BOARD OF DIRECTORS A G E N D A

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1 BOARD OF DIRECTORS A meeting of the Board of Directors will take place on Thursday, 25 September 2014 at 9.30 am in Lecture Hall 1, The Academy, Great Western Hospital, Swindon A G E N D A Our Vision Working together with our partners in health and social care we will deliver accessible, personalised and integrated services for local people. We will provide high quality care whether at home, in the community or in hospital empowering people to lead independent and healthier lives Our Strategic objectives 1. To deliver consistently high quality, safe services which deliver desired patient outcomes 2. To improve the patient and carer experience for every aspect of care we deliver 3. To ensure that staff are proud to work at the Trust and would recommend the Trust as a place of work or receive treatment 4. To secure the long term financial health of the Trust 5. To adopt new approaches and innovation so that we improve services as healthcare changes whilst continuing to become more efficient 6. To work in partnership with other so that we provide seamless care for patients Our strategic priorities Integrated Care - We will make the patient the centre of everything we do Transformation Cost Efficiency - We will work smarter not harder to make best use of limited resources Service Innovation - We will innovate and identify new ways of working Building Capacity - We will build capacity and capability by investing in our staff, infrastructure and partnerships A large print version of this agenda is available by request. Please contact Deborah Rawlings by Deborah.Rawlings@gwh.nhs.uk or by telephone Please note that this meeting will be held in a wheelchair accessible venue. If you would like to attend and have any special access requirements, please let Deborah Rawlings know beforehand and she will do her best to meet your requirements. The Great Western Hospital, Marlborough Road, Swindon, Sn3 6BB

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3 BOARD OF DIRECTORS A meeting of the Board of Directors will take place on Thursday, 25 September 2014 at 9.30 am in Lecture Hall 1, The Academy, Great Western Hospital, Swindon Matters Open to the Public and Press A G E N D A 1 Apologies for Absence and Chairman's Welcome 2 Declarations of Interest Members are reminded of their obligation to declare any interest they may have in any issue arising at the meeting, which might conflict with the business of the Trust. 3 Questions from the public to the Board relating to the work of the Trust 4 Minutes (Pages 1-20) Roger Hill, Chairman 31 July 2014 (public and redacted private minutes) 5 Outstanding actions of the Board (public) (Pages 21-22) 6 Chairman's Report, Feedback from the Council of Governors Roger Hill, Chairman 7 Chief Executive's Report - ongoing concerns with Carillion (Pages 23-28) Nerissa Vaughan, Chief Executive LONG TERM FINANCIAL HEALTH (9.45am) 8 Finance Report for Month 5 (Pages 29-50) Maria Moore, Deputy Chief Executive / Director of Finance & Performance Monthly Monitor Return SAFE SERVICES (10.00am) 9 Patient Safety and Quality Report - August 2014 (Pages 51-96) Hilary Walker, Chief Nurse 10 Summary of the external investigation into the two retained vaginal swab never events in the maternity services in the Bath clinical area (Pages ) Hilary Walker, Chief Nurse 11 Assuring Active Management of 18 Weeks Referral to Treatment - Key Performance Indicator and Compliance Audit Programme (Pages ) Sharon Beamish, Interim Chief Operating Officer

4 12 Health & Safety Policy Statement of Commitment and Occupational Health, Safety and Fire Annual Report 2013/14 (Pages ) Oonagh Fitzgerald, Director of Workforce & Education 13 Acute Stroke Care - update (presentation) Guy Rooney, Medical Director PATIENT AND CARER EXPERIENCE (11.30am) 14 Patient Experience Report - August 2014 (Pages ) Hilary Walker, Chief Nurse 15 Safer Staffing Monthly Report (Pages ) Hilary Walker, Chief Nurse WORKFORCE (12.00pm) 16 People Strategy six month progress report (Pages ) Oonagh Fitzgerald, Director of Workforce & Education LONG TERM FINANCIAL HEALTH (12.20pm) Risk Register (Pages ) Carole Nicholl, Company Secretary & Head of Corporate Governance OTHER (12.30pm) 18 Nominated Individuals for CQC Registration of Regulated Activities (Pages ) Carole Nicholl, Company Secretary & Head of Corporate Governance 19 Briefing paper: impact for Great Western Hospital following changes to the Mental Capacity Act and Deprivation of Liberty Safeguards (Pages ) Hilary Walker, Chief Nurse 20 Non-Executive Directors - Membership on Board Committees (Pages ) Carole Nicholl, Company Secretary & Head of Corporate Governance 21 Urgent Public Business (if any) To consider any business which the Chairman has agreed should be considered as an item of urgent business and to note the reasons for the urgency. 22 Date and Time of next meeting Date: 30 October 2014 Time: 9.30am Venue: Lecture Hall 1, The Academy

5 23 Exclusion of the Public and Press The Board is asked to resolve:- that representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest when the following items are considered: - Minutes Financial Recovery Radiotherapy Audit, Risk and Assurance Committee Minutes Executive Committee Minutes Finance, Investment and Performance Committee Minutes Governance Committee Minutes Mental Health Act and Mental Capacity Act Committee Minutes People Strategy Minutes Urgent Private Business (if any) Roger Hill Trust Chairman, Great Western Hospitals NHS Foundation Trust 18 September 2014

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7 Agenda Item 4 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST MINUTES OF THE MEETING OF BOARD OF DIRECTORS HELD IN PUBLIC ON 31 JULY 2014, AT 9.30 AM IN LECTURE HALL 1, THE ACADEMY, GREAT WESTERN HOSPITAL, SWINDON Present Members Roger Hill (RH) Angela Gillibrand (AG) Robert Burns (RB) Liam Coleman (LC) Oonagh Fitzgerald (OF) Jemima Milton (JM) Maria Moore (MM) Steve Nowell (SN) Guy Rooney (GR) Nerissa Vaughan (NV) Hilary Walker (HW) Chairman Deputy Chairman Non-Executive Director Non-Executive Director Director of Workforce and Education Non-Executive Director Deputy Chief Executive and Director of Finance Non-Executive Director Medical Director Chief Executive Chief Nurse Non-Voting Board Members Kevin McNamara (KM) Director of Strategy Also In Attendance Sharon Beamish (SB) Carole Nicholl (CN) Peter Russell (PR) Interim Chief Operating Officer Company Secretary and Head of Corporate Governance Interim Director of IM&T (part of meeting) Number of members of the public: None. Matters Open to the Public and Press Minute Description Action by whom 100 /14 Apologies for Absence and Chairman's Welcome Action by when Apologies for absence were received from Angela Gillibrand, Non-Executive Director. 101 /14 Declarations of Interest There were no declarations of interest. 102 /14 Questions from the public to the Board relating to the work of the Trust 103 /14 Minutes There were no questions from members of the public. The minutes of the meeting of the Board held on 26 June 2014 were adopted and signed as a correct record, subject to the following amendments: - Minute 78/14, Finance Report The deletion of the sentence HW commented that although this had to be done, the number of patients with mental health issues was very small and the replacement with HW commented that although this had to be done, the number of patients with acute mental health issues was very small. Minute 84/14, Safer Staffing Monthly Report The deletion of the sentence HW explained that she was considering what this report should look like going forward 1 Page 1

8 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST and that some meaningful narrative and context had been added to the data set and the replacement with HW explained that she was considering what this report should look like going forward and she was keen that some meaningful narrative and context should explain the data set. Minute 85/14, Safer Staffing Establishment Review In the fourth paragraph, the deletion of the words such as Jupiter Ward now had only 10 beds but was working to previous rotas and levels were now different on Jupiter Ward. The redacted minutes of the part of the meeting of the Board held in private on 26 June 2014 were received. The redacted minutes of the part of the meeting of the Board held in private on 30 June 2014 were received. The minutes of the joint meeting of the Board and Council of Governors held on 12 June 2014 were received. The redacted minutes of the part of the joint meeting of the Board and Council of Governors held in private on 12 June 2014 were received. Arising upon consideration of the minutes of the joint meeting, JM sought clarification on the eligibility criteria to be a governor. CN explained that Annex 5, Appendix 1, Provision 1.9 of this Trust s Constitution stated that a person might not become or continue as a Governor of the Trust is he was a member of a local authority Health Overview and Scrutiny Committee (HOSC). JM commented that there was a governor of Salisbury NHS Foundation Trust who was a member of a HOSC. CN undertook to look into this and advise JM accordingly. 104 /14 Outstanding actions of the Board (public) The Board received and considered the outstanding actions list. The Board noted progress against the actions and agreed that completed actions be removed. 105 /14 Chairman's Report, Feedback from the Council of Governors The Chairman gave a verbal report as follows: - Governor Briefing on Ophthalmology RH reported that the Chief Executive had given a briefing to governors on the current position regarding the implementation of the recommendations arising out of the Royal College Review of Ophthalmology Services. Governors had been reassured regarding the progress being made and had noted that the hold file was reducing. A further update would be provided to Governors at the Council of Governors meeting in November. Meeting with Leader of Swindon Borough Council RH reported that he had met with Councillor David Renard, Leader of Swindon Borough Council to discuss difficulties in the health system and to outline the material changes that this Trust needed to do in order to maintain an efficient and effective service going forward. Meeting with Chief Executive of Salisbury NHS Foundation Trust RH reported that he and the Chief Executive had met with Peter Hill, Chief Executive of Salisbury NHS Foundation Trust to share views on ways forward to deliver health care services in the community. RESOLVED CN to advise JM August 2014 that the report of the Chairman be received. All to note /14 Chief Executive's Report The Board received and considered a report from the Chief Executive covering the following issues: - 2 Page 2

9 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST Positive results from the GMC National Trainees Survey Additional funding to support transformation of core Community Teams National pay dispute In presenting the report, the following comments were made: - Positive results from the GMC National Trainees Survey NV explained that the survey had generated 100% response rate and that there were no patient safety or undermining behavioural reports, which made this Trust the only on in the Deanery not to have either. NV highlighted that the results showed a marked improvement in General Surgery, although an area for further work was Paediatrics. It was commented that it was considered that this Trust delivered high quality training. Additional funding to support transformation of core Community Teams NV reported that Wiltshire Clinical Commissioning Group would be investing 2m to increase capacity in Community Teams. NV explained that work was underway to transition from 11 Neighbourhood Teams to 20 Community Clusters enabling the Community Teams to work as part of an extended Primary Care Team alongside primary care, social care, mental health and the voluntary sector. National pay dispute NV reported that it had been announced that NHS staff who were members of Unison would be balloted over strike action in response to the Government s rejection of the national pay body review recommendations earlier in the year. If approved, industrial action would take place in October, followed by further waves of strike action potentially into the winter. It was noted that in addition the Royal College of Midwives (RCM) would also being balloting its members on whether or not to take industrial action. In response to a question from NV, OF explained that preparedness for any industrial action was starting now. A meeting had been held earlier in the week and it was noted that previous industrial action had had limited impact on the Trust locally, although the impact of potential RCM action was unknown. OF explained that she would keep Board Directors informed on any planning to mitigate the impact of industrial action. RB questioned whether additional agency staff would be required during any industrial action. NV responded that there was a need to ensure that patients remained safe and as such engagement of additional agency staff might be necessary. OF responded that in the past many staff had chosen not to strike. In response to a further question by RB, it was clarified that staff, agency or bank were not paid when on strike. RESOLVED that the report of the Chief Executive be received. All to note /14 Patient Safety and Quality Report - June 2014 The Board received and considered a report, which set out commentary and progress on activity associated with the key safety, quality and performance indicators and where appropriate the actions being taken where performance was required. The main points summarised in the report and specific comments made were as follows: - Infection Prevention and Control Blood Culture Contamination Rate continued to be below (better than) the national average. GR commented that rates fluctuated and work was underway with support from the Infection Prevention and Control Team to 3 Page 3

10 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST improve performance. There were no MRSA bacteraemia reported during June There was one case of Clostridium difficile reported during June 2014 (totalling 2 cases to date). GR drew attention to the ongoing action as set out in the report. GR explained that thought was also being given to an antibiotic champion and consideration was being given to appropriate isolation times for C.diff patients. There had been a small increase in the number of Hospital attributed MSSA and Ecoli bacteraemia reported in June with 1 MSSA being a repeat positive. GR reported that the five MRSA cases had been reviewed resulting in learning. The importance of standard infection control precautions by staff at all times was emphasised and the need for Occupational Health to provide repeat screening for staff with a history of MRSA had been identified. GR highlighted that a routine commode audit had revealed the need for improved standards of cleaning, which was being actioned by the Matron s Group. GR highlighted that the C Section Surveillance report had identified that there was a higher rate of infections than the 10% that would be expected, GWH (13.7%) and Princess Anne Wing (17.9%). Recommendations for a local action plan were being drawn up, details of which were included in the report. There were no ward or bay closures during June Clinical Audit and Effectiveness The audit programme had been change in month. The number of annual audits would reduce significantly to approximately 500, with improved registering and recording arrangements planned. The database had been modified to enable streamline reporting of audit activity in the future. GR drew attention to examples of good audits as set out in the report. GR explained a new approach to ensure completion of audits and action plans which included face to face contact and support. 64% of audits completed to date had resulted in learning and a change in clinical practice. Four key learning points from the completed audits were outlined. A report on Dr Fosters alerts during June was included showing 4 investigations in progress. Details of reviews no longer required and completed reviews were outlined. NICE adherence and monitoring was set out in the report with Trust wide compliance of 98.5% being achieved in month. Trust participation in National Confidential Enquires into Patient Outcomes and Deaths (NCEPOD) studies remained at 100%. Updates and continuing studies were reported. GR highlighted a forthcoming study which would look at the quality of care provided to patients with a mental health disorder, who were admitted an acute hospital. Clinical Risk and Patient Safety There were no Never Events reported in June The findings of the Maternity Never Event investigation were shared with representatives from this Trust and the Royal United Hospitals Trust (RUH). The findings of the report and agreed action plan were presented to the July Patient Safety Committee. HW advised that she would report a summary of the maternity never events to the September meeting of the Board. 6 new serious incidents were reported in June serious incident investigations had been completed with learning and recommendations identified. Exceptions and action plans from overdue Never Events/serious incidents HW to report Sept Page 4

11 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST were explained and it was noted that 11 action plans were completed and closed during June Two action plans were overdue, but it was expected that they would be closed by the end of August. One Executive Patient Safety Visit was undertaken in June Actions completed or resolved arising out of visits were detailed in the report, together with themes arising from visits. Regulation and Compliance A full review of the sites owned and used by the Trust and cross referencing activity with the registration certificates for those sites was being undertaken. HW advised that the Trust would not be in the next round of formal CQC inspections. It was commented that there had been national media coverage about the rate of inspections slowing down. However, it was noted that the CQC still intended to complete all inspections by December There were 3 CQC outliers relating to: - Maternal non-elective readmissions within 42 days Neonatal non-elective readmissions with 28 days Therapeutic endoscopic procedures on the upper GI tract There were four external reviews, inspections and quality walkabouts in June: - Swindon CCG Quality Walkabout GWH Maternity (W&C s) Peer Review IP&C C.diff review (all Directorates) National Peer Review Paediatrics Diabetes (W&C s) Wiltshire CCG Quality Walkabout: Trowbridge MIU (USC) An update on actions to address the CQC External Inspection October 2013 Great Western Hospital was provided. There were 3 remaining actions relating to environmental cleanliness; medicines administration and response to call bells which would be presented to the Governance Committee in September. The CQC Intelligence Monitoring Report had resulted in the Trust being banded at a 3 (priority banding for inspection). The Trust had two risks and four elevated risks identified. Mortality LC commented that the Trust had seen an increase in the number of whistleblowing cases. NV responded that every trust had whistleblowing and the difficulty was that the Trust did not know who and where the whistle-blowers were or the nature of their concerns. HW advised that the Trust was seeing an increase in the number of concerns raised internally which was the right way for issues to be raised. Front line staff were talking through their concerns. OF commented that staff could see that the Trust was dealing with issues formally when not quality was not being delivered and that messages around high quality care and expected performance were consistent. LC questioned why there was whistleblowing when the Trust was providing a supporting environment in which to raise concerns. NV responded that some in the main concerns were raised internally, but that the whistleblowing framework provided an additional route. 15 pressure ulcer incidents were reported during June, which was 1 more than the monthly trajectory. The Board noted an amendment to the report to reflect this. At this point in the meeting, GR highlighted that the report did not contain any information about mortality as data had not been received in time for inclusion in 5 Page 5

12 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST this report, or in a separate report. GR therefore gave a verbal update explaining that the Hospital Standard Mortality Rate (HSMR) was currently which was a significantly improved position. GR reported that in January, February and March the Trust had had low figures and therefore the average position had reduced. It was noted that the Trust expected to rebase to 105 (previously 108) and therefore the Trust would not be an outlier. GR highlighted that the Trust was now eighth from bottom in South West and he undertook to report in full to the September meeting of the Board. Performance There were four areas for focus - percentage of patient who stayed a maximum of 4 hours in A&E (acute and combined); 18 week referral to treatment and electronic discharge summaries being with GPs within 1 working day of discharge. A dashboard setting out performance for a number of indicators was included in the report. Percentage of patients who stay a maximum of 4 hours in A&E SB highlighted that performance was improving back towards the required level. It was noted that the combined performance in June was 94.22% against a target of 95%. SB commented that there had been a continued rise in attendances but a combined organisation, the Trust had achieved significantly improved performance. From 1 July 2014 the Day Surgery Unit had been closed to inpatients and as at the end of July, bays were being closed in readiness for a ward closure. Furthermore, since March the length of stay was reducing. The Teams were performing very well in changing practices. It was noted that the ECIST recommendation had led to major differences and had provided focus for action. Furthermore, working with partner organisations was improving. It was noted that there were only 14 escalation beds and therefore the need to continue to embed the changes was essential for long term sustainability. NV commented that this Trust had been the only trust in the South West achieving its A&E wait targets. 18 week referral to treatment It was noted that 73 patients would breach the 52 weeks referral to treatment time. However, it was noted that the planned admitted and non-admitted standards as reported to the Board previously had been achieved. It was noted that there were problems associated with new Medway in terms of hold file and backlog and these were being looked into. Alternative ways of working were being used in the interim to manage patients. It was noted that a report on this matter was included elsewhere on the agenda. Dashboard It was noted that there had been an issue regarding the requesting of x-rays through new Medway. There were a number of patients with duplicate entries and alerts had not been issued. Six patients had breached the six week standard and the Trust was working to understand the position of the remaining 198 patients. Capacity and demand in Rheumatology SB advised that closure of Choose and Book for Rheumatology was being discussed with the commissioners, noting that the Trust had concerns around capacity and demand. GR to report Sept Page 6

13 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST RESOLVED that the Patient Safety report be noted and that it be agreed that the Board is assured by the Executive Committee that actions are being progressed as appropriate. All to note /14 18 weeks Referral to Treatment (RTT) (Admitted) - progress report The Board received and considered a report which provided an update on progress with the backlog reduction exercise that had commenced on 1 July It was noted that there had been a significant improvement in the waiting times experienced by patients, and that the vast majority of the longest waiting patients had been treated, or had a planned admission date for their treatment. In addition to the report, slides were presented which compared performance against trajectory, which was monitored on a weekly basis at aggregate Trust and speciality level. It was reported that whilst the number of patients treated from the backlog had been in line with planning assumptions, a growing number of patients were being added to the waiting list for surgery when they had already breached 18 weeks, or were very close to it. It appeared that this was as a result of the more robust measurement of patient pathways following New Medway implementation. However, this constituted a significant risk and as well as clearing the admitted backlog the focus must also shift to including patients in the outpatient system and bringing their waiting times down to support an overall 18 week pathway. SB reported that as of 28 July, there were 838 patients in the backlog. 560 patients had an appointment with 228 to be addressed before the end of September. SB reported that the hold file backlog was being cleared. However new patients were continually coming through, but this was being monitored and dated. SB reported that performance was slightly adrift in respect of oral surgery, which was linked to the Community Dental Team. SB advised that the longest wait was 40 weeks. In terms of any financial penalties for non-performance, MM undertook to confirm the position as part of future financial reporting. MM reported that a letter had already been received from Wiltshire Clinical Commissioning Group confirming that it would not issue fines. RESOLVED (a) that the achievements made to reduce the admitted backlog be noted and supported; and (b) that discussions take place with commissioners about the likely level of elective over performance (if resilience monies are not available) to ensure that this additional work is funded and is not a cost pressure. 109 /14 Review of Outpatient to ensure outpatient administration supports RTT delivery and Hold File Reduction The Board received and considered a report which gave an overview of significant operational issues in the Outpatient Department and the actions required to support 18 week Referral to Treatment (RTT) and hold file reductions. The report invited the Board to approve a fixed term project team for 9 months which would be tasked with completing the actions set out in the report, namely validating patients; reducing the hold file and resolving the root cause. Composition of the Team and timescales for action were set out, together with the associated financial costs over three years. MM All to note SB Ongoing - August Page 7

14 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST In presenting the report, SB highlighted the following points: - It was planned that the 6000 patients without a definite clinical outcome would be validated by the end of September. This had come about due to the new Medway migration. Teams were not doing today s work today and this needed to be addressed. On a rolling monthly basis there was a cohort of patients who had no registered outcome attached to their attendance. This had continued since May and therefore a plan would be worked up to get this back in line by the end of September. Speciality by speciality understood what the issues were. Demand and capacity modelling was needed and agreement with the Clinical Commissioning Group on the actions which were required. There would be a focus on smaller specialities first to check process and then priorities would be addressed. Until the validation was completed the level of risk was unknown. There were issues which would be dealt with in quarter 2. A resilience bid to cover clinical staff had been submitted. NV commented that the Trust would fail to meet the quarter performance target for RTT, but that this was the right action to take for patients and to clear the backlog. It was noted that many trusts were failing their RTT targets. SB reported that staff training was underway, but that part of the problem which had been identified was that staff did not know how to manage the hold file. Staff were receiving training on capacity modelling. In response to a question from RH, SB explained that the resilience bid was for temporary staff. SB explained that currently there were a number of staffing issues to resolve as well as technology issues to ensure robust systems with reduced reliance on individuals. In response to a question by LC, SB explained that management skill was being looked at and would be utilised horizontally and vertically across the organisation. In response to a question from OF about staff arrangements for additional clinics, SB and OF undertook to discuss this outside of the meeting. NV commented that performance was improving and that the Trust was now the top performing Trust in terms of waiting times in A&E in the local area. In terms of RTT, the Trust was doing what it had planned to do to address the backlog. It was considered that the Chair and Chief Executive of behalf of the Board should express thanks to staff in ED for their continuous efforts to improve performance. RESOLVED that the report be received and the required establishment and task force be established to support resolving the hold file with the funding approved as detailed in the report. 110 /14 Patient Experience Report - June 2014 The Board received and considered a report which provided a complaints dashboard, complaint themes and Friends and Family Test (FFT) results. In addition, a presentation was made at the meeting covering scores on the doors; NHS Choices comments; complaints, friends and family; Spotlight Event; Picker Themes and Voice Book. SB & OF to discuss NV & RH SB August August 8 Page 8

15 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST On consideration of the report and presentation the following points were made: - The percentage of positive comments on NHS Choices was uninformative and therefore this should not be included in future reporting. The complaints process needed to include a step to ensure that Chairs of Committees were aware of / see any letters addressed to them. HW reported that there were delays in responding to calls in the Physiotherapy Department and action was underway around this. RH questioned if there was a concern in that area about the quality of care and HW undertook to look into this. JM commented that patients might not answer telephone calls from the Hospital because the call would show up as unknown caller. JM asked that this be looked at. HW undertook to report the number of complaints which were upheld, noting this must be collected for annual reporting purposes. HW undertook to check the amount of CQUIN attached to Friend and Family (F&F) responses and include in the next report, together with detail on planned recovery to get CQUIN back on track. JM commented that giving a patient a form to complete at the end of their care was not good and she suggested that HW work with Healthwatch to improve this. However, it was noted that this was the correct procedure. JM further suggested exploring getting the hostess to hand out F&F when serving a cup of tea on the wards. It was noted that Salisbury NHS FT used technology for F&F and HW undertook to explore this. It was suggested that target F&F response numbers should be given to Wards rather than percentages. It was noted that achieving response targets sat with the Nurse Teams which was challenging. On consideration of spot light events, JM suggested that it might be beneficial for the Trust to be represented at health fairs held in every community area, noting that the focus of the fairs was health. HW undertook to check with JM when these were and NV indicated that attendance at them would be arranged. RB commented that when a patient received an appointment letter it made no reference to being busy at peak times and that there might be delays. He suggested that this should be explained in the appointment letter, together with an instruction to patients to watch the white board. It was noted that action was needed to address the findings of the Picker Survey. HW undertook to review the format of future patient experience reports based on the comments made at the meeting. RESOLVED that the Patient Experience Report be received and it be agreed that Divisional Directors be encouraged to improve Friends and Family responses for their areas, noting that feedback was important, but also that there is a link to CQUIN. 111 /14 Safer Staffing Monthly Report The Board received and considered a paper which provided the actual nursing and midwifery staffing in comparison to that planned and detailed any associated quality impacts. Reasons for shortages were also presented, together with the actions being taken to address the issues. The Board was advised that the green shading on the dashboard did not indicate a RAG rating. HW to review report content All to note HW Sept Ongoing 9 Page 9

16 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST In presenting the report, HW explained that themes from the Heads of Nursing were aligned with the reasons for agency spend. It was reported that new starters were in the recruitment process and it was highlighted that there were some hot spots of high turnover, but actions were planned to focus on these. HW commented that the impact of providing one to one care had not been tested yet and clarity on thresholds for different levels of care was needed. HW highlighted that there were some concerns regarding data validation but this was being addressed. JM questioned whether commissioners could be required to pay for one to one care. It was noted that MM was having discussions with Avon and Wiltshire Mental Health Partnership on this point with a view to a joint proposal. LC commented that it was unreasonable that the Trust was not remunerated for the additional care it provided. HW advised that there would be closer monitoring of one to one care when Jupiter Ward was changed to a dementia friendly environment. NV commented that some Trusts were seeing a reduction in the number of entries of dementia patients because of the intervention of primary care. GR commented that he had concerns about screening in hospital, because at the point the person was in hospital they were sick and there had been criticism from clinicians that in these circumstances individuals might not be themselves. It was noted that dementia screening was needed earlier in a person s care and there was funding in the health system for this, but this was not with the Trust. JM suggested that dementia should be discussed at the Health and Well Being Board. RESOLVED that the report be noted. 112 /14 Nursing Together: A strategy for improving patient care - progress report The Board received and considered a report on progress made in implementing Nursing Together, the Trust s Strategy for nursing covering the following: Strengthening leadership and professional practice Driving improvements in safety and quality of care Delivering effective and efficient services Leading a happy and healthy work life Delivering a workforce fit for the 21 st Century Next steps In response to a question from RH, HW advised that falls prevention and management remained a high priority and that there appeared to be no correlation between falls and agency staff. HW highlighted that there were a number of actions in progress which were leading to improved patient care. HW highlighted that Senior Nurses had worked alongside colleagues in the Academy to develop SCOPE, a programme to enhance nurse skills in providing older persons care. It was noted that the programme was seeking academic accreditation and the first cohort of 12 participants was due to commence in October GR welcomed the accreditation of training, which he believed motivated staff to undertake training. KM to note All to note Page 10

17 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST Arising upon consideration of this, JM sought an update on the progress with improvements around the e-rostering arrangements. OF responded that this would be considered at the next Finance, Investment and Performance Committee and that all Board members were invited to attend. RESOLVED (a) that the report be noted; (b) that the proposal for a future update in November 2014 be supported. 113 /14 Medical Revalidation The Board received and considered a report on Medical Revalidation which provided assurance that doctors were being regulated, with the aim of improving the quality of care provided to patients, improving patient safety and increasing public trust and confidence in the medical system. It was noted that provider organisations had a statutory duty to support their Responsible Officers in discharging their duties under the Responsible Officer Regulations and it was expected that provider Boards would oversee compliance by: monitoring the frequency and quality of medical appraisals in their organisations; checking there were effective systems in place for monitoring the conduct and performance of their doctors; confirming that feedback from patients was sought periodically so that their views could inform the appraisal and revalidation process for their doctors; and ensuring that appropriate pre-employment background checks (including pre-engagement for Locums) were carried out to ensure that medical practitioners had qualifications and experience appropriate to the work performed. The report provided the Board with the assurance that the above had been completed. Appended to the report was a statement of compliance for approval by the Board. It was noted that the statement needed to be completed, but GR gave a verbal outline of each point explaining how the Trust complied with each point. GR explained that the Trust was already taking action towards achieving the aspirations expected in five years time in terms of medical revalidation processes and governance. The Trust had recording systems and GR explained that part of the work he was doing was around automatic feed down of data into the appraisal process to include serious incidents for an individual or teams, complaints and mortality. GR reported that every five years he was required to make a recommendation that clinicians were working within their scope of practice. GR reported that the Trust had undertaken an annual audit, details of which were appended to the report. 91% of appraisals had been achieved with only 65% within the correct timescales. A robust process to identify who was late was now in place and it was expected that this percentage would be improved on next year. In response to a question from SN, GR confirmed that he would declare when a person would not complete an appraisal. GR advised that he was reading every appraisal for his own personal quality assurance and had questioned any appraisals where they were unclear or in need of further information and detail. All to note HW - Nov Page 11

18 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST RESOLVED (a) that the report be noted; and (b) that the Medical Director be delegated authority to complete the compliance statement, with the Chairman or Chief Executive being delegated authority to sign the statement on behalf of the Board. 114 /14 Finance Report for Month 3 The Board received and considered a report on finance for month 3, together with a presentation as follows: - Summary position The position in June was an actual operating deficit of 0.94m compared to a target surplus of 38k, giving an adverse variance of 0.98m from plan for the year to date. Income was 1.09m above plan. Expenditure was 2.30m above plan. Annual savings target was 12m. Cash balance was 4.9m, which was 1.4m above plan. The Trust was forecasting a Continuity of Service Risk Rating (CoSRR) of 2. MM presented slides outlining the key points, and specific comments were made as follows: - Clinical income MM reported that savings plans needed to be developed. Receipt of cash early had improved the Trust s financial position. Growth continued noting that day cases were 622 spells above the draft plan and 430 above the same point last year. MM commented that other Trusts were experiencing similar growth. Inpatient activity was 230 spells down on 2013/14 and 9 spells above the draft plan. MM explained that a decrease meant that patients were utilising community services and home care. MM commented that the number of delayed transfers of care was increasing in respect of community beds. Non-elective acute activity was significantly up on both plan and the same point in 2013/14 with 1372 additional admissions. There was a decreased in speciality spells. In response to a question from JM, MM explained that whilst Minor Injuries Unit spells were down against the 2014/15 plan, spells were up by 420 on 2013/14. GP referral data was being validated noting that there appeared to be a reduction. General surgery remained the biggest growth area. MM commented that there was a national shortage of oral surgery capacity. Emergency Department attendances at the Great Western Hospital were up on the same point in 2013/14 equating to 286 attendances (1.4%). Acute non-elective spells were significantly up on 2013/14 equating to 1372 spells. MM explained that this time last year the majority of growth had been same day cases, but now the Trust was seeing more than one day cases. Emergency admissions were increasing. GR commented that the conversion rate of attendance to admission was the same, but the volume of patients was the issue. JM commented that the increase in ED attendances could possibly be due to the inability of patients to access their GP surgeries. All to note GR to action / NV or RH - Within statement deadline 12 Page 12

