London Ambulance Service NHS Trust

London Ambulance Service NHS Trust Well-led Evidence appendix Waterloo Road London Tel: 020 7783 2000 www.londonambulance.nhs.net Date of inspection visit: 5 to 22 March 2018 Date of publication: xxxx> 2017 This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust. Facts and data about this trust Acute hospital sites at the trust The emergency response service is split into five operational areas across London North West, North Central, North East, South West and South East. Each area is managed by an assistant director of operations. The trust has 70 ambulance stations across London, within 26 local operational areas known as group stations. Each is overseen by group station managers, supported by a team of clinical team leaders. (Source: Trust Website / Routine Provider Information Request (RPIR) Sites) Is this organisation well-led? Leadership Board Members In the provider information sent to us prior to the inspection we noted that of the executive board members at the trust, there were no British Minority Ethnic (BME) members and 60% were female. Of the non-executive board members there were no BME members and 50% were female. Staff group BME % Female % Executive directors 0.0% 60.0% 20171116 900885 Post-inspection Evidence appendix template v3 Page 1

Non-executive directors 0.0% 50.0% All board members 0.0% 54.0% (Source: Routine Provider Information Request (RPIR) Board) Since the last inspection the trust had strengthened the senior leadership team. There was a new chief executive appointed 10 months previously, two new non-executives, and six other new directors appointed. The executive team had expanded from seven to 11 substantive members at director level. The role requirements of the chief executive officer (CEO) had been clear and transparent and included a number of measures to ensure the right person was appointed. The chief executive officer (CEO) told us it was essential to spend time early on getting to know staff, the challenges of the organisation, and the skills and priorities of individuals. We were told by the chair it felt like there had been a tremendous change, and there was a sense of empowerment and clarity of purpose. The chair had ensured the non-executive directors (NED) had the right range of skills covering information technology (IT), finance and auditing, as well as generalised areas. It was acknowledged by the chair that they complemented the executive team. We reviewed the personnel files for the non-executive directors and those pertaining to the executive team. Appropriate checks of the suitability of members had been carried out in accordance with Fit and Proper Person expectations. The executive team had an appropriate range of skills, knowledge and experience. In our discussions they demonstrated professionalism, integrity, and were clearly ambitious and creative. This was borne out by the examples of work already undertaken and commitment to further strategic and operational activities. We were informed the new team was a mix of fresh thinking from outside the London Ambulance Service (LAS) and, in some cases, outside the NHS. There was a core of very experienced NHS professionals. Although the team was comparatively new, there was a healthy degree of challenge and cooperation amongst the members. External stakeholders who we spoke with pre-inspection indicated there was a more joined up approach, and greater responsibility for delivering on the organisational agenda. Having a stand-alone director of people and organisational development had given the necessary focus to a function which needed much better leadership. The executive lead, despite having only been in post a short time, had a very clear vision of what she wanted to achieve and was methodically working through her to do list. There was a non-executive director who was the board lead for freedom to speak up and for the services bullying and harassment work. There had been improved engagement with unions and representatives had been invited to the board meetings. The trust leadership team had a comprehensive knowledge of current priorities and challenges and had taken action to address them, and would continue to do so. There was a programme of board visits to services. Whilst some staff said the executive team were not visible in the wider sector, this was often as a result of not being around when such visits 20171116 900885 Post-inspection Evidence appendix template v3 Page 2

