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

Transcription

1 Title: Hounslow and Richmond Community Healthcare NHS Trust Board of Directors part I meeting (public) Date: Wednesday, 25 July 2018 Time: 10.00am 12.55pm Location: Conference rooms 1 & 2, Thames House, 180 Teddington High Street, Teddington TW11 8HU Membership of the Board Non-Executive Directors: Stephen Swords (Chairman) Philip Hall Joanne Hay Ajay Mehta Judith Rutherford Bindesh Shah Board Advisor: Executive Directors: In attendance: NHS Improvement NExT Director scheme Observers: Ginny Colwell* Patricia Wright, Chief Executive Monique Carayol, Director of Transformation* Stephen Hall, Director of Clinical Services (Richmond and South West London) David Hawkins, Director of Finance & Corporate Services Alison Heeralall, Director of Workforce* Donna Lamb, Director of Nursing and Non-Medical Professionals John Omany, Medical Director Anne Stratton, Director of Clinical Services (Hounslow and North West London) Swarnjit Singh, Trust Secretary Fiona Harcombe, Head of Communication Ella Jaczynska Fiona McKenzie Paul Pegden Smith, Healthwatch Richmond John Marshall, Healthwatch Hounslow *non-voting Board members Enquiries: Swarnjit Singh, Trust Secretary Telephone swarnjit.singh@hrch.nhs.uk Issue date: 18 July 2018 Page 1 of 2

2 Agenda: Part I Time Item Title Lead Welcome and apologies SS Declarations of interest If any member of the board has an interest in any of the items on the agenda, they must declare these at, and if necessary withdraw from the meeting. The register of interests is available at SS Patient story wound care service SH/AS Minutes of the part 1 board meeting held on 23 May SS Chairman s report SS Chief Executive s report PW Governance Quality Governance Committee, 12 July 2018 AM Finance & Performance Committee, 16 July 2018 BS Charitable Funds Committee, 5 July 2018 SS Workforce & Education Committee, 26 April 2018 JH Sustainable Q1 delivery of 2018/19 strategic priorities PW Well led Kirkup report review of implications DL Gosport War Memorial Hospital - review of JO implications Quality Q1 Learning from deaths dashboard JO /18 Doctors revalidation annual report JO /18 Safeguarding adults and children annual reports DL /18 Infection Prevention & Control annual report DL Safe staffing review Teddington Memorial Hospital SH People NHS Equality Delivery System assessment AH / DL NHS Workforce Race Equality Standard submission AH Other Any other business SS Questions received from the public SS Information only items Board scorecard Finance report Forward plan Patient & Public Engagement strategy Page 2 of 2

3 Meeting title Trust Board part 1 meeting Date 25 July 2018 Report title Patient story Tissue Viability and the Wound Care Buddy Agenda item: 3 Lead director Anne Stratton, Director of Clinical Services Hounslow and North West London Report author Executive summary Anne Stratton, Director of Clinical Services Hounslow and North West London The patient story will be a video of patient feedback on the tissue viability service. There will then be a presentation by Mylene Delacruz, Service Manager on the new wound care buddy app which is being used to support staff with wound care. Purpose: Noting Recommendation(s) Board members are asked to note the report and to receive the patient feedback for the service to be presented at the Board meeting. BAF/TRR P3 Engagement with patients, public and stakeholders Report history Nil Appendices Nil

4 Minutes of the Hounslow and Richmond Community Healthcare NHS Trust Board of Directors part I meeting held on Wednesday, 23 May 2018 Present: Stephen Swords, Non-Executive Director (Chairman) Monique Carayol, Director of Transformation* Ginny Colwell, Board Advisor* Philip Hall, Non-Executive Director Stephen Hall, Director of Clinical Services (Richmond and SW London) David Hawkins, Director of Finance & Corporate Services Joanne Hay, Non-Executive Director (from item 3) Alison Heeralall, Director of Workforce* Donna Lamb, Director of Nursing & Non-Medical Professionals John Omany, Medical Director Bindesh Shah, Non-Executive Director Anne Stratton, Director of Clinical Services (Hounslow and NW London) Patricia Wright, Chief Executive (* non-voting attendees) In attendance: Swarnjit Singh, Trust Secretary Fiona Harcombe, Head of Communication & Engagement NHS Improvement NExT Director scheme participant: Ella Jaczynska Fiona McKenzie Welcome and apologies Stephen Swords welcomed all attendees, especially John Omany to his first formal meeting of the Board. Apologies for absence were noted for Ajay Mehta, Non-Executive Director Judith Rutherford, Non-Executive Director, Sue Charteris, Healthwatch Hounslow and Paul Pegden Smith, Healthwatch Richmond. Declarations of interest There were none reported in addition to those already recorded in the publicly-available register. Patient story The Director of Nursing delivered a presentation to Board members which set out the learning from a complaint received. She highlighted the following: Mrs L was a patient who lived at home and had had gradually deteriorating dementia for 10 years. She was not mobile and was cared for by her elderly husband In August 2017, equipment issues around the size and type of hospital-issued bed were raised. The Trust responded after reviewing Page 1 of 9

5 3.2 the practical occupational therapy advice provided which had been correct In September 2017, the patient s niece wrote to correct elements of the response and raise additional concerns regarding recent falls, care in the home and the approach of staff The complaint was successfully resolved however, as the family remained dissatisfied, a Being Open meeting was arranged At the meeting, it was explained that the substance of the discussion was about the approach rather than professional decisions taken The family had produced a document entitled Feedback based on our experiences and perceptions/ideas for improvement and the Trust had identified themes and lessons learned prior to meeting There was a large degree of commonality in both the family s and Trust s themes identified which were: o Engaging with families and carers o Providing clarity from day one about the service and what patients/carers can expect o Communication and responses when relationships appear to be breaking down Board members listened to an audio clip of part of the meeting held with the family The lessons learnt were: o a lack of recognition of changing care needs as patients deteriorate, both for the patient and carer o the co-ordination and management of care between a range of different agencies providing input and the distinction between NHS staff and care home workers o the need for one point of contact for families rather than them having to liaise with/chase/complain to multiple agencies when they are not sure what they all the different public services involved did o How poor communication was a cause of concern and could result in confusion and how trust could be built up Following the meeting, the following actions were taken: o district nursing service completed an assessment and a reclining chair was ordered and contact was made with social services regarding respite care for the patient s husband o The patient was reviewed in three monthly checks to monitor her health o A referral was made to the specialist local authority occupational therapy service for an assessment o The family were written to and were content for the details of their patient experience to be shared with Board members and would be written to again to outline the actions being taken, including the discussion at the Board meeting o An open and honest meeting was held with the service team which included the audit recording and reflections on areas which could have been improved During discussion, Board members raised the following: Page 2 of 9

6 The Trust would raise this case with clinical commissioning group (CCG) and local authority partners to discuss multi-agency working and also locality working This patient s experience provided a helpful case study to promote the need for integrated health and social care and the responsibility of all health and social care professionals for the oversight and care of local patients, particularly in monitoring a patient s deterioration The importance of getting it right first time included asking patients what was best for them was stressed Plans for an advocacy service for patients and carers and which was delivered in partnership with the CCG and local authority should be discussed with local partners in the health economy It was notable that the number of formal complaints received had fallen and the number of enhanced patient advocacy and liaison (PALs) service cases had increased demonstrating how contact with the PALs service was a more interactive and positive approach where helpful solutions can be identified, in partnership with patients and carers Whether a targeted customer service training intervention was needed to improve communication and how enabling and empowering staff to identify the cultural or other changes required could result in better learning and a better patient experience The Board: i. welcomed the presentation and discussion of this patient story; ii. noted the audio clip of the meeting had been shared with the service team to reflect on areas of improved practice; iii. noted that the case was to be shared with a reflective learning iv. panel; agreed the case be used as an example of how locality working could help patients more and share this with partners; v. agreed the patient and family be written to outlining the actions taken and the discussion held by Board members on their case. Minutes of the board meeting held on 28 March 2018 The minutes of the previous meeting were noted as a correct record. The board noted the completed action log and that drafting changes were being made to the Patient & Public Engagement strategy. Chairman s report The report was taken as read. Stephen Swords brought to Board members attention the outcome of the May local council elections in Hounslow and Richmond upon Thames. The board noted the report. Page 3 of 9

7 Chief Executive s report The Chief Executive took the report as read and highlighted the following: The Department of Health & Social Care s consultation on extending personal independent payments (PIPs) and further next steps awaited in the green paper on social care The aim of the Community First Network to provide a cohesive voice for community service and their role in delivering integrated care and Board members would be kept updated on developments The new Urgent Treatment Centre at Teddington Memorial Hospital was on track to open on 2 July 2018 The observations contained in the NHS Confederation lecture 2018 by Dr Jennifer Dixon, Chief Executive, Health Foundation Dixon, Board members watched the Proud to Nurse video, shown at the international nurses day event held on 11 May at the Stoop in Twickenham. The Director of Nursing explained the video was part of a campaign launched at the event and feedback from attendees was positive and feeling valued. Bindesh Shah suggested the video might be shown at the annual general meeting in July. The Chief Executive reported that the nurse in the video attended the patient involved in a motorbike accident outside Teddington Memorial Hospital and had been nominated for an NHS 70 award by the Rt. Hon. Vince Cable MP. The Board noted the report and that consideration would be given to including the Proud to Nurse video at this year s annual general meeting. Quality Governance Committee, 11 May 2018 Stephen Swords took the report as read and highlighted the increased performance in infection prevention and control. The Director of Nursing thanked the operational teams for their improved performance in this area and the leadership of the infection prevention and control team. The Board noted the report. Audit & Risk Committee, 20 April 2018 Philip Hall reported that the meeting considered the draft annual accounts and Committee members were able to take a great level of assurance and had met again on 21 May 2018 to consider the audited accounts and the Head of internal audit opinion. The board noted the report. Self-certification The Chief Executive reminded Board members that last year, NHS trusts were required for the first time to submit self-certifications in respect of the provider licence requirements. The executive committee had reviewed the evidence in support of self-certification and recommended the trust declare compliance with the two conditions, based on the available guidance. Page 4 of 9

8 9.2 The trust board approved the self-certification and authorised the Chief Executive and Chairman to sign the self-certification on behalf of the trust board by 30 May EU general data protection regulations (GDPR) and Data Protection Officer role The Director of Finance reported on the awareness sessions delivered for staff and the work to update relevant information governance policies and ensure contracts were compliant with the requirements. He highlighted a need for the Board to approve a Data Protection Officer (DPO) role which was now a requirement for NHS bodies. He recommended that the DPO s responsibilities be subsumed into the role of the Information Governance and Information Security Manager. During discussion, Board members covered the following: Assurance was provided that, in line with guidance, patient consent was required at the first point of contact not at each care episode There was a need to review the guidance in relation to staff records as there may be implications for data storage arrangements Assurance was given that contracts with Greenbrook and the Richmond GP Alliance were being reviewed and legal advice taken There was a need to resolve the issue of the membership list established during the preparation for application for foundation trust status It was explained that if an organisation was found to be in wilful breach of the regulations, it could be fined From a clinical point of view, it was important to be aware of the following: o Consent was no longer implied and had to be explicit o It was insufficient for a parent to give consent because children had a right to be informed and give their consent, where possible o Internet protocol addresses were now also clarified as personal, identifiable data o A question could be asked at the HR Directors Group to find out what other organisations were doing in getting staff consent o Information governance and consent policies had been amended and others, including workforce, were due for review 10.3 The Board: i. noted the requirements and implications of the EU GDPR directive and the DPO s role; ii. agreed that the DPO s responsibilities are assigned to the Information Governance and Information Security Manager role; iii. agreed that advice be sought from the HR Directors network on what other NHS Trusts were doing for staff consent; and iv. agreed that an update be provided at the September Finance & Performance Committee meeting. Page 5 of 9

9 Delivery of 2017/18 strategic priorities The Chief Executive recorded thanks to the Head of the Programme Management Office for the new format for the end of year report on delivery of the goals linked to strategic priorities. The report demonstrated improved performance from the previous year and there was good evidence of delivery. Philip Hall suggested the report be amended to include community nursing within the narrative. The Board: i. noted the year end position of 2017/18 strategic objectives and goals; and ii. agreed that the report s narrative be updated to include mention of community nursing /18 Annual Report & Accounts The Chief Executive explained that the Trust was required to publish an annual report in three sections: first, a standalone section covering the organisation, the year past and a forward look and performance; secondly, an annual governance statement; and thirdly, summary financial accounts. She confirmed that all sections had been reviewed by executive directors and auditors and minor amendments were needed on the annual report and accounts and sought delegated authority to agree the final versions for submission. During discussion, the following comments were received: it was important to have a format and content which was meaningful for the public, however, certain sections such as the annual governance statement and summary financial accounts were quite prescribed by guidance there were significant areas of the NHS staff survey where the trust performed well, however, this section and bullying and harassment could be more balanced 12.3 The Board: i. received and provided feedback on the content of the draft 2017/18 annual report and accounts, prior to their submission to NHS Improvement; and ii. agreed delegated authority for the Chief Executive and Chairman to agree the final versions for submission Journey to outstanding (J2O) programme The Director of Nursing presented the report which set out the year end position and highlighted the following for Board members: The format of the reporting pack for 2018/19 was due to be changed The peer review process had resulted in positive feedback from staff involved and this would be developed further for 2018/19, including the Page 6 of 9

10 trialling of an app Following internal peer reviews, the trust-level self-assessment was green across all Care Quality Commission (CQC) domains. Assurance was provided that, within the trust-level assessment, some teams were not all green-rated across all five domains and work was taking place with those service areas as part of preparation for the CQC s inspection During discussion, the Chief Executive noted that the 2018/19 J2O programme objectives were quite broad and would need to be detailed further in due course. She highlighted the importance of improving upon the CQC assessments carried out in March 2016 and April 2017 and also reflected on whether there had been a degree of underscoring in the self-assessment carried out. The Board noted the progress achieved in 2017/18 and the draft programme plan for 2018/ /18 Quality account The Director of Nursing reported that the Quality Account required minor amendments including the insertion of stakeholder statements and that the Quality Governance Committee had reviewed the draft report and recommended it be published, following the necessary amendments. The Director of Workforce proposed that mention be included of the introduction of e-rostering to also help raise quality improvement. The Board: i. noted the draft 2018/18 Quality Account; ii. agreed delegated authority for the Chief Executive and Chairman to agree the final version by the 30 June 2018 deadline; and iii. agreed that all Board members read the report as part of preparation for the CQC core services inspection and well led review /18 Mortality review group annual report The report was taken as read. In reply to a question from Bindesh Shah, the Medical Director explained that it was important to consider all deaths that occurred in the community; however, it was unclear whether the trust was receiving data on wider deaths in a timely manner. The Chief Executive explained that the Care Quality Commission had agreed that the mortality review should only consider patients under the active care of the trust. Stephen Swords reported that, along with Ginny Colwell, he had attended the launch of mortality review guidance and it was geared to acute NHS trusts. In reply to a query from the Chief Executive, the Director of Nursing explained that, at the time of the despatch of papers, there was one known death at the inpatient unit included and that, since a further inpatient death had occurred; the total deaths for the year were therefore two. The Board noted the report, in particular, that: Page 7 of 9

11 i. only two unexpected deaths met the criteria for case note review in 2017/18; and ii. to date no investigation reports or learning had been received from our two local CCGs regarding the known deaths of patients with learning disabilities on our caseload /18 Complaints and compliments annual report The Director of Nursing explained this publication was a statutory requirement and highlighted the fact that 91% of complaints received a substantive reply with 25 working days against a target of 90% and the final investigation report from the Parliamentary & Health Service Ombudsman had been received. The following comments were received during discussion: Stephen Swords referred to section 4.8 of the report and re-iterated a point raised at the Quality Governance Committee that it was important to include data that was meaningful Philip Hall welcomed the report and that only 43 formal complaints were received during the year. He suggested the report include the wider learning and actions taken from patient story cases presented to the Board Bindesh Shah drew attention to the limited number of responses to the equality and diversity section 16.3 Board members i. noted the report and that 91% of complaints received a full, written response within 25 working days; ii. noted the findings of the Parliamentary & Health Service Ombudsman following an investigation into three joint complaints; and, iii. agreed delegated authority to the Chief Executive and Chairman to agree the final, amended version Questions received from the public There were none received. Any other business Ratification of Responsible Officer The Chief Executive explained the trust needed to confirm to NHS England that the Medical Director was the Responsible Officer for the trust and that the Board had formally agreed with the Medical Director s appointment as Responsible Officer. The Board agreed the Medical Director be confirmed to NHS England as the trust s Responsible Officer. Page 8 of 9

12 18.3 People-Led Assessment of the Care Environment (PLACE) Stephen Swords reported the PLACE inspection took place on 15 May 2018 and that initial feedback was positive, particularly on the food provided for inpatients; he looked forward to receiving the final report in due course. Page 9 of 9

13 Action log, 23 May 2018, part I Board meeting: Item Action(s) required Lead(s) Progress update Status Patient story 1. Write to the patient and family outlining the actions taken, including the discussion held by Board members DL Completed Closed 2. Use the case as an example of how locality working could help patients more and share this with partners PW Completed Closed Action log - Patient & Public Engagement strategy (carried forward from May meeting) Delegated authority to agree final changes to the strategy version following drafting changes needed after feedback at the March Board meeting PW, SS PPI strategy reviewed and signed off by PW and SS on 18 July 2018 Closed Chief Executive s report Consider including the Proud to Nurse video at this year s annual general meeting (AGM) PW Completed. The video was well-received at the AGM Closed Self-certification Delegated authority to sign the selfcertification on behalf of the Board PW, SS Completed. Self-certifications in respect of provider licence conditions G6(3)and FT4(8) have been submitted Closed EU general data protection regulations 1. Assign the Data Protection Officer s responsibilities to the role of the Information Governance and Information Security Manager DH Completed Closed 1

14 Item Action(s) required Lead(s) Progress update Status 2. Seek advice from the HR Directors network on what other trusts are doing for staff consent in relation to the regulations AH Pan-London Deputy HR Directors network are leading reviews on staff elements and collated common changes needed. The Assistant Director, Workforce, has sought Closed advice from the Trusts GDPR lead on any outstanding aspects. 3. Provide an update at the September 2018 meeting of the Finance & Performance Committee DH In hand for September s Committee meeting Open to 17 September 2018 Delivery of 2017/18 strategic objectives and goals 2017/18 Annual Report & Accounts Update the report s narrative to include mention of community nursing Delegated authority to agree the final versions for submission and publication on our web pages PW Completed Closed PW, SS Completed Closed 2017/18 Quality Account 1. Delegated authority to agree the final version for publication on web pages by 30 June 2018 PW, SS Completed and Quality Account published on time Closed 2. Read the Quality Account publication as part of preparation for the CQC inspection and well led review All Completed Closed 2

15 Item Action(s) required Lead(s) Progress update Status 2017/18 Complaints and compliments annual report Delegated authority to agree the final version PW, SS Completed Closed Responsible Officer Confirm to NHS England the Board s agreement for the Medical Director to be the trust s Responsible Officer PW Completed Closed 3

16 Meeting title HRCH NHS Trust Board part I meeting Date: Report title Chairman s report Agenda item: 5 Lead Director Report author Report summary Stephen Swords, Non-Executive Director and Trust Chairman Swarnjit Singh, Trust Secretary In addition to the verbal report accompanying this item, I wanted to draw attention to: a) the updated summary of executive and nonexecutive director lead areas which have been updated to reflect changes in Board membership (see appendix 1); b) following the 23 May 2018 part I Board meeting, I exercised agreed delegated authority with the Chief Executive to sign off the final versions of the following: Patient & Public Engagement strategy Self-certifications in respect of provider licence conditions G6(3)and FT4(8) 2017/18 Annual Report & Accounts 2017/18 Quality Account 2017/18 Complaints and compliments annual report c) the key items discussed at the 27 June 2018 part II Board meeting: Chairs assurance reports for the Richmond Community in Partnership Committee s meetings held on 18 May 2018 and 15 June 2018 A Chair s assurance report for the Finance & Performance Committee meeting held on 25 May 2018 A Chair s assurance report for the Audit & Risk Committee meeting held on 21 May 2018 An update on the 2018/19 Operating Plan submission to NHS Improvement A report on the Care Quality Commission s core services inspection and well led review assessment Development of the Trust s 2018/23 strategic plan Proposals for a revised corporate governance framework A verbal update on developments in both the NW Page 1 of 4

17 and SW London Sustainability & Transformational Plans Purpose Noting Recommendations Board members are invited to note the report, in particular the updated summary of executive and non-executive subject matter leads. BAF link Risk entry Q1 Appendices Appendix 1: summary of executive and non-executive subject matter leads Page 2 of 4

18 Appendix 1: Summary of Executive and Non-Executive Director and Board Advisor lead areas 2018/19 The arrangements have been reviewed and updated in the light of changes to Board membership and management leads. Area of responsibility Executive Director Lead Non-Executive Director lead Statutory or regulatory roles: Chief Officer Patricia Wright Stephen Swords Chief Financial Officer David Hawkins Bindesh Shah Medical Director John Omany Judith Rutherford Director of Nursing and Non-medical Professionals Donna Lamb Ginny Colwell Safeguarding Adults Donna Lamb Ginny Colwell Safeguarding Children Donna Lamb Joanne Hay Caldicott Guardian Donna Lamb Ginny Colwell Security (including cyber security) David Hawkins Phil Hall Infection Control Donna Lamb Ajay Mehta Counter Fraud David Hawkins Phil Hall Audit Committee Chair n/a Phil Hall Freedom of Information David Hawkins Bindesh Shah Senior Information Risk Officer David Hawkins Bindesh Shah Information Governance, Management & Technology (including Digital) David Hawkins Bindesh Shah Risk Patricia Wright Philip Hall Health & Safety Patricia Wright Judith Rutherford Topic specific roles: Health and social care integration Patricia Wright Stephen Swords Quality Improvement Monique Carayol Ajay Mehta Children s Champion Stephen Hall Joanne Hall Estates and Facilities David Hawkins Ginny Colwell Emergency Planning, including on-call Ann Stratton Judith Rutherford Page 3 of 4

19 Area of responsibility Executive Director Lead Non-Executive Director lead Complaints Donna Lamb Stephen Swords Workforce / Learning and Development Alison Heeralall Joanne Hay Patient Engagement Donna Lamb Ajay Mehta Communication Alison Heeralall Judith Rutherford Clinical audit John Omany Ginny Colwell Adult Champion Anne Stratton Stephen Swords Equality and diversity Alison Heeralall Bindesh Shah (workforce) / Donna Lamb (patient and public) Learning disability Anne Stratton Judith Rutherford Carers Stephen Hall Ginny Colwell NHS Constitution Donna Lamb Judith Rutherford Freedom to speak up Donna Lamb Judith Rutherford Clinical Governance John Omany/Donna lamb Ajay Mehta Corporate Governance Patricia Wright Stephen Swords Workforce Engagement Alison Heeralall Joanne Hay Design champion David Hawkins Stephen Swords Healthy Workplace Alison Heeralall Ginny Colwell Being Open Duty of Candour Donna Lamb Ajay Mehta Accountable officer controlled drugs John Omany Ginny Colwell Dementia Stephen Hall Stephen Swords Procurement David Hawkins Bindesh Shah Page 4 of 4

20 Meeting title Trust Board part I meeting Date: 25 July 2018 Report title Chief Executive s report Agenda item: 6 Lead director Report author Executive summary Purpose: Patricia Wright, Chief Executive Swarnjit Singh, Trust Secretary Board members are provided with a summary of national, regional and local developments. To provide the Board with the Chief Executive s update on significant developments and key issues at a national, regional and local level which impact upon community services. Recommendation Board members are asked to: i. receive the report; and ii. note that an update on how the Trust is responding to the recommendations made by Lord Carter for community and mental health trusts will be presented at its September 2018 meeting. BAF/TRR Report history Appendices Q1, W1, S1 Not applicable 1: Prime Minister s speech on NHS funding: 2: May 2018 report of the Health & Social Care Select Committee report - Integrated Care: organisation, partnerships & systems: alth/650/650.pdf 3: NHS operational productivity: unwarranted variations in Mental health services and Community health services: perational_productivity_-_unwarranted_variations_- _Mental_...pdf 4: NHS community services: taking centre stage: 5: NHS Counter Fraud Authority bulletin: 6: A just culture: Page 1 of 5

21 1. National news Prime Minister s speech on NHS funding 1.1 On 18 June 2018, the Prime Minster, Theresa May, announced a new five year funding settlement for the NHS (see appendix one), giving the service real terms growth of more than three per cent per annum. The Prime Minister has tasked the NHS with producing a 10 year plan to improve performance, specifically on cancer and mental health care. Key elements of the speech included: A package of funding for the NHS covering the five financial years from An average annual uplift of 3.4 per cent per year based on Office for Budget Responsibility projections Funding is frontloaded, meaning the annual rates of growth are: 3.6%; 3.6%; 3.1%; 3.1%; 3.4%. This will equate to 20.5bn more revenue in real terms compared with A further 1.25bn allocated to deal with an increase in pensions costs associated with the new Agenda for Change pay deal The funding is for the NHS England commissioning budget only. This means it does not include capital funding, public health, health education, or social care. In an appearance in front of the Public Accounts Committee, Simon Stevens, NHS England s Chief Executive said there was an explicit commitment from the government that the adult social care budget would be set so as not to put further pressure on the NHS. There is no hard data on these areas and it is not clear whether these budgets, which have seen real reductions in the past, will be restored to previous levels or simply ring-fenced at their current levels In return for the increase in funding, the NHS has been tasked to develop a 10-year plan, via an assembly convened by national leaders. The prime minister has emphasised that this should have strong clinical input The 10-year plan, which will be delivered by the autumn budget, should set out how the service intends to deliver major improvements in mental health and cancer care The Prime Minister set out five priorities for the NHS: putting the patient at the heart of how care is organised; a workforce empowered to deliver the NHS of the future; harnessing the power of innovation; a focus on prevention; and true parity of care between mental and physical health. The Prime Minister said she would like to see the 10-year plan set out ambitious clinically defined access standards for mental health Gosport War Memorial Hospital 1.2 The Gosport Independent Panel was set up to address concerns raised by families over a number of years about the initial care of their relatives in Gosport War Memorial Hospital and the subsequent investigations into their deaths. The report was published in June Rightly, the Trust has taken this report seriously and considered the learning and reflections to take forward. This is covered in a separate agenda item for the Board today where Page 2 of 5

22 assurance is provided that for the issues which arose at Gosport appropriate governance is in place to ensure that the inappropriate use of opioids cannot occur at Teddington Memorial Hospital. Health & Social Care Select Committee report - Integrated Care: organisation, partnerships & systems 1.3 The Health and Social Care Select Committee published the report (see link for appendix two) of its inquiry into the development of new integrated ways of planning and delivering local health and care services. This inquiry focussed on the development of Sustainability and Transformation Partnerships (STPs), Integrated Care Systems (ICSs) and Accountable Care Organisations (ACOs). A summary of the report s key recommendations is shown below: The Government and the NHS must improve how they communicate NHS reforms to the public, making the case for change in the health service The Department of Health and Social Care (DHSC) and national bodies should adopt an evolutionary, transparent and consultative approach to determining the future shape of health and care. The law would need to change to enable the structural integration of health and care The national bodies should clearly define the outcomes they are seeking to achieve for patients by promoting more integrated care, and the criteria they will use to measure this NHS England, NHS Improvement, Health Education England, Public Health England and Care Quality Commission, should develop a joint national transformation strategy setting out how they will support STPs and ICSs STPs should be encouraged to adopt the principle of subsidiarity so that decisions are made at the most appropriate local level ACOs should be introduced in primary legislation as NHS bodies, if a decision is taken, following a careful evaluation of pilots, to extend their use. The national bodies must take proactive steps to dispel misleading assertions about the privatisation and Americanisation of the NHS including the publication of an annual assessment of private sector involvement in NHS care The greatest risks to accelerating progress are the lack of funding and workforce capacity to design and implement change. The Government must recognise the importance of adequate transformation and capital funding in enabling service change. The long-term funding settlement should include dedicated, ring-fenced funding for service transformation and prevention Productivity and efficiency of mental health and community health services 1.4 Lord Carter has published his report into the productivity and efficiency of mental health and community health services (see appendix three link). The review makes 16 recommendations across eight chapters. They are designed to improve productivity and enable the benefits to be reinvested in improving quality and access to care. The report found that: Page 3 of 5

23 There is significant good practice but there need to be stronger mechanisms for sharing this between trusts Workforce productivity is mixed, particularly in services delivered in the community, and NHS Improvement must step up its support for trusts to drive improvements in the engagement, retention and wellbeing of their staff The Getting It Right First Time (GIRFT) programme should extend its approach to community health and mental health services, and specify more efficient and high quality pathways of care for patients The use of mobile working and technology to drive efficiency and productivity is inconsistent and poor in many areas There is scope for trusts to take action across all areas of spend including corporate services, procurement and estates 1.5 The Trust will digest the report; work with NHS Improvement and other providers on areas of implementation and provide the Board with our implementation against each relevant recommendation for the September public Trust Board meeting. NHS Community Services: taking centre stage 1.6 Published by NHS Providers, this report (see link to appendix four) highlights the challenges to deliver promises to bring more patient care closer to home by prioritising NHS community services and doing much more to help people stay well in their own homes and communities, avoiding the need for hospital treatment, if the health service is going to be financially sustainable. This commitment was set out most recently in the Five year forward view (FYFV), which envisaged a significantly expanded role for community services, such as community specialist nurses and physiotherapy. 1.7 The report presents good examples of good practice where community service providers have successfully developed new ways of working, collaborating with other services to improve care for patients. However, at the same time, the report concludes that in practice, support on the ground has failed to match the rhetoric, leaving many providers marginalised, underfunded and short staffed. Secretary of State for Health & Social Care 1.5 In the Cabinet reshuffle that took place after the Chequers agreement on the UK s future relationship with the European Union, the longest serving Health (& Social Care) Secretary was promoted to Foreign Secretary. His replacement, Matt Hancock, moved from Culture Secretary to Richmond House and has represented the constituency of West Suffolk since NHS Counter Fraud Authority 1.5 The NHS Counter Fraud Authority (NHSCFA), a special health authority tasked with leading the fight against fraud, bribery and corruption in the NHS, and wider health service published its latest new bulletin (see link to appendix five) highlighting amongst other things, new guidance on procurement fraud, covering a wide range of fraud risks from the pre-contract stage to invoicing Page 4 of 5

24 and also an example of the recent successful recovery under the Proceeds of Crime Act. The Trust continues to take fraud seriously and works closely with its local counter fraud specialists to ensure that a robust control framework is in place to protect valuable NHS resources for frontline care. 2. Regional and local news NHS 70 th birthday and Annual General Meeting (AGM) 2.1 On 5 July 2018, Trust staff joined colleagues in NHS organisations across England, Wales, Scotland and Northern Ireland to celebrate the 70 th anniversary of the founding on the NHS. Following the reforms implemented by Clement Attlee s government after the Second World War, the NHS has continued to be held in great esteem by the public and this is testament to the excellent work it has done, and continues to do daily, in providing high quality healthcare services. 2.2 On the same day, the Trust held its annual general meeting at Richmond Adult Community College and a health fair, where members of the public were able to have a number of health checks, such as blood pressure tests and receive advice on weight management and healthy eating. A just culture guide 2.3 The Trust had adopted NHS Improvement s guide (see appendix six link) for NHS managers on consistently taking fair action when members of staff are involved in a patient safety incident. This guide supports a conversation between managers about whether a staff member involved in a patient safety incident requires specific individual support or intervention to work safely. It asks a series of questions that help clarify whether there truly is something specific about an individual that needs support or management versus whether the issue is wider, in which case singling out the individual is often unfair and counter-productive. The guide also helps to reduce the role of unconscious bias when making decisions and will help ensure all individuals are consistently treated equally and fairly no matter what their staff group, profession or background. This has similarities with the approach being taken by a number of NHS trusts to reduce disproportionate disciplinary action against black and minority ethnic staff. Care Quality Commission (CQC) inspection and well led review 2.4 The CQC inspection team carried out inspections of core community services on June 2018 (at the Hounslow Urgent Care Centre and Teddington Walk-in-Centre) and on 3-4 July 2018 at Adult community services and End of life care services. On July, the CQC will also carry out a number of interviews with Board Directors as part of its assessment of the organisation against well led framework requirements. Trust staff and I are incredibly proud of the community services the organisation delivers and we look forward to receiving the final CQC report in quarter three of this year. Page 5 of 5

25 Meeting title Trust Board part 1 meeting Date: 25 July 2018 Report title Lead director Report author Quality Governance Committee Chair s report Donna Lamb, Director of Nursing and Non-Medical Professionals Swarnjit Singh, Trust Secretary Agenda item: 7 Executive summary In line with trust corporate governance arrangements, this report provides an update to trust board members of the key issues that arose at the 12 July 2018 meeting of the Quality Governance Committee: Areas of significant assurance: Pressure ulcer review Kirkup review Quality Impact Assessment panel Annual doctors revalidation report Annual Safeguarding Children report Safe staffing 2017/18 annual committee report (see appendix one) Areas of partial assurance: Quarter one infection prevention and control report Year one plan for patient & public engagement strategy The committee also discussed the following reports: District nursing service records audit The Journey to Outstanding programme Chair s reports from the Quality & Safety Committee, Infection Prevention & Control Committee and the Medicines Optimisation & Prescribing Committee Learning from deaths dashboard Serious Incidents Trust risk register Its terms of reference and draft objectives The committee also noted the verbal assurance from the Director of Nursing that the trust s process for managing patient safety alerts (PSA) was robust and that the two PSAs recently received which were in relation to oxygen provision and nasogastric tubes had been responded to completely and within required timescales. In a separate part II meeting, the Committee reviewed Board Assurance Framework entries identified as risks to the Trust s quality strategic objective and a report on claims and litigation cases. Page 1 of 6

26 Purpose: Noting Recommendation Board members are invited to note the report. BAF/TRR Q1, Q2, P3 Report history Not applicable Appendices 1: 2017/18 annual committee report Page 2 of 6

27 Name of Committee Date of meetings 12 June 2018 Quality Governance Committee (QGC) Summary of assurance The committee can report significant assurance to the trust board on the following areas: Item Assurance / action Lead Pressure ulcer The Committee reviewed in detail a report which Director of review considered pressure ulcer cases during 2017/18. Nursing They noted and were assured by the following: there was a 6.5% decrease in category 2-4 pressure ulcers in 2017/18 from the previous year there has been an 8% reduction in HRCH attributable pressure ulcers on 2017/18 from the previous year the Trust already reported suspected deep tissue injuries and ungradable pressure ulcers and these categories were included in new national guidance issued by NHS Improvement in June 2018 the clinical pressure ulcer prevention pathway was implemented in quarter four 2017/18 to help reduce variation and improve patient outcomes a concise root cause analysis tool was introduced in quarter one 2018/19 to enable the review of such cases and to help implement learning points into practice a monthly compliance audit of records has been introduced from June 2018; baseline shows need for improvement in completion of risk assessments and wound templates, use of SSKIN bundle and provision of pressure relieving equipment the establishment of a pressure ulcer task and finish group to help drive improvements as identified through audit to reduce the incidence of attributable pressure ulcers Kirkup review Committee members reviewed a paper highlighting concerns reported in the Kirkup Report published earlier this year into Liverpool Community Trust (LCT) which compares and contrasts areas of Page 3 of 6 Director of Nursing

28 Item Assurance / action Lead learning and/or assurance that may be applicable to the Trust. The Committee noted the Capsticks report published before the Kirkup review had also highlighted concerns regarding LCT. The Committee took significant assurance from the review by executive directors of the Kirkup findings and the statement of the trust s current position in relation to the Kirkup report s key findings. Quality Impact Assessment panel Annual doctors revalidation report The Committee considered the outcome of the Quality Impact Assessment (QIA) panel held on 25 June Committee members welcomed the report and were able to take significant assurance for the following reasons: the Trust had an effective and robust quality impact assessment process in place if a scheme was approved by the panel, there is on-going tracking of performance and quality measures against a specified baseline the panel undertakes proactive review of any schemes already in delivery where trigger points have been hit, any newly identified schemes and any schemes in development that are due for delivery later in the year the panel reviewed 10 of the 17 schemes in this year s cost improvement programme (CIP) and fully approved seven of them one scheme was partially approved pending additional information requested the next QIA panel was scheduled for 31 July 2018 and its outcome would be reported at the September Committee meeting The Committee noted the report which gave assurance that the trust meets relevant regulatory requirements with regards to the appraisal and revalidation of doctors in the trust. Director of Finance Medical Director Annual Committee members discussed the annual Director of Page 4 of 6

29 Item Assurance / action Lead Safeguarding Children report report for children s safeguarding teams and were able to take significant assurance from the achievements during the last financial year, including compliance with training and supervision performance targets and the two external reviews. Nursing 2017/18 annual committee report Committee members welcomed and agreed the annual report Director of Nursing The committee is reporting partial assurance to the trust board on the following matters: Item Position / mitigation plan Lead Quarter one infection prevention and control report The Committee reviewed the outcomes in quarter one for infection prevention and control activity. They noted good progress in getting 100% compliance with hand hygiene audits for the second successive quarter. Committee members took partial assurance from performance in screening new inpatients within 48 hours for MRSA but noted the actions implemented to address this. Director of Nursing Year one plan for patient & public engagement strategy The Committee discussed year one action plan to accompany the trust s agreed public and patient engagement strategy. Although Committee members welcomed the draft plan, they fed back the need to have a clear sense of actions being taken and for SMART measures to be in place to monitor progress. The Committee agreed to consider a revised plan at its September meeting Director of Nursing Committee meeting attendance, 12 July 2018 Present: Ajay Mehta, Non-Executive Director (Committee Chair) Stephen Swords, Non-Executive Director Ginny Colwell, Board Advisor Christine Jordan, Acting Assistant Director, Quality & Clinical Excellence Donna Lamb, Director of Nursing & Non-Medical Professionals David Hawkins, Director of Finance & Corporate Services Remi Aderibigbe, Head of Quality and Patient Safety Page 5 of 6

30 Committee meeting attendance, 12 July 2018 Dugald Millar, Healthwatch Richmond (Observer) John Omany, Medical Director Swarnjit Singh, Trust Secretary Anne Stratton, Director of Clinical Services, NWL Linda Woodward-Stammers, Lead Infection Prevention Control Nurse Sandra Wolper, Head of Pharmacy Jane Nicoli-Jones, Head of Nursing Professional Practice Apologies: John Marshall, Healthwatch Hounslow Page 6 of 6

31 Appendix 1: Draft 2017/18 QGC annual report QUALITY GOVERNANCE COMMITTEE ANNUAL REPORT, APRIL 2017 TO MARCH 2018 A. Introduction The Quality Governance Committee (QGC) is a committee of the Trust Board. Its role is report to the Board on the systems, processes and behaviours for the delivery of patient safety and quality of service and which they relate to patients and carers, the wider community and partner organisations. It is charged with overseeing and seeking assurance on the quality and the safety of services offered to patients, ensuring that good quality and improvement in standard can be evidenced across the activities commissioned through the measurement of agreed quality metrics. The Committee also has a key role to ensure that mechanisms in place to share learning and good practice in order to raise standards. The Quality Governance Committee is responsible for: Providing assurance to the Audit & Risk Committee and Trust Board that there are robust and effective structures, processes, and accountabilities in place for identifying, managing and mitigating risks to the Trust s quality strategic priority Ensuring the principles of good clinical governance are embedded in the management and discharge of its responsibilities as a corporate entity Ensuring there are mechanisms in place to share learning and good practice in order to raise standards Overseeing integrated governance across the Trust and provide the Board with overarching assurance on risk and quality (patient experience, clinical effectiveness and patient safety areas of the annual quality priorities) Below is an outline of the work undertaken by the committee for the period covered in the report. B. Membership and meetings Quality Governance Committee membership: Non-Executive directors: Ajay Mehta, Committee Chair Stephen Swords Board Advisor: Ginny Colwell Executive directors: Donna Lamb, Director of Nursing & Non-Medical Professionals David Hawkins, Director of Finance & Corporate Services Page 1 of 5

32 Dr Rosalind Ranson, Medical Director (to 30 June 2017) Tony Snell, Interim Medical Director (from July 2017) Anne Stratton, Director of Clinical Services, Hounslow and NWL Two local Healthwatch representatives from Hounslow and Richmond respectively were also offered the opportunity of attending the meetings. John Marshall attends on behalf of Hounslow Healthwatch and provides an important and valued patient representative and third sector perspective at meetings. Since the departure of Dr Chris Manning, Richmond Healthwatch was unable to identify an alternative representative for meetings during the year. The Director of Nursing & Non-Medical Professionals is the lead executive director for the Committee. Meetings The committee met six times for the period in question as follows: 10 May 2017, 20 July, 12 September, 9 November, 18 January 2018 and 13 March. Following each meeting, the Committee Chair provided assurance reports to the Trust Board reporting areas of good performance and escalated any necessary areas of concern. C. Key duties The key duties of the committee are as set out in its terms of reference which are drawn from good practice as per the Good Governance Handbook, Monitor s Code of Governance and in line with national requirements. During the year in question the QGC undertook the following key areas of work: Quality Account The QGC considered and recommended that the Trust Board approve the 2016/17 Quality Account. This is the annual report to the public, produced by all providers of NHS healthcare, about the quality of services delivered. The QGC reviewed progress against the annual Quality Account priorities as well as proposals for quality priorities for the forthcoming year. Quality assurance The QGC received quarterly quality reports presenting data and analysis against patient safety and clinical effectiveness and delivery of the 2017/18 Quality Account priorities. The Committee considered reports on serious incidents and reviewed reports on important cases such as three investigation reports from the Parliamentary and health Service Ombudsman. Committee members were able to take assurance that the recommendations and learning identified in these cases was implemented into day-to-day practice. As with previous years, Committee members highlighted the importance of embedding learning from incidents, the significant number of incidents attributable to other NHS organisations. At quarter two, the Committee noted progress with reducing grade three and grade four pressure ulcers, in particular. At each meeting, the Committee has reviewed progress with delivery of the trust s Journey to Outstanding (J2O) programme. Over the year, it has been able to take greater Page 2 of 5

33 assurance on readiness for the CQC s inspection, particularly through the use of external peer reviewers and the embedment of the peer review progress across the Trust. Patient experience The QGC received quarterly quality reports detailing patient experience outcomes. QGC members remained assured that the trust received a low number of complaints from patients when compared with the number of service contacts annually. During the year, the Committee has received updates on the local engagement activities undertaken as part of the development of the Trust s Patient Engagement and Involvement strategy. Committee members had challenged the Trust to demonstrate engagement with a wide range of patients, carers, third sector health and social care bodies. Board Assurance Framework (BAF) and Trust Risk Register (TRR) Until September 2017, the QGC was the lead Board Committee with delegated authority for providing oversight and assurance of the BAF; that responsibility is now held by the Audit & Risk Committee. At part II meetings, the committee reviewed the risks to the delivery of the Trust s quality strategic priority, the associated mitigating actions and follow up. The committee provided strategic scrutiny and review and has supported the on-going development of a robust and rigorous control framework. In quarter four, following progress with the J2O programme and agreement of the public and patient engagement strategy, the committee reviewed and agreed proposals to reduce the risk score for the main BAF risk entries it considered regarding the quality and safety of services and patient engagement. External assurance of the risk and control framework in place at the Trust was provided by a positive report from the internal audit team at RSM Risk Assurance Ltd. who reviewed the evidence and assurances provided in BAF reviews for the risk to delivery of the Trust s quality strategic priority. The QGC also reviewed the TRR at each of its part II meetings. Since quarter three, the Committee has noted the improved quality of TRR entries. Committee members welcomed the rigour shown by the Quality & Safety Committee s line by line review of TRR entries and was assured by the progress shown. Committee reports Throughout the year, the QGC received assurance reports from its sub-committees: Quality & Safety (QSC) The Quality & Safety Committee meetings monthly and provides the QGC with regular reports from this key subcommittee addressing all aspects of quality and clinical governance within the Trust. It is chaired by the Director of Quality & Clinical Excellence with representation from operational senior managers, corporate leads and attendance open to all clinical staff. Areas of concern where the QGC sought and received assurance during the year included the quality of TRR entries (see above), progress in meeting the target for clinical supervision. Committee members have also sought and been able to take greater assurance on the core and wider membership of the QSC following concerns raised regarding attendance at meetings. Infection Prevention & Control Committee The QGC reviewed quarterly reports from this Committee along with quarterly infection prevention and control reports. Committee members raised concerns at the need for Page 3 of 5

34 consistent performance by all teams in hand hygiene audit submissions and training compliance and the need for staff to attend infection prevention and control link practitioner s meetings to help share learning. From quarter four onwards, the Committee was able to note the progress achieved by the new Nursing Infection Prevention Control leadership team through improved performance in these areas. Safeguarding The Committee has regularly reviewed reports from the Safeguarding Committee. One area of concern noted by the Committee was, at times, the capacity of the Safeguarding adults team to attend all external forums for the multi-disciplinary teams involved in safeguarding work across both local boroughs. During the year, it considered a report on the training delivered as part of the PREVENT programme which was then subsequently delivered to Trust Board members. Medicines Optimisation and Prescribing The Committee was able to take assurance from the implementation of clinical guidelines for a syringe pump which allowed or the continuous administration of medicines in a subcutaneous route in adult patients thereby giving them the ability to receive antibiotics at home and reduce acute and community hospital admissions. Learning from deaths Since the introduction of national guidance in quarter two 2017, the Committee reviewed a Mortality policy, in line with a nationally-issued template and also considers a quarterly report on learning from deaths for inpatients at Teddington Memorial Hospital and also for patients with a learning disability. Freedom to Speak Up Guardian The Committee has received six monthly reports from the Trust s Freedom to Speak Up Guardian and been able to take assurance on the negligible level of cases covered under whistleblowing legislation. Safe staffing In line with guidance issued by the National Quality Board and Chief Nursing Officer, the Committee reviewed on behalf of the Trust Board, six monthly reports on the staffing establishment at Teddington memorial Hospital s inpatient unit. It has taken assurance of the Trust s compliance with the national guidance on agreed safe staffing levels. Terms of reference & work plan The Committee reviewed its updated terms of reference at its September and November 2017 meetings. Revisions included clarification of the key strategies the committee should review and clarity on how this committee would effectively support the Audit & Risk Committee by reviewing and reporting on its oversight of entries on the board assurance framework (BAF) which related to quality and also patient engagement. The Committee s work plan is a standing agenda item at every meeting and is regularly reviewed with updates reported. Conclusion I am pleased to report that the Committee fulfilled its responsibilities, with a particular focus on continual quality improvement, learning from incidents and patient engagement. Page 4 of 5

35 I am grateful for the professionalism and support from Directors, Managers, Non-Executive Directors, external partners from Hounslow Healthwatch and all other colleagues involved in ensuring the smooth running of the Committee. Ajay Mehta Committee Chair Donna Lamb Director of Nursing and Non-Medical Professionals Page 5 of 5

36 Meeting title Trust Board part I meeting Date: 25 July 2018 Report title Finance and Performance Committee Chair s report Agenda item: 8 Lead director Report author David Hawkins, Director of Finance and Corporate Services Swarnjit Singh, Trust Secretary Executive summary This report provides an update to trust board members of the key issues that arose at the 16 July 2018 meeting of the Finance and Performance Committee: Areas of significant assurance: Board Assurance Framework risk S1 Board scorecard Bribery Act provisions Areas of partial assurance: Quarter one capital expenditure report The committee also discussed the following items: a commercial report a finance report for month three progress with the 2018/19 cost improvement programme a Chair s assurance report for the Performance Executive Committee meeting held on 19 June 2018 an annual report for the Committee s activities in 2017/18 and a review of its terms of reference Purpose: Noting Recommendation Board members are invited to note the report. BAF/TRR Report history Appendices S1 Not applicable None Page 1 of 3

37 Name of Committee Date of meeting 16 July 2018 Finance and Performance Committee Summary of assurance The committee can report significant assurance to the trust board on the following areas: Item Assurance / action Lead Board Assurance Framework (BAF) risk S1 Committee members reviewed risk entry S1 which dealt with risks to the delivery of the Trust s sustainability strategic objective. They highlighted plans to review the trust risk register so that in-year deliverables for risk S1 were captured and monitored there and linked to the Board Assurance Framework. The Committee agreed a risk score of 12 was appropriate for risk S1 and monthly performance would continue to be monitored, particularly of delivery against the in-year financial plan and against achievement of the cost improvement programme target. Committee members also fed back areas of the risk entry that needed some updating to reflect developments such as work to automate service line costing. Committee members agreed the report demonstrated that risk S1 was currently being effectively mitigated. Director of Finance & Corporate Services Board scorecard Committee members noted the positive outturn for June for Board scorecard indicators. They discussed exception reports for two red-rated indicators for staff turnover and the friends and family test for patients and noted the corrective actions being taken. The Committee also reviewed amber-rated indicators for delayed transfers of care and the safety thermometer. Committee members welcomed the continued good performance overall on performance indicators. Director of Finance & Corporate Services Page 2 of 3