19 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST In response to a request made, MM reported that going forward, activity on majors and minors would be split out and a triage category included in the report. Trust Expenditure Reasons for over expenditure included agency spend, cost of clinical supplies and drugs spend. These areas would be looked at as part of a recovery plan. The pay bill had reduced by 93k in June compared to the previous month, most of which was associated with the Wiltshire maternity contract. A breakdown of agency spend in June was provided and although there was a downward trend, this was insufficient. NV commented that some trusts had banned the use of agency staff. MM responded that this would be discussed by the Finance, Investment and Performance Committee and that a ban on the use of agency nurses was being considered. The use of nurses from the most costly agency would be banned in the first instance. It was clarified that a ban would not apply to all areas because of potential risks to patient care such as in ED, LAMU and ITU. Cost improvement programme The total target savings for the year was 12m, but there was an overall variance to the plan resulting in a shortfall of 0.92m. There was a shortfall in agency spend reduction of 0.44m. Whole time equivalents (wte) The Trust had an additional wte worked in June 2014 compared to June There had been a small decrease in the number of contracted wte from the previous month, but overall the year position was going up. OF commented that by September it was expected that only 35 nursing vacancies would remain. OF reported that agency staff were being encouraged to join the bank, with bank staff being encouraged to become substantive members of staff. Arrangements for bank staff to work extra hours were being reviewed and the Programme Management Office had mapped bank staff processes. In response to a request from JM, MM undertook to provide a split of agency spend (corporate / nursing). RESOLVED MM to split out activity MM to split out spend Sept 2014 Sept 2014 (a) that it be noted that the Month 3 financial position is an underachievement of 981k; and All to note - (b) that it be agreed that the Continuity of Service Risk Rating is a /14 Monitor Quarter Q1 2014/15 Submission The Board received and considered a paper which reminded the Board that it was required to make in year declarations covering finance, governance and other exceptional items. It was noted that the Quality Declaration was now made to Monitor on an annual basis. The paper provided an overview of performance against these requirements for quarter 1: - (a) the Continuity of Service Risk Rating (CoSRR) was 2 and the Trust was Page 13

20 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST expected to sustain a 2 moving forward; (b) the Trust had not achieved the performance target for A & E in quarter 1; (c) there were no exceptional matters that had occurred in quarter 1 that required reporting to Monitor. The Board noted an amendment to the report in that the text relating the Clostridium difficile infection was incorrect and needed to be deleted. A further amendment was noted to the finance declaration to clarify the wording and explain the reasons why the Board anticipated that it could not confirm a CoSRR of 3 which was due to the treatment of its private finance initiative (pfi). It was further agreed that the submission should include reference to the implementation of the new Patient Administration System (PAS) in May. RESOLVED (a) that the Chief Executive and Director of Finance & Performance sign the in-year governance statement on behalf of the Board of Directors confirming:- 1. The Board is unable to confirm that it anticipates that the Trust will continue to maintain a continuity of service risk rating of at least 3 over the next 12 months; 2. The Board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment Framework page 21 diagram 6) which have not already been reported. (b) that having discussed the performance against A&E 4 hour target and RTT/hold file and the actions being taken to recover the position, the Chief Executive and Director of Finance & Performance sign the following statement on behalf of the Board: - 3. The Board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix A of the Risk Assessment Framework and a commitment to comply with all known targets going forward. MM to amend NV/MM NV/MM July 2014 July 2014 July /14 Managing Risk The Board was reminded of its responsibility for risk management throughout the Trust and noted that authority had been delegated to the Executive Committee to ensure effective management of risk and the Audit, Risk and Assurance Committee to ensure that the processes for managing risk were effective and robust. The Board was required to review the Board Assurance Framework (BAF) and the 15+ Risk Register twice per year. The report sought to ensure part of this duty was met. The Board noted that a report on the 15+ Risk Register would be presented to the next meeting as although risks were being managed, (evidenced by the action taking place, changes being made and reports coming through to Committees), progress was not being recorded consistently via the Risk Management System. Work was underway to improve recording and therefore the 15+ Risk Register would be presented to the next meeting of the Board for oversight. CN explained that the BAF had been updated to include recent assurances and identification of gaps in controls and reporting. It was noted that the BAF had been considered by both the Executive Committee and the Audit, Risk and Assurance Committee, neither of which had identified any concerns to draw to the Board s attention. It was considered that the BAF was being used as an effective management tool and the number of assurances and gaps were noted. 14 Page 14

21 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST Finally, the Board was invited to approve the Risk Management Strategy which had been refreshed, having regard to the comments of the Audit, Risk and Assurance Committee. RESOLVED (a) that it be agreed that the Board is assured that an overview of the Board Assurance Framework has been undertaken and that assurances are given that the principal risks to achieving the Trust s principal objectives have been identified, the key controls to mitigate against those risks are specified; the assurances on those controls are adequate and that there are no gaps in the framework to highlight; - - (b) that the Board notes that the 15+ Risk Register has been scrutinised and challenged by the Executive Committee and the Audit, Risk and Assurance Committee and that the Board will be asked to consider assurances from those Committees at the next meeting of the Board; and CN Sept 2104 (c) that the revised Risk Management Strategy be approved. CN /14 Report from West of England Health Science Network Board meeting - 11 June 2014 The Board had before it a report from the West of England Health Science Network Board dated 11 June GR referred to better outcomes in hip replacements, highlighting that the West of England Health Science Network Board was linking in with Professor Tim Briggs who was the national Orthopaedic Surgeon Lead for getting it right first time. Professor Briggs supported the work being done which was commendable. RESOLVED that the report be received. All to note /14 Urgent Public Business (if any) None. 119 /14 Date and Time of next meeting It was noted that the next meeting of the Board would be held on 25 September 2014 at 9.30am in Lecture Hall 1, The Academy, Great Western Hospital, Swindon. All to note 120 /14 Exclusion of the Public and Press RESOLVED that representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest when the following items are considered: - Minutes Outstanding Actions of the Board (private) Operational Resilience Review of CQC Registration and regulated activities Contractual Issues Update on financial recovery 15 Page 15

22 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST Children and Young People s Services Medway Implementation Audit, Risk and Assurance Committee Minutes Executive Committee Minutes Charitable Funds Committee Minutes Finance, Investment and Performance Committee Minutes Governance Committee Minutes People Strategy Minutes Urgent Private Business (if any) The meeting ended at 3.48 pm Chair. Date 16 Page 16

23 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST These minutes may be made available to the public and persons outside of Great Western Hospitals NHS Foundation Trust in compliance with the Freedom of Information Act 2000 MINUTES OF THE MEETING OF BOARD OF DIRECTORS HELD IN PRIVATE ON 31 JULY 2014, AT 9.30 AM IN LECTURE HALL 1, THE ACADEMY, GREAT WESTERN HOSPITAL, SWINDON Present Members Roger Hill (RH) Angela Gillibrand (AG) Robert Burns (RB) Liam Coleman (LC) Oonagh Fitzgerald (OF) Jemima Milton (JM) Maria Moore (MM) Steve Nowell (SN) Guy Rooney (GR) Nerissa Vaughan (NV) Hilary Walker (HW) Chairman Deputy Chairman Non-Executive Director Non-Executive Director Director of Workforce and Education Non-Executive Director Deputy Chief Executive and Director of Finance Non-Executive Director Medical Director Chief Executive Chief Nurse Non-Voting Board Members Kevin McNamara (KM) Director of Strategy Also In Attendance Sharon Beamish (SB) Carole Nicholl (CN) Peter Russell (PR) Interim Chief Operating Officer Company Secretary and Head of Corporate Governance Interim Director of IM&T (part of meeting) Confidential Matters Not Open to the Public and Press Minute Description Action by whom 121 /14 Minutes Action by when The minutes of the meeting of the Board held in private on 26 June 2014 were adopted and signed as a correct record. The minutes of the reconvened meeting of the Board held in private on 30 June 2014 were adopted and signed as a correct record. The minutes of the joint meeting of the Board and Council of Governors held in private on 12 June 2014 were received. 122 /14 Outstanding Actions of the Board (Private) The Board received and considered the outstanding actions list. The Board noted progress against the actions and agreed that completed actions be removed. It was agreed that the report on lessons learnt from the review of Ophthalmology Services be presented to the Board in November 2014 and that the action in respect of the Independent Report on Quality Governance be closed, noting that this would be picked up as part of a full Governance Review in 2015/ /14 Operational Resilience - verbal NV to report Nov Redacted Private Minutes Page 17

24 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST These minutes may be made available to the public and persons outside of Great Western Hospitals NHS Foundation Trust in compliance with the Freedom of Information Act 2000 RESOLVED that the update be received. 124 /14 Review of CQC registration and regulated activities The Board received and considered a report which invited the Board to approve the variations and addition of new regulated activity required to the Trust s current Care Quality Commission (CQC) registration following an extensive review of all activities being undertaken across all the acute and community sites. 125 /14 On-going contractual issues The Board received and considered a paper which outlined a range of ongoing issues 126 /14 Update on financial recovery - verbal MM reported that a report on financial recovery would be considered by the Finance, Investment and Performance Committee in August. It was explained that a plan would be presented to include impact, e.g. ceasing the use of agency staff in some areas. 127 /14 Children and Young People's Services - presentation for discussion To facilitate a discussion, the Board received and considered a presentation on Children and Young People s Services 128 /14 Medway implementation and realised benefits, issues and risk outstanding - presentation The Board received and considered a presentation on the Medway implementation covering the following New Medway what happened Not so good Good Success stories Live Demos Real timeliness reporting New Medway It was noted that at the time of implementing new Medway, two other systems were also being rolled out (introduction of CRIS radiology system and upgrade of PACS picture archiving and communication system). PR explained that a number of short term task and finish groups had been set up to progress resolution of any issues. Good Ways of working had been changed. Going forward there would be good data. RESOLVED that the presentation be received. 129 /14 Ratification of Decision via Board Circular - Contract Award 2 Redacted Private Minutes Page 18

25 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST These minutes may be made available to the public and persons outside of Great Western Hospitals NHS Foundation Trust in compliance with the Freedom of Information Act 2000 The Board was asked to ratify a decision made via Board circular dated 14 July 2014 to award the E-Prescribing and Medicines Administration (EPMA) contract. 130 /14 Audit, Risk and Assurance Committee The minutes of the meeting of the Audit, Risk and Assurance Committee held on 22 May 2014 were received. Furthermore, it was noted that a meeting of the Audit, Risk and Assurance Committee had been held on 24 July /14 Executive Committee The minutes of the meeting of the Executive Committee held on 17 June 2014 were received. Furthermore, it was noted that a meeting of the Executive Committee had been held on 22 July /14 Charitable Funds Committee It was noted that a meeting of the Charitable Funds Committee had been held on 29 July /14 Finance, Investment and Performance Committee The minutes of the meeting of the Finance, Investment and Performance Committee held on 17 June 2014 were received. Furthermore, it was noted that a meeting of the Finance, Investment and Performance Committee had been held on 22 July The Board noted that as there was not a planned meeting of the Board in August, but all Board members were invited to attend the Finance, Investment and Performance Committee meeting in August to consider the financial position of the Trust. 134 /14 Governance Committee The minutes of the meeting of the Governance Committee held on 6 June 2014 were received. 135 /14 People Strategy Committee The minutes of the meeting of the People Strategy Committee held on 20 May 2014 were received. Post Meeting Note To avoid any confusion it is highlighted that the heading of these minutes refers to the Workforce Strategy Committee. This is incorrect and the minutes will be amended to People Strategy Committee when they are adopted and approved as a correct record at the next meeting of that Committee. 136 /14 Urgent Business (Private) (if any) None. Chair. Date The meeting ended at 3.48 pm 3 Redacted Private Minutes Page 19

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27 Agenda Item 5 OF - Oonagh Fitzgerald, CN - Carole Nicholl, AT - Alf Troughton, NV - Nerissa Vaughan, HW - Hilary Walker, BL - Bruce Laurie, KM - Kevin McNamara, LC - Liam Coleman, MM- Maria Moore, HS - Hilary Shand, JH- Janet Husband DATE OF BOARD MINUTE SUBJECT ACTION LEAD DATE COMMENTS MEETING AUGUST Jul /14 Minutes CN to explain to JM restrictions on governor eligibility CN Aug-14 Completed Jul /14 A&E performance Jul /14 Monitor Submission ACTIONS ARISING FROM MEETINGS OF THE TRUST BOARD (matters open to the public) Agreed that NV and Rh would express thanks to staff for all their hard work Submission to be amended to delete C.diff reference, clarify finance declaration and include reference to PAS. SEPTEMBER NV / RH Aug-14 Completed - NV s / messages at meetings MM Aug-14 Completed May-14 14/41 PS&Q Report - Paediatrics RH commented that in view of the growth in demand it would be useful for the Board to be updated on the position on Paediatrics at the July meeting of the Board. NV July 14 / Sep 14 At the meeting of the Executive in July it was agreed that consideration of a paper reviewing paediatrics should be deferred to an extra-ordinary meeting of that Committee in August. Therefore, the report to the Board on this issue is delayed until September. An initial business case has been presented to the FI&P Committee. May-14 14/45 Finance Report- agency versus permanent staff It was recognised that there was work to do around reviewing the balance of permanent staff against agency and locum staff and that a very detailed agency reduction plan was essential. The need to balance operational performance and safety versus cost was recognised. NV emphasised the need to roll out effective e-rostering and have in place sufficient bank staff. NV suggested she would like a report brought forward to the July meeting of the Board on utilisation of staff going forward. OF July 14 / Sep OF stated that she would obtain benchmark data about agency spend by other Trusts for inclusion in a future report as there was a need to add context around agency spend and an explanation that this Trust was not an outlier. A report on agency spend / recruitment is to be considered by the Finance, Investment and Performance Committee in August and it was therefore agreed that this item slip until September. Since this decision, it is recognised that the current skill mix is proving difficult to recruit into and that further consideration is being given to future workforce plans and options will be submitted to October Trust Board. May-14 14/45 Finance Report- E-rostering A report to be presented to the Board in July explaining how e-rostering is being resolved to be linked back to the plans around agency / spend reduction OF July 14 / Sep 14 To be picked up with report on agency / recruitment. An update was provided to the AR&A Committee. Feb-14 13/272 Transforming Leadership Suggestion made that thought be given to how some of the learning can be developed for other staff through the Academy OF Sep-14 The transformation leadership group has now been set up and this action is now closed. Feb-14 13/273 Stroke Indicators that a further presentation on stroke performance be made to the Board in September to include an outline of improvements made and benefits gained, with comparative information with other Trusts across the Southwest. Medical Director Sep-14 Note that a presentation on stroke is being made to the Annual Members Meeting. This will still need to come back to the Board to assure the Board that the actions required have been taken. May-14 41/14 PS&Q Report - Trowbridge The report highlighted issues raised but did not explain what had happened. HW to work with clinical teams to find out and report back information in future report. HW Sep-14 Jul /14 Patient Experience Report HW to refresh the content and style of the Patient Experience report for future meetings HW Sep-14 This is being progressed. Page 21 $x2wxcomm.xls

28 Jul /14 Patient Safety report - never events HW undertook to provide a summary of the never events in the next report HW Sep-14 Included in report - action closed Jul /14 Patient Safety report - mortality Request made that further information be reported to the next meeting GR Sep-14 Included on agenda - action closed Jul /14 RTT - financial penalties MM undertook to confirm the financial penalties for non-performance. MM Sep-14 At the moment Swindon CCG are applying penalties in line with the contract. Action closed. Jul /14 Safer Staffing - dementia JM suggested that care of patients with Dementia should be discussed at the Health and Well Being Board. KM to consider Sep-14 OCTOBER Jul /14 Finance report MM requested to split out major and minor activity and include a triage category in future finance report MM Oct-14 Page 22 $x2wxcomm.xls

29 Agenda Item 7 Meeting and date: BOARD OF DIRECTORS 25 SEPTEMBER 2014 Title: Summary of paper: Chief Executives Report - ongoing concerns with Carillion This paper outlines a range of ongoing issues with Carillion which the Trust is increasingly concerned about in terms of the potential impact on patients, visitors and our staff. Whilst the paper details significant concerns about the one star food hygiene rating, the cleanliness issues identified by the CQC last year and ongoing employee relations issues, there are also a range of hard FM issue the Trust continues to push Carillion to resolve. The paper sets out the key concerns the Trust has about Carillion s ability to tackle these issues to ensure our patients, visitors and staff are receiving the highest quality service. Due to the nature of the issues, the Trust has lost confidence in Carillion s ability to resolve these issues and the Trust continues to pursue all means necessary to ensure they remain focussed on addressing them. Recommendations/ decisions required: Link to Trust Priorities 1. Support the work taking place to use any contractual means available to push Carillion and Semperian to resolve these issues once and for all for our patients. 2. Endorse the establishment of a small project group chaired by Steve Nowell to report to the Board providing a clear plan and timetable and in identifying risks and mitigations for any transition. 3. Request the most senior representation from Semperian and Carillion to present to the full Trust Board meeting to detail their plans for resolving these issues including clear, unambiguous timescales so the Board can hold them to account. Link to Quality (a) We will make the patient the centre of everything we do. (b) We will build capacity and capability by investing in our staff, infrastructure and partnerships. (1) Safety (staffing, falls, never events, handover, SI, safeguarding, infection control, environment, medicines, equipment) (2) Effectiveness (HMSR, SHMI, Mortality, Clinical audits, care bundles, deteriorating patient) (3) Well led (staff survey, staffing levels, sickness rates, flu vaccinations rates, board/ward interactions, staff reports, governance and reporting, risk management, financial control) Risk issues: The information contained in this paper relates to a range of risks currently detailed in the Risk Register - risks which impact on quality, safety and/or reputation. Failure to adequately resolve the ongoing issues with Carillion will have a negative impact on patients, staff and the Trust. Page 23

30 Resource Implications: (financial / human / other resources) Regulations and legal considerations: (CQC considerations / Monitor requirements / link to NHS Constitution rights and pledges as necessary / Trust Constitution / legislative requirements) Quality consideration and impact on patient and carers: Consultation/ Communication: Confidentiality: Equality Impact Assessment: Any additional resource implications will need to be considered, at present legal expenses are being incurred. Failing to meet key standards impacts directly on regulation i.e. CQC cleaning standards, Environmental Health food hygiene ratings. The risks identified in this paper pose a potential risk to patient care and staff wellbeing. Ongoing communication is maintained with Carillion and The Hospital Company through a Joint Management Board. The issue contained in this paper have been raised through the Board but have not yet been adequately resolved to our satisfaction. This report does not contain confidential information, publicity of which would be prejudicial to the public interest. Great Western Hospitals NHS Foundation wants its services and opportunities to be as accessible as possible, to as many people as possible, at the first attempt. This report has been assessed against the Trust s Equality Impact Assessment Tool and there are no proposals or matters which affect any persons with protected characteristics. Name of Lead Executive Director: Name of Author: Maria Moore, Deputy Chief Executive, Director of Finance and Performance Kevin Mcnamara, Director of Strategy Maria Moore, Deputy Chief Executive Page 24

31 Ongoing concerns regarding the quality of Carillion provision Background Board members will be aware of the ongoing problems being experienced in relation to Carillion, the quality of the services they provide together with the management of the services they provide to patients, visitors and the Trust. These issues have been a frequent topic for Board discussions and debate for some time. The concerns the Trust has regarding Carillion and the quality of their provision, relate to three key areas: Soft facilities management cleaning, catering. Hard facilities management - estate maintenance and infrastructure General management focus to deliver substantive improvements and change Some of these ongoing issues have the potential for significant impact on patients, visitors and staff whilst some are an indication of the management effort required by the Trust to ensure a focus on delivery is maintained. The primary areas of concern, amongst a much longer list, are follows: Environmental Health inspection In April this year, the local Environmental Health Team inspected the kitchens and food preparation areas under Carillion s responsibility. The EHO identified a number of issues, including: Chillers for sandwiches kept at the wrong temperatures outside of DH/EHO guidance Inadequate calibration of temperature probes meaning inadequate assurance around food safety Unclear date labelling on food Food storage equipment recording the wrong temperatures with no attempt to resolve Uncovered food in freezers and an example of out of date food Sanitising solution in ward kitchens not always available As a result Carillion have been given a one star environmental health rating (out of five) and received an Improvement Notice. The Improvement Notice was lifted on the 27 th June 2014 however the one star rating remains. Carillion have been working on a plan to improve standards to achieve a three star rating in the next inspection (due October/November) which will leave the Trust at a satisfactory level only. The Trust is unaware of any other Trust being given a one star rating in relation to food hygiene and is something that is completely unacceptable to Board. Immediate action was taken at that time and the Trust placed Carillion under significant pressure to address the concerns immediately. Cleanliness In October 2013, an unannounced inspection by the CQC highlighted concerns and lack of compliance with regards to the standards of cleanliness on the wards. Since that time significant effort has gone into raising standards and ensuring the audit and assurance processes are robust enough to identify any cleanliness issues. However, whilst standards have improved, there is intensive nursing and management input required by the Trust to ensure standards do not slip and concerns remain regarding Carillion s ability to deliver cleaning services to the required standard detracting vital Trust resources from other priority areas. Page 25

32 Industrial relations dispute impacting on quality of service Since December 2011, Carillion have been in an industrial relations dispute with a Trade Union following concerns raised by housekeeping staff about holiday entitlement, working practices and other allegations. This dispute has resulted in a large number (circa 50) employment tribunal claims lodged against Carillion by their own staff. This process is still ongoing with currently no timescale for resolution and it is clear distraction from the day to day service we require and pay for. Current situation The Trust does not hold a contract with Carillion. Instead, through the PFI, Carillion are contracted to provide these services by Semperian effectively the owners of the building under the PFI agreement. This therefore means that Carillion s failings are an issue not only for the Trust in how we protect patients and maintain the quality of patient care, but also for Semperian PPP Investment Partners who we pay for the hospital and to sub-contract the hard and soft FM services. The ongoing problems we have experienced with Carillion and their inability to resolve some of the more long running issues therefore reflect poorly on both Carillion itself and Semperian. The important point for the Board to focus on, is not simply this being a contractual issue between companies, but this is a fundamental issue of ensuring the quality of care and treatment we provide to patients is the best it can be. It is also a reputational issue for the Trust in so far as the continual issues with poor quality are adversely impacting on our reputation amongst patients and key stakeholders. Concerns about food hygiene and cleanliness, have posed a potential risk to patients, visitors and staff which is completely unacceptable. It is the view of the Executive Team that issues have not been taken as seriously as they should be by Carillion as resolving these outstanding issues is slow and any improvements made are not being consistently maintained. Despite senior meetings between the three main parties on these and other issues (the Trust, Carillion and Semperian PPP Investment Partners who contract Carillion) there remain serious concerns about Carillion s ability to deliver services to the required standard. It is therefore increasingly frustrating and disappointing that serious issues regularly arise and the Trust now lacks the confidence in Carillion neither in being able to resolve these issues once and for all, nor in their ability to foresee and prevent other, as yet unknown issues, from impacting on patient services. For us, the absolute priority is patient care and we are unapologetic about expecting the highest standards of service from Carillion and swift action from Semperian our patients expect it and the Board demands it. Our position in the contract There is clearly a risk to quality and safety which needs to be addressed and Carillion have not demonstrated the ability to adequately resolve any one of these major issues to the required standard, let alone all of them together. The Board will be aware that the Trust periodically undertakes a formal benchmarking exercise which provides an opportunity to market test the service, however the benchmarking is due to take place in 2018 and therefore does not provide a more immediate solution. Page 26

33 At the last meeting of the Board, it was resolved that legal advice would be taken to detail what options are available to us as a Trust. The Chief Executive of the Trust has also written to Semperian to ask what plans they have to rectify the situation but as yet we have not received an adequate response. It is acknowledged that as a PFI hospital, the contract for provision is extremely complicated. Good legal advice is therefore crucial and this work which is ongoing. To ensure that impetus is maintained and this course of action is well planned and executed, a project group is being established, Chaired by Steve Nowell as Non-executive Director to oversee this work and also consider the wider implications and planning about potential future provision of the service and to continue to explore the potential for alternative service provisions. There will be risks that need to be managed and mitigated through any potential transition, and this group will report to the Board on plans and progress. In the interim, Carillion is still expected to deliver the services under the contract and we need to ensure they are identifying and addressing issues swiftly and putting in place processes and actions to ensure similar issues do not arise. At the last Board meeting the Board endorsed a review of the Joint Management Board the group which bring the three parties together to ensure the focus on quality and safety is maintained. The scope of this review is being agreed with the Auditors and our new Director of Estates and Facilities. The Trust will continue to push both Carillion and Semperian to double their efforts on achieving a minimum of a three star rating at the next EHO inspection. Recommendations The Board is asked to: 1. Support the work taking place to use any contractual means available to push Carillion and Semperian to resolve these issues once and for all for our patients. 2. Endorse the establishment of a small project group chaired by Steve Nowell to report to the Board providing a clear plan and timetable and in identifying risks and mitigations for any transition. 3. Request the most senior representation from Semperian and Carillion to present to the full Trust Board meeting to detail their plans for resolving these issues including clear, unambiguous timescales so the Board can hold them to account. Page 27

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35 Page 29 Finance Report: 2014/15 Month 5 Maria Moore Deputy Chief Executive/Director of Finance TRUST BOARD 25 th September 2014 Agenda Item 8

36 Summary as at 31 st August Actual YTD deficit of 1.93m m variance to plan Annual Current Month Year to Date Budget Budget Actual Variance Budget Actual Variance '000 '000 '000 '000 '000 '000 '000 Income 290,707 23,967 24, , ,053 2,835 Expenditure (264,797) (21,869) (23,040) (1,170) (112,818) (118,089) (5,271) EBITDA 25,910 2,098 1,450 (647) 10,400 7,965 (2,436) Page Income 2.84m above plan 4. Expenditure 5.27m above plan Depn/ Interest & PDC (24,714) (2,056) (1,969) 86 (10,278) (9,897) 382 Net Surplus / (Deficit) 1, (519) (561) 122 (1,932) (2,054) EBITDA % Income 8.75% 5.92% 8.44% 6.32% 5. Annual Savings Target 12m 6. Forecast after mitigations is 2.9m deficit 7. Cash balance is 2.9m which is 0.3m below plan. 8. Continuity of Service Risk Rating of 1 AND a FRR of 2.

37 Page Clinical Income Clinical income is 1.7m above plan at August, this is mainly relates to investment in Community, increase in NEL activity and national investment for clearing the RTT backlog Activity performance Inpatient activity is 285 spells down on and 22 spells below the draft plan. Since the reporting of data has been completed, a number of admissions have not been recorded in Medway and so do not feature in the activity reported to date. This is equivalent to 153 spells in July/August and is currently being validated. This is mostly in Oral Surgery. Day Cases are 873 spells above draft plan and 1,050 above the same point last year 325 of them being gastroenterology. General Surgery and Urology combined are 324 day cases above levels. Non elective acute activity is significantly up on both plan and the same point in The largest growth is in general surgery 726 above 13/14 YTD. First attendance OP activity is down on and also significantly down on plan. The Trust is arranging for a detailed audit to be carried out after the implementation of Medway to ensure all recording and coding is being reflected on the new system correctly GWH Emergency dept attendances are up on and above plan & MIU attendances are down on plan and up on

38 1. NHS Clinical Income GP Referrals GP referral is 1% lower than this time last year which is equivalent to 374 referrals. Ophthalmology shows the largest reduction which relates to the closure of choose and book for Swindon patients. This reduction far exceeds the overall reduction suggesting that if Choose and Book was open, for Ophthalmology, GP referral would be at a higher level in 2014/15 compared to 2013/14. Page 32 40,000 39,000 38,000 37,000 36,000 35,000 34,000 33,000 YTD August 2014 GP Referrals to New Appointments 2012/13 YTD (All) 2013/14 YTD2014/15 YTD (All) (All) GP Referrals to New Appointments GP Referrals to New Appointments 2012/13 YTD (All) 2013/14 YTD (All) 2014/15 YTD (All) 2014/15 YTD (Cons Resp) 2013/14 Var (All) 2013/14 Var (All) Refs 100 GENERAL SURGERY 3,185 4,710 4,998 4,976 6 % CARDIOLOGY 1,598 1,617 1,813 1, % UROLOGY 1,005 1,151 1,299 1, % OPHTHALMOLOGY 3,253 2,700 1, (59%) (1,587) 501 OBSTETRICS 2,844 2,679 2,070 2,070 (23%) (609) 140 ORAL SURGERY % 32 Other 23,141 26,326 27,484 17,607 4 % 1,158 Total 35,254 39,442 39,068 28,813 (1%) (374)

39 1. NHS Clinical Income ED Performance YTD Emergency department attendances at the GWH are up on the same point in This is equivalent to 316 attendances or 1.0% Page GWH ED Attendances August YTD GWH ED Attendances by month Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

40 1. NHS Clinical Income - NEL Performance Page 34 Acute non elective spells are significantly up on the same point in 2013/14 This is equivalent to 2,336 spells or 14% Patients treated on same day and in one day have increased as a proportion of total Acute NEL spells by month Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD YTD Variance Ratio split GWH NEL Emergency LoS activity % activity % activity % % Same Day 4, % 5, % % 1.0% 1 day 3, % 4, % % 0.6% 2 + day 7, % 8, % % (1.6)% Total 15,972 18,308 2,336

41 1. Elective Activity YTD Elective activity has increased by 5% compared to the same point last year. IP have reduced by 285 which is a 10% reduction DC have increased by 1,050 which is a 8% increase Page 35 16,500 GWH Elective & Day Case Attendances August YTD 3,900 GWH Elective & Day Case Attendances by month 16,000 3,400 15,500 15,000 2, ,500 14,000 2,400 1, ,500 13, ,400

42 2. Trust Expenditure 2.1 Expenditure is 5.27m above This includes:- 4,000 3,500 Expenditure April August ,600 6,550 6,500 Pay overspend of 2.18m year to date, made up of 2.64m premium costs of agency, net vacancy savings of 0.46m. In month variance is 0.69m. Non Pay '000 3,000 2,500 2,000 1,500 1,000 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 6,450 6,400 6,350 6,300 6,250 6,200 6,150 6,100 Pay '000 Page m clinical supplies overspend year to date. In month underspend is 0.08m. Drugs Supplies Other Costs Pay 0.35m overspend on drugs year to date. In month variance is 0.01m.