took place. Where staff had met the member of the non-executive team they said they were approachable and listened. However, they did not always see any materialisation of points raised. The trust recognised the need to review the current pharmacy support to make sure that it had the correct workforce in place to support the medicines optimisation strategy. It had been identified that pharmacy technicians would further support the drive for consistent improvement in medicines management across ambulance stations. The chair told us funding had been approved to address this. There were plans to recruit pharmacists into the 111 service too. The trust had a plan in place to review all medicines related policies and align these to the medicines optimisation strategy. Leadership development opportunities were available, including opportunities for staff below team manager level. The people and organisational strategy included performance development and growth. Performance reviews were used as an opportunity to discuss development opportunities. Work had started on succession planning, and would need to be monitored going forward. Vision and strategy The trust had a clear vision and set of values with quality and sustainability as the top priorities. There was a robust and realistic strategy for achieving these priorities. The vision and purpose of the LAS was clearly stated to staff, along with the underpinning values to provide care, clinical excellence and commitment. The trust s business plan stated four organisational goals, which together aimed at meeting the vision. A separate people and organisational policy set out the means by which the team, staff and stakeholders working in partnership would support the delivery of the plan. Previously there had not been a clinical or IT strategy, both of which were now incorporated into the wider strategic intent. We saw there was a medicines optimisation strategy, and this was integrated into the trust governance structure. The trust was in the process of reviewing all Service Level Agreements and key performance indicators (KPI) for all medicine management services outsourced to external agencies. Staff were fully engaged and understood the trust strategy and vision in relation to medicines optimisation. A business case had been approved and adverts placed to provide additional resources e.g. pharmacy technicians to support the trust pharmacist to increase their clinical involvement in multidisciplinary team meetings. There was work still to be done on the development of an estates strategy, which was expected following the recent appointment of a new director for this area. Clearly this was an area which could impact significantly on service delivery and the working arrangements for frontline staff. The director of strategic assets and property, along with the assistant director of fleet and logistics recognised the need to develop an estates strategy which would reflect clinical and fleet elements. This would need to take into account the wider stakeholder engagement for it to be sufficiently robust, and to meet the changing demands of patient provision. We saw there was an LAS quality improvement plan, which had been developed and acted upon in order to improve the services and to further address sustainability going forward. Staff we spoke with knew and understood the trust s vision and values. The trust had recently published a strategic intent document for the immediate and longer term ambitions. This formed the basis of a period of consultation, which involved staff, the public and patients along with stakeholders. The ultimate aim was to ensure the needs of patients, staff and 20171116 900885 Post-inspection Evidence appendix template v3 Page 3

partnership organisations throughout London; this was taken into account in developing the final strategy. We attended a workshop related to the development of the long term strategy and found the process was engaging, open and facilitated discussion and contributions of ideas and suggestions. Attendees were asked to respond to key questions in an attempt to develop and agree on the strategic direction of the service, taking into account the changing and growing needs of the population. There was clear evidence of seeking input from a wide range of people. There was some awareness of the recent work on developing the strategy but not everyone was sure where this was up to in its development. In our discussion with executive leads for strategy and communications, information provided indicated a very credible and outward looking approach. The methods of external communications were articulated very well to us. However, we had questions as to whether sufficient attention was being brought to IT and to estate and resources strategies, which were not fully addressed in the responses. The trust embedded its vision, values and strategy in corporate information provided to and received by teams. The Pulse page on the trust intranet was one example where information provided such a focus to staff. The trust had planned services to take into account the needs of the local population. Progress on the strategy, emerging work and local plans was regularly monitored and reviewed by the executive team and board. Information provided by NHS Improvement informed us that the trust was ahead of plan at month nine, 2017/18 and were expected to deliver on their plan for the year to deliver its control total in 2018/19. The trust s planned position (excluding sustainability and transformation funds, STF) had improved from a deficit of 8.7m in 2016/17 to a deficit of 4.3m in 2017/18, with a further improvement planned in 2018/19 to a deficit of 0.9m. In both 2016/17 and 2017/18, the trust had over-achieved against its plan. The trust was planning for a deficit of 1.56m in 2018/19. Culture NHS Staff Survey 2017 results better than average The trust has one key finding that exceeded the average when compared to all ambulance trusts in the 2017 NHS Staff Survey: Key Finding Trust Score National Average KF15. % satisfied with the opportunities for flexible working patterns 36% 34% NHS Staff Survey 2017 results worse than average The trust has 18 key findings worse than the average when compared to all ambulance trusts in the 2017 NHS Staff Survey: 20171116 900885 Post-inspection Evidence appendix template v3 Page 4

Key Finding Trust Score National Average Equality and diversity KF20. % experiencing discrimination at work in last 12 months KF21. % believing the organisation provides equal opportunities for career progression / promotion Errors & incidents KF28. % witnessing potentially harmful errors, near misses or incidents in last month Health and wellbeing KF17. % feeling unwell due to work related stress in last 12 months KF18. % attending work in last 3 months despite feeling unwell because they felt pressure KF19. Org and mgmt interest in and action on health and wellbeing 27% 19% 59% 69% 42% 35% 52% 48% 63% 62% 3.20 3.25 Working patterns KF16. % working extra hours 87% 85% Job satisfaction KF4. Staff motivation at work 3.56 3.65 KF8. Staff satisfaction with level of responsibility and involvement 3.46 3.59 KF14. Staff satisfaction with resourcing and support 3.10 3.16 Patient care & experience KF2. Staff satisfaction with the quality of work and care they are able to deliver KF3. % agreeing that their role makes a difference to patients / service users 3.74 3.81 86% 88% KF32. Effective use of patient / service user feedback 3.13 3.24 Violence, harassment & bullying KF22. % experiencing physical violence from patients, relatives or the public in last 12 months 38% 33% KF24. % reporting most recent experience of violence 60% 65% KF25. % experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months KF26. % experiencing harassment, bullying or abuse from staff in last 12 months KF27. % reporting most recent experience of harassment, bullying or abuse 51% 48% 32% 28% 31% 38% 20171116 900885 Post-inspection Evidence appendix template v3 Page 5

