the CCG is likely to have to concede challenges that have been raised and referred to in previous reports. The graph below demonstrates the gradual increase in overall contracted tertiary activity since April The 6 highest referrers for elective tertiary services are: o o o o o o Balmoral Surgery Church Lane Sandgate Road The Cedars Oaklands High St Surgery This CCG has a block contract arrangement with Kings. Actual activity is 7.8% (equating to 0.1m) above plan for the year to Month 8. 3iii AQP and Independent Planned Care The closure of St Saviours has had a significant effect on the level of IS activity, and as at Month 8 other IS providers have not seen a corresponding increase in activity SKCCCGFinanceReportMon Page5of14 OverallPage178of204

178 Overspends in the remaining IS providers are due to T&O and ophthalmology activity. A small number of patients have accessed services in France. Planned care continues to show an overspend against the budget set on outturn in 2014/15. The key areas of high activity are community cataract, audiology and physical therapies. Of these the most significant in monetary terms is physiotherapy. 3iv High Cost Drugs (HCD) The HCD forecast outturn has now stabilised. The Month 10 position shows an overspend of 133,000 for trade high cost drugs EKHUFT HCD spend is included in the block contract. HCD spend is for the following diagnoses. 3v. Non Contract Activity (NCA) The Month 10 Board Report is showing an overspend against budget, of 97,000. This is less than the Month 9 position due to a downturn in the number and value of invoices received SKCCCGFinanceReportMon Page6of14 OverallPage179of204

179 NCA is subject to fluctuation and an estimate is made at month end based on invoicing which is generally two months in arrears. 4 Community 4i Kent Community Health Foundation Trust (KCHFT). The Month 10 position and forecast outturn reflects invoicing to KCHFT for savings identified in district nursing SOP (Standard Operating Procedures) analysis work. SKC CCG have invoiced KCHFT 253,000. Further smaller contract variations (CV) have been drawn up, which will result in savings to the CCG. 5 Placements. 5i Continuing Healthcare (CHC) There are issues sourcing placements for patients with challenging behaviour and domiciliary care in rural SKC. The placements team are attempting to source new providers. Review of forecasts is ongoing by the CCG finance team to ensure that all individual forecasts accurately reflect agreed costs of placements. Queries are being fed back to the SECSU CHC team to enable improved forecasting. The increase in CHC spend over 2014/15 of 7% is covered by budget. However this level of increase is not sustainable going forward. 5ii Mental Health The Month 10 position shows an overspend against budget. All mental health placements are being reviewed in line with the agreement in the KMPT Memorandum of Understanding (MOU), to assess value for money and plans for discharge. 5iii Children The forecast outturn for children s placements has decreased this month following a SECSU and KCHFT review to understand how care packages are agreed and assessed, to ensure that best value and outcomes are achieved SKCCCGFinanceReportMon Page7of14 OverallPage180of204

180 6 Mental Health 6i ASD/ADHD New GP referrals to the service provided by Psicon are still being seen despite this being a service to address backlogs only. Children s transformation monies have been received to cover the backlog in assessments. Work on an all age neurodevelopmental pathway has begun to consider ways of working going forward, as part of the transformation of services. 6ii IAPT New contracts have now been awarded. The new providers have expressed concern around financial penalties attached to high levels of Step 3 activity, and as a result the EK CCGs and providers will work together on a Service Development Improvement Plan (SDIP). The SDIP will focus on increasing the number of patients referred by GPs at the point at which early intervention by IAPT services would be appropriately provided at Step 2. 6iii KMPT Out of Area (OOA) Beds The East Kent CCGs await confirmation from KMPT with regard to the basis for calculation of individual CCG liability. The CCG has set out its own view clearly to the Trust. The EK CCGs continue to have twice weekly telephone calls with KMPT, due to continued fluctuation in usage of out of area beds. Work is ongoing to try to reduce usage. SKC CCG continues to have an underspend against budget, in contracts to the other EK CCGs. 7 Primary Care 7i Prescribing The trend in prescribing spend (red line) continues to move inexorably upward, and SKC spend is consistently above the national (blue line) average level as shown in the graph below. The gap between the trend lines ( ) is growing wider, showing that SKC prescribing spend is growing at a higher rate than nationally SKCCCGFinanceReportMon Page8of14 OverallPage181of204

181 The prescribing overspend continues to be concentrated in a small number of practices. The graph below illustrates the disparity in forecast outturn per Astro PU across the SKC GP practices. While a number of GPs are fully engaged with the CCG s pharmacy initiatives, an increasing number of locums and practices are not. A single meeting task and finish group will be set up to understand the blocks to moving forward. 8 Corporate The CCG is expected to deliver within the corporate budget set SKCCCGFinanceReportMon Page9of14 OverallPage182of204