43 2. Pay Trend The pay bill increased by 0.11m in August compared to the previous month. 1,600k 1,400k Permanent, Bank, Agency & Locum April August ,000k 16,000k Page 37 The use of agency staff reduced in August by 0.01m; Nursing increased by 8% ( 0.03m) Medical reduced by 69% ( 0.05m) Other staff groups increased by 4% ( 0.01m) Bank. Agency & Locums 1,200k 1,000k 800k 600k 400k 200k 0k Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June July August 14,000k 12,000k 10,000k 8,000k 6,000k 4,000k 2,000k 0k Total Pay Bill Bank Locum Agency Permanent Total Linear (Agency) Agency spend in August compared to July:- 16,000k Permanent & Total Pay Bill April August 2014 ED medical reduced by 0.02m 15,500k ED nursing increased by 0.02m Nursing ward staff remained constant Other nursing increased by 0.02m Corporate services reduced by 0.04m AHPs increased by 0.01m Permanent & Total Pay Bill 15,000k 14,500k 14,000k 13,500k 13,000k 12,500k 12,000k Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June July August Permanent Total

44 2. Pay Trends Medical & Nursing Medical staff expenditure reduced by 0.05m in August. Locums increased by 0.05m, this was offset by reductions in permanent and agency staffing of 0.10m. Agency/ Locum ' Medical April August ,900 3,700 3,500 3,300 3,100 2,900 2,700 Total/ Perm. '000 0 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 2,500 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Locum Agency Page 38 Nursing staff expenditure increased in August by 0.10m. Permanent staff increased by 0.04m Bank increased by 0.3m Agency increased by 0.03m Bank/ Agency '000 Perm 3,026 3,113 3,102 3,126 3,200 3,080 3,258 3,220 3,231 3,218 3,166 3,362 3,320 3,385 3,447 3,618 3,569 Total 3,437 3,520 3,556 3,656 3,595 3,447 3,534 3,644 3,688 3,605 3,649 3,750 3,625 3,745 3,687 3,952 3, Nursing Pay April August 2014 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 6,700 6,500 6,300 6,100 5,900 5,700 5,500 5,300 Total/ Perm. '000 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Bank Agency Perm 5,488 5,432 5,469 5,459 5,383 5,603 5,550 5,625 5,628 5,759 5,857 5,839 5,795 5,783 5,909 5,772 5,809 Total 6,175 6,179 6,182 6,340 6,174 6,512 6,377 6,395 6,233 6,545 6,457 6,487 6,472 6,461 6,539 6,463 6,559

45 2.4 Clinical & Non Clinical Supplies 1.18m above plan year to date, due to increase spend on: Supplies Spend April August 2014 Endoscopy 2,700 Audiology 2,500 Wheelchairs Tissue viability '000 2,300 2,100 MRI 1,900 Pharmacy manufacturing 1,700 Page Drugs 0.35m above plan year to date, due to: NICE 0.21m PBR excluded drugs 0.03m Immunoglobins 0.09m '000 1,500 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actual 1,955 1,959 2,548 1,823 1,902 2,160 2,305 2,242 2,384 2,028 2,250 2, Budget 1,730 1,723 2,391 1,854 2,023 2,164 1,940 2,081 1,781 1,875 1,995 2, Actual 2,251 2,140 2,378 2,508 2, Budget 1,900 1,947 2,249 1,930 2,231 Drugs Spend April August ,100 1,900 1,700 1,500 1,300 1, Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actual 1,634 1,401 1,809 1,765 1,528 1,632 1,494 1,662 1,637 1,683 1,806 1, Budget 1,515 1,524 1,473 1,615 1,823 1,685 1,570 1,614 1,530 1,522 1, Actual 1,612 1,900 1,785 1,998 1, Budget 1,738 1,738 1,738 1,748 1,581

46 3. Cost Improvement Programme Page Total target for the year is 12m. 4m agency spend cost avoidance 8m cash releasing efficiency savings 3.2 Overall variance YTD compared to 5/12ths of annual plan is a shortfall of 1.73m. 3.3 The agency spend reduction delivery against target is a 1.16m shortfall to month 5. Annual Plan YTD Plan YTD Actual YTD Variance to Plan Corporate 2, Diagnos tics & Outpatients 2, (309) Integrated Com m unity Health 1, Planned Care 2,483 1, (1,134) Uns cheduled Care 2, (418) Wom en's & Children's 2, (115) Grand Total 12,068 5,132 3,402 (1,730) Target Agency Reduction: Target Reduction Year to Date Q1 Q2 Q3 Q4 Target Spend Actual Variance '000 '000 '000 '000 '000 '000 '000 AHP, Prof & tech Admin Medical & Dental Nursing ,562 2, Total 681 1,340 1, ,265 4,427 1,162

47 4. Whole Time Equivalents 4.1 The Trust had an additional wte worked in August 2014 compared to August Worked (exc Wiltshire Maternity) Ave Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2013/14 4, , , , , , , , , , , , , /15 4, , , , , , Increase Page The number of contracted staff has increased by wte since April Contracted WTE (exc Wiltshire Maternity) Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Movement from Apr'13 Allied Health Prof & Scientific Medical & Dental Nursing 1, , , , , , , , , , , , , , , , , Senior Managers & Admin , , , , , , , , , , , , , , Total 4, , , , , , , , , , , , , , , , , Increase/ (Decrease) in Month 4.66 (17.26) (23.26) (2.38)

48 4. Analysis of worked WTE Agency usage increased from average of 116 wte in 2013/14 to 131 wte in 2014/15 The average ratio of temporary staff to permanent has remained constant Page /14 (exc Wiltshire Maternity) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar AVE Agency Bank Locum Perm 3, , , , , , , , , , , , , % temp 5.9% 5.9% 6.0% 6.0% 6.8% 6.7% 6.5% 6.4% 6.0% 6.3% 5.8% 5.8% 6.2% 2014/15 (exc Wiltshire Maternity) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar AVE Agency Bank Locum Perm 4, , , , , , % temp 5.9% 6.1% 6.0% 6.3% 6.4% 6.2%

49 Page Cash Position 5.1 Cash is 2.9m which is 0.3m below plan Prepayments 1.5m Payment on Account 2.1m Creditors 3.5m Debtors 3.6m As at 31 August 2014 Cashflow m Actual Plan Variance Y/end Forecast EBITDA (3.2) 25.9 Debtors (1.4) (5.2) Creditors (0.8) (2.2) Other change in WC (0.2) Non cash I&E items (0.2) 0.1 (0.3) 0.0 CF from operations (0.6) 23.5 Capital Expenditure (3.6) (3.5) (0.1) (9.2) Asset sale Proceeds Net Interest (6.0) (6.0) 0.0 (14.1) Dividends paid (0.5) Movement in loans (0.6) (0.6) 0.0 (1.9) PDC received / (repaid) Other (0.1) (0.5) Net cash inflow/(outflow) (1.5) (1.3) (0.3) (0.9) Opening Cash balance Closing Cash Balance (0.3) 3.5

50 Recommendations / Decisions Required The Board is required to agree:- a) the Month 5 financial position is a deficit of 1.93m b) that the forecast year end Continuity of Service Risk Rating is a 1 c) that the current FRR is 2 Page 44

51 Rolling Cash Flow Cashflow Forecast Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug m m m m m m m m m m m m m Opening cash balance Income Page 45 NHS Income PCT PFI Payment RTA Income VAT Other income Total Income Expenditure Pay Tax & Pensions NHSLA Creditors PDC Dividend THC Reinvestment Capital expenditure Total Expenditure Net movement (5.836) (7.455) (4.245) (0.076) (0.001) Closing cash balance

52 Three Year Cash Flow Page 46 Net Cash Position April May June July August September October November December January February March m m m m m m m m m m m m

53 Continuity of Services Risk Rating (CoSRR) Scenarios 8.1 The current CoSRR is 1. Weighting Metric Rating Rating Categories Capital Service Cover 50% <1.25 Liquidity 50% <-14 Continuity of Service Risk Rating 1 Page The forecast CoSRR for year end will be included within the recovery plan discussions

54 Financial Risk Rating 9.1 The FRR at Month 2 is 2. Page 48 Weight Rating Categories Financial Criteria (%) Metric to be Scored Metric Rating Achievement of plan 10% EBITDA achieved (%) 76.6% 2 100% 85% 70% 50% <50% Underlying 25% EBITDA margin (%) 6.3% 3 11% 9% 5% 1% <1% Financial efficiency (i) 20% Return Net after Financing -2.6% 2 3% 2% -1% -5% <-5% Financial efficiency (ii) 20% I&E surplus margin (%) -1.5% 2 3% 2% 1% -2% <-2% Liquidity 25% Liquidity ratio in days <10 Overall Financial Risk Rating 2

55 EBITDA 2012/13 to 2014/ April May June July August September October November December January February March m m m m m m m m m m m m EBITDA Cumulative Monthly EBITDA Page April May June July August September October November December January February March m m m m m m m m m m m m EBITDA Cumulative Monthly EBITDA April May June July August September October November December January February March m m m m m m m m m m m m EBITDA Cumulative Monthly EBITDA NOTE EBITDA is higher in due to the Transfer of Wiltshire Community Assets as charges for depreciation and PFI interest are no longer part of Operating Expenses.

56 Reconciliation of Income Movement NHS Acute Activity Income Private Patients Other Non Mandatory/ Non Protected Revenue Research & Development Income Education & Training Income Other Income Total Income '000 '000 '000 '000 '000 '000 '000 As At Month 4 260,001 3,506 3, ,772 13, ,211 Page 50 Escalation Beds Longleat for August School Nursing Investment NMET Funding Health Education Funding 9 9 Madel Funding Palliative Care Agency to cover Sick Leave for Prospect 2 2 Charitable Funds for Sepsis Post 3 3 Charitable Funds AMU/ Ambulatory Care 3 3 Cystic Fibrosis Investment (17) (17) Other Budget Realignments (2) Realign Clinical Trial Budgets (5) (156) (161) As At Month 5 260,158 3,506 3, ,890 14, ,707

57 Agenda Item 9 Meeting and date: BOARD OF DIRECTORS 25 SEPTEMBER 2014 Title: Summary of paper: Patient Safety and Quality Report This report comprises commentary and progress on activity associated with key Safety, Quality and Performance Indicators, including the actions being taken where performance improvements are required. The report is subdivided as follows: A - Infection Prevention and Control Report Blood Culture Contamination rate 3.9% (target maintain 5% or less) MRSA Bacteraemia 0 cases Clostridium Difficile year to date 10 cases, July, 3 cases and August 4 cases. The Department of Health trajectory is to report no more than 28 cases for the Great Western Hospital. Three cases have been reported against the Quarter 1 trajectory of seven. The Trust reported three cases of Clostridium difficile (C.diff) during the month of July with a further four cases during August. These cases were attributed to Dove, Neptune, Saturn (two, instigating a Period of Increased Incidence), Mercury, Falcon and Intensive Therapy Unit. B - Clinical Audit and Effectiveness Report Progress has continued with the audit programme during the past month. There are no exceptions to report this month 64% completed audits to date this year have resulted in learning and a change in clinical practice C - Clinical Risk and Patient Safety Report No Never Events were reported in July & August serious incidents reported in July and August, of which there were 8 community reported Pressure Ulcers, 2 Falls resulting in a fracture, 2 safeguarding and 1 treatment delay or failure. 36 Serious Incidents reported 2014/15 to date 4 serious incident action plans were completed in July serious incident action plans were completed in August Currently 11 action plans resulting from serious incidents are overdue, all of which were escalated to the PSC in September executive patient safety visits were completed in July 2014 and 4 executive patient safety visits were completed in August visits have been undertaken since September D - Regulation and Quality Contract report CQC were notified on 1 st August 2014 of the variations required to the current registered sites and the new CQC regulated activities to be registered. The Trust is now awaiting the revised registration from CQC which reflects the variations. E - Mortality Report The HSMR for May 2014 (the most recent data available from Dr Foster) is While there can be large month to month variation the trend over the last four months has been relatively stable at around the mid to upper 70s. The HSMR for the two months April 14 May 14 has the Trust well below 100 at 75.42, with the rolling twelve month period of June 2013 to May 2014 being at However, the annual Dr Foster rebasing (anticipated during September) predicts that our HSMR is likely to be around 95.7, although this is based on the period June 2013 to May 2014 (the only date range available from Dr Foster) so the final figure will change slightly when adjusted to the last financial year F - Staff Satisfaction There have been no concerns raised through the see something say something Page 51

58 route since May There has however been one grievance and one concern raised by staff directly to their Matron and the issues raised are being addressed. There has been one whistle bowing; reported internally during July. There were none reported during August. G - Pressure Ulcers Reduce Grade 2 and above acquired pressure ulcers by patients ACUTE Target 9 or less a month July - 15 August 10 The higher level of pressure ulcers in the acute wards were predominantly on one medical ward during July. This resulted in a clean sweep of the ward with the Tissue Viability Specialist Nurse (TVSN) and the ward manager. This including checking every patients risk and skin status, appropriateness of intentional rounding tools and wound and care plan. Immediate alterations were made where necessary. Reduce Grade 2 and above acquired pressure ulcers by patients COMMUNITY Target 14 or less a month July 15 August 20 A higher level of pressure ulcers was also found in the community for July, this resulted in a review of the teams with a higher level of pressure ulcers, the results in the graph below show that Chippenham have the highest level of pressure ulcers. The TVSN covering this area is compiling a report with the Team Leader for Chippenham, looking at the specific case load to check that all the require policy interventions are in place and an action plan which will come to the next Tissue Viability team meeting. H - Performance Report A summary of the Trust s performance against key Patient Safety, Quality and Performance Indicators is shown on the Quality and Performance Dashboard at Appendix A Recommendations/ decisions required: (a) that the patient safety report provides assurances to Trust Board; and (b) that actions are being progressed as appropriate. Link to Trust Priorities Link to Quality (a) We will make the patient the centre of everything we do. (b) We will work smarter not harder to make best use of existing resource. (c) We will innovate and identify new ways of working. (d) We will build capacity and capability by investing in our staff, infrastructure and partnerships. (1) Safety (staffing, falls, never events, handover, SI, safeguarding, infection control, environment, medicines, equipment) (2) Effectiveness (HMSR, SHMI, Mortality, Clinical audits, care bundles, deteriorating patient) (3) Caring (patient experience, patient surveys, friends and family test, patient stories, response to call bells) (4) Responsiveness (complaints, waiting times, cancelled operations, ambulance stays, translation services, comfort factors TV and seating) (5) Well led (staff survey, staffing levels, sickness rates, flu vaccinations rates, board/ward interactions, staff reports, governance and reporting, risk management, financial control) Page 52

59 Risk issues: Resource Implications: (financial / human / other resources) Regulations and legal considerations: (CQC considerations / Monitor requirements / link to NHS Constitution rights and pledges as necessary / Trust Constitution / legislative requirements) Quality consideration and impact on patient and carers: Consultation/ Communication: Confidentiality: Equality Impact Assessment: Contractual Financial CQUIN Regulatory CQC/Monitor Financial Implications will be associated with CQUIN Regulatory Implications for some indicators Monitor and CQC (This is shown in Appendix A) Improved communications, and faster access to services, promotes patient choice. Assurances of the quality of care provided. Executive Committee This report does not contain any confidential information. Great Western Hospitals NHS Foundation wants its services and opportunities to be as accessible as possible, to as many people as possible, at the first attempt. This report has been assessed against the Trust s Equality Impact Assessment Tool and there are no proposals or matters which affect any persons with protected characteristics. Name of Lead Executive Director: Name of Author: Dr G Rooney, Medical Director Hilary Walker, Chief Nurse Sharon Beamish, Interim Chief Operating Officer Lisa Hocking, Lead Nurse Practitioner for IP&C, Quality & Governance. Hilary Shand, Director of Operations Page 53

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61 Patient Safety and Quality Report The August 2014/15 dashboard provides the August (some month one data where reporting is in arrears) data for key performance targets required for Monitor, CCG Contract and Quality Account (Appendix A). This report will provide data for July and August. A Infection Prevention & Control - Executive Lead Guy Rooney Infection Prevention & Control August 2014 Indicator 90J Blood Culture Contamination Rate Target: Maintain a rate of 5% or less throughout the year July % August 3.9 % False-positive blood cultures (or contaminated samples) not only increase laboratory work but also prolongs the length of a patient stay and use of broad-spectrum antibiotics, both of which are likely to increase antibiotic resistance and patient morbidity. A blood culture contaminant is defined as a usual skin organism that was isolated from only one set of blood cultures in a patient with no evidence of an infection with that organism. The Department of Health expect providers to a have a contamination rate of less than 3%. Monthly contamination rates are provided for the directorates, that detail each department s contamination rate (number and percentage), this helps focus where local improvements can be made. Further improvement plans are required Trust wide to improve and sustain a low contamination rate; this shall be implemented during the next few weeks and will include the amount of time taken to decontaminate the patient s skin. During July an improvement was observed within the ED following reinforced guidance, which changed practice for some members of staff, although the overall contamination rate increased Trust wide. Initial analysis of Augusts data shows maintenance of the improvement demonstrated within ED, although the number of contaminants produced by medical staff appears to have increased, the cause needs to be subsequently investigated. 6 Blood Culture Contamination Rate Trust Wide Contractual Limit - below 5% (* except blood cultures tested at other laboratories) Contamination Percentage DH Target <3% Contract Limit 1 0 Page 55

62 Indicator 1J MRSA bacteraemia Zero Target for the Trust Monitor di minimus of 6 cases July 0 cases August 0 cases Year to date - Actual 0 There were no MRSA bacteraemias reported during the months of July and August. Key areas of progress to reduce the incidence of avoidable cases have been: 1. MRSA screening compliance maintained the improvement during June; however compliance dropped to 94% in July for elective and emergency admissions. Our contracted screening rate is to achieve 95% for patients who meet the screening criteria. The targeted work with ward mangers to ensure patients are not missed during their hospital stay has maintained compliance for emergency admissions. Targeted work will focus on elective admissions particularly in relation to day cases during the forthcoming month. 2. Revised MRSA screening criteria has now been published by the Department of Health, the changes will be presented to the next ICC, the MRSA policy subsequently revised and re published. Indicator 2J Incidence of Clostridium difficile Target <= 28 for the Acute and Community combined Trust July: 3 cases August: 4 cases (September to date: 1 case; details not included in this report) Year to date - 11 The Department of Health trajectory is to report no more than 28 cases for the Great Western Hospital. Three cases have been reported against the Quarter 1 trajectory of seven. The Trust reported three cases of Clostridium difficile (C.diff) during the month of July with a further four cases during August. These cases were attributed to Dove, Neptune, Saturn (two, instigating a Period of Increased Incidence), Mercury, Falcon and Intensive Therapy Unit. Patient one The patient is under 65 years of age and was C.diff positive on day 12 of admission. The patient was admitted due to post-transplant complications with sepsis and renal impairment and was treated with antibiotic therapy. They were also in receipt of proton pump inhibitor therapy. The cause of the C.diff was thought to be attributed to antibiotic therapy. Patient two The patient was over 65 years of age and C.diff positive on day 8 of admission for severe sepsis with faecal impaction, which was treated with laxatives and antibiotic therapy. The cause of the C.diff was thought to be antibiotic therapy. The patient was recovered, but later passed away due to an unrelated condition. Patient three The patient was over 65 years of age and C.diff positive on day 18 of admission. This was a readmission following recent discharge from GWH with worsening breathlessness and a diagnosis of severe left ventricular failure. The positive C.diff result was not known until after the patient had passed away, the patient was not appropriately isolated at the time of the sample being obtained. The cause of the C.diff was thought to be antibiotic therapy for pneumonia associated with end stage heart failure. As protocol was not followed on this occasion, the ward manager has been advised to Page 56

63 use this case as an opportunity to talk to staff regarding the isolation policy and the appropriateness of obtaining specimens. Patient four The patient was over 65 years of age and C.diff positive on day 9 of admission due a mechanical fall at home initiating an exacerbation of leg ulcers, which were treated with antibiotic therapy. The patient was also in receipt of proton pump inhibitors. The patient was recovered and the cause of the C. diff was thought to be the antibiotic therapy. Patient five The patient was over 65 years of age and C.diff positive on day 13 of admission for a cerebrovascular accident (stroke). Aggressive antibiotic therapy was provided for meningitis, encephalitis and hospital acquired pneumonia upon microbiology advice. There was a delay in isolating this patient upon the start of symptoms. The cause of C. diff was thought to be attributed to antibiotic therapy. Patient six The patient was over 65 years of age and C.diff positive on day 35 of admission. There was a delay in sending a stool specimen, as the patient was symptomatic for a week before a specimen was sent to the laboratory. Antibiotic therapy had been provided for community acquired pneumonia, sepsis and a complicated pleural effusion during admission. Antibiotic therapy was thought to be the cause for the C.diff. Patient seven The patient was over 65 years of age and C.diff positive on day 29 of admission. The patient was transferred from another acute provider where they had been an inpatient for six weeks following a metallic valve repair. Antibiotic therapy was prescribed for hospital acquired pneumonia. The patient has since made a good recovery and discharged home. Period of Increased Incidence A period of increased incidence was instigated on Saturn ward as this was the second hospital acquired case of C.diff on the same ward within a 28 day period. The Department of Health s (DH) C. diff guidelines have been followed with weekly ward audits of the DH S Clostridium difficile High Impact Interventions tool until the weekly score is >90% for three consecutive weeks and no further cases of hospital acquired C. diff have been identified. The antibiotic pharmacist has carried out weekly antibiotic review in each ward. Audit results have been shared with the ward manager. Ward cleaning with a chlorine-containing agent will continue on the ward until no further symptomatic patients are present on the ward. Further testing of the C.diff isolates was performed by the Clostridium difficile Ribotyping Network (CDRN) laboratory. Initial results have not excluded crossinfection. Further fingerprinting is being requested by the Trust. A summary of the increased incidence of quarter two s C.diff cases, recommended actions was presented to the Governance Committee on 5 th September. It was suggested IP&C consider revisiting the use of talking devices to raise the profile of hand hygiene for staff and visitors for the wards areas on rotational basis. Page 57

64 Quarterly Clostridium difficile Infections reported against Trajectory Quarter 1 Quarter Accumulative Quarter Accumulative Quarter Accumulative total to date (trajectory) C.diff trajectory GWH CCG C.diff Reviews Unavoidable 3 - Avoidable 0 - Ongoing additional actions to reduce incidence of C.diff: Prompt isolation of patients with unexplained diarrhoea remains a priority. The IP&C team are confident that staff are aware patients should be isolated within two hours, however understanding the barriers and staff acknowledging the need for isolation and the bed availability to implement needs further exploration to achieve the goal. Antimicrobial prescribing continues to be monitored across all acute wards by the pharmacy team and fed back to divisions within quarterly reports. Additional testing of C.diff specimens from Quarter two is under way to understand the epidemiology and potential for cross infection Engagement of Executives and Matrons on walkabouts/spot checks to provide reassurance of cleaning standards. 1. Infection Surveillance Data: There has been a small increase in the number of Hospital attributed MSSA and Ecoli bacteraemia reported this month, one MSSA was a repeat positive. There are no trajectories set for the following reportable infections: 2014 Q1 July August Q2 to date Total to date MSSA Bacteraemia Ecoli Bacteraemia GRE Bacteraemia Mortalities attributed to C.diff infection Mortalities attributed to MRSA bacteraemia Outbreak Data: Ward Closures July and August 2014 None Bay Closures July and August 2014 None Page 58

65 3. Summary from July Infection Control Committee (ICC) Agenda Item IP&C Risks Summary Viral Haemorrhagic Fever guidance has been issued by Public Health England which provides guidance for potential Ebola patients. IP&C continue to work the Resilience team to ensure receiving areas such as the Emergency Department and Acute Medical Unit together with on call managers and directors are aware of the personal protective equipment requirement to facilitate patient and staff safety. A business case in support an IP&C service during weekends and outbreaks was discussed; this will need to be included with the Operational Resilience Plan to be progressed. Directorate Report Diagnostics and Outpatients Summary of IP&C concerns were presented, these included maintaining a clean environment. MRSA screening is under review for the Day Therapy Centre and Coate Water Unit. National guidance is still awaited. The main risk is the introduction of air conditioning to these areas. Air conditioning is required because of high temperatures which affect the viability of chemotherapy and can be uncomfortable for patients. IP&C are working with Estates and directorate representatives agree a suitable air conditionings unit. Policies No policies were ratified. Page 59

66 B Clinical Audit & Effectiveness - Executive Lead Guy Rooney Clinical Audit & Effectiveness August 2014 The Trust s Clinical Audit and Effectiveness Department supports the facilitation of Clinical Audit and Quality Improvement projects throughout the organisation, to improve and promote quality, safety and effectiveness of patient care. This is achieved by regularly reviewing current practice against specific standards and implement change where required, for example, to avoid incidents that should never happen, reviewing the management and clinical care for patients who die in hospital, avoiding unnecessary length of stays for inpatients and avoiding readmissions into hospital after discharge. Clinical Audit activity is reported to the monthly Division Governance Meetings to enable key areas to be discussed. Exceptions are reported thereafter to the monthly Patient Safety Committee. 1. Clinical Audit Update Progress has continued with the audit programme during the past month. 2. Exceptions There are no exceptions to report this month. 3. Changes in Practice 64% completed audits to date this year have resulted in learning and a change in clinical practice The following are a selection of recently completed audits: 1. WHO Safety Checklist Cardiology June/July 2014 Areas of Good Practice and Key issues: Cardiology Department have modified the WHO checklist recommended by British Cardiovascular Society (BCS) for use within GWH so that it exceeds the recommended standard ensuring better patient outcomes. However, during this audit, it was identified different WHO checklists are used depending upon the surgical procedure carried out; therefore the audit results shows a variation in the results due to the changing denominator for each of the standards measured, as not all patients could be assessed against all the criteria*. Areas for Improvement and Actions: Improved documentation is required to avoid misinterpretation of listed responses to the various questions that are not applicable to the procedure or the patient s recovery. Additional fields are required on the checklist to include a NA option for responding where checks cannot being fully completed. Before a re-audit commences, it is recommended that a more robust methodology is developed in order to audit the checklists for each procedure equally. The audit report has been disseminated to the Cardiology department for awareness and the results have been subsequently presented to the Unscheduled Care Consultant s meeting to highlight the areas of non-compliance and address any improvements required. Number of Standards: 22 Range of Compliance: %* Overall Compliance: 94.6% This audit is considered to be: Not fully compliant with areas for improvement 2. Maternity Swab Count Audit (6th Re-Audit June/July 2014) Areas of Good Practice and Key issues: Page 60

67 The aim of the audit is to assess if swabs, needles and tampons are being counted and checked by a second health care professional before and after perineal suturing. The monthly audit results against 5 criteria have demonstrated high compliance ranging from 90-98%; however, it was disappointing to note this is the first month since February 2014 that the audit has not achieved 100% compliance against all 5 specified criteria. On occasions it was not clear on the documentation if second check was performed pre or post procedure. On one occasion, although perineal suturing was documented in birth notes as required, no suturing proforma was completed and there was no documented evidence of swab checking having been performed. Areas for Improvement and Actions: Documentation - Any areas of non-compliance is now reported to the relevant immediate line manager so appropriate discussions can be held with the individual/s. Number of Standards: 5 Range of Compliance: 90-98% Overall Compliance: 95% This audit is considered to be: Not fully compliant with areas for improvement 3. Vulnerable Women Monthly Audit (Q1 2014/15) Areas of Good Practice and Key issues: This audit monitors practice to ensure pregnant women with complex social factors and additional needs/barriers are addressed. Overall, improvement continues with Health Visitors being contacted and involved in management plans during the Antenatal period. Full compliance has been achieved in ensuring women are referred to the appropriate agencies; and evidence of a documented handover to Health Visitor on day 6 has significantly improved from the previous quarter, and now demonstrates full compliance. This monthly audit identified that the Community Teams were not fully aware of the policy changes which now requires all vulnerable women to have a Safeguarding Proforma and a Common Assessment Framework (CAF) Form completed as standard. Areas for Improvement and Actions: Safeguarding Proforma and a Common Assessment Framework (CAF) Form - To ensure compliance is improved the Safeguarding Midwife will be responsible for raising the awareness of the changes in the policy, the profile of form and its requirements via team meetings, training and education pathways. It is also planned for the profile to be raised via SMART News Letter and/or Safeguarding section in Maternity Services. The feasibility of adding an alert message/notification to Medway as a prompt for community teams is also to be explored. Number of Standards: 7 Range of Compliance: % Overall Compliance: 75% This audit is considered to be: Not fully compliant with areas for improvement 4. Q1 2014/15 Annual Hand Hygiene Audit Integrated Community Health Areas of Good Practice and Key issues: Improvements in compliance from were made in the following areas: Alcohol based hand rub is available at the point of care and Forearms are bare below the elbow, and full compliance was maintained against the correct hand hygiene technique, from 2013/14 across all teams. 11/18 teams achieved full compliance against all seven specified criteria in the annual audit, Respiratory/COPD team and Ailesbury ward were both also non compliant in the audit (both areas failed to meet one of the audit criteria). Page 61

68 Of concern; the number of staff with existing skin problems has increased from 5(3%) in 2013/14 to 16(8%) in 2014/15. This information is not part of the audit criteria but provides valuable information for service leads and the Occupational Health service. Areas for Improvement and Actions: Clinical/Service Leads are responsible for sharing the audit results with their teams and to use the opportunity to promote and maintain best practice in hand hygiene. Action plans are required to be formulated by the Clinical/Service Leads where non-compliance is recorded and ensure that Occupational Health Referrals are made for those staff with existing skin problems. Evidence to support the implementation of the agreed actions has been requested by the audit lead. Number of Standards: 7 Range of Compliance: % Overall Compliance: 99% This audit is considered to be: Not fully compliant with areas for improvement Dr Foster Reviews August 2014 The Trust s Hospital Episode Statistics (HES data) is used by Dr Foster Intelligence, to benchmark our performance against agreed national and local clinical quality and safety indicators; Mortality rates, Re-admissions rates, Length of stay rates, Day case rates, Patient Safety and Service Line indicators. Red Bell alerts are generated when performance rate is higher than expected. All alerts are investigated to ascertain the reason for deviation, and to identify areas for improvement in clinical care or processes within the Trust. 1. New Alerts Operations on Peptic Ulcer (Mortality 6pts) Rest of Male Reproductive Organs Procedure (Mortality 2pts) Other Non-Epithelial Cancer of Skin (Mortality 1pt) Deaths for Menopausal Disorders (Mortality 1pt) Other Liver Disease (Mortality 11pts) Senility and Organic Mental Disorders (Mortality 14pts) A clinical coding review is in progress to ascertain any coding anomalies prior to a full clinical review of the case notes taking place. 2. Reviews in Progress Dr Foster Alert/Review Title Cancer of Prostate (Mortality -7pts) Other Drainage of Peritoneal Cavity (Mortality -21pts) Progress/Stage Clinical review in progress Clinical review in progress 3. Completed Reviews Alert Title: Rest of Respiratory Mortality Alert Key Issues: There were no clinical coding issues or avoidable deaths identified Improvement in identifying patients where NIV is an appropriate treatment Education and measures designed to improve the frequency with which NIV is initiated appropriately Processes to ensure more regular involvement of the palliative care team should be Page 62

69 introduced Senior decision makers (consultants) need to be involved regularly throughout the pathway of care of these patients Areas for Improvement: Present programme of education on NIV for trainees and consultants Wide dissemination of findings to division and trust governance meetings Introduction of a clear process ensuring appropriate initiation of NIV Development of NIV use as a trigger to initiate involvement of the palliative care team Develop system to ensure regular consultant review occurs (throughout entire pathway and especially following deterioration of patients receiving NIV) Reviewing Clinician/s: Clinical Representatives from Unscheduled Care Division Alert Title: Cancer of Rectum and Anus - Mortality Alert Key Issues: Improve accuracy of coding by increasing clinician involvement and feedback to coders Review suggests a lack of palliative care services for these patients - this should be fed back to commissioners for them to review provision One patient suffered an aspiration pneumonia recommended case review by anaesthetic team Areas for Improvement: Improve accuracy of coding - process now in place by Coding Manager to ensure this improves, and results fed back to the team Improve provisions of palliative care Associate Medical Director for Unscheduled Care to feedback results to Clinical Commissioning Group Review Case of aspiration pneumonia Clinical Lead for Anaesthetic department to ensure case reviewed/discussed at next anaesthetic M&M meeting Reviewing Clinician/s: Multidisciplinary- Representatives from Unscheduled & Planned Care Divisions. NICE Adherence & Monitoring August 2014 The NICE Lead is responsible for identifying, disseminating, monitoring the implementation and reporting, of all NICE published guidance. These have been disseminated to the relevant clinical leads and directorates for assessment against current practice. A response is expected within a 4 week time frame. 1. Awaiting/Overdue Responses (from assessment of NICE guideline) Progress continues to be made with the NICE assessments and responses; the number of responses has increased from 8 to 22, of which, 5 are currently overdue. The end of July saw 14 NICE guidelines published and disseminated, however, combined with the holiday period, further responses are expected to become overdue at the end of August Page 63

70 Summary D&O P Care U Care W&C ICH Corp Mat Ser Total Awaiting Responses (within time frame to respond) Overdue Responses Under Review (i.e. where prescribing protocol, pathway to be established or funding to be agreed) The NICE guidelines under review are assessed 3 months post publication to allow adequate time frame for protocols and pathways to become established. Summary D&O P Care U Care W&C ICH Corp Mat Ser Total Under Review Non-Compliant (practice does not fully meet guideline, action plan required from clinical lead) Action plans awaited from clinical leads has increased from 1 to 2 during August. Summary D&O P Care U Care W&C ICH Corp Mat Ser Total Non Compliant (Awaiting Action Plan) NICE Guideline Directorate Deadline (for action plan) QS49 Surgical Site Infection Corp 31/08/14 PH50 Domestic Violence and Abuse Corp 31/08/14 4. Implementing (Implementing NICE guidance with action plan in place) August has seen a significant number of completed action plans for implementing guidelines, reducing the total number from 23 to just 16. Out of which, 9 action plans for implementing NICE guidelines are within time frame, and there are 7 action plans Out of Time Frame (passed the deadline) for implementation. The Clinical Audit team regularly liaise and work with the action plan leads to enquire of the progress and ascertain any obstacles. Summary D&O P Care U Care W&C ICH Corp Mat Ser Implementing Total Out of Time Frame Page 64

71 NICE Guideline Directorate Deadline (Implementation) QS26 Epilepsies in Adults (Acute only) Improving the First Seizure Pathway and updated guidance for A&E USC Feb 2014 QS27 Epilepsies in Children & Young People (Acute only) Assess capacity in Consultant Epilepsy sessions and transition to adult care W&C Feb 2014 QS31 Health & Wellbeing of looked after C&YP (Acute & Community) Review protocol (Community Health, Social Care & CAHMS) Develop health passports and review care pathways inc health visitors & school nursing W&C Apr 2014 CG165 Hepatitis B (Acute only) All Hep B positive patients or patients needing treatment are currently transferred to Oxford. A Fibro scan has been added to the Division business plan as this will be required as part of Capital planning. USC Jun 2014 QS34 Self Harm (Acute) Availability of trained children s nurses on new Paed ED to be available on all shifts. Current facilities for safe assessment are limited to a single room within ED, which does not have 2 exit points. Access to the room is limited as used by other teams; a relative s room is often used which does not comply with guidelines. Currently no facilities on the shared observation/ SAU area for safe and confidential assessment. ED nursing staff in the observation area regularly monitors and intentionally round high risk patients to avoid overdoses being taken and sharps bins being tampered with by service users. QS34 Self Harm (Community) Current guidelines for Minor Injuries Unit (MIU) require updating and formatting into trust standard. Training on the use of the Emergency Department Mental Health Assessment Matrix used in the MIU is required for all registered nurses. The Mental Health Assessment Matrix for under 18yrs in MIU is to be ascertained from the Safeguarding team. Appropriate pathways for both children & adults in MIU s are to be ascertained from the Mental Health Team. Additional staff training is required for staff to feel confident using the assessment forms. USC USC Jun 2014 Jun 2014 Page 65