(Source: NHS Staff Survey 2017) The CEO and executive team were not surprised by the survey results, given the changes that had taken place within the leadership team and instability that had been felt by staff for a protracted period of time. They were pleased that the number of staff who responded to the survey had increased, and recognised there was work to be done to improve a number of areas. Staff survey champions were drawing up action plans, which were to be shared at executive review team meetings. The executive team felt respected, supported and valued, as did most staff spoken with in the core service inspection. However, the trust had a people and organisational strategy, which was anticipated to address some of the issues within the staff survey. The strategy covered seven key themes, including: Talent Engagement Healthy workplace Leadership and management Performance, development and growth Inclusion Recognising and rewarding excellence. In order to deliver these elements the directorate lead had identified the need for five lead roles, each of whom would have clear accountabilities and responsibility in their respective heads of position. A contingency plan was in place if appointments could not be made from the initial recruitment process. We heard about the importance of values based recruitment, driving apprenticeships, and providing opportunities for internal candidates. In addition to this, work was taking place to replace the telling approach often adopted by managers when dealing with staff, with that of a coaching style. Work had started on supporting the development of these skills at manager level, with 20 staff having gone through the programme to date. There was a more focussed approach to workforce planning, which included engaging with other trusts to see what they were doing. This in turn was expected to help the trust to build its own model and tackle recruitment challenges going forward. The trust now had a task and finish group who were responsible for looking at the number of interested applicants to conversion of new staff. As a result there was a wider range of ways of assessing applicants due to be launched in April 2018. This would include on-line assessments, telephone, and Ipad approaches. Based on the good delivery of the financial plan in 16/17 and 17/18, NHS Improvement believed the trust had a culture that supported the delivery of efficient care. The culture was very much patient centred. We heard and saw a formal presentation of the work undertaken in the north-east sector around the cultural problems and how these had been addressed. It was clear a great deal of work had been taken to improve the ownership and accountability within local management teams, to 20171116 900885 Post-inspection Evidence appendix template v3 Page 6

strengthen the governance arrangements and to deal with historical cultural issues which had impacted on performance. Results from the actions taken were shared with us in the quality oversight group, (QOG), and included by way of examples; job cycle times to the lowest on scene time across all other sectors, medicines management improved to 97-100%, and a reduction in negative staff behaviours. The latter was a good indicator that managers addressed poor staff performance where needed. It was not clear how such good examples described above were shared across the organisation. Further, we heard about the differences in the working environment in the emergency operations centre (EOC) at Bow and Waterloo Road. The former was described to us as being a happier place to work, with a chilled vibe. Staff had good ideas, which had not necessarily been cascaded to the benefit of others. For example, call handlers stood up when they were dealing with a difficult call. Other staff could see this and were able to respond through the provision of support. Some staff felt the decision making processes were not always transparent, with passive blocking of suggestions indicating an element of risk aversion. Staff sometimes found it difficult to ascertain where these internal decisions were made. For example, decisions around the limitations of patient related skills for some staff. This included for example, the use of patient group directives. Staff who were able to give steroids to asthma patients, but were not allowed to dispense antibiotics, and not being allowed to close wounds with butterfly strips. At the previous inspection we found the trust had appointed a Freedom to Speak up Guardian, (FTSUG) who at the time held an additional role and responsibilities. This proved to impact on the ability to fulfil the requirements of the FTSUG. As a result the board were presented with a paper suggesting the role would work more effectively by having the role holder not having other duties. There were quarterly reports to the board related to speak up matters, providing oversight and scrutiny. At the time of this inspection an interim person was acting as FTSUG; the position was expected to be advertised in the near future. There were plans to strengthen the arrangements for freedom to speak up so there would be a network of staff around the trust who could act as champions for staff to take concerns to. The interim post holder had a specific remit to raise the profile through communication via the pulse page, Facebook and posters. Good links had been established with the national guardian s office, which also had representatives from five ambulance trusts, providing opportunities for sharing of case studies. For new starters there was an opportunity to hear about the FTSUG. The non-executive director for freedom to speak up was the same person representing bullying and harassment, which aimed at strengthening this area of focus. There had been continued focus on the issue of bullying and harassment and the trust were starting to see signs of improvement. Improvements mainly arose from the focus on changing the language around the subject, and increasing the awareness and skills of staff to both avoid such matters arising and to handle them more appropriately. Stations had been visited to enable discussion of issues around the way people were managed, what was bullying and harassment, the protection of characteristics, use of banter and inappropriate language. Several other activities had been held with staff as a means of addressing this issue, including workshops with staff, one of which we attended. This provided staff with the opportunity to discuss and suggest further areas they could commit to. We heard open discussion about perceived 20171116 900885 Post-inspection Evidence appendix template v3 Page 7