38 Item Assurance / action Lead Bribery Act The Committee received a verbal report from the Director of Finance and Corporate Services who confirmed there were no cases to report this month. Director of Finance & Corporate Services The committee is reporting partial assurance to the trust board on the following matter(s): Item Position / mitigation plan Lead Quarter one capital expenditure report The Committee discussed a report on quarter one capital expenditure. They took partial assurance because expenditure was significantly below plan during the quarter. Director of Finance & Corporate Services Committee members noted the explanation for some delays in capital expenditure and received assurance that the Trust would spend its full year s capital expenditure in 2018/19. Committee meeting attendance, 16 July 2018 Present: Bindesh Shah, Non-Executive Director (Committee Chair) Monique Carayol, Director of Transformation Chris Giles, Assistant Director, Contracts and Performance Stephen Hall, Director of Clinical Services SWL Philip Hall, Non-Executive Director David Hawkins, Director of Finance and Corporate Services Joanne Hay, Non-Executive Director Swarnjit Singh, Trust Secretary Selina Tamrat, Programme Management Office Patricia Wright, Chief Executive Christine Jordan, AD Quality & Clinical Excellence (for Board scorecard item) Alison Heeralall, Director of Workforce (for Board scorecard item) Ian Hughes, Workforce Information and Systems (for Board scorecard item) Apologies: Bridget Welch, Assistant Director, Finance Paul Pegden Smith, Healthwatch Richmond Page 3 of 3

39 Meeting title Trust Board meeting - part I Date: 25 July 2018 Report title Charitable Funds Committee s Chairman s assurance report Agenda item: 9 Lead director Report author Executive summary Director of Clinical Services, Hounslow Borough /NW London Louise Burkill, Personal Assistant to the Chief Executive and Chairman This report provides assurance to the board on the business transacted by the Charitable funds Committee meeting held on 5 July 2018, in line with the trust s governance arrangements: Areas of assurance Finance Report Charitable funds report Accounts (NB these were circulated immediately after the committee meeting with a request that any comments be sent to the Assistant Director of Finance) There were no items on which the Committee took either partial or no assurance. In addition, the committee also discussed a possible application for: 1. Cerebral Palsy Integrated pathway patient management system The committee agreed that subject to further information being supplied - in principal they were generally supportive of the proposal. Purpose: Noting Recommendation Board members are asked to note the report BAF/TRR Report history Appendices S1 n/a none Page 1 of 2

40 Name of Committee Dates of Meetings 5 July 2018 Charitable funds Committee Summary of assurance A. The Charitable funds committee can report assurance to the board on the following areas Agenda Item Assurance / action Lead 4 Financial Report The Committee received assurance that the finances reported for the period April 2018 to May 2018 were an accurate record, and that expenditure met the charitable fund purpose. BW 5 Charitable funds draft Report and Accounts The Committee received the accounts for the period The committee noted that the draft accounts were to be sent to the auditors in September B. There are no items where the executive committee is reporting partial assurance to the board. C. There are no items where the executive committee is reporting no assurance to the board. Applications for funds: There were no applications that had been approved outside of the committee: There was one application for funds that the committee considered: Agenda Item application Lead Item 5 Applications 1. Sensory kit bags for children 14,850 - for funds award approved Committee meeting attendance: Present: In attendance: Stephen Swords, Non-Executive Director (SS) (Committee Chairman) Ajay Mehta, Non-Executive Director, (AM) Anne Stratton Director of Clinical Services (AS) Bridget Welch Assistant Director of Finance (BW) Louise Burkill, Personal Assistant to Chief Executive and Chairman Page 2 of 2

41 Meeting title Trust Board Date: 25/07/18 Report title Chair s assurance report Workforce and Education Committee Agenda item: 10 Lead director Report author Executive summary Alison Heeralall Director of Workforce Alison Heeralall Director of Workforce This report provides assurance in line with governance arrangements, with an update to Board members of the key issues that arose at the 25 April 2018 meeting of the Workforce and Education Committee. Areas of assurance and action: Workforce risks on Board Assurance Framework Workforce performance report Recruitment and Retention Update Staff Engagement and Wellbeing update Learning and Development Strategy and action plan update Workforce Strategy Equality and Diversity Committee Assurance report Areas noting: Changes to national Terms and Conditions Joint Negotiation & Consultative Committee meeting minutes Purpose Noting Recommendation The Trust Board are asked to note the report BAF/TRR Report history Appendices P1a/P2a 1

42 Name of Committee Workforce and Education Committee Date of Meetings 25 April 2018 Summary of assurance The Workforce and Education committee can report assurance/action to the Trust Board on the following areas Item Assurance / action Lead Workforce risks on Board Assurance Framework Workforce performance report Learning and Development Strategy work plan update The committee were assured on: i. the final 2017/18 BAF listings for risks P1/2a and P1/2b and the TRR People risks as at 18 April; ii. agreed that BAF risks were effectively managed and mitigated during the year; agreed the proposed risk descriptor and to maintain the target score for People strategic risk P1/2a for inclusion in the 2018/19 BAF at the part II May Board meeting iii. Action agreed to review the title wording of P1/2b and review the P1/2b risk rating at the next WEC CM/SH The committee were assured by: i. the positive year end achievement of workforce KPIs and e-rostering implementation ii. considered and approved the workforce KPIs submitted in the trust operating plan for 2018/19 The committee: i. noted the Learning and Development Strategy approved by the Executive Committee and received a work update on Learning, Development and OD activity linked to the strategy themes. Director of Workforce Director of Clinical Services Assistant Director of Workforce Assistant Director of Workforce 2

43 Staff Engagement and Wellbeing update Staff engagement and wellbeing update (including Staff Survey 2017 results and action planning) Recruitment and Retention Plan Update on progress The committee: i. were assured by the positive results and progress on last year s staff engagement plan ii. noted the key headlines and discussed focus areas from the survey and the need for deeper understanding to inform the further actions via the focus groups iii. Reviewed and approved the Staff Engagement action plan. iv. Action Add some additional questions to the FFT questionnaire, rather than staff survey, to gain additional insight LW v. Action - Work to review some specific targets and take to H&S Committee, for any further actions LW The committee: i. noted the report and took assurance in relation to the improvements and achieved vacancy and retention targets. ii. reviewed the action plan and continued to support the recruitment and retention initiatives set out in the plans. iii. Action evaluate unconscious bias training at the end of the year Action members to provide further question and comment on the Recruitment and Retention plan to HJ directly Engagement and Wellbeing Manager HRBP (HJ) 3

44 Workforce strategy - future planning Planned Changes to national terms and conditions in 2018 Joint Negotiation & Consultative Committee meeting minutes Equality and Diversity Committee Chair s report The committee: i. Noted the present five year workforce strategy ends in 2019 and this was the start of work during to inform the new workforce strategy, based on the trust strategy being currently reviewed ii. approved the first draft of the workforce strategy strands and overall aim of Making HRCH a great place to work iii. Action reword some of the strands to reflect discussions and recirculate the first draft - AH The Committee noted the national changes in relation to: - Agenda for Change pay deal proposals - Medical terms and conditions (Local Clinical Excellence Awards). The committee: i. noted the minutes of the meeting held on 11 April Action - Ask JNJ, CJ and DL to talk with GC about preceptorship and mentoring for newly registered nurses The committee: noted chair s report from the 14 th March 2018 committee and that the workforce elements of the EDS assessment had been approved by the JNCC. Action JH to pass on equality and diversity information from the clinical audit training as patient action Director of Workforce Director of Workforce Director of Workforce/ Director of Nursing Chair Committee meeting attendance, 19 October 2017 Present: Joanne Hay, Non-Executive Director (Committee Chair)(JH) Alison Heeralall, Director of Workforce (AH) Stephen Swords, Non-Executive Director (SS) Ginny Colwell, Board Advisor (GC) Donna Lamb, Director of Nursing & Non-Medical Professionals (DL) Tom Penman, General Manager Clinical Services (TP) Claire Miller, Deputy Director of Clinical Services for Hounslow and North West 4

45 Committee meeting attendance, 19 October 2017 London (CM) In attendance/observing: Lisa Waugh, Staff Engagement and Wellbeing Manager (LW) Fiona McKenzie, NExT programme Director (FM) Harjinder Johal, HR Business Partner (HJ) Ajay Mehta, Non-Executive Director (AM) Mena Nandha, Interim Resourcing Manager (MN) Tracy Woods, PA to Workforce Director (note taker)(tw) Apologies: Stephen Hall, Director of Clinical Services SWL (SH), Swarnjit Singh, Trust Secretary (SwS); Jane Smith, HR Business Partner (JS); Anne Stratton, Director of Clinical Services, NWL (AS); Linda Thomas, Assistant Director of Workforce (LT). 5

46 Meeting title Trust Board Part I meeting Date: Report title 2018/19 Q1 Delivery of Strategic Objectives and Goals (July 2018) Agenda item: 11 Lead director Report author Patricia Wright Chief Executive Selina Tamrat Assistant PMO Manager Executive summary Background It was agreed at the May Board meeting that the following 2017/18 Strategic Objectives and Goals would be carried forward into Q1 pending sign off of the Trust Strategy at the 25 th July Board meeting: Q1: For all core services to be rated 'Good' in all 5 domains and for each core service to achieve 'outstanding' in a minimum of 1 domain Q2: For all services to be safe today and every day P1: Reduce vacancy rate to 10% with no service above 15% and turnover rate below 17% P2: Improve engagement with our staff P3: Improve engagement with the people we serve W1: If we cannot deliver, and evidence the impact of, integrated services at scale then we risk not being regarded as an outstanding leader of, and of losing control over, the direction of non-acute care with the opportunity to access whole system growth monies. S1: Achieve financial planned targets Q1 delivery of strategic objectives and goals The attached scorecard provides an update against each of the strategic objectives and goals for the Q1 interim period; a refreshed set of 2018/19 strategic priorities aligned to the approved trust strategy will need to be established in Q2. At 12 th July, the following KPIs are RAG rated red in delivery: 1. KPI 2: Number of core services with at least one domain achieving 'outstanding' (blue) rating. Following ratification of The Care Quality Commission Regulations Compliance policy (April 18 April 21) and agreement of the draft 2018/19 J2O programme at PEC, new KPIs for the upcoming year related to this policy and programme were agreed and signed off at the June 1

47 J2O Delivery Board. Whilst a portion of the programme will be responding to the CQC inspection, these KPIs will be related to the key deliverables of self-assessment, action plans, peer reviews and quality improvement towards outstanding. A new reporting dashboard is in progress. 2. KPI 8b: A trust vacancy rate below 10% with no service above 15% Whilst the Trust vacancy rate is below 10% for June, the community nursing services vacancy rate is reported as 19.2% in June and the Hounslow Adults Unplanned and Integrated Care services vacancy rate reported as 22%. 3. KPI 11: Trust rolling turnover rate below 17% by 31/03/19. The trust rolling turnover rate is RAG rated red in June against the monthly target of 16.8%. The increase in June is attributable to Physiotherapy, Speech and Language Therapy and Occupational Therapy services. This was discussed at the DMT Ops meeting on 13th July where it was agreed for specific action plans focussed on these therapy services to be drafted. 4. KPI 17: Monthly agency spend within 5% control total. In Q1 the agency spend was 8% above the control total and therefore RAG rated red. Agency spend is higher in Q1 against the agency cap due to increased use of paediatric medical staff and corporate agency staff. The cap reduced significantly this year also having an impact. A detailed drill down into areas of spend has begun with trajectories in place and a review of future use of all agency staff is underway. Purpose Noting Recommendation(s) The Board is asked to note the Q1 position of the 2018/19 strategic objectives and goals. BAF/TRR Report history Appendices All None Appendix /19 Strategic Objectives and Goals (July 2018) 2

48 2018/19 Strategic Priorities Scorecard Q1 Director Sponsor Quality - Key Actions Review Key Performance Indicators Target Apr-18 May-18 Jun-18 Frequency Additional Comments 1) No. of domains rated 'good' (green) rating across the core services based on evidenced self assessment and action plans 19 (Q1), 21 (Q2), 23 (Q3), 25 (Q4) Quarterly Target was achieved by year end. Deliver year 3 of the Journey to Outstanding (J2O) Plan, with quality and safety as our top priority 2) No. of core services with at least one domain achieving 'outstanding' (blue) rating 0 (Q1) 1(Q2), 3 (Q3), 5 (Q4) Quarterly The Care Quality Commission Regulations Compliance policy (April 18 April 21) has now been ratified, and the draft J2O programme 18/19 agreed at PEC. New KPI s for the upcoming year related to this policy and programme were agreed and signed off at the June J2O Delivery Board. Whilst a portion of the programme will be responding to, the CQC inspection, these KPI s will be related to the key deliverables of selfassessment, action plans, peer reviews and quality improvement towards outstanding. A new reporting dashboard is in progress. 3) No. of domains achieving 'good' across core services following evidenced peer reviews 19 (Q1), 21 (Q2), 23 (Q3), 25 (Q4) Quarterly Target was achieved by year end. Donna Lamb Implement an audit programme which supports the J2O plan 4) External review for 'outstanding' domain completed by end of Q1 Completed by end of Q1 Once Complete Complete Complete Achieved - external reviews have been completed. Full reports reviewed by the Service Manager, Divisional Manager and Director Sponsors. Outcomes of the review reported on via the J2O Delivery Board. Ensure all incidents and serious incidents have an appropriate level of investigation which considers human factors 5) The percentage of relevant staff who have received training and demonstrated compliance in the use of human factors in investigations. Min. 50% by 30/06/18 Once No training delivered in April, May or June 18. To implement a range of learning processes which support staff learning from incidents including those working for the trust on a flexible basis 6) Improve on the % of staff who report they have changed their practice as a result of learning from an incident. Results from Q2 and Q4 18/19 local staff survey. 7) % of serious incidents which include clinical audit to demonstrate quality improvement. 2017/18 Q4 baseline Quarterly Q1 18/19 baseline Monthly Pending Q1 staff FFT No SI's Pending Q1 staff FFT 100% of SI's Q1 Staff FFT launched 100% of SI's Staff friends and family test launched in June - results to be collated by end of July. June 100% - 1 Report submitted, 1 MES audit in action plan

49 Director Sponsor 2018/19 Strategic Priorities Scorecard People - Key Actions Key Performance Indicators 8) (a) Trust vacancy rate below 10% by 31/03/19. 10% (31/03/19) Monthly (b) No service above 15% by 31/03/19 Monthly 8.6% Q1 Review Target Apr-18 May-18 Jun-18 Frequency 12.73% 21.35% 9.3% 26.4% 20.6% 9.2% 19.2% 22.0% Additional Comments The Workforce team held a recruitment open day on the 16th June where registered candidates were invited to an event that involved the testing and interviewing of candidates with the aim of tightening the recruitment process. In M3 services breaching the target are: Community nursing % Hounslow Adults Unplanned and Integrated Care % Alison Heeralall Implement Year 2 of the Workforce Plan 9) Maintain time to hire Max. 10 weeks Monthly 8.3 weeks 7.1 weeks 9.1 weeks The time to hire KPI has been revised for April, May and June as the Trac system had previously been reporting on time taken from advert to in post. The revised KPI for Q1 now accurately reflects time to hire from advert to unconditional offer and therefore does not include notice periods. Trac is showing 21 booked start dates over the next three months and a further 44 recruitments campaigns that have been interviewed and are at the pre employment checks stage. 10) Increase in the number of net new starters N/A Monthly The starter data requires further revalidation and adjustment to June data as the payroll deadline is the 15/16th of the month and any joiners starting after that date would not be included. 11) Trust rolling turnover rate below 17% by 31/03/19. 17% by 31/03/19 Monthly 16.6% 18.7% 18.50% The trust rolling turnover rate is RAG rated red in June against the monthly target of 16.8%. The increase in June is attributable to Physiotherapy, Speech and Language Therapy and Occupational Therapy services. Specific action plans for these therapy services have been drafted and will be discussed at the DMT Ops meeting on 13th July. Anne Stratton Stephen Hall Redesign and delivery of new community nursing model of care and associated staffing 12) Plan agreed and milestones achieved each month N/A Monthly 2 delayed 2 delayed 0 delayed At 12th July there are no delayed milestones. Phase 2 of the project is currently in development and will Alison Heeralall Deliver the Staff Engagement and Wellbeing plan 13) Improve on: - staff engagement from score of 3.95 to 4+ in the annual staff survey - staff engagement scores in staff FFT questions (quarterly) 4+ Annual Quarterly Pending Q2 staff FFT Pending Q2 staff FFT Q1 staff FFT completed Highlights from the staff FFT survey include: Staff reporting how likely they were to recommend HRCH to friends or family if they needed treatment: Extremely likely/likely up 2% (now 92.4%, was 90.36%) Staff reporting how likely were to recommend HRCH as a place to workl Extremely likely / likely up nearly 1% (was 73.1%, now 73.94%) Staff reporting they were satisfied with recognition received for good work? Up 3.2%, Was 56.62%, now 59.82% Donna Lamb Deliver year 1 of the NHSE Always Events programme 14) The number of Always Events in place (baseline from Q4 2017/18 is 3; target for end of Q1 2018/19 is 4) 4 (Q4) Quarterly 3 in place 3 in place 3 in place Always events codesigned statements established for all 3 events (EOLC/LTCs; Dementia; TMH Inpatients). Next steps include: EOLC/LTCs - test the first version of the aim statement by 30/06. Hold review sessions with staff and patients to incorporate feedback and refine the approach as needed; TMH - implement and test the first version of the aim statement by 30 June. Hold review sessions with staff and patients to incorporate feedback and refine the approach as needed; Dementia - Create implementation plans and test the first version of the aim statement by 30/06. Hold review sessions with staff and patients to incorporate feedback and refine the approach as needed

50 2018/19 Strategic Priorities Scorecard Q1 Director Sponsor Whole Systems - Key Actions Key Performance Indicators Apr-18 May-18 Jun-18 Additional Comments Deliver year 1 of the Trust Monique Carayol component of the STPs 15) HRCH component of the Health and Social Care Plans for Hounslow and Kingston & Richmond (K&R) completed See additional comments NWL: HCCG 2018/19 delivery programme plans were developed in partnership and include transformation workstream areas to enable seamless integrated care between primary care and the community, scheduled for presentation to CCG board for approval on 26/06. Building blocks with Hounslow CCG defined for transition to MCP on 11/07. HRCH quarterly in-year transition milestones for Q1-4 at strategic and tangible level identified. SWL: Transformation priority areas have been outlined and provisionally agreed with RCCG. The proposed CQUIN and locality working milestones for 2018/19 are in the process of being agreed with go live from Q2. RCHiP to write formally to RCCG to clarify commissioning intentions to 31/03/19 including milestones to progress transitioning to the next phase of MCP development for the partnership. Patricia Wright To lead where appropriate on the development and delivery of integrated health and social care 16) Development of locality working systems in Hounslow and Richmond in line with NWL and SWL Integrated Care Partnerships See additional comments Regular Richmond Locality Partnership meetings established with membership from CCG, community services, primary care, social services, mental health and Healthwatch. Locality working operational model agreed. Monthly MDTs taking place with social care and GPs in attendance. The number of MDTs taking place are being captured whilst quality metrics and people outcomes are in development. Twickenham and Whitton pilot agreed and scoped in partnership with social services and GPs. Pilot to commence in July and will include identification of share user cohorts, care coordination and weekly MDTs. Voluntary sector partners engaged with agreement to attend weekly MDTs.

51 2018/19 Strategic Priorities Scorecard Q1 Director Sponsor Sustainable - Key Actions Key Performance Indicators Target Review Frequency Apr-18 May-18 Jun-18 Additional Comments David Hawkins Comply with the financial targets agreed against trajectories 17) Monthly spend within 5% of control total monthly plan for: (a) Surplus (b) Agency Within 5% control total Monthly 0.17% above control total 8% above control total Expenditure was in higher in Q1 due to: - Increased agency spend in paediatrics - External consultancy fees - IPU increased pay costs due to extended implementation of new clinical restructure - Agency costs - Increased interpreting services Agency spend is higher in Q1 against the agency cap due to increased use of paediatric medical staff and corporate agency staff. The cap reduced significantly this year also having an impact. A detailed drill down into areas of spend has begun with trajectories in place and a review of future use of all agency staff is underway. Optimise the HRCH estate ensuring we meet the targets set in the Lord Carter Review whilst remaining compliant with CQC s.15 requirements 18) Analysis of estate spend and utilisation on a 6 monthly basis in line with Carter requirements - Un-occupied building area for HRCH Estate must be below 2.5% as per the Carter Review metric; - non-clinical occupied floor area must be below 35% for HRCH clinical premises as per the Carter Review metric Analysis completed in Q1 N/A 6 Monthly 2018/19 following Results to be shared w/c 16/07. implementation of phased agile working.

52 Meeting title Trust Board part I meeting Dates: Report title Response to the Independent Review into Liverpool Community Healthcare NHS Trust Agenda item: 12 Lead director Report authors Donna Lamb, Director of Nursing & Non-Medical Professionals Swarnjit Singh, Trust Secretary, Donna Lamb, Director of Nursing & Non- Medical Professionals, John Omany, Medical Director, David Hawkins, Director of Finance & Corporate Services, Alison Heeralall, Director of Workforce and Patricia Wright, Chief Executive Executive summary The purpose of this paper is to highlight concerns reported in the Kirkup report published in January 2018 and to begin to compare and contrast areas of learning and/or assurance that may be applicable to Hounslow & Richmond Community Healthcare NHS Trust. Purpose: Recommend ation(s) Review Trust Board members areas asked to: i. note and receive the key findings from the Kirkup review into Liverpool Community Health (appendix 1); ii. iii. take significant assurance from the review by executive directors of the Kirkup findings and the statement of the trust s current position (see appendix 3) in relation to them; and note that the Quality Governance Committee reviewed the Kirkup findings more closely together with the Trust s assurances in further detail and took comfort that a similar situation is not likely to arise at the Trust for the reasons laid out in appendix 3. BAF/TRR Report history Appendices Q1 Executive Committee, 10 July 2018; Quality Governance Committee, 12 July : Capsticks report, Quality, safety and management assurance review at Liverpool Community Health NHS Trust: 16/Capsticks%20Report.pdf 2: Dr Bill Kirkup CBE, Report of the Liverpool Community Health Independent Review: _IndependentReviewReport_V2.pdf 3: Executive team assessment of HRCH position against Kirkup s key findings Page 1 of 11

53 Response to the Independent Review into Liverpool Community Healthcare 1. Background 1.1 This paper highlights concerns reported in the Kirkup Report published in January 2018 into Liverpool Community Trust (LCT) and compares and contrasts areas of learning and/or assurance that may be applicable to Hounslow and Richmond Community Healthcare NHS Trust. Liverpool Community Trust (LCT) 1.2 LCT came into being in November 2010 as a result of the then DoH policy Transforming Community Services. It acquired the majority of NHS Sefton s community services and community dentistry for Knowsley in April LCT employed around 2,500 WTE permanent staff, 80% of which were clinicians. Revenue for the same period was 143 million with a surplus of 3.5 million. In April 2014, revenue had reduced to million and staffing was approximately the same. 1.4 Services included adult care, child and adolescent care, community dentistry, prison healthcare and public health. 2. Capsticks review 2.1 In November/December 2013, the Care Quality Commission (CQC) identified a range of serious issues and systemic failings requiring immediate attention. This inspection had, in part, been prompted by a number of whistleblowing concerns raised by LCT staff to the CQC. Concerns had also been raised with a local MP, who had a recent and personal negative experience of services managed by LCT. In February 2014, the MP raised concerns with the Prime Minister and t h e Secretary of State for Health. 2.2 NHS Improvement appointed an interim team of Directors with a remit to turn the failing Trust around. In response to the CQC report, Capsticks LLP completed a quality, safety and management assurance review which was published in March 2016 (see appendix 1). 2.3 The Capsticks report generated a sustained level of concern about LCT s management culture and practices demonstrated by senior managers. It also raised questions about the quality of healthcare provided by LCT both in the community and in HMP Liverpool. Kirkup review 2.4 NHS Improvement commissioned Bill Kirkup CBE to carry out an independent review into issues relating to LCT between November 2010 and December This review also looked at the oversight of the trust by the Trust Development Authority, NHS England and commissioners. 2.5 The Kirkup report received wide media attention and will undoubtedly feature in the future thinking of regulators, commissioners, NHS Trust Boards and patients. It explains how unrealistic self-imposed cost improvement programmes at LCT, in a bid to gain foundation trust status, actually put the safety of patients at Page 2 of 11

54 risk. A culture of bullying meant that staff were scared to speak up, leading to incidents being ignored or not escalated (see appendix 2). 2.6 The Kirkup report summarises the position as: widespread failings in LCT services showing, in stark terms, what can happen if services are taken for granted, and if warning signs are overlooked. An inexperienced Board and senior staff, received inadequate scrutiny because LCT was regarded as low risk, in part due to the nature of the services provided. The end result was unnecessary harm to patients over a period of several years, and unnecessary stress for staff that were, in some cases, bullied and harassed when they tried to raise concerns about a deterioration in patient services. These were replicated in the health services the Trust provided to HM Prison Liverpool and contributed, in part, to the wider problems afflicting the prison that have received attention. 3. Review findings: the importance to HRCH 3.1 The Kirkup report makes a series of findings that are clear and critical of LCT. It is clear in light of all of these failings that the Trust was seriously dysfunctional. There was a lack of leadership at senior and middle levels. The Trust Board lacked the capability to see beyond its goal of becoming a FT, and failed to recognise the significant harm that its programme of cost reduction was inflicting. Demoralised staff were badly treated and sometimes bullied, and there was a failure of nursing management and HR procedures. Serious incidents causing patient harm were not reported, not investigated and lessons not learned. The result was unnecessary harm to patients. The Trust not only failed in its duty to provide safe and effective services, it concealed this from external bodies. Both patients and staff suffered harm for too long as a result. 3.2 For the purpose of this paper, findings have been grouped into the following categories: Organisation and Leadership Patients Services and Patient Care Staff Financial: Stability, Oversight and Governance Commissioners and Bodies with Trust Oversight 3.3 In appendix 3, each of these Kirkup findings have been highlighted in the five thematic categories shown above. Each finding has also been reviewed by the executive team and the trust s position outlined. 3.4 Kirkup identified serious failures across LCT at that time which spanned the organisation from floor to Board and demonstrated how failures had a direct impact on the care provided to patients. 3.5 It is felt that there are significant differences between LCT and HRCH and that such risks to patient safety have not manifested themselves at HRCH. However, Kirkup also identified wider issues across LCT that will also have impact on quality which Page 3 of 11

55 HRCH should assure itself on; one such wider concern is the significant annual CIP target (7% in 2018/19 - the highest in London, although work is taking place with other London trusts to see wqhat they report in their CIPs), and any potential impact upon the delivery of high quality services. 4. Recommendations 4.1 Members are invited to: i. note and receive the key findings from the Kirkup review into Liverpool Community Health (appendix 2); ii. iii. take significant assurance from the review by executive directors of the Kirkup review s findings and the statements of the trust s current position (see appendix 3) in relation to them; and note that the Quality Governance Committee reviewed the Kirkup findings at its July meeting together with the Trust s review and was assured that a similar situation is not likely to arise at the Trust for the reasons laid out in appendix 3. Page 4 of 11

56 Appendix 3: HRCH response to Kirkup findings Kirkup finding Organisation and leadership LCT was dysfunctional HRCH assurance/response/review to this finding There is no evidence that HRCH is dysfunctional. The trust has a stable and relatively experienced board that works well together. External and internal audit findings of systems and processes within the trust are consistently favourable and this has been confirmed by NHSi and CQC. Inappropriate pursuit of Foundation Trust (FT) status dominated management team s time/attention. Board was blind to organisational concerns Set infeasible financial targets that damaged patient services FT pipeline currently paused so this is not a relevant consideration for HRCH. The trust has processes in place, linked to its commercial plan, to assess whether there is sufficient capacity and capability to take on new projects/programmes of work. The board and sub-committee agendas have a good balance of operational and strategic issues. The HRCH programme management process includes a robust QIA process that mitigates against this happening. The trust has strong working relationships with its two main commissioners. It can evidence codesign of services where cost reductions are required and has challenged (successfully) moves to reduce budgets which could compromise patient care. Senior leadership and the Board was out of its depth and did not heed warnings Experienced and stable senior leadership team and Board in place at HRCH. Four current Board members (one executive and three non-executive director) have been with the organisation since its 2011 commencement order. CEO has experience of working in financially challenged organisations Inexperienced management team providing inadequate leadership Inexperienced Chair and NEDs offering insufficient See above. Also, experienced executive director team in place. See above. Also, experienced NEDs in place and along with the Board Advisor have provided Page 5 of 11

57 Kirkup finding Organisation and leadership challenge HRCH assurance/response/review to this finding sufficient examples of challenge at Board and Board Committees on areas such as: Commercial strategy ambition Staff sickness absence levels Concerns about Community nursing (two reports and a workshop since Jan 2018) Medical Director had no clear responsibility for clinical quality Confused and conflicted arrangements resulted in failure to identify serious risks in LCT s cost improvement programme. The Nurse Director was (for part of the period) responsible for clinical quality as well as for setting cost improvement targets. The Finance Director was, for a period, responsible for clinical quality. The Board s reaction to a gathering crisis was based on denial with managers remaining focussed on becoming an FT Kirkup finding Patient services and patient care Significant unnecessary harm occurred to patients. It is clear that services suffered. Medical Director shares responsibility for clinical quality and oversight with the Director of Nursing and Non-Medical Professionals. HRCH has a well-defined CIP process and a successful track record of annual delivery. Clearly differentiated responsibilities for clinical quality (see above) and for delivering the annual financial plan, including CIP (Director of Finance & Corporate Services) The trust board can evidence their rapid response to when things go wrong (TMH IP inadequate rating by CQC in 2016) and robust processes for monitoring and triangulating performance information to provide intelligence about services which are struggling (Community nursing) HRCH s quarterly Quality reports considered by the Quality & Safety and Quality Governance Committees highlight whether patients suffer harm. The trust has high levels of no harm incidents reported on datix, demonstrating a commitment to identification of potential for harm. The Trust has developed a daily situation report for the community nursing service which along with the Quality dashboard give early warning of potential hotspots. Page 6 of 11

58 Kirkup finding Patient services and patient care Ill-equipped to manage services; especially prison healthcare The trust reported 11 serious incidents in 2017/18 which related to patient care. The Trust has been a stand-alone community healthcare trust since its inception in 2011 and has therefore strength, experience and skill in managing a range of core, specialist, urgent care and inpatient community services. The trust also provides some services (neonatal hearing screening, health promotion, immunisations) outside of the boroughs of Hounslow and Richmond and employs a successful matrix model of working to do this. Where the trust has considered diversification (GP OOH services) this is rigorously risk assessed and undertaken in partnership with organisations with suitable expertise. The WMUH UCC is a good example of the trust working with an experienced urgent care provider of GP services as it was recognised this was an area of expertise lacking in the trust. Lack of recognition of relevant experience or capability to manage the HMP Liverpool service. This caused significant harm to patients. Risk (especially clinical risk) was not clear or effective. Processes did not inform impact assessments linked to financial proposals. Incidence of mandatory patient harm incidents HRCH has no intention to provide healthcare services in HMPs and this is not applicable to us. See also comments above about diversification HRCH has a clear strategy including processes for risk identification, mitigation and review. HRCH also has an externally- acknowledged (NHSI) robust process for Quality Impact Assessments of all CIP schemes and these do not proceed to implementation should any adverse impact on the quality or care services be identified. The QIA process includes trigger indicators so that any impact on patient safety, patient or staff experience and clinical effectiveness is identified and responded to promptly. QIA panel outcomes are reported to the Quality Governance Committee. There has been no increase in mandatory patient harm incidents at HRCH during the last 24 Page 7 of 11

59 Kirkup finding Patient services and patient care rose. months. The trust uses statistical process control to identify the normal range of incident reporting; between April 2016 and March 2018, the trust has remained within upper and lower control limits. This is evidenced in our Quality Account 2017/18. All moderate harm incidents are reviewed by a senior clinician. In 2017/18, there were 9 statutory duty of candour cases at HRCH. They all related to SIs with the exception of one case which was identified through a complaint being raised. During 2017/18, the trust used patient safety incident reports to identify when deep dives were required. These included pressure ulcers and falls. Action planning for improvement (following incident reporting) was absent or invisible. Each serious incident (SI) is investigated through a root cause analysis. This includes the development of an action plan. There is good oversight of the action plans accompanying each SI investigation. The closure of SI cases/reports is monitored by the Quality & Safety Committee and reported to the Quality Governance Committee. Kirkup finding Staff Staff were overstretched, demoralised and in some instances, bullied. There is evidence of staff working long hours and of low levels of bullying in the trust, but overall staff engagement is high and staff reporting stress is lower than national averages. (lowest i.e. best out of all community trusts for the last two years. In addition, staff score top out of community trust nationally for being motivated about their roles, satisfied with the care they are able to provide and recommending the trust as a place to work. Despite this, the trust has taken both issues seriously and has implemented an extensive H&WB programme in the last 18 months and is currently undertaking listening events with a wide range of staff to truly understand what needs to be done to reduce staff pressure and continue to increase engagement. Staff did not feel involved The trust has a betterfastercheaper inbox for Page 8 of 11

60 Kirkup finding Staff in planning for the impact of cost measures etc. Did not feel listened to when reporting concerns anyone to submit ideas and also launched a Small changes, bug difference campaign, the aim of which is to involve everyone across the organisation clinical and corporate in meeting the 2018/19 CIP target. Staff are encouraged to report concerns either via the Datix incident recording system or through their line manager or the Trust s Freedom to Speak Up Guardian The trust always responds when concerns are raised (e.g. DN issues 2016 & 2017; Recent concerns re insulin administration) Response to staff concerns/grievances was seriously deficient (including suspension). There were examples of very poor HR and nursing practice and leadership. Sickness levels increased. The trust can evidence appropriate and documented responses to staff raising concerns (see above) No evidence. The trust invested in a dedicated Executive Director of Workforce since November 2015 and has a specific Director of Nursing & non-medical professionals both qualified with many years of experience in their field to ensure their teams are also suitably led and qualified to advise on best practice Sickness levels at a trust-level have been in the range 3%-4% for some time. Divisional performance variations are monitored through DMT and the Finance & Performance Committee A deep dive on sickness absence was presented to F&P in This benchmarked the trust over the last 5 years and provided no evidence for concern, with seasonal variations now incorporated into our KPIs Staff did not share the Trust s principal objective to become an FT. Staff reported being discouraged to report incidents with instances of concerns being downgraded in This is not a current issue for HRCH At HRCH, staff are regularly encouraged to report incidents and concerns and to record them on Datix as part of risk management processes. Focus groups have also been held recently to encourage the consistency of reporting Page 9 of 11

61 Kirkup finding Staff importance. Middle managers were caught in the middle (between LCT s insistence re: cost reductions and maintain safe services). Their response was inadequate/inappropriate and included extreme action against junior staff. This was inexcusable. Staff operated in a climate of fear and insecurity leading to reluctance to speak out. The integration of staff with different organisational culture (Sefton and HMP Liverpool) caused friction and worsening morale. The HRCH QIA process ensures that there is an initial assessment of schemes to ensure there will be no impact on the quality of service delivery, along with ongoing review against trigger points. The trust also holds a quarterly Leader Forum and promotes Leaders at all Levels so that support and sharing of good practice is inclusive for all managers. In addition, the workforce directorate developed an in house Management Essentials programme in 2016 that provide training and tools for any new or existing manager. The trust has a Speak up Guardian that they are encouraged to contact if they feel unable to discuss matters with their managers and managers have recently attended Human Factors training which further encourages an open learning culture There was some initial concern with bringing two very different cultures and working practices together back in 2011 Kirkup finding Financial: stability, oversight and governance LCT was asked to achieve significant four year cost savings (whilst sustaining current service provision) with little or no challenge back to commissioners. This tipped the Trust into a position of major cost pressures. Self-imposed cost pressures were set unrealistically at 15% per year (whereas the upper end is normally 4%). The trust has strong working relationships with its two main commissioners. It can evidence codesign of services where cost reductions are required and has challenged (successfully) moves to reduce budgets which could compromise patient care. A cost pressure level of 15% is unrealistic. The Finance & Performance Committee are concerned at the current level of 7% and require assurance at each meeting regarding progress. Page 10 of 11

62 Kirkup finding Financial: stability, oversight and governance Impact assessments (of planned cost savings) were grossly deficient, nor actively managed or reviewed. Cost improvement measures were overambitious and illconsidered. Simultaneously attempted to generate significant cash surplus during the same period (in pursuit of being an FT) Cumulative impact of cost savings and income generation not adequately considered. HRCH has a robust Quality Impact Assessment process which reviews the impact of each cost improvement scheme, and sets trigger points for ongoing management and review. Again the QIA process will review each scheme to ensure that they are deliverable and will not impact on quality. This is not relevant to HRCH at the current time regarding FT process. HRCH currently has high cash reserves and so does not feature in its aims and ambitions to increase further. HRCH are mindful when considering all efficiency schemes via QIA about their respective impacts, whether they are income generating or cost saving. Kirkup finding Commissioners and bodies with NHS Trust oversight External bodies failed to pick up the problems for four years. Two CCGs (LCT s commissioners) seemed not to have a view on the cumulative impact of cost savings demanded. Service commissioners did not take adequate steps to identify problems with the services delivered by LCT. Regular contract monitoring meetings are held with commissioners, and details of CIP schemes shared. Finance and performance scorecards are also sent to them monthly so that they can see the overall organisational position. Work is also progressing on joint QIPP work. As above this information is shared with commissioners. As above regular contract monitoring and performance meetings are held with commissioners. Page 11 of 11

63 Meeting title HRCH Board part I meeting Date: 25/07/2018 Report title Response to the Gosport Community Hospital Independent Panel review Agenda item: 13 Lead director Report author John Omany, Medical Director John Omany Executive summary The purpose of this paper is to highlight the findings of the Gosport Community Hospital Independent Panel report published in June 2018, and to provide assurance that the Trust has the appropriate governance in place to ensure that the inappropriate use of opioids does not occur at Teddington Memorial Hospital (TMH). Purpose: Noting Recommendation(s) Board members are asked to: a. note the findings form the Gosport Community Hospital review; and b. take significant assurance from the governance processes and checks in place at TMH which ensure that opioid use at TMH is appropriate, and any inappropriate use will be detected. BAF/TRR Q1 Report history Executive Committee, 10 July 2018 Appendices None

64 Response to the Gosport Community Hospital Independent Panel review 1. Background 1.1 This paper is a response to the Gosport Independent Panel led by the former bishop of Liverpool, the Rt. Rev James Jones into the inappropriate use of opioids at the Gosport memorial Hospital, concluded that more than 450 people had their lives shortened after being prescribed powerful painkillers that was not clinically indicated or justified. 2. Context: Opioids 2.1 Opioids are drugs used in pain management and are and are amongst the most effective treatments for severe pain. The most well-known opioids are codeine and morphine. In palliative and end of life care, opioids are used for pain associated with cancer and to relieve the symptoms of cough, breathlessness and diarrhoea arising from both cancer and non-malignant diseases. 2.2 When used appropriately: Opioids are safe and effective drugs to use in cancer pain management and to relieve other symptoms associated with cancer and non-malignant diseases. Opioid abuse and addiction is rare in people with advanced illness when opioids are prescribed under close medical supervision. Correct opioid use, at the end of life, does not shorten life. 3. Gosport Independent Panel findings 3.1 The Gosport report found that: There was an institutionalised regime of prescribing and administering dangerous doses of a hazardous combination of medication. In addition the report found that hospital management, Hampshire Police, the CPS, GMC and NMC all failed to act in ways that would have better protected patients and relatives, and that patients and relatives were powerless in their relationship with professional staff. The inquiry also found that whistle-blowers and families were ignored as they attempted to raise concerns about the administration of opioids at the hospital. 4. HRCH response to the Gosport review findings: 4.1 HRCH has appropriate governance processes in place to ensure the appropriate use of opioid medication at Teddington Memorial Hospital (TMH) and appropriate governance in place to monitor GP and nurse practice on the ward. Nursing staff are empowered and able to speak up should they have any concerns relating to the use of opioids on the ward and concerns raised by staff and relatives are listened to.

65 The pharmacy team carry out regular check on all drug charts and on the ward and will be able to pick up and unusual or inconstant prescribing or ordering of opioids on the ward. There is no evidence of the routine prescribing or institutionalisation of the prescribing of large doses of opioids that is not clinically justified, and no patient is given opioids without appropriate clinical records All deaths at TMH are reviewed as part of our mortality review process; the review process includes a review of the care including the use of medication during the admission and any inappropriate prescribing will be picked up by the process. In terms of a Look Back, none of the staff members who have worked at or had an association with TMH over that past few years have expressed any concerns relating to inappropriate prescribing of opioids or unexplained deaths related to opioid use. At this time there does not appear to be a need for a look back at TMH. The use of the Grasby (MS 16) syringe drivers has also been mentioned in the press, I can confirm that following a NPSA alert in 2010, the MS16 Grasby pumps (hourly administration) was removed from practice in 2010 and replaced with the MS 26 Grasby pumps (24hourly administration) these have now been superseded by the McKinley syringe drivers which HRCH moved to in Recommendations 5.1 The board is asked to note the findings form the Gosport hospital review 5.2 Take significant assurance from the governance processes and checks in place at TMH that ensure that opioids use at TMH is appropriate, and any inappropriate use will be detected.

66 Meeting title Trust Board part I meeting Date: 25/7/2018 Report title Learning from deaths dashboard Agenda item: 14 Lead director Report authors Executive summary John Omany, Medical Director Chris Giles, Assistant Director, Contracts & Performance, and David Griffiths, Information Analyst This is the third Trust Learning from Deaths Dashboard under the new Trust Learning from Deaths Policy. NHSI s National Guidance on Learning from Deaths, published in March 2017 which states, community trusts should ensure their governance arrangements and processes include, facilitate and give due focus to the review, investigation and reporting of deaths, including those deaths that are determined more likely than not to have resulted from problems in care. Trust should also ensure that they share and act upon any learning derived from these processes. The Trust will report separately for adults dying in the Teddington War Memorial Hospital (TMH) and the community as well as for Learning Difficulties, through the LeDeR process, managed by the CCGs. The following are the definitions used for inclusion in the reporting dashboards: Adults Services All deaths of patients in our inpatient care or who have been recently discharged within 30 days are to be screened once the service becomes aware of the death. All deaths occurring while services were being provided in the carrying on of a regulated activity or have, or may have, resulted from the carrying on of a regulated activity (e.g. wrong dose of medication given) are to be screened once the service becomes aware of the death. (These deaths would be reportable to CQC) In addition to the mandatory list above the Trust intends taking a pragmatic approach to identifying other groups that would require review. This list is not exhaustive and may be added to at any time and does not exclude other examples or events. Front line clinicians and managers need to identify any case that might warrant review and where learning would be beneficial; Cases on the adult caseload: Where there is any concern that management could have been better compared to what we would expect for a relation of our own. Where the GP, pharmacist or any other relevant health professional requests a review Where patient family or friend raise issues or concerns Where individual members of clinical team wish for a review to take place The Trust has determined that it will record the total number of deaths Page 1 of 2

67 across the service that were currently on the services caseload, where we are informed of the death. These deaths may be entirely unrelated to the services the Trust provide, e.g. road traffic accident, deaths from unrelated causes, e.g. stroke in a wound management patient, etc. On reviewing this data in twelve months time, the Trust will determine the workload resource associated with screening and reviewing these cases and what, if any, learning would be achieved by doing so. two dashboards have been provided; The first Whole Trust dashboard displays deaths of patients that appear on the organisation total caseload. Month (and deaths) April (161) May (151) June (185) Quarter (and deaths) Q1 2018/19 (497) The second dashboard displays Inpatients Only activity for Teddington War Memorial Hospital. Month (and deaths) April (1) May (0) June (0) Quarter (and deaths) Q1 2018/19 (1) No reviews or investigations have taken place as the criteria were not met. Purpose: Recommendation(s) For review The Board is asked to: i. receive and discuss the mortality dashboard; ii. note that no conclusions, trends or learning can be identified at this time as numbers are very small; and iii. note that the Trust awaits the report from the Richmond CCG regarding learning disability deaths. BAF/TRR Report history Appendices Q1/Q2 12 July 2018 Quality Governance Committee Appendix 1: Learning from deaths dashboard TMH Appendix 2: Learning from deaths dashboard Trustwide Page 2 of 2

68 Hounslow & Richmond Community Healthcare NHS Trust (TMH Inpaents Only): Learning from Deaths Dashboard - June Description: The suggested dashboard is a tool to aid the systematic recording of deaths and learning from care provided by NHS Trusts. Trusts are encouraged to use this to record relevant incidents of mortality, number of deaths reviewed and cases from which lessons can be learnt to improve care. Summary of total number of deaths and total number of cases reviewed under the Structured Judgement Review Methodology Total Number of Deaths, Deaths Reviewed and Deaths Deemed Avoidable (does not include patients with identified learning disabilities) Total Number of Deaths in Scope Total Deaths Reviewed Total Number of deaths considered to have been potentially avoidable (RCP<=3) This Month Last Month This Month Last Month This Month Last Month This Quarter (QTD) Last Quarter This Quarter (QTD) Last Quarter This Quarter (QTD) Last Quarter This Year (YTD) Last Year This Year (YTD) Last Year This Year (YTD) Last Year Time Series: Start date Q1 End date Q Mortality over time, total deaths reviewed and deaths considered to have been potentially avoidable (Note: Changes in recording or review practice may make comparison over time invalid) Q Q2 Q3 Q4 Q Q2 Total deaths Deaths reviewed Total Deaths Reviewed by RCP Methodology Score Score 1 Score 2 Score 3 Score 4 Score 5 Score 6 Definitely avoidable Strong evidence of avoidability Probably avoidable (more than 50:50) Probably avoidable but not very likely Slight evidence of avoidability Definitely not avoidable This Month 0 - This Month 0 - This Month 0 - This Month 0 - This Month 0 - This Month 0 - This Quarter (QTD) 0 - This Quarter (QTD) 0 - This Quarter (QTD) 0 - This Quarter (QTD) 0 - This Quarter (QTD) 0 - This Quarter (QTD) 0 - This Year (YTD) 0 - This Year (YTD) 0 - This Year (YTD) 0 - This Year (YTD) 0 - This Year (YTD) 0 - This Year (YTD) 0 - Summary of total number of learning disability deaths and total number reviewed under the LeDeR methodology Total Number of Deaths, Deaths Reviewed and Deaths Deemed Avoidable for patients with identified learning disabilities Total Number of Deaths in scope Total Deaths Reviewed Through the LeDeR Methodology (or equivalent) Total Number of deaths considered to have been potentially avoidable This Month Last Month This Month Last Month This Month Last Month This Quarter (QTD) Last Quarter This Quarter (QTD) Last Quarter This Quarter (QTD) Last Quarter This Year (YTD) Last Year This Year (YTD) Last Year This Year (YTD) Last Year Time Series: Start date Q1 End date Q Mortality over time, total deaths reviewed and deaths considered to have been potentially avoidable (Note: Changes in recording or review practice may make comparison over time invalid) Q Q2 Q3 Q4 Q Total deaths Deaths reviewed

69 Hounslow & Richmond Community Healthcare NHS Trust (HRCH Trustwide): Learning from Deaths Dashboard - June Description: The suggested dashboard is a tool to aid the systematic recording of deaths and learning from care provided by NHS Trusts. Trusts are encouraged to use this to record relevant incidents of mortality, number of deaths reviewed and cases from which lessons can be learnt to improve care. Summary of total number of deaths and total number of cases reviewed under the Structured Judgement Review Methodology Total Number of Deaths, Deaths Reviewed and Deaths Deemed Avoidable (does not include patients with identified learning disabilities) Total Number of Deaths in Scope Total Deaths Reviewed Total Number of deaths considered to have been potentially avoidable (RCP<=3) This Month Last Month This Month Last Month This Month Last Month This Quarter (QTD) Last Quarter This Quarter (QTD) Last Quarter This Quarter (QTD) Last Quarter This Year (YTD) Last Year This Year (YTD) Last Year This Year (YTD) Last Year Time Series: Start date Q1 End date Q Mortality over time, total deaths reviewed and deaths considered to have been potentially avoidable (Note: Changes in recording or review practice may make comparison over time invalid) Q Q2 Q3 Q4 Q Q2 Total deaths Deaths reviewed Deaths considered likely to have been avoidable Total Deaths Reviewed by RCP Methodology Score Score 1 Score 2 Score 3 Score 4 Score 5 Score 6 Definitely avoidable Strong evidence of avoidability Probably avoidable (more than 50:50) Probably avoidable but not very likely Slight evidence of avoidability Definitely not avoidable This Month 0 - This Month 0 - This Month 0 - This Month 0 - This Month 0 - This Month 0 - This Quarter (QTD) 0 - This Quarter (QTD) 0 - This Quarter (QTD) 0 - This Quarter (QTD) 0 - This Quarter (QTD) 0 - This Quarter (QTD) 0 - This Year (YTD) 0 - This Year (YTD) 0 - This Year (YTD) 0 - This Year (YTD) 0 - This Year (YTD) 0 - This Year (YTD) 0 - Summary of total number of learning disability deaths and total number reviewed under the LeDeR methodology Total Number of Deaths, Deaths Reviewed and Deaths Deemed Avoidable for patients with identified learning disabilities Total Number of Deaths in scope Total Deaths Reviewed Through the LeDeR Methodology (or equivalent) Total Number of deaths considered to have been potentially avoidable This Month Last Month This Month Last Month This Month Last Month This Quarter (QTD) Last Quarter This Quarter (QTD) Last Quarter This Quarter (QTD) Last Quarter This Year (YTD) Last Year This Year (YTD) Last Year This Year (YTD) Last Year Time Series: Start date Q1 End date Q Mortality over time, total deaths reviewed and deaths considered to have been potentially avoidable (Note: Changes in recording or review practice may make comparison over time invalid) Q Q2 Q3 Q4 Q Total deaths Deaths reviewed