72 QS39 Attention deficit hyperactivity disorder (Acute) Process required for patients who require ADHD assessment are done so by qualified ADHD specialist Process in place for the Initiation of medication and monitoring to be done by a ADHD specialist?added to Risk Register W&C Jul Exceptions (where a NICE guideline is relevant to the organisation, but is intentionally not implemented i.e. new drug without a licence, decision not to implement if current treatment has equal outcome or practice exceeds recommendation) There are no exceptions to report this month. 5.1 Compliant with Exceptions (where a NICE guideline is relevant to the organisation, but is unintentionally not fully implemented i.e. service not commissioned, limitations on resources) NICE Guidelines Directorate There are currently no exceptions to report this month 6. Trust Wide Compliance Trust Wide compliance of 98.1% has been achieved this month. D&O P Care U Care W & C ICH Corp GWH 100% 99.3% 96.4% 97.6% 100.0% 71.4% 98.1% NCEPOD August 2014 A key role of NCEPOD is to make recommendations based on the findings of the national studies they undertake and which is mandatory for the Trust to participate. Many of the recommendations are for clinicians, but others are directed at service provision at both local and national level. The NCEPOD local reporter is based within the Clinical Audit & Effectiveness Department and is the primary link between NCEPOD and the Trust. The local reporter is responsible for coordinating the studies within the organisation, and working with the clinical leads and the NCEPOD ambassador (lead clinician). All published recommendations from NCEPOD are locally assessed against current practice and these results inform the Patient Safety Committee. 1. Trust Participation Progress with participation in the NCEPOD studies is on schedule. Trust participation for NCEPOD studies remains at 100%. Page 66

73 2. Forthcoming Studies Study Title Acute Pancreatitis - This study will assess compliance with surgical guidelines for management of acute pancreatitis by evaluating current practice and highlighting areas of excellence and those areas needing improvement Provision of mental health patients in acute hospitals -This study will review the quality of care provided to patients with a mental health disorder, who are admitted to an acute hospital. Start Date December 2014 May Studies in Progress Study Title Progress/Stage Report Date Tracheostomy Care Assessment of Jun 2014 recommendations Lower Limb Amputations Nov 2014 Data Analysis Gastrointestinal Bleeds Jun 2015 Progressing Sepsis Nov 2015 Progressing 4. Completed Studies There are no completed studies this month. Page 67

74 C Clinical Risk and Patient Safety Report - Executive Lead - Hilary Walker Clinical Risk and Patient Safety August 2014 Never Events Reported in July & August 2014 No Never Events were reported in July & August Serious Incidents (SIs) reported July 2014 Incident Number STEIS Number / / / / / /24737 Division Women s & Children s Integrated Community Health Integrated Community Health Integrated Community Health Integrated Community Health Planned Care Unscheduled Care Source/ Commissioning CCG Incident type Grade Paediatrics/Wilts Child Safeguarding Grade 2 Devizes NT/Wilts Wilton NT/Wilts Trowbridge NT/Wilts Marlborough NT/Wilts Ampney Ward/Swin Woodpecker Ward/Swin Community Acquired Category III Pressure Ulcer Community Acquired Category IV Pressure Ulcer Community Acquired Category IV Pressure Ulcer Community Acquired Category III Pressure Ulcer Patient Fall # Mid shaft of femur Grade 1 Grade 1 Grade 1 Grade 1 Grade 1 Adult Safeguarding Grade 2 Serious Incidents (SIs) reported August 2014 Incident Number STEIS Number / / / / /27268 Division Integrated Community Health Planned Care Integrated Community Health Integrated Community Health Integrated Community Health /27887 D&O Source/ Commissioning CCG Chippenham Community Team/ Wilts SAU/Swin Warminster Community Team/ Wilts Warminster Community Team/ Wilts Amesbury Community Team/ Wilts Day Services OPD Page 68 Incident type Community Acquired Category III Pressure Ulcer Treatment delay/failure Community Acquired Category III Pressure Ulcer Community Acquired Category IV Pressure Ulcer Grade Grade 1 Grade 1 Grade 1 Grade 1 Community Acquired Category IV Pressure Ulcer Grade 1 Fractured neck of Grade 1 femur

75 Relevant immediate actions have been taken where appropriate. Investigation leads have been identified. Root cause analysis and serious investigation reports are being completed for the above stated incidents. The progress against investigations and action plans will be monitored by the PSC. 36 Serious Incidents reported 2014/15 to date 80 Total Number of Serious Incidents Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar SI's 2013/14 SI's 2014/15 Cumulativ e Total 2013/14 Cumulativ e Total 2014/15 A total of 71 serious incidents reported for 2013/14, a reduction of 14 reported for the same period 2012/13. Serious Incidents reported by Cause Group and Quarter Qtr /14 to Qtr 1 14/15 Number of Serious Incidents reported in each category Pressure Ulcer Slips, Trips, Falls Safeguarding Maternity Incidents Treatment/ Procedure Never Event Infection Control Unexpected Death Clinical Assessment/Diagnosis Delay Qtr 2 13/14 Qtr 3 13/14 Qtr 4 13/14 Qtr 1 14/15 Page 69

76 Key learning and improvements from serious incident action plans implemented during July & August serious incident action plans were completed in July serious incident action plans were completed in August Incident Numbers Incident Type Confirmed Change or Action Completed Falls incidents Audits have taken place on SAFE (Stratification, on avoidance of falls, in the environment) assessments and intentional rounding Training sessions delivered covering staff accountability in relation to the falls avoidance policy, lying and standing blood pressure recordings, and the roll out of a new care rounding tool. Staff have signed to say they understand the protocol and their professional accountability in adhering to the policy. Introduction of half hourly intentional rounding in some areas at night. Report has been shared at team meeting and ward bulletin to re-enforce with staff the importance of regular and timely patient assessments and for documentation to be timely, accurate and complete. Don t walk by approach implemented and call bell response times are being monitored and improved. Consultant has reviewed the use of sedatives in delirium to ensure nursing and medical teams have clear guidance and has drafted a delirium pathway. The use of codeine in the frail elderly has also been reviewed and a ratified delirium pathway has been produced Community acquired pressure ulcers Training sessions have been delivered to staff with residential homes on the use of the SSKIN (Surface, Keep moving, incontinence, nutrition) bundle Tissue Viability Nurse Consultant has communicated trust wide to staff the correct mattresses available and their usage. Education session delivered to staff regarding knowledge and understanding of the pressure ulcer policy Staff have attended the Tissue Viability Pressure Ulcer Conference to address individual training needs. Head of locality, Tissue Viability Nurse Consultant, Community Team Leader and Wheelchair Service Manager have met, reflected on recent RCA investigations and have planned ways to address gas in the communication process across the teams Acute ward closure Education session delivered to staff on adherence to IP&C policy during a norovirus outbreak. Recommendation of staff must question infection status of patients coming into the ward has been Page 70

77 communicated via safety briefings and ward meetings and forms part of the admission checklist. Daily diary document has been revised by IP&C. This documents that all agreed that patient movements, transfers, & procedures and a copy remains on the ward for the remainder of the 24hr period. Carillion have carried out and completed training with staff with regards to the importance of concentration of chlorine based cleaning solution. Action plans overdue from serious incidents Directorates continue to experience challenges with the timely completion of actions arising from serious incident investigations. We are required to provide our commissioners with evidence of actions implemented as a result of serious incidents, to demonstrate that we have learnt and improved care for our patients. Full completion of actions arising from serious incidents continues to be an ongoing risk, which has been identified and discussed with directorates at Patient Safety Committee. Detailed breakdown of actions arising from serious incidents are provided to the directorates on a monthly basis. At the time of writing 11 action plans resulting from serious incidents are overdue, all of which were escalated to the PSC in September Number of Days Serious Incidetn Action Plan Overdue Overdue Serious Incident Action Plans Corporate Integrated Community Health Planned Care Unscheduled Care Page 71

78 Action plans over 60 days overdue Action plan - October 2013 following Teal ward fall # left NOF. One action is outstanding 1. A Trust wide post fall care protocol Action Plan due March 2014 following Ampney pressure Ulcer category III. One action remains outstanding; 1. Confirmation that the senior sister has held reflective meetings with nursing staff involved, highlighting key issues identified Action Plan due June 2014 following Meldon ward fall # right NOF. One action outstanding; 1. An additional action to be added into the routine SAFE audit to review and identify which staff are not implementing the assessments and individual discussions on the barriers in doing so Action Plan due July 2014 following a Marlborough Community team category III Pressure ulcer. Two actions remain outstanding; 1 to conduct a reflective practice review with all Healthcare Support Workers around appropriate roles and responsibilities in relation to pressure ulcer care. 2 - To introduce a named band 6 case holder for specific residential homes to ensure more consistent monitoring of patients. Executive Patient Safety Visits July & August 2014 Five executive patient safety visits were completed in July 2014 and 4 executive patient safety visits were completed in August visits have been undertaken since September Date Department Executive team 10 th July 2014 Devizes Community Hospital Guy Rooney Medical Director & Roger Hill Chairman 17 th July 2014 Aldbourne Ward Guy Rooney, Medical Director & Angela Gillibrand, Non Executive Director 25 th July 204 Hazel Ward Nerissa Vaughan, Chief Executive, Jemima Milton, Non Executive Director 30 th July 2014 Mercury Ward Julie Marshman, Deputy Director of Quality & Governance & Jemima Milton, Non Executive Director 4 th August 2014 Meldon Ward Oonagh Fitzgerald Director of Workforce & Education & Steve Nowell, Non Executive Director. 6 th August 2014 Salisbury & Amesbury Nerissa Vaughan, Chief Executive & Steve Nowell, Non Executive Director 7 th August 2014 Linnet Ward Nerissa Vaughan, Chief Executive & Roger Hill, Chairman Page 72

79 11 th August 2014 Beech Ward Maria Moore Finance Director, Angela Gillibrand, Non Executive Director 19 th August 2014 Teal Trauma Unit Hilary Walker, Chief Nurse, Jemima Milton, Non Executive Director 6 Executive Patient Safety Visits completed Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Total number of visits Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Actions arising from Executive Patient Safety Visits Actions arising from the visits are being recorded and followed up by the Clinical Risk team. Executive Patient safety Visits completed Total number of actions raised Total number of actions completed Actions completed or resolved include: Mercury Ward - Improvements to staff room - chair removed and carpet cleaned. Aldbourne Ward - Training provided to enable the Ward Manager to use the Safeguard managers report function. Meldon Ward Staff shortage themes reviewed within IR1 s. Salisbury, Amesbury & Wilton Community Team - Care agency concerns raised and added to risk register. Salisbury, Amesbury & Wilton Community Team Report provided on number of incidents reported concerns with care agencies. Page 73

80 D Regulatory Compliance Report - Executive Lead - Hilary Walker Regulation and Quality Contracts August CQC Registration: Health & Social Care Act 208 (Regulated Activities) Regulations 2010 Care Quality Commission (Registration) Regulations 2009 An extensive review of our CQC registration was undertaken across the acute and community sites to ensure that our CQC registration is adequate for the regulated activities undertaken across the sites. Following the registration review a paper was submitted to Trust board in July 2014 highlighting the three gaps (see table below) in registration and recommendations required to the current CQC registration. The board approved the recommendations in July CQC were notified on 1 st August 2014 of the variations required to the current registered sites and the new CQC regulated activities to be registered. The Trust is now awaiting the revised registration from CQC which reflects the variations. Moving forward a quarterly review will be undertaken by the Compliance Team using intelligence from staff, directorates and the Estates department. Directorates and locality leads will be provided with an update following the review and variations to be made to the CQC registration and the CQC will be notified of any variations accordingly. CQC registration gaps: CQC registration variation required 1. 3 community inpatient hospitals needed registration for the Assessment or medical treatment for persons detained under the Mental Health Act satellite sites out of the 22 sites for acute outpatient clinics identified needed to be listed with the CQC as a location for undertaking 2 regulated activities satellite sites for the community outpatient clinics needed to be listed with the CQC as a location for undertaking regulated activities Current Action taken: risk (as at Sept 2014) None CQC notified in August 2014 of variation required to registration None CQC notified in August 2014 of variation required to registration None CQC notified in August 2014 of variation required to registration 2. CQC Notifications CQC Outliers Following the first three outlier submissions to the CQC in June 2014, the CQC raised some queries regarding all these outliers to which the Trust responded on 28 th and 30 th July Page 74

81 CQC have now confirmed that that they do not need to undertake additional enquiries regarding the Therapeutic endoscopic procedures on the upper GI tract at this time. However, CQC have confirmed that our local inspection team will be contacting the Trust to discuss the process for following up on issues which are highlighted through the Mortality and Morbidity meetings. Outliers Maternity: Maternal nonelective readmissions within 42 days Maternity: Neonatal nonelective readmissions within 28 days of delivery Unscheduled Care: Therapeutic endoscopic procedures the upper GI tract Date received from CQC 7 th May th May th May st Submission to CQC 2nd Submission to CQC (following CQC queries) Copies of all sent to Swindon & Wiltshire CCG 20 th June th July th August th June th July th August th June th July th August 2014 CQC Response Awaiting responses following the 2 nd submission to CQC Awaiting responses following the 2 nd submission to CQC CQC confirmed no additional enquiries required at this time 3. New External Reviews, Inspections & Quality Walkabouts Reviewer Wiltshire CCG Quality Walkabout:- Trowbridge Minor Injuries Unit (MIU) (Safeguarding Children Arrangements) Date of Review 30 th June 2014 Feedback (update) The draft report was received from Wiltshire CCG on 19 th August 2014 which highlighted some areas for improvement which includes: Safeguarding supervision required for staff Managerial oversight required for referrals Consistent system required for sharing safeguarding concerns An action plan has been developed and progress is reported by the GWH community Named Nurse Safeguarding Children 4. CQC GWH Inspection update October 2013 Action Plan: Update The CQC action plan has three remaining actions requiring further assurance these are as follows: Page 75

82 Outstanding Actions As per table below, the three remaining actions requiring more assurance are as follows: Action Action summary Plan Number 1 Consistently deliver cleaning to the national specifications for Cleanliness Update & exceptions This action is ongoing. An update was provided to the Governance Committee in September The committee endorsed the actions taken by the IP&C team and highlighted that cleanliness has consistently been improving. Concerns were raised regarding the attainment of the 90% cleaning compliance. An action being taken way from the committee is to review the current cleaning contractual arrangements. It was decided this is an ongoing action and progress will be monitored and reported to the Governance Committee in December Observational assurance for safe medicine administration The wards are participating in a rolling audit program with approximately 600 audit forms returned to date. Each form represents 1 nurse/day. These results are being collated and the results and will presenting these to the Medicines Governance Group. 29 Call bell response times will exceed 95% within 5 minutes Improvements have been noted but not all areas are consistent at 95% within 5 minutes. This action is continuing to be monitored. 5. CQC Intelligence Monitoring Report The final report has now been published on the CQC website. The report highlights the Trust as a banded at a 3 (Priority banding for inspections) with two risks and four elevated risks. It is anticipated that the next quarterly report will be due out in October Page 76

83 E Mortality - Executive Lead Guy Rooney Mortality Report August 2014 Hospital Standard Mortality Rate (HSMR) The HSMR for May 2014 (the most recent data available from Dr Foster) is While there can be large month to month variation the trend over the last four months has been relatively stable at around the mid to upper 70s. The HSMR for the two months April 14 May 14 has the Trust well below 100 at 75.42, with the rolling twelve month period of June 2013 to May 2014 being at However, the annual Dr Foster rebasing (anticipated during September) predicts that our HSMR is likely to be around 95.7, although this is based on the period June 2013 to May 2014 (the only date range available from Dr Foster) so the final figure will change slightly when adjusted to the last financial year. 120 HSMR Mortality GWH and SHA - Most Recent 13 Months GWH SHA Nationally Expected Southern Acute Trust HSMR June 2013 May 2014 The graph below shows the HSMR performance for Acute Trusts in the former South West SHA plus Trusts in the South of England for the period June 2013 to May With the HSMR at it places the Trust twelfth highest overall in the group which is an improvement from the April 2013 March 2014 position where the Trust was eighth highest. Page 77

84 Ashford and St Peter's Frimley Park Hospital East Kent Hospitals Weston Area Health Heatherwood and Yeovil District Hospital Plymouth Hospitals Surrey and Sussex Milton Keynes Royal Berkshire Royal United Hospital Royal Devon and Exeter North Bristol University Hospitals Bristol Dartford and Gravesham Western Sussex Portsmouth Hospitals Brighton and Sussex South Devon Royal Surrey County Taunton and Somerset Maidstone and Tunbridge East Sussex Great Western Hospitals The Royal Bournemouth Oxford University Northern Devon Salisbury Hampshire Hospitals Poole Hospital Dorset County Buckinghamshire Gloucestershire Hospitals Royal Cornwall Hospitals Medway Relative Risk Nationally Expected Standardised Hospital Mortality Indicator (SHMI) The Summary Hospital-level Mortality Indicator (SHMI) reports on mortality at Trust level across the NHS in England. This indicator is produced and published quarterly as an experimental official statistic by the Health and Social Care Information Centre (HSCIC). The SHMI is the ratio between the actual number of patients who die following treatment at the Trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there. Standardised Hospital Mortality Indicator (SHMI) GWH and National Comparison The Trust s SHMI for the rolling period January 2013 and December 2013 is This is lower (better than) the expected value of 100, although has been increasing slightly quarter on quarter. This is not unexpected as a similar trend was seen in HSMR figures, which then saw a marked drop in the first months of Therefore it is expected that the financial year 2013/14 SHMI figure will be lower than the calendar year figure. NB The SHMI is always at least 6-9 months in arrears 106 GWH SHMI Trend SHMI Value Nationally Expected 92 April 2011 to Mar 2012 July 2011 to June 2012 Oct 2011 to Sept 2012 Jan 2012 to Dec 2012 April 2012 to Mar 2013 July 2012 to June 2013 Oct 2012 to Sept 2013 Jan 2013 to Dec 2013 Page 78

85 The chart below shows how the Trust s SHMI compares nationally and demonstrates we were positioned within the lower (better) half overall between January 2013 and December The red line depicts the GWH, and the green horizontal line is the nationally expected norm. 140 SHMI January 2013 to December Summary of key Aims and Actions To provide safe patient care as demonstrated by: A reduction of the GWHNHSFT Hospital Standard Mortality rate to below 90 by December Maintaining this figure through 2015 in order to achieve a rebased figure of below 100 by September NOTE: this will change due to changes in the re-basing process (see commentary below) Moving to the top quartile of Southern Acute Trust performance by December Focus Leadership Coding Mortality Reviews Improvement Action To formalise a Trust clinical lead for Mortality and Patient Safety To seek evidenced based initiatives from other organisations and published work To ensure coding is complete and robust for all patients attending GWHNST In particular to progress and complete the coding of all morbidities for all patients To progress greater working between coders and clinicians: pilot work on LAMU and Orthopaedics. To develop a template to allow standardisation of review of all deaths. To aim to then review all deaths in the Trust. To share and implement the learning from all mortality reviews at clinician (appraisal) and departmental level (Morbidity/Mortality review). Directorates to provide assurance from the ward to the board that this is happening. Page 79

86 Key safety initiatives End Of Life Pathway (EoL) To support trust wide initiatives that support patient safety and consequently support reduction in mortality eg Sepsis six, e- prescribing. To review the monitoring and documentation of patients on the EoL care pathway and ensure correct and appropriate reporting and clinical coding. To work with CCGs to develop a area wide plan for EoL Commentary on areas for improvement: Leadership: Monthly presentations to the Patient Safety Committee on work to improve HSMR are now established. The trust has appointed a new clinical lead for quality (Dr Mark Juniper) and a deputy (Dr Paul Foley). Dr Juniper attended and presented results of local improvement work at a Dr Foster sharing event on sepsis on 8 th September. Key safety initiatives: The sepsis specialist nurse has established a database and approximately 50 patients per month are now being identified with sepsis. The frequency with which key interventions (such as administration of antibiotics within one hour) are achieved has increased substantially since the data has been collected and fed back to departments. Antibiotics within one hour has increased from 7% to approximately 50%. While further improvement is needed, this improvement will be making a contribution to the trust s current low HSMR. Emergency laparotomy is associated with a mortality rate as high as 25%. As part of the EPOCH trial (an improvement project for emergency laparotomy), all emergency laparotomy patients are now being admitted to HDU post operatively and a standard package of care is being given. This is likely to contribute to a reduction in the mortality rate. A further project to improve recognition and treatment of acute kidney injury which is also associated with increased death rates is just being initiated. Coding: Clinical Coding and the Palliative Care Team are auditing patients to ensure all patients receiving palliative care have been correctly coded to identify this as this affects HSMR values. This has identified additional patients where palliative care coding should be added to the patient record and this will then update the Dr Foster data, although the time lag is two months following submission of data by the Trust. Improved coding of palliative care codes means that, the Trust has moved from well below average to exactly average in the palliative codes assigned to patients. Analysis (Dr Foster) suggests the Trust records a lower than average level of the key comorbidities that are used in the calculation of complexity of patient. Further analysis suggests the co- morbidities are better recorded for deceased patients but less so for the general population of patients. The complexity level of all patients has an effect on HSMR. Inclusion of proformas listing key co-morbidities in the new Medway system would be the best way of bringing performance in line with other trusts. General: In addition the Trust is reviewing its systems to ensure all causes of death are discussed with the consultant in charge of the case to confirm the cause. A presentation on standards required for death certification was given to foundation trainees on 9 th September. This included feedback on a Page 80

87 recent case where the death certificate had been rejected by the coroner as well as previous cases where the certification process fell below an acceptable level. It should be noted that Dr Foster are changing their process for re-basing HSMR such that it will be re-based every month in relation to all national data up to that point. As a result there will be no annual step change upwards in HSMR. It is also less likely that HSMR will fall to very low values. The key aims of the work on HSMR will therefore be changes as from next month. Staff Satisfaction August 2014 We are committed to dealing responsibly, openly and professionally with any genuine concerns raised and want staff to feel empowered to raise concerns with earliest opportunity. In all cases we would recommend that, wherever possible, any concerns are raised in the first instance with your line manager. Alternatively there are a number of ways to raise a concern by name or anonymously through See something, say something. There have been no concerns raised through the route since May There has however been one grievance and one concern raised by staff directly to their Matron and the issues raised are being addressed. The Trust is aware of one case whistle bowing; reported during July. There were none reported during August. Pressure Ulcers June 2014 Indicator 49 Reduce Grade 2 and above acquired pressure ulcers by patients ACUTE Target 9 or less a month July - 15 August - 10 Indicator 49W Reduce Grade 2 and above acquired pressure ulcers by patients COMMUNITY Target 14 or less a month July 15 August 20 Page 81

88 The higher level of pressure ulcers in the acute wards were predominantly on one medical ward during July. This resulted in a clean sweep of the ward with the Tissue Viability Specialist Nurse (TVSN) and the ward manager. This including checking every patients risk and skin status, appropriateness of intentional rounding tools and wound and care plan. Immediate alterations were made where necessary. A higher level of pressure ulcers was also found in the community for July, this resulted in a review of the teams with a higher level of pressure ulcers, the results in the graph below show that Chippenham have the highest level of pressure ulcers. The TVSN covering this area is compiling a report with the Team Leader for Chippenham, looking at the specific case load to check that all the require policy interventions are in place and an action plan which will come to the next Tissue Viability team meeting. Page 82

89 E Performance Report - Executive Lead Sharon Beamish Performance August 2014 Key Areas for Focus Indicator 10G % of patients who stay max of 4 hours in A&E Acute Only - This is NOT the Monitor target Target >=95% August 94.33% Indicator 10J % of patients who stay max of 4 hours in A&E Combined - This is the Monitor target Target >=95% August 96.33% ED attendance trend remains fairly even. July to August saw a decrease of 9.2% (-649 attendances). NEL and Admitted via ED Total ED Attendances and Admissions via ED 2013/ / % 30.00% 25.00% 20.00% 15.00% 10.00% ED Conversion % Admitted from ED ED Attendances ED Conversion % Page 83

90 Emergency Care Intensive Support Team (ECIST) KPI s The trust s performance has reduced in comparison to last month in meeting the ECIST KPI s with 3/6 indicators 100 % compliant Total Breaches (week) 1 st assessmen t breaches (week) Minors breaches (week) Bed breaches (week) Specialist breaches (week) ED conversion to admission (week) Target w/c 4 th August w/c 11 th August w/c 18 th August w/c 25 th August < < < < < <25% During this period the trust successfully closed 37 beds in line with the bed reconfiguration to allow works to be carried out on Jupiter Ward and the creation of a winter pressures ward. This impacted on patient flow leading to increased bed breaches as patients were not moved out of ED in a timely fashion and therefore impacted on 1 st assessment breaches due to reduced capacity. This month also saw the changeover of medical teams which impacts on performance although locum use has now reduced. Continuing Breach Action Plan Additional IT support being provided to ED following implementation of New Medway: Follow me server has been rolled out in majors and minors Additional medical and nursing locum staff are being employed at peak times to assist in maintaining flow see graph below for improvements in minors breaches. See and Treat Model used in minors within current staffing resources and additional ENP posts have been recruited to Nursing and medical staff are being flexed across all areas to provide support during times of peak activity ED escalation plan has been finalised and in conjunction with the surge bleep awaits final agreement at AMD level All breaches are reviewed on a daily basis by an ED consultant and the learning from this process is fed back to the team Standard Operational Procedures for Majors, Minors, ED Obs and ED Nurse co-ordinator have been completed Page 84

91 Minors Breaches Trajectory V Actual Performance Trajectory Actual Performance All business plans for future developments around ECIST recommendations have been completed and submitted to the Trust Board, these include: Additional ED consultants to provide extended hours of senior decision making Additional Emergency Nurse Practitioners to provide see and treat /7 Additional staffing for paediatric ED enabling this service to be provided 24/7 Additional ED Assistant support freeing up nursing/medical time Dedicated supervisory nurse in charge Currently funding has only been approved to increasing staffing within the paediatric ED enabling this service to be provided 24/7. Further work is however, currently underway to look at other options for providing the extended ENP service and further Consultant cover. This work will be completed in September. Indicators 11, 12, 13 & Week Referral to Treatment and Hold File Page 85

92 Commentary Against Performance Report: Formal reporting against 18 weeks is a month in arrears. However, it is likely that pathways ending in non-admitted treatment (95% target) and open pathways less that 18 weeks as a percentage of total open pathways (92% target) both achieved the required level of performance for August. To address the admitted backlog, performance against that standard remains significantly below the 90% target, on the basis that patients from the backlog are being treated. This has been the subject of local media coverage in the last week. Work is ongoing to provide assurance that the reported level of performance is robust for non-admitted and open pathways, following the implementation of New Medway. It is of note that the Trust is now 14 weeks on from the implementation of New Medway, and that increasing numbers of patients are now being added to the admitted PTL very late in their pathway, indicating that pathways are now being linked appropriately, but resulting in further pressure to treat patients before they reach 18 weeks. Variance Against Original Admitted RTT Reduction Trajectory: The net reduction in total backlog has fallen by less than the original trajectory (red line) and is currently 483 (blue line) against the original plan of 141 as at 8 th Sept This is due to: 1) A lower level of additional operating than planned over July and August, due to preexisting leave commitments within the Anaesthetics Department meaning that not all lists could be recycled. 2) A spike in trauma work displacing elective orthopaedic activity in late July / early August. 3) More patients have crossed over in to the 18 week backlog each week (represented by the additions to backlog in week row in the table above) and this is largely as a result of more accurate RTT reporting. 4) A spike when Any Qualified Provider (AQP) patients, previously monitored via a separate process, were identified as having already breached, and were added on to the main PTL. 5) It has also been ascertained that patients awaiting Podiatric Surgery were previously excluded from reporting, but these are now included within the totals above from 8 th Sept. Combined, the AQP and Podiatric changes account for 100 patients within the current backlog, but this provides assurance that our reported performance is more robust and in line with national requirements. 6) Delays as a result of the Interventions Not Normally Funded (INNF) / prior approval processes, meaning that further patients joined the backlog. Next Steps to Secure Delivery: The operational focus is now on ensuring that all capacity is clearly mapped and booked for the remainder of Quarter 2 (including 4 or 5 all day theatre lists on each of the remaining Saturdays in September, prioritised towards the struggling specialities) so that any gap can be identified and mitigated, together with ensuring that bed reconfiguration does not compromised elective delivery (35 beds out from 28 th August, assumption of zero medical outliers in to the surgical bed base including Beech Ward from that point.) The blue line has been extended to provide a trajectory of where we will be at the end of Q2. This assumes i) the patients without a TCI remain untreated, ii) no more patients trip in to the week cohort requiring treatment by 30 th September over and above those already on a waiting list, iii) all patients with a TCI date are treated as planned, and do not self cancel & are not hospital-cancelled due to lack of beds, running out of theatre time etc. This would be an end point of a circa 150 patient backlog as at 30 th September, with no patient waiting more than around 26 weeks. However, currently undated backlog patients are still being booked to available capacity in September in some specialities. The assumption of no further patients entering the backlog is not completely robust, because the required improvements to the out patient pathway Page 86

93 have not yet been achieved, such that patients are listed for surgery late in their pathway, as well as the prior approvals delay outlined above. Whilst this is a dynamic position and hard to estimate with precision, it is likely that the 2 factors cancel each other out, and the current 150 estimate is robust at aggregate Trust level. Given that the end of September is now just 2 weeks away, all patients in the week cohort need to be dated and treated, or else they would become carry forward 18 week breaches in to Quarter 3. Waiting time information is reported as unadjusted (that is, without periods of patient nonavailability factored in.) When patients are actually treated, their wait is reported as adjusted (that is, with the periods of non-availability factored in.) Therefore, around 15% of the carry forward breaches in to Q3 will not have breached at the point they are treated from an external reporting perspective. Projected 18 week + Backlog Position at end Q2 (30 th Sept 2014) Trust total ENT OMF T&O General Surgery Urology Podiatric Surgery Ophthalmology Gynaecology 151 at weeks 1 at weeks 15 at weeks 59 at weeks 15 at weeks 18 at weeks 16 at weeks 2 at weeks 25 at weeks Looking Forward to Quarter 3 & Beyond: A backlog of 150 would provide a sustainable position, given that it is no more than around 5% of the total admitted waiting list (that is, the ECIST recommended level.) To achieve 90% admitted RTT on a sustainable basis, given total monthly clock stops of around 1,300, between breached patients per month (slightly less in December) can comfortably be treated, and hold a maximum wait of around 26 weeks. That approach would mean that some specialities (specifically T&O) would continue to fail 90% in to Q3, but that the Trust overall (the Monitor compliance measure) would deliver. This approach will be discussed at the September Swindon & Wiltshire CCG Contract Boards. It is likely that data quality problems in the out patient part of pathway (Medway migration, clock stop algorithm, hold file, delays in outcome processing) will continue to impact on admitted performance. An Interim RTT Project manager commenced in the Trust on 1/9/14, an Interim Out Patient Manager commenced on 15/9/14, and both will work closely with the Divisional Directors and operational teams and Information Department to fully implement and embed the new Elective Access Policy, 18 week compliant clinical pathways and robust measurement, to provide assurance going forward. RTT Assurance Programme presented for discussion to Executive Committee 19 th August, and will go to Trust Board 25 th September. A suite of metrics has been developed to ensure transparent reporting and early warning of going off track. An audit of around 200 patients from financial year 2013/14 will give further objective input in to how the Trust has historically measured 18 weeks RTT, to inform the content of the Assurance Programme moving forward. Significant progress already achieved with IMAS demand & capacity modelling in majority of specialities, and this will be used to arrive at the required capacity for steady state. The 10% breach tolerance (circa 120 patients, delivering a minimum 90% admitted RTT performance each month) will be allocated as follows: 1. Clinically urgent patients / complex pathways where the decision to admit has been too late in the patient s pathway to prevent breach. 2. Patients who have had to be same day cancelled & the 28 day rule applies. 3. Routine patients in order of chronological wait from RTT start to ensure equity of elective access (this is to be done at Trust level, not speciality level.) Page 87