bullying and the efforts made to try to address behaviours earlier on. This included the use of mediation rather than grievances. Action plans had been developed from the workshops and we were provided with a copy. These showed that objectives were smart in format and each desired outcome had a baseline and future target, with end point date and responsible person to oversee. We noted from a formal presentation provided to us that LAS had trained 67 staff as round table facilitators. A further 100 were expected to train in 2018. Refresher workshops commenced in 2017/2018 for all facilitators. A round table post box had been set up to speed up the process and a round table co-ordinator (wellbeing and engagement lead) was supporting the data collection to underpin trend analysis. There had been improved engagement with black and minority ethnic (BME) staff and increased willingness to being facilitators and running round tables. In our discussion with the bullying and harassment specialist they described a legitimate approach as the bullying and harassment specialist; however, it was less clear on how this work was eventually going to be embedded into existing human resources (HR) and learning development practices. Examples given did not include sufficient detail on secure culture changes and permanent operational changes that would arise out of the learning from the arbitration interviews. Since the last inspection, monthly quality and performance review meetings had been reinstated and were used for both clinical and corporate functions. We were told in our discussion with the director of performance that the chief executive officer put a lot of work into this and everyone had the chance to air their views. A few middle managers were not as understanding of the business model which was being applied to the organisation. The feeling of being micromanaged was felt by some. There was a feeling amongst some staff that executives did not have an understanding of departmental functions. Despite this, many praised the change in focus as well as the leadership from the executive team. The CEO was said to demonstrate passion and commitment. With this came the challenge to the CEO of what could and could not be achieved in a particular timeframe. Executive staff had performance objectives and these were discussed at regular face-to-face meetings with the CEO. The corporate governance director was responsible for board development. Previously there had not been any formal induction, development or succession planning. An induction pack had been put together, a board handbook, and there was clear support for the chair on appraisals. A general manager told us the board visited EOC and observed as part of their induction when they were new to LAS; but, no experienced member of the board had sat in the EOC for a long enough period of time just to see what is going on and gain an understanding. The director of operations had been in the service a long time, and gave particular attention to the fact that he had been involved operationally in the ambulance team himself in the past and was seen to be a culture carrier for the organisation. He was able to tell us how he was open to challenge and said he had a relationship with the CEO that was one of mutual challenge and support. Staff had access to support for their own physical and emotional health needs through occupational health (OH). We were made aware there had been a new OH contract since last July, which before had been challenging. Previously, communication about what was available to staff was lacking. Leaflet s with key numbers and information has since been given out to staff. With regard to staff welfare, previously this was not high enough on the agenda for staff. Staff working in the call centre were asked what they wanted and as a result the previously structured debriefing for clinical staff had now been extended to include call room staff. There was now a 20171116 900885 Post-inspection Evidence appendix template v3 Page 8

more cohesive approach to supporting staff and being more visible, e.g. during the recent computer added dispatch (CAD) issues, two bronze welfare officers were available to support staff. The control room were very supportive of time to talk, promoting the importance of mental health of patients and staff. There was promotion of mind, blue lights charities, mental health and mental resilience. A holistic approach had been taken, asking staff what works and what doesn t. They were now trialling approaches and were open and flexible in receiving feedback. There was a positive culture of being open and honest and of learning from adverse situations. The trust applied duty of candour appropriately. We saw evidence of this in its handling of complaints and incident processes, a number of which we reviewed. Appropriate learning and action as a result of concerns raised was seen in the information we reviewed. The trust carried out a mortality review-learning from deaths and reported on their findings. The trust morbidity and mortality review meetings were used to consider escalated serious incidents, including those which suggested it was an anticipated death, unexpected and all preventable measures were taken, potentially preventable and unexpected, or resulted from medical intervention. We reviewed several serious incidents which related to patient deaths. Using our reporting tool, we concluded there was a robust process for the investigation. We acknowledged too that there were additional complexities around investigating a death, which often involved more than one agency. However, we noted improvements could be made to evidencing the involvement of family, when contactable and willing to participate, particularly for agreeing the terms of reference. Further, where an external trust was involved, LAS could be more proactive in including them in the review. All directors and other staff we spoke with during the well-led inspection provided positive comments regarding the progress of the trust and of feeling proud to work in a changed and continually evolving organisation. Staff indicated there was a plan which set out the direction of travel, and this was supported by a desire to change. Positive comments indicated a sense of pride in individual teams, and the extent of their capacity to give over and beyond in support of the vision. Sector delivery group meetings were an example of different groups of people coming together once a week in a non-mandatory manner to discuss organisational and regional needs and demands. This was viewed as a positive cultural change. Staff in the executive team reported having the right level of support. The health and safety lead told us he had focused and detailed information from the chief quality officer, which he found valuable. He also had access to professional development, subscribed to NHS leadership programme and had a mentor. Negative comments we received during the well-led inspection came from the middle management level and included a feeling of superficiality with regard to the changes in the organisation. One person told us there remained issues of bullying, and we were told the closed doors of executives offices made them less visible and approachable. Where previously executives had mixed with staff in the dining room, this did not happen, and executives kept themselves to themselves. Workforce race equality standard 20171116 900885 Post-inspection Evidence appendix template v3 Page 9