70 Meeting title Trust Board part I meeting Date: 25/07/18 Report title 2017/18 Annual Board Report on the Trust s Appraisal & Revalidation processes and Medical Governance Item: 15 Lead director Report author Executive summary Dr John Omany, Medical Director and Responsible Officer Dr John Omany This annual report on the implementation of revalidation for doctors forms part of NHS England s Framework of Quality Assurance for the revalidation of doctors and demonstrates the Trust s compliance with the regulations. Purpose: Noting Recommendation(s) The Board is asked to note the report BAF/TRR Report history Appendices ID 449 Incident reporting governance ID 832 Doctor governance arrangements Executive committee 10 th July 2018, QGC 12 th July, Trust Board 24 th July. 1: NHS England - Annual Organisational Audit End of year questionnaire : Annex E: Statement of compliance Page 1 of 5

71 1. Executive summary 1.1 A comprehensive review of the revalidation process and all systems and processes that relate to the quality assurance of revalidation has been undertaken in preparation for this annual report. The Trust is directly responsible for the 11 employed doctors and indirectly responsible for doctors employed under sub-contracts, mainly GPs. The paper demonstrates that the Trust meets all its relevant regulatory requirements with regards to the appraisal and revalidation of doctors in the Trust. The Trust receives assurance though the performance management of its sub-contracts with other providers of their regulatory compliance. 2. Purpose of the report 2.1 This annual report forms part of the NHS England (NHSE) Framework of Quality Assurance (FQA) for Responsible Officers (RO) and Revalidation. It provides the Trust (HRCH) Board with an annual review of its position in relation to medical appraisal, revalidation and the governance processes and provides assurance to patients, the public and to our wider stakeholders that doctors holding a licence to practise and delivering care on behalf of HRCH are up-to-date and fit to practise. This report follows the format provided by the NHSE FQA. 3. Background 3.1. This is the fifth annual report on revalidation submitted to the HRCH Board (following the launch of Revalidation in 2012). All doctors with a licence to practice must participate in an annual medical appraisal and on a five yearly cycle, the Responsible Officer (RO) of HRCH is required to make one of three statements to the General Medical Council (GMC) in respect of each doctor that has a prescribed connection to the organisation. This statement will be either: a positive recommendation that the doctor is up to date and fit to practise, a request to defer the date of revalidation, or a notification of the doctor s non-engagement in appraisal. Provider organisations have a statutory duty to support their RO in discharging their duties under the Responsible Officer Regulations Governance Arrangements 4.1 Medical Governance in HRCH is structured so that assurance can be given to the Board that all doctors delivering care on behalf of HRCH are up-to-date and fit to practise. 4.2 The Medical Governance framework divides the doctors who deliver care on behalf of HRCH into two groups. The first group are those with a prescribed connection to HRCH (11 doctors) these are the directly employed doctors, and the second group, (which is the much larger group (88) who are not directly employed, and have a prescribed connection elsewhere, but are subcontracted to work for HRCH. 1 The Medical Profession (Responsible Officers) Regulations, 2010 as amended in 2013 and The General Medical Council (Licence to Practise and Revalidation) Regulations Order of Council 2012 Page 2 of 5

72 4.3 The internal medical appraisal system was externally quality assured by NHSE who carried out a visit to the Trust in November The report from that visit was sent to the Trust in March 2017 and the action plan that resulted from that visit was reviewed and signed off by the Executive Committee. 4.4 The RO can give the Board a high level of assurance that systems and processes are in place to ensure that the doctors with a prescribed connection to HRCH, are participating in a robust internal medical appraisal system. 4.5 HRCH is not directly responsible for the medical appraisal and revalidation of the doctors who are subcontracted to work for HRCH, the vast majority of these doctors are GPs, who have a prescribed connection to the regional NHSE RO. The HRCH RO receives assurance from the doctors RO on the fitness to practice of these doctors, as well as when appropriate, discussing any issues that have arisen in relation to individual doctors, with the relevant Medical Director (MD) of HRCH sub-contractor organisations. 4.6 In addition, HRCH has systems in place to collect information such as complaints, incidents and Serious Incidents involving these doctors. 5. Medical Appraisal and Revalidation Performance Data 5.1 For the appraisal year ending 31 st March 2018, there were 11 doctors with a prescribed connection to the Trust. Of the 11 doctors, 10 completed an annual appraisal and 1 had an approved delay in their appraisal completion, in line with the requirements of the GMC. 6. Access, security and confidentiality 6.1 Information Governance guidelines have been adopted in local procedures. No patient identifiable data is included in any appraisal documentation. 6.2 The Trust has a responsibility to provide information to all doctors who deliver care on behalf of HRCH for the purposes of their own medical appraisals. 6.3 Medical appraisal requires significant collation, validation, manipulation and presentation of data at an individual and corporate level. Work is under way to ensure that all incidents and complaints relating individual doctors are recorded on Datix. 7. Revalidation Recommendations 7.1 There were no revalidation recommendations in the last appraisal year as no revalidations were due to be completed. 8. Recruitment and engagement background checks 8.1 The Trust operates a centralised recruitment model for medical staff. The Recruitment and Employment Checks Policy was updated and ratified in February 2018 to ensure that our processes are compliant with NHSE check standards. 8.2 As part of the pre-employment checks, the RO asks the doctor s current organisation to highlight any concerns reported during the doctors Page 3 of 5

73 engagement with their organisation via the NHSE Medical Practice Information Transfer form (MPIT). The doctor is asked to declare any other organisations or roles they undertake in a professional capacity and information can be sought from them to ensure a whole practice based appraisal and revalidation process can take place. 8.3 The provision for monitoring and auditing pre-employment checks in subcontractor organisations has been included in the Trust s Recruitments and Employment Checks Policy. Sub-contractor organisations are complying with our request to supply HRCH with the relevant information via the contract monitoring process. The medical operating model at the Urgent Care Centre (UCC) is dependent on locum doctors, these doctors are sourced from agencies that are part of the NHS Framework, which provides assurance. See Annual Report Template Appendix E. 9. Monitoring Performance and Fitness to Practise 9.1 Although the medical appraisal system underpins the system of monitoring a doctor s fitness to practise, this is not the only mechanism by which a doctor s fitness to practise will be scrutinised and it is expected that our clinical governance systems would highlight any concerns. 9.2 Clinical governance systems within HRCH ensures that reporting mechanisms are in place and monitored, which give information about an individual doctor and the team within which the doctor works. 9.3 The Framework of Quality Assurance statement of compliance requires that: There is a process for obtaining and sharing information of note about any licensed medical practitioner s fitness to practise between this organisation s responsible officer and other responsible officers (or persons with appropriate governance responsibility) in other places where the licensed medical practitioner works. 9.4 As part of contractual arrangements with Greenbrook and RGPA, information was provided, as part of contract monitoring. 10. Responding to Concerns and Remediation 10.1 The Trust follows the national frameworks in relation to disciplinary, performance and remediation issues in relation to medical staff. 11. Risks and Issues 11.1 NHSE require HRCH, through the statement of compliance (Appendix E Questions 6 to 9), to provide assurance to NHSE in relation to all licensed medical practitioners. The subcontractor organisations are responsible and accountable for the management of this group of doctors who have no prescribed connection to HRCH but do have a prescribed connection to NHS England 11.2 The NHSE statement of compliance requires that HRCH ensures that information about complaints, incidents etc is provided for doctors to include Page 4 of 5

74 at their appraisal. Reliably and consistently recording staff names on the Datix system is still an issue but steps are being taken to mitigate this risk With the development of new pathways of care and more complex contracting arrangements, medical governance structures need to be constantly under review and further developed 11.4 Annex E is the statement of compliance which will be submitted by the Chair/Chief Executive of HRCH Annexe F is the NHSE June 2018 Medical Revalidation Annual Organisational Audit (AOA) Comparator Report Hounslow and Richmond Community Healthcare NHS Trust, following our submission of audit data for Corrective Actions, Improvement Plan and Next Steps 12.1 The risk register is used to highlight and track the risk and mitigation plans in relation to the medical governance issues. 13. Recommendations The Board is asked to: Note the NHSE Annual Organisational Audit which has been shared with the higher level responsible officer at NHSE Note the Trust s position in relation to the doctors undergoing medical appraisal within HRCH Note the risks and issues Approve the Statement of Compliance Annex E - to be submitted to NHSE by September 28, Reporting with small numbers 14.1 Appendix 1: NHS England - Annual Organisational Audit End of year questionnaire Appendix 2: Annex E: Statement of compliance Page 5 of 5

75 Annual Organisational Audit (AOA) End of year questionnaire

76 OFFICIAL NHS England INFORMATION READER BOX 0114 Directorate Medical Nursing Finance Commissioning Operations Trans. & Corp. Ops. Patients and Information Commissioning Strategy Publications Gateway Reference: Document Purpose Resources Document Name Author Publication Date Target Audience Additional Circulation List Description Annual Organisational Audit Annex C (end of year questionnaire) Lynda Norton 23 March 2018 Medical Directors, NHS England Regional Directors, GPs #VALUE! The AOA (Annex C of the Framework for Quality Assurance) is a standardised template for all responsible officers to complete and return to their higher level responsible officer via the Revalidation Management System. AOAs from all designated bodies will be collated to provide an overarching status report of progress across England. Cross Reference Superseded Docs (if applicable) Action Required Timing / Deadlines (if applicable) Contact Details for further information Document Status A Framework for Quality Assurance for Responsible Officers & Revalidation April 2014 Gateway ref /17 AOA cleared with Publications Gateway Reference By 00 January 1900 Lynda Norton Professional Standards Team Quarry House Leeds LS2 7UE This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. Please do not use this version of the form to submit your response. 2

77 OFFICIAL Annual Organisational Audit (AOA) End of year questionnaire Version number: 2.0 First published: 4 April 2014 Updated: 24 March 2015, 18 March 2016, 24 March 2017, 23 March 2018 Prepared by: Lynda Norton, Project Manager for Quality Assurance, NHS England Classification: OFFICIAL Promoting equality and addressing health inequalities are at the heart of NHS England s values. Throughout the development of the policies and processes cited in this document, we have: Given due regard to the need to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited under the Equality Act 2010) and those who do not share it; and Given regard to the need to reduce inequalities between patients in access to, and outcomes from healthcare services and to ensure services are provided in an integrated way where this might reduce health inequalities. Please do not use this version of the form to submit your response. 3

78 OFFICIAL Contents Contents Introduction Guidance for submission Section 1 The Designated Body and the Responsible Officer Section 2 Appraisal Section 3 Monitoring Performance and Responding to Concerns Section 4 Recruitment and Engagement Section 5 Comments Reference Please do not use this version of the form to submit your response. 4

79 OFFICIAL 1 Introduction The Framework of Quality Assurance (FQA) and the monitoring processes within it are designed to support all responsible officers in fulfilling their statutory duty, providing a means by which they can demonstrate the effectiveness of the systems they oversee. It has been carefully crafted to ensure that administrative burden is minimised, whilst still driving learning and sharing of best practice. Each element of the FQA process will feed in to a comprehensive report from the national level responsible officer to Ministers and the public, capturing the state of play of medical revalidation across the country. The reporting processes are intended to be streamlined, coherent and integrated, ensuring that information is captured to contribute to local processes, whilst simultaneously providing the required assurance. The process will be reviewed and revised on a regular basis. The AOA (Annex C) is a standardised template for all responsible officers to complete and return to their higher level responsible officer. AOAs from all designated bodies will be collated to provide an overarching status report of medical revalidation across England. Where small designated bodies are concerned, or where types of organisation are small in number, these will be appropriately grouped to ensure that data is not identifiable to the level of the individual. The AOA is designed to assist NHS England regional teams to assure the appropriate higher level responsible officers that designated bodies have a robust consistent approach to revalidation in place, through assessment of their organisational system and processes in place for undertaking medical revalidation. Learning from the experience of the Organisational Readiness and Self-Assessment (ORSA) the AOA has a dual purpose to provide the required assurance to higher level responsible officers whilst being of maximum help to responsible officers in fulfilling their obligations. The aims of the annual organisational audit exercise are to: gain an understanding of the progress that organisations have made during 2017/18; provide a tool that helps responsible officers assure themselves and their boards/management bodies that the systems underpinning the recommendations they make to the General Medical Council (GMC) on doctors fitness to practise, the arrangements for medical appraisal and responding to concerns, are in place; provide a mechanism for assuring NHS England and the GMC that systems for evaluating doctors fitness to practice are in place, functioning, effective and consistent. Please do not use this version of the form to submit your response. 5

80 OFFICIAL This AOA exercise is divided into five sections: Section 1: The Designated Body and the Responsible Officer Section 2: Appraisal Section 3: Monitoring Performance and Responding to Concerns Section 4: Recruitment and Engagement Section 5: Additional Comments The questionnaire should be completed by the responsible officer on behalf of the designated body, though the input of information to the questionnaire may be appropriately delegated. The questionnaire should be completed during April and May 2018 for the year ending 31 March The deadline for submission will be detailed in an containing the link to the electronic version of the form, which will be sent after 31 March Whilst NHS England is a single designated body, for the purpose of this audit, the national and regional offices of NHS England should answer as a designated body in their own right. Following completion of this AOA exercise, designated bodies should: consider using the information gathered to produce a status report and to conduct a review of their organisations developmental needs. complete a statement of compliance and submit it to NHS England by the 28 September The audit process will also enable designated bodies to provide assurance that they are fulfilling their statutory obligations and their systems are sufficiently effective to support the responsible officer s recommendations. For further information, references and resources see pages and Please do not use this version of the form to submit your response. 6

81 OFFICIAL 2 Guidance for submission Guidance for submission: Several questions require a Yes or No answer. In order to answer Yes, you must be able to answer Yes to all of the statements listed under to answer Yes Please do not use this version of the questionnaire to submit your designated body s response. You will receive an with an electronic link to a unique version of this form for your designated body. You should only use the link received from NHS England by , as it is unique to your organisation. Once the link is opened, you will be presented with two buttons; one to download a blank copy of the AOA for reference, the second button will take you to the electronic form for submission. Submissions can only be received electronically via the link. Please do not complete hardcopies or copies of the document. The form must be completed in its entirety prior to submission; it cannot be partcompleted and saved for later submission. Once the submit button has been pressed, the information will be sent to a central database, collated by NHS England. A copy of the completed submission will be automatically sent to the responsible officer. Please be advised that Questions may have been automatically populated with information previously held on record by NHS England. The submitter has a responsibility to check that the information is correct and should update the information if required, before submitting the form. Please do not use this version of the form to submit your response. 7

82 OFFICIAL 3 Section 1 The Designated Body and the Responsible Officer SSection The Designated Body and the Responsible Officer Name of designated body: Hounslow and Richmond Community Healthcare NHS Trust Head Office or Registered Office Address if applicable line 1 Thames House Address line 2180 High Street Address line 3 Address line 4 City Teddington County Middlesex Responsible officer: Title ***** GMC registered first name ***** GMC reference number ***** ***** Medical Director: Title ***** GMC registered first name ***** GMC reference number ***** ***** Clinical Appraisal Lead: Title ***** GMC registered first name ***** GMC reference number ***** ***** Chief executive (or equivalent): Title ***** First name ***** GMC reference number (if applicable) ***** Postcode TW11 8HU GMC registered last name ***** Phone ***** GMC registered last name Phone ***** GMC registered last name Phone ***** Last name ***** Phone ***** ***** ***** No Medical Director No Clinical Appraisal Lead Please do not use this version of the form to submit your response. 8

83 OFFICIAL 1.2 Type/sector of designated body: (tick one) NHS NHS England Acute hospital/secondary care foundation trust Acute hospital/secondary care non-foundation trust Mental health foundation trust Mental health non-foundation trust Other NHS foundation trust (care trust, ambulance trust, etc) Other NHS non-foundation trust (care trust, ambulance trust, etc) Special health authorities (NHS Litigation Authority, NHS Improvement, NHS Blood and Transplant, etc) NHS England (local office) NHS England (regional office) NHS England (national office) Independent / non-nhs sector (tick one) Independent healthcare provider Locum agency Faculty/professional body (FPH, FOM, FPM, IDF, etc) Academic or research organisation Government department, non-departmental public body or executive agency Armed Forces Hospice Charity/voluntary sector organisation Other non-nhs (please enter type) Please do not use this version of the form to submit your response. 9

84 OFFICIAL 1.3 The responsible officer s higher level responsible officer is based at: [tick one] NHS England North NHS England Midlands and East NHS England London NHS England South NHS England (National) Department of Health Faculty of Medical Leadership and Management - for NHS England (national office) only Other (Is a suitable person) 1.4 A responsible officer has been nominated/appointed in compliance with the regulations. To answer Yes : The responsible officer has been a medical practitioner fully registered under the Medical Act 1983 throughout the previous five years and continues to be fully registered whilst undertaking the role of responsible officer. There is evidence of formal nomination/appointment by board or executive of each organisation for which the responsible officer undertakes the role. Yes No Please do not use this version of the form to submit your response. 10

85 OFFICIAL 1.5 Where a Conflict of Interest or Appearance of Bias has been identified and agreed with the higher level responsible officer; has an alternative responsible officer been appointed? (Please note that in The Medical Profession (Responsible Officers) Regulations 2010 (Her Majesty s Stationery Office, 2013), an alternative responsible officer is referred to as a second responsible officer) Yes No N/A To answer Yes : The designated body has nominated an alternative responsible officer in all cases where there is a conflict of interest or appearance of bias between the responsible officer and a doctor with whom the designated body has a prescribed connection. To answer 'No : A potential conflict of interest or appearance of bias has been identified, but an alternative responsible officer has not been appointed. To answer 'N/a : No cases of conflict of interest or appearance of bias have been identified. Additional guidance Each designated body will have one responsible officer but the regulations allow for an alternative responsible officer to be nominated or appointed where a conflict of interest or appearance of bias exists between the responsible officer and a doctor with whom the designated body has a prescribed connection. This will cover the uncommon situations where close family or business relationships exist, or where there has been longstanding interpersonal animosity. In order to ensure consistent thresholds and a common approach to this, potential conflict of interest or appearance of bias should be agreed with the higher level responsible officer. An alternative responsible officer should then be nominated or appointed by the designated body and will require training and support in the same way as the first responsible officer. To ensure there is no conflict of interest or appearance of bias, the alternative responsible officer should be an external appointment and will usually be a current experienced responsible officer from the same region. Further guidance is available in Responsible Officer Conflict of Interest or Appearance of Bias: Request to Appoint and Alternative Responsible Officer (NHS Revalidation Support Team, 2014). Please do not use this version of the form to submit your response. 11

86 OFFICIAL 1.6 In the opinion of the responsible officer, sufficient funds, capacity and other resources have been provided by the designated body to enable them to carry out the responsibilities of the role. Each designated body must provide the responsible officer with sufficient funding and other resources necessary to fulfil their statutory responsibilities. This may include sufficient time to perform the role, administrative and management support, information management and training. The responsible officer may wish to delegate some of the duties of the role to an associate or deputy responsible officer. It is important that those people acting on behalf of the responsible officer only act within the scope of their authority. Where some or all of the functions are commissioned externally, the designated body must be satisfied that all statutory responsibilities are fulfilled. Yes No 1.7 The responsible officer is appropriately trained and remains up to date and fit to practise in the role of responsible officer. To answer Yes : Appropriate recognised introductory training has been undertaken (requirement being NHS England s face to face responsible officer training & the precursor e-learning). Appropriate ongoing training and development is undertaken in agreement with the responsible officer s appraiser. The responsible officer has made themselves known to the higher level responsible officer. The responsible officer is engaged in the regional responsible officer network. The responsible officer is actively involved in peer review for the purposes of calibrating their decisionmaking processes and organisational systems. The responsible officer includes relevant supporting information relating to their responsible officer role in their appraisal and revalidation portfolio including the results of the Annual Organisational Audit and the resulting action plan. Yes No Please do not use this version of the form to submit your response. 12

87 OFFICIAL 1.8 The responsible officer ensures that accurate records are kept of all relevant information, actions and decisions relating to the responsible officer role. The responsible officer records should include appraisal records, fitness to practise evaluations, investigation and management of concerns, processes relating to new starters, etc. Yes No 1.9 The responsible officer ensures that the designated body's medical revalidation policies and procedures are in accordance with equality and diversity legislation. To answer Yes : An evaluation of the fairness of the organisation s policies has been performed (for example, an equality impact assessment). Yes No 1.10 The responsible officer makes timely recommendations to the GMC about the fitness to practise of all doctors with a prescribed connection to the designated body, in accordance with the GMC requirements and the GMC Responsible Officer Protocol. Yes No To answer Yes : The designated body s board report contains explanations for all missed and late recommendations, and reasons for deferral submissions The governance systems (including clinical governance where appropriate) are subject to external or independent review. Most designated bodies will be subject to external or independent review by a regulator. Designated bodies which are healthcare providers are subject to review by the national healthcare regulators (the Care Quality Commission, the Human Fertilisation and Embryology Authority or Monitor, now part of NHS Improvement). Where designated bodies will not be regulated or overseen by an external regulator (for example locum agencies and organisations which are not healthcare providers), an alternative external or independent review process should be agreed with the higher level responsible officer. Yes No Please do not use this version of the form to submit your response. 13

88 OFFICIAL 1.12 The designated body has commissioned or undertaken an independent review* of its processes relating to appraisal and revalidation. (*including peer review, internal audit or an externally commissioned assessment) Yes No Please do not use this version of the form to submit your response. 14

89 OFFICIAL 4 Section 2 Section 2 Appraisal Appraisal 2.1 IMPORTANT: Only doctors with whom the designated body has a prescribed connection at 31 March 2018 should be included. Where the answer is nil please enter 0. See guidance notes on pages for assistance completing this table Number of Prescribed Connections 1a 1b 2 3 Completed Appraisal (1a) Completed Appraisal (1b) Approved incomplete or missed appraisal (2) Unapproved incomplete or missed appraisal (3) Total Consultants (permanent employed consultant medical staff including honorary contract holders, NHS, hospices, and government /other public body staff. Academics with honorary clinical contracts will usually have their responsible officer in the NHS trust where they perform their clinical work) Staff grade, associate specialist, specialty doctor (permanent employed staff including hospital practitioners, clinical assistants who do not have a prescribed connection elsewhere, NHS, hospices, and government/other public body staff). Doctors on Performers Lists (for NHS England and the Armed Forces only; doctors on a medical or ophthalmic performers list. This includes all general practitioners (GPs) including principals, salaried and locum GPs). Doctors with practising privileges (this is usually for independent healthcare providers, however practising privileges may also rarely be awarded by NHS organisations. All doctors with practising privileges who have a prescribed connection should be included in this section, irrespective of their grade). Temporary or short-term contract holders (temporary employed staff including locums who are directly employed, trust doctors, locums for service, clinical research fellows, trainees not on national training schemes, doctors with fixed-term employment contracts, etc). Other doctors with a prescribed connection to this designated body (depending on the type of designated body, this category may include responsible officers, locum doctors, and members of the faculties/professional bodies. It may also include some non-clinical management/leadership roles, research, civil service, doctors in wholly independent practice, other employed or contracted doctors not falling into the above categories, etc). TOTAL (this cell will sum automatically ) Please do not use this version of the form to submit your response. 15

90 OFFICIAL Did the doctor have an appraisal meeting between 1st April 2017 and 31st March 2018, for which the appraisal outputs have been signed off? (include if appraisal undertaken with previous organisation) Yes No Was the reason for missing the appraisal agreed by the RO in advance? Yes No Unapproved incomplete or missed appraisal (3) Approved incomplete or missed appraisal (2) Was this in the 3 months preceding the appraisal due date*, Completed Appraisal (1a) AND was the appraisal summary signed off within 28 days of the appraisal date, AND Completed Appraisal (1b) did the entire process occur between 1 April and 31 March? Please do not use this version of the form to submit your response. 16

91 OFFICIAL 2.1 Column - Number of Prescribed Connections: Number of doctors with whom the designated body has a prescribed connection as at 31 March 2018 The responsible officer should keep an accurate record of all doctors with whom the designated body has a prescribed connection and must be satisfied that the doctors have correctly identified their prescribed connection. Detailed advice on prescribed connections is contained in the responsible officer regulations and guidance and further advice can be obtained from the GMC and the higher level responsible officer. The categories of doctor relate to current roles and job titles rather than qualifications or previous roles. The number of individual doctors in each category should be entered in this column. Where a doctor has more than one role in the same designated body a decision should be made about which category they belong to, based on the amount of work they do in each role. Each doctor should be included in only one category. For a doctor who has recently completed training, if they have attained CCT, then they should be counted as a prescribed connection. If CCT has not yet been awarded, they should be counted as a prescribed connection within the LETB AOA return. Column - Measure 1a Completed medical appraisal: A Category 1a completed annual medical appraisal is one where the appraisal meeting has taken place in the three months preceding the agreed appraisal due date*, the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor within 28 days of the appraisal meeting, and the entire process occurred between 1 April and 31 March. For doctors who have recently completed training, it should be noted that their final ACRP equates to an appraisal in this context. Column - Measure 1b Completed medical appraisal: A Category 1b completed annual medical appraisal is one in which the appraisal meeting took place in the appraisal year between 1 April and 31 March, and the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor, but one or more of the following apply: - the appraisal did not take place in the window of three months preceding the appraisal due date; - the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor between 1 April and 28 April of the following appraisal year; - the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor more than 28 days after the appraisal meeting. However, in the judgement of the responsible officer the appraisal has been satisfactorily completed to the standard required to support an effective revalidation recommendation. Please do not use this version of the form to submit your response. 17

92 OFFICIAL Where the organisational information systems of the designated body do not permit the parameters of a Category 1a completed annual medical appraisal to be confirmed with confidence, the appraisal should be counted as a Category 1b completed annual medical appraisal. Column - Measure 2: Approved incomplete or missed appraisal: An approved incomplete or missed annual medical appraisal is one where the appraisal has not been completed according to the parameters of either a Category 1a or 1b completed annual medical appraisal, but the responsible officer has given approval to the postponement or cancellation of the appraisal. The designated body must be able to produce documentation in support of the decision to approve the postponement or cancellation of the appraisal in order for it to be counted as an Approved incomplete or missed annual medical appraisal. Column - Measure 3: Unapproved incomplete or missed appraisal: An Unapproved incomplete or missed annual medical appraisal is one where the appraisal has not been completed according to the parameters of either a Category 1a or 1b completed annual medical appraisal, and the responsible officer has not given approval to the postponement or cancellation of the appraisal. Where the organisational information systems of the designated body do not retain documentation in support of a decision to approve the postponement or cancellation of an appraisal, the appraisal should be counted as an Unapproved incomplete or missed annual medical appraisal. Column Total: Total of columns 1a+1b+2+3. The total should be equal to that in the first column (Number of Prescribed Connections), the number of doctors with a prescribed connection to the designated body at 31 March * Appraisal due date: A doctor should have a set date by which their appraisal should normally take place every year (the appraisal due date ). The appraisal due date should remain the same each year unless changed by agreement with the doctor s responsible officer. Where a doctor does not have a clearly established appraisal due date, the next appraisal should take place by the last day of the twelfth month after the preceding appraisal. This should then by default become their appraisal due date from that point on. For a designated body which uses an appraisal month for appraisal scheduling, a doctor s appraisal due date is the last day of their appraisal month. For more detail on setting a doctor s appraisal due date see the Medical Appraisal Logistics Handbook (NHS England 2015). Please do not use this version of the form to submit your response. 18

93 OFFICIAL 2.2 Every doctor with a prescribed connection to the designated body with a missed or incomplete medical appraisal has an explanation recorded If all appraisals are in Categories 1a and/or 1b, please answer N/A. To answer Yes: The responsible officer ensures accurate records are kept of all relevant actions and decisions relating to the= responsible officer role. The designated body s annual report contains an audit of all missed or incomplete appraisals (approved and= unapproved) for the appraisal year 2017/18 including the explanations and agreed postponements. Recommendations and improvements from the audit are enacted. Additional guidance: A missed or incomplete appraisal, whether approved or unapproved, is an important occurrence which could indicate a problem with the designated body s appraisal system or non-engagement with appraisal by an individual doctor which will need to be followed up. Measure 2: Approved incomplete or missed appraisal: An approved incomplete or missed annual medical appraisal is one where the appraisal has not been completed according to the parameters of either a Category 1a or 1b completed annual medical appraisal, but the responsible officer has given approval to the postponement or cancellation of the appraisal. The designated body must be able to produce documentation in support of the decision to approve the postponement or cancellation of the appraisal in order for it to be counted as an Approved incomplete or missed annual medical appraisal. Measure 3: Unapproved incomplete or missed appraisal: An Unapproved incomplete or missed annual medical appraisal is one where the appraisal has not been completed according to the parameters of either a Category 1a or 1b completed annual medical appraisal, and the responsible officer has not given approval to the postponement or cancellation of the appraisal. Where the organisational information systems of the designated body do not retain documentation in support of a decision to approve the postponement or cancellation of an appraisal, the appraisal should be counted as an Unapproved incomplete or missed annual medical appraisal. Yes No N/A Please do not use this version of the form to submit your response. 19

94 OFFICIAL There is a medical appraisal policy, with core content which is compliant with national guidance, that has been ratified by the designated body's board (or an equivalent governance or executive group) To answer Yes : The policy is compliant with national guidance, such as Good Medical Practice Framework for Appraisal and Revalidation (GMC, 2013), Supporting Information for Appraisal and Revalidation (GMC, 2012), Medical Appraisal Guide (NHS Revalidation Support Team, 2014), The Role of the Responsible Officer: Closing the Gap in Medical Regulation, Responsible Officer Guidance (Department of Health, 2010), Quality Assurance of Medical Appraisers (NHS Revalidation Support Team, 2014). The policy has been ratified by the designated body s board or an equivalent governance or executive group. There is a mechanism for quality assuring an appropriate sample of the inputs and outputs of the medical appraisal process to ensure that they comply with GMC requirements and other national guidance, and the outcomes are recorded in the annual report template. To answer Yes : The appraisal inputs comply with the requirements in Supporting Information for Appraisal and Revalidation (GMC, 2012) and Good Medical Practice Framework for Appraisal and Revalidation (GMC, 2013), which are: o Personal information. o o Scope and nature of work. Supporting information: 1. Continuing professional development, 2. Quality improvement activity, 3. Significant events, 4. Feedback from colleagues, 5. Feedback from patients, 6. Review of complaints and compliments. o Review of last year s PDP. o Achievements, challenges and aspirations. The appraisal outputs comply with the requirements in the Medical Appraisal Guide (NHS Revalidation Support Team, 2014) which are: o Summary of appraisal, o Appraiser s statement, o Post-appraisal sign-off by doctor and appraiser. Yes No Yes No Please do not use this version of the form to submit your response. 20

95 OFFICIAL 2.5 Additional guidance: Quality assurance is an integral part of the role of the responsible officer. The standards for the inputs and outputs of appraisal are detailed in Supporting Information for Appraisal and Revalidation (GMC, 2012), Good Medical Practice Framework for Appraisal and Revalidation (GMC, 2013) and the Medical Appraisal Guide (NHS Revalidation Support Team, 2014) and the responsible officer must be assured that these standards are being met consistently. The methodology for quality assurance should be outlined in the designated body s appraisal policy and include a sampling process. Quality assurance activities can be undertaken by those acting on behalf of the responsible officer with appropriate delegated authority. There is a process in place for the responsible officer to ensure that key items of information (such as specific complaints, significant events and outlying clinical outcomes) are included in the appraisal portfolio and discussed at the appraisal meeting, so that development needs are identified. To answer Yes : There is a written description within the appraisal policy of the process for ensuring that key items of supporting information are included in the doctor s portfolio and discussed at appraisal. There is a process in place to ensure that where a request has been made by the responsible officer to include a key item of supporting information in the appraisal portfolio, the appraisal portfolio and summary are checked after completion to ensure this has happened. Additional guidance: Yes No It is important that issues and concerns about performance or conduct are addressed at the time they arise. The appraisal meeting is not usually the most appropriate setting for dealing with concerns and in most cases these are dealt with outside the appraisal process in a clinical governance setting. Learning by individuals from such events is an important part of resolving concerns and the appraisal meeting is usually the most appropriate setting to ensure this is planned and prioritised. In a small proportion of cases, the responsible officer may therefore wish to ensure certain key items of supporting information are included in the doctor s portfolio and discussed at appraisal so that development needs are identified and addressed. In these circumstances the responsible officer may require the doctor to include certain key items of supporting information in the portfolio for discussion at appraisal and may need to check in the appraisal summary that the discussion has taken place. The method of sharing key items of supporting information should be described in the appraisal policy. It is important that information is shared in compliance with principles of information governance and security. For further detail, see Information Management for Revalidation in England (NHS Revalidation Support Team, 2014). Please do not use this version of the form to submit your response. 21

96 OFFICIAL 2.6 The responsible officer ensures that the designated body has access to sufficient numbers of trained appraisers to carry out annual medical appraisals for all doctors with whom it has a prescribed connection To answer Yes : The responsible officer ensures that: Medical appraisers are recruited and selected in accordance with national guidance. In the opinion of the responsible officer, the number of appropriately trained medical appraisers to doctors being appraised is between 1:5 and 1:20. In the opinion of the responsible officer, the number of trained appraisers is sufficient for the needs of the designated body. Additional guidance: It is important that the designated body s appraiser workforce is sufficient to provide the number of appraisals needed each year. This assessment may depend on total number of doctors who have a prescribed connection, geographical spread, speciality spread, conflicts of interest and other factors. Depending on the needs of the designated body, doctors from a variety of backgrounds should be considered for the role of appraiser. This includes locums and salaried general practitioners in primary care settings and staff and associate specialist doctors in secondary care settings. An appropriate specialty mix is important though it is not possible for every doctor to have an appraiser from the same specialty. Appraisers should participate in an initial training programme before starting to perform appraisals. The training for medical appraisers should include: Core appraisal skills and skills required to promote quality improvement and the professional development of the doctor Skills relating to medical appraisal for revalidation and a clear understanding of how to apply professional judgement in appraisal Skills that enable the doctor to be an effective appraiser in the setting within which they work, including both local context and any specialty specific elements. Further guidance on the recruitment and training of medical appraisers is available; see Quality Assurance of Medical Appraisers (NHS Revalidation Support Team, 2014). Yes No Please do not use this version of the form to submit your response. 22

97 OFFICIAL 2.7 Medical appraisers are supported in their role to calibrate and quality assure their appraisal practice. To answer Yes : The responsible officer ensures that: Medical appraisers have completed a suitable training programme, with core content compliant with national guidance (Quality Assurance of Medical Appraisers), including equality and diversity and information governance, before starting to perform appraisals. All appraisers have access to medical leadership and support. There is a system in place to obtain feedback on the appraisal process from doctors being appraised. Medical appraisers participate in ongoing performance review and training/development activities, to include peer review and calibration of professional judgements (Quality Assurance of Medical Appraisers). Additional guidance: Further guidance on the support for medical appraisers is available in Quality Assurance of Medical Appraisers (NHS Revalidation Support Team, 2014). Yes No Please do not use this version of the form to submit your response. 23

98 OFFICIAL 5 Section 3 Monitoring Performance and Responding to Concerns Section 3 Monitoring Performance and Responding to Concerns 3.1 There is a system for monitoring the fitness to practise of doctors with whom the designated body has a prescribed connection. To answer Yes : Relevant information (including clinical outcomes, reports of external reviews of service for example Royal College reviews, governance reviews, Care Quality Commission reports, etc.) is collected to monitor the doctor s fitness to practise and is shared with the doctor for their portfolio. Relevant information is shared with other organisations in which a doctor works, where necessary. There is a system for linking complaints, significant events/clinical incidents/suis to individual doctors. Where a doctor is subject to conditions imposed by, or undertakings agreed with the GMC, the responsible officer monitors compliance with those conditions or undertakings. The responsible officer identifies any issues arising from this information, such as variations in individual performance, and ensures that the designated body takes steps to address such issues. The quality of the data used to monitor individuals and teams is reviewed. Advice is taken from GMC employer liaison advisers, National Clinical Assessment Service, local expert resources, specialty and Royal College advisers where appropriate. Additional guidance: Where detailed information can be collected which relates to the practice of an individual doctor, it is important to include it in the annual appraisal process. In many situations, due to the nature of the doctor s work, the collection of detailed information which relates directly to the practice of an individual doctor may not be possible. In these situations, team-based or service-level information should be monitored. The types of information available will be dependent on the setting and the role of the doctor and will include clinical outcome data, audit, complaints, significant events and patient safety issues. An explanation should be sought where an indication of outlying Yes No Please do not use this version of the form to submit your response. 24

99 OFFICIAL quality or practice is discovered. The information/data used for this purpose should be kept under review so that the most appropriate information is collected and the quality of the data (for example, coding accuracy) is improved. In primary care settings this type of information is not always routinely collected from general practitioners or practices and new arrangements may need to be put in place to ensure the responsible officer receives relevant fitness to practise information. In order to monitor the conduct and fitness to practise of trainees, arrangements will need to be agreed between the local education and training board and the trainee s clinical attachments to ensure relevant information is available in both settings. 3.2 The responsible officer ensures that a responding to concerns policy is in place (which includes arrangements for investigation and intervention for capability, conduct, health, and fitness to practise concerns) which is ratified by the designated body s board (or an equivalent governance or executive group). To answer Yes : A policy for responding to concerns, which complies with the responsible officer regulations, has been ratified by the designated body's board (or an equivalent governance or executive group). Additional guidance: It is the responsibility of the responsible officer to respond appropriately when unacceptable variation in individual practice is identified or when concerns exist about the fitness to practise of doctors with whom the designated body has a prescribed connection. The designated body should establish a procedure for initiating and managing investigations. National guidance is available in the following key documents: Supporting Doctors to Provide Safer Healthcare: Responding to Concerns about a Doctor s Practice (NHS Revalidation Support Team, 2013). Maintaining High Professional Standards in the Modern NHS (Department of Health, 2003). The National Health Service (Performers Lists) (England) Regulations How to Conduct a Local Performance Investigation (National Clinical Assessment Service, 2010). The responsible officer regulations outline the following responsibilities: Ensuring that there are formal procedures in place for colleagues to raise concerns. Ensuring there is a process established for initiating and managing investigations of capability, conduct, Yes No Please do not use this version of the form to submit your response. 25

100 OFFICIAL health and fitness to practise concerns which complies with national guidance, such as How to conduct a local performance investigation (National Clinical Assessment Service, 2010). Ensuring investigators are appropriately qualified. Ensuring that there is an agreed mechanism for assessing the level of concern that takes into account the risk to patients. Ensuring all relevant information is taken into account and that factors relating to capability, conduct, health and fitness to practise are considered. Ensuring that there is a mechanism to seek advice from expert resources, including: GMC employer liaison advisers, the National Clinical Assessment Service, specialty and royal college advisers, regional networks, legal advisers, human resources staff and occupational health. Taking any steps necessary to protect patients. Where appropriate, referring a doctor to the GMC. Where necessary, making a recommendation to the designated body that the doctor should be suspended or have conditions or restrictions placed on their practice. Sharing relevant information relating to a doctor s fitness to practise with other parties, in particular the new responsible officer should the doctor change their prescribed connection. Ensuring that a doctor who is subject to these procedures is kept informed about progress and that the doctor s comments are taken into account where appropriate. Appropriate records are maintained by the responsible officer of all fitness to practise information Ensuring that appropriate measures are taken to address concerns, including but not limited to: Requiring the doctor to undergo training or retraining, Offering rehabilitation services, Providing opportunities to increase the doctor s work experience, Addressing any systemic issues within the designated body which may contribute to the concerns identified. Ensuring that any necessary further monitoring of the doctor s conduct, performance or fitness to practise is carried out. 3.3 The board (or an equivalent governance or executive group) receives an annual report detailing the number and type of concerns and their outcome. Yes No Please do not use this version of the form to submit your response. 26

101 OFFICIAL 3.4 The designated body has arrangements in place to access sufficient trained case investigators and case managers. To answer Yes : The responsible officer ensures that: Case investigators and case managers are recruited and selected in accordance with national guidance Supporting Doctors to Provide Safer Healthcare, Responding to concerns about a Doctor s Practice (NHS Revalidation Support Team, 2013). Case investigators and case managers have completed a suitable training programme, with essential core content (see guidance documents above). Personnel involved in responding to concerns have sufficient time to undertake their responsibilities Individuals (such as case investigators, case managers) and teams involved in responding to concerns participate in ongoing performance review and training/development activities, to include peer review and calibration (see guidance documents above). Additional guidance The standards for training for case investigators and case managers are contained in Guidance for Recruiting for the Delivery of Case Investigator Training (NHS Revalidation Support Team, 2014) and Guidance for Recruiting for the Delivery of Case Manager Training (NHS Revalidation Support Team, 2014). Case investigators or case managers may be within the designated body or commissioned externally. Yes No Please do not use this version of the form to submit your response. 27

102 OFFICIAL 6 Section 4 Recruitment and Engagement Section 4 Recruitment and Engagement 4.1 There is a process in place for obtaining relevant information when the designated body enters into a contract of employment or for the provision of services with doctors (including locums). In situations where the doctor has moved to a new designated body without a contract of employment, or for the provision of services (for example, through membership of a faculty) the information needs to be available to the new responsible officer as soon as possible after the prescribed connection commences. This will usually involve a formal request for information from the previous responsible officer. Yes No Additional guidance The regulations give explicit responsibilities to the responsible officer when a designated body enters into a contract of employment or for the provision of services with a doctor. These responsibilities are to ensure the doctor is sufficiently qualified and experienced to carry out the role. All new doctors are covered under this duty even if the doctor s prescribed connection remains with another designated body. This applies to locum agency contracts and also to the granting of practising privileges by independent health providers. The prospective responsible officer must: Ensure doctors have qualifications and experience appropriate to the work to be performed, Ensure that appropriate references are obtained and checked, Take any steps necessary to verify the identity of doctors, Ensure that doctors have sufficient knowledge of the English language for the work to be performed, and For NHS England regional teams, manage admission to the medical performers list in accordance with the regulations. It is also important that the following information is available: GMC information: fitness to practise investigations, conditions or restrictions, revalidation due date, Disclosure and Barring Service check (although delays may prevent these being available to the responsible officer before the starting date in every case), and Please do not use this version of the form to submit your response. 28

103 OFFICIAL Gender and ethnicity data (to monitor fairness and equality; providing this information is not mandatory). It may be helpful to obtain a structured reference from the current responsible officer which complies with GMC guidance on writing references and includes relevant factual information relating to: The doctor s competence, performance or conduct, Appraisal dates in the current revalidation cycle, and, Local fitness to practise investigations, local conditions or restrictions on the doctor s practice, unresolved fitness to practise concerns. See Good Medical Practice: Supplementary Guidance: Writing References (GMC, 2007) and paragraph 19 of Good Medical Practice (GMC, 2013) for further details. The responsible officer regulations and GMC guidance make it clear that there is an obligation to share information about a doctor when required to support the responsible officer s statutory duties, or to maintain patient safety. Guidance, published in August 2016, on the flow of information to support medical governance and responsible officer statutory function (2016) therefore aims to promote improvements to these processes: setting out the common legitimate channels along which information about a doctor s medical practice should flow, describing the information that might apply and arrangements to support its smooth flow providing useful toolkits and examples of good practice The guidance on information flows to support medical governance and responsible officer statutory functions can be accessed via the link below. Please do not use this version of the form to submit your response. 29

104 OFFICIAL 7 Section 5 Comments Section 5 Comments 5.1 Please do not use this version of the form to submit your response. 30

105 OFFICIAL 8 Reference Sources used in preparing this document 1. The Medical Profession (Responsible Officers) Regulations 2010 (Her Majesty s Stationery Office, 2013) 2. The Medical Profession (Responsible Officers) (Amendment) Regulations 2013 (Her Majesty s Stationery Office, 2013) 3. The Medical Act 1983 (Her Majesty s Stationery Office, 1983) 4. Maintaining High Professional Standards in the Modern NHS (Department of Health, 2003) 5. The National Health Service (Performers Lists) (England) Regulations The Role of the Responsible Officer: Closing the Gap in Medical Regulation, Responsible Officer Guidance (Department of Health, 2010) 7. Revalidation: A Statement of Intent (GMC and others, 2010) 8. Good Medical Practice (GMC, 2013) 9. Good Medical Practice Framework for Appraisal and Revalidation (GMC, 2013) 10. Good Medical Practice: Supplementary Guidance - Writing References (GMC, 2012) 11. Guidance on Colleague and Patient Questionnaires (GMC, 2012) 12. Supporting Information for Appraisal and Revalidation (GMC, 2012) 13. Effective Governance to Support Medical Revalidation: A Handbook for Boards and Governing Bodies (GMC, 2013) 14. The GMC protocol for making revalidation recommendations: Guidance for responsible officers and suitable persons (GMC, 2012, updated in 2014) 15. The Medical Appraisal Guide (NHS Revalidation Support Team, 2014) 16. Quality Assurance of Medical Appraisers (NHS Revalidation Support Team, 2014) 17. Providing a Professional Appraisal (NHS Revalidation Support Team, 2012) 18. Information Management for Medical Revalidation in England (NHS Revalidation Support Team, 2014) 19. Supporting Doctors to Provide Safer Healthcare: Responding to Concerns about a Doctor s Practice (NHS Revalidation Support Team, 2013) 20. Guidance for Recruiting for the Delivery of Case Investigator Training (NHS Revalidation Support Team, 2014) 21. Guidance for Recruiting for the Delivery of Case Manager Training (NHS Revalidation Support Team, 2014). 22. Responsible Officer Conflict of Interest or Appearance of Bias: Request to Appoint and Alternative Responsible Officer (NHS Revalidation Support Team, 2014). 23. Appraisal in the Independent Health Sector (British Medical Association and Independent Healthcare Advisory Services, 2012) 24. Joint University and NHS Appraisal Scheme for Clinical Academic Staff (Universities and Colleges Employers Association, 2002, updated in 2012) 25. Preparing for the Introduction of Medical Revalidation: a Guide for Independent Sector Leaders in England (GMC and Independent Healthcare Advisory Services, 2011, updated in 2012) Please do not use this version of the form to submit your response. 31

106 OFFICIAL 26. How to Conduct a Local Performance Investigation (National Clinical Assessment Service, 2010) 27. Use of NHS Exclusion and Suspension from Work amongst Doctors and Dentists 2011/12 (National Clinical Assessment Service, 2012) 28. Return to Practice Guidance (Academy of Medical Royal Colleges, 2012) 29. Medical Appraisal Logistics Handbook (NHS England, 2015) Please do not use this version of the form to submit your response. 32

107 OFFICIAL A Framework of Quality Assurance for Responsible Officers and Revalidation Annex E - Statement of Compliance

108 OFFICIAL Statement of Compliance Version number: 2.0 First published: 4 April 2014 Updated: 22 June 2015 Prepared by: Gary Cooper, Project Manager for Quality Assurance, NHS England Classification: OFFICIAL Publications Gateway Reference: NB: The National Health Service Commissioning Board was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes. 2

109 OFFICIAL Designated Body Statement of Compliance The board / executive management team [delete as applicable] of [insert official name of DB] can confirm that an AOA has been submitted, the organisation is compliant with The Medical Profession (Responsible Officers) Regulations 2010 (as amended in 2013) and can confirm that: 1. A licensed medical practitioner with appropriate training and suitable capacity has been nominated or appointed as a responsible officer; Yes 2. An accurate record of all licensed medical practitioners with a prescribed connection to the designated body is maintained; Yes 3. There are sufficient numbers of trained appraisers to carry out annual medical appraisals for all licensed medical practitioners; yes 4. Medical appraisers participate in ongoing performance review and training / development activities, to include peer review and calibration of professional judgements (Quality Assurance of Medical Appraisers 1 or equivalent); Yes 5. All licensed medical practitioners 2 either have an annual appraisal in keeping with GMC requirements (MAG or equivalent) or, where this does not occur, there is full understanding of the reasons why and suitable action taken; Yes 6. There are effective systems in place for monitoring the conduct and performance of all licensed medical practitioners 1 (which includes, but is not limited to, monitoring: in-house training, clinical outcomes data, significant events, complaints, and feedback from patients and colleagues) and ensuring that information about these matters is provided for doctors to include at their appraisal; Yes 7. There is a process established for responding to concerns about any licensed medical practitioners 1 fitness to practice 8. There is a process for obtaining and sharing information of note about any licensed medical practitioner s fitness to practise between this organisation s Doctors with a prescribed connection to the designated body on the date of reporting. 3

110 OFFICIAL responsible officer and other responsible officers (or persons with appropriate governance responsibility) in other places where the licensed medical practitioner works; 3 Yes 9. The appropriate pre-employment background checks (including preengagement for locums) are carried out to ensure that all licenced medical practitioners 4 have qualifications and experience appropriate to the work performed; Yes 10. A development plan is in place that ensures continual improvement and addresses any identified weaknesses or gaps in compliance. Yes Signed on behalf of the designated body [(Chief executive or chairman (or executive if no board exists)] Official name of designated body: _ Name: _ Role: _ Date: Signed: 3 The Medical Profession (Responsible Officers) Regulations 2011, regulation 11: 4

111 Meeting title Trust Board part I meeting Date: 25 July 2018 Report title Adult and Children Safeguarding /18 annual reports Agenda item: 16 Lead director Report authors Donna Lamb, Director of Nursing and Non-Medical Professionals Adults: Sandie Cox, Adult Safeguarding Professional Lead Children: Anthony Bowen, Named Nurse Safeguarding Children, Dr Vanessa Impey, Named Doctor, and Dr Sudipta Sen, Named Doctor. Executive summary These two safeguarding annual reports provide assurance to the trust board that effective processes are in place to safeguard adults and children and that the trust is compliant with statutory requirements in relation to safeguarding and the Mental Capacity Act (MCA). Key points to note include Adults: The reduction in safeguarding referrals made by other agencies about HRCH care The improved partnership working leading to an overall reduction in section 42 enquiries The development of the MCA film to raise awareness of mental capacity and The work with NHSE to develop templates for MCA and best interests recording Children: External assessments: On 25 September 2017, Richmond received notification of an Ofsted inspection of services for children in need of help and protection, children in care and care leavers. The borough was found to be good in all areas and the report noted that "partnership working is a significant strength A Joint Targeted Area Inspection (JTAI) was undertaken in Hounslow in March The theme of this inspection was around children living with domestic abuse. No serious concerns across the partnership were identified, HRCH worked closely 0