94 52 week waits One of the key reasons for embarking on the backlog reduction programme was to be able to treat the clinically routine patients who had been waiting an unacceptably long time. The majority of these patients were Oral Surgery patients awaiting extraction of wisdom teeth under general anaesthetic, some of them special needs patients where the logistics of theatre list organisation are complex. Good progress has been made in reducing the number of patients waiting in excess of 52 weeks, and progress will continue to be made during September. At the time of writing (15 th Sept) there were 15 patients waiting in excess of 52 weeks from referral. The high point figure was 87 as at end Quarter 1. All but 2 patients have an agreed date before the end of September. 2 patients will continue to be reportable as open pathway breaches in to Q3, but at the time they are treated will not reflect as 52 week waits, because of periods of non-availability. Missing Outcomes (closed in migration) The task force has completed the administrative validation and there are now only 707 outcomes remaining to be closed correctly. The outcomes have been sent to the sub specialties to engage clinicians so that a review of the patient is undertaken to understand if a follow up appointment or discharge is required. The timeframe for the completion of this work is the 15/09/2014 in line with the agreed project plan. Outcomes completed on the Day Outcomes completed on the day of the outpatient appointment are being monitored on a daily basis. The aim is to outcome all patients on the day that they attend their appointment. Recruitment over the last few weeks is continuing to introduce sufficient levels of staffing to achieve this which accounts for increased performance in some areas. Page 88

95 The missing outcomes for July trajectory has slipped by 170 but the task force will be supporting this piece of work, which will be completed to schedule by the 12 th September 2014 Page 89

96 The Hold File The hold file, for all commissioners is currently is 29,540, which is made up of 9,719 patients who have past their due date, 4,556 who will pass their due date in the next 6 weeks. The hold file increased by 509 in week to The breached hold file decreased by On hold past date (breached) On hold past date next 6 weeks On hold future data Totals Hold file Recovery Plan The focus on the hold file is scheduled to start w/c 15 th September 2014, although some preparatory work for this started week beginning 1 st September with the task force. The parameters for clearance of the hold file have been scoped and a trail was run with Gynaecology last week. The trial looked at breached Colposcopy patients, with 63 patients were reporting being on hold past their due date. The patients were administratively validated and this left 17 patients, 10 of these patients required appointments and these were booked. The remaining 7 require clinical validation which has been completed. This exercise allowed the team to test the methodology. The sub specialties have agreed an order of clearance based on patient risk, this focuses heavily on the surgical specialities. Table 1 Hold File for all Sub-specialties Specialty On hold past date Next 6 weeks On hold future date Grand Total Weekly Change Target Target Status Anaesthetics Cardiology , Geriatric Medicine (Care of the Elderly) Clinical Haematology Community Paediatrics Dermatology , Dietetics Ear, Nose & Throat Endocrinology ,146 1, Gastroenterology General Medicine General Surgery 1, , Gynaecology Medical Oncology Midwife Episode Page 90

97 Neurology Obstetrics Ophthalmology 1, ,092 6, ,780 Oral & Maxillo-Facial , Surgery Orthodontics , Orthotics Paediatrics Pain Management Physiotherapy Plastic Surgery Podiatry Clinical Oncology (radiotherapy) Respiratory Medicine Rheumatology ,438 2, Respriatory Physiology (sleep studies) Trauma & Orthopaedics , Urology , Grand Total 9,663 4,486 14,547 28, ,790 Indicator 38G Sufficient slots are made available on the Choose and Book system Target <=4% August 7% There are 42 slot polling issues as at 04/09/2014: 1 Paediatrics 32 Gastroenterology 8 Podiatry 1 Rheumatology The TAL issues are discussed at the weekly PTL meetings and additional capacity identified to ensure that they can be accepted and booked. All departments are focusing on completing the national IMAS demand and capacity modelling tool to be able to reduce the Choose and Book polling ranges to a level that supports delivery of the 18 week pathway. Page 91

98 Indicator 81G Inpatient discharge summaries to be with GPs within 1 working days of discharge, eds reports Acute Target >=95% August 78.7% Apr- 14 May- 14 Jun- 14 Q1 Jul-14 Aug- 14 Sep- 14 Q2 YTD Directorate Diagnostics & Outpatients 94.2% 89.7% 93.9% 92.6% 95.3% 96.7% 95.9% 93.9% Planned Care 66.7% 67.8% 65.4% 66.6% 66.8% 70.4% 68.5% 67.5% Unscheduled Care 82.2% 79.9% 78.6% 80.2% 82.4% 82.3% 82.3% 81.0% Women's & Children's 43.9% 61.9% 57.3% 55.0% 69.9% 84.9% 76.8% 63.5% Grand Total 72.9% 73.8% 71.9% 72.9% 75.2% 78.7% 76.9% 74.6% Diagnostics & On Track Outpatients Planned Care September 75%; October 80%; November 85%; December 85%; January 85%; February 90%; March 95% Unscheduled Care During the month of August the figures ranged from 85.4% to 92.7% which are an improvement on July s percentages. Work is being done to support this steady improvement and it is hoped that we will achieve 90% for most weeks within the September figures. Women & Children Responsibility for the electronic completion of eds reverted back to the Paediatric Medical team on 11th August 2014 with the introduction of the new SHO rota. Training for both SHO and new Registrars has been completed and reasons and importance for completion of eds discussed at induction. The team are now fully aware of the process and understand the clinical risk implications of delays in notification and thus accountability. The team receives a weekly report regarding timeliness and exception reporting of those not meeting target is highlighted to the Consultant of the Week who then addresses this on an individual basis. Page 92

99 GWH Patient Safety and Quality Dashboard No Indicator Annual 2013/14 Regulator Target 2014/15 Apr-14 May-14 Jun-14 Quarter 1 Jul-14 Aug-14 Annual 14/15 Notes 1J Incidence of MRSA bacteraemia COMBINED 5 2J Incidence of Clostridium Difficile COMBINED 23 M, QA, PCT M, QA, PCT <= <= G All cancers - two week wait 94.7% M, PCT 93% 93.5% 94.8% 93.6% 93.9% 93.3% 93.8% 4G Symptomatic Breast two week wait 95.6% M, PCT 93% 95.7% 94.7% 96.9% 95.8% 99.3% 96.7% 5G 31 day wait from diagnosis to first treatment for all cancers 98.8% M, PCT 96% 97.0% 97.4% 98.1% 97.5% 100.0% 98.1% 6G 31 day wait for second or subsequent treatment - Surgery 98.3% M, PCT 94% 100.0% 100.0% 100% 100% 100.0% 100% Page 93 7G 31 day wait for second or subsequent treatment - Drug Treatment 100% M, PCT 98% 100% 98.1% 100% 99.4% 98.2% 99.1% 8G 62 day wait for first treatment from Urgent GP Referral to treatment for all cancers 89.0% M, PCT 85% 93.2% 86.4% 87.4% 89.3% 87.1% 88.5% 9G 62 day wait for first treatment from Consultant/Screening Service to treatment for all cancers 98.8% M, PCT 90% 100.0% 100.0% 100% 100% 100.0% 100% 10J % of patients who stay max of 4 hours in A&E COMBINED 94.1% M, PCT >=95% 92.5% 92.8% 94.2% 93.2% 97.47% 96.33% 94.72% 10G % of patients who stay max of 4 hours in A&E ACUTE 90.9% PCT >=95% 88.4% 88.7% 90.8% 89.3% 95.97% 94.33% 91.69% Includes ED attendances streamed by SEQOL staff 11G 18 week referral to treatment times: Admitted ACUTE 94.9% M, PCT >=90% 94.6% 93.6% 92.9% 93.7% 79.4% 90.8% 12J 18 week referral to treatment times: Non Admitted COMBINED 96.3% M, PCT >=95% 96.8% 97.3% 98.3% 97.5% 98.4% 97.7% 13J 13J1 18 week referral to treatment times: Incomplete Referral to Treatment pathway COMBINED 18 week referral to treatment times: admitted: admitted over 52 week waiters - adjusted 94.8% M, PCT >=92% 93.3% note 92.1% note 90.3% note May figure is being validated following implementation on new Medway system J2 18 week referral to treatment times : admitted over 52 week waiters - non-adjusted J3 18 week referral to treatment times :incomplete over 52 week waiters N/A 54 N/A 13J4 18 week referral to treatment times: admitted backlog waiting over 18 weeks J Hold file - total patients on hold file J Compliance with CQC regulations COMBINED NO M, PCT 21J NHSLA risk management standards for acute - Progressing Project Plan towards level 2 assessment COMBINED YES M, PCT 100% complianc e Sustain Level 2 NO NO NO NO NO NO NO YES YES YES YES YES YES YES Sustain level 2 Data was not available for July due to database issues with the supplier, Jul figure reported is from 11/08/14. Page 1 of 4

100 GWH Patient Safety and Quality Dashboard No Indicator Annual 2013/14 Regulator Target 2014/15 Apr-14 May-14 Jun-14 Quarter 1 Jul-14 Aug-14 Annual 14/15 Notes 22J CNST Maternity risk management standards COMBINED YES M, PCT Achieve Level 2 YES YES YES YES YES YES YES 23G Diagnostics 6 weeks max wait ACUTE 99.7% PCT >=99% 99.7% 99.6% 99.4% 99.6% 99.4% 99.6% 24J Number of patients who are not placed in a single sex bay during their hospital stay COMBINED 0 QA, PCT G Emergency re-admission rate within 30 days of discharge ACUTE 7.9% PCT <=7.1% 8.1% 7.7% 8.8% 8.2% 8.8% 8.4% One Month in arrears 34Gi Emergency re-admission rate within 28 days of discharge ACUTE 7.7% 7.8% 7.5% 8.5% 7.9% 8.5% 8.1% One Month in arrears 35G % of Operations cancelled on the day for non-clinical reasons ACUTE 0.7% PCT <=0.8% 0.6% 0.6% 0.9% 0.7% 0.5% 0.5% 0.6% G&A Elective Activity 36G % of those cancelled that are not rebooked to come in within 28 days ACUTE 1.5% PCT <=5% 0.0% 0.0% 3.6% 1.5% 0.0% 0.0% 1.2% 38G Sufficient appointment slots are made available on the Choose and Book system ACUTE 10.1% PCT <=4% 6.5% 3.4% 5.9% 5.2% 6.4% 7.0% 5.8% Page 94 39G Delayed transfers of care - Number of patients ACUTE 4.1% PCT <=4% 2.5% 3.4% 3.4% 3.1% 4.7% 2.4% 3.2% At Snapshot in last Thursday of the month. % is the % of patients that are DToC out of total bed occ excl Mat, Paeds & ITU. 39W Delayed transfers of care - Number of patients COMMUNITY 11.4% PCT Report 12.2% 10.2% 21.8% 14.5% 25.30% 19.60% 17.5% At Snapshot in last Thursday of the month 40J HSMR - Reduce preventable hospital mortalities monthly COMBINED 93.7 QA <= Normally three months in arrears, with the most recent figures being provisional. 41J HSMR - Reduce preventable hospital mortalities rolling months COMBINED 93.7 QA <= Normally three months in arrears, with the most recent figures being provisional. 45J All adult admissions to be assessed for Venous Thrombo Embolism (VTE) risk on admission COMBINED 95.5% QA, PCT >=95% 95.7% 95.9% 95.9% 95.8% 97.5% 96.3% 49J Reduce Grade 2 and above acquired pressure ulcers by patients COMBINED 308 QA, PCT J Reduce Grade 2 acquired pressure ulcers by patients COMBINED 280 QA, PCT J Reduce Grade 3 acquired pressure ulcers by patients COMBINED 21 QA, PCT J Reduce Grade 4 acquired pressure ulcers by patients COMBINED 7 QA, PCT G Reduce Grade 2 and above acquired pressure ulcers by patients ACUTE 118 QA, PCT G Reduce Grade 2 acquired pressure ulcers by patients ACUTE 113 QA, PCT G Reduce Grade 3 acquired pressure ulcers by patients ACUTE 4 QA, PCT Reported on STEIS 52G Reduce Grade 4 acquired pressure ulcers by patients ACUTE 1 QA, PCT Reported on STEIS 49W Reduce Grade 2 and above acquired pressure ulcers by patients COMMUNITY 190 QA, PCT Page 2 of 4

101 GWH Patient Safety and Quality Dashboard No Indicator Annual 2013/14 Regulator Target 2014/15 Apr-14 May-14 Jun-14 Quarter 1 Jul-14 Aug-14 Annual 14/15 Notes 50W Reduce Grade 2 acquired pressure ulcers by patients COMMUNITY 166 QA, PCT W Reduce Grade 3 acquired pressure ulcers by patients COMMUNITY 18 QA, PCT W Reduce Grade 4 acquired pressure ulcers by patients COMMUNITY 6 QA, PCT J Reduction of harm for falls S=Severe, D=Death COMBINED 23 QA, PCT G Reduction of harm for falls S=Severe, D=Death ACUTE 21 QA, PCT W Reduction of harm for falls S=Severe, D=Death COMMUNITY 2 QA, PCT J Bi-annual Analysis of harm for falls S=Severe, D=Death COMBINED YES QA, PCT Report YES 78G Stroke patients spending 90% of time on stroke unit ACUTE incl rehab 81.6% PCT >=80% 82.5% 80.0% 83.3% 81.7% 82.5% Measure based on recent SSNAP guidance Page 95 79G 81G % High risk of Stroke who experience a TIA are assessed and treated within 24 hours ACUTE Inpatient discharge summaries to be with GPs within 1 working days of discharge- EDS reports ACUTE 63.9% PCT >=60% 75.0% 73.7% 66.7% 71.8% 71.8% 69.2% PCT 95% TBC 72.9% 73.8% 71.9% 72.9% 75.2% 78.7% 74.6% 82G Clinic letters to be typed and with GPs within 2 working days ACUTE 37.2% (p) PCT >=90% TBC 18.2% 17.8% 25.5% 21.0% 27.4% 27.1% 83J % women seen a midwife by 12 wks and 6 days of pregnancy COMBINED 92.5% PCT >=90% 92.1% 92.8% 95.5% 92.9% 96.7% 92.9% 93.5% 90J Blood culture contamination rate Combined 4.3% <= 5% by Dec 3.2% 5.4% 2.7% 3.8% 3.5% 3.9% 3.7% 93W Average Length of Stay COMMUNITY 24.7 Local <20 Days Target revised to 20 days 95W Increase the total number of people who are discharged from a community hospital to their original residence COMMUNITY 85.9% PCT >=75% 82% 87% 89% 86% 88% 82% 86.0% 97W % of patients who require Prophylaxis are given it COMMUNITY 97.9% Local >=90% 99% 99% 100% 99% 100% 100% 99% 98W 100W 101W 102W Number of End of Life Patients who achieve their choice of place of death, through community team input COMMUNITY Average LOS of post acute/rehabilitation patients on the Neighbourhood Team caseload. COMMUNITY Referral to Management Pathways -% non-admitted pathways within 18 weeks for non-admitted patients whose clocks stopped during the period Referral to Management Pathways - % of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the period 93% PCT >=75% 92% 94% 100% 94% 90% 100% 95% PCT <45 Days % PCT >=95% 98.9% 99.3% 97.9% 98.7% 97.4% 98.7% 98.0% PCT >=92% 99.2% 97.4% 97.5% 98.0% 97.0% 98.0% 108W All adult inpatients have a VTE risk assessment on admission to hospital using the national tool (within 4 hours). COMMUNITY - maternity 97.16% PCT >=95% 97.9% 97.4% Transferre Transferre Transferre Transferre d to RUH d to RUH d to RUH d to RUH 97.6% Maternity only. Page 3 of 4

102 GWH Patient Safety and Quality Dashboard No Indicator Annual 2013/14 Regulator Target 2014/15 Apr-14 May-14 Jun-14 Quarter 1 Jul-14 Aug-14 Annual 14/15 Notes 109W 95% of patients who require prophylaxis are given it. COMMUNITY-maternity 100.0% PCT >=95% 100.0% 100.0% Transferre Transferre Transferre Transferre d to RUH d to RUH d to RUH d to RUH 100.0% Maternity only. 110W Patients requiring urgent care are assessed within 4hrs (to Oct) 1hr (from Nov)- Neighbourhood Teams 97% PCT >=95% 65% 95% 96% 85% 75% 92% 85% Note - measure is 1 hour from Nov G % Ambulance Handovers within 30 minutes 96.9% QA, PCT >= 95% 95.9% 95.1% 95.9% 95.6% 98.7% 96.5% 96.3% 148J Never events 4 QA, PCT Page 96 Page 4 of 4

103 Agenda Item 10 Meeting and date: BOARD OF DIRECTORS 25 SEPTEMBER 2014 Title: Summary of paper: Recommendations/ decisions required: Summary of the external investigation into the two retained vaginal swab never events in the maternity services in the Bath Clinical area This paper provides a summary of the findings and recommendations from the external investigation conducted into the two never events involving retained vaginal swab that occurred in maternity services in February 2014 at the Royal United Hospital in Bath. The Board is asked to read and accept the summary which outlines the findings and to approve the recommendations which have been used to develop an action plan to avoid repetition. Link to Trust Priorities We will make the patient the centre of everything we do. Link to Quality Safety (staffing, falls, never events, handover, SI, safeguarding, infection control, environment, medicines, equipment) Risk issues: Resource Implications: (financial / human / other resources) Regulations and legal considerations: Quality consideration and impact on patient and carers: Consultation/ Communication: Confidentiality: Equality Impact Assessment: The Trust must complete the actions identified in the two external reports. Failure to do so will lead to a likelihood of repetition, damage our reputation and increase the number of complaints and litigation. Nominated action leads must be aware of their responsibilities and report action plan progress, when required, to the Patient Safety Committee. NHS England Never Events revised list 2013/14. Nominated leads are responsible for taking proper steps to ensure that patients are protected against the risks of receiving care or treatment that is inappropriate or unsafe. Chief Nurse Patient Safety Committee This report does not contain any confidential information. Great Western Hospitals NHS Foundation wants its services and opportunities to be as accessible as possible, to as many people as possible, at the first attempt. This report has been assessed against the Trust s Equality Impact Assessment Tool and there are no proposals or matters which affect any persons with protected characteristics. Name of Lead Executive Director: Name of Author: Hilary Walker, Chief Nurse Sarah Merritt, Risk and Legal Services Manager Page 97

104 1. Introduction In February 2014 the Maternity Service in the Bath Clinical area reported two incidents of retained vaginal swab following forceps delivery, this type of incident falls under the category of a Never Event under the NHS England revised list of Never Events 2013/14. This was the fourth reported case across the whole maternity service since April An external investigator was appointed to conduct a root cause analysis (RCA) investigation into the two most recent cases and to provide an overarching review of all reported cases. This paper summarises the findings of the two RCA investigation reports. 2. Care and Service Delivery problems identified The swab, instrument and needle count was not completed as per policy, in one case the counting was not completed by two professionals at the beginning and at the end of the procedure. In both cases 2 dressing pads and 2 towels were not included in the counts even though they were on the sterile field, it is concluded that in one of the two cases a dressing pad was possibly mistaken for a swab at the final count. A vaginal examination was not performed at the end of the suturing to check adequate repair which may, if conducted have identified the swab insitu. The count at both pre and post checks was recorded by ticking the boxes rather than actually recording the number of swabs. In both cases additional equipment was added to the sterile field but this was not added to the instrument count and this did not prompt the checking procedure. Induction for new staff/locums does not include an induction to the Maternity Trust paperwork and equipment/packs. Surgical swabs do not have tails which prevents them being clipped to the sterile drapes when they are inserted into the vagina. The WHO Surgical Safety Obstetric checklist was not accurately completed. 3. Recommendations Clinicians must always adhere to the clinical policy and be responsible for making sure that the swab, needle and instrument counts are completed. This should be included in local induction and local training. In the event of an instrumental delivery the responsibility for second checker should always be the midwife who has been caring for the mother prior to the birth. If they cannot carry out this task, because of the needs of the mother or baby, they are responsible for delegating this to another professional/trained maternity support worker. In the event other midwives come into the room to assist, the lead midwife (the primary midwife caring for the mother) should direct them co-ordinating activity in the room to ensure safe practice. The swabs in the packs should be reviewed as they are not a standard size for a large swab. In addition the service should use swabs with tails to enable them to be clipped to the sterile drapes to reduce the likelihood of unintended retention. The recently installed white boards should be used to record the number of swabs, needles and instruments or any other equipment that crosses the sterile field. Any additional items that cross the sterile field after the standard pack has been checked should be counted in, recorded and included in all further counts. The suturing record should be reviewed so that it includes the information about what the standard packs contain and space should be provided to record any additional items opened. Labels from the disposable packs used for delivery and perineal repair should be stuck in the notes along with the instrument packs to ensure the traceability of items. Page 98

105 Consideration should be given to delegating the second checker role to Maternity Support Workers so that they come into the room and focus on making sure that the operator has all the support required during suturing. A vaginal examination should be standard practice post suturing to check the repair and this must be recorded on the suturing record. 4. Conclusion This paper informs Trust Board of the findings of the external investigation and invites the Board to approve the recommendations which have been used to develop an action plan which, when completed, will avoid further incidents of retained vaginal swab. Work to complete any outstanding actions is on target. Page 99

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107 Agenda Item 11 Meeting and date: BOARD OF DIRECTORS 25 SEPTEMBER 2014 Title: Summary of paper: Assuring Active Management of 18 Weeks KPI and Compliance Audit Programme The paper outlines a proposed approach to ensuring sustainable delivery of the three Referral To Treatment (RTT) standards (90% admitted, 95% nonadmitted and 92% open pathways.). It has already been discussed at Executive Committee (19 th August) and refined since. It builds upon how the backlog reduction exercise has been planned and successfully implemented across Quarter 2, following discussion about the Trust s approach at Board in May and June, and the last update on performance in July. The separate Performance Report updates on progress (as at 14 th September) against the backlog reduction, and as we are now almost at the end of the Quarter a more up-to-date verbal update will be provided at Board. Recommendations/ decisions required: Link to Trust Priorities that Board agrees the approach outlined to future monitoring and audit, and supports deployment of the necessary resources to deliver this. Link to Quality (a) We will make the patient the centre of everything we do. (b) We will work smarter not harder to make best use of existing resource. (c) We will innovate and identify new ways of working. (d) We will build capacity and capability by investing in our staff, infrastructure and partnerships. (1) Caring (patient experience, patient surveys, friends and family test, patient stories, response to call bells) (2) Responsiveness (complaints, waiting times, cancelled operations, ambulance stays, translation services, comfort factors TV and seating) (3) Well led (staff survey, staffing levels, sickness rates, flu vaccinations rates, board/ward interactions, staff reports, governance and reporting, risk management, financial control) Risk issues: Resource Implications: (financial / human / other resources) Operational risks to backlog reduction delivery by end Q2 have been worked through since the last update to Board. Key risks to delivery that have been mitigated are ensuring sufficient access to beds following bed reconfiguration at the end of August and delays in prior approval process. Risks that are still being managed are data quality issues that have come to light since New Medway implementation in terms of timely data capture and the robust measurement of the end-to-end pathway, and delays in the out patient element of the RTT pathway (potentially including the Hold File. ) This will need to be the primary operational focus in Q3 to ensure sustainability. The purpose of this report is to ensure complete transparency in our reported position, assurance regarding accurate measurement, and the ability to identify early if performance is going off track on any of the three measures, which are intrinsically inter-linked. Our assumption remains that the Q2 backlog clearance will be fully covered by additional income (central allocation.) Additional requirements for implementation of Access Policy (x10 A&C staff OPD, x3 A&C staff for Elective booking, x1 RTT Project Manager & x2 trainers fixed term) have already been agreed at risk. Page 101

108 Regulations and legal considerations: (CQC considerations / Monitor requirements / link to NHS Constitution rights and pledges as necessary / Trust Constitution / legislative requirements) Quality consideration and impact on patient and carers: Consultation/ Communication: Confidentiality: Equality Impact Assessment: Monitor RTT compliance Robust delivery of RTT Wide clinical, operational & Trust level communication & engagement. This report does not contain any confidential information. Great Western Hospitals NHS Foundation wants its services and opportunities to be as accessible as possible, to as many people as possible, at the first attempt. This report has been assessed against the Trust s Equality Impact Assessment Tool and there are no proposals or matters which affect any persons with protected characteristics. Name of Lead Executive Director: Name of Author: Sharon Beamish, Chief Operating Officer (Interim) Neil Rogers, Divisional Director (Interim) Page 102

109 1. Introduction The majority of the admitted RTT backlog will be cleared by the end of Quarter 2 (start point 1,029 patients in excess of 18 weeks at end Q1 and 87 patients waiting in excess of 52 weeks, likely end point around 150 patients, with none waiting in excess of around 26 weeks.) It is essential to ensure robust monitoring of referral to treatment (RTT) pathways is in place going forward. Clear and transparent performance indicators are crucial to achieving timely operational management of all three RTT performance standards (admitted, non-admitted and open pathways 90%, 95% and 92% targets.) The development of a suite of key performance indicators and robust audit programme are central to ensuring control of Trust-wide performance, and visibility at the appropriate levels of the organisation if this is going off track. The Operational Resilience and Capacity Planning document i has recently made recommendations about the management of RTT measurement, which reinforce the actions laid out in the IMAS Elective Care Guide ii. The following paper outlines a high level gap analysis of where GWH is against these recommendations, and proposes a timeframe for ensuring these recommendations are implemented by the Trust in full. The robust implementation of the revised Elective Access, Bookings & Choice of Date Policy (agreed at Executive Committee), and measurement based on the principles outlined in the policy, is essential to delivering compliance with the RTT standards. Much of the programme outlined here will need to sit alongside the roll-out and training programme associated with the revised policy, including Standard Operating Procedures (SOPs) being in place for all areas. 2. Key Performance Indicators A suite of KPIs will be developed that will be monitored through the weekly PTL (patient tracking list) and RTT meetings. The KPIs will be at a level that can be used by operational managers to identify problems early in the patient s pathway, and manage pathways down to a patient level. These KPIs will consist of both operational management indicators and data quality indicators, to ensure that data is robust and that performance is actively managed. The indicators will need to be refreshed frequently (weekly) to ensure a live position is known and progress/resolution of issues can be rapidly tracked. 3. Operational management indicators. These indicators will be incorporated as appropriate in to the weekly PTL meeting, the weekly RTT meeting, the monthly Operational Resilience meeting (Trust level, where RTT reports from a governance perspective) and monthly Divisional Performance Reviews (Planned Care and D&O Divisions as a minimum.) Reporting up to Executive Committee and Board will be via a revised format of the existing Performance Report. Capacity & demand monitoring and clearance times: as a minimum annual capacity and demand analysis will take place at specialty and sub-specialty (where appropriate) level. This will inform backlog clearance plans and set benchmarks for regular activity monitoring. This would not form a part of the weekly PTL, but is essential to understanding and managing elective services, and to inform the level of activity that needs to be commissioned and delivered to maintain RTT compliance. Single PTL: a single PTL with all elements of the patient pathway present, so that the total RTT challenge can be clearly identified in one place. This PTL should be as live as possible and it should be possible for individuals to tailor their view of the PTL; other Trusts have made this possible through the use of business intelligence solutions that update once every 24 hours. Page 103

110 Total waiting list size: including an understanding of what is sustainable at specialty level and monitoring of how the waiting list size has changed over time Clear banding of patients by risk: there will be agreed internal milestones for all main elements of the patient pathway based on an understanding of the speciality; where these milestones are being exceeded it should be clear from the PTL. The PTL should visually identify patients who require action (ie a RAG rating system that flags patients falling outside certain pre-set bands). For example, for a surgical pathway, 5 weeks to first out patient, 6 weeks to diagnostic test, a further 2 weeks for results / diagnosis & treatment decision, enabling 5 weeks to surgical intervention if appropriate for the patient. Weekly activity monitoring: both prospective and retrospective activity will be visible for inpatient and outpatient services. Through demand and capacity analysis, the activity required should be understood; monitoring against this requirement should provide an early warning system where specialities are struggling to deliver the capacity required. It also provides an opportunity to realign resources such as theatre capacity between specialities where required. Visibility of referral levels are also important for the early and pro-active identification of issues. Understanding of factors effecting efficiency: information such as RoTT (removals other than treatment) and DNA (did not attend) rates should be closely monitored and understood at speciality level. The RoTT rate at GWH is currently very high (circa 19%) in comparison to national benchmarks, and this needs to be understood and managed appropriately at speciality level. Cancellations reporting: monitoring and reporting of cancellations both on the day and in advance needs to be visible weekly and at patient level in order that all patients without a rebooked date can be actively monitored. Long waiters: patient level monitoring of all patients on a pathway (admitted or non-admitted) in excess of 30 weeks will be visible and managed as exceptions. Active management of capacity: tools that enable active management of 6,4,2 rules in theatres and outpatients are key to ensuring that physical resources are used efficiently and by the specialties that most require the capacity. Monitoring should allow any breaches of leave policy to be easily seen and should facilitate the reallocation of capacity between specialties. Forward prediction of end of month performance: a clear focus on monthly performance is important. Predicting this from what activity is booked should be a standard part of the PTL; this is already in place within the suite of metrics used for admitted. Integration of cancer and diagnostic standards: visibility of all elective performance standards should be in one location including all 3 RTT standards and cancer and diagnostic standards. Currently the weekly PTL meetings (via multiple reports) does not cover the open pathways standard or the cancer waiting time standards, and these will be incorporated as soon as is practical. 4. Data Quality Checks Standard data quality information will help to improve the reliability of data and ensure adherence to the Access Policy. Most of the indicators listed below are not currently in place at GWH, and this will be a major focus of our work over Q3. Page 104

111 High level sense check / triangulation : checks such as comparing admitted clock stops to elective activity or referrals to total clock stops should ensure that information reported from different sources is aligned. Where misalignment occurs, this needs to be understood as it may highlight areas of concern regarding data capture or compliance with RTT rules. Missing outcomes and TCI date in the past: regular correction and removal of these patients will help ensure reported performance is accurate. Patients suspended within 3 weeks of DTA (decision to admit): if valid offers are being given to patients, no patient should be suspended or paused within 3 weeks of their decision to admit. Checking exceptions to this will give an indication to where the Access Policy is not being followed. Other checks such as patients who have repeatedly been rebooked after cancellation or DNA would also monitor compliance with the Access Policy. Outcome as added to waiting list but patient don t appear on PTL: a report of patients who received an out patient clinic outcome of added to waiting list who never had a TCI or are not currently on the PTL allows patients who might have been lost to be rapidly followed up. This report is not currently run and may need some cleaning and validation before it can be used as a live tool. 5. Audit programme It is important that we develop an audit programme that supports the delivery of RTT performance through ensuring that the Access Policy is being correctly implemented. This was discussed in general terms at the Audit Committee on 11 th September, where it was agreed that a formal audit of RTT would be appropriate in February 2015 (this would be 9 months after New Medway implementation, and after the Access Policy has embedded and the initial training programme completed.) Alongside this, suggested elements of an ongoing audit programme are outlined in the following table. Audit of Access Policy Standard Operating Procedures (SOPs): monitoring of how the SOPs are being used by individuals is key to ensuring that RTT pathways are being correctly recorded. This is likely to include regular audit of clinician s outcome recording in out patients, and inpatient and outpatient booking staff use of SOPs. Audit of patient pathways: IMAS recommend that operational managers regularly perform random spot checks of pathways that pick a handful of patients and audit whether their pathway has been correctly recorded. Feedback from these audits can highlight training issues and more systematic problems around data recording and database assumptions. This will commence with a random 1/100 open patient pathways at the end of every month. Validations team: Feedback from the validations team is important as it is likely to highlight systematic recording issues and identify process issues and training requirements within the operational teams. The validation team function will evolve from purely looking at patients who have breached and seeing if it is a true breach for external reporting purposes, towards ensuring that the pathway of all patients (whether recorded as breaches of 18 weeks or not) has been accurately recorded and reported. Demand & capacity monitoring: audit of the capacity and demand process will be important; this is likely to take the form of a sign-off process where the models are validated and cross checked to Page 105