The scores presented below are the un-weighted question level score for question Q17b and unweighted scores for Key Findings 25, 26, and 21, split between white and black and minority ethnic (BME) staff, as required for the Workforce Race Equality Standard (WRES). In order to preserve the anonymity of individual staff, a score is replaced with a dash if the staff group in question contributed fewer than 11 responses to that score. NHS staff survey indicator KF25: Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months KF26: Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months KF21: Percentage of staff believing that the organisation provides equal opportunities for career progression or promotion Q17b: In the 12 last months have you personally experienced discrimination at work from manager/team leader or other colleagues? Proportion of respondents answering Yes BME staff White staff % difference between BME and white staff Trust 39% 57% -18% All ambulance trusts 39% 50% -11% Trust 38% 31% 7% All ambulance trusts 32% 27% 5% Trust 47% 62% -15% All ambulance trusts 48% 71% -23% Trust 19% 11% 8% All ambulance trusts 18% 10% 8% (Source: NHS Staff Survey 2017) The director of people and organisational development told us they were disappointed by the staff results from a WRES perspective. They had identified a need to train a cohort of BME staff for interviewing and to tackle unconscious bias. Additionally, they recognised the need to give more assistance at the application stage. We were told the trust was equally weak with regard to disabilities. We were told there was information available which indicated the role of a paramedic was not currently attractive to young BME. In order to improve this there had been engagement with schools, colleges and within the local community. We were told about the continuing programme of inclusivity work and how the WRES agenda was helping the trust to maintain its focus via the chair and CEO. Reverse and sponsored mentoring was being used to help develop an understanding and targeting BME talent. 20171116 900885 Post-inspection Evidence appendix template v3 Page 10

There was a full time consultant leading on WRES who reported to the director of people and organisational development. It was not clear if there was a succession plan for the WRES lead. The WRES team consisted of the executive lead and a recruitment co-ordinator. It was clear on arrival of the WRES lead there were a number of issues to review and that WRES and equality needed a lot of input. Initially a WRES assessment was carried out followed by an action plan, which was completed quickly as a lot of urgent input was required. Board seminars delivered by the WRES lead helped to raise the profile of the issues; the biggest advocate was the Chair. This was followed by six months of listening events and working through the action plan. The trust was now compliant with equality and diversity and WRES. An equality and diversity committee had been set up, which included patient and staff representatives, executive and nonexecutive director (NED) representation. Meetings were scheduled to take place six times per year. Senior team members and the board were engaged and receptive of the work and the changes needed, although there remained work to do with middle management and staff. There were themes of less recruitment opportunity and increased disciplinary of BME staff. This was confirmed by our discussion with BME representatives who we met before the well-led inspection. We were made aware of the continuing difficulties they felt in relation to career opportunities and progress. Similar information we received at the last inspection still remained. For example, the limited numbers of BME getting shortlisted and no feedback as to the reasons why not. Staff who had been interviewed but were unsuccessful told us they did not get feedback to help them focus on addressing weaker areas. These issues had started to be addressed with conflict resolution training, and mediation. People were now going to the WRES lead to raise concerns and these matters were being tackled positively. Equality and diversity training was about to change and move to a two-hour face to face module, facilitated by an external team. This was expected to help in making sure culture was also addressed during the training. In house conversational training for paramedics on equality and diversity was also to be provided. Currently the organisation had equality and diversity training at induction and NHS e-learning as a top-up but this was not sufficient. Bespoke sessions to team leaders had already been rolled out. The current BME mix in paramedics at LAS was reflective of the mix at undergraduate level at university. The WRES lead won a bid last year for 500k and this had gone towards multiple work streams including recruitment strategy, equality and diversity training, a funded paramedic training programme, and reverse sponsorship to mentor 12 BME staff for a year with the outcome of going up a pay band at the end of it. Since the provider information had been sent to us there was one recent appointment of a BME board member at the trust. The WRES lead was expected to sit on all senior and board level recruitment panels. Equality objectives had been set and were still developing, and equality and diversity standard two was to be revisited in the next 18 months. Work was in progress to look at disability equality scheme and this would link into the business disability forum. An electronic staff record (ESR) update for staff to ensure data was captured well and other monitoring such as sexual orientation was also captured. The disability forum was engaged with the EOC to look at access to roles and reasonable adjustments. 20171116 900885 Post-inspection Evidence appendix template v3 Page 11