112 with partners across Hounslow to develop and implement areas identified for improvement within the joint action plan; all actions completed. Safeguarding training targets met in 11 out of 16 data points Additional training delivered where learning from incidents has recommended this WRAP training provided to trust board Safeguarding supervision delivered, achieving consistently high compliance Work plan completed Safeguarding children policy reviewed and ratified Purpose: Approval Recommendation(s) The Trust Board is asked to approve both safeguarding annual reports for publication on our external web pages BAF/TRR Report history Appendices Q1 May 18 safeguarding committee; July Quality Governance Committee 1: 2017/18 Adult Safeguarding annual report 2: 2017/18 Children s Safeguarding annual report 1

113 Appendix 1: Safeguarding Adults Annual Report Contents 1. Introduction... 1 Achievements Work plan 2017/ Personnel Adult Safeguarding Policy and Standards Training and Learning... 2 Safeguarding Adults... 2 Consent / Mental Capacity Act / DoLS... 3 PREVENT Safeguarding alerts and referrals... 4 Self-Neglect... 7 Serious Incidents and Safeguarding... 7 Outcomes of Adult Safeguarding enquiries... 7 Safeguarding Adult Reviews Mental Capacity Act (MCA) Compliance... 9 MCA Deprivation of Liberty Safeguards Safer Recruitment Multi-Agency Partnership Working...11 MARAC (Multi Agency Risk Assessment Committee)...12 Specific adult safeguarding partnership activities in HRCH Adult Safeguarding Development update...12 Hounslow local authority safeguarding processes...12 Safeguarding adults at risk self assessment Key Achievements and Priorities for Achievements Priorities Team Capacity...13 Information Exchange with Local Authorities...13 Proportionate Responses by Local Authorities to concerns raised...14 Clinicians raising safeguarding alerts to Adult Social Care...14 Mental Capacity Act (MCA) Compliance...14 Domestic Violence (including Honour Based Violence)...14 Human Trafficking and Modern Slavery...14 Adult Safeguarding Training Conclusion

114 1. Introduction The purpose of this report is to provide an update on service developments in relation to Safeguarding Adults and to provide assurance to the Hounslow and Richmond Community Healthcare NHS Trust (HRCH) Board that the organisation is fulfilling its statutory Adult Safeguarding responsibilities. It also highlights achievements and areas for development. Achievements Adult Safeguarding concerns raised by others about HRCH care have reduced by 75% from the previous year Only 1 Section 42 Enquiry outcome (for 2 Richmond patients) was upheld in Only 1 Serious Incident was triggered by a S42 Enquiry in Domestic abuse awareness poster campaign across HRCH bases Improved staff awareness resulted in increased safeguarding reporting in 2 key areas of national increase (domestic abuse up by 83%, financial abuse up by 50%) Overall S42 Enquiries reduced (believed to be due to improved joint risk assessment and decision making by health with adult social care) Adult Safeguarding Community Engagement activity across both authorities was maximised this year (posters, postcards, events, awareness sessions with Police) HRCH MCA training film shared and used widely with health, (including trainee GPs) social care, SABs, paid and family carers across UK (excellent feedback received) Safeguarding Adult Lead achieved full access to adult social care records for both local authorities HRCH have access to the Virtual College elearning for Safeguarding (use pending evaluation and approval by HRCH OD Lead) HRCH have been asked by NHSE to develop electronic templates for MCA assessments and Best Interest decisions and adult safeguarding recording for SystmOne which will enable read-across reporting with EMIS (used mainly by GPs) Work plan 2017/2018 HRCH produces an adult safeguarding adults work plan to give clear strategic direction to its work in this area. This is agreed, monitored and revised by the Safeguarding Committee. Outstanding or incomplete items are reflected in the work plan. 2. Personnel HRCH are compliant with their statutory duty to employ a Named Professional. The safeguarding team sits within the Quality and Clinical Excellence directorate. Adult Safeguarding Team staffing ( ) Executive Lead: Donna Lamb Named Professional Lead 1.0 WTE Sandie Cox Current capacity in adult safeguarding is on the risk register as a risk to embedding excellent practice across all services in line with the Care Act and the Mental Capacity Act. It has now been agreed that an additional post at Band 7 will be advertised to move this work stream from safe to outstanding. A safeguarding administrator supports the team and has a particular focus on the oversight of the DoLS process for inpatients at Teddington Memorial Hospital. Page 1 of 16

115 Adult safeguarding advice (including out of office hours) is available from Clinical Managers on call. 3. Adult Safeguarding Policy and Standards HRCH adult safeguarding policies align with the Pan London Procedures. The Trust policy for safeguarding adults at risk was amended and ratified in 2016 and available on the Trust intranet. There are no adult safeguarding policies under review in Q4. The HRCH Consent policy was ratified during Q4. HRCH participates in a multi-agency adult safeguarding provider audit for Hounslow. We have developed an audit tool with Hounslow Safeguarding Adults Board partners; designed to provide some assurance over time that local providers are reporting concerns to adult social care; are guided by the principles of the Mental Capacity Act and are seeking to Make Safeguarding Personal. What we have learnt from these small dip sampling audits (of between 4 and 10 cases per quarter) is: a. Feedback from adult social care is inconsistent and below expectations. This risk is managed by SGAL having access to adult social care records b. Sharing of learning from adult safeguarding is not consistent. This risk is partially mitigated by SGAL using reflective practice sessions, Learn and Share, developing intranet materials with case studies and including examples in training. The adult safeguarding SOP which is in development, will help ensure reflective learning from safeguarding concerns becomes business as usual. 4. Training and Learning Safeguarding Adults The Safeguarding Children and Adults Training Strategy underpins this work stream. All HRCH staff are required to receive training for safeguarding adults. Level 1 (awareness) training is provided during induction to all staff. For patient facing staff there is a requirement to have refresher training every three years. This can be achieved by online training, or by face to face training sessions at Level 2. Level 2 training in adult safeguarding for all staff in contact with patients and also for Managers was benchmarked with the Bournemouth competencies (National Competence Framework for Safeguarding Adults 2010) and the Skills for Health s Core Skills Training Framework, This is provided monthly across the Trust via the Core Skills training programme. This training also needs to be updated every 3 years. For level 2 staff, having completed level 1 at induction, they will not be required to update level 1, but these staff would need to update level 2 every 3 years. HRCH compliance targets are now 85% for both levels. WIRED is used to monitor compliance with this standard. WIRED 2 records currently indicate that targets have been met for both levels. CCG targets are 90%. These have also been consistently met. Safeguarding Adults training Q1 Q2 Q3 Q4 Page 2 of 16

116 Level % 93.18% 95.07% 98.24% Level % 94.32% 86.80% 93.15% Health providers across the UK are still awaiting the final and much overdue recommendations of the Safeguarding Adults Intercollegiate Document (to be renamed Best Practice Guidance) which will provide a consistent assurance framework when released as the final version in The draft document suggests that adult safeguarding training be competency based and related to roles. This is likely to require HRCH to introduce 2 additional levels of training for a limited number of practitioners and to require additional content to be included in existing training. (NHS England Safeguarding Adults: Roles and competencies for health care staff Intercollegiate Document vdraft) Consent / Mental Capacity Act / DoLS The HRCH consent policy requires all clinical staff to have had training on consent (including use of the Mental Capacity Act 2005) every 3 years. The HRCH current target is 85%. This target was not achieved in Quarter 3 (compliance achieved was 81.20%) and these targets had not been consistently met since Q1 last year. Action planning was put in place and this target was met in Q4. Mental Capacity Act training Q1 Q2 Q3 Q % 81.43% 81.20% 89.47% This training is currently available online or through two hour face to face sessions provided by the safeguarding adults lead. The recommendations and actions from the last MCA audit in 2016 have been largely completed (with the SystmOne related actions in progress) and a new audit using the MES system is planned to establish a baseline in Q This will inform action planning for the year. PREVENT PREVENT awareness is incorporated into all face to face safeguarding adults training. All 6 members of the wider safeguarding team have been trained via the Workshop to Raise Awareness of PREVENT Materials (WRAP) provided by NHS England and are rolling out WRAP training across the Trust. Rollout of PREVENT training has been escalated this year to meet our challenging targets (100%) despite staff turnover. Good progress has been made against the previous year. Prevent London have informed us in Q4 that targets have changed and our cohort should correspond with staff who require Safeguarding level 3 training. E-learning is now available and acceptable for compliance. Therefore our compliance level for will rise significantly. PREVENT training Q1 Q2 Q3 *cohort reviewed Basic PREVENT Awareness 93.1% 97% 95.2% 98.5% Q4 Page 3 of 16

117 WRAP 81.6% 93.4% *65.2% 68.7% 5. Safeguarding alerts and referrals HRCH keeps a record of all known safeguarding alerts to the relevant local authorities and whether these are accepted as safeguarding referrals, then closed after fact-finding; managed by casework or progressed to S42 Adult Safeguarding Enquiries. The safeguarding adults lead initially gathers this information from Datix incident forms where potential safeguarding issues are recorded internally and from additional concerns raised externally to the Trust e.g. by acute hospitals, care homes or family carers. Contact with the relevant professionals, the local authority and reviewing electronic records held on SystmOne where necessary, enable proportionate risk assessment. Currently the outcomes of the concerns; for the patient concerned and potentially for the Trust, can only be established by either safeguarding meeting attendance in person or by request to the social work teams concerned and remains extremely time intensive. Learning from outcomes is shared via Datix, supervision and reflective learning sessions and Learn and Share and via Being Open Meetings where these are indicated. Table 1 below shows the number of known adult safeguarding concerns passed to the relevant local authority which remains fairly consistent. Additional information and some assurance relating to HRCH reporting safeguarding appropriately is being provided by small dip sampling audits of adult safeguarding as an output of the Quality Assurance sub group of Hounslow SAB. These audits evidenced that the main concerns related to lack of communication and feedback from adult social care. This risk has been mitigated as the SGAL now has access to adult social care records. Table 1 Datix incidents and safeguarding concerns Local authority Safeguarding concerns raised by/re HRCH (includes PUs) (Previous year for comparison only) Q1 Q2 Q3 Q4 Year Hounslow 12 (13) 15 (18) 12 (21) 11 (12) 50 (64) Richmond 4 (9) 10 (11) 5 (3) 5 (4) 24 (27) Other 0 (0) 1* (0) 0 (0) 0 (1) 1 (1) authorities Totals 16 (22) 25 (29) 17 (24) 16 (17) 75 (92) * Ealing Safeguarding concerns were not reported to the local authority for all cases reported on Datix with a flag for adult safeguarding. This is because the adult safeguarding work stream encompasses risk prevention as well as managed risk enablement for adults with capacity. Page 4 of 16

118 The threshold for reporting via Datix is both lower and wider than for adult safeguarding. Safeguarding concerns relevant to HRCH but reported by another agency are included. Reasons why concerns reported on Datix may not be referred as safeguarding concerns included: The incident did not meet the threshold for a safeguarding concern A safeguarding process was already open (and risks related to the current Enquiry) Adult safeguarding was not felt to be the most effective response (and other inter/professional risk management methods were agreed) The adult at risk did not want a concern to be raised, there were no concerns about their capacity and no vital or public interest and all appropriate actions had been taken. Table 2 Safeguarding concerns re pressure ulcers Local authority Safeguarding concerns for pressure ulcers NB: grade / origin often not confirmed at time of initial report Q1 Q2 Q3 Q4 Year Hounslow 5 (8) 3 (6) 3(9) 1 (9) 12 (32) Richmond 1 (3) 2 (4) 1 (3) 1 (0) 5 (10) Other authorities 0 (0) 1* (0) 0 (0) 0 (0) 1 (0) Totals 6 (11) 6 (10) 4 (12) 2 (9) 18 (42) * Ealing The combined data in Table 1 and Table 2 shows that in ; 24% of the safeguarding alerts raised re HRCH patients concerned pressure ulcers (compared with almost 46% overall in ). Numbers of pressure ulcers referred for safeguarding have also fallen steadily as a result to the use of the Safeguarding pressure ulcer decision tool. Further progress is needed in the implementation of this pressure ulcer decision tool (to include hospices, nursing homes and acute hospitals) to ensure consistently proportionate risk assessment of potential neglect. If a patient had made a capacitious informed decision to decline advice and / or equipment, and this had been recorded, or the tissue damage was consistent with the patient s underlying health status, this should not need to be referred as safeguarding. An additional challenge is the requirement to report concerns promptly, usually without full information. This means that the majority of safeguarding concerns about pressure ulcers signifying neglect are later found to be unsubstantiated re HRCH care. Table 3 below shows the number of incidents which were raised as safeguarding concerns by parties other than HRCH. The local authority identified is the one where the concern was raised. Page 5 of 16

119 Table 3 Adult Safeguarding concerns raised by other parties Local authority Safeguarding concerns raised by others regarding HRCH care Q1 Q2 Q3 Q4 Year Hounslow 1 (6) 4 (2) 1 (14) 0 (3) 6 (25) Richmond 0 (0) 0 (0) 1 (3) 0 (0) 1 (3) Other 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Totals 1 (6) 4 (2) 2 (17) 0 (3) 7 (28) The numbers of concerns raised externally about HRCH care have fallen by 75% from last year. Contributing factors are likely to be improved communication and partnership working; enabling early exploration and resolution of concerns and wider use of the pressure ulcer safeguarding decision tool, including by acute Trusts. Table 4 below provides a breakdown of the type of potential abuse for safeguarding concerns reported to both Local Authorities (LAs). This confirms that overall numbers continue to decrease (a decrease of 34% from 116 in to 76 in ) Potential neglect continues to be the most prevalent abuse type. This includes: Poor discharge arrangements from acute hospitals impacting negatively on care Concerns about the care provided by family, friends or care agencies Inadequate care being provided / arranged by statutory agencies. Reported domestic abuse has increased by 83%. This is likely to reflect increased awareness by HRCH staff and remains an area of focus for the SGAL. Reported financial abuse has increased by 50% over the year. Local awareness raising has been passed on to HRCH staff via SAB seminars, communications and intranet guidance. This will also be an area of development for the coming year. One incidence of serious organisational abuse has been reported this year by HRCH. This affected 7 patients. Reflective learning was undertaken in relation to this. Table 4 Type of potential abuse for all safeguarding concerns referred to LAs ( for comparison) Main Abuse type Q1 Q2 Q3 Q4 Total Discriminatory abuse 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Domestic abuse (incl HBV, FM)* 1 (1) 4 (0) 2 (1) 5 (0) 12 (2) Financial abuse 0 (1) 3 (3) 2 (0) 3 (1) 8 (4) Modern slavery / human trafficking 0 (0) 0 (0) 0 (1) 0 (1) 0 (2) Page 6 of 16

120 Neglect 10 (23) 8 (18) 10 (25) 6 (16) 34 (82) Organisational abuse 0 (0) 7 (0) 0 (0) 0 (0) 7 (0) Physical abuse 1 (1) 1 (1) 1 (1) 2 (1) 5 (4) Psychological abuse 0 (0) 2 (2) 0 (1) 0 (1) 2 (4) Self-neglect 3 (2) 1 (2) 2 (3) 1 (6) 7 (13) Sexual abuse 1 (0) 0 (1) 0 (1) 0 (0) 1 (2) Total 16 (28) 26 (29) 17 (33) 17 (26) 76 (116) *So-called Honour Based Violence (HBV) incl Forced Marriage none reported in the period Self-Neglect Although this has fallen overall, HRCH continues to engage positively with patients, local authorities and other partners to address multiple risks associated with self-neglect at both operational and strategic levels. Mental capacity is a significant factor in addressing risk relating to potential self-neglect. HRCH recognise the importance of ensuring that all patient facing staff in the community have a working knowledge of the MCA 2005 and this remains a key priority in the adult safeguarding work plan. Home Fire Safety Visits are stressed in training and full information and referral information including re hoarding, is on the intranet for HRCH staff. Both Hounslow and Richmond have High Risk Panels to which HRCH staff can refer. Information about these is available on the intranet and shared via advice calls and Datix communications. Serious Incidents and Safeguarding There was 1 Serious Incident triggered by a S42 Enquiry declared in Q1 since then there have been none. Outcomes of Adult Safeguarding enquiries Accurate quarterly reporting data for local authority action on concerns raised by HRCH (and in relation to HRCH care) has been a significant and ongoing challenge. The HRCH Adult Safeguarding Lead has negotiated improved information sharing with Hounslow and Richmond and now has access to adult social care records for both authorities. No adult safeguarding concerns were upheld in Q1, Q3 or Q4 of re care by HRCH. In Q2 there were 2 concerns upheld (a single Richmond incident involving 2 patients). Following a rigorous MDT enquiry a robust action plan was put in place and completed and no further similar incidents have occurred. HRCH collects information about the difference safeguarding makes for its adult patients. Below is one example of the safeguarding process achieving positive outcomes for an adult at risk. This example also shows that HRCH is able to Think Family. Case Example (*not her real name): Mrs Richards* is an 80 year woman with significant chronic health and some mobility issues. She holds the tenancy of a 3 storey council house, where she lived with her dog and managed independently. She had a large bedroom upstairs and was able to access all Page 7 of 16

121 areas of her home. She had a recent hospital admission and was referred for OT input on her return home. There are no concerns about her capacity to make decisions about her accommodation. On an OT assessment visit, our OT ascertained that Mrs Richards had previously allowed her son, son's partner, their 8 children and their family pets to live in her house for an indefinite period, as she felt they had limited options and wanted to help. While she was in hospital, her daughter in law moved her possessions into a downstairs box room with an inappropriate bed for her Mrs Richards needs. Mrs Richards was still able to go upstairs; however, her daughter in law had been stopping her, saying she was unsafe. Our OT put in a rail and practiced stairs, but Mrs Richards did not return to her room upstairs as this was now being used by her family. Mrs Richards also reported to the OT that her dog was given away after it did not get on with her son's dog. On this visit, Mrs Richards reported feeling as though she were being pushed out of her own home. Additionally, the bathroom above her box room had sprung a leak and had come through her ceiling, spoiling her bed; she now was sleeping on a mattress on the floor. The OT discussed these concerns with the Adult Safeguarding Lead. After rapid initial enquiries re Think Family to establish whether there were also concerns about any of the children in the household and to clarify who was involved with this family, our OT was briefed and agreed to return to Mrs Richards, discuss a potential referral for safeguarding, (as per Making Safeguarding Personal) and let her know that our duty of care meant that we would need to discuss these concerns with adult social care in any case. Mrs Richards was visited again the next day and to our surprise, she agreed to safeguarding and the concern was immediately referred to the local authority. The children s social worker involved was updated to ensure there was no conflict of interest. How will safeguarding make a difference? Mrs Richard s voice was heard, and her views sought, by a professional who was focussed on her health and wellbeing. The concerns about the adult at risk were discussed in the context of the family one of the children was already receiving input from children s health and social care. Mrs Richard s desired outcomes will be given weight and the family system will be monitored and supported to achieve greater well-being. This was proportionate yet timely action and made safeguarding personal to Mrs Richards. This is an ongoing case. Safeguarding Adult Reviews A Safeguarding Adult Review was announced by Hounslow in Q3 for someone with whom HRCH had very limited contact in The research question for the independent reviewers is How effectively are front line practitioners supported to make urgent decisions for high risk clients in a crisis. We will be invited to take part in a workshop for professionals who worked with this patient to discuss any recommendations for improving safeguarding processes. Page 8 of 16

122 HRCH would be represented at the Safeguarding Adults Partnership Board SAR subgroup in Hounslow and Richmond by invitation when any new case referred by or relating to HRCH is being discussed. 6. Mental Capacity Act (MCA) Compliance Our Trust s key strategic objective for 2017/18 is patient quality and safety and delivering outstanding care to the people we serve. To achieve this we plan to attract and develop a highly skilled and engaged workforce and we actively engage with patients, public and carers to improve the care we provide. Making (and recording) effective use of the principles of the Mental Capacity Act (MCA) underpin these objectives for adult patients and their carers. Our focus remains on embedding an understanding of these principles and how to use and record them as business as usual for HRCH staff. We are also taking all opportunities to engage with our communities to share this with them as the MCA applies to everyone from their 16 th birthday. The Adult Safeguarding Lead has membership of the National Mental Capacity Act Forum. Safeguarding Committee needs assurance that: People are supported to make their own decisions wherever possible HRCH staff are following the Mental Capacity Act 2005 (MCA) and its Code of Practice when there are concerns that an individual may lack capacity to make a decision about their treatment and care HRCH is compliant with the requirements of consent in CQC s key line of enquiry on whether services are effective. A baseline case file audit was completed at the end of the first quarter and repeated (with improved methodology) in Q2 and Q3. These audits aimed to evaluate: Evidence of mental capacity assessments Information about when treatment is given in the patient s best interests Details about how a best interests decision was made Checks for attorneys, deputies and advance decisions to refuse treatment Details of any decisions made by attorneys, deputies or advance decisions to refuse treatment For TMH inpatients, documentation related to the Deprivation of Liberty Safeguards. The audit found some evidence of at least one of these. However, a stretching target for the end of the year of 80% was not met. Mandatory training was meeting numerical compliance targets but the impact on practice was not measurable. Further action was needed to improve practice by improving understanding of the MCA by front line practitioners. A short and simple training show how to know how film was produced and this is in use for training (and sharing widely) in the financial year A baseline for HRCH practice needs to be established via a MES clinical audit. This is in development for use in It has been delayed by lack of capacity and staff changes in the audit support service. Page 9 of 16

123 Action planning can then be targeted on detailed findings and a programme of further audits will track our progress towards Outstanding which can be shared with stakeholders. MCA Deprivation of Liberty Safeguards Table 5 below shows the administrative DoLS activity for this year for HRCH as the Managing Authority for the Inpatient Unit at Teddington Memorial Hospital. Richmond is the Supervisory Body for TMH and the HRCH Safeguarding Lead has developed a good working relationship with the Richmond DoLS team who have reduced their backlog (although some delays in assessment are still inevitable). These delays also mean that some patents transfer out prior to authorisation being granted. Transformation work at TMH has resulted in a reduction in the number of inpatients meeting the acid test for DoLS. Table 5 DOLS figures for 2017/18 The relevant Supervisory Body for all these applications was London Borough of Richmond Activity for the quarter Q1 Q2 Q3 Q4 Year total activity* Patients subject to standard authorisations at the start of the quarter Standard authorisations approved Patients subject to standard authorisations at the end of the quarter *Not unique number of patients as processes span more than one quarter 7. Safer Recruitment Quarter 4 evidence with narrative and numerical information Number of staff who Number of staff who have DBS check on require DBS (within file no more than 3 total workforce years old for including volunteers vulnerable adults (and celebrities) Standard DBS 3 year guideline N/A % Enhanced DBS 3 year guideline N/A % Additional Information Number of new staff appointed in organisation in the quarter who: Target number and % Provide one checked reference if works in NHS Provided two checked references prior to commencement in post Total number of staff appointed Target number and % 100% 100% Page 10 of 16

124 Had DBS completed prior to post commencement How many staff have taken up a post prior to DBS being issued. Exception report Right to work in UK confirmed prior to commencement Total number of Target number staff appointed and % 22 (those Req DBS) 100% % 100% % As per the Trust s Recruitment and Selection Policy; 100% of staff employed provides one checked reference if the person works in the NHS or two checked references prior to commencement in post if external to the NHS. 100% of relevant staff has their DBS in place prior to commencing patient facing duties. 100% of staff has their right to work in the UK confirmed prior to commencement. These targets have been consistently met in every quarter of The Trust can be assured that recruitment processes in place are mitigating risk to adults as far as is possible. 8. Multi-Agency Partnership Working HRCH remains committed to active partnership working with Hounslow and Richmond Safeguarding Adults Boards. HRCH is represented on all sub-groups and relevant working groups as below and contributes to any joint working or new initiatives including raising awareness of adult safeguarding in our local communities. Richmond SAB is in the process of merging with Wandsworth, creating both challenges and opportunities for adult safeguarding development locally. Local Safeguarding Adults Board (SAB) meetings Meetings Attended by Safeguarding Adult Lead Hounslow SAB Richmond SAB Board Meeting Hounslow (deputising) Board Meeting Richmond (deputising) Quality Assurance Sub group Quality Assurance Sub group Richmond Training Subgroup Training Task and Finish Working Group Human Trafficking and Modern Slavery Delegation of Enquiries Working Group Working Group Community Engagement Subgroup *Community Engagement Subgroup Safeguarding Adults Review sub group by Safeguarding Adults Review sub group by invitation (none in ) invitation (none in ) Channel Panel core member Channel Panel by invitation HSAB self-assessment Challenge Event *Safeguarding Community Information Sessions London Provider Forum for SGA and Prevent (and task and finish group re SGA + SIs) London Safeguarding Network Page 11 of 16

125 MARAC (Multi Agency Risk Assessment Committee) Adult Safeguarding has been screening Richmond MARAC case schedules from Q due to contractual changes. If indicated, Adult Safeguarding researches adult only cases with a health component and will attend MARAC as required. In Hounslow, this function is performed by HRCH Children s Safeguarding team, who inform Adults of any relevant cases for research and / or attendance Specific adult safeguarding partnership activities in Delivered further Richmond Safeguarding Information sessions to Police Liaison Groups Informed practice by attendance at London Safeguarding Annual Event Informed practice by attendance at Mental Capacity Act Conference Informed practice by attendance at Prevent NWL Annual Event Informed practice by attendance at Croydon Anti- Slavery Conference Informed practice by attendance at NHSE Safeguarding Leadership Training (delivered by Bond Solon) Shared our MCA training film widely with health, (including trainee GPs) social care, paid and family carers across UK Met social workers to improve communication and manage expectations Developed and delivered DoLS training for HRCH LAC team with Children s safeguarding Achieved full access to adult social care records for both local authorities Participated in awareness raising campaigns for both authorities 9. HRCH Adult Safeguarding Development update Hounslow local authority safeguarding processes Previous challenges relating to poor communication with both local authorities (and Hounslow in particular) have been mitigated by SGAL having achieved full access to adult social care records. At a tactical level, the Adult Safeguarding Lead continues to build and maintain existing networks with both Local Authorities key contacts. The Adult Safeguarding Lead also acts as a conduit for information between the organisations involved in adult safeguarding. This has impacted on the capacity of this role and an Adult Safeguarding SOP is out to consultation to assist with effective management of the logistics of safeguarding meeting attendance and information exchange. Safeguarding adults at risk self assessment HRCH has reflected on its safeguarding adults practice using the detailed adult safeguarding risk self-assessment tool developed by NHS England. The numerical summary of the latest rating is shown in table 6.Previous year s figures are not given, as the template was changed for and is therefore not directly comparable. Table 6 Summary of risk-self assessment tool Page 12 of 16

126 Rating Assessment Number of areas year end Green Requirement met consistently across the organisation 25 Amber Requirement met in part 1 Red Requirement not met 0 The 1 remaining area assessed as amber relates to sharing learning from SARs with ALL staff (including subcontractors). This will be included in the Adult Safeguarding Workplan. 10. Key Achievements and Priorities for Achievements HRCH MCA Film is being used and widely shared by SABs across the UK HRCH have access to the Virtual College elearning for Safeguarding (use pending evaluation and approval by HRCH OD Lead) HRCH have been asked by NHSE to develop electronic templates for MCA assessments and Best Interest decisions and adult safeguarding recording for SystmOne which will enable read-across reporting with EMIS (used mainly by GPs) Domestic abuse awareness posters mounted hygienically on all toilet cubicle doors in HRCH exclusive use areas Priorities Team Capacity Capacity for adult safeguarding has presented a challenge which has limited the proactive support time which can be realistically offered to frontline practitioners, particularly Community Nurses, AHPs and non-scheduled care staff, who have potential to identify victims of domestic abuse, human trafficking, modern slavery and honour based crimes. This challenge has also impacted a number of the Work plan areas identified for development. This risk will be mitigated in with the approval for recruitment of a full time Band 7 Safeguarding Adult Specialist Clinician. Frontline Team Talk will be a priority for the coming year. The SGAL will be on rotation to team handovers / meetings to troubleshoot, support and advise as issues arise. Information Exchange with Local Authorities At the time of reporting, this remains a challenge (for both parties) to exchange information about concerns, risk management and decisions in a timely manner, although this has improved significantly and continues to improve. The HRCH Safeguarding Lead has built excellent working relationships with the Local Authority Safeguarding Leads and social workers, relevant contact numbers have been exchanged and the SGAL acts as a conduit for information. This Hounslow issue has being progressed thorough the Hounslow Safeguarding Adults Board Quality Assurance Subgroup and has improved during The scale of this issue with Richmond is smaller but also remains a challenge. Page 13 of 16

127 Access to electronic adult social care records has now been achieved with both Boroughs and this has largely resolved the issue from the Trust viewpoint. An Adult Safeguarding Standard Operating Protocol is expected to assist the local authorities, as it will specify appropriate points of contact. This will be launched with small informal meetings of key personnel to bolster partnerships. Proportionate Responses by Local Authorities to concerns raised This is an improving issue and one which has been addressed by all concerned by: Informal discussions by SGAL with social work Enquiry Officers and Safeguarding Adult Managers Formally via the Quality Assurance Subgroups of both SABs (chaired by Head of Safeguarding) By embedding and promoting use of the Safeguarding decision tools (pressure ulcers and falls currently, medication awaiting RSAB sign off to share with HSAB) By building trust and producing good quality, timely information to share that demonstrates our duty of candour and drive to learn and improve care quality. Clinicians raising safeguarding alerts to Adult Social Care Ongoing support is required to ensure that clinicians consistently recognise their role and responsibilities in the referral process to be business as usual. This continues to be addressed with HRCH Managers via planned Adult Safeguarding reflective practice and effective Datix communication. A dip sample quarterly audit for with Hounslow provides some assurance in this area. Mental Capacity Act (MCA) Compliance Ongoing work is required to support staff to fully and consistently understand the principles and application of MCA 2005 and evidence good practice in their recording. Domestic Violence (including Honour Based Violence) SGAL needs to develop more intranet guidance, ensure that this is more fully included in Safeguarding Level 2 training and that we have awareness raising within the Trust in partnership with adult social care and the voluntary sector. Adult staff need to be familiar with MARAC process and to know their responsibilities re referrals and presentations. Human Trafficking and Modern Slavery Training is being developed in partnership with Hounslow Adult Social care and partners on the working group. This will be discussed with Safeguarding Committee and Organisational Development to agree delivery strategy. Excellent E-learning is also available to HRCH staff without cost via Virtual College. Adult Safeguarding Training The Adult Best Practice Guidance Document (NHS England 2016) needs to be adopted as the standard for competence based Adult Safeguarding training for HRCH as soon as the final version is approved (2018). 11. Conclusion This report shows that adult safeguarding at HRCH is generally effective and that targeted work is ongoing in the identified areas for development, although progress has been Page 14 of 16

128 impacted by lack of capacity in the service. In the year to come, the service will be embedding the agreed additional post, and progressing the work plan towards achieving an outstanding service. HRCH continues to be an active and valued partner on both Hounslow and Richmond Safeguarding Adults Boards; attending and participating in the work of the subgroups and attending relevant learning events promoted / provided by the Boards. In this role it is not only supporting interagency working but also identifying risks which may affect the wider population in both of these boroughs and taking relevant action when this is indicated. As of April 2015, safeguarding has been one of CQC s fundamental standards and they require assurance that: There are reliable systems, processes and practices in place to keep people safe and to safeguard them from abuse and neglect That the use of restraint and deprivation of liberty is lawful That consent to care and treatment is sought in line with legislation and guidance That people are protected from avoidable harm, good practice is adopted, lessons are learned, and the service manages safeguarding concerns promptly and appropriately. HRCH Board should also take assurance that the Trust s work with adults seeks to meet these standards and monitors and reports its progress on the Journey to Outstanding. Page 15 of 16

129 Safeguarding Children Annual Report Reporting Time Frame: 1 st April st March 2018 Contents:- 1 Introduction 2 Safeguarding team 2.1 Personnel 3 Safeguarding Children Policies 4 Safeguarding Standards 4.1 Richmond Ofsted 4.2 Hounslow Joint Targeted Area Inspection 5 Safeguarding Training 5.1 Prevent 5.2 Training for the safeguarding team 6 Safeguarding Children Supervision 6.1 WIC 6.2 UCC 6.3 Family Nurse Partnership 6.4 Compliance Data 6.5 Safeguarding team Supervision 7 Serious Case Reviews (SCR) and Serious Incidents 8 Incidents and Risk 8.1 Richmond Root Cause Analysis 8.2 Child Deaths - Hounslow 8.3 SystmOne 9 Safeguarding Team Audit planner Paediatric Medical Team Data 11 Multiagency working 11.1 Children subject to a Child Protection Plan 11.2 Multi-Agency Risk Assessment Conference (MARAC) 11.3 Maternity Concerns meetings 11.4 Child Protection Information Sharing project (CP-IS) 11.5 Multi-Agency Safeguarding Hub (MASH) 12 Safeguarding Children Work Plan 13 Key Achievements During Key Priorities Page 1 of 22

130 1. Introduction The purpose of this report is to provide an update of service developments in relation to Safeguarding Children and to provide assurance to the Hounslow and Richmond Community Healthcare NHS Trust (HRCH) Board that the organisation is fulfilling its statutory Safeguarding Children responsibilities. 2. Safeguarding Team 2.1 Personnel HRCH are compliant with their statutory duty to employ Named Professionals and have Named Nurses and Named Doctors in post. The safeguarding nursing team sits within the Quality and Clinical Excellence directorate whilst the doctors are part of Children s Services. Team staffing Executive Lead: Donna Lamb Named Nurse 1.0 WTE Tony Bowen Named Nurse 1.0 WTE Jane Bennie Specialist Nurse 1.0 WTE Ann Marie Brosnan Specialist Nurse 1.0 WTE Julie Findlater Specialist Nurse 1.0 WTE Janet Osbourne Team Administrator 1.0 WTE Faiza Malik Named Doctor Hounslow Dr Vanessa Impey (1.5 sessions) Named Doctor Richmond Dr Sudipta Sen (1 session) Jane Bennie Named Nurse left HRCH in December 2017 MASH Richmond Locality Kate Rashkes 0.8 WTE Carol May 0.5 WTE MASH Hounslow Locality Shanti Subramaniam 1.0 WTE Nikki Love 0.5 WTE 3. Safeguarding Children Policies Page 2 of 22

131 All HRCH safeguarding children policies are written to align with the Pan London Child Protection Procedures and the government guidance within Working Together to Safeguard Children Safeguarding Children Standards 4.1 London Borough of Richmond Ofsted Inspection On 25 th September 2017, Richmond received notification of an Ofsted inspection of services for children in need of help and protection, children in care and care leavers. The inspection continued over four weeks and the Local Safeguarding Children s Board (LSCB) was reviewed as part of this inspection. Partner agencies received a letter regarding the outcome of the inspection from Achieving for Children on the 8 th December 2017 and the following was noted. Richmond services have received the following judgement: 1. Children who need help and protection: Good 2. Children looked after and achieving permanence: Good 3. Adoption performance: Good 4. Experiences and progress of care leavers: Good 5. Leadership, management and governance: Good Although Ofsted's role is to inspect the local authority's services, they also examine the relationships with partner agencies and how these impact on the services that children and their families receive. The report noted that "partnership working is a significant strength. Relationships between agencies are highly positive, and this means that children and their families receive, in the main, well-coordinated services." While we have always known that partners put the needs of children first, and that positive partnership working is a collective strength in Richmond, it is heartening for this to be recognised and highlighted by Ofsted. 4.2 London Borough of Hounslow Joint Targeted Area Inspection A Joint Targeted Area Inspection (JTAI) was undertaken in Hounslow in March The theme of this inspection was around children living with domestic abuse. No serious concerns across the partnership were identified, HRCH worked closely with partners across Hounslow to develop and implement areas identified for improvement within the joint action plan. 5 Safeguarding Training Safeguarding training is mandatory for all HRCH staff. HRCH training needs analysis provides a framework for eligibility criteria for level 1-4 and is aligned with the Safeguarding Children and Young People: Intercollegiate Document roles and responsibilities for health care staff Safeguarding training figures are entered onto the electronic database WIRED 2. This database is managed by the Learning and Development department which Page 3 of 22

132 produce monthly electronic training reports. All managers and staff have access to the WIRED report for monitoring and compliance purposes. Eligibility for Level 1 - : All staff including non-clinical managers and staff working in healthcare settings. Eligibility for Level 2 Minimum level required for non-clinical and clinical staff that have some degree of contact with children and young people and/or parents/carers. Eligibility for Level 3 Clinical staff working with children, young people and/or their parents/carers and who could potentially contribute to assessing, planning, intervening and evaluating the needs of a child or young person and parenting capacity where there are safeguarding/child protection concerns Training - % Eligible Staff up to date with the following levels Quarter 1 Quarter 2 Target 90% Target 90% Quarter 3 Target 90% Quarter 4 Target 90% Level 1 93% 92.93% 87.68% 98.91% Level 2 86% 91.05% 88%% 93.87% Level 3 94% 96.14% 80.74% 88.14% Level 4/5 100% 100% 100% 100% In order to maintain organisational compliance with safeguarding training targets, training will remain a high priority for the safeguarding team. Training compliance is monitored by the Named Nurse and all staff non-compliant with safeguarding children training are contacted and asked to complete the Hounslow virtual college e-learning programme to ensure compliance. 5.1 Prevent Prevent is part of the Government s counter-terrorism strategy CONTEST and aims to stop people becoming terrorists or supporting terrorism; as such it is described as the only long term solution to the threat we face from terrorism. Prevent focuses on all forms of terrorism and operates in a pre-criminal space, providing support and re-direction to vulnerable individuals at risk of being groomed into terrorist activity before any crimes are committed. Radicalisation is comparable to other forms of exploitation; it is therefore a safeguarding issue staff working in the health sector must be aware of. Raising awareness of the health sector contribution to the Prevent strategy amongst healthcare workers is crucial. The NHS is one of the best placed sectors to identify individuals who may be groomed in to terrorist activity, with 1.3 million people employed by the NHS and a further 700,000 private and charitable staff delivering services to NHS patients. The NHS has 315,000 patient contacts per day in England alone. Page 4 of 22

133 Staff must be able to recognise signs of radicalisation and be confident in referring individuals who can then receive support in the pre-criminal space. The workshop to raise awareness of Prevent (WRAP) provides staff with the following competencies How to support and redirect vulnerable individuals at risk of being groomed into a terrorist related activities; and How to share concerns, get advice, and make referrals into the Channel process and Prevent Case Management. Current Prevent Training figures are as follows: Total Number of Employees: Number of staff who received Basic Prevent Training this quarter Total number of WRAP Facilitators in the organisation Total number of staff who are in date with Basic Prevent Training Percentage of workforce that is in date with Basic Prevent Training Number of staff who attended WRAP this quarter Total number of staff who require WRAP % 600 Total number of staff in your organisation who have attended WRAP since WRAP delivery started Percentage of staff that has attended WRAP (of those who require WRAP) % Five members of the HRCH safeguarding team are accredited to deliver the WRAP training programme. The quarterly Prevent Leads Forum at NHS England is attended by either the Named Nurse Prevent Lead or the Adult Safeguarding/Deputy Prevent lead. Prevent Training figures for NHS England are uploaded on a quarterly basis to unify2 by the performance team. 5.2 Training for the Safeguarding Team The specialist knowledge and skills for all members of the safeguarding team must be maintained in order to fulfil their leadership roles effectively. The Specialist and Named Nurses continue to access appropriate training courses to maintain compliance with Level 4 competencies as set out in the Safeguarding Children and Young People: Intercollegiate Document roles and responsibilities for health care staff All paediatricians both on the Hounslow and Richmond Team of HRCH have Level 3 competency in paediatric safeguarding and training in completion of child protection medicals. The Named and Designated Doctors for HRCH have completed Level 4/5 training. Page 5 of 22

134 The doctors attend safeguarding meetings within the trust and externally; they attend training sessions at the LSCB and participate in workshops / peer review from regional safeguarding networks. All members of the team are 100% compliant with Level 4 and 5 safeguarding training. 6. Safeguarding Children Supervision The universal children services and safeguarding children team continue to work closely together to ensure that caseloads are managed effectively, and supervision levels are maintained. Supervision has continued to be prioritised by the safeguarding children team which is reflected in the high levels of compliance achieved across health visiting teams in particular. Joint supervision can be undertaken between social care and health for families where specific difficulties have been identified, i.e. working relationships, non-engagement of families, stuck families and those who have been subject to a child protection plan for over a year. The safeguarding children team continue to receive telephone calls for ad-hoc advice relating to safeguarding practice. The National Service Framework (NSF) for Children, Young People and Maternity Services (DH, 2004) Standard 5, identifies high quality safeguarding children supervision as the cornerstone of effective safeguarding of children and young people, and should be seen to operate at all levels within the organisation. Accessing safeguarding children supervision contributes to meeting outcomes of Care Quality Commission Standard 7. Effective professional supervision can play a critical role in ensuring a clear focus on a child s welfare. Supervision should support professionals to reflect critically on the impact of their decisions on the child and their family. Employers are responsible for ensuring that their staff are competent to carry out their responsibilities for safeguarding and promoting the welfare of children and creating an environment where staffs feel able to raise concerns and feel supported in their safeguarding role (Working Together to Safeguard Children 2015). Paediatric medical staff within HRCH receives safeguarding supervision and attend monthly peer review meetings where cases are discussed and supervision is provided 6.1 Walk in Centre (WIC) Teddington Memorial Hospital Since introducing safeguarding supervision to the Walk in Centre at Teddington Memorial Hospital and the Urgent Care Centre at West Middlesex Hospital challenges have continued with relation to achieving a good level of compliance. Page 6 of 22

135 Consultation continues with the clinical service managers and the Named Nurse with regards to the way forward for improving staff compliance with supervision. The Named Nurse has continued to work from the Walk in Centre one morning or afternoon per week but this has been dependant on diary commitments. It is proposed that provision of supervision for the WIC will be undertaken by one of the specialist nurses during 2018/19. Current supervision compliance is 67%, the objective is to obtain full staff compliance over a 6 month period due to the nature of service provision at the walk in centre. A safeguarding supervision course has been identified and the clinical service manager for the walk in centre has booked onto the training provided by achieving for children. It is proposed that the service manager becomes the safeguarding lead for the walk in centre in conjunction with the Named Nurse safeguarding children. 6.2 Urgent Care Centre (UCC) A programme of six monthly training sessions commenced in November 2016 incorporating group supervision whereby clinicians from Greenbrook Healthcare are included in order to work in partnership and share good practice. The paediatric liaison health visitor (HV) offers additional one to one supervision in an ad hoc manner as required. The paediatric liaison HV has since August 2017, chaired a weekly meeting reviewing all inter-agency and HV referrals. This is attended by the UCC lead nurse, UCC safeguarding GP and the HRCH Named Nurse safeguarding children. These meetings have given opportunities to share good practice and highlight areas for improvement of individual practice which is then taken back to the clinicians by either the lead nurse or safeguarding GP. The paediatric liaison health visitor will also be contributing information relating to safeguarding to the weekly UCC Blog. Following a review of the safeguarding supervision policy in October 2017 we have developed a more flexible approach to supervision within the UCC and the WIC in line with specific staff and organisational requirements, it is expected that all clinicians working in these settings will have received safeguarding supervision at least once in any six month period. The safeguarding team are currently working with service leads within the WIC and UCC to develop a more robust method of providing supervision to this cohort of staff 6.3 Family Nurse Partnership The family nurse partnership team currently holds the following caseload: Family Nurse Partnership Number of cases in the FNP programme Q1 Q2 Q3 Q Page 7 of 22

136 Number with CPP Number with CIN 1 baby mother Leaving Care 5 (3 mothers, children) Number of these cases discussed in safeguarding supervision with the FNP Supervisor All Family Nurses receive weekly supervision provided by the FNP supervisor and this incorporates safeguarding supervision. Tri partite supervision is established and has continued three monthly between the Family Nurse, Family Nurse Supervisor and the Named Nurse safeguarding children. Following concerns regarding the complexity of the cases held by the family nurses, joint supervision sessions continue on a monthly basis between the family nurses, the Named Nurse and Hounslow Children s Social Care, These case discussion meetings were recognised as good practice in recent Joint targeted area inspection The CYP service had introduced an innovative joint supervision approach to provide externality and objectivity in supervision sessions. The family nurses are up to date with Level 3 Safeguarding Children training. The FNP supervisor has received Level 4 Safeguarding Training as part of the FNP Supervisors Learning Programme. The Supervisor or Family nurse attends the Multi- Agency Pre- Birth meetings at West Middlesex University Hospital (WMUH) when they have clients for discussion. Case discussion meetings with the young mother s antenatal group (YMAG) at West Middlesex Hospital established bi-monthly for information sharing. 6.4 Supervision Compliance data 1 st April st March 2018 % of staff up to date with Quarterly Safeguarding Supervision Team Quarter 1 Quarter 2 Quarter 3 Quarter 4 HVs Hounslow 100% 100% 100% 100% HVs Richmond 100% 100% 100% Service transferred to CLCH FNP 100% 100% 100% 100% Richmond Community Children s 80% 100% 50% 83.33% team Hounslow Continuing Care Team 100% 100% 82% 82% Hounslow Special Schools Team 36% Supervision now with continuing Page 8 of 22

137 care team LAC Hounslow (2 staff member) 100% 100% 100% 100% LAC Richmond (1 staff member) 100% 100% 100% 100% MASH Hounslow (2 member) 100% 100% 100% 100% SPA Richmond (2 member) 100% 100% 100% 100% Specialist Nurses 87% 85.71% 85.71% 57.14% Hounslow Physio and OTs 78% 82.35% 70.59% 89.47% Advanced Nurse Practitioners 100% 0% 100% 100% Richmond Physio and OTs 70% 82.35% 76.92% 100% Hounslow SALT 57% 82.35% 75.76% 75.76% Richmond SALT 0% 70.83% 69.23% 94.12% % of staff up to date with 6 monthly Safeguarding Supervision Team Quarter 1/2 Quarter 3/4 UCC 100% 0% % of staff up to date with 6 monthly Safeguarding Supervision Team Quarter 1/2 Quarter 3/4 WIC 57% 9% 6.6 Safeguarding Team Supervision The Safeguarding Children Team provides peer support within the team, and also access supervision from the Designated Nurses for Safeguarding Children in Hounslow and Richmond on a 6 weekly basis. The Designated Nurses are also available for ad-hoc supervision as required. 7 Serious Case Reviews (SCR) and Serious Incidents In August 2017 a young person who was looked after died. This was discussed at the September 2017 cases sub group of the HSCB and a decision was taken to hold a Serious Case Review in line with Working Together to Safeguard Children guidance, An Internal Management Review (IMR) has been completed for the UCC and LAC services by the Named Doctor for Hounslow. Practitioner events for the Serious Case Review were held in January 2018 The following themes were identified following completion of the IMR Use of safeguarding alerts on SystmOne Page 9 of 22

138 Standardisation of recording of safeguarding information Improvement in multiagency communication to ensure action plans and risks are identified, managed or escalated accordingly Regular audit of health reports to ensure quality Improvement in handover from the London ambulance staff to UCC staff Revision of patient streaming guidelines at the UCC Identification of staff training needs i.e. Domestic violence training Review of safeguarding risks when patients do not wait to be seen at the UCC 8 Incidents and Risk To promote the ethos of openness in line with government guidelines, all staff are encouraged to actively report incidents through HRCH electronic reporting system Datix. Any serious incidents will continue to be logged and reported into the Safeguarding Committee so that lessons are learnt from the cases. 8.1 Richmond Root Cause Analysis An incident occurred in June 2017 where there was a delay in organising a child protection medical for a Richmond child. A root cause analysis subsequently undertaken by the Named Nurses was completed in December The following themes were identified following completion of the RCA All child development staff to be familiar with referral pathways for CSE All staff should be aware of how to escalate concerns Completed Actions The learning from the incident has been shared with all members of the Child development team. Referral pathways into the child development service to be shared with Children s services for both Hounslow and Richmond localities Training provided for all staff within the child development team regarding the referral pathways for children who are at risk of child sexual abuse. 8.2 Child Deaths Hounslow All child deaths that occur within the borough of Hounslow are managed via the Child Death Overview Panel (CDOP). CDOP meets to review the deaths of all children, excluding those who are stillborn or those who die as a result of a planned termination, from birth up to age 18 years normally resident in Hounslow. The Child Death Overview Panel was established in April 2008 and is a subgroup of the HSCB. The government requires each LSCB to establish a Child Death Overview Panel to carry out a review of all child deaths in their area, following the processes set out in Working Together to Safeguard Children (2015). Page 10 of 22