112 ensure that they are representative of the current situation. 6. Timescale & Next Steps The creation of a more comprehensive PTL suite of metrics has already begun, and work is ongoing to pull together all the information that is contained within existing reports. However, some new metrics and a single PTL are likely to take a significant amount of time to achieve. This has not yet been fully scoped, but it is hoped that this will be fully in place by the end of Q3. A new fixed term RTT Project Manager commenced in post on 1 st September 2014, and she will take forward a large amount of this work on a day-to-day basis, under the direction of the Divisional Directors for Planned Care and D&O. Discussions have taken place with the Director of IM&T and the Deputy Chief executive about the need for a designated senior member of the Information Team to work with the operational teams and RTT Project Manager on this. Whilst there is now good visibility of patients awaiting surgery and where they are in their pathway, patients potentially awaiting out patient treatment (including those who may form part of the Hold File ) remain a potential blind spot that needs to be urgently rectified to provide more robust assurance. If there are sizeable numbers who have not yet had treatment, this will potentially compromise 95% (non-admitted) and 92% (open pathways) performance, and also have a knock-on impact on admitted (90% performance) if patients require an operation and they are very close to or have already breached the 18 week standard as a result of out patient delays. The administrative resources already agreed (at risk) for the out patient and booking teams will enable better and timely data recording (out patients), implementation of the Access Policy in terms of choice of date and improved utilisation of theatre lists (elective booking team) and the whole- Trust implementation of the access policy iii. These posts are required to ensure that sound real time recording is in place, in particular in relation to recording accurate out patient outcomes. Without this, RTT monitoring, training and an audit programme will not provide full assurance in terms of the integrity of reporting and operational delivery of the 3 RTT standards. Training in the new Access Policy is required before some of the routine audits outlined above will be achievable. This and the development of SOPs is the key next step. It is suggested that the Board receives an update on progress and the suite of metrics developed at its December meeting, with continued monthly oversight of RTT performance against the 3 standards via the regular Performance Report. 7. References 1 Operational Resilience and Capacity Planning, NHS England June 14 1 Elective Care Guide, Interim Management and Support Jane 14 Referral to Treatment Pathways: A Guide for Managing Efficient Elective Care 1 Access Policy Implementation July 14 - T:\Corporate_Programme_Office\PMO 2014_2015\2.0 Directorate Led Projects\2.4 - PC\ECIST\PC ECIST final submissions \Access policy implementation ORCP business case docx Page 106

113 Agenda Item 12 Meeting and date: BOARD OF DIRECTORS 25 SEPTEMBER 2014 Title: Summary of paper: Health & Safety Policy Statement of Commitment and the Occupational Health, Safety and Fire annual report 2013/14 A formal Board review of health and safety performance is essential. It allows the Trust Board to establish whether the essential health and safety principles of strong and active leadership, employee involvement, and assessment and review have been embedded in our organisation. It tells you whether your system is effective in managing risk and protecting people. Trust Board are required to review the Trust Health & Safety Policy statement of commitment on an annual basis. Executive Committee reviewed the Occupational Health and Safety and Fire Management Annual Report 13/14 and felt assured that there was evidence of safe systems of work in place, a robust audit programme to understand and mitigate risk and a training and development programme to build knowledge, awareness, action and learning. Executive Committee reviewed the performance data regarding sharps injuries and RIDDORS and given their downward trajectory and strong performance against benchmark, Executive Committee recommend to the Trust Board that the Statement should be signed. Recommendations/ decisions required: The Board should review health and safety performance at least once a year. a) The review process should: examine whether the health and safety policy reflects the organisation s current priorities, plans and targets. This is reflected in the Statement of Commitment examine whether risk management and other health and safety systems have been effectively reporting to the Board. This is assessed via the Annual OH&S/Fire Management Report report health and safety shortcomings, and the effect of all relevant Board and management decisions. This is covered in the Annual OH&S/Fire Management Report decide actions to address any weaknesses and a system to monitor their implementation. This is covered in the Annual OH&S/Fire Management Report consider immediate reviews in the light of major shortcomings or events. This is covered in the Annual OH&S/Fire Management Report b) If members are satisfied that then the statement should be signed by the Chief Executive and Chairman on behalf of the Trust Board. Link to Trust Priorities (a) We will make the patient the centre of everything we do. (b) We will work smarter not harder to make best use of existing resource. Link to Quality (1) Safety (staffing, falls, never events, handover, SI, safeguarding, infection control, environment, medicines, equipment) (2) Well led (staff survey, staffing levels, sickness rates, flu vaccinations rates, board/ward interactions, staff reports, Page 107

114 (c) We will innovate and identify new ways of working. governance and reporting, risk management, financial control) (d) We will build capacity and capability by investing in our staff, infrastructure and partnerships. Risk issues: Resource Implications: (financial / human / other resources) Regulations and legal considerations: (CQC considerations / Monitor requirements / link to NHS Constitution rights and pledges as necessary / Trust Constitution / legislative requirements) Quality consideration and impact on patient and carers: Consultation/ Communication: Confidentiality: Equality Impact Assessment: Failure to complete could raise H&S governance issues. None Strongly recommended process as identified by the HSE and also within Leading H&S at work document from Institute of Directors, OHSAS ISO Management Standard and NHS Employers Healthy Workplaces handbook. Ensuring good H&S Management of Staff helps ensure improved patient safety and care. Complete H&S Policy is reviewed and ratified by Trust OH&S Committee on a 2 yearly basis. It is intended that the annually updated & ratified Policy commitment statement from the Exec Co is formally recorded through the OH&S Committee and then included in the H&S Policy. This report does not contain any confidential information. Great Western Hospitals NHS Foundation wants its services and opportunities to be as accessible as possible, to as many people as possible, at the first attempt. This report has been assessed against the Trust s Equality Impact Assessment Tool and there are no proposals or matters which affect any persons with protected characteristics. Name of Lead Executive Director: Name of Author: Oonagh Fitzgerald, Director of Workforce & Education Mark Hemphill, Health and Safety Manager Page 108

115 Agenda Item 14 Meeting and date: BOARD OF DIRECTORS 25 SEPTEMBER 2014 Title: Summary of paper: Patient Experience Report This report provides a snapshot of patient experience, predominantly through the Trust s performance on complaints and through the Friends and Family Test. Complaints in August: The Trust s Customer Service Team responded to 100% of concerns on time. Slower response times in Planned and Unscheduled Care brought the overall, divisional performance, to 67% of complaints being responded to on time. The new complaints process, supporting local resolution, is working with only three complaints needing sign-off by the Chief Executive. The new icasework complaints management system has now been signed off. The Friends and Family Test in August: Best Inpatient response rates ever of 30.1% ED response rates slipping to 12.3% Good quality service being reported by patients with a strong star rating of 4.74 stars out of five. Recommendations/ decisions required: Link to Trust Priorities that the Board notes the current performance. Link to Quality (a) We will make the patient the centre of everything we do. (b) We will work smarter not harder to make best use of existing resource. (c) We will innovate and identify new ways of working. (d) We will build capacity and capability by investing in our staff, infrastructure and partnerships. (1) Safety (staffing, falls, never events, handover, SI, safeguarding, infection control, environment, medicines, equipment) (2) Effectiveness (HMSR, SHMI, Mortality, Clinical audits, care bundles, deteriorating patient) (3) Caring (patient experience, patient surveys, friends and family test, patient stories, response to call bells) (4) Responsiveness (complaints, waiting times, cancelled operations, ambulance stays, translation services, comfort factors TV and seating) (5) Well led (staff survey, staffing levels, sickness rates, flu vaccinations rates, board/ward interactions, staff reports, governance and reporting, risk management, financial control) Risk issues: A delayed response to concerns and complaints can further inflame an unsatisfactory situation and result in referrals to the Ombudsman. If the Trust does not meet required response rates for the Friends and Family Page 109

116 test, financial penalties through CQUIN will occur. Resource Implications: (financial / human / other resources) Associate Medical Directors and Divisional Directors are accountable for the thorough investigation of complaints within their division. They are responsible for ensuring the investigation is carried out and where an action is identified it is implemented. Associate Medical Directors/Divisional Directors should, as a minimum, discuss complaints/responses each month. Associate Medical Directors/Divisional Directors should ensure that anonymised complaints reports are discussed at their Divisional meetings. Divisional Directors are responsible for the responses sent from their Division. Regulations and legal considerations: (CQC considerations / Monitor requirements / link to NHS Constitution rights and pledges as necessary / Trust Constitution / legislative requirements) Quality consideration and impact on patient and carers: Consultation/ Communication: Confidentiality: Equality Impact Assessment: CQC Essential Standards Regulation 19, Outcome 17: People who use services or others acting on their behalf are sure that their comments and complaints are listened to and acted on effectively; and know that they will not be discriminated against for making a complaint CQC Essential Standards Regulation 17, Outcome 1: People who use services can express their views, so far as they are able to do so, and are involved in making decisions about their care, treatment and support; have their privacy, dignity and independence respected; have their views and experiences taken into account in the way the service is provided and delivered The content of this report demonstrates that the Trust actively seeks, listens to and acts on patient feedback. The contents of this report demonstrate the Trust s active approach to gaining feedback from carers and patients. Improving the patient and carer experience increases public confidence in the services that we provide. Effective communication with our patients and their carers to improve the patient experience is part of the Trust s commitment to engage with the communities it serves across Swindon and Wiltshire. This report does not contain any confidential information. Great Western Hospitals NHS Foundation wants its services and opportunities to be as accessible as possible, to as many people as possible, at the first attempt. This report has been assessed against the Trust s Equality Impact Assessment Tool and there are no proposals or matters which affect any persons with protected characteristics. Name of Lead Executive Director: Name of Author: Hilary Walker Rob Mauler Page 110

117 1. Introduction This paper provides the Trust Board with an update in relation to the Trust s management of the Friends and Family Test, complaints process and other patient experience measures. This report responds in part to recommendations made by Trust Board members in July 2014, however in future will form part of an integrated Quality Report. This report covers what our patients told us during August Concerns and Complaints Type Concerns Managed and responded to by Customer Service Closed Closed in Time % Response rate % Complaints Low to Moderate Seriousness % Complaints High and Extreme Seriousness % Low to Moderate seriousness are complaints which typically are about unsatisfactory service or one-off issues. High and Extreme complaints can relate to issues that might happen more frequently, or have more serious consequences, such as quality of clinical decisions or care standards. The chart below shows how response rates have changed since the start of the financial year. Although the % response rate for High to Extreme has declined, this is also in line with numbers of complaints. In April, 31 complaints were closed, with 15 being closed in time. In August we had reduced these complaints to % 100% 100% 100% 99% 97% 100% Concerns 80% 60% 40% 75% 48% 82% 71% 83% 67% Complaints (Low to Moderate) 20% 0% 23% 20% 15% 9% April May June July August Complaints (High to Extreme) Page 111

118 Directorate Diagnostics and Outpatients Women s and Children s New concerns and complaints COMBINED Concerns and Complaints Closed Complaints closed in time % % % Ophthalmology % Planned Care % Unscheduled Care % Integrated Community Health % Corporate % * 17 complaints relate to other areas, including Carillion, not in this table. During August, the Customer Service team was able to resolve all 114 concerns the Trust received within 48 hours. Concerns are those issues which can be resolved quickly, normally by doing something, for example, re-arranging an appointment. The top three areas for concerns related to: the Booking Centre, Orthopaedics, and Bed Bureau. The top themes for Concerns were: Telecommunications, Waiting Time, and Communication I ve been waiting on the phone for 20 minutes and then it cut me off I ve called three times, left messages and nobody has returned my calls I ve been waiting for my appointment, and now I ve found out it has to go for funding. Why did nobody tell me sooner? Patients commented that they are frustrated with telephones not being answered in various departments/clinics. Patients not being able to speak to staff to cancel or rearrange appointments contributed to DNAs and difficulties with rebooking of appointments. Page 112

119 Divisional Performance During August, the Trust received 70 complaints, with 67 of these being assigned for Divisional sign off (this is for complaints rated as low to moderate seriousness). Women s and Children s, Integrated Community Health and Diagnostics and Outpatients divisions achieved response rate targets of above 80%. Unfortunately, Unscheduled Care was only able to respond to 63% within target and Planned Care only 43%. Because of this, it brought the overall response rates for divisions to 67%. Division Number of Concerns Responded in Time Number of Complaints Low to Moderate Seriousness Responded in Time Number of Complaints High and Extreme Seriousness Responded in Time Diagnostics and Outpatients % % 0 - Women s and Children s 7 100% 6 83% 1 0% Planned Care % 28 43% 7 0% Unscheduled Care % 16 63% 2 0% Integrated Community Health 3 100% 4 100% 1 100% The top areas for complaints were A&E, followed jointly by Radiology, Orthopaedics, Linnet Ward, General Surgery and Gastroenterology. The overall themes for Complaints received for August were allocated to Complications during/following Treatment, Communication, and Clinical Care. I came into the Hospital for a procedure, during which you knocked out a crown. I m unhappy about this as it was very expensive. One example of communication, that has recently come to light is from the Booking Centre. Recorded messages were not alerting customers to the service s late night opening (until 8pm) and so callers were queuing at peak times. This message will shortly be changed to help customers understand when the Booking Centre s quieter times are. This should help reduce peak time queuing. Page 113

120 The new complaints process is seeing a significant drop in complaints requiring sign off by the Chief Executive, with only three complaints being investigated during August which required this. These complaints related to discharge arrangements, complications during and following procedures and the provision of aids and appliances and were logged against the Discharge Lounge, Urology and the Wheelchair Service. We are now beginning to see older complaints being resolved and the Customer Services team are working to support the divisions on trying to clear their backlogs. Although we expect to see a drop in the monthly response percentage rate over the next few months, this is unavoidable in order to clear outstanding complaints. No new Parliamentary Health Service Ombudsman (PHSO) cases were received for August however as part of the investigation into one open case, the PHSO have requested to visit GWH and interview staff to help reach an outcome to the case. This is the first time the PHSO have asked for a site visit and interview staff involved in the case. Eight cases remain open for investigation and we await further instructions from the PHSO. The Trust s new complaints management system, icasework, has now been signed off and will start to be rolled out during September. 3. Friends and Family Test The Trust s performance on the Friends and Family test continued to develop. Inpatient response rates have improved again reaching their highest ever rate of 30.1%. Unfortunately, ED response rates have slipped to 12.3%. For quarter four, the Trust must reach a 25% response rate. New methodologies are currently being explored, including using text messaging to improve this. The chart below shows the last six month s response rates Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Inpatient ED Service Time frame Target Achieved? ED Quarter 1 15% Yes Acute Inpatients Quarter 1 25% No ED Quarter 4 25% -- Acute Inpatients Quarter 4 35% -- Acute Inpatients March % -- Page 114

121 Although response rates are not where they need to be yet, the quality of the service is consistently high. In August 2013 patients gave the Trust 4.2 stars out of 5 and a Net Promoter Score of +72. In August 2014 this has risen to 4.74 stars out of 5 with a Net Promoter Score of +77. The Trust has developed an action plan to increase response rates, particularly in Acute Inpatients, which is showing signs of working. Although waiting is still featuring as a theme of patient feedback in the Friends and Family Test, much more focus is given to Friendly Good Excellent & Care. Two comments from the Friends and Family Test. 4. Conclusion As we have seen in previous months, customers are mostly receiving a good standard of care and service, but at times have experienced a wait to access it. This has either been through physically waiting in a waiting room, or virtually on the telephone. Many of these waits have been exacerbated by vacancies, staffing levels and challenges with effective communication. As a Trust, some of our top priorities relate to RTT, food and cleaning standards and staffing. These areas map across to some complaint and Friends and Family themes, with both positive and negative comments. Many excellent comments from the Friends and Family test relate to the quality of service provided by our staff, however complaints often mention a perception of a ward not having enough staff. The Customer Service Team continues to receive VoiceBook comments, and has just launched a new how you can tell us what you think pocket guide to help communication and demonstrate our openness. The team is also facilitating another Spotlight listening event in September in partnership with Healthwatch Wiltshire. Page 115

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123 Agenda Item 15 Meeting and date: BOARD OF DIRECTORS 25 SEPTEMBER 2014 Title: Summary of paper: Safer Staffing monthly report This paper provides the monthly report advising the Board of the actual nursing and midwifery staffing compared to that planned and any associated quality impacts. It also provides an update on the challenges in ensuring data validity and the work underway to address this. In August the proportion of actual versus planned nursing hours were as follows: Day shift: RN 85% AN 105% Night shift RN 97% AN 118% Work done following concerns about data validity has identified a small number of issues which are being worked through and improved. Key quality concerns include infection prevention and control and falls. Improvements have been achieved in Friends and Family response rates for in patient wards. Recommendations/ decisions required: that the Board notes the contents of this report Link to Trust Priorities (a) We will make the patient the centre of everything we do. (b) We will work smarter not harder to make best use of existing resource. Link to Quality (1) Safety (staffing, falls, never events, handover, SI, safeguarding, infection control, environment, medicines, equipment) (2) Effectiveness (HMSR, SHMI, Mortality, Clinical audits, care bundles, deteriorating patient) (3) Caring (patient experience, patient surveys, friends and family test, patient stories, response to call bells) (4) Responsiveness (complaints, waiting times, cancelled operations, ambulance stays, translation services, comfort factors TV and seating) (5) Well led (staff survey, staffing levels, sickness rates, flu vaccinations rates, board/ward interactions, staff reports, governance and reporting, risk management, financial control) Risk issues: Resource Implications: (financial / human / other resources) Regulations and legal considerations: (CQC considerations / Monitor requirements / link Difficulty in recruiting sufficient Registered Nurses poses a risk to delivering consistently safe staffing. (Risk 815) Significant human resource continues to be required to establish reliable and robust systems and processes for the collation and validation of Safer Staffing data None Page 117

124 to NHS Constitution rights and pledges as necessary / Trust Constitution / legislative requirements) Quality consideration and impact on patient and carers: Consultation/ Communication: Confidentiality: Equality Impact Assessment: Safe staffing is a key determinant of high quality care. The staffing data and this report are published monthly on the NHS Choices website. This report does not contain any confidential information. Great Western Hospitals NHS Foundation wants its services and opportunities to be as accessible as possible, to as many people as possible, at the first attempt. This report has been assessed against the Trust s Equality Impact Assessment Tool and there are no proposals or matters which affect any persons with protected characteristics. Name of Lead Executive Director: Name of Author: Hilary Walker Hilary Walker Page 118

125 1. Introduction This report provides a summary overview of Safer Staffing. The detailed Safer Staffing data by Division and Ward being accessible on the Trust T drive, as well as being published on NHS Choices. Therefore the report that follows identifies the key issues only. 2. Publication of data The planned and actual hours of nursing and midwifery staffing continue to be reported monthly to NHS England via UNIFY and published on NHS Choices. For the month of September, data was made public on Monday 15 th September. The associated Trust Board report (this one) will continue to be available via a link from our NHS Choices page to the public to provide a narrative to the figures published, following Trust Board. Some of the common themes emerging from the reports this month are the same as those reported previously, some of which are outside of the influence of safer staffing reporting alone. These include: In some areas the planned hours are reflective of a staffing model to which the ward are not yet working, due to not having yet reached the required staffing establishment. Therefore, the ratio of registered nurse to care staff will fall below that planned. Some shifts were unfilled following a decision made jointly between the senior nurses following risk assessment. Children s unit and SCBU have filled some RN shifts with nursery nurses, whose hours are included in care staff. High levels of sickness remain in a number of areas and continue to be appropriately managed. However, this is having significant impact on daily staffing Newly qualified and overseas staff awaiting confirmation of NMC registration is impacting on the fill rate of registered nurses, as they are shown in the care staff figures. Page 119

126 The impact of providing close support (formerly know as 1:1 care) continues to drive a significant proportion of the use of temporary staff. Work has nearly concluded to agree and provide guidance on thresholds for different levels of observation. 3. Data validity The deep dive, ward by ward, that was carried out to ensure confidence in the Safer Staffing data has raised some issues with roster practice, (for example, use of shift codes, roster maintenance); and systems anomalies, (such as duplicate postings, delays to assignments). These are being resolved by close working with the operational managers and system provider; roster reconfigurations, training, and improved practice. The methodology for validating data remains the same. However, the time to do this is reducing. The ward managers are much clearer about the process and are getting slick at collating data. A change in operational roster practice and clarity around the shifts to be included in the data sets has resulted in more accurate reports, and therefore, easier validation. However, there remains the issue that some errors continue to be identified at safer staffing report validation, and not before. 4. Quality impact A delay to the availability of data within the nursing dashboard has limited the analysis of nursing quality concerns for this report. Falls The number of falls across unscheduled care wards has reduced in August, with some notable reduction on Woodpecker and Jupiter wards; however, Neptune s have risen considerably. New collaborative work to define care expectations when dealing with patients with dementia and patients who have multiple falls is expected to have a positive impact in future months. Infection Prevention & Control The incidence of Clostridium Difficile on Neptune and Saturn wards is of concern. The results of ribotyping are awaited, however, there is a high index of suspicion hand hygiene may be a contributing factor. As such, work is being led on both wards by the Matron and the IPC team to address practice. This relates to all professional groups, following a spotlight on hand hygiene and c-diff the IPC team will test compliance and efficacy of hand hygiene techniques. Friends and Family test Inpatient wards have improved the rate of responses from patients at discharge achieving a 30% response rate, the best achieved since the test was introduced. Conclusion There has been some resolution to the concerns about data validity and work is ongoing to support this process. There has also been a change in roster process which is improving the overall picture. Divisional Directors of Nursing and Heads of Locality continue to be aware of the key staffing and quality issues and are ensuring appropriate actions are taken to make improvements where they are needed. Page 120

127 Agenda Item 16 Meeting and date: BOARD OF DIRECTORS 25 SEPTEMBER 2014 Title: Summary of paper: Recommendations/ decisions required: People Strategy Six month progress report Our people make the difference between good care and great care. The People Strategy ensures that we are harnessing our greatest asset to ensure we have the right people now and in the future with the right values, skills and knowledge to deliver changing pathways of care and services. This progress report provides members with an update of where we are against the deliverables set in the People Strategy when it was approved by the Board in February that the Board approves that the progress made is in line with expectations. Link to Trust Priorities Link to Quality (a) We will make the patient the centre of everything we do. (b) We will work smarter not harder to make best use of existing resource. (c) We will innovate and identify new ways of working. (d) We will build capacity and capability by investing in our staff, infrastructure and partnerships. (1) Safety (staffing, falls, never events, handover, SI, safeguarding, infection control, environment, medicines, equipment) (2) Effectiveness (HMSR, SHMI, Mortality, Clinical audits, care bundles, deteriorating patient) (3) Caring (patient experience, patient surveys, friends and family test, patient stories, response to call bells) (4) Responsiveness (complaints, waiting times, cancelled operations, ambulance stays, translation services, comfort factors TV and seating) (5) Well led (staff survey, staffing levels, sickness rates, flu vaccinations rates, board/ward interactions, staff reports, governance and reporting, risk management, financial control) Risk issues: Resource Implications: (financial / human / other resources) Regulations and legal considerations: (CQC considerations / Monitor requirements / link to NHS Constitution rights and pledges as necessary / Trust Constitution / legislative requirements) Failure to deliver the People Strategy will result in lower levels of staff and patient satisfaction. Leadership, management and time to implement People Strategy. Employment legislation and best practice must be followed. Page 121

128 Quality consideration and impact on patient and carers: Consultation/ Communication: Confidentiality: Equality Impact Assessment: Links to Quality Strategy Individuals, teams, Employee Partnership Forum, Executive Committee, Workforce Strategy Committee and Council of Governors This report does not contain any confidential information. Great Western Hospitals NHS Foundation Trust aims to design and implement services, policies and measures that meet the diverse needs of its service, population and workforce, ensuring that none are placed at a disadvantage over others. This report has been assessed against the Trust s Equality Impact Assessment Tool which is attached. Name of Lead Executive Director: Name of Author: Oonagh Fitzgerald Director of Workforce & Education Oonagh Fitzgerald with contributions from Heads of Department. Page 122

129 Our six commitments Ensuring we have the right people in our organisation continues to be a challenge as we have 357 vacancies. This equates to 7% of our workforce and is placing pressure on staff and services. The vacancy level we are experiencing is the same as other NHS Trusts are reporting due to national shortages of nurses and pressures on some medical specialities. Our vacancy level has meant considerable focus on recruitment and retention in the first six months of the People Strategy and the position is improving month on month but not fast enough. The vacancy level is causing high spend on temporary staff and in particular agency staff. UK and overseas recruitment campaigns continue as well as return programmes to encourage nurses back into the profession. Long term relationships with schools, colleges, and universities are being created and enhanced to ensure a pipeline for future talent entering our organisation. A Dare to Doctor programme was delivered in the summer to attract local people into medical roles. The first Dare to Nurse programme was delivered in August this year with 17 years olds who have identified nursing as a possible career attending for a 2 day camp in the Academy. This included interview and application tips, simulation session, lectures and job shadowing. This will join our suite of existing work experience programmes. Given the number of newly qualified and overseas nurses arriving in our organisation over the summer months, a programme of work was developed and delivered to allow for more clinical contact time for Academy staff and to ensure that staff on the wards are well supported and assessed against the criteria that has been established. Following the Trust two days Corporate Induction, both newly qualified and overseas Nurses complete an additional two days bespoke Clinical Induction Programme, which covers Introduction to Patient assessment Paperwork: Discharge Planning; Assessment of Essential Clinical Skills. Once this Programme is completed all staff entered onto the Preceptorship Programme. The team has updated the original Preceptorship programme which has been re-branded as Stepping up and has a higher focus on workshop sessions and assessing clinical competencies of staff. The first cohort of this new programme began in August with 80 staff in total, divided into 3 groups. An important test of staff opinion is the annual staff survey and results were presented to the Trust Board in March Board members were encouraged that we are in the top 20% of Trusts in the NHS for the majority of indicators but were concerned about of level of work pressure being experienced by staff which has deteriorated from the previous year s results. Recruitment and retention were deemed a priority to ensure that we had sufficient staff in the organisation to deliver the expected high standards of care. Page 123

130 In order to support local action and ownership of people issues, each Division received a tailored report of their staff views from the survey benchmarked against other Divisions and the NHS. The purpose of this exercise was to encourage best practice and learning. The Staff Friends and Family test was implemented in May 14 to understand more regularly staff opinion and due to the level work pressure reported, an additional question was added around staff levels. The results are reported below and in the main demonstrate a promising upward trend. Staff likely or extremely likely to recommend GWH to Friends & Family for treatment Staff likely or extremely likely to recommend GWH as a place to work Staff who agree there is enough staff in the organisation for them to do their job properly Oct Dec 13 May-Jun 14 Aug- Sept 14 61% 70% 76% 56% 55% 62% 24% 36% 31% Further a total of 10 Open Sessions were held across the organisation and led by the Executive team to discuss performance and discuss issues and ideas. In the main, they were well attended and appreciated by staff. We want to support staff to feel they can raised concerns so a small pilot over 3 areas Theatres, Academy and Aldbourne Ward for quality champions commenced in May An evaluation will take place in October 2014 to understand effectiveness and inform whole Trust roll out. Staff can now undertake the Myers-Briggs Type Indicator. This can be delivered through a one-toone feedback session, or as part of a team development initiative. Following the commencement of the Institute of leadership and Management Coaching Programme in May 2014 by a multi-professional group of thirteen staff, a Coaching Register is now administered and managed by the Academy. This will enable appropriate support to be available for staff. Staff can receive a Belbin report, based on their own self-view and the observations of colleagues and managers. This will improve effective working relationships and improve performance of individuals and teams. A Lifestyle advisor has been appointed to champion and organise activities and events for staff to support their health and wellbeing. This includes walks, classes, advice on healthy eating plans and exercise. Role models are giving talks to staff. Page 124

131 Over 400 staff have attended the Nipping things in the bud and Building Resilience Programmes aimed at supporting staff to be more effective at work. The collaborative work between OH and the Dietetic teams continues and this summer saw the start of the weigh to wellbeing programme which has been designed to incorporate health advice and healthy eating plans. Wellbeing and resilience assessments are available for staff as a pro-active measure and have bespoke programmes have been designed for employees who have accessed this service. A programme of training is being delivered following the launch of a new policy framework linked to the People Strategy. This has enabled managers to discuss issues and understand the links between wellbeing and attendance, performance and productivity. It has seen an increase in managers requesting case conferences to enable them to discuss the recommendations made by OH to assist in employees returning to work in a more timely manner and reducing future absence. Following our staff survey results and the information from staff that 30% of them had experienced harassment and bullying from patients in the past 12 months, we launched in August the Respect Us campaign to raise awareness and support our staff and to remind people that any form of verbal or physical abuse will not be tolerated. The campaign also aims to encourage more staff to report verbal or physical abuse, including rude, intimidating or antisocial behaviour. Initial media coverage during launch week was high. It was strongly supported by local media, with coverage in the Swindon Advertiser, the Gazette and Herald, the Wiltshire Times and Swindon Link Magazine. BBC Wiltshire featured the campaign in its news bulletins that week, Jack FM Swindon and Heart FM Wiltshire interviewed ED consultant Dr Stephen Haig. It also featured on ITV Meridian during Good Morning Britain and on BBC Points West. There was great support on Twitter during launch week from a number of organisations as well as members of the public, local MPs and the Police. Facebook interaction rocketed during August because of the Respect Us campaign, which gained a huge amount of support from the public and our own Trust staff. Our Wall of Supporters attracted a significant amount of attention with 1,100 post clicks and an audience reach of 5,000. Page 125

132 This image cannot currently be displayed. The Wall of Supporters continues to grow and find popularity, with new posts this week. Page 126

133 Posters, leaflets, signatures, a dedicated staff intranet page with information and advice, and a feature in the new issue of StaffRoom. During launch week there was a lot of engagement from both GWH and community staff. The new Keeping you safe at work leaflets and Respect Us posters were hand-delivered to all areas, sparking much conversation with staff who were keen to display them. Many had already printed off posters themselves. These are all on display in all public-facing areas. Posters and leaflets have also been sent to the community staff too; once again many have already printed off their own, staff have adopted the signatures and have got in touch to request materials to be sent to their teams. We are in conversation with neighbourhood teams about the idea of Respect Us badges for them to wear on home visits. Page 127

134 What supporters have said Tina Walsh, Team Leader, Hazel Ward "I am supporting the Respect Us campaign because I am not a pop star, a WAG, or a reality star. I am proud to be a midwife, I am proud to care for my patients and support the NHS." Rebecca Bothamley, Community Matron, Wilton Community Team "Myself and colleagues are often exposed to some patients who aggressively swear and shout. This is often a sign of their frustration about their chronic illnesses and a lack of understanding regarding the team who are trying to help them. It is important to raise awareness of this campaign in the community, developing a mutual respect for patients in their own home, which is community staff's place of work and clinical contact." Maureen Bristow, Hospital Receptionist "I am supporting the Respect Us campaign because respect should be given to everyone by everyone regardless of their position." A skills scan to identify skills requirements for nursing teams has commenced across community services. The community teams have completed this for nursing, with training plans now in place to meet any skills gaps identified. The model is now being rolled out to community wards and Therapist roles. In the Acute sector ward managers have been engaged and are in the process of submitting agreed skills lists for each of their areas/ specialism s. The skills scan and resulting training plan for acute inpatient nursing should be completed by December This will enable us to plan more effectively to support shifts in demand and service developments. We have recruited seven new apprentices into the organisation in business and medical administration roles as part of our strategy to encourage entry of local people into health roles. Apprentices participate in a twelve month programme. In line with our strategy to have more robust arrangements in place to spot and develop talent, a process for succession planning of our band 5 nurses into the band 6 roles in community teams agreed. Training funds have been ringfenced and the talent has been identified by managers. Work with Health Education South West has resulted in agreement to commission Open University places for Nursing Degrees. This is in addition to our existing commissions and allows talented health care assistants to complete nurse training alongside part time work. The Trust is further supporting this by committing to a monthly Bursary. The students commence at the start of September Page 128