Friends and family test The Friends and Family Test was launched in April 2013. It asks people who use services whether they would recommend the services they have used, giving the opportunity to feedback on their experiences of care and treatment. The trust scored slightly below the England average for recommending the trust as a place to receive care from January 2017 to December 2017. It is important to note that for the six months showing 0% in the chart below, this does not reflect 0% of patients recommending the trust. Where the number of respondent s is six or less, data is supressed to prevent against the possible risk of individual responders being identified. Therefore meaning that no percentage recommended score is available for these months. Total respondents per month Jan- 17 Feb- 17 Mar- 17 Apr- 17 May- 17 Jun- 17* 47 108 70 108 75 2 6 2 6 125 3 3 Months with an asterix (*) denote those where no percentage recommend figure is available due to data suppression. (Source: Friends and Family Test) Jul- 17* Aug- 17* Sep- 17* Oct- 17 Nov- 17* Dec- 17* Sickness absence rates The trust s sickness absence levels from November 2016 to October 2017 were similar to the England average for ambulance trusts. 20171116 900885 Post-inspection Evidence appendix template v3 Page 12

(Source: NHS Digital) We remained concerned that there were differences in the way line managers dealt with sickness and absence, which impacted on staff s perception of bullying and harassment. For example, some managers contacted staff when they were off sick asking when they were coming back. We reviewed the associated policies around absence. The Special Leave Policy did not mention the responsibility of the individual to notify the line manager of sickness. The Managing Attendance Policy indicated that the staff member was responsible for reporting absence and for maintaining regular contact with the line manager, including advising of their prognosis and likely return to work. Neither policy stated clearly that it was expected practice to agree the frequency of informing the respective line manager of continuing sickness absence. Lack of clarity around the meaning of regular contact or how that contact may be made possibly contributed to mixed management and perceptions of harassment. Governance Board assurance Framework The trust provided a copy of the Board Assurance Framework (BAF) for November 2017, which detailed four strategic goals and accompanying risks. A summary of the goals is below: Goal 1 patients receive safe, timely and effective care. Goal 2 staff are valued, respected and engaged. Goal 3 partners are supported to deliver change in London. Goal 4 efficiency and sustainability will drive us. (Source: Routine Provider Information Request (RPIR) P97_BAF updated post November Board) Since the previous inspection the trust had fully reviewed the quality and governance arrangements, including the reporting processes. 20171116 900885 Post-inspection Evidence appendix template v3 Page 13

The BAF had been developed over the six months prior to our inspection and was a live document, which was regularly reviewed through the various governance meetings and individual executive leads. The format confirmed the expected standards, with a focus on maintaining a strategic focus. The risk compliance and assurance group (RCAG) purpose was to manage and monitor all risk management processes and activities within the trust, and to ensure the objectives of the Risk Management Policy were met. This included the regular review of the corporate risk register and movement on key risks, and holding risk owners to account. We were told by the chair the more technical risks were held on the corporate risk register, a copy of which was provided to us. There were 41 risks on the corporate risk register as of the start of February 2018, of which eight risks had been highlighted as overdue for review in line with their net rating. The corporate risk register was updated following the trust board meeting and information reviewed confirmed this. Staffs understanding of the roles of each local risk register had much improved, as evidenced in the discussion we had with the corporate governance director, and staff working in core services. New risks were now considered collectively and controls agreed accordingly. Consideration had been given to the organisations risk appetite and minutes from board meetings showed good challenge from members. The trust had been supported by NHS Improvement (NHSI). Feedback from NHSI indicated work had been completed on streamlining the governance structures so the flow of information between board and staff working across the organisation was clearer. Restructuring had also made responsibilities and accountabilities clearer. NHS Improvement considered that the trust was continuing on its improvement trajectory, and did not have any major governance concerns at the time of the inspection. The board had been visibly challenging itself on whether it was getting assurance or reassurance. The alignment of the independent audit programme with areas of risk and re-introduction of a programme of quality assurance visits was helping to triangulate their views of the organisation. The decision to move to business partnering between corporate services and operations had started to embed the idea that corporate services were there to enable the people who interacted with patients to do their job well. The trust had created a new corporate governance team since the previous inspection, although interviews were yet to be held for substantive posts to support the corporate governance director. We were told in our discussion with the corporate governance director their early observations at the trust had shown meetings did not always have minutes recorded. There was a lack of oversight and recognition of the value in having standardised approaches to recording information. Systems and processes were said to have been there in name but it was difficult to access papers and information was shared in varying ways. Further, there was lack of understanding of regulatory processes. The trust now had appropriate filing arrangements for governance related documents, including electronic storage. There was more reference to previous minutes, and information was more accessible when needed. One area where this was still to improve however, was in relation to records stored in Bow EOC. It was difficult to access records and find information, for example when the Coroner requested information. 20171116 900885 Post-inspection Evidence appendix template v3 Page 14