139 The CDOP collects core information relating to each child s death and receives reports from other reviews of child deaths, including individual reviews of Sudden Untoward Incidents, hospital reviews of perinatal deaths and Serious Case Reviews. In reviewing the death of each child, the CDOP should consider modifiable factors, for example, in the family environment, parenting capacity or service provision, and consider what action could be taken locally and what action could be taken at a regional or national level. The CDOP reviews annually the numbers and patterns of deaths in Hounslow and the HSCB and its constituent agencies with an annual report including any recommendations for future practice and reducing the number of preventable deaths. Numbers of Child Deaths - Hounslow Child Deaths Quarter 1 Quarter 2 Quarter 3 Quarter 4 Number Did not report Did Not 0 0 Expected data report data Number Unexpected Did not report data Did not report data 0 1 It was noted by the quality review group in Hounslow that the previous quarterly reports did not provide narrative regarding the numbers of child deaths in Hounslow. Following discussion with the designate nurse it was agreed that the narrative would be provided from quarter 3. Currently information regarding cause of death of a baby in quarter 4 is not available. 8.3 SystmOne A number of issues regarding SystmOne were highlighted during 2017/18; these issues were also picked up during the Hounslow JTAI inspection. Following the JTAI, A series of SystmOne meetings were chaired by Julie Hulls designate nurse for Hounslow CCG. Following the introduction of these meetings, the areas identified for improvement were shared by other health agencies and a joint action plan was devised to address the key areas for development. All identified HRCH health actions have been completed to mitigate the identified risks. The Named Nurse is continuing to work with SystmOne Leads and Hounslow CCG to progress other aspects of the action plan. 9 Safeguarding Team Audit planner Three audits were planned for the year ending March 2018: Page 11 of 22

140 Completed Audits Safeguarding supervision audit - This has been completed and was shared at the February safeguarding committee Areas of Good Practice identified following the audit 100% of newly qualified health visitors received supervision on a monthly basis 96% of health visitors received supervision within timescales 90% of health visitors felt that they were able to critically reflect and analyse their clinical practice 83% of health visitors agreed that the SystmOne records evidenced improvements in the outcomes for the child 90% of health visitors felt supported during the supervision session 83% of health visitors received additional unplanned supervision 87% of health visitors felt satisfied with unplanned supervision Comments from Practitioners regarding supervision I enjoy supervision as it gives the opportunity to have a more in-depth look at the individual needs of the child I have had to call for advice when I needed to make a decision about a family and I have received quick advice from the team. As a newly qualified health visitor having monthly supervision sessions has been very helpful, it has given me more confidence and has been very supportive. It is always planned ahead, and with flexibility on both mine and my Safeguarding Supervisors side. My current supervisor is always accessible by telephone or contacts me back and is supportive Recommendations from the Audit All HRCH staff need protected time to receive safeguarding supervision Supervision with experienced health visitors to continue 3 monthly with an offer of extra support as required. Consideration to be given to newly qualified health visitors being offered 2 monthly supervision flowing the initial 6 months post qualification Safeguarding supervisors to signpost practitioners towards appropriate training opportunities locally and through the LSCB. Safeguarding team to support staff with effective record keeping. Newly qualified health visitors to continue to undertake child protection supervision on monthly basis for the first 6 months. Outstanding Audits. SystmOne record keeping audit This was commenced at the end of August 2017, the completion of this audit was delayed due to the Page 12 of 22

141 commencement of an in depth records audit of the vulnerable cases held by the Hounslow health visiting service. HRCH wide review safeguarding training impact audit due to changes in staffing within the Safeguarding team during quarter 4 this audit will now take place as part of the 2018/19 Audit Plan. 10 Paediatric Medical Team Data Medical Team Structure Named Doctor for Hounslow: Dr Vanessa Impey -1.5 sessions Named Doctor for Richmond: Dr Sudipta Sen -1 session Designated Doctor for Hounslow: Dr Nirmala Sellathurai - 2 sessions Designated Doctor for Richmond: Dr Claire Scott - 2 sessions Child Protection Medicals cover The integrated safeguarding rota for child protection medicals operates on a collaborative basis between Hounslow Medical Team, Richmond Medical Team and West Middlesex University Hospital (WMUH). Safeguarding rota/time-table and operational management lies with the above mentioned Named Doctors of the Trust. Total number of requests for child protection medical Number of children not seen following referral and reason given Number of children from Hounslow seen Number of CSA referrals made Hounslow Data of CP medicals Q1 Q2 Q3 Q Cancelled by social worker 1 cancelled by social worker 2 1- Medical refused by Young Person 1 Cancelled by Social Worker 3 1 Taken to WMUH with swollen eye. 2 DNA. SW informed and rereferred Total number of requests for child protection medical Number of children not seen following referral and reason given Richmond Data of CP medicals Q1 Q2 Q3 Q (1 young person refused and 3 were under 12months of age child seen at WMUH 1 Page 13 of 22

142 and seen at WHUH) Number of children from Hounslow seen Number of CSA referrals made Bleeding, went to WMUH Community Paediatricians and therapists input to case conferences: Hounslow Data of CP Case Conference Invitations 7/11/17 9/01/18 10/1/18 31/3/18 Total number of invitations to CPCC Number of children that were 16 (42%) 61 (26%) known to CPCC known to Hounslow Paediatricians Number of responses / reports sent from Hounslow paediatricians 15 (15/16) 94% 50 (81%) Outstanding issues around safeguarding processes: The Flow chart for Hounslow showing pathways for referral for different categories of suspected abuse this has been drafted and is awaiting approval, once approved it will be shared with social care A Prompt sheet for therapists to use to facilitate these difficult discussions with families is being developed by Vanessa Impey Named Doctor with input from a therapist Planned development of SystmOne for statistics for safeguarding assurance by Hounslow named Doctor Routine enquiry about domestic violence Routine enquiry about domestic violence: further extension of this policy to include training of therapists being planned by Hounslow Named Doctor, in discussion at safeguarding committee. 11. Multi-Agency Partnership Working HRCH remains committed to partnership working with Hounslow and Richmond safeguarding children boards. HRCH is represented on all safeguarding children boards and sub-group meetings and contribute to any joint working or new initiatives Children subject to a Child Protection Plan Page 14 of 22

143 Number of Children Number of Children Numbers of Children Subject to CP Plans Quarter 1 16/17 Quarter 1 17/18 Quarter 2 16/17 Quarter 2 17/18 Ricmond In borough Richmond OLA Hounslow In Borough Hounlsow OLA Numbers of Children Subject to CP Plans Quarter 3 16/17 Quarter 3 17/18 Quarter 4 16/17 Quarter 4 17/18 Ricmond In borough Richmond OLA Hounslow In Borough Hounlsow OLA Multi-Agency Risk Assessment Conference (MARAC) The Safeguarding Children Team attends the MARAC for the Hounslow Local Authority area. The Richmond MARAC is covered by Central London Community Health Care. MARAC is a monthly risk management meeting where professionals share information on high risk cases of domestic violence and abuse and put in place a risk management plan. All agencies are signed up to an information sharing protocol. Page 15 of 22

144 The aim of MARAC is to:- Share information to increase the safety, health and well-being of victims/survivors, adults and their children Determine whether the alleged perpetrator poses a significant risk to any particular individual or to the general community Construct jointly and implement a risk management plan that provides professional support to all those at risk and that reduces the risk of harm Reduce repeat victimisation Improve agency accountability Improve support for staff involved in high-risk domestic abuse cases Number of Children Discussed at MARAC Month Richmond Hounslow No of Children Discussed No of Unborn Children discussed No of Children Discussed No of Unborn Children discussed Quarter 1 April May June Quarter 2 July August September Quarter 3 October November December Quarter 4 January 2018 MARAC attended by CLCH 16 1 February 2018 MARAC attended by CLCH 6 3 March 2018 MARAC attended by CLCH 9 2 Following transfer of the Richmond health visiting service in January 2018 to Central London Community Health Trust the HRCH safeguarding team attendance at the Richmond MARAC for children under 5 years of age ceased Maternity Concerns Page 16 of 22

145 Maternity Concerns is a multi-agency meeting which discusses all mothers within the HRCH area who are booked to deliver at either Kingston or West Middlesex Hospitals, who are vulnerable due to previous or current safeguarding concerns for a mother and her unborn baby. The meeting provides a forum for communication between agencies to ensure an appropriate plan is put in place to support the needs of the mother and to ensure effective safeguarding arrangements are in place in preparation for the birth of the baby. Members of the safeguarding team attend and share relevant information with the appropriate HV team. Number of cases discussed at maternity concerns meetings Month Hounslow (West Middlesex Hospital ) Richmond Kingston Hospital Richmond (West Middlesex Hospital ) Quarter 1 April cancelled May June Quarter 2 July August September Quarter 3 October November December Meeting Cancelled 12 Quarter 4 January Covered by CLCH Covered by CLCH February Covered by CLCH Covered by CLCH March Covered by CLCH Covered by CLCH 11.4 CP- IS The Child Protection Information Sharing (CP-IS) project helps the NHS give a higher level of protection to children who present in unscheduled health care settings. These settings include: Emergency departments Walk-in centres Minor injury units GP out of hours services Page 17 of 22

146 Ambulance services Maternity Paediatric wards. Healthcare staff in unscheduled care settings will ultimately be able to see whether any child with whom they deal has a child protection plan or is looked after, regardless of where in the country that child normally resides. Local authorities will feed information on children who are subject to a child protection plan or are looked after from their social care systems into a secure central data store area in the NHS National Spine. Health professionals, during the process of registering a child at their care setting, will be informed of the child s child protection status. As soon as basic demographic information is inputted, if the child is looked after or subject to a child protection plan, an indicator flag will appear on screen, with the contact details for the relevant local authority. A record of who has viewed the indicator flag will be available to social care and healthcare staff, allowing them to see if that child has been visiting a range of different unscheduled healthcare settings Hounslow Progress Hounslow local authority went live with CP-IS on the 20 th February CP-IS has been high on agenda s for a period of time and Greenbrook have been awaiting the integration of CP-IS functionality with SystmOne. They have been working with NHS Digital and were flagged as an early adopter site at Ealing and WMUH. SystmOne has started to deploy the integrated CP-IS functionality and the UCC went live with CP-IS on Monday 11 th December Going live meant that as part of the booking process, SystmOne will automatically look up the CP-IS database to see if there is a record for the child a flag is then placed alongside the patient on the A&E overview screen which alerts staff that the child is subject to a child protection plan or looked after. Staff were made aware that although the UCC is live, the CP-IS functionality will only work where the child s home address is in a live local authority. Ealing, Brent, Harrow and Richmond for instance are not yet live. Richmond Progress Achieving for Children are in the process of procuring their CP-IS solution. It is currently wrapped up in the re-commissioning of their entire social care, prevention and early help systems. Progress is slower than expected due to the need to comply with various regulations regarding this procurement. We currently await an update on timescales following completion of their procurement process. Page 18 of 22

147 Achieving for Children is waiting to implement the required functionality to the Liquid logic ICS systems and is part of a wider system development programme. Training has been provided to the clinical Service Manager and Operational System Support Services Administrator at the walk in centre (WIC), initial training on the use of the summary care record application and how to access the child protection information and training resources have been provided. The walk in Centre went live with CP-IS in December 2017 and access the information via the summary care record application Multi-Agency Safeguarding Hub (MASH) General Overview The MASH is the co-location of police, children s services and health. The model is based on the principle that agencies meeting, working and talking together earlier, increases the chances of saving lives and keeping vulnerable children safe. The MASH therefore aims to prevent missed opportunities to intervene in cases where children might be suffering, or at risk of suffering, significant harm The MASH has three key outcomes: - Early identification and understanding of risk Victim identification and intervention Harm identification and its reduction Hounslow MASH Gathering health intelligence within the required timescales has continued to be a challenge for the specialist health visitors. This was also noted within the Joint Targeted Area Inspection as the report noted that whilst there is a timely response to information requests from most partners, the majority of delays come from health. Health requests and Breaches - Comparative data for Quarter 1 Quarter /18 Page 19 of 22

148 Health Requests Breaches % -Breached 50 0 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Narrative Whilst the quality of the information provided by health is noted by social care as being good, the number of breaches means that there are a significant number of families where the health MASH checks have not been completed. Delays in sharing health intelligence and the breaching of timescales have occurred due to the increasing volume of referrals and the complexity of accessing health information is greater than the capacity within the service. The lack of the provision of health information means that children s services are required to make a decision without health information, which in itself poses a risk. At times the health information has been pivotal in cases being opened to Children s Services for assessment. The number of breaches and the potential impact of this on the safety of the service have been identified as a risk and this has been recorded on the trust risk register. We are currently putting measures into place to minimise the risk whilst we work on longer term solutions with commissioners. Current Support offered to the MASH Practitioners Support is offered to both health Practitioners through regular 1:1 meetings, safeguarding supervision and case audit Additional Support Provided A specialist nurse within the safeguarding team has been trained in the MASH process and has provided additional support to the specialist practitioners within the MASH during times of high volumes of requests. These extra hours supported the reduction in backlog of health checks being completed. Richmond MASH Page 20 of 22

149 The Richmond MASH health practitioners co-located to the Guildhall 2 in Kingston in February Following the transfer of the Richmond Health visiting service to Central London community health care in January 2018, Information sharing agreements were put in place to allow the MASH Practitioners to access the CLCH SystmOne units to allow timely health intelligence reporting. Following consultation with the MASH practitioners and CLCH during quarter 4 it was agreed that the Richmond MASH practitioners would TUPE from HRCH to CLCH On the 1 st of May Safeguarding Children Work Plan The work plan for is a live document and as such is subject to alterations which are reviewed and agreed via the safeguarding committee. 13 Key Achievements during 2017/18 Consistently high levels of child protection supervision have been maintained Continued improvement in training compliance levels Review of staff cohorts required to undertake level 1,2,3 and 4 safeguarding children training in line with the Safeguarding children and young people: Roles and competences for health care staff intercollegiate document. Additional level 3 training session on Children with Disabilities Rolling Programme of WRAP Training sessions WRAP training was provided to the executive board in December 2017 Successful completion of prioritised areas of the annual work plan Review and ratification of the safeguarding children Supervision policy Completion of health actions identified by the joint Targeted Area Inspection on the theme of Domestic abuse for Hounslow which was undertaken in Quarter /17 Full HRCH attendance at LSCB meetings and sub groups Participation in 2 day Hounslow MASH audit undertaken by external Auditor Provision of level 3 training to the Urgent care centre staff delivered by the Named Doctor for Hounslow. Training sessions on the introduction of routine enquiry regarding domestic abuse has been delivered to the community paediatricians by the Named Doctor for Hounslow Hounslow Community Paediatrics service are now processing case conference invitations received and send reports or attend the case conferences for all children known to the service. Introduction of safeguarding Supervision to the WIC and UCC Go live for Hounslow CP-IS Introduction of the use of the neglect tool during the supervision of cases held by the Health visitors which facilitates the feedback of information to children s social care. Page 21 of 22

150 In order to improve efficiency and recording on the child s clinical record, A template has been added to SystmOne for completion during the peer review meeting and is now in use All Photographs from Child Protection medicals are now uploaded and stored in a confidential folder, these images are available for viewing during peer review meetings. 14 Key Priorities for 2018/19 The Safeguarding of children living within the localities of Hounslow and Richmond who are accessing HRCH services Improvement in compliance of Safeguarding supervision and training levels across HRCH Improvement in supervision levels for staff based at the UCC and Teddington urgent treatment centre Introduction and Training on routine enquiry on domestic abuse for therapists Completion of identified areas of the safeguarding team work plan Delivery of training on Domestic abuse for staff based at the UCC following the Serious case review Review of MASH health intelligence processes Improvement in the Timeliness of health intelligence reporting in Hounslow MASH Attendance at multiagency and LSCB meetings and Subgroups CONCLUSION This report provides assurance to the trust board that children are safeguarded across Hounslow and Richmond. Appropriate leadership is in place and there is continued commitment of the safeguarding team to providing high levels of supervision and training, the development of multi-agency approaches to case by case supervision with children s services and improvement in our partnership working with the local safeguarding children boards and partner agencies. Page 22 of 22

151 Meeting title Trust Board part I meeting Date: 25/07/2018 Report title 2017/18 Infection Prevention and Control annual report Agenda item: 17 Lead director Report authors Executive summary Donna Lamb, DIPC and Director of Nursing and Non-Medical Professionals Linda Woodward-Stammers, Deputy DIPC and Lead Infection Prevention and Control Nurse Specialist This infection prevention and control annual report of Hounslow and Richmond Community Healthcare (HRCH) NHS Trust gives an overview of the work that the organisation and infection prevention and control (IPC) team undertook to prevent and control healthcare associated infections (HAIs) during the period April 2017 to March It is a statutory requirement for all NHS organisations that the Director of Infection Prevention and Control (DIPC) for the year produces an annual report on the prevention of HAIs within the organisation for public release. Key areas to note are as follows:- During 2017/18 there were a number of significant changes within the establishment of the IPC team. The actions in the annual plan were re- prioritised and the majority were completed in year. The remaining actions have been carried forward to 2018/19. There were no cases of Clostridium difficile infection reported and no requests to contribute to post infection reviews for MRSA bacteraemia cases identified at either Chelsea and Westminster or Kingston hospitals. There were no CAUTIs identified in quarter one, two and four. However, in quarter three, there were three patients who met the CAUTI criteria and post infection reviews (PIR) were undertaken. The recommendations and lessons learnt were disseminated and implemented by the service manager. There were two Serious Incidents in 2017/18; a Norovirus outbreak and MRSA colonisation outbreak, both occurred on the Pamela Bryant unit (PBU) at Teddington Memorial hospital. The incidents were investigated and action plans developed with the lessons learnt incorporated into the IPC mandatory face to face training and at staff meetings on the PBU. In quarter four the risks identified on the gap analysis 1

152 were transferred to the risk register. There are three risks that relate to IPC; non-compliance with the Code of Practice, vacancies within the IPC team and attendance at IPC training. Mitigations and actions have been assigned to manage the risks. The IPC team provided 8 face to face level 2 training sessions in the last quarter of 2017/18 which were attended by a total of 116 staff. At year end 83% of staff completed level 2 IPC training which was just below the Trust s trajectory of 90%. The IPC team has developed an action plan for the prevention of GNBSI. The action plan has been presented and monitored by the IPCC and shared with both Hounslow and Richmond CCGs. The IPC team has continued to successfully lead and encourage the infection control link practitioners (ICLPs) to reinforce hand hygiene policy amongst their colleagues and promote effective hand hygiene, reflected in assessment compliance scores and feedback. The IPC team continued to revise IPC policy manual chapters due for scheduled review and those requiring update due to changes in best practice, guidance or legislation. There were eleven chapters reviewed during the year. Progress with the IPC annual work plan will be monitored by the IPC Committee throughout 2018/19 to monitor the team s objectives. Purpose Approval Recommendation(s) That the Board approves infection prevention and control annual report 2017/18 for publication on our web pages BAF/TRR Report history Appendices BAF Q1; TRR Q5 Quality Governance Committee, 12 July 1: 2017/18 Infection Prevention and Control annual report 2

153 INFECTION PREVENTION AND CONTROL ANNUAL REPORT 2017/18 HRCH IPC Annual Report 2017/18 v.1.0 Page 1 of 48

154 Lead author: Lead Infection Prevention and Control Nurse Specialist/ Deputy Director of Infection Prevention and Control Co-authors: Infection Prevention and Control Nurse Specialists On behalf of: Director of Infection Prevention and Control for 2017/18 (Director of Nursing and Non-Medical Professionals) Acknowledgements: Infection Prevention and Control Nurses Infection Prevention and Control Support Officer Contributors: Section 11: Head of Pharmacy and Prescribing Section 12: Head of Occupational Health and Wellbeing Section 14: Assistant Director of Estates and Facilities HRCH IPC Annual Report 2017/18 v.1.0 Page 2 of 48

155 Section Page Executive Summary 5 1. Introduction 8 2. The IPC Team 2.1 IPC Committee 2.2 Infection Control Link Practitioners 3 HCAI Surveillance 3.1 Alert organisms 3.2 CAUTI 3.3 Gram Negative Blood Stream Infections 4. IPC Audits 4.1 Hand Hygiene 4.2 HIIs 4.3 Isolation 4.4 MRSA Screening 4.5 Clinical Practice Audits 4.6 Environmental Audits 5. IPC Training 5.1 Mandatory IPC Training 5.2 ANTT E-learning Training 6. Compliance with The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance updated IPC Performance IPC Risk Register Decontamination IPC Incidents 10.1 Serious Incidents 10.2 Communicable Disease Exposures Antimicrobial Stewardship Occupational Health 12.1 Staff Influenza Vaccination Programme 12.2 Inoculation Incidents Policies and Guidelines 26 HRCH IPC Annual Report 2017/18 v.1.0 Page 3 of 48

156 Section Page 14. Estates and Facilities Environmental Cleaning 14.2 PLACE 14.3 Premises Development and Refurbishments 15. External Visits and Inspections Publications Related to IPC Projects and Innovations Conclusion 28 Appendices Appendix 1 Infection Prevention and Control Committee Terms of Reference Appendix 2 Hand Hygiene Compliance Assessment Scores 2017/18 35 Appendix 3 IPC Clinical Practice Assessments 2017/18 37 Appendix 4 Appendix 5 Infection Prevention and Control Annual Work Plan 2018/19 Infection Prevention and Control Key Performance Indicator Dashboard 2017/ HRCH IPC Annual Report 2017/18 v.1.0 Page 4 of 48

157 Executive Summary This report is based on the annual Infection Prevention and Control (IPC) work programme for , and covers the period from 1 April 2017 to 31 March Some activities are governed by the imperatives contained in the Health and Social Care Act 2008, published in October 2006, reviewed in January 2008 and further updated in December 2009 and January and July This Annual Report provides a summary of the key initiatives and activities, together with an assessment of performance against the key performance indicators during IPC Team: There were a number of changes within the IPC team establishment during 2017/18 which has had some impact on the completion of the annual work plan. The majority of the actions were completed and the remaining actions have been carried forward to the 2018/19 plan. These include; organising IPC events, the launch of the revised HIIs audit tools, minimal development of the IPC intranet page and refresher train the trainer sessions for FFP 3 respirators. Surveillance and Key Performance Targets: Healthcare associated infections: In year there were no cases of Clostridium difficile infection reported and no requests to contribute to post infection reviews for MRSA bacteraemia cases identified at either Chelsea and Westminster or Kingston hospitals. Catheter associated urinary tract infections (CAUTIs): There were no CAUTIs identified in quarter one, two and four. However, in quarter three, there were three patients who met the CAUTI criteria and post infection reviews (PIR) were undertaken. The recommendations and lessons learnt were disseminated and implemented by the service manager. MRSA screening: A total of 338 (94%) patients were screened on admission to the PBU. 317 (88%) of which were screened within 48 hours of admission. 21 (6%) of patients were not screened within 48 hours of admission; this was primarily due to non-compliance with policy and was addressed with ward staff on each occasion. The Trust s KPI to screen 95% of new admissions was not achieved but this will be a focus in 2018/19 with the development of a flowchart for MRSA screening being introduced. HRCH IPC Annual Report 2017/18 v.1.0 Page 5 of 48

158 Hand hygiene audits and High Impact Interventions (HIIs): The overall year to date submission for hand hygiene audits was 87% which is a19% improvement from 2016/17 but below the KPI of 90% submission however, in quarter 4 the Trust achieved 100% submission across all services. The overall year to date compliance with hand hygiene compliance score met the target of 90% in all 4 quarters during 2017/18. The overall year to date compliance was 95% which is a 3% improvement on 2016/17. All community nursing teams and the inpatient unit submit HIIs each quarter. This target was met in quarter 4 with 100% of the nursing teams submitting HIIs. It should be noted that there was a 3% improvement in the year to date submission of the HIIs compared to 2016/17 figures. Outbreaks, Serious Incidents and Incidents: There were two incidents that were investigated as Serious Incidents in 2017/18; a Norovirus outbreak and MRSA colonisation outbreak, both occurred on the Pamela Bryant unit (PBU) at Teddington Memorial hospital. The incidents were investigated and action plans developed with the lessons learnt incorporated into the IPC mandatory face to face training and at staff meetings on the PBU. IPC Risk Register/ Gap Analysis: In quarter four the risks identified on the gap analysis were transferred to the risk register. There are three risks that relate to IPC; non-compliance with the Code of Practice, vacancies within the IPC team and attendance at IPC training. Mitigations and actions have been assigned to manage the risks. The risk register has been added as an agenda item for the IPCC and will be reviewed quarterly by the committee. Education & Training: In year it was noted that there was a discrepancy with the reporting of level 2 training. This issue was rectified. In addition, the IPC team also provided 8 face to face level 2 training sessions in the last quarter of 2017/18 which were attended by a total of 116 staff. At year end 83% of staff completed level 2 IPC training which was just below the Trust s trajectory of 90%. ANTT Champions Days: The IPC team organised four ANTT Champions Days in May 2017 which were facilitated by trainers from the Association for Safe Aseptic Practice. 49 members of staff attended the training which was designed to equip managers and staff with the necessary knowledge and skills in order to become ANTT lead/ competency assessors for clinicians in their teams. HRCH IPC Annual Report 2017/18 v.1.0 Page 6 of 48

159 Gram Negative Blood Stream Infections (GNBSI): The IPC team has developed an action plan for the prevention of GNBSI. The action plan has been presented and monitored by the IPCC and shared with both Hounslow and Richmond CCGs. Furthermore the Lead IPC Nurse Specialist is a member of the North West London GNBSI Steering group which is chaired by the CWHHE CCGs Director of Quality and Safety. Infection Prevention and Control Link Practitioners (ICLPs): Quarterly ICLP meetings were scheduled by the IPC team. The purpose of these meetings is to provide updates on specific topics such as communicable diseases, national and local developments and feedback on audits. Hand hygiene compliance is a focus of every meeting, with ongoing training provided on undertaking hand hygiene compliance assessments and improving practice. Two meetings were held during 2017/18 due to capacity issues within the team. Infection Prevention and Control Policy Reviews: The IPC team continued to revise IPC policy manual chapters due for scheduled review and those requiring update due to changes in best practice, guidance or legislation. There were eleven chapters reviewed during the year. HRCH IPC Annual Report 2017/18 v.1.0 Page 7 of 48

160 1. Introduction The Trust has a statutory responsibility to be compliant with the ten criterion set out in the Health and Social Care Act One of the requirements is for the Director of Infection Prevention and Control (DIPC) to produce an annual report that is presented to the Board which is then published on the Trust s intranet page. This report details the Infection Prevention and Control Team (IPCT) activity from April 2017 to March 2018, it includes the measures that were undertaken to prevent and control healthcare associated infections (HAIs) with an assessment of performance against national targets. 2. The IPC Team During 2017/18 there were a number of significant changes within the establishment of the IPC team. These are outlined in the table below; Donna Lamb Dr Sarah Furrows Nicola Sirin Sharon Edgell Linda Woodward- Stammers Deborah Tyler Martyn Case Ciaran Vaughn Director of Infection, Prevention (DIPC) and Control and Director of Nursing and Non-Medical Professionals Infection Control Doctor via SLA with Kingston Hospital Deputy DIPC and Lead IPC Nurse Specialist Interim Deputy DIPC and Control and Lead IPC Nurse Specialist Deputy DIPC and Lead IPC Nurse Specialist Infection Prevention and Control Nurse Specialist Interim Infection Prevention and Control Nurse Specialist Infection Prevention and 1.0 WTE 0.62 PA 1.0 WTE Left October WTE Commenced November February WTE Commenced 1 st February WTE Left December WTE (November nd March 2018) 0.6 WTE (5 th March th April 2018) Commenced November 2017 March WTE Left December 2017 HRCH IPC Annual Report 2017/18 v.1.0 Page 8 of 48

161 Jennifer Morris Fiona Joyce Control Nurse Infection Prevention and Control Nurse Infection Prevention and Control Nurse 0.7 WTE Commenced February WTE Returned from maternity leave 1 st February 2018 An additional 1.0 WTE specialist nurse has been recruited and started in May The actions in the annual plan were re- prioritised and the majority were completed in year. The remaining actions have been carried forward to 2018/ IPC Committee The HRCH IPC Committee meets quarterly and is chaired by the DIPC and reports to the Quality Governance Committee. It is primarily responsible for the supervision of the IPC annual work plan, approval of the quarterly and annual reports, policy and guideline development and ratification, and monitoring of IPC related incidents, outbreaks and gaps in regulatory compliance. The DIPC reports on IPC on a regular basis to the board and specific incidents or issues are escalated as appropriate. Current terms of reference for the IPC Committee and a table of attendance in 2017/18 are attached to this report as appendix Infection Control Link Practitioners Each clinical team/ service within HRCH is required to have an infection control link practitioner (ICLP). Quarterly ICLP meetings are held by the IPC team. The purpose of these meetings is to provide updates on specific topics such as communicable diseases, national and local developments and feedback on audits. Hand hygiene compliance is a focus of every meeting, with ongoing training provided on undertaking hand hygiene compliance assessments and improving practice. It should be noted that an ICLPs network is an essential requirement and an extension of the IPC team. The ICLPs act as ambassadors to disseminate information, promote IPC practices through audits and feedback within their teams. Attendance at ICLP meetings is presented in figure 1. Commitment is required from the ICLPs manager to allow their member of staff to be released from clinical duties. It should be noted that due to some of the ICLPs working part-time and full attendance cannot be achieved. Due to reprioritisation of workload in the latter part of the year the two meetings planned in December and March were cancelled. HRCH IPC Annual Report 2017/18 v.1.0 Page 9 of 48

162 Figure 1: HCAI Surveillance 3.1 Alert Organism Surveillance It is the responsibility of the staff on the Pamela Bryant unit to complete a fortnightly alert organism surveillance return for all positive microbiology results to the IPC team. The purpose of the return is to monitor the number of alert organisms in order to identify any increased incidences of infections. Clinicians who request microbiological samples are responsible for following up the results. If required advice should be sought from the IPC team if colonisation or a new infection is identified during a patient s stay or if there are any concerns relating to a patients infection status. During 2017/18 Community Trusts were not set with upper limits for the following infections; Meticillin sensitive Staphylococcus aureus (MSSA) bloodstream infections; Meticillin resistant Staphylococcus aureus (MRSA) bloodstream infections; Clostridium difficile infections (CDI); Escherichia coli (E. coli) bloodstream infections. However, it is a mandatory requirement that any of the above alert organisms identified from patients under the care of HRCH are reported on the Public Health England data capture system by the acute Trust who process the microbiology samples. In 2017/18 there were no requests for the HRCH IPC team to contribute to any post infection reviews for MRSA bacteraemia or root cause analyses for Clostridium difficile infections identified from patients who acquired a reportable HCAI after being discharged or transferred from HRCH s care. HRCH IPC Annual Report 2017/18 v.1.0 Page 10 of 48

163 The following organisms documented in figure 2 were reported to the IPC team via laboratory results and the ward surveillance returns in 2017/18: Figure 2: Organism reported Number of cases Sample taken <48 hours post admission Sample taken >48 hours post admission Clostridium difficile (antigen positive/ toxin positive) Extended-spectrum betalactamase (ESBL) producing organism Influenza B Herpes Zoster - Shingles MRSA Norovirus Measles 1 N/A N/A Vancomycin-resistant enterococci IPC advice and support was provided by the IPC team to ensure that the above cases were managed in accordance with Trust policies. 3.2 Catheter Associated Urinary Tract Infections (CAUTIs) Urinary tract infection (UTI) are the most commonly reported HAI, accounting for 17.2% of all HAIs in England, with 43% of UTIs associated with an indwelling urethral catheter (Health Protection Agency, ). Patients with invasive devices such as urinary catheters are at a greater risk of developing an infection (NICE, ). In 2017/18 the CAUTI review group continued to investigate all reported CAUTIs identified from patients who were admitted on the Pamela Bryant unit. Meetings are attended by the IPC team, continence nurse specialists and inpatient nursing staff; (1) Health Protection Agency, English national point prevalence survey on healthcare associated infections and antimicrobial use, 2011: preliminary data. London: Health Protection Agency. (2) National Institute of Health and Clinical Excellence (NICE), Infection: prevention and control of healthcare-associated infections in primary and community care. London: NICE. HRCH IPC Annual Report 2017/18 v.1.0 Page 11 of 48

164 There were no CAUTIs identified in quarter one, two and four. However, in quarter three, there were three patients who met the CAUTI criteria and post infection reviews (PIR) were undertaken. The recommendations and lessons learnt were disseminated and implemented by the service manager. 3.3 Gram Negative Blood Stream Infections (GNBSIs) In 2016 the Department of Health announced an ambition for Clinical Commissioning Groups (CCGs) to reduce healthcare associated Gram-negative bloodstream infections by 50% by 2020/21. Nationally it is widely reported that a whole health economy approach will be required to achieve this vision, working with clinical teams and managers to investigate cases of both acute and community acquired bacteraemia, prevent avoidable infections such as catheter associated urinary tract infections and educate all healthcare workers about the threat from Gram-negative bloodstream infections and how to prevent them. The IPC team has developed an action plan for the prevention of GNBSI. The action plan has been presented and monitored by the IPCC and shared with both Hounslow and Richmond CCGs. Furthermore the Lead IPC Nurse Specialist is a member of the North West London GNBSI Steering group which is chaired by the CWHHE CCGs Director of Quality and Safety. 4. IPC Audits 4.1 Hand Hygiene All clinical teams and services are required to submit a hand hygiene audit quarterly, with the exception of the Pamela Bryant unit that carry out a monthly audit. The IPC team can alternatively calculate hand hygiene compliance scores for nursing teams from submitted High Impact Intervention care bundles if sufficient interventions are carried out, as hand hygiene assessment is a component of the care bundles, this negates the need to undertake hand hygiene compliance assessments separately. Hand hygiene compliance is also observed and recorded as part of the IPC clinical practice assessments undertaken by the IPC team. The hand hygiene audits are carried out by trained ICLPs. The assessment is completed using the following standards; 5 moments for hand hygiene and bare below the elbows. Where non-compliance is observed, the ICLP will use the opportunity to train the member of staff on the correct technique so that real-time feedback is used to promote compliance with effective hand hygiene. The IPC Committee has set a quarterly target of 90% for clinical teams/ services to submit a hand hygiene audit appendix 2 The overall year to date submission was 87% which is a19% improvement from 2016/17. In quarter 4 the Trust achieved 100% submission across all services figure 3. The overall year to date compliance with hand hygiene compliance score met the target of 90% in all 4 quarters during 2017/18 figure 4. The overall year to date compliance was 95% which is a 3% improvement on 2016/17. HRCH IPC Annual Report 2017/18 v.1.0 Page 12 of 48

165 Figure 3: Figure 4: 4.2 High Impact Interventions The High Impact Interventions (HIIs) are an evidence-based approach to monitor compliance with IPC practices. They were developed to provide a practical way of highlighting the critical elements of a procedure or care process to prevent infections, the key actions required and a means of demonstrating assurance. The following HIIs are used in clinical practice audits: peripheral intravenous cannula insertion and care, enteral feeding, urinary catheter insertion and care, chronic wound care and central venous catheter ongoing care. An HII spreadsheet has been HRCH IPC Annual Report 2017/18 v.1.0 Page 13 of 48

166 devised by the IPC team to record and rate scores submitted, which are requested from each relevant nursing team on a quarterly basis. Compliance with HIIs are monitored by the IPC Committee. A 90% trajectory has been set for all nursing teams to submit an audit each quarter. This target was met in quarter 4 with 100% of relevant clinical teams submitting HIIs figure 5. It should be noted that there was a 3% improvement in submission compared to 2016/17 figures. Figure 5: % 4.3 Isolation The IPC team continue to monitor the isolation facilities on the TMH inpatient unit and adherence to trust isolation policy; this is updated and reviewed on a weekly basis. During this year, 83 of 89 patients (93%) requiring isolation for infection control precautions were isolated in accordance with trust policy/ advice from the IPC team. In quarter 1, one patient remained in a bay with type 6/7 stools and was not isolated as per Trust policy. In quarter 2, two patients remained in a bay due to the availability of isolation rooms. Both patients were transferred to isolation rooms as soon as they became available. In quarters 3 and 4, the IPC team identified on three occasions that the correct isolation signs were not in place and one incident where the door was left open. All instances of non-adherence to policy were investigated by the IPC team and addressed with ward staff as they were identified. HRCH IPC Annual Report 2017/18 v.1.0 Page 14 of 48

167 4.4 MRSA Screening All new patients admitted to the PBU are expected to be screened for MRSA within 48 hours of admission as per Trust policy. The 5 day decolonisation protocol is prescribed for those who are found to be colonised. Compliance with the MRSA policy is monitored by the IPC team on a monthly basis figure 6. During 2017/18 a total of 338 (94%) patients were screened on admission to the PBU. 317 (88%) of which were screened within 48 hours of admission. 21 (6%) of patients were not screened within 48 hours of admission; this was primarily due to non-compliance with policy and was addressed with ward staff on each occasion. The Trust s KPI to screen 95% of new admissions was not achieved in year and will be a priority for 2018/ (5%) patients screened were found to be colonised with MRSA this is above the national indicator of 3% of the population being colonised with MRSA. Additional training has been provided and an MRSA flowchart has now been developed to assist staff in following the correct procedure. Figure 6: 4.5 Clinical Practice Audits Observational clinical practice audits are undertaken by the IPC nurses and involve observing practice against an IPC audit tool adapted from the Department of Health s Essential steps to safe, clean care: preventing the spread of infection and/or, where appropriate, relevant HIIs. 25 teams/services were assessed across the clinical services during this year and a percentage compliance calculated from the observations obtained appendix 3. The average overall percentage compliance HRCH IPC Annual Report 2017/18 v.1.0 Page 15 of 48

168 for all HRCH teams/ services audited during 2017/18 was 88%, ranging from a low of 77% to a high of 100%. Feedback, training and best practice advice is given to staff during assessments by the IPC nurses. A summary of both positive observations and any findings that need addressing is then distributed to the appropriate service manager/ team leader following each assessment and themes and outcomes are examined in detail at IPC Committee meetings. There have been significant examples of good practice observed during assessments, with the majority of clinicians adhering to trust policy. Some findings addressed have included: poor adherence to the World Health Organization s Five moments for hand hygiene, poor hand hygiene technique demonstrated, inappropriate use of PPE and poor decontamination of equipment. 4.6 IPC Environment and Facilities Audits An IPC environment and facilities audit plan is approved by the IPC Committee each year, based on a risk assessment of each site in terms of the number and types of HRCH services provided, the condition of the built environment and cleaning standards. Selected sites and clinics from which care and treatment are provided by HRCH are audited by the team with regard to cleanliness, the environment (including clinical waste facilities), sharps disposal, hand hygiene and decontamination facilities, as well as elements of IPC practice such as compliance with decontamination procedures and storage of equipment. A scoring system is employed figure 7 to provide an overall compliance score for each site audit, based on the Infection Prevention Society (IPS) quality improvement tools. The compliance ratings are: Good compliance: 85% or above Partial compliance: 76 to 84% Minimal compliance: 75% or below These are overall compliance scores incorporating all aspects of the audits as detailed above and not specifically for the maintenance, cleanliness or facilities functions. The IPC team also reports a separate cleanliness score as well as the overall score, based upon the number of positive and negative cleaning observations made during the audit. A total of 15 sites were audited in 2017/18. Action plans are cascaded with the audit reports for completion by the operations, support services and estates and facilities teams, cleaning contractors, as well as relevant clinical managers and staff. Results are then reported to the IPC Committee and also discussed at other relevant meetings for example, estates and facilities forums. HRCH IPC Annual Report 2017/18 v.1.0 Page 16 of 48

169 Figure 7: Line 1 displays cleaning compliance score Line 2 displays overall environmental audit compliance score IPC Environmental Audits 2017/18 HRCH IPC Annual Report 2017/18 v.1.0 Page 17 of 48

170 4.7 IPC Risk Assessment Audits Due to reprioritisation of the IPC annual plan an audit to assess compliance with the completion of the IPC risk assessment was not undertaken in 2017/ IPC Training 5.1. Mandatory IPC Training It is a statutory requirement that all staff working within HRCH attend IPC training; for clinical staff this is an annual requirement and for non-clinical staff this is every three years. Both the clinical and non-clinical training programmes comply with the UK Core Skills Training framework. The IPC team provided a variety of Infection Prevention and Control teaching sessions. Mandatory and induction IPC training, delivered as classroom sessions and ongoing mandatory training is provided via the National Skills Academy s IPC e-learning course. In addition, the IPC team also provided 8 face to face Level 1 and 2 training sessions in the last quarter of 2017/18 which were attended by a total of 116 staff. HRCH uses the WIRED (Workforce Information Reporting Engine Database) system to monitor training compliance. The trust s target, set by the IPC Committee, is for 90% of clinical staff to have undertaken annual IPC training. During 2017 it was discovered that there were discrepancies on WIRED which meant that the percentage of staff having completed level 2 training was reported incorrectly. These issues have now been resolved and the final figure achieved at the end of March 2018 was 83% figure 8. The IPC Team continue to monitor that staff are transferring this knowledge into clinical practice and are adhering to the correct principles of IPC. Figure 8: HRCH IPC Annual Report 2017/18 v.1.0 Page 18 of 48

171 5.2 ANTT e-learning Training It is essential that all HRCH clinical staff undertaking invasive procedures complete the Aseptic Non Touch Technique (ANTT) e-learning foundation course. This training assists in meeting the requirements of the Health and Social Care Act (2008) Code of Practice on the prevention and control of infections and related guidance and reinforces trust policy. Trust licenses expired at the end of February 2018 and a further 50 licenses were purchased for existing staff and new starters to complete the training. The IPC team organised four ANTT Champions Days in May 2017 which were facilitated by trainers from the Association for Safe Aseptic Practice. 49 members of staff attended the training which was designed to equip managers and staff with the necessary knowledge and skills in order to become ANTT lead/ competency assessors for clinicians in their teams. In conjunction with this, a dedicated ANTT section on the HRCH intranet was produced which contains all the resources necessary for full implementation. 6. The Health and Social Care Act 2008: Code of Practice on the Prevention and Control of Infections and Related Guidance Section 21 of the Health and Social Care Act 2008 enables the Secretary of State for Health to issue the Code of Practice on the prevention and control of infections and related guidance (hereafter referred to as the Code of Practice ). Updated in July 2015, it contains statutory guidance about compliance with the registration requirement relating to infection prevention (regulation 12(2)(h) and 21(b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations The main purposes of the Code of Practice are to: make the registration requirement for infection prevention clear to all registered providers so that they understand what they need to do to comply; provide guidance for the Care Quality Commission s (CQC) staff to make judgement about compliance with the requirement for infection prevention; provide information for people who use the services of a registered provider; provide information for commissioners of services on what they should expect of their providers; provide information for the general public. The Health and Social Care Act (2008) The IPC team works to an annual work plan that is produced to assist the IPC Committee in monitoring the organisation s compliance with the Code of Practice. The work plan is specifically set out against the criteria of the Code of Practice and identifies actions required for compliance and assurance. It is approved by the trust board, monitored by the IPC Committee and forms the IPC team s objectives for the year. The annual work plan for 2018/19 is attached to this report as appendix 4. HRCH IPC Annual Report 2017/18 v.1.0 Page 19 of 48

172 7. IPC Performance On a monthly basis the IPC team populates the IPC key performance indicator dashboard appendix 5. This intends to give an at a glance position of the trust s reportable infection rates and compliance with IPC policies. This forms part of quarterly IPC reports throughout the year and is monitored by the IPC Committee. All indicators are covered in detail within this report. 8. IPC Risk Register/ Gap Analysis It was agreed by the IPCC to transfer the issues from the IPC gap analysis onto the risk register in quarter 4. There are three risks relating to IPC. One of the risks is on the Trust risk register as the risk score is 25. It relates to the possible non-compliance with the Code of Practice It is anticipated that the risk will transfer to the local risk register once a review of the Code of Practice is undertaken in quarter /19 and it is likely that the risk will reduce to 9. The two other risks relate to poor attendance at level 2 training and vacancies within the IPC team. Mitigations are in place and actions assigned to further to manage the risks. 9. Decontamination The designated lead for decontamination is the DIPC/Director of Nursing and Non- Medical Professionals. The Lead IPC Nurse specialist is a member of the Medical Devices Group, chaired by the Assistant Director of Estates and Facilities. All high risk medical devices used within HRCH are either single use only or sent to accredited off-site decontamination facilities to ensure that HRCH complies with statutory requirements. Through mandatory IPC and medical devices training, staff throughout HRCH should be aware of the importance of valid risk assessments and local decontamination protocols with regard to medium to low risk medical devices used within their services. Managers are responsible for ensuring that these are undertaken and documented. The IPC team has continued to review local protocols throughout the year at the request of clinical managers and has provided advice on specific devices and processes for teams and services. An assurance visit to the Sterile Services department (SSD) will be undertaken in quarter 1 of 2018/19 to review the processes at the SSD to review the decontamination processes to provide assurance to the Board that the Trust is meeting its obligations for decontamination. 10. IPC Incidents All IPC related incidents reported on Datix during 2017/18 are summarised by category in figure 9 below. As well as monitoring through other governance channels, IPC related incidents are discussed in detail by the IPC Committee where they are a standing item on the agenda; follow up, actions and lessons learnt are monitored. HRCH IPC Annual Report 2017/18 v.1.0 Page 20 of 48

173 Figure 9: 10.1 Serious Incidents MRSA Colonisation Outbreak on Pamela Bryant Unit An outbreak of MRSA colonisation was investigated and reported as a serious incident between 28/09/17 12/10/17. There were 4 cases of MRSA colonisation, (skin site carriage), acquired on Pamela Bryant Unit (PBU) at Teddington Memorial Hospital (TMH), linked in time and place; confirmed as the same strain and genotype by PHE laboratory at Colindale. The typing results were significant, as they confirm that there was a possible transmission between patients. There were a total of 6 patients included in the outbreak investigation, 2 of whom did not acquire MRSA. None of the 4 patients developed MRSA infection. The following lessons learnt were identified from the incident; PHE Health Protection Team should have been notified when 2 nd case identified IPC level 2 training compliance had not been monitored by ward management Essentia do not report monthly individual cleaning scores for PBU MRSA screening is delayed when patients are admitted on a Friday swabs are not taken until the Monday An action plan was developed and all actions were completed. The serious incident report was signed off by the Quality Governance Committee. HRCH IPC Annual Report 2017/18 v.1.0 Page 21 of 48

174 Norovirus Outbreak on Pamela Bryant Unit A confirmed Norovirus outbreak occurred on Pamela Bryant Unit from 06/12/17-23/12/17. Outbreak control group meetings were held throughout the incident and all patients recovered fully. The outbreak was reported as a serious incident. The investigation concluded that there were three missed opportunities (shown below) to implement the correct infection, prevention and control measures to reduce the risk of transmission; Delay in isolating and reporting the index case Decant of patients into the dayroom to undertake deep clean of a bay whilst the outbreak was still ongoing Delay in reporting the second case The following lessons learnt were identified from the incident; Poor compliance with Level 2 IPC training Delay in isolating index case Delay in recognising and reporting the 2 nd case An action plan was developed and all actions were completed. The serious incident report was signed off by the Quality Governance Committee Communicable Disease Exposures Measles Exposure UCC and WIC The PHE HPU from SW London contacted the IPC team on the 29 th March regarding a patient with a confirmed case of measles who had attended the walk in centre on the 25 th April. The patient was isolated on arrival and therefore no further actions were required as the patient was seen by one doctor and nurse who were both immune for measles. On the 3 rd April the PHE HPU form NW London contacted the team regarding the same patient who had attended the UCC on the 23/3/18 with coryzal symptoms and an exacerbation of colitis. The patient was not isolated as they did not present with any signs and symptoms of measles. Contact tracing for both staff and vulnerable patients was carried out by the UCC lead nurse. Five patients were sent information letters regarding their exposure to measles; two pregnant and three children under the age of one Confirmed Influenza B Pamela Bryant Unit A confirmed case of Influenza B was identified from a patient admitted to the PBU in a bay on the 27 th December Due to deteriorating symptoms the patient was tested for influenza using the point of care testing at Kingston hospital accident and emergency department. The positive result was communicated to the staff from a visiting HRCH member of staff to Kingston hospital. HRCH IPC Annual Report 2017/18 v.1.0 Page 22 of 48

175 Six patients who were exposed to the index case were prescribed antiviral prophylaxis and the bay was closed to admissions. There was no further transmission of infection. 11. Antimicrobial Stewardship Criterion three of the Code of Practice states that the registered provider needs to: Ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance. Antimicrobial stewardship is key to combating antimicrobial resistance (AMR) and is an important element of the UK Five Year Antimicrobial Resistance Strategy (2013 to 2018) and the English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Report Antimicrobial stewardship embodies an organisational and system-wide approach to promoting and monitoring the judicious use of antimicrobials by: Optimising therapy for individual patients; Preventing overuse and misuse; Minimising the development of resistance at patient and community levels. The National Patient Safety Alert (NHS/PSA/Re/2015/007) was jointly issued by Health Education England, NHS England and Public Health England to highlight the challenge of AMR. The trust is addressing antimicrobial resistance through implementation of an antimicrobial stewardship programme. There are best practice antimicrobial prescribing guidelines in place for HRCH prescribers that have been developed in conjunction with local microbiologists for use across the local health economy. Following the Department of Health s guidance on antimicrobial stewardship, a programme of antibiotic audits was continued during 2017/18. The priorities set for 2017/18 were successfully achieved: To maintain increased knowledge and awareness of safe and effective prescribing of antimicrobials by demonstrating continued adherence to local antimicrobial prescribing guidelines; To continue the antibiotic prescribing audit across the trust; To continue to monitor antimicrobial prescribing by non-medical prescribers. To develop additional service specific antibiotic audits to target priority areas. The trust has continued to monitor and report on antimicrobial usage and aimed to maintain knowledge and awareness of safe and effective prescribing of antimicrobials by improving adherence to local antimicrobial prescribing guidelines. Using a standardised template, with indications for the antibiotic choice determined from patient records, services have been audited regularly. Services audited were: TMH Walk in Centre (WIC), Hounslow Urgent Care Centre (UCC), TMH inpatient unit, community nursing teams and the administering of intravenous (IV) therapy in the community, as well as community matrons prescribing. The quarterly audit reports, actions and recommendations are discussed at the Medicines Optimisation HRCH IPC Annual Report 2017/18 v.1.0 Page 23 of 48