135 An internal transfer process has also been developed to aid retention so that we keep talent in our organisation. The Leading Managers Programme commended in September In total, thirty four places have been allocated to date across two cohorts, the second being held at Chippenham Community Hospital. The programme is being delivered by sixteen different senior managers and specialist leads from across the Trust. These Module Leaders have developed the content of the training and created a supporting workbook for their topic. Each module also requires the completion of a competency; these have been drawn from the National Occupational Standards for Management and Leadership. Elements covered include understanding organisational structure, managing, leading and developing teams, recruitment and selection, coding and informatics, procurement and contracting, managing for better performance, risk management and understanding your budget statement. We have also developed an emerging managers programme at introductory/foundation level for any member of staff wanting to develop in their current role, or to further their career at a future time. Its aim is to provide a greater understanding of self, others and teams. The first course is full. Attendees of the Emerging Managers Programme will be completing workbooks and competencies to support learning and translate their knowledge into practice. Page 129

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137 Agenda Item 17 Meeting and date: BOARD OF DIRECTORS 25 SEPTEMBER 2014 Title: Summary of paper: 15+ Risk Register The Board will be aware that it is responsible for risk management throughout the Trust. It delegates some responsibility to the Executive Committee and the Audit, Risk and Assurance Committee and receives assurance from those committees on the effectiveness of the risk management strategy. Twice a year, the Board is required to review the Board Assurance Framework and the 15+ Risk Register. This report seeks to ensure that the requirements of the Board in discharging its responsibilities for risk management are met. At the last meeting in July 2014, the Board had oversight of the Board Assurance Framework and agreed that the principal risks to achieving the Trust s principal objectives had been identified; the key controls to mitigate those risks were specified; the assurances on those controls were adequate and that there were no gaps in the framework to address. However, the Board noted that having been reviewed by the Executive Committee and the Audit, Risk and Assurance Committee, there was further work needed to refresh the 15+ risk register and it was therefore agreed that the 15+ risk register would be presented to this meeting for overview. This paper set out a summary of the risks scoring 15+ on the Risk Register as at 15 th September 2014 and provides assurance to the Board that there are improvements in the management and recording of risks. A full report is attached taken directly from the risk register on 15 th September The 12+ risk register (which includes 15+ risks) was considered by the Audit, Risk and Assurance Committee and the Executive Committee earlier in the month. Neither Committee had any issues of concern to draw to the attention of the Board and both noted improvements made in the management of risks. Whilst there still remain gaps in controls to mitigate risks; planned actions; progress against those action and overall risk reviews, there has been considerable improvement. The Risk and Legal Services Manager continues to work with Divisions to review their risks and to ensure that risk management is accurately reflected on the risk system. A focus has been given to addressing the highest scoring risks to the Trust, but over the coming weeks attention will be focused on those risks scoring above 12. Recommendations/ decisions required: Link to Trust Priorities that it be agreed that the Board is assured by the Executive Committee and the Audit, Risk and Assurance Committee that processes for managing risk within the Trust are adequate. Link to Quality (a) We will make the patient the centre of everything we do. (1) Well led (staff survey, staffing levels, sickness rates, flu vaccinations rates, board/ward interactions, staff reports, governance and reporting, risk management, financial control) Risk issues: Resource Implications: Risk 553 refers maintaining an effective risk management framework None. Page 131

138 Regulations and legal considerations: Quality consideration and impact on patient and carers: Consultation/ Communication: Confidentiality: Equality Impact Assessment: CQC Fundamental Standards (of Quality and Safety) 2014 Monitor s Risk Assessment Framework Individual risk owners/managers are responsible for ensuring proper steps are taken to ensure that patients, staff and the public are protected against risks identified by the organisation, this will be achieved through timely review and management of the risk register. Audit, Risk and Assurance Committee 11 September 2014 / Executive Committee 16 September 2014 no issues to highlight This report does not contain any confidential information. Great Western Hospitals NHS Foundation wants its services and opportunities to be as accessible as possible, to as many people as possible, at the first attempt. Name of Lead Executive Director: Name of Author: Nerissa Vaughan, Chief Executive Carole Nicholl, Company Secretary & Head of Corporate Governance Page 132

139 1. Introduction This report seeks to ensure that the requirements of the Board in discharging its responsibilities for risk management are met. The Board is asked to overview 15+ Risk Register, which was last presented to the Board in January Accompanying this report is the 15+ Risk Register as at 15 September Executive Committee The Executive Committee has operational responsibility to ensure risks are being managed. It has specific responsibility to scrutinise and challenge 15+ Risk Register and it does this at every meeting. Scrutiny and challenge and challenge involves: - identifying any gaps in the 15+ Risk Register; checking that risks are scored appropriately and consistently in accordance with the How To Assess Risk Procedural Document; asking Associate Medical Directors and General Managers to take account of risks identified in other directorates that may be relevant to their own directorate; and challenging that action to address gaps in mitigating risk are being progressed. The 15+ Risk Register is considered by the Executive Committee at each of its meetings. In the Spring it became apparent that whilst risks were being managed, evidenced by the number of reports coming through Committees, the recording of any mitigation and action was not as robust as it should be on the risk management system. A number of actions have been taken to improve this and over the summer significant progress has been made, focussing on the highest level risks. In May a new Risk and Legal Services Manager joined the Trust and she has been tasked with working with Directorate to embed a strong risk management culture. At its meeting held on 16 September 2014, the Executive Committee agreed that there were no issues of concern which should be drawn specifically to the attention of the Board for further action. 3. Audit, Risk and Assurance Committee The role of the Audit, Risk and Assurance Committee is to oversee the implementation of the Risk Management Strategy and to take assurances that the processes supporting the Risk Management Strategy are effective in mitigating risk. It does not have operational responsibility for individual risks, but will take assurances from the Executive Committee that risks are being managed. Its specific responsibilities are: to review the 15+ Risk Register; and to review the Board Assurance Framework. Where the Audit, Risk and Assurance Committee identifies significant gaps in the Trust s risk management process, the Chair of the committee will make a verbal report to Trust Board. The Audit, Risk and Assurance Committee reviewed the processes around the Risk Register on 23 January, 20 March, 24 July and 11 September The Audit, Risk and Assurance Committee agreed that the processes for managing risk were effective but there were some concerns which the Chair of the Committee drew to the attention of the Board around recording risks, scoring, adequate actions and reviews. The Committee was not satisfied that the recording of risk management was as effective as it should be as there were a number of risks where controls, actions and progress were not recorded. Over the summer, considerable focus has been given to improving risk management throughout the Trust and further actions are planned. At its last meeting, the Audit, Risk and Assurance Page 133

140 Committee recognised the significant improvement and agreed that there were no issues of concern to draw to the attention of the Board. 3. Risk Register Analysis There are 22 risks scoring 15+ on the Risk Register. The biggest risk area is safety. Perecentage of Risks by Division 9% 9% 18% 9% 18% 19% 18% Corp D&O Fin/IT/EFM ICHD PC UC W&E Number of Division Risks Corp 4 D&O 4 Fin/IT/EFM 4 ICHD 2 PC 4 UC 2 W&E 2 Grand Total 22 Page 134

141 Scoring, grouping and type of risk Score Number of Risks Risk Group Number of Risks 15 9 Caring 1 Number of Risk Type Risks Admission, Discharge, Transfer Finance 3 CIPS Responsive 2 Contractual Arrangements 1 Grand Total 22 Safety 14 Environment (Safe) 1 Well-Led 2 Equipment (Safe) 1 Grand Total 22 Expenditure 2 Falls 1 Year Risk Identified Fire 1 Number Year Risk Identified of Risks Incidents Medicines (Safe) Patient Experience Safe Processes Safeguarding Staff Capacity 2 Grand Total 22 Waiting Time Standards 2 Grand Total 22 Percentage of Risks by Type Admission, Discharge, Transfer 9% 9% 9% 4% 4% CIPS Contractual Arrangments Environment (Safe) Equipment (Safe) 5% 4% Expenditure Falls 4% Fire 14% 9% Incidents Medicines (Safe) Patient Experience 9% 5% 5% 5% 5% Safe Processes Safeguarding Staff Capacity Waiting Time Standards Page 135

142 4. Headlines Of the 22 risks 9 are overdue a review the longest period of being overdue is 123 days There are 40 open mitigating actions to the 22 risks, 13 of which are overdue a progress report; the longest period of being overdue is 54 days. All risks are set at correct review frequency of monthly or weekly 5. Comment Ongoing action is planned, including a review of risk management at an Executive away day in October; drop in training sessions, coaching; attendance by the Risk and Legal Services Manage at Directorate Boards and ongoing advice. 6. Recommendation that it be agreed that the Board is assured by the Executive Committee and the Audit, Risk and Assurance Committee that processes for managing risk within the Trust are adequate. Page 136

143 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager 1025 Complaint Page 137 Planned Care Orthodontics 01/07/2013 Orthodontic workload outstripping current capacity. Patients need a follow up regime of 6-8 weeks but this is stretched to weeks in some cases and this causes problems for treatment and increasing treatment times for patients. Safety Staff Capacity Maximising existing capacity through utilisation of clinics Business case for expansion written and submitted to August Exec Co. Based on recommendatio ns of external review of demand for re-work/treatment for retired orthodontist's patients, incorporates investment in dental chair, lab equipment and nursing/lab staff 29/08/ Action Required /07/2014 Louise Stevens Page: 1

144 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager 1026 Business Planning Page 138 Planned Care General Surgery 25/10/2013 Risk to GWH patients (e.g. those admitted under the diabetes team) due to inadeqate vascular surgeon support and input. This folows the centralisation of vasular services such that GWH no longer has its own vascular surgeons and all emergency and arterial elective work is performed at Cheltenham hospital. There is currently no formal SLA to formalise this arrangement. (e.g. no current vascular surgeon input into MDT GWH clinics or GWH ward rounds). Safety Safe Processes Have recently agreed the pathway for carotid pts and have agreements for vascular pts to be sent to C&G if required Planned Care consultants and staff to feed back on 2nd draft of Vascular SLA by 30/7/14. 30/07/2014 Vascular, diabeties and radiology intervention contributions added to draft vascular SLA. SLA shared with C&G and to be discuused 15th Sept Further information to add to SLA. SLA to be completed for draft agreement at C&G meeting during September. SC to rewrite and submit to GWH staff before meeting. Circulate by end August Feedback to be received by 30/7/ Action Closed /09/2014 Simon Carter Formal SLA to be negotiated between the two Trusts and put in place ASAP to ensure adequate vascular surgeon input into MDT clinics and ward rounds. 26/09/2014 SLA drafted by GWH and shared with C&G. Meeting to discuss SLA and agree service provision on 15th September Action Required Page: 2

145 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager 1030 Other - Please Explain In The Gaps identified in monitoring closure of serious incident action plans Page 139 Corporate Clinical Risk 04/11/2013 Delays in the completion of actions arising from serious incident investigations, resulting in action plans overdue. Actions arising from serious incidents address the root causes which have been identified in the investigation, which if resolved would reduce the risk of the incident reoccurring. Failing to implement actions identified will not reduce the risk or demonstrate learning from serious incidents. We are required to provide our commissioners with evidence of actions implemented as a result of serious incidents, to demonstrate that we have learnt and improved care for our patients, we are unable to achieve this element of the quality schedule if evidence of change is unavailable. Safety Incidents - Clinical Risk supporting lead investigators with formulation of action plans arising from their investigation, specifying evidence that will be required in the action plan. - On completion of an investigation Clinical Risk forward final report and individual actions to action plan owners to ensure that they have been made aware of their action and the evidence that will be required. -Directorates provided with weekly Clinical Risk reports with RAG rated in progress and overdue action plans, link to each individual action plan and evidence outstanding - Overdue action plans presented to Patient Safety Committee on a monthly basis. Action plans overdue added to committee action tracker. -Individual action leads now named on PSC monthly clinical risk presentation - Overdue action plans listed in Executive Committee Patient Safety And Quality Report, commenced in February 2014 report. Action planning module on safeguard now in use, enabling automated reminders to action leads and ease of reporting total number of actions in progress and overdue Clinical Risk and Patient Safety Advisors to meet with individual action leads immediatley following closure of serious incident investigation. To confirm and agree actions that will be taken and evidence that will be supplied. Clinical Risk and Patient Safety Advisors to support action leads, providing advise on interpretation and implementation of improvements. 31/01/ /02/2015 Clinical Risk and Patient Safety Advisors meeting with action leads following completion of serious incident investigations. Clinical risk continue to provide extensive support to investigators and action owners on a 1:1 basis. Due to volume of serious incidents and action plans this is difficult to achieve Clinical Risk and Patient Safety Advisors aim to meet with all action leads to discuss and advise on implementation. Due to volume of serious incident investigations being supported this is difficult to achieve. 2. Action Closed 1. Action Required /09/2014 Alvan Troughton RJ attends D&O Directorate Quality and Patient Safety meeting, with Page: 3

146 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager Page 140 Clinical Risk Department representative to attend each directorate patient safety committee to ensure that progress of implementation of actions is monitored, and overdue actions are addressed at directorate level committee. Overdue actions - Individual action leads to attend PSC to present progress with action tracker and account for overdue actions. Clinical Risk department to coordinate attendance. SI Request the completion of all actions identiifed on the action plan from responsible directorate leads 30/04/ /01/ /12/2013 Corporate Governance manager attending each of the Divisional Quality and Patient Safety meetings Womens and Childrens attended by Patient Safety Midwife Rachel Jefferies has attended D&O and Planned care directorate meeting. New Action 1b added from Niall Prossers attendence and presentastion to PSQC in decemebr has now been completed. 1A still remaining Action plan lead for actions arising from SI (Gynaecology delay in treatment/diagnosis) presented overdue actions to PSC on 3rd December Action Closed 2. Action Closed 2. Action Closed New risk entry 1077 raised within planned care directorate, for this overdue serious incident action Page: 4

147 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager plan Outstanding action plan discussed at PSC in November action plan leads are being invited to december's PSC 03/12/2013 to account for overdue actions. Page Action 4 - To reintroduce an acknowledgment letter to patients to confirm they have been added to the waiting list for surgery. Draft copy of proposed letter now received as evidence. Awaiting evidence for action 1, 2 & 3. SI Request the completion of all actions identified on the action plan by relevant directorate leads. Evidence to be forwarded to the clinical risk team for closure. 03/12/2013 Action plan lead for actions arising from SI (Intrapartum still birth investigation) presented overdue actions to PSC on 3rd December New risk entry 1078 raised within directorate, for this overdue serious incident action plan Outstanding action plan discussed at PSC in November action plan leads are being invited to Page: 5 2. Action Closed

148 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager december's PSC 03/12/2013 to account for overdue actions. Page 142 Discussion at PSC 4th February update on overdue action plans to be provided by representative from directorate (rather than clinical risk), to encourage ownership Overdue action plans listed in Executive Committee Patient Safety And Quality Report, commenced in February 2014 report. 04/03/2014 Total number of overdue actions presented to patient safety committee, Executive committee and Trust board on a monthly basis. Action plan reports provided to Divisional leads on a monthly basis Action plan reports are now being set up for Divisional leads to run off the live web system Directorate are provided with latest action plan report pre PSC. Directorate 2. Action Closed Explore Action Planning Module on Safeguard Risk Management System to monitor action plans arising from serious incidents, auto generated reminder and report functions. 30/04/2014 Action planning module now in use Report design has now been received from Ulysses, needs to be tested on the system. Then all outstanding actions added to action planning module Action planing module tested, report set up an run by Ulysses. Required ammendments to report Page: 6 2. Action Closed

149 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager format sent back to Ulysses One action plan entered onto system to test function. Request sent to Ulysses to support reporting function and add directorate field Business Planning Page 143 Finance (Inc IT And Estates) FM Offices 18/11/2013 Non-delivery of Cost Improvement Plans (CIPs) resulting in inability to invest in service redesign initiatives and to achieve a balanced financial position Finance CIPS? Monthly monitoring meetings with directorates to review progress against CIP delivery? Report progress to formal committees on a monthly basis?where CIP schemes are not progressing in line with plan, develop new schemes to mitigate against the shortfall Reporting to Finance & Investment Committee on a monthly basis to monitor progress Reporting to Programme Boards and Directorate Performance Meetings To make sure the financial support to directorates is sufficient to provide the necessary information and challenge around developing and monitoring against CIPs. Clearly identifying whether they are cash or efficiency savings. These will then be signed by the directorate to take full ownership to invite directorates to attend and present their financial positiion (including progress against CIPs) to the finance and investment committee on a rolling calendar. 31/10/ /10/2014 CIP Plans Reviewed regularly and detailed reviews being carried out for each directorate. New Finance Structure to ensure level of support is adequate going to EPF Sept 14 the finance and investment committee have supported the recommendation that directorates attend to provide a deep dive on their budgets which will include CIP targets. Unscheduled Care is the first to attend in May Page: 7 1. Action Required 2. Action Closed /10/2014 Karen Johnson

150 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager To establish the details around each of the Directorates CIPs plans to provide assurance that savings plans are in place and will deliver during 13/14 31/10/2014 Directorates have all been allocated CIP plans and these are monitored on a monthly basis. 1. Action Required 1071 Trend Analysis Monthly Workforce Report & Monthly Finance Report Page 144 Workforce & Education Human Resources 01/04/2013 Agency spend in the first 3 months of this finacial year is above the plan as set out for this year which requires a 4m reduction. The risk associated with the medical staffing is amber. The risk associated with nursing and corporate staff is currently red and is being reviewed montly. Finance Expenditure Monthly workforce and finance report which reports on agency spend during the previous month. Optimising Nursing & Midwifery Programme Board Recruitment Plan 2014/ International recruitment campaign to reduce the number of nursing and midwifery vacancies. 30/11/2013 The Trust will consider whether to plan a further international recruitment campaign in January A meeting will be arranged with TTM (current agency used for international recruitment) in January. 2. Action Closed /08/2014 Kimberley Sumbler The Trust has successfuly completed the 2 international recruitment campaigns with start dates planned for October, November 2013 and Jan and February Introduce an incentive scheme for nurses, midwives and AHP's to work extra shifts 12/12/2013 The incentive scheme ended in February The incentive scheme was introduced in November 2013 and will be reviewed on a weekly basis. 2. Action Closed A revised incentive scheme will now be Page: 8

151 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager introduced in December following poor uptake of first scheme. Page 145 A sustained recruitment campaign in England, Scotland, Wales, and Ireland, particulary for Band 5 registered Nurses. 29/07/2014 The Trust has attended a number of recruitment events since April 2014, including Belfast, Dublin and Manchester. A total of 23 offers have been made to registered nurses The Trust attended a successful RCN Recruitment Fair in Glasgow in April and made 10 offers of employment to qualified nurses. 2. Action Closed Agreement has been reached to undertake a third overseas recruitment campaign in Spain and Portugal in May 2014 for 50 nurses. 30/06/2014 The overseas campaign has now been completed and a total of 26 international nurses will be joining the Trust between June and August The campaign will be taking place w/c 12/05/ Action Closed Recruitment Plan 2014/15 has been written which sets out how the Trust plans to meet it's recruitment needs. This plan 31/07/2014 The Recruitment Plan 2014/15 is in place and continues to be managed by the Head of Recruitment. The pipeline of band 5 nurse (new starters) is 72.8wte. From late September 2. Action Closed Page: 9

152 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager will also take into account actions from the agency reduction plan. onwards, assuming no further increase in funded establishment, it is estimated that vacancies will fall sharply to a more sustainable level of 35wte or less. Page 146 Proposal to re-launch summer incentive scheme to staff across the Trust to work extra shifts (where there is currently high agency usage). This will improve continuity of care and reduce reliance on agency workers. If scheme is approved proposed to launch on 4/8/14. 31/08/ Page: 10

153 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager 1104 Business Planning Page 147 Monthly reporting is showing that the delivery of a year end surplus is currently at risk. Recovery plans are being developed to generate a plan in order to close the gap. Finance (Inc IT And Estates) Finance 14/01/2014 Risk of compliance action resulting from non-delivery of year end surplus. Finance Expenditure 1. regular reports to F&I committee highlighting the current financial position with mitigation actions to bring the variance back in line with the plan 2. monthly meetings with directorates to understand and challenge their financial positions, working with them to identify areas that can help bring the budget back in line 3. where necessary weekly meetings with the CE and DoF to scruntinise spend across directorates 4. To put additional controls in place to ensure all spend is essential Review impact of PFI on Trust financial position Develop recover plans and get formal sign off from Board to implement Weekly Divisional financial challenge meetings with the COO and DofF 31/10/ /09/ /09/ /09/2014 Karen Johnson Close scrutiny on agency spend, monthly reporting 30/09/2014 Page: 11

154 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager 1114 Incident Page 148 Corporate Trust-Wide 01/01/2014 The number of severe harm from falls from April to March 2013/14 is 16 fractured NOF and 5 deaths (1 incident occured in the community). The number of severe harm from falls in 2012/13 was 16 (13 acute and 3 commnuity) as a result the tregectory was set this year for 10 severe harm for the acute Trust. Falls per 1000 bed days in 2012/13 was near to the national average of 5.6 falls per 1000 bed days. In 2013/14 falls per 1000 bed days was on average 7.0 Safety Falls Risk assessment tool and falls care plan in place and monitored There is access to fall prevention measures such as low beds and non slip foot wear There is mecahnism in place for learning from incidents at least 7 days after a moderate or severe harm occur Falls trend reports are sent to all wards and directorates There is a falls prevention nurse in place to support clinical staff There is a giood culture of reporting slips, trips and falls The monitoring of falls on the falls dashboard will be extended from the 5 CQUIN wards 2013/14 to include all wards in 2014/15. The dashboard will include falls per 1000 bed days set against the national average; rate of harm set against 2013/14 GWH figures and harm from falls set against 2013/14 GWH figures FallSafe Inspection has been initiated from April 2014 and conducted every 2 weeks. THe inspection is led by the Deputy Chief Nurse and include the Falls Prevention Nurse and Clinical Risk department representative. The aim of the inspection is to check compliance with risk assessment; care planning; monitoring arrangement. Written feedback will be provided to the ward manager, matron and Head of Nursing. Revisits will occur where compliance is poor Implementation of a Falls Dashboard to include rate of harm; falls per 1000 bed days; harm from falls Implement FallSafe inspection of wards looking at falls risk assessment, care planning and monitoring arrangement Falls Prevention Group Terms of reference to be revised and include membership from senior directorate managers, senior pharmacist; physiotherapist, consultants and CCG representatives 09/05/ /04/ /04/2014 dashboard is in use, but needs minor adjustments Informatic team to deliver by 9th May 2014 Action now closed Ward inspection initiated on Teal, Linnet and Kingfisher wards. Significant non-compliance on Teal ward. A report will be submitted to ward managers, matrons and Head of Nursing. Re-inspections will be planned for Teal ward New Falls Prevention Group Launched. TOF agreed by the Patient Safety Committee 2. Action Closed 2. Action Closed 2. Action Closed /08/2014 Julie-Anne Marshman Page: 12

155 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager Page 149 Toni Lynch to be lead for Trust falls starting with a review of the falls strategy to be undertaken and this will be presented to CCG 21st July. Innovations piloting on wards carrying on until the falls strategy is re-evaluated. Falls Operational Group piloting various innovation around falls prevention in wards. To be assessed and re evaulated for further roll out. To review the severe harm cases that occured in the last 3 months and determing further learning and actions. Compare learning and actions with the 8 cases reviewed in June Report finding to PSC and Trust Board 21/07/ /09/ /02/2014 action closed. Group in place The new Falls Prevention Group will review all moderate and Severe harm from falls. Ward managers will present RCA and Ward Falls trends. First cases was reviewed by the group in the April 2014 meeting 2. Action Closed Page: 13

156 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager Page 150 To work with all ward managers to develop a culture of FallSafe Wards. This will include there understanding of trends; identifying falls champions; publish data such as days since the last fall and harm from fall; falls as part of the ward managers objectives; actively reviewing and take action on information presented on the Falls dashboard 30/04/2014 Action closed. group is initated April The Fall Safe Operational Group was launched on 1st April Terms of reference have been agreed by the group and circulated to the Falls Prevention Strategy group for signing off. The Falls Operational Group will be accountable to the Falls Prevention Strategy Group.The group will meet on a monthlly basis ( first Tuesday of each month) Action Closed Page: 14

157 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager 1182 Incident Finance (Inc IT And Estates) Estates & Facilities 23/04/2014 Lack of suitably arrangements in place & trained personnel to provide an effective 24/7 response to the emergency release of trapped persons from a passenger lift. Safety Safe Processes Carillion in-house staff now responding to 'non-complex' entrapments. If the entrapment is more 'complex' and if a medical emergency they will contact the Fire & Rescue Service (who have agreed to this temprary solution) for assistance Carillion to provide suitable trained in-house resource to ensure appropriate release of trapped passengers. 31/10/2014 Specialist external lift release training is bein lined up for relevant Carillion personnel. Expected to be complete during October Action Required /10/2014 Rupert Turk Page 151 Page: 15

158 Risk Owner/Manager Target Current Progress against actions Due Date Next Review Date Action Outcome Actions required to mitigate risk score Likelihood Consequence Score Likelihood Consequence Janette Armstrong 12/05/ Page: 16 Risk Register Report Existing Controls Risk Type Risk Group Safeguarding Risk description including the effect of the risk Safety There is a risk that during the cutover time of new Medway safeguarding alerts will not be accessible to staff seeing children/adults who have alerts on their electronic record Date Raised 28/04/2014 Department Corporate Governance Directorate Corporate Source of Risk Risk Ref 1185 Other - Please Explain In The Identified during Medway risk assurance meeting in Directorate Page 152

159 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager 1221 Business Planning through business plan to include the training and competence of individuals and whole groups of staff in ability to use device safely. the whole trust will be using the new device. Trust-Wide Trust-Wide 02/06/2014 New pump roll out, full replacement of Intravenous infusion pump. new device safety risk due to user competence. Safety Equipment (Safe) ESR inputting of training as completed, to provide up to date compliance levels. Level to reach at least 70% of present workforce (trained only) prior to roll out. training programme in 3 phases, controlled to specific areas at a time. Equipment Library will follow roll out, so that areas with new pump will not receive old pump, and vice versa Trust support to the Company Representives in training staff in use of new device as per plan to roll out. maintain training record and review compliance levels prior to roll out of each ward/work area. 26/09/2014 training now been going on for 2 weeks in first phase, review of training compliance reveals SCBU ready for roll out next week. all staff aware, roll out planned Wenesday 6th August in SCBUCardiac Cath lab already at 80% compliance however will need to roll out in line with Acute cardiac ward due to client /08/2014 Carol Frape Page 153 to report to Health and Safety committee regularly regarding areas that are in present roll out. advise management of areas in roll out and progress reports 26/09/2014 reported to meeting on 23rd July 2014, all staff aware of roll out and will cascade to all staff. Will be on adgenda for duration of roll out. Page: 17

160 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager 1232 Other - Please Explain In The Clinical staff raised the issue of cancer patients overdue appointments on virtual review clinics. Page 154 Planned Care 01/07/2014 HOLD FILE. Both General Surgery (GI) and Urology specialities have significant numbers of patients waiting for overdue follow up appointments residing on the hold file. As these services have a large number of cancer patients for follow up and surviellance, there is a significant clinical risk that cancer patients are overdue their appointment. Safety Safe Processes Hold file numbers raised weekly at PTL meeting. Increases discussed, but unable to support adequate capacity to deal with Clinicains monitoring numbers at monthly governance meetings. Capacity and demand model in progress using IMAS model to determine size of capacity problem for all trust specialities Validate patients on General Surgery (GI) and Urology hold file. Remove administratively those who should not be on it. Complete data entered into IMAS capacity model to gauge scale of the issue. Job plan for clinicains to ensure maximum clinic capacity is attained with existing resources. 29/08/ /08/ /10/2014 New and elective plans complete, currently working on whole pathway plan to include follow up demand Breast team to agree prospective cover for clinics and elective work to prevent further backlog buildup and address hold file. GI team reviewing service provision and staffing level with plan to deal with holdfile numbers. All registrar comittments being reviewed for additional clinic provision at no extra cost. Timetable and rota being reviewed. 1. Action Required 12/10/2014 Simon Carter Review of registrars in place post deanery rotation. Plan to keep additional trust registrar in place for 6 months to add clinic capacity fro hold 04/10/2014 Additional post agreed, to be finalised with Registrars in place as will have small impact on funding. Page: Action Required

161 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager file patients Develope business case to support required capacity for service provision for both services to meet RTT, cancer and follow up targets for capacity and safety. 31/10/2014 Urology case for additional (4th) consultant post drawn up to provide robust service continuity and additional capacity for hold file address. To be submitted to planned care CG meeting for agreement before sending to senior medical staffing group. 1. Action Required Page 155 Page: 19

162 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager 1233 Incident Page 156 Integrated Community Health Locality Management 07/08/2014 Patients will be admitted to hospital or have they transferred home delayed due to the capacity and capability of MEARS (Help To Live at Home Provider). Safety Admission, Discharge, Transfer Community staff are reporting clinical risks as they are discovered through input onto safeguarding system Clinical Risk Team to notify all incidences involving MEARS to CEO. SARUM Head of Locality to request all community team staff to report on safeguard any issues they are aware of around MEARS. CEO escalating concerns to Local Authority and CCG 29/08/ /08/ /08/2014 all teams requested to report on safeguard escalated to new Director of Community Services. discused at exec meeting 18/08/14 2. Action Closed 1. Action Required /09/2014 Maddy Ferrari SARUM Head of Locality to request confirmation from Wiltshire Council contracts lead of restricted access to new Package of Care 07/08/2014 confirmation received that it is business as usual. this now updated to report that Mears are not accepting any new packages of care until further notice. 2. Action Closed Page: 20

163 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager 1235 Business Planning Page 157 Planned Care Orthodontics 31/07/2014 Failure to meet Q2 deadline for recovery of 18 wk position on waiting new patient outpatient appointments Responsive Waiting Time Standards Regular monitoring of clinic utilisation Control of leave authorisation Expansion of service through recruitment of 3rd orthodontic consultant (0.7wte) combined with additional capacity via new orthodontic registrar joining in September. Business case to Exec Co Aug 2014 to request investment 29/08/ Action Required /09/2014 Louise Stevens Page: 21

164 Risk Owner/Manager Target Current Progress against actions Due Date Next Review Date Action Outcome Actions required to mitigate risk score Likelihood Consequence Score Likelihood Consequence Colin Norman 28/08/ Page: 22 Risk Register Report Existing Controls Risk Type Risk Group Fire Risk description including the effect of the risk Safety Possible entrapment of persons through lack of reasonable means of escape. Date Raised 18/07/2014 Department Costa Coffee Shop Directorate Source of Risk Risk Ref 1238 Risk Assessment Scheduled fire drill Page 158

165 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager 1241 Incident plus risk assessments and ongoing issues log sent to Wiltshire Council Page 159 Integrated Community Health Malmesbury/WB/Purton/Cricklade 18/08/2014 Patients will be admitted to hospital or have their transfer home delayed due to the capacity and capability of Leonard Cheshire Care Provider) Safety Admission, Discharge, Transfer Staff are reporting each issue of Leonard Cheshire being unable to attend or not attending as brokered as an IR1 and safeguarding Clinical risk team to identify, group and escalate up all incidences regarding Leonard Cheshire help to live at home providers. NEW head of locality to request all Integrated Teams to report on safeguard & IR1 all incidences re non attendance / unavailability of HTL@H by Leonard Cheshire. 31/10/ /10/ /10/2014 Susan Evans Page: 23

166 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager 1242 Risk Assessment Page 160 Diagnostics & Outpatients Wren Clinic Admin 01/07/2014 There is a risk that Outpatient Activity is not being captured in a timely way leading to inaccurate reporting information. This is as a result of insufficient staffing to meet the needs of the Trust Well-Led Contractual Arrangments Recruitment of additional staff to ensure processes are managed in a timely and effective way Implementation of "cashing up" process to ensure that all outcomes are recorded allowing payment of PbR Implement process for managing Welsh and Overseas patients - ensuring the Trust receive the income that is due Undertake full systems review of OP Procedures and Process (Modernisation) to ensure all obligations met 31/10/ /11/ /11/ /11/ /10/2014 Darren Pearson Page: 24