We were told standard templates were now used for presenting information and there was collective review of papers before going to the board. The formal route included an executive review first. We saw a whole range of papers, which in appearance and content demonstrated a significant improvement in this area. Our review of public board papers found the meeting agendas were well planned, papers were comprehensive and transparent. Reports were well written and contained clear data. There was a strong emphasis on monitoring and quality impact. The percentage of focus on strategy was slightly lower than expected but could be a reflection of the need to develop data to support the changes. Meetings, including that of the board had a slot for reflecting on the behaviours at the meeting, the standard of presented papers, level of debate and noted challenge. This is considered excellent practice. The coaching role of the corporate governance director had assisted in key staff understanding of governance and the BAF, as well as rationalising why they wanted certain items to be presented at committee. We were made aware of an example where the strengthened governance arrangements had assisted the trust to uncover some serious issues related to health and safety, particularly around staff training, an action they had previously been expected to take but had not been followed up on. As a result, and with the support of external contractors, the trust had been given 54 areas of concern on which to focus. Progress was reported monthly to the executive leadership team and the board. During this inspection we were told the follow up independent review had been completed and a draft report had been provided to the trust. The outstanding actions were now at 11. A good example was practical manual handling which had now been rolled out to staff (before they were not getting any apart from induction). This should help with reducing injuries and injury claims and provide a better quality service. Investment in health and safety (H&S) work was clear and ultimately should reduce the impact on staff and claims to the service. However, security, violence and aggression was still an ongoing issue. Policies related to manual handling, violence against staff and lone working were now available to staff. The latter had involved the metropolitan police for its effective implementation. Issues with personal radios had also been addressed, and safety alert buttons were available to all. There were effective structures, systems and processes in place to support the delivery of its strategy including sub-board committees, divisional committees and team meetings. Leaders regularly reviewed these structures. The medicines management group considered all aspects of proposed new drugs introductions, reviews of existing drugs, including the use of patient group directions and medicines obtained from external agencies. Medicines incidents reported on the Datix system were discussed at the medicines management group. The trust was in the process of reviewing all Service Level Agreements and KPIs for all medicine management services outsourced to external agencies. We heard direct evidence of managers using meetings to share essential information such as learning from incidents and complaints and to take action as needed. 20171116 900885 Post-inspection Evidence appendix template v3 Page 15

Information from local QGAM fed into the trust quality oversight group, (QOG). We attended one of the QOG meetings and observed a structured approach to reviewing information under broader topics. This included for example: patient and staff safety, which covered quarterly thematic reports of serious incidents, the patient safety group report, safeguarding assurance, health and safety, and infection control. The patient experience section included a focus on feedback from the patient forum, care protocols, the hospital handover project and feedback from the patient experience feedback group. Quality matters included updates from sectors, exceptions reports, priority areas within the quality accounts, update on the quality indicator programme and risk management. We heard information related to medicines management, the emergency operations centre and progress made in the north-east sector. The risk register was discussed, including the need to add additional issues to the current log. There was attendance at the public board meeting by patient representatives. Board meetings were well attended by executive and non-executives and discussions were open and honest, with reflections on performance, risks and other quality matters. Update on actions were presented and there was a sufficient level of scrutiny and challenge. It was clear from our discussion with non-executive and executive directors that they were clear about their areas of responsibility. Management of risk, issues and performance Finances Overview Historical Data Projections Financial Metrics Previous Financial Year (2015/16) Last Financial Year (2016/17) This Financial Year (2017/18) Next Financial Year (2018/19) Income 319.99m 355.51m 359.44m 367.7m Surplus (deficit) Full costs/ expenditure ( 4.03m) 5.96m 5.7m 1.56m 324.03m 349.54m 353.74m 369.26m Budget 325.44m 337.32m 361.4m 369.26m (Source: Routine Provider Information Request (RPIR) Finances) No fraud or serious concerns have been flagged to NHS Improvement in the last two years. Auditors had not flagged any concerns to regulatory bodies. Financial outcomes had been consistently strong over several years, with cash and revenue plans being delivered in line with plans and national requirements. There were some delays in capital expenditure but the trust was clear on the reasons for this with NHS Improvement. 20171116 900885 Post-inspection Evidence appendix template v3 Page 16