176 and Prescribing Committee and the IPC Committee, as well as fed back specifically to individual services. With an overall average of 91% the audit data has demonstrated adherence to local antimicrobial prescribing guidelines in all criteria monitored (see table 1) WIC and UCC have showed significant improvements from Q2 after implementing the actions plans. The IPU antibiotic audit template will be revised for and will split data into two groups. Those that have been initiated at the IPU and those that have been initiated in acute care to allow for the differences in adherence to the HRCH IPU antibiotic guidelines. This should then give a true reflection of adherence within HRCH.. For these will be separated so we have a more accurate figure. Table 1: Q1 Q2 Q3 Q4 WIC n/a*** 62% n/a*** 96% UCC n/a*** 88% n/a*** 96% Community IV 100% 100% 100% 100% Inpatient Unit 52%**** n/a*** 56%**** n/a*** Matrons 100% 100% 100% 100% ICRS 100% 100% n/a** n/a** CaSH 100% 100% n/a* n/a* Average 90% 92% 85% 98% * The CaSH service was transferred to another NHS Trust after Q2. ** The data provided by ICRS in Q3 and Q4 was not sufficiently detailed to show if prescribing adhered to local guidelines or not. *** WIC, UCC and IPU conduct biannual audits as they also carried out service specific audits on alternating quarters. **** The low figures can be explained due to antibiotics outside our primary care formulary from acute settings transferring with patients into IPU. The audit template did not allow for this. The trust again participated in European Antibiotic Awareness Day and World Antibiotic Awareness Week in November. This was promoted to patients in the UCC and WIC where posters were displayed and patient information leaflets made available. This material included key messages that antibiotics do not cure colds and information on self-help for patients, without the need for antibiotics. The awareness week was also highlighted to all staff in the trust via the HRCH weekly newsletter and posters and they were encouraged to sign up and pledge to be an Antibiotic Guardian. The topic for the Non-medical prescribing forum for November 2018 was antimicrobials to further highlight this to our prescribers. The antimicrobial prescribing element of non-medical prescribing via FP10 prescriptions for Hounslow and Richmond is monitored and also reported quarterly at both the IPC Committee and the Medicines Optimisation and Prescribing Committee. Although it is not possible from this data source to determine the exact indication of use of the antimicrobials prescribed, it can be concluded that in general HRCH IPC Annual Report 2017/18 v.1.0 Page 24 of 48

177 they do not deviate from those that would be expected to be prescribed in the community. The priorities for 2018/19: To maintain increased knowledge and awareness of safe and effective prescribing of antimicrobials by demonstrating continued adherence to local antimicrobial prescribing guidelines; To continue the antibiotic prescribing audits across the trust; To continue to monitor antimicrobial prescribing by non-medical prescribers; To continue to carry out further audits on service specific target priority areas in line with national priorities; 12. Occupational Health 12.1 Staff Influenza Vaccination Programme HRCH commenced planning early for the staff seasonal influenza (flu) vaccination programme for the 2017/18 season; the programme was clinically led with peer vaccinators from HRCH clinical services trained to give the vaccine. A breakdown of the HRCH staff flu vaccination uptake is detailed below. In HRCH, 70.8% of all frontline healthcare workers involved in direct patient care were reported to have received the 2017/18 seasonal flu vaccine, a considerable increase in uptake compared with 52.2% of all HRCH frontline healthcare workers who received the vaccine in 2016/17 (Public Health England, 2018). Season No. involved with direct patient care Total no. HRCH healthcare workers involved in direct patient care Doses given Number % 2017/ / / Inoculation Incidents The HRCH Occupational Health (OH) service is provided by Chelsea and Westminster Hospital NHS Foundation Trust (CWHFT) with the contract monitored by the HRCH Assistant Director of Workforce at contract meetings. The service is a part-time service for 18 hours per week of nursing time. This includes the provision of employment screening, sickness absence management and a work related immunisation programme for staff employed by HRCH. All staff who have contact with patients and clinical specimens are seen prior to employment to ensure that they are protected by the relevant work related immunisations. Skin surveillance and screening on employment is undertaken and advice provided to managers if a member of staff has skin problems. Staff are also referred to the service following exposures and for contact tracing when necessary. There were no contact tracing exercises required during 2017/18. HRCH IPC Annual Report 2017/18 v.1.0 Page 25 of 48

178 Staff are also given advice on infection control matters, for example this year upon exposure to chickenpox and measles at work. There were five body fluid exposures reported to OH. Nil were high risk incidents. All incidents occurred to nurses. Two were scratches and three were sharps injuries. The IPC team follow up injuries reported on Datix to ensure that all affected staff have reported to OH for risk assessment and follow up; all staff reporting to OH are reminded to complete a Datix incident report. These incidents will continue to be monitored by the IPC Committee throughout 2018/19 and sharps safety continues to form part of mandatory IPC training for staff. 13. Policies and Guidelines During this year the IPC team continued to revise IPC policy manual chapters due for scheduled review and those requiring update due to changes in best practice, guidance or legislation. The following were approved by the IPC Committee this year: ESBL producing organisms MRSA screening, decolonisation and management Safe handling and disposal of sharps and prevention and treatment of sharps and splash injuries (including inoculation incidents) Management of blood and body fluid spillages and accidental floods/ leaks Guideline for the cleaning of toys and play equipment Principles of infection prevention and control and standard precautions Personal protective equipment Hand hygiene and bare below the elbows Decontamination, cleaning and disinfection Guideline for managing patients with diarrhoea Pandemic influenza 14. Estates and Facilities 14.1 Environmental Cleaning The HRCH Assistant Director of Estates and Facilities is responsible for overseeing and monitoring environmental cleaning contracts; the estates and facilities team work closely with the IPC team on IPC related estates and facilities matters. Monthly cleaning audits are carried out and cleaning scores are submitted by NHS Property Services and Essentia, the principal contractors/ providers of domestic services for Hounslow and Richmond sites respectively. Cleaning scores for Bedfont clinic are submitted by Lakethorne, the provider of domestic services for that site. Centre House and Whitton Corner Health and Social Care Centre are monitored for cleanliness by HRCH support services staff and the Urgent Care Centre by the acute hospital trust responsible for the premises. Cleaning audit scores are presented and monitored through the quarterly IPC reports. Scores for 2017/18 are displayed in figure 10. The IPC team report separate cleanliness scores as part of environment and facilities audits. These are based upon the number of positive and negative cleaning observations made during the HRCH IPC Annual Report 2017/18 v.1.0 Page 26 of 48

179 audit and independent from the methods of assessment used by the cleaning contractors. Any environmental cleaning concerns which have been raised by both the IPC team through site audits, and staff regarding clinical areas in which they work, have been escalated through the appropriate reporting mechanisms and where required, improvements driven by the Assistant Director of Estates and Facilities. Figure 10: Contractors Site(s) Target Apr May Jun Jul Aug Sep OCS (NHS Property Services) Hounslow Target 90% 93% 92% 93% 92% 91% 86% Essentia Richmond Target 88% 98% 98% 98% 97% 97% 97% Lakethorne Bedfont Target 90% 98% 98% 98% 96% 98% 98% Servest Centre House Target 90% 71% 82% 90% 90% 97% 89% OCS Whitton Corner Target 90% 96% 86% 86% 97% 87% 95% Contractors Site(s) Oct Nov Dec Jan Feb Mar Annual Average OCS (NHS Property Services) Hounslow 92% 91% 92% 90% 91% 91% 91% Essentia Richmond 98% 97% 98% 98% 98% N/A* 98% Lakethorne Bedfont 98% 97% 97% 97% 97% 96% 97% Servest Centre House 90% 97% 89% 100% 95% 99% 91% OCS Whitton Corner 97% 87% 95% 95% 82% 92% 91% * No audits completed in March due to the new ward opening and the new food provider starting PLACE In May 2017 the Patient Led Assessment of the Care Environment (PLACE) was undertaken at TMH. This includes assessment of the cleanliness, condition, appearance and maintenance of the environment. The hospital s score for cleanliness this year was 99.70% and the condition, appearance and maintenance was scored at 95.18%, both higher than the national average. The cleanliness score placed HRCH in the top three nationally for community hospitals Premises Development and Refurbishments The IPC team provided expert advice and guidance on developments and refurbishment throughout 2017/18. A programme of works was completed during the year to improve IPC standards which included the redevelopment of Grace Anderson ward at Teddington Memorial Hospital and upgrades to Bedfont Clinic. The IPC team also provided valuable guidance on the procurement and selection of hygienic fans that are available during hot spells throughout the summer and hand drying equipment for staff areas. 15. External Visits and Inspections There were no formal external visits or inspections during 2016/17 apart from the Quarterly Review Meetings with the Commissioners. The purpose of the meetings is HRCH IPC Annual Report 2017/18 v.1.0 Page 27 of 48

180 to review the quarterly IPC reports. The meetings are an opportunity for the commissioner to provide useful feedback on areas that require improvement and to assist the Trust continuing to improve the quality agenda in improving patient safety. 16. Publications Related to IPC Recent publications and national guidance were added as an agenda item in quarter four and are as follows; NHS Improvement - High Impact Interventions (care process to prevent infection) 4th edition of Saving Lives: High Impact Interventions. NHS Improvement - Reporting and monitoring arrangements and post infection review process for MRSA bloodstream infections. These were noted by the IPCC and any necessary changes to practice or policies are included in the annual plan for 2018/ Projects and Innovations There were no projects or innovations introduced in 2017/18 due to lack of capacity within the team. 18. Conclusion To conclude 2017/18 has been a very challenging but productive year for the IPC team. This was due to a number of staff changes and the use of interim locum IPC nurse specialists covering vacancies. At the time of finalising this report the IPC team is now fully staffed with all vacancies filled with substantive posts. In this financial year the Trust achieved its internal targets for no more than one case of Clostridium difficile and zero MRSA bacteraemia cases. The key priorities and plans for the IPC team in 2018/19 will include the following; An annual review of the Code of Practice to provide assurance to the Board that the Trust is meeting its obligations of the Health Act 2015 Introduction of the revised Saving Lives audit tools Increased face to face training sessions for both level 1 and 2 IPC training Review of ANTT training requirements Introduction of single patient use wash bowls and jugs for PBU Introduction of the decontamination of equipment HII for PBU Introduction of the bed space cleaning checklist for PBU Revised management of diarrhoea and vomiting flowchart Review and installation of new hand hygiene dispensers and dementia friendly soap dispensers Introduction of hygienic hand foam bed end dispensers on PBU Review of isolation signs for PBU HRCH IPC Annual Report 2017/18 v.1.0 Page 28 of 48

181 Support for clinical teams to achieve 100% submission for the HIIs and hand hygiene audits Revision of the hand hygiene audit tool to incorporate the 8 step hand hygiene technique Promotion of the IPC agenda by arranging quarterly IPC roadshows In conjunction with the facilities and soft services provider joint environmental audits will be conducted adopting the National Framework for Cleanliness standards of cleaning Exploring the option to re-introduce PAT dogs on PBU Continued contribution to the Department of Health s ambition of a 50% reduction of healthcare associated Gram-negative bloodstream infections by 2020/21 Infection prevention and control is the responsibility of all staff and a commitment to IPC at all levels within the organisation is crucial to driving and maintaining high IPC standards throughout the trust, with the ultimate aim of providing high quality patient care which will ensure that none of our patients acquire an avoidable infection whilst in our care. HRCH IPC Annual Report 2017/18 v.1.0 Page 29 of 48

182 Appendix 1: INFECTION PREVENTION AND CONTROL COMMITTEE TERMS OF REFERENCE 1. Committee role: To report to the Hounslow and Richmond Community Healthcare NHS Trust Board, through the Quality Governance Committee, serious incidents, risks and outbreaks of infection, infection prevention and control activity and compliance or concerns with regard to meeting Regulation 12 of the Health and Social Care Act (2008): Code of Practice on the prevention and control of infections and related guidance (updated 2015). 2. Committee responsibilities: 2.1. To monitor and review the implementation of the infection prevention and control annual work plan and assist in its effective implementation. 2.2 To monitor the Trust s compliance with the ten criteria specified in the Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance (updated 2015). 2.3 To advise on and approve infection prevention and control related policies and guidelines for the organisation, following appropriate consultation, on behalf of the Trust Board. To monitor and review the implementation of said policies in accordance with the requirements of the Health and Social Care Act (2008) Code of Practice updated 2015). 2.4 To advise the Chief Executive of any serious incident and hazards related to infection prevention and control and of any mitigating actions required. 2.5 To monitor Trust performance on the extent of healthcare associated infection and make appropriate recommendations in line with national guidance sharing the learning outcomes throughout the organisation and local heath economy. 2.6 To approve the Director of Infection Prevention and Control s annual infection prevention and control report and ensure that all elements of the annual plan are addressed and documented within the report. 2.7 To monitor the infection prevention and control audit programme and action plans produced as a result of any deficits identified from the audits undertaken. These will include; hand hygiene audits, relevant Saving Lives High Impact Interventions and other audits required to provide assurance of compliance with the Code of Practice 2.8 To ensure that appropriate resources are available to provide comprehensive infection prevention and control services, and where relevant, identify gaps in service provision and brings these to the attention of the Trust board. 2.9 To work with other stakeholders e.g. clinical commissioning groups, acute hospital trusts and primary care to strengthen the surveillance, prevention and control of infection; liaise with Public Health England local Health Protection Teams in outbreak investigation and control. HRCH IPC Annual Report 2017/18 v.1.0 Page 30 of 48

183 2.10 To assist in the review of any service level agreements for contracted, commissioned or provided services relating to infection prevention and control To escalate to commissioners any significant infection prevention and control issues and to provide updates To consider, monitor and review emergency planning/ business continuity plans in relation to infection prevention and control The committee will review any new or revised international, national or local infection, prevention and control guidance and legislation and ensure that the relevant material is included in the policies and guidelines and any relevant issues are acted upon. 3. Reports to: This sub committee will report, by exception, to the Quality Governance Committee. 4. Receives reports from: Medicines Optimisation Committee, with specific reference to antimicrobial stewardship. Occupational Health Decontamination Estates and Facilities Water Safety committee Health Protection Teams Influenza Steering Group (Winter season) 5. Membership: Director of Infection Prevention and Control (DIPC) - Director of Nursing and Non-Medical Professional(Chair) Lead Infection Prevention and Control Nurse Specialist/ Deputy DIPC (Vice Chair) Infection Prevention and Control Nurse Specialist Infection Prevention Nurse Consultant Microbiologist/ Infection Control Doctor Infection Prevention and Control Support Officer Clinical Commissioning Group Leads for Infection Prevention and Control Head of Pharmacy and Prescribing Occupational Health representative Assistant Director of Estates and Facilities Divisional Manager Community Nursing Deputy Service Manager Musculoskeletal Physiotherapy In attendance: Health Protection Teams or send a report Pamela Bryant Clinical Service Manager Outpatients, Urgent Treatment Centre and Radiology Service Manager Adult Community Nursing Service Managers HRCH IPC Annual Report 2017/18 v.1.0 Page 31 of 48

184 Continence Service Manager Children s Services Nursing representative Allied Health Professional representative IV Therapy Nurse Specialist Tissue Viability Nurse Specialist Representative from RRT and CRS Podiatry Service Manager When required to update the committee: Organisational Development Manager Emergency Planning Officer Immunisation Lead Nurse Head of Quality and Patient Safety 6. Chair: Director of Infection Prevention and Control (DIPC) - Director of Nursing and Non- Medical Professionals (Chair) Lead Infection Prevention and Control Nurse Specialist/ Deputy DIPC (Vice Chair) Another Board member may chair the Committee at the request of/ in the absence of the Director of Infection Prevention and Control (Quality and Clinical Excellence). 7. Quorum: The quorum shall be five members, including either the Director of Infection Prevention and Control or the Lead Infection Prevention and Control Nurse Specialist, and three members who are not direct members of the HRCH Infection Prevention and Control team. 8. Secretariat: Papers, action logs, minutes and agenda to be circulated by the infection, prevention and control support officer one week prior to the meeting. 9. Minimum attendance: Internal HRCH Committee members or a nominated deputy to attend every meeting. 10. Meeting frequency: Meetings will be held at least quarterly. Urgent meetings may be called at the request of the Chair or Vice Chair if required. 11. Terms of reference review: The terms of reference will be reviewed annually or as deemed necessary. The next planned review to be March HRCH IPC Annual Report 2017/18 v.1.0 Page 32 of 48

185 Appendix 1 IPCC Agenda Template No. Item 1 Welcome, introductions and apologies 2 Minutes of the previous meeting 2.1 For accuracy and approval 2.2 Action log 2.3 Matters arising 3 Audits and Surveillance: 1.1 HCAIs 1.2 Hand Hygiene 1.3 CAUTIs surveillance 1.4 High Impact Interventions 1.5 Clinical audits 1.6 Environmental audits 4 Action plans for noting/ monitoring by the IPCC 5 Reports for noting 6 Policies/ documents for ratification/ approval 7 IPC Risk Register for noting 8 Infection prevention and control related incidents for noting 9 Decontamination 10 Recent IPC publications for noting 11 Any other business HRCH IPC Annual Report 2017/18 v.1.0 Page 33 of 48

186 Appendix 1: IPC Committee attendance 2017/18 IPC Committee attendance 2017/18 Meeting date Member or nominated deputy: 04/05/17 25/07/17 16/11/17 06/02/17 Director of Infection Prevention and Control (Chair) Y Y Y Y Lead Infection Prevention and Control Nurse Specialist (Vice Chair) Y Y Y Y Infection Prevention and Control Nurses Y Y Y Y Consultant Microbiologist/ Infection Control Doctor Y Y Y Y CSU Lead for Infection Prevention and Control Y Y Y Y Infection Prevention and Control Support Officer Y Y Y Y Head of Quality and Patient Safety Y N Y N Head of Pharmacy and Non-Medical Prescribing Y Y Y N Occupational Health representative N N Y N Assistant Director of Operational Support Services/ Assistant Director Y Y N Y of Estates and Facilities Inpatient Matron/ Service Manager Y Y Y Y Outpatients, Radiology and Walk In Centre Service Manager Y Y Y Y Adult Services Community Nursing representative/ Continence Service Y Y N Y Manager Children s Continuing Care and Community Nursing Manager N N Y Y Contraceptive and Sexual Health Manager N Y N/A N/A IV Therapy Nurse Specialist Y Y Y Y Tissue Viability Nurse Specialist Y N N N Podiatry Service Manager N N N Y Consultants in Communicable Disease Control/ Health Protection team N N N N Return to section HRCH IPC Annual Report 2017/18 v.1.0 Page 34 of 48

187 Appendix 2: HAND HYGIENE COMPLIANCE ASSESSMENT SCORES 2017/18 HRCH IPC Annual Report 2017/18 v.1.0 Page 35 of 48

188 Return to section HRCH IPC Annual Report 2017/18 v.1.0 Page 36 of 48

189 Appendix 3: IPC CLINICAL PRACTICE AUDITS 2017/18 Return to section HRCH IPC Annual Report 2017/18 v.1.0 Page 37 of 48

190 Appendix 4: INFECTION PREVENTION AND CONTROL ANNUAL WORK PLAN 2018/19 LWS = Linda Woodward-Stammers, Lead Infection Prevention and Control Nurse Specialist CB = Colin Barnes, Infection Prevention and Control Nurse Specialist JM = Infection Prevention and Control Nurse FJ = Infection Prevention and Control Nurse NB = Nina Benton, Infection Prevention and Control Support Officer Action no. Code of Practice* criterion/ IPC KPI code Action 1. All Continuation of evidence gathering to provide assurance of the Trust s compliance with the Code of Practice for CQC registration. 2. Criterion 1 Continued co-ordination of the organisation s quarterly Infection Prevention and Control Committee (IPCC); update of TOR. 3. Criterion 1 The production of the IPC Annual Report for 2018/19, for approval by the IPCC, QGC and the Board. 4. Criterion 1 The production of quarterly IPC reports to update the IPCC, QGC and the Board on IPC activity and performance. 5. Criterion 1 Review of the IPC intranet pages to encourage staff engagement within the Trust and promote ease of use. 6. Criterion 1 Risk assessments to be in place where non-safe sharps are in use. 7. Criteria 1, 4 Organise and hold quarterly infection prevention awareness events aimed at staff and patients/ clients/ visitors. IPC team lead person(s) Target completion date Progress/ commentary Status IPC team March 2019 Annual review March IPC team Meetings quarterly; TOR to be reviewed annually. IPC team July 2019 TOR to be reviewed March IPC team Within one month of the end of each quarter. NB June 2018 Intranet page to be reviewed June Service On-going Managers IPC team March 2019 Quarterly events to be scheduled. HRCH IPC Annual Report 2017/18 v.1.0 Page 38 of 48

191 Action no. Code of Practice* criterion/ IPC KPI code Action 8. Criterion 2 Participate in the facilities audits of HRCH clinical sites in accordance with the agreed audit programme, producing reports and action plans, monitoring their implementation and ensuring follow up as required. 9. Criterion 2 Participate in the annual PLACE inspection. 10. Criterion 2 Decontamination added as an agenda item to the IPCC. Quarterly exception reports to be provided by SSD provider. Yearly assurance visit to SSD. 11. Criterion 2 To effectively participate and advise, from the planning process, on all refurbishments and any new premises to be used by HRCH staff and patients. 12. Criterion 2 To install bespoke soap and hygienic hand rub dispensers at TMH. IPC team lead person(s) Target completion date Progress/ commentary Status NB/DC Ongoing Continues as per programme. LWS May 2018 IPCT April 2018 Completed. Steris Contracts On-going manager LWS May 2018 IPCT Ongoing IPC Team to comment on the retendering of the soft services contract. IPCT/communi cations team September 2018 To review the installation of bed end holders for the hygienic hand rub for the PBU. Risk assessment to be undertaken. 13. Criterion 3 Ensure that the Medicines Optimisation and Prescribing Committee reports in to the IPCC with progress on the Trust s antimicrobial stewardship programme, audits, progress on actions and the monitoring of antimicrobial prescribing. LWS/AMH Head of Pharmacy and Prescribing July 2018 Ongoing with quarterly review through IPCC. HRCH IPC Annual Report 2017/18 v.1.0 Page 39 of 48

192 Action no. Code of Practice* criterion/ IPC KPI code 14. Criterion 5; KPI code: IPC1 KPI code: IPC2 KPI code: IPC3 Action Ongoing reportable HCAI surveillance for TMH inpatient unit. 15. Criterion 5 Ongoing surveillance and post infection review programme for catheter associated urinary tract infections (CAUTIs) to be undertaken for the TMH inpatient unit. Monitoring of the GNBSI action plan. 16. Criterion 5; KPI code: IPC5 MRSA screening for all admissions to the TMH inpatient unit and when clinically appropriate, decolonisation protocol administered/ MRSA care pathway commenced in accordance with trust policy, to be monitored by the IPC team on a monthly basis. 17. Criterion 6 Infection Control Link Practitioners system in place. Ensure an ICLP is nominated for each clinical team/ service. Ensure dedicated time is provided for all ICLPs to deliver the objectives of the role. 18. Criteria 6, 9 All clinical staff who perform ANTT procedures to complete the ANTT e- learning module and be formally competency assessed every 3 years. Licences to be procured in February ANTT to be added to wired so compliance with training can be monitored. IPC team lead person(s) IPCT CB CB (clinical)/ NB (data) IPC team Service Managers Service Managers Service Managers Learning and Development Learning and Development Target completion date Ongoing with quarterly review through IPCC. Ongoing with quarterly review through IPCC. Ongoing with quarterly review through IPCC. Ongoing Ongoing with quarterly review through IPCC. Progress/ commentary Status Q1 no meeting scheduled. Q2 3rd July 2018 Q3 9th October Q4 8th January 50 licences procured in February HRCH IPC Annual Report 2017/18 v.1.0 Page 40 of 48

193 Action no. Code of Practice* criterion/ IPC KPI code 19. Criterion 7; KPI code: IPC7/IPC 12 Action To monitor adherence to the trust s procedure for isolation and the provision of appropriate isolation facilities on the inpatient unit. Biannual IPC risk assessment audit. 20. Criterion 9 Chapters of HRCH IPC Policy Manual/leaflets to be reviewed and updated in accordance with evidence based practice and national guidance. 21. Criteria 2, 9 Contribute to additional guidelines and policies relevant to IPC that are necessary for CQC compliance. 22. Criterion 9 IPC clinical practice assessments to be undertaken across the organisation to assess adherence to IPC policy by teams and services. Results to be collated for review and monitoring. 23. Criterion 9 Undertake other audits (both ad hoc and planned) to monitor implementation and adherence to IPC policies as deemed necessary. 24. Criterion 9 To participate in RCAs/PIRs for C.difficile infections/mrsabs when requested by the CCGs. To investigate outbreaks of infection e.g. Norovirus on the inpatient unit. 25. Criterion 9; KPI code: IPC9 KPI code: IPC10 Support and monitor hand hygiene audits for all clinical teams/ services on a monthly, quarterly biannual basis (see IPC audit plan). IPC team lead person(s) Target completion date Ongoing with quarterly review through IPCC. June/December 18 Progress/ commentary Status IPC team/pbu staff Doors to be installed on the four bedded in the PBU. Glass panels to be installed on the side room doors in PBU. NB IPC team Ongoing Leaflets included in Appendix B IPC team May 2018 May 2018 JM/FJ IPC team IPC Team IPC team Ongoing with quarterly review through IPCC Ongoing with quarterly review through IPCC Ongoing with quarterly review through IPCC. Ongoing with quarterly review through IPCC. Trust wide cleaning policy required. Dress code policy to be reviewed. See IPC audit plan appendix. HRCH IPC Annual Report 2017/18 v.1.0 Page 41 of 48

194 Action no. Code of Practice* criterion/ IPC KPI code Action IPC team lead person(s) Target completion date Progress/ commentary Status 26. Criterion 9; KPI code: IPC8 27. Criterion 10; KPI code: 11 Support and monitor compliance with the HIIs for all clinical teams/ services on a quarterly/biannual basis (see IPC audit plan). IPC training sessions at corporate induction. Monthly face to face sessions organised for 2018/19. IPC e-learning modules available Ad hoc training to be provided as required. 28. Criterion 10 Preferred FFP 3 respirator to be sourced and trialled by clinical teams. SMs from WIC/UCC/Children s services and podiatry to nominate staff to attend train the trainer training session. Train the trainer sessions to be arranged. Maintain a register of trained fit testers and organise a programme of update training. IPC team IPC team IPC team/ procurement SMs IPC team IPC Team Ongoing with quarterly review through IPCC. Ongoing with quarterly monitoring through IPCC. August 2018 August 2018 October 2018 On-going HII care bundles reviewed nationally and re-published. To be incorporated locally for HRCH by the IPC team by the end of Q2. *The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance. Updated 2015 Key performance indicator (KPI) codes: refer to Appendix A. IPC Audit plan: refer to Appendix B Status Key: Compliant. Target completion date due this quarter. Target completion date not met. Target completion date not due this quarter. HRCH IPC Annual Report 2017/18 v.1.0 Page 42 of 48

195 Appendix A of Annual Work Plan: The IPC Internal Key Performance Indicator Dashboard 2018/19 HRCH IPC Annual Report 2017/18 v.1.0 Page 43 of 48

196 Appendix B of Annual Work Plan: IPC Policy Manual Chapter Review 2018/19 Date first Section Chapter No. Chapter Title approved Chapter 10 Mattress Decontamination and Integrity Apr Chapter 08 Handling and Transporting Specimens Apr Chapter 12 Management of Linen Apr Chapter 20 Ectoparasitic Infections (Lice and Scabies) Apr Chapter 21 Varicella-Zoster Virus Apr-2011 Further Reviewed Oct 2013 Jul 2015 Sep 2013 Jan 2016 Oct 2013 Jan 2016 Nov 2013 Jan 2016 Mar 2013 Jan 2014 Jan 2016 May 2018 Current Version Next Schedule review 3.0 May May May May May Chapter 27 Carbapenemase-producing Enterobacteriaceae Jan May Chapter 19 Transmissible Spongiform Encephalopathies Apr Chapter 22 Tuberculosis May Chapter 24 Last Offices for an Infectious Patient Apr-2011 Jan-2014 Apr-2016 Mar-2014 Apr-2016 Mar-2014 Apr May May May Chapter 28 Food Hygiene in Clinical Areas Feb Jul Chapter 01 Infection Prevention and Control Risk Management and Inter-healthcare Patient Transfer Apr Chapter 05 Aseptic Non-Touch Technique (ANTT) Apr-2011 Oct 2011 May 2014 July 2016 May 2014 July Jul Jul-2018 HRCH IPC Annual Report 2017/18 v.1.0 Page 44 of 48

197 Section Chapter No Chapter 15 Chapter Title Notifiable Diseases, Surveillance and Outbreaks of Infection Date first approved Jun-2011 Further Reviewed 01/05/2014 July 2016 Current Version Next Schedule review 2.0 Jul IPC Advice for Contractors Leaflet May Sep IPC Advice for TMH Volunteers Leaflet Nov Sep C.diff Patient Information Leaflet Aug Sep Chapter 14 Antimicrobial Prescribing Apr-2011 Nov 2013 Nov 2014 Nov Nov Chapter 26 Animals in Clinical Areas Nov-2014 Nov Nov Chapter 17 Clostridium difficile Infection May-2011 Nov 2012 Sep 2014 Nov Nov IPC Advice for People Staying at TMH Leaflet Nov Dec MRSA Information Leaflet Nov Dec-2018 Norovirus Leaflet Nov Dec-2018 CPE Information Leaflet Nov Mar-2019 ESBL Information Leaflet Nov Mar-2019 IPC Information for Staff Leaflet Jan Mar-2019 HRCH IPC Annual Report 2017/18 v.1.0 Page 45 of 48

198 Appendix C of Annual Work Plan: IPC Audit Plan 2018/19 HRCH IPC Annual Report 2017/18 v.1.0 Page 46 of 48

199 Return to section HRCH IPC Annual Report 2017/18 v.1.0 Page 47 of 48

200 Appendix 5: IPC INTERNAL KEY PERFORMANCE INDICATOR DASHBOARD 2017/18 IPC1, IPC2, IPC3, IPC4 and IPC6: Annual results calculated from the total number of cases per year IPC5 and IPC7: Annual results calculated from the cumulative total across the year shown as a percentage (reported monthly) IPC8, IPC9 and IPC10: Annual results calculated from the cumulative average across the year shown as a percentage (reported quarterly) IPC11: Annual result calculated from the final figure at month 12 shown as a percentage Return to section HRCH IPC Annual Report 2017/18 v.1.0 Page 48 of 48

201 Meeting title Trust Board part 1 meeting Date 25 July 2018 Report title Nursing Establishment Review for the Inpatient Unit (IPU) at Teddington Memorial Hospital (TMH) Agenda item: 18 Lead director Report authors Executive summary Stephen Hall, Director of Clinical Services Anna McNulty-Howard, Clinical Service Manager for TMH IPU Clare Thompson, Divisional Manager for Planned, Unplanned and Integrated care This report: 1. Provided the Quality Governance Committee (QGC) committee with the six-monthly review of the staffing establishment on the TMH IPU to ensure safe staffing levels and 2. Meets the requirements of the National Quality Board and Chief Nursing Officer report How to ensure the right people, with the right skills, are in the right place at the right time Purpose: Noting. Recommendation(s) To acknowledge the report and take assurance it has been approved by QGC on 12 July BAF/TRR P3 Engagement with patients, public and stakeholders Report history Appendices This is the seventh six-monthly report and covers the period from January June Appendix One Dependency rating scale Appendix Two - Teddington Memorial Hospital Admission Criteria Appendix Three - Summary: Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time. National Quality Board July

202 1.0 Executive Summary Review of nursing establishment and safe staffing on the inpatient unit (IPU) at Teddington Memorial Hospital (TMH) for the period January to June 2018 shows that: No shifts have fallen below the agreed staffing ratios level TMH IPU continue to consistently admit patients that conform to unit admission criteria, however there has been an increase in dependency and complexity Bed occupancy has increased to 92% compared to 87.5% for the last reporting period (and compared to 84% for January2017 to June 2017) Staffing numbers and skill-mix continue to be adjusted to meet the new unit profile and requirements which were recommended through the TMH transformation programme in 2017, however recruitment difficulties have made implementation of the staffing model a challenge 2.1 Background There is a national requirement for all hospitals to publish information, twice a year, to demonstrate the nursing establishment has been reviewed and approved by the Board of Directors. The National Quality Board (NQB) and Chief Nursing Officer (CNO) paper How to ensure the right people, with the right skills, are in the right place at the right time 1 stated nine expectations for Providers. The National Quality Board in July published new guidance on Safe Staffing (see Appendix Three). The key changes proposed to previous NQB guidance are: Recommended principles and tools for provider boards to measure and use to improve their use of staffing resources to ensure safe, sustainable and productive services Care Hours Per Patient Day (CHPPD) is the principal measure of nursing, midwifery and healthcare support worker deployment A triangulated approach ( right staff, right skills, right place & time ) to staffing decisions, rather than making judgements based solely on numbers or ratios of staff to patients 3.0 Key issues Staffing levels at TMH On the IPU at TMH there is a blend of registered nurses and healthcare assistants. The ward is supported by a multi-disciplinary team which is not presently represented in the nursing establishment figures; however, these staff play a key role in the safety experience and outcomes of care experienced by patients and carers these include housekeepers, physiotherapists, occupational therapists and therapy assistants. 1 National Quality Board (2013) How to ensure the right people, with the right skills, are in the right place at the right time. A guide to nursing, midwifery and care staffing capacity and capability. NHS England. Available at content/uploads/2013/11/nqb how to guid.pdf 2 National Quality Board (2016) Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time. Available at content/uploads/2013/04/nqbguidance.pdf 2

203 The model of care proposed during our 2017 transformation programme looked at using a cohort of Band 5 OT s within the rostered establishment to work alongside the nursing team. We recruited two newly qualified rotational Band 5 OT s who were with the team from October 2017 until February As they were new graduates initially needing focused support and supervision, therefore were not counted within the safe staffing figures. Since March 2018 we have been unable to recruit to these OT posts, raising challenges for the implementation of our proposed new staffing model. We have also had ongoing challenges in recruiting to Band 5 registered nurse positions during the period. We have had a reduction of 2.25 wte registered nurses in the staff establishment from to 14.61wte. (17.08wte B5 nurses and OTs are required in the new staffing model). The admission criteria (see Appendix Two), continues to be applied consistently to manage appropriate patient admissions that meet the skills, competencies and numbers of staff designed to support those criteria. 4.1 Analysis 4.2 Meeting the requirements of NQB (2013 & 2016) papers Between January and June 2018, this has shown (against the agreed staffing ratios above) that no shifts across the period have fallen below the agreed level. 4.3 Evidence based workforce planning In August 2017, we introduced the safe-care module in the e-rostering system which enables us to continue to use the AUKUH Acuity/Dependency Toll Implementation Resource Pack, and used our new tool to review patient dependency levels (see Appendix One); bed occupancy; and staffing numbers and ratios. This has shown that the majority of the patients during this period were at levels 3 (88.44%), a decrease from the previous 6 months (98.14%). However, there has been an increase in patients admitted at Levels 4a and 4b from 8.8% of the previous report to 11.6% in this report and a particular increase in Level 4b from 0.2% to 7,6%). We continue to consistently admit more patients that conform to unit admission criteria, but there has been an increase in complexity, and an increase in patients whose condition needs more care support than on admission. Pamela Bryant Ward 4 week average (to 31 st march 2018) Number of patients Average % Level 1 0 0% Level 2 0 0% Level % Level 4a % Level 4b % 3

204 Bed occupancy during the period was 92%. The staffing ratios recommended by the model matched or slightly superseded the actual staffing ratios. Staffing ratios have not been allowed to fall below the 2013 agreed rate, as these were set at an agreed basic acceptable level. Agreed Nurse : Bed Ratio Target DAY SHIFTS Actual Nurse : Bed Ratio Establishment review tool recommended Nurse : Bed Ratio Agreed Nurse : Bed Ratio Target NIGHT SHIFT Actual Nurse : Bed Ratio Establishment review tool recommended Nurse : Bed Ratio 1 : :6.01 1:6.4 1 : : :11.3 Changes from the previous six month establishment review (July December 2017) include: Bed occupancy was high at 92% reflecting the high demands in the system during this winter period, compared to 87.5% for the last reporting period (and compared to 84% for January June 2017) % of patients scored level 3 dependency indicating that there remains a high level of complexity in the care delivered on the ward and there were no patients that scored lower than level 3 in this period (compared to 1.2% in the previous 6 months). There were increased numbers of patients that scored in the 4a and 4b domains, which would indicate that these patients had high dependencies with major physical and or mental issues that needed higher levels of care and security, with one of then requiring one to one specialling. Staffing ratios have remained at agreed rates to support this. The data suggests that nurse staffing levels for the unit continue to meet our currently agreed staff to patient ratios. 4.4 Care Hours per Patient Day (CPPPD) The table below shows the average monthly CHPPD for both day and night duty from January 2018 June 2018: Month Jan 18 Feb 18 March 18 April 18 May 18 June 18 CHPPD (actual) CHPPD (Required) The IPU has been submitting CHPPD to NHS Improvement since April 2018 and this has been added to the inpatient dashboard so that it can be monitored. The results of this show that we have not fallen below our predicted CHPPD and that our ratios are slightly above average. 4

205 4.5 Professional judgement Professional judgement and knowledge are used to inform the skill mix of staff. They are also used at all levels to inform real-time decisions about staffing taken to reflect changes in case mix, acuity/dependency and activity. The Clinical Service Manager continues to use her judgement on a daily basis to inform staffing. This is done by being a visible presence on the unit, so that she is aware of issues and is listening to patient and staff needs. She also looks at key patient indicators such as falls, pressure ulcers, incident reporting and patient feedback and uses these alongside the dependency scores and other metrics to inform staffing on the unit. There have been several occasions in the past six-months where the dependency scores tipped into red and therefore there has been a need to book additional staffing over and above the establishment. In this reporting period, there have been two patients that were at high risk of falls and needed 1:1 care for a short period. This care was supplied from the current ward establishment where possible but there has been a need to book staffing over and above the ward establishment to ensure that these patients remained safe on the ward. 4.6 Right Skills The team have had skills training relevant to their roles and now they are engaging in a piece of work around organisational development and teamwork and also having some grade and role specific input to further develop as a team. There are currently ongoing action learning sets for the Band 6/7 s, competency frameworks for the Band 2 s to get them to band 3 and we are working with Kingston and St Georges University to provide action learning sets for the band 5 nurses. The ward has also taken part in the #endpjparalysis campaign with very good results. We are also involved in the NHSi Falls Collaborative work in order to further improve our care around patient falls. Mandatory training, development & education Statutory and mandatory training compliance (June 2018) Staff appraisal compliance (June 2018) 88% (target 85%) 90% (target 90%) 4.7 Recruitment and retention The overall service vacancy rate for June 2018 sits at 5.1% (trust target 13%), with identified challenges in is still transitioning to the new service staffing model for Band 5 nursing and OT positions. 5

206 4.8 Productive working and eliminating waste There was a rise in length of stay in this six-month period compared to 2017 and the table below shows that the unit has seen slightly less patients through the 29 beds than it did 12 months ago. This may be partly influenced by the higher dependency and complexity of patients admitted during this period, and a larger number of patients needing to undertake continuing healthcare assessment on the unit, including delays to subsequent placements in nursing homes. Month Number of Admissions 2017/18 Number of Admissions 2018/19 Month Average Length of Stay /18 Average Length of Stay /19 Jan Feb Mar April May June TOTAL Jan Feb Mar April May June Efficient deployment and flexibility The unit is now participating in the implementation of the Allocate E-rostering system. Appropriate staff deployment and flexible working arrangements have been reviewed in 2018 as a result of this, in order to ensure ongoing adequate, safe and efficient staffing arrangements are in place. This continues to be reviewed on a regular basis Efficient employment and minimising agency Use of agency staffing on the unit has increased during the January June 2018 period, mainly due to vacancies in the registered nurse Band 5 and occupational therapy Band 5 positions. These posts have been through a number of recruitment cycles with limited success. Agency/registered nurses Day shift Night shift Jan % 5.2% Feb % 2.3% March % 2.8% April % 4.6% May % 0.90% June % 0.9% Total Overall for Period 1.18% 2.78% 3 In days. 6

207 5.0 Conclusion and recommendations For the period January 2018 to June 2018 there have been increasing levels of patient dependency and complexity, increased bed occupancy, and a trend of increasing average length of stay. Nursing/staff establishment have however been shown to remain at agreed safe staffing levels and Care Hours per Patient per Day. No shifts have fallen below these levels. 7

208 Appendix One Dependency rating scale Teddington Memorial Hospital - Inpatient Unit - Safe Staffing Report Model Definitions Dependency Levels: Leve l Dependency Description 1 Low dependency Patient s needs are met in an elderly-care ward or care home. 2 Medium Patient admitted in poor health dependency and can only be managed in an elderly-care ward geared to looking after higher-acuity cases. 3 Higher dependency Patient can be managed in an elderly-care ward geared to looking after higher-acuity cases and patients requiring additional security-related supervision. 4a High dependency Patient has major physical and or mental issues and needs care in a more secure ward. 4b Specialed patient Requiring one-to-one care throughout the day and possibly the night. SNCT Model Summary Can be managed by one nurse/healthcare support worker. Short-term, significant physical, mental and social problems. Long-term, significant physical and mental illness problems. Major physical and mental illness, and social problems. Major physical/mental/social problems. 8

209 Appendix Two - Teddington Memorial Hospital Admission Criteria registered with a NHS Richmond GP aged 18 years or over medically stable Patients must be registered with a Richmond GP Aged 18 years or over Must be medically stable enough to be managed in a nurse and therapy led community setting 1. Sub-acute beds Intravenous therapy; complex wound therapy Patients with conditions which can be safely managed in a community hospital, e.g. urinary tract infections & chest infections, and severe tissue viability that cannot be managed at home Patients with a need for a suitable environment for assessment, observation and levels of nursing & therapy care that is over and above that offered by community nursing and therapy teams 2. Rehabilitation beds Patients with long term conditions or post-operative who are able to engage adequately in core elements of rehabilitation programme. This may include patients requiring double handed care where their rehabilitation goal is to move quickly to single handed care to enable a patient to return home. Patients not currently living with a psychiatric illness requiring professional mental health supervision or assessment Patients who have clear goals that can be determined on multi-disciplinary assessment and will tangibly benefit from rehabilitation Intervention is time limited and length of stay is expected to be less than 28 days Patients must have agreed rehabilitation goals and a discharge plan in place and also agreed by the patient 3. Palliative continuing health care beds Patients with life limiting illness, usually within 3 months of anticipated death Patients able to benefit from symptom relief strategy Intervention is time limited and ranges from days to weeks. 9 9

210 Appendix Three Summary key headlines: Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time. National Quality Board July 2016 This document includes an updated set of NQB expectations for nursing and midwifery staffing to help NHS provider boards make local decisions that will deliver high quality care for patients within the available staffing resource. From May 2016, Care hours per patient day (CHPPD) is the principal measure of nursing, midwifery and healthcare support worker deployment. This data collection is an important first step in the journey to providing a single, consistent metric for NHS providers to record and report all staffing deployment. NHS Improvement is also coordinating work to develop safe staffing improvement resources for a range of care settings including: mental health, learning disability, acute adult inpatients, urgent and emergency care, children s services, maternity services, and community services. The core principles underpinning this work are: to identify and review the best available evidence on safe, sustainable staffing; to be multi-disciplinary in approach to staffing; to be outcomes focused; to complete an economic impact assessment on any proposed safe staffing improvement resource; and to develop these staffing resources with the appropriate experts, focus groups and other key stakeholder groups, including patients, families and carers. NHS Improvement will begin to release these improvement resources later in 2016/17, with approval from the NQB

211 Section 1: Safe, sustainable and productive staffing: measurement and improvement It is critical that boards review workforce metrics, indicators of quality and outcomes, and measures of productivity on a monthly basis as a whole and not in isolation from each other and that there is evidence of continuous improvements across all of these areas. To help optimise allocation of workforce resources and improve outcomes, NHS provider boards should implement in full the Carter recommendations, together with the findings from the model hospital and its equivalents for other care settings. This includes: using local quality and outcomes dashboards that are published locally and discussed in public board meetings, including the use of nationally agreed quality metrics that will be published at provider level developing metrics that measure patient outcomes, staff experience, people productivity and financial sustainability comparing performance against internal plans, peer benchmarks and the views of NHS experts, taking account of any underlying differences reducing wasted time by supporting and engaging staff in using their time in the best way possible to provide direct or relevant care or care support using national good practice checklists to guide improvement action, as well as taking account of knowledge shared by top performers. Reporting, investigating and acting on incidents High quality care produces excellent outcomes for patients, and is safe, effective, caring, responsive and well led. NHS providers should follow best practice guidance in the investigation of all patient safety incidents, including root cause analysis for serious incidents. As part of this systematic approach to investigating incidents, providers should consider staff capacity and capability, and act on any issues and contributing factors identified. NHS providers should consider reports of the red flag issues suggested in the NICE guidance and any other incident where a patient was or could have been harmed, as part of the risk management of patient safety incidents. Incidents must be reviewed alongside other data sources, including local quality improvement data (e.g. for omitted medication) clinical audits or locally agreed monitoring information, such as delays or omissions of planned care. Patient, staff and carer feedback NHS providers should have a strong staff engagement plan, which routinely monitors the impact of their policies, demonstrates an understanding of the links between staff 11 11

212 experience, patient experience and outcomes, and which supports staff retention, as documented by available research. Staff should work in well-structured teams. They should be engaged, enabled to practice effectively and able to make changes to delivery of care to improve quality and productivity. When an establishment review has taken place within an organisation, the board should ensure it considers feedback from frontline staff as part of its assurance activities. Section 2: Care hours per patient day (CHPPD) From May 2016, all acute trusts with inpatient wards/units began reporting monthly CHPPD data to NHS Improvement. Over time, this will allow trusts to review the deployment of staff within a specialty and by comparable ward. When looking at this information locally alongside other patient outcome measures, trusts will be able to identify how they can change and flex their staffing establishment to improve outcomes for patients and improve productivity The introduction of CHPPD for nurse and healthcare support staffing in the inpatient/acute setting is the first step in developing the methodology as a tool that can contribute to a review of staff deployment. Work has begun to consider appropriate application of this metric in other care settings and to include other healthcare professionals such as allied health professionals (AHPs). CHPPD is calculated by adding the hours of registered nurses and the hours of healthcare support workers and dividing the total by every 24 hours of inpatient admissions (or approximating 24 patient hours by counts of patients at midnight). CHPPD is reported as a total and split by registered nurses and healthcare support workers to provide a complete picture of care and skill mix. NHS Improvement will be working with NHS providers to develop and inform the 2016/17 implementation plan for CHPPD. The programme s initial focus will be to assess and evaluate the acute inpatient data collection for nurse staffing by October 2016 to inform the next phase of implementation. In parallel, NHS Improvement will engage with providers to scope the development of the CHPPD metric for other care settings and consider application for other healthcare professionals, such as AHPs

213 Section 3: Updated NQB expectations Triangulated approach to staffing decisions 13 13

214 Meeting forum Trust Board Part I meeting Date: 25 July 2018 Report title NHS Equality Delivery System (EDS) Agenda item: 19 Lead Directors Report authors Report summary Alison Heeralall, Director of Workforce (workforce equality lead) and Donna Lamb, Director of Nursing & Non-Medical Professionals (patient equality lead) Alison Heeralall and Robin Chapman, Patient Experience Manager This report is a self-assessment of the trust position against the NHS EDS domains for 2017/18. The assessment involved reviewing the grading with representatives from staff and the community. The main purpose of the EDS is to help local NHS organisations, in discussion with local partners including local people, review and improve their performance for people with protected characteristics as defined by the Equality Act This paper was developed in line with previous EDS assessments however, as a trust on a journey to outstanding, we will use the framework to identify areas where the trust can be outstanding in its approach to equality and diversity. Part of this will be to widen participation to more patients, public and staff next year. By using the EDS, NHS organisations can also be helped to deliver on the Public Sector Equality Duty (PSED). Patients: The assessment graded seven out of the nine outcomes as achieving, one was scored as developing and one was excelling. Staff: The assessment graded five out of the nine outcomes as achieving and four as developing. This represents continued improvement in the assessment by moving more areas of the EDS domains from developing to achieving since the last assessment. Purpose Approval Recommendations Board members are invited to: 1

215 i. approve the EDS self-assessment; and ii. note that the equality and diversity action plan will be reviewed in light of this EDS assessment, the Workforce Race Equality Standard (WRES) outcomes and the 2017/18 PSED report, with the objective of assuring all areas are achieving by the end of , aspiring to extend domains to excel in longer term as part of our journey to outstanding. Link to BAF/TRR Report history Appendices Q1/Q2 well-led evidence and P1 People None 1: EDS2 Self-assessment 2: NHS EDS framework guidance: 2

216 NHS Equality Delivery System (EDS) grading exercise 1. Background 1.1 The Equality Delivery System (EDS) framework is designed to support NHS commissioners and providers to deliver better outcomes for patients and communities and to ensure better working environments for staff, which are personal, fair and diverse. 1.2 At the heart of the EDS is a set of 18 outcomes grouped into four goals or domains. These outcomes focus on the equality issues of most concern to patients, carers, communities, NHS staff and Boards. It is against these outcomes that performance is analysed, graded and equality objectives set. The first two domains of the EDS framework cover patients and the latter two staff. 1.3 As part of a suite of activities undertaken annually in relation to Equality and Diversity, HRCH reviews its performance against the 18 outcomes and identifies gaps and actions to ensure it can demonstrate continuous improvement in performance against the standards. 2. HRCH assessment against EDS goals 2.1 The trust s self-assessed performance ratings against the EDS framework are set out in appendix 1. The EDS assessment has been reviewed at a number of trust governance committees: Equality and Diversity Committee; for patient elements discussed at the Trust patient forum and noted at QGC; for staff elements discussed and approved by JNCC and noted at WEC prior to coming to the Board. 2.2 EDS grading guidance is set out in the link to appendix 2 shown on the front sheet of this paper (refer to pages of the grading document). There are four grading assessments allowed: Grading outcome Undeveloped Developing Achieving Excelling 3. Conclusions 3.1 The EDS is a continuous development tool and has provided us with an opportunity to engage with local stakeholders to grade our equality performance and to identify areas for action which will form the basis of our equality and diversity action plan. 3