182 9 Balance Sheet Balance Sheet '000s '000s '000s '000s '000s '000s '000s '000s '000s '000s Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Plant, Property, Equipment Accumulated Depreciation Non-Current Assets Accounts receivable 1,401 3,188 2,036 2,537 1,555 1,961 2,367 2,955 1,685 2,139 Cash 4,631 8,747 5,729 5,379 4,751 3, ,381 2,432 Current Assets 6,032 11,934 7,765 7,916 6,306 5,852 2,895 2,979 5,067 4,571 Total Assets 6,144 12,032 7,870 8,022 6,410 5,953 2,996 3,075 5,160 4,662 Accounts Payable 18,048 28,270 22,075 27,045 25,980 28,135 23,331 18,561 23,206 24,103 Current Liabilities 18,048 28,270 22,075 27,045 25,980 28,135 23,331 18,561 23,206 24,103 Assets less Liabilities -11,904-16,238-14,205-19,023-19,570-22,182-20,335-15,485-18,046-19,441 General Fund -11,904-16,238-14,205-19,023-19,570-22,182-20,335-15,485-18,046-19,441 Total Taxpayers Equity -11,904-16,238-14,205-19,023-19,570-22,182-20,335-15,485-18,046-19,441 The Balance Sheet position remains stable. 10 Cashflow The CCG has a duty not to exceed its maximum cash drawdown limit as set by NHS England. The CCG aims to reduce cash balances at the GBS to an absolute minimum at 31st March in each financial year. Cash-flow remains stable to date. As the year progresses the finance team will ensure increased focus on the cash position of the main provider trusts, and ensure that there is a clear understanding around invoicing, particularly those invoices that are disputed by the CCG SKCCCGFinanceReportMon Page10of14 OverallPage183of204

183 12 Better Payment Practice Code (BPPC) The CCG is adhering to the BPPC, by paying 95% of invoices both by number and value within 30 days of receipt, as shown in the graph above. 13 Allocations Transfer Source Allocation Recurrent / Non- Recurrent Amount ( '000) NHS England - Central Baseline Allocation - Programme Recurrent 260,944 NHS England - Central Better Care Fund Recurrent 3,884 NHS England - Central Running Cost Allowance 15/16 Recurrent 4,404 NHS England - Central Return of 14/15 Surplus Non-Recurrent 3,596 NHS England - Central recurrent transfers Recurrent 1,041 NHS England - Central Enhanced Tariff Option Funding Non-Recurrent 657 NHS England - Central GP IT Non-Recurrent 512 NHS England - Central Waiting list validation and improving operational processes Non-Recurrent 6 NHS England - Central Initial allocation of funding for eating disorders and planning ib 2015/16 Non-Recurrent 112 NHS South East Ophthalmic enhanced services Recurrent 8 NHS England - Central Tier 3 Neurology Commissioning Responsibility Transfer Recurrent 29 NHS England - Central Liaison Psychiatry - Mental Health Non-Recurrent 47 NHS England - Central Transformation Fund Non-Recurrent 281 NHS England - Central MoD - Out of hours Non-Recurrent 6 NHS England - Central Liaison Psychiatry Non-Recurrent 47 NHS England - Central Quality Premium award Non-Recurrent 149 NHS England - Central Vanguard: Pioneer - Kent Non-Recurrent 100 NHS England - Central CEOV and non-rechargeable services allocation adjustment Non-Recurrent 121 NHS South East Rebasing of Property Services charges Non-Recurrent 239 Total Resource Limit Month ,183 Recommendations The Governing Body is asked to note the contents of this report, and support the actions set out. Jonathan Bates Chief Finance Officer February SKCCCGFinanceReportMon Page11of14 OverallPage184of204

184 Appendix 1 South Kent Coast CCG Board Report M /16 Annual Year to Date Forecast Budget Budget Actual Variance Actual Variance '000s '000s '000s '000s '000s '000s Acute Local Acute Contracts 114,850 95,708 96, , Other Acute Contracts 12,976 10,814 11, , High Cost Drugs 3,453 2,878 3, , Ambulance Services 8,919 7,432 7, ,919 0 Winter Pressures 1,395 1,163 1, ,395 0 Non-contract 3,396 2,830 2, , Acute Total 144, , ,411 1, ,845 1,855 Community KCHT Contract 23,850 19,875 20, , Other Community 3,143 2,619 2, , Community Total 26,993 22,494 22, , Placements Continuing Health Care 17,420 14,635 14, ,420 0 Mental Health Placements 4,679 3,899 3, , Childrens Placements Placements Total 22,872 19,179 19, , Mental Health IAPT 1,549 1,290 1, , Other 1,244 1, , Children Mental Health 2,255 1,879 1, ,255 0 Dementia KMPT Contract 17,462 14,552 14, ,462 0 KMPT Out of Area Beds Mental Health Total 23,130 19,275 19, , Primary Care Out Of Hours 1,670 1,392 1, ,670 0 Local Enhanced Service 1, , Other Primary Care Other Prescribing 1,662 4,154 3, , GP Prescribing 33,230 24,923 26,023 1,101 34,700 1,470 Oxygen GP IT Primary Care Total 39,599 32,999 33, ,698 1,099 Other Patient Transport 1,708 1,423 1, , Children's Commissioning Prop Co Recharge 1,443 1,202 1, ,443 0 NHS Better Care Fund 4,374 3,645 3, ,374 0 Other Total 8,649 7,208 7, , Corporate Total 4,553 3,814 3, , Reserves Total 2,586 2, , ,586 TOTAL EXPENDITURE 273, , , ,372 0 Resource Limit -276, , ,230 0 TOTAL RESOURCE -276, , ,230 0 SURPLUS / (DEFICIT) 2,811 2,283 2, SKCCCGFinanceReportMon Page12of14 OverallPage185of204

185 Appendix 2. Referals in Key MOU specialties to Month SKCCCGFinanceReportMon Page13of14 OverallPage186of204

186 12 5.1SKCCCGFinanceReportMon Page14of14 OverallPage187of204