167 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager 489 Incident Incidents, complaints and workforce review Page 161 Diagnostics & Outpatients Pharmacy 01/10/2010 Capacity exceeded in manufacturing unit, increased risk of error & potential harm to patients. Linkw with cancer services risk 527. Year on increase in activity in line with haem/onc figures of 15%, capacity reached on a daily basis and exceeded 50% of time since Jan Number of errors within unit increasing, the unit deals in high risk medicines, potential that an error will occur that is not picked up and reaches patient. Current capacity having on effect on patient waiting time to receive chemotherapy. Corresponding reduced staff morale due to length of time taken for resolution, risk of staff resignation which will result in service being pulled altogether. Safety Medicines (Safe) Awareness in manufacturing unit, increased vigiliance Increased amount of pre-made chemotherapy bought in to reduce capacity issues within isolator and technical staff Complete review and implementation of new ordering system, including additional bought in lines to manage increasing capacity against time spent ordering Increased product lines bought in pre-made. Review and update to ordering in procedure to make more efficient. Daily monitoring of workload. Reporting back to service users when capacity exceeded, instruction not to add additional patients. IR1 raised for each week over capacity. Internal error reporting within the PMU. All critical errors (those that have left the department) have IR1 filled out. Record of each staff member for analysis of training requirements. Each step within manufacturing and release process is double checked. Unless in exceptional circumsatnces, no lone working or checking. Nursing staff perform check of drug against prescription prior to administration, further oppurtunity for any errors to be picked up before administration to patient. Case made for restricted service (buy in 80% items, manufacture other 20% high cost short expiry items) until recruit to posts to ensure service remains safe Funding secured for extension of hours and 7 days working - recruitment process to begin in addition to change to current contracts Weekly review of workload and reporting where exceeding maximum, notifying DTC when additional patients can not be catered for by PMU. 29/09/ /09/ band 7s appointed. 1 to start end sept. waiting on start date for second post. Both appointed as band 6, 6 month training requirement exists. Band 6 technician to start Band 4 technician to start Oct continue to stagger recruitment due to training needs In process of recruiting to post - band 4 filled, and band 6 and 7 out to restricted service in place. weekly review of workload continues Still continue to monitor workload and notify users if over capacity Still continue to monitor workload and notify users if over capacity Review of past 3 months workload showed PMU over capacity for 50% of working days. sent to finance RE restricted servcie and cost imlications Page: Action Required 1. Action Required /10/2014 Sarah Mcglue

168 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager 527 Other - Please Explain In The Risk assessment and service review. Current clinical activity data, patient experience, staff experience. Complaints, national survey data, business planning. Note this risk covers Oncology and Haematology. Previously linked to risks 965 and 528. Page 162 Diagnostics & Outpatients Day Therapy Clinic 20/10/2011 There has been an increase in chemotherapy activity by 15% per annum (locally and nationally), staffing has not increased to accordingly to reflect activity. The staff are therefore becoming stressed due to the busy highly specialist and complex nature of the area, as a result there has been an increase in sick leave. With increasing demand on the service the current physical space in Haematology/Oncology clinics, DTC and CWU is inadequate for current service. Service unable to expand to meet requirements. Well-Led Patient Experience Restricted service in place as of Buy in ~80% items, make additional. locum pharmacist started to screen and release chemotherapy Senior technician performing accuracy check where possible to reduce pharmacist involvement in multiple steps. A Chemotherapy Nurse Specialist has been appointed to assist with staff training and development and to review specific Day Therapy Centre chemotherapy patient reviews. The post holder will also provide leave cover for AOS nurse and MPD CNS. DTC, CWU and Dove nursing staff have regular teams meeting to identified any issues of concern and need for referral of staff to Occupational Health. Use of Bank staff when sickness high Recruiting nursing staff on 7 day business case Use of premium agency chemotherapy competent registered nurses Recruiting to MCU 5 day service for Swindon & Wilts Home delivery offered for patients receiving herceptin Business case written for 7 day working on DTC Business case written for staffing due to annual 10% increase in activity Jane Keep invited to meet team 31/03/ /03/2014 IR1's logged for days when unit over capcity each week. sent to DTC to advise PMU cannot provide service for additional patients on days unit over capcity. Team unable to progress any further. Await formal approval Awaiting formal approval for 7 day business case from Exec Co. Due to Trust financial situation- we have informed not to progress business case (10% increase in activity Dove Dtc & CWU) Business cases awaiting Exec Co approval LM, VJ & Ak met with Jane Keep who provided ideas to use for staff engagement. This will be trialled in the first instance before Jane meets with team 2. Action Closed 2. Action Closed /10/2014 Lyndel Moore Page: 26

169 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager Recruiting staff to 7 day business case. Staff awaiting contracts (Band 5 from centralised recruitment) Band 7 job description to job evaluation & then recruit 22/10/2014 Training in progress- ANP commenced this week on DTC ANP training commenced with AOS service ANP x3 recruited to commence in September. Training required to upskill staff 1. Action Required Page To train 3 x ANP to work weekends Interviews tomorrowawait outcome Not successful in recruitment- re-advertised as 3 part time positions. Interviews late June Band 7 post- interview- 20th May & await start date. Requirement for 7 day working Band 7 advertised & shortlisting awaiting interview Band 5 nurses recruited but Band 7 post to be approved at RAP for Page: 27

170 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager advertising. Band 5 nurses- newly qualified and need support rd band 5 nurse recruited, still awaiting contract on 4th nurse. Band 7 post evaluated at Band 7 & now to be RAPed Page Band 5 x 2 have commenced. Awaiting contracts for 2 other Band 5 nurses. Band 7 JD ANP to Job evaluation panel- awaiting outcome Source agency chemo competent nurses Liaise with bank office 11/03/2014 With slight reduction in sickness- no longer using premium agency In place for 2 weeks a chemo competent agency nurse working on DTC. Bank office sourcing another nurse to continue 2. Action Closed 10% increase in annual activity business case to be approved/revie wed. 15/05/2014 Awaiting formal outcome 2. Action Closed Page: 28

171 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager Case of need to take MCU to five day working to be written and MCW + LM to present case at Exec. Co. on 17/06/14 17/06/2014 Case submitted and presented at Exec. Co. on 17/06/ case approved. 2. Action Closed Page 165 Recruit to MCU 5 day service 30/09/2014 Awaiting offer letters to be sent to staff- delays in recruitment process. Staff will not commence in post for a couple of months & will then require training Awaiting advertising on NHS jobsite 1. Action Required Awaiting RAP outcome Paperwork to RAP this week to commence recruitment process Risk #965 under Medical Oncology to be amalgamated with this risk (#527). Risk #965 to be closed. 23/04/2014 Risk #965 under Medical Oncology has been closed as is amalgamated with this risk. 2. Action Closed Page: 29

172 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager Risk #528 to be amalgamated with this risk (#527) and risk #528 to be closed. 23/04/2014 Risk #528 has been closed and amalgamated with this risk (#527). 2. Action Closed 746 Risk Assessment Page 166 Service Review/capacity and demand analysis Diagnostics & Outpatients Rheumatology 23/08/2012 Patient safey and unmanageable clinics are a risk to this department as the clinical capacity isn't sufficient to meet demand Safety Staff Capacity Clinics being over-booked and where appropraite, routine patients cancelled to accomodate urgent patients. Short Term, ad hoc clinics to control demand and support hold file reduction Regular Review of PTL unbooked and booked patients - bringing forward where possible to utilise all capacity and avoid 18 week breaches/delays in care Close new patient referrals (except urgents) for period of 14 weeks as no capacity in the system to manage within 18 week pathway. Present case to Exec Committee and seek approval from CCG. 30/11/2014 Decision to be made on risk stratification tool to be used to reduce the number of referrals in line with capacity - this needs further discusison with the CCG along with full activity data set CCG have not approved closure and want to look at other sustainable solutions in the short medium and long term, including partnership working (not sucessfull) and internal business case for additional staff (business case submitted for Exec Co 16/09/14). Long term plans include setting up GPwSI service for primary care/secondary care support. Wait for approval of business case 1. Action Required /10/2014 Darren Pearson Page: 30

173 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager Seek long term additional funding for clinicians to support capacity and demand 31/10/2014 Business Case submitted for exec co 16/09/ Capacity and Demand model being updated (IST Model) to represent capacity issues. A business case will follow once complete and signed off. 1. Action Required 766 Other - Please Explain In The review Page 167 Unscheduled Care A&E/ED 15/10/2012 insuficient capacity within the ED to safely manage new patients delaying appropriate assessment/treatment while not providing privicy/dignity or a a safe environment with appropriate equipment. (back corridor) Safety Environment (Safe) LAMU commencing assessment area to ease demand on ED Agreement made in conjunction with Consultants to escalate to five patients in the back corridor with two nurses. B/C nurse allocated on most shifts to support SPA Nurse and Access to care working weekends to increase community discharges. ED overspend should reduce with new staffing model recruitment Linnet Ward opened Triage Assessment Bay (TAB) to ensure that the Medical take are directly admitted to the TAB area. LAMU triage assessment bay and SAU assessment bay are helping to manage the demand. Assessment area works well when it can be utilitsed Introduction of new ways of working recommeded by ECISTintroduction of see and treat model and introduction of 2 houlry walk rounds with Majors co-ordinator and Senior doctor to maintain safety and keep flow throughout the Staffin model being recruited into and electronic rostering being re built to ensure that staff are available at times of escalation for the ED All coordinators and consultants agreed that we queue patients withing the ED for closer monitoring. This has been highlighted at staff meetings. Independant Risk Assessment to be undertaken by Rachael Jefferies by 30th May /08/ /07/ /05/2014 ED roster system has been rebulit - still working with skill mix and recruitment. This has been completed 1. Action Required 2. Action Closed /10/2014 Annette Baskerville Page: 31

174 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager department. Back corridor only utilised in time of extremis. Patients now queue in the main department to ensure that close supervision in maintained. SWAST still encouraged to off load onto our trolleys then they can double up crews and leave the ED report to GM potential escalation onto ED due to direct medical access to TAB being stopped. 30/01/2014 ongoing practice 2. Action Closed Page 168 look at staffing model and change allocation of staff to best suit demand of patient admission times. Recruiting into new staffing model to ensure that we can meet demand of service requirements. See and treat to commence on 14th May to reduce surge in ED. consultant 2hourly board rounds have commenced to ensure that cubicles are kept for appropriate patients 29/08/ /08/2014 This is still work in progress. This works in hours but not consistently out of hours due to adequale resourses outlined in business case going to trust board July Action Closed 1. Action Required Page: 32

175 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager 792 Trend Analysis Board Assurance Framework 2012/13 Page 169 Unscheduled Care A&E/ED 01/04/2012 Failure to meet 95% ED 4-hour wait target. Responsive Waiting Time Standards Having a robust escalation policy and breach management meetings in place ECIST meeting now regularly held within the Trust Undertaking projects on LoS and the combined front door to review and streamline our processes Initial assessment within 15 minutes of arrival strreamed to most appropriate area for treatment. As part of ECIST recommendations working towards see and treat model to provide timely treatment / decision to discharge/admit within 4 hours. Working with the support of ECIST to increase the amount of medical take going through Amb Care and Acute Assessment area. Ongoing work around patient flow to aid bed availability Business case to be completed for additional resources required to implement ECIST actions ECIST report received and recommendatio ns from report being implemented SOP for each area to be completed 08/07/ /07/ /07/2014 Completed Complete SOP for majors medical, majors nursing and minors complete 2. Action Closed 2. Action Closed 2. Action Closed /09/2014 Victoria Brown Escalation policy to be signed off at AMD level 31/08/2014 Still awaiting AMD sign off Escalation policy with Chris Grist and Liz Price, awaiting AMD sign off across all specialities 1. Action Required IT review and fix following implementation of New Medway 31/12/2014 Follow me servers installed in Minors, to be rolled out in majors/paeds IT currently undertaking review of all processes and making appropriate Page: Action Required

176 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager changes ECIST have been invited into the trust to support delivery plan 31/08/2014 Funding provided for Paeds ED to open 24/7, no other ED funding at present Business cases presented, awaiting final outcome 2. Action Closed Page x Business cases (Paeds, ED & Amb Care) are currently being written due 4th July 2014 due to go to Trust board for decision later in July ECIST now regularly occurring within the Trust Review systems and processes in minors to improve care, flow to achieve zero breaches in minors 11/08/2014 Systems and process have been reviewed in minors. Business case to Trust Board in July Internal and external review completed. Action plan being developed 2. Action Closed Page: 34

177 Risk Register Report Risk Ref Source of Risk Directorate Department Date Raised Risk description including the effect of the risk Risk Group Risk Type Existing Controls Target Consequence Likelihood Score Actions required to mitigate risk Due Date Progress against actions Action Outcome Current Consequence Likelihood score Next Review Date Risk Owner/Manager 815 Other - Please Explain In The Service review Page 171 Corporate 08/11/2012 Nurse staffing/skill mix levels on some inpatient wards poses risk to quality of care and patient experience Caring Patient Experience Electronic rostering system in use, designed to achieve the most effective use of available staff. Temporary staff support substantive teams when patient safety needs exceed capacity of staff Incentive Scheme in place to reward staff working additional shifts Nursing Cedar Ward reducing skill recruitment plan mix in the short term to by ward required. allow deployment of HCAs Consideration to until RNs can be be given to the recruited. ICHD reviewing short term on a monthly basis recruitment of healthcare assistants until All Heads of Nursing and Registered Julie Brown for Nurses can be Community inpatient appointed. wards due to report back by ward whether additional Auxiliary Nursing Staff should be recruited in the short term. Due by 7th April. Nursing recruitment plan including international recruitment 25/04/ /05/2014 The Recruitment Plan 2014/15 was approved by the Board and is being managed by the Head of Recruitment. Band 5 nurse vacancies have fallen from 133.2wte to 117.4wte. This improvment has taken place whilst the funded establishment has risen by 73.9wte. The pipeline of new starters is 72.8wte which includes a cohort of international nurses. From late September onwards it is estimated that vacancies will fall sharply to a more sustainable level of 35wte or less. 2. Action Closed 2. Action Closed 23/07/2014 Hilary Walker Page: 35

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179 Agenda Item 18 Meeting and date: BOARD OF DIRECTORS - 25 SEPTEMBER 2014 Title: Summary of paper: Nominated Individuals for CQC Registration of Regulated Activities This paper invites the Board to approve the nomination of individuals for the purpose of CQC registration of regulated activities. This matter was considered by the Governance Committee held earlier in the month which recommended approval of the recommendations. This report provides information on why a nominated individual is required, how they are selected and their responsibilities. The report also specifies the requirements of the Care Quality Commission (CQC) and ongoing assurance for compliance with those requirements. A review of the current nominated individual for registration across the acute and community sites has been undertaken, together with consideration of the option of having a nominated individual to our main site (Great Western Hospital) and nominated individuals for our hub sites. Recommendations/ decisions required: (a) that Nerissa Vaughan, Chief Executive be appointed nominated individual for CQC Registration of Regulated Activities at Great Western Hospital and for the main registered sites (hubs) and satellite sites falling within the integrated community; (b) that the above appointment be subject to the individual meeting the checks prescribed in Schedule 3 of the Health and Social Care Act 2008 as set out in this report; (c) that it be agreed that the process for appointment shall be approval by the Board in accordance with CQC guidance and that there be an annual check of continued appointment through the Trust s appraisal process; (d) that the responsibilities of the appointed individual be agreed as set out below with assessment of these forming part of the annual appraisal process: - The nominated individual must take proper steps to ensure that the patients are protected against the risks of receiving care or treatment that is inappropriate or unsafe, this is done by: a) the carrying out of an assessment of the needs of the service user b) the planning and delivery of care c) avoid unlawful discrimination including, where applicable, by providing for the making of reasonable adjustments in service provision to meet the service users individual needs; d) reflect, where appropriate, published research evidence and guidance issued by the appropriate professional and expert Page 173

180 bodies as to good practice in relation to such care and treatment; and e) the nominated individual must have procedures in place for dealing with emergencies in order to mitigate the risks arising from such emergencies to service users. Link to Trust Priorities Link to Quality (a) We will work smarter not harder to make best use of existing resource. (1) Well led (2) Safety Risk issues: Resource Implications: (financial / human / other resources) Regulations and legal considerations: Quality consideration and impact on patient and carers: Consultation/ Communication: Confidentiality: Equality Impact Assessment: The Trust is required to comply with Regulation 5 CQC Registration of regulated activities The nominated lead will need to be aware of their obligations and comply with all requirements. Health and Social Care Act 2008 (Regulated Activities) Regulations A nominated lead is responsible for taking proper steps to ensure that patients are protected against the risks of receiving care or treatment that is inappropriate or unsafe. Chief Nurse Governance Committee recommended approval at its meeting held on 5 September 2014 This report does not contain any confidential information. Great Western Hospitals NHS Foundation wants its services and opportunities to be as accessible as possible, to as many people as possible, at the first attempt. This report has been assessed against the Trust s Equality Impact Assessment Tool and there are no proposals or matters which affect any persons with protected characteristics. Name of Lead Executive Director: Name of Author: Nerissa Vaughan Carole Nicholl, Company Secretary & Head of Corporate Governance Page 174

181 1. Introduction - Requirement for nominated individual A nominated individual is required for CQC registration where the service provider is a body other than a partnership. The body is the Great Western Hospital NHS Foundation Trust for the acute and community services. The nominated individual should be an employed director, manager or secretary of GWH who has responsibility for supervising the management of the regulated activity by GWH for the acute and community services. 2. Selection process The nominated individual selection process is not defined by CQC regulation 5, however; the regulation does give clear requirements. The requirements states that the nominated individual must meet the following checks as described in schedule 3 of the Health and Social care act 2008: (1) of good character, honest, reliable and trustworthy. (2) are physically and mentally able to do the job, with a plan of support that sets out any reasonable adjustments where necessary. (3) does not present a risk to people who use services because of any illness or medical condition they have (4) are not placed at risk by the work they will do because of any illness or medical condition they have (5) Is appropriately skilled with the qualification(s), knowledge and experience to supervise the management of the regulated activity (6) is subject to/has been checked that they are registered with the Independent Safeguarding Authority where they are undertaking a regulated activity of safeguarding service users regulation 11 (Safeguarding Vulnerable Groups Act 2006) (7) is registered under the Independent Safeguarding Authority scheme s phasing-in arrangements. The scheme s phasing in arrangements requires the nominated individual to have an enhanced DBS check and to recheck on a rolling basis after three years of employment. (The trust pre and post employment policy has this process incorporated on page 15) (8) have their qualifications, knowledge and skills updated on a regular basis. (9) have an awareness and knowledge of diversity and human rights and applies in practice the competencies to support people s diverse needs and human rights. (10) is aware of the services policies, procedures, legislation and standards. (11) knows who they are able to contact when expert advice is needed. 3. Responsibility of the individual The nominated individual must take proper steps to ensure that the patients are protected against the risks of receiving care or treatment that is inappropriate or unsafe, this is done by: (a) the carrying out of an assessment of the needs of the service user (b) (c) (d) (e) the planning and delivery of care avoid unlawful discrimination including, where applicable, by providing for the making of reasonable adjustments in service provision to meet the service users Individual needs reflect, where appropriate, published research evidence and guidance issued by the appropriate professional and expert bodies as to good practice in relation to such care and treatment the nominated individual must have procedures in place for dealing with emergencies in order to mitigate the risks arising from such emergencies to service users. The CQC does not define how the nominated individual will ensure the above steps are taken this will be decided by the Chief Nurse and approved by the Board. Page 175

182 4. Requirements to the CQC The Trust is required to notify in writing to the CQC of the nominated individual, this entails submitting the following: 1. Statement of purpose (highlighting the changes to be made and why) 2. Completion of the Application to vary or remove a condition of registration to carry on a regulated activity 3. Evidence to be provided which substantiates all the requirements for the selection of the nominated individual (see above 1-11) 5. Ongoing monitoring and assurance of this regulation 5 for the nominated individual The CQC does not define how regulation 5 for the nominated individual is monitored and evidenced; although, the following would be acceptable as assurance: 1. An annual review of the suitability of the named nominated individual, this could be completed as part of an appraisal in line with existing internal HR processes and policies. 2. The annual review is documented and agreed as part of the appraisal. 3. Declaration submitted to CQC in the autumn each year to confirm that the appraisal process informs ongoing suitability of the individual to continue as the nominated individual. 6. Current nominated individual On 1 st July 2014 under CQC regulation 14, a CQC notice of emergency absence was submitted to the CQC, as Ruth Lockwood (the nominated individual) was absent from managing the regulated activity for a continued period of 28 days or more. As a result of the absence Hilary Walker became the named nominated individual for regulation 5 from July CQC Main Registered Sites 8. Conclusion That the recommendations set out above be approved. Page 176

183 Agenda Item 19 Meeting and date: BOARD OF DIRECTORS 25 SEPTEMBER 2014 Title: Summary of paper: Recommendations/ decisions required: Briefing paper: impact for GWH following changes to the Mental Capacity Act and Deprivation of Liberty Safeguards Recent judicial and governmental activity surrounding The Mental Capacity Act (2005) and its amendment, the Deprivation of Liberty Safeguards (2009) has resulted in significant short and longer term consequences for the Trust. Actions are being planned and implemented to respond to the new requirements including: Staff awareness activities Policy and procedure updates Development of an assurance framework Legal advice to ensure the Trust operates in a legally defensible way Potential redesign of funded establishment to increase capacity for expert advice Independent service evaluation to assess progress (Internal Audit work plan for 2015/16) The work required will be overseen and monitored by the Mental Health Act/ Mental Capacity Act Committee Trust Board members are asked to endorse the proposed actions. Link to Trust Ambitions (a) We will make the patient the centre of everything we do. (b) We will work smarter not harder to make best use of existing resource. (c) We will build capacity and capability by investing in our staff, infrastructure and partnerships. Link to Quality (1) Safety (staffing, falls, never events, handover, SI, safeguarding, infection control, environment, medicines, equipment) (2) Caring (patient experience, patient surveys, friends and family test, patient stories, response to call bells) (3) Well led (staff survey, staffing levels, sickness rates, flu vaccinations rates, board/ward interactions, staff reports, governance and reporting, risk management, financial control) Risk issues: Resource Implications: (financial / human / other resources) Regulations and legal considerations: (CQC considerations / Monitor requirements / link to NHS Constitution rights and pledges as necessary / Trust Constitution / legislative requirements) Quality Risk no on risk register Considerable impact for front line teams in relation to assessment and referral processes. Review of existing resources for expert advice required Legislative requirements in relation to the application of the Mental Capacity Act 2005 (Deprivation of Liberty Safeguards 2009). Legislative requirements in relation to the application of the European Convention of Human Rights (Article 5) 1998 Core requirement for CQC Page 177

184 consideration and impact on patient and carers: Consultation/ Communication: Confidentiality: Equality Impact Assessment: Fundamental to safety and quality of care and patient / carer experience NA This report does not contain any confidential information. Great Western Hospitals NHS Foundation wants its services and opportunities to be as accessible as possible, to as many people as possible, at the first attempt. This report has been assessed against the Trust s Equality Impact Assessment Tool and there are no proposals or matters which affect any persons with protected characteristics. Name of Lead Executive Director: Name of Author: Hilary Walker, Chief Nurse Hilary Walker, Chief Nurse Page 178

185 1. Introduction Recent judicial and governmental activity surrounding The Mental Capacity Act (2005) and its amendment, the Deprivation of Liberty Safeguards (2009) has resulted in significant short and longer term consequences for the Trust. The Trust s Safeguarding Adults at Risk Team have considered what action is needed to respond to the challenges. 2. Previous practice across the Trust An internal audit carried out in May 2013 reviewed the management and control arrangements in place in respect of the following risks: Failure to have local procedures in place and ensure appropriate awareness could result in a failure to comply with MCA and DOLS requirements. Failure to have adequate arrangements in place for staff training could result in noncompliance with DOLS and MCA requirements. Failure to have a robust system in place for monitoring cases arising and learning The audit opinion provided limited assurance and 9 recommendations were made to strengthen the controls in place. While the associated action plan has been implemented, recent observed and reported evidence suggests a continued low level awareness of the 5 guiding principles of the MCA. There does appear to be better knowledge and consideration of Best Interests, although referrals to local IMCA (Independent Mental Capacity Advocate) services are remarkably low. For example, since 2007 only one referral has been made related to serious medical treatment. It is extremely unlikely that there has only been one patient who lacked capacity to consent to such treatment in circumstances when the necessary treatment was being carried out in a planned way (rather than as a medical emergency.) 3. Summary of the changes and their impact In March 2014 the House of Lords published it s select committee report; Mental Capacity Act 2005: post legislative scrutiny report. The report was critical of the lack of implementation and application of the Act by both Health and Social Care services. Medical staff were particularly singled out for their lack of understanding and application of the act. In June the Government s response largely upheld the recommendations made by the select committee. Key recommendations which will impact on the Trust include; To set up an independent body to have oversight and ownership of implementation and application of the Act. Explicit incorporation of Mental Capacity Act compliance as a core requirement for CQC to be met by Health and social care providers, with greater enforcement outcomes Explicit requirements around Mental Capacity Act compliance to be built into commissioning arrangements by CCGs. To invest in a central role for professional/specialist training Also in March 2014 a Supreme Court judgement led to a redefinition of what constitutes a deprivation of liberty, to an acid test requirement of the person is under continuous supervision and control, is not free to leave and the person lacks the mental capacity to consent to these arrangements. The judgement also extends the protection of the DoL Safeguards to domestic settings where the State may be responsible for substantial care arrangements. These changes will result in significant increases in number of eligible patients requiring DoLS applications. The application process is already significantly impacting on clinical staff time. In Q1 2013/14 the Trust made 7 DoLS applications. In Q1 2014/15 this rose Page 179

186 to 68 and is expected to rise further as knowledge and understanding of the new requirements embed within the workforce. The changes are also impacting the Supervisory Bodies (Swindon Borough Council and Wiltshire County Council locally), who are reporting a lack of resources to meet the demand generated by the increase in applications and are unable to fulfil the statutory assessment and authorisation process within statutory timeframes. This is resulting in eligible patients being detained without a legal framework in place. Theoretically, this could lead to a potential breach of Human Rights as well as the Mental Capacity Act (Deprivation Of Liberty Safeguards). These circumstances could leave the Trust in breach of its contractual obligations to the CCGs. The Trust s main Supervisory Bodies; Swindon Borough Council and Wiltshire County Council are operating a triage process to prioritise their responses to applications. Both Supervisory Bodies have appealed to the Government and the Court Of Protection for guidance and support on how to resource their statutory duties and are recruiting and training Best Interest Assessors to meet the demand. The Trust s Adult Safeguarding Facilitator is receiving regular updates about how they are managing the challenges. It is imperative that to ensure that authorisation breaches of the Act are rightfully assigned to the Supervisory Body. A process to ensure the Trust has an audit trail which evidences that the Trust has clearly made the correct reports to the Supervisory body has been implemented and is included in a DoLS resource pack for our staff. Advice about how to manage and implement the revised Safeguards has been slow to emerge. Legal advice is being sought by the Trust to ensure we operate in a proportionate and legally defensible way. It is unlikely there will be any significant revision of the thresholds for DoLS for up to 5 years (as case law is developed), thus the Trust needs short and longer term contingency plans to address the challenges. Consideration about how to apply DoLS to eligible patients in the community has been moving at a slower pace. The process for this differs from that of eligible individuals in hospital or residential placements and requires the managing authority (ie the Trust in some circumstances) to apply directly to the Court of Protection. There are currently a number of applications before the Court that have been made by Local Authorities which are being treated as test cases. A judgement is due on these shortly which is likely to inform Local Authorities and CCG s approaches going forwards. 4. Actions The risks have been assessed and an entry made to the Risk Register. Progress will be monitored monthly by Safeguarding Adults at Risk Facilitator and Operational Lead for Safeguarding Adults, bi-monthly by MHA/MCA Operational group with a reporting process to the MHA/MCA Committee. The actions below correspond to the risks identified. A Mental Capacity Act and Deprivation of Liberty Safeguards Awareness training presentation has been developed. This has been included in the induction programme to all new clinical staff since 22 nd July The Safeguarding Adults at Risk Facilitator is liaising with the Academy and an Associate Medical Director to prioritise training to ensure all staff who work with individuals who may lack capacity understand how to apply the key elements of the Act. A DoLS resource pack has been developed and is being delivered to key wards identified to have high concentration of eligible patients, providing staff with a quick reference guide Page 180

187 to the process as well as tools which speed up the administrative element. To date this work has been completed with 6 wards and a further 3 are planned. Informal and formal awareness raising sessions are being undertaken at every opportunity with all staff groups across the Directorates. The Safeguarding Adults Facilitator has to date contributed to Matrons and Senior Sister meetings as well as Ward training days. Plans to implement a regular DoLS round by the Safeguarding Adults Facilitator to identified wards to go through patient lists, review eligible patients and advise on least restrictive management of care and update on progress of applications and/or expiry of authorised DoLS will be reliant on identifying additional resources. In the meantime the increased support and advice requested by wards is being provided by the Adult Safeguarding Facilitator. Work is required to assess the impact on clinical time needed to fulfil the new requirements. Proposals for this work will be developed by the MHA/MCA operational group. The Mental Capacity Act Policy and Procedure has been reviewed and agreed by MHA/MCA Committee and is currently awaiting ratification through the Trust process. The revised Policy and Procedure provides clear and simple instructions for assessment of capacity and decision making processes. A small multi-professional task and finish group will develop a Mental Capacity Act Assurance framework including measurable targets for policy implementation and staff knowledge. This work will be overseen and reviewed by the MHA/MCA operational group and ratified by the MHA/MCA Committee. Work needs to be undertaken to enable a Trust wide policy review to ensure that all Trust policies and procedures that advise staff on adult service delivery are compatible with the Mental Capacity Act. Proposals for this work will be developed by the MHA/MCA operational group. Consideration should be given to the need for an independent review and service evaluation to assess the Trust s status in relation to our application of the Act. It is suggested that this would be appropriately conducted once the actions already identified have been completed so that an assessment of their impact and effectiveness can be assessed concurrently. This is work that could be included in the Internal Audit work plan for 2015/16 5. Conclusion This paper identifies that since the Supreme Court Judgement there are now significantly more patients in both the Acute and Community Services who will meet the revised test which identifies that they are being deprived of their liberty. The risks to the Trust in view of this relate to staff awareness and understanding of these changes, the impact on clinical time to complete the application responsibilities of the Managing Authority and the Supervisory Bodies resources to meet the increased demand to fulfil their statutory responsibilities within statutory timeframes. The challenge of this work relates to the requirement to develop proportionate processes and practice which balance and reflect equally the demands of the core function of the Trust (the acute and chronic healthcare of patients) with the upholding of the legal and human rights of Page 181

188 the service users of the Trust whilst seeking protection from avoidable legal liability for staff plus ensuring regulatory and contractual compliance for the organisation. The paper outlines the current and proposed work streams to reduce the identified risks and meet the ongoing challenges posed by both these recent legislative events. Page 182

189 NON-EXECUTIVE DIRECTORS - MEMBERSHIP ON BOARD COMMITTEES from 8 August 2014 COMMITTEE Audit, Assurance & Risk Committee At least 3 Non-Executive Directors not including the Chairman 1 to have recent relevant financial experience 1 shall also be the Chair of the Governance Committee ROGER HILL ROBERT BURNS Chair of AR&A Chair LIAM COLEMAN SID ANGELA GILLIBRAND Deputy Chair Committee Member JEMIMA MILTON Committee Member STEVE NOWELL VACANCY Governance Committee 3 Non-Executive Directors The Chair of this Committee shall also be a member of the Audit Risk and Assurance Committee plus 2 Executive Directors Chair Committee Member Committee Member Finance & Investment Committee 3 Non-Executive Directors not including the Chairman of the Trust 2 Executive Directors Committee Member Chair Committee Member Page 183 Mental Health Act/Mental Capacity Act Committee 2 Non-Executive Directors Plus 1 Executive Director Committee Member Chair Committee Member Remuneration Committee All Non-Executive Directors plus Chief Executive Committee Member Committee Member Chair Committee Member Committee Member Committee Member Workforce Strategy Committee 3 Non-Executive Directors not including the Chairman of the Trust plus 2 Executive Directors Charitable Funds Committee Chairman of the Trustees who is a Non-Executive Director plus 1 other Non-Executive Director Plus 2 Executive Directors Joint Nominations Committee Chair of the Trust plus 2 Non-Executive Directors (appointed by Chairman) and 4 Governors (2 to be public) appointed by Council of Governors Committee Member Chair Chair Committee Member Chair Committee Member Committee Member Committee Member Committee Member Chair Agenda Item 20 Updated * August 2014

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