217 3.2 The revised grading guidance is issued by NHS England and makes clear that, in order to achieve higher grades under the EDS framework, NHS bodies really need to report evidence by as many protected characteristics as possible. The trust has several areas of good practice which comply with EDS outcomes sought for patients, however, improvement is required, particularly in the monitoring of patient contacts and outcomes by more protected characteristics than those currently reported. The Trust Board remains committed to delivering on its equality obligations and has made this an ongoing priority to improve our standing in this area. Patient domains 3.3 The clear equality objective that the trust identified from its last EDS grading for domains 1 and 2 of the EDS framework is a need to widen its monitoring of patients protected characteristics as listed under the Equality Act (2010). This will mean looking to increase coverage of patients disability status, religion or belief, pregnancy or maternity status (where applicable), marriage and civil partnership status, sexual orientation and gender reassignment. 3.4 It is acknowledged that monitoring for some of these protected characteristics is sensitive, particularly on sexual orientation and gender reassignment. However, the trust will aim to use a number of approaches to increase is coverage of patient diversity. These will include: i. discussion with local clinical commissioning groups to increase patient diversity data following referrals from primary care as primary care services are also subject to the equality duty to report this information; ii. learning from other NHS trusts who have successfully navigated this area and now routinely report patient contacts by a range of diversity variables; iii. raising awareness amongst our patients and staff (through leaflets and training) on why collecting such data is important, in line with our statutory duties, as a publicly-funded body. Workforce domains 3.5 Whilst the workforce domain 3 provides evidence that the Trust has a diverse workforce with appropriate and equitable policies and processes in place, the assessment also takes into consideration PSED, WRES and Staff survey findings hence why some areas are classed as developing where the trust has agreed continual improvement focus is required. 3.6 The trust has valued based recruitment questions, has values assessed as part of the appraisal process and also has values detailed in job descriptions and HR policies. Work continues to ensure values and associated behaviours are embedded in everything the trust does. Goal 4.2 has been assessed as developing as although policies and organisation changes proposed have an EIA as standard, not all papers that come before the board do so this is an area to consider what is meaningful with the Board. 4. Recommendations 4.1 Board members are invited to: 4

218 i. approve the grading assessment and evidence provided ii. note that the present equality and diversity plan will be updated taking into account this assessment along with this year s WRES and PSED reports 5

219 Appendix 1. EDS Summary Report EDS grading guidance is detailed further in the documentation which can be located via the link shown for appendix 3. There are four grading assessments allowed: Grading outcome Undeveloped Developing Achieving Excelling Evidence in support of assessment and statement: EDS goal 1 Better Health Outcomes EDS Outcome Evidence drawn upon for rating EDS Grading Services are commissioned, procured, designed and delivered to - Public Sector Equality Duty report 16/17 advises the Trust collects 5 of the characteristics routinely. The Trust system has the ability to capture the nine protected characteristics and will be capturing data routinely from 2018/19. - Working with DisabledGo who have been commissioned to review access to our trust sites and provide access guides - The Learning and Disability Team (LD) produced a film around mental capacity and best interest decision making. One of the vignettes was centred on a man with learning disabilities. This film will help staff understand the process, requirements and improve 6 Achieving

220 meet the health needs of local communities their practice relating to the Mental Capacity Act (MCA) The Trust produced a film that promotes the uptake of health checks in primary care for people with learning disabilities. This short (client focussed film) is there to demystify the health check process for people with learning disabilities Co-developed with Hounslow CCG a new LD health Check template for people with learning disabilities In partnership with West Middlesex University Hospital, co-developed and delivered a getting to know your hospital event, this event provides an opportunity to for a behind the scenes tour of the hospital. This is the 4th time we have undertaken this with West Mid and proves a useful medium for clients with learning disabilities to visit the hospital not as a patient (with all of the associated anxieties that there are at that time) The learning disability service has introduced service user interview panels for behaviour therapists, community nurses and Doctors (to date). This gives a real opportunity for service users to influence who will be working with them The Trust has an LD alert flag on the system. The Trust is in the process of ensuring that people with learning disabilities have this alert flagged activated on systmone. This will then ensure that people with an LD are known to services and appropriate reasonable adjustments are made The Trust good practice guidance has been reviewed and will be re-launched during the summer. The good practice guidance will support front line staff to appreciate and understand people with learning disabilities in how to effectively support them when they attend appointments The Trust is working in partnership with the London Borough of Hounslow in developing Project Search on the job training opportunities for young people with disabilities (including learning disabilities). - The Children s Acute Nursing Service (CANS) is based in the Walk In-Centre seeing children 0-15years with minor ailments based within Teddington Memorial Hospital. The lead nurse used to work in the Asthma Service, but saw that there was a gap in services where Children s Advanced Nurse Practitioners could help prevent avoidable A&E attendances amongst children. The service now has 4 Nurses working in the team. In the two years that the service has been running, an incredible 97% of all children have been discharged back home, with 7

221 only 3% referred on to A&E. - This year the trust adopted Always Events methodology to engage with patients and carers. By following this process we were able to understand what really matters to them. Always Events activity was undertaken in three areas to begin with: 1. End of life care (long-term conditions) - to see how best HRCH staff can support patients and those important to them to talk about their preferences and wishes when receiving care now and in the future. 16 interviews held with patients, carers and clinicians in addition to 3 workshops. Co-design event with carers and staff to create an Always Event vision statement 2. Dementia care to see how HRCH can best support patients and carers living with dementia Held 25 interviews with patients, their families and staff A co-design event was held with carers and staff to create an Always Event vision statement and the first Always Event aim statement, which will be tested from July - October using a PDSA (Plan-Do-Study-Act) Cycle 3. TMH Inpatient Unit to ensure patients, carers and the public have awareness of service processes and what happens next: Held 46 interviews with patients, their families and staff over a three-day period A co-design event was held with patients, carers and staff to create an Always Event vision statement and the first Always Event aim statement, which will be tested from April June (2018/19) using a PDSA (Plan- Do-Study-Act) Cycle. 1.2 Individual people s health needs are assessed and met in appropriate and effective ways - Audiology provide annual deaf awareness training. This training is offered jointly with the Richmond borough s Achieving for Children s team. The trainers include audiologists, teachers of deaf children and deaf professionals. - The Children s Hearing Services Working Group which is a multidisciplinary forum of parents, voluntary agencies and public sector practitioners who work in, or are associated with the delivery of hearing services for all children and young people. In Hounslow and Richmond, the CHSWG meetings are attended by representatives from many services, including new born hearing screening, Paediatric Audiology, Speech and Language Therapy, Education Services, Social care, Healthcare Commissioners 8

222 1.3 Transitions from one service to another, for people on care pathways, are made smoothly with everyone well-informed 1.4 When people use NHS services their and both local and national voluntary organisations. - The Hounslow Community Learning Disability Team (CLDT) has developed good practice guidance for HRCH staff - Supporting people with learning disabilities to enable our staff to understand the needs of people with learning disabilities and to offer appropriate care, education and support. - The schools Immunisations team ensure that all genders are respected. an anxious parent called to ask if immunisations sessions were separate sex or mixed sex sessions as her child was worried about this. We explained that sessions were mixed, but respect and appropriate privacy was in place. The parent thanked us as her child was transgender, and was not sure where they should be placed. - Health visiting: Each of our local wards and communities differ greatly with unique health needs, challenges and priorities including dental health problems, obesity rates and immunisation uptake. An example of how we responded and tailored delivery to impact on this was through sharing and analysing data with partners, we identified a large number of children were entering reception that were not potty trained. Our nursery nurses worked with 2 schools in Feltham to deliver a targeted intervention on potty training for all families where this was identified. Evaluation data showed 80% of families said they learnt new techniques to help address the issue. - Additional investment into Learning Disabilities team which increased specialist support for complex cases being transitioned back into borough. - Learning Disabilities team and Hounslow Improving Access to Psychological Therapies service (IAPT) have developed a shared pathway for people with learning disabilities accessing mainstream mental health services. - Referrals into and out of Teddington Memorial Hospital Inpatient unit are overseen by our Rapid response and reablement team. To ensure transition is well planned and appropriate. - The Trust is working with Richmond GP Alliance to develop community pathways for patients with 5 identified long term conditions. e.g. Diabetes and respiratory care - Through the year 2017/18, we have further reviewed our governance of patient safety and have put in place measures to ensure timely action on incidents identified. The management of incidents and serious incidents is through our internal policy; this is based on the NHS Improvement National serious incident framework for NHS England 9 Achieving Developing

223 safety is prioritised and they are free from mistakes, mistreatment and abuse 1.5 Screening, vaccination and other health promotion and includes an equality impact assessment. All patients, staff and the public are treated equally when an incident investigation is undertaken however in order to promote an effective system as an organisation we have also adopted the NHS Improvement Just Culture Guide used to support conversation between managers about whether a staff member involved in a patient safety incident requires specific individual support or intervention to work safely. - The Trust is starting to collect protected characteristics for incidents on Datix which will enable an analysis of SIs for themes on these characteristics. - Duty of Candour Policy (including Being Open) 2017/18 the Trust reported nine duty of candour incidents and shared these with the people involved as per our policy. Promoting a culture of being open is a prerequisite to improving patient safety and the quality of healthcare systems. For patients, effective communication starts from a healthcare need being identified and continues throughout their treatment. Being open when things go wrong is fundamental to the partnership between the care giver(s) and patients and carers. The effects of harming a patient may have devastating emotional and physical consequences for the patient and their families or carers. Being open involves apologising and explaining what happened, which can help patients and staff to cope better with the after-effects of an incident. In this context, an apology is not an admission of liability. Being open and honest can prevent such events becoming formal complaints or litigation claims. It can also help support a just culture - the Trust has dedicated professionals to Lead on Safeguarding children and vulnerable adults who provide assurance to Trust Board that we are compliant with statutory requirements. - The Trust achieved its targets regarding safeguarding training. - School Immunisation programme - One You health promotion in Hounslow and Merton. The Trust reports performance against health promotion activities to evidence that we are reaching local communities. Activities are focused on our knowledge of protected characteristics and targeted were appropriate. 10 Achieving

224 services reach and benefit all local communities - One You cook and eat programme - One You Merton health and wellbeing hub. - HRCH Health Visiting and Family Nurse Partnership teams have also identified Oral Health Champions who have attended Tooth Champion Training sessions. This training has provided the knowledge and the tools for our champions to deliver oral health promotion sessions to all staff. HV staff promotes oral health at every contact with families which supports making every contact count (MECC) and maximises reach through partnership working and delivery. A dental pack is given to every child who attends a transfer-in contact, 1 or 2 year. - Another key priority for Hounslow is addressing the increase in childhood obesity. Our service and local data shows that obesity levels are higher in Heston, Cranfield, Feltham Bedfont and Central Hounslow, We are also aware of the diversity of the different communities in these wards. We work with One You Hounslow to deliver joint health promotion sessions at different faith centres including Gurdwaras and Hindu temple mosques providing parents and extended family members with mini health checks, working with our One You Hounslow service to cover weaning sessions and keeping active advice as part of our think family approach - An increasing number of Children & Young People are identifying as LGBT. It is crucial that in accessing the service both parents and young people feel they can confide and communicate openly with the School Nursing service to meet their health needs directly as well as signposting them and supporting them to access specific services that can help them e.g. with transition issues Excelling 11

225 EDS goal 2 Improved Patient Access and Experience EDS Grading 2.1 People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds 2.2 People are informed and supported to be as involved as they wish to be in decisions about their care The Trust tries to ensure equability of access to services in a number of ways, ensuring that patients accessing an outpatient appointment, diagnostics or planned admission are managed in line with National Waiting List Guidance. - Evidence is available in our 2016/17 public sector equality duty report published on our external web which illustrates patient access to the Hounslow urgent care centre and the Walk-in-Centre based at Teddington memorial Hospital. The patient access data is disaggregated by patient age, gender and ethnicity. No incidences of patients being denied access to treatment occurred. People accessing unplanned urgent care is however representative of the population as a whole. - DisabledGo work being completed this year. - The Trust produced a film that promotes the uptake of health checks in primary care for people with learning disabilities. This short (client focused film) is there to de-mystify the health check process for people with learning disabilities. - HRCH website uses a system called Browse Aloud which when text is highlighted can read aloud the text or translate the English text to any language. - Information leaflets provided for services this includes a section written in the top 5 languages for the boroughs advising on how to obtain the leaflet in a language of their choice. - Translation and interpreting service available for any language difficulties. Teams can book translators where required to attend appointments with patients. - In most cases, treatment information is provided and discussed when the patient is told of the need for a procedure in the initial Outpatients appointment, well in advance of the actual procedure being carried out. This gives the patient time to think about their consent decisions and allows them to refuse or withdraw should they wish to do so. When treatment is refused, the risks and benefits of refusing and alternative options are further explained. Where there are changing needs for the patient, consent decisions are regularly reviewed. - Involving the family in a Continuing Health care Assessment so that they can provide their input and view on the patients needs. - Advocacy services provided by independent services to complainants who may wish 12 Achieving Achieving

226 2.3 People report positive experiences of the NHS 2.4 People s complaints about services are handled respectfully and efficiently support in making a complaint. - HRCH website - In our standard Patient Survey for 2017/18, 91% of patients agreed that they were involved as much as they wanted to be about decisions. - The Trust produced a film around mental capacity and best interest decision making. One of the vignettes was centred on a man with learning disabilities. This film will help staff understand the process, requirements and improve their practice relating to the Mental Capacity Act (MCA - Feedback provided by our patient feedback system called MES includes feedback on all nine characteristics on the standard patient survey. - The following reports include demographic information to the Board and various committees and commissioners. The Annual Complaints Report, quarterly Patient Experience report which also is provided for the two CCGs. In these reports we also list and give examples of compliments received about our services. - Patient stories are also heard at the Board where a patient can "tell their story" - Low number of formal complaints for the Trust with none being investigated by the Ombudsman last year (17-18). 43 formal complaints compared to over 600,000 patient attendances with the Trust. - The Friends and Family Test (FFT) result for the year was 95%Recommend compared to 94% for the London Region. This was after collecting over responses. - New process for obtaining EDS data for complaints to improve EDS and ensure that there is evidence that no one group is being disadvantaged. - We also have a children s specific comment card which is more visually appealing to the standard comment to ensure we are hearing the children s voice. In 2017/18 98% Recommended the children s services provided. - A complaints equality and diversity survey is sent out to all formal complainants and we had a response from seven in 17/18 out of 43. This year we will be using our patient record system to report on protected characteristics for patients so we can analyize if there is a relationship between patient protected characteristics and our services. - Our complaints policy and National statutory complaint function. - examples are: Being open meetings which shows the Trust as being 'open and honest' and dealing 13 Achieving

227 with a complaint in a way that they have chosen. Our response rate to complaints last year was 91% of complaints were answered within time frame. 100% of complaints were acknowledged within 3 working days - Low number of formal complaints for the Trust with none being investigated by the Ombudsman last year (17-18). 43 formal complaints compared to over 600,000 patient attendances with the Trust. The low number of formal complaints with the increased number of Enhanced PALS illustrates that complainants prefer to have their complaints responded to by the quickest route possible whilst still being investigated properly. Achieving 14

228 EDS goal 3 A representative and supported workforce EDS Outcome Evidence drawn upon for rating EDS grading 3.1 Fair NHS recruitment and selection processes lead to a more representative workforce at all levels The Trust has a comprehensive in date policy, which is updated regularly and where there are legislative changes with an Equality Impact Assessment completed. The policy has been consulted on with staff side and can be accessed via the intranet for staff and ensures all applicants regardless of their protected characteristic are treated fairly and equitably throughout the recruitment process. Candidates are all scored on their competency-based interview. NHS Jobs collates data on six of the nine protected characteristics covered by the Equality Act (2010) and the data can be viewed in our 2015/16 public sector equality duty report available on our web pages via this link: Advertising: The NHS Jobs web portal can be accessed via the NHS jobs site which is accessible to everyone. Posts are advertised on NHS jobs normally for two weeks for external and internal posts. Secondments and other development opportunities are also advertised via our internal comms bulletins to help widen publicity and opportunities for staff to develop within HRCH. When shortlisting via NHS Jobs, applicants personal details including name and equal opportunities data cannot be seen when shortlisting thereby minimising potential for bias based on any protected characteristic. NHS jobs and the Trust also follow the good practice Disability Confident (originally Two Ticks) system and offer guaranteed shortlisting for applicants meeting the essential criteria under this. NHS jobs is commonly accessed by candidates from overseas and there are no limitations to the number of posts an individual can apply for. However, this can cause a number of applications to be unsuccessful as candidates may have misunderstood 15 Developing

229 EDS goal 3 A representative and supported workforce EDS Outcome Evidence drawn upon for rating EDS grading the purpose of the job role or the post may not attract the work permit required. This is consistent across the NHS and is not unique to the Trust. The UK Border agency is responsible for issuing work permits. Accreditation and external involvement: The Trust has successfully been accredited with the two ticks symbol for several years running. This has been replaced by the Disability Confident scheme and the trust was reassessed in 2017 and is permitted to use this symbol in its advertising material. This is awarded to organisations who are positive about employing disabled people and we have demonstrated our year on year commitment to this. For applicants under this scheme, we will interview those candidates who meet the minimum criteria and assess them on their abilities to carry out the job. The Trust policies and processes in place are robust and fair and in addition the Trust has trained over 60 recruiting managers in unconscious bias training in relation to recruitment in 2015 and ran extended scope unconscious bias training procured for 200 managers in 2017/18. The trust needs to see if this extended training translates into any better results over the next two years. In addition the Board received unconscious bias training in late A management essentials course launched in 2016 covers recruitment and selection and has been evaluated and updated to include more training including Unconscious Bias and equality and diversity. The Equality and Diversity lead has also worked to produce a new manager s E&D toolkit The corporate induction Equality and diversity training has been reviewed and updated to also include elements of Unconscious Bias. This training is in place for all staff. Whilst the policy, processes and training are in place and would attract a green rating, 16

230 EDS goal 3 A representative and supported workforce EDS Outcome Evidence drawn upon for rating EDS grading based on the information contained in our statutory public sector equality report (PSED) and Workforce Race Equality Standard (WRES), we have identified that progress has been made in improving the number of BME staff in senior positions in the Trust, however there is still a need to review conversion of applicant to offer rates of BME applicants compared to White applicants. Therefore a rating of amber is still proposed and this will be discussed at the Trust Board. In addition, the Workforce Team have reviewed the Management Essentials Programme and have delivered further Recruitment and Selection Training as requested by services with a focus of equality and diversity during 2018/2019. Further training workshops are being organised and will be available to staff outside of the Management Essentials programme. 3.2 The NHS is committed to equal pay for work of equal value and expects employers to use equal pay audits to help fulfil their legal obligations As an NHS Trust we use the national grading and pay system known as Agenda for Change (AfC) for all staff with the exception of Medical and Dental staff and those managers on the Very Senior Manager (VSM) pay. AfC has been nationally equality-proofed by the Department of Health and the NHS unions. Our pay data by protected characteristic is contained in pages of our Equality report which illustrates this by age, disability, gender and race. We have developed a comprehensive process for AfC job matching and evaluation, and consistency checking which is carried out in partnership with staff side. Further AfC matching training was delivered in August The Trust follows nationally negotiated terms and conditions and job matches and consistency checks with Staff side to assure equal pay of equal value. There have been no Equal Pay claims made to HRCH. Our PSED report provides the analysis of pay band by protected characteristic and this is approved by our Trust Board and 17 Achieving

231 EDS goal 3 A representative and supported workforce EDS Outcome Evidence drawn upon for rating EDS grading published on our website in 2017/18. In addition, the trust has completed a detailed Gender Pay Gap report and this has been approved by our Trust Board and published on our website in March The results of these reports are considered by the Equality and diversity committee which feeds through to WEC for staffing matters with any actions incorporated into our Equality and diversity action plan. Our gender pay gap report went to our Trust board and was published on our web pages in March The Trust employs a predominantly female workforce and follows national pay guidance across all grades of staff regardless of gender. Across all Agenda for Change pay scales, females are paid more than their male counterparts on average. In the category Medical/Other males are paid more than females. This difference is influenced by the salary scales for particular VSM Director roles and years of service for Medical staff rather than gender difference. 3.3 Training and development opportunities are taken up and positively evaluated by all staff All our staff have corporate and local induction and complete a range of obligatory and essential training which includes equality and diversity. This ensures staff are equipped to do their job and know their equality duties. Each year staff meet with their managers to agree performance objectives and a personal development plan for training and other support to help them develop professionally and deliver high quality work. A range of training is made available to all staff directly via and through their managers, as well as being advertised on the staff intranet and via staff newsletters. In terms of our staff survey results, we can highlight the following on training: 76% of staff said that they had received training, learning or development in the last 12 months which had helped them perform their jobs better, stay up-to-date with their jobs or stay up-to-date with professional requirements. This was the 18 Developing

232 EDS goal 3 A representative and supported workforce EDS Outcome Evidence drawn upon for rating EDS grading second best score across the country Furthermore, in the staff survey 90% of staff said that they had received an appraisal, performance development review, in the last 12 months. Further review of development opportunities for BME staff and administrative staff, forms part of the trust s equality action plan. As access to career opportunities is still below average at 83% in the 2017 staff survey results this is marked as amber. The Trust has undertaken considerable work to develop an Education and Training plan to ensure that the right training and education is provided to the right staff, at all levels in the organisation to deliver the Trust strategic objectives and vision to enable people to live a healthier and more independent life through high quality seamless care. This education and training also needs to be delivered in the most effective and efficient way to diverse staff groups. This is also an important consideration to enable robust reporting at Trust level of all training supported as well as for the Equality Duty. An Education and Training panel has been set up to manage education and training budgets more carefully going forward. The panel will ensure that requests for education and training are managed more robustly, align to HRCH strategic objectives and ensure that funding is distributed fairly and equitably across our workforce given the reductions. This will encourage an open culture where study leave and funding allocations are discussed amongst a group Data in our last public sector equality duty report contained information on the nine protected characteristics of applicants for training. Our Learning and Development Strategy agreed in January 2018 includes provision for training to meet diversity of staff 19

233 EDS goal 3 A representative and supported workforce EDS Outcome Evidence drawn upon for rating EDS grading 3.4 When at work, staff are free from abuse, harassment, bullying and violence from any source and at different bands. The Trust has a zero tolerance on any form of discrimination experienced by our staff or patients and we have robust policies in place. The policy also includes other unwanted conduct. It also states what other support staff can access to help them and encourages reporting. All staff receive information at induction and also via the staff hand book as well as information on what polices and information can be accessed via the staff intranet. The Management Essentials programme has a Disciplinary module which encompasses bullying and harassment, which forms part of their role as a line manager. There are plans to make this module available to all staff going forward. Staff are encouraged to report all incidents of actual or perceived harassment. The HR team are specialists in managing such cases and work with managers and the staff to look at ways to informally resolve the matters as an initial option based on the staff members view. In addition, the HR team and line managers had a legal update and refresher training on this from our solicitors in 2016 to support them to be able to carry out investigations appropriately. Our equality report highlighted data by four of the nine protected characteristics. It also showed that there were a very low level of grievances and disciplinary cases in 2016/17. The WRES submission demonstrated that in 2016/17, only 5 cases of disciplinary or grievances were formally investigated. The Trust endeavours to address issues of grievances and misconduct informally where possible. The number of cases investigated is very small in comparison with the total workforce which makes drawing significant conclusions difficult. No formal investigations were undertaken against anyone who had declared a disability. There appears to be no pattern in terms of disciplinary or grievances against sex, age, religion or belief or 20 Developing

234 EDS goal 3 A representative and supported workforce EDS Outcome Evidence drawn upon for rating EDS grading marriage/pregnancy. All five cases investigated formally, involved BME staff with four different ethnicities/races. Two of the five cases were investigations the Trust inherited following a TUPE transfer. A review of our formal disciplinary and grievance outcomes was conducted and presented to the Equality & Diversity Committee on 6 October. In line with good practice, this review was essentially a full equality impact analysis and also looked at formal grievance and capability cases. The review drilled down to individual cases and concluded that, in view of the issues considered for respective cases, the outcomes for the cases presented were reasonable. A similar review of cases from the most recent WRES 2018 report shows valid misconduct reasons and the trust is reviewing further work and practice pan London to improve this. 3.5 Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives The Trust has a flexible working policy for all staff and applies to all protected characteristics. We encourage a flexible workforce to assist us in the delivery of services but also enables us to retain staff. Staff are afforded reasonable adjustments to their working patterns, which includes change to hours to assist in their return to work following a period of sickness absence or with their disability. In the trust s 2016/2017 public sector equality duty report, data demonstrated that a large number of staff over 43% of staff work on a flexible part-time basis with the Trust. The Trust will also be collating further information on flexible working arrangements in 2018/19 to help provide robust evidence of the practice and use of flexible working options across the trust and their consistent application, in line with service needs. The trust is also promoting flexible and agile working both in clinical and corporate areas to aid retention and positive work-life balance further. 21 Achieving

235 EDS goal 3 A representative and supported workforce EDS Outcome Evidence drawn upon for rating EDS grading 3.6 Staff report positive experiences of their membership of the workforce The Trust achieved above the national average for staff engagement in comparison to other NHS Community Trusts in the last national survey. The 2017 staff survey results showed that the Trust scored top results nationally, in comparison to other Community Trusts, for staff recommending the trust as a place to work, being motivated at work, believing their role makes a difference, being satisfied with resources and support and with the quality of care they are able to provide. The Trust achieved 3.95 out of an aspirational 4/5 strategic objective and KPI re improving staff engagement in 2017/18 as measured by the national staff survey. The above shows incremental improvement on staff engagement and experiences and could potentially move to excelling this year. Achieving EDS goal 4 Inclusive leadership 4.1 Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their organisations Outcome Self-assessment statement EDS grading The Trust is compliant with its requirement to publish a statutory annual Public Sector Achieving Equality Duty report and also to submit its annual WRES return to NHS England. The Trust has designated leadership roles for equality and diversity with the Director of Workforce holding lead responsibility for equality and inclusion for workforce matters. The Director of Quality is the lead for patient and carer equality and inclusion. The Board Secretary is the trust s Equality lead and progress is overseen by the Equality & Diversity Committee which has Non-Executive Director representation and reports to the Workforce & Education and Quality Governance Committees. 22

236 EDS goal 4 Inclusive leadership Outcome Self-assessment statement EDS grading Unconscious bias training was procured for 200 managers across the organisation in 2017/18 and Board training was provided in late The Director of Quality held a second 6Cs event ion 2016 that focussed on equality and diversity. The trust s Board is diverse when compared with other NHS bodies in London and recently reported as the second most diverse board in London. It currently has 15 Board members in total with twelve voting members, five of which are female and two (three from May 2018) of whom are from a BME background. In addition, the Board has two, female; BME non-voting Directors Board members also had unconscious bias training as part of the Board s December 2016 seminar. Two distinct examples stand out in relation to this EDS goal. Work has been undertaken there has been work undertaken by Board members in Hounslow with Spark, a local organisation that works with education and business to prepare people for working life and enhance their employability through practical, accredited and inspiring work-related experiences. In addition, the trust participated in NHS Improvement s NeXT initiative to improve the representation of BME non-executive directors on NHS Boards in London and as hosted two BME aspirant NEDs and have a further two female NeXT NEDs in 2018 attending its Board. 4.2 Papers that come before the Board and other major Committees identify A new Celebrating Diversity event was held in June 2018, which received 100% positive feedback. This event was led in partnership with staff side, with senior leaders explaining their personal backgrounds and vulnerabilities with key messages to bring authentic self to work. This was an example of excelling and if we do more of this next year, this may move to excel in the next assessment. All Board papers which present a major policy or strategy need to undergo an equality impact analysis (EIA) which helps to embed equality into all that we do. All trust policies have an EIA. Practice is less consistent in strategy and service development and the EIA toolkit is designed to help embed this good practice. 23 Developing

237 EDS goal 4 Inclusive leadership Outcome Self-assessment statement EDS grading equality-related impacts including risks, and say how these risks are to be managed 4.3 Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination Over 60 middle managers have attended the unconscious bias training to help improve recruitment and selection best practice in 2015 and further 200 procured for wider unconscious bias training in 2017/18. In addition, a toolkit has been developed for frontline staff to use and be aware of cultural differences for the diverse patient community we serve so that they are able to receive a service which is fair, personal and diverse, particularly in the areas of diet, dress, end of life and spiritual care. A diversity calendar has been developed and is used regularly in regular, monthly communications to aid trust managers and staff. Furthermore, a toolkit for line managers has been issued to help increase their confidence and capability in managing diverse teams fairly and inclusively. This will be accompanied by an updated intranet site for all trust staff. Achieving 24

238 Meeting title Trust Board part I meeting Date: 25 July 2018 Report title Lead director Workforce Race Equality Standard submission 2017/18 Alison Heeralall, Director of Workforce Agenda item: 20 Report authors Executive summary Jane Smith, HR Business Partner & Ian Hughes, Workforce Information Manager The paper provides a summary of the 2017/18 Workforce Race Equality Standard (WRES) draft submission for the Trust. A separate report on the Public Sector Equality Duty will provide more detail around protected characteristics of HRCH staff and patients and will be reported to the Executive Committee in August Whilst some improvements have been made to the WRES statistics since last year, the trust still needs to maintain focus on improvements, particularly on equal access to career opportunities in terms of training and reducing discrimination. Pan-London groups are also collaborating to share initiatives to improve similar findings collectively. Work via the recent focus groups is being collated for executives to discuss and inform next steps on this. Purpose: Review and approval Recommendation(s) The Board is are asked to: Review and approve the report, along with Appendix 1 which contains the planned WRES required for submission by 1 August 2018 Note that there will be a further review of trust Equality and Diversity plan in Autumn taking into account this WRES report, the 2017/18 PSED report and the Equality Delivery System (EDS) assessment. BAF/TRR People P1 Report history Executive Committee, 10 July 2018 Appendices Draft WRES submission template

239 WRES Report 2017/18 (Draft) 1. Introduction In April 2015, NHS England introduced the NHS Workforce Race Equality Standard (WRES) in response to consistent findings over 20 years that black and minority ethnic (BME) applicants and staff consistently fared worse in employment outcomes and satisfaction surveys. The WRES was designed to enable NHS organisations to demonstrate progress against a number of indicators of workforce equality, including a specific indicator to address the low levels of BME Board representation. Since April 2015, the WRES has been included in the full length NHS Standard Contract, which is mandated for use by NHS commissioners when commissioning non-primary health services. The contract requires all providers of NHS services (other than primary care) to address the issue of workforce race inequality by implementing and using the WRES. Service Condition 13.6 of the NHS Standard Contract 2017/18 and 2018/19 states the following in relation to the WRES: The Provider must implement the National Workforce Race Equality Standard and submit an annual report to the Co-ordinating Commissioner on its progress in implementing that standard. This report is published to support the 2018 Hounslow & Richmond Community Healthcare NHS Trust s Workforce Race Equality Submission a copy of which can be seen in Appendix 1. A separate report on the Public Sector Equality Duty will provide more detail around the protected characteristics of HRCH staff and patients and will be reported to the Executive Committee in August There are nine WRES indicators. Four of the indicators focus on workforce data, four are based on data from national NHS Staff Survey questions, and one indicator focuses upon BME board representation. The WRES highlights any differences between the experience and treatment of white staff and BME staff in the NHS with a view to organisations closing those gaps through the development and implementation of action plans focused upon continuous improvement over time. The WRES is produced in line with Technical Guidance issued by NHS England as part of the standard contract.

240 2. Workforce Composition 2.1 Ethnicity Total Workforce Ethnicity 2018 % 2017 % Hounslow and Richmond population aged 16 to 64* White 57.6% 58.8% 64.2% BME 37.5% 32.4% 35.5% Not Stated 4.9% 8.8% 0.32% *population statistics of Hounslow and Richmond (annual population survey NOMIS) for the population defined as working age adults. Table 1 Table 1 shows that overall workforce is more diverse than the previous WRES report mainly with an increase in BME and decrease in the number of unknown ethnicities. The trust switched to online payslips in 2017/18 and used the opportunity to publicise and empower staff to update their own personal data via Electronic Staff Record (ESR) self-service which may have contributed to the reduction in the numbers not stated. While not assessed as part of the WRES reporting, the ethnicity of the workforce should be reflective of the local population. A comparison with the population of Hounslow and Richmond for the age range demonstrates that the trust workforce is reflective of its population (37.5% BME (trust) versus 35.5% BME (population). However, it should be noted that there are significant differences in the ethnic mix of the two main boroughs served and this will be addressed as part of the PSED. Table 2 (see overleaf) extracted from 2017 and 2018 WRES reports looks at BME as a percentage of staff by grade. This is broken down into non-clinical and clinical workforce by pay band. Comparing 2017 to 2018 WRES, in the non-clinical workforce, there has been a reduction in BME staff as a % of total in grade across most bands 2 to 7 in particular, compared to an increase in some of the more senior non clinical roles in the Trust notably 8b, 8c and VSM. It should be noted that the number of staff in band 2s and the higher bands will be relatively small. There is no particularly pattern in BME staff as a % of total in grade in the Trust clinical workforce with varying % increases or decreases across bands.

241 31st MARCH st MARCH 2018 BME as a % of staff BME as a % of staff Change in grade in grade 1a) Non Clinical workforce Under Band 1 0.0% 0.0% 0.0% Band 1 0.0% 0.0% 0.0% Band % 12.5% -4.2% Band % 43.4% -2.8% Band % 49.1% 1.5% Band % 25.0% -8.3% Band % 41.2% -2.6% Band % 37.0% -16.8% Band 8A 43.8% 42.9% -0.9% Band 8B 16.7% 33.3% 16.7% Band 8C 0.0% 14.3% 14.3% Band 8D 0.0% 0.0% 0.0% Band 9 0.0% 0.0% 0.0% VSM 28.6% 25.0% -3.6% 1b) Clinical workforce of which Non Medical Under Band 1 0.0% 0.0% 0.0% Band 1 0.0% 0.0% 0.0% Band % 52.9% -3.1% Band % 44.6% 0.5% Band % 34.5% 4.9% Band % 40.4% -3.9% Band % 37.2% 1.4% Band % 28.9% -2.3% Band 8A 16.2% 17.1% 0.9% Band 8B 25.0% 20.0% -5.0% Band 8C 0.0% 0.0% 0.0% Band 8D 0.0% 0.0% 0.0% Band 9 0.0% 0.0% 0.0% VSM 0.0% 0.0% 0.0% Of which Medical & Dental Consultants 70.0% 75.0% 5.0% of which Senior medical manager 100.0% 0.0% % Non-consultant career grade 66.7% 75.0% 8.3% Trainee grades 0.0% 0.0% 0.0% Other 0.0% 100.0% 100.0% Table 2 * 1a) includes VSMs and some senior bands that are non-clinical but maybe clinically qualified. It does not include NEDs: EDS 2017 technical guidance states: Very Senior Managers (VSM) include: Chief executives Executive directors, with the exception of those who are eligible to be on the consultant contract by virtue of their qualification and the requirements of the post Other senior managers with board level responsibility who report directly to the chief executive. 2.2 Recruitment The WRES report also looks at the likelihood of staff being appointed following shortlisting in the 2017/18 year by ethnic group. In the 2017 WRES report white applicants had a 26.7% likelihood of being appointed from shortlisting whereas BME had a 17.3% likelihood making it 1.55 times more likely that a white candidate will be appointed compare to BME.

242 In the 2018 WRES report white applicants had a 24.7% likelihood of being appointed from shortlisting whereas BME had a 15.8% likelihood making it 1.56 relatively likely that a white candidate will be appointed compare to BME. Essentially, there has been little change in the position, but the difference remains a matter for concern and action. In response to the 2017 figures, the Trust procured specific unconscious bias training for 200 managers, and has trained 119 managers between November 2017 and March In addition the Trust also includes elements of Unconscious Bias within the Equality and Diversity training provided. In addition, the trust reviewed and updated its recruitment policy which was ratified by Executives in February 2018 to ensure all appointments are merit based. In doing so, it is hoped that this will help contribute to an improved position next year. 3.0 Disciplinary cases This indicator is based on data from a two year average based on the current year and the previous year. The WRES looks at the average number of disciplinary cases over a rolling two years. Overall 0.4% of staff were subject to formal disciplinary investigation, of which 0.15% were white staff compared to 0.7% of BME staff. In the 2017 report all the disciplinary cases were for BME staff accounting for 1% of BME staff. While the Trust undertakes a range of employee relations work, the Trust only had five formal disciplinary cases of which two are pending in 2017/18;, plus three formal disciplinary cases in 2016/17 therefore caution should be taken in drawing conclusions due to the small numbers. The cases are broken down below: 3.1 Of the cases recorded, two sanctions resulted in dismissal, three received warnings, one resigned prior to the conclusion of the investigation. A further two are pending investigation outcomes. 3.2 Two of the cases reported in this period resulted in a further appeal process. The appeal process determined that the sanction imposed was appropriate for the level of misconduct. 3.3 Reasons for warnings and dismissal have been analysed and were all valid reasons for a misconduct warning such as: alcohol use at work, failure to notify trust of criminal conviction, patient safety and health and safety breaches, inappropriate behaviour and unauthorised absence. As our internal analysis shows that the disciplinary actions were for appropriate misconduct reasons. Further work is being done collectively pan London to review initiatives and monitoring to try and improve this. If formal disciplinaries held are all appropriate, one hypotheses is that non-bme are less likely to reach a formal process and trusts are considering options such as an independent director reviewing all potential cases and suspensions pre formal process instigation. 4.0 Training In 2017/18, 79.7% of white staff (compared to total white staff) and 77.2% of BME staff, accessed non-mandatory training giving a ratio of 1.03 White to BME. It should be noted that there is a significant number of staff who did not specify their ethnicity that accessed

243 training. This attributed to 4.4% of all staff who accessed a training course. This is a further improvement from previous years (1.37 in the 2017 report), however it should be noted that the analysis in this report has been based on a bigger dataset than the previous year s report. 5.0 Staff Survey Report As part of WRES submission the Trust is required to report on specific elements of the 2017 staff survey report. Table 3 details the 4 staff survey questions: KF 25. Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months KF 26. Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months 2017 (2016 survey) 2018 (2017 Survey) WHITE BME WHITE BME 24.05% 23.91% 22.95% 21.15% 17.29% 24.57% 16.39% 23.01% KF 21. Percentage believing that trust provides equal opportunities for career progression or promotion Q17. In the last 12 months have you personally experienced discrimination at work from any of the following? b) Manager/team leader or other colleagues Table % 77.93% 90.21% 70.80% 3.98% 9.44% 3.48% 11.50% The Trust saw a reduction in the percentage of staff experiencing harassment and bullying from patients, relatives or the public, and from staff from both white and BME respondents. In contrast, the percentage of staff believing that the Trust provides equal opportunities for career progression or promotion increased for white staff and decreased for BME staff. The Trust has analysed its ESR promotion and acting up by ethnicity to see if there is any correlation and this shows that 52 white staff were promoted or acted up which equated to 7.9% of the headcount. In contrast, 43 BME staff were promoted or acted up which represented 10.1% of the BME headcount making a likelihood of white to BME promotion/acting up of This shows that career and promotion opportunity is positive for BME staff however perception isn t and our initial analysis indicates that more focus should be provided to staff in administrative/ support roles, and we need to publicise the promotion/acting up facts In addition, the last staff survey reported a reduction of white staff experiencing discrimination at work from their manager/team leader or other colleagues (from 3.98% in 2016 to 3.48% in 2017 survey) but an increase for BME staff (from 9.44% in 2016 to 11.5% in 2017). This remains a significant concern. The trust has been holding focus groups across all sites and teams during June and July 2018 to hear from staff directly to inform solutions to improve this. These have been well attended and initial results show that experiences vary and therefore a range of options rather than a one size fits all approach may help.

244 In addition the trust tried a new approach and held a Celebrating Diversity Event on 13 th June 2018 which received 100% positive feedback from attendees and a second event is being planned in Autumn The event served to aid breaking down of any potential perceived barriers through a celebration of our diversity. It also gave the opportunity to share vulnerabilities (across protected characteristics) with a clear unified message emerging to bring your authentic self to work. 6.0 Board The board report shows there has been some improvement of BME representation in voting and non-voting board executive and non-executive members. The 2017 WRES showed that the Trust had the second most diverse Board in London. Board recruitment panels are set up to be diverse in their make-up and include an external NHSi representation. The CEO and executives all attend corporate induction and hold settling in meetings after staff have been six weeks in post. Feedback from new starters is extremely positive about this and something that is recognised as unique and valued by our new starters, which aids inclusivity and approachability WHITE BME WHITE BME Total Board members - % by Ethnicity 71.4% 28.6% 66.7% 33.3% Voting Board Member - % by Ethnicity 80.0% 20.0% 75.0% 25.0% Non-Voting Board Member - % by Ethnicity 50.0% 50.0% 33.3% 66.7% Executive Board Member - % by Ethnicity Non Executive Board Member - % by Ethnicity 87.5% 12.5% 66.7% 33.3% 50.0% 50.0% 66.7% 33.3% Table 4 NB Total Board and voting/non-voting members includes Executives, NEDs and Board Advisor roles 7.0 Conclusions and Recommendations Whilst some improvements have been made to the WRES statistics since last year, the trust needs to maintain focus on improving equal access to career opportunities in terms of training and CPD and reducing discrimination. Work via the recent focus groups will inform next steps on this. The Trust also recently participated in a national roundtable WRES event and is working pan- London to determine if there are any collective actions or shared learning because it has been recognised that London Trusts share similar concerns despite individual trust actions. The Board is asked to: Review and approve the report, along with Appendix 1 which contains the planned WRES required for submission by 1 st August 2018 Note that there will be a further review of trust Equality and Diversity plan in Autumn taking into account this WRES report, the 2017/18 PSED report and the Equality Delivery System (EDS) assessment.