Risk Register As part of the trust s board assurance framework (BAF) the highest profile corporate risks are included next to the BAF goals they relate to. These are summarised below: Risk Related BAF goal Gross rating BAF Risk 7: Patients could suffer avoidable harm across shift change over periods due to deterioration in response times as a result of reduced resource availability. BAF Risk 40: The Trust may not be able to recruit sufficient core front line staff to meet workforce profile requirements in 2017/18. BAF Risk 43: The management of bank workers may not meet current standards relating to training, governance and management. BAF Risk 45: A cyber-attack could materially disrupt the Trust s ability to operate for a prolonged period. BAF Risk 46: Lack of compliance with statutory health and safety requirements due to limited evidence and assurance that required health and safety management systems have been implemented to ensure the health, safety and welfare of staff and others who are affected by the activities of the Trust BAF Risk 47: The Trust may be unable to maintain service levels due to insufficient staff in the Emergency Operations Centre BAF Risk 48: The capability of the Trust to effectively manage major and significant incidents will be impacted as a result of insufficient operational mangers having out of hour s access to blue light equipped vehicles, as a result of changes to Goal 1 patients receive safe, timely and effective care. Goal 4 - efficiency and sustainability will drive us. Goal 1 patients receive safe, timely and effective care. Goal 2 - staff are valued, respected and engaged. Goal 1 patients receive safe, timely and effective care. Goal 2 - staff are valued, respected and engaged. Goal 1 patients receive safe, timely and effective care. Goal 4 - efficiency and sustainability will drive us. Goal 1 patients receive safe, timely and effective care. Goal 2 - staff are valued, respected and engaged. Goal 1 patients receive safe, timely and effective care. Goal 2 - staff are valued, respected and engaged. Goal 1 patients receive safe, timely and effective care. Goal 2 - staff are valued, respected and engaged. Current rating 20 16 16 16 16 12 20 20 20 20 16 16 20 15 20171116 900885 Post-inspection Evidence appendix template v3 Page 17

how HMRC calculate benefit in kind liabilities have resulted in increased personal cost to managers for having access to vehicles with emergency response capability. BAF Risk 49: The preferred LAS strategy may not be deliverable within the Trust's identified strategic timeframe due to the scale of investment and resource required. Goal 4 - efficiency and sustainability will drive us. 25 15 (Source: Routine Provider Information Request (RPIR) P97_BAF updated post November Board) Since the last inspection the trust had reviewed the Board Assurance Framework (BAF) and the strategic risks were recalibrated. There was a reporting template aligned to this, which subcommittees used to prompt risk assessment. Risk registers and data collection tools had been reviewed and improved since the last inspection. There was much greater awareness at sector level of the broader risks and those that related to their part of the service. We were provided with a copy of the new risk management strategy and policy which had been developed and noted; this included an associated implementation plan. A formal presentation of the risk management programme had been prepared for sharing with staff and we were able to review a copy of this. The content presented clear and concise information as to what had been done to improve risk management, and future work to enable the programme to be embedded in practice. The corporate risk register was aligned to the BAF. Corporate risks were reviewed at quality and performance monthly review meetings, chaired by the CEO, the quality assurance committee (QAC), the quality oversight group, by the executive leadership team and within the risk, compliance and assurance group. Minutes of these meetings were shared with us. The LAS Quality Improvement Plan (QIP) was linked to the BAF risks in relation to the special measures status. The QIP presented to the trust board in the January 2018 meeting indicated the results from mock inspections carried out in November 2017, including 24-high priority actions, which were to be addressed. In addition, we saw the meeting covered an update with regard to the actions required following the previous findings from our inspection, and key performance indicators aligned to these. We received information from NHS Improvement indicating they had evidence that financial performance had been consistently strong with the trust achieving or exceeding plans. Discussions by NHS Improvement with the chief financial officer (CFO) and members of the finance team had demonstrated that financial risks had been identified and were being managed by the trust. The trust pharmacist was also the medicines safety officer. A medicines safety improvement plan was in place to strengthen the trusts responses to medicines risks. We were told the future plan was to separate the trust pharmacist and the medicines safety officer role. There was an audit programme with the aim to address any trends in incidents/concerns raised by the quality managers. 20171116 900885 Post-inspection Evidence appendix template v3 Page 18