245 Appendix 1 WRES Submission INDICATOR Percentage of staff in each of the AfC Bands 1-9 OR Medical and Dental subgroups and VSM (including executive Board members) compared with the percentage of staff in the overall workforce Relative likelihood of staff being appointed from shortlisting across all posts Relative likelihood of staff entering the formal disciplinary process, as measured by entry into a formal disciplinary investigation Note: This indicator will be based on data from a two year rolling average of the current year and the previous year 31st MARCH st MARCH 2018 DATA ITEM MEASURE WHITE BME ETHNICITY UNKNOWN/NULL WHITE BME ETHNICITY UNKNOWN/NULL 1a) Non Clinical workforce Prepopulated Prepopulated Prepopulated Prepopulated Prepopulated Prepopulated Verified figures Verified figures Verified figures Verified figures Verified figures figures figures figures figures figures figures Verified figures 1 Under Band 1 Headcount Band 1 Headcount Band 2 Headcount Band 3 Headcount Band 4 Headcount Band 5 Headcount Band 6 Headcount Band 7 Headcount Band 8A Headcount Band 8B Headcount Band 8C Headcount Band 8D Headcount Band 9 Headcount VSM Headcount b) Clinical workforce of which Non Medical 15 Under Band 1 Headcount Band 1 Headcount Band 2 Headcount Band 3 Headcount Band 4 Headcount Band 5 Headcount Band 6 Headcount Band 7 Headcount Band 8A Headcount Band 8B Headcount Band 8C Headcount Band 8D Headcount Band 9 Headcount VSM Headcount Of which Medical & Dental 29 Consultants Headcount of which Senior medical manager Headcount Non-consultant career grade Headcount Trainee grades Headcount Other Headcount Number of shortlisted applicants Headcount Number appointed from shortlisting Headcount Relative likelihood of shortlisting/appointed Auto calculated Relative likelihood of White staff being appointed from Auto shortlisting compared to BME staff calculated Number of staff in workforce Auto calculated Number of staff entering the formal disciplinary process Headcount Likelihood of staff entering the formal disciplinary process Auto calculated Relative likelihood of BME staff entering the formal disciplinary Auto process compared to White staff calculated

246 DATA ITEM 1a) Non Clinical workforce MEASURE Prepopulated figures WHITE Verified figures Prepopulated figures 31st MARCH 2017 BME Verified figures ETHNICITY UNKNOWN/NULL Prepopulated figures Verified figures Prepopulated figures WHITE Verified figures Prepopulated figures 31st MARCH 2018 BME Verified figures ETHNICITY UNKNOWN/NULL Prepopulated figures Verified figures 4 5 Relative likelihood of staff accessing non-mandatory training and CPD KF 25. Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months 42 Number of staff in workforce (White) Auto calculated Number of staff accessing non-mandatory training and CPD (White): Headcount Likelihood of staff accessing non-mandatory training and CPD Auto calculated Relative likelihood of White staff accessing non-mandatory training and CPD compared to BME staff % of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months Auto calculated Percentage 24.05% 23.91% 22.95% 21.15% 6 KF 26. Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months 47 % of staff experiencing harassment, bullying or abuse from staff in last 12 months Percentage 17.29% 24.57% 16.39% 23.01% KF 21. Percentage believing that trust provides equal opportunities for career progression or promotion Q17. In the last 12 months have you personally experienced discrimination at work from any of the following? b) Manager/team leader or other colleagues Percentage difference between the organisations Board voting membership and its overall workforce Note: Only voting members of the Board should be included when considering this indicator % staff believing that trust provides equal opportunities for career progression or promotion % staff personally experienced discrimination at work from Manager/team leader or other colleague Percentage 89.58% 77.93% 90.21% 70.80% Percentage 3.98% 9.44% 3.48% 11.50% 50 Total Board members Headcount of which: Voting Board members Headcount : Non Voting Board members Auto calculated Total Board members Auto calculated of which: Exec Board members Headcount : Non Executive Board members Auto calculated Number of staff in overall workforce Auto calculated Total Board members - % by Ethnicity Auto calculated 71.4% 28.6% 0.0% 66.7% 33.3% 0.0% 58 Voting Board Member - % by Ethnicity Auto calculated 80.0% 20.0% 0.0% 75.0% 25.0% 0.0% 59 Non Voting Board Member - % by Ethnicity Auto calculated 50.0% 50.0% 0.0% 33.3% 66.7% 0.0% 60 Executive Board Member - % by Ethnicity Auto calculated 87.5% 12.5% 0.0% 66.7% 33.3% 0.0% 61 Non Executive Board Member - % by Ethnicity Auto calculated 50.0% 50.0% 0.0% 66.7% 33.3% 0.0% 62 Overall workforce - % by Ethnicity Auto calculated 0.00% 55.3% 0.00% 38.7% 0.00% 6.1% 0.00% 57.4% 37.6% 4.9% 63 Difference (Total Board -Overall workforce ) Auto calculated 16.2% -10.1% -6.1% 9.2% -4.3% -4.9%

247 Meeting title Trust Board part I meeting Date: 25/07/2018 Report title June 2018 Quality & Performance Scorecard and Exception Reports Agenda item: 23 Lead director Report authors Executive summary David Hawkins Director of Finance, Contracts, Procurement and Performance Chris Giles Assistant Director for Contracts and Performance David Murrell Performance Manager Sandeep Walia Performance Analyst The Quality and Performance scorecard presents the Trust s performance against Key Performance Indicators. Indicators are organised under the five CQC Domains: Safe, Effective, Caring, Responsive and Well-Led. A monthly divisional breakdown of these indicators is displayed within the scorecard. A complete comprehensive scorecard for all divisions is available and discussed at both Directorate Management Team (DMT) and Performance Executive Committee (PEC). Scorecard for June 2018 There were two breaches reported for this month: (Well-Led)- W02 A&E Response Rate: 2.5% recorded for current month against a target of 5%. First time in this Financial year it has gone Red. (Well-Led)- W08 Staff Turnover: 18.53% reported for month against a target of 16.8%. Previous month was 18.69% against a target of 17.0% (Rag Rated Amber) An exception report for these have been provided; KPI s in Amber are for the following:- (Safe) S14 - Percentage of Harm free care (Safety Thermometer): Currently at 94.7%. A slight increase by 0.3%, from previous month (94.4%). (Effective) E03 - Clinical Supervision (% of staff in last 3 months): Currently at 88.1%. An increase from previous month by 5.1% (83.0%). (Responsive) R06- Delayed Transfers Of Care: Reported for current month at 6.8% an increase of 2.3% from previous month Page 1 of 2

248 (4.5%) Data Quality We have seen improvements in Data Quality in the reporting of the; (Effective) - E03 - Clinical Supervision indicator. This has been an output of the audit reviewing the data capture of supervision at a departmental level and how this subsequently informs the corporate level reporting. Purpose: Information and assurance on monthly and annual performance against KPIs Recommendation(s) The Board is asked to: Note the April 2018 Quality & Performance scorecard for HRCH; Identify any areas of concern which may require further assurance BAF/TRR Q1, P1, P2, S1 Report history Performance Executive Committee, 17 July 2018; Finance & Performance Committee, 16 July 2018 Appendices June 2018 Quality & Performance Scorecard Page 2 of 2

249 Quality and Performance Scorecard: 2018/19 Reporting Period: June 2018 Quarter 1

250 Quality and Performance Scorecard: June 2018 Contents Page Preface Data Quality Scores Explained... 3 Section 1 Performance Summaries Current Month Summary - Trust and Divisions...4 Trust YTD Monthly Summary...5 Section 2 Areas of Concern... 6 Section 3 Trust Performance Indicators Safe Domain...10 Caring Domain Effective Domain...15 Responsive Domain Well-Led Domain New Divisional Names & Abbreviations Hounslow Adults Unplanned & Integrated Care (HAUIC) Hounslow Planned Care (HPC) Hounslow Childrens Services (HCS) Richmond Adults Planned, Unplanned & Integrated Care Richmond Childrens Services (RCS) Community Nursing (CN) Clinical Improvement Hounslow and Richmond (CIHR) Health and Well-Being (HW) Clinical Managers (CM) Clinical Support Service (CSS) Corporate Services (CORPS) 2

251 Quality and Performance Scorecard: DATA QUALITY SCORES EXPLAINED There is a representation of a 'Data Quality Score' - five coloured 'lights' to the right hand end of each KPI line: The underlying values have been arrived at by the Performance Team from their knowledge of their own processes (and those of other teams) involved in the prodcution of the figures used in the scorecard. Some of these assessments are qualitative or subjective judgements while others may be quantitative or have a demonstrable status. This table gives some examples that may contribute to a particlar indicator's score: DQ DQ Aspect Timeliness On-time Late Not Received Audit/DQ processes Audit and DQ process in place Audit or DQ process in place No audit or DQ process System/process Single e-system/reporting Multiple sources/processes Manual record/process Accuracy Validated and signed-off Consistent and not draft Draft or estimates Granularity Detail allowing drill-down Some detail High level summary 3

252 S 01 S 02 S 03 S 04 S 06 S 10 S 13 S 14 S 15 C 04N C 04Y C 05N C 05Y C 06 C 07 C 09 C 10 E 01 E 02 E 03 R 01 R 02 R 03 R 04 R 05 R 06 R 10 W 01 W 02 W 03 W 04 W 05 W 06N W 06Y W 07 W 08 W 09 W 10 W 11 Incidence of Clostridium difficile Incidence of MRSA Never Events occurring in month Medication errors causing serious harm Number of reported safety incidents (Harmful) Number of new Serious Incidents in month Inpatient Falls per 1,000 Occupied Bed Days Percentage of Harm-free care (Safety Therm.) Percentage of new Harms (Safety Therm.) Trust Composite FFT - % not recommend Trust Composite FFT - % recommend Staff FFT - not recommend as a care-provider Staff FFT - recommend as a care-provider Patient Survey: patients felt respected Patient Survey: patients felt care was right Mixed Sex Accommodation Breaches Formal complaints received Percentage of Staff Appraised Percentage of Staff - Stat. & Mand. Training Clinical Supervision - within 3 months A&E: maximum time of four hours: Arr to Dep RTT WT completed non-admitted pathways RTT WTs incomplete pathways RTT over 52 week waiters Diagnostic waiting times: over 6 weeks Delayed Transfers of care Services meeting contractual waiting times IP FFT response rate A&E FFT response rate Community FFT response rate Trust Composite FFT response rate Staff FFT response rate Staff FFT - not recommend as a workplace Staff FFT - recommend as a workplace Staff Sickness Staff Turnover Vacancy rate Temporary and overtime costs BME staff in Bands 7-9 and VSM CURRENT MONTH INDICATORS: TRUST & DIVISIONS June 2018 HRCH TRUST G G G G - - G A - G G G G G G - - G G A G G G - G A G G R G G R G G - Hounslow AUIC G G G G - - A - - G G A - R A R Hounslow Planned Care G G G G - - G - - G G G - G R G Hounslow Children' s G G G G G G R - R G G Richmond APUIC G G G G - - G - - A G A - R G G Richmond Children's G G G G G G G - G R G Community Nursing G G G G - - A - - G G G - R A R Clinical Imp. H&R G G G G A G G - G R G Health and Wellbeing G G G G G G - - R G G Clinical Support Service G G G G A G - - G G G Clinical Managers G G G G G G - - G G G Corporate Services G G G G A G R - G A G 4

253 S 01 S 02 S 03 S 04 S 06 S 10 S 13 S 14 S 15 C 04Y C 04N C 05N C 05Y C 06 C 07 C 09 C 10 E 01 E 02 E 03 R 01 R 02 R 03 R 04 R 05 R 06 R 10 W 01 W 02 W 03 W 04 W 05 W 06N W 06Y W 07 W 08 W 09 W 10 W 11 Incidence of Clostridium difficile Incidence of MRSA Never Events occurring in month Medication errors causing serious harm Number of reported safety incidents (Harmful) Number of new Serious Incidents in month Inpatient Falls per 1,000 Occupied Bed Days Percentage of Harm-free care (Safety Therm.) Percentage of new Harms (Safety Therm.) Trust Composite FFT - % recommend Trust Composite FFT - % not recommend Staff FFT - not recommend as a care-provider Staff FFT - recommend as a care-provider Patient Survey: patients felt respected Patient Survey: patients felt care was right Mixed Sex Accommodation Breaches Formal complaints received Percentage of Staff Appraised Percentage of Staff - Stat. & Mand. Training Clinical Supervision - within 3 months A&E: maximum time of four hours: Arr to Dep RTT WT completed non-admitted pathways RTT WTs incomplete pathways RTT over 52 week waiters Diagnostic waiting times: over 6 weeks Delayed Transfers of care Services meeting contractual waiting times IP FFT response rate A&E FFT response rate Community FFT response rate Trust Composite FFT response rate Staff FFT response rate Staff FFT - not recommend as a workplace Staff FFT - recommend as a workplace Staff Sickness Staff Turnover Vacancy rate Temporary and overtime costs BME staff in Bands 7-9 and VSM TRUST-LEVEL INDICATORS: Monthly Summaries June 17 to June 18 June-18 G G G G - - G A - G G G G G G - - G G A G G G - G A G G R G G R G G - May-18 R G G G - - G A - G G - - G G - - A G A G G G - G G G G G G A G G - April-18 G G G G - - A A - G G - - G G - - G G A G G G - G R G G G A G G G - March-18 G G G G - - G G - G G G G G G - - G G A G G G - G R G G G G R G A G - February-18 G G G G - - R A - G G - - G G - - G G A G G G - G R G G G R G A G - January-18 G G G G - - R A - G G - - G A - - A G A G G G - G A R G G R G A G - December-17 G G G G - - R A - G G G A G G - - A A R G G G - G G G G R G R G A G - November-17 G G G G - - R G - G G - - G G - - A A A G G G - G G G G A R G G G - October-17 G G G G - - R A - G G - - G G - - A R A G G G - G R G G G R G G G - September-17 G G G G - - R A - G G G G G R - - A G R G G G - G G G G G G A G G G - August-17 G G G G - - R A - G G - - R R - - A G R G G G - G G G G G G G G G - July-17 G G G G - - R A - G G - - G G - - A G G G G G - G G G G G G G G G - June-17 G G G G - - R A - G G G G G A - - A G R G G G - G G G G A G A G G G - 5

254 Section 2: Areas of Concern In June 2018 there are two indicators which are RAG rated Red. Please see below for details of the indicators by reporting domain. Well-Led Domain Indicator Gap to target / current performance: W02 - A&E FFT response rate A&E FFT response rate AA&E FFT Response Rate compliance was below target for Jun-18 at 2.5% against a target of 5%. Breakdown as follows;- Target Current Month YTD 2.50% 4.70% 5% R A FFT A&E 1 - Extremely Likely 2 - Likely 3 - Neither Likely or Unlikely 4 - Unlikely 5 - Extremely Unlikely 6 - Don't Know Total Sample % Recommend % Not Recommend % Response Rate Hounslow Urgent Care Centre (UCC) % 4.6% 2.4% Urgent Treatment Centre (UTC) % 0.8% 2.6% Total % 2.9% 2.5% Reason for performance gap: In June an additional patient satisfaction survey was completed, which included friends and family collection. UTC & UCC This survey was conducted manually, these results were not captured within the electronic system (MES), therefore these responses currently fall outside of this month s reporting figure. Also during this period external inspectors ran a parallel survey within these environments using their own comment cards instead of friends and family cards. These two factors contributed to a reduction in overall collection performance. 6

255 Action Plan Description of Action Start Date End Date Status Outcome UTC UTC admin lead to arrange for FFT volunteers to support filling in of FFT cards in WIC waiting area and after consultations 11/07/ /09/2018 Increase FFT Cards HRCH Communications Team and PALS to design new posters and communications materials to explain purpose of FFT to encourage UTC 11/07/ /09/2018 Increase FFT Cards increased responses To review the location of the tablet in UTC to encourage FFT is gathered in the UTC and to consider as part of redesign of reception area UTC 16/07/ /08/2018 at UTC. Increased FFT feedback via electronic system. UCC Provide HRCH with information from PSQ 10/07/ /07/2018 Green Improved response rate from 2.5 to 3.9. Authors: Angie Moles / Tom Penman / Clare Thompson / Wendy Martin 7

256 Well-Led Domain Indicator W08 - Staff Turnover Gap to target / current performance: Staff Turnover Staff Turnover was below target for Jun-18. The following Divisions did not meet the target:- Target Current Month YTD 18.5% 17.9% 16.8% R A Hounslow Planned Care 30.3% Richmond Children Services 24.9% Clinical Improvement 19.4% The new structure In April 2018 has resulted in some departments being deleted from the trust structure. These include departments that have transferred out of the organisation over the rolling 12 months. Therefore this has affected the average staff denominator which is used to calculate turnover. This coupled with a higher number of leavers has led to the increase in turnover. A number of divisions are small such as Clinical Improvement, Clinical Managers and Health and Wellbeing, which will always be affected disproportionally to the number of staff that have left. Reason for performance gap: Hounslow Planned Care had 42 staff that left in the last 12 months (July 17 to June 18), 28 of which were physio s, 7 occupational therapists. Richmond Children s services had 37 staff leave in the last 12 months, of which 10 staff were speech and language therapists, 5 nurses and 5 healthcare science assistants. 8

257 Description of Action We will devise a retention action plan for therapies looking particularly at physio s, occupational therapists and speech and language therapists. Start Date End Date Status Outcome 01/07/ /10/2018 In Progress Action Plan Discussion at July DMT Meeting with therapy service managers 01/08/2018 Completed Review other sources e.g. FFT, staff survey, exit questionnaires. 01/08/2018 Devise therapy retention action plan 01/09/ /10/2018 Authors: Ian Hughes / Jane Smith/ Harjinder Johal/ Linda Thomas/ Alison Heeralall 9

258 S04 S03 S02 S01 DOMAIN: SAFE Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/ DQ Incidence of Clostridium difficile Incidences Target Not yet available GA/R G G G G R G A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/ DQ Incidences Incidence of MRSA - 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% - - Target Not yet available GA/R G G G G G G A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/ DQ Never Events occurring in month Incidences % 0.0% 0.0% 0.0% 0.0% 0.0% - - Target Not yet available GA/R G G G G G G A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/ DQ Medication errors causing serious harm Incidences % 0.0% 0.0% 0.0% 0.0% 0.0% - - Target Not yet available GA/R G G G G G G A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M 10

259 S14 S13 S10 S06 DOMAIN: SAFE Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Number of reported safety incidents (Harmful) All Incidents Reported as harmful % 35.9% 33.7% 33.9% 38.7% 34.2% 38.0% 34.2% 36.8% Target % 40% 30% 20% 10% Not yet available DQ % A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Number of new Serious Incidents in month New SIs Target Not yet available DQ A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Inpatient Falls per 1,000 Occupied Bed Days Occ Bed Days ,144 2,383 Falls Fall/1000 OBD Target Not yet available DQ GA/R R R G A G G G G 0 A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Percentage of Harm-free care (Safety Therm.) Total Audited ,697 1,810 Harm-free ,601 1,711 % 95.0% 94.1% 95.3% 94.5% 94.4% 94.7% 94.3% 94.5% Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 100% 95% 90% 85% Not yet available DQ RA/G A A G A A A A A 80% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M 11

260 S15 DOMAIN: SAFE Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Percentage of new Harms (Safety Therm.) Total Audited ,697 1,810 New Harms % 1.6% 2.1% 1.4% 1.4% 2.3% 1.5% 1.6% 1.7% Target % 4% 3% 2% 1% Not yet available DQ % A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M 12

261 C05N C05Y C04N C04Y DOMAIN: CARING Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 100% Responses 1,535 1,378 1,445 1,348 1,825 1,181 4,066 4,354 DQ Trust Composite FFT - % recommend Positives 1,490 1,314 1,378 1,295 1,701 1,123 3,860 4,119 % 97.1% 95.4% 95.4% 96.1% 93.2% 95.1% 94.9% 94.6% Target 90% 90% 90% 90% 90% 90% 90% 90% 95% 90% 85% ` MAR 18 - Median to Best 10% NHSI - Community Indicators Scorecard - Jun 18 R/AG G G G G G G G G 80% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Trust Composite FFT - % not recommend Responses 1,535 1,378 1,445 1,348 1,825 1,045 4,066 4,218 Negatives % 0.8% 1.5% 1.6% 1.4% 2.0% 2.9% 1.5% 2.0% Target 10% 10% 10% 10% 10% 10% 10% 10% 12% 10% 8% 6% 4% 2% Not yet available DQ GA/R G G G G G G G G 0% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Previous YTD YTD KPI Description Mar-17 Jun-17 Sep-17 Dec-17 Mar-18 Jun-18 Trend Peer Comparison Quarters 17/18 18/19 Staff FFT - recommend as a careprovider Responses Positives % % 86.4% 67.5% 90.7% 92.4% 84.9% 92.4% Target 67% 67% 67% 67% 67% 67% 67.0% 67.0% 100% 4 80% 3 60% 2 40% 1 20% Q4 17/18 - Best 10% NHSI - Community Indicators Scorecard - Jun 18 DQ R/AG - G G A G G G G 0% 0 Q1A M J Q2J A S Q3 O N D Q4 J F M AQ1M J J Q2 A S O Q3 N D J FQ4M A MQ1J J A Q2 S O N Q3 D J F MQ4 Previous YTD YTD KPI Description Mar-17 Jun-17 Sep-17 Dec-17 Mar-18 Jun-18 Trend Peer Comparison Quarters 17/18 18/19 40% 4 Responses DQ Staff FFT - not recommend as a careprovider Negatives % - 2.9% 4.6% 12.1% 0.8% 1.3% 2.9% 1.3% Target 33% 33% 33% 33% 33% 33% 33.0% 33.0% 30% 3 20% 2 10% 1 Q4 17/18 - Median to Best 10% NHSI - Community Indicators Scorecard - Jun 18 GA/R - G G G G G G G 0% 0 Q1 A M J Q2 J A S Q3 O N D Q4 J F M AQ1 M J J Q2 A S O Q3 N D J FQ4 M A MQ1 J J A Q2 S O N Q3 D J F MQ4 13

262 C10 C09 C07 C06 DOMAIN: CARING Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Patient Survey: patients felt respected Responses Positives % 99.3% 100.0% 100.0% 100.0% 97.7% 98.6% 95.0% 99.0% Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 100% 98% 96% 94% 92% Not yet available DQ R/AG G G G G G G A G 90% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 100% Responses DQ Patient Survey: patients felt care was right Positives % 95.4% 100.0% 100.0% 96.3% 98.9% 98.5% 92.8% 97.7% Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% R/AG A G G G G G R G 95% 90% 85% 80% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Not yet available Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/ DQ Mixed Sex Accommodati on Breaches Breaches Target Not yet available GA/R A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Formal complaints received Complaints Target Not yet available DQ A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M 14

263 E03 E02 E01 DOMAIN: EFFECTIVE KPI Description Latest 6 Months Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 YTD 17/18 YTD 18/19 Trend Peer Comparison DQ Percentage of Staff Appraised All Staff ,462 2,545 Appraised ,114 2,320 % 84.9% 91.9% 94.3% 93.2% 88.1% 92.1% 85.9% 91.2% Target 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 100% 95% 90% 85% 80% 75% Not yet available RA/G A G G G A G A G 70% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Percentage of Staff - Stat. & Mand. Training Staff - Courses 10,820 10,820 10,763 10,886 10,950 11,033 47,684 32,869 Compliant 9,236 9,664 9,834 10,050 10,083 10,326 40,697 30,459 % 85.4% 89.3% 91.4% 92.3% 92.1% 93.6% 85.3% 92.7% Target 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 100% 95% 90% 85% 80% 75% Not yet available DQ RA/G G G G G G G G G 70% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Clinical Supervision - within 3 months Clinincal Staff ,060 2,109 Compliant ,531 1,799 % 84.4% 82.8% 87.6% 84.8% 83.0% 88.1% 74.3% 85.3% Target 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 100% 90% 80% 70% 60% Not yet available DQ RA/G A A A A A A R A 50% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M 15

264 R04 R03 R02 R01 DOMAIN: RESPONSIVE Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 A&E: maximum time of four hours: Arr to Dep All Attends 11,168 10,986 11,236 11,323 12,018 11,055 32,635 34,396 Within 4 hrs 11,099 10,901 11,144 11,239 11,948 10,952 32,458 34,139 % 99.4% 99.2% 99.2% 99.3% 99.4% 99.1% 99.5% 99.3% Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% R/AG G G G G G G G G Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 RTT WT completed non-admitted pathways All Completed Within 18 wks % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Target 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 100% 99% 98% 97% 96% 95% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M 100.0% 98.0% 96.0% 94.0% 92.0% FEB 18 - Median to Worst 10% NHSI - Community Indicators Scorecard - Apr18 NB Arr-Dep in 2 hours Not yet available DQ DQ R/AG G G G G G G G G 90.0% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 RTT WTs incomplete pathways All Waiting Waiting >18 wks % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Target 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 100.0% 98.0% 96.0% 94.0% 92.0% APR 18 - Best 10% NHSI - Community Indicators Scorecard - Jun 18 DQ R/AG G G G G G G G G 90.0% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/ DQ Breaches RTT over 52 week waiters Not yet available Target GA/R A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M 16

265 R10 R06 R05 DOMAIN: RESPONSIVE Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Diagnostic waiting times: over 6 weeks All Seen ,235 1,175 Waited > 6wks % 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Target 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 5% 4% 3% 2% 1% Not yet available DQ GA/R G G G G G G G G 0% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Delayed Transfers of care Occ Bed Days DToC OB Days ,147 2, % 6.8% 7.5% 9.6% 12.2% 4.5% 6.8% 1.6% 7.8% Target 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 20% 15% 10% 5% Not yet available DQ GA/R A R R R G A G R 0% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Services meeting contractual waiting times All Services Within Target % 81.0% 91.4% 89.7% 91.4% 87.9% 87.9% 96.0% 89.1% Target 83.2% 84.1% 85.0% 85.0% 85.0% 85.0% 76.8% 85.0% 100% 90% 80% 70% 60% Not yet available DQ R/AG R G G G G G G G 50% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M 17

266 W04 W03 W02 W01 DOMAIN: WELL-LED Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 DQ Discharges % IP FFT response rate Responses % 61.5% 80.0% 55.0% 72.7% 93.8% 94.4% 95.0% 85.7% 80% 60% 40% Not yet available Target 30.0% 30.0% 30.0% 30.0% 30.0% 30.0% 30.0% 30.0% 20% R/AG G G G G G G G G 0% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 DQ Patients 11,168 10,986 11,236 11,323 12,018 11,055 32,635 34,396 10% A&E FFT response rate Responses ,901 1,622 % 7.5% 7.1% 6.2% 5.9% 5.7% 2.5% 5.8% 4.7% 8% 6% 4% Not yet available Target 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 2% RA/G G G G G G R G A 0% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 8% Patients 21,946 26,094 21,496 44,516 48,712 48,000 69, ,228 DQ Community FFT response rate Responses , ,108 2,684 % 3.1% 2.3% 3.4% 1.5% 2.3% 1.9% 3.0% 1.9% Target % 4% 2% 0% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M MAR 18 - Just better than Median NHSI - Community Indicators Scorecard - Jun 18 Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 8% Patients 33,140 37,095 32,752 55,861 60,746 59, , ,680 DQ Trust Composite FFT response rate Responses 1,535 1,378 1,445 1,348 1,825 1,181 4,066 4,354 % 4.6% 3.7% 4.4% 2.4% 3.0% 2.0% 4.0% 2.5% Target % 4% 2% Not yet available % A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M 18

267 W07 W06N W06Y W05 DOMAIN: WELL-LED Previous YTD YTD KPI Description Mar-17 Jun-17 Sep-17 Dec-17 Mar-18 Jun-18 Trend Peer Comparison Quarters 17/18 18/19 Staff FFT response rate All Staff 0 1,202 1,202 1,105 1,105 1,045 1,202 1,045 Responses % % 30.7% 62.0% 22.4% 22.8% 14.3% 22.8% Target % 80% 60% 40% 20% Q4 17/18 - Median to Best 10% NHSI - Community Indicators Scorecard - Jun 18 DQ % Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Previous YTD YTD KPI Description Mar-17 Jun-17 Sep-17 Dec-17 Mar-18 Jun-18 Trend Peer Comparison Quarters 17/18 18/19 Staff FFT - recommend as a workplace Responses Positives % % 66.4% 65.8% 73.4% 73.9% 65.7% 73.9% Target 61.0% 61.0% 61.0% 61.0% 61.0% 61.0% 61.0% 61.0% 100% 80% 60% 40% 20% Q4 17/18 - Just below Best 10% NHSI - Community Indicators Scorecard - Jun 18 DQ R/AG - G G G G G G G 0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Previous YTD YTD KPI Description Mar-17 Jun-17 Sep-17 Dec-17 Mar-18 Jun-18 Trend Peer Comparison Quarters 17/18 18/19 Staff FFT - not recommend as a workplace Responses Negatives % - 7.6% 15.4% 11.8% 12.9% 12.6% 7.6% 12.6% Target % 40% 30% 20% 10% Q4 17/18 - Just below Best 10% NHSI - Community Indicators Scorecard - Jun 18 DQ % Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Staff Sickness Available FTE x Days Time Lost FTE x Days 30,784 29,510 26,625 29,151 29,594 28,881 89,264 87,626 1,231 1, ,779 2,607 % 4.0% 3.8% 3.7% 3.2% 2.6% 3.1% 3.1% 3.0% Target 3.2% 3.2% 3.2% 3.1% 3.1% 3.1% 3.2% 3.1% 5% 4% 3% 2% 1% JAN 18 - Top of Best 10% NHSI - Community Indicators Scorecard - Jun 18 DQ G/AR [HR] R R R A G G G G 0% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M 19

268 W11 W10 W09 W08 DOMAIN: WELL-LED Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Headcount 1,176 1,173 1, ,374 2,892 Leavers Staff Turnover % 17.09% 17.05% 17.09% 16.63% 18.69% 18.53% 18.0% 17.9% Target 17.8% 17.5% 17.3% 17.0% 17.0% 16.8% 19.5% 16.8% 40% 35% 30% 25% 20% 15% MAR 18 - Median to Best 10% NHSI - Community Indicators Scorecard - Jun 18 DQ G/AR [HR] G G G G A R G A 10% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Vacancy rate Established WTE 1,117 1,064 1,070 1,062 1,058 1,059 3,283 3,179 Vacancy WTE % 11.4% 10.7% 10.6% 8.6% 9.3% 9.2% 11.6% 9.0% 30% 25% 20% 15% Not yet available DQ Target 10.5% 10.3% 10.0% 10.0% 10.0% 10.0% 12.5% 10.0% G/AR [HR] A A A G G G G G 10% 5% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Temporary and overtime costs Total Pay '000s Temp & O/T '000s 3,832 4,077 4,142 4,135 3,914 3,998 9,074 12, ,313 1,796 % 12.5% 13.5% 16.8% 13.9% 16.4% 14.4% 14.5% 14.9% Target 20.8% 20.8% 20.8% 20.0% 20.0% 20.0% 25.0% 20.0% 30% 25% 20% 15% 10% 5% Not yet available DQ GA/R G G G G G G G G 0% A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M Latest 6 YTD YTD KPI Description Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Trend Peer Comparison Months 17/18 18/19 Trust BME % 37.1% 37.3% 37.4% 37.1% 39.0% 36.0% 105.9% 112.1% Senior BME 29.7% 29.8% 30.0% 29.2% 30.0% 30.0% 85.4% 89.2% BME staff in % Ratio BME Bands 7-9 and 1:0.80 1:0.80 1:0.80 1:0.79 1:0.77 1:0.83 1:0.81 1:0.80 Trust:Snr VSM Target % 40% 30% 20% 10% Trust Senior Not yet available DQ % A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M 20

269 Meeting title Trust Board part I meeting Date: 25 July 2018 Report title Month 3 Finance Report Agenda item: 24 Lead director Report author David Hawkins, Director of Finance & Corporate Services Bridget Welch, Assistant Director of Finance Executive summary The attached report details the draft financial position at Month 3, May. The main points to note this month are: The Month 3 position is slightly above plan ( 1k) due to a combination of slightly underachieved income; overspends on non-pay and underspends on pay budgets. The full year forecast position is 1,965k against a planned 1,965k. A Finance Use of Resources score of 1 has been achieved Better Payment Practice code performance (BPPC), i.e. invoices paid within 30 days, by number was 98.8% for NHS and 95.5% for non-nhs. Debtors due more than 90 days totalled 1,151k, up from 659k at the start of the year The position includes the full due value of the income from the Sustainability & Transformation Fund ( 190k) Agency staffing expenditure is above planned cap Purpose: Noting Recommendation(s) Board members are asked to note the report, in particular that the surplus position for the three month period to June 2018 is marginally above plan. BAF/TRR Report history S1 None Appendices Month 3 Finance Report Page 1 of 1

270 Appendix 1: TRUST FINANCIAL PERFORMANCE FOR THE 3 MONTH PERIOD TO 30 June 2018 POSITION OVERVIEW Key Points The financial position of HRCH at Month 3 is a net surplus of 532k against a budget of 531k and plan of 531k. The full year forecast outturn is in line with budget at an EBITDA level, delivering a 3.0% surplus on actual income and with a retained surplus of 1,965k in line with the revised plan. A Single Oversight Framework Use of Resources score of 1 has been achieved. Overall income is 14k more than budget and 147k more than the original plan All Expenditure (incl. depreciation) is 13k overspent against budget and 146k overspent against plan Investment revenue is 16k against a budget of 4k and plan of 4k The 12 month run rate i.e. plan v actual is shown below TDA Plan Statement of Comprehensive Income For the Month Ending 30 June 2018 In Year Changes Budget Year To Date Actual Variance vs Budget Variance vs TDA Plan Income Total income position is reporting a surplus of 7k against budget and a surplus of 140k against plan. The variance reported relates to risk provisions for services including CQUINS and AQP. TDA Plan In Year Changes Budget Forecast Variance vs Budget Variance vs TDA Plan 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s Income (17,247) (133) (17,380) (17,394) (69,773) 389 (69,384) (69,384) (389) Pay 12, ,687 12, ,950 2,109 51,059 51,059 (2,109) Non Pay 3,970 (475) 3,495 4,214 (720) (244) 16,221 (2,529) 13,692 13, ,564 EBITDA - Operating Surplus/(Deficit) 1, ,198 1,133 (65) (10) 4, ,633 4, Investment Revenue (4) (0) (4) (16) (21) 5 (16) (21) 5 0 Depreciation ,033 (39) 1,994 2,033 (39) Surplus/(Deficit) for the financial year , ,656 2, Dividends Payable on Public Dividend Capital (PDC) (17) (66) Net gain/(loss) on transfer by absorption 0 0 Retained Surplus/(Deficit) for the Year 531 (0) , ,965 1, Full Year Month 3 CIP target has been met overall due to non-recurrent underspends on various budgets 209k of Capital expenditure has been incurred as at M3, against a planned 575k Better Payment Practice code performance (BPPC) by number is 98.8% for NHS and 95.5% for Non NHS Debtors due more than 90 days are 1,151k Our position includes 190k (100%) from the General Allocation of the Provider Sustainability Fund Agency spend is above planned caps. Expenditure Pay budgets are underspent by 641k mainly due to vacancies. The variance is across a number of services. Bank and Agency spend to the end of June was 1,796k, of which 697k or 6% of total pay related to bank staff, and 1,099k or 9% related to agency staff. Non pay costs (incl. depreciation) for the period to date are overspent against budget by 654k, mainly due to unidentified CIP and clinical contractual services. Depreciation is under budget by 54k at Month 3. Run Rate by Division The tables at the end of this report set out the run rate by division for the year to date. Please note that as we do not formally report on month 1, the month 1 numbers are estimated as a pro rata allocation of the combined year to date month 2 figures. The x axis on each graph is scaled individually depending on the size of the division or the variance between run rate in each month, therefore the movements on the graph need to be viewed in this context. Full year Position The Trust had been given a control total target of 2.075m surplus by the TDA. This is assumed on the basis of full receipt of 1,268k Provider Sustainability Fund (PSF Fund) funding. On 11 June the Trust was notified of a reduction of 110k to this control total. The Trust is now required to deliver a surplus of 1,965k and our plan and budget have been updated to reflect this change. The PSF allocation is unchanged.

271 CIP savings A full year target of 4,691k had been set for All schemes will be developed through Project Initiation Documents, assessed for quality impacts on QIAs and agreed phasing. At the end of May sufficient progress has been made with approved schemes to be able to identify 2,996k to remove from budgets. The entire target has now been identified, although 0.5m of this is from non-recurrent schemes and 1.461m from high risk schemes. 234k has been identified by month 3 through non recurrent pay run rate. The Trust now needs to continue to develop and deliver efficiency schemes and identify budget savings so that funding can be removed from budgets. Net Surplus Surplus is 1k favourable, reporting a surplus of 532k against a budget of 531k and plan of 531k for the period to 30 June Single Oversight Framework Use of Resources Score The Use of Resources score is 1 against a planned score of 1. Capital Service Capacity Metric is rated as 1 against a target of 1 with servicing capacity of 7 times debt. I&E margin is above plan and contributes to a sustainability risk rating of 1 overall. Distance from Provider Agency Cap is above plan which gives a rating of 2. Overall average score is 1. Temporary Staff Expenditure Single Oversight Framework Rating Use of Resources Score NHS Improvement published the Single Oversight Framework on 30 September There are five key themes, one of which will be accounted for within this report. The Finance and Use of Resources measures the efficiencies previously reported in the enhanced rating referred to as the Financial Sustainability Risk Rating (FSRR), ( this measures the liquidity ratio, the capital servicing capacity, I&E Margin and I&E Margin variance from plan) but also measures compliance with sector controls such as agency staffing and capital expenditure. It is worth noting that providers will now be scored from 1 to 4 with 1 being the highest. All five measures have equal weighting and the average score across all metrics is the Use of Resources score for HRCH. An updated SOF was issued in November The metrics below are unchanged but are viewed in conjunction with a Use of Resources (UoR) Assessment, a periodic review undertaken by NHSI. The framework will be developed with CQC who will publish UoR reports and ratings. Single Oversight Framework Single Oversight Framework- Financial Sustainability, Financial Efficiency Ratings Financial Criteria Metric Actual Rating Plan Liquidity for cash purposes Liquidity Ratio -Days Green Revenue available for debt/capital servicing Capital Services Capacity Green Underlying Performance I&E Margin 3.1% 1 3.1% Green Variance from Plan Variance in I&E margin as % of income 0.01% 1 0% Green Agency Spend Distance from Providers Cap 7.9% 2 0% Amber Combined Risk Rating 1 1 Green Calculating the Financial Performance Metrics Rating Categories Liquidity 20% Liquidity Ratio -Days >0 days >(7) days >(14) days <(14) days Performance against Agency Limits HRCH has been set a target cap of 4,134k agency spend in this financial year. Spend reported at the end of June 2018 is reported as above plan. Plan Year to Date Actual Year to Date Variance % Agency Staff 1,019 1, % Balance Sheet Sustainability 20% Capital Services Capacity >2.5x >1.75x >1.25x <1.25X Underlying Performance 20% I&E Margin >1% 0-1% (1) - 0% <(1)% Variance from Plan 20% Variance in I&E margin as % of income >0% (1)-0% (2)-(1)% <(2)% Agency Spend 20% Distance from Providers Cap >0% 0-25% 25-50% >50% Note A score of 4 on any metric will cap the overall weighted rating at 3, triggering a concern Scores are rounded to nearest whole number

272 Statement of Financial Position The Statement of Financial Position for the Trust at 30 June 2018 is shown below. Statement of Financial Position as at 30 June Actual '000s Actual '000s Non Current Assets Property, plant and equipment 26,860 27,096 Total non current assets 26,860 27,096 Current Assets Inventories - Stock 0 0 NHS & Trade receivables 2,869 2,571 Other receivables 2,729 3,785 Cash and cash equivalents 15,781 15,942 Total current assets 21,379 22,298 Total Assets 48,239 49,394 Current Liabilities Trade and other payables (7,383) (9,057) Provisions (675) (688) Other liabilities Total current liabilities (8,058) (9,745) Net current assets/(liabilities) 13,321 12,553 Non current liabilities 0 0 Total assets employed 40,181 39,649 Sources Plan Actual Variance Full year Plan '000s '000s '000s '000s Investment of depreciaiton ,033 Funding Via surplus Total Sources ,033 Allocation of spend CAPITAL PROGRAMME Position as at 30 June 2018 Plan Actual Variance Full year forecast '000s '000s '000s '000s IT Infrastructure New Technology Estates schemes ,285 Equipment Other Asset Under Construction Inc. above Intangible-Software Inc. above Total Allocations ,033 A spend of 209k has been recorded for Month 3 against a budget of 575k. The majority of this spends related to estates schemes and a small amount on equipment however in month 3 there has been some investment in technology. Cash Cash at 30 June is 15.8m against a target of 13.8m. Cash balances are slightly above plan due to payments received for outstanding invoices and the surplus delivered for Financed by taxpayers' equity Public dividend capital Retained earnings 28,968 28,436 Revaluation reserves 11,213 11,213 Total taxpayers' equity 40,181 39,649 Note that following a desk top revaluation by the District Valuer in March 2017, the value of the land and buildings within Fixed Assets have increased by 47k and 1,843k respectively, a total increase of 1,890k. The revaluation reserve had been increased by 1,890k as at 31 March An increase for a local desk top valuation as at 31 March 2018 has added 443k to the revaluation reserve for buildings only.

273 Debtors Debtors have decreased by 485k since May which was anticipated as year-end debt is cleared and new year contracts agreed. There is minimal change in debt not yet due, (down 90k) and debt over six months old (up 5k) with a significant decrease in debt up to three months old. Debt aged between 3 and 6 months has increased by 227k due mainly to system resilience and a rental invoice remaining unpaid and aging into this category. Cash Flow Statement Cash Flow Statement as at 30 June 2018 '000 Opening Cash and Cash Equivalents (at 31 March 2018) 15,942 Creditors Accounts Receivable - Aged Debtors Position as at 30 June 2018 May-18 '000s A green performance for both NHS and for Non NHS has been reported at 30 June Jun-18 '000s Not yet past due date 1,164 1,074 By up to Three Months 1, By Three to Six Months By More than Six Months Total 3,354 2,869 Operating Activities Operating Surplus / (Deficit) 689 Depreciation / Amortisation 445 (Increase) / Decrease in Debtors 758 Increase / (Decrease) in Creditors (1,665) Increase / (Decrease) in Provisions 0 Increase / (Decrease) in Non Current Provisions (22) Net Cash from Operating Activities 205 Interest Received 16 Capital Expenditure (209) Net Cash before Finance Accounts Payable Position as at 30 June 2018 Better Payment Policy Compliance (BPPC) - cumulative Non NHS NHS Finance Dividend Paid (173) Net Cash 15,781 BPPC (by number) 95.5% Green 98.8% Green Closing Cash and Cash Equivalents 15,781 BPPC (by value) 96.1% Green 99.6% Green

274 Run Rate by Division - Year to Date Clinical Improvement H&R Clinical Managers Clinical Support Service Community Nursing Corporate Services Health and Wellbeing

275 Run Rate by Division - Year to Date Hounslow Adults Unplanned & Integrated Care Hounslow Children's Services Hounslow Planned Care Richmond Adults Planned, Unplanned & Integrated Care Richmond Children's Services All Trust

276 +Meeting title Trust Board part I meeting Date: Report title Board forward plan Agenda item: 25 Lead director Patricia Wright, Chief Executive Report author Swarnjit Singh, Trust Secretary Executive Summary Board members are presented with an updated forward plan Purpose: Information Recommendations Board Directors are invited to note the updated draft forward plan BAF/TRR All risk entries Report history Information item at each part I Board meeting Appendices 1: Board forward plan 1

277 Appendix 1: Part I Board meetings forward plan Date Quality & Performance Strategy & planning Committee meeting reports Q1 delivery of 2018/19 annual Sustainability & Finance & Performance objectives Transformation Partnership Quality Governance Doctors revalidation annual update Audit & Risk report Board approval of Executive Committee 2017/18 Infection Prevention Strategy Workforce & Education & Control report Well-led Committee 2017/18 Medicines Management Annual report Approve revised Governance Framework 2017/18 annual committee reports 2017/18 Health & Safety report 2017/18 Safeguarding adults and children s annual reports and 2018/19 safeguarding adults and children work plans NHS Equality Delivery System grading assessment and equality action plan NHSE Workforce Race Equality Standard submission Nurse revalidation Response to Lord Carter s recommendations for community and mental health trusts Sustainability & Transformation Partnership update 2017/18 public sector equality duty report and action plan Finance & Performance Quality Governance Audit & Risk Charitable Funds 2017/18 annual committee reports Q2 delivery of 2018/19 annual objectives Winter resilience planning Sustainability & Finance & Performance Quality Governance 2

278 Date Quality & Performance Strategy & planning Committee meeting reports Transformation Partnership update Workforce & Education Committee Nursing establishment review Q3 delivery of 2018/19 annual objectives Sustainability & Transformation Partnership update Finance & Performance Quality Governance Audit & Risk Charitable Funds Workforce & Education NHS Staff survey results and action plan 2019/20 Quality Account consultation 2018/19 draft Annual Report 2018/19 draft Quality Account Information Governance Toolkit compliance Draft 2019/20 strategic priorities Sustainability & Transformation Partnership update 2019/20 budgets Risk management strategy Finance & Performance Quality Governance Audit & Risk Charitable Funds May 2019 meeting (date to be confirmed) 2018/19 Quality Account 2018/19 Annual complaints report Delivery of 2018/19 annual objectives Annual self-certification assessment Finance & Performance Quality Governance Audit & Risk NB: Standing items include Minutes of the previous meeting, action log, Chairman s report, Chief Executive s report; Patient story/frontline service presentation; Board Quality & Performance Scorecard, Finance report; Board forward plan 3

279 4

280 Patient and Public Engagement Strategy Author: Donna Lamb Director of Nursing and Non-medical Professionals Approved by: Trust Board Lead Director Donna Lamb Director of Nursing and Non-medical Professionals Version 1.0 Date: 20 July

281 Contents Section Title Page Number 1.0 Vision Context Analysis Alignment Next Steps Risks 12 Appendix 1 Mapping of patient and public engagement Appendix 2 Self-assessment against framework of engagement 2

282 1.0 Introduction Hounslow & Richmond Community Healthcare NHS Trust (HRCH) provides community health services for around 515,000 people predominantly living in the London boroughs of Hounslow and Richmond and a wider population across southwest London. The trust employs over 1,000 staff, who work across a wide range of health centres, hospitals, GP surgeries, children s centres, local council facilities and in community settings including in people s homes. We help people to stay well, manage their own health with the right support and avoid unnecessary trips to, or long stays in, hospital. HRCH is aspirational and is on a journey to becoming an outstanding trust. Our mission is to provide outstanding care and services that we and our families would want to use and recognise that this aim can only be achieved if we proactively ensure that people who we treat and care for and those who care for them, work alongside us to lead, plan, deliver, evaluate, and improve our services. Reports about NHS care, in particular the Francis Inquiry, have made a call for real patient and public involvement in all that is done and a cultural change across the NHS to ensure greater openness, transparency and a duty of candour to patients. The duty to involve patients in the development of services and in their individual care and treatment is also central to the NHS Constitution, which describes the rights of patients and public to the provision of NHS services. The trust s engagement framework Engaging for Outstanding Care represents our commitment to engage as effectively as possible with our local community and we are part of local Sustainability and Transformation Partnerships (STPs) across NW London and SW London to improve health and care through more joined-up working. Patient and public engagement (PPE) is an approach that puts the people at the heart of care to improve service quality. It can be considered to be made up of four key groups of activities: Involving people in decisions about their own care and treatment Engaging people in on-going service delivery Engaging people in making changes to services or re-designing care pathways Engaging people in organisational decision-making We consider patient and public to include: patients and service users; carers, relatives and friends of patients; people living in the areas we serve; communities; patient groups and voluntary sector organisations. We can engage people as individuals or as a group. We can inform people, involve people or work in partnership this is all about engaging people. 3

283 Whilst the Trust has a statutory duty to involve patients and the public in its work, our commitment goes beyond this duty and is embedded in our strategic objectives. We know that engaging with patients can lead to better decision making and better outcomes and that there are many ways in which we can and do put this into practice. These include how we involve patients and carers in decisions about care to how we work together with patients and the wider community in developing and planning our services. However, we also know there is still more we can do to ensure the voices of patients, carers and public stakeholders are at the centre of our everyday business and this strategy sets out our vision and plans to do this. 2.0 Vision Our patients and service users are at the centre of all that we do. Our vision is to put patients at the heart of our services. We believe a truly patient-centred approach focused on listening, understanding and responding to the needs of the whole individual is essential to the delivery of the best possible quality of care. A quality service is one that recognises the needs and circumstances of each patient, carer and ensures that services are accessible, appropriate and effective for all. The trust s vision to provide outstanding care and services that we and our families would want to use is driven by a commitment to outstanding engagement. Empowering and engaging patients, their families and carers and the public underpins our road map towards our journey to outstanding. We want: Patients, services users and carers to be actively involved in decisions about their care and treatment and understand what to do if they are not satisfied People from all backgrounds and communities to have equal access to information and involvement in our services Patients and communities to feel involved and able to influence changes to our services Patients, service users and carers to understand who to talk to, what our plans are for services and how they can be influenced Children and young people having more input and a voice in their care to help shape services. To better understand the population we serve so that we can target resources to those patients and patient groups who will benefit the most. 3.0 Context People have a right in law to be involved in their care, as set out in the Care Quality Commission (CQC) fundamental standard of person-centred care, a standard below which care should never fall. This national standard describes the action that care providers must take to ensure that each person receives appropriate care and treatment based on an assessment of their needs and preferences. The CQC report that enabling people to be more in control of their own care leads to better and often more cost 4

284 effective outcomes. Being involved is an essential characteristic of person-centred care and critical to the move to successful integrated health and care services as set out in the NHS Five Year Forward View and the Care Act. Reports about NHS care, in particular the Francis Inquiry, have made a call for real patient and public involvement in all that is done and a cultural change across the NHS to ensure greater openness, transparency and a duty of candour to patients. The duty to involve patients in the development of services and in their individual care and treatment is also central to the NHS Constitution (2010), which describes the rights of patients and public to the provision of NHS services. The Equality Act (2010) also requires organisations to engage with patients, service users and organisations that represent people with protected characteristics. The launch of the NHS Five Year Forward View (FYFV), published in October 2014, has put a greater emphasis on the role of engagement with all partners in healthcare. The FYFV places a duty on those providing health services to make arrangements to involve users of services in decision making - whether directly or through representatives. The trust needs to be able to demonstrate it is well-led against both the CQC s Key Lines of Enquiry and the NHSI Well-Led Framework. This requires the trust to be able to evidence that people who use services, the public, staff and external partners are engaged and involved to support high-quality sustainable services. 4.0 Analysis The populations of Hounslow and Richmond are significantly different. Hounslow is the fifth fastest growing population in the country. It is a young population with 52% of people under the age of 35. The population is 34% Asian, 7% black and 51% white (2011 census). This compares to Richmond where 7% are Asian, 2% black and 86% white. Richmond also has the highest proportion of patients over the age of 85 in London. Summary of key drivers: (This section re drivers was previously in context section) External drivers Implications Political Strong patient focus Need to be able to meet expectations around PPE Changing commissioning Need to be able to evidence strong patient engagement in co-design of clinical pathways landscape Competitive marketplace Need to be able to demonstrate HRCH is the provider of choice Well-led Framework Need to be able to evidence compliance with CQC KLOE and NHSI WL framework Social and Value for money Need to be able to demonstrate impact of PPE 5

285 economic Technological Legal Changing role of patients and the public in healthcare Demographic profile of population Increasing use of new media and digital health Various legislation (as above) including compliance with CQC fundamental standards Quality accounts Need to be able to demonstrate clear decision making with patients about their care and treatment Need to be able to demonstrate an approach to engagement which aligns with demographic profile as reported in trust Public Sector Equality Duty report. Need to demonstrate opportunities for this are optimised but that patients with protected characteristics are enabled and supported to be part of this Need to be able to demonstrate compliance with statutory requirements Must be agreed with the public and published The implications of these drivers are articulated in the trust strategy and in section 5.1 of this strategy document but engagement with people is a key strategic priority which impacts on all other strategic priorities i.e. quality, sustainability and integration. When the trust has moved to locality working i.e. working with defined population groups of approximately 50,000 in partnership with primary care, there will be greater scope for engagement tailored to the specific needs of population groups. The current proposed model of engagement allows for broad and inclusive forum-type engagement alongside smaller, focussed engagement groups which are service or condition specific. 4.1 Mapping of engagement The term patient and public engagement (or involvement) is a process of working together with patients, carers and other stakeholders (e.g. relatives, carers of patients, patient representative groups and advocates) to design and develop services and the Trusts future plans. There are generally considered to be different levels of patient engagement: Involving people in decisions about their own care and treatment Engaging people in on-going service delivery and in making changes to services or re-designing care pathways Engaging people in organisational decision-making There are a range of ways and opportunities for people we treat and care for and those who care for them to be involved. Tell us how it is through giving feedback on your experience of care; tell us how we can do it differently and better 6

286 Work with us to ensure our recruitment processes are fair and that we recruit people who embody the values and behaviours of the trust Challenge us to keep the patient at the centre of our planning and decision making both at a service/condition level and a strategic level. The mapping (appendix 1) shows the trust s engagement activity at each level. This document is a snapshot in time and will not be exhaustive but it clearly demonstrates the commitment to involving patients and the public in their care, in decisions/planning/design of care and treatment but also in education and awareness raising. As a community provider this plays an important part in community and public health as well as self-care. The trust will maintain a central hub for all patient and public engagement activity which will be reviewed annually, in conjunction with our PSED data, to improve understanding of where we need to focus engagement activities. 4.2 The principles of engagement and why this is important. This has been discussed at a series of events held in community venues. People have been open and receptive to change but the principles of engagement are agreed as being: The time people give to our trust is valuable Include outreach in the model Use existing networks Use less paper and more digital options Be clear about the purpose of the engagement and share the outcome People who have attended the forum have identified why engagement is important: The public being ambassadors for our services Need to understand how services overlap To feedback patient experience and to use this to influence at the point of service delivery For the public to know what they can do, what they can report on and how they can become involved The value of good patient engagement is not underestimated by the trust. It is an important factor in developing the culture of the trust, the quality of care provided, outcomes for patients and patient experience. 4.3 Framework for patient and public engagement The chart at appendix 2 is a self-assessment against a suggested framework for patient involvement and engagement, the ladder of engagement and participation taken from Transforming Participation in Health and Care, NHS England, September

287 This is a useful framework to map our progress to becoming an organisation which works in partnership with communities and patients. We will ensure that there is a partnership approach to each aspect of a decision, including the development of alternatives and the identification of the preferred solution. The trust has made some positive movement over the last nine months as a result of the engagement work undertaken and the evidence from the mapping exercise. The trust will review its position annually and agree where it wants to be at each level of activity i.e. assurance, patient involvement in individual care and treatment, service delivery, development and transformation, patient involvement in monitoring the quality of services and strategy future planning. 4.4 Model of engagement The trust had a Patient and Public Involvement (PPI) Committee for several years. The average attendance was approximately six people although the distribution list for papers was large. The committee was run as a formal committee with an agenda and papers. The approach was often one way; with the trust staff giving information to the committee through papers although there had been some more successful workshopstyle meetings. The people who attended were committed and supportive of the organisation but were not representative of the population the trust serves particularly in terms of age and ethnicity. The purpose of the re-designed model was to: Increase the number and representative nature of the membership Adopt a forum style group with more opportunities for discussion Move the trust towards the involve level in service delivery, development and transformation, patient involvement in monitoring the quality of services and strategy future planning. (see appendix 2) Our proposed model of engagement has been shared at a community event and was well-received (appendix 3). We propose to facilitate larger forums which have a consultative workshop type approach. These will be supported by a range of satellite options which may be virtual and can be developed using a task and finish model. This model is supported by a register of people who have expressed an interest in being involved in patient and public engagement. 8

288 4.5 What does this look like? The trust will hold open forums in community venues, with interpreters available as required. These will be focussed on discussing and involving people in the strategic direction of the trust from both a business and a clinical quality perspective. In addition to this we will deliver the following: Smaller, service/condition specific groups to discuss proposed service developments/reviews. Further development of our register so that we can share information which would benefit from external review with people who have an interest in specific areas Undertaking an outreach programme to raise the profile of the trust amongst patient/community interest/representative groups Agree a workplan with Healthwatch to ensure appropriate levels of engagement with our statutory functions including the NHS Equality Delivery System, Quality Priorities 5.0 Alignment Following a discussion paper at Executive Committee in March 2017, the trust acknowledged that its strategic commitment to improving engagement with patients and the public was not clear and that the operational model was not inclusive or representative enough. The executive committee agreed two main actions: A revision of the 2017/18 strategic objectives to include under people to actively engage with patients, public and carers to improve the care we provide at every 9